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Treasure Hunt - A serious game to support psychotherapeutic treatment of children

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Abstract

Computer and video games for children have gained negative publicity due to reported associations between intensive gaming and aggressive behaviour, school failure, and overweight. While most studies centre upon negative consequences of video games, their innovative potentials tend to be overlooked. One field for the innovative use of computer games is child psychotherapy. By including therapeutic concepts into a video game, children can be offered attractive electronic homework assignments that enable them to rehearse and repeat basic psychoeducational concepts they have learned during therapy sessions. Moreover, therapeutic games can help therapists to structure therapy sessions. Psychotherapeutic computer games translated into foreign languages could form a useful tool in the treatment of migrant children. 'Treasure Hunt' is the first serious game based on principles of cognitive behaviour modification. It is developed for eight to twelve year old children who are in cognitive-behavioural treatment for various disorders. Reactions of children and therapists to experimental versions of the game are positive. Serious games might prove a useful tool to support psychotherapeutic treatment of children.
Treasure Hunt – a serious game to support
psychotherapeutic treatment of children
Veronika BREZINKA
1
Department of Child and Adolescent Psychiatry, Zürich University, Zürich,
Switzerland
Abstract. Computer and video games for children have gained negative publicity
due to reported associations between intensive gaming and aggressive behaviour,
school failure, and overweight. While most studies centre upon negative
consequences of video games, their innovative potentials tend to be overlooked.
One field for the innovative use of computer games is child psychotherapy. By
including therapeutic concepts into a video game, children can be offered
attractive electronic homework assignments that enable them to rehearse and
repeat basic psychoeducational concepts they have learned during therapy
sessions. Moreover, therapeutic games can help therapists to structure therapy
sessions. Psychotherapeutic computer games translated into foreign languages
could form a useful tool in the treatment of migrant children. ‘Treasure Hunt’ is
the first serious game based on principles of cognitive behaviour modification. It is
developed for eight to twelve year old children who are in cognitive-behavioural
treatment for various disorders. Reactions of children and therapists to
experimental versions of the game are positive. Serious games might prove a
useful tool to support psychotherapeutic treatment of children.
Keywords. Home-based e-Health, Human-Computer interaction, learning and
education
Introduction
Although computers and internet are a normal part of life for millions of children, they
have gained mainly negative publicity due to the reported association between
intensive gaming and aggressive behaviour, game addiction, school failure and
overweight [1-3]. As a consequence, most reports on the effects of video games centre
upon their potential negative consequences [4-6], while their innovative potentials tend
to be overlooked [7].
1
Adress for correspondences: Universität Zürich, Child and Adolescent Psychiatry
Neptunstr. 60, CH-8032 Zürich. E-mail: veronika.brezinka@ppkj.uzh.ch
eHealth Beyond the Horizon – Get IT There
S.K. Andersen et al. (Eds.)
IOS Press, 2008
© 2008 Organizing Committee of MIE 2008. All rights reserved.
71
However, these innovative potentials exist. Computer games improve spatial
performance in children, adolescents and adults [8]. Action-video-game playing with
so called first person shooters has been reported to alter a range of visual skills and to
enhance visuospatial attention [9, 10]. Studies also show that commercial computer
games can be used innovatively at school [11]. In the medical sector, various reports
show that computer games have been therapeutically successful with physically
handicapped children and children with chronic disease like asthma [12], diabetes [13]
and cancer [14, 15]. As for psychotherapy, it would be difficult for child therapists to
ignore how fascinated children are by computers and video games. Yet, up to now few
initiatives make use of this fascination to enhance psychotherapeutic treatment. There
are two exceptions: the game ‘Earthquake in Zipland’, based on family therapy, is
designed to support psychotherapy of children whose parents have divorced
(www.ziplandinteractive.com
). ‘Personal Investigator’, a therapeutic game based on
solution focused therapy, tries to motivate adolescents for psychotherapy [16].
Developing a computer-based treatment for children does not simply mean putting
a treatment manual on the screen. In order to motivate children for psychotherapy, the
challenge lies in designing serious games that incorporate therapeutic goals as well as
various skills training. By including therapeutic concepts into a game, children can be
offered attractive electronic homework assignments that enable them to repeat and
rehearse basic psychoeducational concepts they have learned during therapy sessions.
Moreover, a psychotherapeutic game that matches the theoretical orientation of the
therapist can help him / her to structure therapy sessions and to explain important
theoretical concepts in diverse ways and with a metaphor and means attractive to most
children.
1. Method
Cognitive behaviour therapy is one of the best-researched and empirically supported
treatment methods for adults and children. Its theoretical framework is based on the
assumption that emotions and behaviour are largely a product of cognitions; thus
psychological and behaviour problems can be reduced by altering cognitive processes.
Cognitive behaviour therapy offers several intervention programmes for children from
which learning goals for serious games can be derived.
In order to support cognitive-behavioural treatment of children, the Department of
Child and Adolescent Psychiatry of Zürich University is developing a serious game
called ‘Treasure Hunt’. The game is not meant to substitute the therapist, but to support
therapy by offering electronic homework assignments and rehearsing basic
psychoeducational parts of treatment. The theoretical background of the game is
formed by basic concepts of cognitive behaviour therapy for children as outlined in
treatment programmes like ‘Coping Cat’ [17], ‘Friends for Children’ [18] and ‘Keeping
your cool’ [19]. These basic concepts are important for the treatment of both
internalizing and externalizing disorders.
Treasure Hunt is an interactive adventure game with six levels. Each of the six
levels of the game corresponds to a certain step in cognitive-behavioural treatment. The
maximum amount of time needed to solve all tasks of a level is about twenty minutes.
V. Brezinka / Treasure Hunt – A Serious Game to Support Psychotherapeutic Treatment of Children72
1.1. Story
The game takes place aboard an old ship inhabited by Captain Jones, Felix the ship’s
cat and Polly the ship’s parrot. Captain Jones has found an old treasure map in the hull
of his ship. To solve its mystery, he needs the help of a child. Tasks take place in
different parts of the ship – on deck, in the galley, in the dining room of Captain Jones
and in the shipmates’ bunks. Each task corresponds to a certain step in cognitive-
behavioural treatment, implying a linear structure of the game. For each completed
task, the child receives a sea star. The old treasure map has a dark spot in the shape of a
sea star at six important places. The child and Captain Jones will only be able to read
what is written there when they place the missing sea star on the map. After having
solved all the tasks, the last mission consists of a recapitulation of the previous
exercises. Once the child has solved this last problem, he/she will find out where the
treasure is buried. One of the most interesting parts of the game is dedicated to the
hunting of unhelpful (automatic) thoughts by means of an ego-shooter. The child has to
catch a flying fish to be able to read the unhelpful thought written on it and replace it
by a helpful one.
Before joining Captain Jones on the final search for the treasure, the child receives
a sailor’s certificate that summarizes what he/she has learnt through the game and that
is signed by Captain Jones and the therapist.
1.2. Software and Tools
Treasure Hunt is a 2.5 D Flash adventure game programmed with Actionscript and
XML. Flash was used to guarantee platform independence, as only a Flash compatible
internet browser is needed and no programme has to be installed. This facilitates giving
homework to children independent from their computer hardware and operating system
at home. User interaction will be recorded in XML files to help therapists analyze
children’s choices and / or progress.
2. Results
Playability tests with an experimental version showed that children appreciate the game
and its diverse tasks. Several therapists in the Department of Child and Adolescent
Psychiatry of Zürich University have used pilot versions of the game with children
treated for a variety of disorders (anxiety disorder, depression, behavioural disorder).
Because they worked with an experimental version, therapists were not allowed to give
parts of the game as homework assignment, but instead used it during therapy sessions.
They reported to use the game as reinforcement, telling the child ‘if you work well, we
will play Treasure Hunt for the last ten minutes’. All therapists reported positive
reactions of the children in treatment and liked to work with the game themselves.
Although Treasure Hunt was originally developed to offer attractive homework
assignments in between therapy sessions, the pilot showed that the game can also help
young or less experienced therapists to structure therapy sessions and to explain
important cognitive-behavioural concepts like the influence of thoughts on our feelings
or the distinction between helpful and unhelpful thoughts.
While these primary findings are encouraging, conclusions about the effectiveness
of Treasure Hunt are premature, as the professional version of the game is not finished
V. Brezinka / Treasure Hunt – A Serious Game to Support Psychotherapeutic Treatment of Children 73
yet. Treasure Hunt is not developed as a self-help instrument and should be used under
guidance of a behaviour therapist. Our pilot showed that using a computer game in
psychotherapy sessions does not mean that classic therapeutic methods like writing,
drawing or role-playing lose their significance in the treatment of children and
adolescents – on the contrary, as various exercises for further therapy sessions can be
derived from Treasure Hunt. Therapists reported for example that they asked children
to ‘help us to design a next level or to ‘draw flying fish with more unhelpful thoughts’.
Whether Treasure Hunt can really support cognitive-behavioural treatment of
children and enhance child compliance for homework assignments will be evaluated as
soon as the professional version of the game is finished.
3. Discussion and Conclusion
Psychotherapy of children and adolescents is an area in which innovative use of
computers in the form of psychotherapeutic video games may enhance child
compliance and offer new ways of treatment. Such games have the potential to enhance
child compliance, offer attractive homework assignments, structure therapy sessions
and support treatment of migrant children who could play the games in their own
language and share their content with parents and siblings.
Cognitive behaviour therapy offers several intervention programmes for children
from which learning goals for therapeutic video games can be derived. For example
social problem solving, a standard therapeutic intervention for young children [20, 21]
could be incorporated into a game to support psychotherapy with children as young as
five years. Such a game might even be used for the prevention of behaviour problems
in this age group. Incorporating elements of anger management programmes [19, 22]
into video games could be an even greater challenge for the development of serious
games. As most of the children treated for anger and aggression problems are boys, and
boys are reported to show considerably more fascination for computers than girls [8],
creating serious games that include anger management strategies might support
treatment of this notoriously difficult and non compliant group. An alternative pathway
could be the development of therapeutic games built on Dodge’s theory of social-
cognitive biases of aggressive children [23]. If such games could help aggressive
children to reduce hostile attributional biases and to ameliorate cognitive processing of
potentially threatening situations [24, 25], treatment of a chronic and difficult group of
clients might become easier.
There is, however, still a long way to go and considerable resistance to overcome.
Not all game-designers are positive about the concept of serious games, suggesting that
a game that has to be played might lose its attractiveness. On the other hand, many
academics and health professionals are not used to view computer games as something
different from ‘pure fun’ or ‘only a game’ and doubt that a computer game can teach
useful skills. Moreover, there is fear that if psychotherapeutic games are successful,
computers might replace therapists in the long run. However, no psychotherapeutic
game will be able to alleviate childhood problems on its own, and therapeutic games
will show their maximum potentials only under guidance of a therapist who can explain
and comment the concepts introduced in the game.
New developments in gaming technology as well as more research on therapeutic
games will hopefully lead to the creation of more serious games to support child
V. Brezinka / Treasure Hunt – A Serious Game to Support Psychotherapeutic Treatment of Children74
psychotherapy. Ideally, these games should be labelled with a quality seal for
therapists.
Acknowledgments
I thank the Department of Child and Adolescent Psychiatry (Head: Prof. Dr. Dr. H.C.
Steinhausen) and the Technology Transfer Fund of Zürich University for financial
support. Special thanks are due to Markus Ruh (programming), Christoph Wartmann
(design), Denis Chait (renderings) and Wolfgang Güdden (music).
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In the right context, videogames can have a positive therapeutic benefit for a large range of children and adolescents. Videogames have been shown to help children undergoing chemotherapy, children undergoing psychotherapy, children with particular emotional and behavioural problems (attention deficit disorder, impulsivity, autism), and children with medical and health problems (Erb's palsy, muscular dystrophy, burns). In terms of videogames being distractor tasks, it seems likely that the effects can be attributed to most commercially available videogames. However, one of the major problems is that reported positive effects in some instances were from specially designed videogames rather than those that were already commercially available. It is, therefore, hard to evaluate the therapeutic value of videogames as a whole. As with research into the more negative effects, it may well be the case that some videogames are particularly beneficial, whereas others have little or no therapeutic benefit whatsoever. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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We review social cognitive models of children's aggressive behavior and cognitive-behavioral interventions based on these models. Findings of the distortions and deficiencies that aggressive children have in their social information processing are presented. Several current issues in social cognition research in this area are reviewed, including (a) applicability of the social cognitive models to severe aggression and to adolescents; (b) role of prior expectations influencing social perception; (c) influence of social goals, cognitive operation style, and arousal on information processing; and (d) the more distal influences of parent behavior and parent social cognition on children's social cognition. An anger coping program consistent with the social cognitive model is presented, and the outcome effects for this intervention and similar cognitive-behavioral interventions are reviewed.
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An experimental model tested the mediating function of interpersonal cognitive problem solving skills on behavioral adjustment in preschool and kindergarten children. Relative to controls, nursery-trained youngsters improved in three such skills, kindergarten-trained in two. In both the nursery- and kindergarten-trained groups, increased ability to conceptualize alternative solutions to interpersonal problems significantly related to improved social adjustment. Consequential thinking also emerged as a clear behavioral mediator, especially among kindergarten-aged youngsters. Improvement in behavior could not, however, be attributed to change in causal thinking skills. Having identified two significant behavioral mediators in young children, a beginning has been made to isolate specific thinking skills, which, if enhanced, can contribute to healthy social adjustment and interpersonal competence at an early age.
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Two studies were conducted to investigate the use of cognitive/attentional distraction (via commercially available video games) to control conditioned nausea in pediatric cancer patients receiving chemotherapy. The first study compared the nausea severity in children who played video games during chemotherapy-related procedures with that of control-group children who did not play video games. The second study used a combined ABAB withdrawal and repeated measures analysis of variance design that incorporated baseline and intervention assessments within a single session. In both studies, video game-playing resulted in significantly less nausea. The introduction and withdrawal of the opportunity to play video games produced significant changes (reduction and exacerbation, respectively) in nausea. Although video games also reduced self-reported anxiety, the effects were weaker than those for nausea. Pulse rate and systolic/diastolic blood pressure were not consistently affected. (PsycINFO Database Record (c) 2012 APA, all rights reserved)