“Braingame Brian”: Toward an Executive Function Training Program with Game Elements for Children with ADHD and Cognitive Control Problems

Abstract

In the area of childhood attention-deficit hyperactivity disorder, there is an urgent need for new, innovative, and child-focused treatments. A computerized executive functioning training with game elements aimed at en-hancing self-control was developed. The first results are promising, and the next steps involve replication with larger samples, evaluating transfer of training effects to daily life, and enhancing motivation through more gaming elements.

Full text

Clinical Briefs
‘‘Braingame Brian’’: Toward an Executive Function
Training Program with Game Elements for Children
with ADHD and Cognitive Control Problems
Pier J.M. Prins, PhD,
1
Esther Ten Brink, MSc,
2
Sebastiaan Dovis, MSc,
1
Albert Ponsioen, PhD,
2
Hilde M. Geurts, PhD,
3,4,5
Marieke de Vries, MSc,
3
and Saskia van der Oord, PhD
1,6
Abstract
In the area of childhood attention-deficit hyperactivity disorder, there is an urgent need for new, innovative, and
child-focused treatments. A computerized executive functioning training with game elements aimed at en-
hancing self-control was developed. The first results are promising, and the next steps involve replication with
larger samples, evaluating transfer of training effects to daily life, and enhancing motivation through more
gaming elements.
Background
Attention-deficit hyperactivity disorder (ADHD) is
one of the most frequently diagnosed and impairing
neurodevelopmental disorders in childhood,
1
with a preva-
lence of 3%–5% in the general population of schoolchildren
under 16 years.
2
In community samples, ADHD is more fre-
quently diagnosed in boys than in girls (3:1) and in clinical
populations even more.
3
Children with ADHD are hyperac-
tive and impulsive and have difficulty concentrating, plan-
ning, and organizing their (school)work. These characteristics
disturb their learning and achievement at school and hinder
positive social interactions within the family and with peers.
In the end, all may have a negative impact on the children’s
self-image and self-confidence.
4
The need for new, child-focused treatments
To date, psychosocial treatments (behavioral or cognitive-
behavioral), treatment with stimulants (mostly methylphe-
nidate), and their combination are considered empirically
supported for school-aged children with ADHD.
5,6
Psy-
chosocial treatments for ADHD focus on the parents, the
teacher, and the child, for example, with variants of (cog-
nitive) behavioral therapy. Thus far, cognitive behavioral
treatment of the child has received little empirical support in
comparison with medication treatment and behavioral
parent and teacher training.
6
In the area of childhood
ADHD, there is a need for new effective interventions, fo-
cusing directly on the child, in order to facilitate goal-
directed and self-control behaviors.
Reconceptualizing ADHD: Cognitive
and motivational deficits
According to recent neurobiological theories of ADHD,
deficits in cognitive control functions give rise to the daily
problems of children with ADHD.
7
Cognitive control func-
tions, the so-called executive functions (EFs), such as
working memory (WM), inhibition, and cognitive flexibility,
allow individuals to regulate their behavior, thoughts, and
emotions and thereby enable self-control. WM is the ability
to maintain, control, and manipulate goal-relevant infor-
mation. It enables reasoning, planning, problem solving,
and goal-directed behavior.
8
WM impairments in children
with ADHD have been related to deficits in attention,
hyperactivity, and impulsivity. Inhibition is defined as
stopping or slowing down of an overlearned ongoing,
competing, or disrupting response. The inhibition of an
ongoing response is disturbed in ADHD. Cognitive flexi-
bility is the ability to shift to different thoughts or actions
depending on situational demands.
9,10
Meta-analyses have
indicated that children with ADHD are most impaired in
WM (especially visuospatial WM) and inhibition, but less in
cognitive flexibility.
11,12
1
Department of Developmental Psychology, University of Amsterdam, Amsterdam, The Netherlands.
2
Lucertis, Child and Adolescent Psychiatry, Zaandam, The Netherlands.
3
Department of Brain and Cognition, d’Arc, University of Amsterdam, Amsterdam, The Netherlands.
4
Cognitive Science Center, Amsterdam, The Netherlands.
5
Dr. Leo Kannerhuis, Doorwerth/Amsterdam, The Netherlands.
6
Clinical Psychology, KU Leuven, Leuven, Belgium.
GAMES FOR HEALTH JOURNAL: Research, Development, and Clinical Applications
Volume 2, Number 1, 2013
ªMary Ann Liebert, Inc.
DOI: 10.1089/g4h.2013.0004
44

Next to deficits in EFs, children with ADHD have prob-
lems with motivation; they react differently to reward and
punishment compared with normal controls.
13
To optimize
their performance, they need strong reinforcements and
prefer immediate over delayed rewards. When reinforcers
are powerful and frequent, the differences in behavior be-
tween children with ADHD and normal controls are less
pronounced.
As reinforcement is highly associated with motivation, re-
search suggests that an unusually low level of effort or intrinsic
motivation accounts for the performance deficits in children
with ADHD. When tasks are extremely boring, or without
supervision, the attention span of children with ADHD will be
very limited. Adding external incentives to a potentially boring
task may help children with ADHD optimize their motiva-
tional state and normalize their performance.
13
From a clinical perspective, in order to optimize ADHD
children’s performance the deficits in both EFs and motiva-
tion should be addressed in the development of new child-
focused ADHD interventions.
FIG. 1. Brian’s Home.
FIG. 2. The Village.
EXECUTIVE FUNCTIONING TRAINING AND ADHD 45

Training EFs
There is increasing evidence for the efficacy of training
specific EF deficits of children with ADHD with a comput-
erized training. Most evidence has been found for the train-
ability of WM,
14
while the efficacy of training response
inhibition and cognitive flexibility has barely been investi-
gated.
15–17
Klingberg et al.
18
have shown that an intensive,
computerized WM training not only improved the trained
visuospatial WM, but also generalized to other, non-trained
executive functions, such as verbal WM, response inhibition,
and complex reasoning. Furthermore, these authors found a
significant reduction of parent-rated inattention and hyper-
activity/impulsivity symptoms (no effects on teacher rat-
ings). These positive effects at post-test were maintained at 3
months of follow-up.
18
Several studies have replicated these
findings,
19,20
but concerns with regard to transfer issues (i.e.,
whether positive training effects generalize to other, non-
trained EFs and to the child’s self-control behaviors in daily
life) have been raised.
21,22
Most computerized EF training programs are tedious and
boring for children with ADHD. The child has to repeat the
same responses over and over again, for many trials. This
creates a motivation problem. A feature that may increase
children’s motivation is adding game elements to the com-
puterized EF tasks. Parents, teachers, and clinicians have
reported that children with ADHD, when playing a com-
puter game, can sustain attention, concentrate for longer
periods of time, and behave less impulsively.
4
In a recent
study, we have found that children with ADHD were more
motivated for an EF task (visuospatial WM) when game
elements were added, compared with the same EF task
without game elements.
23,24
There are several theoretical explanations for this enhanced
motivation due to gaming in children with ADHD. Adding
game elements to computerized tasks may heighten chil-
dren’s arousal/activation state, which may promote optimal
performance.
24
Also, the immediate reward for performance
that is provided, and the fact that the child does not experi-
ence a delay of gratification may lengthen his or her attention
span and may reduce unwanted interfering hyperactive-
impulsive behavior.
4,25
An EF training program with game elements:
‘‘Braingame Brian’’
The WM training of Klingberg et al.
18
was computerized,
including some animation and feedback, but without elabo-
rate gaming elements. Based on previous research and clini-
cal observations, we expected that adding more game
elements to a standard computerized WM training would
enhance its effects. We further reasoned that training not only
WM, but also inhibition and cognitive flexibility, would en-
hance the efficacy of the EF training even more. We therefore
recently developed an EF-remediation training program with
game elements for children with ADHD, ‘‘Braingame Brian,’’
which not only trains the EF WM, but also inhibition and
cognitive flexibility. Furthermore, the training takes into ac-
count ADHD children’s motivational deficits by adding game
elements to the training tasks.
Description of ‘‘Braingame Brian’’
The EF training ‘‘Braingame Brian’’ (gaming input pro-
vided by Harold de Groot, Shosho, Amsterdam, The Neth-
erlands [www.shosho.com]) is a computerized training of
three EFs: visuospatial WM, inhibition, and cognitive flexi-
bility, embedded in an extensive, game-like world. One may
choose to train one, two, or all three EFs.
‘‘Braingame Brian,’’ named after the main character, Brian,
consists of 25 training sessions of about 40–50 minutes. Each
FIG. 3. Working Memory (WM) task.
46 PRINS ET AL.

session contains two blocks of three training tasks in a fixed
order. The first training task is always a WM training task; the
second and third task, an inhibition training task and a cog-
nitive flexibility task, are presented in changing order. During
each session the three training tasks are performed twice,
which results in a total training time of about 30 minutes per
session. Over a period of 5 weeks, the child trains and plays
the total of 25 sessions. Each day of training, the child plays
one session of approximately 40–50 minutes (30 minutes of
training and 10–20 minutes of walking around in the world).
After each block of training tasks, the difficulty level of the
training task is automatically adjusted to the child’s level of
performance.
The game world has seven different worlds: The area
around the house of Brian’s parents, the village, the unin-
habited island, the backlands, the beach, the swamp, and the
subterranean laboratory. All characters living in these worlds
have a problem. Brian helps them to solve these problems by
doing the training tasks, and by doing so, he invents all kinds
of handy machines. Walking around in the world and seeing
the inventions are the child’s reinforcement for initiating and
completing the training tasks.
To enhance the child’s motivation, each completed block of
training tasks results in an elaboration of the game world and
extra powers for Brian. Before, after, and in between training
tasks the child can walk around in the world. From the first to
the last session the game world becomes more and more
elaborate, and every completed block of training tasks results
in extra powers for Brian. With these extra powers Brian can
create inventions to help people in the village solving their
problems, which makes them happier. Thus, completing
training sessions not only results in a more elaborate game
world and more powers for Brian, but also in happier people
in the village.
An additional external reinforcement system—receiving
points for completing sessions—is used to even further raise
the child’s motivations to do the training. This way, ‘‘Brain-
game Brian’’ addresses both the underlying EF and motiva-
tional deficits.
Data from each training session are sent to a central data-
base. Based on these data, the trainers receive online feedback
about the child’s progress on the training tasks.
The child does the training at home. The number of
trainer/therapist contacts is limited to five and consists of (1)
an intake +instruction session at the clinic and (2) three ses-
sions at the child’s home where the trainer/therapist coaches
the child through the first training session, while the parent is
present. At the end of this first session the child’s initial
training level is set, and the reward system is discussed with
child and parent; the other two contacts are around session 10
and session 20 and may be conducted by telephone. (3) The
final evaluation session is at the clinic.
Intended Benefits
The intended benefits of ‘‘Braingame Brian’’ are the re-
duction of ADHD symptoms and the strengthening of goal-
directed and task-relevant behaviors at home and at school.
It is expected that the child after the training will show more
self-control. ‘‘Braingame Brian’’ meets the urgent need for a
child-focused treatment module in the childhood ADHD
arena. Because of the addition of game elements that will
enhance children’s motivation, it is expected that less
dropout from training will be seen. More and higher impact
of training may be found as children will complete more
sessions and as the training addresses not only the EF WM,
but also the EFs inhibition and cognitive flexibility. Fur-
thermore, a practical asset of this intervention is that the
trainingcanbedoneathomeatatimethatismostconve-
nient for the child.
Finally, ‘‘Braingame Brian’’ may be a cost-effective treat-
ment module as the number of therapist’s contacts over the 25
training sessions is limited to five. Hence, ‘‘Braingame Brian’’
may save therapist’s time.
FIG. 4. Stop task.
EXECUTIVE FUNCTIONING TRAINING AND ADHD 47

The training may easily be implemented at school if there is
a quiet room to conduct the training. Some form of supervi-
sion will be necessary. In that case, the parents can come to
the school to monitor the child while doing the training or a
teacher assistant may accompany the child.
Results
In a first pilot study,
26
we investigated the efficacy of
‘‘Braingame Brian.’’ Forty clinically diagnosed children with
ADHD (8–12 years old) were randomly assigned to ‘‘Brain-
game Brian’’ (n=18) or to a waitlist condition (n=22). Treat-
ment outcome was assessed on EF problems, ADHD
symptoms, and disruptive behavior problems as rated by the
parent and teachers. We expected ‘‘Braingame Brian’’ at post-
test to be effective in improving executive functioning and in
reducing ADHD behaviors. We further expected the effects to
be maintained at a 9-week follow-up. Exploratively, we also
assessed the additive effects of our EF training in a subsample
of the participating children (n=29), who were also treated
with methylphenidate. Results showed that the children in
the EF training condition significantly improved on parent-
rated EFs (BRIEF total score
27
) and ADHD behaviors
(Inattention and Hyperactive-impulsivity subscales of the
Disruptive Behavior Problems Scale
28
), both in the total
sample and in the subsample treated with methylphenidate.
Effects were maintained at follow-up.
25
It should be noted
that the design of this first evaluation study did not control
for expectation and nonspecific treatment effects, and future
research should further examine the efficacy of ‘‘Braingame
Brian’’ with placebo-controlled designs.
Conclusion and Next Steps
‘‘Braingame Brian’’ meets the need for a new, child-focused
treatment for ADHD. To our knowledge, it is the first pro-
gram that trains three EFs at the same time and uses game
elements in the training. Our pilot study has shown promis-
ing evidence for the potential clinical efficacy of this broad
EF-remediation program. However, much remains to be
done. Three important issues need further attention. First,
future studies should replicate these positive results with
larger samples and should disentangle the positive treatment
effects, exploring specific effects for each EF training (WM,
inhibition, or cognitive flexibility). Moreover, training effi-
cacy should be evaluated while controlling for expectation
biases of parents and teachers, by including a placebo
condition.
29
Second, the motivational aspects of the game
world should be examined further; by adding even more
game elements to the training tasks and in the game world,
motivation may be boosted. Third, the EF training ‘‘Brain-
game Brian’’ was developed for children with ADHD, but the
training may be most effective for children with specific EF
deficits. Research should examine for which child with what
specific executive (dys)functioning profile, which EF training
component would be most effective.
Finally, at this point, ‘‘Braingame Brian’’ is not to be con-
sidered a stand-alone treatment module, but one that should
be added, combined, or integrated with existing, empirically
supported treatments for ADHD such as parent and teacher
training programs, and/or medication, to fully have its
therapeutic impact.
Author Disclosure Statement
P.J.M.P., E.T.B., and A.P. are members of Stichting Gaming
& Training, a nonprofit organization that facilitates the de-
velopment and implementation of ‘‘Braingame Brian.’’
S.v.d.O. has been a paid consultant for Janssen Pharmaceu-
ticals with regard to ‘‘Healseeker,’’ a serious game for cog-
nitive function training. S.D., H.M.G., and M.d.V. declare no
competing interests exist.
FIG. 5. Switch task.
48 PRINS ET AL.

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Address correspondence to:
Pier J.M. Prins, PhD
Department of Developmental Psychology
University of Amsterdam
Weesperplein 4
1018 XA Amsterdam, The Netherlands
E-mail: p.j.m.prins@uva.nl
EXECUTIVE FUNCTIONING TRAINING AND ADHD 49