Around 30% of adolescents in special needs education struggle with intense feelings of anxiety [1]. For example, they excessively worry about the future or are afraid that other children won’t like them. Chronic feelings of anxiety can have a tremendous negative impact on adolescents’ mental health, academic achievement and social functioning [2]. Effective intervention programs that help adolescents cope with anxiety are urgently needed, but conventional school-based programs often yield disappointing outcomes [3,4]. In particular, existing interventions often do not take into consideration that many anxious adolescents in special education suffer from coexisting disorders, such as autism spectrum disorder or attention-deficit/hyperactivity disorder, which can limit their ability to benefit from talk therapies [5,6]. Furthermore, a serious barrier in conventional programs for anxiety has been to intrinsically motivate and engage children [7]. We believe video games hold great promise as a novel intervention approach for adolescents in special needs schools.
In 2018 researchers from the GEMH lab have investigated the use of DEEP - a breath controlled virtual reality experience - as an intervention for anxiety in a special school setting. DEEP targets a fundamental causal mechanism that contributes to the development and maintenance of anxiety symptoms: physiological reactivity. Physiological reactivity refers to the body’s response to a stressor. Anxious youth are characterised by intensified physiological responding in stressful situations. For example, they may start to breathe faster or their heart rate may increase. DEEP incorporates two evidence-based techniques, biofeedback and diaphragmatic breathing exercises, to teach players how to regulate high levels of physiological arousal and anxiety [8–10].
Results from a previous pilot study showed that DEEP reduced levels of anxiety directly after playing the game in a sample of 86 typically developing children [11]. However, it is still unknown how DEEP would affect anxiety in children with complex needs nor how long the calm/relaxed state would be maintained following playing DEEP. As the biofeedback mechanisms in DEEP might also help adolescents to recognize their internal physiological states, an important yet uncertain additional effect of DEEP could be an improvement in their ability to regulate behaviour. Since our study was conducted in a special needs school, we were specifically interested in DEEP’s effect on disruptive behaviours in the classroom, which is a place where disruptive behaviours occur frequently and may significantly hamper students’ learning and performances.
Therefore, our study examined the effect of DEEP on daily levels of state-anxiety (i.e., how anxious one feels in the moment) and disruptive classroom behaviour in a sample of eight anxious adolescents attending a secondary special needs school in the Netherlands. Three times a day, the participants reported their state-anxiety and teachers reported on the participant’s classroom behaviour. Observed classroom behaviours were measured with personalised questionnaires about each participating adolescent (e.g. talked out of turn, got out of their chair and walked around the classroom). In addition, we examined the feasibility and implementation potential of DEEP by conducting exit-interviews with the adolescents, their teachers and the school clinicians.Results showed that:
· A total of 6 out of 8 children showed reductions in anxiety and 5 out of 8 participants decreased in disruptive classroom behaviour with the introduction of DEEP.
· The calm/relaxed state participants experienced after playing DEEP lasted around 2 hours on average.
· The exit-interviews with adolescents, teachers, and school clinicians suggested that they enjoyed having access to DEEP, and it could continue to be a feasible intervention to implement in a special needs school setting.
DEEP was perceived as an attractive game-based intervention as adolescents liked the game environment and way of moving using their breathing. Some adolescents disliked that there was no goal in the game and consequently missed challenge. However, the majority of participants described that they learned through DEEP how to ‘empty their minds’ and how to calm down in stressful situations by controlling their breath:
· “Usually I get very angry when somebody is being mean to me, but now I try to stay calm and focus on my breathing.”
· “DEEP helped me to feel calm […]. I now try to focus on my breathing during exams.”
· “The underwater world looked beautiful!”
· “I liked that I could move by my breathing.”
· “I really liked the moving elements. It was cool to see how the fish and plants were moving with my breathing.”
Teachers and school clinicians also emphasised DEEP’s potential as intervention for adolescents struggling with stress, anxiety and self-regulation. Most participants, teachers and the school clinicians indicated that they would want to continue using DEEP. However, there were some concerns regarding the workload and technical requirements for using the VR system (which in this case was an HTC Vive). Therefore, more accessible alternatives such as phone applications or more user-friendly head mounted displays like the Oculus Quest should be explored in the future - something the DEEP development team are now exploring.
In sum, our study demonstrated the potential of DEEP as an intervention to reduce daily levels of state-anxiety and disruptive classroom behaviour in a special school setting. On overage, our results showed that the calm or relaxed state of participants after playing DEEP lasted for 2 hours. Therefore, school clinicians are recommended to tailor implementation strategies of DEEP to the individual with different needs early or later in the day, considering individual variation in the duration of the effect of DEEP. The implementation of game-based interventions might be a promising avenue for the special school setting, as video games can be tailored to the diverse needs and learning paces of the heterogeneous special school population.
The team are now working to improve the gameplay experiences of DEEP, by adding more elements and increasing the world through which users can move. Intervention outcomes could also potentially be increased by providing the players insight in their (breathing) progression in the game so they can make the transfer from the skills learned in DEEP to their behaviors in the classroom.
Eastern philosophy and now modern psychology show that taking a moment to stop and practice meditative breathing has extensive health benefits for us all. We all occasionally need an escape, a chance to reconnect with our brains and bodies. DEEP is hopefully a gateway to helping people get there. The DEEP team now intend to share the experience in a variety of settings. From hospital waiting rooms, to schools and preparing expecting mothers for birth and even helping people with respiratory conditions such as COPD, hyperventilation and possibly even breathing pattern disorders that may result in people recovering from COVID.
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