Designing Neurogames to Support Patients under Psychotherapy

Treatment: Opportunities and Challenges of the MUSE Headband

Michael Pantf

order

and Andre Hellwig

Fraunhofer Institute for Software and Systems Engineering ISST, Dortmund, Germany

Hochschule f

ur Gesundheit, Bochum, Germany

Keywords:

Serious Game, Neurofeedback, Psychotherapy, Brain Computer Interface, Electroencephalography.

Abstract:

In childhood and adolescence, mental development processes are crucial for a person’s long-term, cognitive

health. Many young people have at least one characteristic that leads to psychological impairment and must

be accompanied by therapy. Therapy success requires the constant execution of therapeutic exercises during

and after therapy sessions. However, keeping the motivation of the patients upright for continuous cooperation

is a key challenge, since the exercises are perceived as laborious. A digital, playful training application offers

the potential to support the therapy of children and adolescents. Measuring brain activity plays an impor-

tant role as it shows how good patients can push away negative thoughts affecting their mental disorder. For

this purpose the fundamentals of serious games, neurofeedback, brain computer interfaces (BCIs) and elec-

troencephalography (EEG) as well as different therapy-accompanying measures were examined. Based on the

ﬁndings and a focus group with psychotherapists (N=3), a serious game was designed as a motivational con-

centration and attention training to support psychotherapy. During the game the easy-to-use MUSE headband

measures concentration and integrates neurofeedback as a game mechanic. User tests with children (N=21)

were performed to evaluate the developed prototype and gather further information on usability, technology

acceptance and playfulness of the neurogame.

1 INTRODUCTION

Mental disorders are global public health issues. They

account for more than 10% of the global burden of

disease (Vigo et al., 2016) and no fewer than 800,000

people die each year as a result of suicide (World

Health Organization, 2018). The number of people

under the age of 15 who suffer from depression has in-

creased signiﬁcantly in recent years and has increased

more than tenfold compared to the year 2000. Ac-

cording to Naab et al. (Naab et al., 2017) a nation-

wide study in Germany of 2,863 families with chil-

dren aged 7 to 17 years showed that 14.5% of the

children had characteristics of at least one impairing

mental health problem. Same or even higher per-

centages across Europe up to 27.9% in Bulgaria were

shown by Husky et al. (Husky et al., 2018). How-

ever, less than half of the children received therapy or

the parents considered it in need of treatment. Typi-

cal disorders that occur in young children are: post-

traumatic stress disorders, depressive disorders, atten-

tion deﬁcit / hyperactivity disorders (ADHD), anx-

iety disorders, autistic disorders, attachment disor-

ders and sleep disorders. Successful therapy can only

be achieved through careful and independent imple-

mentation of therapy-accompanying exercises. How-

ever, many patients do not perform their exercises

regularly because they ﬁnd the tasks tedious or bor-

ing (Mader et al., 2016). Accompanying and sup-

porting measures, which are used in psychotherapy

to reduce symptoms, are mindfulness exercises, re-

laxation procedures as well as concentration and at-

tention training. These measures are used to treat a

wide range of mental illnesses and have been proven

through studies. However, the patient lacks motiva-

tion to carry out the exercises continuously, since ther-

apeutic success does not occur immediately. In order

to enable treatments for the large number of young

patients and to motivate them to carefully carry out

exercises accompanying therapy, motivational, tar-

get group-speciﬁc support of the therapy is required.

Here, the use of electronic devices offers the potential

to close gaps in therapy and to open up new treat-

ment options or to supplement existing ones. Chap-

ter 2 introduces background information about neu-

rofeedback, Brain Computer Interfaces and Serious

296

Pantförder, M. and Hellwig, A.

Designing Neurogames to Support Patients under Psychotherapy Treatment: Opportunities and Challenges of the MUSE Headband.

DOI: 10.5220/0010738500003123

In Proceedings of the 15th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2022) - Volume 5: HEALTHINF, pages 296-305

ISBN: 978-989-758-552-4; ISSN: 2184-4305

Game Design. Chapter 3 outlines the conducted re-

search method. Chapter 4 presents the ﬁndings, chap-

ter 5 discusses results and chapter 6 summarizes re-

sults and gives ideas about future work.

2 BACKGROUND

According to Li et al. (Li et al., 2014), a lot of re-

search has been done in recent years to develop new

and inexpensive technologies that can be used to treat

mental health. Digital applications such as serious

games can be used as a therapy-accompanying mea-

sure and motivational incentive to support the therapy

of children and adolescents with different mental ill-

nesses. Thereby therapeutic effects can be achieved

by training certain skills as well as conveying psy-

chotherapeutic content. Such games have been used

successfully in psychotherapy to treat various mental

disorders. The success of serious games in the context

of therapy lies primarily in their ability to increase

therapy compliance and motivate patients to indepen-

dently carry out therapy-supporting exercises at home

(Brezinka and Hovestadt, 2007; Fernandez-Cervantes

et al., 2015). In addition, they offer the potential to

convey psychotherapeutic content in a playful way

and thus increase the learning success in exercises

accompanying therapy. When performing such exer-

cises, various physiological effects occur, which can

be recorded with the help of neurofeedback devices

(Goldbeck and Schmid, 2003; Forsner et al., 2014).

2.1 Neurofeedback

Today, neurofeedback is considered a scientiﬁcally

recognized method for optimizing brain activity by

minimizing or maximizing certain activities. Stud-

ies have shown that patients with various mental dis-

orders have brain activities that differ from healthy

people. A large number of disorders, diseases and un-

wanted behavior patterns can be attributed to incorrect

regulation of brain activity (Fiałek and Liarokapis,

2016; Sourina et al., 2011). Neurofeedback is mea-

sured with Brain Computer Interfaces (BCIs) and dis-

plays patient brain activity in real time. As part of

neurofeedback training, the patient should learn to

control his brain activity and to consciously change

it. Neurofeedback training is intended to teach the

patient how to regulate abnormalities in his brain ac-

tivity himself (Heinrich et al., 2007). The user can re-

ceive various feedback about his internal status. Ac-

cording to Hammond (Hammond, 2011),neurofeed-

back has been used in clinical and research appli-

cations for decades to treat patients with mental ill-

nesses and has already been used successfully in nu-

merous psychiatric and neurological disorders, such

as depression, concentration and memory problems,

stress disorders, ADHD and autism. In addition,

neurofeedback training can also be used to promote

health, preventive measures and improve cognitive

performance in healthy people, such as coping with

stress or training the memory. This makes neuro-

feedback training an important treatment method for

a wide range of mental disorders as an alternative to

medication. Neurofeedback training can be carried

out in various forms such as neurogames, simple vi-

sual feedback or audio feedback (Liu et al., 2016). So

far, there is no generally applicable standard for neu-

rogames. Various works, however, use this term in

a similar context as digital games, which use neuro-

feedback devices, such as brain computer interfaces,

for interaction within a game. BCIs measure brain ac-

tivity and recognize certain brain patterns that can be

interpreted and translated into commands for commu-

nication with BCI applications. Their use enables the

internal state of the user to be included in the game

and to provide feedback on physiological processes

in the body that are normally not perceptible (Hein-

rich et al., 2007). In this way, the application can be

adapted to the feelings and experiences of the user in

order to integrate them more into the game. With the

help of neurofeedback within a serious game, aware-

ness of one’s own inner state can be developed, self-

reﬂection can be facilitated and mindfulness can be

promoted (Sliwinski et al., 2017).

2.2 Brain Computer Interfaces and

MUSE Headband

A Brain-Computer-Interface (BCI), also called

Brain-Machine-Interface (BMI), is with respect to

Graimann, Allison and Pfurtscheller (Graimann

et al., 2009), an artiﬁcial system that measures the

user’s brain activity, interprets it and translates it into

control signals for BCI applications. Since the mea-

sured activity comes directly from the brain without

requiring physical movement, it is referred to as the

brain-computer interface. A BCI can, according to

Graimann et al. not read minds, but classify special

activity patterns in brain signals that are associated

with certain tasks or events. Brain-computer in-

terfaces represent a sub-category of the so-called

“prostheses”. These are devices that not only receive

output from nervous systems, but can also offer input

and thus interact with the peripheral and central

nervous system. Brain computer interfaces enable

the use of interactive applications by interpreting

and translating various brain patterns into control

Designing Neurogames to Support Patients under Psychotherapy Treatment: Opportunities and Challenges of the MUSE Headband

297

commands (Wolpaw et al., 2002). They enable a

new human-computer interaction as an alternative to

conventional input devices such as a mouse, keyboard

and touch displays and can thus be used by people

with serious physical disabilities as a non-muscular

means of communication (Graimann et al., 2009;

Perales and Amengual, 2017; Sourina et al., 2011).

BCIs can also be used as neurofeedback training as

a treatment alternative for various cognitive disor-

ders. However, brain-computer interfaces are not

suitable for controlling complex applications because

their information transfer rate is not sufﬁcient for

this. Complex tasks like controlling a robot arm,

reaching for a bottle or chatting quickly require more

information per second than can be provided by a

BCI (Graimann et al., 2009). In addition, so-called

artifacts can occur during signal acquisition, which

arise as interference in the signal due to other activ-

ities and must be removed (Fiałek and Liarokapis,

2016; Graimann et al., 2009). Non-invasive elec-

troencephalography (EEG) is the most widespread

technology. It is used to record the electrical activity

of the scalp using electrodes. Compared to other

BCI technologies, EEGs are inexpensive, portable

and offer a reasonable compromise between spatial

and temporal resolution (Graimann et al., 2009;

Scherer et al., 2017; Vourvopoulos et al., 2017).

With the help of an EEG, the electrical potential of

the scalp can be measured using surface electrodes.

According to Sourina et.al. (Sourina et al., 2011), this

potential arises from cerebral cortex activity in the

brain and reﬂects the state of the brain. This makes

it possible to recognize emotions, mental states

and movement ideas of the user in a non-invasive

manner in real time (Sourina and Liu, 2015). The use

of EEG technology in various research disciplines

has increased in recent years since more and more

inexpensive, easily transportable and user-friendly

devices have been commercially available which

provide sufﬁcient measurement quality (Krigolson

et al., 2017; Przegalinska et al., 2018; Scherer et al.,

2017). This research focuses on the MUSE headband,

as it is an easy to use EEG headband. Studies show

that it is also a reliable source for measuring gamma

waves as the source of concentration (Krigolson

et al., 2017; Przegalinska et al., 2018). Compared

to the Mindwave, which is often used as a BCI for

neurogames and offers only 1 EEG, MUSE measures

brain activity with 7 EEG sensors.

2.3 Neurogames in Psychotherapy

”Harvest Challenge” is a neurogame intended to serve

as intention training for children with attention deﬁcit

and hyperactivity disorder between the ages of 8 and

13 years. Munoz et al. (Mu

noz et al., 2015) de-

cided to use the MindWave neurofeedback headset as

part of this application, since it is comfortable for the

user to use and requires little conﬁguration time. Har-

vest Challenge was designed for use in various edu-

cational institutions and for neuropsychological care,

but should also be usable by children at home. The

digital game was developed in an interdisciplinary

team of designers, developers, neuropsychologists

and psychiatrists and incorporates the internal state of

the user into the application with the help of an EEG.

The goal of the game is to improve certain skills of

the child. This includes patience, planning skills as

well as the ability to follow instructions and achieve

goals. The improvement of these skills should also

lead to an increased learning process as well as an

improved control of attention. Within the application,

the player controls a boy who lives in a Colombian

coffee region and has to perform various tasks in the

form of mini-games. The relaxation and concentra-

tion level of the user is integrated in different ways

for interaction within the game. As part of a mini-

game, the player has to select predetermined objects

that rotate in a circle. In order to select an object,

he must stop the rotation by increasing his attention

level when the object is at a predetermined position.

Another mini-game is that the player has to collect

vegetables. However, this is only possible if the user

reaches a certain concentration level and should train

him to keep his concentration. At the end, the course

of the user’s mental activity during the game is visual-

ized by a diagram. So far, no studies on the effective-

ness of Harvest Challenge have been published. This

application shows how a neurogame for children with

ADHD can involve the player’s level of concentration

in different ways to actively inﬂuence the game in or-

der to train the ability to concentrate, while improv-

ing other relevant skills. Schoneveld et al. (Schon-

eveld et al., 2018) as well as Jacob and Teuteberg (Ja-

cob and Teuteberg, 2017) present the game ”Mind-

Light” in their work developed by the PlayNice Insti-

tute, which also uses the MindWave from Neurosky

to include neurofeedback. This is a neurogame for the

therapy of children with increased anxiety symptoms.

Various techniques such as neurofeedback, confronta-

tion training, and attention modiﬁcation training are

included within the game to train children to deal

with their anxiety. In the context of the application,

the player takes on the role of a child who wants to

save his grandmother from evil forces. Various re-

laxation techniques are taught to the user within the

game. He should also learn that he can overcome his

fears by adjusting his state of mind. The relaxation

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level of the player is included in the application and

represented by a shining light, which helps the player

to navigate through the game world and defeat oppo-

nents. The user must remain as relaxed as possible in

order to use light to transform threatening objects and

shapes into harmless ones. Schoneveld et al. exam-

ined in a study with 174 children between the ages of

7 and 12 whether MindLight is just as effective for the

therapy of children with anxiety symptoms as cogni-

tive behavior therapy. Half of the children played the

game, while the other half received conventional ther-

apy. Both treatments showed a signiﬁcant decrease in

anxiety symptoms, with MindLight having the same

effectiveness as cognitive behavior therapy. Mind-

Light thus proved to be an effective measure for the

prevention of anxiety for children within the scope of

the study. This neurogame demonstrates how differ-

ent coping strategies can be conveyed as a therapeutic

measure in a child-friendly manner within an appli-

cation and how the player’s internal state can be inte-

grated in order to inﬂuence the game environment and

atmosphere and thereby achieve a therapeutic effect.

The MindWave headset however used in both projects

utilizes only one EEG sensor which could lead to in-

accurate measurements. No neurogame has currently

evaluated the MUSE headband, which might lead to

better results.

3 METHODS

The general research method used as a guiding frame-

work follows the user-centered development princi-

ples described by Abeele et al. (Abeele et al., 2011).

Firstly, a review of related work and current BCI

and EEG technologies for a focus group with psy-

chotherapists was prepared to identify requirements

and potentials of neurogames. Secondly, a neurogame

prototype using the MUSE headband was developed.

Thirdly, a gameplay test with healthy children was

conducted to evaluate game design of the developed

prototype and used technology.

3.1 Requirements Analysis: Focus

Group

As part of the preparation for this work, a prelim-

inary semi-structured focus group with psychother-

apists working in a clinic (N=3) was carried out to

identify needs and potentials for neurogames. In this

clinic, children and adolescents between the ages of 6

and 19 are treated with mental illnesses such as anx-

iety disorders, depression, eating disorders, ADHD

and disorders of social behavior. In preparation for

the focus group, an initial research was carried out

on the use of mindfulness exercises, relaxation pro-

cedures as well as attention and concentration train-

ing to accompany and support psychotherapy in or-

der to gain a basic understanding. Questions and ﬁrst

ideas concerning the development of a neurogame

(for instance interaction, gameplay, learning) with the

MUSE headband have been prepared for the focus

group as well. Goal of the focus group was the iden-

tiﬁcation of requirements for a neurogame supporting

psychotherapy.

3.2 Neurogame Development

Following the ﬁndings of the focus group, a neu-

rogame prototype was developed in constant interac-

tion with the psychotherapists (N=3). The different

states of the prototype were shown to the therapists re-

motely. The test subjects were advised to think aloud

while watching the game being played live. Within

the application, two players control their characters

through different levels of a pyramid with the aim

of getting to the lowest level to ﬁnd the Pharaoh’s

treasure. Each level consists of a dark, randomly

generated labyrinth. Level design and scripting was

done using the Unity game engine. A script gener-

ates a random map using depth-ﬁrst search for given

x and y dimensions and then places a given num-

ber of stone tablets, treasures as well as the exit at

random positions within the labyrinth. The integra-

tion of a labyrinth as a puzzle element was chosen

because labyrinth tasks are used as part of therapies

for children as a measure to promote concentration.

Both players have a special light source, the radius

of which is determined by the concentration level of

the respective player. For this purpose, the users wear

the MUSE headband, which measures the concentra-

tion of the users using gamma waves and incorporates

them into the game. To include the EEG data in the

application, both headsets must be connected to the

MUSE Direct application via Bluetooth and the data

must be transferred via Open Sound Control (OSC)

using ports 7000 and 7001. UDP is used as the trans-

port protocol. The data retrieval within the Unity ap-

plication is realized with the help of the extOSC Unity

asset. The higher the concentration level, the larger

the radius of the light and the faster the players can

move. In order to ﬁnd their way around the labyrinth,

the players have to train to control their concentration

and receive direct feedback based on the light. The

concentration level is required to increase the light ra-

dius. To exit a level, the players have to ﬁnd and re-

member symbols that open the door to the next, more

difﬁcult level. Every level has a time limit. Play-

Designing Neurogames to Support Patients under Psychotherapy Treatment: Opportunities and Challenges of the MUSE Headband

299

ers have to proceed carefully through the labyrinth,

to ﬁnd and remember all necessary symbols to open

the exit gate. Each level has a time limit to add dif-

ﬁculty. In addition, the game aims to improve social

skills and teamwork, as the players have to cooper-

ate in order to advance to the next level. Working

together and pursuing a common goal can also have a

motivating effect on the players. Here, the users are

dependent on the performance of the other. They have

to agree on how they want to search through the lev-

els, tell each other when they have found certain ob-

jects within the labyrinth and help each other to ﬁnd

the way. According to Wiemeyer et al. (Wiemeyer

et al., 2016), a common goal as well as mutual de-

pendency are required for cooperation and teamwork

to take place. By taking these aspects into account,

players should be encouraged to communicate and co-

operate with one another in the context of the serious

game. The control of the characters and interaction

with objects within the labyrinth is done by controller.

3.3 Technology Acceptance and Game

Experience

A total of N=21 healthy children were recruited to

participate in the ﬁrst user test in a high school, in-

cluding n=13 male and n=8 female subjects. The age

of the test participants was 10 or 11 years. Subjects

had to play the game cooperatively for about 10 min-

utes and should think aloud. Afterwards they have

been given a questionnaire consisting of 30 items in-

cluding (1) general game preferences, (2) gameplay

and movement controls of the prototype (UTAUT -

Uniﬁed theory of acceptance and technology use), (3)

fun and replayability (GEQ-core - Game experience

questionnaire) and the (4) integration of concentration

measurement and inﬂuences on the gameplay (GEQ-

ig and GEQ-sp).

4 FINDINGS

4.1 Focus Group

Therapists (N=3) conﬁrmed the need for digital ap-

plications to support the therapy of children and ado-

lescents against the background of the large number

of young patients and showed a largely positive at-

titude towards the use of digital media as a therapy-

accompanying measure. They stated that exercises

to promote mindfulness, relaxation, attention or con-

centration are often used as part of a therapy and

suggested that a therapy-accompanying serious game

could aim to promote one of these states of conscious-

ness. The results of the focus group were divided into

three therapeutic and learning objectives that a seri-

ous game supporting psychotherapy has to offer: (1)

Training of attention and concentration skills, (2) Pro-

motion of social and team skills and (3) Distraction

from counterproductive thoughts and support for psy-

chotherapy.

1. Training of attention and concentration skills:

The digital game has to be designed to train the

players’ attention and concentration skills in order to

teach children with a lack of concentration or atten-

tion deﬁcit, to control their concentration in a targeted

manner and to maintain their attention over a longer

period of time. It should also help them to get into

a concentrated state (n=2). Furthermore, the mem-

ory skills of the players can be promoted in this con-

text (n=1). The digital prototype is also intended to

motivate users to deal with the increasingly complex

tasks within the game over a certain period of time

and thereby improve problem-solving skills (n=1).

2. Promotion of social and team skills: Since chil-

dren and adolescents with an attention disorder often

lack social relationships due to the symptoms of their

disorder and therefore have poor social skills and,

in some cases, suffer from social exclusion (n=3).

The digital prototype has to improve social skills

and teamwork among users promote to improve their

social behavior and meet social needs. Two sub-

jects (n=2) suggested to add a multiplayer mode in

which player can play together cooperatively (n=2)

and competitively (n=1).

3. Distraction from counterproductive thoughts

and support for psychotherapy: The game is also

intended to distract users from counterproductive

thoughts, praise them for successfully completing the

levels and thereby give them a sense of achieve-

ment, since children with ADHD often cannot com-

plete tasks successfully and suffer from emotional

problems (n=2). Furthermore, the digital application

should support the psychotherapy of the children and

motivate them to deal with therapeutic content, as

well as to carry out therapy-supporting exercises on

their own responsibility (n=2).

4.2 Prototype Gameplay Test

The gameplay questionnaire consisted of items in the

following categories: (1) general game preferences,

(2) gameplay and movement control of the prototype,

(3) fun and replayability, and (4) integration of con-

centration measurement and inﬂuences on the game-

play. The test took place in the regular school envi-

ronment of the subjects.

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Figure 1: Players must navigate through a dark labyrinth to ﬁnd the exit to the next level. Depending on the concentration of

the player, areas surrounding the player are better illuminated.

4.2.1 General Game Preferences

It was found that the male participants (n=9) play

video games more often on average than the female

participants (n=3). Each of the male respondents said

they played a video game before. The majority of

them play one or more times a week (n=8). The ma-

jority of female respondents, on the other hand, play

video games less frequently, n=2 of the female par-

ticipants stated that they never played video games

before. The subjects cited spending time, fun and en-

tertainment as well as the opportunity to play with

others as motivations for playing. Approx. 81% of

those surveyed also stated that they preferred to play

together with others rather than alone. As part of the

evaluation, the data of the male and female subjects

as well as the experienced and inexperienced play-

ers were compared. All subjects who stated that they

used video games at least once a week were classi-

ﬁed as experienced players. Subjects who rarely or

never play video games were classiﬁed as inexperi-

enced players.

4.2.2 Gameplay and Movement Controls

All subjects stated in the questionnaire that they un-

derstood the rules of the game quickly and well. 90%

of the children also said that they mostly or always

knew what to do. It showed that especially subjects

who play video games more often always knew what

to do. This can be attributed to the fact that these

subjects are already familiar with various game prin-

ciples and mechanics. Within the questionnaire, all of

the respondents also stated that they found nothing in

the rules of the game to be confusing. The control of

the characters and interaction by controller was rated

by all children as pleasant and easy as well as quick

to learn. Even players who said they had never used a

controller could quickly learn how to use it. The ma-

jority of respondents also believed that no improve-

ment in control was necessary. However, some of the

children said they preferred a narrower or a PlaySta-

tion controller.

4.2.3 Fun and Replayability

As part of the questionnaire, n=18 stated that they

liked the topic of the Egyptian treasure hunt very

much. All study participants also stated that they en-

joyed the game and would like to try again. When

asked what was the most fun and what they liked

best, n=8 answered with ”everything”, n=6 of the re-

spondents stated that they liked the search for objects

most within the labyrinth. During the performance of

the game tests, it was also observed that the subjects

were very happy when they found a stone tablet or

a treasure. Furthermore, n=4 stated that they found

the inclusion of concentration particularly good in the

game. Other favorite game aspects of the children

were memorizing the symbols, completing the levels

within a given time, playing together and communi-

cating with a teammate, the tension, uncertainty and

darkness, the graphics as well as the leaderboard as

feedback on their own performance. It was also ob-

served that the players were strongly motivated by the

score and the desire to score more points than another

team.

4.2.4 Integration of Concentration via the EEG

Within the questionnaire, the subjects were asked to

rate the comfort of the MUSE-EEG. The average of

those questioned stated that the EEG was “rather com-

fortable”. The experienced players rated the comfort

of the device on average as somewhat more pleasant

than the inexperienced players. This could be due to

the fact that experienced players are used to using dif-

ferent devices when playing video games and there-

fore have greater technology acceptance or are bet-

Designing Neurogames to Support Patients under Psychotherapy Treatment: Opportunities and Challenges of the MUSE Headband

301

ter able to put themselves in the game and thereby

hide the EEG. However, the game tests showed that

in some cases the EEG was too large for the chil-

dren’s head and therefore did not sit well or even

slip. 86% of the children stated that they were able

to concentrate mostly to very well while playing. It

turned out that the female test subjects were able to

concentrate better than the male ones in the question-

naire. The female test participants indicated on aver-

age that they were able to concentrate very well while

playing. The male participants were able to concen-

trate “mostly well” on average. This could be due to

girls’ penchant for riddle and puzzle games as well as

their innate abilities that give them an edge in such

games. However, there is the question of whether it is

a false self-assessment or whether the female partic-

ipants were actually able to concentrate better. This

cannot be checked on the basis of the recorded EEG

data either, since the recordings cannot be assigned to

the questionnaires.

5 DISCUSSION

The results show unique possibilities for designing

neurogames to support psychotherapy. The majority

of the children appeared very concentrated and im-

mersed in the game while the game tests were be-

ing carried out. It could be observed that the players

looked very carefully in the labyrinth and rarely over-

looked objects. In addition, the concentration level

of the test subjects was never permanently low. In-

dividual players were even able to maintain a consis-

tently high concentration. Some children were also

very proud when they were able to reach a high level

of concentration and communicated this to their team-

mate. The children judged the targeted control of the

light by the concentration in very different ways. Two

subjects found this to be difﬁcult to very difﬁcult, n=9

players rated the targeted control as simple to very

easy and n=10 children said ”it works”. Although

the female participants reported that they were able

to concentrate better than the male participants, the

evaluation of the targeted control of light through con-

centration showed no difference between female and

male test subjects. Instead, control by concentration

was judged by the experienced players on average to

be easier than by the inexperienced. This could be

attributed to the fact that the inexperienced players

also rated the game difﬁculty as more difﬁcult and

that various actions in the game were more difﬁcult

due to their less experience with game principles and

mechanics. However, a negative assessment of the

targeted control of the light by the concentration can

also be related to the fact that in some cases the EEG

slipped during the game or received no or only insuf-

ﬁcient data for a short time, which represented a low

concentration level in the game. The average of the

respondents nevertheless stated that the control of the

light by the concentration was perceived as “rather not

frustrating” and also in the long term as “rather not

exhausting”. The female participants rated the per-

manent concentration as less strenuous than the male

participants and also stated that they felt less frustra-

tion. This could be due to a different frustration tol-

erance of the female and male subjects or related to

the fact that the female players felt they could con-

centrate better. The children were also asked within

the questionnaire whether they felt more concentrated

after playing than before. Here, n=18 of the respon-

dents stated that they had been more concentrated af-

ter playing. There were no differences between male

and female as well as experienced and inexperienced

players. Over the course of the game tests, it was

also observed that some children behaved loudly and

restlessly before playing, but appeared calm, concen-

trated and immersed in the game during play. To an-

alyze the concentration curve of the test subjects, the

gamma value shares of the players were saved dur-

ing the game sessions. An increased gamma value

indicates better concentration. It was found that the

gamma waves of the children were individually very

differently pronounced.

Start Intro Level 0 Level 1 Level 2 Level 3 Outro

Player 8 Player 9 Player 12 Player 18 Player 20

gamma value

Figure 2: Progression of the gamma value during the game

sessions by various players.

Start Intro Level 0 Level 1 Level 2 Level 3 Outro

gamma value

Figure 3: Average progression of the gamma value over all

players.

The average gamma value increase of the child

with the lowest values was approx. 1.7%, that of the

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302

child with the highest values was 13.7%. It was also

shown that the test subjects’ values ﬂuctuated dur-

ing play. Overall, the gamma value percentage of all

players increased during the course of the game ses-

sion compared to the start of the game, indicating that

all children were able to increase their concentration.

However, this increase was different for each individ-

ual. Figure 2 shows a comparison of the gamma val-

ues of ﬁve different players during the game sessions.

For the average of the subjects, the gamma value pro-

portion increased continuously from the start of the

application up to level 2, where the values reached

their peak. Here the gamma values were on average

more than twice as high as at the beginning of the

game test, so the average of the children was most

concentrated in level 2. In level 3 as well as in the

outro, the gamma value decreases again on average.

The course of the average gamma value share of the

subjects is shown in ﬁgure 3.

While testing the game some problems with

MUSE were discovered. Due to the variation in head

sizes, a few subjects had problems tracking their EEG

data. The MUSE headband did not always ﬁt the head

of a test person well. In addition, there were some dis-

connections of the MUSE headband during the game-

play tests, so the test subjects had to start from the

beginning.

6 CONCLUSION AND FUTURE

WORK

Through the implementation and evaluation of a pro-

totypical serious game, it is possible to show that a

playful, digital application offers the potential to sup-

port the psychotherapeutic treatment of children and

adolescents by motivating the users to independently

carry out exercises accompanying therapy. In addi-

tion, it was shown that the inclusion of measuring

neurofeedback in this context can help to support ex-

ercises in a self-effective way. Player are able to un-

derstand what concentration is all about and how this

can support therapy. As part of the evaluation, a sufﬁ-

ciently large number of children were interviewed to

receive extensive feedback and clear results regard-

ing the prototype developed. Male and female test

subjects with different gaming experience and pref-

erences could be interviewed in order to capture the

opinion of different groups of people. Here, however,

the number of female participants was signiﬁcantly

lower than the number of male participants. In addi-

tion, there were only two subjects who had no experi-

ence with video games and three test participants who

stated that they used video games on a daily basis.

In the context of the evaluation, it would have been

interesting to test a higher number of subjects with

no or extensive gaming experience in order to better

compare these groups of people with one another and

to be able to make generally valid statements about

these groups. In addition, subjects aged 10 or 11 only

were tested, which is why no statements can be made

about children in a different audience age. The goals

of the digital prototype were to train the players’ abil-

ity to pay attention and concentrate, to promote social

and team skills as well as to distract from counter-

productive thoughts and support psychotherapy. As

part of the user tests carried out, it was observed that

subjects who were initially restless and excited be-

came calmer during the session and concentrated on

the game. In addition, the recording of the gamma

values showed that the concentration of each subject

increased during the game, albeit to different degrees.

In order to be able to make further statements about

the course of concentration of the users while playing,

it would make sense to measure the brain activity of

the test subjects while performing other activities and

then to compare them with the brain activity while

playing the prototype. Some children found it difﬁ-

cult to concentrate and to control their concentration

in a targeted manner. Here the players need more in-

dividual support from the digital mentor, for example

through exercises or techniques to increase concen-

tration, which are taught during the game. The tests

also showed that the gamma values of the test partic-

ipants were very different. It is therefore important

that the game is based on the individual concentra-

tion values of the users and not on general values. As

part of the game tests, the prototype showed the po-

tential to promote the social skills and competences

of the children by playing together. Here it could

be observed that some children were calm and re-

served at the beginning of the game, but increasingly

communicated with each other during the game and

helped each other to ﬁnd their way in the labyrinth.

All of the children surveyed stated that they enjoyed

playing with a teammate and enjoyed the cooperative

elements. It also conﬁrmed that children can learn

from each other and motivate each other when play-

ing together. Consequently, it makes sense to let chil-

dren play a serious game together. The prototype is

intended to distract players from counterproductive

thoughts and motivate them to deal with therapeutic

content. All of the subjects stated that they had a lot

of fun with the game and wanted to play it repeatedly

during the game tests. Various game elements, such

as the use of the resources of time and points, con-

tribute to the motivation of the players and the ran-

dom generation of the labyrinths ensures the replay

Designing Neurogames to Support Patients under Psychotherapy Treatment: Opportunities and Challenges of the MUSE Headband

303

value. Consequently, a digital serious game offers

the potential to support the psychotherapy of children

and adolescents and to motivate them to deal with

therapeutic content, as well as to carry out therapy-

supporting exercises on their own responsibility. The

tests carried out also showed that feedback about their

performance was important to the children. It was

observed that they were motivated by the feedback

about their concentration and were proud when they

reached a high level of concentration. In addition,

the test subjects showed strong interest in the leader-

board, through which they were able to classify their

performance. As a result, there were positive effects

from the EEG-based feedback on the internal con-

dition of the children. A representation of the con-

centration curve could also be included in order to

give users more detailed and individual feedback. Al-

though different sources show that boys and girls have

different game preferences (Kinzie and Joseph, 2008;

Scharkow et al., 2015; Procci et al., 2011), the game

developed in this work was enjoyed by both male and

female testers. It was found here that by combining

action and puzzle elements, an application could be

developed that appeals to both genders. This conﬁrms

the Procci et al. (Procci et al., 2011) that by mixing

game elements that correspond to the preferences of

boys and girls, a game can be developed that triggers

the interests of both genders. It also emerged that the

topic of Egyptian treasure hunt and the role of the ex-

plorer were welcomed by both boys and girls. As part

of the intro, it was observed that the children’s abil-

ity to read was at different levels and some of the test

subjects had problems reading the dialogue. Here it

would make sense to speak the text of the mentor to

relieve the children and avoid frustration. Animations

from the mentor can also be included to make them

appear more alive and to increase immersion. Fur-

thermore, the game tests revealed that some of the

children found aspects of the application to be too

difﬁcult or too easy. This requires an adaptive level

of difﬁculty, which adapts individually to the skills

and performance of the children in order to maintain

a ﬂow state and to neither bore nor overwhelm the

players. The testing of the prototype was carried out

with mentally healthy subjects. The next step is to

check whether people with a mental disorder still ben-

eﬁt from the positive effects of the game. It is also

uncertain how long-lasting the motivation is to play

the prototype, and this should be tested in a long-term

study.

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