8 337 GENERAL DISCUSSION method that increase the likelihood of youth choosing a mental health game. Importantly, these delivery forms need not be mutually exclusive. IMPLICATIONS FOR GAME DESIGN The research presented in this dissertation has implications for game design and development. Our systematic review in Chapter 2 revealed that many studies assessing the effectiveness of digital games incorporated multimodal interventions. In these cases, digital games, particularly applied games, were utilised alongside treatment as usual or other therapeutic components, and offered simultaneously within the same intervention program. While we were not able to evaluate the additional effect of the game on the overall intervention’s effectiveness, indicating a need for future research to elucidate the relative effectiveness of games and explore how traditional interventions can be optimally enhanced through game add-ons, it is evident that multimodal interventions are common practice in clinical settings (Horne-Moyer et al., 2014) and may enhance generalisability of treatment effects (e.g., Wijnhoven et al., 2022). Considering this trend, future game development should anticipate that applied games will often complement therapy. Developers should contemplate implementing features relevant to therapists and practitioners. For instance, integrating a coding system into the game and including a ‘backend’ interface for therapists to monitor observed behaviours could be beneficial. This would allow for the automatic tracking and coding of in-game play behaviours, offering therapists insights into (dis)engagement with the game and its therapeutic techniques (Bijkerk et al., 2023). It could also serve as a tool to assess and determine progress of clients, offering early-stage support and addressing difficulties or increasing motivation for engagement. Furthermore, these measurements of in-game play behaviours may be utilised to assess clients’ behaviour in practical settings (i.e., the game environment), potentially combined with psychophysiological measures, avoiding the bias and stigma often associated with self-report measures (Caqueo-Urízar et al., 2022; Fadnes et al., 2009). This information is not only valuable for therapists but can also be used to provide feedback to players, maintaining motivation and engagement throughout the digital intervention. It can also inform researchers and game developers about the most effective game mechanics and mechanisms of change. Moreover, these backend measurements can be employed to dynamically adjust the game to the player’s actions, diverse needs and learning paces
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