8 327 GENERAL DISCUSSION In Chapter 3, we investigated whether engagement with specific therapeutic techniques in MindLight predicted improvements in anxiety symptoms. Drawing from the anxiety literature, we identified two types of in-game play behaviours: engaged behaviours that facilitate a higher ‘dosage’ of therapeutic techniques and contribute to successful gameplay, and avoidant or safety behaviours that reduce opportunities to engage and practice with the therapeutic techniques. Clinical research emphasizes the significance of reducing avoidant and safety behaviours for better treatment outcomes (McManus et al., 2008; Morgan & Raffle, 1999; Salkovskis et al., 1999). We assessed in-game play behaviours during the initial and final play sessions, and examined how changes from the first to the last session predicted improvements in anxiety. Results revealed that changes in gameplay behaviours, particularly those representing therapeutic exposure techniques, predicted improvements in anxiety symptoms three months later. Specifically, children actively engaging with the game, as evidenced by increased exploration behaviour, reported lower anxiety levels. Conversely, children increasing their avoidance (i.e., hiding from the fear events) and safety behaviours (i.e., turning on lights in the game) reported higher anxiety levels after three months. Thus, more engagement with the specific therapeutic techniques contributed to effective anxiety reduction. Additionally, our analysis revealed that baseline anxiety was not associated with in-game play behaviours during the initial session. Children exhibiting high initial anxiety symptoms engaged with the game in a manner akin to children with milder symptoms. This demonstrates that heightened symptom severity does not impede game engagement. In Chapter 4, we found that baseline anxiety levels, maternal mental health and children’s self-efficacy did not influence the changes observed over time in both mother- and child-reported anxiety. These results show that nonspecific factors do not hamper nor increase the effectiveness of MindLight. Additionally, we examined whether MindLight exhibits beneficial effects on outcomes associated with anxiety symptoms. The results revealed that MindLight is equally effective as CBT in reducing mother-reported internalising problems and increasing child-reported self-efficacy. Additionally, both interventions led to decreases in mother-reported externalising problems. CBT, however, exhibited a larger reduction at post-test and the 6-month follow-up. These findings indicate that MindLight shows promise as an effective intervention not only for addressing symptoms of anxiety but also for improving more general mental health outcomes. In the study outlined in Chapter 5, we investigated the impact of expectations for improvement on engagement during MindLight gameplay,
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