Computers in Human Behavior 28 (2012) 1091–1096

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Computers in Human Behavior

journal homepage: www.elsevier.com/locate/comphumbeh

Individual differences in response to cognitive training: Using a multi-modal,

attentionally demanding game-based intervention for older adults
Laura A. Whitlock, Anne Collins McLaughlin ⇑, Jason C. Allaire
Department of Psychology at North Carolina State University, USA

a r t i c l e i n f o a b s t r a c t

Article history: The effectiveness of a game-based cognitive training intervention on multiple abilities was assessed in a
Available online 17 February 2012 sample of 39 older adults aged 60–77. The intervention task was chosen based on a cognitive task anal-
ysis designed to determine the attentional and multi-modal demands of the game. Improvements on a
Keywords: measure of attention were found for the intervention group compared to controls. Furthermore, for
Older adults the intervention group only, initial ability scores predicted improvements on both tests of attention
Cognitive ability and spatial orientation. These results suggest cognitive training may be more effective for those initially
Intervention
lower in ability.
Video games
Individual differences
Ó 2012 Elsevier Ltd. All rights reserved.

1. Introduction nitive training in memory than the older-old (Verhaeghen, Marcoen,

& Goossens, 1992), although memory training gains may be more
Age-related cognitive decline is a well-established phenomenon reflective of strategy acquisition than ability improvement. It is also
that begins in early adulthood and often accelerates with age, with possible that lower functioning older adults may be unable to fully
older adults exhibiting deficits in many areas of cognitive perfor- participate in a cognitive intervention due to the inherent difficulty
mance, specifically fluid intelligence (Baltes & Mayer, 1998; of cognitive training and thus, be less likely to benefit.
Salthouse, 2004). Fluid intelligence comprises a number of abilities However, it has also been suggested that cognitive activity may
that allow abstract thinking, reasoning, directing and controlling most benefit lower functioning older adults. Studies specifically
attention, and learning new information. However, effective cogni- examining the relationship between baseline ability and training
tive training interventions have the potential to impact many gain found that there were higher benefits from cognitive training
abilities and could result in improved quality of life and longer for those initially low in ability (Ball, Edwards, & Ross, 2007) and
independence for older adults. Many cognitive training interven- ability and education (Boron, Turiano, & Willis, 2007). Older adults
tions with older adults have shown improvements in ability test with higher abilities may have already been performing near ceil-
scores (Ball et al., 2002; Basak, Boot, Voss, & Kramer, 2008; Bugos, ing, and thus could not show as much improvement. It may also be
Perlstein, McCrae, Brophy, & Bedenbaugh, 2007; Noice, Noice, & that there is a threshold for stimulation and activity that results in
Staines, 2004), improvements on subjective tests of well-being high ability scores and the high functioning older adults already
(Wolinsky et al., 2006), and activities of daily living (Willis et al., participate above that threshold as part of their daily lives. Thus,
2006). a cognitive intervention adds little beyond the threshold they
There is debate as to whether there are populations of older had already reached. However, adding activities to the lives of low-
adults that could most benefit from cognitive interventions. For er functioning adults may result in cognitive improvement. Similar
example, while neural plasticity in response to training has been ob- findings have occurred in animal models where environmental
served in older adults (Boyke, Driemeyer, Gaser, Buchel, & May, enrichment during adulthood has been shown to improve behav-
2008; Erickson et al., 2007), plasticity is generally considered to de- ioral flexibility (Kemperman, Gast, & Gage, 2002).
cline with age (Burke & Barnes, 2006). Therefore, the younger-old
and consequently higher-functioning may have more potential for
neural reorganization and compensation during an intervention. 1.1. Games as tools for cognitive training
Indeed, the younger-old have been shown to benefit more from cog-
There is growing interest in the use of video games for training
cognitive abilities. Video and computer games can be complex and
⇑ Corresponding author. Address: Department of Psychology, Box 2650, North flexible activities that use multiple cognitive abilities, can offer
Carolina State University, Raleigh, NC 27695, USA. motivational rewards, and can be played socially. Games have been
E-mail address: [email protected] (A.C. McLaughlin). shown to improve younger adults’ cognitive abilities in areas such

0747-5632/$ - see front matter Ó 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.chb.2012.01.012
1092 L.A. Whitlock et al. / Computers in Human Behavior 28 (2012) 1091–1096

as visual attention (Feng, Spence, & Pratt, 2007; Green & Bavelier, to the 3D game world, and finally navigate through the 3D world to
2003; Green, Li, & Bavelier, 2010) and mental rotation ability reach their destination. During this process they must also attend
(De Lisi & Cammarano, 1996; Feng et al., 2007; Okagaki & Frensch, to important and constantly changing on-screen indicators within
1994; Terlecki, Newcombe, & Little, 2008). Older adults also appear the game world, such as the health of their character in the game,
to benefit from cognitive enhancement via video games. A recent and selectively ignore other on-screen information that might
study examined the use of a real-time strategy game called Rise distract them from their task. Due to these characteristics, WoW
of Nations in a cognitive training program for older adults (Basak appeared to be a cognitively demanding game and a formal analy-
et al., 2008). The game required the player to gather resources, sis was performed to identify the cognitive abilities used during
research technologies, and build and control large armies all in real play. A cognitive task analysis (CTA), identifying the cognitive
time. Participants in the experimental group played the game for skills, or mental demands needed to perform proficiently (Militello
23.5 h and showed significant improvements in task switching, & Hutton, 1998), was conducted of both novice and expert perfor-
working memory, visual short-term memory and reasoning when mance in the game based on a verbal protocol (Bainbridge &
compared to the control group (Basak et al., 2008). Thus, any game Sanderson, 1990). Two novice players and two expert players, all
chosen for an intervention should likely include multi-tasking and younger adults, were used for the analysis.
switching between multiple cognitive abilities such as memory, The CTA identified a number of cognitive abilities required by
spatial manipulations, and reasoning to be effective. the game during play for novice and expert experience levels.
Although the CTA suggested that novice and expert players pro-
1.2. Motivation ceeded through the game in different ways, all players engaged
in a number of demanding cognitive processes such as rapidly
Video games are also promising as a tool for cognitive training switching their attention between sub-tasks requiring different
because they are designed to be fun to play. Cognitive training cognitive abilities, necessitating effortful attentional control. This
appears to be most effective when participants are pushed to the confirmed that playing World of Warcraft was a cognitive complex
limits of their abilities, which can be frustrating and discouraging task, both for players experiencing the game for the first time and
if the players feel overwhelmed. While participants may be for those who have been playing for years. We are currently aware
initially motivated to complete exercises to improve their mental of only one other study that utilized task analysis a priori in inter-
abilities, over time they may lose motivation and fail to invest vention design (Ackerman, Kanfer, & Calderwood, 2010).
effort. However, games are designed to be rewarding to play. They
usually have extrinsic motivators like sound effects and high score 1.4. Hypotheses
screens that motivate the player to continue in the face of
challenges. Using extrinsic motivators like sound effects can World of Warcraft was predicted to improve the cognitive ability
dramatically reduce failure rates even in highly difficult tasks like of older adults through the task requirements of using multiple cog-
air traffic control (Schneider, 1985). nitive abilities under attentionally demanding conditions. In partic-
Comparatively few studies have tested the effectiveness of ular, it was expected to improve older adults’ spatial orientation
using video games to improve cognitive abilities in older adults, ability and attentional control because of the high demands for
perhaps because of the perception that older adults are reluctant those abilities during play. Additionally, it was hypothesized that
to adopt new technology or that they may be unwilling to play vi- initial ability level would affect improvement such that experimen-
deo or computer games. However, older adults are likely to use tal participants exhibiting lower initial ability would improve more
technology when they perceive there to be benefits to using it than those exhibiting higher initial ability, due to the intervention
(Melenhorst, Rogers, & Bouwhuis, 2006) and that the technology targeting ability improvement, which affects performance on mul-
has relevance to their lives (Selwyn, Gorad, Furlong, & Madden, tiple tasks, rather than mere skill acquisition for a single task.
2003). Older adults have also exhibited interest in a wide variety
of games though they tended to prefer sedentary games to physi-
2. Method
cally active games (Hoppes, Hally, & Sewell, 2000). They have also
been shown to be especially interested in games that can be played
2.1. Participants
on varying levels of strategic complexity, such as dominoes
(Hoppes et al., 2000). Several elements have been identified as
Participants were contacted through a database of older adults
important to older adults’ enjoyment of game playing, including
who had participated in psychology research and through commu-
mental fitness, competition and winning, filling their time in a
nity newsletters. Control group participants received $50.00 at the
way that provides satisfaction, and a sense of belonging in social
end of the study and experimental group participants received
games (Hoppes, Wilcox, & Graham, 2001). Video games can be
$70.00. As a condition of eligibility, all participants in both exper-
designed to contain all of these elements.
imental and control groups had a home computer less than three
years of age and a dedicated home internet connection. Demo-
1.3. Overview of the intervention game
graphic information and ability test scores are reported in Table 1.
A game that fulfilled the requirements of multi-tasking and
switching between multiple cognitive abilities was World of 2.2. Materials
Warcraft (WoW), a massively multiplayer online role playing game
created by Blizzard Entertainment. In WoW players complete Participants completed a series of ability tests during the pre-
quests in a persistent virtual world to receive rewards and their and post-test sessions to measure initial ability and change over
characters gain levels, pushing them toward more difficult and the experimental period. These included tests of spatial ability,
complex challenges, many of which require collaboration and executive function, and memory.
social interaction with other human players. Navigating to a novel
location within the virtual world, for example, might require 2.2.1. Mental Rotation Test (MRT)
players to read a textual description of the goal location, examine The MRT was a measure of mental rotation ability and consisted
a 2D overhead map of the region, decide an optimal path to their of a version of the test made from the Vandenberg & Kuse images
goal using the map, translate that path from the 2D overhead view (Peters et al., 1995; Vandenberg & Kuse, 1978). Participants
 L.A. Whitlock et al. / Computers in Human Behavior 28 (2012) 1091–1096 1093

Table 1 2.2.5. Stroop Test

Demographics and Pre-Test Ability Scores by Group. The Stroop Test (Stroop, 1935) was used to measure attentional
n = 20 n = 19 control. Participants were given a list of color names printed in dif-
Control Experimental ferent colors of ink. They were asked to read aloud the name of the
Gender colors in which the words are printed, not the text of the words
Female n = 11 n=9 themselves. Scores consisted of time to read aloud 100 color names
Male n=9 n = 10 where lower times indicated better performance.
M (SD) M (SD) F
Age 66.80 (4.93) 68.58 (4.38) 1.44 2.2.6. Progressive matrices
Frequency of computer use1 5.94 (1.26) 5.37 (1.16) 2.09
The test used to measure reasoning ability was a progressive
Education2 5.21 (1.51) 4.47 (1.47) 2.32
Health3 3.84 (1.01) 4.16 (0.83) 1.1 matrices test (Newton & Bristoll, 2011), similar to Raven’s Progres-
sive Matrices (Raven, Raven, & Court, 2003). Participants identified
Pre-Test Ability Scores
Shipley Vocabulary4 35 34 0.83 the pattern in a series of images and an image that would best
Stroop5 131.18 (29.87) 132.83 (26.09) 0.03 complete the series or selected an image that did not belong in
Object Perspective6 56.47 (27.47) 46.97 (39.08) 0.78 the group. A higher score indicated better performance.
Digit Symbol Substitution7 48.20 (12.23) 47.47 (9.92) 0.04
Mental Rotation8 62.50% (16.04) 58.10% (17.55) 0.68
Progressive Matrices9 5.10 (2.27) 5.53 (2.37) 0.33
2.2.7. Everyday Cognition Battery: Memory test (ECB Memory)
ECB Memory10 25.80 (2.59) 24.74 (3.33) 1.25 ECB Memory (Allaire & Marsiske, 1999) tested cued recall mem-
ory. The test consisted of information, such as a medicine/nutrition
There were no significant differences between experimental and control groups on
these demographic and pre-test measures.
label, followed by multiple-choice questions. Participants were
1
Higher scores indicated more frequent computer use, on a 7-point scale ranging given 1 min to study the information then turned to the next page
from ‘‘once every few months’’ to ‘‘daily, most of the day.’’ and were given 1 min to answer the questions. Higher scores
2
Higher scores indicated more education, on an 8-point scale ranging from ‘‘less indicated better performance.
than high school graduate’’ to ‘‘MD, JD, PhD, or other advanced degree.’’
3
Higher scores indicated better self-reported health, on a 5-point scale ranging
from ‘‘poor’’ to ‘‘excellent’’. 2.2.8. Shipley Institute of Living Scale: Vocabulary
4
Measure of vocabulary; administered only at pre-test. The Shipley Vocabulary test (Shipley, 1946) is a 40-question
5
Attentional control, lower scores indicated better performance. multiple choice test of synonym vocabulary. For each question par-
6
Spatial orientation, lower scores indicated better performance. ticipants are shown an initial word and asked to select from four
7
Perceptual speed.
8
Spatial rotation.
possible answers which word means the same thing, or most
9
Measure of reasoning ability. nearly the same thing, as the initial word. Higher scores indicate
10
Everyday cognition. better performance.

2.3. Equipment
indicated which two of four images represented rotated versions of
a larger image and a higher score indicated better performance. The intervention took place using participants’ home computers
and hardware specifications varied. However, all computers met
the game’s minimum system requirements: Windows XP or Win-
2.2.2. Object Perspective Test
dows Vista, Intel Pentium 4 1.3 GHz, 512 MB RAM, and GeForce 2
The Object Perspective Test (Kozhevnikov & Hegarty, 2001)
class graphics cards.
measured spatial orientation, defined as the ability to imagine
how a stimulus appeared from another perspective. It consisted
2.4. Design and procedure
of an array of seven objects with a circle drawn below. Participants
were told to imagine being at the position of one object while
The study used a pretest–postest, control group design. Partici-
facing another object and then asked to draw on the circle the
pants were assigned to either the WoW (experimental) group or
direction of a third object in relation to their current orientation.
control group prior to coming in for the study. At pretest partici-
Score on this test was the summed degree errors, and therefore a
pants completed the series of ability tests and questionnaires
higher score indicated worse performance.
either in singly or as part of a group depending on participant
availability. Participants’ corrected near vision was assessed with
2.2.3. Paper Folding Test a Snellen eye chart during the pre-test session to screen for partic-
The Paper Folding Test (Ekstrom, French, Harman, & Dermen, ipants whose vision might interfere with their ability to perform
1976) was a measure of spatial visualization, defined as the ability on the cognitive tests. No participants were excluded on the basis
to manipulate complex spatial information when several stages are of their vision results. The Stroop and near vision tests were
required to produce the solution (Voyer, Voyer, & Bryden, 1995). administered individually. The participants in the experimental
Participants imagined folding paper based on an illustration with group were scheduled to return for a training session. The 2-h
the last picture in each series showing a hole punched in the paper. pre-training session consisted of lecture and demonstration (1 h)
Participants then mentally unfolded the paper and indicated which followed hands-on practice with playing WoW (1 h). They were
of five choices represented the correct location of holes in the pa- given training materials to assist them, including a locally-
per. Scores were the number of items answered correctly, and developed illustrated game manual created for the study as well
higher scores indicated better performance. as the official game manual. All participants reached a criterion
of performance by the end of this training session where they
2.2.4. Digit Symbol Substitution Test could navigate the virtual world and perform simple in-game tasks
The Digit Symbol Substitution Test (Wechsler, 1981) was a using the WoW interface.
measure of perceptual speed. The test consisted of a key of nine Experimental participants returned home and played the game
digits, one through nine, each paired with a simple symbol. Partic- at home for approximately 14 h over a 2 week period, or about an
ipants were given 90 s to draw the symbols in boxes below the hour a day. They were instructed to try their best to complete a
digits and a higher score indicated better performance on the task. series of tasks and take on increasingly difficult challenges within
1094 L.A. Whitlock et al. / Computers in Human Behavior 28 (2012) 1091–1096

the game, and were given a list of suggested tasks of increasing dif- pre-test score such that more positive change scores indicated
ficulty. ‘‘Hints’’ were given for earlier tasks as scaffolding. During more improvement. In the first block, pre-test scores significantly
the 2 weeks they were encouraged to contact the experimenters predicted change scores (b = .38, p = .04).
with any questions, either by phone, email, or within the game The second block, which added the interaction term, signifi-
itself. After approximately 2 weeks both groups returned for the cantly accounted for 29.5% of the variance in change scores. The
posttest where they completed the ability tests and questionnaires. interaction term consisting of the two variables was significant
Experimental group participants additionally completed a ques- (b = .73, p < .01). The experimental group, but not the control
tionnaire about their experience with the game. group, improved differentially on a measure of spatial orientation,
such that participants in the experimental condition with poorer
3. Results pre-test performance tended to have higher change scores (Fig. 1).

3.1. Intervention effect 3.2.3. Mental rotation, recognition memory, reasoning, perceptual
speed, spatial visualization
Results were analyzed with a 2 (experimental group)  2 (pre- Multiple regression analyses were also conducted on the other
vs. post-test session) mixed model ANOVA. For the Stroop Test, a ability test measures. There was a significant main effect of pre-
measure of attentional control, there was a significant group by test score for the Mental Rotation Test (b = .50, p = .02), ECB
session interaction, F(1, 37) = 4.19, p = .05, g2 = .10, such that Memory (b = .72, p < .01), and Reasoning (b = .69, p < .01) such
participants in the experimental group improved more between that participants who performed more poorly at the pre-test
pre- and post-test than did participants in the control group. There tended to improve more, but no significant interactions of pre-test
were no significant interaction effects for the Mental Rotation Test, score and group on change scores were found. There were no sig-
the Object Perspective Test, the Digit Symbol Substitution Test, nificant main effects or interaction effect for the Digit Symbol Sub-
Progressive Matrices Test, or the ECB: Memory. The Paper Folding stitution Test. No regression analysis was performed for the Paper
test was administered only at post-test; a one-way ANOVA of Folding Test because it was administered only at post-test.
Paper Folding post-test scores found no significant difference
between the experimental and control groups.
4. Discussion

3.2. Individual differences

4.1. Theoretical contributions

Two-block hierarchical regression analyses were used to exam-

The results of this study add to the body of evidence suggesting
ine the relationship between the predictors of initial pre-test per-
the efficacy of certain types of video games as cognitive interven-
formance and group on change scores for all ability tests except the
tions for older adults. World of Warcraft, a game selected because
Paper Folding Test, which was performed only at post-test. For all
of its demanding attentional characteristics, was found to improve
regression analyses the first block consisted of the predictors of
the cognitive ability of older adults. This highlights the usefulness
group and pre-test scores, and the second block tested for an inter-
of cognitive task analysis (CTA) as a tool when selecting or design-
action effect by adding the interaction term of pre-test score and
ing a cognitive intervention. Past studies showed that surface
group.
features of a game may be misleading when considering their
potential to improve cognitive ability, e.g., one 3-D puzzle game
3.2.1. Attentional control – Stroop Test demonstrated improvement of mental rotation ability (De Lisi &
Because a lower Stroop score indicated better performance, the Cammarano, 1996) and a different 3-D puzzle game showed no
change score was calculated by subtracting the post-test score effect (Feng et al., 2007). CTA can help identify underlying qualities
from the pre-test score, such that more positive change scores indi- that may be most conducive to ability improvement, such as
cate more improvement. The first block, consisting of the predic- requiring the use of multiple types of cognitive abilities and atten-
tors of group and pre-test scores, accounted for 22.7% of the tional control.
variance in change scores. Both group (b = 0.31, p = .04) and pre- No relationship was found between age and cognitive change.
test score (b = 0.35, p = .02) predicted change scores such that both This is contrary to expectations of greater change in younger par-
experimental participants and participants who started with high- ticipants due to an increased capacity for neural plasticity. How-
er Stroop scores (indicating worse performance) tended to improve ever, the participants in this study consisted of a relatively young
more. sample of older adults. The range of ages for participants in this
The second block, which added the interaction term, accounted study may have simply been too limited to determine a relation-
for 36% of the variability in change scores. There was a significant ship between age and potential benefit from a cognitive interven-
interaction between group and pre-test score (b = 0.51). As can be tion of this type.
seen in Figure 1, participants in the experimental condition who The relationship found between initial ability level and ability
had higher pre-test scores (indicating worse performance) tended change in the intervention group suggests that lower-ability older
to have higher change scores (b = .48, p = .01). For participants in adults may stand to benefit more from cognitive training. It is
the control condition no relationship existed between initial important to note, however, that this study involved a relatively
performance and change. These findings indicated that the exper- high-functioning sample of older adults. It is possible that among
imental group, but not the control group, improved differentially high-functioning older adults, the ‘‘lower-high’’ can benefit more
on a measure of attentional control based on initial performance. than the ‘‘higher-high.’’ It may be that there is an ideal range for
Experimental participants who performed more poorly on the benefit from cognitive interventions – initial ability low enough
Stroop pre-test (as indicated by higher scores) improved more than to benefit, but young enough to have higher plasticity (and thus,
participants who performed initially well (Fig. 1). likely to have higher abilities). Given that our sample was all rela-
tively young, the lower-ability participants in our study may have
3.2.2. Spatial orientation – Object Perspective Test differed from the higher-ability participants in the cognitive de-
Because a lower score indicated better performance, the change mand required by their daily activities, and that the intervention
score was calculated by subtracting the post-test score from the served as a cognitive equalizer for the training group. Future
 L.A. Whitlock et al. / Computers in Human Behavior 28 (2012) 1091–1096 1095

Fig. 1. Scatterplots illustrating the relationship between pre-test scores on the Stroop and Object Perspective Tests and change scores for each experimental group.

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Acknowledgement
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