Evaluating the feasibility of using a multiplayer role-playing game as a mental health intervention in adolescent patients with chronic health or mental condition

Our study involves adolescents and young adults between the ages of 14-19 who have a chronic health or mental condition which requires regular medications, therapies, or medical or mental health services in order to maintain or achieve good health. We are studying if involving teens in an online role playing game community could help with the feeling of isolation, trauma, anxiety, or depression that many adolescents with these conditions tell us they feel.

Those who fulfill criteria for and are interested in joining the study may participate in online gaming sessions with other teens using a role playing game called Masks. Masks is a game where participants create a character with super powers and work together with other players to achieve a common goal. The game would be moderated by one of our study staff to make sure everyone involved feels comfortable, safe, and that their confidentiality is protected. In addition to playing the game, we ask that participants complete longer surveys at the beginning and end of the study as well as brief surveys after each gaming session. Each participant's confidentiality is protected throughout the study. Compensation will be provided to each of the participants.

To read more about who can participate in this study, click here.

Meet the System:

We will be using the roleplaying system Masks, where players assume the roles of young superheroes in a team as they come of age in the face of superheroic trials and tribulations. The mechanics of the system are focused around the emotional state and personal development of characters. To learn further about the system in the context of this study, read more here.

Meet the Gamemasters:

Nick Eggers is a P1 student at the University of Pittsburgh School of Pharmacy. He has been playing and running RPGs since high school and is also the current president and founder of RollPlayers, a tabletop gaming club on Pitt campus.

David Happe is an undergraduate Computer Science student at the University of Pittsburgh. He is also a member of the technical support staff at the Epidemiology Data Center, part of the University's Graduate School of Public Health. A former officer of Pitt's tabletop gaming club RollPlayers, he enjoys playing absurdist characters that both amuse and confuse.

Alexis Hester, BS, graduated from Northeastern University with a degree in chemistry. She is now a second year medical student at the University of Pittsburgh School of Medicine. She has been playing and running RPGs since college, and Masks is one of her favorite systems.

Koehler Powell, BA, graduated from Carleton College with a degree in biology. She is currently a second year medical student at the University of Pittsburgh School of Medicine. She has been playing and running RPGs since college, and her favorite RPG genre is superhero fiction. Koehler credits her first character, a super-powered healer, with nudging her on the path towards medicine.

Read more about the research team here.

Sponsors of the Study:

The University of Pittsburgh Office of the Chancellor PittSeed Grant is the main funding source for this study. In addition, the University of Pittsburgh ETUDES Center is a sponsor of this study.

Contact:

With any questions or inquiries, please contact the Primary Investigator, Dmitriy Babichenko.

Graphics by Magpie Games. Used with permission.

About the Project:

Background:
Numerous studies have revealed that children and adolescents with chronic health or medical condition, as well as their caregivers, are at an increased risk for depression and anxiety, with serious direct and indirect negative effects on treatment adherence, family functioning, and health-related quality of life [1]–[3]. Additionally, living with a chronic conditions can place adolescents at higher risk for poor educational, vocational, and social outcomes and lead to isolation from peers [4], [5]. Regular participation in social activities with peers is particularly crucial in adolescence where it can provide a critical key component for developing healthy psychological development [6], [7]. Moreover, support from peers can also play a significant role in helping young people with chronic health or mental conditions cope with the illness and with its “inherent psychosocial and lifestyle changes” [8].


In order to address some of the issues inherent to social isolation and lack of peer support, we propose a novel method of engaging adolescents with chronic health or mental conditions through role-playing game (RPG) communities.

A tabletop RPG is a role-playing game in which the players “describe their characters' actions through speech” and determine the actions of their characters based on their character sheets [8], [9]. The outcomes of the characters' actions are determined by a formal system of rules and guidelines. “Within the rules, players have the freedom to improvise; their choices shape the direction and outcome of the game” [9]–[11].

Specific Aims of the Study:

  1. To determine if regular participation in a guided multiplayer role-playing game has positive impact on self-reported social isolation, social support, and depression in adolescents with chronic health or mental health conditions

  2. To identify participant participation and engagement with RPG game-based interventions

  3. To determine if (and under what conditions) participation in a multiplayer RPG facilitates chronic illness-related conversation among peers

Who may be able to participate?
Adolescents aged 14-19 who have one or multiple chronic medical, behavioral, or mental health condition(s), lasting or expected to last 12 months or longer. What may this include?

  1. A condition that has long-term limitations in your functioning or activities (i.e. asthma, hearing problem, epilepsy, learning disability)

  2. A condition requiring medication prescribed by a doctor, other than vitamins

  3. A condition limiting or preventing your ability to do the things that most people of the same age can do

  4. A condition requiring physical, occupational, or speech therapy

  5. A condition requiring treatment or counseling

The study will be conducted online using a digital platform. Therefore, participants would need to have access to a computer and headset with a microphone.

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The Roleplaying System:
We will be using the tabletop roleplaying system MASKS for our online gaming community. Masks is a tabletop roleplaying system in which players assume the roles of young superheroes in a team (like the Teen Titans or the X-men) as they come of age in the face of superheroic trials and tribulations. The players select playbooks, which are based around the type of superhero they want to be, and create their own characters to play as. For example, a player who wants to be a hero who has a secret identity to protect their normal teenage life, like Spiderman or Ms. Marvel, would pick the Janus playbook.

Despite "tabletop" being in the name, physical proximity is not required to play Masks or most other games of its kind. Games can easily be conducted using voice chat over telepresence with tools like Discord and Roll20, allowing for play anywhere with reliable internet access.

It is similar to other tabletop roleplaying games like Dungeons and Dragons because the key element of gameplay is acting as a character in scenarios designed and led by a gamemaster (GM). By acting as their characters in response to these scenarios, the group creates a narrative that they experience together. Dice and other tools to decide outcomes are used to add an element of unpredictability to the narrative, and aid in the improvisation process.

However, Masks is different because its mechanics are more focused around a character's emotional state and personal development than in most other games. For example, the Label system explains mechanically how the characters grow into their powers based on the realizations they make about themselves, and the influence of others around them. Instead of taking damage in ways that could lead to their characters dying, the system focuses more on the feelings that challenges and enemies can impose on the characters. A character who fails to use their powers against a formidable opponent in a stressful situation could feel insecure, or potentially, angry. By focusing on emotional states rather than physical health, players are free to invest in their characters without fear of them dying, while being given opportunities to create dramatic and narrative tension.

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[1] A. J. Goreczny and M. Hersen, Handbook of Pediatric and Adolescent Health Psychology. Allyn and Bacon, 1999.
[2] C. Sharp, R. McNeil, S. Wales, P. Cooper, and K. Dawson, “Young adults with cystic fibrosis. Social well-being and attitudes,” Aust. Nurs. J. July 1993, vol. 2, no. 4, pp. 38–40, Oct. 1994.
[3] G. S. Sawicki and H. Tiddens, “Managing treatment complexity in cystic fibrosis: Challenges and Opportunities,” Pediatr. Pulmonol., vol. 47, no. 6, pp. 523–533, 2012.
[4] “2017 Patient Registry Annual Data Report,” p. 96, 2017.
[5] B. Marshall, “Understanding Changes in Life Expectancy,” 16-Nov-2017. [Online].
Available: https://www.cff.org/Research/Researcher-Resources/Patient-Registry/Understanding-Chan ges-in-Life-Expectancy/. [Accessed: 03-Mar-2019].
[6] A. L. Quittner, D. H. Barker, C. Snell, M. E. Grimley, K. Marciel, and I. Cruz, “Prevalence and impact of depression in cystic fibrosis.,” Curr. Opin. Pulm. Med., vol. 14, no. 6, pp. 582–588, Nov. 2008.
[7] A. L. Quittner et al., “Prevalence of depression and anxiety in patients with cystic fibrosis and parent caregivers: results of The International Depression Epidemiological Study across nine countries,” Thorax, vol. 69, no. 12, pp. 1090–1097, Dec. 2014.
[8] “What is a Role-Playing Game?” [Online]. Available: http://www.darkshire.net/~jhkim/rpg/whatis/. [Accessed: 19-Jun-2019].
[9] “Tabletop role-playing game,” Wikipedia. 09-May-2019.
[10] G. Delmas, R. Champagnat, and M. Augeraud, “From Tabletop RPG to Interactive Storytelling: Definition of a Story Manager for Videogames,” in Interactive Storytelling, 2009, pp. 121–126.
[11] R. P. Lopes, “City of dred – a tabletop RPG learning experience,” 7th Int. Conf. Educ. New Learn. Technol. EDULEARN, pp. 6987–6995, 2015.

The Research team:

Principal Investigator:

Dmitriy Babichenko, PhD, is the principal investigator of this study and a Clinical Associate Professor at the School of Computing and Information at the University of Pittsburgh. His research interests include clinical decision support systems, use of serious games in higher and post-graduate education, and use of transformational games in healthcare.

Clinical Team/Co-Investigators:

Kayla Booth, BA, is a Visiting Assistant Professor at the School of Computing and Information at the University of Pittsburgh and the Assistant Director for the iSchool Inclusion Institute (i3). She has extensive experience in conducting qualitative research with underrepresented and vulnerable populations. In particular, her research centers the ethical treatment and empowerment of her participants. She has extensive experience in working with individuals and communities towards the design, implementation, and evaluation of tech-based interventions, particularly within educational and mental health contexts.

Lorin Grieve, PharmD, is an Instructor at the University of Pittsburgh School of Pharmacy who has completed a postgraduate fellowship for Clinical Simulation at the VA Hospital in Pittsburgh with a focus on active learning strategies. Lorin believes that ver years of experience designing games for entertainment purposes will allow ver to apply gaming techniques to the classroom; gamifying the experience and increasing student engagement and motivation. Gameful instructional design has proven to be valuable in shaking up traditional pedagogy, and Lorin works tirelessly in developing novel experiences in the PharmD curriculum.

Traci Kazmerski, MD, MS, is an Assistant Professor at the University of Pittsburgh School of Medicine in the Department of Pediatrics and Division of Adolescent and Young Adult Medicine. She is a pediatric pulmonologist at the Children's Hospital of Pittsburgh of UPMC. She recently completed fellowships at the Harvard-Wide Pediatric Health Services Research program and the Institute of Healthcare Improvement in Boston, MA. Her research centers on the improvement of comprehensive health care for adolescents and young adults with pediatric-onset chronic disease. Her current project is focused on improving the sexual and reproductive health care of adolescent and young adult women with cystic fibrosis.

Scott Maurer, MD, is an associate professor of pediatrics at the University of Pittsburgh School of Medicine within the Division of Pediatric Hematology/Oncology and is the chief of the Division of Palliative Medicine and Supportive Care at UPMC Children's Hospital of Pittsburgh. Dr. Maurer provides palliative care consultative services to patients on all services in the hospital. He focuses on advanced care planning, decision making support, pain and symptom management, care coordination, end-of-life, and bereavement care for pediatric patients with life-limiting illness. Together with colleagues from the supportive care team, obstetrics, genetics, and neonatology, Dr. Maurer co-founded a perinatal palliative care program at the University of Pittsburgh.

Ravi Patel, PharmD, is the Lead Innovation Advisor at the University of Pittsburgh School of Pharmacy. Dr. Patel's current work includes the application of creativity and innovation in pharmacy education and practice. Dr. Patel teaches in the Pharmacy Innovation course and helps run the operation of the Pharmacy Innovation Program at the School of Pharmacy.

Ana Radovic, MD, MSc, is an assistant professor of pediatrics at the University of Pittsburgh School of Medicine within the Division of Adolescent and Young Adult Medicine. Dr. Radovic is interested in increasing adolescent and parent participation in mental health treatment when depression treatment is recommended within primary care. She is especially interested in using internet technology such as social media to enable connections between adolescent and young adult peers as well as parent peers who have mental health illness in common. Currently, she has a career development award, PCOR K12, to develop and study the feasibility of stakeholder (user) designed technology interventions which address the need to increase participation in treatment.

Daniel Weiner, MD, is an associate professor of pediatrics at the University of Pittsburgh School of Medicine within the Division of Pediatric Pulmonary Medicine. Dr. Weiner was the local principal investigator for a number of multicenter cystic fibrosis clinical trials, including studies of novel pharmaceuticals to enhance ion transport, pancreatic enzyme–replacement therapies, and hydrating therapies (hypertonic saline). He continued investigating measurements from Multiple Breath Washout studies as an outcome for clinical trials in Cystic Fibrosis.

Student Researchers:

Nick Eggers is a P1 student at the University of Pittsburgh School of Pharmacy. He is also the current president and founder of RollPlayers, a tabletop gaming club on Pitt campus.

David Happe is an undergraduate Computer Science student at the University of Pittsburgh. He is also a member of the technical support staff at the Epidemiology Data Center, part of the University's Graduate School of Public Health, and is a former officer of Pitt's tabletop gaming club RollPlayers.

Alexis Hester, BS, graduated from Northeastern University with a degree in chemistry. She is now a second year medical student at the University of Pittsburgh School of Medicine.

Koehler Powell, BA, graduated from Carleton College with a degree in biology. She completed a local year-of-service program, PULSE, and worked for the Mid-Atlantic Mothers' Milk Bank before starting at the University of Pittsburgh School of Medicine, where she is currently a second year medical student.