Therapy computer games

In recent years, the topic of computer games for therapeutic use has come into scientific focus.
In principle, ADHD symptoms can be improved by therapy computer games¹, e.g.

• Attention²
• Executive functions³
• cognitive functions (meta-analysis, k = 8 RCT)⁴
  • the visual-spatial short-term memory
  • the visual-spatial working memory
• However, improvements in behavioral aspects such as inhibition and monitoring were not statistically significant (meta-analysis, k = 8 RCT)⁴

A therapeutic computer game has already been approved by the FDA for ADHD.

• 1.10.1. EndeavorRx
• 1.10.2. Plan-It Commander
• 1.11.3. RECOGNeyes
• 1.10.4. Empowered Brain
• 1.10.5. AR-Therapist: Augmented Reality - Behavioral Therapy - Game Concept
• 1.10.6. The Secret Trail of Moon
• 1.10.7. Computer therapy games for other mental disorders

1.10.1. EndeavorRx¶

In June 2020, the FDA (US Food and Drug Administration) approved the first ever video game that can be prescribed by a doctor. It is used to treat ADHD.

180 children between the ages of 8 and 12 played EndeavorRx for 25 minutes 5 days a week for 4 weeks, 168 children played a game other than placebo. The mean change (SD) from baseline on the TOVA-API was 0.93 in the treatment group and 0.03 in the control group.⁵ The fact that the study was sponsored by the software manufacturer makes us skeptical. On the other hand, Faraone, one of the authors, is a very renowned scientist in the field of ADHD and The Lancet is a very renowned scientific journal.
A preliminary study also found evidence of a positive effect.⁶

AKL-T01 was developed as therapy software for clinical trials on children with ADHD.⁷ AKL-T01 had the following effects:

• Improvement in the Test of Variables of Attention (TOVA) - Attention Performance Index (API) with AKL-T01 without stimulants in children aged 8 to 12⁸
• Improvements in ADHD-related impairments and symptoms in children aged 8 to 14 years over two four-week treatment periods⁹

EndeavorRx® is an improved application based on AKL-T01 marketed in the USA.⁷

The manufacturer describes further:

“EndeavourRx was granted clearance based on data from five clinical trials involving more than 600 children diagnosed with ADHD, including a prospective randomized controlled trial published in the Lancet Digital Health Journal, which showed that EndeavourRx improved objective measures of attention in children with ADHD. After four weeks of EndeavourRx treatment, one-third of the children no longer had a measurable attention deficit on at least one measure of objective attention. In addition, about half of the parents noted a clinically meaningful change in their child’s daily impairments after one month of treatment with EndeavourRx. This increased to 68% after a second month of treatment. The improvement in ADHD-HI impairments after one month of treatment with EndeavourRx was maintained for up to one month.”¹⁰

Another study, which is probably still ongoing, is investigating the effectiveness of the game over a longer application period of 2 months and the extent to which improvements persist after the end of treatment.

SDT-001 is an application that translates the language and expressions used in EndeavorRx® into Japanese.
An earlier Phase 2 study compared to a sham control (single-task device) found both groups showed improvements over time in total clinician-rated ADHD rating scale (ADHD-RS-IV) scores (ADHD-RS-T), as well as inattention (ADHD-RS-I) and hyperactivity/impulsivity (ADHD-RS-H) scores, with SDT-001 performing itndsentially (non-significantly) better⁷
In a Phase 3 study, SDT-001 showed a significantly greater improvement in physician assessment of inattention, hyperactivity and overall ADHD-RS-IV scores⁷

1.10.2. Plan-It Commander¶

The therapy computer game “Plan-It Commander” was/is developed by the authors of the studies mentioned below,¹¹ so that the assessment of its effectiveness by independent studies remains to be seen. The symptoms that are said to have been improved in non-blinded studies are

• Time management (parent assessment)¹²
• Responsibility (parent assessment)¹²
• Working memory (parent assessment)¹²
• Planning and Organizational Skills (Parent Assessment)¹³ in girls overall and in boys with high Disorder of Social Behavior and low Hyperactivity.

1.11.3. RECOGNeyes¶

A small study found that people with ADHD who controlled the game RECOGNeyes with their eyes showed improvements in terms of

• Impulsiveness
• Response time
• Fixation gaze control

while the control group, who controlled the game with the mouse, showed no improvement.¹⁴

1.10.4. Empowered Brain¶

A very small preliminary study showed that the higher their ADHD symptoms were, the better people with ADHD completed the game parts of Empowered Brain.¹⁵ The software appears to be developed more from a diagnostic perspective.

1.10.5. AR-Therapist: Augmented Reality - Behavioral Therapy - Game Concept¶

One study describes a concept of an augmented reality game for the purpose of behavioral therapy for ADHD, including measurement of ADHD-relevant parameters.¹⁶

1.10.6. The Secret Trail of Moon¶

A report describes the development of this game for ADHD treatment.¹⁷
A study of n = 76 children reported significant improvement, particularly in the patients who were more engaged with the MOON treatment, in terms of:¹⁸

• Material organization
• Working memory
• Impulsiveness

However, the Global Strengths and Difficulties Questionnaire score did not improve by the hoped-for 3 points.

1.10.7. Computer therapy games for other mental disorders¶

Some therapy games are known for other therapeutic goals, e.g:

• Nevermind¹⁹
  • Stress
  • Measured stress (anxiety, trauma responses) makes playing conditions more difficult
  • No “official” medical application
  • Is controlled by biofeedback
• Elude²⁰
  • Depression
  • Elude aims to raise awareness and provide information about depression. It is intended to be used in a clinical context as part of psycho-education to improve the understanding of friends and relatives about people suffering from depression, about what people with ADHD are going through.
• Treasure hunt²¹²²
  • Anxiety, aggression, depression
  • Created specifically for therapeutic purposes
    • Evaluated on 200 children by 41 therapists
    • Supports the therapeutic work
  • For children from 9 to 13 years
  • Goals:
    • Learn to distinguish between thoughts, feelings and behavior
    • Replace negative thought patterns with positive ones
• Depression Quest²³
  • Depression
  • In a selectable adventure, the player as a depressive tries to balance the illness, job, relationships and even treatment.
• Actual Sunlight²⁴
  • Depression
  • A short interactive story about love and depression.
  • Not suitable for children
• Sym²⁵
  • Social phobia is addressed in this game
• Rage Control²⁶
  • Aggression
  • Developed by the Boston Children’s Hospital
  • Uses active biofeedback
• Boson X
  • Depression
  • Commercial, non-therapy-oriented game
  • Whether this reduces the brooding phases in people with ADHD is disputed²⁷²⁸
• Tetris
  • Trauma prevention
  • Non-therapy-oriented play
  • Use within the first 6 hours after a potentially traumatizing experience, after players were asked to recall the event, reduced risk of traumatization²⁹
    • According to our (unverified) hypothesis, however, any mental activity and any media consumption that offers a light (!) mental activity (entertainment programs, entertainment films without dramas, light video games without social or violent components) could be suitable as trauma prophylaxis, provided they are used before the first sleep after the event. Of course, the content must not be thematically related to the event.
      According to our idea, the potentially traumatizing experiences are (at least partially) “overwritten” or “relativized” in working and short-term memory by subsequent “light” media consumption before they can be transferred to long-term memory via the hippocampus during sleep. Against this background, it could be beneficial to delay the first sleep after a potentially traumatizing event for as long as possible, to promote an abundant consumption of less significant media and, if necessary, to give medication that reduces the activity of the hippocampus.