Efficacy of a Virtual Reality Biofeedback Game (DEEP) to Reduce Anxiety and Disruptive Classroom Behavior: Single-Case Study

Rineke Bossenbroek*, Aniek Wols, Joanneke Weerdmeester, Anna Lichtwarck-Aschoff, Isabela Granic, Marieke M. J. W. van Rooij

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

6 Citations (Scopus)
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Background: Many adolescents in special education are affected by anxiety in addition to their behavioral problems. Anxiety leads to substantial long-term problems and may underlie disruptive behaviors in the classroom as a result of the individual's inability to tolerate anxiety-provoking situations. Thus, interventions in special needs schools that help adolescents cope with anxiety and, in turn, diminish disruptive classroom behaviors are needed.

Objective: This study aimed to evaluate the effect of a virtual reality biofeedback game, DEEP, on daily levels of state-anxiety and disruptive classroom behavior in a clinical sample. In addition, the study also aimed to examine the duration of the calm or relaxed state after playing DEEP.

Methods: A total of 8 adolescents attending a special secondary school for students with behavioral and psychiatric problems participated in a single-case experimental ABAB study. Over a 4-week period, participants completed 6 DEEP sessions. In addition, momentary assessments (ie, 3 times a day) of self-reported state-anxiety and teacher-reported classroom behavior were collected throughout all A and B phases.

Results: From analyzing the individual profiles, it was found that 6 participants showed reductions in anxiety, and 5 participants showed reductions in disruptive classroom behaviors after the introduction of DEEP. On a group level, results showed a small but significant reduction of anxiety (d=-0.29) and a small, nonsignificant reduction of disruptive classroom behavior (d=-0.16) on days when participants played DEEP. Moreover, it was found that the calm or relaxed state of participants after playing DEEP lasted for about 2 hours on average.

Conclusions: This study demonstrates the potential of the game, DEEP, as an intervention for anxiety and disruptive classroom behavior in a special school setting. Future research is needed to fully optimize and personalize DEEP as an intervention for the heterogeneous special school population.

Original languageEnglish
Article number16066
Number of pages18
JournalJMIR mental health
Issue number3
Publication statusPublished - 24-Mar-2020
Externally publishedYes


  • anxiety
  • disruptive behavior
  • single-case study
  • applied game
  • serious games
  • special education
  • attention-deficit/hyperactivity disorder (ADHD)
  • autism spectrum disorder (ASD)
  • adolescents

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