A "Proof of Concept" Randomized Controlled Trial of a Video Game Requiring Emotional Regulation to Augment Anger Control Training

Peter Ducharme, Jason Kahn, Carrie Vaudreuil, Michaela Gusman, Deborah Waber, Abigail Ross, Alexander Rotenberg, Ashley Rober, Kara Kimball, Alyssa L Peechatka, Joseph Gonzalez-Heydrich, Peter Ducharme, Jason Kahn, Carrie Vaudreuil, Michaela Gusman, Deborah Waber, Abigail Ross, Alexander Rotenberg, Ashley Rober, Kara Kimball, Alyssa L Peechatka, Joseph Gonzalez-Heydrich

Abstract

Emotional dysregulation leading to clinically significant anger and aggression is a common and substantial concern for youth and their families. While psychotropic medications and cognitive behavioral therapies can be effective, these modalities suffer from drawbacks such as significant side effects, high rates of attrition, and lack of real-world skill translation. Regulate and Gain Emotional Control (RAGE-Control) is a video game designed as an engaging augment to existing treatments. The game facilitates emotional regulation skill building through practice modulating physiological arousal while completing a challenging inhibitory task. We compared reduction in anger, aggression, oppositionality, and global severity between two treatment conditions: Anger Control Training (ACT) augmented with RAGE-Control and ACT with a sham version of the game, in a pilot double-blind randomized controlled trial. To begin to understand mechanisms of change, we examined heart rate during game play over the course of the study and explored associations between symptom changes and heart rate changes. Materials and Methods: Forty youth with clinically significant anger dyscontrol (age 10-17) were randomly assigned to 10 sessions of ACT with RAGE-Control or ACT with sham video game. Results: Both treatments similarly reduced self-reported anger. However, ACT with RAGE-Control led to larger improvements in aggression (CI: -17 to -1.0, ES: 0.55, p = 0.015); oppositionality (CI: -9.0 to -7e-6, ES: 0.48, p = 0.032); and global severity (CI: -1.0 to -5e-6, ES: 0.51, p = 0.023) relative to sham. Participants in the RAGE-Control group saw a decrease in median heart rate during game play (β = 1.2, p < 0.001). Larger pre to post decreases in heart rate were significantly associated with larger pre to post decreases in aggression and oppositional behaviors. Discussion: Augmenting ACT with RAGE-Control reduced behavioral expression of anger, but not the experience of angry feelings, as compared to ACT with a sham version of the game. Increased heart rate control, demonstrated by reduction in median heart rate during gameplay, was associated with decreased aggression and oppositional behavior. Together these findings support that augmenting traditional treatment with technology facilitating heart rate control through skill practice translates to enhancements in real-life behavioral change. Therefore, further exploration into engaging skill-focused games such as RAGE-Control is warranted. Clinical Trial Registration:ClinicalTrials.gov, identifier: NCT01551732.

Keywords: anger control; biofeedback; cognitive behavior therapy; emotional control; self-regulation; video game.

Conflict of interest statement

PD reports grants from the Deborah Munroe Noonan Memorial Research Foundation, Alrashed Family, and from Tommy Fuss Foundation, during the conduct of the study. JK reports grants from Noonan Foundation, during the conduct of the study. Boston Children's Hospital (BCH) owns the technology discussed in this paper. JK, PD, ARot, and JG-H founded and have equity in Neuromotion Labs, a company that creates emotional regulation training technologies, outside the submitted work. JK and AP report personal fees and other (equity) from Neuromotion Labs, outside the submitted work. In addition, ARot (along with JG-H, JK, and PD) have a pending patent US20140323013A1: Emotional control methods and apparatus licensed; In addition, JG-H has a patent European Patent 99112065.0-2201. Aug 17, 1999 US Patent 6,211,876. April 3, 2001 pending. CV reports Neuromotion Labs allowed her to use technology related to the RAGE Control videogame for free for another study that she was the Principal Investigator for. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2021 Ducharme, Kahn, Vaudreuil, Gusman, Waber, Ross, Rotenberg, Rober, Kimball, Peechatka and Gonzalez-Heydrich.

Figures

Figure 1
Figure 1
Participant recruitment and study flow.
Figure 2
Figure 2
Median heart rate during gameplay by Session.

References

    1. Eisenberg N, Spinrad TL. Emotion-related regulation: sharpening the definition. Child Dev. (2004) 75:334–9. 10.1111/j.1467-8624.2004.00674.x
    1. Blake CS, Hamrin V. Current approaches to the assessment and management of anger and aggression in youth: a review. J Child Adolesc Psychiatr Nurs. (2007) 20:209–21. 10.1111/j.1744-6171.2007.00102.x
    1. Eisenberg N, Fabes RA, Guthrie IK, Reiser M. Dispositional emotionality and regulation: their role in predicting quality of social functioning. J Pers Soc Psychol. (2000) 78:136–57. 10.1037/0022-3514.78.1.136
    1. Webster-Stratton C, Reid MJ. Strengthening social and emotional competence in young children -The foundation for early school readiness and success: incredible years classroom social skills and problem-solving curriculum. Infant Young Child. (2004) 17:96–113. 10.1097/00001163-200404000-00002
    1. Graziano PA, Garcia A. Attention-deficit hyperactivity disorder and children's emotion dysregulation: a meta-analysis. Clin Psychol Rev. (2016) 46:106–123. 10.1016/j.cpr.2016.04.011
    1. Cavanagh M, Quinn D, Duncan D, Graham T, Balbuena L. Oppositional defiant disorder is better conceptualized as a disorder of emotional regulation. J Atten Disord. (2017) 21:381–9. 10.1177/1087054713520221
    1. Samson AC, Phillips JM, Parker KJ, Shah S, Gross JJ, Hardan AY. Emotion dysregulation and the core features of autism spectrum disorder. J Autism Dev Disord. (2014) 44:1766–72. 10.1007/s10803-013-2022-5
    1. Leibenluft E, Stoddard J. The developmental psychopathology of irritability. Dev Psychopathol. (2013) 25:1473–87. 10.1017/S0954579413000722
    1. Nock MK, Ferriter C. Parent management of attendance and adherence in child and adolescent therapy: a conceptual and empirical review. Clin Child Fam Psychol Rev. (2005) 8:149–66. 10.1007/s10567-005-4753-0
    1. Miller GE, Prinz RJ. Engagement of families in treatment for childhood conduct problems. Behav Ther. (2003) 34:517–34. 10.1016/S0005-7894(03)80033-3
    1. Pappadopulos E, Woolston S, Chait A, Perkins M, Connor DF, Jensen PS. Pharmacotherapy of aggression in children and adolescents: efficacy and effect size. J Can Acad Child Adolesc Psychiatry. (2006) 15:27–39.
    1. Maayan L, Correll CU. Weight gain and metabolic risks associated with antipsychotic medications in children and adolescents. J Child Adol Psychop. (2011) 21:517–35. 10.1089/cap.2011.0015
    1. Breaux R, Langberg JM. Development and refinement of the RELAX intervention, an intervention targeting emotion dysregulation and interpersonal conflict in adolescents with ADHD: results from a pilot study. Child Adolesc Mental Health. (2020) 5:147–63. 10.1080/23794925.2020.1759468
    1. Chorpita BF, Weisz JR. MATCH-ADTC: Modular Approach to Therapy for Children With Anxiety, Depression, Trauma, or Conduct Problems. Satellite Beach, FL: PracticeWise; (2009).
    1. Barkley RA. Focus on the side effects of psychosocial treatments for children and teens with ADHD: a special issue. ADHD Rep. (2018) 26:1–4. 10.1521/adhd.2018.26.1.1
    1. Bourchtein E, Langberg JM. Adverse effects associated with implementing behavioral treatment with adolescents with ADHD. ADHD Rep. (2018) 6:19–22. 10.1521/adhd.2018.26.1.19
    1. Benoit Allen K, Silk JS, Meller S, Tan PZ, Ladouceur CD, Sheeber LB, et al. . Parental autonomy granting and child perceived control: effects on the everyday emotional experience of anxious youth. J Child Psychol Psychiatry. (2016) 57:835–42. 10.1111/jcpp.12482
    1. Cheek C, Fleming T, Lucassen M, Bridgman H, Stasiak K, Shepherd M, et al. . Integrating health behavior theory and design elements in serious games. JMIR Ment Health. (2015) 2:e11. 10.2196/mental.4133
    1. Jaeggi SM, Buschkuehl M, Shah P, Jonides J. The role of individual differences in cognitive training and transfer. Mem Cognit. (2014) 42:464–80. 10.3758/s13421-013-0364-z
    1. Proença JP, Quaresma C, Vieira P. Serious games for upper limb rehabilitation: a systematic review. Disabil Rehabilitation Assist Technol. (2018) 13:95–100. 10.1080/17483107.2017.1290702
    1. Bul KC, 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) 18:e5173. 10.2196/jmir.5173
    1. Bul KC, Doove LL, Franken IH, Oord SV, Kato PM, Maras A. A serious game for children with attention deficit hyperactivity disorder: who benefits the most? PLoS ONE. (2018) 3:e0193681. 10.1371/journal.pone.0193681
    1. Rodriguez A, Rey B, Alcañiz M, Bañosb R, Guixeresa J, Wrzesiena M, et al. . GameTeen: new tools for evaluating and training emotional regulation strategies. Annu Rev Cybertherapy Telemed. (2012) 14:334. 10.3233/978-1-61499-121-2-334
    1. Vara MD, Baños RM, Rasal P, Rodríguez A, Rey B, Wrzesien M, et al. . A game for emotional regulation in adolescents: the (body) interface device matters. Comput in Hum Behav. (2016) 57:267–73. 10.1016/j.chb.2015.12.033
    1. Cejudo J, Latorre S. Effects of the spock videogame on improving emotional intelligence in adolescents. Electron J Res Educ Psychol. (2015) 13:319–42. 10.14204/ejrep.36.15060
    1. David OA, Predatu R, Cardo? RA. Effectiveness of the REThink therapeutic online video game in promoting mental health in children and adolescents. Internet Interv. (2021) 25:100391. 10.1016/j.invent.2021.100391
    1. Scholten H, Malmberg M, Lobel A, Engels RC, Granic I. A randomized controlled trial to test the effectiveness of an immersive 3D video game for anxiety prevention among adolescents. PLoS ONE. (2016) 11:e0147763. 10.1371/journal.pone.0147763
    1. Schoneveld EA, Malmberg M, Lichtwarck-Aschoff A, Verheijen GP, Engels RC, Granic I. A neurofeedback video game (MindLight) to prevent anxiety in children: a randomized controlled trial. Comput Hum Behav. (2016) 63:321–33. 10.1016/j.chb.2016.05.005
    1. Hunter JF, Olah MS, Williams AL, Parks AC, Pressman SD. Effect of brief biofeedback via a smartphone app on stress recovery: randomized experimental study. JMIR Serious Games. (2019) 7:e15974. 10.2196/15974
    1. Fernández-Aranda F, Jiménez-Murcia S, Santamaría JJ, Gunnard K, Soto A, Kalapanidas E, et al. . Video games as a complementary therapy tool in mental disorders: PlayMancer, a European multicentre study. J Ment Health. (2012) 21:364–74. 10.3109/09638237.2012.664302
    1. Fagundo AB, Santamaría JJ, Forcano L, Giner-Bartolomé C, Jiménez-Murcia S, Sánchez I, et al. . Video game therapy for emotional regulation and impulsivity control in a series of treated cases with bulimia nervosa. Eur Eat Disord Rev. (2013) 21:493–9. 10.1002/erv.2259
    1. Giner-Bartolomé C, Fagundo AB, Sánchez I, Jiménez-Murcia S, Santamaría JJ, Ladouceur R, et al. . Can an intervention based on a serious videogame prior to cognitive behavioral therapy be helpful in bulimia nervosa? A clinical case study. Front Psychol. (2015) 6:982. 10.3389/fpsyg.2015.00982
    1. Tárrega S, Castro-Carreras L, Fernández-Aranda F, Granero R, Giner-Bartolomé C, Aymamí N, et al. . A serious videogame as an additional therapy tool for training emotional regulation and impulsivity control in severe gambling disorder. Front Psychol. (2015) 6:1–12. 10.3389/fpsyg.2015.01721
    1. Sharifzadeh N, Kharrazi H, Nazari E, Tabesh H, Khodabandeh ME, Heidari S, et al. . Health education serious games targeting health care providers, patients, and public health users: scoping review. JMIR Serious Games. (2020) 8:e13459. 10.2196/13459
    1. Kokol P, Vošner HB, Završnik J, Vermeulen J, Shohieb S, Peinemann F. Serious game-based intervention for children with developmental disabilities. Curr Pediatr Rev. (2020) 16:26–32. 10.2174/1573396315666190808115238
    1. Kahn J, Ducharme P, Rotenberg A, Gonzalez-Heydrich J. “RAGE-Control”: a game to build emotional strength. Games Health J. (2013) 2:53–7. 10.1089/g4h.2013.0007
    1. Ducharme P, Wharff E, Hutchinson E, Kahn J, Logan G, Gonzalez-Heydrich J. Videogame assisted emotional regulation training: an ACT with RAGE-Control case illustration. Clin Soc Work J. (2012) 40:75–84. 10.1007/s10615-011-0363-0
    1. Segerstrom SC, Nes LS. Heart rate variability reflects self-regulatory strength, effort, and fatigue. Psychol Sci. (2007) 18:275–81. 10.1111/j.1467-9280.2007.01888.x
    1. Geisler FC, Kubiak T. Heart rate variability predicts self-control in goal pursuit. Eur J Pers. (2009) 23:623–33. 10.1002/per.727
    1. Reynard A, Gevirtz R, Berlow R, Brown M, Boutelle K. Heart rate variability as a marker of self-regulation. Appl Psychophysiol Biofeedback. (2011) 36:209. 10.1007/s10484-011-9162-1
    1. Appelhans BM, Luecken LJ. Heart rate variability as an index of regulated emotional responding. Rev Gen Psychol. (2006) 10:229–40. 10.1037/1089-2680.10.3.229
    1. Geisler FC, Vennewald N, Kubiak T, Weber H. The impact of heart rate variability on subjective well-being is mediated by emotion regulation. Pers Individ Dif. (2010) 49:723–8. 10.1016/j.paid.2010.06.015
    1. Boyce WT, Quas J, Alkon A, Smider NA, Essex MJ, Kupfer DJ. Autonomic reactivity and psychopathology in middle childhood. Br J Psychiatry. (2001) 179:144–50. 10.1192/bjp.179.2.144
    1. El-Sheikh M, Harger J, Whitson SM. Exposure to interparental conflict and children's adjustment and physical health: the moderating role of vagal tone. Child Dev. (2001) 72:1617–36. 10.1111/1467-8624.00369
    1. Hinnant JB, El-Sheikh M. Children's externalizing and internalizing symptoms over time: the role of individual differences in patterns of RSA responding. J Abnorm Child Psychol. (2009) 37:1049. 10.1007/s10802-009-9341-1
    1. Scott BG, Weems CF. Resting vagal tone and vagal response to stress: associations with anxiety, aggression, and perceived anxiety control among youths. Psychophysiology. (2014) 51:718–27. 10.1111/psyp.12218
    1. Gatzke-Kopp LM, Willner CJ, Jetha MK, Abenavoli RM, DuPuis D, Segalowitz SJ. How does reactivity to frustrative non-reward increase risk for externalizing symptoms?. Int J Psychophysiol. (2015) 98:300–9. 10.1016/j.ijpsycho.2015.04.018
    1. Nocavo RW. Anger control therapy. In: Hersen M, Sledge W. editors. Encyclopedia of Psychotherapy. San Diego, CA: Academic Press; (2002). p. 41−8.
    1. Sukhodolsky DG, Vitulano LA, Carroll DH, McGuire J, Leckman JF, Scahill L. Randomized trial of anger control training for adolescents with Tourette's Syndrome and disruptive behavior. J Am Acad Child Psy. (2009) 48:413–21. 10.1097/CHI.0b013e3181985050
    1. Anthes E . Pocket psychiatry: mobile mental-health apps have exploded onto the market, but few have been thoroughly tested. Nature. (2016) 532:20–3. 10.1038/532020a
    1. Torous J, Roberts L. Needed innovation in digital health and smartphone applications for mental health transparency and trust. JAMA Psychiatry. (2017) 74:437–38. 10.1001/jamapsychiatry.2017.0262
    1. Kerr MA, Schneider BH. Anger expression in children and adolescents: a review of the empirical literature. Clin Psychol Rev. (2008) 28:559–77. 10.1016/j.cpr.2007.08.001
    1. American Psychiatric Association . Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text Revision. Washington, DC: American Psychiatric Publishing, Inc; (2000).
    1. Kay SR, Wolkenfeld F, Murrill LM. Profiles of aggression among psychiatric patients: 1. Nature and Prevalence. J Nerv Ment Dis. (1988) 176:539–46. 10.1097/00005053-198809000-00007
    1. Barkley RA. Defiant Children: A Clinician's Manual for Assessment and Parent Training. 3rd ed.New York, NY: Guilford Press; (2013).
    1. Barkley RA, Edwards G, Laneri M, Fletcher K, Metevia L. The efficacy of problem-solving communication training alone, behavior management training alone, and their combination for parent-adolescent conflict in teenagers with ADHD and ODD. J Consult Clin Psychol. (2001) 69:926. 10.1037/0022-006X.69.6.926
    1. Ducharme P, Wharff E, Kahn J, Hutchinson E, Logan G. Augmenting anger control therapy with a videogame requiring emotional control: a pilot study on an inpatient psychiatric unit. Adolescent Psychiatry. (2012) 2:323–32. 10.2174/2210676611202040323
    1. Waltz J, Addis ME, Koerner K, Jacobson NS. Testing the integrity of a psychotherapy protocol: assessment of adherence and competence. J Consult Clin Psych. (1993) 61:620. 10.1037/0022-006X.61.4.620
    1. Guy W. ECDEU Assessment Manual for Psychopharmacology. Rockville, MD: US Department of Heath, and Welfare Public Health Service Alcohol, Drug Abuse, and Mental Health Administration; (1976).
    1. Benjamini Y, Yekutieli D. The control of the false discovery rate in multiple testing under dependency. Ann Stat. (2001) 29:1165–88. 10.1214/aos/1013699998
    1. Glickman ME, Rao SR, Schultz MR. False discovery rate control is a recommended alternative to Bonferroni-type adjustments in health studies. J Clin Epidemiol. (2014) 67:850–7. 10.1016/j.jclinepi.2014.03.012
    1. Strimmer K. A unified approach to false discovery rate estimation. BMC Bioinformatics. (2008) 9:303. 10.1186/1471-2105-9-303
    1. Strimmer K. fdrtool: a versatile R package for estimating local and tail area- based false discovery rates. BMC Bioinformatics. (2008) 24:1461–2. 10.1093/bioinformatics/btn209
    1. Sukhodolsky DG, Solomon RM, Perine J. Cognitive-behavioral, anger-control intervention for elementary school children: a treatment-outcome study. J Child and Adolesc Group Ther. (2000) 10:159–70. 10.1023/A:1009488701736
    1. Berkowitz L, Harmon-Jones E. Toward an understanding of the determinants of anger. Emotion. (2004) 4:107. 10.1037/1528-3542.4.2.107
    1. Sukhodolsky DG, Golub A, Stone EC, Orban L. Dismantling anger control training for children: a randomized pilot study of social problem-solving versus social skills training components. Behav Ther. (2005) 36:15–23. 10.1016/S0005-7894(05)80050-4
    1. Jamshidifarsani H, Tamayo-Serrano P, Garbaya S, Lim T. A three-step model for the gamification of training and automaticity acquisition. J Comp Assist Learn. (2021) 37:994–1014. 10.1111/jcal.12539
    1. Ceranoglu TA. Video games in psychotherapy. Rev Gen Psychol. (2010) 14:141–6. 10.1037/a0019439
    1. Sukhodolsky DG, Smith SD, McCauley SA, Ibrahim K, Piasecka JB. Behavioral interventions for anger, irritability, and aggression in children and adolescents. J Child Adolesc Psychopharmacol. (2016) 26:58–64. 10.1089/cap.2015.0120
    1. American Psychiatric Association . Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Text Revision. Washington, DC: American Psychiatric Publishing, Inc; (2013).
    1. Kahn J, White E, Gonzalez-Heydrich J. Be Mightier: Video-game based treatment to improve emotional regulation in the home. In: Presentation at: The International Society of Internet Research. Auckland: (2019).
    1. Mohr DC, Zhang M, Schueller SM. Personal sensing: understanding mental health using ubiquitous sensors and machine learning. Annu Rev Clin Psychol. (2017) 13:23–47. 10.1146/annurev-clinpsy-032816-044949

Source: PubMed

Sponsoren und Mitarbeiter

Krankheiten

Drogeninterventionen

3
Abonnieren