Archives of Psychiatric Nursing 41 (2022) 132–143

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Archives of Psychiatric Nursing

journal homepage: www.elsevier.com/locate/apnu

A scoping review of gamification for mental health in children: Uncovering

its key features and impact☆
Huiting Xie
Institute of Mental Health, Buangkok Green Medical Park, 10 Buangkok View, 539747, Singapore

A R T I C L E I N F O A B S T R A C T

Keywords: Mental health conditions in children and adolescents have wide-ranging effects, limiting opportunities for future
Gamification productive lives. While there has been an upsurge of interest in using games for learning, gamification to
Serious gaming optimize health outcomes is worth reviewing when this approach to address mental health conditions is in its
Mental health
infancy. A literature search was conducted with two hundred and fifteen articles involving participants up to
Children and adolescents
19 years of age with diagnosable mental health conditions, involving the concept of game design elements to
motivate health in the context of comparing gamification and non-gamification approaches were retrieved after
employing Boolean operators and pre-determined search strategies. Literature of participants with addiction to
alcohol or substance use and organic brain issues were excluded as their mental health recovery differed
regardless of gamification impact. Findings, extracted from 8 included articles following rigorous screening and
critical appraisal, showed that gamification to relieve mental health symptoms were conducted via mobile de­
vices or computers. Key features of the games involved applications or video where players with mental health
conditions took on roles in a virtual world with narratives. Real-life knowledge and skills to manage the
symptoms of mental health conditions were learned in the process as players leveled up in the game. Only one
study utilized gamification platforms that could detect breathing changes but it was shown to be only helpful
towards relief of anxiety symptoms. Nevertheless, the potential for gamification for mental health outcomes
remains promising.

About 1 to 2 in every 10 children, 10 % to 20 %, of children and Gamification for healthcare

adolescents suffer from mental health conditions (World Health Orga­
nization, 2020). The most common problems are conduct disorders,
attention deficit hyperactivity disorder (ADHD), emotional disorders
(anxiety and depression) and autism spectrum disorders and in areas
such as the United Kingdom, the incidence of mental health conditions
have been rising (Murphy & Fonagy, 2012; Ogundele, 2018).
In children and adolescents, mental health conditions account for
16 % of the global burden of diseases (World Health Organization,
2020), with wide-ranging effects impacting on educational attainment,
social relationships or even physical health (Murphy & Fonagy, 2012).
Many of these mental health conditions can start as early as age 14 years
and extend to adulthood, limiting the opportunities for the sufferers to
lead fulfilling and productive lives. Moreover, suicide is the third lead­
ing cause of death in 15 to19 year-olds (World Health Organization,
2020). Hence, there is a dire need to address mental health conditions in
children and adolescents before lives are lost or even if lives are pre­
served, to prevent consequences on their livelihoods in adult years.
While gaming, a crucial aspect of human culture has been used for
the purpose of entertainment, gamification, employing game elements
or the process of gaming and gameful experiences are increasingly
transferred to traditionally game-free contexts such as for healthcare
and fitness (Krath et al., 2021).
In the field of education, there has been an upsurge of interest in
using games for learning. Learners, whose preferences and abilities have
been shaped by digital technologies and most notably video games, no
longer accept being told the information they need to learn but prefer to
discover the information for themselves through construction, interac­
tion and, above all, fun (Xie et al., 2017). This has emerged from the
optimism that the motivating features that are evident in games could
also be deployed to motivate learning. This is echoed by Phillips et al.
(2019) who emphasized that people enjoy playing games and winning.
Popular culture, social media, and the ubiquity of smartphones have fed
into the desire to engage in games.

☆
The author has no conflict of interest to disclose.The author would like to acknowledge the Nursing team at the Institute of Mental Health for their support.
E-mail address: hui_ting_xie@imh.com.sg.

https://doi.org/10.1016/j.apnu.2022.07.003
Received 17 December 2021; Received in revised form 26 May 2022; Accepted 3 July 2022
Available online 11 July 2022
0883-9417/© 2022 Elsevier Inc. All rights reserved.
H. Xie Archives of Psychiatric Nursing 41 (2022) 132–143

There has been a proliferation of interest in gamification to optimize Review questions

health outcomes. Gamification in healthcare is defined as the use of
game design elements to motivate positive health (Phillips et al., 2019). Specifically, this review aims to address the following questions:
In the United States, the healthcare authorities have recognized the
increasing use of gamification in healthcare and regulated the gaming ▪ What are the gamification approaches that impacted mental
products when the intended uses are to treat, diagnose, cure, mitigate, or health outcomes?
prevent disease as medical devices (Phillips et al., 2019). In addition, a ▪ What is the impact of gamification approaches on mental health
systematic review has concluded that gamification is effective for health outcomes in children and adolescents compared to usual care
and wellbeing, especially those that target behavioral outcomes, that did not include gamification?
particularly physical activities (Johnson et al., 2016). Similarly, gami­
fication in healthcare is also suggested for helping patients in the areas Methods
of nutrition, weight control, medication adherence and hands’ hygiene
(Pereira et al., 2014). This scoping review was conducted with methods guided by the
Joanna Briggs Institute which included the core elements of partici­
Gamification for mental healthcare pants, concept, and context (PCC) in its eligibility criteria (Joanna Briggs
Institute, 2020).
In the mental health arena, gamification to address mental health
conditions is still in its infancy (Fleming et al., 2017). Yet, it is possible
Eligibility criteria
that gamification could also bring about positive mental health out­
comes as games are potentially appealing to increase the reach of mental
Types of participants
health interventions to people with mental health conditions some who
The literature was included if the participants were children and
may otherwise not seek help. Furthermore, gamification can be enjoy­
adolescents up to the age of 19 years old as defined by the World Health
able for people with mental health conditions who are keen to “win” the
Organization (2020). Literature involving participants with identified
game, or see how the story unfolds. Such dynamics may contribute to
mental health conditions were included in this review. A diagnostic
reducing high attrition rates in naturalistically implemented internet-
criterion such as those based on the Diagnostic and Statistical Manual of
based interventions (Fleming et al., 2017). In addition, benefits of
Mental Disorders (DSM–5) was not set for this review as the diagnostic
gamification to support to the improvement in cognitive, social, and
criteria varied across countries and publication times of the literature.
emotional states of the elderly persons have also been demonstrated
Literature where participants with addiction to alcohol or substances use
(Martinho et al., 2020).
were excluded as their mental health recovery would be different
regardless of the impact of gamification. Similarly, literature where
Gamification for mental healthcare in children and adolescents
participants had organic brain issues or brain trauma were excluded as
the current treatment of such injuries would be surgical intervention
It is well-known that children and adolescents learn better through
rather than gamification or other psychological approaches, hence the
game play rather than didactic lectures with greater acceptability,
outcomes for them would differ greatly from those who undergone
enjoyment and possibly retention of information (Aljezawi & Albash­
psychological approaches.
tawy, 2015; Blakely et al., 2009; Manzano-León et al., 2021). Hence,
gamification is a valid learning strategy (Manzano-León et al., 2021) and
Concept
potentially applicable in healthcare for children and adolescents. Yet,
Gamification in healthcare is defined as the use of game design ele­
the effectiveness of gamification for mental health in children and ad­
ments to motivate positive health (Phillips et al., 2019). To gather
olescents remains largely unknown. A preliminary search on Clinical
findings about the effectiveness of gamification approaches for mental
Key of Elsevier in December 2020 found seven clinical trial proposals on
health outcomes, literature that involved outcomes including changes in
gamification for mental health but none were specific to children and
symptoms of mental health conditions, behavioral changes, and mental
adolescents. A systematic review of serious games for mental health
health recovery were included. Mental health recovery is a deeply per­
revealed that promising evidence on the effectiveness of gamification for
sonal process of not only gaining symptomatic relief from mental health
children and adolescents’ mental health has only been specific to
conditions but also managing one’s psychiatric disorder while main­
depressive symptoms via the injection of game elements to the existing
taining a positive sense of self, roles and life beyond the mental health
use of cognitive behavior therapy for depression (Fleming et al., 2017).
system (Onken et al., 2002).
Yet, in another study, while gamification was shown to enhance mental
health outcomes, such as the perception of pleasure and enjoyment as
Context
well as greater acquisition of new friendships to enhance social support
In order to facilitate a comprehensive search of the literature, studies
as compared to the control group which did not engage in game play, it
conducted in acute care, primary health care, or the community settings
is this same group, which also had worsen sleep quality and physical
were included for this review. However, since this review focused on the
health compared to the control group (Smyth, 2007).
effectiveness of gamification approaches, only studies that compared
While, the potential for gamification for healthcare have been
gamification to other non-gamification approaches in the comparator
demonstrated, the evidence for gamification for mental healthcare is
group, which typically utilizes pharmacological or psychological ap­
lacking. Specifically in children and adolescents, the evidence is limited
proaches without the use of gamification were included. Studies that did
and findings are mixed. Yet, it is pertinent to address mental health is­
not make any comparison were excluded.
sues in children and adolescents. Hence, this paper aims to presents a
scoping review of the literature to uncover the evidence regarding the
effectiveness of gamification for mental health in children and Search strategies
adolescents.
A three-step search strategy was utilized as recommended by Joanna
Briggs Institute (2020). The first step is an initial limited search of at
least two appropriate online databases relevant to the topic. The

133
H. Xie
databases were MEDLINE and Cumulative Index to Nursing and Allied
Health Literature (CINAHL), two databases containing healthcare liter­
ature, which could offer a glimpse of the available studies specific to the
scope of this review, gamification for mental health conditions. This
initial search was to look for words contained in the title and abstract of
retrieved papers, and of the index terms used to describe the articles. For
example, it was found that the terms “game”, “gaming” and “play” could
also be used to describe the concept of “gamification” hence the search
needed to include all these terms to enable a thorough search.
A second search using all identified keywords and index terms was
undertaken across all included databases including the terms used to
describe gamification and also terms such as “treatment”, “prevention”,
“mental health”, “mental illness” or “recovery” to uncover literature
about the use of gamification specific to impact mental health recovery
in participants with mental health conditions. Thirdly, the reference lists
of identified reports and articles were searched for additional sources
and grey literature.
Databases such as MEDLINE, CINAHL and PsycInfo, which are da­
tabases hosting literature relating to therapeutic healthcare purposes,
nursing relevant approaches and mental health literature respectively
were searched to gather literature regarding gamification interventions
for mental health (treatment or prevention). Limits for studies that have
been peer-reviewed and published in English from the year 2010 to 2021
were set to reflect the recent development in the field. Boolean operators
such as “AND’ or “OR” were also used to combine the search terms.
Literature search was conducted using (mental health OR mental illness)
AND (Child OR Adolescent) AND (treatment OR prevention OR mental
health recovery) AND (game OR gaming OR gamification OR play).
Results
Search results
A total of 215 articles were retrieved using the search strategies
outlined earlier with a check of citations yielding two further articles for
inclusion (see Appendix A for the Prisma Flow Diagram detailing the
search results). After duplicates were removed, a total of 47 articles were
identified and 21 articles with no findings were screened out following
review of the title and abstract as some of the articles were clinical trial
protocols or editorial reports. In addition, articles on gamification
prevalence rather than the effectiveness of gamification were also
excluded. Upon review of the full-text articles, 18 were excluded with
various reasons such as studies that did not compare gamification with a
non-gamification approaches to elicit the impact of gamification ap­
proaches. To enhance the homogeneity of the sample for this review,
studies, which were not aligned with the eligibility criteria set forth for
this review such as participants who were not children and adolescents
with mental health conditions or the outcomes of the studies not being
recovery from mental health conditions were also excluded after
reviewing the full-text of the retrieved articles (see Appendix B for full-
text articles excluded with reasons). Eight articles were included in the
final review for synthesis of findings.
Characteristics of the included studies
All the eight included studies were conducted in the western coun­
tries with two studies in the United Kingdom (Fletcher-Watson et al.,
2016; Hammond et al., 2014), 1 study in Australia (Wilkes-Gillan et al.,
2016), 2 in Netherlands (Bul et al., 2016; Schoneveld et al., 2018), 2 in
United States (Knox et al., 2011; Pramana et al., 2018). One of the
studies were conducted with participants recruited from the Urban
community in Europe but country was not specified (David et al., 2019).
Participants across all the eight included studies were aged between
five to 17 years old, spending across the children and adolescents age,
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Archives of Psychiatric Nursing 41 (2022) 132–143
the eligibility criteria for this review. One study specifically identified
children below six years old with autism (Fletcher-Watson et al., 2016)
for participation. Otherwise, the rest of the studies included participants
with attention deficit hyperactivity disorder (ADHD), emotional issues
such as depression or anxiety disorders or developmental coordination
disorder (DCD).
As this review specifically included literature involving control
groups, all of the study designs were randomized controlled trials
involving wait-list controls with the exception of the two studies
comparing outcomes of two different groups of participants receiving
gamification with cognitive behavior therapy (Pramana et al., 2018;
Schoneveld et al., 2018), (see Appendix C for summary of findings for all
the included studies).
Features of gamification approaches
Use of mobile devices
The gamification approaches mostly involved the use of mobile de­
vices such as ipads (David et al., 2019; Fletcher-Watson et al., 2016). In
both of these studies, applications were placed on ipads where education
and games to engage participants were delivered and participants
learned about strategies to manage their mental health conditions
through these applications. Take the REThink application for example
(David et al., 2019), participants undertook Rational Emotive Behavior
Education (REBE) and Rational Emotive Behavioral Therapy by playing
and going through different levels within the application to gather in­
formation in order to manage their emotional problems.
Smart phones may also be used. An application was also installed on
participants’ mobile devices for participants to learn about strategies for
anxiety management through the Smartphone-enhanced Child Anxiety
Treatment (SmartCAT) (Pramana et al., 2018). Within this application,
there was a series of interactive games and activities to reinforce skill
understanding, an in vivo skills coach that cues the participant to use
cognitive behavioral therapy skills during real-world emotional expe­
riences, a home challenge module to encourage home-based exposure
tasks, a digital reward system that contains digital points and trophies,
and a therapist-patient messaging interface.
When mobile devices were used, participants engaged with the game
on their own providing great accessibility. It was found that an average
of 50 min daily on the game were spent (David et al., 2019).
Videogames on computer
Beside the use of mobile devices, gamification approaches using
computers, through the playing of videogames were also common (Bul
et al., 2016; Knox et al., 2011; Schoneveld et al., 2018). Games were
installed onto computers and learners engaged in the game.
In such games, there were usually narratives whereby participants
played a character in a story plot and went through different levels as
they engage in the gamification approaches such as the internet-enabled
“Plan-It Commander” in Bul et al. (2016) or the “Journey to Wild
Divine” in Knox et al. (2011). In addition to providing accessibility of
games to learners with the use of mobile devices or computers, such
accessibility also enabled a secured platform for therapist to interact
with participants. In Pramana et al. (2018), therapists follow up on
participants by sending messages through the game to provide strategies
on illness management or reinforcement of positive behavior through
thank you messages (Bul et al., 2016). Similarly, participants may also
interact among themselves through messaging platforms to stimulate
prosocial behavior to ask for help (Pramana et al., 2018).
While majority of the games were played on mobile devices or
computers, there were also gamification approaches which took place in
the presence of the therapist. (Hammond et al., 2014; Wilkes-Gillan
et al., 2016). The latter involved six clinic play-sessions with weekly
home-modules and one month home follow up. At the clinic play
H. Xie Archives of Psychiatric Nursing 41 (2022) 132–143

sessions, the playroom was consistently set up with a variety of toys and 2014). Motor proficiency self-perceived ability and motor coordination
physical games. Therapists observed participants playing the games and satisfaction with motor tasks were significantly better in children un­
provided guidance on proper behavior during the game play. In Ham­ dertaking gamification on Wii Fit.
mond et al. (2014), physical set-up of wii playstation was put up for
participants to engage in ten minutes thrice weekly sessions for one In children and adolescents with mood disorders
month using Wii Fit for motor training for people with the mental health Among the eight included studies, there was the most amount of
condition of Developmental Coordination Disorder (DCD). evidence regarding gamification in children and adolescents with anx­
iety disorders. Three studies examined mental health outcomes
Duration following gamification approaches versus non-gamification approaches
Generally, participants were engaged in the games for at least an and in all these studies, participants who undertook gamification had
hour daily over six to ten weeks. For such computer enabled games, the significantly better outcomes than those who did not. In Knox et al.
duration was usually about an hour daily (Bul et al., 2016; Schoneveld (2011), children aged nine to 17 years diagnosed with Generalized
et al., 2018) over six and ten weeks, respectively. In Knox et al. (2011), Anxiety disorders (GAD) in the United States were engaged in game-
school-age children in the USA spent an average of seven hours per week based biofeedback sessions on an average of seven to nine hours per
playing video games, and eighth and ninth grade students average about week on the computer. In a game titled “The Journey to the Wild
nine hours per week over at least eight weeks depending on the par­ Divine”, a tree moved rhythmically in the breeze and participants had
ticipants’ interests. This averaged to about one to one hour and 18 mins the goal of building a bridge across a valley. Participants were encour­
daily. aged to slow their breathing in response to soft music. As the person’s
breathing slowed and tension decreased, the bridge was built. If the
participant experienced frustration or anxiety, the bridge disappeared.
Impact of gamification on mental health outcomes
After a continuous amount of relaxation, the bridge was completed and
the participant may ‘cross’ to the next activity. The game involved
Children and adolescents with attention deficit hyperactivity disorders
video-game-like technology and graphics to garner participants’ interest
(ADHD)
and engagement in biofeedback. Participants also learned deep breath­
In two of the included studies, gamification approaches were
ing, imagery, and relaxation to aid their anxiety condition. Anxiety level
compared against wait-list control in children and adolescents. The
between participants who engaged in the game was compared with
impact of a computer video-based game “Plan-It Commander” was
participants who did not engage in the game and results favored the
compared against treatment as usual in children eight to 12 years old
participants undertaking gamification. They had reduced anxiety and
across four outpatient mental health care clinics and institutions in the
depression scores on standardized tests, unlike participants who had
Netherlands and Belgium. Though greater improvements in parents-
usual treatment without engaging in any game play.
rated time management skills and parent-reported planning/orga­
In Schoneveld et al. (2018), seven to 12 years old with elevated
nizing skills was shown in the group undertaking gamification, no sta­
anxiety symptoms found on the Spence Children’s Anxiety Scale
tistical significance differences in these outcomes were noted between
participated in a study involving the playing of Mindlight, a video-game
the gamification group and the control group without gamification (Bul
played on the computer for one hour per week, for six consecutive
et al., 2016).
weeks. The effectiveness of Mindlight on anxiety symptoms was
On the contrary, in study participants aged five to 11 years old
compared with another group of participants engaging in cognitive
recruited from pediatrics medical clinics and ADHD support groups in
behavior therapy (CBT), the gold standard treatment for anxiety disor­
Australia, ten weeks of weekly gamification sessions at a playroom with
der (Schoneveld et al., 2018). MindLight, employed exposure tech­
the therapist in the clinic showed a significant change between the group
niques, one of the most empirically-validated treatment components of
receiving gamification and the treatment as usual group. Participants’
CBT for anxious individuals. Neurofeedback approaches were incorpo­
peer interaction skills and behavior ratings were significant better in the
rated to decrease anxiety symptoms and incorporate attention modifi­
gamification group as compared to the control group (Wilkes-Gillan
cation for children to minimize paying attention to threatening cues.
et al., 2016).
According to the developer, MindLight could overcome cost effective­
ness and de-contextualisation limitations of cognitive behavioral ther­
Children and adolescents with autism
apy and face to face sessions limitations for children. The results showed
Only one study examined the mental health outcomes in children
that MindLight was favored over CBT at post-test, 3-months and 6-
and adolescents with autism. Children with autism below six years from
months follow up.
Edinburgh, United Kingdom, either received treatment as usual plus
Similarly, the gamification approach was compared with CBT in
having the opportunity to play games through an ipad application; or
participants averaging nine to 14 years old with generalized anxiety
only treatment as usual involving one to one support in primary schools,
disorders in the United States. Participants were undertaking a gamified
without the game (Fletcher-Watson et al., 2016). In the game, children
application, using the Smartphone-enhanced Child Anxiety Treatment
were educated on key social communication skills and displayed
(SmartCAT), as an adjunct to CBT (Pramana et al., 2018). SmartCAT
appropriate social behavior through playing a character within a story
contained a series of interactive games and activities to reinforce skill
plot in the game. However, no significant differences in behavioral is­
understanding. An in-vivo skills coach provided cues for participants to
sues associated with autism was noted between the children receiving
use cognitive behavioral therapy skills during real-world emotional
gamification interventions and those without after the intervention, at
experiences. A home challenge module was built in to encourage home-
two months and six months follow-up.
based exposure tasks, a digital reward system that contains digital points
and trophies and a therapist-patient messaging interface were also in
In children and adolescents with Developmental Coordination Disorder
built into SmartCAT. Though only significant differences in the duration
(DCD)
of engagement between participants undertaking gamification with CBT
Only one study examined the mental health outcomes in children
and those with CBT only and without gamification was demonstrated in
with DCD following gamification approaches involving ten minutes
the study, it was reported that a participant who hardly used the app was
thrice weekly for one month using Wii Fit compared with another ran­
diagnosed and referred for depression while the other participants who
domized control group receiving the usual treatment. (Hammond et al.,

135
H. Xie
frequently engaged with the game had their anxiety symptoms
managed.
In David et al. (2019), it was shown that a game had a significant
impact on emotional symptoms (a moderate-effect size, d = 0.46),
depressive mood (a large-effect size, d = 0.84), emotional regulation (a
moderate-effect size, d = 0.64), and the ability for emotional control
(d = 0.69) in community-dwelling participants aged ten to 16 years from
Europe as compared to waitlist control with treatment as usual and
participants undergoing Rational Emotive Behavior Education (REBE)
only. The game, REThink, comprised both Rational Emotive Behavior
Education (REBE) and Rational Emotive Behavioral Therapy (EEBT).
Hence, among the included studies, the impact of gamification on
children and adolescents with attention deficit hyperactivity disorders
(ADHD) was conflicting with one study showing effectiveness and one
showing otherwise. The mental health impact on children and adoles­
cents with autism and developmental coordination disorder (DCD) was
limited to only a single study. The impact of gamification on children
and adolescents on emotions seems to be most evident with three studies
demonstrating a positive impact of gamification on children and ado­
lescents in participants with anxiety and one study demonstrating
impact on those with emotional and depressive mood.
Discussion
In this review, eight articles meeting the pre-determined eligibility
criteria retrieved from the stated search strategies were considered. As
game-based approaches for mental health are in their infancy (Fleming
et al., 2017), a review was conducted to address the review questions of
what the gamification approaches that impacted mental health out­
comes are and the impact of gamification approaches on mental health
outcomes in children and adolescents comparing to approaches that did
not include gamification. Published results were predominantly from
western countries like United States and United Kingdom. Methodo­
logical quality or risk of bias had not been reviewed prior to the decision
to include the articles, which is consistent with the guidance on con­
ducting a review (Joanna Briggs Institute, 2020; Peters et al., 2015).
Gamification approaches were heterogenous across the literature
with different names and on different platforms. In most of the litera­
ture, gamification to relieve mental health outcomes was conducted via
mobile devices or computers. Gamification typically involved users with
mental health conditions using applications or video games playing
certain characters in a virtual world with narratives or storylines. Real-
life knowledge and skills to manage the symptoms of mental health
conditions were learned in the process as players level up or progressed
in the game. Only one study utilized gamification platforms that could
detect breathing changes for biofeedback, but it was shown to be only
helpful towards relief of anxiety symptoms. Messaging platforms could
also be built into the games. Games like these could not only be enter­
taining but facilitated stress release and social support (Fleming et al.,
2017). With these messaging platforms, the support of therapist or
paraprofessional support could be present, which was in line with prior
studies reporting that effectiveness can be enhanced with therapist or
paraprofessional support (Fleming et al., 2014).
Though most of the gamification approaches involved children and
adolescents having access to the games at their own time and target, the
dynamics of the game to unfold its storyline and players’ desire to level
up or win the game, motivated these children and adolescents to com­
plete the games in these naturalistically implemented interventions
(Fleming et al., 2017).
The impact of gamification had been examined in children and
adolescents with attention deficit hyperactivity disorders, autism,
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Archives of Psychiatric Nursing 41 (2022) 132–143
developmental coordination disorder (DCD) and anxiety or mood dis­
orders, the most prominent impact of gamification was reported in the
relief of anxiety and emotional symptoms. People who had undergone
gamification consistently fared better than those undergoing cognitive
behavior therapy. While systematic reviews have found cognitive
behavior programs as the most common and effective treatment of
mood disorders and depression (Fleming et al., 2014), incorporating
game design elements to such therapy could be promising for the
treatment of anxiety disorders in children and adolescents (Fleming
et al., 2017).
Across the studies included in this review, most children and ad­
olescents engaged in the game for about an hour daily over six to ten
weeks unlike cognitive behavior therapy which typically requires ten
to 20 weeks of weekly sessions with a therapist as reported in a sys­
tematic review by James et al. (2005). Gamification provides a
potentially more efficient solution by delivering more engaging and
interactive strategies to facilitate cognitive behavioral therapy skills
in everyday lives, augmenting clinician-delivered therapies, or offer­
ing a vehicle for standardizing patients’ access to specific cognitive
behavior strategies as reported in a preliminary study by Bakker et al.
(2018).
Conclusion
It is already known that there is a need to address mental health
conditions in children and adolescents. While games have been
frequently associated with entertainment and education, application of
game elements are increasingly being applied in traditionally game-
free contexts including healthcare. Children and adolescents, being
exposed to digital interventions while growing up, may be in a prime
position to accept gamification for health. Not only has this review
added on to the knowledge base regarding the key features of gamifi­
cation, the impact of gamification were also examined in this review.
Key features of gamification for mental health in children and adoles­
cents largely involved the use of mobile devices or computer with
opportunities to progress in the game. Players with mental health
conditions took on roles in a virtual world with narratives or storylines
and learning real-life knowledge and skills to manage the symptoms of
mental health conditions and leveled up while engaged in the game.
Comparing with non-gamified approaches, the most prominent impact
of gamification is in the management and treatment of mood and
anxiety symptoms in children and adolescents with evidence suggesting
that gamification of traditional cognitive behavior therapy could take a
shorter duration to achieve its impact. This review has also highlighted
the need for further studies to provide consistent evidence towards the
use of gamification for attention deficit disorder and other mental
health conditions in children and adolescents. While the evidence of
the utility of gamification on mood and anxiety symptoms is most
prominent, the impact on biological responses in mental health con­
ditions require further investigation.
Healthcare providers planning or implementing strategies and
therapies to help children and adolescents manage their mental health
conditions could consider incorporating the key features of gamifica­
tion uncovered in this review, especially in the management of mood
and anxiety symptoms where the greatest pool of evidence existed.
Cognitive beahvioral therapy and other psychological therapies and
tools could be presented in a gaming format. More studies on the
impact of gamification on biological changes in people with mental
health conditions could be considered. Given the potential evolution of
technology, the potential for gamification for mental health outcomes
remains promising.
H. Xie Archives of Psychiatric Nursing 41 (2022) 132–143

Appendix A

PRISMA 2009 Flow Diagram

Records idenfied through Addional records idenfied

database searching through other sources
(n = 215 ) (n = 2)

MEDLINE= 73

CINAHL= 51
Identification

PsycInfo= 91

Records aer duplicates removed

(n = 47 )
Screening

Records screened Records excluded

(n = 47 ) (n = 21)

Full-text arcles assessed Full-text arcles excluded,

Eligibility

for eligibility with reasons

(n = 26) (n = 18)

Studies included in
synthesis
Included

(n = 8)

Appendix B

Full-text articles excluded with reasons.

Reasons for exclusion Articles excluded

No comparison between gamification approaches and with Perception of the outcomes of gamification approaches were reported without comparison with a non-gamification
a non-gamification approach approach

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(1550–5952), 7(10), 19–24.
2. James, T., & Countryman, J. (2012). Psychiatric Effects of Military Deployment on Children and Families: The Use of
Play Therapy for Assessment and Treatment. Innovations in Clinical Neuroscience, 9(2), 16–20.

Comparison is made between one gamification approach with another gamification approach:

3. Wang, Y. X., Lu, G. B., Ge, P., Ou, P., Liu, G. H., Qian, Q. F., … & Yu, Q. J. (2019). Clinical efficacy of interactive group
sandplay versus individual sandplay in the treatment of preschool children with autism spectrum disorder. Zhongguo
Dang dai er ke za zhi = Chinese Journal of Contemporary Pediatrics, 21(4), 342–347.
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Reasons for exclusion Articles excluded

Comparison is made between different severity of mental health conditions:

4. Bul, K. C., Doove, L. L., Franken, I. H., Oord, S. V. D., Kato, P. M., & Maras, A. (2018). A serious game for children with
Attention Deficit Hyperactivity Disorder: Who benefits the most?. PloS one, 13(3), e0193681.
Participants were not children and adolescents with Participants were parents and mental health outcomes of gamification were evaluated in parents:
mental health conditions

5. Sanders, M. R., Baker, S., & Turner, K. M. (2012). A randomized controlled trial evaluating the efficacy of Triple P
Online with parents of children with early-onset conduct problems. Behavior research and therapy, 50(11), 675–684.
6. Blackwell, S. E., Watson, P., Iyadurai, L., Bonsall, M. B., & Holmes, E. A. (2017). Reducing intrusive traumatic
memories after emergency caesarean section: A proof-of-principle randomized controlled study. Behavior research and
therapy, 94, 36–47.
7. Comer, J. S., Furr, J. M., Miguel, E. M., Cooper-Vince, C. E., Carpenter, A. L., Elkins, R. M., Kerns, C. E., Cornacchio,
D., Chou, T., Coxe, S., DeSerisy, M., Sanchez, A. L., Golik, A., Martin, J., Myers, K. M., & Chase, R. (2017). Remotely
delivering real-time parent training to the home: An initial randomized trial of Internet-delivered parent–child
interaction therapy (I-PCIT). Journal of Consulting and Clinical Psychology, 85(9), 909–917.

8. Weisleder, A., Cates, C. B., Harding, J. F., Johnson, S. B., Canfield, C. F., Seery, A. M., Raak, C. D., Alonso, A., Dreyer,
B. P., & Mendelsohn, A. L. (2019). Links between Shared Reading and Play, Parent Psychosocial Functioning, and
Child Behavior: Evidence from a Randomized Controlled Trial. The Journal of pediatrics, 213, 187–195.e1.

Participants were healthy employees:

Participants did not have mental health conditions but an
organic brain issue
No gamification approach articulated in the article
Mental health outcomes were not evaluated as an outcome
of gamification
9. Litvin, S., Saunders, R., Maier, M. A., & Lüttke, S. (2020). Gamification as an approach to improve resilience and
reduce attrition in mobile mental health interventions: A randomized controlled trial. PloS one, 15(9), e0237220.
10. Corti, C., Urgesi, C., Poggi, G., Strazzer, S., Borgatti, R., & Bardoni, A. (2020). Home-based cognitive training in
paediatric patients with acquired brain injury: preliminary results on efficacy of a randomized clinical trial. Scientific
reports, 10(1), 1–15.
11. Corbett, B. A., Key, A. P., Qualls, L., Fecteau, S., Newsom, C., Coke, C., & Yoder, P. (2016). Improvement in social
competence using a randomized trial of a theatre intervention for children with autism spectrum disorder. Journal of
autism and developmental disorders, 46(2), 658–672.
Gamification is the outcome of the study and not an intervention:

12. Henchoz, Y., Studer, J., Deline, S., N’Goran, A. A., Baggio, S., & Gmel, G. (2016). Video Gaming Disorder and Sport
and Exercise in Emerging Adulthood: A Longitudinal Study. Behavioral Medicine (Washington, D.C.), 42(2),
105–111.

Mental health experience of the therapist providing gamification was evaluated in the study and not mental health
outcomes of the recipients of gamification intervention:

13. Blalock, S. M., Lindo, N. A., Haiyasoso, M., & Morman, M. K. (2019). Child-Centered Play Therapists’ Experiences of
Conducting Group Play Therapy in Elementary Schools. Journal for Specialists in Group Work, 44(3), 184–203.

Weight loss and not mental health outcomes following gamification was evaluated in the study. Mental health outcomes
were implied following weight loss:

14. Freira, S., Lemos, M. S., Fonseca, H., Williams, G., Ribeiro, M., Pena, F., & do Céu Machado, M. (2018).
Anthropometric outcomes of a motivational interviewing school-based randomized trial involving adolescents with
overweight. European Journal of Pediatrics, 177(7), 1121–1130.

Reading capability and not mental health outcomes were evaluated in the study:

15. Palmer SL, Leigh L, Ellison SC, Onar-Thomas A, Wu S, Qaddoumi I, Armstrong GT, Wright K, Wetmore C, Broniscer
A, Gajjar A. Feasibility and efficacy of a computer-based intervention aimed at preventing reading decoding deficits
among children undergoing active treatment for medulloblastoma: results of a randomized trial. J Pediatr Psychol.
2014 May;39(4):450–8.
Smoking cessation and not mental health outcomes were evaluated in the study:

16. Khazaal Y, Chatton A, Prezzemolo R, Zebouni F, Edel Y, Jacquet J, Ruggeri O, Burnens E, Monney G, Protti AS, Etter
JF, Khan R, Cornuz J, Zullino D. (2013). Impact of a board-game approach on current smokers: a randomized
controlled trial. Substance abuse treatment, prevention, and policy, 8(1), 3.

Mental health literacy and stigma were evaluated in the study and not participants’ mental health:

17. Shandley, K., Austin, D., Klein, B., & Kyrios, M. (2010). An evaluation of ‘Reach Out Central’: an online gaming
program for supporting the mental health of young people. Health education research, 25(4), 563–574.

Study findings has yet to be published. Only study protocol published noted to be published after making contact with
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Reasons for exclusion Articles excluded

the studio that creates the game.

18. Wijnhoven, L. A., Creemers, D. H., Engels, R. C., & Granic, I. (2015). The effect of the video game Mindlight on
anxiety symptoms in children with an Autism Spectrum Disorder. BMC psychiatry, 15(1), 1–9.

However, the results of the game on anxiety symptoms in children without autism that was published in a separate study
would be discussed in this review.

Appendix C

Summary of findings table.

Article Design Participants Intervention Control Measurement Findings

(Wilkes- Randomized Children with - 10 weeks 10-week wait 1) The Test of Playfulness Play-based intervention was
Gillan controlled trial Attention Deficit - 6 clinic play-sessions period, treatment as (ToP) was used to effective for improving the
et al., with wait-list Hyperactivity Disorder weekly home-modules usual (Details not examine children’s play social play skills of children
2016). control (ADHD (5 to 11 years) - 1 month home follow provided). skills in peer-to-peer with ADHD aged 5 to 11 years
from paediatric up play interactions pre, in peer-to-peer interactions in
Treatment services and ADHD The playroom was post and one-month the clinic and home
fidelity parent support groups consistently set up with following the environments.
evaluated by across metropolitan a variety of toys intervention.
interview of Sydney, Australia including: a basket-ball Play skills of children with
parents on hoop, bowling set, soft The ToP is a 29-item unidi­ ADHD in the intervention-
treatment Intervention group: bat and ball games, cars, mensional instrument that first group during their
adherence n = 15 figurines, nerf guns, a requires observational intervention phase (pre to
tent, dress-ups, play- scoring. post intervention) was
Allocation Control group: n = 14 doh, a sand box, floor 2) significantly greater than the
concealment games (e.g., Twister™) Conners Comprehensive change in the overall play
with opaque Behavior Rating Scales skills of children with ADHD
envelopes - and toys from (CCBRS). in the control-first group
electronic games (e.g., during their 10 week wait
Blinded ratings Angry Birds™, Club period (t = 8.02, p < 0.001;
of children’s Penguin™). 95 % CI = 18.79–31.71).
play sessions
The change in the overall ToP
- 2 Therapists, 1 scores for the intervention-
managing cooperative first group was: 23.8 (mean),
play between dyad of 6.1–48.3 (range), 10.6 (SD).
children with ADHD
and their playmate The change in the overall ToP
and another working scores for the control-first
with parents group during their 10-week
discussing about social wait period was: − 1.4
interaction strategies (mean), − 7.5–10.1 (range),
at home 5.4 (SD).

During the waitlist period,

children’s baseline 1 mean
ToP score was 49.29
(SD = 7.14) and the baseline
2 mean ToP score was 47.90
(SD = 10.30).

For the control-first group, no

significant differences were
found in children’s social play
skills over the 10-week period
of no intervention
(t = − 0.959, p = 0.355; 95 %
CI = − 4.51–1.74).
(Bul et al., Randomized Children with ADHD (8 10 weeks Internet-based Treatment as usual (1)Time management The intervention group
2016). controlled cross- to 12 years old) across serious game for the first questionnaire (2) the showed significantly greater
over trials 4 outpatient mental intervention (called 10 weeks and subscale Plan/Organize of improvements in parent-rated
health care clinics and “Plan-It Commander”) crossed over to the the Behavior Rating time management skills
institutions in the developed by health serious game Inventory of Executive compared to participants in
Netherlands and care professionals, intervention in Function (BRIEF; parent group 2. Group 1 also showed
Belgium. researchers, and game addition to version) and (3) the subscale more improvement in parent-
experts in collaboration treatment as usual Cooperation of the Social reported planning/organizing
Intervention group: with parents and for the subsequent Skills Rating System (SSRS; skills compared to group 2,
n = 170 children with ADHD. 10 weeks. parent version) although this did not meet
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(continued )
Article Design Participants Intervention Control Measurement Findings

administered at baseline statistical significance

Control group: n = 82 The game was (T0), at 10 weeks (T1), and (P = 0.07). There were no
programmed so that at 10-week follow-up (T2). differences concerning
participants could participants’ cooperation
notplay >65 min in one skills.
24-h period to prevent
excessive use of the
game.
(Fletcher- Randomized Children with autism FindMe app for a period Treatment as usual Brief observation of social There were no significant
Watson controlled trial below 6 years from of 72 days on average on communication change group differences in parent-
et al., with waitlist Communication Clinic iPads. One-to-one support (BOSCC), an in- report measures
2016). control. at the Royal Hospital in nursery or development way of scoring postintervention, nor in a
for Sick Children, The app was designed to primary school, parent–child interaction to measure of parent–child play
Participants and Edinburgh, United give children an including specialist provide a change-sensitive at follow-up.
parents were Kingdom a local hub opportunity to rehearse units and integrated measure of key autistic
blind to for autism diagnosis two key social mainstream classes; behaviors.
hypotheses and intervention communication skills: some children
regarding the services. attending to people and receive low levels of The measure was collected
skills being following social cues. In speech and at 2 months and Follow-Up
targeted by the Randomisation was Part 1, the correct language therapy (6 months).
intervention. stratified by ADOS response was to touch (52 % of the sample
social-communication the single person shown reported <30 min
algorithm score on the screen In Part 2, per month) and
(12–17, versus ⩾ 18) to the character was occasionally
ensure that both depicted in a shop and occupational
groups had equal looked and pointed to a therapy.
representation of desired item in one of six
children with more or locations around the
less severe autism screen. The correct
symptom profiles response was to touch
the item being pointed
Intervention group: and looked at; this was
n = 27 the only motor skill
required to successfully
Control group: n = 27 play the app.

Collection of five tokens

resulted in presentation
of a short animation
sequence designed to
provide a positive
reinforcement.
(Hammond A randomized Children with 10 min thrice weekly for Regular Jump Motor proficiency (child) No differences in the baseline
et al., crossover Developmental Co- 1 month using Wii Fit Ahead programme. was measured using the characteristics between the
2014). controlled trial ordination Disorder during the lunch break short form of the Bruininks- two groups
(DCD) experience from Oseretsky Test (2nd edition;
two primary schools in BOT-2) Significant gains were seen in
Mid-Sussex, UK with motor proficiency, the child’s
average age ranging Children’s self-perceived perception of his/her motor
from 7 to 11 years old ability and satisfaction with ability and reported
motor tasks (child). emotional well-being for
Intervention group: many, but not all children.
n = 10 The Co-ordination Skills
Questionnaire (CSQ) at each Both groups showed
Control group: n = 8 of three time points: improved BOT-2 total scores
baseline (week 0), after following The Wii Fit
Phase 1 (end of week 4) and intervention period.
after Phase 2 (end of week
18). For both the CSQ Ability and
Satisfaction scores, a mixed
anova comparing the two
intervention groups over
time, revealed no significant
main effects of group
[Ability: F(1,16) = 0.22,
P = 0.649; Satisfaction: F
(1,16) = 0.33, P = 0.577] and
no group and time
interactions [Ability: F
(1.489,23.827) = 2.24,
P = 0.139; Satisfaction: F
(1,16) = 1.43, P = 0.254].

The greatest (significant)

gains were seen in gross
motor proficiency, which may
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(continued )
Article Design Participants Intervention Control Measurement Findings

be predictable given that the

games focus on balance skills
and bilateral co-ordination,
and less so in fine motor
precision and visuomotor
integration.
Knox et al., Randomized Children aged 9 to The eight-session Waitlist control Overall anxiety, assessed by The intervention and
2011). controlled trial 17 years who reported biofeedback total scores on the comparison groups did differ
with waitlist symptoms of anxiety intervention included Multidimensional Anxiety on pre-test total scores on the
control such as excessive psychoeducation, Scale for Children (MASC) MASC [t(1,22) = − 2.44;
worry and fear or identification of triggers somatic/autonomic P = 0.021], with the
carried a diagnosis of and signs of anxiety, and symptoms, indicated by intervention group having
an anxiety disorder in vivo practice. MASC Somatic/Autonomic significantly lower mean total
such as generalized subscale . perceived scores than the comparison
anxiety disorder in Participants played the tenseness, determined by group (M = 59.08, SD
United States game an average of 7 to MASC Tense/Restless =13.94; and M = 72.09,
9 h per week on the subscale SD = 11.35, respectively).
Intervention group: computer over at least
n = 9 after 6 dropped 8 weeks. Trait anxiety, measured by In order to account for pre-
out the (State–Trait Anxiety test group differences,
Inventory for Children ANCOVA was used in
Control group: n = 8 (STAIC) subsequent analyses, with
after 6 dropped out pre-test scores as the
Depression, indicated by covariate and it was revealed
No identifiable pattern total scores on the that significant differences in
of attrition Children’s Depression posttest scores of anxiety and
Inventory (CDI). depression measures between
the two groups. The
intervention group reduced
anxiety and depression scores
on standardized tests.
(Pramana Open clinical 35 participants (aged SmartCAT (Smartphone- Non-gamified Self-reported additional One participant who hardly
et al., trials, 9–14 years; enhanced Child Anxiety SmartCAT as psychiatrist consultation used the app was diagnosed
2018). Non-randomized mean = 11.19) with Treatment), a gamified adjunct to Cognitive due to relapse. and referred for depression
diagnosis of app as adjunct to behavioral therapy while the other six patients
generalized anxiety cognitive behavioral used the app more often had
disorder, social anxiety therapy (CBT). their symptoms managed.
disorder, and/or
separation anxiety SmartCAT contains (1) a Gamified SmartCAT was used
disorder based on the series of interactive frequently throughout
5th edition of the games and activities to treatment. On average,
Diagnostic and reinforce skill patients spent 35.59 min on
Statistical Manual of understanding, (2) an in the app(SD 64.18) completing
Mental Disorders vivo skills coach that 13.00 activities between each
(DSM-V) recruited cues the participant to therapy session (SD 12.61). At
openly from United use cognitive behavioral the 0.10 significance level,
States therapy skills during the app usage of the gamified
real-world emotional system (median 68.00) was
Intervention group: experiences, (3) a home higher than that of the earlier,
n = 35 challenge module to non-gamified
encourage home-based SmartCATversion (median
Control group: n = 35 exposure tasks, (4) a 37.00, U = 76.00, P < 0.01).
digital reward system
that contains digital
points and trophies, and
(5) a therapist-patient
messaging interface.

This was implemented

as an adjunctive
component to brief
cognitive behavioral
therapy in an open
clinical trial.
(Schoneveld Randomized 7 to 12 years old with Children played Cognitive Anxiety was assessed with Latent growth curve modeling
et al., controlled non- elevated anxiety MindLight for six 1-h behavioral therapy self- and parent-reports at showed an overall significant
2018). inferiority trial symptoms found on sessions, at school after pre- and post-program, and quadratic decrease in child-
Spence Children’s regular school hours at 3- and 6-month follow- and parent-reported anxiety
Anxiety Scale found on every week. ups symptoms
screening at 8 primary Mindlight, a video-game over time
schools across will be played for one
Netherlands. hour per week, for six Non-inferiority of MindLight
consecutive weeks. to CBT could be demonstrated
Intervention group: at post-test, 3-month FU, and
n = 86 Mindlight, 6-months FU for total anxiety
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(continued )
Article Design Participants Intervention Control Measurement Findings

uses exposure child report, total anxiety

Control group: n = 88 techniques, one of the
most empirically-
validated treatment
components of CBT for
anxious individuals. It
uses neurofeedback
which can decrease
anxiety symptoms and
incorporate attention
modification for
children to minimize
paying attention to
threatening cues. It
overcomes cost
effectiveness and de-
contextualisation
limitations of cognitive
behavioral therapy and
face to face sessions
limitations for children
(David et al., Randomized Children and Participants played each
2019). control trials adolescents, aged level on an Apple iPad
with waitlist between 10 and Air 2.
controls 16 years, were
recruited on a from a REThink and REBE
urban community in groups have completed
Europe. the seven modules
developed for this study
Intervention group 1,
REThink consisting of Participants in the
Rational Emotive REThink group played
Behavior Education twice the seven levels of
(REBE) and Rational the game, divided into
Emotive Behavioral seven modules.
Therapy (EEBT),
N = 54
the application time of a
Intervention group 2, module was
REBE only: n = 55 approximately 50 min,
meetings with students
Control group: n = 56 taking place after the
classes.
Treat as usual. After finalizing module four,
children and adolescents
Waitlist control. completed the mechanisms’
questionnaires.
After finalizing module four,
children and adolescents
completed the mechanisms’
questionnaires.
Strengths and Difficulties
Questionnaire—child
version (SDQ) [28] is a 25-
item scale that was used to
assess emotional symptoms,
as a primary outcome and
the total level of
psychological difficulties,
conduct problems,
hyperactivity attention, peer
problems, and prosocial
behavior, as secondary
outcomes.
mother report and total
anxiety father report.
For personalized anxiety child
report, noninferiority could
only be shown at 3-months
FU.
Results indicated that the
REThink intervention had a
significant impact on
emotional symptoms (a
moderate-effect size,
d = 0.46) and on depressive
mood (a large-effect size,
d = 0.84). Furthermore,
REThink had a significant
impact on children’s ability to
regulate their emotions, with
a significant effect on
emotional awareness
(d = 0.64), and on the ability
for emotional control
(d = 0.69).

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Further Reading
Sanders, M. R., Baker, S., & Turner, K. M. (2012). A randomized controlled trial
evaluating the efficacy of Triple P Online with parents of children with early-onset
conduct problems. Behaviour Behavior Research and Therapy, 50(11), 675–684.