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“THE SECRET TRAIL OF MOON (TSTM)”: Proof of concept and usability of a virtual reality chess gamified serious video game to treat ADHD. (Preprint)


Abstract and Figures

BACKGROUND Attention-Deficit/Hyperactivity Disorder (ADHD) affects between 4% and 8% of children worldwide. The treatment of choice is multimodal treatment. Unfortunately, multimodal treatment is usually insufficient to fully correct ADHD. Accordingly, the incorporation of new treatments such as serious video games may be a good strategy. Here, we present a Virtual Reality (VR) chess-based serious video game (“The Secret Trail of Moon”, TSTM), which was specifically designed to treat core ADHD symptoms and executive dysfunction. OBJECTIVE This study aims to describe the development, proof of concept and usability of TSTM. METHODS We included information about: 1) a brief market study (n=56) over the potential interest of professionals in using a serious video game such as TSTM, and 2) a proof-of-concept and usability study including 37 children and adolescents who tested the initial versions of TSTM during an ongoing randomized controlled clinical trial testing the effectiveness of TSTM. RESULTS Eighty-six percent and 83% of participants liked and would like to continue playing TSTM, respectively. Thirteen and nine-tenths percent were reported to have either perceived dizziness or VR motion sickness. We found no statistically significant differences after comparing either ADHD combined vs. inattentive subtypes or frequent vs. infrequent video game players. Furthermore, wearing glasses did not affect our results. CONCLUSIONS Serious video games such as TSTM may help educational and medical professionals to either diagnose or treat ADHD. TSTM, a VR chess gamified serious video game was well-tolerated and most participants liked and wanted to continue playing TSTM. CLINICALTRIAL NCT04355065;
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Original Paper
A Virtual Reality Game (The Secret Trail of Moon) for Treating
Attention-Deficit/Hyperactivity Disorder:Development and Usability
Maria Rodrigo-Yanguas1,2*, BSc; Marina Martin-Moratinos1,2*, BSc; Angela Menendez-Garcia1, BSc; Carlos
Gonzalez-Tardon3, BSc, PhD; Ana Royuela4, PhD; Hilario Blasco-Fontecilla1,2,5,6, MD, PhD
1Department of Psychiatry, Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana-Puerta de Hierro University Hospital, Majadahonda,
2Autonoma University of Madrid, Madrid, Spain
3Universitat Pompeu Fabra, Mataro, Spain
4Clinical Biostatistics Unit, Health Research Institute Puerta de Hierro-Segovia de Arana, Center for Biomedical Research in Epidemiology and Public
Health Network, Madrid, Spain
5Spain Biomedical Research Networking Center for Mental Health Network (CIBERSAM), Madrid, Spain
6ITA Mental Health, Madrid, Spain
*these authors contributed equally
Corresponding Author:
Hilario Blasco-Fontecilla, MD, PhD
Department of Psychiatry
Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana-Puerta de Hierro University Hospital
Avenida, Manuel de Falla 1
Majadahonda, 28222
Phone: 34 655214857
Background: Attention-deficit/hyperactivity disorder (ADHD) affects between 4% and 8% of children worldwide. The treatment
of choice is multimodal treatment. Multimodal interventions for ADHD may be improved by incorporating new treatments, such
as treatment via serious video games. The Secret Trail of Moon (TSTM) is a virtual reality serious video game that was designed
for cognitive training related to core ADHD symptoms and executive dysfunction.
Objective: We aimed to describe the development and usability of TSTM.
Methods: The usability study included 37 children and adolescents who tested TSTM during the early usability stage (preinclusion)
of a randomized controlled clinical trial for testing the effectiveness of TSTM. Chi-square tests were performed to compare
patients with ADHD (ADHD combined subtype vs inattentive subtype) and to compare frequent and infrequent video game
players in the second study. We used SPSS version 20 for Macintosh (IBM Corporation).
Results: A total of 31/37 (86%) and 30/37 (83%) of participants liked playing TSTM and wanted to continue playing TSTM,
respectively. Further, 5/37 (14%) of participants reported that they experienced either perceived dizziness or virtual reality motion
sickness. We found no statistically significant differences after comparing the ADHD combined subtype to the inattentive subtype
and frequent video game players to infrequent video game players.
Conclusions: Serious video games, such as TSTM, may complement the current multimodal approach for treating ADHD.
Trial Registration: NCT04355065;
(JMIR Serious Games 2021;9(3):e26824) doi: 10.2196/26824
attention-deficit/hyperactivity disorder; chess; virtual reality; serious video game; psychotherapy; cognitive training; usability;
new technologies; transfer; randomized controlled trial
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Rodrigo-Yanguas et alJMIR SERIOUS GAMES
Attention-deficit/hyperactivity disorder (ADHD) is the most
common neurodevelopmental disorder of childhood and
adolescence; it affects 4% to 8% of children worldwide [1].
Apart from the core ADHD symptoms (inattention,
hyperactivity, and impulsivity), patients with ADHD frequently
present with poor social skills, problems in planning, and the
inability to complete tasks on time [2]. The prognosis of ADHD
is complicated by comorbidities, and impairments may intensify
during adolescence or adulthood [2,3]. The treatment of ADHD
is multimodal and can include the use of medication,
psychoeducation, and psychological intervention [4].
Unfortunately, the current multimodal approach for ADHD
treatment has some shortcomings [5]. For instance, motivation
is critical for people with ADHD, and they sometimes lack the
motivation to engage in treatment [6]. Furthermore,
psychotherapies can be expensive [7] and have high rates of
treatment discontinuation [8,9]. As such, the incorporation of
new treatments that promote high levels of motivation may be
a good strategy for improving ADHD outcomes and prognoses.
Some recent proposals include the use of board games, such as
chess [10]; neurofeedback [11,12]; virtual reality (VR) [13]; or
serious video games [14]. All of these new approaches have the
potential to keep people with ADHD motivated and engaged
during therapy. Indeed, serious video games can be very
stimulating and provide immediate reinforcement [15]. In
addition, they present some advantages, such as [15] (1) the
precise control of variables, (2) easy data collection that allows
for the evaluation of a patient's progress, (3) the provision of
immediate feedback to the user, and (4) a more attractive
presentation (ie, a video game format). It is not surprising that
various serious video games have recently been developed to
treat ADHD [15-17]. However, it is also important to mention
some disadvantages. For instance, a major problem for people
with ADHD is their vulnerability to some addictions, particularly
the addiction to video games. Children and adolescents with
ADHD are more likely to present with internet gaming disorder
[18]. Thus, when developing a serious video game for treating
ADHD, it is necessary to find a balance between obtaining a
good level of user satisfaction and avoiding increasing the risk
of becoming addicted to this video game. Independent of the
factors that influence addiction in the design of a serious video
game, researchers can control the patients who enter into a study,
since addiction is linked with adverse childhood experiences
[19,20] and game addiction is specifically linked with ADHD
severity level [21].
Another problem is the lack of evidence regarding the transfer
of improvements and benefits. In other words, it is not known
whether improvements in video game performance would
translate into improvements in other cognitive tasks in a subject's
daily life. For instance, regular chess use has been demonstrated
to transfer benefits to the educational domain (eg, by improving
mathematics performance) [22]. However, evidence about a
potential transfer to the health domain is lacking. The challenge
of cognitive training and transfer was addressed by Rabipour
and Raz [23]. These authors recommended the potential use of
brain training to ameliorate the undesired symptoms of ADHD.
They also raised the question of the transfer “of practiced skills
to other untrained cognitive domains.” Furthermore, high-quality
evidence that supports the massive use of video games to treat
ADHD is scarce. Indeed, there is just 1 video game that has
recently been approved by the Food and Drug Administration
for decreasing the severity of ADHD [24].
The development of any serious video game requires a series
of stages [15,25,26]—(1) defining the learning goals (theoretical
background and initial design); (2) creating prototypes (proof
of concept); and (3) testing usability and clinical effectiveness
(in this order). A recent example is Plan-It Commander—a
serious game that was developed for children with ADHD [15].
They initially defined the learning goals and created a prototype
to test the game’s usability and user satisfaction [15]. Afterward,
they tested its clinical effectiveness in a randomized controlled
trial [16]. They found that girls as well as boys with higher
levels of conduct problems were the subgroups that benefited
the most from playing the video game [27].
In addition to the development stages reported above, we present
the third step (usability) of the development of The Secret Trail
of Moon (TSTM)—a serious video game that was specifically
created to train patients with ADHD and increase various
cognitive abilities. This usability study allowed us to (1) obtain
initial feedback from patients with ADHD; (2) detect bugs and
integrate improvements; and (3) confirm that the use of our VR
video game was attractive, was intuitive, and did not generate
severe adverse effects in users.
Deconstructing TSTM: Theoretical Background,
Design, Development, and Description
Development Stages
The development stages of TSTM are shown in Figure 1.
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Figure 1. Design and development stages of the user-centered design study.
Theoretical Background
Information about the first stage of TSTM development can be
found elsewhere [28]. The main characteristics of TSTM are
summarized in Table 1. These characteristics were influenced
by work that was conducted by others [29].
TSTM is the result of interdisciplinary collaboration among
health care professionals, researchers, serious video game
consultants, and a single educational and therapeutic game
development company. This collaboration made it possible to
integrate several theoretical models of ADHD with clinical
experience, the use of chess and VR by patients with ADHD,
and other playful elements of video games that increase players’
motivation for engaging in therapy [30].
TSTM is theoretically driven by (1) both the Barkley [2] and
Brown [21] models of ADHD and executive dysfunction and
(2) our personal clinical experience of using chess with patients
with ADHD [10]. The original Barkley model was based on the
work of other researchers, such as Bronowski and Fuster [31,32].
This model focuses mainly on the hyperactive-impulsive ADHD
subtype (type 2). The primary premise of the Barkley ADHD
model is a deficit in behavioral inhibition. This deficit in
inhibition is related to problems in the following four executive
neuropsychological functions: (1) working (nonverbal) memory;
(2) the self-regulation of affect-motivation and arousal; (3) the
internalization of speech (verbal working memory); and (4)
reconstitution, which is understood as the ability to manipulate
verbal and nonverbal mental representations (behavioral analysis
and synthesis) [2].
The Brown ADHD model postulates that the core deficit
depends on executive dysfunction. In the Brown model, ADHD
is considered to involve 6 major deficits in activation, focus,
effort (motivation), emotion, memory, and action. In the Brown
model, similar to the Barkley model, executive dysfunction is
core to ADHD. However, both models have some differences
[21]. The Barkley model focuses on the combined type of
ADHD and emphasizes the relevance of behavioral inhibition.
In contrast, in the Brown model, behavioral inhibition is just 1
of the 6 defective executive functions [2,21].
The TSTM prototype that was used in this usability study had
5 minigames; each minigame targeted specific cognitive abilities
(Table 2) and particularly focused on inhibitory control, selective
attention, cognitive flexibility, or processing speed [2,33]. The
minigames were embedded into a VR forest context in order to
provide a more immersive and motivating experience [28].
Furthermore, as stressed by Rabipour and Raz [23], “regular
interaction with nature appears to facilitate improvements in
cognitive function and behavioral control.” A minigame was
defined as “a small, isolated game within the larger game
environment that integrates unique game elements offering tools
to improve strategic behavior” [15].
After an initial design of TSTM was produced, we iteratively
tested modified versions in order to detect and correct all bugs
[34]. Furthermore, we integrated all suggestions that were made
by different users who tested the initial version. Accordingly,
we included several modifications that allowed us to create a
redesigned video game (redesign stage) [34]. We gathered
further information on usability criteria, such as effectiveness,
efficiency, user satisfaction, and the adverse consequences of
use, and fixed some extra bugs. Thanks to this, we constructed
the first functional prototype.
In conclusion, TSTM is a serious video game that is defined as
either a game that was designed for a primary purpose other
than entertainment [35] or a “computer-based [game] designed
for training purposes” [36]. We also used gamification [37,38]
to introduce chess and to teach the basic rules of chess to
participants who did not know how to play the game.
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Table 1. Brief description of The Secret Trail of Moon (TSTM) characteristics (based on Baranowski [30]).
DescriptionTSTM Characteristics
General characteristics
Attention-deficit/hyperactivity disorder (ADHD) and attention-deficit disorder (ADD)Health topics
Individuals aged 12-22 yearsTargeted age groups
Exclusion criteria: epilepsy and dizziness (severe)Other targeted group characteristics
A VRaserious video game aimed at cognitive training related to various cognitive abilities and core
ADHD symptoms
Short description of the game idea
IndividualTarget players
The Thomas Brown model of executive functions and the Barkley Behavioral Inhibition ModelGuiding knowledge, behavior change
theory models, or conceptual frame-
Improvements in attention-deficit/hyperactivity disorder symptomatologyIntended health behavior changes
Cognitive abilitiesKnowledge elements to be learned
Feedback and monitoring, the achievement of goals and planning, the shaping of knowledge, repetition,
natural consequences, rewards, and regulation and identity techniques
Behavior change procedures or thera-
peutic procedures used
Clinical supportClinical or parental support needed
YesData are shared with parent or clinician
Adventure and puzzlesType of game
A kid appears suddenly in a cave and is greeted by a curious black fox that talks. While traveling together,
they eventually meet a scurrying raccoon, and together they form the MOONbteam. Through their ad-
ventures in the woods, they will learn about an impending war between two animal factions that want
to fill the power vacuum that the King of the Forest—Cernuous—left when he vanished. Wanting to
unite all animals again, they set out on a quest to find Cernuous and put an end to the war that threatens
the coexistence and nature of the forest itself.
This is a VR adventure experience that is augmented by some specifically designed mechanics. The
main goal of the game is to find the King of the Forest throughout several chapters by following the
main storyline of the MOON team while resolving problems (game mechanics) in the forest.
How the story relates to targeted behav-
ior change
Game components
Cognitive training by using game mechanicsPlayer’s game goals and objectives
Restricted cognitive training (25 minutes per session and per day) and exploring the forest (10 minutes)Rules
Smasher (minigame for sustained attention and impulse control), Enigma (minigame for working
memory), Kuburi (minigame for visuospatial ability), Teka Teki (minigame for planning), and chess
(minigame for reasoning)
Game mechanics
Help enhance metacognitive thinking strategies through game play, clinical support, and VR immersionProcedures to generalize or transfer
outside of the game
Virtual environment
In the forest, there are ruins of ancient civilizations that praised chess.Setting
The MOONbteam consists of the player as well as Movi (raccoon) and One (fox), who will help and
accompany the player throughout the game.
Characters will help regulate behavior and be a role model for the playerAbilities
PlayStation 4 VR (Sony Group Corporation)Game platform(s) needed to play the
PlayStation 4 VR sensor (Sony Group Corporation)Sensors used
6-8 hoursEstimated play time
aVR: virtual reality.
bMOON: Movi and One.
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Table 2. Description of each minigame.
Within this minigame, participants must break a rock that
is blocking their way by following the appropriate set of
chess pieces.
Smasher Sustained attention (based on the Brown model of at-
tention-deficit/hyperactivity disorder)
Inhibitory control
Participants must memorize the associations among differ-
ent elements. Afterward, they must match the association
as quickly as possible.
Enigma Working memory
Cognitive flexibility
Participants must create a drawing by using the face and
orienting some cubes.
Kuburi Visuospatial ability
According to the classic Baddeley model (1992),
the visuospatial agenda is part of working mem-
Cognitive flexibility
Participants can obtain a key if they can help the fox follow
her path to the lock. However, the path is obstructed by
different blocks. The number of possible movements will
decrease, thus increasing the difficulty.
Teka Teki Planning game
Participants must learn the basic rules of chess (ie, the
movement of pieces, value of pieces, most relevant moves,
etc). The level of difficulty progressively increases.
Chess Reasoning
Math calculations
Study 1 (Market Study)
Sample and Procedure
The objective of our market study was to determine whether
brain training via a serious video game, such as TSTM, would
be of interest to mental health and education professionals. A
survey that included the characteristics of TSTM and general
questions about the game was designed. We used the Google
Forms platform to disseminate Spanish and English versions
of the survey through professional networks [39]. A total of 57
people responded, but 1 person was excluded, as he was neither
a health worker or an education worker (he was a programmer).
The local Committee of Medical Ethics did not require official
review for study 1.
Statistical Analyses
We only analyzed the percentage of responses. No statistical
test was needed.
The survey was completed by 56 mental health (mostly
psychologists and neuropsychologists) and education
professionals (teachers, pedagogues, counselors, etc), of which
71% (40/56) either treat and educate or have treated and
educated people with ADHD. A total of 91% (51/56) and 87%
(49/56) of the professionals thought that a serious video game
such as TSTM could be useful and stated that they would use
it as a therapy and educational tool, respectively (Table 3).
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Table 3. Results of our market survey study (study 1).
Yes, n (%)Factors and questions
51 (91)Potential use: “Do you think a scientifically validated tool with these features which can help you in ADHD treatment could
be useful?”
49 (87)Practical use: “Would you use it in therapy session?”
54 (96)Profile adaptation: “Do you think it is relevant to be able to adapt the tool to various ADHD profiles? (Inattentive, hyperactive...)”
55 (98)Adaptive settings: “Would you like to be able to modify variables according your patient needs? (Distracters, number of elements
to memorize...)”
44 (75)Enjoyable immersion: “Would you like the game to tell a story (script, plot, characters...) in order to facilitate immersion?”
Responses about the characteristics of TSTM helped us to
prioritize some development goals Some of the
recommendations that were made were in line with literature
that stressed the relevance of using attractive graphics or
minigame mechanics with an increasing difficulty curve [15,40].
Study 2 (Usability Study)
Sample and Procedure
The second study included the first 40 consecutive patients with
ADHD who were offered inclusion into a randomized controlled
clinical trial (RCT) for testing the effectiveness of either TSTM
or web-based chess [41]. This RCT study was a prospective,
unicentric, randomized nonequality trial for patients with
ADHD. All participants underwent drug titration (up to the
optimum drug dose) and were determined to be clinically stable
before the baseline evaluation. Patients were randomized into
the following three groups: TSTM group (cognitive training via
TSTM), the therapeutic chess group (web-based cognitive
training via chess), and the control group (patients were called
every week, but no cognitive intervention was used) [42]. The
allocation ratio was equal in all 3 groups (35 participants per
The patients included in this early usability stage tested the
initial version of TSTM between December 6, 2019, and
February 22, 2020, at preinclusion. In order to provide all
available information before entering into the RCT, patients
were offered the opportunity to test TSTM at preinclusion. Of
the first 40 patients, 3 were excluded from the statistical analyses
either because they did not complete the test or because the data
provided were incomplete. The remaining 37 patients tested
TSTM and eventually entered the study. However, not all
patients were allocated to TSTM group, as randomization took
place during the inclusion visit (day 0), and the data presented
in this paper were recorded at preinclusion.
The inclusion criteria were (1) an age of 12-22 years, (2)
competency in the Spanish language, and (3) written informed
consent. The exclusion criterion was epilepsy, since the use of
VR is not recommended for individuals with epilepsy, as per
the official recommendations of PlayStation VR [43]. Ethical
approval was obtained from the local Committee of Medical
Ethics at Puerta de Hierro University Hospital – Majadahonda
(Madrid, Spain; research project code: PI 187/19; approved on
December 1, 2019). Written informed consent was obtained
from participants and at least 1 parent.
The materials used for this study included the video game itself
(TSTM), VR glasses, PlayStation 4 controllers (Sony Group
Corporation), test kit consoles, monitoring screens, and
headphones. The VR software runs on a PlayStation 4 (Sony
Group Corporation) test device, which allows for the tracking
of movement through the camera (eg, position, head movement,
speed, etc).
Demographics, previous VR experience, and vision problems
were noted by using an ad hoc questionnaire. The testing time
was always monitored by a professional looking through a
screen (Figure 2).
Initially, participants attended a single session in which they
tested the TSTM experience. Patients with ADHD were given
the opportunity to test a single minigame. After passing the
tutorial of the minigame to be tested, a higher level of difficulty
was tested. Patients could test each minigame for as long as
they liked (ie, only for the duration of that session). After testing
a single minigame, patients rated their opinion about the
minigame by using an ad hoc questionnaire, which included (1)
5 general questions about the TSTM experience and (2) 2
questions about possible adverse effects. Based on previous
studies [44-46], we included information about perceived
dizziness and motion sickness, which were rated by using a
3-point Likert scale and 2 questions about patients’ feelings
before and after testing TSTM. Standard questionnaires were
used as a reference [47] by adapting them to the characteristics
of our video game and using language adapted for children. We
arbitrarily determined that a user satisfaction rate of 75% would
indicate a good level of acceptance by users.
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Figure 2. Picture of the principal investigator (HBF) facing The Secret Trail of Moon.
Statistical Analyses
Participants were divided into the ADHD combined and
inattentive subtypes because some authors consider these
subtypes to be different disorders and believe that they should
be treated separately. Thus, we feared that the different subtypes
of ADHD would impact our usability measures. A descriptive
analysis was performed by using the mean proportions (%) of
participants’ ratings for categorical variables and means and
SDs for numerical variables. Chi-square tests were performed
to compare patients with ADHD (ADHD combined subtype vs
inattentive subtype) and to compare frequent and infrequent
video game players. We used SPSS version 20 for Macintosh
(IBM Corporation).
Sociodemographic Characteristics
Table 4 displays the basic demographic and clinical
characteristics of participants. The testing time for the video
game lasted between 10 and 40 minutes (mean 21.31 minutes,
SD 6.77 minutes). Most participants were male (25/37, 68%),
were right-handed (29/37, 78%), never repeated a school year
(26/37, 70%), and were diagnosed with at least 1 comorbid
mental disorder (28/37, 76%). Further, 38% (14/37) of
participants wore glasses, 59% (22/37) had previously used VR,
and 70% (26/37) played video games regularly. We found no
statistically significant differences between the combined and
inattentive subtypes of ADHD.
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Table 4. Demographics of the attention-deficit/hyperactivity disorder (ADHD) and attention-deficit disorder (ADD) subtypes (N=37).
PvalueParticipants with ADD
(inattentive subtype; 16/37,
Participants with ADHD
(combined subtype; 21/37,
All subtypes (N=37)Demographic characteristics
.22214.31 (2.387)13.38 (2.156)13.78 (2.28)
Age (years), mean (SD)a
.525108.76 (19.44)104.07 (16.69)106.42 (17.91)
Intelligence quotient, mean (SD)b
Gender, n (%)
111 (69)14 (67)25 (68)Male
.7234 (25)7 (33)11 (30)Repeated at least 1 school year, n (%)
.595Handedness, n (%)
13 (81)16 (76)29 (78)Right-handed participants
0 (0)1 (5)1 (3)Left-handed participants
3 (19)2 (9)5 (14)Ambidextrous participants
112 (75)16 (76)28 (76)Comorbidity with at least 1 mental disorder (yes), n (%)
.4325 (31)9 (43)14 (38)Wears glasses, n (%)
110 (63)12 (57)22 (59)Previous use of virtual reality, n (%)
.20310 (63)16 (76)26 (70)Regularly plays video games, n (%)
aData were collected from 37 participants.
bData were collected from 26 participants.
Usability Results
Figure 3 displays the proportion of children and adolescents
who liked each minigame. All minigames were based on the
opinions of the participants, and percentages ranged from 80%
(chess: 4/5) to 100% (Kuburi: 22/22; Teka Teki: 23/23). With
regard to the results for comprehensibility, the ease of play, and
the ease of control of the PlayStation 4 controller, all proportions
surpassed 60% (22/36). All minigames were easy to play, and
only Teka Teki had an easy-to-play percentage of below 80%
(22/36, 61%). Teka Teki was the only minigame in which the
participants pointed out that it was difficult to achieve
improvement after repeating the minigame. We found no
statistically significant differences after comparing the ADHD
combined subtype to the inattentive subtype and frequent video
game players to infrequent video game players.
Table 5 displays the percentages of children and adolescents
who had positive opinions, which were based on the two highest
scores (“much” or “very much”). With regard to the discomfort
of VR glasses and motion sickness, we considered any level of
discomfort to be a negative opinion, even if it was just “a little
bit” of discomfort. Most children and adolescents provided very
positive responses to all questions. Furthermore, 5 out of 36
(13.1%) children and adolescents reported the discomfort of
VR glasses and motion sickness, and just 1 (3%) reported this
Figure 3. Specific questions about each game’s mechanics (Smasher, Kuburi, Enigma, Teka Teki, and chess). The questions were as follows: (1) “Was
the minigame fun” (factor: fun), (2) “Did you find it easy to understand the instructions” (factor: comprehensible), (3) “Did you find the minigame easy
to play” (factor: easy to play), (4) “Did you find the controller easy to use” (factor: proper control), (5) “Do you understand the game better as the level
increases” (factor: improvement after repeating), (6) “Did you think visual graphics were beautiful” (factor: enjoyable graphics), and (7) “Did you find
it short” (factor: too short)?
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Table 5. The satisfaction of patients with attention-deficit/hyperactivity disorder after testing The Secret Trail of Moon (TSTM).
Positive experience (n=36a), n (%)Factors and questions (responses)
31 (86)Satisfying experience: “Did you like the experience?” (much or very much)
30 (83)Desire to repeat: “Would you repeat it?” (much or very much)
30 (83)Enjoyable graphics: “Did you find it beautiful?” (much or very much)
27 (75)Enjoyable music and sound: Did you like the music and sound?” (much or very much)
28 (78)Easy to understand: “Did you find it easy to understand the game?” (much or very much)
5 (14)Perceived dizziness: “Did you feel dizzy when playing the video game?” (much or very much)
5 (14)VR motion sickness: “Did you become motion sick while playing the video game?”
26 (73)Feelings before testing TSTM: “How do you feel?” (good or very good)
36 (100)Feelings after testing TSTM: “How do you feel?” (good or very good)
aInformation regarding satisfaction was not recorded for 1 patient out of the 37 included in the second study.
Our study expands on current knowledge concerning the
development of serious video games for treating patients with
ADHD [15-17,25-28,33,48]. Before serious video games are
incorporated into the multimodal treatment of ADHD, they must
demonstrate clinical usefulness and have tolerable side effects
Our results suggest that TSTM was fun, was understandable,
was easy to play, was intuitive, was easy to master, used
enjoyable graphics, and was of adequate duration for most
participants. However, there were some interesting differences
between each minigame that may suggest that certain
components of TSTM need more improvement. The most
enjoyable minigames (Teka Teki and Kuburi) were the most
dynamic and interactive minigames. The areas for improvement
in Smasher appear to be making it a little bit easier to understand
and extending the play time. Kuburi was the minigame with the
highest usability ratings across all parameters. Enigma was the
minigame that was the most difficult for users to comprehend.
Thus, we may have made the graphics too attractive or enhanced
minigame mechanics with an increasing difficulty curve [15,40].
Teka Teki was the most difficult minigame to play and the only
minigame in which participants found it difficult to achieve
improvement after repeating the minigame. As such, this
minigame may need some improvement, such as using a less
stringent difficulty curve and thus preventing a potential decline
in initial motivation [15,40]. As for chess, we obtained the
opinions of just 5 patients. Therefore, there is too little
information to extract any meaningful data on the game.
Compared to a similar study, our study yielded better satisfaction
percentages than those reported by the users of Plan-It
Commander [15]. For instance, compared to the 72% of
participants who reported feeling good or very good before
testing Plan-It Commander, 100% (36/36) of our participants
reported feeling good or very good after testing TSTM.
Furthermore, our results are comparable to those reported in
the Plan-It Commander study with regard to players’ motivation
to play the game again and their opinions of the game [15].
Finally, a small proportion of participants (5/36, 14%) reported
experiencing either perceived dizziness or motion sickness,
which was clinically meaningful in just 1 child (1/36, 3%).
Wearing glasses was not related to either of the two side effects.
Both perceived dizziness and motion sickness are the potential
side effects of VR that are the most frequently reported in
literature [44-46].
Our usability study presents the following limitations. First, not
all of the participants tested the same versions of each minigame
during the usability phase, although the changes made were
kept at a minimum. We used the preinclusion period of the RCT
to fix the bugs detected by participants, and we made some
improvements based on their ongoing suggestions in an iterative,
continuous way. Thus, the data reported in this paper were the
data collected during the preinclusion period. However, after
the preinclusion period, all included participants in the RCT
eventually tested the same TSTM version. Second, our
questionnaire was not validated but was based on questionnaires
that were used in similar studies [15]. Finally, we based TSTM
development on 2 predominant theoretical models of ADHD.
However, there are other ADHD models that integrate cognitive
and affective science data and may be interesting to consider
when constructing a therapeutic video game for treating ADHD
Conclusion and Future Directions
Serious video games and VR are new technologies that can be
used as therapeutic tools for the treatment of mental disorders
[24,50]. Compared to traditional treatments, serious video games
have many advantages [48,50], such as helping individuals
maintain their commitment to therapy [2,13,14]. Furthermore,
VR has already proven its therapeutic utility for some mental
disorders [47,51,52], but such evidence for ADHD is limited
[53]. Moreover, there is an increasing number of studies that
have reported encouraging results about the use of serious video
games and gamified versions of different tests for treating and
diagnosing ADHD populations, respectively [15-17,54-56].
Thus, in a recent clinical trial that included 857 children with
ADHD, the researchers reported that the patients who were
randomized to a serious video game (Akili interactive)
intervention group improved more than those who were
randomized to the digital control intervention group and
experienced fewer adverse events [24]. In another study that
JMIR Serious Games 2021 | vol. 9 | iss. 3 | e26824 | p. 9 (page number not for citation purposes)
Rodrigo-Yanguas et alJMIR SERIOUS GAMES
compared a serious game intervention (Plan-It Commander)
group to a treatment-as-usual crossover group (the intervention
was used as an adjunct treatment for children with ADHD), the
10-week serious game intervention proved to be a more effective
strategy [16]. However, the creation, development, and empirical
testing of a serious video game are not easy tasks [29,57]; the
game must be proven to be safe, and its use is not easy to
implement in real settings.
TSTM—a VR serious video game that was designed for patients
with ADHD—was fun, was intuitive, and displayed a favorable
profile of side effects that were in line with those reported in
literature [44-46]. Additionally, TSTM may have the potential
to be used as an add-on cognitive training tool for medically
treated patients with ADHD.
We thank all of the children, adolescents, and parents for their participation in this study. The authors thank Lorraine Maw, MA,
for her editorial assistance. HBF is the principal investigator of an iPFIS research contract (contract number: IFI16/00039) [58]
and coprincipal investigator of an Ministerio de Asuntos Económicos y Trasformación Digital (MINECO) research grant (grant
RTI2018-101857-B-I00); is the recipient of (1) a Fundación para la innovación y la prospective en salud en España Grant and
(2) an Instituto de investigación sanitaria Puerta de Hierro intensification grant; and is involved in two clinical trials (NEWROFEED
study [trial number: NCT02778360]; ESKETSUI2002 study [trial number: NCT03185819]). MRY is the recipient of an iPFIS
research contract (contract number: IFI16/00039) [58]. MMM is the recipient of a Centro para el Desarrollo Industrial grant
(Fondo Europeo de Desarrollo Regional [FEDER] funded; grant IDI-20180701; file number: 00107278).
Conflicts of Interest
In the last 24 months, HBF received lecture fees from Shire. He is a member of the Advisory Board of ITA Mental Health [59].
The remaining authors do not have any conflicts of interest regarding the publication of this manuscript.
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Rodrigo-Yanguas et alJMIR SERIOUS GAMES
ADHD: attention-deficit/hyperactivity disorder
RCT: randomized controlled clinical trial
TSTM: The Secret Trail of Moon
VR: virtual reality
Edited by N Zary; submitted 01.01.21; peer-reviewed by M Gotsis, Z Aghaei, A Khaleghi, D Lin, WB Lee; comments to author 02.04.21;
revised version received 11.04.21; accepted 15.06.21; published 01.09.21
Please cite as:
Rodrigo-Yanguas M, Martin-Moratinos M, Menendez-Garcia A, Gonzalez-Tardon C, Royuela A, Blasco-Fontecilla H
A Virtual Reality Game (The Secret Trail of Moon) for Treating Attention-Deficit/Hyperactivity Disorder: Development and Usability
JMIR Serious Games 2021;9(3):e26824
doi: 10.2196/26824
©Maria Rodrigo-Yanguas, Marina Martin-Moratinos, Angela Menendez-Garcia, Carlos Gonzalez-Tardon, Ana Royuela, Hilario
Blasco-Fontecilla. Originally published in JMIR Serious Games (, 01.09.2021. This is an open-access
article distributed under the terms of the Creative Commons Attribution License (,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR
Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on,
as well as this copyright and license information must be included.
JMIR Serious Games 2021 | vol. 9 | iss. 3 | e26824 | p. 13 (page number not for citation purposes)
Rodrigo-Yanguas et alJMIR SERIOUS GAMES
Full-text available
Background Attention-deficit/hyperactivity disorder (ADHD) affects between 4% and 8% of children worldwide. The treatment of choice is multimodal treatment. Multimodal interventions for ADHD may be improved by incorporating new treatments, such as treatment via serious video games. The Secret Trail of Moon (TSTM) is a virtual reality serious video game that was designed for cognitive training related to core ADHD symptoms and executive dysfunction. Objective We aimed to describe the development and usability of TSTM. Methods The usability study included 37 children and adolescents who tested TSTM during the early usability stage (preinclusion) of a randomized controlled clinical trial for testing the effectiveness of TSTM. Chi-square tests were performed to compare patients with ADHD (ADHD combined subtype vs inattentive subtype) and to compare frequent and infrequent video game players in the second study. We used SPSS version 20 for Macintosh (IBM Corporation). Results A total of 31/37 (86%) and 30/37 (83%) of participants liked playing TSTM and wanted to continue playing TSTM, respectively. Further, 5/37 (14%) of participants reported that they experienced either perceived dizziness or virtual reality motion sickness. We found no statistically significant differences after comparing the ADHD combined subtype to the inattentive subtype and frequent video game players to infrequent video game players. Conclusions Serious video games, such as TSTM, may complement the current multimodal approach for treating ADHD. Trial Registration NCT04355065;
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Drug abuse is a serious public health issue that may have irreversible consequences. Research has revealed that childhood psychological trauma can promote addictive behaviors in adulthood and that drugs are often used as a coping mechanism. Men are less likely to report trauma and seek help than women. The purpose of this qualitative study was to explore the experience of men in Iceland who have abused drugs and experienced childhood psychological trauma, to increase knowledge and deepen the understanding of trauma and addiction. Participants were seven men who had both experienced childhood trauma and had a history of drug abuse. Two interviews were conducted with each participant. The main findings suggest that participants abused drugs as a coping mechanism due to the trauma experienced in childhood. For some participants, seeking companionship was a key component of their drug use. Participants were mostly dissatisfied with treatment resources in Iceland; waiting lists were long and too much focus was on religion. Five main themes were identified: emotional impact, self-medication for pain, gender expectations, impermanence of thoughts, and loss of a sense of wholeness. Increased societal and professional awareness of the linkage between trauma and drug abuse is needed, as are additional resources specific to men who have experienced childhood trauma and drug abuse. It is important to integrate trauma focused services into health-care settings to educate health-care professionals on trauma and the consequences thereof, in addition to utilizing screening tools such as the Adverse Childhood Experience Questionnaire for those seeking assistance.
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In the last few years, several computerized tasks have been developed to increase the objectivity of the diagnosis of attention-deficit hyperactivity disorder (ADHD). This article proposes the “running raccoon” video game to assess the severity of inattention in patients diagnosed with ADHD. Unlike existing tests, the proposed tool is a genuine video game in which the patient must make a raccoon avatar jump to avoid falling into different gaps. The distance to the gap is recorded for each jump. To evaluate the proposed game, an experiment was conducted in which 32 children diagnosed with ADHD participated. For each participant, the median and interquartile range of these distances were calculated, along with the number of omissions. Experimental results showed a significant correlation between the participants’ inattention (measured by the Attention-Deficit/Hyperactivity Disorder Symptoms and Normal Behavior rating scale (SWAN) inattention subscale) with each of these three measures. In addition to its accuracy, other benefits are its short duration and the possibility of being run on both standard computers and mobile devices. These characteristics facilitate its acceptance in clinical environments or even its telematic use. The obtained results, together with the characteristics of the video game, make it an excellent tool to support clinicians in the diagnosis of ADHD.
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BackgroundA lack of ability to inhibit prepotent responses, or more generally a lack of impulse control, is associated with several disorders such as attention-deficit/hyperactivity disorder and schizophrenia as well as general damage to the prefrontal cortex. A stop-signal task (SST) is a reliable and established measure of response inhibition. However, using the SST as an objective assessment in diagnostic or research-focused settings places significant stress on participants as the task itself requires concentration and cognitive effort and is not particularly engaging. This can lead to decreased motivation to follow task instructions and poor data quality, which can affect assessment efficacy and might increase drop-out rates. Gamification—the application of game-based elements in nongame settings—has shown to improve engaged attention to a cognitive task, thus increasing participant motivation and data quality. Objective This study aims to design a gamified SST that improves participants’ engagement and validate this gamified SST against a standard SST. Methods We described the design of our gamified SST and reported on 2 separate studies that aim to validate the gamified SST relative to a standard SST. In study 1, a within-subject design was used to compare the performance of the SST and a stop-signal game (SSG). In study 2, we added eye tracking to the procedure to determine if overt attention was affected and aimed to replicate the findings from study 1 in a between-subjects design. Furthermore, in both studies, flow and motivational experiences were measured. ResultsIn contrast, the behavioral performance was comparable between the tasks (P
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Background Attention-deficit hyperactivity disorder (ADHD) is a common paediatric neurodevelopmental disorder with substantial effect on families and society. Alternatives to traditional care, including novel digital therapeutics, have shown promise to remediate cognitive deficits associated with this disorder and may address barriers to standard therapies, such as pharmacological interventions and behavioural therapy. AKL-T01 is an investigational digital therapeutic designed to target attention and cognitive control delivered through a video game-like interface via at-home play for 25 min per day, 5 days per week for 4 weeks. This study aimed to assess whether AKL-T01 improved attentional performance in paediatric patients with ADHD. Methods The Software Treatment for Actively Reducing Severity of ADHD (STARS-ADHD) was a randomised, double-blind, parallel-group, controlled trial of paediatric patients (aged 8–12 years, without disorder-related medications) with confirmed ADHD and Test of Variables of Attention (TOVA) Attention Performance Index (API) scores of −1·8 and below done by 20 research institutions in the USA. Patients were randomly assigned 1:1 to AKL-T01 or a digital control intervention. The primary outcome was mean change in TOVA API from pre-intervention to post-intervention. Safety, tolerability, and compliance were also assessed. Analyses were done in the intention-to-treat population. This trial is registered with, NCT02674633 and is completed. Findings Between July 15, 2016, and Nov 30, 2017, 857 patients were evaluated and 348 were randomly assigned to receive AKL-T01 or control. Among patients who received AKL-T01 (n=180 [52%]; mean [SD] age, 9·7 [1·3] years) or control (n=168 [48%]; mean [SD] age, 9·6 [1·3] years), the non-parametric estimate of the population median change from baseline TOVA API was 0·88 (95% CI 0·24–1·49; p=0·0060). The mean (SD) change from baseline on the TOVA API was 0·93 (3·15) in the AKL-T01 group and 0·03 (3·16) in the control group. There were no serious adverse events or discontinuations. Treatment-related adverse events were mild and included frustration (5 [3%] of 180) and headache (3 [2%] of 180). Patient compliance was a mean of 83 (83%) of 100 expected sessions played (SD, 29·2 sessions). Interpretation Although future research is needed for this digital intervention, this study provides evidence that AKL-T01 might be used to improve objectively measured inattention in paediatric patients with ADHD, while presenting minimal adverse events. Funding Sponsored by Akili Interactive Labs.
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Background: Neurofeedback (NF) has gained increasing interest among non-pharmacological treatments for Attention Deficit Hyperactivity Disorder (ADHD). NF training aims to enhance self-regulation of brain activities. The goal of the NEWROFEED study is to assess the efficacy of a new personalized NF training device, using two different protocols according to each child's electroencephalographic pattern, and designed for use at home. This study is a non-inferiority trial comparing NF to methylphenidate. Methods: The study is a prospective, multicentre, randomized, reference drug-controlled trial. One hundred seventy-nine children with ADHD, aged 7 to 13 years will be recruited in 13 clinical centres from 5 European countries. Subjects will be randomized to two groups: NF group (Neurofeedback Training Group) and MPH group (Methylphenidate group). Outcome measures include clinicians, parents and teachers' assessments, attention measures and quantitative EEG (qEEG). Patients undergo eight visits over a three-month period: pre-inclusion visit, inclusion visit, 4 "discovery" (NF group) or titration visits (MPH group), an intermediate and a final visit. Patients will be randomized to either the MPH or NF group. Children in the NF group will undergo either an SMR or a Theta/Beta training protocol according to their baselineTheta/Beta Ratio obtained from the qEEG. Discussion: This is the first non-inferiority study between a personalized NF device and pharmacological treatment. Innovative aspects of Mensia Koala™ include the personalization of the training protocol according to initial qEEG characteristics (SMR or Theta/Beta training protocols) and an improved accessibility of NF due to the opportunity to train at home with monitoring by the clinician through a dedicated web portal. Trial registration: NCT02778360 . Date registration (retrospectively registered): 5-12-2016. Registered May 19, 2016.
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The current feasibility study examined the adherence, reliability, and assessment potential of an evidence-based game-like mobile Monitoring Tool (Akili Interactive Labs), to monitor 100 participants’ cognition for eight sessions at a summer camp for children with special needs. A validated measure of attention was administered at baseline. In the last session, participants completed an exit questionnaire. The Monitoring Tool was found to be enjoyable, and showed a high rate of adherence. No Monitor-related adverse events were reported. Monitor metrics showed good reliability across repeated measurements, indicating it is stable over long-term cognitive monitoring. There was evidence that the Monitoring Tool was able to detect differences in cognition between the children diagnosed with attention deficit hyperactivity disorder and autism spectrum disorders.
Objective: Serious videogames and virtual reality (VR) have gained increasing interest for treating attention deficit hyperactivity disorder (ADHD). "The Secret Trail of Moon" (TSTM) study is a clinical trial devoted to testing the efficacy of TSTM, a VR serious videogame developed to train in five major cognitive skills usually compromised in patients with ADHD. This study is a three-arm nonequality trial comparing TSTM to online chess training and a control group (CG). This study aims to demonstrate that augmentation with either TSTM or online chess is efficacious in clinically drug-stable patients with ADHD. Materials and Methods: This study is prospective, unicentric, and randomized with a CG. One hundred five patients with ADHD, ages 12-22 years old, and pharmacologically stable were enrolled. Patients were randomized into three groups: TSTM group, online chess group (therapeutic chess [TC]), and CG. Objective and subjective measures of the patient and parents are included. Patient visits differ for each group. TSTM group patients have 15 face-to-face visits: preinclusion visit, inclusion visit, 12 training visits, and final visit. TC and CG patients have 3 face-to-face visits (preinclusion, initial visit, and final visit) and 12 e-mail or phone communications during training (TC) or follow-up (CG group). This study was approved by the local Institutional Review Board (IRB). Results: Not applicable. This is a study protocol. Conclusion: This is the first study testing an augmentation strategy using either a serious videogame or chess in clinically drug-treated patients with ADHD. Using VR serious videogames present with several advantages over traditional videogames. Trial Registration: NCT04355065.
Background and Objectives Hedonic hunger (HH) occurs when individuals are driven to consume highly palatable food for pleasure, rather than to satisfy a caloric need. Currently, the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) does not recognize HH as a use disorder. Previous research has noted physiological, neurobiological, and treatment similarities between HH, binge eating behavior and substance use, leading to the speculation of the existence of food addiction (FA). The purpose of the current review was to explore the literature on the developmental similarities between substance use, HH, binge eating behavior, and other use disorders to provide more evidence for the recognition of FA as an official use disorder, to add to the evidence in favor of a developmental model of use disorders, and to inform the development of interventions that target modifiable symptoms associated with use disorders. Methods We provide a narrative review of the literature on developmental factors associated with both HH and substance use. Results & Discussion Adverse childhood experiences and attachment have been previously linked to both substance use and maladaptive eating behaviors. Adverse childhood experiences are linked with insecure attachment and emotion dysregulation, which is linked with compulsive behaviors and substance use. Clinical and research implications are discussed in terms of a developmental model of use disorders and the formal recognition of FA in the next edition of the DSM.
The use of new technologies has become widespread worldwide. There is increasing concern about "Internet addiction disorder" (IAD), "Internet gaming disorder" (IGD), and "Mobile phone addiction" (MPA). Attention Deficit Hyperactivity Disorder (ADHD) has been associated with IAD and IGD. However, evidence is lacking about the relationship between ADHD and MPA. Naturalistic case-control study. 112 patients (51 children with and 61 children without ADHD) between 7 and 17 years old were compared regarding IAD, IGD, and MPA. We used the TEA questionnaire for the assessment of executive function and ADHD (ATENTO), and the ADITEC questionnaire to get gender-differentiated information for IAD, IGD, and MPA. Female children scored higher on MPA (Mean ± Standard Deviation, M ± SD) (25.93 ± 17.64 vs. 14.77 ± 19.43, p=0.03), while male children scored higher on IGD (30.09 ± 21.65 vs. 12.51 ± 16.61, p<10-3). Severity of hyperactivity/impulsivity and IGD were moderately correlated (r=0.349, p=0.013), but the correlation disappeared after controlling for the impact on the social domain as measured by the ATENTO questionnaire (r=171, p=0.250). Most parents are concerned that their children may be addicted to IAD/IGD/MPA. Female gender is associated with MPA, while male gender is associated with IGD. ADHD is a risk factor for developing IAD and IGD. Combined type and predominantly hyperactive/impulsive ADHD are each associated with IGD. Good social adjustment protects against developing IGD. There are gender vulnerabilities for IAD/IGD/MPA. ADHD is a risk factor for IGD, but good social adjustment buffers this association.
The first video game therapy to treat children with attention-deficit/hyperactivity disorder (ADHD) was given a nod. Prescription-only EndeavorRx is indicated for children aged 8 to 12 years who have an attention issue.