Jurnal Game Autis Word

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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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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 o @


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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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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,[email protected].

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/[email protected]. 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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