Vakili & Langdon, Cogent Psychology (2016), 3: 1143732

http://dx.doi.org/10.1080/23311908.2016.1143732

CLINICAL PSYCHOLOGY & NEUROPSYCHOLOGY | RESEARCH ARTICLE

Cognitive rehabilitation of attention deficits in
traumatic brain injury using action video games: A
controlled trial
Received: 07 October 2015 Alexandra Vakili1* and Robyn Langdon2
Accepted: 12 January 2016
Abstract: This paper investigates the utility and efficacy of a novel eight-week
*Corresponding author: Alexandra Vakili,
Clinical Neuropsychologist, Westmead cognitive rehabilitation programme developed to remediate attention deficits in
Hospital, Sydney, Australia
E-mail: alexandra.vakili@gmail.com
adults who have sustained a traumatic brain injury (TBI), incorporating the use of
both action video game playing and a compensatory skills programme. Thirty-one
Reviewing editor:
Sirous Mobini, University of East London,
male TBI patients, aged 18–65 years, were recruited from 2 Australian brain injury
UK units and allocated to either a treatment or waitlist (treatment as usual) control
Additional information is available at group. Results showed improvements in the treatment group, but not the waitlist
the end of the article
control group, for performance on the immediate trained task (i.e. the video game)
and in non-trained measures of attention and quality of life. Neither group showed
changes to executive behaviours or self-efficacy. The strengths and limitations of
the study are discussed, as are the potential applications and future implications of
the research.

Subjects: Allied Health; Neurological Rehabilitation; Neuropsychological; Rehabilitation;

Rehabilitation Medicine

Keywords: cognitive rehabilitation; action video game; traumatic brain injury; attention

1. Introduction
Traumatic brain injury (TBI) often results in cognitive impairments that cause significant ongoing
impediments to work, study, daily living and social relationships. An examination of clinically signifi-
cant cognitive impairments following TBI, found a high frequency of impairments in attention, mem-
ory and executive functioning at time of admission, and at 18 months, 3 years and 5 years post
trauma. Yet no consensus has been reached on the most effective way to rehabilitate cognitive defi-
cits in TBI.

ABOUT THE AUTHOR PUBLIC INTEREST STATEMENT

This research was conducted as part of a PhD The rehabilitation of cognitive deficits following
at Macquarie University, Sydney, Australia. The traumatic brain injuries (TBI) is paramount to
author is currently a paediatric neuropsychologist bettering the functioning of patients who have
working with children and adolescents. The sustained such injuries. In addition, to the wider
author is currently building cognitive rehabilitation community reducing the level of disability of
programmes for use with Psychiatric inpatients people who have sustained TBI’s has large
with a particular focus on executive functioning. economic benefits.
However, to implement cognitive rehabilita-
tion programmes successfully we need adequate
empirical investigations and ecologically valid
outcome measures. We also need to address the
economic limitations of public health care systems
and utilise technology to overcome some historical
limitations in this approach.

© 2016 The Author(s). This open access article is distributed under a Creative Commons Attribution
(CC-BY) 4.0 license.

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Historically, remediation of attention deficits in TBI has utilised a restorative drill and practice ap-
proach with visual or auditory stimulus–response paradigms. Cicerone et al. (2000, 2005, 2011) re-
viewed the literature on cognitive rehabilitation for attention deficits following TBI and concluded
that while attention training benefits patients beyond the specifically trained task, the effects may
be small and/or remain relatively task-specific. These researchers also identified the need to exam-
ine the impact of attention training on other cognitive functions, such as executive functions, and
activities of real-world daily living.

Few well-controlled studies have examined the effects of cognitive rehabilitation on executive
deficits in TBI, with most research to date focusing on individualising treatments to a particular pa-
tient’s needs. In his methodological reviews, Cicerone et al. (2000, 2005, 2011) concluded that the
most effective methods to improve everyday problems caused by executive deficits in TBI patients
promoted internalisation of self-regulating strategies, for example, using verbal self-instruction,
self-questioning and self-monitoring. While research has found only limited evidence for the effec-
tiveness of group-based executive functioning training in TBI, goal management training has been
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reported to produce modest improvements in daily activities Rees, Marshall, Hartridge, Mackie, &
Weiser, (2007).

Against this background, this paper reports a novel cognitive rehabilitation programme for atten-
tion deficits in TBI using the economically viable approach of action video games and incorporating
a psycho-educational approach.

1.1. Rationale for using action video games

The exponential increase in sophisticated technology over the past 20 years has opened up many
new possibilities for relatively inexpensive computer-assisted cognitive rehabilitation approaches. A
systematic review of these approaches found significant improvements in performance on related
laboratory tests, such as standardised neuropsychological assessments of cognitive functioning, but
the durability and generalisability of findings have yet to be adequately assessed (Chesnut et al.,
1999). Given that the typical demographic of TBI survivors is young males, a computer-assisted in-
tervention that appeals to this demographic may enhance the benefits of such programmes. One
such approach utilises commonly available “video gaming”, cutting down demands for specialised
equipment and face-to-face therapist contact.

Of particular relevance to the present study, playing action video games has been shown to im-
prove visual attention. Green and Bavelier (2003) reported in their influential Nature paper that
10 days of training on an action video game increased basic attentional skills. Their first experiment
showed that video game players possess enough attentional capacity to attend to both target and
distracter stimuli, whereas the attentional resources of non-video game players had depleted by the
most difficult trial. In a second experiment, these authors showed that video game players were also
able to process more items at once compared with non-players, supporting a higher capacity of the
visual attentional system of the video game players. In a third experiment, the video game players
outperformed the non-players in localising a target amongst a spatial array of distracters, indicating
an increased spatial attention capacity. Their fourth experiment examined temporal characteristics
of visual attention using an experimental, identification/detection “attentional blink” task and found
that video game players had better temporal processing of visual information and enhanced task-
switching ability.

Their fifth and final experiment aimed to establish that the group differences were due to the ef-
fects of video game training as opposed to any pre-existing differences and selection bias towards
playing or not playing games. Non-players were trained on the action video game, “Medal of Honor”,
for 1 hour a day for 10 days. Training resulted in improvements on all aforementioned tasks.
However, while other researchers have replicated the results of experiments one to four from Green
and Bavelier (Boot, Kramer, Simons, Fabiani, & Gratton, 2008; Dye & Bavelier, 2010), Boot et al. (2008)
failed to replicate the fifth experiment. Nevertheless, other related research has found that action

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video game players make faster and more accurate judgments on the Attentional Network Test, a
test examining one’s alerting, orienting and executive attention, when compared to non-players
(Dye, Green, & Bavelier, 2009) and that training on video game playing improves strategies of divided
attention (Greenfield, DeWinstanley, Kilpatrick, & Kaye, 1994).

In the light of the above findings, the current study utilises an action video game and a commer-
cially available video game console (i.e. the Sony PlayStation) as a cognitive rehabilitation tool for
TBI.

1.2. Rationale for incorporating a psycho-educational approach

There is some debate in the literature as to the best way to accomplish generalisation of learning.
Some suggest that to enable functional change, skills should only be taught in the specific situation
in which they will be utilised (e.g. teaching job skills in the work environment: Guercio & Fralish,
1998), while others believe that by teaching more general principles, learning can be transferred to
a wider range of scenarios, enabling generalisation (Schutz & Trainor, 2007). Of relevance to the
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present study, the attention process training (APT) programme aims to retrain attention by providing
various tasks of increasing difficulty (Sohlberg & Mateer, 1987) with additional tasks incorporated to
promote generalisation. These researchers have since assessed the effectiveness of combining APT
with compensatory techniques (e.g. brain injury education and support) (Moore Sohlberg, McLaughlin,
Pavese, Heidrich, & Posner, 2000) and found improvement on various neuropsychological measures
of attention and executive functioning, and self-reported changes in attention and memory func-
tioning, thus suggesting generalisation of treatment effects.

In the current study, we provide compensatory strategies as part of a comprehensive adjunct

psycho-educational programme to enhance the generalisation of attention training via action vid-
eo-gaming to TBI patients’ everyday lives.

1.3. Study hypotheses

We hypothesise that the action video-gaming and psycho-education programme will result in im-
provements in attentional blink task performance and other, more ecologically valid attention
measures such as The Test of Everyday Attention. Additionally, we hypothesise that there will be
generalisation of improved skills to real-world executive behaviours which will thereby translate into
improved self-efficacy and quality of life.

2. Methods

2.1. Participants
Thirty-one participants were recruited from two brain injury rehabilitation units in Sydney, Australia.
Five participants dropped out before completion, leaving 26 participants at the time of the final
analysis. All participants were male, between 18 and 65 years old, and had sustained a TBI at least
one year prior to the first assessment.

2.2. Measures

2.2.1. Participant demographics

The following demographic information was taken: age at injury (in years), age at first assessment
(in years), time since injury (in months), days of post-traumatic amnesia (PTA) and years of
education.

2.2.2. Game performance

Two measures indexed game performance: number of “deaths” before level completion and shoot-
ing accuracy. Specifically, at the initial or second training session, participants recorded the number
of times their character died before completing mission three. Their shooting accuracy percentage,

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as provided by the game, was recorded at the end of the initial session. At the last training session,
participants were asked to return to mission three and the number of deaths and shooting accuracy
were again recorded.

2.2.3. Attentional blink task

Stimuli were generated by a Toshiba laptop computer and displayed on a 13-inch (32.5 cm) colour
monitor. Subjects viewed the display binocularly from a distance of approximately 35 cm. Each trial
comprised of a fixation cross presented for 500 ms followed by a sequence of black, uppercase dis-
tracter letters and a single white target letter. Half of the trials also included a black “X”. Each stimu-
lus in the sequence appeared at the same location in the centre of a uniformly grey screen for 15 ms,
with an interstimulus interval of 75 ms. In half of the trials with an “X”, the “X” appeared at one of
eight time lags following the white letter. Participants were instructed to look for the white letter and
a black “X” and responded by identifying the white letter and indicating if an X was present or ab-
sent. After 15 practice trials, there were 4 blocks of 40 test trials each. In each block, five initial
warm-up trials were not included in the analysis. In accord with previous research, the dependent
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variable (DV) was percentage correct detection of the X, given correct letter identification, at each of
the eight lags.

2.2.4. The test of everyday attention (Robertson, Ward, Ridgeway, & Nimmo-Smith, 1996)
The subtests and domains of everyday attention are outlined in Table 1. Version A was used for the
initial assessment and version B for post-treatment assessment. The DVs are age-normed scores
and take account of the practice effects that typically occur at the second administration (range
0–20). Reliability statistics for the Test of Everyday Attention range from .57 to .87. Convergent valid-
ity has been shown with other attention measures (Stroop, Trails A and B and Matching familiar
figures test) and divergent validity has been shown with intelligence and academic attainment tests.

2.2.5. Quality of life

The Comprehensive Quality of Life Scale Fifth Edition—for Intellectual/Cognitive Disability
(ComQol-I5) (Cummins, McCabe, Romeo, Reid, & Waters, 1997) measures subjective quality of life
across seven domains: Material well-being; Health; Productivity; Intimacy; Safety; Place in
Community; and Emotional well-being. As per the manual, scores indicating level of satisfaction

Table 1. Subtests of the test of everyday attention and the cognitive factors they examine
Subtest (s) Description of tasks Cognitive factor
Map search Searching a visual array and select- Visual selective attention/speed
ing targets whilst ignoring distract-
ers. Task is timed
Telephone search Searching a visual array and select- Visual selective attention/speed
ing targets whilst ignoring distract-
ers. Task is timed
Visual elevator (number correct) Switching between counting forward Attentional switching
and backward according to visual
stimuli that demand multiple occa-
sions of switching
Elevator counting Sustaining attention to two re- Sustained attention
petitive auditory stimuli at the same
time
Telephone search (dual task decre- Sustaining attention to two stimuli Sustained attention
ment) at the same time (one auditory and
one visual)
Elevator counting with distraction Counting auditory stimuli while Auditory-verbal working memory
ignoring distracting stimuli
Elevator counting with reversal Switching between counting forward Auditory–verbal working memory
and backward according to auditory
stimuli

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(rated on a five-point scale ranging from “very sad” to “very happy”) were weighted by subjective
importance (five-point scale ranging from “not important at all” through to “could not be more im-
portant”) to calculate a subjective quality of life score for each domain (range −20 to 20). Reliability
statistics for the ComQol-I5 range from .0–.97. No data on validity have been provided (Table 2).

2.2.6. Self-efficacy
The General Self-Efficacy Scale (GSES: REF) is a 10-item self-report questionnaire that uses 5-point
Likert scales (1–4) to examine optimistic self-beliefs about coping with life’s demands (range 10–40).
The GSES has reliability statistics ranging from .76 to .90. Convergent and divergent validity have
been shown.

2.2.7. Executive functioning

The Behavior Rating Inventory of Executive Functioning-Adult version (BRIEF-A) is a 75-item self-
report questionnaire. The participant is instructed to report during the past month how often each
of a number of executive behaviours have been a problem: “never”, “sometimes” or “often”.
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Responses are summed into nine factors: inhibit, shift, emotional control, self-monitor, initiate,
working memory, plan/organise, task monitor and organisation of materials. These scales are com-
bined to form two indexes, The Behavioural Regulation Index (BRI) and Metacognition Index, and an
overall summary score, The Global Executive Composite. All scores were converted to T scores as per
the manual (range 35–88). Reliability statistics are adequate to good (internal consistency .80–.98;

Table 2. The eight-week psychoeducational programme

Week Module Topics
1 Introduction and psycho education Having a positive approach to
rehabilitation Short and long term
effects of TBI
How to play Medal of Honor
2 Attention What is attention?
What impacts my ability to pay
attention?
Self-monitoring
Pacing strategies
3 Memory What are the different phases of
memory?
Where do I have the most difficulty?
Encoding strategies
Storage strategies
Retrieval strategies
4 Anger Management Becoming motivated
Recognising anger before onset
Strategies for coping with anger
5 Problem-Solving The goal-plan-predict-do-review
framework
6 Fatigue and Lack of Motivation What is fatigue and what causes it?
Using task analysis
7 Goal Setting Identifying goals
Planning goal execution
Executing goal-directed behaviours
8 Programme review and building Mantras
confidence
Being assertive

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inter-rater reliability .30–.50; test retest reliability .76–.85). Correlation studies have shown good
convergent and divergent validity.

2.3. Procedure

2.3.1. Pre and post-treatment assessment

Potential participants were alternately assigned into either an attention training or treatment as
usual (TAU) group. The Test of Everyday Attention was administered first, following the manual. The
questionnaires were then administered with instructions simplified if necessary and questions read
aloud for those participants with reading difficulty. The attentional blink task was always adminis-
tered last. Administration took between one and two hours. Post-treatment assessment occurred
between one and three weeks after the programme.

2.3.2. Attention-training
Participants attended a two-hour group rehabilitation session once a week for eight weeks. Groups
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consisted of four to five participants, each with his own PlayStation 2, 19-inch flat screen, game,
memory card and rehabilitation programme. In each session, participants played “Medal of Honor:
Rising Sun” (MoHRS; Electronic Arts, 2003), a first-person shooter action video game, set in Second
World War, for approximately three-quarters of the session. The remainder of the time was dedi-
cated to a psycho-education programme addressing common consequences of brain injury and in-
troducing compensatory strategies.

2.3. Statistical analysis

Baseline comparisons between groups for all measures were completed using one way Analysis of
Variance (ANOVA). Mixed model ANOVAs analysed the interaction of Time by Group (i.e. examining
pre-post changes in the attention-training group relative to any changes over time in the TAU group)
for all outcome DVs. Spearman correlations examined relations between improvement in game
scores (Shooting Accuracy and Number of Deaths) and improved outcome measures for the treat-
ment group.

3. Results

3.1. Participant attrition

As per Figure 1, all 15 attention-training participants completed the training and post-treatment
assessment. Of the initial 16 TAU participants, five dropped out prior to the second assessment, leav-
ing 11 in the post-treatment assessment comparison group. Of these 11, only 5 went on to complete
attention-training, which was offered to all TAU participants.

3.2. Baseline group comparison

Baseline data were examined in three ways: (1) all 31 participants (the intent-to-treat groups of 16
TAU and 15 attention-training participants; (2) the 26 participants who completed post-treatment
assessment (the per protocol groups of 11 TAU and 15 attention-training participants); and (3) the 5
participants who dropped out before the post-treatment assessment compared to the 26 who com-
pleted the protocol.

3.2.1. Participant demographics

Refer to Table 3 for a summary of the data. Analysis of all 31 participants showed that the attention-
training and TAU groups did not differ at baseline on current age, age at time of injury, years of edu-
cation or length of PTA; all p-values > .05. Time since injury was significantly different (F(1,30) = 4.746,
p < .05), with the attention-training group having a longer time since injury compared to the TAU
group. However, analysis of the 26 participants who completed the study found no differences on
any demographics; all p-values > .05. The five participants who dropped out were also no different
from the rest on any demographic; all p-values > .05.

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Figure 1. Participant attrition.

Time One
N=31
Pre Treatment Assessment

Treatment Waitlist
Randomised
n=15 n=16

Time Two Treatment Waitlist Dropout

Post Treatment Assessment n=15 n=11 n=5

Time Three Completed

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Dropout
Program
Post Treatment Assessment
n=6
(for Waitlist only) n=5

3.2.2. Treatment outcome measures

Analysis of all 31 participants showed no significant differences between groups on the baseline at-
tentional blink measures, Test of Everyday Attention, executive functioning (BRIEF-A) or quality of
life (ComQol-I5); all p-values > .05. Baseline self-efficacy (GSES) was, however, significantly higher in
the TAU group (F = 4.68, p < .05). However, analysis of the 26 participants who completed the study
showed no differences between groups on any outcome measures; all p-values > .05. The five par-
ticipants who dropped out had higher baseline ratings of emotional well-being (ComQol-I5 satisfac-
tion with emotional wellbeing (p < .005) and weighted importance × satisfaction score; (p < .05) but
were found to be no different from the participants who completed the programme on other Quality
of Life factors and all other measures; all p-values > .05.

3.3. Pre- to post-treatment analyses

3.3.1. Game performance

As shown in Table 4, at the final session attention-training participants had significantly improved in
their shooting accuracy (t = −4.896, p < .0005) and the number of deaths it took to complete a level
(t = 8.271, p < .0005).

Table 3. Participant demographics

Attention- Initial TAU Final TAU cohort Drop-outs by
training group cohort n = 16 n = 11 time two = 5
n = 15
Age (at first assess- 27.73 (11.43) 28.63 (6.54) 29.36 (6.34) 27.00 (7.42)
ment)
Age (at time of 24.67 (10.91) 26.63 (6.88) 27.00 (7.09) 25.80 (7.12)
injury)
Months since injury 38.93 (30.05) 21.81 (9.02) 22.18 (10.50) 21.00 (5.34)
PTA (Days) 41.87 (43.87) 43.64 (35.64) 37.30 (32.02) 50.50 (44.26)
Education (Years) 11.33 (1.91) 10.37 (1.09) 10.45 (1.29) 10.20 (.45)

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Table 4. Changes in game performance in the attention-training group following 8 weeks of

training
Mean Std. Dev. t p
Accuracy Pre 17.35% .113 −4.896 <.0005
Post 30.00% .180
Deaths Pre 11.38 6.76 8.271 <.0005
Post 1.85 2.27

3.3.2. Attentional blink

Twenty-three participants completed the attentional blink task at both assessments. Three partici-
pants were not included because they either refused to participate (n = 1) or discontinued the task
prematurely (n = 2).
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The mixed model ANOVA used a 2 × 2 × 8 (Pre-post by Group by Lag) design. Results showed a
significant main effect of lag (F(7,15) = 10.463, p < .0005), such that detection of the black X, given
correct report of the letter, improved as the lag between the letter and the X increased. Neither the
main effect of Pre-post, (F(1,21) = 3.897, p = .062), nor the interaction of Pre-post by Group were
statistically significant (F(1,21) = 1.90, p = .183). Although the two-way interaction was not signifi-
cant, the pattern of data is suggestive of differential effects across groups. Given the relatively small
sample size and the possible limitations of power, further exploratory analyses were performed by
splitting the groups. In the separate 2 × 8 (Pre-post by Lag) analyses, the TAU group showed a signifi-
cant main effect of Lag (F(7,4) = 6.061, p < .0005) and a non-significant effect of pre-post
(F(1,10) = .129, p = .727). In contrast, the attention-training group showed significant main effects of
Lag (F(7,5) = 4.577, p < .0005) and Pre-post (F(1,11) = 8.315, p < .05), such that performance, irrespec-
tive of Lag, was superior after attention-training.

3.3.3. Test of everyday attention

Results were analysed using a 2 × 2 (Pre-post by Group) analysis (see Table 5). Significant two-way
interactions were found for Map Search (2 min), Elevator Counting with Distraction and Visual

Table 5. 2 × 2 mixed model ANOVA interactions for the test of everyday attention
Mean F interaction (1,24) p
Attention-training TAU
Map 1 minute Pre 5.07 4.45 .879 .358
Post 6.93 5.00
Map 2 minute Pre 3.20 3.00 7.442 .012
Post 5.67 1.64
Elevator with distraction Pre 7.20 9.09 8.688 .007
Post 8.67 6.91
Visual elevator accuracy Pre 9.00 9.45 .044 .836
Post 7.80 8.55
Visual elevator time Pre 4.64 4.91 10.394 .004
Post 6.21 1.55
Elevator counting with reversal Pre 7.07 8.55 2.552 .123
Post 7.40 7.18
Telephone search Pre 7.40 4.55 1.97 .173
Post 8.27 2.73
Dual task Pre 7.00 6.00 2.085 .162
Post 7.20 3.73

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Elevator Time. All other main effects and interactions were not statistically significant. The interac-
tion for Map Search (2 min) occurred because the attention-training group showed a significant im-
provement from pre- to post-treatment assessment (t(14) = −2.193, p = .046), while the TAU group
showed a significant decrement in their performance (t(10) = 2.443, p = .035). The same general
pattern was seen for Elevator with distraction and Visual Elevator Time. With regard to Elevator with
distraction, the Pre-post difference for the attention-training group showed a trend toward improve-
ment (t(14) = −1.785, p = .096), while the TAU group showed a significant decrement (t(10) = 2.39,
p = .038). With regard to Visual Elevator Time, the improvement for the attention-training group was
non-significant (t(13) = −1.465, p = .167), while the TAU group showed a significant decrement
(t(10) = 3.187, p = .010).

3.3.4. Executive functioning (BRIEF-A)

No effects reached statistical significance (see Table 6 for a summary of the data); all
p-values > .05.
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3.3.5. Self efficacy (GSES)

All results (see Table 6) were non-significant; all p-values > .05.

Table 6. Results of 2 × 2 mixed model ANOVAs for the behavioural rating inventory of executive
functioning-adult version (BRIEF-A) scales and the general self-efficacy scale (GSES)
Mean F interaction (1,24) p
Attention-training TAU
BRIEF-A
Inhibit Pre 60.04 59.27 .266 .611
Post 59.2 56.09
Shift Pre 62.47 59.72 .543 .468
Post 61.4 54.09
Emotion Pre 61.73 59.91 .097 .758
Post 56.27 56.36
Self monitor Pre 60.4 54 .211 .65
Post 58.4 54.273
Behavioural regulation index Pre 64 60.55 .001 .97
Post 60.4 56.72
Initiate Pre 56.47 54.72 .033 .857
Post 54.73 52.18
Working memory Pre 62.53 59.72 .091 .765
Post 63.6 59.09
Plan/organise Pre 60.13 52.91 .167 .687
Post 58.6 53.36
Task monitor Pre 57.6 53 0 .989
Post 57 52.46
Organisation of materials Pre 49.6 51.09 .388 .539
Post 52.47 50.82
Metacognitive index Pre 58.33 54.73 .221 .642
Post 61.4 55.55
General executive index Pre 61.67 57.73 .015 .902
Post 59.87 55.46
GSES
Pre 27.38 31.30 1.129 .297
Post 29.00 31.20

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3.3.6. Quality of life (ComQol-I5)

See Table 7 for a summary of results for the weighted satisfaction by importance scores for the
seven scales. The Pre-post by Group interaction was significant for material well-being and emo-
tional well-being. All other interactions were non-significant; and no main effects were significant
(all p-values > .05). Simple comparisons revealed that the attention-training group self-reported
significantly higher scores for material well-being after training compared to baseline (t(15) = −2.616,
p = .02), while scores for the TAU group dropped, although not significantly (t(11) = 1.605, p = .14).
The pattern for Emotional well-being was generally similar; the scores for the attention-training
group showed improvement after treatment, although non-significant (t(15) = −1.378, p = .19), while
the TAU group showed a trend toward lower scores (t(11) = 2.149, p = .057).

3.3.7. Game Improvement and Outcome Improvement

Spearman correlations revealed that improvements in fewer “deaths” correlated with improve-
ments in elevator counting with distraction (r = .365, p < .043), while all other correlations were non-
significant (p > .05).
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4. Discussion
This study aimed to investigate the effect of an eight-week cognitive rehabilitation programme for
TBI incorporating action video gaming and psycho-education. Participants in the attention-training
condition showed significant improvements in game performance (shooting accuracy and the num-
ber of deaths it took to complete a level). This finding shows the direct benefit of the video game
experience on the video game playing itself and is consistent with previous research. Additionally, it
extends the existing research into the effects of action video game experience to also include a TBI
population. However, it is the generalisation of these skills to other tasks and measures that is of
paramount importance.

Results for the experimental attentional blink task showed an effect of lag in both groups, indicat-
ing greater attentional blindness at shorter time lags. Separate analyses indicated that whereas the
TAU group did not change from pre- to post-treatment, the attention-training group demonstrated
a significant improvement in detection of the second target across all time lags. This finding is con-
sistent with the findings of Green and Bavelier (2003), who observed a similar reduction in atten-
tional blink across all lags following 10 h of video game training in healthy participants.

Table 7. 2 × 2 mixed model ANOVA for the comprehensive quality of life scale
QoL Mean F interaction (1,24) p
Attention-training TAU
Material Pre 1.133 5 8.515 .008
Post 9.2 −1.318
Health Pre 6.63 3.27 .192 .665
Post 8.93 3.41
Productivity Pre 8.9 11.5 1.784 .194
Post 12.7 11.86
Intimacy Pre 15.4 11.82 .002 .964
Post 12.27 8.91
Safety Pre 7.73 7 .227 .638
Post 10.33 7.86
Community Pre 5.93 4.05 1.223 .28
Post 9.93 3.09
Emotional Pre 6.27 7.45 6.095 .021
Post 10.23 .91

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Only three tasks on the Test of Everyday Attention (TEA) revealed different profiles of pre- to post-
treatment assessment across groups; Map Search (2 min), Elevator Counting with Distraction and
Visual Elevator (Time). Comparisons indicated that the attention-training group showed a significant
improvement on Map Search (2 min) with similar, albeit not significant, improvements on the other
two TEA measures. In contrast, the TAU group showed significant declines. On the TEA, two versions
of the test are administered and normative scores for the second administration account for prac-
tice effects. The important implication here is that the reduction in scaled scores suggests that the
TAU group did not benefit from practice as would be expected or their performance deteriorated. In
contrast, the attention-training group was able to benefit from practice and, moreover, improved,
albeit only significantly for Map Search (2 min). One final comment is the fact that Map Search and
Visual Elevator are timed. Hence, consistent with some reviews (Rees et al., 2007), it may be that our
results reflect changes in processing speed rather than attention per se.

There were no benefits of training seen on any scales from the BRIEF-A (executive functioning) or
on the GSES (self-efficacy). This null finding is consistent with a review by Rees et al. (2007), who
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found limited evidence for the effectiveness of group training on executive functioning. However, it
is also possible that our self-report measurements were confounded by poor insight in TBI. Results
for quality of life were more promising. The interactions between time of assessment and group
were significant for material well-being and emotional well-being. Analysis of the pre- and post-
treatment scores indicated that the attention-training group had significantly higher ratings of ma-
terial well-being after treatment, while the control group showed no such change. It must be
acknowledged, however, that the attention-training participants were compensated $20 per session
for their participation; thus, their perceived material well-being may have been directly impacted by
this compensation, rather than being related to any work or job related gains. This explanation is less
likely to account for the interaction effect for emotional well-being: the control group showed a
significant drop in emotional well-being, while the treatment group showed some benefit from
training, at least to some degree.

Before final conclusions, limitations of the study are acknowledged. Firstly, our programme incor-
porated both restorative and compensatory techniques. Each of these components has been shown
to impact different skills, with more evidence for the effectiveness of restorative techniques in the
rehabilitation of attention, and greater evidence of the effectiveness of compensatory techniques in
increasing the generalisation of skills learnt to everyday functioning. By incorporating both into one
programme, it is not possible to tease apart the independent effects of these two techniques.
Nevertheless, the finding that improvement in game performance correlated with at least one at-
tentional outcome measure suggests that there was a direct restorative contribution from the gam-
ing experience itself. Secondly, our control group did not receive any therapeutic intervention.
Therefore, may be the case that benefits were due to participating in ANY group, regardless of the
activity being undertaken. As noted above, though, the finding that improvement in actual game
performance correlated with at least one attentional outcome measure suggests that not all bene-
fits were due to general group participation. Future research should nevertheless aim to include an
active control group. Finally, as with much of the cognitive rehabilitation research our sample size
was small, resulting in limitations of power.

This study also had strengths, however. First and foremost, we report the development and test-
ing of an economically viable option for a health care system that has limited resources. The materi-
als used (a Sony PlayStation and TV) are readily available and inexpensive. The game we used is
commercially available, and the programme can be adapted for any commercially available action
video game. In fact, video game consoles are often already available in Brain Injury Rehabilitation
Units and certainly in people’s homes. Second, the group nature of the programme means that the
therapist can treat multiple participants at one time. Not only is this an efficient use of the thera-
pist’s time, but it also enables therapeutic benefits of social interaction and group participation.
Other strengths include that this study utilised a number of measures that are more ecologically
valid than some more widely used alternatives. The Test of Everyday Attention uses everyday tasks

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 Vakili & Langdon, Cogent Psychology (2016), 3: 1143732
http://dx.doi.org/10.1080/23311908.2016.1143732

such as searching through maps or telephone books and assesses the same set of different domains
that match the factor structure known to represent attention functioning (Robertson et al., 1996).
We also used behavioural questionnaires to gauge behavioural changes in executive functioning,
rather than an intermediate cognitive measure. A measure of quality of life was also included to as-
sess the broader impact of the training on multiple aspects of daily functioning. We do acknowledge,
however, that data from self-report questionnaires may be confounded by poor insight in TBI.

In conclusion, the current study has shown that comprehensive cognitive rehabilitation pro-
grammes that address both restorative and compensatory techniques, have the potential to benefit
individuals with TBI. Given the limitations of the study, the findings provide a rationale for more rig-
orous cognitive rehabilitation research with larger sample sizes. Importantly, the current programme
was designed to enable access to cognitive rehabilitation in an economically viable way. Given the
availability of video games in the homes of many TBI patients and the likelihood that they may
spend a portion of their day playing video games, the programme could potentially be adapted for
home use with an administration manual to assist a family member or caregiver in supervising the
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TBI patient and to enable adequate explanation through the process.

Funding and Rehabilitation, 92, 519–530.

The authors received no direct funding for this research. http://dx.doi.org/10.1016/j.apmr.2010.11.015
Cummins, R. A., McCabe, M. P., Romeo, Y., Reid, S., & Waters, L.
Competing Interests (1997). An initial evaluation of the comprehensive quality
The authors declare no competing interest. of life scale-intellectual disability. International Journal of
Disability, Development and Education, 44, 7–19.
Author details http://dx.doi.org/10.1080/0156655970440102
Alexandra Vakili1 Dye, M. W., & Bavelier, D. (2010). Differential development of
E-mail: alexandra.vakili@gmail.com visual attention skills in school-age children. Vision Research,
Robyn Langdon2 50, 452–459. http://dx.doi.org/10.1016/j.visres.2009.10.010
Dye, M. W., Green, C. S., & Bavelier, D. (2009). The development
E-mail: robyn.langdon@mq.edu.au
of attention skills in action video game players.
1
Clinical Neuropsychologist, Westmead Hospital, Sydney,
Neuropsychologia, 47, 1780–1789.
Australia.
http://dx.doi.org/10.1016/j.neuropsychologia.2009.02.002
2
Faculty of Human Sciences, Department of Cognitive
Green, C. S., & Bavelier, D. (2003). Action video game modifies
Science, Macquarie University, Sydney, Australia.
visual selective attention. Nature, 423, 534–537.
http://dx.doi.org/10.1038/nature01647
Citation information
Greenfield, P. M., DeWinstanley, P., Kilpatrick, H., & Kaye, D.
Cite this article as: Cognitive rehabilitation of attention
(1994). Action video games and informal education:
deficits in traumatic brain injury using action video games:
Effects on strategies for dividing visual attention. Journal
A controlled trial, Alexandra Vakili & Robyn Langdon,
of Applied Developmental Psychology, 105–123.
Cogent Psychology (2016), 3: 1143732.
http://dx.doi.org/10.1016/0193-3973(94)90008-6
Guercio, A., & Fralish, K. B. (1998). Integration of cognitive
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