Background: Attention-Deficit/Hyperactivity Disorder (ADHD) is a prevalent neurodevelopmental condition characterized by inattention, hyperactivity, and impulsivity, significantly impacting the psychological, social, and academic well-being of affected children and adolescents. Traditional ADHD diagnostic methods often rely on subjective reports, which can be biased. Recent advancements in serious games offer potential for objective assessment tools. Objective: This study aimed to evaluate the discriminative power and concurrent validity of the serious game Attention Slackline in distinguishing children and adolescents with ADHD from those without the condition and in correlating game performance with standardized ADHD assessment scales. Methods: A sample of 32 children and adolescents diagnosed with ADHD and 39 healthy controls participated in the study. Participants were divided into two age groups: children (aged 6-11) and adolescents (aged 12-17). The serious game Attention Slackline was administered alongside established ADHD assessment scales (Child and Adolescent Assessment System (SENA) and ADHD Rating Scale IV (ADHD-RS). Performance in the game was compared across ADHD and control groups using multivariate ANCOVA, controlling for age and sex, and correlated with self-reported and family-reported ADHD symptoms. Results: Children with ADHD demonstrated significantly worse performance in Attention Slackline than the controls (t = -2.263; p = .027; | d | = 0.901), whereas no significant differences were observed in adolescents (t = 0.750; p = .734; | d |= 0.191). Task performance was negatively correlated with family-reported hyperactivity/impulsivity symptoms in children across both tests (r = -.427 and r = -.505), but a lack of significant correlations was observed in adolescents. Conclusions: The findings support the validity of Attention Slackline for assessing hyperactivity/impulsivity symptoms in children with ADHD. However, its efficacy decreases in adolescents, potentially due to developmental factors, such as compensatory strategies and ceiling effects in task performance. The gamified nature of the tool enhances engagement, which is crucial for young populations, while maintaining the diagnostic utility of measuring impulsivity. The age-dependent validity aligns with previous research indicating that Continuous Performance Test paradigms are less effective in older populations due to developmental maturation. Attention Slackline shows potential as a complementary tool for ADHD diagnosis in children, offering an engaging and objective assessment of hyperactivity/impulsivity. Future research should aim to establish clinical cut-off points and refine the task's complexity to align with individual characteristics.

Background: Attentional bias modification can help address implicit attention from individuals who smoke toward smoking cues, which trigger cravings and lapses that impede smoking cessation. We developed an attentional bias modification mobile game, Fruit Squish, to support individuals who smoke in quitting as part of a multi-component smoking cessation mobile application, Quit Journey. Users advance in the game by tapping on neutral (i.e., fruit) rather than smoking-related (e.g., cigarette pack) imagery that they are presented with, essentially training them to avoid focusing on smoking cues. Objective: This study aimed to gauge acceptance of an attentional bias modification smoking cues mobile game among young adults who smoked and were socioeconomically disadvantaged. Methods: We recruited 38 individuals who smoked cigarettes, aged 18-29 years, who were neither four-year college graduates nor enrollees in four-year colleges to participate in 12 semi-structured virtual focus groups. Sessions were audio recorded and transcribed verbatim. We used ATLAS.ti software to code the transcripts for salient themes based on the Second Unified Theory of Acceptance and Use of Technology constructs (i.e., effort expectancy, facilitating conditions, hedonic motivation, performance expectancy, social influence) and sentiment (i.e., negative, neutral, positive). Results: Performance expectancy of the mobile game was the dominant technology acceptance construct discussed (30.90%). Perceived usefulness of the game was mixed in sentiment owing to perceptions that the game aimed to distract individuals who smoke during cravings and concerns that cue imagery in the game could trigger cravings. Hedonic motivation was the second most discussed technology acceptance construct (15.45%), with participants describing the game as neither fun nor engaging. Participants referenced their past experiences with mobile games and mobile device characteristics as facilitating conditions to using the game (9.09%). Although effort expectancy was minimally discussed (5.45%), the game was characterized as easy to use. To improve the game, participants suggested adding new levels with increasing difficulty (e.g., increase stimuli speed, limit session time) and new game elements (e.g., leaderboard). Other suggestions included improving game graphics and renaming the game to capture its relation to smoking cessation. Conclusions: Young adults with low socioeconomic status who smoke had mixed reactions to a mobile smoking cues attentional bias modification game. Results suggest the need to communicate the rationale underlying attentional bias modification games to users and their potential positive effects on smoking cessation. To promote the uptake and sustained use of attentional bias modification mobile games, they need to be on par with commercially available entertainment mobile applications. Research is needed to explore the efficacy of gamified attentional bias modification on cognitive biases in real-life settings.

Background: Virtual reality (VR) technology has emerged as a promising tool for cognitive rehabilitation in neuropsychiatric patients. These patients often suffer from significant cognitive impairments, which are associated with decreased quality of life and increased disease burden. Traditional treatments have limited in improving cognitive functions, making VR-based interventions an area of growing interest. Objective: This meta-analysis aims to evaluate the efficacy of VR-based interventions on cognitive function in neuropsychiatric patients by synthesizing data from randomized controlled trials (RCTs). Methods: Following PRISMA guidelines, we conducted a comprehensive search across PubMed, Web of Science, Medline, EMBASE, and Cochrane Library for RCTs from January 2010 to December 2024. Studies were included if they evaluated VR-based interventions’ impact on cognitive outcomes in patients with neuropsychiatric disorders. Data extraction and risk of bias assessment were performed independently by two researchers. Meta-analyses were conducted using random-effects models, and standardized mean differences (SMD) as effect size. Results: A total of 21 RCTs involving 1051 participants were included. Overall, VR-based interventions significantly improved cognitive functions of neuropsychiatric patients (SMD, 95% CI: 0.67 [0.33, 1.01], Z = 3.85, P = .0001). Subgroup analyses revealed significant benefits for Cognitive Rehabilitation Training (SMD, 95% CI: 0.75 [0.33, 1.17], Z = 3.53, P = .0004), Exergame-based Training (SMD, 95% CI: 1.09 [0.26, 1.91], Z = 2.57, P = .01), and Tele-rehabilitation and Social Functioning Training (SMD, 95% CI: 2.21 [1.11, 3.32], Z = 3.92, P <.0001). Conversely, Immersive Cognitive Training, Music Attention Training, and Vocational and Problem-Solving Skills Training did not yield significant improvements (Z = 1.86, P = .06; Z = 0.35, P = .72; Z = 0.88, P = .38). Disease-type subgroup analyses indicated significant improvements in schizophrenia (SMD, 95% CI: 0.92[0.22, 1.62], Z = 2.58, P =.01), and mild cognitive impairment (SMD, 95% CI: 0.75[0.16, 1.35], Z = 2.47, P =.01), but not in brain injuries, Parkinson's disease, or stroke (Z=0.34, P=.73; Z=1.26, P=.21; Z=1.16, P=.24). Conclusions: This meta-analysis revealed that VR-based interventions can improve cognitive functions among individuals with neuropsychiatric disorders, with notable improvements observed in Cognitive Rehabilitation Training, Exergame-based Training, and Tele-rehabilitation and Social Functioning Training. These results offer valuable evidence supporting the use of VR technology in rehabilitation for neuropsychiatric conditions and inform the optimization of future intervention approaches. Clinical Trial: PROSPERO CRD42023445000; https://www.crd.york.ac.uk/PROSPERO/view/CRD42023445000

Background: Virtual Reality (VR) has experienced a surge in use for medical education, offering immersive environments where students can practice high-risk procedures such as pericardiocentesis safely and easily. This life-saving intervention is associated with high cognitive and emotional stress for the practitioner, making it crucial to evaluate not only the usability of a VR simulation of it, but also the physiological stress responses of its users. Heart Rate Variability (HRV) provides an objective measure of stress and can therefore be used to evaluate it. Finally, prior experience with VR can affect this stress response. Objective: This study aimed to (1) assess the usability of VR simulations for pericardiocentesis, (2) examine correlations between physiological stress, measured through HRV, and usability perceptions; and (3) investigate whether prior VR experience influences usability scores and stress levels Methods: Final-year medical students (N = 119) performed a VR-based pericardiocentesis simulation. Usability was evaluated using the System Usability Scale (SUS), Post-Study System Usability Questionnaire (PSSUQ), Simulator Sickness Questionnaire (SSQ), and Presence Questionnaire (PQ). Physiological stress was assessed via HRV parameters (rMSSD, PNN20, PNN50, LF/HF ratio, SD1/SD2, Poincaré Area). Prior VR experience was recorded, and data were analyzed using descriptive statistics, Spearman correlations, and Mann-Whitney U tests to examine relationships between usability, stress, and experience Results: Usability assessments showed moderate to high usability across all participants. SSQ scores indicated mild simulator sickness, primarily in the nausea and oculomotor dimensions. Significant negative correlations were observed between HRV parameters (rMSSD, PNN50, Poincaré Area) and SSQ scores (p < 0.05), suggesting that higher physiological stress during the experience is linked to more pronounced simulator sickness symptoms. Prior VR experience was associated with higher SUS scores and lower simulator sickness, though no significant impact on HRV responses was found Conclusions: VR simulations for high-risk procedures like pericardiocentesis are generally well received by medical students in terms of usability. However, physiological stress, as indicated by HRV, correlates with increased simulator sickness, highlighting the need for optimizing VR design to reduce discomfort. Prior VR experience enhances usability perceptions and reduces simulator sickness but does not significantly affect physiological stress markers. Future research should focus on balancing immersive learning with user comfort in medical VR applications, particularly for stress-inducing scenarios. Simulations without any interactions not already present in the real scenario simulated (teleportation, heads-up displays, etc.) are appropriate as first-time VR experiences for users

Background: The global waste problem is becoming more complex due to the increasing amount and volume of waste that a country cannot manage. Indonesia is one of the developing countries that has experienced this problem. Objective: This research proposes a model called Circonomy, which seeks to address waste management and enhance the circular economy in Indonesia. Our model, Circonomy, is inspired by the Waste Bank, which is regulated by Indonesian government regulations as one of the community-based waste management initiatives. This model comprises IoT-based components integrated with mobile and web applications, with a semantic web and gamification approach. Our research has contribution by proposing a model to enhance waste management and encourage users to reduce, reuse, and recycle waste (3Rs of waste management) by providing incentive schemas using IoT technology, Semantic Web, and Gamification. Methods: Design Research and Science Methodology is used to build the prototype as model implementation, which consists of six main activities, i.e.: (1) Problem Identification, (2) Solution Proposal, (3) Prototyping, (4) Evaluation, and (5) Statement of Learning, and (6) Communications. Results: The prototype has the main features of automatically weighing and recording waste collection using a load cell, motor servo, and ultrasonic sensor. The data obtained from the sensor is then sent to Wifi ESP 32, recorded at mobile and web applications, and presented at LED as bin status information. We have tested and evaluated our model in terms of technology and approach. There are some limitations to the accuracy of our smart bin’s detection related to the occupancy of the bin. The position of the ultrasonic sensor determines the accuracy of the bin’s occupancy calculation since not all the waste has the exact dimensions. Therefore, the placement and viewpoint of the ultrasonic sensor on the bin are crucial. However, we discover that the gamification approach is promising to be embedded in our model and prototype by adopting its concepts, such as points, rewards, and leaderboards. Conclusions: There is much to be done for our future works by adding more features from gamification concept, such as challenges and badges. The semantic web should be optimized through linked data to our gamification approach to connect and motivate all the stakeholders in waste management and circular economy activities.

Background: Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that often begins in childhood and requires long-term treatment and management. Given the potential adverse effects of pharmacological interventions in children, interest in alternative treatments has increased. Among alternative therapies, serious games have emerged as a promising digital therapeutic approach and are increasingly recognized as an important intervention for children with ADHD. Objective: This systematic review aims to evaluate the effectiveness of serious games as digital therapeutics for children with ADHD. It focuses on assessing therapeutic outcomes, including improvements in attention, hyperactivity-impulsivity, social skills, motor skills, executive functions, and enjoyment. Methods: The review was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A comprehensive literature search was performed across 5 databases: PubMed, Web of Science, Scopus, IEEE Xplore, and ACM Digital Library, covering English studies published from January 2010 to January 2024. Eligibility criteria were established based on the PICOS (Participants, Intervention, Comparison, Outcomes, Study design) framework, with digital therapeutics guidelines pragmatically applied to inform inclusion criteria, exclusion criteria, and quality assessment. Standardized tools including the Cochrane Risk of Bias Tool for randomized controlled trials, the Cochrane Risk of Bias Tool for Non-Randomized Studies of Interventions (ROBINS-I) for nonrandomized controlled trial studies, and the Critical Appraisal Skills Program checklists were used to evaluate risk of bias. Data on study design, targeted abilities, game software and hardware, and intervention parameters (duration, frequency, and length) were extracted and synthesized descriptively. Results: Of the 35 studies identified (1408 participants), gender data were available for 22 studies (888 participants), comprising 660 male and 228 female participants. Analysis revealed multiple abilities focused across many studies: 80% (28/35) assessed attention, 29% (10/35) addressed hyperactivity-impulsivity, 17% (6/35) explored improvements in social skills, 20% (7/35) evaluated motor skills, and 43% (15/35) investigated executive functions. Furthermore, in 89% (31/35) of the trials, children exhibited a positive attitude toward game interventions. Evidence suggests that serious games may contribute to improvements in attention, hyperactivity-impulsivity, social skills, and executive functions in children with ADHD. Although findings on motor skills were inconclusive, interventions incorporating somatosensory inputs demonstrated benefits for hand-eye coordination. Conclusions: The findings support the potential of serious games as a digital therapeutic modality for children with ADHD, offering benefits in core symptoms and associated impairments while promoting engagement. Trial Registration: PROSPERO CRD420250509693; https://www.crd.york.ac.uk/PROSPERO/view/CRD420250509693

Background: Emotion recognition bias in depression is well documented [1] and is proposed to play a causal role in depression [2]. A Cognitive Bias Modification (CBM) intervention targeting the bias in emotional expression perception was developed, but despite robust training effects on emotion perception, the effect on mood was unreliable and weak [3]. We propose a new gamified version of CBM (GCBM) to address potential limitations that may attenuate therapeutic effects. Objective: This study aimed to investigate the effectiveness of a single session of GCBM on emotion perception and to assess whether the gamified version of the task would produce the same robust training effects on the interpretation of emotional expressions as the original CBM. The second aim was to compare the effectiveness of a single session of CBM training, CBM (no training) control, and GCBM training on immediate mood. Methods: We report a between-subjects web-based experimental study that recruited participants from the general population (N = 916). We tested the effectiveness of GCBM in changing participants' responses to ambiguous facial expressions. The primary outcome was emotion recognition bias, measured by increased identification of happy faces. We also compared the effects of a single session of GCBM training, CBM training and CBM control conditions on immediate mood which was measured by the Immediate Mood Scaler (IMS). Results: Results showed that participants in the GCBM intervention condition classified more ambiguous faces as 'happy' after the training compared to controls, indicating an increased perception of happiness in ambiguous faces (B = 1.57, P < .001). There was also evidence that GCBM training produced more positive changes in immediate mood compared to the CBM control condition (B = -3.64, P = .003) and compared to the CBM training condition (B = 1.69, P = .048). Conclusions: GCBM demonstrated promising results in changing participants' emotion recognition bias to ambiguous facial expressions and enhance immediate mood compared to both CBM and control conditions. These results suggest that GCBM holds promise to be a better alternative to CBM for addressing mood-related cognitive biases. Further exploration of GCBM's long-term effects on mood and its clinical application is needed. Clinical Trial: Open Science Framework mv6sk; https://osf.io/mv6sk

Background: Overweight and obesity seriously affect physical and psychological health worldwide. They are common public health issues in young adults who are considered a 'vulnerable group' prone to adopt unhealthy lifestyles that can lead to overweight and obesity. Virtual reality exergames could help to increase balance performance among Parkinson’s disease patients and improve depression and pain interference among individuals with chronic neck pain. Still, limited research has been conducted on the use of virtual reality exergames among overweight and obese young adults and their willingness and acceptability remain unclear. Objective: This study aimed to assess the acceptability of and willingness to use virtual reality exergames for weight loss among overweight or obese young adults. Methods: This was a qualitative study. Sixteen young adults who were overweight or obese were recruited in Guangzhou, China and divided into four focus groups. They were interviewed between September and October 2023 through semi-structured interviews. NVivo 14 was used to transcribe, code, and thematically analyze interviews. Results: Four main themes and eight subthemes emerged from the data. The main themes included perception of previous weight loss measures (regarded exercise and diet as the main measures for weight loss, difficulties in holding on to the weight loss methods), acceptability of virtual reality exergames (increasing opportunities for exercise, a powerful means for propelling doing exercise, positive impact on psychological well-being, more appealing to office workers than students), willingness to use virtual reality exergames, and concerns (weight loss effect, other concerns). Conclusions: Virtual reality exergames were seen as beneficial for maintaining exercise and promoting psychological well-being among overweight or obese young adults, despite concerns about effectiveness, cost, and privacy. Almost all young adults indicated their willingness to try these kinds of games if given the opportunity. These findings suggested that virtual reality exergames could be a promising tool for weight management in this population.

Background: Immersive virtual reality (VR) and artificial intelligence have been used to determine whether a simulated clinical exam setting can reduce anxiety in first-year occupational therapy students preparing for objective structured clinical examinations (OSCEs). Test anxiety is common among postsecondary students, leading to negative outcomes such as increased dropout risk, lower grades, and limited employment opportunities. Students unfamiliar with specific testing environments are particularly prone to anxiety. VR simulations of OSCEs may allow students to become familiar with the exam setting and reduce anxiety. Objective: This study aimed to assess the efficacy of a VR simulation depicting clinical settings to reduce student anxiety about a clinical exam while gathering perspectives on their first-year coursework experiences to better understand their learning environment. Methods: An experimental, nonrandomized controlled trial compared state anxiety, trait test anxiety, and OSCE grades in 2 groups of first-year occupational therapy students analyzed using independent t tests (2-tailed). Group 1 (NoVR) was not exposed to the VR simulation and acted as a control group for group 2 (YesVR), who were exposed to the VR simulation. The VR used artificial intelligence in the form of a generative pretrained transformer to generate responses from virtual patients as students interacted with them in natural language. Self-reported psychometric scales measured anxiety levels 3 days before the OSCE. YesVR students completed perceived preparation surveys at 2 time points—3 weeks and 3 days before the OSCE—analyzed using dependent t tests. Semistructured interviews and focus groups were conducted within 1 week after the OSCE. Student perspectives on their classes and VR experiences were summarized using interpretative thematic analysis. Results: In total, 60 students—32 (53%) in the NoVR group and 28 (47%) in the YesVR group—participated in the study, and the YesVR group showed a significant reduction in state anxiety (t₅₈=3.96; P<.001; Cohen d=1.02). The mean difference was 11.96 units (95% CI 5.92-18.01). Trait test anxiety and OSCE scores remained static between groups. There was an increase in all perceived preparedness variables in the YesVR group. In total, 42% (25/60) of the participants took part in interviews and focus groups, providing major themes regarding factors that affect OSCE performance, including student experience and background, feedback and support, fear of unknown, self-consciousness, and knowledge of the exam environment. Conclusions: Intolerance of uncertainty may lead students to interpret ambiguous exam situations as overly precarious. Findings suggest that VR simulation was associated with reduced state anxiety, although results from this small, nonrandomized sample should be interpreted cautiously. Qualitative data indicated that VR helped students gain familiarity with clinical exam settings, potentially decreasing uncertainty-based anxiety. Future research with larger or randomized samples is needed to confirm these findings and explore advanced VR tools offering feedback to enhance learning.

Background: Smartwatch-based gamification holds great promise for enhancing fitness apps and promoting physical exercise; however, empirical evidence on its effectiveness remains inconclusive, partly due to “one-size-fits-all” design approaches that overlook individual differences. While the emerging research area of tailored gamification calls for more accurate user modeling and better customization of game elements, existing studies have relied primarily on rating scale–based measures and correlational analyses with methodological limitations. Objective: This study aimed to improve smartwatch-based gamification through an innovative user modeling approach to better motivate physical exercise among different user groups with tailored solutions. It incorporated both individual preferences and needs for game elements into the user segmentation process and used the maximum difference scaling (MaxDiff) technique, which can overcome the limitations of traditional methods. Methods: With data collected from 2 MaxDiff experiments involving 378 smartwatch users and latent class statistical models, the relative power of each of the 16 popular game elements was examined in terms of what users liked and what motivated them to exercise based on which distinct user segments were identified. Prediction models were also proposed for quickly classifying future users into the right segments to provide them with tailored gamification solutions on smartwatch fitness apps. Results: We identified 3 segments of smartwatch users based on their preferences for gamification. More importantly, we uncovered 4 segments motivated by goals, immersive experiences, rewards, or social comparison. Such user heterogeneity confirmed the susceptibility of the effects of gamification and indicated the necessity of accurately matching gamified solutions with user characteristics to better change health behaviors through different mechanisms for different targets. Important differences were also observed between the 2 sets of user segments (ie, those based on preferences for game elements vs those based on the motivational effects of the elements), indicating the gap between what people enjoy using on smartwatches and what can motivate them for physical exercise engagement. Conclusions: To our knowledge, this study is the first to investigate MaxDiff-based user segmentation for tailored gamification on smartwatches promoting physical exercise and contributes to a detailed understanding of preferences for, and the effectiveness of, different game elements among different groups of smartwatch users. As existing tailored gamification studies continue to explore ways of user modeling with mostly surveys and questionnaires, this study supported the adoption of MaxDiff experiments as an alternative method to better capture user heterogeneity in the health domain and inform the design of tailored solutions for more application types beyond smartphones.