# **Adversarial Review and Ethical Evaluation of Mental Health Representation, Accessibility, and Educational Validity in Interactive Media**

The representation of psychiatric disabilities, specifically psychosis, in interactive digital media requires rigorous scrutiny to prevent the reinforcement of harmful societal stigmas. Historically, commercial video games have relied heavily on psychiatric conditions to engineer horror, tension, or narrative convenience. Analysis of popular video games released over the past two decades indicates that approximately 97% of games depicting mental illness utilize negative, misleading, and highly problematic framing, predominantly associating these conditions with violence, fear, insanity, and hopelessness1. Furthermore, characters experiencing psychosis are routinely reduced to antagonists, monstrous caricatures, or one-dimensional entities whose sole narrative purpose is to dispense cryptic clues or initiate supernatural events2.  
This adversarial review evaluates the supplied character profiles, scenes, dialogue, world descriptions, restraint and quiet-room staging, portal mechanics, and learning objectives of the proposed serious game. The primary objective is to identify and remediate design choices that could unintentionally teach players that individuals experiencing psychosis are violent, monstrous, deceptive, childlike, permanently incoherent, supernaturally gifted, or valuable only because they dispense clues. The guiding philosophy of this evaluation does not recommend removing intensity merely because the material is uncomfortable. The disorientation of an altered reality and the systemic failures of institutional care are profoundly intense subjects. Changes are only mandated when the intensity becomes exploitative, stigmatizing, misleading, inaccessible, or detached from the character’s inherent humanity.

## **Severity-Ranked Issue List, Scene Analysis, and Redesign Protocols**

The review of the provided narrative and mechanical assets reveals several significant ethical and representational flaws that span critical, major, moderate, and minor severities. The analysis dissects the exact scene framing that causes each concern and mandates concrete redesign parameters to align the experience with clinical ethics, human dignity, and educational validity.

### **Critical Issues**

**Critical Issue 1: Ontological Conflation of Psychosis and Supernatural Lore** The provided design for the "Crossing Over" sequence intrinsically links the character's psychiatric condition to the activation of supernatural portal mechanics. The framing suggests that the character's clinical hallucinations are actual, literal glimpses into a supernatural realm, and their psychiatric distress is the catalyst for opening dimensional gateways. Presenting a psychiatric disability as a supernatural superpower or a mystical conduit delegitimizes the profound distress, divided attention, and disrupted self-experience associated with actual psychosis. It aligns with historical and harmful tropes that treat mental illness as a magical trait rather than a serious health condition requiring compassionate care, accommodation, and scientific understanding2. Furthermore, this framing fails to distinguish documented clinical phenomena from speculative fictional themes, directly violating ethical representation guidelines.  
The redesign mandates that the final experience must state, entirely through its environmental design and mechanics, that the supernatural portal is a property of the fictional world's lore, completely independent of the character’s psychiatric diagnosis. The character’s fear, meaning-making processes, divided attention, and disrupted self-experience must be depicted as a research-informed response to an overwhelmingly stressful environment. The character is dealing with a dual burden: navigating a genuinely supernatural environmental anomaly while simultaneously managing the cognitive load of their clinical condition. Their psychosis must never be the mechanism that opens, controls, or interacts with the portal.  
**Critical Issue 2: The Spectacle and Weaponization of Hospital Restraint** In the "Ward Containment" scene, the character is forcefully placed in a mechanical restraint chair as a punitive consequence for refusing to comply with the visitor's instructions. The staging emphasizes the aesthetic of horror, utilizing flickering lights, aggressive camera angles focusing on leather straps, and the character begging for release. The player-character is positioned to observe this as a standard, expected, and consequence-free procedure. This framing violates fundamental clinical ethics and legal standards. Restraints and seclusion have no therapeutic value; they are extreme emergency safety measures of last resort, known to cause severe emotional and physical harm, and frequently re-traumatize individuals who already possess significant trauma histories4. The Illinois Mental Health and Developmental Disabilities Code, alongside federal standards, strictly prohibits the use of restraints for punishment, discipline, retaliation, or staff convenience7. Utilizing restraints as a visual spectacle exploits patient trauma for entertainment and teaches players that coercion is a valid therapeutic tool.  
The intensity of the restraint scene must be preserved to illustrate systemic realities, but the focus must shift entirely from horror exploitation to clinical reality, tragedy, and the preservation of human dignity. The redesign must ensure that the quiet room is utilized only when there is an imminent, documented threat of serious physical harm to the character or others9. The staging must be clinical, brightly lit, and humane, explicitly removing all sensationalized horror aesthetics. The player must witness the staff explicitly attempting and exhausting non-restrictive de-escalation protocols first, such as offering choices, reducing stimuli, and verbal redirection9. If mechanical restraint or seclusion occurs, the player must observe the staff prioritizing the character's bodily dignity, explaining the process calmly to the character, ensuring continuous face-to-face monitoring, and engaging in immediate post-incident debriefing and aftercare12.

### **Major Issues**

**Major Issue 1: The Inextricable Linkage of Psychosis to Aggression** The character’s provided profile notes that upon experiencing auditory hallucinations or sensory overload, they automatically become hostile and lunge at the visitor. Associating mental illness inextricably with dangerous and violent behaviors is the most pervasive, inaccurate, and damaging stigma perpetuated by interactive media1. Evidence indicates that individuals with severe mental illness are vastly more likely to be victims of violence than perpetrators. Automatically linking psychosis to aggression dehumanizes the character and forces the player into a defensive, combative posture rather than an empathetic one.  
The character’s reaction to internal stimuli must be entirely rewritten to reflect internal distraction, profound fear, or sensory overload rather than outward aggression. The character should exhibit divided attention, perhaps asking the player to repeat themselves, turning away to speak to an unseen entity, or seeking a low-stimulus corner of the room to cope with the sensory influx. If the character expresses fear, it must mechanically prompt the player to engage in grounding techniques—such as adjusting the environmental lighting or speaking in a calm, predictable cadence—rather than preparing for a physical altercation.  
**Major Issue 2: Player Success Requiring Delusion Reinforcement and Character Humiliation** The dialogue mechanics designed for information extraction require the player to select options that falsely validate the character's paranoid delusion about a surveillance conspiracy. By playing along with the delusion, the player manipulates the character's altered state of reality to extract a necessary key code. This mechanics positions the visitor as a deceptive controller and amateur therapist, stripping the character of autonomy and dignity. It unintentionally teaches players that individuals with psychosis are easily manipulated, childlike, and that their altered reality can and should be leveraged for personal gain.  
The dialogue tree must be fundamentally redesigned so that agreeing with the literal content of the delusion increases the character's distress, spikes their anxiety metrics, and breaks trust, resulting in a failure state for that interaction. Success must instead require the player to employ empathetic listening and grounding techniques. The player must be mechanically rewarded for acknowledging the character's underlying emotional state without validating the delusion itself. By selecting dialogue such as, "I can see you are terrified of those cameras, and I want to help you feel safe in this room," the player validates the human emotion. The clue must be offered voluntarily by the character as a direct result of a trusting, dignified interaction, not extracted through psychological manipulation.

### **Moderate Issues**

**Moderate Issue 1: Erasure of Personhood and the Diagnostic Caricature** Following the sequence where the character provides the necessary lore regarding the portal, they are removed from the game environment, disappearing entirely. Prior to this, they display no personal preferences, humor, or future plans, functioning solely as a narrative dispenser. This constitutes a phenomenon known as "decorative representation," wherein the character is not recognized as an individual human being but merely as a representative of the illness and a mechanical stepping stone for the protagonist2. The character is reduced to a symptom bundle.  
The redesign must integrate elements of the character's ordinary life, identity, and relationships into both the environment and the dialogue. The character should discuss mundane preferences, such as a favorite type of music they use for self-soothing, a specific hobby they miss, or plans to call a sibling once they are discharged. After dispensing the necessary narrative information, the character must remain a persistent part of the game world. They should be seen engaging in continuous coping mechanisms, reading, or partaking in daily routines, reinforcing their ongoing existence, autonomy, and humanity independent of the player's quest.  
**Moderate Issue 2: Environmental Deprivation of Dignity** The world description of the psychiatric facility depicts a barren, isolated environment lacking personal property, privacy, or comfort items, leaning heavily into antiquated "asylum" tropes. Real patients in psychiatric facilities possess legal rights to keep personal property, communicate privately, and reside in a humane, least restrictive environment16.  
The environment must be dressed to reflect a modern, rights-respecting facility, even if that facility is under duress. The design must include personalized comfort items within the character's space, clear access to telephones designed for private communication, and individualized safety plan documents on display. These documents should list healthy coping mechanisms chosen by the character, such as deep breathing, journaling, or listening to music, indicating collaborative care rather than mere containment10.

### **Minor Issues**

**Minor Issue 1: Educational Claims Exceeding Legitimate Scope** The marketing text and tutorial prompts claim the game will allow the player to "experience exactly what schizophrenia feels like." No digital simulation can reproduce the exact, highly individualized, and complex experience of psychosis. Such claims are scientifically invalid, ethically presumptuous, and risk trivializing the chronic reality of the condition. The stated learning objectives and promotional materials must be adjusted to reflect that the game offers a research-informed perspective on the emotional, communicative, and systemic challenges associated with psychosis, but it explicitly does not simulate the clinical condition itself.  
**Minor Issue 2: Overwhelming Sensory Effects Without Accessible Alternatives** The game relies on intense, unskippable audio distortion and visual screen-tearing to simulate the character's psychological distress. While intended to build empathy, these effects cause severe sensory overload, creating cognitive roadblocks for neurodivergent players or those with trauma histories18. This issue is addressed comprehensively in the Accessibility Requirements section of this report, mandating the implementation of granular cognitive and sensory accessibility settings to ensure the intensity remains manageable for a diverse player base.

## **Restraint-Scene Dignity Checklist**

To ensure that any depiction of clinical restraint or seclusion strictly adheres to human rights standards and avoids exploitative tropes, the following checklist must be implemented for narrative and staging validation. This framework aligns with the standards set by the American Psychiatric Nurses Association, the Illinois Mental Health Code, and the Substance Abuse and Mental Health Services Administration (SAMHSA)4.

| Restraint Phase | Clinical Standard and Ethical Requirement | Narrative and Mechanical Implementation in Game Staging |
| :---- | :---- | :---- |
| **1\. Necessity & Imminence** | Restrictive interventions are illegal unless used to prevent immediate, serious physical harm. They are never for discipline or convenience7. | The scene must clearly establish that all non-restrictive, de-escalation interventions (verbal redirection, quiet space, safety plans) have failed. The intervention is only initiated in response to an immediate, visible physical threat9. |
| **2\. Medical Monitoring** | Patients in seclusion or violent restraint require continuous, face-to-face monitoring and rapid medical evaluation12. | Staff must be depicted maintaining constant observation. The scene must include verbal confirmation of vital signs, circulation checks, and an assessment by a licensed medical professional within one hour of initiation12. |
| **3\. Communication** | Staff must maintain therapeutic communication, explaining the process and requirements for release14. | Staff must communicate with the restrained individual in a calm, non-threatening manner, actively listening to the character's distress and explaining exactly why the intervention is happening9. |
| **4\. Bodily Comfort & Dignity** | The environment must be safe, clean, and provide the least restrictive posture possible15. | The scene must depict staff offering hydration, bathroom access, and climate control. If physical restraints are used, the character must be allowed to move their limbs for at least five minutes every hour15. |
| **5\. Maximizing Consent** | Even during involuntary procedures, seeking cooperation minimizes trauma and preserves residual autonomy17. | The scene should depict staff seeking the character's cooperation at every micro-step (e.g., "We are moving you to the bed now, will you walk with us?") to maximize autonomy under restrictive conditions. |
| **6\. Release Criteria** | Interventions must end the exact moment the imminent danger passes. Maximum time limits apply based on age (e.g., 4 hours for adults)15. | The narrative must establish that the intervention concludes immediately when the character regains behavioral control. It is never prolonged to "teach a lesson"7. |
| **7\. Aftermath & Debriefing** | Post-incident trauma is mitigated through immediate debriefing, psychological first aid, and relationship repair14. | The scene must conclude with immediate post-incident aftercare, depicting trauma-informed debriefing to discuss the event and emotional support to repair the therapeutic relationship14. |

## **Educational Framework and Learning Objectives**

The educational validity of a serious game depicting psychiatric disabilities relies on establishing rigid boundaries around what the medium can achieve. The experience cannot, and must not claim to, reproduce every person’s psychosis exactly. It can, however, model empathetic interaction, expose systemic realities, and challenge cognitive biases. The following five learning objectives must guide the design:

1. **Systems of Care Recognition:** Players will identify the differences between dignity-preserving, collaborative interventions and coercive, punitive treatments within mental health care environments, understanding the historical and legal contexts of least restrictive care.  
2. **Empathetic Navigation of Altered Realities:** Players will demonstrate the ability to engage with a character experiencing an altered state of reality by validating their underlying emotional distress (such as fear, confusion, or sensory overload) without confirming the literal content of their delusions or hallucinations.  
3. **De-escalation and Cognitive Load Management:** Players will utilize non-confrontational communication strategies—such as reducing environmental stimuli, maintaining appropriate physical distance, utilizing plain language, and offering clear, calm choices—to assist a character experiencing psychological overload.  
4. **Identification of Stigmatizing Tropes:** Players will recognize and critically evaluate common societal stigmas and media tropes that inaccurately link severe mental illness with inherent violence, monstrosity, deception, or supernatural mysticism.  
5. **Preservation of Autonomy and Personhood:** Players will interact with the character as a holistic individual by recognizing and accommodating their personal preferences, ordinary identity, and inherent human dignity, independent of their psychiatric symptoms.

## **Post-Session Debriefing Protocols**

Debriefing in serious games is a pedagogical necessity for consolidating learning, addressing emotional bleed, and preventing the internalization of misconceptions. The post-session debrief must strictly evaluate the player's in-game choices and mechanical strategies. It must explicitly avoid any psychological assessment of the player's real-world personality, moral character, or mental health status.  
The debrief evaluation framework operates by presenting a diagnostic summary of the player's dialogue and mechanical choices. For example, the system will state, "When the character expressed fear of the surveillance cameras, you chose to validate the presence of a conspiracy rather than validate their emotional distress. This choice is categorized as 'Delusion Reinforcement'." Following this choice analysis, the system will map the mechanical consequences of the action, explaining that attempting to leverage the delusion for a clue resulted in an increase in the character's anxiety metrics, leading to a breakdown in trust.  
The debrief will then reveal the optimal, trauma-informed alternative pathway, demonstrating that choosing to acknowledge the fear and offering a transition to a quieter room would have prioritized grounding and established a cooperative dynamic. This structure explicitly connects the gameplay mechanics to the real-world necessity of patience, active listening, and reducing cognitive load for individuals in distress.

### **Debrief Questions Connecting Mechanics to Empathy and Uncertainty**

To facilitate critical reflection, the game must prompt the player with the following six questions at the conclusion of the experience:

1. How did the limitation of your dialogue choices reflect the inherent difficulty of communicating effectively when someone's perception of reality differs drastically from your own?  
2. During the sequence where the environment's sensory output (audio and visual distortion) increased, how did that mechanical pressure impact your ability to make logical, empathetic decisions regarding the character's care?  
3. When the game required you to abandon the pursuit of your primary objective (obtaining the portal lore) to focus entirely on the character's immediate emotional safety, how did that shift your perspective on the character's value within the narrative?  
4. Reflect on the restraint sequence: In what ways did the physical environment and the mechanics of the scene highlight the power imbalance between the institutional healthcare system and the individual?  
5. How did the uncertainty of not knowing whether the character's reactions were driven by the supernatural portal or their clinical distress force you to change your approach to problem-solving and investigation?  
6. Which specific mechanical actions (e.g., adjusting environmental lighting, selecting plain-language dialogue) did you find most effective in returning a sense of dignity and autonomy to the character, and why?

## **Accessibility Requirements for Audio, Visual, Motion, Haptic, and Cognitive Load**

Creating an emotionally intense serious game requires stringent adherence to accessibility guidelines to ensure that the intended intensity does not become an insurmountable barrier. Accessibility in this context is not merely a functional adjustment; it is a fundamental requirement for inclusive cultural production19. Following the W3C Web Content Accessibility Guidelines (WCAG), Cognitive Accessibility (COGA) guidance, and Xbox Accessibility Guidelines (XAG), the following comprehensive requirements must be implemented22.

### **Audio and Visual Accessibility**

Sensory processing differences require that audio and visual information be highly customizable. Games often relay vital information through audio cues, which can exclude players who are deaf or hard of hearing, while overwhelming audio mixes can trigger sensory overload for neurodivergent players25.

| Accessibility Domain | Implementation Requirement |
| :---- | :---- |
| **Multi-Channel Audio Mixing** | Provide separate, granular volume sliders for dialogue, environmental effects, background music, and the specific distorted audio cues used to represent psychological distress. This allows players to reduce overstimulating noise without losing narrative context25. |
| **Audio Independence** | Ensure no essential narrative or mechanical information is conveyed by sound alone. All auditory cues must be accompanied by accurate closed captioning and directional visual indicators26. |
| **Subtitle Customization** | Subtitles must default to high-contrast, large, sans-serif fonts (minimum 18px or 14px bold for mobile interfaces), with robust options to adjust size, background opacity, and speaker identification27. |
| **Visual Distortion Mitigation** | Provide global toggles to disable screen-tearing, chromatic aberration, flickering lights, and high-frequency visual noise. While atmospheric, these effects can trigger vestibular disorders, photosensitive epilepsy, and severe sensory overload24. |
| **Contrast and Legibility** | Ensure high contrast ratios (minimum 4.5:1) for all user interface elements. Crucial interactive elements and navigation paths must not rely on color alone to convey meaning, accommodating players with color vision deficiencies28. |

### **Motion and Haptic Accessibility**

Physical inputs and feedback mechanisms must accommodate varying motor capabilities and sensory processing thresholds to prevent physical discomfort and interface fatigue27.

| Accessibility Domain | Implementation Requirement |
| :---- | :---- |
| **Haptic Customization** | Haptic feedback must be entirely optional and adjustable via intensity sliders. Intense vibration used to simulate anxiety or heartbeats can cause significant discomfort or physical pain for players with certain motor or sensory conditions27. |
| **Camera Stabilization** | Provide immediate options to disable camera shake, head-bobbing, and forced perspective shifts to prevent simulation sickness and vestibular disorientation28. |
| **Input Flexibility** | Avoid requiring repeated, rapid inputs (e.g., button-mashing or quick-time events) to progress. Allow complete remapping of all digital controls27. |

### **Cognitive Load and Emotional Accessibility**

Understanding how instruction and environmental design influence cognitive load is paramount for serious games. Cognitive load theory delineates between intrinsic load (the complexity of the task itself) and extraneous load (unnecessary demands caused by poor interface or environmental design)32. To optimize learning and empathy, extraneous cognitive load must be minimized, and emotional accessibility must be prioritized18.

| Accessibility Domain | Implementation Requirement |
| :---- | :---- |
| **Pacing and Time Constraints** | Adhere to the principle of "adequate time." Remove all hidden or artificial time limits during dialogue selection and puzzle-solving sequences to prevent cognitive overload. Allow the player to pause the game at any moment, during which all sensory effects must immediately cease24. |
| **Content Warnings & Customization** | Implement granular, highly visible content warnings before the game begins, specifically noting themes of psychiatric distress, institutional restraint, and supernatural horror. Provide an option for real-time, in-game warnings before entering scenes with intense psychological content, allowing players to prepare or skip the sequence22. |
| **Scaffolding and Reminders** | Ensure narrative and puzzle processes do not rely heavily on the player's working memory. Provide an easily accessible, persistently updated journal or objective log that summarizes the narrative progress, the character's immediate emotional needs, and control schemes in clear, plain language23. |
| **Clarity of Consequence** | Ensure users are aware of what will happen when interacting with sensitive dialogue. Avoid abstract concepts in the UI and provide clear hint text for emotional interactions to prevent accidental harm to the character23. |

## **Multi-Disciplinary Review Plan**

To ensure the design remains robust, ethical, and clinically sound throughout the development lifecycle, a comprehensive, multi-disciplinary review plan must be executed prior to any public release. This process cannot be relegated to post-production; it must inform the core architecture of the game.

1. **Lived-Experience Consultation:** The studio must establish a compensated advisory board consisting of individuals with lived experience of psychosis, psychiatric hospitalization, and physical restraint. Their primary mandate is to review the dialogue, characterization, and the depiction of the institutional environment. Their input is critical to ensure the narrative honors their humanity, avoids exploitative tropes, and accurately reflects the nuanced reality of navigating altered states2.  
2. **Clinical and Psychiatric Review:** Partner with trauma-informed psychiatric clinicians and psychiatric nurses (specifically those familiar with APNA standards for seclusion and restraint) to audit the de-escalation mechanics and restraint staging. They must verify that the depiction of clinical interventions, even when representing systemic failures, accurately reflects the legal and physical realities of mental health care, avoiding sensationalized inaccuracies14.  
3. **Accessibility and Usability Auditing:** Engage accessibility specialists and neurodivergent game testers to formally evaluate the efficacy of the sensory toggles, cognitive scaffolding, and emotional pacing. This phase must utilize established frameworks, such as the APX (Accessibility Player Experiences) triangle, to ensure the game remains entirely playable and emotionally accessible across a diverse spectrum of cognitive and sensory profiles without sacrificing narrative weight29.  
4. **Trauma-Informed Narrative Design Review:** Conduct a structural review with narrative designers formally trained in trauma-informed media practices. Their specific task is to ensure the integration of the supernatural portal lore does not bleed into or delegitimize the clinical representation of the character's psychosis, maintaining the strict ontological boundary required by this review.

## **Final Release Recommendation**

**Recommendation:** REVISE PRIOR TO RELEASE.  
**Reasoning:** The current iteration of the design contains critical structural and narrative flaws that inadvertently perpetuate severe, real-world stigmas against individuals with psychiatric disabilities. Specifically, the presentation of a supernatural portal as a direct manifestation or benefit of a real mental illness minimizes the profound reality of psychosis, reducing a chronic health condition to a convenient narrative device. Furthermore, utilizing hospital restraints as a horror spectacle violates fundamental ethical standards of representation, exploiting profound human trauma for entertainment value. Additionally, the automatic linking of auditory hallucinations to physical aggression directly feeds into the false and dangerous narrative that mental illness inherently equates to violence, a trope that actively harms marginalized populations1.  
However, the core concept possesses the potential to be a groundbreaking, empathetic experience. The intensity of the subject matter does not need to be sanitized; the discomfort of witnessing systemic institutional failure or the disorientation of an altered reality can serve as powerful, transformative educational tools.  
To achieve approval for public release, the development team must execute the redesign protocols outlined in the Issue List, strictly implement the Restraint Dignity Checklist, and fully integrate the comprehensive cognitive and sensory accessibility requirements. The narrative architecture must be fundamentally restructured to declare that the supernatural portal is a property of the fictional lore, completely separate from the diagnosis. Most importantly, the character must be elevated from a symptom-bundle to a fully realized human being deserving of dignity, agency, and rigorous, compassionate design.

#### **Works cited**

1. Gaming With Stigma: Analysis of Messages About Mental Illnesses in Video Games, [https://mental.jmir.org/2019/5/e12418](https://mental.jmir.org/2019/5/e12418)  
2. Representation of mental illness in video games beyond stigmatization \- Frontiers, [https://www.frontiersin.org/journals/human-dynamics/articles/10.3389/fhumd.2023.1155821/full](https://www.frontiersin.org/journals/human-dynamics/articles/10.3389/fhumd.2023.1155821/full)  
3. Depiction of mental illness and psychiatry in popular video games over the last 20 years, [https://pmc.ncbi.nlm.nih.gov/articles/PMC9421125/](https://pmc.ncbi.nlm.nih.gov/articles/PMC9421125/)  
4. Restraint and Seclusion \- Therapist Neurodiversity Collective, [https://therapistndc.org/advocacy/restraint-and-seclusion/](https://therapistndc.org/advocacy/restraint-and-seclusion/)  
5. Seclusion and restraints | Mental Health America, [https://mhanational.org/position-statements/seclusion-and-restraints/](https://mhanational.org/position-statements/seclusion-and-restraints/)  
6. Ethical Considerations in Physical Restraint and Seclusion: Best Practices for Educators, [https://mindsetsafetymanagement.com/ethical-considerations-in-physical-restraint-and-seclusion-best-practices-for-educators/](https://mindsetsafetymanagement.com/ethical-considerations-in-physical-restraint-and-seclusion-best-practices-for-educators/)  
7. North Suburban Human Rights Authority Report of Findings Centegra Health System HRA \#11-100-9016 \- Illinois Guardianship & Advocacy Commission, [https://gac.illinois.gov/content/dam/soi/en/web/gac/hra/reports/2011/11-100-9016.pdf](https://gac.illinois.gov/content/dam/soi/en/web/gac/hra/reports/2011/11-100-9016.pdf)  
8. ADMINISTRATIVE CODE, [https://www.ilga.gov/agencies/JCAR/EntirePart?titlepart=08900384](https://www.ilga.gov/agencies/JCAR/EntirePart?titlepart=08900384)  
9. Model Policy \- City of DeKalb, [https://www.cityofdekalb.com/DocumentCenter/View/11342/4053---Mentally-Ill-and-Suicidal-Persons](https://www.cityofdekalb.com/DocumentCenter/View/11342/4053---Mentally-Ill-and-Suicidal-Persons)  
10. 23-100-9006 Elgin Mental Health Center (Findings, Public Response) \- Illinois Guardianship & Advocacy Commission, [https://gac.illinois.gov/content/dam/soi/en/web/gac/hra/hrareports/23-100-9006%20Final%20Report.pdf](https://gac.illinois.gov/content/dam/soi/en/web/gac/hra/hrareports/23-100-9006%20Final%20Report.pdf)  
11. Threlkeld v. White Castle Systems, Inc., 127 F. Supp. 2d 986 (N.D. Ill. 2001\) \- Justia Law, [https://law.justia.com/cases/federal/district-courts/FSupp2/127/986/2512245/](https://law.justia.com/cases/federal/district-courts/FSupp2/127/986/2512245/)  
12. COPIES ARE ONLY VALID ON THE DAY PRINTED-OFFICIAL POLICY RESIDES IN MCN \- Hospital Sisters Health System, [https://www.hshs.org/getmedia/2879456a-b79b-4410-9ca6-491255ec44e5/Medical-Staff-D-22-Restraint-and-Seclusion-Policy.pdf](https://www.hshs.org/getmedia/2879456a-b79b-4410-9ca6-491255ec44e5/Medical-Staff-D-22-Restraint-and-Seclusion-Policy.pdf)  
13. IDHS: ISD Policy Guidelines for Behavioral Interventions \- Dhs.state.il.us, [https://www.dhs.state.il.us/page.aspx?item=137244](https://www.dhs.state.il.us/page.aspx?item=137244)  
14. APNA Standards of Practice: Seclusion and Restraint, [https://www.apna.org/standards-of-practice-seclusion-and-restraint/](https://www.apna.org/standards-of-practice-seclusion-and-restraint/)  
15. Restraint and Seclusion Guidelines: Rights of People Receiving Behavioral Interventions, [https://disabilityrightstx.org/en/handout/restraint-and-seclusion-guidelines-rights-of-people-receiving-behavioral-interventions/](https://disabilityrightstx.org/en/handout/restraint-and-seclusion-guidelines-rights-of-people-receiving-behavioral-interventions/)  
16. FOR IMMEDIATE RELEASE North Suburban Regional Human Rights Authority Report of Findings HRA \#16-100-9009 Streamwood Behavioral H, [https://gac.illinois.gov/content/dam/soi/en/web/gac/hra/reports/2016/16-100-9009.pdf](https://gac.illinois.gov/content/dam/soi/en/web/gac/hra/reports/2016/16-100-9009.pdf)  
17. Understanding your legal medical rights for mental health | Illinois Legal Aid Online, [https://www.illinoislegalaid.org/legal-information/understanding-your-legal-medical-rights-mental-health](https://www.illinoislegalaid.org/legal-information/understanding-your-legal-medical-rights-mental-health)  
18. Do Not Play With My Emotions. Design for Emotional Accessibility \- White Rose Research Online, [https://eprints.whiterose.ac.uk/id/eprint/229279/1/CHIPlay\_PoP\_Final.pdf](https://eprints.whiterose.ac.uk/id/eprint/229279/1/CHIPlay_PoP_Final.pdf)  
19. Neurodivergent-Focused Game Accessibility: A Systematic Literature Review \- MDPI, [https://www.mdpi.com/2673-7272/6/1/18](https://www.mdpi.com/2673-7272/6/1/18)  
20. Restraint and Seclusion, 2010 \- Association for Behavior Analysis International, [https://www.abainternational.org/about-us/policies-and-positions/restraint-and-seclusion,-2010.aspx](https://www.abainternational.org/about-us/policies-and-positions/restraint-and-seclusion,-2010.aspx)  
21. University of Illinois Medical Center, [https://gac.illinois.gov/content/dam/soi/en/web/gac/hra/reports/2010/10-030-9006.pdf](https://gac.illinois.gov/content/dam/soi/en/web/gac/hra/reports/2010/10-030-9006.pdf)  
22. Xbox Accessibility Guideline 123: Mental health best practices \- Microsoft Learn, [https://learn.microsoft.com/en-us/xbox/accessibility/xbox-accessibility-guidelines/123](https://learn.microsoft.com/en-us/xbox/accessibility/xbox-accessibility-guidelines/123)  
23. Cognitive accessibility guidelines \- Accessibility and inclusive design manual, [https://accessibility.education.gov.uk/guidelines/coga](https://accessibility.education.gov.uk/guidelines/coga)  
24. W3C Accessibility Guidelines (WCAG) 3.0, [https://w3c.github.io/wcag3/guidelines/](https://w3c.github.io/wcag3/guidelines/)  
25. Game Accessibility Features—How to Make Games More Inclusive \- TestDevLab, [https://www.testdevlab.com/blog/gaming-accessibility-features](https://www.testdevlab.com/blog/gaming-accessibility-features)  
26. Xbox Accessibility Guideline 103: Additional channels for visual and audio cues, [https://learn.microsoft.com/en-us/xbox/accessibility/xbox-accessibility-guidelines/103](https://learn.microsoft.com/en-us/xbox/accessibility/xbox-accessibility-guidelines/103)  
27. Game Accessibility \- Accessible Minds, [https://accessiblemindstech.com/game-accessibility/](https://accessiblemindstech.com/game-accessibility/)  
28. Full list \- Game Accessibility Guidelines, [https://gameaccessibilityguidelines.com/full-list/](https://gameaccessibilityguidelines.com/full-list/)  
29. Accessibility Heuristics and Evaluation Criteria for Mobile Games \- Game Developer, [https://www.gamedeveloper.com/game-platforms/accessibility-heuristics-and-evaluation-criteria-for-mobile-games](https://www.gamedeveloper.com/game-platforms/accessibility-heuristics-and-evaluation-criteria-for-mobile-games)  
30. Making Games Accessible | MultiLingual, [https://multilingual.com/magazine/october-2025/making-games-accessible/](https://multilingual.com/magazine/october-2025/making-games-accessible/)  
31. Where to Begin: Games Accessibility \- Morgan L. Baker, [https://leahybaker.com/gamesaccessibility101/](https://leahybaker.com/gamesaccessibility101/)  
32. Effects of adaptive scaffolding on performance, cognitive load and engagement in game-based learning: a randomized controlled trial \- PMC, [https://pmc.ncbi.nlm.nih.gov/articles/PMC11360721/](https://pmc.ncbi.nlm.nih.gov/articles/PMC11360721/)  
33. Measuring Cognitive Load Using In-Game Metrics of a Serious Simulation Game \- Frontiers, [https://www.frontiersin.org/journals/psychology/articles/10.3389/fpsyg.2021.572437/full](https://www.frontiersin.org/journals/psychology/articles/10.3389/fpsyg.2021.572437/full)