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

Objective Although hyperactivity would seem to increase energy expenditure, attention deficit/hyperactivity disorder (ADHD) appears to increase the risk for being overweight. The present study examined the Body Mass Index (BMI) in children with ADHD and its relationship with age, gender, ADHD and comorbid symptom severity, inhibitory control, developmental coordination disorder (DCD), sleep duration and methylphenidate use. Method Participants were 372 Dutch children with ADHD combined type aged 5–17 years participating in the International Multicenter ADHD Genetics (IMAGE) study. We categorized BMI according to international age- and gender-specific reference values and calculated BMI-standard deviation scores (BMI-SDS). The control population was matched for age, gender and ethnicity and originated from the same birth cohort as the ADHD group. Inhibitory control was measured by the computerized Stop-signal task. Prevalence differences of underweight, overweight and obesity between groups were expressed in odds ratio’s. We used linear regression analyses with gender, age, parent- and teacher-rated ADHD and comorbid scores, inhibitory control, sleep duration, motor coordination and methylphenidate use to predict BMI-SDS. Results Boys with ADHD 10–17 and girls 10–12 years of age were more likely to be overweight than children in the general Dutch population. Younger girls and female teenagers, however, seemed to be at lower risk for being overweight. Higher oppositional behavior and social communication problems related to higher BMI-SDS scores, whereas more stereotyped behaviors related to lower BMI-SDS scores. We found no effects of the other examined associated risk factors on BMI-SDS. Conclusion ADHD in boys is a risk factor for overweight. In girls with ADHD, the prevalence of overweight is age-dependent and most pronounced in girls 10–12 years of age. They have a fourfold risk of being obese. Higher oppositional and social communication problems pose an increased risk for overweight, whereas sleep duration, motor coordination problems and methylphenidate use do not.

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

Nondigital board games are being used to engage players and impact outcomes in health and medicine across diverse populations and contexts. This systematic review and meta-analysis describes and summarizes their impact based on randomized and nonrandomized controlled trials. An electronic search resulted in a review of n = 21 eligible studies. Sample sizes ranged from n = 17 to n = 3110 (n = 6554 total participants). A majority of the board game interventions focused on education to increase health-related knowledge and behaviors (76%, n = 16). Outcomes evaluated included self-efficacy, attitudes/beliefs, biological health indicators, social functioning, anxiety, and executive functioning, in addition to knowledge and behaviors. Using the Cochrane Collaboration tool for assessing bias, most studies (52%, n = 11) had an unclear risk of bias (33% [n = 7] had a high risk and 14% [n = 3] had a low risk). Statistical tests of publication bias were not significant. A randomeffects meta-analysis showed a large average effect of board games on health-related knowledge (d* = 0.82, 95% confidence interval; CI [0.15-1.48]), a small-to-moderate effect on behaviors (d* = 0.33, 95% CI [0.16-0.51]), and a small-to-moderate effect on biological health indicators (d* = 0.37, 95% CI [0.21-0.52]). The findings contribute to the literature on games and gamified approaches in healthcare. Future research efforts should aim for more consistent high scientific standards in their evaluation protocols and reporting methodologies to provide a stronger evidence base.

Self monitoring, personal goal-setting and coaching, education and social support are strategies to help patients with chronic conditions in their daily care. Various tools have been developed, e.g., mobile digital coaching systems connected with wearable sensors, serious games and patient web portals to personal health records, that aim to support patients with chronic conditions and their caregivers in realizing the ideal of self-management. We describe a platform that integrates these tools to support young patients in diabetes self-management through educational game playing, monitoring and motivational feedback. We describe the design of the platform referring to principles from healthcare, persuasive system design and serious game design. The virtual coach is a game guide that can also provide personalized feedback about the user’s daily care related activities which have value for making progress in the game world. User evaluations with patients under pediatric supervision revealed that the use of mobile technology in combination with web-based elements is feasible but some assumptions made about how users would connect to the platform were not satisfied in reality, resulting in less than optimal user experiences. We discuss challenges with suggestions for further development of integrated pervasive coaching and gamification platforms in medical practice.

ObjectiveThe aim of the current study was to identify which subgroups of children with Attention Deficit Hyperactivity Disorder (ADHD) benefitted the most from playing a Serious Game (SG) intervention shown in a randomized trial to improve behavioral outcomes.MethodPre-intervention characteristics [i.e., gender, age, intellectual level of functioning, medication use, computer experience, ADHD subtype, severity of inattention problems, severity of hyperactivity/impulsivity problems, comorbid Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD) symptoms] were explored as potential moderators in a Virtual Twins (VT) analysis to identify subgroups for whom the SG intervention was most effective. Primary outcome measures were parent-reported time management, planning/organizing and cooperation skills.ResultsTwo subgroups were identified. Girls (n = 26) were identified as the subgroup that was most likely to show greater improvements in planning/organizing skills as compared to the estimated treatment effect of the total group of participants. Furthermore, among the boys, those (n = 47) with lower baseline levels of hyperactivity and higher levels of CD symptoms showed more improvements in their planning/organizing skills when they played the SG intervention as compared to the estimated treatment effect of the total group of participants.ConclusionUsing a VT analysis two subgroups of children with ADHD, girls, and boys with both higher levels of CD and lower levels of hyperactivity, were identified. These subgroups mostly benefit from playing the SG intervention developed to improve ADHD related behavioral problems. Our results imply that these subgroups have a higher chance of treatment success.

Background Promotion of physical activity, healthy eating, adequate sleep, and reduced sedentary behavior in adolescents is a major priority globally given the current increase in population health challenges of noncommunicable diseases and risk factors such as obesity. Adolescents are highly engaged with mobile technology, but the challenge is to engage them with mobile health (mHealth) technology. Recent innovations in mobile technology provide opportunities to promote a healthy lifestyle in adolescents. An increasingly utilized approach to facilitate increased engagement with mHealth technology is to involve potential users in the creation of the technology. Objective This study aimed to describe the process of and findings from co-designing and prototyping components of the PEGASO Fit for Future (F4F) mHealth intervention for adolescents from different cultural backgrounds. Methods A total of 74 adolescents aged 13 to 16 years from Spain, Italy, and the United Kingdom participated in the co-design of the PEGASO F4F technology. In 3 iterative cycles over 12 months, participants were involved in the co-design, refinement, and feasibility testing of a system consisting of diverse mobile apps with a variety of functions and facilities to encourage healthy weight–promoting behaviors. In the first iteration, participants attended a single workshop session and were presented with mock-ups or early-version prototypes of different apps for user requirements assessment and review. During the second iteration, prototypes of all apps were tested by participants for 1 week at home or school. In the third iteration, further developed prototypes were tested for 2 weeks. Participants’ user experience feedback and development ideas were collected through focus groups and completion of questionnaires. Results For the PEGASO F4F technology to be motivating and engaging, participants suggested that it should (1) allow personalization of the interface, (2) have age-appropriate and easy-to-understand language (of icons, labels, instructions, and notifications), (3) provide easily accessible tutorials on how to use the app or navigate through a game, (4) present a clear purpose and end goal, (5) have an appealing and self-explanatory reward system, (6) offer variation in gamified activities within apps and the serious game, and (7) allow to seek peer support and connect with peers for competitive activities within the technology. Conclusions Incorporating adolescents’ preferences, the PEGASO F4F technology combines the functions of a self-monitoring, entertainment, advisory, and social support tool. This was the first study demonstrating that it is possible to develop a complex mobile phone-based technological system applying the principles of co-design to mHealth technology with adolescents across 3 countries. The findings from this study informed the development of an mHealth system for healthy weight promotion to be tested in a controlled multinational pilot trial.

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