3 173 IN-GAME PLAY BEHAVIOURS PREDICT IMPROVEMENTS IN ANXIETY Anxiety disorders are the earliest form of psychopathology to emerge in childhood, the most prevalent and frequently diagnosed disorders in youth (Beesdo et al., 2009), and associated with adverse health outcomes (Brent et al., 1986; Essau, 2003, Kessler et al., 1996; Pine et al., 1998; Weissman et al., 1999; Woodward & Ferguson, 2001). Beyond the numbers for clinical diagnoses, sub-clinical levels of anxiety symptoms are estimated at 40% in children (Muris et al., 2000a), which increase the risk for full-blown anxiety disorders at older ages. Currently, programs based on cognitive behavioural therapy (CBT) have been shown to be most effective (Butler et al., 2006; Fisak et al., 2011; InAlbon & Schneider, 2007; Kendall, 2011; Mychailszyn et al., 2012). However, CBT outcomes are mixed and effect sizes are small to moderate (Fisak et al., 2011; Mychailszyn et al., 2012). These disappointing outcomes of CBT-based indicated prevention programs might be related to limitations regarding the way in which interventions are delivered, rather than the therapeutic principles on which they are based (Granic et al., 2014; Kazdin, 2011). These limitations include a didactic-based approach that might not be engaging and motivating for some children (Gosch et al., 2006), few opportunities to practice newly-acquired knowledge, non-adherence of practitioners to the protocol (Eichstedt et al., 2014), and low accessibility and high costs of interventions (Collins et al., 2004; Farmer et al., 1999; Kataoka et al., 2002). The aforementioned limitations can be addressed by using game-based interventions (see Granic et al., 2014 for full discussion; Rideout et al., 2010; Olson, 2010). On this basis, the video game MindLight (GainPlay Studio, 2014) was developed in order to prevent the escalation of anxiety in at-risk children. The game incorporates evidence-based techniques by translating these techniques into game mechanics. Game mechanics are the actions in the game that are designed for the player to repeat over and over; they are the vehicles by which certain skills are trained (see Table 1). Results from an indicated randomised controlled trial (RCT; Schoneveld et al., 2016) showed that after playing 5 sessions of MindLight, at-risk children showed significant reductions in anxiety symptoms by three-month follow-up. In addition, a second indicated RCT showed that playing MindLight for 6 sessions is as effective as a CBT-based indicated prevention program (i.e., Coping Cat; Van Starrenburg et al., 2017) in reducing anxiety symptoms from pre- to post-measurement, including the three- and six-month follow-up (Schoneveld et al., 2018)1. Finally, results from 1 The effect sizes for the MindLight group were 0.60 from pre- to post-measurement, 0.75 at three-month follow-up, 1.07 at six-month follow-up, comparable to meta-analytic results on CBT (Mychailyszyn et al., 2012) and Kendall’s Coping Cat in particular (Lenz, 2015).
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