OPINION
STUART JOHNSTONE
Computer Gaming and ADHD: Potential Positive Influences on Behavior
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arents often express concerns about the effect few evidence-based alternatives, but there are now sev‑ that technology, particularly video games, eral technology-based treatment approaches with good has on their children. Indeed, video games supporting evidence. have been associated with problems such The most interesting of these technology-based as social isolation and a drop-off in academic achie approaches, which are in fact very compatible, are cog‑ vement, and games containing violence have been nitive training and neurofeedback. Cognitive training shown to increase aggressive thoughts and behavior involves using purpose-designed computer software to [1]. Frequent interaction with video games has also promote the use of particular psychological abilities (for been associated with subsequent problems in cognitive example, memory, attention, inhibitory control) with the functions such as attention and impulse-control [2]. aim of improving these abilities with practice. These However, it is important to note that tasks typically include performance technology and video games can also feedback and have algorithms that vary Technology and difficulty level according to the child’s be used to improve behavior. During video games my 15 years of research examining the performance to promote challenge, brain electrical activity and behavior of engagement, and learning. Neurofeed‑ can be used children with Attention Deficit Hyper‑ back involves the non-invasive measure‑ to improve activity Disorder (ADHD), there has ment of an individual’s live brain activity behavior. been an increase in the use of technol‑ (EEG) using electrodes on the scalp, with ogy and gaming in the treatment of the user provided with ongoing simpli‑ this disorder. Children with ADHD show high levels fied feedback about that activity via computer. As an of inattentive, impulsive, and/or hyperactive behav‑ example, the current level of attention could be shown ior and as a consequence may struggle in their daily as a number, a bar graph, or an engaging visual display. lives, particularly in academic and social areas. The The aim of neurofeedback is to promote awareness and most common treatment involves daily stimulantcontrol of psychological “state” factors that are reliably based medication, which has a short-term impact on reflected in the EEG, such as high versus low attention the behavioral symptoms. However, there are also high or being relaxed versus tense. drop-out rates and a drop-off in effect [3], as well as Each of these approaches has research support as side effects of stimulant-based medication treatment a method to reduce symptoms of ADHD and improve including headaches, palpitations, insomnia, growth behavior[5], [6]. These approaches are technologyretardation, and increased negative behavioral symp‑ dependent and are made possible by the processing toms [4]. During data collection sessions in our labs, capacity of the computer to simultaneously handle worried parents would often inquire about alternatives multiple processes such as applying algorithms to to medication-based treatments for ADHD, concerned EEG data in real time, accurately measuring task per‑ about the long-term effects. Ten years ago there were formance information, presenting variations of train‑ ing/feedback scenarios, and storing large amounts of data. Developments in consumer-level EEG mea‑ Digital Object Identifier 10.1109/MTS.2013.2249355 Date of publication: 14 March 2013 surement technology have also facilitated this area of 20 |
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research, presenting devices that are easy to use and fluctuates second-by-second and that there is an asso‑ measure EEG accurately [7]. ciation between attention and performance. Again, Our research aim is to bring these two treatment task and behavioral improvements were reported, approaches together to enhance the behavioral ben‑ with these improvements being larger for those with efits to children with ADHD. As the principles apply ADHD than without, and slightly larger for children equally to remediation of deficient pro‑ who did cognitive training with atten‑ cesses as they do to enhancement of tion monitoring. Task and intact processes, we are also interested Feedback from the children in our behavioral in extending this training research to studies called for more varied and inter‑ children without ADHD. Our approach esting training scenarios, given that usage improvements is technology-based and targeted is quite intense in the training period. The were reported. towards particular fundamental cogni‑ challenge issued by the children, some as tive processes such as working mem‑ young as 7 years, was to “make the train‑ ory and inhibitory control, as well as psychological ing more fun”. Given their access to and experience state factors such as attention and relaxation levels. with console- and web-based gaming, they asked for It is these cognitive and state factors that provide a industry-standard gaming features such as a unifying foundation for our effective engagement with the theme, compelling graphics and audio, scenario varia‑ information in our external world. For example, being tions, achievement monitoring, unlocks. This challenge able to keep information in memory and use it flex‑ was taken up by an independent software development ibly, respond and withhold responses as appropriate, company in conjunction with the university. Game ignore distractions, and stay focused and calm pro‑ developers with experience in the use of EEG feedback vides an ideal psychological context for learning in a in gaming applications were given the brief of designing classroom situation. Note that our targeted approach a series of games that adhered closely to the research differs from the generalist approach seen in popular training mechanisms and principles, and hid the train‑ commercial brain training products, which have been ing in the fun. shown to have little effect on behavior[8]. The advantages of this type of technology-based Our targeted and technology-based approach approach to behavioral control training are numer‑ has been investigated in two studies. The first study ous. Importantly, from a health perspective, the built on existing working memory training research dependence on drug-based treatment approaches and to include another fundamental and closely-related related side-effects may be reduced. The training can psychological factor, inhibitory control [9]. Inhibi‑ be used as a stand-alone intervention or as an adjunct tory control is the process that mediates our ability to to existing intervention approaches. From an imple‑ restrain an action or response when it isn’t appropri‑ mentation perspective, the training can be designed to ate, as exemplified in the game “Simon says.” Train‑ be fun and easy to understand and complete, not nec‑ ing inhibitory control has been shown to improve essarily requiring professional assistance and there‑ behavioral control in other domains, such as increas‑ fore could be low-cost to the end-user. From an access ing resistance to sweet foods and alcohol [10]. In our perspective, dissemination could be widespread as the study children with ADHD carried out training at training tasks could be used on personal computers, home using purpose-built software for twenty five smart-phones and even the new-generation of smartsessions over a five week period with each session TVs, thus improving the reach of these interventions. lasting about twenty minutes. Along with improv‑ The principles that underlie this targeted approach ing at the training tasks, parents and another poten‑ to training fundamental psychological processes in tially less-biased adult observers reported significant children might also be applied to adolescents and behavioral improvements after training, with larger adults, and extend to the health domain where behav‑ improvements for those who trained with a variable, ioral control is affected; for example in unhealthy as compared to fixed, difficulty level. behaviors such alcohol consumption, smoking and The second study used a much larger sample, overeating. This area of research is in its infancy. including children without ADHD, as well as a reward There is much work to be done to more fully under‑ system, greatly improved graphical user interface, stand the mechanisms of action of these approaches and attention-monitoring via a portable, wireless, to improving behavior, and to determine how to opti‑ dry-sensor EEG recording device [11]. The software mize the outcomes for users. Our approach is just one aimed to promote an awareness of attention during example of how technology and gaming can have a cognitive training, with reward for good performance positive influence on behavior. It is an exciting time to in the context of focused attention. The objective be working in a research area that will benefit greatly nature of the attention information is crucial, and from the rapid ongoing advances in communications, helps children understand that their level of attention computer, and EEG technology. IEEE TECHNOLOGY AND SOCIETY MAGAZINE
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Author Information The author is Associate Professor, School of Psychol‑ ogy, University of Wollongong, Australia. Email:
[email protected].
References
[1] C. A. Anderson et al., “Violent video game effects on aggression, empathy, and prosocial behavior in Eastern and Western countries: A meta-analytic review,” Psych. Bull., vol. 136, pp. 151–173, 2010. [2] D. A. Gentile et al., “Video game playing, attention problems, and impulsiveness: Evidence of bidirectional causality,” Psychol. Popular Media Culture, vol. 1, no. 1, pp. 62–70, 2012. [3] J. Swanson, R. D. Baler, and N. D. Volkow, “Understanding the effects of stimulant medications on cognition in individuals with at‑ tention-deficit hyperactivity disorder: A decade of progress,” Neuropsychopharmacology, vol. 36, pp. 207–226, 2011. [4] J. M. Swanson et al., “Effects of stimulant medication on growth rates across 3 years in the MTA follow-up,” J. Amer. Acad. Child Adolesc. Psychiatry, vol. 46, no. 8, pp. 1015–1027, 2007.
[5] M. Arns et al., “Efficacy of neurofeedback treatment in ADHD: The effects on inattention, impulsivity and hyperactivity – A metaanalysis,” Clin. EEG Neurosci., vol. 40, pp. 180–189, 2009. [6] T. Klingberg et al., “Computerized training of working memory in children with ADHD: A randomized, controlled trial,” J. Amer. Acad. Child Adolesc. Psychiatry, vol. 44, no. 2, pp. 177–186, 2005. [7] S. J. Johnstone, J. Bruggemann, and R. Blackman, “EEG from a single channel dry sensor recording device,” Clin. EEG Neurosci, vol. 43, pp. 112–120, 2012. [8] A. M. Owen et al., “Putting brain training to the test,” Nature, vol. 465, no. 7299, pp. 775–776, 2010. [9] S. J. Johnstone et al., “Combined working memory and inhibition training for children with ADHD,”ADHD Attention Deficit Hyperactivity Disord., vol. 2, pp. 31–42, 2010. [10] K. Houben et al., “Resisting temptation: Decreasing alcohol-relat‑ ed affect and drinking behavior by training response inhibition,” Drug Alcohol Depend., vol. 116, pp. 132–136, 2011. [11] S. J. Johnstone et al., “Neurocognitive training for children with and without ADHD,”ADHD Attention Deficit Hyperactivity Disord., vol. 4, pp. 11–23, 2012.
NEWS AND NOTES
T&S Magazine Earns STC Award of Excellence
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EEE Technology and Society Magazine has earned an Award of Excellence from the Society for Technical Communication (STC), New York and Philadelphia Metro Chapters, for 2012.
Digital Object Identifier 10.1109/MTS.2013.2251762 Date of publication: 14 March 2013
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