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Effects of Game-Based Relaxation Training on Attention Problems in Anxious Children

Michele Knox, Jennifer Lentini, & Stacey Aiton
The University of Toledo College of Medicine

Correspondence: Jennifer Lentini, M.D.
PI: Michele Knox, Ph.D.
The University of Toledo College of Medicine
3130 Glendale Avenue, Toledo, OH 43614


Results of recent research have suggested that game-based, biofeedback relaxation training may reduce symptoms of both Attention-DeficitHyperactivity Disorder (ADHD) and Anxiety Disorders in children and youths. Inattention and poor concentration are common features of both of these disorders. However, it has not yet been explicitly studied whether the problems with attention and concentration that are characteristic of anxious youths may be lessened with this intervention. The present study examines the effects of an intervention combining game-based relaxation training with psychoeducationand behavioral practice in a sample of twenty-three 9 to 17 year olds. It was hypothesized that intervention participants would show significant improvements on the attention problems subscale of the Child Behavior Checklist – Parent Report Form relative to participants in the waitlist control group.Results indicated significant improvements in posttest attention problems scores for the intervention group relative to the control group. The findings of this preliminary study suggest that game-based relaxation training may be beneficial for attention and concentration problems in anxious children and adolescents.


Anxiety is a common mental health problem in childhood and adolescence (Cartwright-Hatton et al, 2006; Shaffer, 1996). According to the Diagnostic and Statistical Manual of Mental Disorders 4th Edition (DSM-IV-TR), anxiety disorders are characterized by intense fear and panic that is abnormal or inappropriate (American Psychiatric Association, 2000). This intense fear occurs in the absence of an anxiety-provoking stimulus or in situations that normally do not produce anxiety. The anxiety can lead to panic attacks which are severe incidencesof fear that can cause shortness of breath, palpitations, chest pain/discomfort, choking or smothering feelings, and fear of losing control. Children and adolescents with anxiety also may experience restlessness, fatigue, irritability, muscle tension, and sleep disturbance.
In addition to these symptoms, inattention and poor concentration arecommon features of anxiety in children and youths (American Academy of Child and Adolescent Psychiatry, 2007; Semrud-Clikeman & Ellison, 2009). These problems appear to relate, at least in part, to a tendency for anxious people to attend too much to potentially threatening or dangerous situations. Children with anxiety tend to selectively attend to what they perceive to be the more threatening aspects of situations (Beck & Clark, 1997; Field, 2006; Hadwin et al, 1997; Vasey et al 1995). Such tendencies may cause them to be less attentive to the more important or relevant information in their environments. Thus, children with anxiety are thought to have problems with “attentional allocation,” (Rapee et al, 2009) such that attention is focused on targets that may not be useful or appropriate for meeting the child’s long-term goals. Thus, these children, unlike children with Attention-Deficit/Hyperactivity Disorder, may not have impaired ability to concentrate or pay attention, but rather tend to focus on unnecessary or unhelpful features of their environments. For example, in cases of social phobia, individuals attend too intensely to bodily symptoms such as blushing, trembling or sweating (Bogels & Mansell, 2004), and too little to relevant information in the environment. Intense self-focused attention may cause these individuals to evidence poor concentration in academic and other settings. An intervention called Task Concentration Training (TCT) was developed to address this problem in social phobics. During TCT, patients learn to direct their attention to the task at hand and away from their bodily symptoms. This technique has been shown to effectively alter the attentional focus of adult patients, providing improvements beyond those offered by cognitive therapy and traditional applied relaxation (Bogels, 2006).

Treatment of attention problems though relaxation training

Research conducted over the past four decades has indicated that relaxation training may produce improvements in attention span for children and adolescents (Lupin et al, 1976; Braud, 1978; Dunn & Howell, 1982; Denkowski et al, 1983; Chang, 1991).
In a study of the effects of meditation as a form of relaxation training, college studentswho completed meditation sessions demonstrated significantly better scores on a test of attentional capacity (Tang, 2007). Research also suggests that attention and impulsivity can be altered by children who have been taught traditional biofeedback techniques, such as relaxation training with an electromyometer, progressive relaxation, or interactive metronome training (Weize, 2004). A study of 9 to 13 year olds with ADHD was conducted using “coherence training” to alter aspects of cognitive functioning (Lloyd et al, 2010). Coherence training involves teaching the regulation of heart rhythms through techniques designed to shift attention, regulate breathing, and activate positive emotion. The goal of the training is to achieve psychophysiologicalcoherence, a highly efficient functional mode associated with increased nervous system harmony, enhanced emotional stability, and improved cognitive performance (McCraty, 2005). Improvements in immediate and delayed word recall and episodic secondary memory were evident in the treated participants following six weeks of coherence training (Lloyd et al, 2010).
Some recent research has demonstrated decreases in both inattention and anxiety following training in meditation. A study with combat veterans diagnosed with post-traumatic stress disorder (a type of anxiety disorder) suggested that biofeedback training may improve attention (Gingberg, 2010). A study using meditation training illustrated that undergraduate students in an experimental group preformed significantly better on a test of attention and had significantly lower anxiety compared to a control group (Tang et al, 2007). In another study (Harrison et al, 2004), 26 children diagnosed with ADHD were taught meditation. The participants in the study evidencedimprovements in self-reported and parent-reported attention. Anxiety was also reduced over the course of the study. Grosswald et al, (2008) conducted a study using a type of concentration meditation to lower anxiety and stress, and results suggested that ADHD symptoms could be lessened through this method.

Treatments utilizing computer technology to aid in the treatment of anxiety and inattention

Biofeedback has been utilized successfully to help individuals with a variety of stress-related disorders achieve a state of relaxation (Yucha et al, 2008). Biofeedback has the goal of improving the individual’s ability to control physiological processes. There are various types of biofeedback, some of which address improved control over central nervous system activity (e.g., neurofeedback)and others that promote improved control over peripheral nervous system activity (e.g., thermal biofeedback). Biofeedback allows the participant to view on a computer screen real-time indicators of parameters such as heart rate variability (HRV) and skin conductance level (SCL). HRV and SCL are functions of the Autonomic Nervous System (ANS). An increase in ANS activity may indicate that the person is stressed and a decrease can indicate relaxation (McCraty & Tomasino, 2006). HRV measures compare the time between heartbeats; low variability implies that the participant is stressed (McCraty & Tomasino, 2004). SCL is a measure of the action of the sweat glands in the fingertips; increased perspiration suggests that the participant is experiencing excitement or anxiety. Relaxation, on the other hand, leads to low levels of perspiration. These real-time measures, HRV and SCL, can be plotted on a graph or depicted in a variety of ways on a computer screen. Through biofeedback-based relaxation training, the individual can learn to manipulate images on the screen that are influenced by HRV and SCL (Culbert et al, 1996). This is achieved through practice and use of deep breathing, imagery, and muscle relaxation. The training also helps the participant to find which relaxation methods work best for him/her and helps him/her stay “on task” when intrusive thoughts/feelings appear (Banquet, 1973; Condron et al, 2009; Lagopoulos et al, 2009).

A number of studies illustrate that, like adults, children and adolescents can learn to control peripheral nervous system processes such as heart rate and electrodermal activity (Dikel & Olness, 1980; Cobb & Evans, 1981; Siniatchkin, 2000). In recent years, technology has been developed that makes use of video-game-like technology and graphics which maysignificantly increase interest and engagement in biofeedback, particularly among young people. In game-based relaxation training, as physiological coherence is achieved, the participant can make different actions occur onscreen through involvement in video-game-like activities.

Neurofeedback is a type of biofeedback which measures and provides the user feedback based on ratios of alpha and beta waves detected via electroencephaolograph (EEG). This intervention often uses similar gamed-based formats to maintain interest and motivation. Neurofeedback is gaining evidence in favor of its effectiveness as a treatment for ADHD. A recent meta-analysis by Arns, De Ridder, Strehl, Breteler, & Coenen, (2009), for example, suggested that neurofeedback can produce clinically meaningful improvements in symptoms of ADHD, in children and youths. This measure of central nervous system activity is used in the treatment of ADHD to alter the ratio of theta to beta activity in the prefrontal cortex. This approach is based on research indicating that individuals with ADHD have been shown to generate high levels of theta activity relative to beta activity in the prefrontal cortex (Hughes & John, 1999).
Although neurofeedback appears a promising treatment for children and youths with ADHD, it may not be the treatment of choice for the poor concentration that characterizes anxiety. That is, because individuals with anxiety appear to have problems with inattention that occur for reasons that are not directly linked to the central nervous system, promoting improved attentional capacity in anxious individuals may involve different approaches. As reviewed above, such individuals seem to need to learn to redirect focus away from anxiety-promoting stimuli and to prevent or reduce the escalation ofperipheral nervous system activity. Additionally, while neurofeedback may be cost-prohibitive for some individuals (Anglada & Hakala, 2008) biofeedback technology for peripheral nervous system activity can be relatively less expensive because it can be completed using fewer sessions and less expensive equipment (Schwartz & Andrasik, 2003).

To date, very little research has been conducted on the effectiveness of game-based biofeedback and relaxation training. Although there is not yet ample empirical evidence demonstrating the efficacy of these new programs, it stands to reason that such technology may be useful for work with children and youths, in part because children and adolescents in the United States are often avid users of videogames (Gentile & Walsh, 2002; Gentile et al, 2004). Research by Pop-Jordanova (2009) examined the use of HRV biofeedback training for the treatment of anxiety, conduct disorder and ADHD in children. Results after 15 sessions of training showed that children from all groups improved; the best resultswere obtained for children with conduct and anxiety disorders. Another study, examined the efficacy of this approach with 24 children diagnosed with ADHD (Amon & Campbell, 2008). The children learned to manipulate their heart rate using breathing techniques taught during the game. The experimental group showed significant reductions in parent-reported ADHD symptoms. Researchers also noted that children took great interest in the study and were stimulated and motivated by the use of technology and video game format. These results suggest that video game-based treatments may be an enjoyable and motivating medium for treatments intended for children and adolescents. Results of apilot study indicated that 14 to 35 percent of high school students performed higher on standardized tests in reading and math after biofeedback training (McCraty & Tomasino, 2004). This result was hypothesized to occurbecause participants learned to maintain high-performance states by learning to better manage test anxiety and promote ANS coherence (McCraty & Tomasino, 2004).

The present study examines symptoms of inattention in a sample of 9 to 17 year olds who received game-based relaxation training combined with psychoeduction and behavioral practice. This intervention was found in previous research to result in significant improvements in both anxiety and depression (Knox et al, manuscript under review). It is posited that anxious children and youths who receive this intervention will demonstrate improvements in attention. Therefore it is hypothesized that intervention participants will show significant improvements on the attention problems subscale of the Child Behavior Checklist – Parent Report Form relative to participants in the waitlist control group.



Thirty-one participants consented to take part in the study. However, eight participants (two females and six males) failed to complete the study, leaving a final sample of 23 children/adolescents (nine females and 14 males). The portion of the sample who dropped out did not differ from completers in terms of demographics (age, gender, or SES) or in pretest scores [scores on the Attention Problems subscale for the Child Behavior Checklist (CBCL)]. The final sample of 23 participants ranged in age from 9 to 17 years (M = 12.7, SD = 2.38). Each participant had clinically significant symptoms of anxiety, either a clinical disorder or problems such as excessive worry or fear. They were referred from pediatricians, nurse practitioners, and other mental health providers. The large majority of the participants were receiving traditional mental health treatment for anxiety or other mental health problems prior to and during the study (medication, therapy or both). None of the participants started medication during the course of the study. Twelve participants were assigned to the intervention group and the next 11 were assigned to the waitlist control group. The participants were assigned sequentially to groups, starting with the intervention group, because it was not clear at the beginning of the study if there would be enough referrals to enroll a control group.
Independent sample t-tests and chi-square analysis were conducted to examine differences between the groups. The intervention and control groups did not differ on age, gender, or socioeconomic status (SES).


Two biofeedback programs were utilized in this study. In the Freeze Framer software program, as the player relaxes, he/she can color and add characters to a meadow, make a rainbow, or float a hot-air balloon (Institute of HeartMath,
2010). In the other program (The Wild Divine Project, 2009) the participant achieves many different goals (e.g., making a fire, building a wall, shooting a bow and arrow) in a fantasy land (Bell, 2003). This game also uses images and sound to aid in rhythmic breathing and coherence.


The Attention Problems subscale for the Child Behavior Checklist (CBCL) was utilized in this study. The CBCL is a questionnaire completed by parents of primary caregivers that measures children and youth’s emotional and behavioral symptoms. The CBCL is very well established and has been reported to have high test-retest reliability, internal consistency, and discriminant validity (Achenbach & Edelbrock, 1983). Socioeconomic Status was evaluated using the Updated Occupation Prestige and Socioeconomic Scores (Nakao & Treas, 1994).


The study was approved by the University Institutional Review Board. Participants completed informed assent forms, and their parents/caregivers completed informed consent forms prior to their participation in the study. Parents completed the CBCL upon enrollment into the study prior to treatment (pre-test). The game-based relaxation biofeedback (intervention) condition was based on a session-by-session protocol combining relaxation training and practice with psychoeducation about how stress can affect people, how relaxation can relieve or prevent stress, and when and how to use relaxation techniques in real life. Participants were also helped to identify signs of anxiety as well as events and thoughts that trigger anxiety. Participants were assigned behavioral practice that was designed to help them most effectively incorporate the use of relaxation into their daily lives. Appendix 1 shows the session-by-session protocol that was used. Each session lasted 45 minutes to one hour. The control group was waitlisted, and offered game-based relaxation training after the end of the study. At the completion of the study, parents completed a post-test CBCL questionnaire.


The intervention group’s mean T-score on the CBCL Attention Problems subscale was 65.25(SD=12.57) at pretest. This score falls in the “borderline” range of the CBCL. The intervention group’s posttest mean T-score was61.08 (SD=10.69), a score which falls in the “normal” range. The waitlist control group’s mean T-score on the CBCL Attention Problems subscale was 58.82 (SD=17.42) at pretest, and 61.27 (SD=9.52) at posttest. Both scores fell in the “normal” range. ANCOVA was used with condition (intervention or control) as the fixed factor. The dependent variable was the post-test CBCL Attention Problems subscale T-scores. The covariate was pre-test CBCL Attention Problems subscale T-scores. This analysis revealed significant differences between the intervention and control groups at post-test (F(2,22)= 6.31, p=.008; partial η2=0.39) favoring the intervention group. Post-hoc T-Test analyses revealed that the intervention group’s scores reduced significantly from pre to post-test (t(11)=3.12; p=.01), but the control group’s scores did not.


The present study examines the efficacy of game-based biofeedback relaxation training, in combination with psychoeducation and behavioral practice as a treatment for attention problems in anxious youths. Children and youths who completed the intervention showed significantly more improvement in parent-reported attention compared with the wait-list control group. The control group showed no improvement on the attention problems sub-scale, while the intervention group’s scores improved significantly, suggesting that this intervention may be beneficial in improving the attention problems experienced by anxious children.
Whether this intervention improves on existing treatments such as neurofeedback is unknown. It is possible however, that biofeedback and neurofeedback achieve similar outcomes. Many years of research have correlated increased Alpha brain wave activity with meditative states. Alpha waves are recorded at a slower and very regular 8 Hz frequency and Beta waves at quicker and less regular 12 Hz on EEGs. The link between HRV, SCL, and brain wave activity are correlational; that is they happen concurrently. One does not cause the other. When a person is more relaxed, his/her heart rate is more rhythmically varied, sweat gland activity is decreased and Alpha brain wave activity is increased. These are “end measures/results” of the mental meditation efforts. People often find that deep breathing, peaceful imagery, or positive memories help them produce decreased Autonomic Nervous System arousal, as measured by the above outputs. Thus, both methods may be beneficial.
There are a number of limitations to the current study. The relatively small sample size may limit the generalizability of the findings. Attrition was also an issue; of the original sample of 31 participants, eight participants dropped out of the study. Although there were no identifiable differences between those who dropped out and those who remained in the study, it is possible that attrition posed a threat to the internal and external validity of the study.
Assignment to condition was sequential rather than random. Future studies should employ random assignment in order to better ensure the validity of the research. Also, the large majority of the participants in the study were undergoing treatment at the start of and during the study, which included medication, therapy, or both. Subsequent researchshould involve collection of more detailed information about medications and other medical or mental health treatment. This would allow for more precise conclusions about the implications of the findings.
Another problem encountered during the study was that the finger electrodes were not designed for children and as a result were quite large. Consequently, they did not collect HRV and SCL on children consistently so that data could not be used (data was not collected about 20% of the time). Therefore, physiological data could not be provided. The use of child-sized hardware would benefit future clinical use and research involving this intervention.
Because anxiety is known to affect cognitive performance (Derakshan & Eysenck
2009), further research is indicated to examine whether the improvements in attention lead to enhancements in cognitive performance. This should be taken a step further to see if these improvements lead to improved academic achievement. Because anxiety is one of the most common problems afflicting the school age population, such research could have important implications for the school-age population. Future research also is recommended to examine the relative effects of this intervention as compared to medication and therapy for anxiety and attention problems in children and youths. If replicated, these findings may provide important information for parents and caregivers considering options for treatment.


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Appendix 1

Game-Based Relaxation Training Study Protocol: Intervention Condition

Session #1
Pre-test measures
Rate Anxiety on 1-10 Visual Analogue Scale (VAS)
Feelings that get in my way; What it means to feel “upset.”
Feelings are OK We need a healthy way to deal with them.
How the brain affects the body (favorite food example).
When we are frustrated, scared, worried, angry or upset, our heart rhythms are irregular and uneven.
Activity: How stress gets in my way.
List: Things and situations that make me feel anxious or stressed.
List/Draw: Where I notice tension in my body.
What will be better in my life when stress is no longer getting in my way.
Teach Relaxation
Introduce Freeze Framer and Wild Divine.
Rate Anxiety on VAS

Session #2
Rate Anxiety on VAS
Feelings are OK
Need a healthy way to deal with them
How to relax
How the brain affects the body (favorite food example).
When we are frustrated, scared, worried, angry or upset, our heart rhythms are irregular and uneven.
Where I notice tension in my body.
Triggers of fear, worry, and insecurity.
Examples of thought triggers:
I’ll never pass the test
I’m so stupid/ugly/fat/clumsy/unpopular….
I’ll never get all this done
I can’t believe I said that. I am so ……
I know I’ll screw this up
I can’t…
Everybody thinks I’m….
Continue with Freeze Framer and Wild Divine.
Rate Anxiety on VAS
PLAN: When I will relax this week

Session #3
Rate Anxiety on VAS
How did relaxation at home go?
How to relax
Modify relaxation plan if needed
Continue with Freeze Framer and Wild Divine.
Rate Anxiety on VAS
PLAN: When I will relax this week

Session #4
Rate Anxiety on VAS
How did relaxation at home go?
Modify relaxation plan if needed
Continue with Freeze Framer and Wild Divine.
Rate Anxiety on VAS
PLAN: When I will relax this week

Session #5
Rate Anxiety on VAS
How did relaxation at home go?
Modify relaxation plan if needed
Continue with Freeze Framer and Wild Divine
Rate Anxiety on VAS
PLAN: When I will relax this week

Session #6
Rate Anxiety on VAS
How did relaxation at home go?
Modify relaxation plan if needed
Continue with Freeze Framer and Wild Divine.
Rate Anxiety on VAS
PLAN: When I will relax this week

Session #7
Rate Anxiety on VAS
How did relaxation at home go?
Modify relaxation plan if needed
Continue with Freeze Framer and Wild Divine.
Rate Anxiety on VAS
Identifying additional triggers, plan for in-vivo use
PLAN: When I will relax this week

Session #8
Rate Anxiety on VAS
How did relaxation at home go?
Modify relaxation plan if needed
Continue with Freeze Framer and Wild Divine.
Rate Anxiety on VAS
Review triggers to stress, more plans for in-vivo use
PLAN: When I will relax this week
Post-test measures
Referral if needed


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