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1 Stichting E-hulp.nl Van Diemenstraat CN Amsterdam Deze scriptie is aangemeld voor de Scriptieprijs Online Hulp Een overzicht van alle scripties over hulpverlening via internet is te vinden op Wij wensen u veel leesplezier. De Scriptieprijs is een initiatief van stichting E-hulp.nl, kennis- en adviescentrum voor online hulpverlening. E-hulp.nl adviseert instellingen uit Zorg en Welzijn bij het ontwikkelen en implementeren van online hulpverlening. Wij houden al het nieuws bij over online hulpverlening, hebben een handboek online hulpverlening geschreven, faciliteren een linkedin groep en een Netwerk Online Hulp en organiseren jaarlijks het Congres Online Hulp.

2 Working Memory Training and Online Multiplayer Games: Can a combination of the two be the future in treating children with ADHD? Asselbergs J.A.G.J. Master Thesis Instituut voor Psychologie, Erasmus Universiteit Rotterdam Klinische kinder- en jeugdpsychologie Student nummer: Coach: Dr. Birgit Mayer Co-reader: Dr. Elke Geraerts

3 Acknowledgement First I would like to express my gratitude to my thesis advisor Dr. Birgit Mayer (Erasmus University of Rotterdam) for allowing me to conduct my master thesis under her supervision. I wish to thank you for giving me the freedom to embark on such an ambitious project and for expressing confidence in my capabilities to bring this adventure to a successful end. Thanks for your guidance and support during my research. It was a great pleasure to have you as my coach. Furthermore I want to thank Dr. Elke Geraerts (Erasmus University of Rotterdam) for being my co-reader. To conclude I wish to thank my dad for his support and allowing me the time to continue with my study when I was feeling ready for it. Thanks dad. Last but not least I want to thank my girlfriend for her ongoing support and for the joy she brings when we are together. Thanks Lin, for being there for me when times were hard. You really mean the world to me. Mom, this one is for you. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the author. 1

4 Abstract Objective: This study examined the benefits of integrating game elements into standard working memory (WM) training software. In particular it observed the effect game elements have on motivation, WM performance and inattentive/hyperactive behaviour in children with ADHD. Method: A total of 44 children with ADHD aged 7 to 15 years were randomly assigned to the control condition (training without game elements), the medium condition (training with few game elements) or the MORPG condition (training with a lot of game elements). The training software could be used at home and the participants were asked to use the software for at least 2 hours a week over a period of 3 weeks. Results: Participants in the MORPG condition showed greater motivation compared to the medium and control condition; scored significantly better on WM performance and displayed less inattentive behaviour after the training. Participants in the medium and control condition didn t show a significant effect on WM performance and inattentive behaviour post-training. They did, however, show a significant increase in hyperactive behaviour. Conclusions: This study shows that training in a domestic setting can improve WM performance and decrease inattentive behaviour in children with ADHD, but only when the training software is able to capture the interest and motivation of the participants. Failing to meet these requirements will greatly diminish the potential of WM training and may even lead to unwanted effects, such as increased hyperactive behaviour. Introduction No matter how hard he tried, little Shelley just couldn t be still for long. Sometimes he would get out of his seat and run around the classroom. Every morning he promised his mommy, I ll be good today. But every day something went wrong. Why do you keep doing things I tell you not to do? asked his daddy. By the time I think about what I am going to do, I ve already done it! Shelley said sadly. Quote from Shelley, the hyperactive turtle by Deborah M. Moss (1989) Just like Shelley the hyperactive turtle described in the quote above do a lot of school-aged children around the world display symptoms of hyperactivity and inattention severe enough to meet the criteria for Attention deficit/hyperactivity disorder (ADHD). ADHD is one of the most common disorders diagnosed in childhood and affects 3-7% of school-aged children around the world (American Psychiatric Association [APA], 1994; Biederman, Mick & 2

5 Faraone, 2000; Gallucci et al., 1993; Kadesjö & Gillberg, 1998). Children with ADHD experience serious impairments in both social functioning and academic performance. Characteristic problems are: problems with concentration and attention, controlling one s impulses and excessive movement (Barkley, 2004). Although some of these problems will diminish when the children become older, most of them will still exist into adulthood (Rasmussen & Gillberg, 2000). Because ADHD has become such a common diagnose in recent years, it should come as no surprise that the subject of ADHD has gained a lot of attention from different fields of study. Researchers who focus on school and learning for instance have actively studied the effect of ADHD treatment on academic performance (Daley & Birchwood, 2010; Weyandt & DuPaul, 2006). Other fields which have shown interest in the subject of ADHD, just to name a few are: human resource management (De Graaf et al., 2008; Prevatt, Shifrin & Proctor, 2010), clinical research (Winstanley, Eagle & Robbins, 2006) and neuroscience (Bush, Valera & Seidman, 2005; Krain & Castellanos, 2009). Although this vast amount of research on ADHD has provided scholars with a lot of insight and understanding regarding ADHD and how it affects people, it is still not clear what causes this disorder in the first place. Some researchers have identified risk factors like: childhood exposure to environmental toxins (Curtis & Patel, 2008) or maternal smoking and drug use (Chabrol & Peresson, 1997). Food additives seem to be another risk factor contributing to hyperactive behaviour (Bellanti et al., 2005; Konofal, Cortese, Lecendreux, Arnulf, & Mouren, 2005; Pelsser & Buitelaar, 2002) and Fliers, Franke and Buitelaar (2005) found that heredity plays a part as well, suggesting that several genes may be associated with ADHD. The last decade there is also a growing body of literature arguing that people with ADHD have altered brain function and anatomy and especially executive dysfunction seems to be getting a lot of attention (Ball et al., 2011; Powell & Voeller, 2004; Tripp & Wickens, 2009). Although research into executive function (EF) has increased distinctly over recent years, the theoretical framework in which it is situated is not entirely new. In the 1950s, the British psychologist Donald Broadbent already made a distinction between "controlled" and "automatic" mental processes. This distinction was later more fully characterized by the work of Shiffrin and Schneider (1977), who introduced the concept of selective attention, to which EF is closely linked. The concept of EF is broadly defined in the literature by using a wide range of processes associated with EF. For instance Lezak (1983) uses Volition, purposive action, planning and effective performance to describe EF. Others associate EF with a 3

6 supervisory attentional system (Norman & Shalice, 1986), a purposeful and coordinated organization of behaviour and concept formation (Banich, 2004), reasoning and cognitive flexibility (Piguet et al., 2002). Despite the lack of clarity, there exists a general consensus that EF refers to cognitive tasks originating from the dynamics of frontal cortical networks and includes higher order functions such as cognitive flexibility, response-inhibition and WM (Welsh, 2002; Wiebe et al., 2011). Cognitive flexibility is the ability to switch between different strategies and behavioural responses in line with the context of the situation (Wiebe, Espy & Charak, 2008). Response inhibition is the ability to filter out interfering information and suppress inappropriate actions in a given situation (Anderson, 2002; Raaijmakers et al., 2008). WM is the ability to actively hold information in the mind needed to do complex tasks such as reasoning, comprehension and learning (Baddeley, 2007). One of the components of EF that is often associated with ADHD is WM. This relationship between WM and ADHD has been studied extensively and it has been repeatedly demonstrated that there is a positive link between ADHD and WM deficits (Dowson et al., 2004; Kofler et al., 2011; Mariani & Barkley, 1997; Westerberg, Hirvikoski, Forssberg & Klingberg, 2004; Willcut, Doyle, Nigg, Faraone & Pennington, 2005). Deficits in WM for instance are associated with having problems maintaining attention (Pickering, 2006) and are also linked with the ability to stay still for a longer period of time (Klingberg, Forssberg & Westerberg, 2002). Working memory Working memory can be defined as the cognitive system responsible for the temporary storage and manipulation of information which is essential for sustaining focused behaviour in practical situations (Kane et al., 2007). The term "working memory" was first introduced by Miller (1956). In his seminal work he argued that the memory span of young adults was around seven elements, also called chunks. Atkinson and Shiffrin (1968) also applied the term, "working memory" to describe their concept of short-term memory. Short-term memory is the ability to remember information over a short period of time (spanning just a few seconds). Most scholars nowadays use the concept of working memory to replace or include the older concept of short-term memory. Extensive research has been done regarding the theory of working memory and the literature identifies four main types of theoretical models. 4

7 Atkinson-Shriffin model. In order to describe the way memory works Atkinson and Shriffin (1968) proposed a multi-store model consisting of three stages: sensory memory, short term memory and long-term memory. Information is first detected and processed by one of the five senses and enters the sensory memory. If attended to this information it enters the short-term memory. Information from the short-term memory is then transferred to the long-term memory when the information is rehearsed. If rehearsal doesn t occur the information will be discarded from memory through the processes of displacement or decay. Baddeley and Hitch. According to the influential model proposed by Baddeley and Hitch (1974), WM consists of two storage systems and a central executive. The first storage system is the phonological loop and is specialized in the storage and manipulation of verbal information. The second storage system is the visuo-spatial sketchpad and is used for the storage of visual and spatial information. The central executive is responsible for coordination between the phonological loop and the visuo-spatial sketchpad and integrating the information stored in both systems. In a more recent study Baddeley (2000) extended his model of working memory by adding a fourth component, which he called the episodic buffer. The episodic buffer acts as a third storage system, devoted to integrate verbal, spatial and visual information in chronological order and combine this information into a unitary episodic representation. Cowan. An alternative view concerning working memory is provided by Cowan (1995; 2005), who regards working memory not as a separate system, but as a part of long-term memory. Working memory consists of long term memory representations that have been activated and the ability of the individual to then focus attention to these activated representations. This focus of attention is regarded as capacity limited and can hold up to four of the activated representations. Oberauer (2002) extended this model by adding a third component, which represents a more narrow focus of attention, limited to only one element. This third component is embedded in the above mentioned focus of attention and is used for singleelement processing. For instance, you may hold four numbers at a time in your focus of attention. Now imagine that you want to multiply each number by two. In this case Oberauer s additional component singles out a number for processing and after the number is multiplied by two it shifts the focus to the next number, doing so until all the numbers have been processed. 5

8 Ericsson and Kintsch. A more recent model is the long-term working memory model of Ericsson and Kintsch (1995). They propose that we use skilled memory in everyday tasks. For instance when we read a book, we are required to hold numerous concepts in our working memory; way more than the seven chunks proposed by Miller (1956). With a limited capacity of only seven chunks our working memory would be full after just a few sentences and wouldn t we be able to comprehend the complex relations between the different thoughts expressed in the text. Humans achieve this by storing most of the information in our long-term memory and connecting them together with the aid of retrieval structures. We therefore only need to hold a small amount of concepts in our working memory that then serve as directions to retrieve any information related to the concepts found in our long term memory. Working memory is generally considered to be a limited capacity structure. One of the first researches to quantify this limit was Miller (1956). In his influential work he discovered that the average memory span of young adults was around seven chunks, regardless whether the chunks consisted of letters, numbers, words, or other units. More recent research (e.g. Hulme, Roodenrys & Mercer, 1995) however showed that this capacity isn t fixed and highly depends on the units used. If the processing tasks are more demanding, then fewer attentional resources will be available for processes related to storage and, in turn, lead to lower WM span outcomes. Conversely, if the processing task is less challenging, than more attentional resources will be available, leading to higher WM span scores. For instance the memory span is lower when unknown words are used compared to known words. Cowan (2001) has also tried to measure the capacity of our working memory and found that young adults were able to store four chunks in there working memory. This number was lower for children and older adults. Other theories suggest that working memory isn t a limited capacity system by itself, but that there is a constraint to the time a chunk can remain active in short-term memory without rehearsal (Baddeley 1986; Richman, Staszewski & Simon, 1995). While it has long been assumed that working memory capacity has a strict limit (Cowan et al., 2001, Miller, 1956), an increasing amount of evidence suggests that WM capacity can be increased through intentional training (Klingberg et al., 2005; Morrison & Chein, 2010; Verhaegen, Cerella & Basak, 2004; Westerberg et al., 2007). This notion that targeted training can improve WM capacity has generated a lot of attention and a brief overview regarding the literature on WM training will be provided in the next section. 6

9 WM training Research regarding WM training has gained a lot of attention in modern-day literature. Especially the prospect of improving WM performance in children with ADHD, or other intellectual disabilities has caught the interest of many scholars (e.g. Klingberg et al., 2002; Prins, Dovis, Ponsioen, Ten Brink & Van Der Oort, 2011). Research however hasn t been limited to this population. For instance other studies have been conducted in patients with multiple sclerosis (e.g. Vogt et al., 2009), or adults who have experienced a stroke (e.g. Westerberg et al., 2007). WM training comes in different forms and can be broadly classified in two groups of training. One group consists of strategy training, intended to promote the use of supplemental domain-specific strategies, helping trainees to increase their WM capacity (MCNamara & Scott, 2001); whereas the other group uses core training, which entails the continuous repetition of demanding WM tasks designed to train WM performance (Klingberg et al., 2005; Vogt et al., 2009). Strategy training. One approach to improving WM performance is through the use of strategy training. Strategy training paradigms involve techniques intended to facilitate effective processing, maintenance and retrieval from WM. Some of the most used techniques are: grouping of items into chunks, rehearsing out loud, using mental imagery to make items more meaningful and creating a story using the items to be memorized. Research on strategy training supports the argument that WM performance can be improved by teaching these various strategies. For instances a recent study by Turley-Ames and Whitfield (2003) found that WM performance increased significantly in children as a result of rehearsal strategy. In their study they used 124 undergraduate psychology students at Washington State University. The participants were randomly assigned to either the control condition (85 participants) or the rehearsal condition (66 participants). All participants were presented a number of operation word sequences with set sizes ranging from 2 to 6 and with three trials of each set size, hence a total of 15 trials. Each trial consisted of a simple math problem and after providing the right answer to the math problem a to-be-remembered word appeared. Each trial had a 7 second time restriction. After completing the operation span pretest, the rehearsal group received instructions and was asked to rehearse the to-be-remembered words aloud as many times as possible, before going to the next trial. The children in the control group only received the standard instructions. Afterwards 12 additional practice trials 7

10 were administrated so the rehearsal group could practice using rehearsal strategy, followed by a post-operation span test. The results of this study showed a significant increase in WM span scores for the rehearsal group compared to the participants in the control group. Other strategies that have shown to be effective in training WM are, amongst others: the grouping of items into chunks (St Clair-Thompson, Stevens, Hunt & Bolder, 2010) and telling a story using the to-be-remembered items (McNamara & Scott, 2001). Although these strategies can be effective in training WM and be useful in everyday situations that require lists or groups of information to be memorized, like remembering phone numbers, reliance on these tactics have typically been shown to improve performance only in trained tasks or tasks that are closely related. A classic example of this phenomenon can be found in a famous case study carried out by Chase and Ericsson (1982). A participant and devoted cross-country runner was able to recall a digit span of 79 after hearing them only once. He was able to achieve this amazing feat by chunking the digits into different running times (e.g. 339 would be 3 minutes and 39 seconds, a near world record on the mile). However when the subject was changed from digits to letters there was no transfer effect and his memory span fell back to six elements. The results of strategy training tend to be only applicable in trained context or similar tasks (near transfer) and do not generalize to a more distant task context (far transfer) (Morrison & Chein, 2011). Core training. Core training programs typically involve the repetition of WM tasks designed to systematically target WM processes. Core training programs can consist of multiple tasks focusing on different aspects of WM. One of such training program that has received extensive research is Cogmed (Holmes, Gathercole & Dunning, 2009; Klingberg et al., 2002; 2005) and covers a large battery of various WM tasks, such as: backward digit span, location memory and a version of the N-back task. Another training program that uses a battery of WM tasks is COGITO (Schmiedek, Lovden & Lindenberger, 2010). By using a multifaceted training program there is a higher chance that at least one of the tasks has a positive effect on WM performance. In addition massive transfer effects can be gained potentially by focusing on different aspects of WM. The downside however is the difficulty to pinpoint the exact components of the training program that lie beneath the improved performance and determine which specific aspects of WM are affected. In order to single out these effects research has also been carried out by focusing on just one specific WM mechanism (e.g. Dahlin, Neely, Larsson, Backman & Nyberg, 2008; Verhaeghen et al., 2004). 8

11 Probably the most cited study that found a positive link between core training and WM performance is the study by Klingberg et al. (2005). In their study 44 children with ADHD (aged 7-12) were randomly assigned to either the treatment group or the control group. The training program consisted of WM tasks implemented in a computer program that the children could use at home or at school. The program included verbal WM tasks (remembering digits letters or phonemes) and WM visuospatial tasks (remembering the position of objects in a 4 x 4 grid). The duration of the training covered 5 weeks, with the children completing 90 trials on each day of training. The level of difficulty was automatically adjusted on a trial-by-trial basis, equalling the WM span of the child. The control group received the same treatment, except that the difficulty of the WM trials remained on their initial level. After the training the children in the treatment group showed a significant improvement on an untrained visuospatial WM task (span-board task). In addition the children also performed better on: response inhibition (Stroop task), verbal WM (digit-span task), complex reasoning (Raven task) and showed a significant reduction on a number of parent-rated ADHD symptoms. A more recent study by Prins et al. (2011) compared motivation and training performance of a regular WM training program compared to a WM training program with game elements. A total of 51 children with ADHD (aged 7-12) were randomly assigned to either the experimental group or the control group. The children in the control group used a training program similar to the one used by Klingberg et al. (2005). The children were presented with a 4 x 4 grid and had to reproduce the sequence in which the squares were lit. After two consecutive correct reproductions, the sequence increased by one and after two consecutive wrong answers, the sequence decreased by one. Contrary to the training program used by Klingberg et al. no additional animations or forms of feedback were included in the control condition. The children in the experimental condition received the same WM task; however game elements were added to the training program. These game elements included a storyline, animations, a goal, identification with a game character, rewards and response cost (shots) earned or lost throughout the game, competition, and control (the child chose when to do a sequence). The training consisted of three sessions, with a training session held once a week. After the training, the children who used the game version showed a significant increase in memory span, whereas the children in the control group showed no significant gains. In addition the children in the experimental group also showed greater motivation, and better training performance (i.e. more sequences reproduced and fewer errors). 9

12 The literature on WM training acknowledges that WM performance can be improved by targeted training. Both strategy training paradigms and core training programs have shown to be effective in improving WM span. However the results of strategy training tend to be only applicable in trained context or similar tasks and do not generalize to a more distant context. Research on core training on the other hand showed many instances of positive transfer effects, both near and distant (Jaeggi, Buschkuehl, Jonides & Perrig, 2008; Olesen, Westerberg & Klingberg, 2004; Westerberg et al., 2007). Although core training yields the best results, doing the same WM tasks over and over can be a very boring affair. This is especially true for children diagnosed with ADHD. When tasks are very boring, repetitive, or without supervision the attention span of children with ADHD will be very limited (Shanahan, Pennington & Wilcutt, 2008). Adding incentives to an otherwise boring task may help children with ADHD enhance their motivation and boost their performance (Sergeant, Oosterlaam & van der Meere, 1999). One feature that has shown to raise the motivation and interest of children is the computerization of tasks (Pfiffner, Barkley & DuPaul, 2006). Parents, teachers and clinicians for instance have reported that children with ADHD concentrate for longer periods of time, can sustain their attention and behave less impulsively when playing computer games (Barkley, 2006). The role of computer games in improving motivation. There is a general consensus amongst academics that motivation plays a key role in effective learning and that motivation influences how and why people learn as well as how they perform (Pintrich & Schunk, 1996). According to the self-determination theory proposed by Deci and Ryan (1985) can motivation be either extrinsic or intrinsic. Extrinsic motivation refers to doing something in order to receive an external reward or avoid external punishment such as: grades, money or detention. Intrinsic Motivation on the other hand refers to doing something because it is inherently interesting or enjoyable (Ryan & Deci, 2000). According to the basic needs theory three psychological needs are posited to underlie one s intrinsic motivation to initiate behaviour, namely: competence, autonomy and relatedness (Deci & Ryan, 2002). Competence refers to the need to be effective in dealing with the environment in which a person finds oneself; autonomy refers to the need to experience one s behaviour as emanating from or endorsed by the self, instead of being initiated by forces outside oneself; relatedness refers to the need to interact with others and experience warm caring relationships. 10

13 Numerous studies on motivation and learning have shown that people perform better when they are intrinsically motivated as compared to being extrinsically motivated. In a study by Vansteenkiste, Simons, Lens, Soenens & Matos (2005) for instance, 95 female and 54 male obese Belgium children (age 11-12) were randomly divided over two experimental groups and one control group. Participants of one experimental group were told that learning physical exercises are helpful for attaining physical attractiveness (extrinsic goal). The other experimental group was told that learning physical exercises are beneficial for attaining physical health (intrinsic goal). The participants in the control group weren t told anything about the relevance of the exercises. Results showed that the intrinsic goal group had higher autonomous motivation, better test performance and greater persistence both in short term and long term, compared to the control group. The extrinsic goal group on the other hand showed less autonomous motivation, poorer test performance and less long term persistence (although better short term persistence) then the control group. Many professionals in the field of education are aware that a key issue with learners of all ages is motivation. Games, on the other hand, seem to be able to instinctively motivate players to learn the complex rules and mechanics of a game in order to play the game effectively. This difference in motivation can be attributed to an inherent difference in motivational approach. Traditional teaching methodologies typically use extrinsic motivation, in the form of external reward or punishment to motivate their students; while games appeal to the intrinsic motivation of a player, by relying on his/her desire to take part in the activity for its own sake. Integrating videogame elements into teaching programs could be a powerful way to facilitate intrinsic motivation and increase performance (Habgood, Ainsworth & Benford, 2005). The popularity of computer games is still growing and recently they have also caught the interest of educators and training professionals. The last decades there has been a major change in teaching methodologies from a traditional, didactic model of instruction to a learner-centered model, putting more emphasize on learning by doing, instead of learning by listening. This shift away from traditional teaching paradigms has fostered the research how various aspects of game design can be used to support intrinsic motivation and be integrated into educational programs (Cordova & Lepper, 1996; Dickey, 2005, 2007; Gee, 2003; Ricci, Salas & Cannon-Bowers, 1996). Malone (1980) and later Malone and Lepper (1984), proposed a set of game characteristics that facilitate an intrinsically motivating experience, including: challenge, fantasy, control, curiosity, competition, cooperation, and recognition. 11

14 Challenge. Challenge is an often tested characteristic that is closely related to the concept of flow, a thin channel of difficulty where a player becomes completely absorbed in a game experience, loses track of time and finds himself in a zone of optimal concentration (Csikszentmihalyi, 1990; Habgood et al., 2005). If the game is too simple players will get bored easily; too hard and they will become frustrated and lose their motivation. Hence difficulty must be balanced perfectly in order to induce and maintain flow. A more recent study by Piselli, Claypool & Doyle, 2009 showed that players enjoy games more when they are challenged and can only beat the game by a thin margin. In addition they found that players find more fulfilment in a narrow loss, than in an overwhelming win. This aspect of challenge is closely linked to the player s feeling of competence and self-efficacy. Players who conquer a challenging part in the game experience a greater feeling of competence and self-worth, encouraging them to advance even further in the game (Malone, 1980; Orvis, Horn & Belanich, 2008; Piselli et al., 2009). Fantasy. Fantasy, emotion and motivation, are closely tied together. Creating a world in which the player can escape their daily routine is an important aspect of game design. This escapism provides the player with an opportunity to fulfil different emotional needs which may not be met in real life (Freud, 1950). By telling an elaborative story and using charismatic characters with whom the players can identify themselves, a genuine feeling of really being part of the game materializes. When a player feels connected to the game in any way, his motivation to follow the storyline will be enhanced and fuels the player s desire to continue playing (Malone & Lepper, 1984). Control. Another important aspect that can facilitate intrinsic motivation is the matter of control. By providing a game climate in which the players are in control of when to do certain tasks, instead of prompting them to do the task right now, the feeling of autonomy and in effect one s intrinsic motivation will be greatly enhanced. Games typically make use of quests to accomplish this. Quests are tasks given by in-game characters that a player must fulfil in order to advance or grow stronger. By providing the players with the freedom to choose which quests to accept or when to complete them, a feeling of control will be induced; which in turn leads to enhanced motivation (Dickey, 2005). 12

15 Curiosity. Curiosity is an aspect that is closely linked with fantasy in a sense that it has a lot to do with the storyline and character development. When a game has a very enticing storyline, which keeps the gamers wondering how the story will continue, players will keep on playing just to settle their curiosity (Pace, 2004). The same goes for character development. In many games players can level up their characters, making them stronger and providing them with new powers. Players tend to be curious as to what new powers they will get and how these new found abilities will influence game dynamics (Qin et al., 2009). Cooperation, Competition & Recognition. Cooperation, competition & recognition are three interpersonal motivation types and refer to the interaction players have with people whom the player takes social cues from and evaluates himself against (Deen & Schouten, 2010). Players for instance check their rankings to see how their abilities stack up to one another and become motivated to outrank them (competition). Collaboration can be seen in games as forming guilds or working together to defeat certain boss-enemies; while recognition refers to the respect a player receives from others when he reaches a certain status, such as being the leader of a guild or displaying a very high level of skill. Deen and Schouten (2010) argue that this interaction with other players facilitates feelings of competence and autonomy, and in turn increases motivation. Computer games come in many different forms and can be categorized into a number of genres, such as: puzzle, strategy, adventure, sport, shooters and massive multiplayer online role playing games (MMORPG). Although each genre can be used for educational purpose, the relative new game genre of MMORPG may exhibit the most potential when it comes to capitalizing on the seven game characteristics proposed by Malone and Lepper (1984). MMORPG is one of the most popular genres at the moment and provides a flexible environment that fosters the intrinsic motivation of its players. A MMORPG can be characterized by an interactive, narrative environment in which players are free to do what they want. These enormous worlds and elaborate storylines are powerful tools to induce fantasy and encourage curiosity. Another typical element of MMORPG s are quests. Players can receive quests from non player characters and have total control over which quests to accept and when to complete these tasks. This feeling of control gets further enhanced by the freedom the player has to explore the surroundings and decide upon what to do next. 13

16 MMORPG s, as their name implies, have many players online at the same time interacting with each other, offering ample opportunities for cooperation competition and recognition. Players can team up in order to defeat stronger enemies, form guilds, or help others complete certain quests. Players gain experience points for completing quests or defeating enemies, making them stronger and evolve into more powerful creatures. This might include the gain of new spell casting abilities or the ability to wear better armour or wield better weapons. By putting emphasize on character development the players identify themselves with their character and see their avatar as an extension of oneself (Dickey, 2007). Leaderboards can be used to fuel competition and recognition by letting players compete for top spot and gain the respect of other players. Another way to enhance these feelings is to offer special weapons or armour to the high level players and to put one s combat level right next to their name for everyone to see (Piselli et al., 2009). Theoretical framework Motivation: Motivation plays a key role in effective learning and influences how and why people learn, as well as how they perform (Pintrich & Schunk, 1996). One precondition of delivering sub-par performances is motivation. Students for example, who are motivated to learn, perform better then unmotivated students. The same can be applied to the context of WM training. Participants who are motivated to use the WM training program are likely to reach better results than participants lacking this motivation. One approach to increase participant s motivation in training programs is the use of game elements. The inclusion of game elements makes the, somewhat boring, training tasks more enjoyable and motivates the participants to continue their training. One research that has investigated this relationship is the study by Prins et al. (2011). They studied the effect of game elements in WM training on motivation and training efficacy in children with ADHD. They found that the use of game elements indeed had a positive effect on both training efficacy and motivation, arguing that the motivation of the user can be improved by adding game elements. Some limitations of their study however are the few game elements they 14

17 added and the relative short duration of the training, namely 3 sessions of 15 minutes (15 minutes scheduled training and 15 minutes optional afterwards). The inclusion of such few game elements may succeed in keeping the children motivated during this short time span, however the chances are that they get bored very easily if the duration of the training would be much longer. This thesis follows the line of reasoning that game elements improve motivation and will even go one step further by comparing three different WM training conditions with each other. A control condition that uses training software without game elements; a medium condition that uses training software with a few game elements and a MORPG condition that uses WM training integrated in a MORPG, hence a lot of game elements. This study posits that the participants in the MORPG condition will show the highest motivation, followed by the participants in the medium conditions. The participants in the control condition will show the least motivation. WM performance: WM performance is known to play a role in academic outcomes, such as math (Ashcraft & Krause, 2007; Miller & Bichsel, 2004) and reading comprehension (Seigneuric, Ehrlich, Oakhill & Yuill, 2000). Furthermore studies have repeatedly demonstrated that there is a positive link between ADHD and WM deficits (Dowson et al., 2004; Kofler et al., 2011; Mariani & Barkley, 1997; Westerberg et al., 2004; Willcut et al., 2005). Recent studies have found that WM performance can be increased by targeted training (e.g. Klingberg et al., 2005; Prins et al., 2011). One underlying key aspect in training is motivation and one can argue that higher motivation (in the form of more game elements) leads to better training results. Alternatively one can also reason that game elements pose a distraction and interfere with training efficacy, resulting in poorer results. For instance, showing a victory animation or walking around in the game world takes away valuable time that otherwise could be spent doing another WM task. Although this last argument certainly has its merits, this thesis suggests that the motivational benefits gained by game elements outweigh the distraction they may cause. In other words, this study hypothesizes that the MORPG condition will have the largest positive effect on WM performance, followed by the 15

18 medium condition. The control condition will have the smallest positive effect on WM performance of the three training conditions. ADHD symptoms: The ultimate outcome of treating WM deficits in children with ADHD is a decrease of the displayed symptoms. Research has shown that improved WM performance may lead to significant reduction in symptoms of inattention and hyperactivity. For instance Beck, Hanson, Puffenberger, Benninger and Benninger (2010) found that parent ratings indicated significant improvement on inattention, overall number of ADHD symptoms, planning/organization, and WM. These findings are in line with the work of Klingberg et al. (2005), who found that improved WM performance in children with ADHD resulted in a reduction of the parent-rated inattentive symptoms of ADHD, both post-intervention and at a 3-month follow-up. In line with the literature this study assumes that an increase in WM performance will lead to a decrease in inattentive and hyperactive behaviour and proposes that the MORPG condition will have the largest negative effect on ADHD symptoms, followed by the medium condition. The control condition will have the smallest negative effect on ADHD symptoms of the three training conditions. Corresponding to the aforementioned hypotheses the following conceptual model can be built (Figure 1). The degree of game elements is believed to have a positive effect on motivation. Motivation in turn should have a positive effect on time spent on WM tasks and WM performance; and a negative effect on inattentive behaviour and hyperactive behaviour. Time spent on WM tasks is believed to positively affect WM performance, whereas an increase in WM performance should have a negative effect on both inattentive and hyperactive behaviour. 16

19 Figure 1 Conceptual model Method Research design The research strategy adopted in this study is a randomized controlled trial, consisting of two experimental conditions and a control condition. Participants in the control condition received training using basic WM training software without game elements. The medium condition received training using WM training software with few game elements and the participants in the MORPG condition received WM training using WM training software with a lot of game elements. Subjects The research started out with 50 participants from the Netherlands who were gathered from forums targeted at parents with children who have ADHD (e.g. and and different agencies that provide care and support to children with psychological disorders like ADHD and autism spectrum disorders. Inclusion criteria were: (a) diagnosed with ADHD or showing strong signs of ADHD symptoms (reported by their parents); and (b) aged between 7 and 15 years. The participants were matched for age, gender and ethnicity and evenly divided over the three conditions. 17

20 From the initial 50 children who agreed to participate in this experiment two dropped out before the start of the training due to computer problems. During the course of the training four children discontinued the training leaving a final sample of 44 children (14 in the control condition; 15 in the medium condition and 15 in the MORPG condition) who completed the whole experiment. Noteworthy is that 91% (40/44) of the research sample was officially diagnosed with ADHD and that the other 9% (4/44) showed strong signs of ADHD symptoms (as reported by their parents) but were not officially diagnosed yet. Materials and outcome measures Besides the three different training programs described below, this study also used the following questionnaires: SWAN Rating Scale for parents (Dutch version), the Child Behaviour Checklist 6-18 years (Dutch version), a general checklist, and an exit questionnaire. SWAN Rating Scale for parents. This questionnaire is often used in research to get a good representation of the ADHD symptoms (e.g. Hay, Bennett, Levy, Sergeant & Swanson, 2007; Polderman et al., 2007). The Swan consists of 18 items, which are scored on a seven point scale (-3 = far above average; -2 = above average; -1 = somewhat above average; 0 = average; 1 = somewhat below average; 2 = below average; 3 = far below average) (Swanson, Schuck, Mann, Carlson & Sergeant, 2005). Individual scores were calculated for both the inattention scale (9 items) and the hyperactivity-impulsivity scale (9 items). A high score indicates a higher level of ADHD symptoms, whilst a negative score indicates that the child shows better than average attention/hyperactive behaviours. This questionnaire was presented to the parents before the training and after the training to see if there was a significant difference in inattentive and hyperactive behaviour at the end of the training. Child Behaviour Checklist 6-18 years (CBCL). The CBCL is commonly used by scholars as a screening instrument to portray the behavioural and emotional problems of a research sample (e.g. Biederman, Monuteaux, Kendrick, Klein & Farone, 2005; Karatekin, White & Bingham, 2010). In this study only the second part of the CBCL, which measures behavioural and emotional problems, was administrated to the parents and consisted of 120 items. The items are scored on a three point scale (0 = not at all, 1= sometimes, 2=often). The 120 items 18

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