PRISM Gadgets and Gizmos

1. PRISM Gadgets and Gizmos Ann E. Maloney, MD University of Vermont, College of Medicine at Maine Medical Center Research Institute 2008_1_17

2. Thanks • MaineHealth • Dept. Of Psychiatry • MMCRI • Mentors

3. Learning Goals • Discuss new technologies: games and handhelds with health applications • Consider the pros and cons of complex and portable devices in healthcare

4. Disclosure • No conflict of interest to report with games companies or pharma • Acknowledge slides provided by Digital Mill, RWJ Foundation footage • No off label use of drugs

5. Two Sides of Games for Health Professional Practice PersonalTreatment Treatment Self Modeling Pain/OR Anxiety Mental Health Exergaming Simulation PT Training/Ed Disease Management Applications Health Messaging & Behavior Change Cognitive

6. What gadgets are in your pocket right now? • Pager • Palm—MDs like Epocrates • Blackberry—e mail connectivity • Podcasting NEJM on Nano at the gym • Cell-texting to others on team • What others do you consider key professional gizmos?

7. Digital Natives • Prensky coined the phrase digital native (attributed to those born beginning in 1985) in describing this generation. • Prensky posits that children not only live in a much richer and distinctly different informational environment than their parents, but that this digital environment has helped to shape them into fundamentally different types of thinkers, potentially on a biological/neural level, requiring a change in messaging methodologies to successfully engage and educate them.

8. Video Game Industry Seeks Political Clout By SETH SCHIESELPublished: January 15, 2008 NYT • …Along with the evolving political climate, games have also become more accessible and less threatening in the broader culture. Nintendo’s Wii console, introduced in 2006, has been a big part of that shift, drawing in both children and older players with its simple point-and-wave control scheme. • Music-oriented game franchises like Dance Dance Revolution and Guitar Hero have become mass-market hits, while middle-aged women have become the top audience for puzzle games like Bookworm.

10. Adults Teens Own Cell Phone 73% 67% Own Digital Camera 55% 43% Own Video Camera 43% 37% Play Video Games 40% 83% Own Laptop 30% 32% Own MP3 Player 20% 45% Own PDA or Blackberry 11% 7% Who has what gadget 2006

11. Overview of Health Games Research • http://www.youtube.com/watch?v=kjGJTST8DSg • 5 min 14 secs, discussion

12. Anesthesia Distraction/Patel et al • About 15 million children receive anesthesia for surgery & other diagnostic and invasive procedures in USA per yr • Anxiety scores pre and post intervention with Game Boy: • 63% children in GB group showed no change or a decrease in anxiety • 26% children in M group showed no change or a decrease in anxiety

13. Dance Dance Revolution

14. Games For Health

15. Re-Mission/Hope Lab • Randomized, controlled, multi-center trial of Re-Mission on adolescents & young adults w/cancer: • Adherence to cancer medications • Knowledge about cancer information embedded within the game • Quality of life • Self-efficacy • 375 m/f cancer patients (13-29) enrolled at 34 medical centers in US, Canada & Australia, randomly assigned PCs with a popular video game only or control video game plus Re-Mission.

16. Re-Mission Results/Hope Lab • Adherence, cancer-related knowledge, QoL, & self-efficacy assessed at baseline and at 1M, 3M after game delivery. 80%+ of patients played game. • Patients' QoL, knowledge about cancer info embedded w/game, & their self-efficacy to communicate about cancer and manage side effects increased in the Re-Mission group. • Patients' overall composite score on the self-efficacy scale also increased significantly over time for the Re-Mission group. • Young people who played Re-Mission maintained higher blood levels of chemotherapy & showed higher rates of antibiotic utilization, both suggesting Re-Mission helps patients adhere to cancer therapy regimens.

19. A Pew Internet and American Life Project report, Teens and Technology noted that amongst U.S. teens aged 12 – 17: 87% use the Internet, up from 73% in 2000; 51% of those that use the Internet go online on a daily basis 89% of those online use e-mail; and 65% use Instant Messaging (IM)

20. DATA ON ONLINE DIGITAL LIVES OF YOUTH • 43% online teens have been contacted by strangers (Pew Report, April 18, 2007) and about 7% all teems have engaged in behavior to contact this stranger • 65% of parents are checking their teens’ online behavior • Relationships are tricky in real life, they are different online

21. MySpace, Facebook, etc • In addition, another Pew report found that 55% of online teens use social networking sites, with nearly half visiting them at least once a day. • Second Life, Whyville, Webkins start kids early online • “We have to go to PBSkids.org” , Mommy

22. Time on Screens • One report noted that today’s youth spend nearly 6.5 hours a day engaged with a variety of media channels such as TV, computers, MP3 players and the like. (Kaiser Family Foundation, 2006) • AAP has 3 recs—less than 2 hours, encourage other activity, not for infants and toddlers • MDs feel messages futile (5-2-1-0)

23. Connectivity • When there is home Internet access, 50% of white teens have a high-speed connection as compared to 39% of African-American and 42% of Hispanic teens. • Implications for asking research subjects to use internet

24. What are providers to do? • Are there healthier games we can exploit? • What conversations can we have and NOT turn off kids? • Guidance and advice on limits, safety measures

26. Emerging Data on DDR • Tan et al 2004- HR at least at ACSM minimums • Petit et al—170% Energy expended in DDR vs sitting games (traditional thumb games) • Wetzsteon et al 2006 tested weight bearing games testing Ground forces (special shoes) on health of bones since few youth get enough activity per day • Unnithan 2005, energy expenditure Cosmed (Vo2 device) showed high use in DDR • Madsen 2007 applied DDR in a clinical program for obese youth (13  2.6 years-old) and found that playtime varied between 120 minutes per week (mpw) and 45 mpw , mostly negative study

27. Get Kids in Action UNC School of Public Health, Maloney et al 2008 accepted in Obesity • Randomized 60 7-8 yo for home DDR vs controls • Physical activity Anthropometrics (ht, wt, BMI, bodyfat%) and info on screen time, sleep etc • Rx 120 minutes/wk • Logs of DDR play plus ActiGraphs documented activity levels

28. Decreased Sedentary Screen Time (SST) • The DDR group reported a decrease in SST of -1.2  3.7 hours per week (hpw) (p<0.05), while the controls reported an increase in SST of +3.0  7.7 hpw . • The difference in SST between the two groups was significant, with less SST in the DDR group.

29. Main Outcome DDR 89 min per week x 10 weeks

30. Could we use this in Maine Middle Schools—peer lead Generation FIT

31. Future directions • Hopes for technology • Concerns using technology in youth messaging • CDC interest, laptop programs, other ideas

32. Top Concerns re Youth • Safety, exploitation • Obesity and sedantariness • Missing team sports, missing chances for social cues “social cognition”, family time, etc

33. Intrusions/Information Anxiety/What did I miss? • Multitasking difficulties • Figuring out a day off from technology, or when not to turn on cell phone • Un-monitored Fax machine and personal experience with suicide note faxed to me • E mail that goes to spam, does not get seen

34. The Child Psychiatrist Worries • 43% online teens have been contacted by strangers (Pew Report, April 18, 2007) and about 7% all teems have engaged in behavior to contact this stranger • 65% of parents are checking their teens’ online behavior • Relationships are tricky in real life

35. Citations of “Downside” • Future—youth may not anticipate that MySpace activities today have implication for that Duke basketball future--could take away their scholarship, job, grad school ( • Eastin 2006 and the increased costs of the “worried well” or health anxiety—does this lead to extra workups? • MMO and 14.5 year old boys having seizures, n=9 so far (likely under reported)—neuro implications • Time distortion and the 2 hours limits (per AAP), novice and experts cannot estimate accurately time online, Pau 2006

36. Concerns cont’d • High confidence but wrong often about sex/gender, Cornetto 2006 • Oxy, darvocet, Adderall etc worries that hit rates are up over 18 mo period of time, Schifano 2006 • Money and its meaning, developmentally complex abstractions • Moody 2001, shallow relationships online

37. Social and Cognitive Development • Odd kids and lots of hours online—not learning during the developmentally specific windows of opportunity—could be lost windows of learning • Anorexia, borderline PD, suicide can be romanticized, Alao 2006

38. Suggestions-we may need to change our messaging • Instead of saying to a teen “Don’t do…” see Ybarra et al Archives Ped Adol Feb 2007) • Try instead messages like: • “ I know a lot of teems go on MySpace…be sure you can hide your identity and know how to discontinue a relationship at anytime…” • Finkelhor’s team noted tipping point for interpersonal victimized kids, online time coupled with Adverse experiences=?

39. Objectives Met? • Participants will become familiar with percent of youth online and about % parent who provide supervision • Participants will learn about some of the downsides to online life for youth with some research findings about risks and benefits. • Together we will talk about how technologies are changing the doctor patient relationship

40. The beat goes on!