Therapeutic Use of Life Simulation Games for People with Cognitive Impairments

Edmund F. LoPresti1,2,3, Michael McCue1, Deborah Endres1

1University of Pittsburgh, Pittsburgh, PA 15260; 2 Learning Technologies Program, Hiram G. Andrews Center, Johnstown, PA 15905;

3AT Sciences, LLC, Pittsburgh, PA 15213

BackgroundSimulations - have been used extensively by military, public safety, and health care organizations to prepare for potential emergencies - could also help prepare people with cognitive impairments for situations which might be associated with functional difficulties, social difficulties, or anxietyThe Sims 2 (Electronic Arts, http://www.thesims2.com) - a real-life simulation game - players create characters, maintain a household, pursue careers, and raise families - based on Maslow’s Hierarchy of Need), characters have fundamental physical needs as well as desires related to self-actualization - provides a consistent environment which can allow someone to explore real-world situations in an environment safely removed from reality Second Life (http://www.secondlife.com) - an online community in which participants interact as avatars in interactive graphical environments. - provides real-time social interactions between peers - a number of social and support groups already exist within Second Life for people with disabilities, including autism and strokePotential Dangers - immersion in virtual environments could limit a person’s participation in real-life relationships - a therapist’s active role is crucial to facilitate transference of lessons learned in the game to application in real life - avatars in Sims and Second Life lack nuances of body language and vocal inflection that are present in real-life scenarios; for individuals with autism, this simplification can make communication easier to process, but could also limit transference to real-world communicationClinical Application - The Sims game has been used in a Cognitive Skills Enhancement Program (CSEP) at the Hiram G. Andrews Center. - CSEP provides services to young adults with a variety of cognitive impairments (including intellectual disability, learning disability, autism spectrum, and traumatic brain injury) to support self-awareness, social skills, and functional cognitive skills, especially related to preparing clients for a work environment.

Self-Awareness: Character Creation

-Clients are encouraged to create a character whose personality matches their own. -Players define a character’s personality by choosing the character’s primary life aspiration and characteristics along five personality dyads. - A member of the CSEP staff who is familiar with the client reviews the personality choices and discusses with the client to determine whether the personality seems like an honest and realistic match to the client’s own personality.

Self-Awareness

• Clients have the opportunity to see how their personality traits effect their character’s behavior in the game. • Staff have observed clients with motivation, socialization, or hygiene issues in real life facing those same issues in their characters’ lives, along with the negative consequences. • The game can also force clients to face their cognitive impairments; for example, attention deficit and impulsivity on the part of the client can have negative consequences on a character’s ability to meet their needs. • Clients have expressed observations such as the character needing a regular routine like the client has, or conversely wanting the character to be less anxious and dependent on routine than the client is in real life.

Planning and Problem Solving

• Clients need to prioritize what to buy their characters with a limited budget; prioritize actions, satisfying basic needs before desires or satisfying the most urgent needs first. • Clients are challenged to plan how to meet a character’s needs and desires. • Some planning relates to a client’s response to setbacks; such as housefires or job difficulties. • One client expressed interest in using the game to recreate past problems and exploring what could be done differently.

Employment

• Clients must make sure their character finds a job, goes to work on time, and develops needed job skills.• Clients can give their character his or her own business; requiring the character to interact with customers and employees and anticipate customers’ needs

• The game provided some clients an avenue for exploring social issues. • All clients must learn how to foster their characters’ friendships, since socialization is one of the characters’ needs which must be met.• Clients can also explore how different characters react differently to the same events.

Social Skills

Potential Use of Second Life

Second Life has characteristics which could complement use of The Sims. While Second Life lacks the structure of The Sims, it has the potential to simulate a wide variety of situations. Further, it can allow for more realistic social scenarios, whether role-playing real world situations with staff or interacting with others in Second Life support groups or the general environment.Second Life also has the capacity to transmit information to a therapist by e-mail or instant message; so that a client could participate in a therapeutic activity in Second Life, and a therapist could be notified of the results.

The Sims character creation screen showing selection of the character’s personality. The player must choose one aspiration, and has a certain number of “points” to distribute among the personality dyads.

aspirations

personality dyads

A client must find a way to meet the character’s needs and wants while maintaining the character’s budget.

basic needs

wants and fears

budget

A character needs to develop job skills (bottom) or manage a business (right)

Table 2. Impact of Features on Potential Clinical Applications Sims Second Life Self-awareness Client explicitly creates a character

based on him- or herself. These personality choices affect the characterÕs behavior.

Client controls the avatar directly in real-time interactions with the environment and other avatars.

Cognitive Problem-Solving

Client must balance the characterÕs needs and react to occasional crises. Nature and frequency of problem-solving demands are random.

Problem solving scenarios could be constructed. Scenarios could be initiated by the client or by the environment.

Social Problem-Solving

Client must choose how best to interact with other characters from a defined list of interaction options.

Controllable, real-time social simulations can be created through live interactions between clients and therapist avatars and/or other clientsÕ avatars. Therapist could change his/her avatarÕs appearance as needed for role-playing. Social situations can be more open-ended and realistic. Interaction will still lack body language and other cues. Other aspects of the communication can be constrained by the therapist. Requires real-time interaction between a therapist and client, but the therapist could be at a remote location.

Attention Client must attend to the characterÕs needs and wants; as well as to events in the environment (e.g. telephone ringing, fire alarm, people walking by outside).

Could create tasks which the client must perform despite therapist-controlled distractors.

Activities of Daily Living

Built in requirements for characters to shower, use toilet, cook, clean house, maintain budget

No built-in support; but a larger variety of activities could potentially be simulated in greater detail.

Jobs Built-in support for a character to get a job or be self-employed.

No built-in support for simulating real-world jobs; but a variety of real-world job tasks could be simulated.

Table 1. Comparison of features between The Sims and Second Life The Sims Second Life Social Interaction No interaction with real people

within the game. Clients can interact with other clients, staff/therapists, or other Second Life members within Second Life. Therapeutic areas could be made private so that only staff and clients could enter.

Modifications Some aspects of the game can be modified.

Extensive capabilities to create new content.

Feedback / Tracking

A clinician can track a clientÕs overall progress based on a characterÕs general level of well-being; but detailed information requires client feedback or direct observation.

Objects can send e-mail to clinicians to report client performance.

Price Sims must be purchased for each computer.

Membership in Second Life is free; owning ŅlandÓ (e.g. a location within Second Life where a therapeutic intervention would take place) requires a paid membership.

Responsiveness Usually fast once the game is loaded.

There can be a lag in the systemÕs response depending on Internet connection speed.

Potential confounding factors

On a shared computer, a client could take over another clientÕs character.

Therapeutic environments within Second Life could be private; but Second Life as a whole in an open online community with dangers common to other such communities, if clients explore outside the constrained environment.