RAGE-Control: Teaching Emotional Self-regulation Through Videogame Play

Experiencing mild anger and aggression in frustrating situations is typical in childhood;
however, over time most children develop the capacity to regulate their anger in emotionally
provoking situations. Those who continue to struggle with emotional and behavioral regulation
are at heightened risk for social isolation, delinquency, substance abuse, and academic
problems later in life. Moreover, adults who were aggressive as children experience poor
physical and mental health, and may find limited career opportunities.

Although anger regulation is a common and clinically significant psychiatric concern for
children and adolescents, effective treatment options are limited. As a result, clinicians
increasingly rely on psychotropic medications to blunt anger. Psychotropic medications can
reduce anger and aggression in the short term, but they fail in the long-term goal of
teaching self-regulation, and carry the risk of serious side-effects, including obesity,
metabolic syndrome, and type II diabetes. However, engaging youth with anger issues in
therapeutic treatments can be difficult, with high rates of attrition. These difficulties
underline the need for innovative treatments that can effectively engage patients and enhance
their ability to control their emotions and behaviors.

In response to this need, clinicians at Boston Children's Hospital developed Regulate and
Gain Emotional Control (RAGE-Control), a therapeutic videogame that requires players to
maintain low levels of physiologic arousal while rapidly reacting to incoming stimuli and
inhibiting erroneous responses. It was initially designed for use with Cognitive Behavioral
Therapy (CBT) to motivate children to remain engaged in therapy, and to foster the learning,
practice, and generalization of self-regulation skills in the midst of frustrating or anger
provoking situations. Pilot data from an open label trial of RAGE-Control on a pediatric
psychiatric inpatient unit demonstrated improvement in patient self-reported anger and
aggression after 5 sessions of CBT with RAGE-Control, when compared with a treatment as usual
group. A subsequent outpatient randomized controlled trial comparing CBT with RAGE-Control to
CBT with a sham videogame demonstrated that patients who participated in the RAGE-Control
intervention had significantly greater improvements in overt aggression and oppositionality,
parental stress, and family atmosphere. The participants in the RAGE-Control group also had
fewer drop outs, and twice as many treatment responders as the participants in the control
arm.

Inclusion Criteria:

- Problems with anger and/or aggression

- Score of at least 4/10 on phone screen with parents measuring anger and aggression

Exclusion Criteria:

- Changes in dosing of psychotropic medications within the 8 weeks prior to the start of
the study, or anticipated medication changes during the study.

- Starting therapy within the 8 weeks prior to starting the study, or anticipated new
therapy beginning during the study.

- Actively participating in any type of Cognitive Behavioral Therapy for less than 12
weeks and/or attending Cognitive Behavioral Therapy weekly or more.

- Intellectual disability (IQ < 80)

- Suicidal ideation

- Homicidal ideation

- Psychosis/meets criteria for psychotic disorder