@Article{info:doi/10.2196/67007, author="Luo, Ziyue and Deng, Sisi and Zhou, Ruihao and Ye, Ling and Zhu, Tao and Chen, Guo", title="Comparative Efficacy of Video Games Versus Midazolam in Reducing Perioperative Anxiety in Pediatric Patients: Systematic Review and Meta-Analysis", journal="JMIR Serious Games", year="2025", month="Mar", day="10", volume="13", pages="e67007", keywords="video games", keywords="midazolam", keywords="perioperative period", keywords="anxiety", keywords="meta-analysis", keywords="pediatric patients", abstract="Background: Pediatric patients undergoing surgery frequently experience significant anxiety, which can result in adverse effects such as prolonged sedation and behavioral changes associated with pharmacological interventions such as oral midazolam. Video games offer a nonpharmacological distraction method that shows promise in alleviating procedural anxiety without significant adverse effects. However, the effectiveness of video games compared to midazolam in managing perioperative anxiety remains uncertain. Objective: This study aimed to evaluate the effectiveness of video game interventions in reducing perioperative anxiety in pediatric patients undergoing general anesthesia. Methods: We conducted a comprehensive search across PubMed, Embase, Web of Science, and the Cochrane Library, supplemented by reference screening. Primary outcomes included anxiety levels assessed during parent separation and mask induction procedures, while secondary outcomes encompassed emergence delirium, postoperative behavior, and length of stay in the postanesthesia care unit (PACU). The risk of bias was assessed using the Risk of Bias 2 scale. Data were synthesized descriptively and through meta-analysis, with the certainty of the evidence evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. Results: Six randomized controlled trials involving 612 participants were included in the analysis. Children who participated in video game interventions reported significantly lower anxiety levels during parent separation (standardized mean difference, SMD ?0.31, 95\% CI ?0.50 to ?0.12; P=.001), with high certainty, and during mask induction (SMD ?0.29, 95\% CI ?0.52 to ?0.05; P=.02), with moderate certainty, compared to those receiving oral midazolam. Additionally, significant differences in postoperative behavior changes in children were observed compared to oral midazolam (SMD ?0.35, 95\% CI ?0.62 to ?0.09; P=.008). Children in the video game intervention groups also had a shorter length of stay in the PACU (mean difference, MD ?19.43 min, 95\% CI ?31.71 to ?7.16; P=.002). However, no significant differences were found in emergence delirium (MD ?2.01, 95\% CI ?4.62 to 0.59; P=.13). Conclusions: Video game interventions were more effective than midazolam in reducing perioperative anxiety among pediatric patients, improving postoperative behavior, and shortening the length of stay in the PACU. However, video games alone did not outperform midazolam in managing emergence delirium. Further high-quality research is needed for more conclusive results. Trial Registration: PROSPERO CRD42023486085; https://tinyurl.com/yc3suavb ", doi="10.2196/67007", url="https://games.jmir.org/2025/1/e67007" } @Article{info:doi/10.2196/65562, author="Miranda, Macedo Juliana and Browne, Vieira Rodrigo Alberto and da Silva, Alves Weslley Quirino and Rodrigues dos Santos, Paulo Jo{\~a}o and Campbell, Grubert Carmen Silvia and Ramos, Almeida Isabela", title="Effects of a Session of Exergames and Traditional Games on Inhibitory Control in Children With Autism Spectrum Disorder: Randomized Controlled Crossover Trial", journal="JMIR Serious Games", year="2025", month="Mar", day="5", volume="13", pages="e65562", keywords="children", keywords="pediatric", keywords="autism", keywords="ASD, autistic", keywords="behavior", keywords="exergame", keywords="physical education", keywords="exercise", keywords="physical activity", keywords="cognition", keywords="anthropometric", keywords="Flanker test", keywords="inhibitory control", keywords="randomized control trial", keywords="crossover", abstract="Background: Autism spectrum disorder (ASD) is characterized by deficits in executive functions, such as inhibitory control, which affect behavior and social adaptation. Although physical activity--based interventions, such as exergames, have shown potential to improve these functions, their comparative effects with active traditional games remain underexplored, particularly regarding inhibitory control in children with ASD. Objective: We aim to analyze the effects of a session of exergames and active traditional games on inhibitory control in children with ASD. Methods: This randomized controlled crossover trial included 9 male children with ASD (mean age 8.6, SD 1.4 y). Participants completed three 20-minute experimental sessions in random order, with a minimum interval of 48 hours: (1) active traditional games, (2) exergames using Just Dance 2022, and (3) a control session with manual painting activities. Inhibitory control was assessed 5 minutes postsession using a modified flanker task in the E-Prime (version 3.0; Psychological Software Tools Inc) program, recording reaction time (RT) and accuracy in congruent and incongruent phases. Repeated measures ANOVA was used to compare RT and accuracy between experimental and control conditions. Data are presented as means and 95\% CIs. Results: There was a statistically significant effect of condition on RT in the incongruent phase (P=.02). RT in the exergame session (849 ms, 95\% CI 642 to 1057) was lower compared to the traditional games (938 ms, 95\% CI 684 to 1191; P=.02) and control (969 ms, 95\% CI 742, 1196 to P=.01) sessions. No significant differences were observed in RT during the congruent phase or in accuracy across either phase. Conclusions: A 20-minute session of exergame improved inhibitory control performance in children with ASD compared to active traditional games and painting activities. Trial Registration: Brazilian Registry of Clinical Trials (ReBEC) RBR-5r9xzbq, Universal Trial Number U1111-1302-3490; https://ensaiosclinicos.gov.br/rg/RBR-5r9xzbq ", doi="10.2196/65562", url="https://games.jmir.org/2025/1/e65562" } @Article{info:doi/10.2196/60185, author="Legarra-Gorgo{\~n}on, Gaizka and Garc{\'i}a-Alonso, Yesenia and Ram{\'i}rez-V{\'e}lez, Robinson and Alonso-Mart{\'i}nez, Loreto and Izquierdo, Mikel and Alonso-Mart{\'i}nez, M. Alicia", title="Effect of a Gamified Family-Based Exercise Intervention on Adherence to 24-Hour Movement Behavior Recommendations in Preschool Children: Single-Center Pragmatic Trial", journal="JMIR Serious Games", year="2025", month="Mar", day="4", volume="13", pages="e60185", keywords="children", keywords="gamification", keywords="exercise", keywords="physical fitness", keywords="domains of physical activity", keywords="game", keywords="fitness", keywords="child", keywords="family-based", keywords="exercise program", keywords="randomized controlled trial", keywords="strength", abstract="Background: Adherence to 24-hour movement behavior recommendations, including physical activity (PA), sedentary time, and sleep, is essential for the healthy development of preschool children. Gamified family-based interventions have shown the potential to improve adherence to these guidelines, but evidence of their effectiveness among children is limited. Objective: This study aimed to evaluate the effectiveness of a gamified family-based exercise intervention in promoting adherence to 24-hour movement behavior recommendations among preschool-aged children. Methods: This 12-week study is a single-center, pragmatic randomized controlled trial that included 80 preschool children (56\% boys) and their families, who were randomly assigned to either the gamification group (n=40) or the control group (n=40). The ``3, 2, 1 Move on Study'' incorporates family-oriented physical activities and gamification techniques to increase PA domains, reduce sedentary behavior, and improve sleep patterns. The primary outcome was to increase\thinspacemoderate to vigorous PA (MVPA) by 5 minutes/day, as measured by accelerometer at follow-up. Accelerometer-determined daily time spent (PA domains, sedentary behavior, and sleep), physical fitness (cardiorespiratory, speed-agility, muscular, physical fitness z-score), basic motor competencies (self-movement and object movement), and executive function (memory, cognitive flexibility, and inhibitory control) were also included as secondary outcomes. Results: The 71 participants included in the per-protocol analyses (32 girls, 45\%; 39 boys, 55\%) had a mean (SD) age of 5.0 (0.5) years. Change in MVPA per day after the intervention (12 weeks) increased in both groups by +25.3 (SD 24.6) minutes/day in the gamification group and +10.0 (SD 31.4) minutes/day in the routine care group, but no significant between-group differences were observed (8.62, 95\% CI --5.72 to 22.95 minutes/day, $\eta$p2=.025; P=.23). The analysis of secondary outcomes showed significant between-group mean differences in the change in physical behaviors derived from the accelerometers from baseline to follow-up of 26.44 (95\% CI 8.93 to 43.94) minutes/day in favor of light PA ($\eta$p2=.138; P=.01) and 30.88 (95\% CI 4.36 to 57.41) minutes/day in favor of total PA, which corresponds to a large effect size ($\eta$p2=.087; P=.02). Likewise, the gamification group substantially increased their score in standing long jump and physical fitness z-score from baseline (P<.05). Conclusions: In the ``3, 2, 1 Move on Study,'' a gamified intervention showed a modest but relevant increase in MVPA and other domains of 24-hour movement behavior among preschool-aged children. Therefore, gamified family-based interventions may provide a viable alternative to improve adherence to 24-hour movement behavior recommendations. Trial Registration: ClinicalTrials.gov NCT05741879; https://clinicaltrials.gov/study/NCT05741879?tab=history ", doi="10.2196/60185", url="https://games.jmir.org/2025/1/e60185" } @Article{info:doi/10.2196/57802, author="Mia, Raihan Md and Ahamed, Iqbal Sheikh and Nemanich, Samuel", title="Gamified mHealth System for Evaluating Upper Limb Motor Performance in Children: Cross-Sectional Feasibility Study", journal="JMIR Serious Games", year="2025", month="Feb", day="28", volume="13", pages="e57802", keywords="mobile health", keywords="mHealth", keywords="digital health", keywords="mobile apps", keywords="smartphones", keywords="iPad", keywords="gamification", keywords="serious games", keywords="digital interventions", keywords="digital technology", keywords="spatiotemporal", keywords="upper limb movement", keywords="motor performance", keywords="motor skills", keywords="pediatrics", keywords="toddler", keywords="children", keywords="youth", abstract="Background: Approximately 17\% of children in the United States have been diagnosed with a developmental or neurological disorder that affects upper limb (UL) movements needed for completing activities of daily living. Gold-standard laboratory assessments of the UL are objective and precise but may not be portable, while clinical assessments can be time-intensive. We developed MoEvGame, a mobile health (mHealth) gamification software system for the iPad, as a potential advanced technology to assess UL motor functions. Objective: This feasibility study examines whether MoEvGame can assess children's whole-limb movement, fine motor skills, manual dexterity, and bimanual coordination. The specific aims were to (1) design and develop novel mHealth gamified software tools to examine theory-driven features of UL movement, (2) analyze spatiotemporal game data with new algorithms and statistical techniques to quantify movement performance as a parameter of speed, accuracy, and precision, and (3) validate assessment methods with healthy participants from schools. Methods: Elementary school children (N=31, median 9.0, IQR 4.0-14.0 years old) participated by playing 5 games. The game tasks were focused on key features of skilled motor control: (1) whole limb reaching, (2) fine motor control and manual dexterity, and (3) bilateral coordination. Spatiotemporal game data were transferred and stored in a cloud-based data management server for further processing and analysis. We applied change point detection (ie, the pruned exact linear time method), signal processing techniques, and other algorithms to calculate movement speed and accuracy from spatiotemporal parameters. Different statistical methods (ie, Pearson correlation, mean, standard deviation, P value, 95\% confidence interval) were used to compare speed-accuracy tradeoffs and evaluate the relationship between age and motor performance. Results: A negative correlation was identified between speed and accuracy in the whole limb movement (r=--0.30 to --0.42). Significant relationships between age and upper limb performance were found: older participants exhibited lower errors with faster completion times compared to younger participants. Significant differences in bimanual coordination were found related to phase synchronization (in-phase congruent [mean 28.85, SD 18.97] vs antiphase congruent [mean 112.64, SD 25.82] and in-phase mirrored [mean 23.78, SD 16.07] vs antiphase mirrored [mean 121.39, SD 28.19]). Moreover, the average speed (revolutions per second) and travel distance (m) of the in-phase mode were significantly higher than those of the antiphase coordination. Conclusions: Results of this feasibility study show that spatiotemporal data captured from the mHealth app can quantify motor performance. Moving beyond traditional assessments, MoEvGame incorporates gamification into ubiquitous and accessible technology as a fast, flexible, and objective tool for UL motor assessment. ", doi="10.2196/57802", url="https://games.jmir.org/2025/1/e57802", url="http://www.ncbi.nlm.nih.gov/pubmed/40053722" } @Article{info:doi/10.2196/55720, author="Heuvelink, Annerieke and Saini, Privender and Ta?ar, {\"O}zg{\"u}r and Nauts, Sanne", title="Improving Pediatric Patients' Magnetic Resonance Imaging Experience With an In-Bore Solution: Design and Usability Study", journal="JMIR Serious Games", year="2025", month="Feb", day="13", volume="13", pages="e55720", keywords="MRI", keywords="magnetic resonance imaging", keywords="imaging", keywords="radiology", keywords="pediatrics", keywords="children", keywords="patient guidance", keywords="patient experience", keywords="design", keywords="usability", keywords="breath hold", abstract="Background: Annually, millions of children undergo a magnetic resonance imaging (MRI) examination. Hospitals increasingly aim to scan young children awake, as doing so benefits both patients and health care systems. To help hospitals reduce the need for anesthesia, we have developed solutions to prepare pediatric patients at home and in the hospital. Objective: The goal of our project was to design, develop, and test a solution that extends our preparation solutions by guiding and engaging children during their MRI examination. Methods: Pediatric In-bore was designed to deliver a familiar experience by reusing design elements from our preparation solutions. It offers child-friendly movies and auditory and visual guidance about examination progress and breath holding. To evaluate children's liking and understanding of the solution, we conducted a usability study. Ten healthy children participated in a mock MRI examination featuring pediatric In-bore. We observed task compliance (ability to lie still and hold one's breath) and conducted guided interviews to assess their experience and understanding of the guidance offered. Results: Participants (aged 5 to 10 years) were generally positive about pediatric In-bore. They liked the main character (Ollie the elephant) and her movie. Auditory and visual guidance were generally liked and understood. All but one participant successfully managed to lie still during the mock examination, and 6 (60\%) out of 10 participants successfully held their breath. Conclusions: Pediatric In-bore appears promising for engaging and guiding young children during awake MRI. It completes the Pediatric Coaching solution that now offers guidance throughout the MRI journey. Future research can expand on this work by evaluating the clinical impact of the Pediatric Coaching solution in a larger and more diverse sample of pediatric patients. ", doi="10.2196/55720", url="https://games.jmir.org/2025/1/e55720" } @Article{info:doi/10.2196/63384, author="Zhu, Wenqing and Gu, Shuneng and Li, Jian and Lin, Jin and Hu, Chanling and Liu, Rui", title="Transformative Gamified Binocular Therapy for Unilateral Amblyopia in Young Children: Pilot Prospective Efficacy and Safety Study", journal="JMIR Serious Games", year="2025", month="Jan", day="16", volume="13", pages="e63384", keywords="amblyopia", keywords="binocular treatment", keywords="digital therapy", keywords="game", keywords="stereoacuity", keywords="visual acuity", abstract="Background: Amblyopia is a common cause of visual impairment in children. Compliance with traditional treatments for amblyopia is challenging due to negative psychosocial impacts. Recent shifts in amblyopia treatment have moved from suppressing the dominant eye to enhancing binocular visual function. Binocular digital therapy has become a promising approach. Objective: The aim of this study was to evaluate the effects of binocular gamified digital therapy on visual acuity and stereoacuity (SA) in children with unilateral amblyopia. Methods: This pilot prospective study enrolled 11 children aged 4-6 years with unilateral amblyopia. Following at least 8 weeks of refractive correction, participants underwent binocular gamified digital therapy for 60 minutes per day, 5 days a week. The therapy used a roguelike shooting game delivered under binocular conditions through two independent channels with a real-time artificial intelligence visual engine. Assessments of distance visual acuity (DVA), near visual acuity (NVA), and SA were conducted at baseline and again at 4, 8, and 12 weeks. Results: At 12 weeks, the following significant improvements were noted: amblyopic eye DVA improved by 1.0 line (P=.01; d=0.77), binocular DVA improved by 0.7 lines (P=.006; d=1.00), and SA improved by 0.3 logarithm (log) arcseconds (P=.01; d=0.97). At 8 weeks, improvements included amblyopic eye DVA by 0.9 lines (P=.046; d=1.00) and SA by 0.28 log arcseconds (P=.02; d=0.90). No significant adverse events were observed, although one participant developed progressive esotropia. Conclusions: Binocular gamified digital therapy is effective and safe for improving visual outcomes in children aged 4-6 years with unilateral amblyopia. Trial Registration: Chinese Clinical Trial Registry ChiCTR2300072066; https://www.chictr.org.cn/showproj.html?proj=198625 ", doi="10.2196/63384", url="https://games.jmir.org/2025/1/e63384" } @Article{info:doi/10.2196/58421, author="Huang, Chien-Yu and Yu, Yen-Ting and Chen, Kuan-Lin and Lien, Jenn-Jier and Lin, Gong-Hong and Hsieh, Ching-Lin", title="Predicting Age and Visual-Motor Integration Using Origami Photographs: Deep Learning Study", journal="JMIR Form Res", year="2025", month="Jan", day="10", volume="9", pages="e58421", keywords="artificial intelligence", keywords="origami", keywords="child development screening", keywords="child development", keywords="visual motor integration", keywords="children", keywords="developmental status", keywords="activity performance", keywords="deep learning", abstract="Background: Origami is a popular activity among preschool children and can be used by therapists as an evaluation tool to assess children's development in clinical settings. It is easy to implement, appealing to children, and time-efficient, requiring only simple materials---pieces of paper. Furthermore, the products of origami may reflect children's ages and their visual-motor integration (VMI) development. However, therapists typically evaluate children's origami creations based primarily on their personal background knowledge and clinical experience, leading to subjective and descriptive feedback. Consequently, the effectiveness of using origami products to determine children's age and VMI development lacks empirical support. Objective: This study had two main aims. First, we sought to apply artificial intelligence (AI) techniques to origami products to predict children's ages and VMI development, including VMI level (standardized scores) and VMI developmental status (typical, borderline, or delayed). Second, we explored the performance of the AI models using all combinations of photographs taken from different angles. Methods: A total of 515 children aged 2-6 years were recruited and divided into training and testing groups at a 4:1 ratio. Children created origami dogs, which were photographed from 8 different angles. The Beery--Buktenica Developmental Test of Visual-Motor Integration, 6th Edition, was used to assess the children's VMI levels and developmental status. Three AI models---ResNet-50, XGBoost, and a multilayer perceptron---were combined sequentially to predict age z scores and VMI z scores using the training group. The trained models were then tested using the testing group, and the accuracy of the predicted VMI developmental status was also calculated. Results: The R2 of the age and the VMI trained models ranged from 0.50 to 0.73 and from 0.50 to 0.66, respectively. The AI models that obtained an R2>0.70 for the age model and an R2>0.60 for the VMI model were selected for model testing. Those models were further examined for the accuracy of the VMI developmental status, the correlations, and the mean absolute error (MAE) of both the age and the VMI models. The accuracy of the VMI developmental status was about 71\%-76\%. The correlations between the final predicted age z score and the real age z score ranged from 0.84 to 0.85, and the correlations of the final predicted VMI z scores to the real z scores ranged from 0.77 to 0.81. The MAE of the age models ranged from 0.42 to 0.46 and those of the VMI models ranged from 0.43 to 0.48. Conclusion: Our findings indicate that AI techniques have a significant potential for predicting children's development. The insights provided by AI may assist therapists in better interpreting children's performance in activities. ", doi="10.2196/58421", url="https://formative.jmir.org/2025/1/e58421" } @Article{info:doi/10.2196/59124, author="Martin-Moratinos, Marina and Bella-Fern{\'a}ndez, Marcos and Rodrigo-Yanguas, Mar{\'i}a and Gonz{\'a}lez-Tard{\'o}n, Carlos and Li, Chao and Wang, Ping and Royuela, Ana and Lopez-Garcia, Pilar and Blasco-Fontecilla, Hilario", title="Effectiveness of a Virtual Reality Serious Video Game (The Secret Trail of Moon) for Emotional Regulation in Children With Attention-Deficit/Hyperactivity Disorder: Randomized Clinical Trial", journal="JMIR Serious Games", year="2025", month="Jan", day="8", volume="13", pages="e59124", keywords="attention-deficit/hyperactivity disorder", keywords="ADHD", keywords="emotional regulation", keywords="serious video games", keywords="virtual reality", keywords="cognitive training", keywords="music", keywords="chess", abstract="Background: Difficulties in emotional regulation are often observed in children and adolescents with attention-deficit/hyperactivity disorder (ADHD). Innovative complementary treatments, such as video games and virtual reality, have become increasingly appealing to patients. The Secret Trail of Moon (MOON) is a serious video game developed by a multidisciplinary team featuring cognitive training exercises. In this second randomized clinical trial, we evaluated the impact of a 20-session treatment with MOON on emotional regulation, as measured by the Strengths and Difficulties Questionnaire. Objective: We hypothesize that patients with ADHD using MOON will show improvements in (1) emotional regulation, (2) core ADHD symptoms, (3) cognitive functioning, and (4) academic performance, compared to a control group; additionally, we anticipate that (5) changing the platform (from face-to-face using virtual reality to the web) will not affect emotional regulation scores; and (6) the video game will not cause any clinically significant side effects. Methods: This was a prospective, unicentric, randomized, unblinded, pre- and postintervention study with block-randomized sequence masking. Participants included individuals aged between 7 and 18 years who had a clinical diagnosis of ADHD and were receiving pharmacological treatment. They were randomized into 2 groups using an electronic case report form: the MOON group, receiving standard pharmacological treatment plus personalized cognitive training via a serious video game, and the control group, receiving standard pharmacological treatment. We provided both the groups with psychoeducational support on ADHD. Analysis was conducted using the Student 2-tailed t test and 2-factor ANOVA. An independent monitor supervised the study. Results: A total of 76 patients with ADHD participated in the trial, with an equal randomization (MOON: n=38, 50\% and control: n=38, 50\%) and a total dropout rate of 7. The primary hypothesis, a 3- or 4-point reduction in the global Strengths and Difficulties Questionnaire score, was not met. However, significant improvements were observed in material organization (P=.03), working memory (P=.04), and inhibition (P=.05), particularly among patients more engaged with the MOON treatment. Conclusions: Serious video games, when integrated into a multimodal treatment plan, can enhance outcomes for symptoms associated with ADHD. Trial Registration: ClinicalTrials.gov NCT06006871; https://clinicaltrials.gov/study/NCT06006871 International Registered Report Identifier (IRRID): RR2-10.2196/53191 ", doi="10.2196/59124", url="https://games.jmir.org/2025/1/e59124" } @Article{info:doi/10.2196/60674, author="Peterson, M. Colleen and Visclosky, Timothy and Flannagan, A. Carol and Mahajan, Prashant and Gabanyicz, Andrew and Bouchard, Jean-Jacques and Cervantes, Vincent and Gribbin, William and Hashikawa, Nobuhide Andrew", title="Evaluating a Virtual Reality Game to Enhance Teen Distracted Driving Education: Mixed Methods Pilot Study", journal="JMIR Form Res", year="2024", month="Nov", day="26", volume="8", pages="e60674", keywords="safety", keywords="virtual reality", keywords="VR", keywords="distracted driving", keywords="intervention", keywords="inattention", keywords="smartphone", keywords="novice drivers", keywords="risky driving", keywords="mobile phone", keywords="awareness", keywords="game", keywords="driving education", keywords="gamification", keywords="adolescent", abstract="Background: Inexperienced adolescent drivers are particularly susceptible to engaging in distracted driving behaviors (DDBs) such as texting while driving (TWD). Traditional driver education approaches have shown limited success in reducing motor vehicle crashes among young drivers. Objective: We tested an innovative approach to help address the critical issue of DDB among teenagers. We investigated the effectiveness of using a novel virtual reality (VR) game ``Distracted Navigator'' to educate novice teenage drivers about DDB. Methods: The game consisted of maneuvering a spaceship around asteroids while engaging in simulated DDB (eg, inputting numbers into a keypad). A physician-facilitated discussion, based on the theory of planned behavior, linked gameplay to real-life driving. Teenagers were recruited for the in-person study and randomly assigned at the block level to intervention (VR gameplay or discussion) and control groups (discussion only), approximating a 2:1 ratio. Unblinded, bivariate statistical analyses (all 2-tailed t tests or chi-square tests) and regression analyses measured programming impact on TWD-related beliefs and intentions. Content analysis of focus group interviews identified thematic feedback on the programming. Results: Of the 24 participants, 15 (63\%) were male; their ages ranged from 14 to 17 (mean 15.8, SD 0.92) years, and all owned cell phones. Compared to the control group (n=7, 29\%), the intervention group (n=17, 71\%) was more likely to report that the programming had positively changed how they felt about texting and driving (?218=--8.3; P=.02). However, specific TWD attitudes and intentions were not different by treatment status. Irrespective of treatment, pre- and postintervention scores indicated reduced confidence in safely TWD (ie, perceived behavioral control; $\beta$=--.78; t46=--2.66; P=.01). Thematic analysis revealed the following: (1) the VR gameplay adeptly portrayed real-world consequences of texting and driving, (2) participants highly valued the interactive nature of the VR game and discussion, (3) both the VR game and facilitated discussion were deemed as integral and complementary components, and (4) feedback for improving the VR game and discussion. Conclusions: Our findings show that the novel use of immersive VR experiences with interactive discussions can raise awareness of DDB consequences and is a promising method to enhance driving safety education. The widespread accessibility of VR technology allows for scalable integration into driver training programs, warranting a larger, prospective, randomized study. ", doi="10.2196/60674", url="https://formative.jmir.org/2024/1/e60674" } @Article{info:doi/10.2196/47754, author="Fahr, Annina and Kl{\"a}y, Andrina and Coka, S. Larissa and van Hedel, A. Hubertus J.", title="Effectiveness of Game-Based Training of Selective Voluntary Motor Control in Children With Upper Motor Neuron Lesions: Randomized Multiple Baseline Design Study", journal="JMIR Form Res", year="2024", month="Nov", day="18", volume="8", pages="e47754", keywords="neurorehabilitation", keywords="single-case design", keywords="interactive computer play", keywords="cerebral palsy", keywords="surface electromyography", keywords="motor control", keywords="mirror movements", keywords="involuntary movements", abstract="Background: Selective voluntary motor control (SVMC) is the ability to control joint movements independently. Impairments in SVMC can affect functional activities, but only a few interventions directly target SVMC. Therefore, we developed a game-based intervention for children with upper motor neuron lesions to improve SVMC. The intervention trained selective activation of a muscle or joint movement while providing immediate feedback about involuntarily occurring muscle activations or movements in another joint. The intervention was provided in a playful manner with a custom-made game environment and a technology-based interface to capture muscle activation or joint movements. Objective: This study aimed to investigate the effectiveness of this game-based intervention and explore treatment response--related factors in children with impaired SVMC undergoing inpatient neurorehabilitation. Methods: We conducted a single-case research study with a randomized, nonconcurrent, multiple baseline design. The study consisted of a random-length baseline phase where no SVMC-specific intervention was provided and an intervention phase with additional SVMC training. Concurrently in both phases, children attended their individual multimodal rehabilitation program at our clinic, Swiss Children's Rehab. During the intervention phase, participants completed ten 45-minute sessions with our game-based SVMC training. SVMC was measured repeatedly throughout both phases and at the 3-month follow-up with a short custom-made assessment. Results: Eighteen children with reduced SVMC from upper motor neuron lesions participated in the study. The mean age of the children was 12.7 (SD 2.9) years, and they mostly had spastic cerebral palsy. A linear mixed-effects model revealed a significant trend (P<.001) for improved SVMC already in the baseline phase. This trend did not change significantly (P=.15) when the game-based SVMC training was introduced in the intervention phase, suggesting no additional improvements due to the SVMC training. Although we could not find an overall treatment effect, we could explain 89.4\% of the total random variation of the treatment effect by patient and therapy characteristics. Children with spasticity in the trained movement (20.1\%), and those who trained the more affected side (23.5\%) benefited most from the intervention. At the 3-month follow-up, SVMC had deteriorated compared to the end of the intervention but was still better than at the beginning of the study. Conclusions: The regular concomitant rehabilitation program already yielded improvements in SVMC, while the game-based SVMC training showed no additional effects. Although the intervention did not show a group effect, we could identify patient and therapy characteristics that determine who is likely to profit from the intervention. Trial Registration: German Clinical Trials Register DRKS00025184; https://tinyurl.com/msnkek9b ", doi="10.2196/47754", url="https://formative.jmir.org/2024/1/e47754" } @Article{info:doi/10.2196/51833, author="Yewale, Prasad and Rathi, Renu and Mate, Swapnali", title="Study to Evaluate the Comparative Efficacy of Medhya Rasayana (Pharmacological) Versus Nonpharmacological Interventions in Management of Gadget Addiction in Children: Protocol for Parallel, Triple-Arm, Randomized Clinical Trial", journal="JMIR Res Protoc", year="2024", month="Nov", day="11", volume="13", pages="e51833", keywords="addiction", keywords="Ayurveda", keywords="gadget addiction", keywords="children", keywords="Kaumarbhritya", keywords="Medhya Rasayana", keywords="yoga", keywords="complementary and alternative medicine", abstract="Background: Gadget addiction is a common behavioral problem among children. It is known to hamper social and academic life as well as adversely affect the lives of children. Ayurveda offers many therapeutic modalities and Ayurvedic medicines that can be used in the management of gadget addiction in children. The purpose of this study is to evaluate and compare the effectiveness of nonpharmacological therapies and the pharmaceutical intervention Medhya Rasayana in treating childhood gadget addiction. Objective: This study aims to provide a detailed description of the study methodology that will be used to compare the efficacy of nonpharmacological versus pharmaceutical interventions in the treatment of children's gadget addiction. Methods: A randomized, parallel, triple-arm interventional study will be conducted on diagnosed participants of gadget addiction with an age group of 6- to 16-year-old children, which will be selected and equally distributed in 2 groups. Group P will be given Medhya Rasayana (pharmacological intervention), group N will be nonpharmacological Ayurveda intervention, and group C (cognitive behavioral therapy) will be an external group. The Study duration is 180 days with assessment at baseline, midpoint, and endpoint Appropriate statistical techniques, such as ANOVA and regression analysis, will be used to examine the data and evaluate the efficacy of the 3 groups' interventions. We will perform subgroup analysis according to initial addiction severity, gender, and age. Primary outcome measures include a reduction in gadget addiction and changes in the psychosocial well-being of participants. Standardized questionnaires and instruments will be used to collect data. Results: In December 2023, the randomized controlled study got underway. Since participants may begin at any time, our goal is for everyone to be finished by December 2024. Conclusions: This research will provide crucial new information about the relative effectiveness of Ayurveda nonpharmacological therapies and Medhya Rasayana in treating children's gadget addiction. The results will guide evidence-based treatments aimed at reducing the negative impact of excessive gadget use on this susceptible population's psychosocial development. In the end, the findings are meant to help policy makers and medical professionals create sensible plans to deal with the rising issue of childhood gadget addiction. International Registered Report Identifier (IRRID): PRR1-10.2196/51833 ", doi="10.2196/51833", url="https://www.researchprotocols.org/2024/1/e51833" } @Article{info:doi/10.2196/55730, author="Houzangbe, Samory and Lemay, Martin and Levac, E. Danielle", title="Toward Physiological Detection of a ``Just-Right'' Challenge Level for Motor Learning in Immersive Virtual Reality: Protocol for a Cross-Sectional Study", journal="JMIR Res Protoc", year="2024", month="Sep", day="23", volume="13", pages="e55730", keywords="virtual reality", keywords="pediatric rehabilitation", keywords="physiological data", keywords="engagement", keywords="just-right challenge", abstract="Background: Motor learning, a primary goal of pediatric rehabilitation, is facilitated when tasks are presented at a ``just-right'' challenge level---at the edge of the child's current abilities, yet attainable enough to motivate the child in persistent efforts for success. Immersive virtual reality (VR) may be ideally suited for ``just-right'' task challenges because it enables precise adjustments of task parameters in motivating environments. Rehabilitation-specific VR tasks often use dynamic difficulty algorithms based on task performance to personalize task difficulty. However, these approaches do not consider relevant cognitive processes that could also impact ``just-right'' challenges, such as attention and engagement. Objective physiological measurement of these cognitive processes using wearable sensors could support their integration within ``just-right'' challenge detection and prediction algorithms. As a first step, it is important to explore relationships between objectively and subjectively measured psychophysiological states at progressively challenging task difficulty levels. Objective: This study aims to (1) evaluate the performance of wearable sensors in a novel movement-based motor learning immersive VR task; (2) evaluate changes in physiological data at 3 task difficulty levels; and (3) explore the relationship between physiological data, task performance, and self-reported cognitive processes at each task difficulty level. Methods: This study uses the within-participant experimental design. Typically developing children and youth aged 8-16 years will be recruited to take part in a single 90-minute data collection session. Physiological sensors include electrodermal activity, heart rate, electroencephalography, and eye-tracking. After collecting physiological data at rest, participants will play a seated unimanual immersive VR task involving bouncing a virtual ball on a virtual racket. They will first play for 3 minutes at a predefined medium level of difficulty to determine their baseline ability level and then at a personalized choice of 3 progressive difficulty levels of 3 minutes each. Following each 3-minute session, participants will complete a short Likert-scale questionnaire evaluating engagement, attention, cognitive workload, physical effort, self-efficacy, and motivation. Data loss and data quality will be calculated for each sensor. Repeated-measures ANOVAs will evaluate changes in physiological response at each difficulty level. Correlation analyses will determine individual relationships between task performance, physiological data, and self-reported data at each difficulty level. Results: Research ethics board approval has been obtained, and data collection is underway. Data collection was conducted on December 12, 2023, and April 12, 2024, with a total of 15 typically developing children. Data analysis has been completed, and results are expected to be published in the fall of 2024. Conclusions: Wearable sensors may provide insights into the physiological effects of immersive VR task interaction at progressive difficulty levels in children and youth. Understanding the relationship between physiological and self-reported cognitive processes is a first step in better identifying and predicting ``just-right'' task challenges during immersive VR motor learning interventions. International Registered Report Identifier (IRRID): DERR1-10.2196/55730 ", doi="10.2196/55730", url="https://www.researchprotocols.org/2024/1/e55730" } @Article{info:doi/10.2196/63505, author="Braddock, Amy and Ghosh, Parijat and Montgomery, Emma and Lim, Crystal and Ghosh, Jaya and Henry, Nicole and Popescu, Mihail and Kimchi, Kimberly and Guo, Congyu and Bosworth, Taylor K. and Koopman, J. Richelle", title="Effectiveness of an mHealth App That Uses Financial Incentives and Gamification to Promote Health Behavior Change in Adolescents and Caregivers: Protocol for a Clinic-Based Randomized Controlled Trial", journal="JMIR Res Protoc", year="2024", month="Sep", day="10", volume="13", pages="e63505", keywords="mHealth", keywords="adolescents", keywords="apps", keywords="caregivers", keywords="obesity", keywords="healthy lifestyle", keywords="CommitFit", keywords="mobile health", abstract="Background: Adolescent and adult obesity continues to be a public health epidemic in the United States. Despite the popularity of mHealth apps with gamification among adolescents, there are insufficient studies to evaluate the efficacy of gamified mHealth apps and financial incentives to motivate sustained health behavior change in adolescents or their adult caregivers. Objective: This study aims to evaluate the effectiveness of gamification techniques and financial incentives used in the novel ``CommitFit'' mHealth app to motivate health behavior change and improve various mental and physical health metrics in adolescents and their caregivers. Methods: This study is a 3-month randomized controlled trial (RCT) with 30 adolescents (aged 13-15 years) and their adult caregivers (N=60). It evaluates ``CommitFit,'' which uses gamification including points and leaderboards to motivate logging and achievement of self-selected health behavior goals (eg, more water, sleep, physical activity, fruits, or vegetables or fewer sugary beverages). The RCT had three arms, each with 10 dyads: (1) CommitFit-only users; (2) CommitFit\$, where adolescents were paid US \$0.05 for each point they earned; and (3) waitlist control. Intervention dyads used the app for 3 months and had the option to use it for the fourth month without prompts or extra financial incentives. User analytic software was used to evaluate the frequency of user logs and goal achievement. Monthly surveys evaluated self-reported change in the 5 CommitFit health behaviors. Changes in BMI and blood pressure were evaluated for all participants at 3 clinical visits. Mental health, gamification, and behavior economics surveys were completed during the clinical visits. Results: Recruitment began in August 2023 and was completed in 10 weeks. The research team successfully recruited and enrolled 30 dyads. Researchers emailed and called 89 caregivers on a physician-approved adolescent patient list, a 33\% recruitment rate. Data collection and analysis will be conducted in the spring and summer of 2024. The results of this study are anticipated to be published between late 2024 and early 2025. Conclusions: This RCT will expand knowledge of the effectiveness of gamification techniques, financial incentives, and mHealth apps to motivate sustained health behavior change among adolescents and caregivers. These results may offer new opportunities to caregivers, health insurers, health care systems, and clinicians to motivate health behavior change in adolescents and caregivers, with the ultimate goal of preventing or reducing obesity and obesity-related diseases. Additional gamification, mental health surveys, and app user analytics included in the study may provide further insight into the characteristics of adolescents or caregivers who would benefit the most from using a gamified mHealth app like CommitFit. International Registered Report Identifier (IRRID): DERR1-10.2196/63505 ", doi="10.2196/63505", url="https://www.researchprotocols.org/2024/1/e63505" } @Article{info:doi/10.2196/49692, author="Sarasmita, Ary Made and Lee, Ya-Han and Chan, Fan-Ying and Chen, Hsiang-Yin", title="Digital Serious Games to Promote Behavior Change in Children With Chronic Diseases: Scoping Review and Development of a Self-Management Learning Framework", journal="J Med Internet Res", year="2024", month="Aug", day="19", volume="26", pages="e49692", keywords="children", keywords="chronic disease", keywords="digital game", keywords="patient education", keywords="serious game", abstract="Background: Digital serious games (SGs) have rapidly become a promising strategy for entertainment-based health education; however, developing SGs for children with chronic diseases remains a challenge. Objective: In this study, we attempted to provide an updated scope of understanding of the development and evaluation of SG educational tools and develop a framework for SG education development to promote self-management activities and behavior change in children with chronic diseases. Methods: This study consists of a knowledge base and an analytical base. This study followed the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. To build the knowledge base, 5 stages of research were developed, including refining the review question (stage 1), searching for studies (stage 2), selecting relevant studies (stage 3), charting the information (stage 4), and collating the results (stage 5). Eligible studies that developed SG prototypes and evaluated SG education for children with chronic diseases were searched for in PubMed, Embase, Google Scholar, and peer-reviewed journals. In the analytical base, the context-mechanism-output approach and game taxonomy were used to analyze relevant behavioral theories and essential game elements. Game taxonomy included social features, presentation, narrative and identity, rewards and punishment, and manipulation and control. A total of 2 researchers selected the domains for the included behavioral theories and game elements. The intended SG framework was finalized by assembling SG fragments. Those SG fragments were appropriately reintegrated to visualize a new SG framework. Results: This scoping review summarized data from 16 randomized controlled trials that evaluated SG education for children with chronic diseases and 14 studies on SG frameworks. It showed that self-determination theory was the most commonly used behavioral theory (9/30, 30\%). Game elements included feedback, visual and audio designs, characters, narratives, rewards, challenges, competitions, goals, levels, rules, and tasks. In total, 3 phases of a digital SG framework are proposed in this review: requirements (phase 1), design and development (phase 2), and evaluation (phase 3). A total of 6 steps are described: exploring SG requirements (step 1), identifying target users (step 2), designing an SG prototype (step 3), building the SG prototype (step 4), evaluating the SG prototype (step 5), and marketing and monitoring the use of the SG prototype (step 6). Safety recommendations to use digital SG-based education for children in the post--COVID-19 era were also made. Conclusions: This review summarizes the fundamental behavioral theories and game elements of the available literature to establish a new theory-driven step-by-step framework. It can support game designers, clinicians, and educators in designing, developing, and evaluating digital, SG-based educational tools to increase self-management activities and promote behavior change in children with chronic diseases. ", doi="10.2196/49692", url="https://www.jmir.org/2024/1/e49692", url="http://www.ncbi.nlm.nih.gov/pubmed/39158952" } @Article{info:doi/10.2196/57198, author="Patton, R. Susana and Gal, L. Robin and Bergford, Simon and Calhoun, Peter and Clements, A. Mark and Sherr, L. Jennifer and Riddell, C. Michael", title="Digital Gaming and Exercise Among Youth With Type 1 Diabetes: Cross-Sectional Analysis of Data From the Type 1 Diabetes Exercise Initiative Pediatric Study", journal="JMIR Pediatr Parent", year="2024", month="Jun", day="13", volume="7", pages="e57198", keywords="exercise", keywords="exercises", keywords="exercising", keywords="physical activity", keywords="physical activities", keywords="digital game", keywords="digital games", keywords="gaming", keywords="electronic game", keywords="electronic games", keywords="computerized game", keywords="computerized games", keywords="pediatric", keywords="pediatrics", keywords="child", keywords="children", keywords="youth", keywords="adolescent", keywords="adolescents", keywords="teen", keywords="teens", keywords="teenager", keywords="teenagers", keywords="diabetes", keywords="diabetic", keywords="DM", keywords="diabetes mellitus", keywords="type 2 diabetes", keywords="type 1 diabetes", keywords="TD1", keywords="TD2", keywords="mobile phone", abstract="Background: Regular physical activity and exercise are fundamental components of a healthy lifestyle for youth living with type 1 diabetes (T1D). Yet, few youth living with T1D achieve the daily minimum recommended levels of physical activity. For all youth, regardless of their disease status, minutes of physical activity compete with other daily activities, including digital gaming. There is an emerging area of research exploring whether digital games could be displacing other physical activities and exercise among youth, though, to date, no studies have examined this question in the context of youth living with T1D. Objective: We examined characteristics of digital gaming versus nondigital gaming (other exercise) sessions and whether youth with T1D who play digital games (gamers) engaged in less other exercise than youth who do not (nongamers), using data from the Type 1 Diabetes Exercise Initiative Pediatric study. Methods: During a 10-day observation period, youth self-reported exercise sessions, digital gaming sessions, and insulin use. We also collected data from activity wearables, continuous glucose monitors, and insulin pumps (if available). Results: The sample included 251 youths with T1D (age: mean 14, SD 2 y; self-reported glycated hemoglobin A1c level: mean 7.1\%, SD 1.3\%), of whom 105 (41.8\%) were female. Youth logged 123 digital gaming sessions and 3658 other exercise (nondigital gaming) sessions during the 10-day observation period. Digital gaming sessions lasted longer, and youth had less changes in glucose and lower mean heart rates during these sessions than during other exercise sessions. Youth described a greater percentage of digital gaming sessions as low intensity (82/123, 66.7\%) when compared to other exercise sessions (1104/3658, 30.2\%). We had 31 youths with T1D who reported at least 1 digital gaming session (gamers) and 220 youths who reported no digital gaming (nongamers). Notably, gamers engaged in a mean of 86 (SD 43) minutes of other exercise per day, which was similar to the minutes of other exercise per day reported by nongamers (mean 80, SD 47 min). Conclusions: Digital gaming sessions were longer in duration, and youth had less changes in glucose and lower mean heart rates during these sessions when compared to other exercise sessions. Nevertheless, gamers reported similar levels of other exercise per day as nongamers, suggesting that digital gaming may not fully displace other exercise among youth with T1D. ", doi="10.2196/57198", url="https://pediatrics.jmir.org/2024/1/e57198" } @Article{info:doi/10.2196/35132, author="Moreira, Rui and Silveira, Augusta and Sequeira, Teresa and Dur{\~a}o, Nuno and Louren{\c{c}}o, Jessica and Cascais, In{\^e}s and Cabral, Maria Rita and Taveira Gomes, Tiago", title="Gamification and Oral Health in Children and Adolescents: Scoping Review", journal="Interact J Med Res", year="2024", month="Apr", day="4", volume="13", pages="e35132", keywords="gamification", keywords="mechanisms of gamification", keywords="gamification components", keywords="intrinsic and extrinsic motivators", keywords="oral health care", keywords="health behavior", keywords="oral health care applications", abstract="Background: Oral health is a determinant of overall well-being and quality of life. Individual behaviors, such as oral hygiene and dietary habits, play a central role in oral health. Motivation is a crucial factor in promoting behavior change, and gamification offers a means to boost health-related knowledge and encourage positive health behaviors. Objective: This study aims to evaluate the impact of gamification and its mechanisms on oral health care of children and adolescents. Methods: A systematic search covered multiple databases: PubMed/MEDLINE, PsycINFO, the Cochrane Library, ScienceDirect, and LILACS. Gray literature, conference proceedings, and WHOQOL internet resources were considered. Studies from January 2013 to December 2022 were included, except for PubMed/MEDLINE, which was searched until January 2023. A total of 15 studies were selected following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The eligibility criteria were peer-reviewed, full-text, and empirical research related to gamification in oral health care, reports of impact, and oral health care outcomes. The exclusion criteria encompassed duplicate articles; unavailable full texts; nonoriginal articles; and non--digital game--related, non--oral health--related, and protocol studies. Selected studies were scrutinized for gamification mechanisms and outcomes. Two main questions were raised: ``Does gamification in oral health care impact oral health?'' and ``Does oral health care gamification enhance health promotion and literacy?'' The PICO (Patient, Intervention, Comparison, Outcome) framework guided the scoping review. Results: Initially, 617 records were obtained from 5 databases and gray literature sources. After applying exclusion criteria, 15 records were selected. Sample size in the selected studies ranged from 34 to 190 children and adolescents. A substantial portion (11/15, 73\%) of the studies discussed oral self-care apps supported by evidence-based oral health. The most clearly defined data in the apps were ``brushing time'' (11/11, 100\%) and ``daily amount brushing'' (10/11, 91\%). Most studies (11/15, 73\%) mentioned oral health care behavior change techniques and included ``prompt intention formation'' (11/26, 42\%), ``providing instructions'' (11/26, 42\%), ``providing information on the behavior-health link'' (10/26, 38\%), ``providing information on consequences'' (9/26, 35\%), ``modeling or demonstrating behavior'' (9/26, 35\%), ``providing feedback on performance'' (8/26, 31\%), and ``providing contingent rewards'' (8/26, 31\%). Furthermore, 80\% (12/15) of the studies identified game design elements incorporating gamification features in oral hygiene applications. The most prevalent gamification features were ``ideological incentives'' (10/12, 83\%) and ``goals'' (9/16, 56\%), which were found in user-specific and challenge categories, respectively. Conclusions: Gamification in oral health care shows potential as an innovative approach to promote positive health behaviors. Most studies reported evidence-based oral health and incorporated oral health care behavior change techniques. ", doi="10.2196/35132", url="https://www.i-jmr.org/2024/1/e35132", url="http://www.ncbi.nlm.nih.gov/pubmed/38573750" } @Article{info:doi/10.2196/49906, author="Toma, Marian-Vladut and Turcu, Elena Cristina and Turcu, Octavian Corneliu and Vlad, Sorin and Tiliute, Eugen Doru and Pascu, Paul", title="Extended Reality--Based Mobile App Solutions for the Therapy of Children With Autism Spectrum Disorders: Systematic Literature Review", journal="JMIR Serious Games", year="2024", month="Feb", day="19", volume="12", pages="e49906", keywords="autism", keywords="autistic", keywords="autism spectrum disorder", keywords="ASD", keywords="virtual reality", keywords="augmented reality", keywords="extended reality", keywords="mixed reality", keywords="mobile app", keywords="children", keywords="preschool", keywords="mobile phone", abstract="Background: The increasing prevalence of autism spectrum disorder (ASD) has driven research interest on the therapy of individuals with autism, especially children, as early diagnosis and appropriate treatment can lead to improvement in the condition. With the widespread availability of virtual reality, augmented reality (AR), and mixed reality technologies to the public and the increasing popularity of mobile devices, the interest in the use of applications and technologies to provide support for the therapy of children with autism is growing. Objective: This study aims to describe the literature on the potential of virtual reality, AR, and mixed reality technologies in the context of therapy for children with ASD. We propose to investigate and analyze the temporal distribution of relevant papers, identify the target audience for studies related to extended reality apps in ASD therapy, examine the technologies used in the development of these apps, assess the skills targeted for improvement in primary studies, explore the purposes of the proposed solutions, and summarize the results obtained from their application. Methods: For the systematic literature review, 6 research questions were defined in the first phase, after which 5 international databases (Web of Science, Scopus, ScienceDirect, IEEE Xplore Digital Library, and ACM Digital Library) were searched using specific search strings. Results were centralized, filtered, and processed applying eligibility criteria and using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The results were refined using a technical and IT-oriented approach. The quality criteria assessed whether the research addressed ASDs, focused on children's therapy, involved targeted technologies, deployed solutions on mobile devices, and produced results relevant to our study. Results: In the first step, 179 publications were identified in Zotero reference manager software (Corporation for Digital Scholarship). After excluding articles that did not meet the eligibility or quality assessment criteria, 28 publications were finalized. The analysis revealed an increase in publications related to apps for children with autism starting in 2015 and peaking in 2019. Most studies (22/28, 79\%) focused on mobile AR solutions for Android devices, which were developed using the Unity 3D platform and the Vuforia engine. Although 68\% (19/28) of these apps were tested with children, 32\% (9/28) were tested exclusively by developers. More than half (15/28, 54\%) of the studies used interviews as an evaluation method, yielding mostly favorable although preliminary results, indicating the need for more extensive testing. Conclusions: The findings reported in the studies highlight the fact that these technologies are appropriate for the therapy of children with ASD. Several studies showed a distinct trend toward the use of AR technology as an educational tool for people with ASD. This trend entails multidisciplinary cooperation and an integrated research approach, with an emphasis on comprehensive empirical evaluations and technology ethics. ", doi="10.2196/49906", url="https://games.jmir.org/2024/1/e49906", url="http://www.ncbi.nlm.nih.gov/pubmed/38373032" } @Article{info:doi/10.2196/49019, author="Liang, Haiyan and Wang, Xi and An, Ruopeng", title="Influence of Pok{\'e}mon GO on Physical Activity and Psychosocial Well-Being in Children and Adolescents: Systematic Review", journal="J Med Internet Res", year="2023", month="Nov", day="13", volume="25", pages="e49019", keywords="Pok{\'e}mon GO", keywords="artificial intelligence", keywords="physical activity", keywords="psychosocial well-being", keywords="children", keywords="adolescent", abstract="Background: Pok{\'e}mon GO, an augmented reality game with widespread popularity, can potentially influence players' physical activity (PA) levels and psychosocial well-being. Objective: This review aims to systematically examine the scientific evidence regarding the impact of Pok{\'e}mon GO on PA and psychosocial well-being in children and adolescents. Methods: Using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) framework, we conducted keyword and reference searches in the PubMed, CINAHL, Web of Science, and Scopus databases. We performed title and abstract screening, full-text review, evidence synthesis, and identified research gaps. Results: Our review included 10 studies that explored the effect of Pok{\'e}mon GO on PA or psychosocial well-being among children and adolescents. These studies used diverse designs across multiple countries and regions. Pok{\'e}mon GO use measures encompassed frequency, experience, adherence, and motivation. PA assessment methods ranged from self-reported questionnaires to technology-based evaluations and qualitative approaches. Psychosocial well-being measures included emotional intelligence, personal well-being, self-control, emotionality, and sociability. In general, the estimated impact of Pok{\'e}mon GO on PA was positive, with gaming elements and engagement correlating with increased PA levels. However, the effect on psychosocial well-being presented mixed results, with positive associations for sociability but a complex relationship involving well-being and internet gaming disorder. The limitations of these studies comprised the absence of randomized controlled trials, heterogeneity in study designs and outcome measures, and potential confounding bias. Conclusions: Overall, Pok{\'e}mon GO tends to positively affect PA levels, while the impact on psychosocial well-being remains complex and requires further investigation. Future research should investigate the mechanisms connecting Pok{\'e}mon GO use with PA and psychosocial well-being and the potential risks of excessive gameplay. These findings can help inform public health interventions to harness gaming technologies for promoting PA and enhancing well-being among the younger generation. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42023412032; https://www.crd.york.ac.uk/PROSPERO/display\_record.php?RecordID=412032 ", doi="10.2196/49019", url="https://www.jmir.org/2023/1/e49019", url="http://www.ncbi.nlm.nih.gov/pubmed/37955949" } @Article{info:doi/10.2196/42697, author="Wu, Jinlong and Xu, Zhuang and Liu, Haowei and Chen, Xiaoke and Huang, Li and Shi, Qiuqiong and Weng, Linman and Ji, Yemeng and Zeng, Hao and Peng, Li", title="Effects of Commercial Exergames and Conventional Exercises on Improving Executive Functions in Children and Adolescents: Meta-Analysis of Randomized Controlled Trials", journal="JMIR Serious Games", year="2023", month="Oct", day="19", volume="11", pages="e42697", keywords="commercial exergames", keywords="exergame", keywords="randomized controlled trial", keywords="RCT", keywords="conventional exercises", keywords="executive function", keywords="children", keywords="adolescent", keywords="pediatric", keywords="youth", keywords="exergaming", keywords="randomized", keywords="meta-analysis", keywords="meta analyses", keywords="review method", keywords="systematic review", abstract="Background: Exergames are promising exercise tools for improving health. To the best of our knowledge, no systematic review has compared the effects of commercial exergames and conventional exercises on improving executive functions (EFs) in children and adolescents. Objective: This study aimed to investigate the effects of commercial exergames and conventional exercises on improving EFs in children and adolescents. Methods: Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 5 randomized controlled trial (RCT) databases (PubMed, Web of Science, Scopus, PsycINFO, and SPORTDiscus) were searched from their inception to July 7, 2022, to identify relevant RCTs. The Cochrane Collaboration tool was used to evaluate the risk of bias for each study. GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) was used to evaluate the overall quality of evidence. Results: In total, 8 RCTs including 435 children and adolescents were included in the analysis. Commercial exergames had no significant benefit on overall EFs compared to conventional exercises (Hedges g=1.464, 95\% CI --0.352 to 3.280; P=.06). For core EFs, there was no evidence to suggest that commercial exergames are more beneficial for improving cognitive flexibility (g=0.906, 95\% CI --0.274 to 2.086; P=.13), inhibitory control (g=1.323, 95\% CI --0.398 to 3.044; P=.13), or working memory (g=2.420, 95\% CI --1.199 to 6.038; P=.19) than conventional exercises. We rated the evidence for overall EFs, cognitive flexibility, inhibitory control, and working memory as being of very low quality due to inconsistency (large heterogeneity) and imprecision (low number of people). Additionally, no effects of the intervention were observed in the acute and chronic groups. Conclusions: We do not have strong evidence to support the benefit of commercial exergaming on EFs because we did not observe a Hedges g close to 0 with tight CIs. Further research is needed to confirm this hypothesis. Trial Registration: PROSPERO CRD42022324111; https://www.crd.york.ac.uk/prospero/display\_record.php?RecordID=324111 ", doi="10.2196/42697", url="https://games.jmir.org/2023/1/e42697", url="http://www.ncbi.nlm.nih.gov/pubmed/37856191" } @Article{info:doi/10.2196/49216, author="Kim, Seong-Yeol and Song, Minji and Jo, Yunju and Jung, Youngjae and You, Heecheon and Ko, Myoung-Hwan and Kim, Gi-Wook", title="Effect of Voice and Articulation Parameters of a Home-Based Serious Game for Speech Therapy in Children With Articulation Disorder: Prospective Single-Arm Clinical Trial", journal="JMIR Serious Games", year="2023", month="Oct", day="11", volume="11", pages="e49216", keywords="articulation disorder", keywords="home-based therapy", keywords="serious game", keywords="children", keywords="speech", keywords="voice", abstract="Background: Articulation disorder decreases the clarity of language and causes a decrease in children's learning and social ability. The demand for non--face-to-face treatment is increasing owing to the limited number of therapists and geographical or economic constraints. Non--face-to-face speech therapy programs using serious games have been proposed as an alternative. Objective: The aim of this study is to investigate the efficacy of home therapy on logopedic and phoniatric abilities in children with articulation disorder using the Smart Speech game interface. Methods: This study is a prospective single-arm clinical trial. Children with articulation disorders, whose Urimal Test of Articulation and Phonology (U-TAP) was --2 SDs or less and the Receptive and Expressive Vocabulary Test score was --1 SD or more, were enrolled. A preliminary evaluation (E0) was conducted to check whether the children had articulation disorders, and for the next 4 weeks, they lived their usual lifestyle without other treatments. Prior to the beginning of the training, a pre-evaluation (E1) was performed, and the children trained at home for ?30 minutes per day, ?5 times a week, over 4 weeks (a total of 20 sessions). The Smart Speech program comprised oral exercise training, breathing training, and speech training; the difficulty and type of the training were configured differently according to the participants' articulation error, exercise, and vocal ability. After the training, postevaluation (E2) was performed using the same method. Finally, 8 weeks later, postevaluation (E3) was performed as a follow-up. A voice evaluation included parameters such as maximum phonation time (MPT), fundamental frequency (F0), jitter, peak air pressure (relative average perturbation), pitch, intensity, and voice onset time. Articulation parameters included a percentage of correct consonants (PCC; U-TAP word-unit PCC, U-TAP sentence-unit PCC, and three-position articulation test) and alternate motion evaluation (diadochokinesis, DDK). Data obtained during each evaluation (E1-E2-E3) were compared. Results: A total of 13 children with articulation disorders aged 4-10 years were enrolled in the study. In voice parameters, MPT, jitter, and pitch showed significant changes in repeated-measures ANOVA. However, only MPT showed significant changes during E1-E2 (P=.007) and E1-E3 (P=.004) in post hoc tests. Other voice parameters did not show significant changes. In articulation parameters, U-TAP, three-position articulation test (TA), and DDK showed significant changes in repeated-measures ANOVA. In post hoc tests, U-TAP (word, sentence) and TA showed significant changes during E1-E2 (P=.003, .04, and .01) and E1-E3 (P=.001, .03, and .003), and DDK showed significant changes during E1-E2 only (P=.03). Conclusions: Home-based serious games can be considered an alternative treatment method to improve language function. Trial Registration: Clinical Research Information Service KCT0006448; https://cris.nih.go.kr/cris/search/detailSearch.do/20119 ", doi="10.2196/49216", url="https://games.jmir.org/2023/1/e49216", url="http://www.ncbi.nlm.nih.gov/pubmed/37819707" } @Article{info:doi/10.2196/40219, author="O'Connor, Antonia and Tai, Andrew and Brinn, Malcolm and Hoang, Hien Amy Nguyen Thuc and Cataldi, Daniele and Carson-Chahhoud, Kristin", title="Co-design of an Augmented Reality Asthma Inhaler Educational Intervention for Children: Development and Usability Study", journal="JMIR Pediatr Parent", year="2023", month="Jul", day="25", volume="6", pages="e40219", keywords="asthma", keywords="asthma education", keywords="pediatric", keywords="pediatric asthma", keywords="co-design", keywords="usability", keywords="development", keywords="smartphone", keywords="tablet", keywords="augmented reality", keywords="health education", keywords="mobile app", keywords="mobile phone", abstract="Background: Smartphone and tablet apps that deliver health care education have been identified as effective in improving patient knowledge and treatment adherence in asthma populations. Despite asthma being the most common chronic disease in pediatrics, there are few apps that are targeted specifically for children. Only half of children with asthma have acceptable control of their symptoms, and 40\%-98\% do not use their inhalers correctly. With children being increasingly connected to technology, there is an opportunity to improve asthma inhaler technique education by delivery via smartphone or tablet apps. Augmented reality (AR) technology was used in this study to capitalize on growing technological innovations. Digital health interventions that use a co-design process for development have the highest likelihood of successful uptake and effectiveness on their intended outcomes. Perceived usability also has been shown to improve the effectiveness of education as well as the acceptance of the intervention. Objective: The aims of this study were to describe the co-design process, development, and design outcomes of a smartphone or tablet app that incorporates AR technology to deliver asthma inhaler technique education to children with asthma. This study also aimed to provide a usability evaluation, using the System Usability Scale to inform our work and future research, and recommendations for others performing similar work. Methods: The development of the AR asthma inhaler technique education app was based on an iterative co-design process with likely end users (children with asthma, their caregivers, and health care professionals). This involved multiple stages: recruitment of end users for qualitative interviews and usability testing with a previously designed educational intervention, which used an AR-embedded smartphone or tablet app; ideation of content for a specific asthma inhaler technique education intervention with end users; development of the specific asthma inhaler intervention; and 2 further rounds of interviews and usability testing with the redesign of the initial prototype. Results: We included 16 participants aged 9-45 years. Using the co-design process, the AR asthma inhaler technique education app was designed, incorporating the preferences of end users. After iteration 1, animation was included based on the feedback provided. Iteration 2 feedback resulted in increased AR experiences and the removal of the requirement of a paper-based resource to trigger AR in the third iteration. Throughout all rounds, the ease of use of the app and the novel nature of the intervention were frequently described. The usability of the intervention overall was perceived to be excellent, and the mean System Usability Scale score of the intervention was found to be highest in the final round of evaluation (90.14). Conclusions: The results from this co-design process and usability evaluation will be used to develop a final AR asthma inhaler technique educational intervention, which will be evaluated in the clinical setting. International Registered Report Identifier (IRRID): RR2-10.1177/16094069211042229 ", doi="10.2196/40219", url="https://pediatrics.jmir.org/2023/1/e40219", url="http://www.ncbi.nlm.nih.gov/pubmed/37490325" } @Article{info:doi/10.2196/44920, author="Lebby, R. Stephanie and Shyam, Sangeetha and Ramadas, Amutha and Bohm, R. Andrew and Hill, C. Julia and Fortuna, L. Karen and Zoltick, R. Stephanie", title="Prospective Association Between Video and Computer Game Use During Adolescence and Incidence of Metabolic Health Risks: Secondary Data Analysis", journal="JMIR Pediatr Parent", year="2023", month="Jul", day="6", volume="6", pages="e44920", keywords="video games", keywords="obesity", keywords="pediatrics", keywords="computer games", keywords="portable device", keywords="teenager", keywords="adolescents", keywords="health data", keywords="BMI", keywords="diabetes", keywords="high blood pressure", keywords="high cholesterol", keywords="metabolic disorder", abstract="Background: Video and computer games are popular activities, with 72\% of adolescents aged 13 to 17 years reporting video game use on either a computer, game console, or portable device. Despite high levels of video and computer game use in adolescence, relatively little scientific literature exists examining the association and effects of video and computer games on adolescents. Objective: The objective of this study was to examine the prevalence of video and computer game use among US adolescents and rates of positive screens for obesity, diabetes, high blood pressure (BP), and high cholesterol. Methods: A secondary data analysis was conducted using the National Longitudinal Study of Adolescent to Adult Health (Add Health) data, including adolescents aged 12 to 19 years between 1994 and 2018. Results: Respondents (n=4190) who played the most video and computer games had a significantly (P=.02) higher BMI and were more likely to self-report having at least one of the evaluated metabolic disorders: obesity (BMI >30 kg/m2), diabetes, high BP (BP >140/90), and high cholesterol (>240). With increased video or computer game use, there was a statistically significant increase in high BP rates in each quartile, with those with more frequent use also having higher rates of high BP. A similar trend was observed for diabetes, though the association did not reach statistical significance. No significant association was observed between video or computer game use and diagnoses of dyslipidemia, eating disorders, or depression. Conclusions: Frequency of video and computer game use is associated with obesity, diabetes, high BP, and high cholesterol in adolescents aged 12 to 19 years. Adolescents who play the most video and computer games have a significantly higher BMI. They are more likely to have at least one of the evaluated metabolic disorders: diabetes, high BP, or high cholesterol. Public health interventions designed to target modifiable disease states through health promotion and self-management may support the health of adolescents aged 12 to 19 years. Video and computer games can integrate health promotion interventions in gameplay. This is an important area for future research as video and computer games are integrated into the lives of adolescents. ", doi="10.2196/44920", url="https://pediatrics.jmir.org/2023/1/e44920", url="http://www.ncbi.nlm.nih.gov/pubmed/37410530" } @Article{info:doi/10.2196/42680, author="Saiger, John Michael and Deterding, Sebastian and Gega, Lina", title="Children and Young People's Involvement in Designing Applied Games: Scoping Review", journal="JMIR Serious Games", year="2023", month="Mar", day="16", volume="11", pages="e42680", keywords="serious game", keywords="game design", keywords="end user", keywords="participatory design", keywords="co-design", keywords="user involvement method", keywords="interventions", keywords="game development", keywords="children", keywords="pediatric", keywords="young people", keywords="child", keywords="youth", keywords="review method", keywords="scoping", keywords="applied game", abstract="Background: User involvement is widely accepted as key for designing effective applied games for health. This especially holds true for children and young people as target audiences, whose abilities, needs, and preferences can diverge substantially from those of adult designers and players. Nevertheless, there is little shared knowledge about how concretely children and young people have been involved in the design of applied games, let alone consensus guidance on how to do so effectively. Objective: The aim of this scoping review was to describe which user involvement methods have been used in the design of applied games with children and young people, how these methods were implemented, and in what roles children and young people were involved as well as what factors affected their involvement. Methods: We conducted a systematic literature search and selection across the ACM Digital Library, IEEE Xplore, Scopus, and Web of Science databases using State of the Art through Systematic Review software for screening, selection, and data extraction. We then conducted a qualitative content analysis on the extracted data using NVivo. Results: We retrieved 1085 records, of which 47 (4.33\%) met the eligibility criteria. The chief involvement methods were participatory design (20/47, 43\%) and co-design (16/47, 37\%), spanning a wide range of 45 concrete activities with paper prototyping, group discussions, and playtesting being the most frequent. In only half of the studies (24/47, 51\%), children and young people participated as true design partners. Our qualitative content analysis suggested 5 factors that affect their successful involvement: comprehension, cohesion, confidence, accessibility, and time constraints. Conclusions: Co-design, participatory design, and similar high-level labels that are currently used in the field gloss over very uneven degrees of participation in design and a wide variety of implementations that greatly affect actual user involvement. This field would benefit from more careful consideration and documentation of the reason of user involvement. Future research should explore concrete activities and configurations that can address the common challenges of involving children and young people, such as comprehension, cohesion, confidence, and accessibility. ", doi="10.2196/42680", url="https://games.jmir.org/2023/1/e42680", url="http://www.ncbi.nlm.nih.gov/pubmed/36928258" } @Article{info:doi/10.2196/34588, author="Johnson, W. Rowan and White, K. Becky and Gucciardi, F. Daniel and Gibson, Noula and Williams, A. Sian", title="Intervention Mapping of a Gamified Therapy Prescription App for Children With Disabilities: User-Centered Design Approach", journal="JMIR Pediatr Parent", year="2022", month="Aug", day="9", volume="5", number="3", pages="e34588", keywords="neurodevelopmental disability", keywords="mobile health", keywords="self-determination theory", keywords="gamification", keywords="physiotherapy", keywords="occupational therapy", keywords="speech pathology", keywords="behavior change", keywords="mobile phone", abstract="Background: Mobile health (mHealth) apps for children are increasing in availability and scope. Therapy (physiotherapy, speech pathology, and occupational therapy) prescription apps to improve home or school program adherence work best when developed to be highly engaging for children and when they incorporate behavior change techniques (BCTs) within their design. Objective: The aim of this study was to describe the development of a user-centered therapy prescription app for children (aged 6-12 years) with neurodevelopmental disabilities (eg, cerebral palsy, autism spectrum disorder, and intellectual disability) incorporating intervention mapping (IM) and gamified design. Methods: We used an iterative, user-centered app development model incorporating the first 3 steps of IM. We conducted a needs analysis with user feedback from our previous mHealth app study, a literature review, and a market audit. Change objectives were then specified in alignment with the psychological needs of autonomy, competence, and relatedness identified in self-determination theory. From these objectives, we then selected BCTs, stipulating parameters for effectiveness and how each BCT would be operationalized. A gamification design was planned and implemented focusing on maximizing engagement in children. In total, 2 rounds of consultations with parents, teachers, and therapists and 1 round of prototype app testing with children were conducted to inform app development, with a final iteration developed for further testing. Results: The IM process resulted in the specification of app elements, self-determination theory--informed BCTs, that were embedded into the app design. The gamification design yielded the selection of a digital pet avatar with a fantasy anime visual theme and multiple layers of incentives earned by completing prescribed therapy activities. Consultation groups with professionals working with children with disabilities (4 therapists and 3 teachers) and parents of children with disabilities (n=3) provided insights into the motivation of children and the pragmatics of implementing app-delivered therapy programs that informed the app development. User testing with children with disabilities (n=4) highlighted their enthusiasm for the app and the need for support in the initial phase of learning the app. App quality testing (Mobile Application Rating Scale-user version) with the children yielded means (out of 5) of 4.5 (SD 0.8) for engagement, 3.3 (SD 1.6) for function, 3.3 (SD 1.7) for aesthetics, and 4.3 (SD 1.1) for subjective quality. Conclusions: mHealth apps designed for children can be greatly enhanced with a systematic yet flexible development process considering the specific contextual needs of the children with user-centered design, addressing the need for behavior change using the IM process, and maximizing engagement with gamification and strong visual design. ", doi="10.2196/34588", url="https://pediatrics.jmir.org/2022/3/e34588", url="http://www.ncbi.nlm.nih.gov/pubmed/35943782" } @Article{info:doi/10.2196/34476, author="Cederved, Catarina and Back, Jon and {\AA}ngstr{\"o}m-Br{\"a}nnstr{\"o}m, Charlotte and Ljungman, Gustaf and Engvall, Gunn", title="Co-creation of a Serious Game About Radiotherapy: Participatory Action Research Study With Children Treated for Cancer", journal="JMIR Hum Factors", year="2022", month="May", day="31", volume="9", number="2", pages="e34476", keywords="children", keywords="participatory action research", keywords="game design", keywords="radiotherapy", keywords="education", keywords="supportive care", keywords="oncology", abstract="Background: Children with cancer who have to undergo radiotherapy can experience fear, because they have no prior knowledge of the treatment. One way of teaching children about the treatment and reducing their fear is to prepare them for it through serious games. Involvement of the end user in the design process within medicine is a way of ensuring that the product being developed will fit the intended user. Objective: The aim was to outline the contributions made by children and their parents through participatory action research when designing a serious game about radiotherapy. Methods: By means of participatory action research, children and their parents participated in the development of a serious game about radiotherapy. Nine children (7-10 years old) were included, each with an accompanying parent. A qualitative approach was used that included interviews and participant observation. Six rounds of iterative development process were used with the children and their parents. Meetings with the children were held either face-to-face or online. Each round resulted in a list of suggestions for changes to the game. A thematic analysis was performed based on the list of proposed changes, underpinned by all gathered data, to highlight how the children's participation changed the game. Results: Two main themes were identified. The first theme was ``The children's participation was affected by their health and treatment'' and included the following subthemes: ``an opportunity to share emotions and perceptions of radiotherapy'' and ``the possibility to participate was affected by the severity of the disease.'' The second theme was ``participation allowed becoming an active part of game development'' and included the following subthemes: ``the opportunity to express sentiments about the game,'' ``the emergence of a playable game through the children's contributions,'' and ``the necessity of understanding the text.'' Conclusions: The method used in this study made the children active participants, and our results suggest that this method can be used by health care researchers to cocreate serious games with children. It is necessary to inform the children involved that the process takes time, and that the process can be altered to allow as much participation as possible without placing a burden on them. The children's illness affected their possibility to take part; thus, it is crucial to accommodate the children's needs when conducting similar studies. The parents' participation facilitated the meetings for their children, even though their involvement in the game design was negligible. ", doi="10.2196/34476", url="https://humanfactors.jmir.org/2022/2/e34476/", url="http://www.ncbi.nlm.nih.gov/pubmed/35639467" } @Article{info:doi/10.2196/33782, author="Comeras-Chueca, Cristina and Villalba-Heredia, Lorena and Perez-Lasierra, Luis Jose and Lozano-Berges, Gabriel and Matute-Llorente, Angel and Vicente-Rodriguez, German and Casajus, Antonio Jose and Gonzalez-Aguero, Alex", title="Effect of an Active Video Game Intervention Combined With Multicomponent Exercise for Cardiorespiratory Fitness in Children With Overweight and Obesity: Randomized Controlled Trial", journal="JMIR Serious Games", year="2022", month="May", day="24", volume="10", number="2", pages="e33782", keywords="active videogames", keywords="VO2peak", keywords="obesity", keywords="prepuberty", keywords="cardiorespiratory", keywords="fitness", keywords="gaming", keywords="childhood", keywords="intervention", abstract="Background: Childhood overweight and obesity have become major global health problems and are negatively related with the cardiorespiratory fitness (CRF) level in school children and adolescents. Exercise, specifically multicomponent training, is effective for CRF improvement, but the main challenge is to ensure adherence to exercise in children with overweight and obesity. Therefore, new ways of exercising that are more attractive and motivational for this population are needed and playing or training with active video games (AVGs) has been proposed as an effective alternative because they require full-body movement and therefore increase energy expenditure. Objective: The main aim of this study was to investigate the effects of an AVG intervention combined with multicomponent training on CRF at maximal and submaximal intensities in children with overweight or obesity. Methods: We recruited 28 children (13 girls and 15 boys) aged 9 to 11 years with overweight or obesity from medical centers and divided them into 2 groups, an intervention group (n=20) that participated in a 5-month supervised AVG exercise program combined with multicomponent exercise, and a control group (n=8) that continued daily activities without modification. A maximal stress test to measure CRF using a walking-graded protocol with respiratory gas exchange was performed by the participants. Results: The AVG group showed a significant decrease in heart rate and oxygen uptake for the same intensities in the submaximal stages of the maximal treadmill test, as well as a lower oxygen uptake percentage according to the individual maximal oxygen uptake, whereas the control group did not show overall changes. No change in the peak oxygen uptake (VO2peak) was found. Conclusions: A 5-month AVG intervention combined with multicomponent exercise had positive effects on CRF at submaximal intensity, showing a lower heart rate and oxygen uptake at the same intensities and displaying a lower oxygen uptake percentage according to the individual (VO2peak). Greater benefits were found in children with the highest fat percentage. Trial Registration: ClinicalTrials.gov NCT04418713; https://clinicaltrials.gov/show/NCT04418713 ", doi="10.2196/33782", url="https://games.jmir.org/2022/2/e33782", url="http://www.ncbi.nlm.nih.gov/pubmed/35471240" } @Article{info:doi/10.2196/28276, author="Ntalindwa, Theoneste and Nduwingoma, Mathias and Uworwabayeho, Alphonse and Nyirahabimana, Pascasie and Karangwa, Evariste and Rashid Soron, Tanjir and Westin, Thomas and Karunaratne, Thashmee and Hansson, Henrik", title="Adapting the Use of Digital Content to Improve the Learning of Numeracy Among Children With Autism Spectrum Disorder in Rwanda: Thematic Content Analysis Study", journal="JMIR Serious Games", year="2022", month="Apr", day="19", volume="10", number="2", pages="e28276", keywords="autism", keywords="learning", keywords="ICT", keywords="e-learning", keywords="education", keywords="children", keywords="ASD", keywords="teaching", keywords="teachers", keywords="communication", keywords="communication technology", keywords="online content", keywords="Rwanda", keywords="gamification", keywords="school", keywords="school-age children", keywords="behavior", abstract="Background: Many teachers consider it challenging to teach children with autism spectrum disorder (ASD) in an inclusive classroom due to their unique needs and challenges. The integration of information communication technology (ICT) in the education system allows children with ASD to improve their learning. However, these ICT tools should meet their needs to lead a productive life. Objective: This study aimed to examine the possibilities of re-creating and adapting digital content to improve the learning of numeracy among children with ASD in inclusive school settings. Methods: We conducted 7 focus group discussions (FGDs) with 56 teachers from 7 schools and 14 parents from April to November 2019. Each of the FGDs took around 1 hour. Two clustered sets of questions were used: (1) general knowledge about teaching children with ASD and (2) analysis of selected online educational video content of early math (specifically, counting numbers). The researchers used video to understand current methodologies used in teaching children with ASD, possibilities of adaptation of the content in the current teaching environment, future challenges when the content is adapted, and possible solutions to overcome those challenges. All data, including audio recordings, field notes, and participants' comments, were transcribed, recorded, and analyzed following the steps recommended in qualitative data analysis. Results: The researchers identified ten themes from the analysis of the data: (1) awareness of the existence of ASD among children in schools and the community, (2) acceptance of children with ASD in an inclusive classroom and the community, (3) methods and models used when teaching children with ASD, (4)realia used to improve the learning of children with ASD, (5) the design of educational digital content, (6) the accessibility of online educational content, (7) quality of the content of the educational multimedia, (8) the opportunity of using the translated and re-created content inside and outside the classroom, (9) the relevance of the digital content in the Rwandan educational system, and (10) enhancement of the accessibility and quality of the digital content. We found that participants assumed that the content translation, gamification, and re-creation would help teach children with ASD. Moreover, they recommended contextualizing the content, increasing access to digital devices, and further research in the education of different subjects. Conclusions: Although many studies have identified the possibilities of using ICT to support children with ASD, few studies have documented the possibilities of integrating the existing technologies tested in the international community. This study is charting new territory to investigate online content to suit the context of schools. This study recommends further exploration of possible methodologies, such as applied behavior analysis or verbal behavior therapy, and the development of contextualized technologies that respond to the educational needs of children with ASD. ", doi="10.2196/28276", url="https://games.jmir.org/2022/2/e28276", url="http://www.ncbi.nlm.nih.gov/pubmed/35438638" } @Article{info:doi/10.2196/35415, author="Aminabadi, Asl Naser and Golsanamlou, Ozra and Halimi, Zohreh and Jamali, Zahra", title="Assessing the Different Levels of Virtual Reality That Influence Anxiety, Behavior, and Oral Health Status in Preschool Children: Randomized Controlled Clinical Trial", journal="JMIR Perioper Med", year="2022", month="Apr", day="18", volume="5", number="1", pages="e35415", keywords="virtual reality", keywords="anxiety", keywords="behavior", keywords="oral health training", abstract="Background: Compared with a traditional behavior management strategy and oral health training, virtual reality (VR) integrated with multisensory feedback possesses potential advantages in dentistry. Objective: This study aimed to assess the impact of different levels of VR on anxiety, behavior, and oral health status. Methods: This study was carried out in the Department of Pediatric Dentistry at the Tabriz University of Medical Sciences from December 2020 to June 2021. We randomly assigned 60 healthy children aged 4 years to 6 years to 4 groups, each consisting of 15 children. The study consisted of 2 consecutive sessions. During the first visit, the plaque index was calculated, and oral health education was carried out in all groups using Immersive VR (group I), Semi-immersive VR (group II), Nonimmersive VR (group III), and tell-show-do (TSD; group IV). In the second session, an amalgam restoration was performed in all groups. Participants' anxiety and behavior were recorded using the face version of the Modified Child Dental Anxiety Scale (MCDAS[f]) and Frankl scale. The plaque index was recorded in 2 follow-up sessions. Results: The greatest prevalence of positive behavior (P=.004) and the lowest anxiety (P<.001) were recorded in group I, followed by group II, group III, and group IV. The plaque index scores showed a reduced trend between the first session and follow-up sessions (P<.001), but the values did not differ significantly between the 4 groups during the 3 sessions (P=.28, P=.54, P=.18). Conclusions: The most positive behavior was observed in the Immersive VR group, followed by the Semi-immersive VR, Nonimmersive VR, and TSD groups. Moreover, oral health education using VR resources can improve oral health status in children. Trial Registration: Iranian Registry of Clinical Trials 20210103049926N1; https://www.irct.ir/trial/53475 ", doi="10.2196/35415", url="https://periop.jmir.org/2022/1/e35415", url="http://www.ncbi.nlm.nih.gov/pubmed/35436233" } @Article{info:doi/10.2196/26760, author="Washington, Peter and Kalantarian, Haik and Kent, John and Husic, Arman and Kline, Aaron and Leblanc, Emilie and Hou, Cathy and Mutlu, Cezmi Onur and Dunlap, Kaitlyn and Penev, Yordan and Varma, Maya and Stockham, Tyler Nate and Chrisman, Brianna and Paskov, Kelley and Sun, Woo Min and Jung, Jae-Yoon and Voss, Catalin and Haber, Nick and Wall, Paul Dennis", title="Improved Digital Therapy for Developmental Pediatrics Using Domain-Specific Artificial Intelligence: Machine Learning Study", journal="JMIR Pediatr Parent", year="2022", month="Apr", day="8", volume="5", number="2", pages="e26760", keywords="computer vision", keywords="emotion recognition", keywords="affective computing", keywords="autism spectrum disorder", keywords="pediatrics", keywords="mobile health", keywords="digital therapy", keywords="convolutional neural network", keywords="machine learning", keywords="artificial intelligence", abstract="Background: Automated emotion classification could aid those who struggle to recognize emotions, including children with developmental behavioral conditions such as autism. However, most computer vision emotion recognition models are trained on adult emotion and therefore underperform when applied to child faces. Objective: We designed a strategy to gamify the collection and labeling of child emotion--enriched images to boost the performance of automatic child emotion recognition models to a level closer to what will be needed for digital health care approaches. Methods: We leveraged our prototype therapeutic smartphone game, GuessWhat, which was designed in large part for children with developmental and behavioral conditions, to gamify the secure collection of video data of children expressing a variety of emotions prompted by the game. Independently, we created a secure web interface to gamify the human labeling effort, called HollywoodSquares, tailored for use by any qualified labeler. We gathered and labeled 2155 videos, 39,968 emotion frames, and 106,001 labels on all images. With this drastically expanded pediatric emotion--centric database (>30 times larger than existing public pediatric emotion data sets), we trained a convolutional neural network (CNN) computer vision classifier of happy, sad, surprised, fearful, angry, disgust, and neutral expressions evoked by children. Results: The classifier achieved a 66.9\% balanced accuracy and 67.4\% F1-score on the entirety of the Child Affective Facial Expression (CAFE) as well as a 79.1\% balanced accuracy and 78\% F1-score on CAFE Subset A, a subset containing at least 60\% human agreement on emotions labels. This performance is at least 10\% higher than all previously developed classifiers evaluated against CAFE, the best of which reached a 56\% balanced accuracy even when combining ``anger'' and ``disgust'' into a single class. Conclusions: This work validates that mobile games designed for pediatric therapies can generate high volumes of domain-relevant data sets to train state-of-the-art classifiers to perform tasks helpful to precision health efforts. ", doi="10.2196/26760", url="https://pediatrics.jmir.org/2022/2/e26760", url="http://www.ncbi.nlm.nih.gov/pubmed/35394438" } @Article{info:doi/10.2196/33389, author="Silva-Lavigne, Nicole and Valderrama, Alena and Pelaez, Sandra and Bransi, Myriam and Balli, Fabio and Gervais, Yannick and Gaudy, Thomas and Tse, Man Sze", title="Acceptability of Serious Games in Pediatric Asthma Education and Self-management: Pilot Study", journal="JMIR Pediatr Parent", year="2022", month="Apr", day="7", volume="5", number="2", pages="e33389", keywords="asthma", keywords="pediatrics", keywords="video games", keywords="eHealth", keywords="self-management", abstract="Background: Asthma is the most common chronic pediatric disease. Despite existing tools to manage asthma, 40\%-55\% of children with asthma experience uncontrolled asthma. Serious games (SGs) represent a novel approach in promoting asthma education and self-management for children. Objective: In this qualitative pilot study with an embedded quantitative design, we aim to use focus groups and questionnaires to describe the perceived role of SGs in different aspects of asthma self-management by children and their parents. These aspects include asthma perception and knowledge, the impact of asthma and barriers to asthma self-management, and the support system for asthma self-management. Methods: A total of 5 children with asthma and their parents were invited to participate in an organized gaming session. Children and their parents completed a pregaming questionnaire on their medical history and asthma knowledge. Then, they were invited to test 4 original SG prototypes, after which the children answered a postgaming questionnaire on their asthma knowledge and perception of the SGs. Children and their parents subsequently participated in parallel focus groups, which were video-recorded or audio-recorded, transcribed verbatim, and analyzed by reaching consensus among members of the research team. Results: The mean age of the children was 10.3 (SD 1.5) years, with 20\% (1/5) of the children being male. Qualitative data from the transcripts were coded into three separate domains: asthma self-management perception and knowledge, impact of asthma and barriers to asthma self-management, and support system for asthma self-management. We specifically explored the perceived roles of SGs within each domain. A key takeaway message was identified for each of these three domains: heterogeneity of asthma knowledge and the ability of SGs to encourage knowledge transfer through games, consequences and limitations of asthma and the ability of SGs to allow for identification and management of real-life situations through games, and insufficient support system and the ability of SGs to encourage playing with others for support and shared knowledge. Conclusions: Our pilot study explored the role of SGs in the self-management of asthma, as perceived by children and their parents. Our findings support the acceptability of SGs in asthma education and self-management in pediatrics and the necessity for future development in this field. ", doi="10.2196/33389", url="https://pediatrics.jmir.org/2022/2/e33389", url="http://www.ncbi.nlm.nih.gov/pubmed/35389354" } @Article{info:doi/10.2196/34698, author="Vanden Bempt, Femke and Economou, Maria and Dehairs, Ward and Vandermosten, Maaike and Wouters, Jan and Ghesqui{\`e}re, Pol and Vanderauwera, Jolijn", title="Feasibility, Enjoyment, and Language Comprehension Impact of a Tablet- and GameFlow-Based Story-Listening Game for Kindergarteners: Methodological and Mixed Methods Study", journal="JMIR Serious Games", year="2022", month="Mar", day="23", volume="10", number="1", pages="e34698", keywords="serious gaming", keywords="language comprehension", keywords="enjoyment", keywords="feasibility", keywords="GameFlow", abstract="Background: Enjoyment plays a key role in the success and feasibility of serious gaming interventions. Unenjoyable games will not be played, and in the case of serious gaming, learning will not occur. Therefore, a so-called GameFlow model has been developed, which intends to guide (serious) game developers in the process of creating and evaluating enjoyment in digital (serious) games. Regarding language learning, a variety of serious games targeting specific language components exist in the market, albeit often without available assessments of enjoyment or feasibility. Objective: This study evaluates the enjoyment and feasibility of a tablet-based, serious story-listening game for kindergarteners, developed based on the principles of the GameFlow model. This study also preliminarily explores the possibility of using the game to foster language comprehension. Methods: Within the framework of a broader preventive reading intervention, 91 kindergarteners aged 5 years with a cognitive risk for dyslexia were asked to play the story game for 12 weeks, 6 days per week, either combined with a tablet-based phonics intervention or control games. The story game involved listening to and rating stories and responding to content-related questions. Game enjoyment was assessed through postintervention questionnaires, a GameFlow-based evaluation, and in-game story rating data. Feasibility was determined based on in-game general question response accuracy (QRA), reflecting the difficulty level, attrition rate, and final game exposure and training duration. Moreover, to investigate whether game enjoyment and difficulty influenced feasibility, final game exposure and training duration were predicted based on the in-game initial story ratings and initial QRA. Possible growth in language comprehension was explored by analyzing in-game QRA as a function of the game phase and baseline language skills. Results: Eventually, data from 82 participants were analyzed. The questionnaire and in-game data suggested an overall enjoyable game experience. However, the GameFlow-based evaluation implied room for game design improvement. The general QRA confirmed a well-adapted level of difficulty for the target sample. Moreover, despite the overall attrition rate of 39\% (32/82), 90\% (74/82) of the participants still completed 80\% of the game, albeit with a large variation in training days. Higher initial QRA significantly increased game exposure ($\beta$=.35; P<.001), and lower initial story ratings significantly slackened the training duration ($\beta$=?0.16; P=.003). In-game QRA was positively predicted by game phase ($\beta$=1.44; P=.004), baseline listening comprehension ($\beta$=1.56; P=.002), and vocabulary ($\beta$=.16; P=.01), with larger QRA growth over game phases in children with lower baseline listening comprehension skills ($\beta$=?0.08; P=.04). Conclusions: Generally, the story game seemed enjoyable and feasible. However, the GameFlow model evaluation and predictive relationships imply room for further game design improvements. Furthermore, our results cautiously suggest the potential of the game to foster language comprehension; however, future randomized controlled trials should further elucidate the impact on language comprehension. ", doi="10.2196/34698", url="https://games.jmir.org/2022/1/e34698", url="http://www.ncbi.nlm.nih.gov/pubmed/35319480" } @Article{info:doi/10.2196/26810, author="Yu, Yanqiu and Mo, Kit-Han Phoenix and Zhang, Jianxin and Li, Jibin and Lau, Tak-Fai Joseph", title="Impulsivity, Self-control, Interpersonal Influences, and Maladaptive Cognitions as Factors of Internet Gaming Disorder Among Adolescents in China: Cross-sectional Mediation Study", journal="J Med Internet Res", year="2021", month="Oct", day="27", volume="23", number="10", pages="e26810", keywords="cognition", keywords="adolescent health", keywords="health risk behaviors", keywords="internet", keywords="self-control", keywords="China", abstract="Background: Gaming disorder, including internet gaming disorder (IGD), was recently defined by the World Health Organization as a mental disease in the 11th Revision of the International Classification of Diseases (ICD-11). Thus, reducing IGD is warranted. Maladaptive cognitions related to internet gaming (MCIG) have been associated with IGD, while impulsivity, self-control, parental influences, and peer influences are key risk factors of IGD. Previous literature suggests that MCIG is associated with the aforementioned 4 risk factors and IGD, and may thus mediate between these risk factors and IGD. These potential mediations, if significant, imply that modification of MCIG may possibly alleviate these risk factors' harmful impacts on increasing IGD. These mediation hypotheses were tested in this study for the first time. Objective: This study tested the mediation effects of MCIG between intrapersonal factors (impulsivity and self-control) and IGD, and between interpersonal factors (parental influences and peer influences) and IGD among adolescents in China. Methods: An anonymous, cross-sectional, and self-administered survey was conducted among secondary school students in classroom settings in Guangzhou and Chengdu, China. All grade 7 to 9 students (7 to 9 years of formal education) of 7 secondary schools were invited to join the study, and 3087 completed the survey. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) checklist was used to assess IGD. MCIG was assessed by using the Chinese version of the Revised Internet Gaming Cognition Scale. Impulsivity, self-control, and parental or peer influences were measured by using the motor subscale of the Barratt Impulsiveness Scale, the Brief Self-Control Scale, and the modified interpersonal influence scale, respectively. Structural equation modeling was conducted to examine the mediation effects of MCIG between these risk factors and IGD. Results: The prevalence of IGD was 13.57\% (418/3081) and 17.67\% (366/2071) among all participants and adolescent internet gamers, respectively. The 3 types of MCIG (perceived rewards of internet gaming, perceived urges for playing internet games, and perceived unwillingness to stop playing without completion of gaming tasks) were positively associated with IGD. Impulsivity, self-control, parental influences, and peer influences were all significantly associated with the 3 types of MCIG and IGD. The 3 types of MCIG partially mediated the associations between the studied factors and IGD (effect size of 30.0\% to 37.8\%). Conclusions: Impulsivity, self-control, and interpersonal influences had both direct and indirect effects via MCIG on IGD. Modifications of the 3 types of MCIG can potentially reduce the harmful impacts of impulsivity and interpersonal influences on IGD and enhance the protective effect of self-control against IGD. Future longitudinal studies are warranted. ", doi="10.2196/26810", url="https://www.jmir.org/2021/10/e26810", url="http://www.ncbi.nlm.nih.gov/pubmed/34704960" } @Article{info:doi/10.2196/22942, author="Stunden, Chelsea and Stratton, Kirsten and Zakani, Sima and Jacob, John", title="Comparing a Virtual Reality--Based Simulation App (VR-MRI) With a Standard Preparatory Manual and Child Life Program for Improving Success and Reducing Anxiety During Pediatric Medical Imaging: Randomized Clinical Trial", journal="J Med Internet Res", year="2021", month="Sep", day="22", volume="23", number="9", pages="e22942", keywords="virtual reality", keywords="magnetic resonance imaging simulation", keywords="certified child life specialists", keywords="pediatrics", keywords="magnetic resonance imaging procedures", keywords="alternatives to sedation", keywords="preparing children for MRI", abstract="Background: The experience of undergoing magnetic resonance imaging (MRI) can be anxiety provoking, particularly for pediatric patients and their families. Alternative methods to improve success and experiences without the use of sedation are needed. Objective: This study aims to compare the effectiveness of a virtual reality (VR)---based simulation app (VR-MRI) with a standard preparatory manual (SPM) and a hospital-based Child Life Program (CLP) on success and anxiety during a simulated pediatric MRI scan. Our secondary aim is to compare caregivers' reported anxiety, procedural data, caregiver usability, child satisfaction, and fun. Methods: This unblinded, randomized, triple-arm clinical trial involved 92 children aged 4-13 years and their caregivers. Recruitment was conducted through posters, public libraries, community centers, and social media. At a 2-hour session, participants were instructed to prepare for a simulated MRI head scan using one of three randomly assigned preparation materials: the VR-MRI app, SPM, or the CLP. Data were collected before preparation, during a simulated MRI head scan, and after the simulated scan. The primary outcomes were the success of the simulated MRI scan (MoTrak head motion tracking system), and child-reported anxiety (Venham picture test). We secondarily measured caregivers' reported anxiety (short State-Trait Anxiety Inventory), procedural data (minutes), usability (Usefulness, Satisfaction, and Ease of Use Questionnaire), and child-reported satisfaction and fun (visual analog scales). Results: A total of 84 participants were included in the final analysis (VR-MRI: 30/84, 36\%; SPM: 24/84, 29\%; and CLP: 30/84, 36\%). There were no clinically significant differences between the groups in terms of success during the MRI simulation (P=.27) or the children's reported anxiety at any timepoint (timepoint 1, P=.99; timepoint 2, P=.008; timepoint 3, P=.10). Caregivers reported being significantly more anxious after preparing with the manual than caregivers in the other 2 groups (P<.001). Child and caregiver anxiety had a significant relationship, increasing together with moderate effect (r84=0.421; P<.001). Participants using VR-MRI took the most time to prepare (P<.001) and participants using the manual took the least time (P<.001). No statistically significant relationships were found between time preparing and time completing the simulated assessment (P=.13). There were no differences found in ease of use (P=.99), ease of learning (P=.48), and usefulness (P=.11) between the groups; however, caregivers reported being significantly more satisfied with the VR-MRI app and CLP than SPM (P<.001). Children reported the most satisfaction with the CLP (P<.001). There were no differences in how much fun the preparation materials were perceived to be (P=.37). Conclusions: Digital preparation experiences using VR-based media could be a viable solution to improve the success of nonsedated MRI scans, with outcomes comparable with hospital-based in-person preparatory programs. Future research should focus on validating the results in a real MRI setting. Trial Registration: Clinicaltrials.gov NCT03931382; https://clinicaltrials.gov/ct2/show/NCT03931382 ", doi="10.2196/22942", url="https://www.jmir.org/2021/9/e22942", url="http://www.ncbi.nlm.nih.gov/pubmed/34550072" } @Article{info:doi/10.2196/24566, author="Bowling, B. April and Slavet, James and Hendrick, Chelsea and Beyl, Robbie and Nauta, Phillip and Augustyn, Marilyn and Mbamalu, Mediatrix and Curtin, Carol and Bandini, Linda and Must, Aviva and Staiano, E. Amanda", title="The Adaptive GameSquad Xbox-Based Physical Activity and Health Coaching Intervention for Youth With Neurodevelopmental and Psychiatric Diagnoses: Pilot Feasibility Study", journal="JMIR Form Res", year="2021", month="May", day="14", volume="5", number="5", pages="e24566", keywords="exercise", keywords="diet", keywords="sleep", keywords="mental health", keywords="children", keywords="adolescent", keywords="health promotion", keywords="telehealth", keywords="exergaming", abstract="Background: The prevalence of neurodevelopmental and psychiatric diagnoses (NPDs) in youth is increasing, and unhealthy physical activity (PA), diet, screen time, and sleep habits contribute to the chronic disease disparities and behavioral challenges this population experiences. Objective: This pilot study aims to adapt a proven exergaming and telehealth PA coaching intervention for typically developing youth with overweight or obesity; expand it to address diet, screen, and sleep behaviors; and then test its feasibility and acceptability, including PA engagement, among youth with NPDs. Methods: Participants (N=23; mean age 15.1 years, SD 1.5; 17 males, 9 people of color) recruited in person from clinic and special education settings were randomized to the Adaptive GameSquad (AGS) intervention or wait-list control. The 10-week adapted intervention included 3 exergaming sessions per week and 6 real-time telehealth coaching sessions. The primary outcomes included feasibility (adherence to planned sessions), engagement (uptake and acceptability as reported on process questionnaires), and PA level (combined light, moderate, and vigorous as measured by accelerometer). Descriptive statistics summarized feasibility and engagement data, whereas paired, two-tailed t tests assessed group differences in pre-post PA. Results: Of the 6 coaching sessions, AGS participants (n=11; mean age 15.3 years, SD 1.2; 7 males, 4 people of color) completed an average of 5 (83\%), averaging 81.2 minutes per week of exergaming. Of 9 participants who completed the exit questionnaire, 6 (67\%) reported intention to continue, and 8 (89\%) reported feeling that the coaching sessions were helpful. PA and sleep appeared to increase during the course of the intervention over baseline, video game use appeared to decrease, and pre-post intervention PA per day significantly decreased for the control (?58.8 min; P=.04) but not for the intervention group (?5.3 min; P=.77), despite potential seasonality effects. However, beta testers and some intervention participants indicated a need for reduced complexity of technology and more choice in exergames. Conclusions: AGS shows promise in delivering a health behavior intervention remotely to youth with NPDs, but a full-scale efficacy trial with a larger sample size is needed to confirm this finding. On the basis of feedback from beta testers and intervention participants, the next steps should include reduced technology burden and increased exergame choice before efficacy testing. Trial Registration: ClinicalTrials.gov NCT03665415; https://clinicaltrials.gov/ct2/show/NCT03665415. ", doi="10.2196/24566", url="https://formative.jmir.org/2021/5/e24566", url="http://www.ncbi.nlm.nih.gov/pubmed/33988508" } @Article{info:doi/10.2196/23626, author="Rantala, Arja and Jansson, M. Miia and Helve, Otto and Lahdenne, Pekka and Pikkarainen, Minna and P{\"o}lkki, Tarja", title="Parental Experiences of the Pediatric Day Surgery Pathway and the Needs for a Digital Gaming Solution: Qualitative Study", journal="JMIR Med Inform", year="2020", month="Nov", day="13", volume="8", number="11", pages="e23626", keywords="anxiety", keywords="children", keywords="day surgery", keywords="delivery of health care", keywords="digital solution", keywords="gamification", keywords="nursing", keywords="pain", keywords="qualitative study", keywords="technology", abstract="Background: The parents of hospitalized children are often dissatisfied with waiting times, fasting, discharge criteria, postoperative pain relief, and postoperative guidance. Parents' experiences help care providers to provide effective, family-centered care that responds to parents' needs throughout the day surgery pathway. Objective: The objective of our study was to describe parental experiences of the pediatric day surgery pathway and the needs for a digital gaming solution in order to facilitate the digitalization of these pathways. Methods: This was a descriptive qualitative study. The participants (N=31) were parents whose children were admitted to the hospital for the day surgical treatments or magnetic resonance imaging. The data were collected through an unstructured, open-ended questionnaire; an inductive content analysis was conducted to analyze the qualitative data. Reporting of the study findings adheres to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. Results: Parental experiences of the children's day surgery pathway included 3 main categories: (1) needs for parental guidance, (2) needs for support, and (3) child involved in his or her own pathway (eg, consideration of an individual child and preparation of child for treatment). The needs for a digital gaming solution were identified as 1 main category---the digital gaming solution for children and families to support care. This main category included 3 upper categories: (1) preparing children and families for the day surgery via the solution, (2) gamification in the solution, and (3) connecting people through the solution. Conclusions: Parents need guidance and support for their children's day surgery care pathways. A digital gaming solution may be a relevant tool to support communication and to provide information on day surgeries. Families are ready for and are open to digital gaming solutions that provide support and guidance and engage children in the day surgery pathways. ", doi="10.2196/23626", url="http://medinform.jmir.org/2020/11/e23626/", url="http://www.ncbi.nlm.nih.gov/pubmed/33185556" } @Article{info:doi/10.2196/16365, author="Fija{\v c}ko, Nino and Gosak, Lucija and Cilar, Leona and Nov{\vs}ak, Alenka and Creber, Masterson Ruth and Skok, Pavel and {\vS}tiglic, Gregor", title="The Effects of Gamification and Oral Self-Care on Oral Hygiene in Children: Systematic Search in App Stores and Evaluation of Apps", journal="JMIR Mhealth Uhealth", year="2020", month="Jul", day="8", volume="8", number="7", pages="e16365", keywords="mobile health", keywords="oral health care", keywords="gamification", keywords="mobile store", keywords="evidence-based dentistry", keywords="behavior change technique", keywords="Mobile Application Rating Scale user version", abstract="Background: Poor oral hygiene is a great public health problem worldwide. Oral health care education is a public health priority as the maintenance of oral hygiene is integral to overall health. Maintaining optimal oral hygiene among children is challenging and can be supported by using relevant motivational approaches. Objective: The primary aim of this study was to identify mobile smartphone apps that include gamification features focused on motivating children to learn, perform, and maintain optimal oral hygiene. Methods: We searched six online app stores using four search terms (``oral hygiene game,'' ``oral hygiene gamification,'' ``oral hygiene brush game,'' and ``oral hygiene brush gamification''). We identified gamification features, identified whether apps were consistent with evidence-based dentistry, performed a quality appraisal with the Mobile App Rating Scale user version (uMARS), and quantified behavior scores (Behavior Change score, uMARS score, and Coventry, Aberdeen, and London-Refined [CALO-RE] score) using three different instruments that measure behavior change. Results: Of 612 potentially relevant apps included in the analysis, 17 met the inclusion criteria. On average, apps included 6.87 (SD 4.18) out of 31 possible gamification features. The most frequently used gamification features were time pressure (16/17, 94\%), virtual characters (14/17, 82\%), and fantasy (13/17, 76\%). The most common oral hygiene evidence-based recommendation was brushing time (2-3 minutes), which was identified in 94\% (16/17) of apps. The overall mean uMARS score for app quality was high (4.30, SD 0.36), with good mean subjective quality (3.79, SD 0.71) and perceived impact (3.58, SD 0.44). Sufficient behavior change techniques based on three taxonomies were detected in each app. Conclusions: The majority of the analyzed oral hygiene apps included gamification features and behavior change techniques to perform and maintain oral hygiene in children. Overall, the apps contained some educational content consistent with evidence-based dentistry and high-quality background for oral self-care in children; however, there is scope for improvement. ", doi="10.2196/16365", url="https://mhealth.jmir.org/2020/7/e16365", url="http://www.ncbi.nlm.nih.gov/pubmed/32673235" } @Article{info:doi/10.2196/10987, author="Amantini, Ribeiro Susy Nazar{\'e} Silva and Montilha, Pascotto Alexandre Alberto and Antonelli, Caseiro Bianca and Leite, Moura Kim Tanabe and Rios, Daniela and Cruvinel, Thiago and Louren{\c{c}}o Neto, Natalino and Oliveira, Marchini Thais and Machado, Moreira Maria Aparecida Andrade", title="Using Augmented Reality to Motivate Oral Hygiene Practice in Children: Protocol for the Development of a Serious Game", journal="JMIR Res Protoc", year="2020", month="Jan", day="17", volume="9", number="1", pages="e10987", keywords="video games", keywords="education, dental", keywords="user-computer interface", keywords="computer simulation", keywords="pediatric dentistry", abstract="Background: New technologies create possible new ways of action, interaction, and learning which is extremely relevant in the field of oral health education. There is a lack of protocol in using an immersive interactive ludic-educational interface to motivate oral hygiene practice in children by means of augmented reality. Objective: This study aims to present a protocol on the development of a serious game to motivate oral hygiene practice in children. Methods: A serious game will be designed by augmented reality techniques to improve toothbrushing effectiveness of children aged 6 to 10 years. The functional structure of this interface is activated by means of movements recognized by Kinect (Microsoft Corp). The toothbrushing technique will be available in the game, enabling the children to execute the movement in the virtual environment. By identifying errors, this game will be tailored to improve the oral health of children by correcting the technique and teaching the user the adequate toothbrushing method. A template analysis will be performed to identify barriers and facilitators in each scenario. Results: After the implementation of the virtual interactive and immersive panels, enrollment will begin and evaluations will be made by means of questionnaires distributed to participants who interact with the game. Thus, an analysis of the product efficacy will be conducted. The expected outcome will be to obtain a digital instrument to motivate oral hygiene practice and enhance health awareness in children. Conclusions: The serious game will support the prevention of oral diseases by sharing scientific research in the school environment and community. International Registered Report Identifier (IRRID): PRR1-10.2196/10987 ", doi="10.2196/10987", url="https://www.researchprotocols.org/2020/1/e10987", url="http://www.ncbi.nlm.nih.gov/pubmed/31951216" } @Article{info:doi/10.2196/13776, author="Tark, Riin and Metelitsa, Mait and Akkermann, Kirsti and Saks, Kadri and Mikkel, Sirje and Haljas, Kadri", title="Usability, Acceptability, Feasibility, and Effectiveness of a Gamified Mobile Health Intervention (Triumf) for Pediatric Patients: Qualitative Study", journal="JMIR Serious Games", year="2019", month="Sep", day="30", volume="7", number="3", pages="e13776", keywords="psychological stress", keywords="coping skills", keywords="psychological feedback", keywords="mobile app", keywords="mHealth", keywords="mental health", keywords="chronic illness", keywords="cancer", keywords="pediatrics", abstract="Background: Mental disorders are notably prevalent in children with chronic illnesses, whereas a lack of access to psychological support might lead to potential mental health problems or disruptions in treatment. Digitally delivered psychological interventions have shown promising results as a supportive treatment measure for improving health outcomes during chronic illness. Objective: This study aimed to evaluate the usability, acceptability, and feasibility of providing psychological and treatment support in a clinical setting via a mobile game environment. In addition, the study aimed to evaluate the preliminary effectiveness of the mobile health game. Methods: Patients aged 7 to 14 years with less than a year from their diagnosis were eligible to participate in the study. In total, 15 patients were invited to participate by their doctor. A total of 9 patients (age range: 7-12 years; mean age 9.1 years) completed the 60-day-long study in which the Triumf mobile health game was delivered as a digital intervention. In an engaging game environment, patients were offered psychological and treatment support, cognitive challenges, and disease-specific information. The fully digital intervention was followed by a qualitative interview conducted by a trained psychologist. The results of the interview were analyzed in conjunction with patient specific in-game qualitative data. Ethical approval was obtained to conduct the study. Results: Patients positively perceived the game, resulting in high usability and acceptability evaluations. Participants unanimously described the game as easy to use and engaging in terms of gamified activities, while also providing beneficial and trustworthy information. Furthermore, the overall positive evaluation was emphasized by an observed tendency to carry on gaming post study culmination (67\%, 10/15). Psychological support and mini games were the most often used components of the game, simultaneously the participants also highlighted the education module as one of the most preferred. On average, the patients sought and received psychological support or education on 66.6 occasions during the 60-day intervention. Participants spent the most time collecting items from the city environment (on average 15.6 days, SD 8.1), indicative of exploratory behavior, based on the quantitative in-game collected data. During the intervention period, we observed a statistically significant decrease in general health problems (P=.003) and saw a trend toward a decrease in depression and anxiety symptoms. Conclusions: This study demonstrated that a game environment could be a promising medium for delivering comprehensive supportive care to pediatric patients with cancer alongside standard treatment, with potential application across a variety of chronic conditions. Importantly, the results indicate that the study protocol was feasible with modifications to randomized controlled trials, and the game could be considered applicable in a clinical context. By giving an empirical evaluation of delivering psychological support via the game environment, our work stands to inform future mobile health interventions. ", doi="10.2196/13776", url="https://games.jmir.org/2019/3/e13776", url="http://www.ncbi.nlm.nih.gov/pubmed/31573904" } @Article{info:doi/10.2196/14429, author="Ravindran, Vijay and Osgood, Monica and Sazawal, Vibha and Solorzano, Rita and Turnacioglu, Sinan", title="Virtual Reality Support for Joint Attention Using the Floreo Joint Attention Module: Usability and Feasibility Pilot Study", journal="JMIR Pediatr Parent", year="2019", month="Sep", day="30", volume="2", number="2", pages="e14429", keywords="autism spectrum disorder", keywords="interpersonal skills", keywords="virtual reality, instructional", abstract="Background: Advances in virtual reality (VR) technology offer new opportunities to design supports for the core behaviors associated with autism spectrum disorder (ASD) that promote progress toward optimal outcomes. Floreo has developed a novel mobile VR platform that pairs a user receiving instruction on target skills with an adult monitor. Objective: The primary objective of this pilot study was to explore the feasibility of using Floreo's Joint Attention Module in school-aged children with autism in a special education setting. A secondary objective was to explore a novel joint attention measure designed for use with school-aged children and to observe whether there was a suggestion of change in joint attention skills from preintervention to postintervention. Methods: A total of 12 participants (age range: 9 to 16 years) received training with the Joint Attention Module for 14 sessions over 5 weeks. Results: No serious side effects were reported, and no participants dropped out of the study because of undesirable side effects. On the basis of monitor data, 95.4\% (126/132) of the time participants tolerated the headset, 95.4\% (126/132) of the time participants seemed to enjoy using Floreo's platform, and 95.5\% (128/134) of the time the VR experience was reported as valuable. In addition, scoring of the joint attention measure suggested a positive change in participant skills related to the total number of interactions, use of eye contact, and initiation of interactions. Conclusions: The study results suggest that Floreo's Joint Attention Module is safe and well tolerated by students with ASD, and preliminary data also suggest that its use is related to improvements in fundamental joint attention skills. ", doi="10.2196/14429", url="http://pediatrics.jmir.org/2019/2/e14429/", url="http://www.ncbi.nlm.nih.gov/pubmed/31573921" } @Article{info:doi/10.2196/10902, author="Dunn, Amy and Patterson, Jeremy and Biega, F. Charmaine and Grishchenko, Alice and Luna, John and Stanek, R. Joseph and Strouse, Robert", title="A Novel Clinician-Orchestrated Virtual Reality Platform for Distraction During Pediatric Intravenous Procedures in Children With Hemophilia: Randomized Controlled Trial", journal="JMIR Serious Games", year="2019", month="Jan", day="09", volume="7", number="1", pages="e10902", keywords="anxiety", keywords="distraction", keywords="hemophilia", keywords="intravenous", keywords="mobile phone", keywords="needle", keywords="pediatric", keywords="virtual reality", abstract="Background: Needles are frequently required for routine medical procedures. Children with severe hemophilia require intensive intravenous (IV) therapy to treat and prevent life-threatening bleeding and undergo hundreds of IV procedures. Fear of needle-related procedures may lead to avoidance of future health care and poor clinical outcomes. Virtual reality (VR) is a promising distraction technique during procedures, but barriers to commercially available VR platforms for pediatric health care purposes have prevented widespread use. Objective: We hypothesized that we could create a VR platform that would be used for pediatric hemophilia care, allow clinician orchestration, and be safe and feasible to use for distraction during IV procedures performed as part of complex health care. Methods: We created a VR platform comprising wireless, adjustable, disposable headsets and a suite of remotely orchestrated VR games. The platform was customized for a pediatric hemophilia population that required hands-free navigation to allow access to a child's hands or arms for procedures. A hemophilia nurse observing the procedure performed orchestration. The primary endpoint of the trial was safety. Preliminary feasibility and usability of the platform were assessed in a single-center, randomized clinical trial from June to December 2016. Participants were children with hemophilia aged 6-18 years. After obtaining informed consent, 25 patients were enrolled and randomized. Each subject, 1 caregiver, and 1 hemophilia nurse orchestrator assessed the degree of preprocedural nervousness or anxiety with an anchored, combined modified visual analog (VAS)/FACES scale. Each participant then underwent a timed IV procedure with either VR or standard of care (SOC) distraction. Each rater assessed the distraction methods using the VAS/FACES scale at the completion of the IV procedure, with questions targeting usability, engagement, impact on procedural anxiety, impact on procedural pain, and likability of the distraction technique. Participants, caregivers, and nurses also rated how much they would like to use VR for future procedures. To compare the length of procedure time between the groups, Mann-Whitney test was used. Results: Of the 25 enrolled children, 24 were included in the primary analysis. No safety concerns or VR sickness occurred. The median procedure time was 10 (range 1-31) minutes in the VR group and was comparable to 9 (range 3-20) minutes in the SOC group (P=.76). Patients in both the groups reported a positive influence of distraction on procedural anxiety and pain. Overall, in 80\% (34/45) of the VR evaluations, children, caregivers, and nurses reported that they would like to use VR for future procedures. Conclusions: We demonstrated that an orchestrated, VR environment could be developed and safely used during pediatric hemophilia care for distraction during IV interventions. This platform has the potential to improve patient experience during medical procedures. Trial Registration: Clinical Trials.gov NCT03507582; https://clinicaltrials.gov/ct2/show/NCT03507582 (Archived by WebCite at http://www.webcitation.org/73G75upA3) ", doi="10.2196/10902", url="https://games.jmir.org/2019/1/e10902/", url="http://www.ncbi.nlm.nih.gov/pubmed/30626567" }