Thank you very much. As soon as I get my slides on, I can talk, because I'm an academic, and I can't do otherwise. So today, I'd like to talk to you about a program of research and an approach that we've been taking trying to develop and evaluate games that are designed

to promote emotional health and well-being in children and adolescents in particular. And I want to tell you particularly about some of the biofeedback games that we've been designing and testing. A little bit about myself. I am a developmental psychologist by graduate training. And I got my PhD at University of Toronto.

Most of my research has been on trying to look at the interventions that work for children that have anxiety and depression problems, as well as aggression. And for a long time, I tried to look at the kind of conventional programs like cognitive behavioral therapy, which if you were in the last session, you heard a little bit about. And that's basically the evidence-based practice

for children with anxiety and depression problems. And for a long time, I ran randomized control trials with these conventional programs in schools, in mental health agencies. And we continued to get reasonable results. They're the small to moderate effect sizes that normally most people get when they run these trials,

which means that anywhere between 40% to 60% of the kids aren't benefiting. But we still find a reasonable effect. For psychology, that's pretty good, actually. But I started to get really frustrated with those results. And so what you see now is really the result of what pushed me into thinking about games for mental health. So here's the problem.

The World Health Organization and a whole lot of other people and a lot of research and meta-analyses have shown us that anxiety and depression are the leading cause of disability worldwide. I can give you numbers. They run in the tens of billions across the world. About one in four children or adolescents, so up to 18 years old, has a diagnosable anxiety disorder.

This is the same for depression. One in four of us here in the room has been diagnosed or is diagnosable. Almost everyone, I think all of us, knows somebody with anxiety and depression if we ourselves have not suffered. It's a huge problem. And about 40% of people are suspected to have the problems

but remain undiagnosed. In terms of prevention and treatment, as I said, we generally get these small to moderate effect sizes and 80% of people who really need the help don't seek treatment, mainly for two reasons. One is stigma, so we don't wanna say that we're having problems, that we're vulnerable, especially adolescents.

And second is detection problems. So teachers, parents, even mental health experts who are more concerned with aggressive behavior problems can't see the anxiety and depression early enough to get the help that people need. But certainly GPs, general practitioners, are having a really difficult time

identifying these people. So one of the ways that we can address a whole lot of problems when it comes to treatment and prevention of mental health concerns might come from the use of video games. So let me tell you why. First, in most of our conventional programs,

kids are bored. It's a lot of this didactic kind of thing that I'm doing right now with you. The kids are listening, taking notes on the thinking traps they have and how they should change their thinking problems into more positive habits. And we give them lots of exercise and homework to take home, but it's dead boring under normal circumstances.

They also don't get to practice these skills that we try to give them in emotionally engaging contexts. Those are the contexts where they most need these skills. They need to learn how to use their restructuring and reframing of cognitive bad habits in the context when they're really anxious or when they're feeling depressed and isolated.

So they don't get to practice usually in our conventional programs. Cost and access, you guys all must know that it's a big problem. With games, you have very little stigma as well. There are very few people that wanna go into a school program and say, please sign me up. I have a problem with depression and anxiety and I'm a 16 year old. There's huge stigma,

but if you had games that could actually train these same kind of skills, you might have a different effect on kids. And personalization, usually what we do in conventional CBT programs, cognitive behavioral programs, is we take the same program and we give it to a classroom full of you guys, right? And we say, this is the kind of things

that you all have to learn, equally at the same time with the same amount. So there's no personalization to each of our own issues. What kinds of anxieties do we have? We have social anxiety or do we have phobias of heights and so on. Personalization is a wonderful thing that games can give. They offer this opportunity to tweak

and dynamically adjust to each player in the state that they're in emotionally in terms of the skills they know and so on. And most of you know here, most of you play games, and you know that they adjust to the level and the skill capacity of the player.

So we have recently, well recently in the last couple of years, launched the GEM Lab, which is the Games for Emotional and Mental Health. And we have three sort of pillars to the GEM Lab. We have research, which is really important, that comes obviously from my academic background. We are really interested in disseminating this research

and I wanna end with talking about some less conventional ways of disseminating research that we're thinking about. And then we have game design. And this part is what's pretty much lit me up for the last two years, is working with artists and designers together with the scientists to design games that actually will

not only help kids get better, but also delight them, engage them, bring them into a space that is an artful experience that they can transform their own emotional habits. So let me tell you about some of this multidisciplinary game design that we're involved in.

It's called the GEM Framework and we're really coming from a perspective that if some of you know the sort of what they're calling serious games world, you know that there's a whole lot of people in the education space and the medical space trying to create what's called serious games. I hate the term serious games. I hate it because the whole reason

I went into game design and using games in these intervention purposes was to stop being serious with kids, was to go to the level of these kids and go, what would delight you? What would make you want to learn something new? What would make you transform your habits that you have grown into for eight, 10, 12, 14 years?

And it's a space to respect them. It's a place where you want to play with them and I don't think that's serious. So this is a lovely quote that I love and it really points to what we do at the GEM Lab is to try to prioritize art at the same level as the science. I'm deep down a scientist. I will show you randomized control data

but I wanna say that it's really, really important to also prioritize the art. So Leo Tolstoy said, real science studies and makes accessible that knowledge which people at that period of history think important and real art transforms this truth from the domain of knowledge to the domain of feelings.

And I love that. That's exactly what I'd love to try to do. And so I don't know how many of you know Maurice Sendak's work. That's what I love about Maurice Sendak. At least half of you know it no matter what country I'm in. So he was a real strong proponent of writing for children at their level

which means at the same level that you and I are at. It meant writing about the range of emotions not just the happy, happy, joy, joy ones but the anxious ones, the angry, frustrated ones and the depressed ones. So in all of his books he had this range of emotions depicted and that's what we wanna do in our games. He said grownups desperately need to feel safe

and then they project onto the kids. But what none of us seem to realize is how smart kids are. They don't like what we write for them, what we dish up for them because it's vapid. So they'll go for the hard words. They'll go for the hard concepts. They'll go for the stuff where they can learn something. Not didactic things but passionate things.

And that's how we overcome our demons. That's how I think we get through our anxiety and our isolation and sadness is by overcoming them and addressing them. And of course games are this beautiful context. Games are emotional. At their very best, as artistic interactive pieces,

games can first of all mirror one's emotional experiences and provide rich experience for self-reflection and illuminate pathways to transcend pain. That's how I think of games, the best of games. And these are some of my favorites that many of you may recognize. So what we do in the science part of it

is that we start off with this framework where the scientists and the academics get together with clinicians. So these are clinical PhD masters, clinical clinicians in mental health agencies. And we sit together with the youths or players who are experiencing anxiety and depression. And we think about how we can take

the scientific principles, meld them with the clinical techniques and then work with game designers from the very beginning. This is at the level of when we're even applying for grants and talk with them about what a game would look like that would have an impact on, but still use clinical principles, but have an impact on anxiety and depression.

And then we do research, both outcome research with randomized control trials as well as process research. This is research where we look at what the actual game players in the game did and we track it in game with back-end data, but also by coding what happens to the face of the children when they're playing the games. And then we look at what patterns

are associated with better versus worse outcomes so that we can then feed back that research data into the game design and strengthen and tailor those games. Finally, we wanna disseminate to schools, to mental health agencies and so on. This is obviously the part that we wanna have an impact with our research and our development.

But we also want to commercialize. I have no idea what this group thinks of that. But in an academic context, it's immediately where everybody goes, no, don't do that, don't monetize. And yet, I wanna make a very, very strong case for the fact that us academics need to get the hell off of our ivory tower

and come down to the place where parents and kids are actually accessing these products that could actually help them. It is not evil to make money if we can then take that money and make more games that help more people. And actually, this is the way to have access, probably in an unprecedented way that we've had. Sorry, that was supposed to be the end of my talk,

but I got all excited. During our design process, we've worked with and we continue to work with really important partners out in the commercial and professional game world. So people who are working at Entertainment Arts and Microsoft, people at USC, Robin Hunnicke, who is the executive producer of Journey,

and so on, Arden. And these people are the ones that are actually designing the games with us and helping us. They know how to do this for entertainment purposes and they're really important for our group. So it seems simple, right? We take science, take these scientific principles, we translate them into game mechanics that are beautiful and engaging.

We then change something in the mind by these kids playing our games and we have happy, healthy people. Of course, it's not that simple. I'm not gonna get into this because of time constraints, but we have a whole process that is an entirely different talk that really goes into how we create a vision, a creative brief that focuses us on the vision.

And they're separated. The game design and the intervention or psychological change goals are actually different at one point. They interact, but they're different and we need to keep that separate so that we can look at user platform specifications, backend specifications, and so on. Then we take our vision there in the middle

and we paper and clickable prototype it so that we make sure that we're looking at the same thing and we pilot and validate it both in terms of the play test and user tests and user engagement, but also in terms of the psychological mechanisms. That all happens before any code is done.

And this is really important for those of you who are interested in designing and developing these games because people go in and go, okay, we're gonna design cute little games and it goes immediately into code. And there are so many specifics that you have to get down in terms of understanding the psychological mechanisms, but also the game mechanics

because the bottom line ends up becoming a lot of funding can go to waste. I love this quote by Frank Lloyd Wright. You can use an eraser on the drafting table or a sledgehammer on the construction site. The reason we do all this backend work before we start even coding is because it's really, really expensive to start changing beautiful games after they don't work.

So what we do in our process is we start then, finally, with a coded playable prototype. And we have two streams of development that goes on and they're interactive. So game design proceeds and intervention design proceeds, but they have to inform one another. And just to take a piece of that and tell you a little bit more about that,

I'll just give you an example. So in terms of the game design, in the first playable prototype, what we wanna know is do we have kids engaged? Do they like it? Is it fun? Do we have the ramp up right? So are they getting trained up on the skill that we want really quickly? Do they understand how to play the game? Really basic stuff about game design. In terms of psychological or intervention design, are we actually triggering the emotions we wanted?

We wanted to trigger anxiety so that we get these kids to go through anxiety. Are they feeling anxiety in our game? Reactants, a lot of people start a game and they start feeling manipulated because they know it's a good, good game. Do we have any of that? And then they ignore that game, right? So do we have any reactants from our players? If so, we have to dampen it down.

Cognitive load and so on. These are just first things. Then we have a second prototype. That second prototype then gets, based on that data, gets then tested for more refined issues. Not only engagement, but now does the mechanic work? Is there replayability? Do people care about playing the game over and over?

Would the kid pick it up by themselves? In terms of the intervention design, are we actually having an impact on anxiety, depression, or things like connection when we wanna build social or interactive games? So this is sort of the process, the general process that we go through. Let me give you an example of a couple of the games we're working on. The first is Mind Light.

So Mind Light's a neurofeedback 3D video game to prevent and treat anxiety. You'll see names under there which are great graduate students and my colleagues that are working on these projects. Gameplay was the game design studio that we worked with. And so the game works like this. It's a neurofeedback game.

You put this headset on and it reads your brainwaves. It's a one-channel EEG headset, okay? The more relaxed you are, the brighter your light shines in this game. The more anxious you are, the darker it gets. When scary things happen in the game, you become anxious and it gets darker. In order to be able to go through the game, it's a haunted like mini horror game for kids.

And because the important thing here is that they get to learn to recapture their calm after they've been scared and that they can do it. There's two evidence-based techniques that we took from clinical treatment that we know work in clinical treatment.

One is exposure therapy, simple idea. What we do in clinical context is that we train patients to be able to deal with their fears by coming closer and closer to the thing they fear while they engage in relaxation techniques like deep breathing, muscle relaxation, and so on, okay?

So that's exposure therapy and this is exactly what they do in the game. They have to go and face these fears in the game and then get over their fears by calming down so their light exposes the darkness underneath. And we also use attention bias modification. So people who are anxious, like if I was anxious right now giving a talk, they are hyper vigilant to cues

that are negative in their environment and they don't pay attention to potentially positive cues. German audiences and Dutch audiences always trigger my anxiety because they have flat affect. Canadian audiences, which I am Canadian, do the polite smiling thing and so my anxiety disorder gets triggered here

and does not in Canada. And it's a really interesting and completely consistent thing, right? So anxiety disorder people, though, would only be focusing on those negative faces and I wouldn't be focusing on the delightful positive smiling faces as well. What we try to do with attention bias modification is get people to focus more on the positive and less so on the negative

through a whole bunch of training. Here's the game, a trailer for the game. So that's the neuro headset. Kids can put it on really easily. They have to face these scary things that pulse.

These are the attention bias modification. They have to focus on the smiling face.

Really hard to remain calm in the context of these scary things. It's not this music in the game and it becomes increasingly harder

so it becomes increasingly scary so you get the idea.

They do this over and over again. There's six hours of gameplay. So what we do in terms of the research aspect

is we test first the design aspects. So were they actually engaged in what we design for them to be engaged with? So in other words, if they're running away from all the scary stuff but they're not actually motivated to stay there, to try to keep calm and uncloak those negative things, we've screwed up something. We have to make sure that the design

is motivating the reward system that we want from them, right? Don't you love this picture? We also do a lot of video taping of the kids. We look at and code for affect, emotional expressions on the faces to make sure that they are experiencing anxiety, fear, stress, but also they're concentrating,

they're delighted and so on. And we're really happy to know that last year that we got a nomination for the most significant impact at Games for Change which is something that we're at least on the right track for. Track for. Okay, and then we do these pretty intensive

randomized control trials, okay? We screen about 1,200 kids and we look at their total anxiety before they've played, pre, post is after they've played and follow up, really importantly, is three months after they've stopped playing the game or whatever the control group is, okay?

So I'm at eek. Okay, I'm gonna tell you about, oh sorry, this was not the right order. Okay, sorry. Sorry, let me just show you this. Okay, this is the first study that I'm gonna tell you about. Mind light started high in anxiety. The kids got less anxious, significantly less anxious at post treatment,

so after playing for two and a half weeks and then after they stopped playing, their anxiety remained low. This is a huge, huge promising effect for us. The control group, which was another game, didn't improve as much from pre to post but eventually caught up. So we were at least in a promising space

but we were still worried maybe our game isn't as effective as it could be. We made some tweaks and then we have, now I gotta show you the whole thing. Sorry, here. So this is the second two lines that you'll see is the second randomized control trial with a second group of 1,200 kids who were assigned to either mind light

or cognitive behavioral therapy, now done with therapists and we tried to compare the two and what you see is a perfect almost overlap, in fact kind of eerie overlap between the data where we are basically being as effective a game as cognitive behavioral therapy and the improvements last and continue on.

So something about the game they continue to take on, equally as a therapeutic context. So we're very encouraged by that. In terms of next steps, we'd like to be able to port to mobile so that a lot of other people and a lot of other kids will be able to use it on iPads.

We wanna use heart rate variability instead of or additionally to the neurofeedback because it's just a lot more accessible. We wanna commercialize so that a lot of people can get this into their hands. So instead of having just 300 kids that I have access to in a context of a school, we wanna be able to get this out into the hands in an affordable price.

By the way, the neurofeedback headset is quite cheap. And then we wanna do uptake research, how many families buy the game and what's the impact later on. I wanna just end my last three minutes with a discussion about Deep, which is a biofeedback game that uses a belt and it's a VR game.

And I'm gonna give you a very short video. Deep VR is a meditative virtual reality game

that you control by breathing. Like a lot of people, I've had problems with anxiety and occasional bouts of depression as well. Over the years, I found one of the most effective ways for me to navigate those times is through breathing exercises, pranayama yoga and meditation. It so happened that when the Oculus Rift

was first hitting Kickstarter, I was going through a particularly difficult time, something that was rather intense. When my Oculus finally arrived, I started to build meditation chambers, star fields and ocean scapes to just kind of sit in, to just be outside of the world that was kind of causing me these problems.

Eventually, it occurred to me that perhaps it would be possible to incorporate the breathing exercises as well. And so from there, I managed to hack together some early versions of the breathing controller using the Arduino and some stretch sensors and a lot of Googling. So the control. So the idea is that as you breathe in,

you go up in this underwater landscape, as you breathe out, you go down. And we train non-didactically, without ever saying anything, this deep breathing, diaphragmatic breathing that we know physiologically regulates people. And again, we're testing for emotional design. We're also now looking at the extent to which people pick up this breathing technique

through the game, how fast, and the different types of people who come into the game and the different patterns of change so that eventually what we can do is take that data and tailor it and use an AI system that changes the environment that these people are in depending on where they start off with so that the experience is tailored to each person.

So I'll end with this last part. Where we're going is interaction and social games. The deep VR game as well as Mind Light, we want to make social so that we get kids working together and playing together to help each other's anxiety levels and depression

as well as parents and children working together. And really the social atmosphere is where we wanna go because we're not into the idea of kids stuck on their phones or iPads all the time. What we really want is these kids to be able to have a context where they can playfully engage in those things and then put them down and be confident and happy and connected socially with others in their environment.

So that's where we really wanna get to is going from our research to validated mechanics to commercialization that might have been an impact that's unprecedented for us in clinical psychology. Thank you very much.

Yeah, thank you. We now have time for I think one or two questions. So, ah, there's one. No, it's my son. Oh. Did you choose to make slides

but then skip them when you were talking? Because I was out of time. I was going out of time. Any other questions? Oh, there's one in the back. No, no, please, the mic, because we recorded.

Great talk, thank you. How much funding did you have for the Midnight Game? The Mya, this is the first question everybody wants to, the game costs approximately 250 but that's a huge, huge discounted price

because we did a lot of in-kind research and so on. So I would suspect if you're really doing this kind of level of a game, it would cost about twice as much right now. Actually, I missed the talk but I just wanted to say I really like the end.

Thanks. Keep doing your stuff. Thanks. Thanks. Great, because we don't have much time left, I would say we just go over to the next session. Okay, thanks so much, it was amazing.