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Wijnhoven et al. BMC Psychiatry (2015) 15:138
D! 10.118"#s12888$015$0522$%
&'D P*'C+ ,en -ccess
'he eect o the vi/eo ae Min/lihton an%iety sy,tos in chil/ren ithan -tis &,ectr Disor/er +ie4e -. M. W. Wijnhoven
126 Daan 7. M. Creeers
12 *ter C. M. . nels
13 an/ !sa9ela ranic
1
-9stract
Bac4ron/: !n the clinical settin a lare ,ro,ortion o chil/ren ith an atis s,ectr /isor/er (-&D)e%,erience an%iety sy,tos. Becase an%iety is an i,ortant case o i,airent or chil/ren ith an -&D
it is necessary that eective an%iety interventions are i,leente/ or these chil/ren. *ecently a serios
ae calle/ Min/liht has 9een /evelo,e/ that is ocse/ on /ecreasin an%iety in chil/ren. 'his a,,roach is
9ase/ on recent research sestin that vi/eo aes iht 9e sita9le as an intervention vehicle to
enhance ental health in chil/ren. !n the ,resent st/y it ill 9e investiate/ hether Min/liht is eective in
/ecreasin (s9) clinical an%iety sy,tos in chil/ren ho are /ianose/ ith an -&D.
Metho/s#Desin: 'he ,resent st/y involves a ran/oi;e/ controlle/ trial (*C') ith to con/itions (e%,eriental
verss control) in hich it is investiate/ hether Min/liht is eective in /ecreasin (s9) clinical an%iety sy,tos
in chil/ren ith an -&D. ? "0) con/ition. Chil/ren in
the e%,eriental con/ition ill ,lay Min/liht or one hor ,er ee4 or si% consective ee4s. Chil/ren in the control
con/ition ill ,lay the ,;;le ae 'ri,le 'on also or one hor ,er ee4 an/ or si% consective ee4s. -ll chil/renill co,lete assessents at 9aseline ,ost$intervention an/ 3$onths ollo$,. etherlan/s2E ost$Bra9ant P.. Bo% 3 52F E Boe4el 'he >etherlan/s
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(htt,:##creativecoons.or#,9lic/oain#;ero#1.0#) a,,lies to the /ata a/e availa9le in this article nless otherise state/.
http://creativecommons.org/publicdomain/zero/1.0/http://creativecommons.org/publicdomain/zero/1.0/http://creativecommons.org/publicdomain/zero/1.0/
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Wijnhoven et al. BMC Psychiatry (2015) 15:138 Pae 2 o @
Bac4ron/
In the clinical setting, a large proportion of children with
an autism spectrum disorder (ASD) experience anxiety
symptoms. Between 11 and !" of all children with
an ASD experience some degree of impairing anxiety #1$.
%ore specifically, &1 of the children with an ASD
suffer from su'clinical anxiety #&$ and approximately "
of the children with an ASD meet the criteria of at least
one anxiety disorder #$. Some of the most fre*+uently
reported anxiety disorders and symptoms seen in children
with an ASD are simple pho'ias, generalied anxiety
disorder, separation anxiety disorder, o'sessi-e*
compulsi-e disorder and social pho'ia #1$.
%oreo-er, anxiety is an underlying cause of se-eral
symptoms of ASD. or example, anxiety underlies or
affects the stereotype and rigid 'eha-ior #"$ and the
pro'lems in social functioning #/$ that children with an
ASD often show. Anxiety also underlies comor'idsymptoms of children with an ASD, for example oppos*
itional and aggressi-e 'eha-ior #0$ and depressi-e
symptoms #$. urthermore, anxiety in children with an
ASD has a negati-e impact on adapti-e functioning, daily
li-ing s2ills and relationships with peers, teachers and
family #! = 1$. 3herefore, it is important that anx*iety in
children with an ASD is treated and pre-ented from
further escalation.
4ecognition of anxiety symptoms in children with an
ASD is not new. In the original description of children
with an ASD, 5anner #11$ stated that a num'er of these
children had Hsu'stantial anxiety pro'lemsI. 6et, thee-aluation and treatment of anxiety in children with an
ASD has only recently recei-ed empirical attention #1$.
%any studies showed the effecti-eness of adapted -er*
sions of cogniti-e 'eha-ioral therapy (7B38 e.g. #1&$) or
new inter-entions especially de-eloped for children with
an ASD (e.g. #1$), reasoning that the traditional form of
7B3 is not suita'le for children with an ASD. 9n the
other hand, a recent study of :an Steensel and B;gels
#1"$ has shown that 7B3 is effecti-e in reducing anxiety
symptoms in children with an ASD, and that 7B3 is as
effecti-e for children with an ASD as for children with*
out an ASD.
years old. 3hey concluded that it
was a potential alternati-e to usual care for adolescents
with depressi-e symptoms in primary care settings and
that it could 'e used to address some of the unmet de*
mands for treatment. %ore recently, the serious game
%indlight (?laynice Institute) has 'een de-eloped for the
treatment of anxiety disorders in children. A recent study
has tested the effect of %indlight on anxiety symp*toms in
school children #&$. 3his study showed that 'oth the
anxiety of the children who played %indlight as the
anxiety of the children who played the control game
significantly decreased o-er time.
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Wijnhoven et al. BMC Psychiatry (2015) 15:138 Pae 3 o @
It is hypothesied that %indlight has the potential to
ser-e as an effecti-e new inter-ention for children with
ASD and comor'id (su') clinical anxiety symptoms, and
that it can o-ercome the limitations of 7B3. irst, it is
2nown that children with ASD often feel a close affinity
for technology and games, which means that the partici*
pating children are pro'a'ly intrinsically moti-ated to
play a game li2e %indlight in therapy #&"$. %oreo-er, it
has 'een reported that computer 'ased training could 'e
an effecti-e tool in treatment for children with ASD, due
to its -isual and structured character #1/$. %indlight uses
-isual aids and structured sensory information to a great
extent, 'oth for creating a JscaryK exposure en-iron*mentand for teaching important treatment concepts.
urthermore, %indlight includes fre+uent practice and
exposure opportunities. Because %indlight can 'e played
repeatedly, with the difficulty le-el increasing as children
'ecome 'etter players, there is a great deal of practice andexposure in-ol-ed in playing this game. As a result, the
gap 'etween 2nowledge and 'eha-ior may 'e su'*
stantially decreased and effecti-e cogniti-e and emo*
tional coping s2ills can 'e automatied and possi'ly
generalied with practice. inally, therapy s2ills can 'e
practiced at home, which means that children ha-e an
easier access to mental health care. In this way, the wait*
ing lists can 'ecome shorter and the therapy costs can 'e
decreased when implementing a game li2e %indlight as
therapy tool.
In the present study, the primary aim is to in-estigate
whether %indlight is effecti-e in reducing (su') clinical
anxiety symptoms in children with an ASD. 3he sec*
ondary aim is to examine whether %indlight is effecti-e
in reducing parent report of child anxiety, and the anxiety*
related depressi-e symptoms, social functioning and
'eha-ior pro'lems of the participating children. 3o
in-estigate these aims, a multi method symptom assess*
ment is used, including parent, teacher and child reports
#1$. If %indlight turns out to 'e effecti-e for anxious chil*
dren with an ASD, it could 'e considered as a new thera*
peutic inter-ention next to the already existing approaches
for anxiety in children with an ASD.
Metho/s3he study design will 'e reported in line with the 79*
S943 &1 Statement for reporting parallel group ran*
domied trials #&/$. 3he medical ethics committee 7%9
Arnhem*imegen in the etherlands has gi-en appro-al
for the conduction of this study (C/&.>1.1"). %ore*
o-er, the study is registered in the Dutch 3rial 4egister for
473Ks (34/0>).
Desin
3he present study in-ol-es a randomied controlled trial(473) with two conditions (experimental -ersus control),
in which it is in-estigated whether the new -ideo game
%indlight is effecti-e in treating (su') clinical anxiety
symptoms in children with an ASD. or this study, chil*
dren in the age of ! =10 years old with a diagnosis of anASD according to the Diagnostic and Statistical %anual
of %ental Disorders "th =dition = 3ext 4e-ision (DS%*I:*348 #&0$) will 'e screened for anxiety symptoms. 3he
children with (su') clinical anxiety symptoms will 'e
selected and approached for participation.
After the selection and recruitment, children will 'e
randomly assigned to the experimental or control condi*tion.
At 'aseline (3), children, parents and teachers will fill in
+uestionnaires. %oreo-er, parents will undergo a semi*
structured inter-iew (ADIS*?8 #&$) to determine whether
their child meets the criteria of one or more anxiety
disorders. At post*inter-ention (31) and at *months follow*
up (3&), children, parents and teachers will fill in
+uestionnaires again to e-aluate the effect of %indlight. At *months follow*up, parents will undergo the semi*structured
inter-iew again to test whether %indlight also had an effect
on the present anxiety disorder
(s) in the participating children. ig. 1 shows a schematico-er-iew of the design in the present study.
Partici,antsK elii9ility
7hildren with an ASD (DS%*I:*34 Autistic disorder,
Asperger disorder, ?DD*9S8 #&0$) in the age 'etween !
to 10 years old will 'e assessed for eligi'ility 'y a screen*
ing. 3his screening consists of filling in an anxiety +ues*
tionnaire 'y 'oth children (S7AS*78 #&!$) and parents
(S7AS*?8 #&>$). Ehen children ha-e at least su'clinical
le-els of anxiety, they are eligi'le for participation in the
study. %oreo-er, they ha-e to ha-e sufficient 2nowledge
of the Dutch language. =xclusion criteria are a'sence of
parental permission and presence of prominent suicidal
ideation or other se-ere psychiatric pro'lems that need
immediate treatment (e.g. se-ere traumaKs).
Proce/re
7ontexts of recruitment are mental health institutes (e.g.
FFG 9ost Bra'ant) and special education schools in the
etherlands. irst, parents will recei-e a letter with in*
formation a'out the screening and the study. %oreo-er,children and parents will 'e as2ed to fill in the S7AS*7H ?
#&!, &>$. Ehen children ha-e at least su'clinical le-els of
anxiety and meet the other inclusion criteria, children and
parents will 'e approached to participate in the study. If
children and parents agree with participation, acti-e
written informed consent of the parents and the children
who are a'o-e the age of 1& will 'e o'tained.
After o'taining acti-e written informed consent, chil*
dren will 'e randomly allocated to the experimental or
control condition. 7hildren in the experimental condi*tion
will play %indlight indi-idually for one hour per
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Wijnhoven et al. BMC Psychiatry (2015) 15:138 Pae 5 o @
Arthur is left on the doorstep of a scary mansion 'y his
parents. Arthur must learn to use his own inner strength to
o-ercome his greatest fears so the shadows in the house
can hold no power o-er him.
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Wijnhoven et al. BMC Psychiatry (2015) 15:138 Pae " o @
todayL &) Ehat did you find difficultHEhat did you find
easyL ) Ehat did you learn in the gameL ") 7ould you
apply and practice the s2ills you ha-e learned in scary or
difficult situations in daily lifeL In session & =0, the ther*apist will start the session with discussing the pre-ious
wee2 and the s2ills the child has practiced at home. Ehen
the child mentions that he has practiced the s2ills in a
scary or difficult situation, this will 'e reinforced 'y the
therapist. In this way, the therapist does not add ex*plicit
therapeutic elements to the gaming sessions, 'ut children
do get stimulated to thin2 a'out their anxiety and the way
they can apply and practice the s2ills they ha-e learned in
the game in daily life.
&t/y otcoe easres
3a'le 1 shows an o-er-iew of the different time points,
the +uestionnaires that were filled in on each time point
and the informants that were in-ol-ed.
&creenin easres
3o test their eligi'ility, children will 'e screened on anx*
iety symptoms using the S7AS*7 for child report and the
S7AS*? for parent report #&!, &>$. 7hildren are eligi'le
for participation when the child andHor the parent report
the presence of su'clinical child anxiety. %oreo-er,
demo*graphical +uestions (e.g. sex, age, educational
le-el) will 'e as2ed to 'oth children and parents. inally,
some +ues*tions a'out the childKs gaming 'eha-ior (e.g.
J
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Wijnhoven et al. BMC Psychiatry (2015) 15:138 Pae F o @
already has 'een shown that the original (American) -er*
sion of the 7DI & (?) #"$ has a good relia'ility, internal
consistency and con-ergent -alidity #"1$.
Depression according to the parents will 'e measured
with the Dutch translation of the 7hild Depression In*
-entory & for parents (7DI &?8 #>$) will 'e used to
measure parental assessment of depressi-e symptoms of
their child. 3he 7DI &? consists of 1 items measured on
a "*point scale ranging from (not at all), 1 (some of the
time), & (often), or (most of the time) (e.g. J%y child
loo2s sadK8 J%y child seems lonelyK). 3he parent has toassess to which extent the items are in accordance with
their childKs thoughts and feelings.
Social functioning according to the parents and teacher
will 'e measured with the J:ragenlist -oor In-entarisatie-an Sociaal gedrag -an 5inderenK (:IS5), a Dutch trans*
lation of the 7hildrenKs Social Beha-iour Muestionnaire
(7SBM8 Cutein #"&$). 3he :IS5 consists of "> itemsmeasured on a *point scale ( K not applica'le, 1 K
sometimes applica'le, & K often applica'le). 3he items are
di-ided o-er six pro'lem scales 'eing not well tai*lored
to social situations8 limited tendency to engage in social
interactions8 orientation pro'lems in time, space and
place8 not understanding social information8 stereo*type
'eha-ior8 and anxiety for and resistance against changes.
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Wijnhoven et al. BMC Psychiatry (2015) 15:138 Pae 8 o @
of depressi-e symptoms and parentHteacher report of so*cial functioning and 'eha-ior pro'lems.
&trenths an/ liitations
3he present study design has a few strengths and limita*
tions. A strength is that it is the first study in-estigating the
effect of a serious game in a clinical context with children
who are diagnosed with an ASD and who ha-e comor'id
(su') clinical anxiety symptoms, which could lead to a new
way of treating anxiety in children with an ASD. An
additional strength is that children with an ASD often feel a
close affinity for technology and games #&", 1/$, and that
the participating children are pro'a'ly intrinsically moti-ated
to play a game li2e %indlight in therapy. urthermore,
%indlight includes fre+uent prac*tice, exposure
opportunities, -isual aids and structured sen*sory
information, which all stimulate the automatiation and the
generaliation of s2ills to daily life in the participat*ingchildren. Another strength is that this study may lead to the
implementation of %indlight in mental health insti*tutes,
which may result in an easier access to mental health care,
shorter waiting lists and lower therapy costs. inally, this
study has multiple outcome measures, which ma2es it
possi'le to in-estigate other direct effects of %indlight on
anxiety*related symptoms (e.g. depressi-e symptoms) of the
participating children.
A limitation of the present study design is that the chil*
dren in the control condition might ha-e played 3riple
3own already 'efore the start of the study. 3his may ha-e
a positi-e (e.g. more practice) or negati-e (r 'oredom)
influence on the effect of the game. %oreo-er, only short*
term effects (*months follow*up) of %indlight will 'e
in-estigated. In this way, no conclusions can 'e drawn
a'out the long*term effects of %indlight on anxiety
symptoms of the participating children. inally, there are
no standardied protocols for offering and implementing a
-ideo game in a clinical therapy session. 3his implies that
the 'est form of implementation still needs to 'e disco-*
ered and impro-ed 'y experience.
!,lications or ,ractice
Anxiety symptoms are highly common in children with an
ASD. Still, treatment on anxiety in children with an ASDonly recently has recei-ed some empirical attention. 3his
may 'e caused 'y the fact that anxiety is often underdiag*
nosed in children with an ASD #1$. In this way, anxiety
treatment for children with an ASD is not common and the
de-elopment of e-idence*'ased anxiety treatments has not
'een focused upon until recently. By de-eloping and
in-estigating new anxiety treatments for children with an
ASD, these may 'e more fre+uently offered in mental health
institutes in the future. %oreo-er, if %indlight turns out to 'e
effecti-e for anxious children with an ASD, it could 'e
considered as a good and suita'le therapeutic
alternati-e to the already existing inter-entions for anxiety
in children with an ASD. %indlight could then 'e imple*
mented as an e-idence*'ased treatment for children with
an ASD in mental health institutes and special education
schools.
Conclsion
3his paper aimed to descri'e a study that will in-estigate
the effect of the serious game %indlight on (su') clinical
anxiety symptoms of children with an autism spectrum
disorder in the age of ! =10 years old. It is expected thatchildren in the experimental condition will show lower
le-els of anxiety symptoms at *months follow*up, com*
pared to children in the control condition. If %indlight
turns out to 'e effecti-e, this could pro-ide a significant
contri'ution to the e-idence*'ased treatment of anxiety in
children with an ASD.
Co,etin interestsMin/liht has 9een /evelo,e/ 9y the Playnice !nstitte. Pro. /r. !sa9ela ranic
an/ Pro. /r. *ter nels are the on/ers o this institte. 7oever Min/liht
is not yet coerciali;e/. 'he chance o co,etin interests is only ,resent in
case o coerciali;ation o this ae. Dr. Daan Creeers an/ +ie4e
Wijnhoven (M&c) /eclare that they have no co,etin interests.
-thorsK contri9tions
+ie4e Wijnhoven (M&c) is res,onsi9le or the /ata collection the /ataanalysis an/ or re,ortin the st/y reslts. Dr. Daan Creeers Pro./r. *ter nels an/ Pro. /r. !sa9ela ranic are s,ervisors rant
a,,licators an/ ,rinci,al investiators. -ll athors have contri9te/ tothe ritin o this anscri,t. Moreover all athors have rea/ an/
a,,rove/ the inal anscri,t.
-c4nole/eentsetherlan/s.2E ost$Bra9ant
P.. Bo% 3 52F E Boe4el 'he >etherlan/s.3'ri9os !nstitte Da
Costa4a/e 5 3521 & trecht 'he >etherlan/s.
*eceive/: 2 -,ril 2015 -cce,te/: 8 One 2015
*eerences
1. White &W sal/ D llen/ic4 ' &cahill +. -n%iety inchil/ren an/ a/olescents ith atis s,ectr /isor/ers.Clin Psych *ev. 200@2@:21"=2@./oi:10.101"#j.c,r.200@.01.003.
2. &tran O
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severity on social nctionin in chil/ren ith atis
s,ectr /isor/er. O Dev Phys Disa9il. 20122:235=5.
/oi:10.100F#s10882 $012$@2"8$2.
Wijnhoven et al. BMC Psychiatry (2015) 15:138
". Cervantes P Matson O+ 'rec4 A -/as 7+. 'he relationshi,
o coor9i/ an%iety sy,to severity an/ challenin
9ehaviors in inants an/ to//lers ith atis s,ectr
/isor/er. *es -tis &,ectr Disor/. 2013F:1528=3.
/oi:10.101"#j.ras/.2013.0@.005.F. asa *- Aal9 + Ma;re4 M Aanne &
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Pae @ o @
2@. &cholin - >ata M7 &,ence &7. &,ence chil/renKs an%iety scale
(Dtch translation o ,arent version). -ster/a >+: niversity o
-ster/a 1@@@.
30. ata M7 &cholin - *a,ee * -99ott M &,ence &7 Waters -.
- ,arent$re,ort easre o chil/renKs an%iety: ,sychoetric ,ro,ertiesan/ co,arison ith chil/$re,ort in a clinic an/ noral sa,le. Behav
*es 'her. 2002:813=3@. /oi:10.101"#&0005 $F@"F(03)00200$".
3@. 'i9reont B Braet C *oelos O. 7an/lei/inChil/renKs /e,ression inventory (her;iene versie).
-ster/a: Pearson -ssessent an/ !norationB. 2008.
0. Aovacs M. Chil/renKs De,ression !nventory 2 (CD! 2).
2n/ e/. >orth 'onaan/a >: Mlti$7ealth &ystes
!nc 2011.1. Bae 'est *evie Aovacs M. HChil/renKs De,ression !nventory 2 (CD!
2)I (2n/ e/.). O Psychoe/ -sses. 201230:30=8.
/oi:10.11FF#0F3282@112"0F.
2. +teijn oc4 MA Aa;/in -. Parent e%,ectancies or chil/thera,y: assessent an/ relation to ,artici,ation in
treatent. O Chil/
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