adhd rehabilitation through video gaming: a systematic review using prisma guidelines of the current...

7/21/2019 ADHD rehabilitation through video gaming: a systematic review using PRISMA guidelines of the current findings an…

http://slidepdf.com/reader/full/adhd-rehabilitation-through-video-gaming-a-systematic-review-using-prisma 1/16

October 2015 | Volume 6 | Article 1511

REVIEWpublished: 22 October 2015

doi: 10.3389/fpsyt.2015.00151

Frontiers in Psychiatry | www.frontiersin.org

Edited by:

Ashok Mysore,

St. John’s Medical College Hospital,

India

Reviewed by:

Magdalena Romanowicz,

Stanford University, USA Johnson Pradeep,

St. John’s Medical College

Hospital, India

*Correspondence:

Thiago Strahler Rivero

[email protected]

Specialty section:

This article was submitted to Child

and Neurodevelopmental Psychiatry,

a section of the

journal Frontiers in Psychiatry

Received: 12 May 2015

Accepted: 09 October 2015

Published: 22 October 2015

Citation:

Strahler Rivero T, Herrera Nuñez LM,

Uehara Pires E and

Amodeo Bueno OF (2015) ADHD

rehabilitation through video gaming: a

systematic review using PRISMA

guidelines of the current findings and

the associated risk of bias.

Front. Psychiatry 6:151.

doi: 10.3389/fpsyt.2015.00151

ADHD rehabilitation through videogaming: a systematic reviewusing PRISMA guidelines of the

current findings and theassociated risk of biasThiago Strahler Rivero1* , Lina Maria Herrera Nuñez 2 , Emmy Uehara Pires 3 and

Orlando Francisco Amodeo Bueno1

1 Grupo de Investigação em Memória Humana, Departamento de Psicobiologia, Universidade Federal de São Paulo,

São Paulo, Brazil, 2 Departamento de Psicologia, Universidad Libre, Cali, Colombia, 3 Departamento de Psicologia,

Universidade Federal Rural do Rio de Janeiro, Seropédica, Brazil

Empirical research studies have highlighted the need to investigate whether video game

can be useful as a tool within a neuropsychological rehabilitation program for attention

deficit hyperactivity disorder (ADHD) patients. However, little is known about the possible

gains that this kind of video game-based interventions can produce and even if these

gains can be transferred to real life abilities. The present paper aims to uncover key

information related to the use of video game in ADHD neuropsychological rehabilitation/

intervention by focusing on its gains and its capability to transfer/generalize these gains

to real life situation via a systematic review of the empirical literature. The PRISMA guide-

lines were adopted. Internet-based bibliographic searches were conducted via seven

major electronic databases (i.e., PsycARTICLES, PsycINFO, Web of Science, Core

Collection BIOSIS Citation Index, MEDLINE, SciELO Citation Index, and PubMed) to

access studies examining the association between video game interventions in ADHD

patients and behavioral and cognitive outcomes. A total of 14 empirical studies meetingthe inclusion criteria were identified. The studies reported the attention, working memory,

and the behavioral aspects as the main target of the intervention. Cognitive and behav-

ioral gains were reported after the video game training (VGT). However, many bias related

to the choice of outcome instruments, sampling and blindness of assessors, weaken the

results power. Additional researches are important to clarify the effects and stability of the

VGT programs, and an important effort should be made to construct better methods to

assess improvements on everyday cognitive abilities and real world functioning.

Keywords: neuropsychological rehabilitation, video game intervention, ADHD, real life, systematic review, PRISMA

http://www.frontiersin.org/Psychiatry/archive

http://www.frontiersin.org/Psychiatry/editorialboard


http://dx.doi.org/10.3389/fpsyt.2015.00151

http://www.frontiersin.org/Psychiatry/

http://www.frontiersin.org/

mailto:[email protected]


http://www.frontiersin.org/Journal/10.3389/fpsyt.2015.00151/abstract





http://loop.frontiersin.org/people/173595/overview














mailto:[email protected]

https://creativecommons.org/licenses/by/4.0/







http://crossmark.crossref.org/dialog/?doi=10.3389/fpsyt.2015.00151&domain=pdf&date_stamp=2015-10-22





Strahler Rivero et al. ADHD rehabilitation through video gaming


INTRODUCTION

RationaleAttention deficit hyperactivity disorder (ADHD) is the most com-mon childhood behavioral disorder and typically first diagnosedduring the school years (1, 2). It is characterized by inappropriateand persistent symptoms o inattention and/or hyperactivity/

impulsivity that interere in the quality o school, social and workunctioning in daily lie (3). ADHD individuals tend to have awide spectrum o everyday problems, including sel-regulationdeficits, behavioral, social, and motivational symptoms rangingrom heightened levels o aggression, poor sustained attention,cognitive flexibility deficits, shortened reward delay gradient,lower working memory span, difficulties on response inhibition,and temporal processing (4). ADHD can be treated using com-bined interventions, including stimulant medications, behavioraltherapy, parent psychoeducation, and cognitive and social skillstraining (5). Several studies are ocusing on the impact o reha-bilitation programs or ADHD patients, some o them aiming atthe restorative (drill and practice) treatment, others taking into

consideration the everyday lie impact o the training (unctionalapproach).

New tools are being tested and implemented in the ADHDtreatment as an approach to tap engagement, scaling, and adap-tive training, such as virtual reality, neuroeedback, and videogames. Games are now, more popular than ever in history, withnumbers o players escalating to larger number every year (6).Although, many would argue that games can have detrimentaleffects, video games demonstrate a capacity to enhance cognitivetasks based on principles varying rom probabilistic inerence toocused attention (7). Te use o health games has been a recenttrend to serve as an ancillary mechanism in assisting individualswith cognitive problems (8–11). From a therapeutic perspective,

this cognitive boost given by the video game could then be usedin psychiatric and neurologic conditions treatment, where tradi-tionally, the usual cognitive rehabilitation techniques are used toimprove outcomes in conditions such as ADHD.

raditional Computer-based training (CompB) uses sof-wares designed to help patients improve cognitive unctioningthrough sessions involving repetitive exercises. Few o them have

video game elements that enhance the training effectiveness andthe engagement with the treatment process; the latter directlyinfluences drop rates and the overall efficiency o the trainingprogram (12).

Video game training (VG) shows the same characteristics asthe CompB, plus the video game elements. Green and Bavelier

(13) suggested that video game has a causal role in increasing thenumber o items kept in visual attention. Initial studies, inves-tigating a single administration o video game in children andadolescents with ADHD, report that video game use promotesa state o great cognitive perormance (by promoting cognitiveeedback), increasing the activation state and excitement oparticipants (promoting enhanced motivational perormance),increasing attention (14–16), and inhibitory responses (11, 17).Te use o VG in rehabilitation process employs video game ele-ments (mechanisms, dynamics, and esthetics), which empowerthe learning and motivational process, and add CompB

characteristics, such as adaptive difficulty, database settings,and big data tools to work with much inormation generated viatraining.

Many studies have investigated the impact o video game usein behavior, habits, personality, and cognitive skills. Regardingcognition, studies indicate that healthy video game players out-perorm non-players in the perormance o various tasks related

to cognitive abilities, such as probabilistic inerence, visual acuity, visual search capability in the ace o distractors, visuospatialattention, divided attention, hand–eye coordination, time per-ception in milliseconds, and reaction time (18, 19).

In act, in ADHD participants, some studies suggest that videogame promotes an optimal cognitive perormance by providingcontinuous eedback (20), improving attention (16), and inhibi-tory control (11), and heightening the activation/arousal state,which enhances motivational perormance (11). It is importantto investigate i these video game benefits can be employed tocreate new treatment protocols or use with ADHD patients.Some authors still support the idea that high motivational statepromotes release o striatal dopamine (11, 14). Is it possible that

this neurobiological state o increased motivation could increasethe treatment engagement, thus decreasing the dropout rates?What are the challenges aced during the implementation o

video games based treatment protocols? What kind o bias affectsevaluation o using video games in the treatment o ADHD?

Te current systematic review aims to bridge a gap in theliterature related to the use o videogames in the treatment oADHD. It employs Preerred Reporting Items or SystematicReviews and Meta-Analyses (PRISMA) guidelines.

ObjectivesTis review investigates and synthesizes a comprehensive set ocognitive gains resulting rom controlled studies employing video

games as an intervention or ADHD and the risks o bias involvedin such evaluations. It also seeks to provide critical inormationon the assessment o generalizability o such cognitive gains toreal world situations.

METHODS

Tis review was perormed according to the PRISMA guidelines(21), thus providing a comprehensive ramework which objec-tively assesses indicators o quality and risk o biases o includedstudies.

Protocol and RegistrationTe protocol or this review was not previously registered.

Eligibility CriteriaAll original studies investigating the phenomenon o neuropsy-chological rehabilitation via video game technologies or ADHDand the resultant gains and transer o such gains to real liesituations were eligible or this systematic review. Further criteriaadopted were: (i) publication date between 2000 and 2014, (ii)being an empirical study, (iii) written in English, Spanish orPortuguese language, (iv) published in a scholarly peer-reviewed

journal, (v) conducted an intervention/rehabilitation/treatment












or ADHD using video game technology, and (vi) a cognitive orcognitive-related construct objectively delimited as the aim o

video game use. Additionally, studies were excluded rom reviewi they were: (i) single-case report, (iii) single intervention ses-sion, (iv) insufficient data to be analyzed, and (v) non-cognitiveor behavioral training (i.e., only motor training).

Information Sources and SearchStudies were identified by searching relevant papers via EBSCO(2000-August, 2014-December), and included the ollowing elec-tronic databases: Academic Search Complete, PsycARICLES,PsycINFO; via Web o Science (2000-January, 2014-December),which included Web o Science Core Collection, BIOSIS CitationIndex, MEDLINE, SciELO Citation Index. In addition, therewas an independent literature search on PubMed (2000-August,2014-December). Finally, reerence lists o retrieved studies werehand searched in order to identiy any additional relevant studies.Key words and combination o key words were used to search theelectronic databases and were organized ollowing the PopulationIntervention Comparison Outcome (PICO) model (Figure 1). In

this model, the search strategy can be organized based on thetopics: population (P), intervention (I), control group (C), andoutcome (O) and several searches in the aorementioned data-bases. Further, seven more studies retrieved rom a reerence inanother study (22–25) were included.

(“attention deficit hyperactivity disorder” OR ADHDOR ADD OR “attention-deficit/hyperactivity disorder”

OR “Attention Deficit Disorder with Hyperactivity”OR “Attention Deficit Hyperactivity Disorders” OR“Attention Deficit-Hyperactivity Disorders”) AND(video gam* OR computer gam* OR videogame ORgame base OR game like OR game intervention) AND(treatment OR rehabilitation OR intervention) AND(cognitive unctions OR ollow-up assessment OR

generalization OR transer effects)

Study Selection and Data CollectionProcessesAfer perorming the initial literature searches, each study titleand abstract was screened or eligibility by the first author. Fulltext o all potentially relevant studies were subsequently retrievedand urther examined or eligibility. Te PRISMA flow diagram(see Figure 1) provides more detailed inormation regarding theselection process o studies. Inormation rom the included stud-ies was then analyzed and recorded in an electronic spreadsheetdesigned by the first author. Different types o data were extractedrom each study including: (i) country in which the data were

collected and participants’ characteristics, (ii) cognitive unctionintervention target, (iii) intervention protocol, (iv) risk o bias inindividual studies, (v) ollow-up assessment, (vi) Generalizationand transer effects, and (vii) limitation, among others.

Te Cochrane Collaboration’s tool or assessing risk o bias wasadopted to evaluate the risk o bias in individual studies (7, 26).Te ollowing risk o biases was analyzed: (i) selection bias (i.e.,biased allocation to interventions due to inadequate generation

Electronic database searches

(n = 677)

Hand search reference lists

(n = 7)

Titles and abstracts initially

screened

(n = 684)

Full-text articles assessed

for eligibility

(n = 18)

Full-text articles excluded

Insufficient data n = 1

Noncognitive and behavioral target n = 2

Single intervention session n = 1

Total n = 4

Studies included for review

(n = 14)

Records excluded after title and

abstract examination

(n = 666)

n o i t a c i f i t n e d I

S c r e e n i n g

E l i g i b i l i t y

I n c l u d e d

FIGURE 1 | PRISMA flow diagram of the study selection process.












o a randomized sequence, mainly addresses group allocationproblems and outcome interpretation), (ii) perormance bias (i.e., biases due to the knowledge o the allocated interventionsby participants and personnel during the study), (iii) detectionbias (i.e., biases due to knowledge o the allocated interventionsby outcome assessors), (iv) attrition bias (i.e., biases due to theamount, nature or handling o incomplete outcome data), and (v)

reporting bias (i.e., bias resulting rom selective outcome report-ing and/or not reporting relevant results outcomes that wouldhave been expected to be reported [see or a complete descriptionHiggins and Green (7, 26)].

As a complement to these types o biases mentioned, other twotypes were included (i) sampling bias (i.e., bias resulting in sam-ples that do not represent the study population, mainly related tosubject selection problem which undermines the generalizationo results) and (ii) measurement bias (i.e., bias due to inappropri-ate use o scales or tests to measurement o ADHD symptomsand cognitive unctions mainly related to non-validated criteriaor inconsistent use).

RESULTS

Study SelectionTis review identified 677 studies (EBSCO n = 352; Web oScience n = 283; PubMed n = 42) afer the initial search in theaorementioned electronic databases and seven (n = 7) retrievedrom a list o reerences contained in another study was includedin the identification process. Te screening phase involved theexamination o titles and abstracts o all studies identified. Tisprocess resulted in 666 studies being excluded, as they weredeemed not suitable or the present review. A total o 358 stud-ies were not exclusively dealing with ADHD patients; 211 didnot employ video games or intervention; 97 were studies not

ocused on cognitive unctions. Consequently, 18 studies wereselected or the eligibility phase. Out o these, our studies wereexcluded mainly or (i) insufficient data to be analyzed (n = 1), (ii)non-cognitive or behavioral training (i.e., only motor training)(n = 2), and (iii) single intervention session (n = 1). Followingthis procedure, 14 empirical studies ully met the previouslystipulated eligibility criteria or inclusion in the systematic reviewprocess (see Figure 1).

Study CharacteristicsMore inormation about the essential methodological eaturesand general characteristics o all reviewed studies can be ound

alongside Tables 1 and 2.

Country in Which the Data Were CollectedFour studies were rom the United States (27–30, 32, 35–37), twowere rom Te Netherlands (9, 27), two rom Singapore (30, 36),two rom United Kingdom (34, 37), two rom Sweden (38, 39),one rom Germany (33), and another one rom Australia (31).

ParticipantsTe studies reviewed included 715 participants. In terms ogender distribution (1), the vast majority o the studies reviewed

recruited more male participants (n = 543, 75.92%) than emaleparticipants (n = 172, 24.08%). Not surprisingly, all o thereviewed studies explicitly included children samples.

Furthermore, all studies enrolled ADHD participants,eight studies included inattentive and combined ADHDsubtypes (27–30, 35–38) and one study included hyperactivesubtype alongside with combined and inattentive (31). Other

studies did not speciy the participants ADHD subtype (9,32–34, 39)

Stimulant medication is a common conounder in videogame treatment studies. In a clinical study, beore starting therehabilitation process, it is important to know the effects o themedication use in the participant and how long these effectshave been occurring. Tis caution ensures the reliability o theobserved effects and results. Five studies recruited medicationree participants. Six studies had nearly 75% o its participantson medications. In three studies, over 90% o the subjects wereon medications.

Finally, the intelligence o the children and adolescents withADHD is relevant inormation or the pre-assessment and

intervention. All selected studies included a measure o intel-ligence quotient (IQ) as an exclusion criterion [such as WechslerIntelligence Scale or Children (WISC), Wechsler AbbreviatedScale o Intelligence (WASI), Raven’s Matrices], but three did notprovide this inormation (32, 35, 37)

Operationalization of Cognitive Treatment TargetsOperationalization o a cognitive unction comprises describinghow a treatment target was objectively defined and characterizedin the reviewed studies. Six studies (28, 30, 32, 33, 36, 37) targetedseveral attention unction such as selective, sustained, orienting,divided, vigilance, and alternating. Eight studies had their videogame built ocusing on working memory (9, 27, 28, 31, 34, 35,

38, 39) Te other three studies (27, 31, 32) had inhibitory controlabilities as their main treatment target.

Operationalization of Video Games GenreOperationalization o a video game genres aims to describethe game’s mechanics, dynamics, and esthetics employed ineach VG (40). en studies (9, 27, 29–31, 34, 35) employed 3DAdventure mini games, this kind o games employs elements opuzzles, exploring, discovering, and mini games related to brainchallenges. wo games (32, 36) were constructed as simulators,which depict real world situations. Furthermore, one game (28)was a mixed board and computerized brain challenge mini gamesand one game used simple mini games (37).

Methodological Features of StudiesConcerning studies’ key methodological eatures, all reviewedstudies were o empirical nature and the great majority oreviewed studies were randomized controlled trial (RC) (12studies rom 14), ofen considered the gold standard or a clini-cal trial. However, Lim et al. (36) used a controlled trial withoutrandomization and Lim et al. (30), an uncontrolled open-labeltrial, as described in their articles.

en studies used rating scales or collecting data, but ouro them used rating scales only (27, 30, 35, 36), one study (37)









O c t o b e r 2 0 1 5

| V ol um e 6

| A r t i c l e 1 5 1

8

F r on t i e r s i nP s y c h i a t r y | www.f r on

t i e r s i n. or g

TABLE 2 | ADHD neuropsychological rehabilitation through video game interventions.

Supporting

research

Type of

study and

design

Country of

origin

Video game

type

Independent outcome measures Post training assessment Follow-u

Rating instruments Cognitive tests

van der Oordet al. (27 )

RCT Netherlands 3D adventuremini games

BRIEF, DBDRS (parentand teacher-rated)

No cognitive tests 6 Weeks of the final train ing day 9 Weeksthe trainin

Tamm et al.

(28 )

RCT United

States of

America

Board and

computadorized

mini games

SNAP-IV. BASC-II, C

GI, ATTC, BRIEF

(parent and

teacher-rated)

TEA-Ch, WISC-IV,

WJ-III, D-KEFS,

Quotient ADHD

system

12 Weeks after baseline NA

Chacko et al.

(25, 29 )

RCT United

States of

America

3D adventure

mini games

DBD (parent and

Teacher-rated)

AWMA, WRAT4-PMV,

CPT

3 Weeks after the final training day NA

Lim et al. (30 ) CT Singapore 3D adventure

mini games

ARS-IV (parent-rated) No cognitive tests After the final training day – week 8 Three on

booster t

Maintena

protocols

Johnstone

et al. (31 )

RCT Australia 3D adventure

mini games

BRS (parent-rated and

other significant adult)

Go no go, Oddball

task, Flanker task,

Couting span,

Digit-span

30–35 days after the pre-training

session

6 Weeks

the trainin

Steiner et al.

(32 )

RCT United

States of

America

Simulator (flying) CRS-R, BRIEF,

BASC-2 (parent and

teacher-rated)

IVA-CPT 1 Month after the intervention NA

Tucha et al.

(33 )

RCT Germany 3D adventure

mini games

No rating scales Computerized

neuropsychological

tasks of attention

After the final training day – Week 8 NA

Prins et al. (9 ) RCT Netherlands 3D adventure

mini games

No rating scales Corsi block Tapping

Test

Week 3 NA

Holmes et al.

(34 )

RCT United

Kingdom

3D adventure

mini games

No rating scales AWMA, WASI After the final training day 6 Months

the trainin












































































TABLE 2 | Continued

O c t o b e r 2 0 1 5

| V ol um e 6

| A r t i c l e 1 5 1

9

F r on t i e r s i nP s y c h i a t r y | www.f r on

t i e r s i n. or g

Supporting

research

Type of

study anddesign

Country of

origin

Video game

type

Independent outcome measures Post training assessment Follow-u

Rating instruments Cognitive tests

Beck, et al.

(35 )

RCT United

States of

America

3D adventure

mini games

CRS-R, BRIEF (parent

and teacher-rated)

No cognitive tests Parent: 1 and 4 months after their child

completed the intervention

Teacher:1 month after the intervention

and 4 months after the intervention for

the experimental group

4 Months

the trainin

Lim et al. (36 ) CT Singapore Simulator (racing) ARS-IV (parent and

teacher-rated)

No cognitive tests After the final training day – Week 10 NA

Shalev et al.

(37 )

RCT United

Kingdom

Mini games PRS – Parents Rating

Scale (Parent-rated)

Passage copying,

Math exercises,

Reading

comprehension

Within 2 weeks of completing the

treatment

NA

Klingberg

et al. (38 )

RCT Sweden 3D adventure

mini games

The span-board

task, digit-span, The

stroop interference

task, Raven’s colored

progressive matrices

5–6 Weeks after the baseline 3 Months

the trainin

Klingberg

et al. (39 )

RCT Sweden 3D adventure

mini games

No rating scales Visuospatial WM

task, span board,

stroop task, Raven’s

colored progressive

matrices and choice

reaction time task

5–6 Weeks after the baseline NA

RCT, Randomized Clinical Trial; CT, Clinical Trial; ARS-IV, ADHD rating scale IV; PRS, Parents Rating Scale; CRS-R, Conners’ Rating Scales–Revised, BRIEF, Behavior rating invento

Assessment Scale for Children; IVA-CPT, Integrated Visual and Auditory and Continuous Performance Test; BRS, Behavior Rating Scale; SNAP-IV, DSM-IV ADHD Rating Scale; CG

Control Scale, TEA-Ch, Test of everyday attention for children, WISC-IV, Wechsler Intelligence Scale for Children, WJ-III, Woodcock Johnson Tests of Achievement, D-KEFS, Delis–

Behavior Disorders Rating Scale; AWMA, Automated working memory assessment; WRAT4-PMV, Wide range achievement test 4 – Progress monitoring version; DBD, Disruptive B abbreviated scale of intelligence.















































































associated rating scales and ormal education evaluation, ourstudies (27, 31, 32, 38) used rating scales and cognitive testsmethods and one study employed the three above cited tools (29)to assess participants. Additionally, our studies employed onlycognitive tests as outcome evaluation tools (9, 33, 34, 39).

With respect to rating scales employed in the outcome, threestudies employed parent evaluation only (27, 30, 37), five studies

used Parent and eacher rating (29, 32, 35, 36, 38), one study (31)employed parents and other significant adult and one study associ-ated ratings rom parents, teachers, clinicians, and the participants(28). Moreover, our studies (9, 33, 34, 39) did not use any type oexternal assessor, only the participant’s results in cognitive tests.

Video Game Protocols Characteristics and Effects of

Video Game Intervention on ADHD ParticipantsFour distinct characteristics were analyzed in relation to videogame protocols, amount o time per training session, amount osessions per week, amount o weeks and i the study employedmaintenance phase.

welve studies employed a minimum o 30 min o video

game playing per training session; only two studies trained theirparticipants or less than 30 min (31, 39).

Te two most common weekly training regimen were: two ses-sions per week (28, 32, 33, 36, 37) and a ree to play style where theparticipants can choose how many times they can play per weekrom a total o 25 sessions (27, 31, 34, 35, 38). Moreover, one studyapplied three sessions per week (30), another one applied fivetimes a week (29), and the last one has not specified the numbero times per week (39).

Te minimum number o training weeks was 3 (9). Six studiestrained their participants during 5–6 weeks (27, 29, 31, 35, 38,39), five studies employed an 8-week regimen o training (28,30, 33, 36, 37), one study used 6–10 weeks regimen (34) while

another had 16 weeks o intervention (32).Te last characteristic that was evaluated related to the train-

ing protocols was whether the studies had a maintenance phase,where the participants came back to the training center to haveone or more training sessions afer the study was concluded.Only one study employed monthly booster sessions. Tis was or3 months (30).

In terms o the effects ound o video game interventionon ADHD participants, ten studies used scales to measure theoutcomes o their intervention. Five studies (27, 28, 30, 32, 38)ound a reduction on both inattentive and hyperactive-impulsivesymptoms. wo studies described a reduction in inattentivesymptoms only (35, 37) and another one ound a reduction on

hyperactive-impulsive symptoms only (36). In relation to scales,studies reported enhancement in abilities related to inhibitionand metacognition (27), initiation, planning/organization andworking memory (35), attentional control (28), motivation ontask (9), and schooling skills, such as reading comprehension andpassage copying (37).

Seven studies employed more than scales in order to evaluatetheir students. Tese studies used standardized tests as outcomemeasures afer video game intervention. Five studies (9, 29, 34,38, 39) ound a better perormance on working memory skills,like visuospatial and verbal working memory. wo studies (28,

33) reported enhanced perormance on attention skills such asselective, sustained, divided, vigilance, set-shifing, and responsespeed. Tree studies ound that video game intervention pro-moted better scores or ADHD participants in executive unc-tions, such as flexibility skills (33) and response inhibition (38,39). Besides, these last two studies ound that participants had abetter perormance on complex reasoning tasks. Only one study

evaluated short-term memory (verbal and spatial), and the resultssupport or a better perormance afer the VG (34).

Follow-Up Assessment Seven studies (27, 29–31, 34, 35, 38) had a ollow-up session toassess the maintenance o the gains related to the video gameintervention. Te time varied rom as early as 3 weeks ( 29) to6 months later (34) in the maximum. All the seven studies, exceptor one (29) showed maintenance in the training gains in eachollow-up assessment.

Transfer and Generalization EffectsSeven studies did not evaluate transer effects (9, 27, 30, 31, 34,

35, 37). Four studies related transer to non-trained skills such asflexibility (33) and working memory (29, 34, 38, 39). wo studiesused reports rom parents (32) and participants (28) account orimprovements on attentional, organizational, and study skills.One study (36) used mathematics and English exercise work-sheets as a measure o skill transer. However, the results werenot presented in the study.

Other than some study skills as stated above, no other lie skillswere evaluated or generalization in any o the studies.

Limitations AssessmentsTis review provides a systematic overview and important guide-lines or uture research in ADHD neuropsychological interven-

tion using video games. However, urther studies are necessaryto clariy certain aspects about the study design and method,outcome measures, ollow-ups investigations and transer effectso the training.

For example, regarding the difficulties about the study designand method, two mentioned the need or well-designed RCs(30, 36), three other studies did not adopt a wait-list, a placeboand a control training condition (29, 31, 34), two did not controlgame elements, difficulty level and medication (9, 31), and oneused a non-adaptive training (27). More specifically, five studieshighlighted that the small sample size could have affected thestatistical power o the trial (28, 32, 36, 38), other two studies haddifferent group characteristics, more boys (9) and medium-to-

high socioeconomic status (32).Te assessments and outcome measures have an important

role in gains and effectiveness o the intervention. Indeed, twostudies had non-response rate rom the children’s teachers (28,30), one study did not have teachers’ ratings (37), another one,the parents were not blind (30) and one study did not apply aneuropsychological assessment afer the training (33), whichmakes the results interpretation and the evaluation o the trainingprogram efficacy difficult. Moreover, variability on some outcomemeasures (27) and low power differences in teachers’ ratings (30)were also discussed.









TABLE 3 | Assessment of risk of bias in individual studies.

Study Selection bias Performance

bias

Detection

bias

Attrition bias Reporting

bias

Other bias

Sampling bias Measurement bias

van der Oord et al. (27 ) – ‘+ ‘+ – – – ‘+

Tamm et al. (28 ) ? ‘+ ‘+ – – – –

Chacko et al. (25, 29 ) – – – – – – –

Lim et al. (30 ) – ‘+ ‘+ – – ‘+ ‘+

Johnstone et al. (31 ) ‘+ – ? ‘+ ‘+ – –

Steiner et al. (32 ) – ‘+ ‘+ ‘+ – ? –

Tucha et al. (33 ) ? ? – – – ‘+ ‘+

Prins et al. (9 ) ‘+ ‘+ – – – ‘+ ‘+

Holmes et al. (34 ) – ? – – – – ‘+

Beck et al. (35 ) ‘+ ‘+ ‘+ – – – ‘+

Lim et al. (36 ) – ‘+ ‘+ – + ‘+ ‘+

Shalev et al. (37 ) – ‘+ ‘+ – ‘+ – ‘+

Klingberg et al. (38 ) – – – – – – –

Klingberg et al. (39 ) – – – ? – ‘+ ‘+

‘+ high risk of bias; –low risk of bias; ?unclear risk of bias.




In intervention studies, one o the most significant results isthe effect and the benefits o the training programs. However,some studies did not obtain inormation about training gains orall cognitive assessments (34), the effects in everyday lie (39), theeffect o combining medication with training (38), the trainingeffects in other populations (35, 38), the stability or durability othe effects (9, 39).

Follow-up assessments are essential to assess whether gainsattributed to intervention are maintained over time. Despitethe importance o perorming this kind o assessment, suchanalyses were not conducted (9, 37). On the other hand, ourstudies emphasized the necessity or longer ollow-up intervals(29, 31, 35, 38).

Other difficulties mentioned include the potentially demoti- vating effect o high requency o clinic visits (36) and the techni-cal issues such as saving data on computers that can impact on

validation o the training modules (27).

Risk of Bias in Individual StudiesA general overview and summary o possible risks o bias across

all reviewed studies is presented in Table 3. However, among allstudies analyzed, only two studies (29, 38) did not meet any typeo bias.

In terms o selection bias, three studies (9, 31, 35) were ratedas high risk due to increased likelihood o bias resulting rom(i) non-random component in the sequence generation processand/or (ii) non-random allocation o participants that involved

judgment or other non-random method o categorization o par-ticipants (e.g., results o test scores assessing ADHD). Potentialperormance bias was ound to be o high risk across eight studies(9, 27, 28, 30, 32, 35–37) as in these studies, blinding o key studyparticipants and personnel were not achieved, thus representingpotential sources o biases at the outcome levels. Detection bias

potentially posed high risk in eight studies (32, 33, 35, 37) due toknowledge o the allocated interventions by outcome assessors.Regarding attrition bias, only three studies (31, 32) were rated ashigh risk or potential attrition bias due to the amount or unclear

nature o handling o the missing data. Reporting bias was ratedhigh risk in three studies (31, 36, 37) as some key variables thatwould have been expected to be reported were not.

Assessment o other sources o biases involved the examinationo sampling bias and measurement bias. Sampling bias was ratedas high risk in five studies (9, 30, 33, 36, 39) due to (i) widespreaduse o sel-selected samples, (ii) lack o probability-sampling

techniques, and/or (iii) recruitment o male-only samples. Inaddition, measurement bias was judged as high risk in the vastmajority o studies (9, 27, 33, 35, 39) due to (i) inconsistent con-ceptualization o cognitive target, (ii) inconsistent measuremento the outcomes, and/or (iii) inconsistent selection o tools andinstruments to evaluate outcome.

DISCUSSION

Te present review aimed to identiy relevant empirical evidenceor the effect o video games interventions on cognitive trainingor ADHD patients.

Despite the trend that proposes that video game shows causal

effects or cognition training on healthy subjects [e.g., visualattention (30)], it is still quite challenging to assess the impact o

video games in the rehabilitation process. Several conounderssuch as amily’s perception, teachers’ perception, stimulant drugsuse, IQ level, assessors intervention, game genre, participant’sgender, game’s mechanics–dynamics–esthetics and transer/generalization evaluation tools are some o these challenges.

Furthermore, there is still controversy about how to measuregeneralization and transer effects to patient’s daily lie. Quite aew o the analyzed studies claim to have produced generalizationto near non-trained skills, however, the tasks employed as gener-alization measure are very similar to the video game employed inthe training (29, 33, 38, 39) [to urther this discussion, see Green

and Bavelier (41)]. Other studies propose that their game transergains to real lie abilities; yet the instruments (such as verbal reportrom parents and participants) are not appropriate to this kind omeasurement (28, 32). It is essential to the advance o the video












game research field that the results and findings are analyzed inthe light o a risk bias assessment to assess the strength o ourcumulative evidence in the area.

Even with a steady growth in the number o “games” designedto reduce cognitive deficits, most training sofwares are designedor one aspect only and their evaluation alls into what we reer toas the “dual problem,” ailing to achieve their rehabilitation aims:

(1) games ocused on training cognitive skills (such as workingmemory) but using only symptoms scales to evaluate outcomesand treatment success; and (2) games ocused on training cogni-tive skills (such as working memory) but using only cognitive/neuropsychological testing to assess outcomes and treatmentsuccess. Tis dual problem needs to be overcome by usingassessments tailored to the patient’s own problems in addition tosymptoms scales and neuropsychological testing.

Concerned by this issue, some studies have ecologically validscales such as Behavior Rating Inventory o Executive Function(BRIEF in order to get closer to measuring aspects related tothe real lie o the participants. Bisoglio et al. (42) proposed animportant advance to VG field would be the implementation

o individualized baseline measures to be subsequently used astreatment response predictors. Tese kinds o measures exist andhave been used since 1968 or fields such as neuropsychologicalrehabilitation and occupational therapy. Tese are instrumentssuch as the Goal Attainment Scale (GAS), (43). Te GAS is anindividualized measure o change that involves defining a set ogoals or each research participants and speciying a unique rangeo outcomes which reflects the patient’s real lie struggles (44).GAS has been widely used with success or several areas relatedto rehabilitation, including neuropsychological rehabilitation oSensory Modulation Disorder (45), ADHD (46), Metacognitionon mental health (47), Acquired Brain Injury (48), and more [ora revision on its use, see Krasny-Pacini et al. (49)]

Country in Which the Data Were Collectedand Participant’s CharacteristicsIn terms o geographic dispersion, most studies (i.e., 12) wereconducted either in the United States and/or European context,while our studies were rom Asian/Australian regions. Across allreviewed studies, participants’ patterns suggested that the studiesgenerally recruited more (i) male participants than emale, (ii)children and adolescents’ samples than adults and/or elderly ones,and (iii) combined ADHD subtypes rather than inattentive andhyperactive-impulsive populations. Given the present findings,it is important that uture research on video game interventionsor ADHD include: (i) a more representative sample ADHD

subtypes, considering the ADHD distribution percentages, (ii)Recruit subjects rom across the lie span, (iii) Include subjectsrom across all cultures. On the other hand, the relative increaseo participants being recruited in VG/treatment studies is,perhaps, a positive aspect.

Operationalization Cognitive TreatmentTargetsIn terms o outcome measures, assessors and tools employedor rating and cognitive evaluation, attention should be paid by

researchers to the way that cognitive targets are operationalizedor posterior treatment and assessment in their research.

Evidence rom the present review suggests that the studiesanalyzed measured attention, working memory and inhibitioncontrol. With regard to the attention construct, or instance,measured by a more “pure” and construct-based test, such asthe Continuous Perormance est (CP) is different rom the

Behaviour Assessment Scale or Children (BASC) and can lead tomisinterpretation o the results when compared. Other importantpoint here is that the outcome that the researchers are looking oris change in patient daily lie problems, but again, as pointed outby owne et al. (50), the instruments employed to evaluate thisoutcome did not resemble the real-world demands. In terms oinstruments to evaluate outcome, 93% used symptom and behav-ioral scales, 79% o the studies employed psychometric tests, butonly 14% o the studies utilized ormal measures to evaluateacademic gains afer VG. However, only one o the games hadelements that resemble problems evaluated by the symptoms andbehavioral scales (28).

Almost all studies employ symptoms and behavioral scales

as measures o changes in daily lie problems, thus expectingthat instruments that mainly remain on parents’ and teacher’sperception will be sufficiently sensitive to track changes basedon cognitive training only. Boot et al. (8) emphasizes that i thebaseline measures or transer effect are inadequate, it will behard to evaluate the findings and to understand i the near andar transer effects exist or are methodological noise.

wo o the present researches used only parents to evaluatethe outcomes, seven, employed parents and teachers and oneassessed parents and other significant adults. Only one research(28) reported that a rating filled by the participants about theirperception o skill gains afer the VG was employed. It is impera-tive not to limit to the perceptions o one assessor only (not to

incur in a single responder bias, see Fergunson et al. ( 51) andto refine and produce a more sensitive change measurement,including social perception o change, participant’s perception ochange, structured changes expected afer the training, along withcognitive changes measured via neuropsychological tests.

Video Game Characteristics andIntervention ProtocolVideo game can provide different types o involvement andexperiences. One o the most important is the similarity with reallie situations. For example, only one game cannot be includedin a straight classification o drill and practice game, all the othergames, regardless o being a 3D Adventure mini games, a simula-tor or an action adventure game via Kinect®, eature a repetitivetraining nature. Te issue regarding these mini games or drilland practice is that in several studies, it is difficult to differentiatethe game mechanics rom the outcome neuropsychological testemployed.

Te intervention protocol used in the reerenced studiespresented itsel relatively homogenous. Our review shows thatmost o the training protocols employed a minimum o 30 mino video game playing per session (27–30, 32–38), twice a weekat least (28, 32, 33, 36, 37), and a wide variation in the duration












o the training – all the studies rom 3 to 16 weeks. One possibleexplanation or not perorming ew and short duration sessionsconcerns about the smaller statistical power, and, consequently,difficulties in measuring the intervention efficacy. According tothe retraining approach (52), the persistent and repetitive prac-tice improves or restores the target skills o interest. Regardingthe maintenance phase, only one study reported one monthly

boost session during three consecutive months (30). Tis find-ing shows the lack o knowledge about the preservation o thetraining effects, since the maintenance/booster sessions assiststhe durability and may maximize the gains in the interventionprogram. Unortunately, the researchers do not know how ofenor how many sessions are necessary to have success (22).

In rehabilitation processes, learning transerence could occurin very similar contexts (near transer) and/or in situationsthat seem remote or dissimilar knowledge (ar transer). Yet,measuring the transer is very difficult, especially, o cognitiveabilities. Shipstead et al. (23) proposes that most o the problemsto evaluate near transer in working memory studies are related to(i) working memory near transer effects are measured by short-

term memory tasks and, (ii) the excessive use o near transertasks that closely resemble the method o training. Te authorspropose that different measures o near transer need to be used,ones that are distinct rom the training task or video game. Asconcluded by Boot et al. (8), i the game is similar to the test, youare learning the test itsel.

Risk of Bias in Individual StudiesIn addition to the analysis, the studies reviewed also underwentsystematic scrutiny regarding their methodological eatures.From this, it was evident that the majority o studies adoptedclinical trial designs (13 o 14 studies), but maybe or the costinvolved, only six studies were RCs.

Te clinical trials evaluated in the present study showed, ingeneral, adequate methods or participants’ selection. Te majorproblem related to selection process was the use o non-randomallocation o participants (i.e., clinical doctors determinedthe group) or the unclear inormation related to the allocationprocesses. Since the grouping is related to the intervention andsome studies did not have an active waiting list control group, itwas hard to keep the outcome assessors, research personnel, andparticipants blind to the respective treatment allocation, whichis directly related to the high amount o studies with potentialperormance bias. Tis knowledge o treatment group allocationdirectly rises the risk to detect changes in the outcome measures,undermining the intervention finding which was pointed out

elsewhere by Boot et al. (8).A recent study tried to cope with this problem by using not

only an active control group, but a non-contact control group,which allows to compare the normal expected changes in peror-mance, thus enhancing the detectability o their study (53). Asto the sampling method used, probability-sampling was oundto be severely lacking. Tereore, uture research should try tocarry out research using samples that are more representative.Te vast majority o studies presented bias related to the choiceo measurement tools and instruments to evaluate outcome. Tisbias seems to be related to the poor conceptualization o how to

evaluate cognitive targets and how these cognitive targets arerelated to real lie situations.

Tereore, some studies use only neuropsychological tests asoutcome measure, others employed only behavioral and symp-toms scales, which diminishes the observation power o thesestudies. Boot et al. (8) criticizes studies that employ ew measure-ments to access game change. In our present study, at least three

studies employed only one test or scale to evaluate outcomes. Onthe other side o this coin, Green et al. (54) discusses that theexcessive use o scales and tests to measure the same cognitivetarget could lead to a ype I error, besides this more tests leadto more learning, which reduce the potential to observe transerrom the treatment. Once again, at least our studies employedsix or more instruments or large batteries to evaluate cognition.Still within Green et al. (54) comment o the subject, we are notonly evaluating the effect o training x on ability y test by thetool z and then by the tool w, but, in act, we are evaluating theeffect o training x on ability y in test w afer the subject beingtested on test z . Te test z affects the perormance on test w andso on. In short, the main bias present in the reviewed studies

can be broadly associated with the ollowing domains: (i) opera-tionalization and measurement issues, (ii) sampling issues, and(iii) perormance and change detection issues. It is envisaged bythe authors that uture research should account or these limita-tions in order to publish better quality studies in the video gamerehabilitation field.

Cognitive, Behavioral, and TransferOutcomesOne o the main objectives o the present review was to identiysignificant cognitive and behavioral changes that have beenassociated with VG. Results demonstrated five distinct cognitiveabilities gains measured by neuropsychological tests. More spe-

cifically, gains in: (i) working memory skills, such as visuospatialand verbal working memory (9, 29, 34, 38, 39) (ii) attention skillssuch as selective, sustained, divided, vigilance, set-shifing, andresponse speed. (28, 33), (iii) executive unctions, such as, flex-ibility skills (33) and response inhibition (38, 39), (iv) complexreasoning tasks. (38, 39), (v) short-term memory (verbal andspatial) afer the VG (34). It is reasonable to assume that thesechanges were affected by the motivation and interest o the par-ticipants. In general, the games tend to involve challenging tasksthat keep the player’s attention, which contributes to a positiveplasticity. Likewise, current games are designed with elementsthat train intensively these skills, but, most o all, promote theability to learn, express individual independence and creativity,

learn to think systematically and develop social interaction. All othese skills trained in specific situations imposed at each stage othe game are closely linked to unctions improved in the studies.

Te eight gains related to symptoms and behavior reductionwere (i) on both inattentive and hyperactive-impulsive symptoms(27, 28, 30, 32, 38) (ii) in inattentive symptoms only (35, 37) (iii)on hyperactive-impulsive symptoms only (36), (iv) enhancedinhibition and metacognition skills (27), (v) enhanced initiation,planning/organization and working memory (35), (vi) enhancedattentional control (28), (vii) enhanced motivation on task (9),and (viii) gains in academic skills, such as reading comprehension












and passage copying (37). Although several studies have reportedbehavioral improvements, it is important to remember that someparents and teachers were not completely blind and impartialto the experiment, such a study should be. Tis act may haveinfluenced the filling o scales, or instance.

In relation to ollow-up assessment and generalization andtranser effects, seven studies had a ollow-up session to evaluate

the maintenance o the gains related to the video game interven-tion. Te time varied rom 3 weeks to 6 months afer the lasttraining session. Six studies reported maintenance o the traininggains in each ollow-up assessment session. Only 43% o thestudies evaluated transer effects. Four studies related transer tonon-trained skills such as flexibility (33) and short-term memory(29, 34, 38, 39). wo studies used reports rom parents (32) andparticipants (28) to account or improvements on attentional,organizational and study skills. None o the studies employed anymethodology to generalization effects. It was observed that thereis a great variation o maintaining the benefits achieved throughcognitive training, variables such as the protocol used, thenumber o sessions and duration o the intervention, individual

characteristics o a given population, can influence the support ocognitive and unctional gains.

Summary of LimitationsIn the current review, we identified 14 studies that used videogames or ADHD intervention. As Bisoglio et al. (42) also high-lighted, most o them showed some kind o methodological defi-ciencies. A significant limitation was the insufficient descriptiono experimental and control conditions, which shows the needor standardization in intervention programs. Some trials didnot design a well RC or adopted a wait-list, placebo, or controltraining condition (29–31, 34, 36). Another common problemwas small sample size (28, 32, 36, 38), the lack o homogeneous

group characteristics (9, 32) or the non-standard use o stimulantmedication during the rehabilitation. Tese problems couldhave affected the statistical power o the trials, thus generatinginconsistent results.

An additional actor or consideration is the wide variety ooutcome measurements, parent and teacher reporting scalesand cognitive tests. Four o the studies we reviewed used justbehavior scales: ADHD Rating Scale – ARS-IV, Behavior RatingInventory o Executive Function – BRIEF, Disruptive BehaviorDisorders Rating Scale – DBDRS and Conners’ Rating Scales–Revised – CRS-R (27, 30, 35, 36). Just our studies still appliedcognitive tests, rom “gold standard” tests as WISC to computer-ized neuropsychological tasks (9, 34, 38, 39). Te other ones

associated both tools. On the other hand, it is important to notethat video game interventions, usually, did not include unc-tional outcome measures, in other words, everyday unctioningand real lie VG benefits are not examined. Tese analyzedinstruments provide inormation about symptoms, unctionsand skills, but we do not know i the results are influenced bylearning or transer effects, creating an unclear efficacy o theintervention (13).

Tere is also a clear lack o inormation on the ollow-upassessments and transer and generalization effects o training.

Ideally, intervention programs should include ollow-up assess-ments, but some studies were not conducted and others empha-sized the need o longer-term intervals (9, 29, 31, 35, 37, 38).Unlike other methods, some video games were not designed toimprove cognitive or behavior domains, which could be limitedor treatments.

Despite the limitations o the studies, the results provide a

perspective o the main problems in interventions or ADHDusing video games. Overall, innovative and easible programs areneeded as another useul tool in ADHD treatments. As a trainingtool associated with neuropsychological rehabilitation protocols,

video games seem to be essential, both as a motivational andengagement tool and as the main actor in the drill and practicetraining.

CONCLUSION

Attention deficit hyperactivity disorder is a common and chronicchildhood disorder with symptoms typically exhibited duringelementary school years. It is characterized by difficulties in devel-

oping sel-control, impairment in academic perormance, poorpeer and amily relationships and psychosocial disadjustment.

As a training tool associated with neuropsychological reha-bilitation protocols, video games seem to be essential, both as amotivational and engagement tool and as the main actor in thedrill and practice training.

Te present review constitutes a relevant step toward under-standing the video games as an intervention tool in rehabilitationprograms. Considerable advances and new games show us apromising training method or ADHD treatment. However, thelack o blinded assessors and the inappropriate use o scales andtests diminishes the power o these findings.

Despite the positive effects shown by VG, there are some limi-

tations, such as the variety in the nomenclature, the heterogene-ous protocols and methodologically limited literature, which, soar, imposes limits to establish recommended neuropsychologicaltraining protocols with video game. More well-designed RCswith larger samples sizes are necessary to confirm the efficacy othe trials conducted in this area. Other studies will also need tomore explicitly clariy the mechanisms associated with traininggains, which are hindered, or example, by the use o stimulantdrugs during the rehabilitation protocols.

Furthermore, additional researches are important to clariythe effects and stability o the VG programs, and an importanteffort should be made to construct better methods to assessimprovements on everyday cognitive abilities and real world

unctioning. Te current review provides recommendationsand methodological alerts or improving both the process andoutcome related issues in research ocused on the use o videogames in training programs or persons with ADHD.

AUTHOR CONTRIBUTIONS

All the authors conceptualized, designed, drafed, and reviewedthe paper. Author R, LN, and EP collected the data and authorOB acted to solve any conflict related to the studies selection.












REFERENCES1. American Psychiatric Association. Diagnostic and Statistical Manual o

Mental Disorders, Fifh Edition (DSM-5). 5th ed. Washington, DC: American

Psychiatric Association (2013).

2. Polanczyk G, Rohde LA. Epidemiology o attention-deficit/hyperactivity

disorder across the liespan. Curr Opin Psychiatry (2007) 20(4):386–92.

doi:10.1097/YCO.0b013e3281568d7a

3. Swanson JM, Sergeant JA, aylor E, Sonuga-Barke EJS, Jensen PS, Cantwell

DP. Attention-deficit hyperactivity disorder and hyperkinetic disorder.Lancet

(1998) 351(9100):429–33. doi:10.1016/S0140-6736(97)11450-7

4. O’Brien JW, Dowell LR, Mostosky SH, Denckla MB, Mahone EM.

Neuropsychological profile o executive unction in girls with attention-defi-

cit/hyperactivity disorder. Arch Clin Neuropsychol (2010) 25(7):656–70.

doi:10.1093/arclin/acq050

5. Johnston C, Park JL. Interventions or attention-deficit hyperactivity

disorder: a year in review. Curr Dev Disord Rep (2015) 2:34. doi:10.1007/s40474-014-0034-2

6. Entertainment Sofware Association (ESA). "2015 Essential Facts About the

Computer and Video Game Industry." Te Entertainment Sofware Association .

(2015). Available rom: http://www.theesa.com/wp-content/uploads/2015/04/

ESA-Essential-Facts-2015.pd

7. Green CS, Pouget A, Bavelier D. Improved probabilistic inerence, as a general

learning mechanism with action video games. Curr Biol (2011) 20:1573–9.

doi:10.1016/j.cub.2010.07.040

8. Boot WR, Blakely DP, Simons DJ. Do action video games improve perception

and cognition? Front Psychol (2011) 2:226. doi:10.3389/psyg.2011.00226

9. Prins PJ, Dovis S, Ponsioen A, Brink E, Van der Oord S. Does computerized

working memory training with game elements enhance motivation and

training efficacy in children with ADHD? Cyberpsychol Behav Soc Netw (2011)

14(3):115–22. doi:10.1089/cyber.2009.0206

10. Boot WR, Kramer AF, Simons DJ, Fabiani M, Gratton G. Te effects o video

game playing on attention, memory, and executive control. Acta Psychol (2008) 129:387–98. doi:10.3389/psyg.2011.00226

11. Lawrence V, Houghton S, annock R, Douglas G, Durkin K, Whiting K.

ADHD outside the laboratory: boys’ executive unction perormance on tasks

in videogame play and on a visit to the zoo. J Abnorm Child Psychol (2002)

30(5):447–62. doi:10.1023/A:1019812829706

12. Pfiffner L, Barkley RA, DuPaul GJ. reatment o ADHD in school settings.

3rd ed. In: Barkley RA, editor. Attention Deficit Hyperactivity Disorder: A

Handbook or Diagnosis and reatment . New York, NY: Guilord (2006). 736 p.

13. Green CS, Bavelier D. Effect o action video games on the spatial distribu-

tion o visuospatial attention. J Exp Psychol Hum Percept Perorm (2006)

32(6):1465–78. doi:10.1037/0096-1523.32.6.1465

14. Koepp MJ, Gunn RN, Lawrence AD, Cunningham VJ, Dagher A, Jones , et al.

Evidence or striatal dopamine release during a video game. Nature (1998)

393(6682):266–8. doi:10.1038/30498

15. Kuntsi J, Oosterlaan J, Stevenson J. Psychological mechanisms in hyperac-

tivity: I. Response inhibition deficit, working memory impairment, delay

aversion, or something else? J Child Psychol Psychiatry (2001) 42(2):199–210.

doi:10.1111/1469-7610.00711

16. ahiroglu A, Celik G, Avci A, Seydaoglu G, Uzel M, Altunbas H. Short-

term effects o playing computer games on attention. J Atten Disord (2010)

13(6):668–76. doi:10.1177/1087054709347205

17. Shaw R, Grayson A, Lewis V. Inhibition, ADHD, and computer games: the

inhibitory productivity o children with ADHD on computerized tasks and

games. J Atten Disord (2005) 8:160–8. doi:10.1177/1087054705278771

18. Bialystok E. Effect o bilingualism and computer video game experience

on the Simon ask. Can J Exp Psychol (2006) 60:68–79. doi:10.1037/

cjep2006008

19. Dye MW, Green CS, Bavelier D. Te development o attention skills in action

video game players. Neuropsychologia (2009) 47(8–9):1780–9. doi:10.1016/j.

neuropsychologia.2009.02.002

20. Granic I, Lobel A, Engels RC. Te benefits o playing video games. Am Psychol

(2014) 69(1):66–78. doi:10.1037/a0034857

21. Moher D, Liberati A, etzlaff J, Altman DG, Te PRISMA Group. Preerred

reporting items or systematic reviews and meta-analyses: the PRISMA state-

ment. Open Med (2009) 3(3):123–30. doi:10.1016/j.ijsu.2010.02.007

22. Melby-Lervåg M, Hulme C. Is working memory training effective? A meta-an-

alytic review. Dev Psychol (2013) 49(2):270. doi:10.1037/a0028228

23. Shipstead Z, Redick S, Engle RW. Is working memory training effective?

Psychol Bull (2012) 138(4):628–54. doi:10.1037/a0027473

24. Sonuga-Barke E, Brandeis D, Holtmann M, Cortese S. Computer-based cogni-

tive training or ADHD: a review o current evidence. Child Adolesc Psychiatr

Clin N Am (2014) 23(4):807–24. doi:10.1016/j.chc.2014.05.009

25. Chacko A, Feirsen N, Bedard AC, Marks D, Uderman JZ, Chimiklis A.

Cogmed working memory training or youth with ADHD: a closer examina-tion o efficacy utilizing evidence-based criteria. J Clin Child Adolesc Psychol

(2013) 42(6):769–83. doi:10.1080/15374416.2013.787622

26. Higgins JP, Green S, editors. Cochrane Handbook or Systematic Reviews o

Interventions Version 5.1.0. Te Cochrane Collaboration (2011). Available

rom: www.cochrane-handbook.org

27. Van der Oord S, Ponsioen AJ, Geurts HM, en Brink EL, Prins PJ. A pilot study

o the efficacy o a computerized executive unctioning remediation training

with game elements or children with ADHD in an outpatient setting: outcome

on parent-and teacher-rated executive unctioning and ADHD behavior.

J Atten Disord (2014) 18(8):699–712. doi:10.1177/1087054712453167

28. amm L, Epstein JN, Peugh JL, Nakonezny PA, Hughes CW. Preliminary data

suggesting the efficacy o attention training or school-aged children with

ADHD. Dev Cogn Neurosci (2013) 4:16–28. doi:10.1016/j.dcn.2012.11.004

29. Chacko A, Bedard AC, Marks DJ, Feirsen N, Uderman JZ, Chimiklis A, et al. A

randomized clinical trial o Cogmed working memory training in school-age

children with ADHD: a replication in a diverse sample using a control condi-tion. J Clin Child Adolesc Psychol (2013) 55(3):247–55. doi:10.1111/jcpp.12146

30. Lim CG, Lee S, Guan C, Fung DSS, Zhao Y, eng SSW, et al. A brain-com-

puter interace based attention training program or treating attention deficit

hyperactivity disorder. PLoS One (2012) 7(10):e46692. doi:10.1371/journal.

pone.0046692

31. Johnstone SJ, Roodenrys S, Blackman R, Johnston E, Loveday K, Mantz S, et al.

Neurocognitive training or children with and without AD/HD. Atten Defic

Hyperact Disord (2012) 4(1):11–23. doi:10.1007/s12402-011-0069-8

32. Steiner NJ, Sheldrick RC, Gotthel D, Perrin EC. Computer-based

attention training in the schools or children with attention deficit/hyper-

activity disorder: a preliminary trial. Clin Pediatr (2011) 50(7):615–22.

doi:10.1177/0009922810397887

33. ucha O, ucha L, Kaumann G, König S, Lange KM, Stasik D, et al. raining

o attention unctions in children with attention deficit hyperactivity

disorder. Atten Defic Hyperact Disord (2011) 3(3):271–83. doi:10.1007/

s12402-011-0059-x

34. Holmes J, Gathercole SE, Place M, Dunning DL, Hilton KA, Elliott JG.

Working memory deficits can be overcome: impacts o training and medica-

tion on working memory in children with ADHD. Appl Cogn Psychol (2010)

24(6):827–36. doi:10.1002/acp.1589

35. Beck SJ, Hanson CA, Puffenberger SS, Benninger KL, Benninger WBA.

Controlled trial o working memory training or children and adolescents

with ADHD. J Clin Child Adolesc Psychol (2010) 39(6):825–36. doi:10.1080

/15374416.2010.517162

36. Lim CG, Lee S, Guan C, Fung DS, Cheung YB, eng S, et al. Effectiveness o

a brain-computer interace based programme or the treatment o ADHD: a

pilot study. Psychopharmacol Bull (2010) 43(1):73–82.

All the authors have final approval o the published article andboth authors agree to be accountable or all aspects o the workin ensuring that questions related to the accuracy or integrityo any part o the work are appropriately investigated andresolved.

FUNDING

SR has received a research grant rom FAPESP (Fundação deAmparo a Pesquisa do Estado de São Paulo) and rom AFIP(Associação do Fundo de Incentivo a Pesquisa).




http://dx.doi.org/10.1097/YCO.0b013e3281568d7a

http://dx.doi.org/10.1016/S0140-6736(97)11450-7

http://dx.doi.org/10.1093/arclin/acq050

http://dx.doi.org/10.1007/s40474-014-0034-2

http://dx.doi.org/10.1007/s40474-014-0034-2

http://dx.doi.org/10.1016/j.cub.2010.07.040

http://dx.doi.org/10.3389/fpsyg.2011.00226

http://dx.doi.org/10.1089/cyber.2009.0206


http://dx.doi.org/10.1023/A:1019812829706

http://dx.doi.org/10.1037/0096-1523.32.6.1465

http://dx.doi.org/10.1038/30498

http://dx.doi.org/10.1111/1469-7610.00711

http://dx.doi.org/10.1177/1087054709347205

http://dx.doi.org/10.1177/1087054705278771

http://dx.doi.org/10.1037/cjep2006008


http://dx.doi.org/10.1016/j.neuropsychologia.2009.02.002


http://dx.doi.org/10.1037/a0034857

http://dx.doi.org/10.1016/j.ijsu.2010.02.007

http://dx.doi.org/10.1037/a0028228

http://dx.doi.org/10.1037/a0027473

http://dx.doi.org/10.1016/j.chc.2014.05.009

http://dx.doi.org/10.1080/15374416.2013.787622

http://dx.doi.org/10.1177/1087054712453167

http://dx.doi.org/10.1016/j.dcn.2012.11.004

http://dx.doi.org/10.1111/jcpp.12146

http://dx.doi.org/10.1371/journal.pone.0046692


http://dx.doi.org/10.1007/s12402-011-0069-8

http://dx.doi.org/10.1177/0009922810397887

http://dx.doi.org/10.1007/s12402-011-0059-x

http://dx.doi.org/10.1007/s12402-011-0059-x

http://dx.doi.org/10.1002/acp.1589

http://dx.doi.org/10.1080/15374416.2010.517162

http://dx.doi.org/10.1080/15374416.2010.517162

http://dx.doi.org/10.1080/15374416.2010.517162

http://dx.doi.org/10.1080/15374416.2010.517162

http://dx.doi.org/10.1002/acp.1589

http://dx.doi.org/10.1007/s12402-011-0059-x

http://dx.doi.org/10.1007/s12402-011-0059-x

http://dx.doi.org/10.1177/0009922810397887

http://dx.doi.org/10.1007/s12402-011-0069-8



http://dx.doi.org/10.1111/jcpp.12146

http://dx.doi.org/10.1016/j.dcn.2012.11.004

http://dx.doi.org/10.1177/1087054712453167

http://dx.doi.org/10.1080/15374416.2013.787622

http://dx.doi.org/10.1016/j.chc.2014.05.009

http://dx.doi.org/10.1037/a0027473

http://dx.doi.org/10.1037/a0028228

http://dx.doi.org/10.1016/j.ijsu.2010.02.007

http://dx.doi.org/10.1037/a0034857





http://dx.doi.org/10.1177/1087054705278771

http://dx.doi.org/10.1177/1087054709347205

http://dx.doi.org/10.1111/1469-7610.00711

http://dx.doi.org/10.1038/30498

http://dx.doi.org/10.1037/0096-1523.32.6.1465

http://dx.doi.org/10.1023/A:1019812829706


http://dx.doi.org/10.1089/cyber.2009.0206


http://dx.doi.org/10.1016/j.cub.2010.07.040

http://dx.doi.org/10.1007/s40474-014-0034-2

http://dx.doi.org/10.1007/s40474-014-0034-2

http://dx.doi.org/10.1093/arclin/acq050

http://dx.doi.org/10.1016/S0140-6736(97)11450-7

http://dx.doi.org/10.1097/YCO.0b013e3281568d7a







37. Shalev L, sal Y, Mevorach C. Computerized progressive attentional training

(CPA) program: effective direct intervention or children with ADHD. Child

Neuropsychol (2007) 13(4):382–8. doi:10.1080/09297040600770787

38. Klingberg , Fernell E, Olesen PJ, Johnson M, Gustasson P, Dahlström K,

et al. Computerized training o working memory in children with ADHD-a

randomized, controlled trial. J Am Acad Child Adolesc Psychiatry (2005)

44(2):177–86. doi:10.1097/00004583-200502000-00010

39. Klingberg , Forssberg H, Westerberg H. raining o working memory in chil-

dren with ADHD. J Clin Exp Neuropsychol (2002) 24(6):781–91. doi:10.1076/

jcen.24.6.781.8395 40. Hunicke R, LeBlanc M, Zubek R. MDA: a ormal approach to game design

and game research. In Fu D, Henke S, Orkin J, editors. Challenges in Game

Artificial Intelligence, Papers rom the 2004 AAAI Workshop. echnical Report

WS-04-04. Menlo Park, CA: Te AAAI Press (2004). p. 1–5.

41. Green CS, Bavelier D. Exercising your brain: a review o human brain plas-

ticity and training-induced learning. Psychol Aging (2008) 23(4):698–701.

doi:10.1037/a0014345

42. Bisoglio J, Michaels I, Mervis JE, Ashinoff BK. Cognitive enhancement

through action video game training: great expectations require greater evi-

dence. Front Psychol (2014) 5:136. doi:10.3389/psyg.2014.00136

43. Kiresuk J, Sherman RE. Goal attainment scaling: a general method or

evaluating comprehensive community mental health programs. Community

Ment Health J (1968) 4:443–53. doi:10.1007/BF01530764

44. Kiresuk , Smith A, Cardillo J. Goal Attainment Scaling: Applications, Teory,

and Measurement . Hillsdale, NJ: Erlbaum (1994).45. Miller LJ, Coll JR, Schoen SA. Randomized control pilot study o the effective-

ness o occupational therapy or children with sensory modulation disorder.

Am J Occup Ter (2007) 61(2):228–38. doi:10.5014/ajot.61.2.228

46. Solanto MV, Marks DJ, Wasserstein J, Mitchell K, Abikoff H, Alvir JM, et al.

Efficacy o meta-cognitive therapy or adult ADHD. Am J Psychiatry (2010)

167(8):958–68. doi:10.1176/appi.ajp.2009.09081123

47. Grant AM. Te impact o lie coaching on goal attainment metacognition

and mental health. Soc Behav Pers Int J (2003) 31(3):253–63. doi:10.2224/

sbp.2003.31.3.253

48. Gerber GJ, Gargaro J. Participation in a social and recreational day programme

increases community integration and reduces amily burden o persons with

acquired brain injury. Brain Inj (2015) 20:1–8. doi:10.3109/02699052.2015.1

004745

49. Krasny-Pacini A, Hiebel J, Pauly F, Godon S, Chevignard M. Goal attainment

scaling in rehabilitation: a literature-based update. Ann Phys Rehabil Med

(2013) 56(3):212–30. doi:10.1016/j.rehab.2013.02.002

50. owne J, Ericsson KA, Sumner AM. Uncovering mechanisms in video game

research: suggestions rom the expert-perormance approach. Front Psychol

(2014) 5:161. doi:10.3389/psyg.2014.0016151. Ferguson CJ, San Miguel C, Garza A, Jerabeck JM. A longitudinal test o

video game violence influences on dating and aggression: a 3-year longitu-

dinal study o adolescents. J Psychiatr Res (2012) 46(2):141–6. doi:10.1016/j.

jpsychires.2011.10.014

52. Prigatano GP. Neuropsychological Rehabilitation Afer Brain Injury . Baltimore,

MD: Johns Hopkins Univ Press (1986).

53. Baniqued PL, Kranz MB, Voss MW, Lee H, Cosman JD, Severson J, et al.

Cognitive training with casual video games: points to consider. Front Psychol

(2014) 4:1010. doi:10.3389/psyg.2013.01010

54. Green CS, Strobach , Schubert . On methodological standards in training

and transer experiments. Psychol Res (2014) 78(6):756–72. doi:10.1007/

s00426-013-0535-3

Conflict of Interest Statement: Te authors declare that the research was con-

ducted in the absence o any commercial or financial relationships that could causea potential conflict o interest.

Copyright © 2015 Strahler Rivero, Herrera Nuñez, Uehara Pires and Amodeo

Bueno. Tis is an open-access article distributed under the terms o the Creative

Commons Attribution License (CC BY). Te use, distribution or reproduction in

other orums is permitted, provided the original author(s) or licensor are credited

and that the original publication in this journal is cited, in accordance with accepted

academic practice. No use, distribution or reproduction is permitted which does not

comply with these terms.

http://dx.doi.org/10.1080/09297040600770787

http://dx.doi.org/10.1097/00004583-200502000-00010

http://dx.doi.org/10.1076/jcen.24.6.781.8395


http://dx.doi.org/10.1037/a0014345


http://dx.doi.org/10.1007/BF01530764

http://dx.doi.org/10.5014/ajot.61.2.228

http://dx.doi.org/10.1176/appi.ajp.2009.09081123

http://dx.doi.org/10.2224/sbp.2003.31.3.253


http://dx.doi.org/10.3109/02699052.2015.1004745

http://dx.doi.org/10.3109/02699052.2015.1004745

http://dx.doi.org/10.1016/j.rehab.2013.02.002


http://dx.doi.org/10.1016/j.jpsychires.2011.10.014



http://dx.doi.org/10.1007/s00426-013-0535-3

http://dx.doi.org/10.1007/s00426-013-0535-3

http://creativecommons.org/licenses/by/4.0/




http://dx.doi.org/10.1007/s00426-013-0535-3

http://dx.doi.org/10.1007/s00426-013-0535-3





http://dx.doi.org/10.1016/j.rehab.2013.02.002

http://dx.doi.org/10.3109/02699052.2015.1004745

http://dx.doi.org/10.3109/02699052.2015.1004745



http://dx.doi.org/10.1176/appi.ajp.2009.09081123

http://dx.doi.org/10.5014/ajot.61.2.228

http://dx.doi.org/10.1007/BF01530764


http://dx.doi.org/10.1037/a0014345



http://dx.doi.org/10.1097/00004583-200502000-00010

http://dx.doi.org/10.1080/09297040600770787




adhd rehabilitation through video gaming: a systematic review using prisma guidelines of the current...

Documents