Behavioral Outcome Effects of Serious Gaming as an Adjunct to Treatment for Children With Attention-Deficit/Hyperactivity Disorder: A Randomized Controlled Trial.

BACKGROUND: The need for accessible and motivating treatment approaches within mental health has led to the development of an Internet-based serious game intervention (called "Plan-It Commander") as an adjunct to treatment as usual for children with attention-deficit/hyperactivity disorder (ADHD). OBJECTIVE: The aim was to determine the effects of Plan-It Commander on daily life skills of children with ADHD in a multisite randomized controlled crossover open-label trial. METHODS: Participants (N=170) in this 20-week trial had a diagnosis of ADHD and ranged in age from 8 to 12 years (male: 80.6%, 137/170; female: 19.4%, 33/170). They were randomized to a serious game intervention group (group 1; n=88) or a treatment-as-usual crossover group (group 2; n=82). Participants randomized to group 1 received a serious game intervention in addition to treatment as usual for the first 10 weeks and then received treatment as usual for the next 10 weeks. Participants randomized to group 2 received treatment as usual for the first 10 weeks and crossed over to the serious game intervention in addition to treatment as usual for the subsequent 10 weeks. Primary (parent report) and secondary (parent, teacher, and child self-report) outcome measures were administered at baseline, 10 weeks, and 10-week follow-up. RESULTS: After 10 weeks, participants in group 1 compared to group 2 achieved significantly greater improvements on the primary outcome of time management skills (parent-reported; P=.004) and on secondary outcomes of the social skill of responsibility (parent-reported; P=.04), and working memory (parent-reported; P=.02). Parents and teachers reported that total social skills improved over time within groups, whereas effects on total social skills and teacher-reported planning/organizing skills were nonsignificant between groups. Within group 1, positive effects were maintained or further improved in the last 10 weeks of the study. Participants in group 2, who played the serious game during the second period of the study (weeks 10 to 20), improved on comparable domains of daily life functioning over time. CONCLUSIONS: Plan-It Commander offers an effective therapeutic approach as an adjunct intervention to traditional therapeutic ADHD approaches that improve functional outcomes in daily life. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN): 62056259; http://www.controlled-trials.com/ISRCTN62056259 (Archived by WebCite at http://www.webcitation.org/6eNsiTDJV).

Development and User Satisfaction of "Plan-It Commander," a Serious Game for Children with ADHD.

The need for engaging treatment approaches within mental health care has led to the application of gaming approaches to existing behavioral training programs (i.e., gamification). Because children with attention deficit/hyperactivity disorder (ADHD) tend to have fewer problems with concentration and engagement when playing digital games, applying game technologies and design approaches to complement treatment may be a useful means to engage this population in their treatment. Unfortunately, gamified training programs currently available for ADHD have been limited in their ability to demonstrate in-game behavior skills that generalize to daily life situations. Therefore, we developed a new serious game (called "Plan-It Commander") that was specifically designed to promote behavioral learning and promotes strategy use in domains of daily life functioning such as time management, planning/organizing, and prosocial skills that are known to be problematic for children with ADHD. An interdisciplinary team contributed to the development of the game. The game's content and approach are based on psychological principles from the Self-Regulation Model, Social Cognitive Theory, and Learning Theory. In this article, game development and the scientific background of the behavioral approach are described, as well as results of a survey (n = 42) to gather user feedback on the first prototype of the game. The findings suggest that participants were satisfied with this game and provided the basis for further development and research to the game. Implications for developing serious games and applying user feedback in game development are discussed.

Skittish, shielded, and scared: relations among behavioral inhibition, overprotective parenting, and anxiety in native and non-native Dutch preschool children.

This study examined behavioral inhibition and overprotective parenting as correlates and predictors of anxiety disorder symptoms in preschoolers with a multi-cultural background (N=168). Parents of 3- to 6-year-old children completed a set of questionnaires twice, 12 months apart. Parents were also interviewed with the Anxiety Disorders Interview Schedule for DSM-IV at the 12-month point to assess the clinical severity of children's anxiety symptoms. Behavioral inhibition consistently emerged as a significant concurrent correlate of anxiety symptoms and this was particularly true for social anxiety symptoms. Overprotective parenting also emerged as a significant correlate of anxiety, but only in the case of non-social anxiety symptoms and mainly in non-native Dutch children. Prospective analyses revealed that behavioral inhibition was a significant predictor of social anxiety symptoms, while overprotective parenting did not explain significant variance in the development of children's anxiety over time. The support for an interactive effect of behavioral inhibition and overprotective parenting was unconvincing. Finally, it was found that children who exhibited stable high levels of behavioral inhibition throughout the study ran the greatest risk for developing an anxiety disorder.

The assessment of an inhibited, anxiety-prone temperament in a Dutch multi-ethnic population of preschool children.

The Behavioral Inhibition Questionnaire-Short Form (BIQ-SF) is a 14-item parent-rating scale for assessing an inhibited, anxiety-prone temperament in preschool children. This study examined the psychometric properties of the BIQ-SF scores in a multi-ethnic community population of Dutch boys and girls aged 2.5-6 years (total N = 2,343, from which various subsamples were derived). Results revealed that the factor structure of the BIQ-SF was as hypothesized: a model with six correlated factors representing children's inhibited behaviors in various social and non-social contexts provided a good fit for the data. The internal consistency of the BIQ-SF was generally satisfactory and scores on the scale were found to be fairly stable over a time period of up to 2 years. Parent-teacher agreement was acceptable, and relations between the BIQ-SF and observations of an inhibited temperament were moderate. Finally, BIQ-SF scores were positively associated with measures of anxiety and internalizing symptoms, whereas no significant links were found with externalizing symptoms. Altogether, these results provide support for the reliability and validity of the BIQ-SF as an economical method for assessing behavioral inhibition and anxiety proneness in young children.

Relations between behavioral inhibition, big five personality factors, and anxiety disorder symptoms in non-clinical and clinically anxious children.

This study examined the relations between behavioral inhibition, Big Five personality traits, and anxiety disorder symptoms in non-clinical children (n = 147) and clinically anxious children (n = 45) aged 6-13 years. Parents completed the Behavioral Inhibition Questionnaire-Short Form, the Big Five Questionnaire for Children, and the Screen for Child Anxiety Related Emotional Disorders-Revised. Results indicated that, compared to parents of non-clinical children, parents of clinically anxious children rated their offspring higher on neuroticism and behavioral inhibition, but lower on extraversion, conscientiousness, and intellect/openness. Further, extraversion emerged as the strongest correlate of an inhibited temperament, and this appeared true for the clinically anxious as well as the non-clinical children. Finally, in both the clinical and non-clinical samples, higher levels of behavioral inhibition and neuroticism were unique and significant predictors of anxiety disorders symptoms.