María Rodrigo-Yanguas1,2Carlos González-Tardón3
Marcos Bella-Fernández1,2,4
Hilario Blasco-Fontecilla1,2,3,5*
- 1Servicio de Psiquiatría, Puerta de Hierro Health Research Institute-Segovia de Arana (IDIPHISA)-Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
- 2Faculty of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
- 3Consulting Asistencial Sociosanitario SL, Madrid, Spain
- 4Department of Psychology, Universidad Pontificia de Comillas, Madrid, Spain
- 5Centro de Investigación Biomédica en Red de Salud Mental, Madrid, Spain
Objective: To carry out a quasi-systematic review of the use of serious video games for health as a cognitive rehabilitative tool in patients diagnosed with attention-deficit hyperactivity disorder.
Method: A quasi-systematic review of serious video games used as an evaluative and rehabilitative tool in patients with ADHD was conducted. It included behavioral patterns in the use of video games and addiction problems in this population. For its elaboration the PRISMA GUIDES were followed. The search was carried out in three PubMed databases, MEDLINE, and PsycInfo using the keywords: [game OR serious game OR computer game) AND (psychotherapy OR rehabilitation OR intervention OR mental disorders) AND (adhd)], [(adhd) AND (Video game addiction)]. All articles written in English, Spanish, or Portuguese from January 1970 to June 2021 were included: those in which reference was made to the use of video games and/or new technologies as a therapeutic and evaluative tool in children and adults diagnosed with ADHD, as well as those that referred to behavioral and clinical patterns in the use of video games.
Results: We found 605 articles of which 128 were reviewed (44 observational studies, 26 quasi-experimental studies, 26 experimental studies, 8 systematic reviews, 9 narrative texts, 6 case reports, 7 pilot studies, 8 systematic reviews, and 2 meta-analyses). Serious video games can be used to ameliorate ADHD symptoms while improving adherence to treatment. Some serious video games show high accuracy properties assessing ADHD features.
Conclusion: Serious video games for health are increasingly being used as a cognitive rehabilitation tool in patients with attention-deficit hyperactivity disorder (ADHD).
Systematic Review Registration: [www.crd.york.ac.uk/prospero], identifier [CRD42021247784].
Introduction
The use of video games, particularly by children, is increasingly a matter of concern worldwide. Indeed, “Internet gaming disorder” (IGD) is considered a behavioral addiction (1). IGD is associated with male gender (2) and attention-deficit hyperactivity disorder (ADHD) (3), the most prevalent neurodevelopmental disorder worldwide [prevalence ranges between 5 and 10%; (4)]. Despite the problematic side of the relationship between ADHD and video games, some video games, particularly those called “serious” video games, might be useful in either the diagnosis or treatment of ADHD. Serious video games are defined as those video games specifically designed for educational or health purposes, in contrast with “non-serious,” regular or commercial video games, whose purpose is mostly entertainment. Design of serious video games shares common characteristics with commercial video games. Thus, advances in commercial video games design (e.g., music and graphics designed to make video games more attractive) are also advantageous for serious video games. At the same time, serious video games also take advantage of developments in cognitive and health sciences, such as learning and reward theories or developments of cognitive tasks for psychological therapy (5). Unfortunately, there are virtually no articles trying to balance the pros and cons of the relationship between video games and ADHD. Accordingly, a balanced and constructive review on this topic needs to be offered.
Children with ADHD are particularly vulnerable to developing a severe addiction to gaming (6). Indeed, we have recently reported that ADHD was associated with a three-fold risk of having IGD, but this association was buffered by good social adjustment (7). Besides this negative side of the ADHD–IGD relationship, the use of some video games can help improve the accuracy of ADHD diagnosis. For instance, we have recently reported that an infinite runner-based computer game assisted a clinician in improving the diagnosis of ADHD (8). Another positive use of video games is as a treatment tool for patients with ADHD. Wilkinson et al. (9) and, more recently, other authors (10–14) published systematic reviews concluding that video games might be used as a therapeutic tool in several mental disorders, including ADHD. Vilani et al. (15) concluded that video games can be used to improve emotional regulation and intelligence, and was called into action to introduce video games at both educational and psychological levels. Indeed, several video games have been created for the cognitive rehabilitation of patients with ADHD. The video game “Braingame Brian” (16) promoted some improvement in children with ADHD, including executive functioning (17). Also, regular practice with the video game “Plan-it Commander” helped improve time management, organization, planning, and prosocial skills (18). Similar results were reported with several video games such as “ENGAGE” (19), “Adventurous Dreaming Highflying Dragon” (20), “Movi-Kids” (21), “SmartBrain” (22),”SmartMind” (23), and Akili Interactive (24). These two positive areas of video game use are summarized by a recent systematic review concluding that video games can be used either to diagnose or treat ADHD (25).
Serious video games may also be used to evaluate cognitive functions related to ADHD. Instances of this are Cyber Cruise (26) and CogMed Working Memory training (27) for memory, and Cuibrain and Boogie Academy (28).
In particular, several video game versions of the CPT are available, such as MOXO-CPT (29), Kinect-based CPT (30), virtual reality-based CPT (31), the virtual classrooms ClinicaVR: Classroom CPT (32), and AULA Nesplora (33), as well as general purpose games such as EndeavorRX (34), Empowered Brain, and The Secret Trail of the Moon (35).
The aim of the present study is to systematically review all sound scientific literature published to date about the relationship between video games and ADHD considering three prisms: (1) the problematic (addictive) use of video games, (2) the potential use of video games to improve the diagnosing of ADHD, and (3) the potential therapeutic role of video games in patients with ADHD. We think that a holistic, comprehensive view of this interesting relationship will assist developers and health staff in the development of serious video games with diagnostic and therapeutic properties, as well as the inclusion of some ethics into the development of such tools (i.e., avoiding the addictive properties of some video games in a particularly vulnerable population, those diagnosed with ADHD).
Materials and Methods
We have developed a quasi-systematic review following the PRISMA guidelines1 with the aim of providing the scientific community with an overview of the potential use of serious video games for health as a therapeutic tool for cognitive rehabilitation in patients diagnosed with ADHD. For this, we have taken into consideration all the scientific literature written about cognitive rehabilitation through video games in ADHD, behavioral patterns during their use, and the growing problem of addiction to new technologies in said subpopulation.
Our systematic review has been prospectively registered in the PROSPERO register of systematic reviews, where it is provisionally published as it was submitted (CRD42021247784).
We proceeded to perform in June 2021 a first search in PubMed, PsycInfo, and Medline databases, in keeping with other recent systematic reviews in the field (5, 36, 37), under the two terms (1) “(game OR serious game OR computer game) AND (psychotherapy OR rehabilitation OR intervention OR mental disorders) AND (adhd)”; and (2) “(adhd) AND (Video game addiction).”
Finally, we conducted a new search with the same terms by using the search engine in Google Scholar2 (10 first pages). All those articles with scientific rigor published in English, Spanish, or Portuguese were selected from January 1970 to June 2021: those that referred to the use of video games and/or new technologies as a therapeutic and evaluative tool in children and adults diagnosed with ADHD, as well as those that alluded to behavioral and clinical patterns in the use of video games.
Excluded were those in which the game was used only as an evaluation method without providing further relevant data, those lacking scientific rigor, and all those in which there was no explicit reference to the existence of a relationship between the use of video games and clinical patterns of ADHD.
In total, 605 articles were selected, of which 339 were eliminated because they were not related to the purpose of our study and 70 because they were repeated. Of the remaining 196, 4 were discarded because they were in a language in which none of the authors were competent, 9 were eliminated for not focusing on the relationship between ADHD and video games, 47 were eliminated for not providing knowledge relevant to the subject of study, in 5 we could not access the full article because of lack of library funds, and 6 were discarded for other reasons. Finally, to the 125 articles reviewed, 3 new articles found in the reading of other articles were added.
A total of 128 articles were reviewed, of which 44 were observational studies, 26 were quasi-experimental studies, 26 were experimental studies, 9 were narrative texts, 8 were systematic reviews, 7 were pilot studies, 6 were case reports, and 2 were meta-analyses. Figure 1 shows the diagram flow with the decission process.
Figure 1. Flowchart of the review following the PRISMA guidelines.
All studies were classified according to their level of evidence for primary research questions,3 ranging from level I (high quality randomized trial or prospective study) to level V (expert opinion).
Results
In order to address the main theme of our research from a general framework that encompasses the beneficial study of the use of video games in patients with ADHD, but also behavioral and clinical patterns that may become maladaptive in their use, we decided to distribute the 128 articles among three tables: the use of video games as a cognitive rehabilitation tool (n = 49), video games as an evaluation tool (n = 11), and behavioral and clinical patterns in the use of video games (n = 23).
Table 1 refers to the use of video games as a tool aimed at treating ADHD. Serious video games for health can produce significant improvements in attention (17, 22, 28, 38–43), hyperactivity and impulsivity (17, 19, 20, 23, 38, 40, 44–46), executive functions (16, 18, 24, 41, 45, 47), memory (39, 41, 47–54), reading-writing skills (11, 41, 43, 55, 56), emotional regulation (19, 36, 37, 52, 55, 57), motor skills (18, 23, 28), and visual skills (53, 58, 59), among other advantages (18, 47, 48, 51, 55). These improvements may in turn have a beneficial effect in school performance (21, 50).
Table 1. Serious video games for health as a therapeutic tool in ADHD patients.
Nonetheless, some studies (54, 60, 61) did not find evidence of any improvement in ADHD symptomatology. Rajabi et al. (23) found improvement in impulsivity, but not in attention. Bul et al. (44) showed greater improvement in hyperactivity and behavioral problems in moderate patients compared with patients with more severe symptoms.
Serious video games may also improve adherence to treatment (24, 63). This positive effect may be related to patients perceiving video games as enjoyable activities (24, 65), apart from the perception of improvement in the patient’s quality of life (45, 48) and anxiety (37, 66), among others.
Table 2 shows the articles that refer to the use of video games as an evaluation tool for the diagnosis of ADHD. Different video games have been designed to evaluate the presence and severity of ADHD nuclear symptoms (30, 72–77), prospective memory (26), executive functions (78), stress (79), and prosocial behavior (80). Serious video games showed high sensitivity and specificity values (73, 75, 76), as well as a high correlation with CPT measurements (8, 72) and measurements similar to neuropsychological tests (73).
Table 2. Serious video game for health as an assessment tool in ADHD patients.
Table 3 groups articles related to various behavioral patterns in patients with ADHD when they are using video games. Patients with ADHD show greater problems in attention (81–83), motor control tasks, and working memory tasks (84). They also have difficulty inhibiting responses and make more risky decisions (85, 86), their performance decreases when reinforcement is delayed, and they seem to be more sensitive to reward (87) and punishment (88). Likewise, several studies concluded that a relationship exists between ADHD and intrinsic factors such as male gender and greater number of hours a day in the use of video games; along this line, several studies found that playing more than 1 h per day may worsen ADHD symptoms (82, 83).
Table 3. ADHD behavioral patterns with video game use.
Discussion
The present systematic review suggests that serious video games may be used as effective, playful therapeutic tools for patients with ADHD. In keeping with Strahler Rivero et al. (36), we also found that the use of serious video games for health focuses mainly on the diagnosis of and training to reduce problems in attention, memory, impulse control, emotional regulation, and time management, among others (16–19, 21, 26, 47, 48, 76, 78, 80). Furthermore, serious video games may favor adherence to treatment (24, 62, 65) and allow for a more personalized efficient neurocognitive design. It has been observed that these patients, while practicing with video games, show greater difficulties related to the inhibition of tasks (102), compulsive behaviors (103), and the need for continuous and immediate reinforcement for good performance (81, 85). Finally, patients diagnosed with ADHD have a higher risk of addiction to new technologies due to hypoactivity of the cortical regions. This low activity level is related to lack of control of impulses, time management, greater sensitivity to sounds, lights, and immediate rewards, among others (104). The literature agrees that it is the “impulsivity” trait that is most related to addiction to video games (105, 106).
The evidence presented in Table 1 shows how serious video games provide benefits to ADHD patients. This benefit goes beyond improvements in core ADHD symptoms, reaching other domains such as emotional regulation, which in turn leads to improvements in school and social performance. Treatments for ADHD are usually costly in terms of time, energy, and economic resources for patients and families. This way, serious video games may serve as a complementary activity which may reduce those costs.
All of the video games presented in Table 2 showed good properties when assessing ADHD symptoms, as well as related psychological deficits. Also, some of the video games (30, 72) show high correlations with objective ADHD tests, suggesting the possibilities for designing video games which perform as valid tests for ADHD factors and symptoms.
Table 3 shows the wide variety of psychological deficits associated with ADHD. The most relevant and prominent are, apart from core ADHD symptoms, deficits in attention and memory, proneness to make risky decisions, and a more pronounced sensibility to both positive and negative reinforcement. As seen above, most serious video games reviewed in the present work were found to improve these deficits in inattention, hyperactivity, impulsivity, and executive functions, among others. Concerning decision making, our review did not find serious video games applied to ADHD samples. Nonetheless, a recent review (107) found that serious simulation games improved decision making on samples of professionals like doctors and nurses. However, a generalization of this effect to ADHD patients should be taken with caution. Last, sensibility to reinforcement should be taken into account, more than treated, when designing video games with rewards (Sújar et al., submitted4).
Adherence to treatment is improved, taking special care on a series of features of serious video games (this assertion also applies for commercial video games). A motivating general theme for the game (space, pirates, etc.) can greatly improve adherence, as well as the use of frequent and immediate rewards and novelty in challenges (Sújar et al., submitted) (see text footnote 4). About serious video games features with an effective impact on ADHD improvements, two caveat should be considered. First, serious video games tend to get important inspiration from cognitive treatment tasks already validated (which, in turn, improves validity for serious video games), and second, in general terms, immediate feedback and rewards improve not only adherence but also performance, particularly in ADHD patients (Sújar et al., submitted) (see text footnote 4). Nevertheless, scientific literature on the specific topic of video game components and its influence on clinical improvements is scarce and falls beyond the scope of the present review, so our discussion on the matter should be taken with caution.
Finally, we must pay attention to the problems that derive from an excessive use of new technologies in the general population, and in particular in ADHD. Several investigations show how patients with ADHD are more prone to addiction to video games (7, 25, 108). As exposed above, video games, and particularly their abuse, may have a number of negative consequences (109). Nonetheless, Ruiz-Manrique et al. (53) found that therapy with serious video games may decrease abuse of video games. Concerta (110) and psychological therapy and psychoeducation (111) seem to have a similar effect.
Males seem to be more affected by video game addiction (108, 112, 113). This is consistent with the greater prevalence of ADHD in males than females (4). Also, ADHD symptomatology differs between males and females (114, 115). Evidence suggests that males tend to start playing video games earlier, whereas females’ progression to video game addiction tends to be faster (116). In males, time management seems to modulate the relationship between ADHD symptoms and video game addiction, while in females, ADHD modulates the relationship between time management and video game addiction.
In this systematic review we wanted to provide the scientific community with a holistic view of video games and attention-deficit hyperactivity disorder with the main objective of creating new cognitive rehabilitation tools based on video games that are more efficient and motivating for patients. The scope of this review is broader than other recent reviews, covering the appearance of ADHD symptoms and related psychological deficits, as well as their assessment and treatment through serious video games and the benefits of ADHD therapy though video games.
Despite the fact that favorable evidence has grown exponentially in recent years, there are several limitations in published studies such as the lack of replication of studies, the low systematization of research, and low master size, among others.
Conclusion
Serious video games are a tool for the diagnosis and treatment of ADHD symptoms and other related issues. A therapist should maintain a comprehensive view of video games, including both their problematic use (IGD) but also their potential use as either diagnostic or therapeutic tools. However, the present conclusion is reached after reviewing predominantly male samples, so generalizations to female patients should be made carefully. In the creation and design of a therapeutic video game for patients with ADHD, some relevant aspects should be taken into account: it is necessarily a diagnostic evaluation in order to offer personalized training in those areas and sub-areas more severely affected. The training must be constant over time, the difficulty level must be adjusted to the patient’s competence and in which his progression becomes visible, receiving a positive reinforcement in the first immediate moment and progressively increasing the delay time. In addition, other factors to consider are time management, inhibitory control, reasoning, competitive nature, and transference to situations of daily life, as well as the virtual world in which the game is developed.
Data Availability Statement
The original contributions presented in the study are included in the article, further inquiries can be directed to the corresponding author.
Author Contributions
MR-Y and HB-F conceived the original idea and formulated the problem, applied the inclusion and exlusion criteria, and selected the articles for revision. MR-Y designed the search syntaxes. MR-Y and MB-F performed the searches. MR-Y and HB-F wrote the drafts for the manuscript. CG-T and MB-F critically reviewed the manuscript. All authors reviewed and accepted the final version of the manuscript.
Funding
This research was partially funded by the Spanish National Project (grant number RTI2018-101857-B-I00), an iPFIS research contract (www.isciii.es; IFI16/00039), a FIPSE grant, and an intensification of research activity for health professionals grant (2019) at the Puerta de Hierro Health Research Institute -Segovia de Arana (IDIPHISA).
Conflict of Interest
In the last two years, HB-F has received lecture fees from AB-Biotics, Rovi, Praxis, and Shire. He has been paid by Praxis for the design and writing of an article. He was the recipient of a FIPSE Grant (www.fipse.es) in 2018. CG-T and HB-F were employed by Consulting Asistencial Sociosanitario SL.
The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher’s Note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
Footnotes
- ^ http://www.prisma-statement.org
- ^ https://scholar.google.es/
- ^ https://www.elsevier.com/__data/promis_misc/Levels_of_Evidence.pdf
- ^ Sújar A, Martín-Moratinos M, Rodrigo-Yanguas M, Bella-Fernández M, González-Tardón C, Delgado-Gómez D, et al. A general tutorial guide for the development of serious video games to treat attention decifit/hyperactivity disorder (ADHD). JMIR Serious Games.
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Keywords: ADHD, videogames, cognitive rehabilitation, addiction, revision
Citation: Rodrigo-Yanguas M, González-Tardón C, Bella-Fernández M and Blasco-Fontecilla H (2022) Serious Video Games: Angels or Demons in Patients With Attention-Deficit Hyperactivity Disorder? A Quasi-Systematic Review. Front. Psychiatry 13:798480. doi: 10.3389/fpsyt.2022.798480
Received: 20 October 2021; Accepted: 11 February 2022;
Published: 27 April 2022.
Edited by:
Sara Calderoni, Stella Maris Foundation (IRCCS), ItalyReviewed by:
Stela Maris Aguiar Lemos, Minas Gerais State University, BrazilSay How Ong, Institute of Mental Health, Singapore
Copyright © 2022 Rodrigo-Yanguas, González-Tardón, Bella-Fernández and Blasco-Fontecilla. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) 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.
*Correspondence: Hilario Blasco-Fontecilla, hmblasco@yahoo.es