The Effect of a Brain Training Game on ADD7 FINAL

Running head: BRAIN TRAINING ON ADD/ADHD

The Effect of a Brain Training Game on ADD/ADHD Attention Symptoms

Jasmine Jensen

Franklin Pierce University

BRAIN TRAINING ON ADD/ADHD

Abstract

ADD and ADHD are disorders characterized by inattentiveness and/or impulsivity and

hyperactivity. They are conditions typically treated with stimulant medication. However,

because of a potential for side effects or abuse, there is a desire for alternatives. Behavioral

therapy can cause familial problems or reward dependency, and homeopathic treatments show

no significance at present. Brain training games have been a recent source of research interest.

Recent studies have found that brain training games do not generalize to overall cognitive ability

but can increase cognitive performance in the specific task being trained. Brain training games

selected for improving attention could increase attention capabilities in those with ADD/ADHD

as it does for those without the conditions. Subjects were given a brain training regimen and

before and after attention scores on the Stroop test were compared. A non-parametric t-Test

was used to analyze the difference scores. Results were not significant. Marginal significance

with a small subject group indicates a good possibility for higher significance with more

subjects. Limitations, implications, and future research possibilities are also discussed.


The Effect of a Brain Training Game on ADD/ADHD Attention Symptoms

ADD/ADHD and Treatment

Attention Deficit Disorder (ADD) and Attention Deficit/Hyperactivity Disorder (ADHD) are

conditions that the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) described as

including inattentiveness and can be paired with symptoms of hyperactivity and/or impulsivity.

Some inattentive symptoms can include making careless mistakes as a result of not paying

attention to detail, being easily distracted or forgetful, and having trouble keeping attention on

tasks or when spoken to. Symptoms not only need to be present for a diagnosis, but must also

have caused impairment before the age of seven, be present in two or more settings, and not

occur during the course of another psychiatric disorder (DSM-IV, 2000). Prescription medication

is used in the treatment of most ADD/ADHD patients (Dryer, Kiernan, & Tyson, 2012). The

primary medications used are stimulants such as methylphenidate (Ritalin),

dextroamphetamine (Dexedrine), or a combination of amphetamine and dextroamphetamine

(Adderall). Stimulants have been demonstrated to reduce ADD/ADHD symptoms effectively. In

a study by Rothenberger, Becker, Breuer, and Döpfner (2011), methylphenidate was given to

children for an observational period of at least three months. Methylphenidate was frequently

described as “superior to prior treatment,” with only 3% discontinuation for adverse effects (p.

257). There has been concern more recently about children’s’ long term use of these

medications (Dryer et al., 2012).

A questionnaire for parents, their children/adolescents, and practitioners, asked for

opinions on the effectiveness of various treatments for ADD/ADHD (Bussing, Koro-Ljungberg,

Noguchi, Mason, Mayerson, and Garvan , 2012). It broke down treatments into four categories:


“Medical and allied health interventions/medication,” “school-based interventions,” “parent

interventions,” “and nontraditional treatments”. It was found that overall, people consider

school-based interventions more effective, followed by parent interventions, medical and allied

health interventions/medication, and nontraditional treatments. Teachers, health professionals,

and parents found medication to be a more effective treatment than the children and

adolescents taking it. As an exception, both parents and their children found that short-acting

ADD medication was less desirable because it causes embarrassment to have to take them

during school hours.

There was also a difference between parents who have children with ADD/ADHD, and

those who do not. Parents with children who have the disorder rated medication more

effective than non-traditional treatments, than compared to parents who do not have children

with ADD/ADHD (Dryer et al., 2012). This difference could be caused by the parents of

ADD/ADHD children preferring non-traditional treatments in the beginning of their child’s

condition, but then resorting to medication after they found the treatments did not have a

satisfactory effect (Bussing et al., 2012).

Counseling and behavior therapy for children with the disorder was also considered

stigmatized as being “a form of intervention that can increase conflicts between parents and

teenagers” (p. 98). There was also concern that behavior therapy “might create reward

dependence instead of teaching teenagers to control their behavior independently… [and]

would be only performing the desired behavior for a reward” (p. 98). On the other hand, health

care professionals are particularly concerned about the side effects associated with such

powerful drugs. A couple of these side effects include sleep problems and weight loss. Despite


the negative side effects and negative feelings towards medications by health care

professionals, parents are still willing to give their children stimulants. This could be a sign of

desperation, as before an ADD/ADHD diagnosis parents were more optimistic about non-

traditional methods of treatment.

In 60%-65% of cases, childhood ADHD symptoms persist into adulthood (Retz et al.,

2012). Even in adults, there are negatives to medication therapies. Stimulants have the

potential for abuse, if not by the patients themselves than by others. It is not uncommon for

ADD/ADHD sufferers to give away or sell their medication, particularly in high school and

college. Short-acting medications are the most frequently abused prescription stimulants (Mao,

Babcock, & Brams, 2011). This is not only because of the greater availability of short-acting

stimulants amongst adults, but also because long-acting stimulants are likely to be designed for

extended release. Extended release stimulants “are associated with lower peak plasma levels

and less dramatic withdrawal symptoms compared with immediate release agents” causing less

of a high (p. 246). It was found that 79.8% of patients abused short-acting stimulants. That

statistic does not include the number of non-patients who abuse short-acting stimulants. In

people without ADHD, stimulant medication has a much stronger effect, therefore carrying

possibility of creating addiction and dependence. With the potential for abuse of the short-

acting medications, it might be expected that long-acting extended release medications would

be prescribed more than short-acting medications. Extended release stimulants have been

found to be very effective (Retz et al., 2012). When it comes to medication therapy, the

majority of children with ADHD are treated with long-acting stimulants. However, 14% of

children use short-acting stimulants as compared to 46% of adults (Mao et al., 2011). Among


many reasons, one of the common reasons why more adults would use short acting

medications is for the ability to manage their own treatment. College students with ADHD not

only have a higher rate of stimulant abuse, but also alcohol use and illicit drug use. “Those with

ADHD were 3.3 times more likely to have used marijuana and 4.5 times more likely to have tried

tobacco at an earlier age and to continue using the substance” (Weyandt & DuPaul, 2012, p.

200).

Psychopharmacological treatments are the most popular method of ADD/ADHD

management, but there are other treatments options available (Vaughan, March, & Kratochvil,

2012). It is now recommended that children who are diagnosed with the disorder first attend

behavioral therapy (Vaughan et al., 2012). Behavioral therapy can be used to teach children

how to manage their symptoms until they are old enough to be safely prescribed medication.

Other, more non-traditional treatments are also sometimes paired with stimulants. These

treatments focus on dietary supplements such as specific types of vitamins and minerals, diet

restrictions, and other herbal and homeopathic treatments (Hurt, Lofthouse, & Arnold, 2011).

Most supplements are not recommended for ADHD patients unless they have a pre-existing

deficiency. Of a variety of evaluated alternatives for ADHD treatment, only a RDA/RDI

multivitamin supplement showed any evidence of improvement in concentration, attention,

nonverbal intelligence, and excess motor behavior. RDA/RDI is recommended for ADHD

patients who have decreased appetites from stimulant medication. Herbal and homeopathic

treatments are not recommended by most practitioners on account of a lack of supporting

research for their effectiveness. However, it has been claimed by parents such as Judyth

Reichenberg-Ullman and Robert Ullman, that homeopathic medicine worked for their child,


emphasizing that homeopathic medicine’s effects are highly individual (Reichenberg-Ullman &

Ullman, 1996). Although the effects of homeopathic medicine have been demonstrated to be

less successful at alleviating ADHD symptoms, it is possible that individual differences have an

effect on homeopathic remedies, as they have an effect on pharmacological treatments.

There are several treatments that have been tested as alternatives. Social-skills training

and parental training was evaluated in a study by Storebø, Gluud, Winkel, & Simonsen (2012),

which found that training children did not significantly influence ADHD symptoms, social skills,

or emotional competencies. Neurofeedback is becoming a well-known treatment for several

disorders, including ADD/ADHD. Formerly known as electroencephalographic (EEG)

biofeedback, it was originally found to be useful in treating some medical disorders, particularly

cardiovascular disorders (Lofthouse, Arnold, Hersch, Hurt, & DeBeus, 2012). Both biofeedback

and neurofeedback work through the conditioning mechanisms of learning in order to teach the

body/brain to improve its regulation of itself with real-time video/audio information about its

electrical activity. When measuring electrical signals in the brain, it has been shown that many

ADHD patients have more slow-waves compared to normal brains. Numerous studies have

reported benefits from using neurofeedback for the treatment of ADD. However, many of the

experiments have methods that could be improved by doing a double-blind study. Finally,

cognitive training interventions that target executive functioning problems in ADHD are

beginning to be researched in children (Nigg, 2011).

In adults, cognitive-behavioral therapy (CBT) and other structured, directive treatments

have gained solid footing. Directive treatment allows adults suffering from ADHD the ability to

address individual difficulties (Mapou, 2012).The confidence in stimulant therapy is a trademark


of the move towards medicating people with ADHD, even in young children, in the past couple

decades (Davis-Berman & Pestello, 2010). This could be caused by the general assumption that

ADHD is biological or neurological in nature. “No single test can diagnose a child as having

ADHD. Instead, a licensed health professional needs to gather information about the child, and

his or her behavior and environment” (National Institute of Health, p. 5). The diagnostic criteria

for ADHD is subjective, and as a result, it was found when testing a large group of ADHD

patients that 57% did not fulfill all the criteria for ADHD and 29.3% had no ADHD symptoms at

all (DuBose-Ravenel, 2002). If ADHD is not entirely neurological in nature, it could be suggested

that it could be effectively treated like Obsessive-Compulsive Disorder or phobias often are: by

teaching or training them to recognize their triggers and learn to overcome the stressors, very

much like behavioral therapy for ADHD.

Games

Videogames, historically, have been given a bad reputation by the general public.

Videogamers have often been accused of being addicted to their games. Indeed, in a 6-week

long experiment in which participants played internet videogames conducted by Han et al.

(2010), changes in frontal-lobe activity was observed that may be similar to early stages of

addiction (Han, Kim, Lee, Min, & Renshaw, 2010). Han, Lyoo, and Renshaw (2012) found that

differences in the anterior cingulate, thalamus, and occipito-temporal areas may contribute to

clinical characteristics of professional gamers and patients with online game addictions (Han et

al., 2012). Men become addicted to videogames more often than women, and this could be

because the reward pathway is activated more in men (Hoeft, Watson, Kesler, Bettinger, & Reiss,

2007).


There is also a concern that violent videogames will make someone more violent.

Playing violent videogames or being exposed to violent images can be a predictor of whether or

not someone will be more aggressive in later tasks (Bartholow, Bushman, & Sestir, 2006).

However, in a study of aggressive computer games with adolescents, it was found that the level

of aggression the participants experienced after playing aggressive videogames was dependent

upon what their level of aggressiveness was before testing (Grigoryan, Stepanyan, Stepanyan, &

Agababyan, 2007). Interestingly, Montag et al. (2012) found that when observing participants

playing the first-person-shooter game, “Counterstrike” with an fMRI, their brains had

habituated to the effects of the violent scenes being used as unpleasant stimuli (Montag et al.,

2012).

The phrase "videogames will rot your brain" is a common phase uttered by concerned

parents to their gaming children. Though videogames have addictive potential for some, their

positive uses are not discredited. There are brain differences in active gamers. Basak, Voss,

Erickson, Boot, and Kramer (2011), found that when training adults to play a complex real-time

strategy videogame, found that those who were better at the game had a greater general brain

volume in areas that involve the learning of tasks that involve perceptual, cognitive, and motor

skills (Basak et al., 2011). The cognitive benefits and application of various videogames,

including games marketed for 'brain training,' have been a recent source of research interest.

Games such as “Brain Age,” produced by Nintendo and based on the work of Japanese

neuroscientist Ryuta Kawashima, have brought the idea of brain training to the public, as well as

the scientific, mind. In a study where Kawashima’s brain training game was compared

experimentally with New Super Mario Bros for the Nintendo Wii or paper games, it was found


“Brain Age” had no impact on overall cognitive abilities greater than the other games tested

(Lorant-Royer, Munch, Mesclé, & Lieury, 2010). However, Owen (2010) discusses a study done

by neuroscientist Smith et al. (2009) that had a much more rigorous brain training regimen that

produced significant improvements in the areas of memory and attention. Across studies,

however, it has been widely concluded that brain training games, when exposed to scientific

scrutiny, have been found to increase cognitive performance in the specific task being training

(memory, attention, etc.) but does not generalize to overall cognitive ability (Hackley, 2011).

The idea that the brain can be exercised like the body is popular and highly marketable.

As Baxter (2011) said, “The engagement and polish of a well-designed lifestyle game have the

potential to interest large demographics” (p. 109). Though many older people are beginning to

play games on their technological media, it is still a large demographic group that has little to

do with gaming. Nacke, Nacke, and Lindley (2009) found that regardless of age, a brain training

game on the Nintendo DS, rather than with pen and paper, was more arousing. The elderly had

more positive responses to games that involved logic problem-solving than did the young

tested. This shows that the market for brain training videogames extends past the younger

generations, and may be quite effective if developed with activities that they respond positively

to, such as logic problem-solving games. “Brain Age” itself was tested on the elderly by a team

that included its creator, Kawashima, and was found to have a significant effect on the

participants’ executive functions and processing speed (Nouchi et al., 2012). With the ability to

improve the cognitive performance of the elderly, comes a need for systems that are easy for

them to use. Many elders have trouble using the technological media that these brain training

games are used on. As such, Boquete et al. (2011), developed and tested new technology that


makes brain training for the elderly more accessible and user-friendly.

Videogames have been tested in the classroom as well, although actively criticized.

Miller and Robertson (2011) clarified that they did find significant improvement between the

group who was using the Nintendo brain training game and the control group speed and

accuracy of computation (Miller & Robertson, 2011). As demonstrated by this study, the

usefulness of “Brain Age” in a school setting can essentially be as flashcards for mathematical

calculations.

Videogames are being developed for clinical use. For sufferers of traumatic brain injury

(TBI), there is often damage in spatial and verbal memory. In a case study, a patient with TBI

was rehabilitated using 3D video games based on virtual reality (Caglio et al., 2009). Although

Alzheimer’s disease patients beget significant benefits from the more intense cognitive training

and stimulation, no evidence was found that brain training games provide significant benefit

(Ballard, Khan, Clack, & Corbett, 2011). Technologies are being developed and adapted for use

in the mental health industry for psychiatric conditions as well (Brinkman, 2011). For example,

virtual reality technology has been adapted to treat people with phobias such as a fear of flying.

A study found that a cognitive therapy-based fantasy video game significantly decreased

depressive symptoms (Sassi, 2012). The use of videogames and other technologies could be a

natural step forward in the treatment of a variety of psychiatric conditions.

Games as Treatment for ADD/ADHD

With the possibility of improving individual cognitive abilities, and the use of brain

training games for clinical use, brain training games such as “Brain Age” might be used to

benefit conditions where specific cognitive abilities are targeted. Stevens and Bavelier (2012),


had promising results when training selectively for attention skills. They also discuss the

possibility of using a training regimen for attention in place of medication (Ballard, Khan, Clack,

& Corbett, 2011). Poor attention is a prominent symptom of ADD and ADHD. Brain training

using games directed toward improving attention could increase attention capabilities in people

with ADD/ADHD. This study’s hypothesis was that brain training will improve attention in

people with ADD/ADHD. The independent variables were whether or not the participant has

ADD/ADHD or not and their before and after attention scores, and the dependent variable was

the participant’s attention score as measured by the Stroop effect.

Method

Participants

Participants included college students from Franklin Pierce University. Ten of the

participants had a diagnosis of ADD or ADHD and no other psychiatric condition, while six had

no history of a psychiatric condition. ADD/ADHD participants were also unmedicated.

Participants were treated according to APA ethical guidelines and had given informed consent.

Recruitment was done by offering class credit, by personal invitation, or through poster

advertisements.

Apparatus

A Nintendo DS handheld game system was used to play the game “Brain Age” (Nouchi et

al., 2012).

Procedures

Before beginning brain training, participants were administered the Stroop test to

determine their starting attention score. Once per day, 5 days per week (Monday-Friday), each


participant was supervised playing “Number Cruncher” under the “Brain Age Check” feature in

the game for 10 minutes. See Figure 1. This game was chosen because of the attention

necessary to filter out the various stimuli affecting the senses. Brain training continued in this

way for 4 weeks for both experimental and control groups. After the 4 weeks, each participant

was administered the Stroop test for a second time to determine their attention score after the

training period.

Results

For Mean±SD and other descriptive statistics, refer to Table 1. Figure 2 shows that the

ADD/ADHD group mean was different and their data was more variable than the control group

mean. An F-max test was done to confirm a lack of homogeneity of variance between the

condition groups. It was significant at F(9,5)=7.22, p=.0212. A difference scores was calculated

for each participant. A lack of homogeneity along with a small participant group justified the

use of a non-parametric t-Test to analyze the difference scores. It was not significant at t(12)=-

1.65, p=.0628. Refer to Figure 2 for the average before and after Stroop scores, and Figure 3 for

the average difference scores for each condition.

Discussion

The hypothesis that brain training games directed toward improving attention could

increase attention capabilities in people with ADD/ADHD was not supported. However, the

ADD/ADHD condition had a greater average reduction in time and an improved average

difference score of more than two times greater than the control condition. The marginally

significant outcome in combination with the small subject group indicates a good possibility that

significance may be found with more subjects.


The small subject group was one of the greatest limitations of this study. Another

limitation was the game used for training. There was only one activity available in the “Brain

Age” franchise that specifically trained attention alone rather than in addition to memory. This

is contrary to Owen (2010), who selectively trained for memory and attention. Although Nacke,

Nacke, and Lindley (2009) and Nouchi et al. (2012) used “Brain Age,” they did not selectively

train for a specific cognitive skill. The training period, therefore, was very repetitive. In the

future, a brain training game for attention would ideally be composed of a variety of activities.

This would reduce the possibility of a practice effect as well as make the game more enticing for

the subjects. If additional testing yields significance, the brain training game that is entertaining

would be ideal, as those with ADD/ADHD will be more likely to participate in training of their

own freewill.

As brain training games have become more popular, quite a few websites have been

created for the purpose. Websites such as www.mybraintrainer.com, www.happy-neuron.com,

and www.luminosity.com charge subscription fees to play a variety of games that purportedly

improve a number of cognitive abilities. Luminosity even has a tracking system to keep track of

one’s regimen and progress. While these websites have a greater number of games to choose

from, many of the activities whose purpose is to improve attention have a contamination of

memory training within them. However, these websites do have the benefit of convenience,

which will become even more important if extended research supports this theory. Another

option is that a brain training program specifically tailored for the improvement of attention

capabilities in order to treat ADD and ADHD could be developed.

The greatest implication of this study is the possibility to use brain training games as a


form of non-pharmaceutical treatment for ADD and ADHD. However, it is important to

remember that the brain training regimen only produces a possible increase in attention

abilities, but not necessarily a reduction in attention-related ADD/ADHD symptoms. It will be

prudent in the future to have the subjects psychologically tested to see if there has been a

reduction of attention-related ADD/ADHD symptoms. Perhaps in replications of the study,

ADD/ADHD subjects could keep a symptom log of their daily observations throughout the

training period. If a reduction in symptoms is found, brain training could be a viable alternative

to stimulant medication in ADD and ADHD patients.

If a reduction of attention-related ADD/ADHD symptoms is found, it may be possible that

other deficiencies related to the condition(s) could be trained for. Perhaps brain training games

could be used to reduce hyperactivity in those with ADHD. Future research could continue on

this path. Furthermore, it begs the consideration of other conditions that could experience

symptom reduction with brain training games. The processing speed and executive processing

of the elderly has improved with the use of brain training games (Nouchi et al., 2012). Perhaps

it is possible that the progression of similar deficiencies in people with Alzheimer’s disease, for

example, can be slowed down.


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Table 1.

Descriptive Statistics for Difference Scores

Condition ADD/ADHD Control

Mean 207.250000 97.709520

Median 204.733300 55.549960

Min -21.63330 39.33336

Max 578.80000 213.33330

Standard Deviation 194.9513000 72.5567900

Note. The mean for the ADD/ADHD group is over twice that of the control group.


Figure 1. Brain Age game “Number Cruncher” on the Nintendo DS, handheld gaming device.

The number of numbers with a specified feature (number, color, rotating, pulsing) is asked to be

identified while different numbers with various features as also presented as extraneous,

distracting stimuli.


Figure 2. This graph displays the mean before and after Stroop scores in time (ms) for

ADD/ADHD and Control conditions. Error bars for the ADD/ADHD group represent the positive

standard deviation and the error bars for the control group represent the negative standard

deviation. The ADD/ADHD condition had a greater mean reduction in time than the control

condition.

Before After0

200

400

600

800

1000

1200

ADD/ADHDControl

Time of Stroop Test

Tim

e (

ms)


Figure 3. Graph displays the mean difference scores between before and after time (ms) for

ADD/ADHD and Control conditions. Error bars represent the standard deviation, showing the

lack of homogeneity of variance. The ADD/ADHD condition is over twice as much as the control

condition.

ADD/ADHD Control0

50

100

150

200

250

Condition

Tim

e (

ms)

Documents

The Effect of a Brain Training Game on ADD7 FINAL