Prevention in Addiction

Using serious games to motivate adolescents to (re)train their brain

Wouter Boendermaker, M.Sc.University of Amsterdam

Games for Health: Europe, November 2nd, 2015

Addiction and adolescents

• Underage alcohol and cannabis consumption is relatively high in The Netherlands.

• Reckless use in adolescence can lead to later addiction problems

• Costly prevention campaigns: explicit messages (‘smoking is bad’) seem ineffective

Dual Process Model of Addiction

• Dual Process Model focuses on less visible (implicit) cognitive processes

• Imbalance between two processes leads to and maintains addiction problems:

1. Too strongly developed automatic reactions to drug-related cues

2. Relatively weak cognitive control processes

More info: Wiers, R.W., Bartholow, B.W., Wildenberg, E. van den, Thush, C., Engels, R.C.M.E., Sher, K.J., Grenard, J., Ames, S.L., & Stacy, A.W. (2007). Automatic and controlled processes and the development in addictive behaviors in adolescents: A review and a model. Pharmacology, Biochemistry and Behavior, 86, 263-283.

TrainingLuckily, we can (re)train these processes, using computerized trainings:

1. Cognitive Bias Modification (CBM)• Automatic memory associations / interpretations (CBM-I)• Selective attention processes• Approach / avoidance behavior

2. Executive Function (EF) training:• Working memory (updating new information)• Inhibition (stopping behavior)• Cognitive flexibility (switching between rule sets)

Several online training projects: www.impliciet.eu

Problem in adolescents

Although effective as intervention in long-time users, prevention in adolescents is more problematic:• Drinking / blowing is very popular (peer pressure)• Substance use, although high, is seldom seen as problematic• General lack of motivation to change behavior

• And: The training tasks we use are generally (very) boring, take a long time and are quite repetitive

They have no (intrinsic) motivation to train

Solution(?): Motivate with game elements

Gamification: how?• Use of game elements in the field of CBM is fairly new

Boendermaker, W. J., Prins, P. J. M., & Wiers, R. W. (2015). Cognitive Bias Modification for Adolescents with Substance Use Problems – Can Serious Games Help? Journal of Behavioral Therapy and Experimental Psychiatry, 49, 13-20.

Gamification: how?

Focus on two ways to gamify these trainings (steps 2 & 4):

2. Take a single training-paradigm and turn it into a game• Intrinsic motivation• But: evidence based?

4. Develop a game shell around the training(s), train for game-points• Easier to realise, paradigms remain intact• But: extrinsic motivation

Shell game: CityBuilder

• Earn game-points through training; spend in virtual world• Goal: build your own virtual city, complete assignments, get bonusses,

achievements, compare your city with friends, etc.• Broad and modular: Five original training paradigms (attention, approach,

inhibition, memory, switching) are embedded and can be switched on/off, and can run as ‘real’ or ‘placebo’

Graphic support by Elisabeth Enthoven

Integrated game:Ninja Mouse

• Directly linked to regular inhibition task

• Integrated alcohol / cannabis stimuli (pictures)

• Actions in the game are ‘fun’; paradigm very close to original

Integrated in Facebook for social context

Developed with UvA master student Game Design, Antonios Georgiadis and Human Centered Multimedia master student Ans de Nijs

Boendermaker, WJ, Boffo, M & Wiers, RW (2015). Exploring Elements of Fun to Motivate Youth to do Cognitive Bias Modification. Games for Health Journal 4 (6).

Integrated game:Shots Game

• Directly linked to regular attentional bias task

• Integrated alcohol / cannabis stimuli (pictures)

• Actions in the game are ‘fun’; paradigm very close to original

More examples on: www.wouboe.nl Developed with Human Centered Multimedia master student Sylvia van Schie

Boendermaker, WJ, Sanchez Maceiras, S., Boffo, M & Wiers, RW (in prep). Attentional Bias Modification with Serious Game Elements: The Shots Game

Studies & Results

• RCT’s at schools and universities in The Netherlands among 500+ adolescents aged 14-21. • Focus on heavy alcohol and cannabis users. • Training takes 4-8 sessions of 30-40 minutes and can

be done at school or at home.

In general, the games are evaluated more positively, and students tend to train more in the game conditions. However, this effect quickly fades of time (sessions).

DiscussionBoth the shell game and the integrated games appear to be effective, but temporary motivators to train.

Several questions remain:• How can we keep motivation high throughout the entire (multi-session) training?• Could the word game create unrealistic expectancies (i.e., commercial games) among

regular youth, and hence lead to disappointment?• What happens to motivation at the post-training assessment where no game elements are

used?• While games may help to increase motivation to train, motivation to change often remains

low; can game elements also tap into this aspect?

Conclusion: serious games can help, but may not provide a complete solution to the motivational problem in adolescent substance users.

Advise: combine with Motivational Interviewing and/or Cognitive Behavioral Therapy for optimal results.

Thank you!Many thanks to:• Reinout Wiers• Pier Prins• Marilisa Boffo• Thomas Gladwin• Sebastiaan Dovis• Elisabeth Enthoven• Frank Nack (UvA Game studies)• Many bachelor & master students

Questions?

www.impliciet.euwww.wouboe.nl

Integrated games: RocketLauncher

• Based on approach / attention theory• Integrated alcohol stimuli (pictures)• Actions in the game are ‘fun’• But: only loosely connected to evidence based trainings (e.g. no more repeated

stimulus-response pairings)

Developed with UvA Game Studies student Rosanne Joosten

More examples on: www.wouboe.nl