1. Prescribing Video Games (not Medication) for ADHD: How to Make it Work Randy Kulman, Ph.D. randy@learningworksforkids.com @rkulman In Collaboration With Gary Stoner, Ph.D. Ashley Alves Lara Goodrich, M.A. LearningWorks for kids Games for Healthwww.learningworksforkids.com June 12-1, 2013 Boston, MA @lw4k

2. What Im PlayingGardens of Wheres my Cut the Time Water? Rope

3. Overview Diagnosis, demographics, associated Executive Functions (EF), and treatment of ADHD What do we know about ADHD kids involvement with video games and digital media, impact of digital media on attention Characteristics of video games that makes them a powerful tool with kids with ADHD The importance of Efs in video games and daily activities How differentiated instruction, generalization, and strategic approaches make video games teaching tools LearningWorks for Kids Strategies

4. Signs of ADHD may include: difficulty in following through on instructions problems organizing tasks and activities difficulty sustaining attention in tasks restlessness and excessive movement high levels of activity and always being on the go physical and verbal impulsivity executive functioning issues 3 major forms of ADHD

5. Demographics of ADHD 5-9 % of Population Diagnosed with ADHD 20-50% have Learning Disabilities 30-40% Oppositional Defiant Disorder 20-30 Anxiety Disorder 2.7 million kids taking meds (66% of those diagnosed) CDC 2007 Major treatments educational, behavioral High percentage of EDF, mild ADHD; kids who are struggling with traditional education

6. What do we know about ADHD kids and video games? Clinical and anecdotal observations - too much and often too intensely! (but this is exactly why we need to use this behavior) No research evidence of difference concerning frequency or duration of play between ADHD and typically-developing children ages 10 to 12. Similar enjoyment for the same types of games (Bioulac 2008). South County Child and Family Consultants Data

7. LWK study of ADHD kids and parents on video game play (Current sample of 49 children with a primary ADHD diagnosis based upon a full neuropsychological evaluation) Survey asks parents to describe their own media usage to see if it is correlated to attitudes regarding video games Also asks them to describe their concerns and hopes for benefits of video games and other digital media Digital media use of ADHD kids- Most time television, video games, music (different from what is seen in national studies of typically developing kids)

8. Time per week for parentsinvolvement with kids video game playHow many hours per week do you (parents)spend observing or interacting with your childwhen they play video games? 30% no time 49% less than 1 hour 19% 1-5 hours 2% 10+ hoursDo you play video games with your child? 56% Sometimes 25% Never 12% Often 3% Always

9. Concerns and benefits regarding video game playDescribe the level of concern that you have about yourchilds video game play leading to video game addiction. 70% Not at all concerned 14% Mildly concerned 6% Concerned 4% Somewhat concerned 4% Extremely concernedHow much do you believe that video games can help yourchild with problem solving? 34% Somewhat 25% Quite a bit 19% A little bit 13% A great deal 8% Not at all

10. How do children with ADHD perform on video games? May not always perform as well as their typically- developing peers (Lawrence, et al 2002) May process information somewhat slowly on video games. (Lawrence et al. 2002, 2004). Perform as well as their peers in simple games but not as well in complex games. (Lawrence et al. 2004). No difference in inhibitory performance of children with ADHD and TD Kids with Crash Bandicoot and Frogger (Shaw 2005). The similarity of performance in this study suggested that enjoyable video games provide a context in which their performance is enhanced.

11. Do Video/Computer Games and Television Impact Attention Span? Short-term effects suggest that more than an hour of computer-game play a day is correlated to poor scores for ADHD, Inattentive Type (Taharoglu 2010). Total time spent with screen media is positively associated with attention problems (Swing, Gentile, et al. 2010). Four-year-olds watching Spongebob can have an immediate negative effect on childrens executive- functioning skills (Lillard 2011). Television/Video-game use along with exposure to violent content not predictive of attention problems or grade point average (Ferguson 2010) Is digital media the cause of increasing rates of ADHD?

12. Do Video Games and Television Impact Attention Span? Improves capacity to rapidly filter visual distractions, but may negatively effect focus on slow streams of information (Bavelier) Leads to listlessness and discontent in slow-paced and less stimulating academic, work, and social environments (Merzenich) Attention skills improved by video games (detecting differences and orienting attention) are liabilities in classroom resulting in distractibility (Gentile)

13. Why use video games and digital media to help kids with ADHD? Kids with ADHD or Video Games and Digital Media Attention DifficultiesMay become easily bored and Require ever-changing skills unable to sustain attention Employ video, sounds, words, and actions Multi-modal Often require immediate Provide clear and immediate feedbackreinforcement or consequence Constantly let player know what he is to stay focused on a task. doing wrong and rightOften require that their body or Extremely engaging mind to be actively engaged. Many require physical and cognitive involvement

14. Why use video games and digital media to help kids with ADHD? Kids with ADHD or Attention Video Games and Digital Media Difficulties Usually have problems with Teach by trial and error or following directions. guided discovery Require that the player understand the instructions in order to succeed May struggle to learn new Most negative feed back from information and experience video games and other digitalfrustration or low self-esteem as a media occurs privately. result. Causes less embarrassment and frustration Teaches the player how to handle these emotions

15. Summary of why to use video games with kids with ADHD Love, interest, flow, attention and engamement are potentials for learning (especially in contrast to traditional learning) ADHD kids require repeated practice and strategic thinking for which video games are good teaching tools Many games practice the executive skills such as planning, working memory, cognitive flexibility, organization, and time management that define ADHD

16. What are Executive Functions? A construct of cognitive capacities that enable independent, purposeful, goal- directed behavior The CEO or the conductor of the brain A collection of brain processes that guide thought and behavior Located primarily in the prefrontal cortex but involving other neural networks Skills, not fixed capacities

17. Dawson and Guare Model of Executive/Thinking SkillsFocus Task Persistence Sustained attention Task initiationSelf-Awareness Metacognition Social thinkingSelf-Control Regulation of affect Response inhibitionWorking MemoryOrganizationPlanningFlexibilityTime Management

18. Executive/Thinking Skills in School and Home Doing homework - organization, planning, focus, time management Phonological awareness - working memory Written language - organization, focus, planning Assembling a toy - planning and organization, focus Cleaning ones room - focus, organization

19. The Importance of Teaching Thinking Skills Preschoolers who learn EFs perform better academically (Diamond, McClelland) Improving working memory enhances reading, reduces ADHD symptoms (Cogmed research) Self Control enhances future life success (Marshmallow test) Protects children from mental health issues

20. Research on Executive/Thinking Skills and Video Games LWK pilot research on differentiated instruction, targeting areas of EF weakness with video games Combination of board and video games improve fluid reasoning and processing speed (Mackey, 2011) Working memory video games improve WM, fluid reasoning skills (Cogmed studies) Computer-based training improves executive attention in preschoolers (Rueda, 2005) Video game like math and reading programs improves learning, reduces attention symptoms Games (non video) that increase cognitive load and used as a teaching tool by parents reduce ADHD symptoms in Preschoolers (Halperin, 2012)

21. And yet. Lots of kids play games Lots of kids have difficulty with planning. We can observe that sitting a child in front of a video gamewithout guidance or purposewill not translate into noticeable improvements in cognitive functioning or academic success.

22. How well do game based skills transfer to the real world? Game play alone results in modest improvements in real-world executive skills Children with learning and attention problems have problems in generalizing strategies Kids like to talk about playing video games and may be willing to learn from that Games prompt partnering and motivation to learn executive skills Practice and rehearsal of executive skills

23. BUTgames are not enough!!! The key to success is effective teaching or mediation (can be done in the game) Teachers (including peers, parents, and imbedded instruction) make the connection between game-based learning and real-world skills Actual learning requires knowledge of the skill, understanding how and when to use it, and practice across many situations

24. How do digital technologies teach executive functions?The LearningWorks for Kids model: Games as a vehicle for "engaging the gears" of a childs brain Opportunities for children to practice an executive skill in a fun and engaging fashion A teaching opportunity for parents, teachers, and clinicians An opportunity to detect, reflect, and connect on the use of executive skills A "new literacy," an understanding of ways of doing, thinking, and valuing things in the context of relationships and school practices (James Paul Gee)

25. Effective teaching with digital technologies: Goals need to be explicit and shared "Its not about the game. Finding other teaching opportunities for developing executive skills Limiting video game-play Getting peers, siblings, or other family members involved Noticing and reinforcing improvements in the use of executive skills

26. Play Together Talk before, during, and after gameplay. Choose gameplay goals with your child. Have fun playing the game with your child! Reflect on gameplay, emphasizing the use of the targeted thinking or academic skills. Direct your discussion to how these same skills are useful in daily activities.

27. Make it Work Explain the benefits of digital play, and introduce the skills being exercised in the game. Encourage non-digital activities that use the same skills. Regularly connect game-based skills to things your child is struggling with in the real-world.

28. Executive skills Questionnaire

29. Prescription of Games, Technologies, and Recommendations

30. Gardens of Time PlayBook

31. Gardens of Time: Video PlayBook

32. Beyond Games: myHomework

33. Beyond Games: Evernote

34. Thank You! Randy Kulman, Ph.D. randy@learningworksforkids.com @rkulman LearningWorks for kids Games for Healthwww.learningworksforkids.com June 12-1, 2013 Boston, MA @lw4k