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Brain games not quite ready for prime time

The definitive version of this post was originally published on December 23, 2014 on the PLOS Neuroscience Community website, where I serve as an editor.


Ever since video games have become widely available, they have reflected a strong generational divide: most of today’s grandparents probably never played video games, whereas most of their grandchildren play them on a daily basis. Now, after recent scientific discoveries have revealed that video games might influence brain function for the better, many companies have started selling “brain games”, or computerized cognitive training programs, creating a market worth close to $1 billion per year.

What’s more, some of these companies are seeking the Food and Drug Administration’s approval to use these computer programs in healthy older adults to compensate the effects of aging on cognition. But there may be quite a long way to go before the sight of an elderly person bashing their handheld console in the clinic waiting room becomes daily routine: the neuroscience of video games and their cognitive impact is still in its infancy, and academic researchers in the field are warning that the promises made by some companies amount to quackery more than solid science. A new meta-analysis, recently published in PLOS Medicine, reviews the field and points out which types of brain games might work—and which might not.

A meta-analysis is a type of medical research article where scientists aggregate together the results of individual studies to assess whether a particular intervention has consistent effects across studies, and also to determine how large those effects are. This meta-analysis focused on the effects of computerized cognitive training in healthy older adults (roughly 60 years and older).

Better at What?

Studies were included if the participants were tested on cognitive tests both before and after the training. Importantly, those tests needed to be different than the ones trained in the brain games: we know that playing Sudoku makes you better at playing Sudoku, but the real question is whether it makes you better at something else, too. The type of computerized cognitive training in the studies varied widely, from studies that simply had participants play video games (Tetris, Rise of Nations or Medal of Honor were among the list) to custom-developed programs specifically designed to train one or several capacities such as working memory, attention, processing speed, verbal memory, visuospatial skills or executive functions.

Altogether, the authors identified 52 studies of sufficient quality to be included in the meta-analysis. Overall, they found that computerized cognitive training was associated with a significant, but very small improvement in cognitive performance. Most importantly, the authors offer a few pointers for further studies.

  • First, because the improvement of performance brought on by computerized cognitive training is expected to be small, studies should be sufficiently powered, i.e. have enough participants (about 90 people would be the minimum).
  • Also, group-based training had a positive effect on performance, whereas at-home training did not.
  • Perhaps surprisingly, training between 1 and 3 times per week proved effective, but studies with more intensive training sessions did not, suggesting that the negative consequences of fatigue might offset the larger amount of time dedicated to practice.
  • On the other hand, studies where each practice session was shorter than 30 minutes were negative.
Overall efficacy of computerized cognitive training on cognition. Each line represents one study, with the line’s position on the horizontal axis indicating whether the study found an effect (lines to the right of the 0 vertical axis) or not (lines to the left of the 0 vertical axis). The red line at the bottom summarizes the overall effect of all studies combined. As indicated, there is a significant, but small overall beneficial effect of computerized cognitive training on cognition.

Overall efficacy of computerized cognitive training on cognition. Each line represents one study, with the line’s position on the horizontal axis indicating whether the study found an effect (lines to the right of the 0 vertical axis) or not (lines to the left of the 0 vertical axis). The red line at the bottom summarizes the overall effect of all studies combined. As indicated, there is a significant, but small overall beneficial effect of computerized cognitive training on cognition.

Cognitive Improvement Not Tied to Working Memory

The researchers also found that the details of what the computer programs had the participants do were important. For instance, working memory is often thought of as our mental notepad, the limited quantity of information that we can keep in mind from one moment to the next (working memory is often assessed by having participants keep series of digits in memory for a few seconds. How good are you at keeping in memory a phone number that you just read? For most of us, 7 digits is the upper limit of our working memory capacity). Working memory is thus implicated in multiple aspects of cognition. Nevertheless, the meta-analysis revealed that training that specifically targeted working memory did not improve other cognitive functions.

As any scientific research project, meta-analyses have limitations, mostly related to the heterogeneity of the individual studies that they attempt to combine. Here, a major shortcoming concerned the fact that most studies did not assess whether the effects of computerized cognitive training lasted beyond the moments immediately following the practice session. Thus, the meta-analysis cannot answer the crucial question of whether “brain games” can have any lasting positive impact on cognition, let alone fend off the adverse effects of aging. Also, the potential benefits of computerized cognitive training were generally assessed only with psychology laboratory tests, leaving aside the burning question of whether any gain on those tests translates into progress in real-life situations such as remembering appointments or resisting distractions while driving a car.

Importantly, about half of the studies used “wait-lists” or other types of passive control groups (in a wait-list control group, the participants assigned to the control group were first run on the baseline cognitive tests and then put on a waiting list to receive the cognitive training at the end of the study). As pointed out in the comments to the article, passive control groups might have created artificially large differences with the intervention groups as opposed to active control groups, where participants were trained using something else than computer programs. Active control groups are generally considered better from a methodological standpoint, but are more time- and resource-consuming.

Consensus Paper Warns on ‘Unwarranted Enthusiasm of Brain Training Industry’

The meta-analysis is not the only one to temper the enthusiasm for “brain games”: a few weeks earlier, a large group of cognitive psychologists and neuroscientists, led by the Stanford Center on Longevity and the Berlin Max Planck Institute for Human Development, released a consensus paper on the evidence—or lack thereof—of the benefits of brain training. The consensus paper did not conduct a rigorous review of the existing literature, but because its authors were prominent scientists who know the state of the art of research inside out, the conclusions overlap with those of the meta-analysis to a very large extent.

Importantly, the authors of the consensus paper caution against the unwarranted enthusiasm of the “brain training industry” that massively overstates its products’ benefits. In their words, “the small, narrow, and fleeting advances [due to computerized cognitive training] are often billed as general and lasting improvements of mind and brain.” The consensus paper laments the exploitation by that industry of the understandable anxiety that older adults might have regarding the decline of their cognitive function.

All of this is not to say that computerized cognitive training has no effect whatsoever. Indeed, the meta-analysis does point to significant albeit small benefits. The authors of both the meta-analysis and the consensus paper suggest key points to improve the quality of future research to the highest scientific standards. To conclude, you don’t need to stop playing that Game Boy right now, but don’t forget to pause every once in a while and also make time for hiking, gardening, socializing, and so on—all of which will benefit your brain and mind just as much!

References

Lampit, A., Hallock, H., & Valenzuela, M. (2014). Computerized Cognitive Training in Cognitively Healthy Older Adults: A Systematic Review and Meta-Analysis of Effect Modifiers PLoS Medicine, 11 (11) DOI: 10.1371/journal.pmed.1001756

#SfN14 highlights: The Neuroscience of Gaming

The definitive version of this post was originally published on November 17, 2014 on the PLOS Neuroscience Community‘s Collaborative coverage of SfN2014, where I serve as an editor.


ME08.The Neuroscience of Gaming. Social Issues Roundtable. Sun Nov 16 2014, 1–3 PM.

The Social Issues Roundtable on the Neuroscience of Gaming brought together four panelists with varied backgrounds, most of whom had an intimate knowledge of both video games and of the recent neuroscience studies that focused on them. The roundtable format meant that, after each panelist had given a brief presentation on their work and ideas, a long questions and answer session with the attendance took place, generating an interesting discussion.

Here are brief overviews of some of the speakers’ talks. My apologies to the speakers that I did not cover. Of course, all inaccuracies or outright misunderstandings in what follows are mine alone.


ME08. An Inside Look on Gaming Design — Daniel Greenberg.

Daniel Greenberg has a legit pedigree as a designer of video games, as he worked for several big-name game companies (yay, Atari!) on several big-name games (does The Lord of the Rings Online ring a bell, anyone?).

Bad Games: Video games are now in a place where comics were in the 1950’s: the focus of mostly negative scrutiny by scientists, physicians, psychologists and public health specialists. The problem with such negative scrutiny is that it might cause society to overlook the positive effects of video games, e.g. practice by doing, experiential learning.

Good Games: Furthermore, game play itself mimics the scientific method: you are first confronted with an unknown system, with which you interact, forming and testing hypotheses and validating or rejecting them depending on the observed results. Games don’t explain, they encourage exploration and building on one’s errors through a tolerance to the consequences of those errors (infinite lives!). Video games train a number of sensorimotor and cognitive skills, especially so-called “shooters”. “Play-fighting” is also an important part of a child’s social development, and video games provide such a form of social play.

Healthy Games: Games have been developed for improving adherence to treatment in cancer (Re:Mission), cognitive-behavioral therapy in depression (SPARX), pain management (SnowWorld). Games have also been used as tools for science (e.g. FoldIt). They have been shown to be effective in well-controlled studies. So these games clearly represent an interesting lead to explore further.


ME08. Advances in Education, Training, and Therapeutic Outcomes Using Games — Adam Gazzaley.

Why is it interesting to use video games in neuroscience research? Dr. Gazzaley’s lab is all about improving cognition in both healthy and impaired people. Current diagnostic and therapeutic approaches for cognitive impairment, but also the educational system, are essentially open-loop approaches that, according to Dr. Gazzaley, are just not good enough. Now, video games have become ubiquitous, and they are examples of closed-loop systems where an agent impacts a system that in turn feeds information back to the agent, allowing them to modify their actions.

Dr. Gazzaley credits Daphne Bavelier, then at the University of Rochester and now at the University of Geneva, Switzerland, with basically creating a whole field, that of studying the positive effects of video games on cognition. Dr. Gazzaley views video games as a tool to harness brain plasticity. He asked this question: can we create a custom-designed video game to enhance cognition in older adults?

Dr. Gazzaley then developed just such a game, Neuroracer, together with people from LucasArts (a famous video game company). Neuroracer featured multitasking, combining a driving task with a perceptual discrimination task. Performance in players of Neuroracer decreased progressively as players were older. However, intense training on the game allowed older adults (60 years old and older) to become even better than naive 20-year-olds. Crucially, this learning effect was maintained over a 6-month period, and the researchers also found transfer of improved performance on other cognitive tasks (a crucial point, since getting better at a video game per se would not bring much improvement to the lives of seniors). The behavioral changes were paralleled by changes in brain rhythms, measured by EEG.

The principles of Neuroracer are now being tested and developed by a R&D company, Akili, composed of LucasArts alumni. FDA approval is being sought.


ME08. When Gaming Goes Too Far: The Negative Implications of Problematic Gaming — Mark Griffiths.

Dr. Griffiths asks the following questions in his work: What do we mean when we talk of video games addiction? Does gaming addiction actually exist? If it does, what are people actually addicted to?

According to him, any behavior is addictive if it fulfills 6 criteria: salience (the total preoccupation with the behavior in someone’s life, such that it becomes one’s single most important thing in life); mood modification; tolerance (more of the behavior is needed to achieve the same mood modification effect); withdrawal; conflict (the most important criterion according to Dr. Griffiths: the compromise to your life—education, work, relationships—caused by the behavior); and relapse. (Dr. Griffiths notes that the newly introduced criteria for internet gaming disorder in the DSM-5 mostly overlap with these.) Generic risk factors that may facilitate online addictions include access, affordability, anonymity, convenience, disinhibition, escape, and social acceptability.

Dr. Griffiths mentioned that, according to those strict criteria, the proportion of people addicted to video games is likely very low. However, according to the approximately 100 studies published on video game abuse so far, excessive or problematic engagement seems to concern 8–12% of young persons, whereas addiction would affect 2–5% of children, teenagers and students. Dr. Griffiths thinks that these numbers are way too high: if that were the case, the problem would be much more visible, and most US cities would have a video game addiction clinics. Part of the problem may lie in the varying and inconsistent definitions of addiction, problematic use etc. across studies. Also, and that is a very important point, almost all those studies were performed on self-selected samples, as opposed to epidemiologically representative samples. Therefore, consensus is required to improve the quality of research in the field and make studies more easy to compare with each other.


Open discussion

The open discussion gave rise to some great exchanges between the audience and the speakers. Here are a few of the questions.

“Could video games, especially ‘sandbox games’ (where the player can interact with the game environment in a non-restrictive fashion, as opposed to games with a very linear progression), be used more prominently in education?”

To sum up the speakers’ answer: They might, but it is really important that both the content and the game design be optimal. Games with a lot of educational content were developed in the 1990’s, but they were not engaging and were therefore mostly ignored by children.

“When we play video games, we ‘become’ and identify with the protagonist the game to some extent. Could video games therefore be used to improve attitudes towards people of different races or sexual orientations?”

Yes, studies with avatars have already been performed and have shown that they indeed improved identification with people of different characteristics.

“What is your favorite game, video or otherwise?” (a gem of a question!)

To Gazzaley, Portal 2 was the best. Mark Griffiths answered Tetris (“because I’m red-hot at it!”). Farah admitted to not having ever played a video game, and Greenberg did not get to answer the question.


What I took home from the session

I was impressed by the large attendance and by the fact that most now agree that video games have a unique potential, both in improving our understanding of cerebral functions, but also in improving brain functions themselves! I also liked the fact that the potentially negative effects of video games (addiction was the most discussed aspect in this roundtable, but violent behaviors or social isolation were also mentioned in passing) are studied with strong underlying investigational and scientific principles, far from fear-mongering and propaganda, but without blinding ourselves to the fact that these negative effects are real.

Announcing The Neuroscience of Gaming at SfN 2014

Here I briefly introduce one of the sessions I will blog about at SfN 2014, together with a short interview of Dr. Adam Gazzaley, one of the speakers at the session. The definitive version of this post was originally published on November 11 2014 on the PLOS Neuroscience Community website, where I serve as an editor.


ME08. The Neuroscience of Gaming. Social Issues Roundtable
Sunday, Nov 16, 2014, 1:00 PM — 3:00 PM. WCC 201
Featured speaker: Adam Gazzaley

One of the sessions that I’m most looking forward to at the SfN’s 2014 annual meeting is the Roundtable on the Neuroscience of Gaming. Why? Well, I started playing video games since I was in primary school, and they have been part of my life ever since. The Roundtable will bring together four speakers with varied backgrounds and expertise:

  • Daniel Greenberg is the president of Media Rez, a software and game development studio based in Washington DC whose goal is to develop games that support behavior change in health and learning.
  • Adam Gazzaley directs a cognitive neuroscience lab at the University of California in San Francisco that focuses, among others, on developing custom-made video games to improve cognitive functions.
  • Mark Griffiths, from Nottingham Trent University, in the UK, specializes in behavioral addictions such as gambling and video gaming addictions.
  • Martha Farah, who heads a cognitive neuroscience lab the University of Pennsylvania, will focus on the ethical and social aspects of using neuroscience in games.

I’m particularly interested in hearing about Dr. Gazzaley’s work. I’ve been thinking for a while that video games, in addition to being a great form of entertainment (and a cultural artefact!), represent fantastic tools to probe the function of the brain. Think about it: you are being exposed to complex, multisensory stimuli (obviously visual and auditory, but also tactile through vibrating controllers for instance), to which you have to respond by specific motor commands in a precise temporal window. The whole thing is orders of magnitude more engrossing than a typical psychophysical experiment, yet the basic principles remain. If you are able to intervene in the design of the game to have the player perform a task in which you’re interested, retrieve from the system when game events are happening, and synchronize that with measurements of brain activity, you can use video games as a very powerful scientific tool.

Well, Dr. Gazzaley and his team are doing precisely that — and more, since (among others) they are also adding non-invasive brain stimulation to their armamentarium. If you would like to know more about Dr. Gazzaley’s previous and current work, look to his study on how training on a custom-designed video game improved cognitive abilities in older adults, which was published by Nature last year (it was also highlighted on the cover, and it’s a very good one, too). More recently, Dr. Gazzaley was interviewed in a New York Times Magazine article on the controversy surrounding the “brain training” industry. He is also among the signatories of a recent consensus paper from the scientific community on the same issue. We can expect to hear more about this fascinating subject during the Roundtable.

Five Questions to: Adam Gazzaley

Adam Gazzaley, MD, PhD

Adam Gazzaley, MD, PhD

What, in your view, is the one most exciting finding that neuroscience has produced?

Evidence describing the anatomy and physiology of neuroplasticity.

If you could use a magic wand to improve one aspect of how research is conducted, what would you do?

The convergence of different perspectives and methodologies on the same issue would be more common.

What aspect of your research work do you prefer?

Working as a team with a group of intelligent and inspired people.

Is your career similar to what you had in mind as an undergraduate?

Similar, but more involved with health that I ever imagined.

What advice would you give an undergraduate neuroscience major (or recent graduate) about how best to advance in the field?

Search what you love to do, and don’t be afraid to think different.


I would like to thank Dr. Gazzaley for taking the time to answer my questions. I hope that I have convinced you to attend the Social Issues Roundtable on the neuroscience of gaming — but in case you missed the live session, I’ll blog about it, so keep watching this space!

Too bad you can't hear the soundtrack!

Too bad you can’t hear the soundtrack!

Video games for neuroscience research

Video games have been an important part of my life since I was a kid. I think I remember the first time I saw one, the Nintendo Game & Watch Super Mario Bros game, which must have been in the 1980’s. Since then, I’ve never stopped playing video games, with a particular fondness for the Nintendo brand (The Legend of Zelda: A Link to the Past remains my favorite). Video games are also the focus of scientific research, in general tackling the question of the bad things that they do to our children’s brains (I’ll leave it to Google to provide a handful of links for you), or more rarely, but perhaps more scientifically, the good things they do to our children’s brains (and everybody’s, really). But what I’d like to briefly touch on here is how video games can be used as tools to advance research in neuroscience; means as opposed to ends.

You might have heard of EyeWire in recent news: this game, put together by Sebastian Seung and his laboratory at the Massachusetts Institute of Technology, puts you in the boots of a neuron-tracker. Seung’s team here takes advantage of the abilities of humans to recognize objects in patterns and perceptually “close” shapes based on incomplete delineations of their edges. So far, we still have the upper hand over computers at these tasks. The task–track the spaghetti-like processes of a single neuron through stacks upon stacks of gray-scale electron microscopy slices of a mouse’s retina–seems to fulfill the very definition of tedium. However, thanks to a very well-thought and seamless interface (the game plays through a standard Internet browser), “filling out” your neuron’s axons and dendrites is easy, strangely captivating, even fun. Not Legend of Zelda levels of fun, perhaps, but definitely better than your one-billionth session of Minesweeper.

EyeWire vs. MineSweeper

EyeWire vs. Minesweeper

But beyond the fun that EyeWire may bring you, there is the rewarding feeling that you are genuinely helping neuroscience progress. Using the patient work (or play) of thousands of volunteers, Seung’s team was able to reconstruct dozens of a particular type of retinal neuron, called starburst amacrine cells, and discover a unique wiring pattern that would afford the retinal circuit the ability to selectively detect motion in a given direction. You can read much more about it on the project’s own blog. The findings were published in the scientific journal Nature, with the unusual mention of “The EyeWirers” as the last author, the much-coveted spot traditionally reserved to the supervising member of the research team.

Perhaps less groundbreaking in size, but no less significant in terms of the results obtained, the study performed by the group of Itzhak Fried, a neurosurgeon at the University of California in Los Angeles, asked whether human memory could be improved through brain stimulation. Fried’s laboratory is exceptional in that it focuses on studying the human brain’s function by recording its electrical activity from a unique vantage point: electrodes placed in the skull, directly touching the brain.

Such an invasive procedure is sometimes necessary in patients who suffer from epilepsy that can’t be controlled by medication alone: surgical removal of the part of the brain that causes the seizures might bring relief. Of course, physicians must first ascertain that the seizures do in fact originate in a circumscribed brain region, and that this brain region is not crucial for indispensable functions such as motor control or language. Hence the need for intracranial electrodes: recording seizures from within the brain allows pinpointing their origin, while injecting electrical current through the electrodes transiently alters the function of the brain region around it. If the patient briefly loses control over his arm or becomes temporarily unable to speak, the physicians mark this area as eloquent cortex that must be left undamaged during the surgery.

Fried’s team here focused on spatial memory, the ability of making a mental map of one’s environment in order to better navigate through it. There is very strong evidence from research in animal models that spatial memory involves regions of the brain called the hippocampus and entorhinal cortex, which in humans lie in the medial part of the temporal lobe and often cause seizures. The researchers had patients perform a spatial navigation task while they intermittently simulated their entorhinal cortex.

This is where video games enter the picture: the spatial navigation task consisted of virtual 3D city blocks with distinctive store fronts, rendered on a computer screen. The patients’ initial position within those streets was picked at random, and their task (their mission, in video game parlance) was to walk back to this or that store. Now, one could argue that practically every video game involves some degree of spatial navigation, as long as the action is not confined to a single static screen (think Super Mario Bros not Tetris). But the task used by the researchers here specifically made me think of two iconic games: Crazy Taxi, where you had to pick passengers in your shiny yellow cab (a convertible… so much for realism) and drop them at the other end of town within a time limit; and of course the Grand Theft Auto series, in which you generally play a gangster whose idea of public transportation is breaking into any car they like (including cabs, which triggers a mini game almost identical to Crazy Taxi!). What’s great about this task design is that it perfectly meets the needs of the researchers while being at least somewhat entertaining and challenging for the participants.

"CrazyTaxi gameplay" by Image from Imageshack. Licensed under Fair use of copyrighted material in the context of Crazy Taxi via Wikipedia - http://en.wikipedia.org/wiki/File:CrazyTaxi_gameplay.jpg#mediaviewer/File:CrazyTaxi_gameplay.jpg

“CrazyTaxi gameplay” by Image from Imageshack. Licensed under Fair use of copyrighted material in the context of Crazy Taxi via Wikipedia – http://en.wikipedia.org/wiki/File:CrazyTaxi_gameplay.jpg#mediaviewer/File:CrazyTaxi_gameplay.jpg

Here, the results of the experiment were perhaps even more stunning than the task design: the patients were better at learning how to navigate in novel environments when they received entorhinal stimulation. In their publication in the New England Journal of Medicine, the authors framed these results within the context of the memory loss that is a hallmark of many brain diseases, including Alzheimer’s disease. One cannot help but think, however, of the implications of this research for improving brain function over its normal limits in healthy people.

What these two examples share, and what makes them useful for neuroscientists, is what has been termed gamification: the use of game concepts and mechanisms in non-game contexts. Among the likely advantages of gamification are the improved engagement of participants and the multiple measures of participant performance it can provide. I expect that examples of gamification in neuroscience research will become more and more frequent in the near future.

References

Kim, J., Greene, M., Zlateski, A., Lee, K., Richardson, M., Turaga, S., Purcaro, M., Balkam, M., Robinson, A., Behabadi, B., Campos, M., Denk, W., & Seung, H. (2014). Space–time wiring specificity supports direction selectivity in the retina Nature, 509 (7500), 331-336 DOI: 10.1038/nature13240

Suthana, N., Haneef, Z., Stern, J., Mukamel, R., Behnke, E., Knowlton, B., & Fried, I. (2012). Memory Enhancement and Deep-Brain Stimulation of the Entorhinal Area New England Journal of Medicine, 366 (6), 502-510 DOI: 10.1056/NEJMoa1107212