Objective: The treatment of ADHD is multimodal: Pharmacological, psychoeducational and psychotherapy, mainly cognitive-behavior therapy. Unfortunately, cognitive therapy is expensive and unattractive for some patients diagnosed with ADHD, which might lead to halting therapy. To alleviating this deficit, we have created a therapeutic video game -The Secret Trail of Moon (TSTM)-, which is based on a set of Virtual Reality (VR) exercises allied with a gamified version of chess. The combination of VR, video game and chess allows a greater immersion of cognitive load and training, adherence and transference to daily life. Materials and Methods: The video game is based on both Thomas Brown's model of executive dysfunction in ADHD patients and Barkley's model of Behavioral Inhibition in these patients. TSTM is composed of 6 different mechanics aimed at working with: attention, memory, planning, visuospatial capacity, impulse control and reasoning. The technology used has been VR goggles, an actual gaming console and a standalone application. The software runs on a PlayStation 4 test device Results: TSTM has been elaborated in three phases: 1) Theoretical foundation, design and programming; 2) Validation and proof of concept phase; 3) Clinical trial phase. The validation and proof of concept phase allowed us to improve TSTM according to the users' experience in order to achieve a more powerful cognitive training. Currently, TSTM is its third phase. The main hypothesis is that TSTM training produces improvements in patients with ADHD. Conclusions: This article shows the first steps and development of TSTM. Currently, TSTM is undergoing its first clinical trial to demonstrate clinical efficacy to treat ADHD patients.
In the last 50 years, the boom of video games as a recreational form is being
exponential. However, it is only recently that they have begun to be used successfully as a
therapeutic tool in mental health [
In particular, serious video games have begun to be used for the treatment of
Attention Deficit Hyperactivity Disorder (ADHD) [
Clinical guidelines recommend multimodal treatment as the first therapeutic
option. Multimodal treatment includes a combination of different proportions of: 1)
Pharmacological treatment; 2) psychoeducational treatment (parents and teachers);
and 3) Psychotherapy, mainly cognitive-behavioral psychotherapy [
For this reason, several authors are investigating new, more attractive, cheap and effective alternative tools for treating ADHD. To this end, we have designed a therapeutic video game using virtual reality (VR). The novelty of our video game "The Secret Trail of Moon" (TSTM) is that we inclused a gamified version of chess at the very core of the video game. We used chess as a gamified “excuse” of training executive functions.
Chess is an ancestral game based on simple rules but demands a high cognitive
load including attentional processes, executive functions, and memory, among others
[
On the other hand, VR offers three advantages compared to the use of 2D video
games: [
The aim of TSTM is to create an innovative, more immersive and motivating therapeutic tool for the cognitive treatment of patients diagnosed with ADHD. 2 2.1
TSTM is a therapeutic video game based on VR for the cognitive training in patients with ADHD.
Adventures and puzzle A kid appears suddenly on a cave and it's greeted by a curious black fox that talks. Travelling with him eventually met a scurry raccoon and together they form the Moon team. Through the adventures in the woods they'll learn about an impending war between two animal factions that wants to fill the power vacuum that the King of the Forest Cernunnos left when it vanished. Wanting to unite all animals again, they set on a quest to find Cernunnos and put an end to the war that threatens the coexistence and the nature of the forest itself.
This is a VR adventure experience toppled with some specifically designed mechanics. The main goal of the game is to find the King of the Forest through several chapters, following the main storyline of the Moon Team while resolving problems all along the Forest.
Cognitive training (25 minutes) and Exploring the forest (10 games minutes).
Game time estima- 8 hours tion In the first phase of development this video game is composed of 6 mechanics. Each mechanism has been designed to stimulate a deficient area in patients with ADHD: attention, working memory, planning, visuospatial capacity, impulse control and reasoning.
Game mechanic (Working área)
Purpose of the mechanics
Images of the game Smasher (Attention) Enigma (Working memory) Focus your attention and press the "X" button on the control when the target sequence appears in order to destroy the rock that is in your way.
For a given time, remember a target sequence and place it in the correct order as quickly as possible.
Kuburi (Visuospatial capacity)
Make the default drawing using 3D cubes formed by 6 different faces Teka Teki (Planning)
Get the key to your lock by moving the walls that are in your way using the fewest possible movement. Kitsune (Impulse control) Chess (Reasoning)
Avoid objects that are in the way by following the indications that are shown. 12 chess lessons that increase in difficulty, from knowing the pieces to performing checkmate in 1 move.
The novelty of the video game is the use of the game of chess as a central axis. The game of chess consists of a board with 64 squares, half white and half black, and two sides, one white and one black. Each side starts with 16 pieces (6 pieces of different type). The aim of the game is to checkmate the opponent's king.
In TSTM, chess appears in three different forms: A) As game mechanics; B) As a central element of mechanics; and C) As a thread in the plot of the video game: A) Chess as game (Figure 1). A course of 12 sessions has been structured, consisting of tutorials and exercises in each of them. The first lesson is about the knowledge of the board and the pieces. The level increases successively until it reaches checkmate in 1 move. B) Chess as a central element of the mechanics (Figure 2). The elements of the game of chess, board and pieces, allow us to perform many cognitive exercises in which it is not necessary to know the rules of chess. An example is the attention game "Smasher". The patient must be attentive to the appearance of the "pawn-knight" sequence and then press the X button on the controller.
Chess as a thread in the plot and lore (Figure 3). TSTM is located in a forest with chess elements that explain the story of this world. The patient will go together with two animals that accompany him. During his trip, the player will unlock information about the forest's relationship with chess. The final test of the video game is to play a game of chess against the enemy. 2.2
The video game TSTM has been designed with the joint participation of the Traslational Research Group at Puerta de Hierro University Hospital-Majadahonda (Dr. Hilario Blasco-Fontecilla and Maria Rodrigo-Yanguas), the company Gammera Nest (including Marina Martin-Moratinos), and the collaboration of an expert in gamification (Carlos Gonzalez-Gardon). In the design and development has participated an interdisciplinary team formed by a psychiatrist, psychologists, programmers, modelers, art, sound and production.
The initial design of the video game has been modified in an iterative way
following a User-Centered Model.[
We used Unity Game Engine to develop this VR Experience to Sony Playstation VR device. We specifically programmed each one of the cognitive variables that we want to improve. We also use this VR technology to improve this data and provide to the professional with a report that is the more complete as possible. We track head movement, head speed, focus and reaction time and we showed them to the professional so they can render their own conclusions. 3
The TSTM development and validation process is divided into three stages: 1) Theoretical foundation, design and programming stage; 2) Usability stage (Proof of concept); 3) Clinical trial stage (ID: NCT04355065).
A) Theoretical foundation, design and programming stage (See Methodology section). B) Usability stage (Proof of concept). The objective was to detect errors in the video game and to evaluate the experience of the patients in order to improve the version of TSTM.
C) Clinical trial stage. We are currently in this stage (Trial registration: NCT04355065). The research is being carried out at the Puerta de Hierro University Hospital. It is a randomized, non-blind clinical trial with a control group. 105 patients with a diagnosis of ADHD and in stable pharmacological treatment are randomized to enter one of the three groups: 1) Control group; 2) Online therapeutic chess group; 3) TSTM group. All patients and parents are evaluated pre- and post-intervention. The training is done during 12 weeks. Our main working hypothesis is that patients who perform training in TMT or chess will have improvements in executive functions compared to patients who do not perform any type of intervention (control group). Currently, we have 83 patients evaluated and in active training: Control group (n=28), Therapeutic chess group (n=27) and TSTM group (n=28). 1. Theoretical foundation and programming Psychological Models= Thomas Brown's model of executive functions.
Barkley Behavioral Inhibition Model. Chess.
Technology= It is designed in partnership with Sony Iberia for the Playstation 4 systems, and specifically, to Playstation VR goggles.
The aim of the TSTM video game is to create an innovative therapeutic tool for
cognitive training in patients diagnosed with ADHD. TSTM has been created for the
treatment of the main deficits of ADHD as reported from the main theoretical
conceptual frameworks on the main deficits of patients with ADHD: inattention,
hyperactivity, and lack of impulse control, among others [
Before testing the therapeutic properties of TSTM, we had to overcome a second stage, testing the usability and proof of concept. The question at this second stage was: would it make sense creating a VR videogame with good therapeutic properties but boring that anyone else would like to play? We have surpassed this second phase and our results are really good. Unfortunately, we did not have the time to writte this paper, but we can advance that more than 90% of the users reported that they liked TSTM, and the scores in most of the mechanics surpassed this 90% (RodrigoYanguas and Martin-Moratinos et all, unpublished, in elaboration).
Currently, TSTM is being validated through a first clinical trial in patients stabilized on medication following an add-on strategy in a three-arm randomized design (https://clinicaltrials.gov/ct2/show/NCT04355065). The completion date will be October/November 2020. The main objective is to test if TSTM can be used as a cognitive training tool in patients diagnosed with ADHD. 4.2
TSTM is the first VR serious video game developed for the cognitive treatment of patients with ADHD that includes chess at its very core. TSTM has a solid theoretical basis and has been validated in a proof of concept before starting the clinical trial.
In the future, we hope to be able to design more mechanics to achieve more complete cognitive work and to be able to integrate artificial intelligence to be able to train from home.
We have followed Play Station's recommendations about not using Virtual Reality glasses for long periods of time on children under 12.
Protection of people and animals. The authors state that the procedures followed conformed to the ethical standards of the responsible human experimentation committee and in accordance with the World Medical Association and the Declaration of Helsinki.
Confidentiality of data. The authors state that they followed their centre's protocols on the publication of patient data.
Right to privacy and informed consent. The authors have obtained the informed consent of the patients and/or subjects referred to in the article. This document is in the possession of the correspondent author.
The development of TSTM has been made possible thanks to support from I-PFIS, CDTI and the material support from Sony Interactive Entertainment.
In the last two years, Dr. Hilario Blasco-Fontecilla has received lecture fees from Takeda. He is the recipient of a MINECO grant (RTI2018-101857-B-I00; 20192021). He was the Spanish IP of a clinical trial comparing neurofeedback (Mensia Koala®) with Medikinet® (www.mensia.com). He has also received funding from a clinical trial sponsored by Janssen (ESKETINSUI2002). The remaining authors report no conflict of interest.