Multiplayer Video Game-Mediated Communication: a Qualitative Study

MULTIPLAYER VIDEO GAME-MEDIATED COMMUNICATION: A QUALITATIVE STUDY

MARGARET E MATTOX

A Thesis Submitted to the Graduate Faculty of

WAKE FOREST UNIVERSITY GRADUATE SCHOOL OF ARTS AND SCIENCES

in Partial Fulfillment of the Requirements

for the Degree of

MASTER OF ARTS

Communication

May 2019

Winston-Salem, North Carolina

Approved By:

Ananda Mitra, PhD, Advisor

Steve Giles, PhD, Chair

Paul Pauca, PhD

ACKNOWLEDGMENTS

“If we take everything game developers have learned about optimizing human experience and organizing collaborative communities and apply it to real life, I foresee games that make us wake up in the morning and feel thrilled to start our day. I foresee games that reduce our stress at work and dramatically increase our career satisfaction. I foresee games that fix our educational systems. I foresee games that threat depression, obesity, anxiety, and attention deficit disorder. I foresee games that help the elderly feel engaged and socially connected. I foresee games that raise rates of democratic participation. I foresee games that raise rates of democratic participation. I foresee games that raise rates of democratic participation I foresee games that tackle global -scale problems like climate change and poverty. In short, I foresee games that augment our most essential human capabilities to be happy, resilient, creative—and empower us to change the world in meaningful ways.” Jane McGonigal, 2010

Thank you, Dashiell and Cora, for inspiring this idea and making every page of research so worth it, even the dusty ones with words that clacked together like dentures that were too big. My Pistol Petey, my Darlin’ Dash, I love you with all my heart. My sweet, bright, beautiful babies, thank you for being the phenom that lights up my world every. single. day. Thank you for your patience while I wrote all night and read all day. You have been helpful, inspirational, patient, kind. I love you Google plex! Thank you, Mom and Dad, for co-parenting with me, I couldn’t have done this without you! Thank you for doing pick up and drop offs more often than I have this month. Thank you for keeping the kids so that I could write all night. Thank you, Mom, for helping me edit…and edit…and edit. I know, I never met a comma that I didn’t want to bring along for the trip. Also, thank you both for setting the bar so high. Because of you, I knew that it would take more than a 200-year-old tree, a destroyed house, 7 moving vans, illness and a ghost. I knew I was made of the same soil that birthed Irene, Dwight, Wiley, and Elaine. And thank you Matt and Barbara, for all the skiing and hiking, and plays and stories in the mountains. Now I have time to learn to play that bass! Thank you Paul Pauca for all of your help. You are not even part of my department, yet you answered emails at night and checked on me in the morning as I wrote and wrote and wrote. You are truly an amazing human being! Thank you Ananda, for being so enthusiastic about my idea, connecting me with Ravin, and for believing in my research. Thank you Steve for bringing me in on the Sugar Sweetened Beverage campaign and for giving me the opportunity to prove myself. Thank you, Sheila White, for understanding when I spazzed out in my sleepy state and did something funky to my charts and page numbers, and for being so encouraging and supportive, and for giving me the time to go to Amity’s mother’s memorial, and to spill this out in one big thank you hiccup. Thank you. Thank you Hu Womack for turning me onto Jane McGonigal’s research and for helping me find news way to dig out articles on this emerging research topic. Thank you Ray Celeste, for your wizardry with charts and formats and song tunes and life – I wish I could make this sentence burst into an Ethel Merman song and tap dance

ii across the page. You are the absolute sun in the sky every week at school. And thank you, Chris Miller, for the miles of smiles. Thank you, Marquis, for not making me feel like I’m older than your Mom. Thank you, Jack and Pablo, for being so damn interesting to listen to in class, and you too - Ray Celeste, Chole, Caitlyn, Natalie. Thank you, Natalie/Big ole’ brain, Chloe/Big ole’ cat, Caitlyn/Big ole’ attitude – you go get it mama, all of it. The two years have ended, and I never saw you dance or got that dance lesson, I will have to track you down wherever you land. Thank you Sarah (hey peanut, you’re precious), Amber, Annie, Candice, Kristen, Kaitlyn, and Shelby. Thank you. My life is much benefited because you beautiful ladies exist. Well, you - Ray Celeste, Caitlyn, and Natalie - you three ain’t ladies, you’re dames and broads. Speaking of dames, thank you Mary Dalton - I think we need to go drink some top-shelf silver Tequila and tell stories. Thank you Marina Krcmar, for supporting this when it was a too long, unwieldy paper, (that turned into piles of articles snaking around the entire first floor of my house and ending in a bloated 200-page rough draft) and for your singular example of badassness. Thank you, Ron, for having my back, and having really snazzy fashion sense, and having – I’ve heard rumors – really great Zumba moves. And Molly, for inspiring me to write another paper out of this tome, and also for your cat burglar black on black – you always look like you’ve just sashayed in from a small private plane somewhere after doing some espionage. Thank you Jen, for entrusting me with your class. I loved teaching so much. Even when things were frustrating and exhausting, I still loved it. And for the way that your classes hummed along on some in- phase, psychic wavelength and every week seemed to provide me with the exact thing that I needed to hear in order to keep putting one foot in front of the other. And Becca, for those times I was entrusted to dodge the spitballs and teach your rowdy class, and for so many brain tickling articles. And speaking of brain tickling, thank you Hyde for being our very own Oliver Sacks. Thank you Michael Hazen for loaning me thesis examples. And Allan, for all of those amazing parties at your house. And Glacier, for sharing your water bowl and tennis balls with Beatrice. And Jarrod, for really being one of the perennial good guys. Thank you Candice, for keeping up with my cups, phone, car keys, paper jams, 5 millionth copy of an article. For giving me tissues and a pat on the back, for watching my kids, my dog, my computer - you really are the roots that hold up the department’s tree. Thank you Llewellyn for offering to proofread 160 pages, and helping me not die of embarrassment after that massager with coffee stain comment that …um…yeah...that day...good grief. Thank you Cagney, for traipsing around from one end of the Triad to the other with me, and for picking up that one extra shot. Thank you Stuart (1.0) and Bianca. Stuart, you were there at the beginning of a road that led me here. It began when we were watching the sun creep out of bed then explode into another dawn, not while wandering through Europe, but back in the tiny apartment under the bougainvillea with the owl in the avocado tree. The curved door loft, where once the accompanist for the opera singer used to stay and drive the red hills and Keystone Cop rollercoaster streets of Echo Park, when Hollywood was an orange orchard and the studios and movie palaces stood downtown, not in humbled, tattered, graffitied beauty, but with regal promise. Yes, back then, those sunrises were the beginning of meeting that tickle that is the work that drives you through the night and into the day, bypassing sleep, toward a different sort of adventure, one that winds through the center of you and eventually leads that thing, that piece, that thought, that work, out to other people.

iii

And thank you Bianca, for New Orleans, and that phone call on the edge of the lake when all my stitches were loose and floating in last summer’s water when you sent me needle and thread through binary code, you beautiful hurricane of a Mazzamurello fairy. This is my year for Burning Man. Thank you. Yes, I’ve seen the calls from both of you. It’s just that I’ve spent...well...the last two years really, paddling.... with my house split open and resting on a broken broomstick, next to dirty stockings that peered out from the foundation, not a ruby slipper in sight. And the last two months I’ve had to paddle more furiously, in depths over my head, the tip of my nose just above water, under a thunderous waterfall. I will call back, I swear. Kyle, I can hear you. You shut your mouth; I’ll call you too. Thank you Stewart (2.0) for feeding me when I forgot to eat, for bringing me caffeine, for packing and unpacking and packing and unpacking and packing and unpacking (add another 6) with me, helping with the babies, and the festival. And for your seminal example of being a smooth criminal. And Lyndon, you’re a saint, I think you really might be. And Kristin, always with the cups of hot tea at 3 am, and the retorts that crack the air like summer heat lightning, and Kaki, for doing all the guided calming spells with the babies after my surgery, when I had those tubes and could barely walk and the littles were so stressed - you roadhouse pixie, wild pea, bull riding, poem. Our little band of single parents, marching ever forward! Thank you Michelle for being my home and helping me find my way home when the world was too sharp and utterly unfamiliar. Thank you Samantha, for all of your help always, my sister. For sleeping in the walk-in freezer that is the temperature at which I keep my house, and letting the cats crawl all over you while you took care of me after surgery, and then again when everything felt too heavy and hard, and again when I had to move, and again when the film festival collided head-on with the sleepless thesis presentation week, and for the Prince off, and the dinner and dancing when Christmas echoed with the first tear-stained absence of my kiddos. For all the everything, thank you. Wanderlust - you’re my amazing Sammy Davis Baker Jr. Thank you Roby, for dancing with me to bad techno in that cigar bar at the Bellagio and letting me stain the carpet at your flat, and for all the times you loaned me Sam, and for teaching my son his first dirty joke. Thank you Leslie, for holding my hand and walking me into school when it was raining locusts and for the exhilarating example you set by writing that huge book (look, now you’re in my acknowledgements, we should both be wearing one of Irene’s slips). You’re a smart cookie, Dr. Sexy Frost. And Kimber, for showing everyone how it’s mother scratchin’ done. (Can I cuss in a thesis acknowledgement? I feel like cussing…is that bad?) And for taking me to your herbalist who made me drink tea dirt and helped me get back in the saddle, and thank you for being our magical-ninja-tango-princess. And thank you Lisa, for making me believe that one day I will be able to have a life that is 1/18th the magical sparkaliciousness that decorates the very air you breathe, you are the calm in any storm. Who needs the mother of dragons when we can have the mother of goats! And Amity, for clothing my daughter, for your resilience this last few months with losing your mother, for sharing Sue and all her light with us, for being my tribe, and for being... really just the classiest pole dancer I’ve ever met. Thank you Amanda, for being my consummate steel magnolia and also for letting me absentmindedly leave kittens at your house. Thank you LouAnne, for holding me up and holding me together, for sending me talking pets and salt shakers and reminding me of the magic, and for being so

iv hilarious that I can’t breathe. I love you Sissy. Thank you Jada, you long legged water bug – I want to bite your face. My friend Detroit did that thing the other day, that you do when you’re eating hotdogs and you smell something bad, it made me laugh so hard I peed a little. Thank you Shelly, for telling me all those stories about mice that morning that I was dropping off the forgotten lunches and dragging myself to class, running on fumes. And for getting me to start writing again. And for that time you invited the 80’s hair metal band to my birthday party and you celebrated me by smashing all the dishes in that house by the train tracks, with the tiny bird skull in the violin rosin can on the mantel, and the window panes that fell out, when you opened the windows, and got lost in the waist high grass of the yard that led to the old man’s house who ate canned peaches while 24 cats twined around his ankles. Thank you. And thank you Frankie, for answering the phone at 2am when I couldn’t stay up another hour and telling me that I could, and reminding me of that again the next day at 4am. And for sending me songs for the sunrises, and for the music of your voice, and the inspiring example of exquisite craftsmanship and tireless work ethic that is the beauty of your hands. And Plato says it best, “There were originally three sexes begotten by the Sun (male), Earth (female) and Moon (hermaphrodite). Each of these sexes was doubled and united as a whole...(until) Zeus slic(ed) each one in half ...As a consequence of this split, each part began to crave for its "other half." It is this... true love that is the recognition of one’s proper half...when one of them meets with the other half, the actual half of oneself ... and the pair are lost in an amazement of love and friendship and intimacy, and one will not be out of the other’s sight (no matter the distance), as I may say, even for a moment: these are the people who pass their whole lives together (no matter if they are apart)...the intense yearning which each of them has toward the other...something which their souls...evidently desires. (You, my minotaur), have an inner richness and grace far beyond the ordinary (Mashup – Plato, Symposium, 385-370 BC, & Mattox, 2019). Thank you. “The best gesture of my brain is less than your eyelids flutter which says we are for each other: then laugh, leaning back in my arms for life’s not a paragraph, and death I think is no parenthesis” (cummings, 1926). I love you

TABLE OF CONTENTS

ACKNOWLEDGEMENTS ii

LIST OF FIGURES, CHARTS AND ILLUSTRATIONS vii

LIST OF ABBREVIATIONS ix

ABSTRACT xi

CHAPTER ONE 1

INTRODUCTION 1

THEORETICAL FRAMEWORK 7

CHAPTER TWO 12

LITERATURE REVIEW 12

ADHD: A Disorder of Communication Competency 12

Parental Stress and Dysregulated Communication 18

Parent-Led Behavioral Treatments and Parental Stress 20

Video Games and Transformational Play 22

Video Games and Reciprocal Play 26

A Sense of Belonging: Video Game Play and Social Connectedness 27

Enacted Communication: Game Play and Self Efficacy 31

Discrete Video Games 32

Addiction Tendencies: Motivation for Therapeutic Game Play 34

The Communication of Rewards in the ADHD Brain 35

The Good, the Bad…the Useful - Commercial Video Games 39

Playing in the Sandbox and Building Identity 42

Commercial Video Game Communication Intervention: Wearable Gamification Communication Modification Device (WGCMD) 45

CHAPTER THREE 54

METHODOLOGY 54

Overview of Study 54

DATA COLLECTION 55

Demographics 59

RESULTS 63

SUMMARY 76

REFERENCES 83

APPENDICES 109

Bracket of Experiential Bias 109

Questionnaire 123

Interview Demographics 148

Interview Questions 150

BPT Examples 153

WGCMD Technology Information – Ravin Sardana 161

CURRICULUM VITA 172

vii

LIST OF FIGURES, CHARTS AND ILLUSTRATIONS

FLOW DIAGRAM: Figure 1 9

TRANSFORMATIONAL PLAY DIAGRAM: Figure 2 10

COMMUNICATION COMPETENCE CHART: Figure 3 13

ADDITIONAL ADHD IMPAIRMENTS: Figure 3b 14

MAP OF THE MAIN GENRES OF VIDEO GAMES: Figure 4 30

INTERNET GAMING DISORDER; CONDITION FOR FURTHER STUDY” IN THE DSM-5, APA 2013 Figure 5 34

MINECRAFT IN EDUCATIONAL GOAL BASED MOTIVATION STUDY Figure 6 40

SUMMARY OF SPECIFIC POTENTIALLY ATTRACTIVE COMPONENTS IN MPVG’S AND THEIR POTENTIAL USE FOR WELLBEING: Figure 7 42

PROTOTYPE WGCMD Figure 8a 46

WGCMD SCREEN Figure 8b 46

TASKS VIEW/CHILD & APP VIEW ON SMARTPHONE/PARENT Figure 8c 46

SAMPLE AVATAR USING MARIO CHARACTER Figure 9 46

APP TO ADD FRIEND Figure 10 48

ADHD COMMUNICATION COMPETENCY PROBLEMS AND PARENTAL STRESS Figure 11a 50

PARENT-LED COMMUNICATION COMPETENCY MODIFICATIONS Figure 11b 51

DISCRETE GAMIFICATION COMMUNICATION COMPETENCY MODIFICATION Figure 11c 52

COMMERCIAL MULTIPLAYER SANDBOX GAMIFICATION COMMUNICATION COMPETENCY MODIFICATION Figure 11d 53

viii

COMMUNICATION THEORY OF IDENTITY PROPOSITIONS Figure 12 62

SHIGERU MIYAMOTO QUOTE: Figure 13 82

LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS

ADHD Attention deficit hyperactivity disorder - ADHD

MPVG Multiplayer video games

VGP Video game play

BPT Behavioral parent training

WGCMD Wearable gamification communication moderation device

CMC Computer mediated communication

CTI Communication theory of identity

BBT Broaden and build theory

Discrete video games - Lab based, separate and distinct from universally accessible and social shared commercial games, limited, educationally geared gratification

Commercial video games - Off the shelf, mass produced, ready-made, store bought, socially shared, popular, geared toward entertainment gratification

Multiplayer video games - Games that are played collaboratively, competitively or cooperatively by using either multiple input devices, or by online virtual game play

Third Space - the places in which social associations take place, digital third place space equates to ideal social spaces in the analogue/physical world in which effective communicative interactions can exist

Sandbox - sandbox is a style of video game in which there are minimal character limitations, the player is allowed to constantly roam, select tasks, and is able to change their virtual world . Sandbox can also be called an open-world or free-roaming game.

Minecraft - is a massive sandbox game where players place and break Lego-like blocks in a 3D environment. They “mine” for the materials that they need to live and to build with. Players can build anything from a rollercoaster to Homer Simpson’s house, the possibilities to create complex devices and buildings is endless. Players mine and craft tools, raise crops and animals, join groups, fight intruders and at certain levels they can host multiplayer servers.

ABSTRACT

Attention deficit hyperactivity disorder (ADHD) is the most commonly diagnosed maladaptive childhood condition. It has recently been defined as a communication competency disorder which affects language, conversational fluency, interpretation of social rules and nonverbal cues, body awareness and control, and cohesive organization of ideas. These impairments negatively impact ADHD children and affect their ability to engage in reciprocal play, to achieve social inclusivity and belonging, and to develop a secure sense of identity and self-efficacy in social and academic domains.

The present study explored parental thoughts regarding how and why ADHD children use multiplayer commercial video games (MPVG) and the association between game play and parental stress. The relationship between parental thoughts and feelings about their children’s relational identity through playing MPVG was also examined.

How willing were parents to overlook their fears regarding the relationship between addiction and ADHD, and the potential negative outcomes they have experienced with their child’s game play in order to use that same game play in a positive fashion. A question that drove this research was whether parents believed that the negative effects of commercial video game play could be moderated through a positive communication competency intervention using commercial game play.

Parental willingness to use a wearable communication intervention gaming device that linked the child’s behavioral gains with digital game play rewards was examined and potential associated parental stress was explored. It was speculated that parents would perceive this conceptualized device to improve motivation for children to engagement in behavioral modifications and it would reduce parental stress when compared to the non-

xii gamified behavioral treatment options involving more labor-intensive enforcement of rules and regulations.

Results showed that most parents perceived their child’s existing computer mediated communication (CMC) through MPVG as supportive and socially positive, even after equating video game play use with loss of control, anxiety, and stress. When results were assessed through the Communication Theory of Identity (CTI), MPVG play was shown to reflect gains in personal, relational, communal and enacted identity formation for ADHD children. The theoretical lens of CTI equated parents responses about their children’s use of MPVG play to benefits of para social interaction/communal identity formation, interpersonal utility/relational identity formation, decision utility and entertainment/enacted identity formation. Reductions in parental stress was anticipated but no significant relationships were reported between use of MPVG and meaningful reductions in parental stress. Despite these findings, all parents expressed interest and a likelihood to use MVGP through the conceptualized behavioral intervention WGCMD if it were not violent, it had strong parental controls, and it did not increase parental stress in relation to excessive time and desire for game play.

Parental thoughts, feelings, and experiences were explored via qualitative data collection and analysis. Data was collected through interviews, questionnaires, and chat room exchanges. Analysis showed that parent perceptions of MPVG play indicated that children experienced feelings of belonging, positive reciprocal play, strengthened identity, increased social agency and increased self-efficacy. Parental concerns included observations and fears regarding obsessive and addictive relationship with game play,

xiii inability to control amount of time spent in game play, and concerns that game play reduced real world relationship formation.

KEYWORDS

Communication theory of identity, gamification, commercial multiplayer video games,

Minecraft, parental stress, ADHD

xiv

INTRODUCTION

Children with attention deficit hyperactivity disorder (ADHD) suffer from impairments of communication competence in all domains which causes high rates of stress in parents. ADHD is one of the most common neurodevelopmental dysfunctions of childhood, affecting up to 11% of all children. Communication impairments involve inattention, hyperactivity, and other cognitive processes expressed as neuroanatomy and development changes. These impairments are responsible for problems in communication, behavioral, and social competence with diminished self-efficacy (Baird,

Stevenson, and Williams, 2000). Existing behavioral treatment interventions lack long- term effectiveness and have been shown to elevate parental stress. Parent stress can be bidirectionally correlated to further child-parent communication impairment and dysregulation of children’s behaviors (Jensen, 1999).

Language is the ultimate expression of the attentional system (Baird, Stevenson, and Williams, 2000). Children with ADHD have deficits of coordination in the interlinked neural system, which involve the capacity for language creation, interpretation, and expression, in written, verbal and nonverbal forms. Jerome Wakefield differentiates harmful medical disorders from normal forms of human suffering if the disorder is due to an internal biological mechanism failing to perform the function for which it was designed (Baird, Stevenson, and Williams, 2000). This definition posits

ADHD as a harmful medical communication disorder which affects the child’s ability to engage in multiple competency domains. These social problems inhibit feelings of belonging and opportunities for reciprocal play which cause subsequent self-efficacy deficits in areas of personal and relational identity formation.

Evidence based behavioral parent training (BPT) programs have been shown to improve communication competency deficits but have only exhibited short-term success in specific domains (Pelham, Fabiano, & Massetti, 2005). The lack of program effectiveness can be shown through reported lack of long-term positive results which are exacerbated by diminished motivation on the part of the child to engage in these treatment interventions. Parents abandoned therapeutic protocols within months of completing training programs (Danforth, Harvey, Ulaszek & McKee, 2006; Pelham,

Fabiano, & Massetti, 2005). Further research indicates that the benefits of BPT are offset by increases in parental stress due to cost, time requirements, and the effort needed to implement and regulate interventions (Rogers, Wiener, Marton, & Tannock, 2009). This elevation in parental stress contributes to dysregulation in ADHD children’s behaviors at home and amongst peers. As parental stress increases so do children’s communication competency problems which creates a negative gain feedback loop further leading to

BPT’s ability to produce long term intervention gains (Escobar et al., 2005; Schreyer,

2009; Johnston, 2001; Harpin, 2005).

In order for an intervention to be effective, it must motivate children to engage in and retain the behavioral and communication modification lessons without increasing parental stress. The majority of behavioral therapy research fails to examine how parental stress and child motivation impact long term effectiveness of behavior change outcomes.

Existing behavioral therapy research fails to engender far transfer effects, making the use of commercial multiplayer video games (MPVG) a possible communication competency support intervention.

The most central definition of gamification is the ‘ication’ suffix. This suffix indicates that it is a process fitting the communication model, in which two or more parties partake in an exchange of messages with an attempt to convey meaning (Werbach,

2014). The object of gamification is understood through intention of design, and need for achievement of intent, by the participants who convey and interpret messages through the gaming process (Huotari and Hamari, 2012). The process of communication, via gamification, offers self-efficacy, autonomy, and belonging through opportunities for transformational reciprocal play (Werbach, 2014).

VGP can calm and regulate children so they are not verbally or behaviorally disruptive. Game play can also be the source of conflict and stress between parents and children over the enforcement of time allowances regulating permissions for game play engagement. Video game play as ADHD digital medicine, through brain training and social and behavioral improvements through play, is an emerging area of research

(Kollins, 2017). MPVG use by ADHD children has been shown to improve communication competence by addressing deficits in opportunities for reciprocal play, social belonging, self-efficacy, physical and spatial deficits, and identity formation

(Granic, Lobel & Rutger, 2013; Russoniello et al., 2009; McGonigal, 2011). Despite much controversy surrounding the addictive nature of VGP, research shows that repetitive game play may have a positive impact on the transfer of cognitive skills acquired in game to real-world functional competencies (Thorens et al., 2016).

Children today form identities around the regular use, and at times overuse, of socially shared commercial game play experiences (Olson, 2010). New research indicates that the obsessional desire for ADHD children to enact identity through competitive and

3 rewarding communicative game play can be utilized to promote positive social and behavioral change (Granic et al., 2014). Personal identity formation within MPVG can be derived, not only through the relational component of enacted play, and but also through a reciprocal association of in-group communal identity formation (Klimmt, Hefner &

Vorderer, 2009).

Ray Oldenburg (1989) calls the places in which social associations take place, third places. He equates the digital third place space to ideal social spaces in the analogue/physical world in which communicative interactions can exist (Ducheneut,

Moore & Nickell, 2007). If the use of discrete ADHD video games as digital medicine were used to the exclusion of commercial and socially rich multiplayer video games (like

Minecraft, Roblox, or The Sims) it could impact children’s motivation and social competency gains. Sharing knowledge and creativity within game play advancement gives ADHD children agency and helps to build social capital through in-group social inclusion and communication reward narratives (Klimmt, Hefner, & Vorderer, 2009).

The combination of reward conditioning and interpenetration of identity in the never-ending unfolding world of virtual safe space sandbox games provides positive peer support and engagement for children through digital play use. These gains and the fun nature of VGP can cause children’s desire for VGP to become obsessive or addictive (Li,

Liau, Khoo, 2011). This obsessional drive to engage in game play is what makes the potential intervention uses of commercial MPVG much greater than that of discrete games. Discrete games are not mass produced and are developed specifically with medicinal purposes in mind.

The relationship between children’s negative MPVG over-use and increases in parental stress will be examined, alongside reductions in parental stress that are associated with game play use as a digital babysitter. Additionally, this research attempts to explore the gap in the literature between parents perceptions of the addictive nature of

VGP and the potential positive uses of that same obsessive identity. This obsession is an intrinsic motivator that includes desired for gains in shared belonging and controlled play use. If used correctly, it has the potential to guide ADHD children toward self-regulation of communication competency issues.

A qualitative method will attempt to understand the lived experience that parents of ADHD children have with their child’s video game play through interviews, questionnaires, and Facebook support group data. The positive or negative thoughts, feelings and beliefs that parents experience regarding their children’s social agency experiences and communal relationships and MPVG identity will be examined for narrative themes that illustrate shared beliefs.

This study also attempts to explore the willingness of parents to use a wearable communication modification device (WGCMD) that uses MPVG as a behavior change motivator. The communication theory of identity (CTI) is the theoretical frame through which potential use of the conceptualized communication mediation device has been assessed and supported. The concept behind the WGCMD aligns on task communication behaviors with extrinsic rewards in the shared third places of in-game enacted identity.

Enacted behavioral gains would be linked to time allowed in game play and digital object rewards acquired in virtual communities within commercial sandbox MPVG. The social agency of shared MPVG could potentially provide children with incentives to self-

5 regulate, while simultaneously reducing parental stress associated with the need to enforce the behavioral modification rules and communication guidelines of traditional behavioral interventions.

This WGCMD would be easily programmable and modifiable by parents in order to create daily and weekly goals for their child. The device would vibrate when the child was engaging in off task behavior, causing the child to lose time in VGP and to level down accordingly. Broaden and Build, Flow and Transformational Play were all theories that were explored when conceptualizing and researching potential use of the WGCMD.

Gameplay time limitations would be established in accordance with household norms and game play time allowances would reflect task and communication gains through leveling up on the WGCMD. If this child regulated intervention could replace the parent as the regulatory entity of behavioral and communicative modifications, there is potential for reductions in parental stress while increasing gains in prosocial parent-child communication. Parental controls would be an essential component of this technological concept.

THEORETICAL FRAMEWORK

This research uses the Communication Theory of Identity (CTI) as a theoretical frame through which to examine the ways in which parents perceive their child’s relationship with video game play (VGP). CTI frames social behavior as a form of enacted identity with identity being understood through the multilayered social construction of individuals and communities. This theory looks at the use of communication as an element in the process of identity interpenetration and integration,

combining community, communication, social relationships, and self-concepts ((Hecht,

Choi, 2012).

The opportunity for game players to engage in situations that allow them to learn about themselves, and even to create themselves can be viewed as personal identity formation. Relational identity reflects the way social connectivity and belonging inform identity through jointly negotiated and formed digital, social relationships in game play.

Enacted identity can be conceptualized as an expressive performance which transforms daily existence into performative play. Communal identity serves as a framework to look at opportunities for learning that occurs through shared history, memory or cultural codes

(Hecht, Choi, 2012).

This research looks to explore parental thoughts regarding their child’s sense of identity within video game play. A wearable gamification communication modification device has been conceptualized to help ADHD link analogue expectations with the identity gains experienced in commercial sandbox multiplayer video game that is linked to analogue expectations. Child motivation is expected to increase by positive gaming identities being transposed into analogue areas of impaired communication giving the

7 opportunity for a fluid connection to be created between the two worlds. Improvements in analogue behaviors would be incentivized through receipt of VGP time allowances and through digital in game rewards. Past research indicates that over time these behaviors will become enacted identity and the transformational play identity will begin to exist outside the digital third place. This behavioral modification play may result in improvements related to increased socially expansive play possibilities, and improved relational and communal identity through belonging, improved self-efficacy. Parental stress is anticipated to be lowered and child motivation is anticipated to increase with regards to engagement in behavioral modification techniques. Results through transformational play are expected to improve far transfer outcomes.

Flow Theory, Broaden and Build Theory of Positive Emotion (BBT), and

Transformational Play Theory are the theoretical frameworks this research utilized when conceptualizing the WGCMD. Mihaly Csikszentmihalyi’s Flow Theory, Barbara

Fredrickson’s BBT and Sasha Barab’s Transformational Play Theory are all based in the field of positive psychology but for purposes of this research have been applied to the field of communication inquiry.

Csikszentmihalyi’s Flow theory identifies nine elements through which the transformation sensation of being fully immersed in an enjoyable task can be understood.

While in a Flow state skill and challenge are balanced; awareness merges with action; goals are perceived more clearly; feedback is unambiguous and concentration is focused which creates a sense of full body control; self-consciousness is abandoned; time is elusively transformed and there is an experience of internal meaning or purpose (Beard,

2015).

Csikszentmihalyi’s Flow state is often referred to as being in the zone. The zone has become a term used by gamers to explain when the player loses all track of time, forgets external pressures, and is fully engaged in construction, deconstruction and transformation of identity through the controlled, safe communication of the MPVG

(Marczewski, 2012). For an illustration of the process of Csikszentmihalyi’s Flow Zone see Figure 1.

FLOW THEORY DIAGRAM

Figure 1. Flow Theory Diagram; Marczewski, 2012

Fredrickson’s BBT posits that positive emotions, (joy, play, interest) work together to broaden one’s awareness and interest. This broadening stimulates exploration which acts as the base for knowledge and personal growth while allowing for expansion of both world and self-view. Better communication competence possibilities are built

9 through this state with social relations and interpersonal communication skills all improving (Fredrickson, 1998). Parents of ADHD children experience high levels of parental stress (Whalen, Odgers, Reed, Henker, 2011). Traditional parent-led behavioral parent therapy (BPT) have been shown to increase stress levels which bi-directionally increased impaired communication outcomes between parent and child and child and other social interactions. (Chronis, Chacko, Fabiano, Wymbs, and Pelham, 2004) The theories of Flow and BBT help to ground gamification studies as educational and behavioral mechanisms that can lessen parental stress by creating child motivated agency that feels like play (Vella, et al. 2017).

Transformational play theory builds on this concept by highlighting three interconnected elements that involve the player as a person with intentionality who is engaging content with legitimacy and consequential context (Barab, Gresalfi, Ingram-

Goble, 2010). For an illustration of Transformational Play see Figure 2.

TRANSFORMATIONAL PLAY DIAGRAM

Figure 2. Transformational Play Diagram; Barab, 2010

Transformational play provides a framework through which ADHD children can transform into empowered individuals who have to understand and enact communication and behavioral goals to accomplish desired ends. This theory provides a gamification behavior modification tool that could lead to child led motivation and behavioral regulation that could lessen parental stress while improving the child’s home, academic and social communication competence.

LITERATURE REVIEW

ADHD: A Disorder of Communication Competency

ADHD is a neurobehavioral communication disorder that is diagnosed in childhood and can continue into adulthood. ADHD has to do with the way the brain affects emotion, behavior, and learning. One of the more commonly overlooked aspects of ADHD is its direct effect on the three components of communication: speech, language, and pragmatics (Kim, Kaiser, 2000). Children suffering from ADHD are at a higher risk for articulation disorders; differences in fluency and vocal quality; a lack of awareness of increased volume and pitch variations; increased use of vocal pauses and verbal fillers; and impaired listening comprehension which makes keeping track of conversational threads difficult (Bertin, 20014). Distractibility and processing differences create language challenges which include word use, vocabulary, grammar, narrative ability, and receptive and expressive language with significant language and reading delays being commonly experienced by ADHD children (Bertin, 20014). These symptoms all combine to impact effective speech competence.

Pragmatics relate to spoken language, and social and nonverbal cues. Central

ADHD symptoms of working memory, and executive function impairment intrude on the communication skill set of pragmatics. This intrusion affects domains of spoken language, social, and nonverbal norms (Baird, Stevenson, Williams, 2000). Blurting, talking excessively, tangential disorganized thoughts, misreading social cues, inability to monitor tone and volume of voice, inability to comprehend gestures, and other non-literal meanings, all work to meet the criteria for the new DSM-5 category of “social communication disorder” (DSM-5, 2019).

ADHD is not a new disease that has arisen from rude children, less discipline, over scheduling, media consumption, food additives, or a lack of parental management.

The derogatory stereotypes ,coupled with communication competency issues experienced by ADHD children, has caused concerned parents to experience parenting stress at extremely high levels (Pappas, 2011). Parenting stress has been shown to directly correlate to increases in children’s dysregulated communicative competence, both in the home and in other social interactions (Rabiner, 2016).

Communication competence is defined as functional and effective verbal and nonverbal communication behaviors evaluated by oneself and others to be appropriate to the situation and in line with one’s communication goal (Hymes, 1966). For an illustrated overview of communication competence, please see Figure 3.

COMMUNICATION COMPETENCY CHART

Figure 3. Communication Competence Chart; Learnalberat.ca ©, 2003

The Center of Disease Control reports that ADHD is one of the most common and impairing childhood disorders, with ongoing psychiatric problems potentially causing issues of unemployment, anxiety, relationship failure, school failure, depression, and incarceration (Klein et al., 2012; Molina et al., 2009; Hecht man et al., 2016).

ADDITIONAL ADHD IMPAIRMENTS

• Inability to exercise cognitive and behavioral age-appropriate inhibition • difficulty with attention and concentration • failure to listen to instructions and respond to details • impulsivity, and hyperactivity • inability to regulate mood (becoming easily frustrated, sad, or angry) • the need for constant movement and fidgeting • excessive and loud talking • the inability to regulate behaviors or organize tasks • failure to fulfill expectations • hypersensitivity or over responsivity • poor conception of time and faulty time management skills

Figure 3b. Additional ADHD Impairments; Reynolds, Lane, 2009; Asherson, 2015; APA, CDC, NIH, 2019.

ADHD children’s deficits in organization, time management and planning are often the result of impairments in executive functions. These problems make it difficult to plan or carry out assignments, manage materials needed to complete tasks, develop or adhere to schedules, remember details, set priorities and manage time (Abikoff et al.,

2009). ADHD children are chaotic, forgetful, louder, messier, less punctual and more emotionally labile. These problems contribute to significant communication problems and contribute to potentials for social, and academic failure, substance abuse, and riskier behaviors than those occurring in typical children. Impaired behaviors can and do make

14 positive and reciprocal peer relationships difficult, and they engender low self-efficacy which can cause severe social problems at school and home.

The frontal lobe in ADHD children’s brains has been shown to mature later. This delay is linked to problems in working memory, organization, language, motivation, judgement, impulse control, social behavior, attention, time perception, planning, problem solving, and making decisions (Silver, 2018). Research also shows that structures in the ADHD child’s brain are smaller than the same area in typical children

(Sinfield, 2018). The network of neurons in the ADHD brain that are involved with reward, focus planning, attention, task shifting, working memory and movement, communicate differently than a typical brain. Deficiencies in the frontal cortex, the limbic system, and the neural circuits of the basal ganglia and/or the relay pathways of the reticular activating system are thought to be responsible for ADHD symptoms and subsequent communication issues (Silver, 2018).

The neurotransmitters dopamine and norepinephrine are also dysregulated. There is either too little dopamine, not enough receptors for it, or the dopamine is not being used efficiently which causes problems with norepinephrine synthesis and reward pathways (Silver, 2018). Stimulant medicines can help with this particular aspect of

ADHD by encouraging more dopamine to be produced and keeping it in the synapses longer (Silver, 2018). Video game play also results in dopamine production which is linked to intrinsic reward pathway activation (Silver, 2018).

To refer to ADHD as just an attention deficit issue is a misrepresentation. ADHD is a neurodevelopmental communication competency disorder with written, verbal and nonverbal language impairments . These well documented risks for children,

15 adolescence, and adults with comorbid occurrences of psychopathology (Barkley, 1990,

1996; Hinshaw, 1994; Weiss & Hechtman, 1993, Frick & Nigg, 2012; E.G. Willcutt,

Hartung, Lahey, Loney, & Pelham, 1999). Children develop and learn to use speech appropriately through listening and paying attention to other people and through the acquisition of social skills gained in reciprocal play. When social understanding and expressive language is compromised, it can impede on opportunities to engage in reciprocal play which limits the acquisition of these vital social skills (Panskeep, 2007).

ADHD children parental approaches to MPVG can be understood through several theoretical lenses including CTI, BBT, Flow, and the Theory of Transformational Play.

The lack of reciprocal play among ADHD children draws them to collaborative MPVG as a way to creatively restructure the communicative process of personal and relational identity creation. The unstructured and endlessly vast nature of sandbox games engages the reward system with dopamine release further cementing positive gains found in the uses of video gaming connectivity.

ADHD children are able to engage in digital play by accessing modes of appropriate and effective peer interaction expressed in the core symbols, meanings, and labels of shared third places VGP. The Collaborative Multimodal Treatment Study of

Children with ADHD (the MTA) has shown that ADHD children experience difficulties and negative outcomes across various domains of functioning, with clear difficulties evidenced in peer relationships (Wells et al., 2000). Children with ADHD are more likely to attempt or commit suicide than depressed children (Crosnoe, 2011). ADHD adults have a 30% higher risk for a suicide event than non-ADHD adults and stimulant medication shows no effect regarding risk factors (Balaz, & Kereszteny, 2017).

Academically, ADHD children underachieve in school, require special classes, need tutoring support, and tend to perform below their intellectual abilities (Barkley,

DuPaul, & McMurray, 1990; Biederman, Faraone et al., 1990; Lahey, Schaughency,

Strauss, & Frame, 1984; Semrud-Clikeman et al., 1992). Inhibition in executive function leads to classroom issues of memory, reasoning, and general cognitive function (Daley,

& Birchwood, 2010). Classroom interventions for ADHD students have historically focused on teacher-led management strategies. These strategies have become increasingly problematic due to funding cuts, overcrowded classrooms, and the testing responsibilities of modern day overworked school teachers. ADHD children have needed, but not received, individual academic resource assistance because schools lack specific strategies to provide long-term success for this at-risk population of children (DuPaul & Eckert,

1998, Fabiano & Pelham, 2003; DuPail, Weyandt, & Janusis, 2011). In a 2013 review of the evidence experts in the field recommended accommodations such as peer tutoring, strategic instruction, and computer assisted instruction (DuPail, Weyandt & Janusis,

2011).

Parents are the gatekeepers of their child’s adoption and use of video gaming technology. The frequent self-report of video games as high-tech babysitters shows a clear selective and purposeful orientation of parental use for the child to engage in game play so that parents can focus their attention elsewhere (Griffiths, 2013). If game play is necessary for parents to use as a way to meet needs for personal task completion, or as a way to regulate child behaviors and lower stress, then desire for VGP becomes shared by parent-child. It therefore becomes all the more imperative that MVGP be a purposeful

17 opportunity for social and educational use with addiction tendencies being addressed through adoption of parental controls.

Parental Stress and Dysregulated Communication

The demands on the parent of a typically-developing child can elicit considerable stress in many adults (Cox, Owen, Lewis, & Henderson, 1989). These daily responsibilities are made all that more challenging when the child has a chronic, pervasive disorder characterized by deficiencies in communication, sustained attention, hyperactivity, impulse control, and dysregulation of motor activity in response to situational demands (Mash & Johnston, 1990; American Psychiatric Association, 1987).

Using the Parent Stress Index and the Conners’ Parent Rating Scale, parents of ADHD children showed higher overall stress than parents of autistic children or children with epilepsy (Gagliano et al., 2014).

When compared to other groups, parents of children with ADHD displayed less ability to protect themselves from the negative emotional impacts that accompany the child’s dysregulated communication processes displays. These experiences which create reduced feelings of parenting self-efficacy, lower parental satisfaction, and increased parental stress (Gagliano et al., 2014). Increases in parent stress is bi-directionally linked to displays of parent-child communication dysregulation and to increases in other communication impairments (Biederman et al., 1995).

These higher rates of parenting stress are often linked to dysfunctional parent behaviors, losses in temper, corporal punishment, substance abuse, negative attitudes about parenting, depression, anxiety, guilt, and limited social networks. Any of these issues create increased problems and impaired parent-child communication (Johnston &

Mash, 2001; Donenberg & Baker, 1993; Kashdan et al, 2010; Whalen, Odgers, & Reed,

2010).

ADHD is known to be associated with poor self-efficacy in children and adolescents, with anxiety and depression commonly occurring as comorbid disorders which exacerbate stress and anxiety in parents (Escobar et al., 2008, Steinhausen et al.,

1998). Children with ADHD have trouble making and keeping friends due to being socially disruptive, and to improperly gauging social cues. Mothers experience self-blame and perceived blame from family members, peers, and teachers regarding their child’s behavioral impairments (Harborne et al., 2004, Peters & Jackson, 2008).

The communication between children with ADHD and their parents can be impeded upon by social and financial pressures. Disruptive behaviors are associated with higher than average parent-child and sibling-to-sibling conflict which can create marital distress. All of these factors cause the ADHD child to feel guilt, sadness, and stress which have also been linked to increases in oppositional behaviors and communication dysregulation (Escobar, et al, 2005; Schreyer, 2009; Johnston, 2001; Harpin, 2005).

Children who are hyperactive, unresponsive to discipline and who lack control, tend to have parent responses that are more harsh, punitive and corporal in punishment

(Stevens-Long, 1973; Mulhern & Passman, 1981; Bugental, Caporeal, & Shennum,

1980). Heightened levels of parental stress have been shown to increase with the child’s age, which correlate to increases in disparity between the child’s function level and the expectations regarding their social, communication, and academic competence and abilities (Gagliano, 2014).

Predictors of parenting stress in families of children with ADHD include severity of ADHD symptoms, level of hyperactivity, and extent to which inattention/distractibility contribute to diminished communication competence (Anastopoulos, Guevremont,

Shelton, & DuPaul, 1992; Baker & McCall, 1995; Vitanza & Guarnaccia, 1999; Breen &

Barkley, 1988; Podolski & Nigg, 2001).

Parent-Led Behavioral Treatments and Parental Stress

There are a wide range of therapeutic options through which parents of ADHD children can increase competency in their children. These include various parent training programs to increase communication impairments and the associated dysregulated behaviors. The most common psychosocial interventions are behavioral parent training programs and will be collectively referred to as behavioral parent trainings (BPT) (see

Appendix B for examples of widely used programs).

The ADHD child’s inattention, disruptive and underachieving classroom behaviors mean that educational support accommodations are needed in order to achievement academic participation. These additional parenting demands are bi- directionally associated with children’s dysregulated behaviors (Rogers, Wiener, Marton,

& Tannock, 2009; Loe & Feldman, 2007).

Gains in communication via the use of BPT were studied in the comprehensive

Multimodal Treatment Study of Children with ADHD (MAT) and the Parent Training

Interventions (PTI) for ADHD in Children Review by measuring improvements in reduction of the number and intensity of isolated problematic behaviors. Few studies examined social and academic communication concerns, and none directly addressed parental stress or depression (MAT, 2009, Kaplan & Anderson, 2016).

The findings of The Meta-Analysis of Parenting Stress in Families with Children with ADHD indicated that the various therapeutic options may improve the child’s behavior in the short term but there is little evidence for long term efficacy. BPT, or other treatment programs, have shown casual relation to elevations, not reductions, in chronic parental stress (Rogers, Wiener, Marton, & Tannock, 2009).

Depression and stress comorbidly occur in parents of ADHD children, which can decrease motivation to engage in treatment modalities and create barriers for implementation of changes (Chacko, Wymbs, Flammer-Rivera, Pelham, Walker, 2008).

For single parents, the expense and time dedication required to complete treatment programs, on top of home and work responsibilities, spikes parental stress levels

(Chronis, Chacko, Wymbs, Pelham, Walker, 2004). Attending classes and implementing specific home guidelines can feel burdensome when added onto daily parental duties, causing treatment adherence to be connected to stress elevations resulting in long-term effectiveness to be lacking (Rogers, Wiener, Marton, & Tannock, 2009).

Though well-established and evidence based, BPT is most effective when parents and teachers partner in training, and when BPT protocols are combined with medication.

Effectiveness of BPT parent/teacher partnerships should be weighed by the consideration that treatment is recommended to be re-initiated when children and adolescents go through “development transitions” (Rogers, Wiener, Marton, & Tannock, 2009).

Developmental transitions are a near-constant state for a growing child.

BPT private program options can be cost prohibitive and time consuming, running anywhere from 10 to 35 week-long sessions. Programs require participation in the treatment and training group and then parent participation via homework that is

21 assigned to help structure children’s communication competency challenges. For some parents this provides a much-desired structure through which they can try to communicate more successfully with their ADHD child (Whalen, Odgers, & Reed,

2011). For some parents the structure and time that BPT demands can feel like an additional item on an endless to-do list The early abandonment of BPT treatment strategies, and failure of far transfer success in strategy gains, is demonstrated across studies (Hoofdakker et al., 2007, Whalen, Odgers, & Reed, 2011, Danforth, Harvey,

Ulaszek, & McKee, 2006; Pelham, Fabiano, & Massetti, 2005).

The vast majority of the BPT research has been conducted in controlled academic or medical lab settings, is free of charge, and treatment completion is monitored through close follow-up to encourage attendance and participation. This experience is very different from the hundreds and thousands of dollars that private BPT can cost. Post-tests of BPT show that pharmaceutical interventions in combination with BPT or used alone, improve children’s communication outcome results but substantive parental stress levels remained problematic (Danforth, Harvey, Ulaszek, & McKee, 2006; Pelham, Fabiano, &

Massetti, 2005).

Video Games and Transformational Play

Games are one of the most popular leisure activities among children, especially

ADHD children. Recent research in positive media psychology has looked at the ways multi-player, interactive video gaming facilitates improved communication and mental well-being, particularly by giving children who struggle with social skills an avenue through which they have an opportunity to thrive (Oliver & Raney e.g. 2011, 2012,

2015). Examination of the research reveals that the benefits of play, focusing specifically

22 on VGP, has been richly explored with real-world gains include cognition, motivation, emotion, and social benefits, all working together to increase communication and wellbeing (Granic, Lobel & Engels 2014).

Building on the benefits of VGP research has shown that computer mediated communication (CMC) and peer engagement can reduce social anxiety and present opportunities to meet communication competence and social relatedness needs that may not be easy to meet in the real world (Ferguson & Olson, 2012). VGP in ADHD children can show greater motivation in areas of stress reduction, communication competence building, and social connectedness, and can have the Pinocchio effect -game play eventually becomes the desired and pervasive real-life experience (Sanchez, Brown,

2017, Bonus, Peebles, Mares & Sarmiento, 2017; McGonigal 2003).

The Broaden and Build Theory explores how knowledge and communication skills garnered through modeling, self-control, problem-solving, role playing and collaboration, in the video game experience, can be transferred to real world scenarios with lasting positive results (Dede, 2009). Central to the theory is the idea of the broadened state in which the individual is more able to engage in knowledge acquisition, communication problem solving, and social bonding, and can build longer lasting physical, intellectual, and social resources (Fredrickson, 2013).

BBT has added onto the exploration of self-determination theory (STD) which has been used to examine the effects of VGP on communication, socialization and interpersonal attachment by suggesting that game play can create communication competence and social connectedness similar to non-VGP (Przybylski, Rigby & Ryan,

2009, Ferguson & Olson, 2010). BBT was used to research the collaborative video game

Pokémon Go. Research demonstrated that PG game play contributed to immediate improvements in learning and well-being, with longer lasting positive social and communication outcomes (Bonus, Peebles, Mares & Sarmento, 2017). Given this research it seems plausible that a sandbox multiplayer game with which ADHD children have social agency, nostalgia, and identity would lead to results similar to those found in the Pokémon Go study.

These discoveries, coupled with new research on brain training, ADHD assistance

APPS, and unique video games for improvements in communication for ADHD children, make for a rich landscape of emerging technologies. The communal and relation identity formation within MPVG, coupled with easily modifiable coding of open source sandbox games like Minecraft, could provide the perfect entry for game play. Shared agency allows for peer social exchanges that engender communication competence improvements with increased on-task behaviors, and fewer bi-directional problems between parents and children arising from increased parental stressors.

Videogames are powerful mediums through which educational goals can be achieved in narratively rich worlds of curriculum (Barab, 2010). Three interconnected elements, person, content and context are the highlighted relationships at work in transformational play. Students, or players, are positioned as empowered actors who must understand and utilize content in order to enlist and transform scenarios (Barab, 2010).

Transformational games can establish entire worlds where children are transformed into central learners. For example, children can become a scientist, veterinarian, or engineer who must understand the content in order to communication and problem solve from that identity formation position (Barab, 2010). These games offer a place where what a

24 participant knows is directly related to what they are able to communicate and to the identity they are able to inhabit (Barab, Gresalfi, & Ingram-Goble, 2010).

If VGP transforms the identify formation of the player, so that game and player become interchangeable, it becomes essential to understand the mental health outcomes associated with game play. Is time spent playing in video games associated with mental health, cognitive and social skills in young children? was the first study to analyze the relationship between video games and mental health. Results suggested that VGP helped to facilitate communication, lessen peer relationship problems, and increase intellectual function (Kovess-Masfety et al., 2015).

Studies have found positive correlations between game play and multiple domains including areas of superior temporal attention, spatial distribution of attention, enhanced capacity in attentional blink task, faster task switching and decision making, enhanced capability to suppress visual distracting information, superior ability to make accurate decisions under high load conditions, and superior performance on divided attention tasks

(Castel, Pratt, & Drummond, 2005; Green & Bavelier, 2003; Riesenhuber, 2004; Castel et al., 2005; Green & Bavelier, 2006; Andrews & Murphy, 2006; Boot, Kramer, Simons,

Fabiani, & Gratton, 2008; Karle, Watter, & Shedden, 2010; Chisholm, Hickey,

Theeuwes, & Kingstone, 2010; Mishra, Zinni, Bavelier, & Hillyard, 2011; Greenfield, de

Winstanley, Kilpatrick, & Kaye, 1994; Chang, Liu, Chen, & Hseih, 2017).

More than just fun and game a four-year longitudinal study, showed that playing strategy and role-playing games predicted strategic self-reported increases in communication competence and problem-solving among a sample of 1492 high school participants (Adachi & Willoughby, 2013). A follow up 2016 study by Matthew Barr

25 entitled, Video games can develop graduate skills in higher education students: A randomized trial, measured the effects of playing commercial video games on development skills such as problem solving, communication, resourcefulness and strategic adaptability (Barrie, 2006, 2007; Hughes & Barrie, 2010, Barr, 2016).

Video Games and Reciprocal Play

Academics are not the only challenge that ADHD children face in school. The

National Institute for Play describes play experiences as providing children with important lessons of social identity, self-concept, experiential learning, and relatedness or belonging (Houck et. al., 2012). Children with ADHD are often excluded from reciprocal play opportunities and denied an important core tenant for healthy development. The cortical development of an ADHD child’s brain may be up to three years behind that of their peers in ability to observe and implement social cues and norms creating problematic interactions and diminished opportunities for play (Myers, 2014). ADHD children are overwhelmingly rejected in social situations with rejection developing after brief peer exposure and becoming persistent once it is established (Bickett & Milich,

1990; Erhardt & Hinshaw, 1996).

Three hundred children with clinically diagnosed ADHD participated in the

Multimodal Treatment Study of Children with ADHD (MTA, 2009). Peer rejection and dyadic friendships were shown to contribute to long-term emotional and behavioral problems with outcomes of delinquency, depression, anxiety and global impairment

(Mrug et. al., 2013). The MTA was a 14-month study that combined of intensive medication management with behavior therapy. Post testing showed no specific improvements in peer impairment or social isolation (Mrug et. al., 2013). These statistics

26 demonstrate a quantifiable need for additional research into intrinsic behavior modifications that children can utilize to make peer functioning, social interactions, and reciprocal play potential more self-regulated and successful over time.

Play offers physical, emotional, cognitive, and communication benefits by allowing children and adolescents to build motor skills, social behavior repertoires, identity norms, and to develop adaptability to behaviors existing in ever changing contexts (Nijhof et. al., 2018). Recent research has shown that interactive VGP can increase coordination and motor skills, enhance adaptability to stress, produce cognitive benefits and engender social belonging through increases in identity formation and self- efficacy (Nijhof et. al., 2018).

A Sense of Belonging: Video Game Play and Social Connectedness

Belonging is a central human desire. It involves the process of feeling worthy of respect and inclusion by being securely connected to feelings of community (Osterman,

2000). Hecht and Choi’s CTI features belonging as a fundamental process of communication in which individuals internalize social connection, relationships, and sense of self into identities (Hecht, Choi, 2014). Several need theorists suggest a correlation between social connectedness/belonging and achievement motivation

(Osterman, 2000). The research of Dewey and Vygotsky states that it is through collaboration and belonging to part of a group, that learning occurs. (Dewey, Vygotsky,

1958; Osterman, 2000).

In a 2007 study, the concept of belonging, or social identity, was examined as being the central aspect through which humans define identity, belonging, communication, intrinsic motivation and self-efficacy (Freeman, Anderman, Jensen,

2007; Connell & Wellborn, 1991; Deci, Vallerand, Pelletier, & Ryan, 1991; Ryan, I995).

Interacting successfully with peers and significant adults is one of the most important aspects of a child's development, yet 50 to 60% of children with ADHD have difficulty with peer relationships (Lavoie, 1995).

Due to their inability to control intrusive, disruptive, and impulsive behaviors, up to 70% of ADHD children report that they have no close friends by the time they reach the third grade. This experience of antisocial peer relationships can result in communication fissures and the inability for collaborative play-engagement (Barkley,

2006). Acceptance by peers is important for the communal properties of identity and psychosocial well-being in ADHD children. If social rejection continues into adolescence

ADHD children are more likely to experience being bullied, become bullies, or to align with deviant peer groups who engage in risk seeking behaviors (Meltzer, Gatward &

Goodman, 2003; Hoza, Mrug, Gerdes, 2005; King, & Young, 1981).

ADHD children have diminished relational identity formation opportunities and these perceived social characteristics impact the way children and adolescents form identity norms and develop feelings of self-worth. (Saunders & Chambers, 1996;

Barkely, 2006, Barber, & Eccles, 2008; Crosnoe, 2011). Peer rejection is not a domain that responds to standard ADHD treatments of behavioral therapy or medication. Peer relationships require additional interventions to lessen social isolation (Hoza, Gerdes et al., 2005). Suggestions for improving underlying social skill deficits and negative global impairment outcomes for ADHD children include cognitive-behavioral training combined with structured interactions in the natural peer environment (Mrug et. al.,

2013). A study using data from The School Children Mental Health Europe showed that

28 collaborative VGP correlated with increased states of belonging and could be used as a protective communicative modality for children suffering from peer relationship problems (Kovess-Masfety et al., 2017).

Game-based belonging was examined in a study of relational identity formed through communal play within the augmented reality (AR) game, Pokémon Go.

Researchers used the theoretical lens of Fredrickson’s BBT and, Csikszentmihalyi’s

Theory of Flow and Sasha Barab’s Transformational Play to explore the ways in which reciprocal play created opportunities for belonging, decreased social anxiety, and increased self-efficacy with overall gains in communication competence.

The Pokémon Go findings suggested that playing a video game led to positive communication outcomes and feelings of well-being, higher resilience, and moderated social anxiety (Bonus, Maries, & Sarmiento, 2017). Building on this research, a 3-week intervention with the co-operative action role-playing game Torchlight II was used to increase at-risk students’ opportunities for team collaboration (Hanghoj, Lieberoth,

Misfeldt, 2018). In the gaming scenario of the Torchlight study, at-risk students were positioned as active participants who were attempting to overcome shared challenges via play, with participation and communication being reframed as inclusive. Qualitative analysis confirmed positive findings (Hanghoj, Lieberoth, Misfeldt, 2018).

A Pew Research Center survey of teens aged 13-17 found that 80% of video gamers played with friends either cooperatively or competitively and 52% of teenagers reported that video games lessened feelings of loneliness by helping them feel connected

(Entertainment Software Association, e.g. ESA, 2016). The immersive and social context of MPVG can support feelings of belonging and in-group communal identity formation;

29 can engender improvements in self-concept; can increase reciprocal play in which social skills can be communicated and practiced; and can improve prosocial communication behaviors with potential for gains to be seen in relationship outside of the gaming environment (Gentile & Gentile, 2008, Gentile et al., 2009, Granic, Lobel, & Rutger,

2013). The Map of main genres of video games shows social and nonsocial gains from playing different types of games at different levels of complexity, see figure 4.

MAP OF MAIN GENRES OF VIDEO GAMES

Figure 4. Map of the Main Genres of Video Games; Granic, Lobel, Engels, 2013

Enacted Communication: Game Play and Self Efficacy

Bandura’s social cognitive theory defines self-efficacy as the expectation that one can master a situation and produce a positive outcome (Bandura, 1977). Research has demonstrated that people develop self-efficacy from four main sources: performance accomplishment, observation of others, verbal persuasions, and social mastery experiences (Maddux, 2005). Due to their disrupted communication skills ADHD children experience higher rates of failure in verbal persuasion, and social mastery experiences (Maddux, 2005). People with high efficacy beliefs may approach difficult tasks with an intrinsic interest in the activity. People with these beliefs perceived tasks to be challenges that can be mastered, as opposed to limitations that should be avoided.

Research indicates that it’s important to assess and treat ADHD communication issues early in a child’s life in order to avoid long lasting effects of low self-efficacy

(CBCL; Achenbach, 1991; Houck et al., 2010).

Self-esteem and self-concept diminish in a mediating fashion according to problems with peer relationship, school performance and social communication (Houck et al., 2010). Poor self-esteem includes maladaptive coping strategies, poor social skills, and communication abilities and diminished peer and familial relationships (Asherton et al., 2012; Hosain, Berenson, Tennen, Bauer, & Wu, 2012; Mrug et al., 2012).

Based on the uses and gratifications theory (Ruggiero, 2000), several studies have shown causal relationships between playing preferred video games, increased in self- esteem, and reported of positive emotional experiences (Granic, Lobel, & Rutger, 2013;

Russoniello et al., 2009; McGonigal, 2011). The Benefits of Playing Video Games showed Isabela Granic looking at neuroscientific research with rats. The research

31 examined the way that play fighting was shown to release chemicals in parts of the brain associated with highly social activities, and to promote growth and development in those areas. In her study she proposed that there may be a similar mechanism through which

MPVG, and play fighting experiences could improve social competence in children.

Improvements would be seen through dominance, self-identity, nurturance, and growth and would allow gains in cognitive, emotional, communicative, and prosocial skills

(Pellis & Pellis, 2007, Granic, Lobel, & Rutger, 2013).

Csikszentmihalyi describes the holistic sensation that people have when they are totally involved in a task as the flow zone. Being in “the zone” is a term used by gamers when the player loses all track of time, forgets external pressures and enacts their identity through the process of experiential communication (Nakamura & Csikszentmihalyi,

2002). Flow experiences involving CMC and MPVG have repeatedly been linked to positive outcomes through lessened anxiety, heightened self-esteem, deepened commitment toward achievement goals, and additional communication gains (Nakamura

& Csikszentmihalyi, 2002; Csikszentmihalyi, Rathunde, & Whalen, 1993; Granic, Lobel,

Engels, 2013).

Discrete Video Games

Study results indicate that it would be illuminating to compare measures and outcomes of the BPT 8-week group with the gamification tool Plan it Commander, a serious game designed as an adjunct treatment for ADHD children. Serious games consist of any meaningful use of digital resources which combine entertainment and gain of experience but whose central mission is not entertainment (Laamarti, Eid, Saadik, 2014).

Despite the availability of numerous evidence-based behavioral modification therapies psychologists often find parents unable to sustain these treatment interventions.

Since efficacy of such therapies dissipates once abandoned, researchers have begun to test new intrinsic engagement and adaptive treatments through computers and MPVG

(Rivero, Nunes, Pires and Bueno, 2015). Evans, Owens, Bunford, 2014; Pelham &

Murphy, 1986; Pelham & Hinshaw, 1992; Hinshaw et al., 1998). Plan it Commander is just such a serious gamification tool, specifically developed to help ADHD children with specific domains of time management, social skills, self-efficacy, and working memory.

In 2010 the Kaiser Family Foundation surveyed 2,000 children ages 8-18 and found children’s screen time totals an average of 7 hours and 38 minutes per day, with more than 53 hours per week being spent in front of media which adds up to more than a full-time job (S. Bean, 2015). Some parents and pediatricians find this statistic alarming and elevates concerns that media use is an addictive activity. This survey looked at why parents were drawn to media with parents concluding that they can’t imagine how they’d get through the day without it (Rideout, Hamel, 2006). A commonly reported reason for parents putting their child in front of a television or video game is to babysit the child

(Evans et al. 2011; Götz et al. 2007; St. Peters et al. 1991). According to research almost half of parents have stated that they use television, or VGP as a babysitter in order to benefit from the time their child spends in front of the device; i.e. accomplish personal goals (Beyens, Egger, 2014; Evans et al. 2011; Bentley et al., 2016).

The current landscape of new technologies and normative state of technological use was not available to the current generation of parents, making this uncharted territory.

In study after study parents express various levels of concern about the way technology

33 has permeated todays childhood (Plowman, McPake, Stephen, 2010). When parental attitudes are more closely examined, most parents view technology not as a threat but as a positive, and sometimes essential, part of parenting (Plowman, McPake, Stephen, 2010).

Addiction Tendencies: Motivation for Therapeutic Game Play

Studies have shown that ADHD children struggle with self-regulation regarding total amount of time spent in game play with possible gaming addiction concerns surpassing control groups (Turel, Romashkin, Morrison, 2016).

INTERNET GAMING DISORDER; “CONDITION FOR FURTHER STUDY”

1. Preoccupation or obsession with Internet games. 2. Withdrawal symptoms when not playing Internet games. 3. A build-up of tolerance – more time needs to be spent playing the games. 4. The person has tried to stop or curb playing Internet games, but failed to do so. 5. The person has had a loss of interest in other life activities, such as hobbies. 6. A person has had continued overuse of Internet games even with the knowledge of how much they impact a person’s life. 7. The person lied to others about his or her Internet game usage. 8. The person uses Internet games to relieve anxiety or guilt – it’s a way to escape. 9. The person has lost or put at risk an opportunity or relationship because of Internet games. Figure 5. DSM-5; APA, 2013

The World Health Organization’s International Classification of Diseases (ICD-

10), stated that participants who used digital or VGP to fulfill at least three of the six criteria of addiction could be classified as having a gaming disorder (World Health

Organization, 2018). However, there are no longitudinal studies of more than 3 years to determine whether gaming addiction is an acute but temporary problem or whether it shares the chronically recurring pattern of other addictions (Liu, 2014).

A number of studies that have found connections between obsessive online gaming and heightened anxiety, depression, neuroticism, aggression, appetite and sleep disturbances, as well as, lack of physical activity (Anderson and Murphy, 2003;

Charlton, 2002; Chumbley and Griffiths, 2006;Wallenius et al, 2007). There has also

34 been research that has associated excessive use of VGP with psychosocial issues like less peer engagement, poor daily satisfaction, and diminished academic performance

(Gentile et al. 2004; Skoric et al. 2009 Wang et al.2008; Rehbein et al. 2010, Lemmens et al 2001). Many other studies have found extremely positive associations with VGP like intrinsic motivation at high levels, joyful entertainment, creative outlets, improved physical motor skills, lowered stress and anxiety, educational, social, and/or therapeutic values, opportunities to explore new skills in a safe and controlled environment, knowledge of computer concepts, enhanced executive function and working memory, and CMC working to strengthen social efficacy and build friendship groups (Wan and

Chiou, 2007; Lim and Lee 2009; Thomas and Martin 2010; Griffiths 2002, Dickey

2011; Aldrich 2005; Papastergiou 2009). Recent research has looked at ways to use the addictive properties of MPVG’s as a tool to motivate positive use of game play in therapeutic and educational ways (Granic, Lobel, Engels, 2014).

Rooij el al.’s Video Addiction Test correlates hours per week spent gaming and video game addiction but did not establish an indicator of addiction that corresponded to an exact amount of time spent gaming (Rooij et al., 2012). Further studies are needed to determine video gaming’s causal relationship and psychopathology to addiction and other disorders (Carli et al., 2012; Liu, 2014).

The Communication of Rewards in the ADHD Brain

A new systematic review in the publication Frontiers in Human Neuroscience looked at 116 studies, including 22 that examined how playing video games led to structural changes in the brain. The ways in which video games affect attention is one of the most well researched areas, with studies showing heavy gamers being able to sustain

35 longer sessions of attention to demanding tasks with less activation (Palaus, Marron,

Viejo Sobera, Redolar-Ripoll, 2017). Additional studies show correlations between game play and improvements in sustained or selective attention, which is of particular interest regarding VGP therapies for ADHD children (Palaus, Marron, Viejo-Sobera, Redolar,

Ripoll, 2017). Palaus et. al, summarizes that VGP can change:

“…virtually all parts of the brain…such as fibers connecting to the visual, temporal, and prefrontal cortices, as well as the hippocampus, the thalamus, and fibers connecting the basal ganglia …(and can)… increase the size and efficiency of brain regions related to visuospatial abilities skills used to navigate and perceive where objects are in relation to each other, and cause changes in prefrontal areas linked to improvements in cognitive control related functions, particularly working memory and communication, while whole brain activation patterns can be used as a tool to predict skill acquisition rates, both long term gamers and volunteers were showed to have an enlarged right hippocampus following video game play” (Palaus, Marron, Viejo-Sobera, Redolar-Ripoll, p. 33, 2017).

Other areas of the brain that respond to video games is the reward system activation pathway, which causes the release of dopamine (Hale, 2017). Dopamine is a large player in the motivational component of reward-motivated behaviors. Excessive

VGP can alter the way the brain processes rewards and create neural changes similar to those of people suffering from gambling or drug addiction (Hale, 2017). These studies have linked addiction research to obsessive VGP, especially multiplayer online games

(Hale, 2017). One of the lead neurological researchers, Marc Palaus, was quoted as saying,

“We focused on how the brain reacts to video game exposure, but these effects do not always translate to real-life changes…it’s likely that video games have both positive (on attention, visual, and motor skills) and negative aspects (risk of addiction) and it is essential we embrace this complexity” (Wood, p. 2, 2018).

The effects of VGP on brain regions is still in its infancy.

A 2018 report from The Entertainment Software Association (TESA) showed that more than 150 million Americans play video games and 60% of Americans play video

36 games daily,. Seventy percent of parents said that video games were a positive part of their children’s life (Theesa.com, 2018). Parents of ADHD children wondered why their children, who couldn’t sit still in any situation, could sit transfixed for hours in front of a video game. No studies have linked causality of game play with ADHD or with the more maladaptive symptoms of ADHD.

Video games may be more gratifying for ADHD children because their dopamine reward circuitry may be otherwise deficient (Klass, 2011). With VGP, ADHD children are able to have sustained attention while activating multiple areas of the brain at once.

The video game provides a shotgun blast of stimulation and engagement, followed by intermittent rewards.

Studies using game-based learning methods have promised an instruction tool that can strongly engage inattentive, restless children and might increase executive function and focus while reducing hyperactivity (Houghton et al., 2004 Mautone et al., 2005;

Raggi & Chronis, 2006; Ota & DuPaul, 2002, McClanahan, 2012; Veenstra et al., 2012;

Fabio & Antonietti, 2014; Xu, Reid & Steckelberg, 2002).

Much research has examined the addictive and negative impact of video games on childhood achievement. (Skoric, Teo, Neo 2009). However, recent studies have looked at ways in which video game players exceed non-players in tested communication measurements of problem solving, visual search accuracy when distracted, spatial attention, hand-eye coordination, and reaction time (Grayson et al., 2006).VGP has been shown to create optimal cognitive function in ADHD children by improving attention due to single task hyper focusing, creation of inhibitory control, and generation of a

37 continuous heightened arousal state that increased motivational performance both inside and out of the digital world (Thiago, Nunez, Pires, & Bueno 2015; Rivero et al., 2015).

In their paper ADHD rehabilitation through video gaming: a systematic review using PRISMA guidelines, 14 empirical studies focused on gains in neuropsychological intervention and rehabilitation, as related to game use, and the ability to transfer those gains to non-digital life abilities (Rivero et al., 2015). The positive effects of VGP as a motivational and implementation tool in ADHD rehabilitation programs faces some limitations based on scarce literature (Rivero et al., 2015).

Brain-computer-interface 8-week clinical trials showed that the ADHD child’s brain could be ‘rewired’ or ‘renormalized’ to regulate attention through a brain-computer interface-based video gaming system called ATENTIV (Beverly, 2018). Scott Kollins,

PhD, Professor of Psychiatry and Behavioral Sciences at Duke School of Medicine and

Director of the ADHD Program, stated that “this new imaging study provides provocative preliminary evidence that changes in attentional functioning in ADHD patients as a result of treatment with the ATENTIV Game is mediated through neoplastic processes”

(Beverly, p. 2, 2018). These findings are an important step toward better understanding the mechanisms underlying these new approaches to improving ADHD communication competencies.

Children whose brains are seeking out neurochemical rewards are drawn to activities that provide it. Those with social issues and anxiety can find connection through screen mediated relationships, and those who struggle to learn in a traditional classroom are given opportunities to excel when taught in a virtual world. The

38 combination of initial positive research regarding VGP as a rehabilitation possibility, makes for exciting future research possibilities.

The Good, the Bad … the Useful - Commercial Video Games

Open sourced, sandbox, multiplayer video games, such as Minecraft have become synonymous with the childhood experience of play. Children form identities around the habitual use of these social CMC devices. By comparison, a discrete game lacks the social agency and ability for identity formation of playing a game that is wildly understood and popular among peers. The fact that these games exist outside of the in- group dialogue surrounding commercial, mass-produced games could lessen willingness and motivation to engage in play (Barr, 2016). Transformational play and BBT support the idea that identity formation and social agency could be strengthened by choosing a child’s preferred commercial MPVG as the support modification vehicle. Use of favored commercial games could engender increases in motivation of use and in far transfer effects related to game play gains.

Barr’s work demonstrated that playing commercial video games could have a role as a therapeutic support tool (Barr, 2016). This research is significant. The two main

ADHD gaming trials used unique, discrete, non-commercial video games. When compared to mass produced, commercial video games that help form collaborative and relational identity possibilities, it’s possible that these discrete games will lack collective agency and legitimacy. ADHD children rely on the collaborative identity that they achieve by sharing knowledge and narratives associated with popular commercial video games. Additionally, the social currency of existing commercial multi-player games

39 drives children’s motivation, through competition, collaboration, nostalgia, cooperation and goal fulfillment in multiple communication competence domains (Barr, 2016).

CTI research has examined studies of commercial VGP as having potential for increased social benefits in terms of developing closeness, friendship, and belonging through CMC (Hinkhoj, Lieberoth, & Misfeldt, 2018). This research examines the ways commercial game architecture can be used in the development of educational games to garner initial focus and inclusion of at risk-students, while establishing goals that the children are motivated to achieve (Stewart, Bleumers & Centeno, 2013).

Goal setting theory is the most influential framework in motivational psychology.

The work of Hanghoj et al was used by the Nebel, Schneider, Schledjewski, and Rey study on goal setting. This study raised the questions of how to utilize motivation and optimize the instructional elements of gameplay for goal-based learning (Nebel,

Schneider, Schledjewski, & Rey, 2016, Hanghoj et al., 2014). The researchers used the sandbox commercial game Minecraft as a content creation educational tool through which to compare different goal types. Minecraft was used because of the three advantages it had over other content creation methods, see figure 6 for examples of these advantages.

MINECRAFT IN EDUCATIONAL GOAL BASED MOTIVATION STUDY

1. Ease of use and ease of creating and modifying content 2. Open sourced easily adaptable code 3. Ability to create a training course in months compared to developing new game design, which can take years

Figure 6. Minecraft Study; Nebel, Schneider, Schledjewski, & Rey, 2016

As the learners played Minecraft they were able to transform their role from player to programmer and back again. Players were able to take an active role in the construction of logic circuits and collaborative communication with other players. In

Minecraft there are no instructions or guidelines to the game. New learning research through the forum of Minecraft has the ability to involve active forms of communication, learning, exploration, creation, and reflection.

Video game play occurs in a complex and potentially distracting environment but keeps players focused through the use of goal setting attributes. This makes for a promising mechanism for directing attention and motivation toward relevant goals

(Nebel, Schneider, Schedlowski, Rey, 2017). Students with ADHD struggle in many domains that can be assisted through the gains in interactive purposeful game play, particularly shared commercial MPVG play as is shown in figure 6 below.

SUMMARY OF SPECIFIC POTENTIALLY ATTRACTIVE COMPONENTS IN MPVG’S AND THEIR POTENTIAL USE FOR WELLBEING

Figure 7. Summary of specific potentially attractive components in MPVG’s and their potential use for wellbeing; Granic, Lobel, Engels, 2013.

Playing in the Sandbox and Building Identity

“Many games, such as Minecraft, are better described as electronic places to visit than traditional video games, but in the process of interacting with them, we create experiences, which in turn become our narratives and stories.” (Robert B. Marks, CGMagazine, 2017) Minecraft and Roblox are sandbox video games with no set instruction. Sandbox means the game has minimal character limitations which allows the player to roam, select tasks, create narratives, and endlessly change the virtual world. The multiplayer feature of sandbox games means that virtual worlds and societies exist simultaneously within the game creating vast social opportunities for communities of players in the form of organizations like guilds, cities, or clans. This lack of formal instruction for play forces

42 players to communicate game play knowledge with one another, and to utilize blog posts and YouTube channels in order to facilitate advancement of game play.

Minecraft enables players to explore and share resources, while building endless worlds out of 3D cubes. As Roblox is a relatively new player in the sandbox world, there exists little research surrounding it. The research regarding Minecraft will therefore be utilized as an example of how sandbox games can be useful tools.

Minecraft can be compared to a three-dimensional, procedurally generated, virtual

Lego world. The game has no rules and the player learn through collaborative play with each other. Learning and game play advancement also happens via creative problem solving, and by watching YouTube videos or reading online postings of strategies other players have learned. Some basic information can also be gained from books and magazines published about Minecraft. Minecraft is a collaborative and cooperative game that demands creativity, exploration, resource gathering, problem solving, spatial awareness, organization, reward delay, planning and sometimes combat.

Minecraft has been used for several years as an educational tool for topics as varied as geometry, storytelling, literacy, sustainability, chemistry and project management with many other educational, collaborative, goal oriented possibilities yet to be researched (Short, 2012; Bebbinsgton, 2014; Martinez, 2014; Saito, Takebayashi &

Yamaura, 2014; Hanel, 2013). Mojang, the video game developer of Minecraft, supports the interest in educational and therapeutic research that has surrounded the game. Mojang has developed a teacher-friendly version of the game with easier to modify codes and creation tools for virtual assessments.

Minecraft is an easily to modify game with a basic structure, and communication opportunities across expansive global player communities which are connected through numerous blogs and YouTube channels. Players use these communication forums to explore and implement use features while crafting then recrafting identity narratives. The open source Java code allows educators or players to rewrite source code, all of which make this game unique as a research vehicle when compared to other games that lack ease of adaptability and extended player support resources (Nebel, Schneider & Rey,

2015). The modification friendliness of the Java application might make Minecraft the easiest way to customize collaborative reward based experimental research. Through this research users can share content, modify that shared content, and create opportunities to learn through playing, through creating, through teaching others, and through working collaboratively (Nebel, Schneider & Rey, 2015).

Research has already demonstrated that when basic real world, social based, consequential rules were established within the game of Minecraft such as; “If you break it you fix it,” “Make the world beautiful,” “Don’t damage other people’s belongings” and

“Work together and get along,” then the virtual world of incentivized collaboration and relationship building was more often actualized in analogue/real world outcomes

(Wendel, Gutjahr, Battenberg, Ness, Fahnenschreiber; et al. 2013). These findings are particularly helpful in terms of moderating the impulsive and often disruptive communication instincts that are well documented in ADHD children’s social interactions.

BBT has shown that increased positive play experiences builds personal growth, as measured through improvements in self-efficacy, and expansive worldviews,

44 belongingness, social expansion and identity formation. Theoretically, this creates the opportunity to mediate historically negative behaviors and social outcomes via the use of

MPVG to explore identity construction and transform learning potentials.

Commercial Video Game Communication Intervention: A Wearable Gamification Communication Modification Device (WGCMD)

Digital treatment interventions, particularly on mobile devices, could potentially increase access to treatment at reduced costs. These interventions could simultaneously increase compliance via improved child motivation.

Given that there is still some parental concern about the addictiveness of VGP, particularly in the ADHD child population. This study seeks to qualitatively explore what parents think about their child’s communication behaviors within VGP. How willing are parents to overlook negative VGP association, and personal fears about addiction, in order to engage in game play in potentially therapeutic and positive way. Parents historic, current, and potential use of behavioral modifications and willingness to try a commercial video game-based intervention was also inquired about. What parents felt about their child’s relationship to VGP was of interest, in addition to the question of whether or not

VGP increases or decreases parental stress levels. The positive versus negative experiences of parents with regards to their child’s use of MPVG was also explored.

These perspectives are thought to inform the willingness of parents to use the WGCMD.

This research has conceptualized a WGCMD to assist in ADHD children’s communication competence impairments in multiple domains. The device would be wearable and similar to Fitbit, with tasks that could be added to by the parent or teacher.

The WCGMD would link tasks to timers and the device would vibrate to warn the user if

45 their time allowance is about to elapse. For a prototype of the WCGMD see Figure 8a, 8b and 8c.

WGCMD WGCMD TASKS VIEW APP VIEW PROTOTYPE SCREEN FOR CHILD FOR PARENT ON SMARTPHONE

8a. Prototype 8b. WGCMD 8c. Tasks view/child & App view WGCMD Screen Smartphone/parent WGCMD; Mattox, Sardanda, 2019

The child would pick an avatar and a leveling up screen that would personalize the device see Figure 9.

WGCMD SAMPLE AVATAR

Figure 9. Sample avatar using Mario character; Mattox, Sardana, 2019

With each successful goal met, the avatar would move closer to leveling up and the child would move closer to acquiring their digital reward of time allowed for MPVG.

Once they reach a certain level they also acquire their actual digital in-game object

46 rewards (ex. diamond sword, TNT, dragon egg in Minecraft). The program would be shareable through an app, so that it could be used by teachers or afterschool caregivers.

The tasks, time management, communication behaviors, academic expectations and goals, would be communicated between parent and child and updated weekly. Daily and weekly time spent in game play and digital rewards goals (ex. a sword, pick ax, TNT in Minecraft ) would be established by the parent and child each week and would link to the child’s favorite commercial multiplayer game. For the sake of this concept this research uses the game Minecraft.

If the children began to get off track regarding time management, or other task/communication expectations, the device would vibrate to warn the child that they are about to lose points, or level down. Successfully managing goals and expectations would allow the children to gain time for VGP ( at a later pre-established time) and achievement of digital object in-game rewards. When the child reaches a specific level, they are able to level up and access their digital reward (ex. put a dragon’s egg into their chest).

The device communicates to the child when a gaming friend levels up and gains new digital reward items. This enables the social and competitive aspects of game play to be capitalized upon and to motivate the child to work harder and level up themselves.

Through a smartphone app, the parent can control who their child links as a friend, for an example see figure 8.

APP TO ADD FRIEND TO WGCMD

Figure 8. View of App allowing parents to add friends; Mattox, Sardana, 2019

The WGCMD is conceptualized to be sharable with tablets, computers and gaming systems. Rewards would be transferred from the device into the third places of the game. The user would not be able to play the actual video game that they are gaming time toward on their wearable device.

Children would be able to control the time they were able to spend in VGP through the management of their communication behaviors. The self-regulated motivation for rewards of time in game play and digital rewards would become synonymous with behavioral gains. This is anticipated to improve conflictual communications between parent and children regarding adherence to behavioral expectations and allowed time for VGP.

The socially cooperative and competitive aspect of peer interaction is anticipated to increase motivation, and provide for child led improved executive function, time management, increased goal setting, and decreased disruptive behaviors/communication within digital and analogue environments. Other anticipated increases that are expected are improved communication competencies correlating with decreases in parental stress.

Research Question 1

How do parents view their child’s communication within multiplayer video game play and the relationship of VGP to peer relationships?

Research Question 2

What value do parents perceive multiplayer video game play to have in relation to their child’s experience of identity and self-efficacy?

Research Question 3

What are parent’s thoughts about addiction potential in multiplayer video games, how willing are they to let their ADHD child use the conceptualized WGBCD, what are their opinions regarding motivation of use, and positive or negative potentials for communication moderated outcomes?

The following charts illustrate connections made in the literature review (see 6a-

6d). Chart 6a illustrates the issues of ADHD as it relates to negative outcomes in behavior regulation, peer problems, academic problems, problems of reciprocal play, belonging, self-efficacy, and parental stress. 6b illustrates parent-led communication modifications programs and how these programs affect the various domains in the short-term and how long-term effectiveness over time influences the same domains. Chart 6c examines using discrete games as behavior modification interventions and how use of discrete games affects the various domains in short-term. Anticipated long-term effectiveness over time

49 is shown regarding how it influences the same domains. Chart 6d. shows the use of commercial multiplayer video games as behavior modification intervention.

It shows how these interventions affect the various domains in the short-term and how long-term effectiveness is anticipated to influence the same domains over time - behavior regulation, peer problems, academic problems, problems of reciprocal play, belonging, self-efficacy and parental stress.

ADHD COMMUNICATION COMPETENCY PROBLEMS AND PARENTAL STRESS

Figure 10a. ADHD Communication Competency Problems and Parental Stress; Mattox, 2019

PARENT-LED COMMUNICATION COMPETENCY MODIFICATION

Figure 10b. Parent-Led Communication Competency Modifications; Mattox 2019

DISCRETE GAMIFICATION COMMUNICATION COMPETENCY MODIFICATION

Figure 10c. Discrete Gamification Communication Competency Modification; Mattox 2019

COMMERCIAL MULTIPLAYER SANDBOX GAMIFICATION COMMUNICATION COMPETENCY MODIFICATION

Figure 10d. Commercial Multiplayer Sandbox Gamification Communication Competency Modification; Mattox 2019

METHODOLOGY

Overview of Study

The present study explored parent thoughts regarding their ADHD child’s communication competency while playing multiplayer video games. The research was also interested in parents feelings about the addictive nature of video game play and how, or if, it related to their child’s game use. Parents willingness to utilize the obsessive desire ADHD children have for video game play was explored. The likelihood of parents to utilize the addictive tendencies in game play as an intrinsically motivating tool was a driving question. Parental perceptions of whether children might be able to increase motivation and self-regulate their problems of communication competency if behavioral gains were tied to time allowance in VGP and rewards in shared game play was examined.

A qualitative research approach was chosen in order to richly explore, illuminate, extrapolate, and contextualize the complexity of parental thoughts about ADHD children’s enacted experiences of identity in VGP as framed through the communication theory of identity. Parents thoughts and feelings about their child’s use of VGP, and VGP contribution to parental stress was examined, as were the child’s relationships with experiences of reciprocal play, belonging, and self-efficacy.

The researchers experience with the issue of ADHD and MPVG was illuminated through existing research involving VGP and the theoretical frames of positive psychology theories BBT, Flow, and Transformational Play. A behavioral modification was conceptualized that would link rewards in MPVG with a wearable task list, behavioral expectation device. The device is conceptualized to be an engaging,

54 motivating, socially inclusive, video game communication competency intervention. This concept was found to be supported in the literature. The research looked at how likely parents would be to allow their child to use the MPVG wearable device as a behavioral intervention tool, and what, if any, were hesitations regarding use.

To study these issues data was drawn from questionnaires, interviews and parent support group Facebook data. A questionnaire was administered to parents, or caregivers, between the ages of 18 and 64 who had ADHD children that engaged in multiplayer video game play. The questionnaire was used to connect themes and theoretical concepts across parental experiences of their children’s video game use (addictive, supportive, dysregulating, social/identity support, stress producing or relieving), and how the children’s level of impairment impacted s perceptions of self-efficacy, peer relationships, and family dynamics. Ten in-depth interviews were conducted, and Facebook ADHD parent support group chat room data was collected during the 5-week date range of the study. The questionnaire was posted in Dr.’s offices, and in coffee shops, was distributed through schools, and was posted online. The availability of the questionnaire gave mothers and fathers of any race equal opportunity to participate. However, the majority of participants were white mothers. Future research should account for this participation bias and should target populations to expand diversity.

DATA COLLECTION

A multiple method approach was chosen for this study using qualitative analysis of questionnaires, interviews, and Facebook parent support group data. Interview participants were recruited using snowball sampling methods (Network Sampling).

Limited resources, and time constraints made random sampling of parents of ADHD

55 children unfeasible for this study. The questionnaire was distributed, and Facebook chat data was collected throughout the duration of the approximately 5-week study.

Participants were parents or caregivers between the ages of 18 and 64 of at least one

ADHD child who played MPVG. Future research should use true random sampling.

A questionnaire was created to explore parent’s perceptions of their children’s central ADHD behavioral and communication issues, their parental stress, and their child’s relationship to, or possible addictive use of, VGP (Appendix, B). The Conners

Comprehensive Behavior Rating Scale, The Vanderbilt ADHD Diagnostic Rating Scale, and the Weiss Functional Impairment Rating Scale were used to generate questions that reflected the phrasing and language that these valid and reliable scales used. Those scales provided insight into parent assessment of the most problematic behavioral and communicative issues experienced by children. These results were examined for relationships and themes linking behaviors, parent stress, game play use, self-efficacy, social agency, peer relationship and identity formation/social support to game play.

Questions to help understand the level of stress parents experienced and how that stress informed or is informed by the child’s problematic behaviors were based on the phrasing and language in the Parental Stress Scale and the Perceived Stress Scale, both valid and reliable measures. Lastly, an adapted version of the Perceived Video Addiction

Scale was incorporated to contextualize how parents viewed their child’s relationship with, and use of, VGP. Open ended questions were incorporated into the questionnaire to collect more in-depth data. Scope of research and data collection tools were submitted to the IRB for approval.

Data was collected and analyzed from three separate sources, questionnaires, interviews, and Facebook ADHD Parent Support Groups, in an effort to establish consistency and confirmability which Cypress equates to reliability and validity in the article Rigor or Reliability and Validity in Qualitative Research: Perspectives, Strategies,

Reconceptualization, and Recommendations (Cypress, 2017).

A Facebook page was created on which the questionnaire link was posted, and

Facebook Parent ADHD support groups were directed to the link through chat posts. It was also distributed to multiple ADHD psychological support groups, to teachers and to the IEP counselors at The Arts Based School and The Downtown School. A flyer inviting interview participants was posted at local coffee shops, in the lobby of Robinhood

Pediatrics, and in the lobby of Sloan Academics in Winston-Salem, N.C.

Interviews were conducted to further explore and understand parental thoughts and opinions of video game use. VGP use as a potential therapeutic behavioral tool and any previous experience with behavioral modification programs (frustrations, gains, effectiveness) were examined.

The questionnaire collected basic demographic data to determine moderating influences of parental stress such as, single parenting, support systems, work pressures, additional special needs children, and co-existing diagnoses. It also asked for a baseline of current weekly hours of VGP, although inconsistencies in open ended responses seemed to indicate response bias reporting in that question field.

The questionnaire rated the level and type of ADHD behaviors that most commonly occur; the level of disruption associated with those behaviors; academic and peer relationships; self-esteem; social anxiety issues; and relationship to VGP

(ex. calming or agitating). The parent was asked to check all behavioral modifications they had used with their child and to describe which modifications worked, which didn’t, and why. The next section of the questionnaire sought to establish levels of parental stress and levels of perceived parental stress.

Open ended questions were used to glean more in-depth information about VGP in general, parental perceptions of their child’s use of VGP, and how VGP related to parental stress. Parents analyzed their child’s tendency to engage in obsessive or addictive VGP and assessed their child’s positive gains and negative relationship to video game play. Data collected from the questionnaire was based on the personal responses each participant answered in Qualtrics with regards to demographics.

The questionnaire asked which technological aids, specifically designed to support ADHD behaviors, were currently being used and how likely parents would be to use the conceptualized technology WGCMD. The WGCMD was described to all parents and discussion followed regarding thoughts, hesitations, and likelihood of use. Some people who completed the online questionnaire also participated in the interview.

Interviews were conducted over the phone and then analyzed. The interview and demographic questions included all possible questions that might be asked, so that assessment of questions could be approved through the IRB process (Appendix C, D).

Of the 10 interview participants, two were 50-year-old fathers, the rest were women who ranged in age from 28-56. If the participant completed the questionnaire, duplicate interview questions were not asked. ADHD behavioral issues, behavioral modification use of VGP, parent stress levels, ADHD apps and games, WGCMD were all explored. All identifiable details were deleted from the data.

Facebook data was taken from parental support groups during the 5-week period of data collection. Thread topics were gathered according to the following themes; peer relationships, communication concerns; language and reading issues; behavioral modification suggestions; video game use; addiction in relation to video game use; parent stress; home disruptions; reciprocal game play; and in-game identity.

This study allowed for further understanding of the communication problems facing ADHD children and parents, and parental thoughts regarding their child’s relationship to VGP. Parental stress in relation to VGP and in relation to VGP and addiction, and parent assessment of effective and ineffective communication and behavioral modifications were explored. This research then assessed parental thoughts regarding the likelihood to use the WGCMD concept.

Demographics

A total of 77 questionnaires were completed by parents of ADHD children.

Within this sample 4 respondents were male, 3 were fathers and 1 was a grandfather, the remainder, with the exception of one caregiver, one stepmother, and one grandmother, were female mothers. The majority of participants were white, with the exception of two

Asian women, and one Hispanic woman.

To understand answers to the questions regarding stress, additional stressors were determined including co-occurring diagnoses, work demands, relationship status, and provided support. Almost half of the children had co-occurring diagnoses. Anxiety and dyslexia were the most prevalent comorbidly occurring diagnoses. Married participants made up the bulk of the population at 58 participants. Forty-five participants worked full

59 time outside of the home, 17 worked part time and 16 didn’t work. Friends and family provided regular help with childcare to 42 participants and 35 received no help.

With regards to video game play, almost half of the participants described their child’s relationship to video game play as obsessive, addictive, highly addictive, or attached. Only two participants reported use of ADHD intervention video games or

APPS, both were Chore Monster. Both participants reported that the APPS were ineffective. When asked how likely parents were to try an ADHD game or APP, almost all participants responded that they were likely to try them. Of the listed behavior modifications, almost all participants listed the use of taking away electronics as the most effective behavioral control. Timers, checklists, and sticker charts were the next most popular modification, followed by cognitive therapy and time outs. Taking away electronics was stated as being the most effective, with many people saying that nothing really worked for long.

The majority of participants reported that their child spent more than 7 hours a week involved in VGP. Cross analysis of multiple-choice answers regarding VGP, with open ended question responses, indicated that the 1-2 and 2-3 hours spent in game play self-report multiple choice answers might be skewed due to response bias. Respondents were fairly evenly split regarding whether their child was taking medication for ADHD.

This study built upon the literature review which discovered a gap between new discrete video games - designed to be behavioral therapeutic interventions for ADHD children but lacking in shared peer and communal social agency - and emerging research on commercial multiplayer video games - exploring how the addictive nature and social engagement of popular, commercial games could inspire and drive motivation of use as a

60 therapeutic intervention. Discrete lab generated games have limited production and lack the in-group popular draw and shared narrative engagement experienced through the use of mass-produced commercial video games, like Minecraft, Roblox, or Fortnite.

Commercial video game use as a powerful motivational tool, informed and guided the second gap. Research also explored a gap in the literature regarding parents thoughts and feelings about the addictive nature of commercial video game play and the potential for that same obsessive need for shared belonging within controlled commercial game play to be used as an intrinsic motivation device to potentially guide ADHD children toward self-regulation of their communication competency issues. The study gauged parental willingness or unwillingness to use game play therapeutically and examined whether willingness was related to fears of addictive gaming tendencies, or patterns of addictive tendencies. Parental perceptions of game play and its relationship, if any, to parental stress was also examined. Interviews more deeply explored parental stress, parent perceptions of their child’s relationship to video game play, feelings surrounding potential for gaming addiction, and how willing they would be to exploit those addictive tendencies in a positive therapeutic manner.

The communication theory of identity (CTI) served as a theoretical frame. CTI

“posits that individuals internalize social interactions, relationships, and a sense of self into identities through communication. In turn, identity is expressed or enacted through communication. In other words, the relationship between communication and identity is reciprocal” (Hecht, Choi, pg. 139, 2014). The theoretical framework of CTI was used to examine parents perceptions of video game play in relation to their child’s sense of self or personal identity; social connection or relational identity; agency or communal

61 identity; and communication through game play or enacted identity. The following propositions are ways to further use CTI as an analysis tool see Figure 7.

COMMUNICATION THEORY OF IDENTITY PROPOSITIONS

Figure 12. Communication Theory of Identity Propositions; Hecht, Choi, 2014

RESULTS

A qualitative analysis identified and examined ideas and assumptions which informed the content of the data. Inductive inference, and CTI framing was used to observe patterns and generalizations about identity, social agency, belong, self-efficacy, peer relationships, relationships to the identity inherent in game play, parent stress and social connection through game play.

Research Question 1

How do parents view their child’s communication within multiplayer video game play and the relationship of VGP to peer relationships?

The data showed that parents viewed MCVG play as a positive mediator for social engagement through increases in belonging as indicated through responses equating their child’s relationship to video game play as “part of the group” and “feels like one of the kids”. Gains in belonging allowed for relational identity formation via the collaboration of other children engaged in social game play. Communal identity formation was achieved through the children’s association with sharing of gaming core symbols (creeper t-shirts, slang terms, “there’s never too much coal” or “derpy”, in-group knowledge, Stampylongnose, PopularMMOs & DanTDM youtubers). Reduced feelings of isolation were equated with positive responses on the questionnaire of “more successful social interactions when playing video games than in other types of play”.

Increased feelings of communication competence and self-worth were shown by higher parent reports of physical control and focus while their child engaged in game play.

These nonverbal controls showed identity being performed through appropriate and

63 effective communication. Sibling communication conflict was eased by participating in game play through turn-taking and social cue adoption. Safe and controllable third places identity allowed identity to be formed through expectation and motivation as was shown in the video game section of the questionnaire. Decreases in social anxiety paralleled increases in time spent in game play, as well as, reported feelings of inclusion and self- efficacy increases which emergence from the game world. Gains in real world spaces were reported by parents through self-efficacy and belonging questions. These interpersonal relationships within digital landscapes could be viewed as the communication process of embodied identity

Social engagement was defined in the questionnaire as time spent in MPVG, feeling socially connected when engaged in MPVG, and in the interviews through descriptions of gaming friendships and how they differed from experiences of peer impairments in school and after school activities. A commonly recurring theme in the

Facebook data was social isolation, peer difficulties, parent worry, stress, and sorrow. In two separate groups, parents reached out to other parents in an effort to establish friendships for their children around MPVG.

“What do parents think about penal sort of friends but playing video games together? My son gets so much joy out of playing video games, but he doesn’t have many people to play with and I won’t let him go online and play with strangers. It seems like this would be a safe place to ask parents if their kids play the same games, he likes Fortnite, Minecraft, Roblox, and Terraria and we have a PlayStation. Breaks my heart that my son is by himself so much of the time, he’s a sweet kid. Not interested in sport because he’s not aggressive. He’ll be 11 next month. PM me if you’re interested or reply in this thread and maybe we could get a hole group of kids to play together.”

“I have an idea for other gaming families. If you have a child that doesn’t have many friends and they need friends to play video games with (online) please post age and what type of system, they have below. Let’s try to match kids up to play in THIS group. Does anyone’s child need an online virtual gaming buddy? Comment blow and watch the comments so we can try to pair them up.”

All interview participants said that their child experienced peer relationships issues of varying degrees, from bullying and social isolation, to only having a few friends. When asked more about communication problems in peer interactions the following were reported as being most problematic; blurting, poor social cues, inattention in social exchanges resulting in off topic responses, problems with taking turns, has difficulty playing quietly and nonverbal issues such as standing too close, speaking too loudly, touching or leaning or bumping into people. Less often communication issues that were reported were; hitting, deliberately annoying other people, rigidity with regard to subjects or game play or social expectation. When asked about peer relationships in MPVG responses were almost across consistently positive.

“She has trouble making friends, kids can be cruel. She is shy at first but when she gets relaxed, she’s an entirely different child. She loves to play video games with her friend. I think she takes pride in knowing a lot about games like Roblox and Minecraft. Her friend is always amazed by how much she knows. She likes Roblox but I worry because she can play with strangers and I don’t like not being able to really control who he is going to interact with.”

“When he got his glasses things at school got even worse, little assholes. I’d teach him kick somebody’s ass, but it wouldn’t do any good, he’s not that kind of kid. He did this camp last summer at his day care sort of place and they learned , I don’t know, how to do things, change things in his Minecraft game and he loved that. He met this kid there and they still play together, through the computer though, all the time. It’s good that he met that kid and I got him this headset and can hear them talking about stuff they’ve learned, it’s good for him. And ya know computers ain’t going anywhere anytime soon so it’s good for him to be interested in that kind of thing.”

The majority of questionnaire respondents reported at least occasional communication impairment in the fields of making and keeping friends, having problems getting along with other children, and having difficulty with parties (not invited, avoids them, misbehaves). Those who reported less communication impairment in peer relationships also typically reported that their child rarely or sometimes had more

65 successful social interactions when playing video games than in other types of play, and that their child only sometimes felt socially connected when playing video games. These variations show the ways in which identity was formed through enduring and changing processes. Children with more extreme behaviors and peer relationship problems had responses that were always, often, and very often. Even when those social domains had reported only sometimes or rarely to statements regarding social gains in VGP parents tended to answer often or very often to “My child forgets their problems when playing video games”. Something about the phrasing or the questions about overuse of VGP surrounding the statement “My child has more successful social interactions when playing video games than other types of play” meant that it was more frequently reported as rarely or sometimes when the similar statement of “My child feels socially connected when engaged in multiplayer video game play” would be reported as often or very often.

Results showing frequent and chronic communication problems with peers, getting into trouble more often than other children, and feeling lonely correlated to social connection, increased self-esteem and confidence in VGP all indicated positive relational and communal identity formation through the process of video game communicative play. There were some responses within Facebook posts that started with complaints of addictive or highly problematic VGP. In these threads parents reported that their child was increasingly socially isolated due to their game play use. Within the context of a stream of comments regarding the negative nature of VGP there were complaints that the entirety of their child’s social communication and friendships existed within the third places of their game play worlds and that they were isolated from real world engagement and connection.

“It has been a great motivational tool and I like the imaginative/creative aspect of it. However, it frightens me to see how his interest in this game has quickly turned into an obsession, and how isolating it is becoming for him, all his friendships seem to revolve around the game.”.

This in-group social world digital identity was expressed as CMC and defined though membership in that digital community. When asking parents whether they felt that VGP offered friendships and a sense of identity and belonging to their child through a stand- alone Facebook post, discussion changed tracks and proceeded positively with statements like, “My son loves making friends while playing!” and “It definitely helps my son socialize more than he can at school for sure”.

The themes within the data was that MPVG was perceived by parents as a helpful tool working to enable children to feel more connected, to communicate more successfully, to build friendships, to share identity and to experience belonging. There are cases in which parents feel that the defined membership identity expressed through shared core symbols was isolating and addicting. This substantiated the existing CMC literature that showed the anonymity of CMC helped to increase successful social interactions when dealing with dysregulated communication competence, as well as, the reward response literature that explored video game play as more addictive for ADHD kids. The reports of isolation were related to the fact that children relied solely on CMC for positive communication interactions, this means that parental controls must act as a gatekeeper for total time children engage in game play. This result support the need for the WGCMD as a child regulator intervention that feeds off game play motivation desires. Data indicated support that parents would view multiplayer video game play as a positive communicative and social mediation to help increase associative identity, belonging and self-efficacy.

Research Question 2

What value do parents perceive multiplayer video game play to have in relation to their child’s experience of identity and self-efficacy?

In interviews, parents reported that their child felt positive identity formation through communal association with video game. This was reported through discussion of the purchasing clothing and other identifiers, backpacks, stickers, hats, water bottles, that communally connected their child to their video game of choice. The use of these core symbols creates semantic identity prosperities that can work conversationally with children who share the meaning of the symbols and labels. One parent stated;

“I don’t really spend a whole lot on my kid’s clothes. Target is sort of a splurge. I tend to shop sales or buy lots at the start of a season on eBay because they grow out of everything so quickly. Well, I mean, the one place I do spend is on Minecraft and Star Wars t-shirts and stuff for my son. He has a hard-enough time at school, so I want to give him, you know, the new cool YouTube blogger shirt or something, that little advantage. I find them on this online site and, yeah, they are more than I would typically spend but when I take him to school, a couple of times now, I’ve noticed some boys saying “Cool - DanTDM” or other things about his shirt or whatever to him and that makes it worth the, I don’t know, 10 or 15 dollars.”

Another parent discussed the associative communal value of shared identity by sharing;

“I get my son a new Minecraft backpack at the start of the school year, even though he could still use his old one. I got my daughter one too. She likes Minecraft, not as insanely as her brother, but she likes it. They actually get along when they play together and it’s the only time her brothers friend includes with her. I think it’s good for her, maybe she will get more interested in STEM. (laughs) Start with the backpack and work backwards.”

Sticker charts were a very popular way to track and communicate positive behavioral gains with many parents describing use of Minecraft, Fortnite, Angry Birds stickers as a way to motivate their child to stay on task. Taking away electronics was the

68 top punitive response to dysregulated behaviors which again supports the findings that addiction could be harnessed’ for positive gains. The obsessive desire for engagement with and through video game play makes it a perfect tool to for children to self-direct communication competency impairments and actualize gains. Communication skills of body control and awareness were shown to be vastly improved in game play with hand eye coordination being positively correlated to time spent engaged in complex video gain play navigation. The positive social and relational identity formation through video game play was mentioned across Facebook data, interview and questionnaires.

One parent discussed how their child was able to keep in touch with a friend, who had moved away by playing online with him. Another parent expressed the ways video game play enabled continued long-distance communication and shared relational identity with friends from their home town.

“Playing video games is really good for him because he can keep in touch with his friends from when we lived in NY and it gives them something that they share, that is constantly growing and changing. If they had just tried to stay in touch by texting or calling each other it probably wouldn’t have worked as good because, they wouldn’t have that thing that they are still doing together, they are still doing their adventures and stuff, playing their game.”

Some parents reported that playing video games calmed their children while in another area of the questionnaire they reported that their child was agitated after engaging in game play. Most parents reported a desire to reduce the amount of time their child played video games, ranging from mild to strong, and responses leaned more toward often or very often when stating that they felt that their child couldn’t resist playing video games.

Research Question 3

Interviews and Facebook posts consistently mentioned children sneaking to play video games at times when they were not allowed, stealing phones, waking up in the middle of the night to play, waking up too early in the morning in order to play and difficulty task switching away from video game play was problematic with descriptors ranging from “frustrating” to reports of “meltdowns” and “tantrums”. Parents desire to impose reasonable time limitation expectations regarding VGP was stressed again and again in the open-ended responses interviews and through Facebook data and coincided with feelings that they could not control their child’s game play. One parent described

VGP as mostly positive because:

“It is his currency but negative in that he seems to be sucked back into it.”

The obsessive and addictive nature of VGP was reported as a negative process that made parents feel unable to control or communicate competently. Addictive and obsessive identity formation framed the motivation of identity processes. It is the same negative drive toward overuse of video game that is anticipated to drive mediated behavioral gains via increased motivation for participation in multiplayer games.

“It’s a mixed bag, the positive is how it calms him, and negative is that the stimulation colors all other activities that become boring by contract, He then doesn’t want to do sports and even things like chess with his grandfather because he gets restless.”

In several Facebook post threads parents expressed a desire to discontinue all

VGP but felt unable to do so. There was a great deal of conversation about feeling out of control, upset, helpless, and frustrated with regards to their child’s relationship to VGP.

“I struggle so much with video games….The one thing that makes him happy is video games, Fortnite in particular. I try to control the screens, but I forget a lot, my husband is away during the week and I’m alone with 3 kids. I don’t have the strength. I feel like dealing with a drug addict. I need to regain control. I’m worried this will rule his life.”

“Physically take the video games away. I read you have no control…you do have control.”

“He gets 1 hr. of games or tablet after school if his teacher gives me a thumbs up (ha had a good day). I found this gives him something to work towards and he can choose what to do with his one hour, which helps him feel in charge.”

“Play if with them, my son had no friends in the world, so I even go as far as to play blooming Xbox with him, but I also make him come gardening with me.”

In spite of VGP, if not properly regulated, becoming problematic and creating parental stress regarding use, 100% of parents reported that they used VGP as a digital babysitter. Digital babysitting use of MPVG was reported to mediate gains of focus and to regulate behaviors while the child was engaging in the process of game play. In one interpretation of identity, VGP use was shown to enabled self-identity enactment as “an enjoyable activity that brings my son joy” while allowing gains in personal identity management of time required for self-focus “my daughter knows when it’s time for her to stop playing, she is good about all that.”

The majority of parents reported more social and identity gains than problems or losses with regard to video game play. Feelings of contentment, connection, and overall happiness were reported in interviews and through positive Facebook threads. VGP

“enabling players to separate from identification with their problems” was an item in the questionnaire that received positive responses from more than half of the participants.

These findings showed the varied ways in which MPVG created and recreated layers of identity, both in the third place world of the game, as well as, externally and causally in relation to social engagement of video game play. The data supported the themes and concepts of identity as an enacted and enacting process through the theoretical lens of communication identity theory.

Positive psychology theoretical assumptions found in Broaden and Build, Flow, and Transformational Play framed the conceptualization of the WBCMD. Even parents who felt the greatest concerns regarding VGP’s responsibility in creating severe parent- child communication disruptions with regards to overuse, expressed interest in ADHD gamification interventions. All participants, reported being likely, highly likely, or extremely likely to use the WGCMD concept. There were reports of both positive and negative reports regarding VGP and parent-child communication. Conflict surrounding game time limitations were reported to increase parental stress, game play as a digital babysitter, and happiness regarding their child’s engagement and enjoyment of video game play were reported as decreasing parental stress. Five respondents reported that parental stress was not an issue. Additional research should be conducted in this area.

Research that focused on children’s thoughts and feelings would be a useful follow up to this research.

With only a few outlying exceptions, all parents expressed interest in use of

ADHD support Apps or games. Cost, shared identity and agency, age appropriateness, parental controls, and non-violent subject matter were all concerns.

“I would try an ADHD game, but I don’t know what that is. It it’s a game that helps with ADHD that would be great, but it would have to be something that he can talk about at school bc that’s the big hook of the games he plays, it gives him some pride at school “

“My daughter only will play a video game that her friends at the studio are also playing.”

“I believe games are powerful tools, so why not train brains in powerfully positive ways? Expense is a barrier, lack of knowledge, no other friends have use them.”

“I would be very interested. I did not know they were out there and will research immediately.”

“I think with parental controls, as long as they are not violent, these could be a big positive.”

“If I heard good things or success stories I would try it. But if it would just become another argument about usage or over usage, that wouldn’t be ideal. Also, not sure he would get any “message” related to the game.”

“He is highly suspicious of things that make him feel different so it would have to be very sneaky.”

Regarding the WGCMD, all respondents, regardless of conflict or reported fears of child’s addiction to video game play, reported that they were either likely or extremely likely or very likely to use this support intervention if parental controls were established to reduce conflict over use, and if cost was not an issue. This again shows the way in which motivation works as a powerful identity communication process.

There is a need to build on the existing research showing the use of video gaming for increased child-led motivation and real-world gains in ADHD communication competence regulations. Discrete video games lack the interactive social agency of shared commercial, MPVG. Sand-box commercial multiplayer games use open source coding which makes them much easier to code and to adapt according to ongoing research goals. Adaptability make outcomes potential affordable versus costly. Discrete games designed uniquely to serve as a psycho-social support tools or digital medicine interventions are costly and time consuming to create and lack the social agency and shared symbols of commercial video games.

The conceptualized WGCMD is speculated to assist in ADHD children’s communication competence in multiple domains. The device is anticipated to engender communal and relational identity formation opportunities and allow the social and competitive aspect of MVG play to serve as a motivating force for users to work hard and level up themselves. This device was conceptualized to utilize the socially cooperative and competitive aspect of transparency among peers increasing motivation and providing child led self-monitoring. Gains in executive function and time management, increased goal setting and decreased disruptive behaviors/communication are anticipated with subsequent decreases in parental stress. The immediate associating with digital rewards and peer competition/support are expected to pair with analogue academic and behavioral gains through play that is both fun and socially essential, the ADHD child might be able to build healthier behavioral and academic habits and a stronger sense of belonging.

Findings from the existing literature indicate that the WGCMD technology would be an effective intervention that could utilize a child-led reward system of self-regulation and self-motivation for behavioral gains via connection to gains in ability to engage in

VGP and to gain digital rewards for use in future game play. The data collected pointed to the WGCMD as being something parents viewed as potentially valuable and worth exploring. Use of WGCMD might increase both short and long-term motivation while supporting existing communal and relational identity formations developed through years of shared play in the third-place digital landscape. This meaningful transformational play, within the historically and social world of commercial MPVG play, gives ADHD children agency, consequentiality of reciprocal play, and the legitimacy of successful communication. Through MPVG providing a socially essential aspect of play and

74 subsequent joy, the ADHD child could be given opportunities to build healthy behavioral and academic habits within an inclusive social tapestry of belonging.

Future research should be conducted to assess self-efficacy gains from engaging in reciprocal play and whether increases in belonging and self-efficacy would be causally related to decreases in parent stress. Analogue communication competence gains should be studied as they associatively relate to time spent in the MPVG communication processes of collaborative game play. Prototype creation and testing is suggested. (See

Appendix F for technological information regarding future prototype of WGCMD).

SUMMARY

ADHD is a communication disorder categorized as a neurodevelopmental, chronic condition that can cause communicative and behavioral development to be three years or more behind the child’s chronological age. ADHD begins in childhood and can often have lasting effects on communicate competence into adulthood, with 2 out of every 3 children still exhibiting symptoms as adults. ADHD causes a reduction of dopamine receptors and transporters in two regions of the brain causing dysfunction in the brain’s pathways that relate to motivation and reward (Volkow et al., 2009). This pathway is central to motivation, learning, communication cues, and how to associate stimuli with rewards (Volkow et al., 2009). ADHD causes communication issues that are causally related to social anxiety, difficulties with peer relationships and reciprocal play, academic success, belonging, and self-efficacy . These issues allow ADHD to meet the new DSM-5 category of social communication disorder.

This qualitative study assessed; parental thoughts and beliefs about the child’s current relationship to video game play; perceptions of whether video game play use was positively or negatively in association with their child’s identity; parent stress as it related to video game play, and the likelihood that parents would allow their child to use the

WGCMD intervention. Parents of ADHD children who played MPVG were contacted through Facebook groups, local schools, pediatric offices, and call to research postings in

Winston-Salem, N.C. Data was collected through questionnaires which combined multiple choice questions and open-ended questions. In depth interviews, and Facebook

ADHD parent support group threads occurred during the same 5-week data collection period.

ADHD children are not able to competently engage in the communication process because they either don’t understand the message or they respond inappropriately due to inattention, impulsivity, and other executive function and working memory deficits.

Gamification can be viewed as a process in line with the communication model, just as identity formation can be viewed as a process. Game play affords the creation of various types of identity formation and enables a message of meaning that impacts and influences the ADHD child by giving opportunities for positive communication interactions and achievements in digital social connectivity. The process of communication via gamification offers competence, autonomy, and relatedness via the powerful evolutionary component of reciprocal play.

The most solidly evidence-based treatment for ADHD involves use of pharmacological treatments which have been shown to elevate dopamine and increase attention to cognitive tasks, and increase improvements in communication and improvements in dysregulated behaviors (Shier et al., 2013). The potential side effects, and failure to prevent or alter long-term negative ADHD peer and self-efficacy outcomes, makes medicine an unattractive option for many families (Swanson et al., 2017).

Behavioral therapy programs, BPT, are the other well researched communication treatment modality. BPT can consist of 10-35 week-long costly training programs comprised of complex daily schedules, and reward systems structures that parents have to implement (Wells, 2000). These interventions have been well researched and have not been shown to have long-term effectiveness partially due to substantial parental investments of both time and money. Across application, studies have compared BPT

77 alone, combined medication and BPT, and medication alone. Medication shows the only substantial increase in effectiveness (Wells et al., 2000).

BPT programs, and other parent-led behavioral modification therapies (see

Appendix A), have shown immediate results of reductions in parental interpretations of negative parenting but little differentiation in other domains. Recent studies indicated that

BPT, and other parent-led modification programs, resulted in increases in parental stress and subsequent abandonment of program implementations (Wells et al., 2000). Research indicated that high levels of parental stress bi-directionally corresponded to higher levels of children’s communication dysregulation and behavioral issues, creating a feedback loop of problems at home, at school, and amongst peers.

Parental stress is related to a number of factors, one of which is parental worry regarding implementation of behavioral accommodations that allow for the ADHD child’s educational needs to be met. These concerns, along with the need to foster successful interactive learning with classroom peers and needs to accomplish academic goals that engendered successful classroom participation, have been shown to cause parents to feel overwhelmed. Many BPT modalities suggested training programs for both parents and teachers, in order to create effective interventions to organize and regulate

ADHD children in the classroom. These are time consuming for teachers who face large classroom sizes, requirements for testing and assessments, on top of teaching demands for all students (Wei, 2002). Classroom difficulties, resulting in communication differences, can cause peer conflicts which also contribute to parental stress.

Parental stress is also associated with the fact that ADHD children are subjected to higher incidents of bullying, of peer alienation, lack in friendships, and are left out of

78 social activities. Chronic peer and academic problems can cause ADHD children to be excluded from opportunities to engage in reciprocal play. Play is an essential communication process of development. Lack of play correlates to a lack of belonging, to increases in social anxiety and comorbidly to occurring anxiety disorder diagnoses with low self-efficacy that can become chronic and persistent over time. All of these factors into stress experienced by both child and parent.

We went all out for my son’s 11th Fortnite themed birthday party, I mean I spent money on the plates, all that, and we had games and gifts for all the kids. I never once thought that, I mean they are Mom’s…how could they do that? I never imagined that no one would show up. He was destroyed and I, it’s awful. Just so awful. How could other Mom’s do that do a kid I didn’t know what to do or say. I just cried with him. (Interviewed Mother of 11-year-old boy, discussing peer issues)

Difficulty with communication and dysregulated home behaviors plus high levels of parental stress have led parents to the use of VGP as a peer mediation (Beyens,

Eggermont, 2014). The use of CMC in VGP allows previously socially isolated children a mediated way to communicate safely and effectively. Nonverbal body language is more controlled through hyper focused attention in game play. Identity is able to form communally and associatively through the process of game play and can be adapted and changed according to the evolving nature of the gaming third place worlds.

Video games were initially believed to increase dysregulated communication and behavior (Kulman, 2014). ADHD children are drawn to VGP because they are able to stimulate a dopamine surge which allows focus and reward pathways to be activated

(Dunckley, 2014).Research shows that game play can actually improve both verbal and nonverbal communication and can elicit gains in executive function, working memory, and hand eye coordination (Kulman, 2014, Trisolini, Petilli, and Daini, 2017).

Recent research has led to the development of video games that offer behavioral gains and social skills supports for ADHD children similar to those evidenced in BPT programs. The current research applies BPT support mechanisms to the development of discrete video games. Research seems to indicate that these discrete “lab based” games will not result in far transfer results because of their lack of shared in-group game play social agency potential. Outcomes of initial studies have yet to report peer relationship or parental stress outcomes, which are essential domains for well-being of an ADHD child.

The importance of communal identity, established through shared experience in commercial multiplayer VGP, and relational identity, established through peer sharing of digital gains and level achievement, cannot be overlooked. There is great potential for social expansiveness actualized through the process of expressed communal identity within commercial game play. Shared commercial game play is imbedded with a long history of shared symbols and narratives. Research seems to indicate that imbedding the effective behavioral goals and gains of BPT into MPVG will offer the potential for optimized communication interventions and strong motivation toward use with far transfer results.

This research study examined the issues associated with ADHD communication deficits and the limitations of interventions. The positive uses of video game play are: social inclusion; belonging; increased self-efficacy; increased in executive function; improved motor skills; improved hand eye coordination; increased opportunity for identity formation regarding self, relational, and communal enacted experience. Video game play provides ADHD children with the ability to hyper focus and achieve gains within VGP play that are difficult in their analogue existence due to distractibility,

80 inattention, and impulsivity. Peer relationship are strengthened due to increases in reciprocal play and opportunities for computer medicate communication, the ability to occupy malleable and controllable third places, and identity formation potentials that can be structured and restructured.

Video games are not, however, the golden ticket. ADHD children have slow reward pathways that are engaged and excited through video game play with dopamine response similar to those seen in gambling and substance addictions. Research shows that

ADHD children are more drawn to and motivated by the desire to engage in video game play. Half of questionnaire parents, and almost all of interviewees, reported either their child having obsessive or addictive desire for video game play. Some participants made note that their child’s use of video game play made them feel out of control and that they wanted to regulate their child’s game play use but didn’t feel like they could. In spite of these concerns over children’s relationship with game play, and parental concern about addiction research and obsessive use of game play, results were positive. One hundred percent of participants expressed an interest in the conceptualized wearable device that linked to commercial video game play as a way to drive motivation. By having game play use regulated by level up gains in communication competency, and through effective parental controls, ADHD children and parents could use game play for much needed structure and much needed support. The vast social, behavioral, transformational, and multi-dimensional possibilities that exist within the world of MPVG hold intriguing potentials for use that correlates to therapeutic gains.

This research proved that parents are desperate for effective for ways to help their

ADHD children belong. They are desperate for effective ways to mediate and support

81 dysregulated behaviors and to aid in off target communication problems. They are desperate to take advantage of the positive opportunities richly afforded by video play, but they fear losing control of the gaming abyss.

“The world fears the inevitable plummet into the abyss. Watch for that moment and when it comes, do not hesitate to leap. It is only when you fall that you learn whether you can fly.” Flemeth, Dragon Age Origins, 2009.

SHIGERU MIYAMOTO: CREATOR OF THE WORLD OF MARIO

Figure 13. Shigeru Miyamoto: Creator of the World of Mario; RealQuotes, 2011.

REFERENCES

4 Ways to Develop Self-Efficacy Beliefs (Self-Esteem or Confidence). (2014, January 20).

Retrieved December 15, 2017, fr. (n.d.).

15 Surprising Benefits of Playing Video Games. (2017, September 12). Retrieved December

14, 2017, from http://mentalfloss.com/article/65008/15-surprising-benefits-playing-

video-games

A factor‐analytic investigation of computer ‘addiction’ and engagement - Charlton - 2002 -

British Journal of Psychology - Wiley Online Library. (n.d.). Retrieved May 8, 2019,

from https://onlinelibrary-wiley-

com.go.libproxy.wakehealth.edu/doi/abs/10.1348/000712602760146242

A Randomized Controlled Trial of a Play- Based Intervention to Improve the Social Play Skills

of Children with Attention Deficit Hyperactivity Disorder (ADHD).pdf. (n.d.).

ADHD and Social Anxiety - 10 Ways to Break Free Socially. (2017, March 6). Retrieved

December 15, 2017, from Adult ADHD : ADHD Boss website:

http://adhdboss.com/adhd-social-anxiety/ admin, A. (2016, October 3). The Stress on Parents of Raising a Teen with ADHD – Moms

and Dads Differ. Retrieved April 29, 2019, from ADD Resource Center website:

https://www.addrc.org/the-stress-on-parents-of-raising-a-teen-with-adhd-moms-and-

dads-differ/

Allahverdipour, H., Bazargan, M., Farhadinasab, A., & Moeini, B. (2010). Correlates of video

games playing among adolescents in an Islamic country. BMC Public Health, 10, 286.

https://doi.org/10.1186/1471-2458-10-286

Ames, M. G., & Burrell, J. (2017, February 25). “Connected Learning” and the Equity

Agenda: A Microsociology of Minecraft Play. 446–457.

https://doi.org/10.1145/2998181.2998318

Axline, V. M. (2012). Play Therapy: The Groundbreaking Book That Has Become a Vital

Tool in the Growth andDevelopment of Children. Random House Publishing Group.

Baek, Y., & Touati, A. (2017). Exploring how individual traits influence enjoyment in a

mobile learning game. Computers in Human Behavior, 69(Supplement C), 347–357.

https://doi.org/10.1016/j.chb.2016.12.053

Bailey, E. (2016, November 28). You’re Not Shy or Stuck Up. You Have Social Anxiety

Disorder. Retrieved December 15, 2017, from ADDitude website:

https://www.additudemag.com/slideshows/social-anxiety-disorder-in-adults-with-adhd/

Baker, J. R., & Hudson, J. L. (2015). Children with social phobia have lower quality

friendships than children with other anxiety disorders. Anxiety, Stress, and Coping, 28(5),

500–513. https://doi.org/10.1080/10615806.2014.978863

Bandura, A. (1977). Self-efficacy: toward a unifying theory of behavioral change.

Psychological Review, 84(2), 191–215.

Bandura, Albert. (1982). Self-Efficacy Mechanism in Human Agency. American Psychologist,

37, 122–147. https://doi.org/10.1037/0003-066X.37.2.122

Barab, S. A., Gresalfi, M., & Ingram-Goble, A. (2010). Transformational Play: Using Games

to Position Person, Content, and Context. Educational Researcher, 39(7), 525–536.

https://doi.org/10.3102/0013189X10386593

Barab, S., Pettyjohn, P., Gresalfi, M., Volk, C., & Solomou, M. (2012). Game-based

curriculum and transformational play: Designing to meaningfully positioning person,

content, and context. Computers & Education, 58(1), 518–533.

https://doi.org/10.1016/j.compedu.2011.08.001

Behavioral Parent Training as a Treatment for Externalizing Behaviors and Disruptive

Behavior Disorders: A Meta-Analysis - ProQuest. (n.d.). Retrieved December 14, 2017,

from https://search.proquest.com/openview/570bf1194dfc798a57fef7aca3eb2237/1?pq-

origsite=gscholar&cbl=48217

Bento, G., & Dias, G. (2017). The importance of outdoor play for young children’s healthy

development. Porto Biomedical Journal, 2(5), 157–160.

https://doi.org/10.1016/j.pbj.2017.03.003

“Beyond Minecraft: The Best Games and Apps for Kids with ADHD and LD” with Randy

Kulman, Ph.D., and James Daley. (2017, February 14). Retrieved December 14, 2017,

from ADDitude website: https://www.additudemag.com/product/best-games-and-apps-

for-adhd-kids/

Bonus, J. A., Peebles, A., Mares, M.-L., & Sarmiento, I. G. (2017). Look on the Bright Side

(of Media Effects): Pokémon Go as a Catalyst for Positive Life Experiences. Media

Psychology, 0(0), 1–25. https://doi.org/10.1080/15213269.2017.1305280

Bowman, N. D., Weber, R., Tamborini, R., & Sherry, J. (2013). Facilitating Game Play: How

Others Affect Performance at and Enjoyment of Video Games. Media Psychology, 16(1),

39–64. https://doi.org/10.1080/15213269.2012.742360

Broaden and Build Theory. (2015, March 26). Retrieved December 14, 2017, from The

Positive Psychology People website:

http://www.thepositivepsychologypeople.com/broaden-and-build-theory/

Broaden-and-Build Theory of Positive Emotions (+PDF). (2016, August 30). Retrieved

December 14, 2017, from https://positivepsychologyprogram.com/broaden-build-theory/

Bul, K. C., Kato, P. M., Van der Oord, S., Danckaerts, M., Vreeke, L. J., Willems, A., …

Maras, A. (2016). Behavioral Outcome Effects of Serious Gaming as an Adjunct to

Treatment for Children With Attention-Deficit/Hyperactivity Disorder: A Randomized

Controlled Trial. Journal of Medical Internet Research, 18(2).

https://doi.org/10.2196/jmir.5173

Burdette, H. L., & Whitaker, R. C. (2005). Resurrecting Free Play in Young Children:

Looking Beyond Fitness and Fatness to Attention, Affiliation, and Affect. Archives of

Pediatrics & Adolescent Medicine, 159(1), 46–50.

https://doi.org/10.1001/archpedi.159.1.46

Bussing, R., Meyer, J., Zima, B. T., Mason, D. M., Gary, F. A., & Garvan, C. W. (2015).

Childhood ADHD Symptoms: Association with Parental Social Networks and Mental

Health Service Use during Adolescence. International Journal of Environmental

Research and Public Health, 12(9), 11893–11909.

https://doi.org/10.3390/ijerph120911893

Carl I. Fertman, & Brian A. Primack. (2009). Elementary Student Self Efficacy Scale

Development and Validation Focused on Student Learning, Peer Relations, and Resisting

Drug Use. Journal of Drug Education, 39(1), 23–38. https://doi.org/10.2190/DE.39.1.b

Chee, V., & Smith. (2006). Online Gaming and the Interactional Self: Identity interplay in

situated practice. 20.

Chin-Sheng, W., & Chiou, W.-B. (2007). The Motivations of Adolescents Who Are Addicted

to Online Games: A Cognitive Perspective. Adolescence; Roslyn Heights, 42(165), 179–

197.

Chronis, A. M., Chacko, A., Fabiano, G. A., Wymbs, B. T., & Pelham, W. E. (2004).

Enhancements to the Behavioral Parent Training Paradigm for Families of Children with

ADHD: Review and Future Directions. Clinical Child and Family Psychology Review,

7(1), 1–27. https://doi.org/10.1023/B:CCFP.0000020190.60808.a4

Chumbley: Affect and the computer game player: the... - Google Scholar. (n.d.). Retrieved

May 8, 2019, from https://scholar-google-

com.go.libproxy.wakehealth.edu/scholar_lookup?title=Affect%20and%20the%20comput

er%20game%20player%3A%20The%20effect%20of%20gender%2C%20personality%2

C%20and%20game%20reinforcement%20structure%20on%20affective%20responses%2

0to%20computer%20game-

play&author=J.%20Chumbley&author=MD.%20Griffiths&journal=CyberPsychology%2

0%26%20Behavior&volume=9&issue=3&pages=308-316&publication_year=2006

Cognitive Benefits of Playing Video Games. (n.d.). Retrieved December 14, 2017, from

Psychology Today website: https://www.psychologytoday.com/blog/freedom-

learn/201502/cognitive-benefits-playing-video-games

Cognitive Psychology. (n.d.). Retrieved from https://www.journals.elsevier.com/cognitive-

psychology collaborative.pdf. (n.d.).

Colwell, J., Grady, C., & Rhaiti, S. (1995). Computer games, self-esteem and gratification of

needs in adolescents. Journal of Community & Applied Social Psychology, 5(3), 195–

206. https://doi.org/10.1002/casp.2450050308

Communication Competence. (n.d.). Retrieved April 29, 2019, from OER Commons website:

https://www.oercommons.org/authoring/6192-communication-competence/view

Compton, S. N., Walkup, J. T., Albano, A. M., Piacentini, J. C., Birmaher, B., Sherrill, J. T.,

… March, J. S. (2010). Child/Adolescent Anxiety Multimodal Study (CAMS): rationale,

design, and methods. Child and Adolescent Psychiatry and Mental Health, 4, 1.

https://doi.org/10.1186/1753-2000-4-1

Cosi, S., Canals, J., Hernández-Martinez, C., & Vigil-Colet, A. (2010). Parent-child agreement

in SCARED and its relationship to anxiety symptoms. Journal of Anxiety Disorders,

24(1), 129–133. https://doi.org/10.1016/j.janxdis.2009.09.008

Craig, A. B., Brown, E. R., Upright, J., & DeRosier, M. E. (2016). Enhancing Children’s

Social Emotional Functioning Through Virtual Game-Based Delivery of Social Skills

Training. Journal of Child and Family Studies, 25(3), 959–968.

https://doi.org/10.1007/s10826-015-0274-8

Cummings, H. M., & Vandewater, E. A. (2007). Relation of adolescent video game play to

time spent in other activities. Archives of Pediatrics & Adolescent Medicine, 161(7),

684–689. https://doi.org/10.1001/archpedi.161.7.684

Cypress, B. S. (2017). Rigor or Reliability and Validity in Qualitative Research: Perspectives,

Strategies, Reconceptualization, and Recommendations. Dimensions of Critical Care

Nursing, 36(4), 253. https://doi.org/10.1097/DCC.0000000000000253

David Beck Schatz, & Anthony L. Rostain. (2006). ADHD With Comorbid Anxiety: A

Review of the Current Literature. Journal of Attention Disorders, 10(2), 141–149.

https://doi.org/10.1177/1087054706286698

David-Ferdon, C., & Kaslow, N. J. (2008). Evidence-based psychosocial treatments for child

and adolescent depression. Journal of Clinical Child and Adolescent Psychology: The

Official Journal for the Society of Clinical Child and Adolescent Psychology, American

Psychological Association, Division 53, 37(1), 62–104.

https://doi.org/10.1080/15374410701817865

Deterding, S., Dixon, D., Khaled, R., & Nacke, L. (2011). From Game Design Elements to

Gamefulness: Defining “Gamification.” Proceedings of the 15th International Academic

MindTrek Conference: Envisioning Future Media Environments, 9–15.

https://doi.org/10.1145/2181037.2181040

Developing 21st century skills through gameplay: To what extent are young people who play

the online computer game Minecraft acquiring and developing media literacy and the

Four Cs skills? - ProQuest. (n.d.). Retrieved December 14, 2017, from

https://search.proquest.com/openview/5f6401089e192ba37c96075319704492/1?pq-

origsite=gscholar&cbl=18750&diss=y early psychosocial issues with adhd kids.pdf. (n.d.). efficacy of school teambuilding.pdf. (n.d.).

Ellison, N. B., Steinfield, C., & Lampe, C. (2007). The Benefits of Facebook “Friends:” Social

Capital and College Students’ Use of Online Social Network Sites. Journal of Computer-

Mediated Communication, 12(4), 1143–1168. https://doi.org/10.1111/j.1083-

6101.2007.00367.x

Ferguson, C. J., & Olson, C. K. (2013). Friends, fun, frustration and fantasy: Child

motivations for video game play. Motivation and Emotion, 37(1), 154–164.

https://doi.org/10.1007/s11031-012-9284-7

Figure 1 Conceptual Map of the Main Genres of Video Games (With... (n.d.). Retrieved May

8, 2019, from ResearchGate website: https://www.researchgate.net/figure/Conceptual-

Map-of-the-Main-Genres-of-Video-Games-With-Examples-Organized-According-

to_fig1_259112690

Flow (Csíkszentmihályi). (2014, August 22). Retrieved December 14, 2017, from Learning

Theories website: https://www.learning-theories.com/flow-csikszentmihalyi.html

Flow, Player Journey and Employee Satisfaction - Gamified UK. (n.d.). Retrieved May 8,

2019, from https://www.gamified.uk/2012/11/30/flow-and-satisfaction/

Fredrickson, B. L. (2003). The value of positive emotions. https://doi.org/10.1511/2003.4.330

Fredrickson, B. L. (2004). The broaden-and-build theory of positive emotions. Philosophical

Transactions of the Royal Society B: Biological Sciences, 359(1449), 1367–1378.

https://doi.org/10.1098/rstb.2004.1512

Fredrickson, B. L., & Losada, M. F. (2005). Positive Affect and the Complex Dynamics of

Human Flourishing. The American Psychologist, 60(7), 678–686.

https://doi.org/10.1037/0003-066X.60.7.678

Fredrickson, B. L., Mancuso, R. A., Branigan, C., & Tugade, M. M. (2000). The Undoing

Effect of Positive Emotions. Motivation and Emotion, 24(4), 237–258.

Gagliano, A., Lamberti, M., Siracusano, R., Ciuffo, M., Boncoddo, M., Maggio, R., …

Germanò, E. (2014). A Comparison between Children with ADHD and Children with

Epilepsy in Self-Esteem and Parental Stress Level. Clinical Practice and Epidemiology in

Mental Health: CP & EMH, 10, 176–183.

https://doi.org/10.2174/1745017901410010176

Gans, S., & MD. (n.d.). The Relationship Between ADHD and Social Anxiety Disorder.

Retrieved December 15, 2017, from Verywell website: https://www.verywell.com/the-

relationship-between-add-and-sad-3024754

Gentile, D. A., Lynch, P. J., Linder, J. R., & Walsh, D. A. (2004). The effects of violent video

game habits on adolescent hostility, aggressive behaviors, and school performance.

Journal of Adolescence, 27(1), 5–22. https://doi.org/10.1016/j.adolescence.2003.10.002

Ginsburg, K. R. (2007). The Importance of Play in Promoting Healthy Child Development and

Maintaining Strong Parent-Child Bonds. Pediatrics, 119(1), 182–191.

https://doi.org/10.1542/peds.2006-2697

Good Video Games + Good Learning. (n.d.). Retrieved from https://books-google-

com.go.libproxy.wakehealth.edu/books/about/Good_Video_Games_+_Good_Learning.ht

ml?id=6NY2i9stxZwC

Granic, I., Lobel, A., & Engels, R. C. M. E. (2014). The benefits of playing video games. The

American Psychologist, 69(1), 66–78. https://doi.org/10.1037/a0034857

Griffiths, D. C. (2013). Virtual Ascendance: Video Games and the Remaking of Reality.

Rowman & Littlefield.

Griffiths, M. (2002). Benefits of Videogames. 20, 5.

Griffiths, M. (2010). Online video gaming: what should educational psychologists know?

Educational Psychology in Practice, 26(1), 35–40.

https://doi.org/10.1080/02667360903522769

Group, M. C. (2004). National Institute of Mental Health Multimodal Treatment Study of

ADHD Follow-up: 24-Month Outcomes of Treatment Strategies for Attention-

Deficit/Hyperactivity Disorder. Pediatrics, 113(4), 754–761.

https://doi.org/10.1542/peds.113.4.754

Hagerty, B. M., & Patusky, K. (1995). Developing a measure of sense of belonging. Nursing

Research, 44(1), 9–13.

Hansen, S., Meissler, K., & Ovens, R. (2000). Kids Together: A Group Play Therapy Model

for Children with ADHD Symptomalogy. Journal of Child and Adolescent Group

Therapy, 10(4), 191–211. https://doi.org/10.1023/A:1016631228545

Hecht, M. L., & Choi, H. (n.d.). The Communication Theory of Identity as a Framework for

Health Message Design. 16.

High, A. C., & Caplan, S. E. (2009). Social anxiety and computer-mediated communication

during initial interactions: Implications for the hyper personal perspective. Computers in

Human Behavior, 25(2), 475–482. https://doi.org/10.1016/j.chb.2008.10.011

Hinshaw, S. P. (2007). Moderators and mediators of treatment outcome for youth with

ADHD: understanding for whom and how interventions work. Ambulatory Pediatrics:

The Official Journal of the Ambulatory Pediatric Association, 7(1 Suppl), 91–100.

https://doi.org/10.1016/j.ambp.2006.04.012

Hook, M., Baxter, S., & Kulczynski, A. (2016). Children’s participation in brand-based social

networks: examining the role of evaluative social identity, self-esteem and anticipated

emotions on commitment and desire to recommend. International Journal of Consumer

Studies, 40(5), 552–561. https://doi.org/10.1111/ijcs.12300

Houck, G., Kendall, J., Miller, A., Morrell, P., & Wiebe, G. (2011). Self-Concept in Children

and Adolescents with ADHD. Journal of Pediatric Nursing, 26(3), 239–247.

https://doi.org/10.1016/j.pedn.2010.02.004

Hoza, B., Mrug, S., Gerdes, A. C., Hinshaw, S. P., Bukowski, W. M., Gold, J. A., … Arnold,

L. E. (2005). What Aspects of Peer Relationships Are Impaired in Children With

Attention-Deficit/Hyperactivity Disorder? Journal of Consulting and Clinical

Psychology, 73(3), 411–423. https://doi.org/10.1037/0022-006X.73.3.411

Humphreys, K. L., Aguirre, V. P., & Lee, S. S. (2012). Association of Anxiety and ODD/CD

in Children With and Without ADHD. Journal of Clinical Child & Adolescent

Psychology, 41(3), 370–377. https://doi.org/10.1080/15374416.2012.656557

Hurt, E. A., Hoza, B., & Pelham, W. E. (2007). Parenting, Family Loneliness, and Peer

Functioning in Boys with Attention-Deficit/Hyperactivity Disorder. Journal of Abnormal

Child Psychology, 35(4), 543–555. https://doi.org/10.1007/s10802-007-9111-x

Huxley, P., Evans, S., Madge, S., Webber, M., Burchardt, T., McDaid, D., & Knapp, M.

(2012). Development of a social inclusion index to capture subjective and objective life

domains (Phase II): psychometric development study. Retrieved from

https://www.ncbi.nlm.nih.gov/books/NBK84045/

Inkpen, K., Booth, K. S., Klawe, M., & Upitis, R. (1995). Playing Together Beats Playing

Apart, Especially for Girls. The First International Conference on Computer Support for

Collaborative Learning, 177–181. https://doi.org/10.3115/222020.222164

Jennifer Theule, Judith Wiener, Rosemary Tannock, & Jennifer M. Jenkins. (2013). Parenting

Stress in Families of Children With ADHD: A Meta-Analysis. Journal of Emotional and

Behavioral Disorders, 21(1), 3–17. https://doi.org/10.1177/1063426610387433

Jensen, P. S. (1999). A 14-month randomized clinical trial of treatment strategies for attention-

deficit/hyperactivity disorder. Archives of General Psychiatry, 56(12), 1073–1086.

Jeong, E. J., & Kim, D. H. (2011). Social activities, self-efficacy, game attitudes, and game

addiction. Cyberpsychology, Behavior and Social Networking, 14(4), 213–221.

https://doi.org/10.1089/cyber.2009.0289

John, W. C. K., Angeline, K., Chia, L. W., & Shanti, D. (2008, February 14). Passion and

Intrinsic Motivation in Digital Gaming [Research-article].

https://doi.org/10.1089/cpb.2007.0004

Johnston, C., & Mash, E. J. (2001). Families of children with attention-deficit/hyperactivity

disorder: review and recommendations for future research. Clinical Child and Family

Psychology Review, 4(3), 183–207.

Jones, C. M., Scholes, L., Johnson, D., Katsikitis, M., & Carras, M. C. (2014). Gaming well:

links between videogames and flourishing mental health. Frontiers in Psychology, 5.

https://doi.org/10.3389/fpsyg.2014.00260

Kaplan, M., & Anderson, D. (2016). An Intensive Parent-Training Intervention Model for

Behavior Disorders in Children and Adolescents. Journal of the American Academy of

Child & Adolescent Psychiatry, 55(10), S344. https://doi.org/10.1016/j.jaac.2016.07.071

Katz, E., Blumler, J. G., & Gurevitch, M. (1974). Uses and gratifications research. Public

Opinion Quarterly, 509–523.

Kellie Vella, Daniel Johnson, Vanessa Wan Sze Cheng, Tracey Davenport, Jo Mitchell,

Madison Klarkowski, & Cody Phillips. (2017). A Sense of Belonging: Pokémon GO and

Social Connectedness. Games and Culture, 1555412017719973.

https://doi.org/10.1177/1555412017719973

Kim, E. J., Namkoong, K., Ku, T., & Kim, S. J. (2008). The relationship between online game

addiction and aggression, self-control and narcissistic personality traits. European

Psychiatry, 23(3), 212–218. https://doi.org/10.1016/j.eurpsy.2007.10.010

Kim, O. H., & Kaiser, A. P. (2000). Language Characteristics of Children with ADHD.

Communication Disorders Quarterly, 21(3), 154–165.

https://doi.org/10.1177/152574010002100304

King-Kallimanis, B., Gum, A. M., & Kohn, R. (2009). Comorbidity of Depressive and

Anxiety Disorders for Older Americans in the National Comorbidity Survey-Replication.

The American Journal of Geriatric Psychiatry, 17(9), 782–792.

https://doi.org/10.1097/JGP.0b013e3181ad4d17

Klimmt, C., Hefner, D., & Vorderer, P. (2009). The Video Game Experience as “True”

Identification: A Theory of Enjoyable Alterations of Players’ Self-Perception.

Communication Theory, 19(4), 351–373. https://doi.org/10.1111/j.1468-

2885.2009.01347.x

Kovess, V., Carta, M. G., Pez, O., Bitfoi, A., Koç, C., Goelitz, D., … Otten, R. (2015). The

School Children Mental Health in Europe (SCMHE) Project: Design and First Results.

Clinical Practice and Epidemiology in Mental Health : CP & EMH, 11(Suppl 1 M7),

113–123. https://doi.org/10.2174/1745017901511010113

Kovess-Masfety, V., Keyes, K., Hamilton, A., Hanson, G., Bitfoi, A., Golitz, D., … Pez, O.

(2016). Is time spent playing video games associated with mental health, cognitive and

social skills in young children? Social Psychiatry and Psychiatric Epidemiology, 51(3),

349–357. https://doi.org/10.1007/s00127-016-1179-6

Kristin Romvig Overgaard, Heidi Aase, Svenn Torgersen, & Pål Zeiner. (2016). Co-

Occurrence of ADHD and Anxiety in Preschool Children. Journal of Attention

Disorders, 20(7), 573–580. https://doi.org/10.1177/1087054712463063

Kroenke, K., Spitzer, R. L., Williams, J. B. W., & Löwe, B. (2009). An ultra-brief screening

scale for anxiety and depression: the PHQ-4. Psychosomatics, 50(6), 613–621.

https://doi.org/10.1176/appi.psy.50.6.613

Lau, H. M., Smit, J. H., Fleming, T. M., & Riper, H. (2017). Serious Games for Mental

Health: Are They Accessible, Feasible, and Effective? A Systematic Review and Meta-

analysis. Frontiers in Psychiatry, 7. https://doi.org/10.3389/fpsyt.2016.00209

Leeuw, R. N. H. de, & Buijzen, M. (2016). Introducing positive media psychology to the field

of children, adolescents, and media. Journal of Children and Media, 10(1), 39–46.

https://doi.org/10.1080/17482798.2015.1121892

Li, D., Liau, A., & Khoo, A. (2011). Examining the Influence of Actual-Ideal Self-

Discrepancies, Depression, and Escapism, on Pathological Gaming Among Massively

Multiplayer Online Adolescent Gamers. Cyberpsychology, Behavior, and Social

Networking, 14(9), 535–539. https://doi.org/10.1089/cyber.2010.0463

Lim, S., & Lee, J.-E. R. (2008). When Playing Together Feels Different: Effects of Task

Types and Social Contexts on Physiological Arousal in Multiplayer Online Gaming

Contexts. CyberPsychology & Behavior, 12(1), 59–61.

https://doi.org/10.1089/cpb.2008.0054

Mailonline, B. R. S. F. (2016, March 9). Gamers are SMARTER and perform better at school,

finds study. Retrieved December 14, 2017, from Mail Online website:

http://www.dailymail.co.uk/sciencetech/article-3484010/Gamers-SMARTER-perform-

better-school-Study-finds-link-playing-games-intelligence-children.html

Malti, T., Gummerum, M., Keller, M., Chaparro, M. P., & Buchmann, M. (2012). Early

Sympathy and Social Acceptance Predict the Development of Sharing in Children. PLOS

ONE, 7(12), e52017. https://doi.org/10.1371/journal.pone.0052017

Marcia L. Michaels, Alicia Barr, Mark W. Roosa, & George P. Knight. (2007). Self-Esteem:

Assessing Measurement Equivalence in a Multiethnic Sample of Youth. The Journal of

Early Adolescence, 27(3), 269–295. https://doi.org/10.1177/0272431607302009

Marczewski, A. (2012). Flow, Player Journey and Employee Satisfaction. Retrieved from

https://www.gamified.uk/2012/11/30/flow-and-satisfaction/

Maria Rogers, & Rosemary Tannock. (2013). Are Classrooms Meeting the Basic

Psychological Needs of Children With ADHD Symptoms? A Self-Determination Theory

Perspective. Journal of Attention Disorders, 1087054713508926.

https://doi.org/10.1177/1087054713508926

Markram, H. (2006). The Blue Brain Project. Nature Reviews Neuroscience, 7(2), 153.

https://doi.org/10.1038/nrn1848

Mazzone, L., Postorino, V., Reale, L., Guarnera, M., Mannino, V., Armando, M., … Vicari, S.

(2013). Self-Esteem Evaluation in Children and Adolescents Suffering from ADHD.

Clinical Practice and Epidemiology in Mental Health : CP & EMH, 9, 96–102.

https://doi.org/10.2174/1745017901309010096

McElhaney, K. B., Antonishak, J., & Allen, J. P. (2008). “They Like Me, They Like Me Not”:

Popularity and Adolescents’ Perceptions of Acceptance Predicting Social Functioning

Over Time. Child Development, 79(3), 720–731. https://doi.org/10.1111/j.1467-

8624.2008.01153.x

Measuring Affective, Physiological and Behavioural Differences in Solo, Competitive and

Collaborative Games.pdf. (n.d.).

Mihaly Csikszentmihalyi. (2010, March 25). Retrieved December 14, 2017, from Pursuit of

Happiness website: http://www.pursuit-of-happiness.org/history-of-happiness/mihaly-

csikszentmihalyi/

Mihaly Csikszentmihalyi: Flow Theory & Works. (n.d.). Retrieved December 14, 2017, from

Study.com website: http://study.com/academy/lesson/mihaly-csikszentmihalyi-flow-

theory-works.html

Minecraft Is Now the Second Best-Selling Game of All Time. (n.d.). Retrieved December 14,

2017, from Time website: http://time.com/4354135/minecraft-bestelling/

Mobiledia. (n.d.). A Nation of Kids with Gadgets and ADHD. Time. Retrieved from

http://techland.time.com/2013/07/08/a-nation-of-kids-with-gadgets-and-adhd/

Mohr, C., & Schneider, S. (2013). Anxiety disorders. European Child & Adolescent

Psychiatry, 22 Suppl 1, S17-22. https://doi.org/10.1007/s00787-012-0356-8

Montola, M., Stenros, J., & Waern, A. (2009). Pervasive Games: Theory and Design. San

Francisco, CA, USA: Morgan Kaufmann Publishers Inc.

Mrug, S., Molina, B. S. G., Hoza, B., Gerdes, A. C., Hinshaw, S. P., Hechtman, L., & Arnold,

L. E. (2012). Peer Rejection and Friendships in Children with Attention-

Deficit/Hyperactivity Disorder: Contributions to Long-Term Outcomes. Journal of

Abnormal Child Psychology, 40(6), 1013–1026. https://doi.org/10.1007/s10802-012-

9610-2

Murder on Grimm Isle: The impact of game narrative design in an educational game‐based

learning environment - Dickey - 2011 - British Journal of Educational Technology -

Wiley Online Library. (n.d.). Retrieved May 8, 2019, from https://onlinelibrary-wiley-

com.go.libproxy.wakehealth.edu/doi/full/10.1111/j.1467-8535.2009.01032.x

Nakamura, J., & Csikszentmihalyi, M. (2014). The Concept of Flow. In M. Csikszentmihalyi,

Flow and the Foundations of Positive Psychology (pp. 239–263).

https://doi.org/10.1007/978-94-017-9088-8_16

Nebel, S., Schneider, S., & Rey, G. D. (2016). Mining Learning and Crafting Scientific

Experiments: A Literature Review on the Use of Minecraft in Education and Research.

Journal of Educational Technology & Society, 19(2), 355–366.

Oliver, M. B., & Raney, A. A. (2011). Entertainment as Pleasurable and Meaningful:

Identifying Hedonic and Eudaimonic Motivations for Entertainment Consumption.

Journal of Communication, 61(5), 984–1004. https://doi.org/10.1111/j.1460-

2466.2011.01585.x

Olson, C. K. (2010). Children’s Motivations for Video Game Play in the Context of Normal

Development. Review of General Psychology, 14(2), 180–187.

https://doi.org/10.1037/a0018984

O’Neill, S., Rajendran, K., & Halperin, J. M. (2012). More than child’s play: the potential

benefits of play-based interventions for young children with ADHD. Expert Review of

Neurotherapeutics, 12(10), 1165–1167. https://doi.org/10.1586/ern.12.106

Organizing for Instruction. (n.d.). Retrieved May 8, 2019, from

https://www.learnalberta.ca/content/eslapb/understanding_the_acquisition_language_in_s

tages_working_towards.html

Panksepp, J. (2007). Can PLAY Diminish ADHD and Facilitate the Construction of the Social

Brain? Journal of the Canadian Academy of Child and Adolescent Psychiatry, 16(2), 57–

66.

Papastergiou, M. (2009). Digital Game-Based Learning in high school Computer Science

education: Impact on educational effectiveness and student motivation. Computers &

Education, 52(1), 1–12. https://doi.org/10.1016/j.compedu.2008.06.004

Peers, C., & Fleer, M. (2014). The Theory of ‘Belonging’: Defining concepts used within

Belonging, Being and Becoming—The Australian Early Years Learning Framework.

Educational Philosophy and Theory, 46(8), 914–928.

https://doi.org/10.1080/00131857.2013.781495

100

Pelham, W. E., & Waschbusch, D. A. (1999). Behavioral Intervention in Attention-

Deficit/Hyperactivity Disorder. In Handbook of Disruptive Behavior Disorders (pp. 255–

278). https://doi.org/10.1007/978-1-4615-4881-2_11

Pfiffner, L. J., & Haack, L. M. (2014). Behavior Management for School Aged Children with

ADHD. Child and Adolescent Psychiatric Clinics of North America, 23(4), 731–746.

https://doi.org/10.1016/j.chc.2014.05.014

Pham, Q., Khatib, Y., Stansfeld, S., Fox, S., & Green, T. (2015). Feasibility and Efficacy of an

mHealth Game for Managing Anxiety: “Flowy” Randomized Controlled Pilot Trial and

Design Evaluation. Games for Health Journal, 5(1), 50–67.

https://doi.org/10.1089/g4h.2015.0033 piers self-concept scale.pdf. (n.d.).

Polman, H., de Castro, B. O., & van Aken, M. A. G. (2008). Experimental study of the

differential effects of playing versus watching violent video games on children’s

aggressive behavior. Aggressive Behavior, 34(3), 256–264.

https://doi.org/10.1002/ab.20245

Post, P. (1999). Impact of child-centered play therapy on the self-esteem, locus of control, and

anxiety of at-risk 4th, 5th, and 6th grade students. International Journal of Play Therapy,

8, 1–18. https://doi.org/10.1037/h0089428

PROMIS Peer Relationships Scoring Manual.pdf. (n.d.).

Psychometric Properties of the Screen for Child Anxiety Related Emotional Disorders

(SCARED) in a No.webarchive. (n.d.).

101

Psychosocial causes and consequences of pathological gaming - ScienceDirect. (n.d.).

Retrieved May 8, 2019, from https://www-sciencedirect-

com.go.libproxy.wakehealth.edu/science/article/pii/S0747563210002116

PsycNET Record Display - PsycNET. (n.d.). Retrieved December 13, 2017, from

/record/2011-08237-001

Public Access - 8 Cognitive Benefits of Playing Video Games for Kids. (n.d.). Retrieved

December 15, 2017, from Engadget website: https://www.engadget.com/2017/02/09/8-

cognitive-benefits-of-playing-video-games-for-kids/

R, D., & Kulman, y. (2015, March 4). Why Is Minecraft So Appealing to Children With

ADHD? Retrieved December 14, 2017, from LearningWorks for Kids website:

http://learningworksforkids.com/2015/03/minecraft-appealing-children-adhd/

R, Kulman, y, & Ph.D. (2014, November 3). Video Games Can Help Kids with ADHD – If

You Choose Wisely. Retrieved December 14, 2017, from ADDitude website:

https://www.additudemag.com/video-games-help-adhd/

Randy Kulman. (13:47:16 UTC). CHADD 2014 Should Children with ADHD Play Minecraft?

Healthcare. Retrieved from https://www.slideshare.net/rklearningworks/chadd-with-

book-pictures-for-slideshare

Rehbein, F., Psych, G., Kleimann, M., Mediasci, G., & Mößle, T. (2010). Prevalence and Risk

Factors of Video Game Dependency in Adolescence: Results of a German Nationwide

Survey. Cyberpsychology, Behavior, and Social Networking, 13(3), 269–277.

https://doi.org/10.1089/cyber.2009.0227

102

Rieger, D., Reinecke, L., Frischlich, L., & Bente, G. (2014). Media Entertainment and Well-

Being—Linking Hedonic and Eudaimonic Entertainment Experience to Media-Induced

Recovery and Vitality. Journal of Communication, 64(3), 456–478.

https://doi.org/10.1111/jcom.12097

Riia Luhtanen, & Jennifer Crocker. (1992). A Collective Self-Esteem Scale: Self-Evaluation

of One’s Social Identity. Personality and Social Psychology Bulletin, 18(3), 302–318.

https://doi.org/10.1177/0146167292183006

Riordan, B. C., & Scarf, D. (2016). Crafting minds and communities with Minecraft.

F1000Research, 5, 2339. https://doi.org/10.12688/f1000research.9625.2

Ritterfeld, U., Cody, M., & Vorderer, P. (2009). Serious Games: Mechanisms and Effects.

Routledge.

Safren, S. A., Otto, M. W., Sprich, S., Winett, C. L., Wilens, T. E., & Biederman, J. (2005).

Cognitive-behavioral therapy for ADHD in medication-treated adults with continued

symptoms. Behaviour Research and Therapy, 43(7), 831–842.

https://doi.org/10.1016/j.brat.2004.07.001

Sanchez, R., Brown, E., Kocher, K., & DeRosier, M. (2017). Improving Children’s Mental

Health with a Digital Social Skills Development Game: A Randomized Controlled

Efficacy Trial of Adventures aboard the S.S. GRIN. Games for Health Journal, 6(1), 19–

27. https://doi.org/10.1089/g4h.2015.0108

Saunders, B., & Chambers, S. M. (1996). A review of the literature on Attention-Deficit

Hyperactivity Disorder children: Peer interactions and collaborative learning. Psychology

in the Schools, 33(4), 333–340. https://doi.org/10.1002/(SICI)1520-

6807(199610)33:4<333::AID-PITS8>3.0.CO;2-N

103 scared anxiety scale.pdf. (n.d.).

Schall, J., Wallace, T. L., & Chhuon, V. (2016). ‘Fitting in’ in high school: how adolescent

belonging is influenced by locus of control beliefs. International Journal of Adolescence

and Youth, 21(4), 462–475. https://doi.org/10.1080/02673843.2013.866148

Schindler, C. K. (2016). The role of personality traits, social anxiety, depressive symptoms,

and other psychosocial factors in the motivation for social internet use. Retrieved from

https://ttu-ir.tdl.org/ttu-ir/handle/2346/68039

Scott, S., & Dadds, M. R. (2009). Practitioner Review: When parent training doesn’t work:

theory-driven clinical strategies. Journal of Child Psychology and Psychiatry, 50(12),

1441–1450. https://doi.org/10.1111/j.1469-7610.2009.02161.x self-concept.pdf. (n.d.). selfdeterminationtheory.org - An Approach to human motivation & personality. (n.d.).

Retrieved December 15, 2017, from http://selfdeterminationtheory.org/

Sense of Belonging at School: Defining Attributes, Determinants, and Sustaining Strategies.

(n.d.). Retrieved December 14, 2017, from IAFOR website:

https://iafor.org/journal/iafor-journal-of-education/volume-5-issue-2/article-5/

Shaw, R., Grayson, A., & Lewis, V. (2005). Inhibition, ADHD, and computer games: the

inhibitory performance of children with ADHD on computerized tasks and games.

Journal of Attention Disorders, 8(4), 160–168.

https://doi.org/10.1177/1087054705278771

Skoric, M. M., Teo, L. L. C., & Neo, R. L. (2009). Children and Video Games: Addiction,

Engagement, and Scholastic Achievement. CyberPsychology & Behavior, 12(5), 567–

572. https://doi.org/10.1089/cpb.2009.0079

104

Slagle, M. (2017, December 4). Study suggests digital treatment through a video game could

improve attention in ADHD. Retrieved May 1, 2019, from DCRI website:

https://dcri.org/video-game-adhd/ social acceptance.pdf. (n.d.).

Spencer, T. J., Faraone, S. V., Surman, C. B. H., Petty, C., Clarke, A., Batchelder, H., …

Biederman, J. (2011). Toward defining deficient emotional self-regulation in children

with attention-deficit/hyperactivity disorder using the Child Behavior Checklist: a

controlled study. Postgraduate Medicine, 123(5), 50–59.

https://doi.org/10.3810/pgm.2011.09.2459

Steve Nebel, Sascha Schneider, Janine Schledjewski, & Günter Daniel Rey. (2017). Goal-

Setting in Educational Video Games: Comparing Goal-Setting Theory and the Goal-Free

Effect. Simulation & Gaming, 48(1), 98–130. https://doi.org/10.1177/1046878116680869

Stone, J. (n.d.). Communication Competence: Creating Satisfying Interpersonal Relationships.

Retrieved from

https://www.academia.edu/34624225/Communication_Competence_Creating_Satisfying

_Interpersonal_Relationships

Strahler Rivero, T., Herrera Nuñez, L. M., Uehara Pires, E., & Amodeo Bueno, O. F. (2015).

ADHD Rehabilitation through Video Gaming: A Systematic Review Using PRISMA

Guidelines of the Current Findings and the Associated Risk of Bias. Frontiers in

Psychiatry, 6. https://doi.org/10.3389/fpsyt.2015.00151

Swan, K., & Ray, D. (2014). Effects of Child-Centered Play Therapy on Irritability and

Hyperactivity Behaviors of Children With Intellectual Disabilities. The Journal of

Humanistic Counseling, 53. https://doi.org/10.1002/j.2161-1939.2014.00053.x

105

Swan, K., & Schottelkorb, A. (2014). Contact work in child-centered play therapy: a case

study. Person-Centered & Experiential Psychotherapies, 14, 1–17.

https://doi.org/10.1080/14779757.2014.976798

Tahmassian, K., & Jalali Moghadam, N. (2011). Relationship Between Self-Efficacy and

Symptoms of Anxiety, Depression, Worry and Social Avoidance in a Normal Sample of

Students. Iranian Journal of Psychiatry and Behavioral Sciences, 5(2), 91–98.

Trisolini, D. C., Petilli, M. A., & Daini, R. (2017). Is action video gaming related to sustained

attention of adolescents? The Quarterly Journal of Experimental Psychology, 0(ja), 1–21.

https://doi.org/10.1080/17470218.2017.1310912

T_Shelton_Parenting_1992.pdf. (n.d.). Retrieved from

https://libres.uncg.edu/ir/uncg/f/T_Shelton_Parenting_1992.pdf

(uk), N. C. C. for M. H. (2013). SOCIAL ANXIETY DISORDER. Retrieved from

https://www.ncbi.nlm.nih.gov/books/NBK327674/ video game rock and roll quote - Google Search. (n.d.). Retrieved May 8, 2019, from

https://www.google.com/search?client=safari&rls=en&biw=927&bih=818&tbm=isch&s

a=1&ei=Qf7SXPqlGeTF_QaLtb74AQ&q=video+game+rock+and+roll+quote&oq=vide

o+game+rock+and+roll+quote&gs_l=img.3...5519.9882..10039...1.0..1.212.2331.28j2j1..

....1....1..gws-wiz-

img...... 0j0i67j0i8i30j0i30j0i24.DBdaatYKdBc#imgrc=EdYzCKepDHmIDM:

Violent video games and aggressive behavior in young women - Anderson - 2003 -

Aggressive Behavior - Wiley Online Library. (n.d.). Retrieved May 8, 2019, from

https://onlinelibrary-wiley-com.go.libproxy.wakehealth.edu/doi/abs/10.1002/ab.10042

106

Wang, C. K. J., Khoo, A., Liu, W. C., & Divaharan, S. (2008). Passion and Intrinsic

Motivation in Digital Gaming. CyberPsychology & Behavior, 11(1), 39–45.

https://doi.org/10.1089/cpb.2007.0004

Wehmeier, P. M., Schacht, A., & Barkley, R. A. (2010). Social and Emotional Impairment in

Children and Adolescents with ADHD and the Impact on Quality of Life. Journal of

Adolescent Health, 46(3), 209–217. https://doi.org/10.1016/j.jadohealth.2009.09.009

Weis, R., & Cerankosky, B. C. (2010). Effects of video-game ownership on young boys’

academic and behavioral functioning: a randomized, controlled study. Psychological

Science, 21(4), 463–470. https://doi.org/10.1177/0956797610362670

Wells, K. C., Pelham, W. E., Kotkin, R. A., Hoza, B., Abikoff, H. B., Abramowitz, A., …

Schiller, E. (2000). Psychosocial Treatment Strategies in the MTA Study: Rationale,

Methods, and Critical Issues in Design and Implementation. Journal of Abnormal Child

Psychology, 28(6), 483–505. https://doi.org/10.1023/A:1005174913412

Wendel, V., Gutjahr, M., Battenberg, P., Ness, R., Fahnenschreiber, S., Göbel, S., &

Steinmetz, R. (2013). Designing a collaborative serious game using Minecraft. 7th

European Conference on Games Based Learning, ECGBL 2013, 2, 569–578.

Whalen, C. K., Odgers, C. L., Reed, P. L., & Henker, B. (2011). Dissecting daily distress in

mothers of children with ADHD: an electronic diary study. Journal of Family

Psychology: JFP: Journal of the Division of Family Psychology of the American

Psychological Association (Division 43), 25(3), 402–411.

https://doi.org/10.1037/a0023473

What is Flow in Psychology? Definition and 10+ Activities to Induce Flow. (2019, January 8).

https://positivepsychologyprogram.com/what-is-flow/

107

Wilens, T. E., Biederman, J., Brown, S., Tanguay, S., Monuteaux, M. C., Blake, C., &

Spencer, T. J. (2002). Psychiatric Comorbidity and Functioning in Clinically Referred

Preschool Children and School-Age Youths With ADHD. Journal of the American

Academy of Child & Adolescent Psychiatry, 41(3), 262–268.

https://doi.org/10.1097/00004583-200203000-00005

Williams, R. (2016, October 31). And breathe: the computer games helping kids relax. The

Guardian. http://www.theguardian.com/lifeandstyle/2016/oct/31/breathtaking-winners-

the-computer-games-helping-kids-relax

Yen, et al.. (2007). The Comorbid Psychiatric Symptoms of Internet Addiction: Attention

Deficit and Hyperactivity Disorder (ADHD), Depression, Social Phobia, and Hostility.

Journal of Adolescent Health, 41(1), 93–98.

https://doi.org/10.1016/j.jadohealth.2007.02.002

Zeman, J., Klimes-Dougan, B., Cassano, M., & Adrian, M. (2007). Measurement Issues in

Emotion Research With Children and Adolescents. Clinical Psychology: Science and

Practice, 14(4), 377–401. https://doi.org/10.1111/j.1468-2850.2007.00098.x

Zwi, M., Jones, H., Thorgaard, C., York, A., & Dennis, J. A. (2011). Parent training

interventions for Attention Deficit Hyperactivity Disorder (ADHD) in children aged 5 to

18 years. Cochrane Database of Systematic Reviews, (12).

https://doi.org/10.1002/14651858.CD003018.pub3

108

APPENDICES

Appendix A

Bracketing of Experiential Bias

The research for this study stemmed from the author’s observations over the past four years of her 10-year old son Dashiell, and 8-year old daughter Cora Belle. Dashiell was diagnosed with ADHD in the first grade, and Cora Belle in the second grade. I received both diagnoses after several years of behavioral issues in school, followed by appointments with occupational and behavioral specialists. The ADHD formal diagnosis was documented by Sloan Academics, an independent psychologist specializing in educational and psychological assessment and support. Dashiell and Cora were found to have very high IQ’s with emotional, behavioral and academic functionality that was approximately three years behind that of their peers.

Before and after their diagnoses, I did the following in an attempt to lessen their disruptive ADHD behaviors;

allergy testing gluten, sugar, and dye dietary alleviation, scheduled naps up until the age of 6 (even using locked crib tents to keep them in the bed) scheduled bedtimes and meal routines psychological testing counseling social skills play groups BPT (through the Positive Parenting book and website, not group meetings) reward based behavior charts and lists time-outs vitamin supplements and other holistic medicines acupuncture Taekwondo co-sleeping/attachment parenting shadowing in the classroom IEP’s days of homeschooling

109

involvement in sports after school group activities yoga mindfulness/breathing exercises stimulant medication to help with restlessness at night - melatonin and massage

Psychological testing was a very helpful assessment and has been an essential component in establishing the Independent Education Plan (IEP) for each child. The supports that are a part of the IEP’s – extra time on tests, writing in booklet, talk to text, being separated from other children during testing - have all enabled academic gains. It’s important to note that my children go to an Arts Based Charter School, which has a small class size and extremely supportive community, so these results are not typical.

Social skills behavior and BTP were not well received by the children and had no successful results. Dietary changes made no difference in behaviors at home or at school.

Bedtime routines are essential, variation from the routine results in additional dysregulated behaviors. Stimulant medication has shown some positive results in oppositional and off task behaviors in school but increases behaviors at home (when the medication wears off) and has done nothing to aid with peer relationships or social cue awareness. Group sports are helpful with expelling excess energy but problematic with peer relations and off task behavior. Private counseling has minimally helped support peer anxiety and self-efficacy issues. We have had an attachment parenting, family bed since the children were very young. Every attempt to move away from the family bed has resulted in increased anxiety, sporadic bedwetting and frequent night waking.

Some of these measures have helped with specific issues, but none have shown long term effectiveness in multiple domains. Both children continue to co-sleep with me, have extremely disruptive behavioral issues, need academic support, perform below their

110 capacity at school, and have worrisome peer relationship issues. Dashiell frequently says that he has no friends at school. Cora has many friends but remains in a state of anxiety surrounding her friendships.

Dashiell takes Adderall, which has helped somewhat with focus and impulse issues at school. Behaviors at home, once the medication wears off, have increased. Cora experienced too many negative side effects for medication to be effective. Dashiell’s dysregulation at the end of the day increases Cora’s irritability. She is sensitive to the fact that he has trouble regulating the volume of his voice, and to his intrusion into their shared space. At the end of the day, Dashiell’s negative attention seeking behaviors increase. Cora is more able to control her behaviors at school, but then explodes with them when she gets home. She is increasingly more intolerant of her brother at home than at school. This type of behavior tracks through summer vacation. Cora is more tolerant of her brother and his behaviors when she is not coming out of a social engagement, like a sleep over or camp.

My initial experience with ADHD occurred when my son Dashiell was a toddler.

He was never still, always happy, insatiably curious and into everything. Mealtimes consisted of food in the cracks and crevices of every surface and Dashiell wiggling fruitlessly to free himself from the straps of his high chair. At the age of four he disassembled and reassembled a seesaw so that the pieces fit together, just not as a functioning seesaw. He was kicked out of three play schools for impulsive and disruptive behavior. I told myself that those schools were not the right fit for him, and spent hours researching un-schooling, positive playschools, and child-led learning. When we would go to the local playground, Dashiell would insist on bringing a satchel of toys so that he

111 could share with all the other children. But something alarming started to happen. The other children didn’t want to play with him. Slowly, he started to be left out of birthday parties and playdates.

I noticed that he would get frustrated and do things like run through another child’s sand castle or tear up their Legos. He started getting picked on by other children and one day was dragged by his hair by one child, while two other children kicked him. I stopped talking to the other Mom’s and shadowed him to run interference when we were around other children. I bribed other Mothers, with cold wine and cheese, so that they would bring their child over to play. I read as many parenting books as I could and questioned why he was learning to speak much more slowly than his peers.

When the teacher at his very expensive new school, which was supposed to fit his personality perfectly, recommended that I take him for psychological testing, my heart sunk. I was getting messages from everyone around me that something was wrong with my beautiful child. I would later learn that he was part of the 11% of children with attention-deficit/hyperactivity disorder (ADHD) of the impulsive and inattentive nature.

A few years after Dashiell’s birth, my daughter Cora Belle was born. She was beautiful, full of life and soon to be diagnosed with ADHD as well.

The daily responsibilities of raising children elicits high levels of stress in adults with or without children with special needs (Cox, Own, Lewis, & Henderson, 1989). I love being a mother more than anything. That being said, the stress of being a single, working mother with a co-parent who lives across the country, is exacerbated by my children’s ADHD behaviors and social-psychological difficulties.

112

At ages 6 and 7, I took each child for extensive psychological testing, in order to understand their behaviors and hopefully figure out how best to support their needs. Each child exhibited extremely high levels of intelligence along with extremely high levels of

ADHD that was comorbidly occurring with dyslexia and generalized anxiety. Special attention to their education and social support was a necessity, which meant changing schools multiple times. We finally found a charter school that had the services, the desire to meet their unique strengths and needs, and a community into which they fit nicely.

Their ADHD causes inattention, which means that both children struggle to focus in class. Both tested far behind their academic capabilities which required that I go through a six-month process of testing’s, meetings, interviews, forms and more meetings in order to set up Independent Education Programs (IEP)’s for each of them. I hired private tutors to work with them 3-4 days a week and I struggled to make them work on reading and mathematical goals at home. At the age of 10, Dashiell caught up with his peers in reading and shot ahead. In one portion of a recent standardized test he was assessed as reading at an 11th grade level. Reading is now something that he can hyper focus while doing, which means everything else in the world melts away while he consumes books. He is in his Flow zone, sitting like a stone for hours while he absorbs page after page. Reading is one of the only times he is still. Cora Belle can similarly spend hours engrossed in math gamifications like Prodigy or Reflex Math online game programs. Her math skills recently also shot up and exceeded grade expectations. The only other time that the children have been so focused is when they watch media or play video games.

113

The social skill problems, that are a part of most ADHD children’s experience, have been much more difficult to address than my children’s academic issues. Both children see the school guidance counselor weekly and have outside therapists who address and support the accompanying social anxiety of their ADHD. My daughter is able to make and keep friends at school but the process of keeping her impulsive behaviors in check is very stressful. She frequently comes home and dissolves into tears, picks fight that lead to screaming tantrums, and engages in physical altercations with her brother that involve kicking, scratching, biting and hitting.

Dashiell has always struggled to make and keep friends. He intrudes on conversations and unknowingly violates people’s physical space. He tends to sing spontaneously and loudly, is slow to pick up on social cues, and has trouble controlling his body movements. Sometimes it looks as if he is performing a high-speed uncoordinated ballet of movements, while other times he resembles a long-limbed baby deer, on ice. These behaviors frustrate other children and have led to him being bullied, left out of social activities, rarely asked to attend play dates, being sidelined in sports and has created feelings of insecurity and a lack of belonging.

Both Dashiell and Cora Belle have attended social skills training classes, been given reward-based sticker charts, magnet boards, check lists, and goals that correspond to behaviors. Daily routines are posted in the house. We’ve read books that discuss successful behaviors. Twice a month they work with a small school group of other

ADHD children, they’ve had privileges taken away, been promised or lost allowances but nothing seems to work. As a parent you want your child to have good friends and to have a grounded sense of belonging; you want them to succeed at school; you want to teach

114 them good habits, like keeping their room clean and being organized with their school work. I have worked hard to support my children, their education, and their social network. In the process, they have had to watch me lose my cool or break down and cry on more than one occasion.

When my children were 6 and 4, they were introduced to the sandbox video game

Minecraft by a teenage babysitter. Minecraft can be compared to a three-dimensional, procedurally generated, virtual Lego world. The game has no rules, the player learns by playing and by watching YouTube videos or online postings of things other players have learned. It’s a game that demands creativity, exploration, resource gathering, crafting, collaboration, and sometimes combat. In our house, Minecraft allowed for a unique experience to occur. When my highly combative children played the game together, they worked collaboratively and peacefully for hours. It was rare for them to be in such close quarters and not impeding on one another’s space, struggling for control, and ultimately fighting. They were taking turns, sharing, not breaking anything, and no one was running to me in hysterics.

Part of Dashiell’s ADHD involves proprioceptive processing issues, meaning that he lacks the nonverbal communication awareness of personal space and he regularly bumps into people and things. Proprioceptive processing means that he frequently, and accidentally, knock things off surfaces, topples furniture over, and mistakenly pulls drawers out. The combination of these behaviors can irritate the people around him enormously. While watching him play Minecraft, and later Roblox and Disney Infinity. I noticed that Dashiell seemed much more in control of his body. He was so focused on the game play that he was not intruding into Cora’s personal space. He exhibited little to no

115 fidgeting, and he wasn’t excessively moving and leaning on or touching things. It seemed as if this impulse was being soothed through the game play. I watched amazed as he happily sat, fairly still, and played quietly with his sister. The goals that he was trying to accomplish in the game – build his house, mine, set up a farm etc. - seemed to override his typical impulses toward attention seeking behaviors and help him control his body in space. Seeing both children so calm and focused was of particular interest, especially regarding Dashiell, whose social and spatial issues were much more severe than were his sisters.

I had always adhered to the pediatric warnings that suggested limiting screen time. My children were allowed little or no screen time during the school week and a few hours on the weekend. Watching Dashiell and Cora build structures and install lighting, share resources and skills, laugh, talk and work together collaboratively made me rethink my media rules. It also gave me a moment of peace in the typical chaotic turmoil of my children’s behaviors. I decided to see what would happen if I gave them longer amounts of time to play together. I was curious as to whether their bickering and power struggles would diminish. This also made me reflect on Dashiell’s social situation, or lack thereof.

Would he be able to have more successful playdates if the kids he invited over engaged in this type of non-competitive, collaborative VGP? I decided to try it out.

Historically Dashiell’s playdates would find me engaging the kids in non-digital play like riding scooters, playing a board game, Lego’s etc. while I stayed close at hand to run interference when the playdate would invariably start to go off the rails. With the new Minecraft playdate time I started by telling Dashiell, and an ADHD child from his class, that they could play Minecraft together, but they had to follow 3 rules.

116

Rule number one: they had to be collaborative and work together.

Rule number two: no one could destroy anything that another person had built.

Rule number three: they had to co-operate and could not fight.

They were ecstatic to play and eagerly discussed the YouTubers they watched, skills they had learned and wanted to try, and described the things they wanted to build.

Over a six-month period, I rotated through playdates with 3 boys who were between 6 and 8 years old, all of whom have ADHD, and one 7-year old boy without

ADHD. For the majority of time they were playing together at my house, I let them play

Minecraft. At the start of setting up these playdates, I had to stay close to the game room in order to reinforce the rules, settle fights, remind them to collaborate, and make sure that no one impulsively destroyed something another person had made. The drive to tear up another kid’s creation is a common ADHD impulsive behavior. The last 45 minutes of the playdate I would ask them to go outside to play, or to engage in some kind of non- digital play. Initially there were some issues with trying to redirect the VGP and some accompanying dysregulated behaviors. But as subsequent follow up playdates occurred, the transitions and post-game play all became smoother.

After a child had come to two or three playdates, I found that I no longer had to hover outside the door in order to reinforce the rules. When the kids were on their own, outside of the world of their game, they would independently research websites,

YouTube videos and discussion forums that offered tips and techniques. When they next got together, they discussed these YouTubers in a personal manner, as if they all shared a close friend. They collected and evaluated strategies and concepts developed by these other players. They compared, contrasted and used these strategies to create unique

117 solutions and ways to use resources, all in pursuit of accomplishing specific goals. They were collaboratively creating the game along with their role in it, and they were also creating their relationship to a wider world of Minecraft identity and community the longer they played. Although I now faced a new struggle, my kids wanting to play these video games all the time, I found the whole process fascinating.

A few months into these playdates I noticed that Cora’s irritability and Dashiell’s self-esteem both seemed to be improving. Both of their self-soothing behaviors of finger nail biting, and Dashiell of chewing on his shirt, started to lessen. When I took the children to the park, Cora didn’t immediately run away from her brother, she invited him to play with her and the other children, and Dashiell relied a bit less on impulsive behaviors.

Prior to this trail run of playdates, going to school had been a heart heavy process that filled all of us with anxiety. We would frequently have bouts of tears, and whining.

Dashiell complaining that no one liked him, and that no one wanted to sit with him at lunch. Little by little he stopped clinging to me at the door of the school, begging me to take him home. In a conference with his teacher I was told that his friendships in the classroom were improving. He had two friends, one I had been setting up playdates with and another friend. They had started getting together to draw Minecraft worlds during recess. Eventually they branched out and began creating comic books together about subjects outside of Minecraft.

It seemed to me that playing multiplayer Minecraft with friends had helped to calm my kids socially and behaviorally, especially Dashiell. The research indicates that impulsive, inattentive, disruptive behaviors are more prevalent in boys with ADHD

118

(Skogli et. al, 2013). It seemed that Dashiell’s experience of repeated successful social interactions inside the ever-expansive world of a multiplayer game was generating social gains of confidence and feelings of belonging. The successful digital play was making non digital play not just possible but more successful.

The VGP initially provided an opportunity for Dashiell and Cora to practice calmer, more collaborative, and cooperative play, working together to succeed in their shared gaming goals. The time they spent playing the video games calmed some of the fraught family dynamics, both inside and outside of the game play. I noticed improvements in Dashiell and Cora’s ability to share, cooperate and navigate leadership roles in their analogue existence and an increase in their desire to play together.

Spending time creating and navigating this world of VGP seemed to help Dashiell discover a sense of belonging amongst his peers and increased his confidence socially. As he continued to experience increases in social self-efficacy and interaction, my worry and stress, regarding his peer difficulties, improved, as did my sleep, followed by my irritability with the kids. Of my two children only Dashiell showed an obsessive, almost dangerously addictive, drive to play video games. I was curious as to how much of this was due to increases in a sense of belonging and peer connectivity that he received through VGP and how much might be related to the appealing addictive qualities that video games had for ADHD children. I wondered if the phenomena I was observing was unique to my experience and to our family.

These observations and questions guided my research on the relationship between parental stress, ADHD behaviors, social issues, conflict, anxiety and stress, educational uses of gaming, positive and negative aspects of VGP, research around gamification,

119 along with warnings about possible psychosocial maladaptive behaviors and addiction associated with routine VGP. The questions driving me were could the addictive nature of VGP engender child-led motivation to engage in game play that then acts as a behavioral therapeutic option? Could behavioral gameplay reduce parental stress? Would parents be open to video game behavior modifications or would the obsessive and addictive nature of VGP prevent them from exploring this as an option? Finally, what was the current research regarding ADHD digital support mechanisms, and would it be possible to combine that design and application research with multiplayer, sandbox commercial games in which children have agency, identity and social ties?

My research has looked to examine parent stress, the serious social and behavioral issues facing ADHD children, and the possible use of a digital, game based, behavior modification treatment protocol. This thesis has given an overview of the problem of

ADHD and parental stress then moved on to research regarding established behavioral modification techniques. It looked at the efficacy of behavioral parent treatments (BPT), the way in which these programs interact with gains or losses in parental stress and

ADHD child behavioral outcomes. I looked to summarize the use of gamification, or serious games, with regards to education and social outcomes. Then I explored the existing and emerging uses of digital and game-based interventions for ADHD children.

My research study involved interviews, Facebook data and questionnaires of parents of game playing ADHD children regarding their child’s behaviors, treatments they have explored, outcomes, perceived parent stress, and thoughts regarding their child’s relationship to VGP. I pilot tested parent’s thoughts and opinions about using a

120 child-led, self-motivating wearable gamification communication modification device

(WGCMD) as a behavior modification tool for the ADHD child.

Gamification, specifically for ADHD children, is a relatively new field of research. Parental adoption of game play as behavior support for ADHD is in its’ infancy, with little research available. The fledgling nature of this research, and my personal reflection of my own experience, led me to a qualitative methodology through which I looked to examine individual parents’ thoughts and beliefs. My theoretical assertion was that the behavioral and emotional gains a child actualizes through multiplayer video game play (MVGP) will improve social skills and increase self-efficacy. These gains are speculated to correlate to increases in belonging and reductions in feelings of isolation.

Opportunities for cooperative play within the multiplayer world of the game are expected to translate into individual and social gains outside of the digital play. These gains in social connection and rewarded behavioral control are anticipated to lessen parental stress. Lowered parental stress has been shown to improve well-being in both ADHD children and their parents.

Through this research I had hoped to learn whether other parents viewed their children’s relationships and experience with VGP as stress relieving or stress producing. I was looking to ascertain what parents thought about the potential for capitalizing on the

ADHD child’s addictive and compulsive desire for game play as a way to motivate children toward behavioral change via rewards realized digitally in highly sought-after multiplayer video game worlds. I wanted to understand parental thoughts about their likelihood to use a digital technology into which they could program tasks, time management expectations, behavioral and academic goals that linked to a socially shared

121 commercial sandbox video game. I further questioned whether agency in the shared VGP would motivate engagement in behavioral modifications and allow the child, not the parent, to monitor gains and losses. I speculated that the child’s desire for digital rewards, and social acknowledgement of rewards by peers, through shared MVGP, would be transformational and broadening and would create a situation in which desire for advancement in the game play would correspond with academic and social learning advancements will feeling like shared play.

“A baby is an inestimable blessing and bother” – Mark Twain

122

Appendix B Parent Stress and ADHD Behavior Modification

Start of Block: Informed Consent:

Q1 Parent Stress, ADHD Behavior Modification- Consent Form My name is Marti Mattox and I am communications graduate student of Wake Forest University who is conducting a research study. You are invited to participate in this research study. The purpose of this study is to investigate parent stress, child ADHD behaviors, and thoughts about video game play and behavior strategies.

You are invited to take an online survey that should take about 15 minutes. You will be asked questions about your child’s ADHD, your stress as a parent, video game play, ways you have dealt with your child’s behavior, and your thoughts about video game-based support for behavior problems. Your participation in this research is voluntary. If you do not wish to participate, please close your browser window. You may discontinue your participation at any time without penalty by closing your browser window. Any responses entered to that point will be deleted. You may also choose not to answer any question(s) you do not wish to answer for any reason. Please note that while in transmission on the internet, your responses may not be entirely secure. When completing the survey, please choose a location with adequate privacy and internet security.

The risks from participating in this study are not more than what would be encountered in everyday life. While we cannot promise you will benefit from participating in this study, we hope it will aid in understanding ADHD behaviors, video game play, and parental stress. The researcher will take the following precautions to protect the confidentiality of your information. The surveys will be conducted via Qualtrics. Qualtrics is an online survey tool that is account based, password protected, and protected from third party advertising and influence and the researcher has selected anonymized responses. Only the researcher will know the account's password and username, which will be stored on the researcher's password-protected laptop computer. Qualtrics servers have been tried and tested by most major corporations and government organizations that demand high level data security. Qualtrics offers Transport Layer Security (TLS) encryption (HTTPS) and survey security options like password protection and HTTP referrer checking. Qualtrics data is stored in data centers that are audited and SAS 70 certified. Qualtrics has SAS 70 Certification and meets the rigorous privacy standards imposed on health care records by the Health Insurance Portability and Accountability Act (HIPAA). All Qualtrics accounts are hidden

123 behind passwords and all data is protected with real-time data replication. Any participant contact information will be deleted and will never be linked to the data. If you have questions about this study, please feel free to contact Marti Mattox at: [email protected] or call: 323-369-4188. If you have questions about your rights as a research subject, contact the Office of Research and Sponsored Programs, 336-758- 5888, [email protected]. Please reference the study number, IRB #IRB00023402, in your message along with the study team and IRB contact information.

If you do not wish to participate in this study, you may exit this screen now or select ‘disagree. ‘We encourage you to print or save a copy of this page for your records (or future reference). By clicking "I agree", you indicate that you are at least 18 years old and that you agree to participate in this research project. You will advance to the survey.

o Agree o Disagree

End of Block: Informed Consent:

Start of Block: Demographic Information

Q2 What is your age?

o 18-24 years old o 25-34 years old o 35-44 years old o 45-54 years old o 55-64 years old

124

Q3 Please indicate your sex.

o Male o Female o Nonbinary

Q4 Please indicate your relationship to the child.

o Mother o Step-Mother o Father o Step-Father o Grandmother o Grandfather o Primary Caregiver Other

Q63 Please indicate your ethnicity.

______

Q5 Do you have a child who has been clinically diagnosed with ADHD?

o Yes o No

125

Q6 Does your child have any other diagnosis, dyslexia, dysgraphia, anxiety disorder, etc.

______

Q7 Do you have more than one child with special needs living in the home? If yes, please list the gender, age and diagnosis of the additional child or children.

______

Q8 Does your child enjoy playing video games?

o Yes o No

Q9 On average, how many total hours a week does your child play video games? (Please include educational video games, like Prodigy or Reflex Math, in total hours of video game play.)

o 1-2 hours a week o 2-3 hours a week o 4-5 hours a week o 6-7 hours a week o More than 7 hours a week

126

Q10 Please indicate the age of your child.

o 1-3 years old o 4-5 years old o 6-7 years old o 8-9 years old o 10-11 years old o 12-13 years old o 14-15 years old o 16-17 years old

Q11 Are you a single parent?

o Yes o No

Q12 Do you work outside the home?

▢ Yes

▢ If yes, do you work part time?

▢ If yes, do you work full time?

▢ No

127

Q13 Do you have family or friends who regularly help with child care?

o Yes o No

End of Block: Demographic Information

Start of Block: ADHD Symptoms

128

Q14 Is your child currently taking medication for ADHD?

o Yes o No

129

Q15 Please consider the age of your child when rating these behaviors. When rating, Never Occasionally Often Very Often please think about your child's most recent behaviors.

Does not pay attention to detail, makes careless o o o o mistakes Loses things necessary for tasks or activities (toys, assignments, o o o o books) Does not seem to listen when spoken to directly o o o o Has difficulty organizing tasks and activities o o o o Is forgetful in daily activities o o o o Has difficulty waiting his or her turn o o o o Interrupts or intrudes in others' conversations o o o o and/or activities

Has difficulty playing quietly o o o o

130

Acts as if driven by a motor o o o o Has an explosive temper o o o o Runs or climbs when staying seated is expected o o o o Is fearful, anxious, or worried o o o o Is self-conscious or easily embarrassed o o o o Is afraid to try new things for fear of making o o o o mistakes Has problems with making or keeping friends o o o o Feels lonely, unwanted, or unloved o o o o Worries more than others (about being alone; illness or o o o o death)

Daydreams o o o o Excitable, impulsive

o o o o

131

Is touchy or easily annoyed by others o o o o Deliberately annoys people o o o o Gets into more trouble than others of the same age o o o o

132

Q16 Click the box that best Very often Never or Sometimes Often or describes your or very n/a not at all or somewhat much child IN THE much LAST MONTH Has problems with brothers & sisters o o o o o Causes problems with caregiver or between o o o o o parents Makes parenting difficult o o o o o Isolates the family from friends or social activities o o o o o Takes time away from family member's work or o o o o o activities Provokes others to scream at him/her o o o o o Excessively uses TV, computer, or video games o o o o o Has problems getting ready for school or bed o o o o o

133

Has problems with completing tasks in a timely manner, o o o o o eating, dressing, etc. Causes problems at school o o o o o Receives time outs or detention o o o o o Misses classes or is late for school o o o o o Has difficulty keeping up with homework o o o o o Receives grades that are not as good as his/her ability o o o o o Is teased or bullied by other children o o o o o Has problems getting along with other children o o o o o Has problems participating in sports, music, clubs o o o o o Has difficulty with parties (not invited, avoids them, o o o o o misbehaves)

Has problems making friends o o o o o

134

Has problems keeping friends o o o o o My child feels bad about himself/herself o o o o o My child feels frustrated by not being able to control his/her o o o o o behavior My child is calmed by TV, computer and video game o o o o o play My child feels socially connected when engaged in multiplayer o o o o o video game play My child is agitated by playing video games o o o o o My child is aggressive after playing video games o o o o o My child feels confident when playing video games o o o o o

135

Q61 Does your child play violent video games rated M for mature?

o Yes o No

End of Block: ADHD Symptoms

Start of Block: Behavior Modifications

Q17 What behavior modifications have you used with your child, please check all that apply.

136

Q17 What behavior modifications have you used with your child, please check all that apply.

o Parent-Child Interaction Therapy (ages 2-7, 14-17 weekly sessions) o Parent Management Training (ages 3-13, 10 weekly sessions) o Positive Parenting Program (ages 2-17, 12 weekly sessions o The Incredible Years (2-12, 12-20 weeks) o Parenting Coach o Play Therapy o Cognitive Therapy o Sticker Charts o Checklists o Timers, alarms o Daily Report Cards o Time out's o Taking away electronics o Taking away sweets o Taking away toys o Taking away privileges (play dates) o Role playing rewards and consequences o Point/token systems o Behavioral Books o ADHD behavioral videogames

137

o ADHD APPS o Spanking o Monetary rewards o Elimination diets o Allergy testing o Supplements o Biofeedback, EEG Training

Q18 Of the behavioral modifications that you have used, please describe which interventions worked, which didn't work, and why. Please mention if some methods worked in the beginning but failed to work long term.

______

End of Block: Behavior Modifications

Start of Block: Perceived Stress Scale

138

Q19 These questions ask you about how often you have felt or thought Almost Never Sometimes Fairly Often Very Often a certain Never way during the last month.

In the last month, how often have you felt unable to cope with all o o o o o the things you have to do? In the last month, how often has your parenting felt o o o o o unmanageable? In the last month, how often have you felt that you were able to control the o o o o o important things in your life? In the last month, how often have you felt difficulties were piling up so high you o o o o o could not overcome them? In the last month, how often have you lost your o o o o o temper with your child?

139

In the last month, how often have you felt on top of o o o o o things? In the last month, how often have you used electronics as a babysitter, so o o o o o that you can get things accomplished? How often have you felt confident in your parenting o o o o o decisions? How often have you been upset because of something that happened o o o o o with your child? How often have you felt unable to control your child's behavior at o o o o o home and in public? In the last month, how often has your child's use of video game o o o o o play lessened your stress?

140

In the last month, how often has your child's use of video game o o o o o play increased your stress? How often has your child's behavior affected your family in o o o o o general? How often have you felt confident in your ability to handle your o o o o o personal problems? In the last month, how often have you been upset because of something that o o o o o happened unexpectedly? In the last month, how often has your child's desire for video game o o o o o play felt unmanageable? In the last month, how often has your child's behavior o o o o o caused you stress?

141

In the last month, how often has your child's behavior affected his or her o o o o o relationships with other children?

End of Block: Perceived Stress Scale

Start of Block: Video Game Play

Q20 How would you describe your child's relationship to video games? (Example: Take it or leave it, highly enjoyable, obsessive, addictive etc.)

______

Q21 Which type of game play does your child enjoy most? (Example: Single player games alone, Single player games taking turns with other children, Multiplayer games with other children)

______

Q22 What type of device does your child typically use when playing video games and what are their favorite games? (Ex: PlayStation, X-box, Tablet, Phone, Computer etc. Minecraft, Fortnite, Disney Infinity, Grand Theft Auto etc.,

______

142

Q24 Have you used any APPS or games designed to help support or guide your child's ADHD behavior? If yes, please explain.

______

Q25 Do you view your child's video game play as a positive or negative activity? Please explain.

______

Q26 Does video game play increase or decrease your parental stress, or is it unrelated? Please explain below.

______

143

Q27 Please rank the following statements as they relate to Never Rarely Sometimes Often Very Often your child's video game play.

My child is not interested in anything else when playing o o o o o video games I want to reduce the amount of time that my child plays video games, but I fail o o o o o every time I try My child forgets their problems when playing video games o o o o o I am unable to control my child's use of video games o o o o o My child cannot resist playing video games o o o o o In video game play, defeating enemies/leaping up a level gives my child o o o o o pleasure. In video game play, defeating enemies/leaping up a level gives my child o o o o o increases in self esteem

144

My child has more successful social interactions when playing video games o o o o o than in other types of play My child becomes agitated and aggressive after playing video o o o o o games My child is calmed by playing video games o o o o o My child is more focused when playing video games than at o o o o o any other time My child thinks video games are a very enjoyable activity o o o o o

End of Block: Video Game Play

Start of Block: Digital Behavior Modifications

Q28 Have you used ADHD games for your child? Ex: Chore Monster, Epic Win, Settle Your Glitter, etc.? If so, please describe your experience.

______

145

Q30 If you have never used any ADHD games with your child, how likely are you to try one? Please discuss any positive or negative thoughts related to gamification and your ADHD child.

______

End of Block: Digital Behavior Modifications

Start of Block: Block 8

Q62 How likely would you be to let your child use a wearable device that did the following? Allowed you to program a list of expected behaviors/tasks for your child Allowed you to assign each behavior/task an expected amount of time Reminded your child to stay on track and on time Tracked your child's successes and failures Rewarded successful behavior/time management within your child's favorite multiplayer video game Ex. Rewards = gaining digital cash in Roblox

o Extremely likely o Likely o Not likely o Never

End of Block: Block 8

Start of Block: Digital Behavior Modifications

146

Q32 Please select '4' as the correct answer to the following question: 2+2 = ?

o 6 o 8 o 4 o 7

Q33 Thank you for participating in this research project. If you are interested in being interviewed about these topics, please contact Mart Mattox: email: [email protected] cell: 323-369-4188

End of Block: Digital Behavior Modifications

147

Appendix C

Interview Demographic Questionnaire

1. Date questionnaire completed ______2. Your age ______3. Your gender ______4. Ethnicity ______5. Age and gender of your child/ren ______6. Number of children ______7. Your occupation ______8. Marital status: (circle your answers) single married never married remarried divorced widowed cohabitating 9. If you have a partner, what is their age, gender and occupation? ______10. Is your child involved in any activities? e.g. sports, afterschool programs Y/N If yes, what does she/he do? ______11. How many of family members live in your house, what are their ages? ______12. How many of your family live nearby and where do they live? ______(circle your answers) Next door next street same neighborhood same town other______13. Do you have any relatives or friends who help you? Y/N If yes, what kind of help do they give? Financial emotional house work other ______14. Have you ever been diagnosed with ADHD? Y/N 15. Have any other of your child(ren) been diagnosed with ADHD? ______16. Do your child(ren) take medication or supplements for ADHD? If yes, what do they take? ______17. Have your child(ren) been diagnosed with any other special needs? Y/N_ If yes, what is their diagnosis?______18. Have you been diagnosed with anxiety or depression? Y/N 19. Have your ADHD child(ren) been diagnosed with anxiety or depression? Y/N 20. Does your ADHD child(ren) need special educational support? Y/N If yes, what type of support?______21. Have you tried behavior modification with your child(ren)? Y/N (circle any that has been tried)

Parent Management Training

148

Parent-Child Interaction Therapy Positive Parenting Program The Incredible Years Hiring a parenting coach Play Therapy/Counselling Cognitive Therapy Traditional One-on-One Therapy Sticker Charts Times, alarms Daily Report Cards Time Outs Spankings Taking away electronics Taking away sweets Taking away toys Taking away privileges (play dates) Role playing reward and consequences Points/tokens systems Behavioral Books ADHD behavioral videogames ADHD APPS Monetary Rewards Elimination diets Allergy Testing Supplements Biofeedback, EEG Training ______22. If you have used behavior interventions, how effective have they been? 23. Does your child(ren) regularly play video games? Y/N If yes, how important are video games to your child? ______

24. Does your child(ren) use any ADHD supportive video games or APPS? Y/N If yes, how long have they been using gamification / ADHD APPs or video games? ______

25. How many hours a week, on average, does your child(ren) spend playing video games, Including educational VGP at school?______

26. Does VGP affect your child(ren)’s ADHD behaviors? If yes, how are your child(ren)’s behaviors affected? ______

149

Appendix D

Interview Questions If participant has completed the questionnaire, many of the questions below will be redundant and will not be asked. The interview is meant to provide deeper insight into the research topic. The researcher has compiled a comprehensive list of potential questions. This list does not indicate that every question will be asked during the interview, only that specific interview questions will be drawn from and guided by this inclusive list.

1. When did you first notice that your child has ADHD? What was your experience physically, emotionally? 2. How has your/child(ren)’s behaviors been received by family, friends, peers, and school? 3. How much does your child(ren)’s ADHD affect your child’s life, your family and you? 4. How often do you feel you need help? 5. How often do you feel your child(ren)needs help? 6. Does your child have difficulties socially/making friends/keeping friends/being invited on playdates or to birthday parties/being bullied/feeling left out? 7. What are your feelings about being a parent? Where do you get most advice/support? 8. How often do you feel overwhelmed by your child(ren)’s behaviors? 9. How often do you feel overwhelmed and stressed? 10. How much of your stress is related to parenting your ADHD child? 11. Does your child have difficulty following direction? 12. Does your child have difficulty with time management? 13. Does your child have difficulty staying on task? 14. What is your child(ren)’s most problematic behaviors? 15. Does your child ever focus intently (hyper focus) on something, almost as if everything else has disappeared? If yes, what do they hyper focus on? 16. Do you feel your child is smarter than is reflected in their academic performance? 17. What types of behavior modifications techniques have been helpful, and which have not? Please explain 18. How long have you (or did you) participate in specific behavior modifications? 19. If you stopped participating, what caused you to stop? 20. Do parent-led, parent-enforced behavioral techniques feel stress producing or stress relieving? 21. At what age did you realize your child(ren) had ADHD? 22. At what age did your child (ren) begin to play video games? 23. Do you allow your child(ren) to play violent video games, M-rated games? 24. Does your child(ren) prefer collaborative or competitive video games ex. Minecraft or Mario Carts? 25. Does your child(ren) prefer single player or multiplayer games? 26. How often does your child(ren)play video games in school, reflex math, prodigy, after school programs etc.?

150

27. How often does your child(ren) play video games at home? 28. How would you describe your child(ren) when he/she is playing video games as compared to when he/she is engaged in other activities? 29. What type of experience does VGP provide for your child(ren)? 30. Do you ever feel guilty regarding the amount of time your child(ren) plays video games? 31. Is it difficult to redirect your child(ren) to activities other than playing video games? 32. Do video games increase or decrease conflictual behaviors in your home? 33. If you have more than one child, do your children play video games together? 34. Do your child(ren) fight more when engaging in VGP than when engaged in other types of play? 35. Is VGP calming for your child(ren) or agitating? 36. Does your child(ren) play multiplayer games with other children? 37. Do you feel that your child(ren) learns from playing video games? 38. Do your child(ren) have more social ease or more social conflict when playing video games? 39. Does your child(ren) have online video game friends? 40. Do you think that VGP encourages or discourages a feeling of belonging in your child(ren)? 41. Does solo versus multi-player game play encourage or discourage feelings of belonging? 42. Are you aware that video games can be addictive, especially for ADHD children? 43. If yes, how do you address the issue of video game addiction with your child(ren)? 44. Do you think your child(ren) could benefit from behavioral modification VGP? 45. If yes, what type of digital intervention would be most helpful for your child(ren)? Time management, staying on task, finishing assignments, controlling volume, controlling body, being aware of social cues…. etc. 46. What, if any, are the multiplayer games that your child(ren) are most fond of playing? 47. What, if any, hesitation would you have about using gameplay as a behavioral support tool for your child(ren)? 48. Does your child(ren)’s VGP contribute to feelings of parenting stress? 49. Does your child(ren)’s VGP help lessen feelings of parenting stress? 50. Do you feel guilt regarding the amount of time your child(ren) plays video games? 51. How do the ways in which your child(ren) play in the digital world compare to the ways in which he/she plays in the analogue world? 52. Do you ever play video games with your child(ren)? 53. Do you have any other comments you want to add? 54. Imagine there was a device that you could program with your child’s behavioral and time management goals. For example: AM Get out of bed with alarm – x minutes Brush Teeth - x minutes Get dressed - x minutes

151

Walk dog/Make bed etc. - x minutes Eat - x minutes Free time - x minutes Gather school items – x minutes Get in car, seat belt fastened - x minutes (Point deductions for fighting with siblings/parent, exceeding time, getting off task etc.) The device would signal to the child when they were getting off task (vibrate/sound/graphic depiction of lost points) or encourage/reward them for staying on task (vibrate/sound/graphic depiction of gaining points) The points/rewards would link to gains/rewards in their favorite multiplayer video game (for ex. digital cash accumulation to use in Roblox). Possibly compete with friends and other ADHD children for point accumulation = child-directed behavioral modification. Would you consider using the technology? If yes, what are your thoughts? If no, what are your hesitations? Thank you for your participation!

152

Appendix E

BEHAVIORAL PARENT THERAPY EXAMPLES (BPT)

1.Parent Child Interaction Therapy

2. The Incredible Years

3. Positive Parenting Program – PPP

4. Parent Management Training Institute

5. COPE

1- Parent Child Interaction Therapy

PCIT is an evidence-based treatment for young children with behavioral problems.

The decision to whether PCIT is the most appropriate treatment for you and your child is between you and your mental health professional.

PCIT is conducted through "coaching" sessions during which you and your child are in a playroom while the therapist is in an observation room watching you interact with your child through a one-way mirror and/or live video feed. You wear a "bug-in-the- ear" device through which the therapist provides in-the-moment coaching on skills you are learning to manage your child's behavior.

PCIT is done across two treatment phases. The first phase of treatment focuses on establishing warmth in your relationship with your child through learning and applying skills proven to help children feel calm, secure in their relationships with their parents, and good about themselves. Desired outcomes of the first phase of treatment in PCIT include: • Decreased frequency, severity, and/or duration of tantrums • Decreased activity levels • Decreased negative attention-seeking behaviors (such as whining and bossiness) • Decreased parental frustration • Increased feelings of security, safety, and attachment to the primary caregiver • Increased attention span • Increased self-esteem • Increased prosocial behaviors (such as sharing and taking turns) The second phase of treatment will equip you to manage the most challenging of your child's behaviors while remaining confident, calm, and consistent in your approach to discipline. In this phase, you will learn proven strategies to help your child accept your limits, comply with your directions, respect house rules, and demonstrate appropriate behavior in public. 153

Desired outcomes of the second phase of treatment in PCIT include: • Decreased frequency, severity, and/or duration of aggressive behavior • Decreased frequency of destructive behavior (such as breaking toys on purpose) • Decreased defiance • Increased compliance with adult requests • Increased respect for house rules • Improved behavior in public • Increased parental calmness and confidence during discipline With consistent attendance and homework completion, PCIT can be completed within 12-20 sessions, though treatment is not time-limited. Treatment is considered complete when you have mastered both sets of skills and rate your child's behavior within normal limits on a behavior rating scale.

2 -The Incredible Years

The Attentive Parenting® program is a 6-8 session group-based “universal” parenting program. It can be offered to ALL parents to promote their children’s emotional regulation, social competence, problem solving, reading and school readiness. This is not a program for children with significant behavior or developmental problems or family mental health difficulties, although it may be used as a supplement to the Basic program or for follow up booster sessions. +Attentive Parenting® Program Topics § Attentive child-directed play promotes positive relationships and children’s confidence § Attentive academic and persistence coaching promote children’s language and school readiness § Attentive emotion coaching strengthens children’s emotional literacy and empathy § Attentive social coaching promotes children’s cooperative friendships § Attentive, imaginative parenting promotes children’s emotional regulation skills § Attentive, creative play promotes children’s problem solving and empathy For more details, please see the program Content & Objectives: Attentive Parenting Content and Objectives View the Attentive Parenting® Poster +Attentive Parenting® Program Description § 6 DVD set; shown in 6-8 sessions § Comprehensive Leader Manual § Parent weekly “Attentive Parenting® Tips” (brief points to remember from program) § Home Activities § Wally Detective Books (set of 4) § Incredible Toddlers: A Guide and Journal of Your Toddler’s Discoveries book § The Incredible Years: A Troubleshooting Guide for Parents of Children Aged 2-8 Years book § Attentive Parenting® Poster § Set of 6 stickers § Refrigerator Magnet

154

Supplemental materials support and enhance the programs and may be purchased separately. § Incredible Parents Conversation Card Game § Piggybank Poster § Incredible Years® Stickers (“You are incredible!” “I am an incredible parent!”) Purchasing Information +Implementation Cost Information Please see basic cost information provided below. This is meant to give a general overview of upfront and ongoing costs. Please don’t hesitate to contact us for more particular questions regarding program & book discounts, training costs, etc. UP FRONT COSTS: Attentive Parenting® Program: $1,050.00 (Purchase) Group Leader Training: Contact us if you are interested in attending training for this program. See Workshop Information. ONGOING COSTS: Books for parents The Incredible Years: A Troubleshooting Guide for Parents of Children Aged 2-8 Years: $17.95 per copy (if purchasing between 2-99 copies) Incredible Toddlers: A Guide and Journal of Your Toddler’s Discoveries: $18.95 per copy (if purchasing between 2-99 copies) Logistics: Venue for leading groups, Child care, Food CONSULTATION Be sure to plan for ongoing consultation by phone or in person for new group leaders. Consultation is conducted by certified Incredible Years® Mentors and Trainers. This early support and feedback ensure the parenting groups are delivered with fidelity and are successful. Consultation Fee: $200/hour CERTIFICATION Group Leaders are encouraged to apply for certification/accreditation, which promotes fidelity to the program by ensuring optimal outcomes. See Certification section for more details and information on pricing. Once Group Leaders are certified, they are eligible for training as an Incredible Years® Peer Coach to support to new group leaders as well as teachers. Coaching for teachers involves classroom observations and individual teacher and coach meetings. See Incredible Years Peer Coach Certification for more details. Learn more about Implementation TRIPLE P – POSITIVE PARENTING PROGRAM WHAT IS TRIPLE P? Triple P is a parenting program, but it doesn’t tell you how to be a parent. It’s more like a toolbox of ideas. You choose the strategies you need. You choose the way you want to use them. It’s all about making Triple P work for you. WHAT DOES TRIPLE P DO? The three Ps in ‘Triple P’ stand for ‘Positive Parenting Program’ which means your family life is going to be much more enjoyable. Triple P helps you: • Raise happy, confident kids • Manage misbehavior so everyone in the family enjoys life more • Set rules and routines that everyone respects and follows • Encourage behavior you like

155

• Take care of yourself as a parent • Feel confident you’re doing the right thing HOW DO YOU DO TRIPLE P’S POSITIVE PARENTING PROGRAM? Because all families are different, Triple P has a range of ways to get your positive parenting program. Choose anything from single visit consultations to public seminars; group courses to private sessions. You can even do Triple P Online, at home or wherever you like! DOES IT WORK? If you’re going to invest your time doing a parenting program, you want to be confident that you will get results. The Triple P – Positive Parenting Program has more evidence to back it up and show it works than any other parenting program in the world. Triple P has been tested with thousands of families over more than 35 years and been shown to help families in many different situations and cultures. In fact, Triple P’s evidence base now includes: • More than 800 international trials, studies and published papers, including • More than 280 evaluation studies, which also includes • More than 145 randomized controlled trials Triple P has been shown to help reduce kids’ and teens’ problem behavior and also reduce children’s emotional problems. The evidence also shows it helps parents feel more confident, less stressed, less angry and less depressed. And that’s positive!

3 - Parent Management Training Institute

Changing Lives, One Child at a Time

Is there a child in your life who is struggling with behavioral difficulties or anxiety? As mental health counselors it is our obligation to use programs that work, children deserve no less. So, here at the Parent Management Training Institute (PMTI) we specialize in evidence-based treatments for children between the ages of 2-17 who have moderate to very severe behavioral difficulties and/or anxiety. For a combined 25-years we have helped change the lives of thousands of children from all over the world. In order to reach people from far away who need our help, we have found great success conducting these programs online, on the phone and of course in-person.

Caregivers and Professionals Children PMT Training Treatment Programs Training is conducted at our clinic in Connecticut, at your Parent facility, online via WebEx, or you can purchase a recorded Management webinar to view at your convenience. Training Problem Solving Please click below for more information. Skills Training Basic PMT Training Coping Cat for Advanced PMT Training

156

Childhood Anxiety Certification in PMT Go-Zen for Case Consultation Childhood Anxiety ADHD Evaluations School Behavioral Consultation

Sessions are Conducted Online via Webex On the Phone or In-person

Did you know? Conduct disorders are the most common psychiatric disorders in children and persist into adulthood in about 50% of cases? The costs to families and society are high and impact many public sector agencies.

Parenting Management Training has been shown to significantly decrease childhood behavioral problems. The total savings to families and society over 25 years are estimated at $20,000 per family but the most significant positive impact is obviously on the lives of the children themselves!

4 -COPE Creating Opportunities for Personal Empowerment

FOR PRIMARY CARE PROFESSIONALS/PRACTICES, HEALTHCARE SYSTEMS AND SCHOOLS Programs 7-Session Manual-based Program Package $385 per instructor 15-Session Manual-based Program Package $450 per instructor

Annual Renewal* $250 per instructor FOR PARENTS/TEENS, PRIMARY CARE PROFESSIONALS/PRACTICES, HEALTHCARE SYSTEMS, SCHOOLS 7-Session Self-delivered Teen Online $79 per access code/teen

Note: Above prices do not reflect special limited-time promotional pricing discounts that may be in effect from time to time. Check Pricing/Order Forms pages for current pricing. Additional Student Manuals/Workbooks For use in the 7- and 15-Session Manual-based Programs. Each student/patient uses a separate manual/workbook. All prices are in U.S. Dollars. FOR PRIMARY CARE PROFESSIONALS/PRACTICES, HEALTHCARE SYSTEMS AND SCHOOLS Student Manuals 7-Session Child $20

157

7-Session Teen $20 7-Session Teen +HEP $25 7-Session Teen (Spanish version) $20 7-Session Young Adult $20 15-Session TEEN $32 15-Session TEEN (Spanish version) $32

Hard Copy Per Manual Price**. ** plus, shipping Print-Your-Own Manual Price *** $5/$8 *** A Print-Your-Own Student Manuals option is now available for larger schools/districts/providers (minimum 200/type , i.e. 7-session, Children, 7-Session Teen, etc., student manuals and additional manuals must be purchased in groups of 200 ) that provides a 75% savings off the printed manual price (contact us for further details). Discounted All-Inclusive Program Packages These packages are designed to allow schools and facilities to quickly train multiple instructors and cost-effectively provide relevant services to support specific needs of multiple students/patients. All-Inclusive Program Packages are currently only available in the United States. Package content varies but most include all program-delivery materials, multiple instructor training (24/7 online), student manuals/workbooks (in different formats), online teen self-delivered program (where applicable), printed student certificates of achievement, admission into the online instructors networking group and color program wall posters for bulletin boards. All prices are in U.S. Dollars. FOR GRADE SCHOOLS, MIDDLE SCHOOLS, HIGH SCHOOLS AND COLLEGES/UNIVERSITIES Programs 6th Graders: Elementary School Graduation Package (220 students) $2160 (separately: $2540) 7th Graders: Middle School Orientation Package (220 students) $2160 (separately: $2540) 8th Graders: High School Preparation Package (230 students) $2830 (separately: $3330) 9th Graders: High School Orientation Package (230 students) $2830 (separately: $3330) 9th Graders: High School Wellness Package (230 students) $2890 (separately: $3400) 12th Graders: College Preparation Package (230 students) $2830 (separately: $3330)

FOR PRIMARY CARE PROFESSIONALS/PRACTICES AND HEALTHCARE SYSTEMS Introductory Discounted All-Inclusive Program Package (28 patients) $870 (separately: $1022) Annual Renewal* $250/instruction

*Program Delivery License Renewal Options (pick one): 1. Payment of $250 Renewal Fee (click button below), or 2. Purchase of 20 hard-copy student manuals/workbooks or 200 Print-Your-Own Manuals since your previous license renewal date (per instructor). Does not include five manuals received with program purchase.

158

Annual renewal is waived for schools purchasing a Discounted, All-Inclusive Program Package. All prices are in U.S. Dollars. Helping Children, Teens and Young Adults Get Healthy, Happy and Hopeful Discover the COPE Program It's a fact that right now in the U.S., children, teens and young adults are not getting the mental health treatment they need. Many are on long waiting lists, and fewer than 25% are receiving help. According to the latest research, at least 5% of children and 9-20% of all adolescents suffer from depression, and the risk is even higher if their parents experience depression as well. And those numbers are even higher in minority populations. Common stressors/symptoms include: • Bullying • Weight Management/Obesity • Holidays • Back-to-school • Schoolwork/grades/academic performance • Sports performance • Relationships with friends and parents • Divorce/family disruption/new family • Romantic break-ups • Peer pressure/acceptance • Moving/new school • Transitioning from middle to high school • Low self-esteem • Headaches • Sleep disturbances • Social withdrawal/avoidance • Anger, irritability and aggression • Change in appetite • Feeling of hopelessness, sadness • Fear of failure • General/social anxiety • Pressure to succeed • Family loss or tragedy • Loss of a friend or classmate • Anxiety and depression - suicide Faced with these facts, it's clear that timely, evidence-based prevention and help for depressed and anxious children, teens and young adults is an absolute must. That is why the COPE Programs were created. COPE understands young people's needs and offers access to education and skills-building exercises to help prevent and manage negative emotions while enhancing healthy behaviors. Through a series of brief, easy-to-follow sessions, complete with skills-building activities, the evidence-based COPE Programs convey that there is hope for change, and that both depression and anxiety are treatable. COPE recognizes that we can't control trigger events, but we can control our responses to them. For less than the cost of just one session with a therapist, the COPE Program

159

teaches children, teens and young adults how to recognize and stop automatic negative thoughts and replace them with positive thoughts instead. The result is feeling emotionally better and behaving in healthy ways COPE uses colorful illustrations and animations to help explain concepts and practices. A variety of programs and delivery methods are available: • 7-Session Child (instructor delivered) • 7-Session Teen (instructor and self-delivered online) • 15-Session Teen Healthy Lifestyles (instructor delivered) How You Think Affects How You Feel and Behave The Science Behind the COPE Programs The COPE Programs are based on a Cognitive Behavioral Therapy-based skill-building approach that includes reducing negative thoughts, increasing healthy behaviors, and improving communications and problem-solving skills. When a person learns to COPE in positive ways, the brain lays down new pathways, helping him or her grow new neuronal connections and deal with stress, anxiety and depressive symptoms in healthy ways. By helping individuals change their thoughts from negative to positive, their feelings and behaviors naturally follow suit. Convincing children, teens and young adults that they can accomplish whatever it is that is important to them reinforces that what their mind believes they can achieve. COPE helps them face their fears and take control of their emotions. “COPE helped me to think a lot better about myself.” — Teen WHAT COPE PROVIDES COPE has been used effectively in clinics, K-12 schools and universities, and office practices in individual, group and classroom formats. Several separate studies* have shown that the evidence-based COPE Program results in reduced depressive and anxiety symptoms, as well as improved self-concept. COPE Gets Real Results! In a large High School-based COPE Trial, teens who participated in the program in comparison to teens who did not receive COPE had: • Higher average scores on the social skills specifically cooperation, assertion, and academic competence • Higher academic performance • Less alcohol uses • Less depression • Greater healthy lifestyle behaviors • Less overweight/obesity

Appendix F

WGCMD Technological Information

Ravin Sardana

160

ADHD or otherwise known as Attention Deficit Disorder, is a communication disorder that many people suffer from in today’s society. Individuals with this disorder have trouble concentrating and have difficulty controlling their impulsive behavior and this is a disorder that usually starts in childhood and continues throughout adulthood.

With this disorder, individuals can suffer from managing relationships with closed ones, have trouble with self-image issues and experience struggles in the academic setting. In today’s digital economy, technology and modern medicine can be utilized to help individuals who are suffering from this condition, manage their symptoms and subside the progression of the condition.

Behavior modification therapies have been utilized by psychologists and psychiatrists in order to help their ADHD patients normalize their daily activities and lead a life with minimal difficulties. ADHD patients can resort alone to behavioral modification therapies to help them with their daily tasks or they can combine the therapy with ADHD medication (Adderall, Ritalin, etc.) to navigate their life. ADHD medication like Adderall and Ritalin help the patient on a neurological level whereas, behavior modification focuses on specific problems that individuals experience and how they can be eliminated. It evaluates various methods that hyperactivity and inattention can impact various aspects of one’s life, whether it may be their academic life, personal relationships with others, or work life.

Through behavioral modification, psychologists can treat for specific issues by focusing on treating for the domains of impairment but that requires working with families, schools, primary care, and more (Pelham, 2016). Even though behavioral modification treatments have shown some success they haven’t proved effective in the

161 long term. In addition, they lead to a lot of parental stress since the implementation requires heavy involvement from the parents. The parental stress consequently creates a negative environment in the house and communication impairments for the ADHD child.

It is quite evident that as time has progressed technology has become more prevalent in our day to day lives and has also influenced our behavior greatly. Humans have unconsciously started adapting to new technology that serves some need in their life and once they never look back as this change starts becoming permanent rather quickly.

Technology that provides a new and better solution that has a positive impact on one’s life can have a massive impact on this world.

It is a known fact that children are attracted to video games, but video games are more popular among children with ADHD. One of the popular games among children nowadays is Minecraft. Minecraft is a game that allows players to utilize their creativity and build various structures in a 3D world. This game has specially been found useful to

ADHD children because of its ability to help build the focus and improve the communication competency of the ADHD children. Additionally, with Minecraft, they have the freedom to build new things and try new techniques without fear of making mistakes, something that is hard to replicate in the real world. (Daley, 2019).

As we think about combining behavioral modification tools with new technology in order to have a positive impact on children suffering from ADHD, the most practical and effective solution seems to be a wireless-enabled wearable technology device. Its basic premise would be displaying tasks that need to be completed by the kids in order for them to level up and receive a reward in the video game they like playing most. For

162 the scope of this paper, due to the availability of sheer amount of data, the video game we will focus on is Minecraft.

Figure 1 shows what the device would look like. This device would comprise of an OLED screen STMicroelectronics STM32L151RD ARMBased 32-Bit microcontroller and some flash memory. It would also have a 3.7 V Li-Polymer battery which should ensure the device only needs to be charged every 5-7 days. It would also have Bluetooth

4.0 which would allow the device to sync with the smartphone application. The device would work through the parent and child meeting on a regular basis in order to come up with a list of tasks and expectations that the child needs to do until their next meeting and the consequent rewards their child would receive for leveling up by completing the tasks.

The device would be linked to an application on the parent’s smartphone allowing the parents to easily sync new tasks and details about each task to the device wirelessly using Bluetooth technology (Figure 2). The application would be a web-based application which would allow use on smartphones that have different operating systems. Figures 2 and 3 show the prototype for how the application would look like on the parents phone.

Once the tasks are synced to the device, they are displayed on the device for the child to do as shown in Figure 4. Task display helps focus and motivation. Once the child finishes a task, they can check it off on their device and this would cause them to level up. This game-based reward helps them enact responsibility in a gamification manner.

Each task completed allows the child to level up. Task completion is represented by an animation on the screen on their device. This animation would be completely customizable, so for instance if the child likes Mario, the animation for that child would like Figure 5. Numerous options will be provided within the app in order to cater to a

163 wide variety of desires according to specific kids all over the world. This animation would work as a reward through which they gain time allowance to use in video game play. The gamification of daily tasks is speculated to increase self-regulation and personal motivation.

One of the details about the task that the parent has to enter is the time it should take to finish that particular task. This is done so the device can alert the child if the task has not been completed in that time. The alert will be in the form of vibrations which is made possible through a small vibration motor in the device. These vibrations would help them stay on track and help in minimizing one of the biggest problems that ADHD kids face i.e. getting distracted.

At the end of the day, once all tasks have been completed, and the parents have approved and verified the completion, their child will be rewarded via a digital gain in their game. The reward would be not only associated with specific time allowance for video game play, to help prevent arguments over extended time. When they time is over, it’s over. Digital gains in the video game but be in-game rewards, such as a pickaxe, or certain materials that will help them explore the world of Minecraft.

Modifications, or mods, in Minecraft are independent, user made additions to the game. There are a number of ways that these mods can be installed on the computer.

However, it is important to keep it as simple as possible so that parents can implement the process. The simplest method would be to install a mod launcher like Curse or At launcher for instance. Once a mod launcher has been installed mods can be installed to the game with a click of button by simply browsing through the list of mods and installing whichever one you one prefers. In order to prevent the child circumventing this

164 process and implementing mods them self, the parent would need to make use of parental controls provided by the operating system that the parent is using and/or the application the child wants to use such as Minecraft.

Social life is another aspect of life that can sometimes be difficult for kids with

ADHD. In order to improve the communication competency of these kids, the device allows you to add friends with other kids who are using this device (Figure 3). This would have to be done on the parent’s phone which is synced with the device. Once another user is added the child will be able to see their friends’ successes in accomplishing tasks. This would not only help motivate the child to complete their own task whilst, helping them improve their communication competency.

Once this initial system is successful, there are a number of ways this system could be improved. First and foremost, it could be expanded to other applications. A framework for schools could be created which would allow the teacher’s to get in sync with all children that have ADHD and help them out using this system. Since the child’s behavior at school is also important, the teacher’s use of the intervention could play a crucial role in helping shape the child’s behavior. This would be a future development, as initial success would be essential in order to convince schools to implement this application since teacher training would be required. It would help individuals with

ADHD find an innovative and creative method to maneuver their way around their communication disorder. Additionally, it would encourage video game designers to incorporate features that aid children with mental health and physical health disorders.

165

Figure 1. Prototype WGCMD.

166

Figure 2. Tasks view/child & App view on Smartphone/parent

167

Figure 3. View of App allowing parents to add friends

168

Figure 4. The WGCMD screen view

169

Figure 5. Sample Avatar (Ex: Mario)

170

REFERENCES

“More Than Meds: A Guide to ADHD Behavior Modification.” ADDitude, 28 Nov. 2016, https://www.additudemag.com/slideshows/more-than-meds-a-guide-to-adhd- behavior-modification/.

Minecraft Addiction Is Real—Especially for Kids with ADHD!https://www.additudemag.com/slideshows/managing-minecraft-addiction-in-kids- with-adhd/. Accessed 27 Apr. 2019.

Classic Mario Level Complete Words – Phone Wallpapers. http://www.tzrb.net/Classic- Mario-Level-Complete-Words20xvjhcbhg/. Accessed 28 Apr. 2019

171

MARTI MATTOX 323 369 4188 | [email protected] www.linkedin.com/in/marti-mattox-762b255

Industry Expertise: Distribution, Marketing, Curating, Programming & Acquisitions

Film industry and business leader with proven success launching and running an award-winning audio visual marketing firm for independent films in Los Angeles market. Can produce, write, edit and market content; cultivate and manage client relationships, manage complex projects. History of working closely with studio executives, directors, talent, producers and nonprofit organizations. Conducts outreach efforts with filmmakers, producers and business leaders to fuel development efforts. — Demonstrated expert contributions to film industry. Conceptualized scripted, budgeted, produced and co-edited Heavy Metal Nanny, LA-based reality television pilot. Winner: New York Television Festival for best new reality star. In turn around with Universal and A&E. Co-produced with Gail Anne Hurd and Valhallha Entertainment. — Created and co-launched Big Science Film, Inc., an award-winning motion picture advertising company. Developed targeted and memorable trailers, TV spots and sales promos for critical renowned indie films, VOD distribution, international markets, plus Oscar and Golden Globe campaigns. Recipient: 40+ Golden Trailer nominations and awards. — Showcased commitment to volunteer and nonprofit organizations throughout career. Consultant for NC Division of Air Quality. Established program to transition government funded outreach program to 501(c)(3) to secure funding from personally created state wide coalition of businesses and private partners. Event management for RiverRun International Film Festival. Core areas of performance include: Business Development, Strategic Planning, Implementation, Storytelling, Filmmaking Campaign Development, Execution, Critical & Creative Thinking, Writing & Editing Marketing & Operations, Fundraising Efforts, Studio Distributor Relationships PROFESSIONAL EXPERIENCE

BAPTIST HOSPITAL / ROBERT WOOD JOHNSON FOUNDATION / WAKE FOREST UNIVESITY • Winston-Salem, NC Project Manager Pitched concept to Baptist Hospital for 70,000 grant from the Robert Wood Johnson Foundation to address excess sugar sweetened beverage consumption in children. Received grant then scripted, produced, edited and focus group tested promotional video while simultaneously working with the Wake Forest Communications Graduate Program chair to frame and support the research theoretically and quantitatively.

RIVERRUN INTERNATIONAL FILM FESTIVAL • Winston-Salem, NC Event Manager Coordinated, budgets and produced parties, awards, dinners, premieres and receptions, as well as sponsor and filmmaker events and premieres for industry recognized International Film Festival. Managed large staff of volunteers to successfully execute galas and cocktail receptions all within 11-day window and limited budget. Collaborated with operations manager, venues and local businesses.

BIG SCIENCE FILM, INC. • Los Angeles, CA (www.bigsciencefilm.com) Co-president & Creator, CFO (2000-2014), Consultant (2015-Present); Established and executed startup and grew business into one of the longest-running independent film trailer agencies in the LA film market. Managed staff of assistants, editors, freelance graphic designers, voiceover talent and writers. Produced creative content and finishing deliverables, wrote copy and creative briefs, managed all financials. Key liaison between clients and lead editors. • Led creation of trailers, TV campaigns, promo reels and other sales materials. Worked with Universal, Warner Independent Pictures, Focus Features, The Weinstein Company, IFC, Magnolia, National Geographic, Picturehouse and others. • Collaborated closely with acclaimed directors, producers, studio executives, sales agents and talent to ensure creation of all creative and technical requirements, budget and time deadlines. Developed creative marketing for some of greatest filmmakers of our time, including Robert Altman, Woody Allen, Steven Soderbergh, Jim Jarmusch, Ang Lee, Sofia Coppola, Richard Linklater and Mira Nair. • Worked on award winning movies including Milk, Brokeback Mountain, Eternal Sunshine of the Spotless Mind, Scoop, The Virgin Suicides and others.

HEAVY METAL NANNY • Los Angeles, CA (youtube: Heavy Metal Nanny) Executive Producer & Creator • Los Angeles, CA Created reality TV show featuring Christophe Liglet a heavily tattooed musician and French nanny who believes his band, Skinmask, will help achieve his rock star dreams while also being creating financial security and nursing care for his severely autistic son. Attended festival and press engagements. Official Selection and Winner NYTF Festival. Co-produced second sizzle with Gale Anne Hurd (The Walking Dead) Valhalla Entertainment, Universal and A&E. Project is in turn-around.

172

FRANCIS FORD COPPOLA’S AMERICAN ZOETROPE • Los Angeles, CA Film Division Director Recruited by former Trimark Pictures President to provide oversight and collaboration in running LA office of privately-run film studio and early adopter of digital filmmaking. Oversaw marketing of projects, story and script development coverage and budgets. Collaborated with All-Story magazine editor to develop short story content for film project use. Hired and managed office staff and interns. • Coordinated marketing and sales materials for Cannes premiere of Sofia Coppola’s The Virgin Suicides. • Attended Cannes Film Festival and Sundance Film Festival as marketing and acquisition representative.

TRIMARK PICTURES • Los Angeles, CA Marketing Manager Worked closely with producers, directors, sales representatives, agents, talent and executives in all aspects of marketing, acquisition, production and distribution of independent film slate for mini-major studio that became Lions Gate Entertainment in 2000. • Contributed as member of development, marketing and budget teams for independent film projects. Attended Sundance, AFM, LAIFF and other markets and festivals. • Winner: Best Marketing Stunt at Sundance, for Vincenzo Natali’s award-winning film CUBE.

ADDITIONAL EXPERIENCE SEARCHING FOR CINEMA • Winston-Salem, NC Co-Director/Producer/Writer/Editor 15 Minute Short Documentary Film

FLOTSAM • Winston-Salem, NC Executive Producer Helped fund film by award-winning UNCSA filmmakers premiered at New Orleans Film Festival.

NORTH CAROLINA SPECIALTY FOOD: Annual Conference • Raleigh, NC Lecturer on Brand Creation Created and delivered lecture seminar on building and selling an effective brand.

Additional: North Carolina Division of Air Quality: Marketing Consultant Harvard Based Mind Body Institute through UCLA: Marketing Consultant/Editor/Manager Piedmont Environmental Alliance: Board Member UVA: Visiting Lecturer Department of Natural Resources West Virginia: Raised and Released 6 Peregrine Falcon Fledglings Augustine Literacy Project: Volunteer Tutor for low income children struggling with literacy skills Freelance Writer: Salon.com; Sidewalk Mice; The Colton Review, A Room of Her Own, Writer’s Pad

EDUCATION & ADDITIONAL INFORMATION

WAKE FOREST UNIVERSITY, Winston-Salem, NC Masters in Communication Awarded Full Scholarship, Stipend and Assistant Teaching Position, Research Assistant

THE UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL, Chapel Hill, NC Bachelor of Arts: Major in Radio, Television and Motion Picture & Anthropology, Minor in Studio Art Honors: Magna Cum Laude; Phi Beta Kappa; Golden Key Honor Society; Dean’s List; Merit Scholarship Activity: UNC-Chapel Hill Fencing Team, Environmental Org. Student Leader Org, Women’s Support Group, Rape Crisis Hotline. Empowerment Project Intern, Literary Journal, Big Sister Program, Environmental Education Teacher, Academic Tutor.

173