Content uploaded by Marina Martin-Moratinos
Author content
All content in this area was uploaded by Marina Martin-Moratinos on Sep 05, 2022
Content may be subject to copyright.
Original Paper
A Virtual Reality Game (The Secret Trail of Moon) for Treating
Attention-Deficit/Hyperactivity Disorder:Development and Usability
Study
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,
Spain
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
Spain
Phone: 34 655214857
Email: hmblasco@yahoo.es
Abstract
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: ClinicalTrials.gov NCT04355065; https://clinicaltrials.gov/ct2/show/NCT04355065
(JMIR Serious Games 2021;9(3):e26824) doi: 10.2196/26824
KEYWORDS
attention-deficit/hyperactivity disorder; chess; virtual reality; serious video game; psychotherapy; cognitive training; usability;
new technologies; transfer; randomized controlled trial
JMIR Serious Games 2021 | vol. 9 | iss. 3 | e26824 | p. 1https://games.jmir.org/2021/3/e26824 (page number not for citation purposes)
Rodrigo-Yanguas et alJMIR SERIOUS GAMES
XSL
•
FO
RenderX
Introduction
Background
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.
JMIR Serious Games 2021 | vol. 9 | iss. 3 | e26824 | p. 2https://games.jmir.org/2021/3/e26824 (page number not for citation purposes)
Rodrigo-Yanguas et alJMIR SERIOUS GAMES
XSL
•
FO
RenderX
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.
JMIR Serious Games 2021 | vol. 9 | iss. 3 | e26824 | p. 3https://games.jmir.org/2021/3/e26824 (page number not for citation purposes)
Rodrigo-Yanguas et alJMIR SERIOUS GAMES
XSL
•
FO
RenderX
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-
works
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
Story
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.
Synopsis
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
Avatar
The MOONbteam consists of the player as well as Movi (raccoon) and One (fox), who will help and
accompany the player throughout the game.
Characteristics
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
game
PlayStation 4 VR sensor (Sony Group Corporation)Sensors used
6-8 hoursEstimated play time
aVR: virtual reality.
bMOON: Movi and One.
JMIR Serious Games 2021 | vol. 9 | iss. 3 | e26824 | p. 4https://games.jmir.org/2021/3/e26824 (page number not for citation purposes)
Rodrigo-Yanguas et alJMIR SERIOUS GAMES
XSL
•
FO
RenderX
Table 2. Description of each minigame.
DescriptionTargetMinigame
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-
ory.
•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
•Planning
•Math calculations
Study 1 (Market Study)
Methods
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.
Results
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).
JMIR Serious Games 2021 | vol. 9 | iss. 3 | e26824 | p. 5https://games.jmir.org/2021/3/e26824 (page number not for citation purposes)
Rodrigo-Yanguas et alJMIR SERIOUS GAMES
XSL
•
FO
RenderX
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?”
Discussion
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)
Methods
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
branch).
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.
JMIR Serious Games 2021 | vol. 9 | iss. 3 | e26824 | p. 6https://games.jmir.org/2021/3/e26824 (page number not for citation purposes)
Rodrigo-Yanguas et alJMIR SERIOUS GAMES
XSL
•
FO
RenderX
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).
Results
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.
JMIR Serious Games 2021 | vol. 9 | iss. 3 | e26824 | p. 7https://games.jmir.org/2021/3/e26824 (page number not for citation purposes)
Rodrigo-Yanguas et alJMIR SERIOUS GAMES
XSL
•
FO
RenderX
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,
43%)
Participants with ADHD
(combined subtype; 21/37,
57%)
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
clearly.
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)?
JMIR Serious Games 2021 | vol. 9 | iss. 3 | e26824 | p. 8https://games.jmir.org/2021/3/e26824 (page number not for citation purposes)
Rodrigo-Yanguas et alJMIR SERIOUS GAMES
XSL
•
FO
RenderX
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.
Discussion
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
[15,25,26,28].
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
[30,49].
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. 9https://games.jmir.org/2021/3/e26824 (page number not for citation purposes)
Rodrigo-Yanguas et alJMIR SERIOUS GAMES
XSL
•
FO
RenderX
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.
Acknowledgments
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.
References
1. Dulcan M. Practice parameters for the assessment and treatment of children, adolescents, and adults with
attention-deficit/hyperactivity disorder. American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc
Psychiatry 1997 Oct;36(10 Suppl):85S-121S. [doi: 10.1097/00004583-199710001-00007] [Medline: 9334567]
2. Barkley RA. Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment (3rd ed.). New York:
The Guilford Press; 2006.
3. Kieling R, Rohde LA. ADHD in children and adults: diagnosis and prognosis. Curr Top Behav Neurosci 2012;9:1-16. [doi:
10.1007/7854_2010_115] [Medline: 21499858]
4. Mehta S, Mehta V, Mehta S, Shah D, Motiwala A, Vardhan J, et al. Multimodal behavior program for ADHD incorporating
yoga and implemented by high school volunteers: a pilot study. ISRN Pediatr 2011;2011:780745 [FREE Full text] [doi:
10.5402/2011/780745] [Medline: 22389788]
5. Castellanos FX, Lee PP, Sharp W, Jeffries NO, Greenstein DK, Clasen LS, et al. Developmental trajectories of brain volume
abnormalities in children and adolescents with attention-deficit/hyperactivity disorder. JAMA 2002 Oct 09;288(14):1740-1748.
[doi: 10.1001/jama.288.14.1740] [Medline: 12365958]
6. Sonuga-Barke EJS, Brandeis D, Cortese S, Daley D, Ferrin M, Holtmann M, European ADHD Guidelines Group.
Nonpharmacological interventions for ADHD: systematic review and meta-analyses of randomized controlled trials of
dietary and psychological treatments. Am J Psychiatry 2013 Mar;170(3):275-289. [doi: 10.1176/appi.ajp.2012.12070991]
[Medline: 23360949]
7. Jensen PS, Garcia JA, Glied S, Crowe M, Foster M, Schlander M, et al. Cost-effectiveness of ADHD treatments: findings
from the multimodal treatment study of children with ADHD. Am J Psychiatry 2005 Sep;162(9):1628-1636. [doi:
10.1176/appi.ajp.162.9.1628] [Medline: 16135621]
8. Pottegård A, Bjerregaard BK, Kortegaard LS, Zoëga H. Early discontinuation of attention-deficit/hyperactivity disorder
drug treatment: a Danish nationwide drug utilization study. Basic Clin Pharmacol Toxicol 2015 Apr 07;116(4):349-353
[FREE Full text] [doi: 10.1111/bcpt.12325] [Medline: 25220739]
9. van den Ban E, Souverein PC, Swaab H, van Engeland H, Egberts TCG, Heerdink ER. Less discontinuation of ADHD
drug use since the availability of long-acting ADHD medication in children, adolescents and adults under the age of 45
years in the Netherlands. Atten Defic Hyperact Disord 2010 Dec 30;2(4):213-220 [FREE Full text] [doi:
10.1007/s12402-010-0044-9] [Medline: 21258431]
10. Blasco-Fontecilla H, Gonzalez-Perez M, Garcia-Lopez R, Poza-Cano B, Perez-Moreno MR, de Leon-Martinez V, et al.
Efficacy of chess training for the treatment of ADHD: A prospective, open label study. Rev Psiquiatr Salud Ment
2016;9(1):13-21. [doi: 10.1016/j.rpsm.2015.02.003] [Medline: 25911280]
11. Cho BH, Kim S, Shin DI, Lee JH, Lee SM, Kim IY, et al. Neurofeedback training with virtual reality for inattention and
impulsiveness. Cyberpsychol Behav 2004 Oct;7(5):519-526. [doi: 10.1089/cpb.2004.7.519] [Medline: 15667046]
JMIR Serious Games 2021 | vol. 9 | iss. 3 | e26824 | p. 10https://games.jmir.org/2021/3/e26824 (page number not for citation purposes)
Rodrigo-Yanguas et alJMIR SERIOUS GAMES
XSL
•
FO
RenderX
12. Bioulac S, Purper-Ouakil D, Ros T, Blasco-Fontecilla H, Prats M, Mayaud L, et al. Personalized at-home neurofeedback
compared with long-acting methylphenidate in an european non-inferiority randomized trial in children with ADHD. BMC
Psychiatry 2019 Aug 01;19(1):237 [FREE Full text] [doi: 10.1186/s12888-019-2218-0] [Medline: 31370811]
13. Bioulac S, Micoulaud-Franchi J, Maire J, Bouvard MP, Rizzo AA, Sagaspe P, et al. Virtual remediation versus
methylphenidate to improve distractibility in children with ADHD: A controlled randomized clinical trial study. J Atten
Disord 2020 Jan 22;24(2):326-335. [doi: 10.1177/1087054718759751] [Medline: 29562853]
14. Weerdmeester J, Cima M, Granic I, Hashemian Y, Gotsis M. A feasibility study on the effectiveness of a full-body videogame
intervention for decreasing attention deficit hyperactivity disorder symptoms. Games Health J 2016 Aug;5(4):258-269.
[doi: 10.1089/g4h.2015.0103] [Medline: 27304677]
15. Bul KC, Franken IH, Van der Oord S, Kato PM, Danckaerts M, Vreeke LJ, et al. Development and user satisfaction of
"Plan-It Commander," a serious game for children with ADHD. Games Health J 2015 Dec;4(6):502-512. [doi:
10.1089/g4h.2015.0021] [Medline: 26325247]
16. Bul KCM, Kato PM, Van der Oord S, Danckaerts M, Vreeke LJ, Willems A, et al. Behavioral outcome effects of serious
gaming as an adjunct to treatment for children with attention-deficit/hyperactivity disorder: A randomized controlled trial.
J Med Internet Res 2016 Feb 16;18(2):e26 [FREE Full text] [doi: 10.2196/jmir.5173] [Medline: 26883052]
17. Jaklevic MC. Watch your medicine: Video game therapy for children with ADHD. JAMA 2020 Jul 21;324(3):224. [doi:
10.1001/jama.2020.11924] [Medline: 32692373]
18. Menendez-García A, Jiménez-Arroyo A, Rodrigo-Yanguas M, Marin-Vila M, Sánchez-Sánchez F, Roman-Riechmann E,
et al. Internet, video game and mobile phone addiction in children and adolescents diagnosed with ADHD: a case-control
study. Adicciones 2020 Dec 04:1469 [FREE Full text] [doi: 10.20882/adicciones.1469] [Medline: 33338245]
19. Takgbajouah M, Buscemi J. Applying the developmental model of use disorders to hedonic hunger: a narrative review. J
Addict Dis. Epub ahead of print 2021 May 18. [doi: 10.1080/10550887.2021.1926881] [Medline: 34002675]
20. Georgsdottir MT, Sigurdardottir S, Gunnthorsdottir H. "This Is the Result of Something Else": Experiences of men that
abused drugs and had experienced childhood trauma. Am J Mens Health 2021 Apr 21;15(2):15579883211009348 [FREE
Full text] [doi: 10.1177/15579883211009348] [Medline: 33880945]
21. Mathews CL, Morrell HER, Molle JE. Video game addiction, ADHD symptomatology, and video game reinforcement.
Am J Drug Alcohol Abuse 2019 Jun 06;45(1):67-76. [doi: 10.1080/00952990.2018.1472269] [Medline: 29874473]
22. Rosholm M, Mikkelsen MB, Gumede K. Your move: The effect of chess on mathematics test scores. PLoS One 2017 May
11;12(5):e0177257. [doi: 10.1371/journal.pone.0177257] [Medline: 28494023]
23. Rabipour S, Raz A. Training the brain: fact and fad in cognitive and behavioral remediation. Brain Cogn 2012
Jul;79(2):159-179. [doi: 10.1016/j.bandc.2012.02.006] [Medline: 22463872]
24. Kollins SH, DeLoss DJ, Cañadas E, Lutz J, Findling RL, Keefe RSE, et al. A novel digital intervention for actively reducing
severity of paediatric ADHD (STARS-ADHD): a randomised controlled trial. Lancet Digit Health 2020 Apr;2(4):e168-e178
[FREE Full text] [doi: 10.1016/S2589-7500(20)30017-0] [Medline: 33334505]
25. Flynn RM, Colón-Acosta N, Zhou J, Bower J. A game-based repeated assessment for cognitive monitoring: Initial usability
and adherence study in a summer camp setting. J Autism Dev Disord 2019 May 17;49(5):2003-2014. [doi:
10.1007/s10803-019-03881-w] [Medline: 30656527]
26. Lange B, Flynn S, Rizzo A. Initial usability assessment of off-the-shelf video game consoles for clinical game-based motor
rehabilitation. Phys Ther Rev 2013 Jul 19;14(5):355-363. [doi: 10.1179/108331909X12488667117258]
27. Bul KCM, Doove LL, Franken IHA, Oord SVD, Kato PM, Maras A. A serious game for children with Attention Deficit
Hyperactivity Disorder: Who benefits the most? PLoS One 2018 Mar 15;13(3):e0193681. [doi: 10.1371/journal.pone.0193681]
[Medline: 29543891]
28. Rodrigo-Yanguas M, Martin-Moratinos M, Gonzalez-Tardon C, Blasco-Fontecilla H. Virtual reality and chess. A video
game for cognitive training in patients with ADHD. In: CEUR Workshop Proc. 2020 Presented at: VI Congreso de la
Sociedad Española para las Ciencias del Videojuego; October 7-8, 2020; Madrid, Spain p. 205-215 URL: http://ceur-ws.
org/Vol-2719/paper20.pdf
29. Baranowski T. Descriptions for articles introducing a new game for health. Games Health J 2014 Apr;3(2):55-56. [doi:
10.1089/g4h.2014.0008] [Medline: 26196042]
30. Sonuga-Barke EJ. The dual pathway model of AD/HD: an elaboration of neuro-developmental characteristics. Neurosci
Biobehav Rev 2003 Nov;27(7):593-604. [doi: 10.1016/j.neubiorev.2003.08.005] [Medline: 14624804]
31. Bronowski J. Human and Animal Language. In: A Sense of the Future: Essays in Natural Philosophy. Cambridge, MA:
The MIT Press; Sep 1977:104-131.
32. Fuster JM. The Prefrontal Cortex. New York: Raven Press; 1980.
33. Brown TE. ADD/ADHD and impaired executive function in clinical practice. Curr Psychiatry Rep 2008 Oct 17;10(5):407-411.
[doi: 10.1007/s11920-008-0065-7] [Medline: 18803914]
34. Fullerton T. Game Design Workshop: A Playcentric Approach to Creating Innovative Games. Boca Raton, Florida: CRC
Press; 2018.
35. Bergeron B. Developing Serious Games. Hingham, United States: Cengage Learning, Inc; 2006.
JMIR Serious Games 2021 | vol. 9 | iss. 3 | e26824 | p. 11https://games.jmir.org/2021/3/e26824 (page number not for citation purposes)
Rodrigo-Yanguas et alJMIR SERIOUS GAMES
XSL
•
FO
RenderX
36. Wang R, DeMaria S, Goldberg A, Katz D. A systematic review of serious games in training health care professionals.
Simul Healthc 2016 Feb;11(1):41-51. [doi: 10.1097/SIH.0000000000000118] [Medline: 26536340]
37. Deterding S, Sicart M, Nacke L, O'Hara K, Dixon D. Gamification: Using game design elements in non-gaming contexts.
2011 May Presented at: CHI '11: CHI Conference on Human Factors in Computing Systems; May 7-12, 2011; Vancouver,
British Columbia, Canada. [doi: 10.1145/1979742.1979575]
38. Matera M. Explore Like a PIRATE: Gamification and Game-Inspired Course Design to Engage, Enrich and Elevate Your
Learners. San Diego, California: Dave Burgess Consulting, Incorporated; 2015.
39. Cognitive training tool for ADHD patients. Google Forms. URL: https://docs.google.com/forms/d/
1XfYLgxtZjYzSQa3x2phVPQp07pNI_LUHEfbDHYLbvOg/viewform?edit_requested=true#responses[accessed 2021-08-06]
40. Anguera JA, Brandes-Aitken AN, Rolle CE, Skinner SN, Desai SS, Bower JD, et al. Characterizing cognitive control
abilities in children with 16p11.2 deletion using adaptive 'video game' technology: a pilot study. Transl Psychiatry 2016
Sep 20;6(9):e893-e893 [FREE Full text] [doi: 10.1038/tp.2016.178] [Medline: 27648915]
41. Fontecilla HMB. The Secret Trail of Moon (serious videogame) and chess on ADHD: a clinal trial. ClinicalTrials.gov.
URL: https://clinicaltrials.gov/ct2/show/NCT04355065 [accessed 2021-08-06]
42. Rodrigo-Yanguas M, Martin-Moratinos M, Menendez-Garcia A, Gonzalez-Tardon C, Sanchez-Sanchez F, Royuela A, et
al. A virtual reality serious videogame versus online chess augmentation in patients with attention deficit hyperactivity
disorder: A randomized clinical trial. Games Health J 2021 Aug;10(4):283-292. [doi: 10.1089/g4h.2021.0073] [Medline:
34370610]
43. Información importante sobre salud y seguridad. PlayStation. URL: https://legaldoc.dl.playstation.net/ps3-eula/psn/e/
e_health_es.html [accessed 2021-08-06]
44. Roettl J, Terlutter R. The same video game in 2D, 3D or virtual reality - How does technology impact game evaluation and
brand placements? PLoS One 2018 Jul 20;13(7):e0200724. [doi: 10.1371/journal.pone.0200724] [Medline: 30028839]
45. Merhi O, Faugloire E, Flanagan M, Stoffregen TA. Motion sickness, console video games, and head-mounted displays.
Hum Factors 2007 Oct;49(5):920-934. [doi: 10.1518/001872007X230262] [Medline: 17915607]
46. Jones T, Moore T, Choo J. The impact of virtual reality on chronic pain. PLoS One 2016 Dec 20;11(12):e0167523. [doi:
10.1371/journal.pone.0167523] [Medline: 27997539]
47. Lewis JR. IBM computer usability satisfaction questionnaires: Psychometric evaluation and instructions for use. Int J Hum
Comput Interact 1995 Jan;7(1):57-78. [doi: 10.1080/10447319509526110]
48. Botella C, Quero S, Baños RM, Perpiñá C, García Palacios A, Riva G. Virtual reality and psychotherapy. Stud Health
Technol Inform 2004;99:37-54. [Medline: 15295145]
49. Nigg JT, Casey BJ. An integrative theory of attention-deficit/ hyperactivity disorder based on the cognitive and affective
neurosciences. Dev Psychopathol 2005;17(3):785-806. [doi: 10.1017/S0954579405050376] [Medline: 16262992]
50. Gamberini L, Barresi G, Majer A, Scarpetta F. A game a day keeps the doctor away: A short review of computer games in
mental healthcare. J Cyber Ther Rehabil 2008;1(2):127-145 [FREE Full text]
51. Botella C, Serrano B, Baños RM, Garcia-Palacios A. Virtual reality exposure-based therapy for the treatment of post-traumatic
stress disorder: a review of its efficacy, the adequacy of the treatment protocol, and its acceptability. Neuropsychiatr Dis
Treat 2015;11:2533-2545 [FREE Full text] [doi: 10.2147/NDT.S89542] [Medline: 26491332]
52. Botella C, Fernández-Álvarez J, Guillén V, García-Palacios A, Baños R. Recent progress in virtual reality exposure therapy
for phobias: A systematic review. Curr Psychiatry Rep 2017 Jul 24;19(7):42. [doi: 10.1007/s11920-017-0788-4] [Medline:
28540594]
53. Rohani DA, Sorensen HBD, Puthusserypady S. Brain-computer interface using P300 and virtual reality: A gaming approach
for treating ADHD. 2014 Presented at: 2014 36th Annual International Conference of the IEEE Engineering in Medicine
and Biology Society; August 26-30, 2014; Chicago, Illinois, USA. [doi: 10.1109/embc.2014.6944403]
54. Friehs MA, Dechant M, Vedress S, Frings C, Mandryk RL. Effective gamification of the stop-signal task: Two controlled
laboratory experiments. JMIR Serious Games 2020 Sep 08;8(3):e17810 [FREE Full text] [doi: 10.2196/17810] [Medline:
32897233]
55. Peijnenborgh JC, Hurks PP, Aldenkamp AP, van der Spek ED, Rauterberg G, Vles JS, et al. A study on the validity of a
computer-based game to assess cognitive processes, reward mechanisms, and time perception in children aged 4-8 years.
JMIR Serious Games 2016 Sep 22;4(2):e15 [FREE Full text] [doi: 10.2196/games.5997] [Medline: 27658428]
56. Delgado-Gómez D, Sújar A, Ardoy-Cuadros J, Bejarano-Gómez A, Aguado D, Miguelez-Fernandez C, et al. Objective
assessment of attention-deficit hyperactivity disorder (ADHD) using an infinite runner-based computer game: A pilot study.
Brain Sci 2020 Oct 09;10(10):716 [FREE Full text] [doi: 10.3390/brainsci10100716] [Medline: 33050130]
57. Duncan LR, Hieftje KD, Culyba S, Fiellin LE. Game playbooks: tools to guide multidisciplinary teams in developing
videogame-based behavior change interventions. Transl Behav Med 2014 Mar 4;4(1):108-116 [FREE Full text] [doi:
10.1007/s13142-013-0246-8] [Medline: 24653781]
58. Instituto de Salud Carlos III. Instituto de Salud Carlos III. URL: https://www.isciii.es [accessed 2021-08-06]
59. Especialistas en tratamientos de salud mental. Ita Salud Mental. URL: https://itasaludmental.com/ [accessed 2021-08-12]
JMIR Serious Games 2021 | vol. 9 | iss. 3 | e26824 | p. 12https://games.jmir.org/2021/3/e26824 (page number not for citation purposes)
Rodrigo-Yanguas et alJMIR SERIOUS GAMES
XSL
•
FO
RenderX
Abbreviations
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
Study
JMIR Serious Games 2021;9(3):e26824
URL: https://games.jmir.org/2021/3/e26824
doi: 10.2196/26824
PMID:
©Maria Rodrigo-Yanguas, Marina Martin-Moratinos, Angela Menendez-Garcia, Carlos Gonzalez-Tardon, Ana Royuela, Hilario
Blasco-Fontecilla. Originally published in JMIR Serious Games (https://games.jmir.org), 01.09.2021. This is an open-access
article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/),
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 https://games.jmir.org,
as well as this copyright and license information must be included.
JMIR Serious Games 2021 | vol. 9 | iss. 3 | e26824 | p. 13https://games.jmir.org/2021/3/e26824 (page number not for citation purposes)
Rodrigo-Yanguas et alJMIR SERIOUS GAMES
XSL
•
FO
RenderX
