Excessive Spending in a "Free-to-Play" Smartphone Game.

BACKGROUND AND OBJECTIVES: Although gaming disorder is increasingly recognized, there has been limited consideration of the impact of free-to-play games with in-game purchases, also called microtransactions. METHODS: Case report (n = 1). RESULTS: A patient with posttraumatic stress disorder, major depressive disorder in remission, polysubstance use disorders in remission, and opioid use disorder on buprenorphine/naloxone developed gaming disorder (based on International Classification of Diseases, 11th revision) and spent up to 40% of his monthly income on microtransactions within a smartphone game. Treatment consisted of relinquishing access to electronic payment mechanisms, motivational interviewing, and couples therapy. DISCUSSION AND CONCLUSIONS: The case highlights how in-game purchases may cause patients with gaming disorder to experience financial consequences, and the need for further characterization of the clinical ramifications of microtransactions. SCIENTIFIC SIGNIFICANCE: To the best of our knowledge, this is the first report in the medical literature of a patient with gaming disorder developing excessive in-game spending from expenditures on microtransactions. (Am J Addict 2020;29:528-530).

Making EGMs Accountable: Can an Informative and Dynamic Interface Help Players Self-regulate?

Electronic gaming machines (EGMs) are recognised as one of the most harmful gambling forms, because they promote high-speed repetitive gambling and automatically reinvest winnings. These features, amongst others, make it difficult for EGM gamblers to keep track of their play. Tools to assist gamblers exist, but have limited effectiveness because they require user registration and manual activation, leading to low uptake. The present study aimed to evaluate the effect of a more informative interface (including removal of automatic reinvestment of winnings) and pop-up messages on gambling behaviour, and on player experience. A total of 213 Australian participants, recruited through social media, played a simulated online EGM. The experiment was a two (standard vs. informative interface) × two (pop-ups absent vs. present) between-subjects design. The informative interface: promoted keeping track of spins played; increased accurate estimation of amount spent (as did pop-up messages) and time played; and provided game usage figures which acted as cues to quit play. Once the initial deposit (but not winnings) was expended, informative interface users could opt to reinvest their winnings, although many opted to exit at that point. No difference in total spending or dissociation was observed between experimental groups. Informative interface users reported no reduction in enjoyment. Pop-up messages reduced enjoyment with the standard interface, but increased enjoyment when paired with an informative interface. These findings indicate that a more informative interface and pop-up messages may be useful in reducing the harmful nature of EGMs.

The (cost-) effectiveness of exergaming in people living with dementia and their informal caregivers: protocol for a randomized controlled trial.

BACKGROUND: Physical activity is linked to benefits such as increased physical fitness, cognition, emotional and social functioning, general health and well-being in older people. Some evidence suggests that this also applies to people living with dementia. However, it can be harder for them to perform physical activities, due to several barriers, such as issues with orientation and balance problems. A relatively new type of physical activity called exergaming may help them overcome these barriers. Exergaming is "physical exercise interactively combined with cognitive stimulation in a gaming environment". The aim of our study is to evaluate the effectiveness and cost-effectiveness of exergaming compared to regular activities in people living with dementia, who attend day-care centres. Additionally, we want to investigate whether the exergaming activity for the person living with dementia, also (indirectly) affects the informal caregiver, as well as which facilitators and barriers to implementation of exergames for this target group exist. METHODS: A cluster Randomized Controlled Trial (RCT), with economic and process evaluations alongside will be carried out. In the Netherlands, 24 day-care centres are randomized in the experimental or control group. The study group will consist of 224 dyads (community-dwelling participants with dementia and their informal caregivers), who are interviewed at baseline, and at 3 and 6 months of follow-up. The participant with dementia has to visit the day-care centre for at least two days per week, have a diagnosis of mild to moderate dementia and have an informal caregiver present, who is willing to participate. Societal cost data will be collected during interviews, using healthcare utilization diaries, and from day-care centres. The process evaluation will only involve the experimental group, and will include an online survey, qualitative interviews and focus groups. DISCUSSION: This study will contribute to the evidence base that more effective exercise among people with dementia will result in positive effects on their wellbeing and quality of life. This will motivate people with dementia to be physically active. We also envision that there might be a positive effect on the burden of care experienced by their informal caregivers. TRIAL REGISTRATION: This trial was registered at the Netherlands Trial Register (NTR) on December 10, 2015 (number: NTR5537 ), this publication is based on protocol amendment number 01, issue date 28 December 2018. This includes all items from the World Health Organization Trial Registration Data Set [see Additional file 1].

Feasibility of a Low-Cost, Interactive Gaming System to Assess Balance in Older Women.

The use of low-cost interactive game technology for balance rehabilitation has become more popular recently, with generally good outcomes. Very little research has been undertaken to determine whether this technology is appropriate for balance assessment. The Wii balance board has good reliability and is comparable to a research-grade force plate; however, recent studies examining the relationship between Wii Fit games and measures of balance and mobility demonstrate conflicting findings. This study found that the Wii Fit was feasible for community-dwelling older women to safely use the balance board and quickly learn the Wii Fit games. The Ski Slalom game scores were strongly correlated with several balance and mobility measures, whereas Table Tilt game scores were not. Based on these findings, the Ski Slalom game may have utility in the evaluation of balance problems in community-dwelling older adults.

An alternative to the balance error scoring system: using a low-cost balance board to improve the validity/reliability of sports-related concussion balance testing.

OBJECTIVE: Recent guidelines advocate sports medicine professionals to use balance tests to assess sensorimotor status in the management of concussions. The present study sought to determine whether a low-cost balance board could provide a valid, reliable, and objective means of performing this balance testing. DESIGN: Criterion validity testing relative to a gold standard and 7 day test-retest reliability. SETTING: University biomechanics laboratory. PARTICIPANTS: Thirty healthy young adults. ASSESSMENT OF RISK FACTORS: Balance ability was assessed on 2 days separated by 1 week using (1) a gold standard measure (ie, scientific grade force plate), (2) a low-cost Nintendo Wii Balance Board (WBB), and (3) the Balance Error Scoring System (BESS). MAIN OUTCOME MEASURES: Validity of the WBB center of pressure path length and BESS scores were determined relative to the force plate data. Test-retest reliability was established based on intraclass correlation coefficients. RESULTS: Composite scores for the WBB had excellent validity (r = 0.99) and test-retest reliability (R = 0.88). Both the validity (r = 0.10-0.52) and test-retest reliability (r = 0.61-0.78) were lower for the BESS. CONCLUSIONS: These findings demonstrate that a low-cost balance board can provide improved balance testing accuracy/reliability compared with the BESS. CLINICAL RELEVANCE: This approach provides a potentially more valid/reliable, yet affordable, means of assessing sports-related concussion compared with current methods.

A grounded theory approach to understanding in-game goods purchase.

Video game companies are increasingly diversifying their profit models. Rather than relying exclusively on the sale of video game titles or the subscription model, video game companies are maximising the revenues and extending the lifecycle of their games by means of a strategy based on the sale of in-game goods. This study contributes to the theory on in-game goods purchases by explaining why and how video game players purchase different types of in-game goods. We used an inductive approach involving qualitative data analysis based on grounded theory. Six types of in-game goods are grouped into three categories: functional-based goods, probability-based goods, and ornamental-based goods. After acknowledging the heterogeneity of the categories, a conceptual framework is developed by conducting 21 in-depth interviews, from which it emerges that players purchase functional-based goods, probability-based goods, and ornamental-based goods for different motives and through the different behavioural processes. First, the purchase of functional-based goods is a strategy for entering the flow experience. Second, the purchase of probability-based goods is a compromise for purchase restrictions. Third, the purchase of ornamental goods is driven by the synergism of intrinsic motivations and exposure in the virtual world. Therefore, video game researchers should not treat in-game goods as a homogeneous concept. The findings also suggest that it is critically important for video game developers to strike a balance between the challenges of the gameplay and the skills of players because excessively raising (or lowering) the level of difficulty could pose a threat to the company's sustainable profit.

Evidence that digital game players neglect age classification systems when deciding which games to play.

This article considers players' experiences seeking out new games to play, and their use of the Australian National Classification Scheme in doing so. The global video game industry is booming, with hundreds of games being released each month across numerous platforms. As a result, players have an unprecedented number of games available when choosing what games to purchase. However, a number of confounding issues around the emergent content of games and the subjective nature of game reviewing makes it difficult to relate what kinds of experiences a given game will facilitate. In this study, we surveyed game players in order to find their game platform and acquisition preferences; strategies and experiences when choosing games; and attitudes towards classification systems. Our findings suggest that players find it difficult to choose what games to purchase, and that existing classification systems are mostly only beneficial when choosing games for minors.

The changing face of desktop video game monetisation: An exploration of exposure to loot boxes, pay to win, and cosmetic microtransactions in the most-played Steam games of 2010-2019.

It is now common practice for video game companies to not just sell copies of games themselves, but to also sell in-game bonuses or items for a small real-world fee. These purchases may be purely aesthetic (cosmetic microtransactions) or confer in-game advantages (pay to win microtransactions), and may also contain these items as randomised contents of uncertain value (loot boxes). The growth of microtransactions has attracted substantial interest from both gamers, academics, and policymakers. However, it is not clear either how frequently exposed players are to these features in desktop games, or when any growth in exposure occurred. In order to address this, we analysed the play history of the 463 most-played Steam desktop games from 2010 to 2019. Results of exploratory joinpoint analyses suggested that cosmetic microtransactions and loot boxes experienced rapid growth during 2012-2014, leading to high levels of exposure by April 2019: 71.2% of the sample played games with loot boxes at this point, and 85.89% played games with cosmetic microtransactions. By contrast, pay to win microtransactions did not appear to experience similar growth in desktop games during the period, rising gradually to an exposure rate of 17.3% by November 2015, at which point growth decelerated significantly (p<0.001) to the point where it was not significantly different from zero (p = 0.32).

Fortnite microtransaction spending was associated with peers' purchasing behaviors but not gaming disorder symptoms.

Monetized video games have received academic and regulatory scrutiny following concerns that these products may foster addiction-like behaviors, including compulsive spending. Previous studies have reported that individuals with markedly higher in-game financial expenditure are more likely to endorse symptoms of addictive behavior (i.e., gaming or gambling disorder). The present study recruited 428 adult Fortnite players from online forums and investigated gaming motivations and behaviors, as well as online social network influences, in relation to microtransaction spending and gaming disorder (GD) symptoms. The results showed that microtransaction spending was predicted by social influences (i.e., the frequency of spending by the participants' closest friend who spends money on Fortnite), greater accessibility to Fortnite across multiple devices, and having a higher in-game level. Spenders reported stronger motivation to acquire in-game rewards and were more likely to perceive game items as representing good value for money. Higher spenders were older and reported using more payment methods, having a close friend who pays for Fortnite more often, and spent more hours playing Fortnite. Problematic gaming was associated with trait impulsivity, weekly time spent playing the game, and the perception that reducing time spent playing would diminish one's sense of self-worth. Fortnite loot box spending was not associated with GD symptoms. These data suggest that different implementations of in-game monetization schemes may have different risk potential for consumers across games.

Loot box engagement and problem gambling among adolescent gamers: Findings from a national survey.

Loot boxes represent a form of microtransaction in many video games that have some resemblance with gambling. Research on this subject is still in its infancy, and particular there are few studies involving young people. Using cross-sectional survey data from a representative sample of 1,137 participants aged 12-16 years, this study examined loot box engagement patterns and links with problem gambling severity. Nearly half (45.6%) of the participants that were involved in gaming in the past year engaged in loot box activities at some level, and loot box users were predominantly male. The vast majority of the males (93%) had earned, bought, or sold items from a loot box whereas 15% of the females reported engagement with loot boxes. There was a significant positive correlation between loot box engagement and problem gambling severity when controlling for core demo-graphic factors. Compared to participants with no engagement or participants who solely obtained a loot box, the proportions of at-risk and problem gamblers were higher among those, who had purchased or sold items from a loot box. The findings provide new insights into the links between loot box engagement and problem gambling among adolescent populations. Specifically, the study provides new knowledge on different engagement patterns among loot box users and their implications. On this basis, different measures to reduce loot box purchases and reduce marketplace structures are discussed.

The relationship between problem gambling, excessive gaming, psychological distress and spending on loot boxes in Aotearoa New Zealand, Australia, and the United States-A cross-national survey.

Loot boxes are digital containers of randomised rewards available in many video games. Due to similarities between some loot boxes and traditional forms of gambling, concerns regarding the relationship between spending on loot boxes in video games and symptoms of problematic gambling have been expressed by policy makers and the general public. We present the first investigation of these concerns in large cross-sectional cross-national samples from three countries (Aotearoa New Zealand, Australia, and the United States). A sample of 1,049 participants were recruited through Qualtrics' Survey Targeting service from a broad cross-section of the population in Australia (n = 339), Aotearoa New Zealand (n = 323), and the United States (n = 387). Participants answered a survey assessing problem gambling, problem gaming symptomology, and how much they spent on loot boxes per month. On average, individuals with problem gambling issues spent approximately $13 USD per month more on loot boxes than those with no such symptoms. Loot box spending was also associated with both positive and negative moods, albeit with small effect sizes. Analyses showed both interactions and correlations between problematic gambling and problematic gaming symptoms, indicating both some commonality in the mechanisms underlying, and independent contributions made by, these proposed diagnostic criteria. These results provide context for dialogues regarding how best to reduce the impacts of loot box spending among those with problematic gambling symptoms.

Videogame assisted exercise training in patients with chronic obstructive pulmonary disease: A preliminary study.

BACKGROUND: Exercise training is key to the comprehensive management of patients with chronic obstructive pulmonary disease (COPD). Interactive game-based systems have been proposed to improve effectiveness and compliance with exercise training. AIM: To evaluate the effectiveness of Wii Fit balance board as an additional tool for exercise training in patients with COPD. As a secondary aim we will evaluate the costs. METHODS: In a randomized controlled trial, patients were divided into experimental (EG) and control (CG) groups. The CG performed exercise training on a cycle ergometer three times a week for 6 weeks. The EG also followed a program (yoga, strength training, aerobic exercise) using the Wii Fit system. Pre and post treatment six-minute walking distance (6MWD) test, transitional dyspnea index (TDI), the Medical Research Council (MRC) score the Saint George's Respiratory Questionnaire (SGRQ), the body max index, airflow obstruction, dyspnea, and exercise capacity index (BODE) were assessed. RESULTS: The 6MWD increased from 410.7 (105.3) to 477.5 (122.4) and from 376.6 (81.0) to 420 (77.6) meters, in CG and EG respectively, p=0.0001 without any difference between groups. Both groups experienced significant improvements in TDI and SGRQ, but not in MRC and BODE, without any significant difference between groups. CONCLUSION: A Wii Fit balance board based video game program was feasible but did not add any benefit to a well conducted standard exercise training program in patients with COPD.

An analysis of the accessibility of video lottery terminals: the case of Montréal.

BACKGROUND: Researchers and public health officials in Canada, the United States and Australia have for some time noted broader geographic accessibility to gambling establishments, above all in socioeconomically underprivileged communities. This increase in availability could lead to more and more gambling problems. This article focuses, in an ecological perspective, in particular on a spatial analysis of the geographic accessibility of sites possessing a VLT permit in the Montréal area, i.e. Montréal Island, the South Shore and Laval, from the standpoint of the development of an indicator of the vulnerability (socioeconomic components and demographic components) to gambling of populations at the level of certain neighbourhood units (dissemination areas). With the recent development of geographic information systems (GIS), it is now possible to ascertain accessibility to services much more accurately, for example by taking into account the configuration of the road network. RESULTS: The findings of our analysis reveal widespread geographic accessibility to sites possessing a VLT permit in the downtown area and in pericentral districts. In some neighbourhood units, a site possessing a VLT permit may be within a three-minute walk. In the region studied overall, average walking time to a VLT site is nine minutes. Access to this type of service on foot is usually limited in the outskirts. However, a number of groups of sites possessing VLT permits are found along certain axial highways. According to local spatial self-correlation analyses, the findings suggest a significant link between walking accessibility to sites possessing VLT permits and the vulnerability of the communities. In a number of neighbourhood units with ready access to VLT's the populations display high vulnerability. CONCLUSION: These findings reveal that accessibility to sites possessing a VLT permit is often linked to the vulnerability (socioeconomic and demographic components) of communities. Reliance in our analyses on neighbourhood units with fairly small areas enabled us to emphasize the rectilinear dimension of the spatial distribution of sites possessing VLT permits. This is a significant link that public health officials must consider when elaborating programs to combat pathological gambling.

The influence of gaming expenditure on crime rates in South Australia: a local area empirical investigation.

Although there has been much speculation about the possible links between gambling and crime rates, relevant quantitative evidence has been practically non-existent in Australia to date. This paper reports the results of research that utilised a model designed to investigate the potential relationship between electronic gaming machine expenditures and property (income-generating) crime rates reported to police in local areas in South Australia in 2002-2003. The research found that the higher the expenditures on gaming machines in a particular local area per adult, the higher the income-generating crime rate in that area. No such relationship was found between gaming machine expenditure and non-income-generating crime rates. However, further research is required before any policy-relevant conclusions can be drawn.

A low-cost video game applied for training of upper extremity function in children with cerebral palsy: a pilot study.

The aim of the present study was to determine the user satisfaction of the EyeToy for the training of the upper limb in children with cerebral palsy (CP). User satisfaction was measured in 12 children with CP, using a postexperience questionnaire, primarily based on a presence questionnaire. In general, children with CP were satisfied with and motivated by the EyeToy training. In addition, a first evaluation study was performed to determine the effect of this training method on the upper limb function. Ten children with CP were randomly assigned to the intervention (mean age 11 years, 9 months; SD 2,3) and the control group (mean age 12 years, 3 months; SD 3,2). After a treatment period of 6 weeks, the intervention group completed a user satisfaction questionnaire. Functional outcome was measured using the Melbourne Assessment scores. Percentage scores of the Melbourne Assessment of 7 of the 10 children were the same or changed only 1% to 2% from baseline to followup. However, in the experimental group, two children improved more, 9% and 13% respectively. In conclusion, it can be said that the EyeToy is a motivational training tool for the training of children with CP and has the potential to improve upper extremity function.

Upper extremity movement reliability and validity of the Kinect version 2.

PURPOSE: Studies have shown that marker-less motion detection systems, such as the first generation Kinect (Kinect 1), have good reliability and potential for clinical application. Studies of the second generation Kinect (Kinect 2) have shown a large range of accuracy relative to balance and joint localization; however, few studies have investigated the validity and reliability of the Kinect 2 for upper extremity motion. This investigation compared reliability and validity among the Kinect 1, Kinect 2 and a video motion capture (VMC) system for upper extremity movements. DESIGN: One healthy, adult male performed six upper extremity movements during two separate sessions. All movements were recorded on the Kinect 1, Kinect 2 and VMC simultaneously. Data were analyzed using MATLAB (Natick, MA), Microsoft Excel (Redmond, WA), and SPSS (Armonk, NY). RESULTS: Results indicated good reliability for both Kinects within a day; results between days were inconclusive for both devices due to the inability to exactly repeat the desired movements. Range of motion (ROM) magnitudes for both Kinects were different from the VMC, yet patterns of motion were very highly correlated for both devices. CONCLUSION: Simple transformations of Kinect data could bring magnitudes in line with those of the VMC, allowing the Kinects to be used in a clinical setting. Implications for Rehabilitation The clinical implications of the investigation support the notion that the Kinects could be used in the clinical setting if an understanding of their limitations exists. Using the Kinects to make assessments with a given data collection session is acceptable. Using the Kinects to make comparisons across different days such as before or after an intervention should be approached with caution. The Kinect 2 provides a more cost effective option compared to the VMC. Additionally, the Kinect is more portable, requires less time to set-up, and takes up less space, thus increasing its overall usability compared to the VMC.

Risk Factors for Internet Gaming Disorder: Psychological Factors and Internet Gaming Characteristics.

Background: Understanding the risk factors associated with Internet gaming disorder (IGD) is important to predict and diagnose the condition. The purpose of this study is to identify risk factors that predict IGD based on psychological factors and Internet gaming characteristics; Methods: Online surveys were conducted between 26 November and 26 December 2014. There were 3568 Korean Internet game users among a total of 5003 respondents. We identified 481 IGD gamers and 3087 normal Internet gamers, based on Diagnostic and Statistical Manual for Mental Disorders (DSM-5) criteria. Logistic regression analysis was applied to identify significant risk factors for IGD; Results: The following eight risk factors were found to be significantly associated with IGD: functional and dysfunctional impulsivity (odds ratio: 1.138), belief self-control (1.034), anxiety (1.086), pursuit of desired appetitive goals (1.105), money spent on gaming (1.005), weekday game time (1.081), offline community meeting attendance (2.060), and game community membership (1.393; p < 0.05 for all eight risk factors); Conclusions: These risk factors allow for the prediction and diagnosis of IGD. In the future, these risk factors could also be used to inform clinical services for IGD diagnosis and treatment.

Free-to-play: About addicted Whales, at risk Dolphins and healthy Minnows. Monetarization design and Internet Gaming Disorder.

INTRODUCTION: Video games are not only changing due to technical innovation, but also because of new game design and monetization approaches. Moreover, elite gamer groups with financial in-game-investments co-finance all users of free-to-play-games. Besides questions on youth protection, the growing popularity of free-to-play games has fostered discussions on supposed associations to Internet Gaming Disorder (IGD). METHOD: Children and adolescents using free-to-play browser games were examined in a German school-based representative study (N=3967; age range 12 to 18). Based on a clinical self-report AICA-S (Wölfling et al., 2011), students were categorized into non-problematic, risky, and addicted users. Psycho-social problems (SDQ; Goodman, 1997), perceived stress (PSS; Cohen, Kamarck & Mermelstein, 1983), coping strategies (BriefCOPE; Carver, 1997), and Average Revenue per (Paying) User (ARPU) were investigated as dependent variables. Furthermore, an industry classification (Freeloaders, Minnows, Dolphins, and Whales) for free-to-play gamers was used for additional relations regarding IGD, SDQ, PSS, BriefCOPE, and ARPU. RESULTS: Among free-to-play gamers the prevalence of IGD amounted to 5.2%. Subjects classified with IGD displayed higher psycho-social symptoms than non-problematic users, reported higher degrees of perceived stress, and applied dysfunctional coping strategies more frequently. Additionally, we found a higher ARPU among subjects with IGD. CONCLUSION: ARPU is significantly associated with IGD. Whales share significant characteristics with addicted video gamers; Dolphins might be classified as risky consumers; Minnows and Freeloaders are rather non-pathological gamers. Vulnerability for stress, dysfunctional coping, and free-to-play gaming represent an unhealthy combination.