A VR-based serious game for studying emotional regulation in adolescents

Technology for supporting emotion regulation of individuals with developmental disabilities: A scoping review

BACKGROUND

Emotional competencies are skills necessary to adequately understand, express, and regulate emotional phenomena. Among the emotional competencies is emotion regulation. Not having adequate development of this emotional competence is related to psychological problems such as depression. One of the characteristics of individuals with developmental disabilities is the presence of difficulties with emotion regulation. These difficulties can affect an individual's autonomy, social competence, and the development of independent life.

AIMS

This paper presents a scoping review to identify the technology designed and developed to support the emotion regulation of individuals with developmental disabilities.

METHODS AND PROCEDURES

We combined the guidelines for a systematic literature review in computer science and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. The process resulted in twelve stages through which we conducted this scoping review. First, a search query was defined and executed in computer science's five most representative search engines. We used different inclusion, exclusion, and quality criteria for selecting the works included in this review.

OUTCOMES AND RESULTS

Thirty-nine papers aimed at supporting the emotional competencies of individuals with developmental disabilities were included, of which nine support emotion regulation. As a result, different areas of opportunity in developing technology to support the emotion regulation of individuals with developmental disabilities are discussed.

CONCLUSIONS AND IMPLICATIONS

Technology supporting emotion regulation in individuals with developmental disabilities is a growing but little-explored field. For the literature supporting emotion regulation, we detected opportunities for study. Some of them aimed at investigating whether we could use technologies developed for other emotional competencies to support emotion regulation and how the characteristics of this technology can support individuals with developmental disabilities.

e-Estesia: A Serious Game for Reducing Arousal, Improving Emotional Regulation and Increasing Wellbeing in Individuals with Gambling Disorder

Gambling disorder (GD) is associated with deficits in emotion regulation and impulsivity-related personality traits. In recent years there has been an increase in the use of serious games (SG) to address these factors with positive results. The aim of this study was to analyze the efficacy of the intervention with a new SG (e-Estesia), as an adjunct to a CBT intervention for GD. The sample comprised two groups (experimental group (n = 40) and control group (n = 64)) of patients with GD diagnosis. Both groups received 16 weekly CBT sessions and, concurrently, only the experimental group received 15 additional sessions with e-Estesia. Pre-post treatment with e-Estesia administered in both groups were: DSM-5 Criteria, South Oaks Gambling Screen, Symptom Checklist-Revised and measure of relapses, dropout and compliance of treatment. As regards the experimental group were also administered: Difficulties in Emotion Regulation Scale, Emotion Regulation Questionnaire, and Impulsive Behavior Scale. No statistically significant differences in the general psychopathological state, emotion regulation or impulsivity were found when comparing the groups. However, patients enrolled in the e-Estesia intervention had significantly less relapses and better indicators of treatment compliance than the control group. Considering these results, the use of complementary tools such as SG are useful for addressing GD.

Digital Interventions for Emotion Regulation in Children and Early Adolescents: Systematic Review and Meta-analysis

Background

Difficulties in emotion regulation are common in adolescence and are associated with poor social and mental health outcomes. However, psychological therapies that promote adaptive emotion regulation may be inaccessible and unattractive to youth. Digital interventions may help address this need.

Objective

The aim of this systematic review and meta-analysis was to synthesize evidence on the efficacy, feasibility, and acceptability of emotion regulation digital interventions in children and early adolescents aged 8 to 14 years.

Methods

Systematic searches of Web of Science, MEDLINE, PsycINFO, EMBASE, Education Resources Information Centre, ACM Digital Library, and IEEE Xplore up to July 2020 identified 39 studies, of which 11 (28%) were included in the meta-analyses (n=2476 participants). A bespoke tool was used to assess risk of bias.

Results

The studies evaluated digital games (27/39, 69%), biofeedback (4/39, 10%), virtual or augmented reality (4/39, 10%), and program or multimedia (4/39, 10%) digital interventions in samples classified as diagnosed, at risk, healthy, and universal. The most consistent evidence came from digital games, which reduced negative emotional experience with a small significant effect, largely in youth at risk of anxiety (Hedges g=–0.19, 95% CI –0.34 to –0.04). In general, digital interventions tended to improve emotion regulation, but this effect was not significant (Hedges g=0.19, 95% CI –0.16 to 0.54).

Conclusions

Most feasibility issues were identified in diagnosed youth, and acceptability was generally high across intervention types and samples. Although there is cause to be optimistic about digital interventions supporting the difficulties that youth experience in emotion regulation, the predominance of early-stage development studies highlights the need for more work in this area.

Application of Serious Games in Health Care: Scoping Review and Bibliometric Analysis

Background

Serious games (SGs) as one kind of intervention that can improve the level of knowledge and change behavior to affect health outcomes has been increasingly applied in health care.

Objective

Analyze hotspots and trends of the application of SGs in health care and provide reference and direction for further research in the future.

Methods

The Web of Science (WoS) Core Collection database was used for extracting the literature on SGs in health care for the period from the database established to 11 October, 2021. Scoping review and bibliometric analysis were used to deeply analyze and visualize countries, categories of studies, annual study output, cited authors, cited journals, cited articles, and keywords of healthcare field.

Results

A total of 1,322 articles were retrieved, then every articles' title and abstract were read one by one, and 795 articles were included after screening with an exponential increase in publication volume. The United States of America made the greatest contribution to global publications regarding SGs in health care. From the total, 20.8% of articles fall under the category of health care sciences services. The target groups were mainly concentrated in children (18.0%), youth (13.8%), the elderly (10.9%), adolescents (9.1%), and adults (3.4%). Baranowski T (n = 103 citations) is the most influential author, followed by Kato PM (n = 73 citations) and Desmet A (n = 58 citations). The top three cited journals were "Plos One" (n = 268 citations), "Games for Health Journal" (n = 209 citations), and "Journal of Medical Internet Research" (n = 197 citations), and the top three cited articles were "A meta-analysis of serious digital games for healthy lifestyle promotion," "A Systematic Review of Serious Games in Training Health Care Professionals," and "Video game training enhances cognitive control in older adults." More and more studies focus on specific age groups, such as children, adolescents, and the elderly. The research hotspots and trends included "rehabilitation," "medical education," and "design."

Conclusions

The application of SGs in health care remains important areas for future research. "Rehabilitation," "medical education," and "design" reflected the latest research hotpots and future trends.

A Multimodal Approach for Real Time Recognition of Engagement towards Adaptive Serious Games for Health

In this article, an unobtrusive and affordable sensor-based multimodal approach for real time recognition of engagement in serious games (SGs) for health is presented. This approach aims to achieve individualization in SGs that promote self-health management. The feasibility of the proposed approach was investigated by designing and implementing an experimental process focusing on real time recognition of engagement. Twenty-six participants were recruited and engaged in sessions with a SG that promotes food and nutrition literacy. Data were collected during play from a heart rate sensor, a smart chair, and in-game metrics. Perceived engagement, as an approximation to the ground truth, was annotated continuously by participants. An additional group of six participants were recruited for smart chair calibration purposes. The analysis was conducted in two directions, firstly investigating associations between identified sitting postures and perceived engagement, and secondly evaluating the predictive capacity of features extracted from the multitude of sources towards the ground truth. The results demonstrate significant associations and predictive capacity from all investigated sources, with a multimodal feature combination displaying superiority over unimodal features. These results advocate for the feasibility of real time recognition of engagement in adaptive serious games for health by using the presented approach.

Awareness, Prevention, Detection, and Therapy Applications for Depression and Anxiety in Serious Games for Children and Adolescents: Systematic Review

BACKGROUND

Depression and anxiety in children and adolescents are major health problems worldwide. In recent years, serious games research has advanced in the development of tools to address these mental health conditions. However, there has not been an extensive analysis of these games, their tendencies, and capacities.

OBJECTIVE

This review aims to gather the most current serious games, published from 2015 to 2020, with a new approach focusing on their applications: awareness, prevention, detection, and therapy. The purpose is also to analyze the implementation, development, and evaluation of these tools to obtain trends, strengths, and weaknesses for future research lines.

METHODS

The identification of the serious games through a literature search was conducted on the databases PubMed, Scopus, Wiley, Taylor and Francis, Springer, PsycINFO, PsycArticles, Web of Science, and Science Direct. The identified records were screened to include only the manuscripts meeting these criteria: a serious game for PC, smartphone, or virtual reality; developed by research teams; targeting only depression or anxiety or both; aiming specifically at children or adolescents.

RESULTS

A total of 34 studies have been found that developed serious games for PC, smartphone, and virtual reality devices and tested them in children and adolescents. Most of the games address both conditions and are applied in prevention and therapy. Nevertheless, there is a trend that anxiety is targeted more in childhood and depression targeted more in adolescence. Regarding design, the game genres arcade minigames, adventure worlds, and social simulations are used, in this order. For implementation, these serious games usually require sessions of 1 hour and are most often played using a PC. Moreover, the common evaluation tools are normalized questionnaires that measure acquisition of skills or reduction of symptoms. Most studies collect and compare these data before and after the participants play.

CONCLUSIONS

The results show that more awareness and detection games are needed, as well as games that mix the awareness, prevention, detection, and therapy applications. In addition, games for depression and anxiety should equally target all age ranges. For future research, the development and evaluation of serious games should be standardized, so the implementation of serious games as tools would advance. The games should always offer support while playing, in addition to collecting data on participant behavior during the game to better analyze their learning. Furthermore, there is an open line regarding the use of virtual reality for these games due to the capabilities offered by this technology.

Study protocol for a randomised controlled trial to evaluate the effectiveness of a serious game targeting interpersonal emotion regulation in early adolescents

Background

Adaptive interpersonal emotion regulation (iER) is a vital tool for positive relations. During early adolescence, peer relations become increasingly important, making this age group a relevant target group for interventions promoting positive interactions with each other, yet no evidence-based intervention exists for iER and early adolescents specifically.

Methods

This randomised controlled trial (RCT) aims to test effectiveness and feasibility of a serious game training iER skills in early adolescents by comparing outcomes with a control group playing a game without psychoeducational content in a pre- and post-test design. German- and English-speaking early adolescents (10–14 years) are eligible for participation. IER skills improvement as assessed by a vignette task is the primary outcome and will be analysed with a chi-square test. Secondary outcomes include feasibility and acceptability, emotional competence, personal emotion regulation, gender, and sex.

Discussion

This RCT will test whether playing a serious game about iER strategies results in an improvement of iER skills and whether the game is feasible and acceptable for early adolescents with the ultimate aim to implement the game in schools and help early adolescents achieve positive peer relationships.

Trial registration

ClinicalTrials.govNCT04808102, Registered on 19 March 2021

Virtual reality for the enhancement of emotion regulation

In recent decades, a growing body of literature has focused on emotion regulation (ER), which refers to the ability to implement strategies in order to modulate emotional responses and reach desirable goals. To date, impaired ER (i.e., emotion dysregulation) has been identified as a transdiagnostic factor across a wide range of psychopathological conditions, which shows the importance of improving patients' ability to regulate negative and positive emotions in clinical practice. In addition to the increasing evidence showing its efficacy in the treatment of several clinical conditions, virtual reality (VR) has recently emerged as a potentially powerful tool for enhancing ER, thus breaking new ground in the development of cutting-edge transdiagnostic interventions. In the present narrative review, we will provide an overview of the existing evidence about VR-based interventions in the field of ER, emphasizing the promising findings and the barriers that still have to be addressed. To this aim, the available VR-based literature will be analysed in relation to four categories of ER strategies: situational strategies, attentional strategies, cognitive strategies, and response modulation strategies. Furthermore, new emerging fields of research targeting innovative aspects of ER will be highlighted, including the use of VR to promote positive emotions and interpersonal ER skills. Besides, its cost-effectiveness will be discussed, taking into account the costs for both developers (e.g., clinicians and researchers) and end-users. Finally, future directions in this promising field of research will be outlined.

A Serious Game to Improve Emotion Regulation in Treatment-Seeking Individuals With Gambling Disorder: A Usability Study

Background: Serious games have shown positive results in increasing motivation, adherence to treatment and strengthening the therapeutic alliance in multiple psychiatric disorders. In particular, patients with impulse control disorders and other disorders in which the patient suffers from inhibitory control deficits (e.g., behavioral addictions) have been shown to benefit from serious games. Aim: The aim of this study was to describe the characteristics and to evaluate the usability of a new serious videogame, e-Estesia. This serious videogame was designed to improve emotion regulation in patients with gambling disorder (GD). Preliminary results from a pilot sample are also reported. Method: A pilot sample of 26 patients undergoing treatment for GD was recruited (ranging from 22 to 74 years, mean = 41.2 and SD = 12.9; 80.8% men). Participants used e-Estesia on a tablet, which was connected to a thoracic band that sent heart rate (HR) and heart rate variability (HRV) data to the videogame platform in order to provide biofeedback. The System Usability Scale was completed by patients to determine the usability of e-Estesia. Results and Discussion: e-Estesia performed comparatively well for all the explored groups (i.e., sex, age, and online vs. offline gambling: mean usability score = 83.8, SD = 13.1). Around 84.6% of the patients endorsed that it was easy to use. Female patients with GD presented higher HRV during the use of the serious videogame compared to men.

Preventive digital mental health interventions for children and young people: a review of the design and reporting of research

Digital health interventions (DHIs) have frequently been highlighted as one way to respond to increasing levels of mental health problems in children and young people. Whilst many are developed to address existing mental health problems, there is also potential for DHIs to address prevention and early intervention. However, there are currently limitations in the design and reporting of the development, evaluation and implementation of preventive DHIs that can limit their adoption into real-world practice. This scoping review aimed to examine existing evidence-based DHI interventions and review how well the research literature described factors that researchers need to include in their study designs and reports to support real-world implementation. A search was conducted for relevant publications published from 2013 onwards. Twenty-one different interventions were identified from 30 publications, which took a universal (n = 12), selective (n = 3) and indicative (n = 15) approach to preventing poor mental health. Most interventions targeted adolescents, with only two studies including children aged ≤10 years. There was limited reporting of user co-design involvement in intervention development. Barriers and facilitators to implementation varied across the delivery settings, and only a minority reported financial costs involved in delivering the intervention. This review found that while there are continued attempts to design and evaluate DHIs for children and young people, there are several points of concern. More research is needed with younger children and those from poorer and underserved backgrounds. Co-design processes with children and young people should be recognised and reported as a necessary component within DHI research as they are an important factor in the design and development of interventions, and underpin successful adoption and implementation. Reporting the type and level of human support provided as part of the intervention is also important in enabling the sustained use and implementation of DHIs.

Game-Calibrated and User-Tailored Remote Detection of Stress and Boredom in Games

Emotion detection based on computer vision and remote extraction of user signals commonly rely on stimuli where users have a passive role with limited possibilities for interaction or emotional involvement, e.g., images and videos. Predictive models are also trained on a group level, which potentially excludes or dilutes key individualities of users. We present a non-obtrusive, multifactorial, user-tailored emotion detection method based on remotely estimated psychophysiological signals. A neural network learns the emotional profile of a user during the interaction with calibration games, a novel game-based emotion elicitation material designed to induce emotions while accounting for particularities of individuals. We evaluate our method in two experiments ( n = 20 and n = 62 ) with mean classification accuracy of 61.6%, which is statistically significantly better than chance-level classification. Our approach and its evaluation present unique circumstances: our model is trained on one dataset (calibration games) and tested on another (evaluation game), while preserving the natural behavior of subjects and using remote acquisition of signals. Results of this study suggest our method is feasible and an initiative to move away from questionnaires and physical sensors into a non-obtrusive, remote-based solution for detecting emotions in a context involving more naturalistic user behavior and games.

New Technologies for the Understanding, Assessment, and Intervention of Emotion Regulation

In the last decades, emotion regulation (ER) received increasing attention and became one of the most studied topics within the psychological field. Nevertheless, this construct has not been fully updated with the latest technological advancements. In this perspective, we will show how diverse technologies, such as virtual reality (VR), wearable biosensors, smartphones, or biofeedback techniques, can be applied to the understanding, assessment, and intervention of ER. After providing a brief overview of the currently available technological developments, we will discuss the benefits of incorporating new technologies in ER field, including ecological validity, intervention personalization, and the integration of understudied facets of ER, such as the implicit and interpersonal dimension.

User-Centered Virtual Reality for Promoting Relaxation: An Innovative Approach

Virtual reality has been used effectively to promote relaxation and reduce stress. It is possible to find two main approaches to achieve such aims across the literature. The first one is focused on generic environments filled with relaxing "narratives" to induce control over one's own body and physiological response, while the second one engages the user in virtual reality-mediated activities to empower his/her own abilities to regulate emotion. The scope of the present contribution is to extend the discourse on VR use to promote relaxation, by proposing a third approach. This would be based on VR with personalized content, based on user research to identify important life events. As a second step, distinctive features of such events may be rendered with symbols, activities or other virtual environments contents. According to literature, it is possible that such an approach would obtain more sophisticated and long-lasting relaxation in users. The present contribution explores this innovative theoretical proposal and its potential applications within future research and interventions.

Toward Emotionally Adaptive Virtual Reality for Mental Health Applications

Here, we introduce the design and preliminary validation of a general-purpose architecture for affective-driven procedural content generation in virtual reality (VR) applications in mental health and wellbeing. The architecture supports seven commercial physiological sensing technologies and can be deployed in immersive and non-immersive VR systems. To demonstrate the concept, we developed the "The Emotional Labyrinth," a non-linear scenario in which navigation in a procedurally generated three-dimensional maze is entirely decided by the user, and whose features are dynamically adapted according to a set of emotional states. During navigation, affective states are dynamically represented through pictures, music, and animated visual metaphors chosen to represent and induce affective states. The underlying hypothesis is that exposing users to multimodal representations of their affective states can create a feedback loop that supports emotional self-awareness and fosters more effective emotional regulation strategies. We carried out a first study to, first, assess the effectiveness of the selected metaphors in inducing target emotions, and second, identify relevant psycho-physiological markers of the emotional experience generated by the labyrinth. Results show that the Emotional Labyrinth is overall a pleasant experience in which the proposed procedural content generation can induce distinctive psycho-physiological patterns, generally coherent with the meaning of the metaphors used in the labyrinth design. Furthermore, collected psycho-physiological responses such as electrocardiography, respiration, electrodermal activity, and electromyography are used to generate computational models of users' reported experience. These models enable the future implementation of the closed loop mechanism to adapt the Labyrinth procedurally to the users' affective state.

A Review of Emotion Recognition Using Physiological Signals

Emotion recognition based on physiological signals has been a hot topic and applied in many areas such as safe driving, health care and social security. In this paper, we present a comprehensive review on physiological signal-based emotion recognition, including emotion models, emotion elicitation methods, the published emotional physiological datasets, features, classifiers, and the whole framework for emotion recognition based on the physiological signals. A summary and comparation among the recent studies has been conducted, which reveals the current existing problems and the future work has been discussed.

Videogames for Emotion Regulation: A Systematic Review

INTRODUCTION

Emotion regulation (ER) supports multiple individual functions and promotes mental health and wellbeing. Among the tools that may be used to help people in managing their affective states, videogames are reaching attention and are showing positive effects. Yet, little is known about their effectiveness.

OBJECTIVE

This study aims to assess the amount and quality of studies investigating the effects and modalities of the use of videogames for ER.

MATERIALS AND METHODS

A systematic literature search according to PRISMA guidelines was performed. Subsequently, according to expert advice other few studies have been added.

RESULTS

Twenty-three studies met the inclusion criteria and were included in the review; they can be categorized into three groups, namely (1) cross-sectional and qualitative studies, (2) experimental studies investigating the effects of videogame experience on ER and (3) ER intervention with serious games.

DISCUSSION

Discussion of the reviewed studies highlights that frequent gaming with commercial games offers more opportunities for ER improvement (related to gameplay and enjoyment of fictional properties) than limited-time experiences, such as those supported by bespoke serious games. This research area is still in its infancy and findings need to be interpreted with caution; furthermore, future reviews are encouraged to include clinical populations.

CONCLUSION

Videogames offer several opportunities for ER and a challenge for educational and psychological interventions.