An Integrative Model for the Effectiveness of Biofeedback Interventions for Anxiety Regulation: Viewpoint.

Biofeedback has shown to be a promising tool for the treatment of anxiety; however, several theoretical as well as practical limitations have prevented widespread adaptation until now. With current technological advances and the increasing interest in the use of self-monitoring technology to improve mental health, we argue that this is an ideal time to launch a new wave of biofeedback training. In this viewpoint paper, we reflect on the current state of biofeedback training, including the more traditional techniques and mechanisms that have been thought to explain the effectiveness of biofeedback such as the integration of operant learning and meditation techniques, and the changes in interoceptive awareness and physiology. Subsequently, we propose an integrative model that includes a set of cognitive appraisals as potential determinants of adaptive trajectories within biofeedback training such as growth mindset, self-efficacy, locus of control, and threat-challenge appraisals. Finally, we present a set of detailed guidelines based on the integration of our model with the mechanics and mechanisms offered by emerging interactive technology to encourage a new phase of research and implementation using biofeedback. There is a great deal of promise for future biofeedback interventions that harness the power of wearables and video games, and that adopt a user-centered approach to help people regulate their anxiety in a way that feels engaging, personal, and meaningful.

A Stimulated Recall Method for the Improved Assessment of Quantity and Quality of Social Media Use.

BACKGROUND: Social media are as popular as ever, and concerns regarding the effects of social media use on adolescent well-being and mental health have sparked many scientific studies into use effects. Social media research is currently at an important crossroads: conflicting results on social media use's effects on well-being are abundant, and recent work in the field suggests that a new approach is required. The field is in need of an approach involving objective data regarding use where necessary and attention to different kinds of detail such as the why and how of social media use. OBJECTIVE: We present a novel paradigm implementing a principle from educational sciences called stimulated recall and demonstrate how it can be applied to social media use research. Our stimulated recall paradigm implements a number of elements that can fill the gaps currently present in social media and well-being research. METHODS: Objective data are collected regarding users' social media behaviors through video footage and in-phone data and used for a structured stimulated recall interview to facilitate detailed and context-sensitive processing of these objective data. In this interview, objective data are reviewed with the participant in an act of co-research, in which details such as the reasons for their use (eg, boredom) and processes surrounding their use (eg, with whom) are discussed and visualized in a stimulated recall chart. RESULTS: Our ongoing study (N=53) implementing this paradigm suggests this method is experienced as pleasant by participants in spite of its personal and intensive nature. CONCLUSIONS: The stimulated recall paradigm offers interesting and necessary avenues for approaching social media use research from new angles, addressing aspects of use that have thus far remained underexposed. The answers to questions such as "Why do adolescents use social media?" "In what ways exactly do they use social media?" and "How does social media use make them feel in the moment?" are now within reach, an important step forward in the field of social media use and well-being research.

A randomized controlled trial to test the effectiveness of a peer-based social mobile game intervention to reduce smoking in youth.

Smoking is a major cause of worldwide morbidity and mortality. Almost no evidence-based intervention programs are available to help youth quit smoking. We argue that ineffective targeting of peer influence and engagement difficulties are significant barriers to successful youth smoking cessation. To address these barriers, we developed the mobile game intervention HitnRun. A two-armed randomized controlled trial (RCT; n = 144) was conducted and young smokers (Mage = 19.39; SDage = 2.52) were randomly assigned to either play HitnRun or read a psychoeducational brochure. Prior to, directly following the intervention period, and after three-month follow-up, weekly smoking behavior, abstinence rates, intervention dose, and peer- and engagement-related factors were assessed. Results indicated similar reductions in weekly smoking levels and similar abstinence rates for both groups. Yet, we found a dose effect with HitnRun only: The longer participants played HitnRun, the lower their weekly smoking levels were. In the brochure group, a higher dose was related to higher weekly smoking levels at all measurement moments. Exploratory analyses showed the most powerful effects of HitnRun for participants who connected with and were engaged by the intervention. Future work should build on the promising potential of HitnRun by increasing personalization efforts and strengthening peer influence components.

Use of the Principles of Design Thinking to Address Limitations of Digital Mental Health Interventions for Youth: Viewpoint.

Numerous reviews and meta-analyses have indicated the enormous potential of technology to improve the appeal, effectiveness, cost, and reach of mental health interventions. However, the promise of digital mental health interventions for youth has not yet been realized. Significant challenges have been repeatedly identified, including engagement, fidelity, and the lack of personalization. We introduce the main tenets of design thinking and explain how they can specifically address these challenges, with an entirely new toolbox of mindsets and practices. In addition, we provide examples of a new wave of digital interventions to demonstrate the applicability of design thinking to a wide range of intervention goals. In the future, it will be critical for scientists and clinicians to implement their scientific standards, methods, and review outlets to evaluate the contribution of design thinking to the next iteration of digital mental health interventions for youth.

When winning is losing: A randomized controlled trial testing a video game to train food-specific inhibitory control.

Overweight and obesity are major causes of worldwide morbidity and mortality. A two-armed randomized controlled trial (n = 104) examined the effectiveness of Hit n Run, a video game based on the principles of Go/No-Go inhibition training, in young adults who reported disinhibited eating. Adults (aged 18 to 30) were randomly assigned to play Hit n Run or received an informative brochure (Healthy Eating Step by Step; HESbS). Prior to and directly following the intervention week general and food-specific inhibitory control, caloric intake, and perceived attractiveness of food pictures were assessed. Results revealed no improvements in food-specific inhibitory control or caloric intake in either intervention group. Similar improvements for general inhibitory control and similar decreases in perceived attractiveness of food-related stimuli were observed for both Hit n Run and HESbS. Future research should aim to clarify how video game design can implement working mechanisms of cognitive training tasks to facilitate the development of effective game-based interventions.

Investigating the impact of a health game on implicit attitudes towards food and food choice behaviour of young adults.

Improving diets by stimulating fruit and vegetable consumption might be beneficial, in particular when they substitute energy-dense products. The aim of present study was to investigate whether a health game can be used to positively affect healthy implicit attitudes (IAs) towards food and subsequent food choice behaviour of young adults. A 2 (Time: baseline vs. post-test) x 2 (Condition: health game vs. control game) x 2 (Baseline IAs: healthy IAs vs. less healthy IAs) mixed-subjects design was used with 125 participants (age: M = 20.17, SD = 1.88). IAs towards food were assessed at baseline and post-test using an Implicit Association Test (IAT). Additionally, food choice behaviour was assessed after game play. At baseline, the majority of participants had healthy IAs (i.e., favouring fruit over chocolate snacks). At post-test, significantly less healthy IAs were observed in the control condition, while this reduction was not significant in the health game condition. Regarding food choice behaviour, participants with healthy baseline IAs were more likely to select fruit in the health game condition than participants with healthy baseline IAs in the control game condition. However, participants with less healthy baseline IAs were less likely to select fruit in the health game condition than in the control condition. We found tentative support that health games can be used to influence IAs towards food and positively affect food choice behaviour. However, this influence was only observed for those with healthy baseline IAs. The current version of the health game would primarily benefit those already healthy and could negatively affect those that need the intervention most, so modifications are recommendable.

Preventing Childhood Anxiety Disorders: Is an Applied Game as Effective as a Cognitive Behavioral Therapy-Based Program?

A large proportion of children experience subclinical levels of anxiety and cognitive-behavioral therapy (CBT) aimed at preventing anxiety disorders is moderately effective. However, most at-risk children do not seek help or drop out of programs prematurely because of stigma, lack of motivation, and accessibility barriers. Applied games have received increased attention as viable alternatives and have shown promising results, but direct comparisons between applied games and the gold-standard CBT are lacking. Our aim was to investigate whether the applied game MindLight is as effective as CBT (i.e., Coping Cat) within an indicated prevention context. We conducted a randomized controlled non-inferiority trial with a sample of 174 children (7- to 12-year olds) with elevated levels of anxiety, comparing MindLight to CBT. Anxiety was assessed with self- and parent-reports at pre- and post-program, and at 3- and 6-month follow-ups. Intention-to-treat and completers-only confidence interval approach and latent growth curve modeling showed an overall significant quadratic decrease in child- and parent-reported anxiety symptoms over time and, as predicted, the magnitude of improvement was the same for MindLight and CBT. The within-group effect sizes were small to medium at post-test (- 0.32 to - 0.63), and medium to large (- 0.60 to - 1.07) at 3- and 6-month follow-ups. Furthermore, MindLight and CBT were rated equally anxiety inducing, difficult, and appealing; CBT was rated as more relevant to daily life than MindLight. The current study adds to the growing research on applied games for mental health and shows that these games hold potential as alternative delivery models for evidence-based therapeutic techniques.

Emotion differentiation and its relation with emotional well-being in adolescents.

Emotion differentiation (ED) refers to the precision with which people can identify and distinguish their emotions and has been associated with well-being in adults. This study investigated ED and its relation with emotional well-being (i.e. depressive symptoms, positivity and negativity intensity and propensity, implicit theories of emotions) in adolescents. We used an experience sampling method with 72 participants (Mage = 14.00, 71% girls) to assess adolescents' positive and negative emotions at different time points over the course of two weekends and a baseline questionnaire to assess emotional well-being. Differentiating negative emotions was related to less negativity intensity and propensity, and to the belief that emotions are malleable. Differentiating positive emotions was not related to any of the assessed well-being variables. Together, these results suggest that a detailed awareness of one's negative emotional states is an important dimension of well-being, also in adolescence.

A mathematical model of embodied consciousness.

We introduce a mathematical model of embodied consciousness, the Projective Consciousness Model (PCM), which is based on the hypothesis that the spatial field of consciousness (FoC) is structured by a projective geometry and under the control of a process of active inference. The FoC in the PCM combines multisensory evidence with prior beliefs in memory and frames them by selecting points of view and perspectives according to preferences. The choice of projective frames governs how expectations are transformed by consciousness. Violations of expectation are encoded as free energy. Free energy minimization drives perspective taking, and controls the switch between perception, imagination and action. In the PCM, consciousness functions as an algorithm for the maximization of resilience, using projective perspective taking and imagination in order to escape local minima of free energy. The PCM can account for a variety of psychological phenomena: the characteristic spatial phenomenology of subjective experience, the distinctions and integral relationships between perception, imagination and action, the role of affective processes in intentionality, but also perceptual phenomena such as the dynamics of bistable figures and body swap illusions in virtual reality. It relates phenomenology to function, showing the computational advantages of consciousness. It suggests that changes of brain states from unconscious to conscious reflect the action of projective transformations and suggests specific neurophenomenological hypotheses about the brain, guidelines for designing artificial systems, and formal principles for psychology.

Jealousy in adolescents' daily lives: How does it relate to interpersonal context and well-being?

Past studies have shown that jealousy peaks in adolescence. However, little is known about how and when adolescents experience jealousy in their daily lives. The current study aimed to examine the relation between state jealousy, the more general propensity to feel jealous, the interpersonal contexts in which jealousy arises, and different forms of social comparison. The impact of jealousy on perceptions of well-being was also explored. We used an experience sampling method during two weekends with 68 adolescents (Mage = 13.94; 64.70% girls). Jealousy was common: On average, 90% of our sample experienced jealousy in 20% of the assessments. Adolescents reported more jealousy with peers than with family. Additionally, they experienced more jealousy when in online contexts than when in face-to-face peer contexts. The normative nature of jealousy, its developmental function and relation with well-being, and implications for understanding jealousy triggered in (highly social) online contexts are discussed.

Video Gaming and Children's Psychosocial Wellbeing: A Longitudinal Study.

The effects of video games on children's psychosocial development remain the focus of debate. At two timepoints, 1 year apart, 194 children (7.27-11.43 years old; male = 98) reported their gaming frequency, and their tendencies to play violent video games, and to game (a) cooperatively and (b) competitively; likewise, parents reported their children's psychosocial health. Gaming at time one was associated with increases in emotion problems. Violent gaming was not associated with psychosocial changes. Cooperative gaming was not associated with changes in prosocial behavior. Finally, competitive gaming was associated with decreases in prosocial behavior, but only among children who played video games with high frequency. Thus, gaming frequency was related to increases in internalizing but not externalizing, attention, or peer problems, violent gaming was not associated with increases in externalizing problems, and for children playing approximately 8 h or more per week, frequent competitive gaming may be a risk factor for decreasing prosocial behavior. We argue that replication is needed and that future research should better distinguish between different forms of gaming for more nuanced and generalizable insight.

Executive function in children with externalizing and comorbid internalizing behavior problems.

BACKGROUND: The goal of this study is to investigate differences in executive function (EF) in children with different levels of disruptive behavior problems (DBP). METHODS: Ninety-three children between 7 and 12 years old with DBP were compared to 63 normally developing peers on a battery of EF tasks that varied in the amount of required emotion regulation ('hot' EF). RESULTS: Differences in EF were found between DBP and comparison groups as indexed by hot EF tasks. Self-reported emotion scales, in conjunction with physiological recordings of heart rate, confirmed that emotions were elicited during hot EF. CONCLUSIONS: Results suggest that difficulties in hot EF underlie externalizing problem behaviors in middle childhood.

The effect of the video game Mindlight on anxiety symptoms in children with an Autism Spectrum Disorder.

BACKGROUND: In the clinical setting, a large proportion of children with an autism spectrum disorder (ASD) experience anxiety symptoms. Because anxiety is an important cause of impairment for children with an ASD, it is necessary that effective anxiety interventions are implemented for these children. Recently, a serious game called Mindlight has been developed that is focused on decreasing anxiety in children. This approach is based on recent research suggesting that video games might be suitable as an intervention vehicle to enhance mental health in children. In the present study it will be investigated whether Mindlight is effective in decreasing (sub) clinical anxiety symptoms in children who are diagnosed with an ASD. METHODS/DESIGN: The present study involves a randomized controlled trial (RCT) with two conditions (experimental versus control), in which it is investigated whether Mindlight is effective in decreasing (sub) clinical anxiety symptoms in children with an ASD. For this study, children of 8-16 years old with a diagnosis of an ASD and (sub) clinical anxiety symptoms will be randomly assigned to the experimental (N = 60) or the control (N = 60) condition. Children in the experimental condition will play Mindlight for one hour per week, for six consecutive weeks. Children in the control condition will play the puzzle game Triple Town, also for one hour per week and for six consecutive weeks. All children will complete assessments at baseline, post-intervention and 3-months follow-up. Furthermore, parents and teachers will also complete assessments at the same time points. The primary outcome will be child report of anxiety symptoms. Secondary outcomes will be parent report of child anxiety, child/parent report of depressive symptoms, and parent/teacher report of social functioning and behavior problems. DISCUSSION: This paper aims to describe a study that will examine the effect of the serious game Mindlight on (sub) clinical anxiety symptoms of children with an ASD in the age of 8-16 years old. It is expected that children in the experimental condition will show lower levels of anxiety symptoms at 3-months follow-up, compared to children in the control condition. If Mindlight turns out to be effective, it could be an important contribution to the already existing interventions for anxiety in children with an ASD. Mindlight could then be implemented as an evidence-based treatment for anxiety symptoms in children with an ASD in mental health institutes and special education schools. TRIAL REGISTRATION: Dutch Trial Register NTR5069 . Registered 20 April 2015.

Neural Rhythms of Change: Long-Term Improvement after Successful Treatment in Children with Disruptive Behavior Problems.

Neural changes were investigated for children with disruptive behavior problems one year after a treatment program ended. Thirty-nine children and their parents visited the research lab before, after, and a year after treatment ended. During those lab visits, electroencephalography (EEG) was recorded during a challenging Go/No-go task. Treatment consisted of intensive 14-week combined cognitive behavioral therapy and parent management training sessions. For the analysis, participants were divided into long-term improvers (IMPs) and long-term nonimprovers (NIMPs) based on changes in their externalizing problem scores. The results showed early no-go theta power (4-8 Hz, 100-250 ms) decreased for long-term IMPs compared to NIMPs. When participants were divided based on changes in their comorbid internalizing symptoms, effects were stronger and reductions in theta power were found for early as well as later phases (250-650 ms). We provided preliminary evidence that theta power is a useful neural measure to trace behavioral change linked to improved self-regulation even up to a year after treatment ended. Results may have implications for the characterization of children with disruptive behavior problems and may lead to the development of novel markers of treatment success.

The role of anxiety in the development, maintenance, and treatment of childhood aggression.

The majority of aggressive children exhibit symptoms of anxiety, yet none of our developmental models of aggression incorporate the role of anxiety, and our treatments ignore this comorbidity. This article outlines a novel theoretical model that specifies three hypotheses about comorbid anxious and aggressive children: (a) unpredictable parenting induces anxiety in children that in turn triggers aggressive behavior; (b) prolonged periods of anxiety deplete children's capacity to inhibit impulses and trigger bouts of aggression, and aggression in turn functions to regulate levels of anxiety; and (c) minor daily stressors give rise to anxiety while cognitive perseveration maintains anxious moods, increasingly disposing children to aggress. Little or no research has directly tested these hypotheses. Extant research and theory consistent with these claims are herein reviewed, and future research designs that can test them specifically are suggested. The clinical implications most relevant to the hypotheses are discussed, and to improve the efficacy of treatments for childhood aggression, it is proposed that anxiety may need to be the primary target of treatment.

Effectiveness of applied and casual games for young people's mental health: A systematic review of randomised controlled studies.

Many youth experience mental health problems and digital games hold potential as mental health interventions. This systematic review provides an overview of randomised controlled studies assessing the effectiveness of digital applied and casual games for improving mental health in youth aged 6-24 years. A systematic search of PsycINFO, Web of Science and Pubmed yielded 145 eligible studies. Studies on (sub)clinical participant samples (n = 75) most often focused on attention-deficit/hyperactivity disorder (ADHD), autism and anxiety. Applied games were found most effective for improving social skills, verbal memory and anxiety, whereas casual games were found most effective for improving depression, anxiety and ADHD. Studies involving healthy youth (n = 70) were grouped into papers examining anxiety in medical settings, momentary effects on positive and negative affect, and papers employing a longitudinal design measuring mental health trait outcomes. Promising results were found for the use of games as distraction tools in medical settings, and for applied and casual games for improving momentary affect. Overall, our findings demonstrate the potential of digital games for improving mental health. Implications and recommendations for future research are discussed, such as developing evaluation guidelines, clearly defining applied games, harmonising outcome measures, including positive outcomes, and examining nonspecific factors that may influence symptom improvement as well.

Does stress increase imitation of drinking behavior? An experimental study in a (semi-)naturalistic context.

BACKGROUND: That alcohol consumption is strongly influenced by the drinking behavior of social company has been demonstrated in observational research. However, not everyone is equally vulnerable to other people's drinking, and it is important to unravel which factors underlie these individual differences. This study focuses on the role of psychosocial stress in attempting to explain individual differences in the propensity to imitate alcohol consumption. METHODS: With a 2 (confederate's drinking condition: alcohol vs. soda) × 2 (participant's stress condition: stress vs. no stress) experimental design, we tested whether the tendency to imitate other people's drinking was related to participants' induced stress levels. The young male adults (N = 106) were randomly assigned to each of the conditions. In each session, directly after the stress or no-stress period, confederates and participants entered a bar laboratory where we observed their drinking behavior. Prior to entering the session, confederates were instructed to drink alcohol or soda. RESULTS: Participants in both stress and no-stress conditions consumed substantially more alcohol when confederates drank alcohol than when they drank soda. There was no difference in alcohol consumed between stress and no-stress conditions. No moderating effect of stress on the tendency to drink along with peers was found. CONCLUSIONS: Generally, it appears that among young male adults, imitation of alcohol consumption is a robust phenomenon not dependent on individual stress levels.

Effectiveness of a cognitive-behavioral therapy (CBT) manualized program for clinically anxious children: study protocol of a randomized controlled trial.

BACKGROUND: In the Netherlands, the prevalence of anxiety disorders is 20%; and children with anxiety are at increased risk for psychopathology throughout adulthood. Recently, a revised version of a cognitive behavioral therapy manualized program called 'Thinking + Doing = Daring' (TDD) was developed for children between 8 and 12 years old with an anxiety disorder. The main aim of this project is to conduct a Randomized Controlled Trial (RCT) to evaluate the effectiveness of TDD. METHODS/DESIGN: The CBT program will be tested with a RCT with 120 clinically anxious children (8-12 years old) referred to one of three mental health care agencies. Children will be randomly assigned to the experimental (N = 60, TDD) or to the control condition (N = 60, treatment as usual). The primary outcome measure will be the child's anxiety symptoms level. Secondary outcome measures will be externalizing (e.g. aggression) and internalizing problems (e.g. depression). Two potential mediators of change will be examined in the current study: therapeutic alliance and parenting. Mother and child in both the experimental and control condition will be surveyed at baseline, post treatment and after 6 and 12 months (follow-up). It is hypothesized that children in the experimental condition will show a stronger decrease in anxiety symptoms compared to children that receive treatment as usual. Moreover, we expect that a strong therapeutic alliance and decreases in parental control and rejection will contribute to treatment success. DISCUSSION: Early treatment for anxiety problems has the potential to not only result in anxiety reductions, but also to prevent future problems such as substance abuse and psychopathology throughout adulthood. Our results will be immediately relevant to practice, since we are partnering with 'real world' community agencies. If the CBT program proves more effective than treatment as usual, it could be implemented in community mental health care agencies across the Netherlands and beyond. Moreover, it has the potential to make treatment in these community settings shorter, more efficient and therefore cost-effective. TRIAL REGISTRATION: Nederlands Trial Register NTR2967.

Emotion regulation in children with behavior problems: linking behavioral and brain processes.

Past studies have shown that aggressive children exhibit rigid (rather than flexible) parent-child interactions; these rigid repertoires may provide the context through which children fail to acquire emotion-regulation skills. Difficulties in regulating emotion are associated with minimal activity in dorsal systems in the cerebral cortex, for example, the anterior cingulate cortex. The current study aimed to integrate parent-child and neurocognitive indices of emotion regulation and examine their associations for the first time. Sixty children (8-12 years old) referred for treatment for aggression underwent two assessments. Brain processes related to emotion regulation were assessed using dense-array EEG with a computerized go/no-go task. The N2 amplitudes thought to tap inhibitory control were recorded, and a source analysis was conducted. In the second assessment, parents and children were videotaped while trying to solve a conflict topic. State space grids were used to derive two dynamic flexibility parameters from the coded videotapes: (a) the number of transitions between emotional states and (b) the dispersion of emotional states, based on proportional durations in each state. The regression results showed that flexibility measures were not related to N2 amplitudes. However, flexibility measures were significantly associated with the ratio of dorsal to ventral source activation: for transitions, ΔR 2 = .27, F (1, 34) = 13.13, p = .001; for dispersion, ΔR 2 = .29, F (1, 35) = 14.76, p < .001. Thus, in support of our main hypothesis, greater dyadic flexibility was associated with a higher ratio of dorsomedial to ventral activation, suggesting that children with more flexible parent-child interactions are able to recruit relatively more dorsomedial activity in challenging situations.

The strong effect of other people's drinking: two experimental observational studies in a real bar.

Research has demonstrated that when people are with heavy-drinking peers, they consume more alcohol than when they are in the company of light-drinking peers. This social influence process has usually been investigated in clinical laboratories or seminaturalistic drinking settings such as laboratory bars. The question remains whether these robust effects can be replicated in real-life drinking settings. The aim of these experimental studies was to examine social influence processes in real bars. In Study 1 a two (confederate drank alcoholic vs. nonalcoholic drinks) by two (male vs. female participant) between-participant design was used to test imitation in same-sex dyads (N = 79). Study 2 tested differences in imitation between same- and other-sex dyads with a two (confederate drank alcoholic vs. nonalcoholic drinks) by two (male vs. female confederate) between-participant design (N = 60). Both studies showed that participants consumed more alcohol in the alcohol condition than the nonalcohol condition. No sex differences emerged in the extent to which participants imitated their drinking partners. Study 2 demonstrated no difference in imitation between same-sex and other-sex dyads. Results support the ecological validity of research on imitation of alcohol consumption conducted in laboratory bars.