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Designing and evaluating Brain Powered Games for cognitive training and rehabilitation in at-risk African children

  • B. Giordani (a1) (a2), B. Novak (a3), A. Sikorskii (a4), P. Bangirana (a5), N. Nakasujja (a5), B. M. Winn (a3) and M. J. Boivin (a1) (a6)...

Valid, reliable, accessible, and cost-effective computer-training approaches can be important components in scaling up educational support across resource-poor settings, such as sub-Saharan Africa. The goal of the current study was to develop a computer-based training platform, the Michigan State University Games for Entertainment and Learning laboratory's Brain Powered Games (BPG) package that would be suitable for use with at-risk children within a rural Ugandan context and then complete an initial field trial of that package.


After game development was completed with the use of local stimuli and sounds to match the context of the games as closely as possible to the rural Ugandan setting, an initial field study was completed with 33 children (mean age = 8.55 ± 2.29 years, range 6–12 years of age) with HIV in rural Uganda. The Test of Variables of Attention (TOVA), CogState computer battery, and the Non-Verbal Index from the Kaufman Assessment Battery for Children, 2nd edition (KABC-II) were chosen as the outcome measures for pre- and post-intervention testing. The children received approximately 45 min of BPG training several days per week for 2 months (24 sessions).


Although some improvements in test scores were evident prior to BPG training, following training, children demonstrated clinically significant changes (significant repeated-measures outcomes with moderate to large effect sizes) on specific TOVA and CogState measures reflecting processing speed, attention, visual-motor coordination, maze learning, and problem solving.


Results provide preliminary support for the acceptability, feasibility, and neurocognitive benefit of BPG and its utility as a model platform for computerized cognitive training in cross-cultural low-resource settings.

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This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (, which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
* Address for correspondence: M. J. Boivin, Department of Psychiatry and Neurology & Ophthalmology, Michigan State University, 965 Fee Road, Room A227, East Lansing, Michigan 48824, USA. (Email:
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Abubakar, A, Van De Vijver, FJ, Mithwani, S, Obiero, E, Lewa, N, Kenga, S, Katana, K, Holding, P (2007). Assessing developmental outcomes in children from Kilifi, Kenya, following prophylaxis for seizures in cerebral malaria. Journal of Health Psychology 12, 417430.
Akhutina, T, Foreman, N, Krichevets, A, Matikka, L, Narhi, V, Pylaeva, N, Vahakuopus, J (2003). Improving spatial functioning in children with cerebral palsy using computerized and traditional game tasks. Disability and Rehabilitation 25, 13611371.
Bagenda, D, Nassali, A, Kalyesubula, I, Sherman, B, Drotar, B, Boivin, MJ, Olness, K (2006). Health, neurologic, and cognitive status of HIV-infected, longsurviving, and antiretroviral-naive Ugandan children. Pediatrics 117, 729740.
Bangirana, P, Allebeck, P, Boivin, MJ, John, CC, Page, C, Ehnvall, A, Musisi, S (2011). Cognition, behaviour and academic skills after cognitive rehabilitation in Ugandan children surviving severe malaria: a randomised trial. BMC Neurology 11, 96.
Bangirana, P, Boivin, MJ, Giordani, B (2013). Computerized cognitive rehabilitation therapy (CCRT) for African children: evidence for neuropsychological benefit and future directions. In Neuropsychology of Children in Africa: Perspectives on Risk and Resilience (ed. Boivin, M. J. and Giordani, B.), pp. 277298. Springer Science and Business Media: New York, NY, Specialty Topics in Pediatric Neuropsychology, DOI: 10.1007/978-1-4614-6834-9_1.
Bangirana, P, Giordani, B, John, CC, Page, C, Opoka, RO, Boivin, MJ (2009 a). Immediate neuropsychological and behavioral benefits of computerized cognitive rehabilitation in Ugandan pediatric cerebral malaria survivors. Journal of Developmental and Behavioral Pediatrics 30, 310318.
Bangirana, P, Musisi, S, Allebeck, P, Giordani, B, John, CC, Opoka, OSR, Byarugaba, J, Ehnvall, A, Boivin, MJ (2009 b). A preliminary examination of the construct validity of the KABC-II in Ugandan children with a history of cerebral malaria. African Health Sciences 9, 186192.
Barkley, R (2007). School interventions for attention deficit hyperactivity disorder: where to from here? School Psychology Review 36, 279286.
Barkley, R, Fischer, M, Smallish, L, Fletcher, K (2006). Young adult outcome of hyperactive children: adaptive functioning in major life activities. Journal of the American Academy of Child and Adolescent Psychiatry 45, 192202.
Bisiacchi, PS, Suppiej, A, Laverda, A (2000). Neuropsychological evaluation of neurologically asymptomatic HIV-infected children. Brain and Cognition 43, 4952.
Boivin, MJ (2002). The effects of early cerebral malaria on the cognitive ability of Senegalese children. Journal of Developmental and Behavioral Pediatrics 23, 353364.
Boivin, MJ, Bangirana, P, Byarugaba, J, Opoka, RO, Idro, R, Jurek, AM, John, CC (2007). Cognitive impairment following cerebral malaria in children: a prospective study. Pediatrics 119, e360.
Boivin, MJ, Busman, RA, Parikh, SM, Bangirana, P, Page, CF, Opoka, RO, Giordani, B (2010). A pilot study of the neuropsychological benefits of computerized cognitive rehabilitation in Ugandan children with HIV. Neuropsychology 24, 667673.
Boivin, MJ, Giordani, B (1993). Improvements in cognitive performance for schoolchildren in Zaire, Africa, following an iron supplement and treatment for intestinal parasites. Journal of Pediatric Psychology 18, 249264.
Boivin, MJ, Giordani, B (2009). Neuropsychological assessment of African children: evidence for a universal basis to cognitive ability. In Cultural Neuroscience: Cultural Influences on Brain Function, vol. 178 (ed. Chiao, J. Y.), pp. 113135. Elsevier Publications: New York.
Boivin, MJ, Green, SD, Davies, AG, Giordani, B, Mokili, J, Cutting, WA (1995). A preliminary evaluation of the cognitive and motor effects of pediatric HIV infection in Zairian children. Health Psychology 14, 1321.
Brouwers, P, DeCarli, C, Tudor-Williams, G, Civitello, L, Moss, H, Pizzo, P (1994). Interrelations among patterns of change in neurocognitive, CT brain imaging and CD4 measures associated with anti-retroviral therapy in children with symptomatic HIV infection. Advances in Neuroimmunology 4, 223231.
Buonomano, DV, Merzenich, MM (1998). Cortical plasticity: from synapses to maps. Annual Review of Neuroscience 21, 149186.
Cantwell, DP, Baker, L (1991). Association between attention-deficit/hyperactivity disorder and learning disorders. Journal of Learning Disabilities 24, 8895.
Castellanos, FX, Giedd, JN, Marsh, WL, Hamburger, SD, Vaituzis, AC, Dickstein, DP, Sarfatti, SE, Vauss, YC, Snell, JW, Lange, N, Kaysen, D, Krain, AL, Ritchie, GF, Rajapakse, JC, Rapoport, JL (1996). Quantitative brain magnetic resonance imaging in attention-deficit hyperactivity disorder. Archives of General Psychiatry 53, 607616.
Castellanos, FX, Lee, PP, Sharp, W, Jeffries, NO, Greenstein, DK, Clasen, LS, Blumenthal, JD, James, RS, Ebens, CL, Walter, JM, Zijdenbos, A, Evans, AC, Giedd, JN, Rapoport, JL (2002). Developmental trajectories of brain volume abnormalities in children and adolescents with attentiondeficit/hyperactivity disorder. Journal of the American Medical Association 288, 17401748.
Coffey, H (2009). Digital game-based learning. LEARN NC ( Accessed 9 October 2013.
Cohen, CK (1988). Statistical Power Analysis for the Behavioral Sciences, 2nd edn. Lawrence Erlbaum Associates: Hillsdale, NJ.
Darby, D, Maruff, P, Collie, A, McStephen, M (2002) Mild cognitive impairment can be detected by multiple assessments in a single day. Neurology 59, 10421046.
Draganski, B, Gaser, C, Busch, V, Schuierer, G, Bogdahn, U, May, A (2004). Neuroplasticity: changes in grey matter induced by training. Nature 427, 311312.
DuPaul, GJ (2007). School-based interventions for students with attention deficit hyperactivity disorder: current status and future directions. School Psychology Review 36, 183194.
DuPaul, GJ, Stoner, G, O'Reilly, MJ (2002). Best practices in classroom interventions for attention problems. In Best Practices in School Psychology, vol. 2 (ed. Grimes, T. J.), pp. 11151127. National Association of School Psychologists: Washington, DC.
Engle, RW, Tuholski, S, Kane, M (1999). Individual differences in working memory capacity and what they tell us about controlled attention, general fluid intelligence, and functions of the prefrontal cortex. In Models of Working Memory (ed. Myake, A. and Shah, P.), pp. 102134. Cambridge University Press: Cambridge.
Eysenbach, G (2011). CONSORT-EHEALTH: improving and standardizing evaluation: reports of web-based and mobile health interventions. Journal of Internet Medical Research 113, e126.
Falleti, MG, Maruff, P, Collie, A, Darby, DG (2006). Practice effects associated with the repeated assessment of cognitive function using the CogState battery at 10-minute, one week and one month test-retest intervals. Journal of Clinical and Experimental Neuropsychology 28, 10951112.
Filipek, PA, Senrud-Clikerman, M, Steingard, RJ, Renshaw, PF, Kennedy, DN, Biederman, J (1997). Volumetric MRI analysis comparing subjects having attention-deficit hyperactivity disorder with normal controls. Neurology 48, 589601.
Foster, G, Williamson, J (2000). A review of current literature of the impact of HIV/AIDS on children in sub-Saharan Africa. AIDS 14, S275S284.
Fundaro, C, Miccinesi, N, Baldieri, NF, Genovese, O, Rendeli, C, Segni, G (1998). Cognitive impairment in school-age children with asymptomatic HIV infection. AIDS Patient Care and Standards 12, 135140.
Giordani, B, Boivin, MJ, Opel, B, Dia Nseyila, DN, Lauer, RE (1996). Use of the K-ABC with children in Zaire, Africa: an evaluation of the sequential-simultaneous processing distinction within an intercultural context. International Journal of Disability, Development and Education 43, 524.
Greenberg, LM (1991). Test of Variables of Attention Interpretation Manual (ed. Lawrence, M.), Greenberg Press: Minneapolis, MN.
Hardy, KK, Willard, VW, Bonner, MJ (2011). Computerized cognitive training in survivors of childhood cancer: a pilot study. Journal of Pediatric Oncology Nursing 28, 2733.
Heimann, M, Nelson, KE, Tjus, T, Gillberg, C (1995). Increasing reading and communication skills in children with autism through an interactive multimedia computer program. Journal of Autism and Developmental Disorders 25, 459480.
Hinson, JM, Jameson, TL, Whitney, P (2003). Impulsive decision making and working memory. Journal of Experimental Psychology: Learning, Memory, and Cognition 29, 298306.
Hoekzema, E, Carmona, S, Tremols, V, Gispert, JD, Guitart, M, Fauquet, J, Rovira, M, Bielsa, A, Soliva, JC, Tomas, X, Bulbena, A, Ramos-Quiroga, A, Casas, M, Toben, A, Vilarroya, O (2010). Enhanced neural activity in frontal and cerebellar circuits after cognitive training in children with attention-deficit/hyperactivity disorder. Human Brain Mapping 31, 19421950.
Holding, PA, Taylor, HG, Kazungu, SD, Mkala, T, Gona, J, Mwamuye, B, Mbonani, L, Stevenson, J (2004). Assessing cognitive outcomes in a rural African population: development of a neuropsychological battery in Kilifi District, Kenya. Journal of the International Neuropsychological Society 10, 246260.
Hooft, IV, Andersson, K, Bergman, B, Sejersen, T, Von Wendt, L, Bartfai, S (2005). Beneficial effect from a cognitive training programme on children with acquired brain injuries demonstrated in a controlled study. Brain Injury 19, 511518.
Jaeggi, S, Buschkuehl, M, Jonides, J, Shah, P (2011). Short- and long-term benefits of cognitive training. Proceedings of the National Academy of Sciences of the United States of America 108, 1008110086.
Jeremy, RJ, Kim, S, Nozyce, M, Nachman, S, McIntosh, K, Pelton, SI, Yogev, R, Wiznia, A, Johnson, GM, Krogstad, P, Stanley K for the Pediatric AIDS Clinical Trials Group (PACTG) 338 & 377 Study Teams (2005). Neuropsychological functioning and viral load in stable antiretroviral therapy-experienced HIV-infected children. Pediatrics 115, 380387.
Kaufman, AS, Kaufman, NL (2004). Manual for the Kaufman Assessment Battery for Children, Second Edition. AGS Publishing: Circle Pines, MN.
Kihara, M, Carter, JA, Holding, PA, Vargha-Khadem, F, Scott, RC, Idro, R, Fegan, GW, de Haan, M, Neville, BGR, Newton, CRJC (2009). Impaired everyday memory associated with encephalopathy of severe malaria: the role of seizures and hippocampal damage. Malaria Journal 8, 273.
Kihara, M, Carter, JA, Newton, CRJC (2006). The effect of Plasmodium falciparum on cognition: a systematic review. Tropical Medicine and International Health 11, 386397.
Klingberg, T (2010). Training and plasticity of working memory. Trends in Cognitive Sciences 14, 317324.
Klingberg, T, Fernell, E, Olesen, PJ, Johson, M, Gustafsson, P, Dahlstreom, K, Gillberg, CG, Forssberg, H, Westerberg, H (2005). Computerized training of working memory in children with ADHD – a randomized, controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry 44, 177186.
Klingberg, T, Forssberg, H, Westerberg, H (2002). Training of working memory in children with ADHD. Journal of Clinical and Experimental Neuropsychology 24, 781791.
Labrique, A, Vasudevan, L, Chang, LW, Mehl, G (2013). H_pe for mHealth: more “y” or “o” on the horizon? International Journal of Medical Informatics 82, 467469.
Mahncke, HW, Connor, BB, Appelman, J, Ahsanuddin, ON, Hardy, JL, Wood, RA, Joyce, NM, Bnoiske, T, Atkins, SM (2006). Memory enhancement in healthy older adults using a brain plasticity-based training program: a randomized, controlled study. Proceedings of the National Academy of Sciences of the United States of America 103, 15231528.
Maruff, P, Werth, J, Giordani, B, Caveney, AF, Feltner, D, Snyder, PJ (2006). A statistical approach for classifying change in cognitive function in individuals following pharmacologic challenge: an example with alprazolam. Psychopharmacology 186, 717.
McNab, F, Varrone, A, Farde, L, Jucaite, A, Bystritsky, P, Forssberg, H, Klingberg, T (2009). Changes in cortical dopamine D1 receptor binding associated with cognitive training. Science 323, 800802.
Merrell, C, Tymms, PB (2001). Inattention, hyperactivity, and impulsiveness: their impact on academic achievement and progress. British Journal of Educational Psychology 71, 4356.
Merrell, C, Tymms, PB (2005). Inattention, hyperactivity, achievement and progress. Journal of Applied Measurement 6, 118.
Mollica, CM, Maruff, P, Collie, A, Vance, A (2005). Repeated assessment of cognition in children and the measurement of performance change. Child Neuropsychology 11, 303310.
Mollica, CM, Maruff, P, Vance, A (2004). Development of a statistical approach to classifying treatment response in individual children with ADHD. Human Psychopharmacology 19, 445456.
MTA Cooperative Group (2009). The MTA at 8 years: prospective follow-up of children treated for combined-type ADHD in a multisite study. Journal of the American Academy of Child and Adolescent Psychiatry 48, 484500.
Murphy, K, Barkley, RA, Bush, T (2002). Young adults with ADHD: subtype differences in comorbidity, educational, and clinical history. Journal of Nervous and Mental Disease 190, 147157.
Olesen, PJ, Westerberg, H, Klingberg, T (2004). Increased prefrontal and parietal activity after training of working memory. Nature Neuroscience 7, 7579.
Pappadopulos, E, Jensen, P, Chait, A, Arnold, L, Swanson, J, Greenhill, L, Hechtmann, L, Chuang, S, Wells, KC, Pelham, W, Copper, T, Elliott, G, Newcorn, JK (2009). Medication adherence in the MTA: saliva methylphenidate samples versus parent report and mediating effect of concomitant behavioral treatment. Journal of the American Academy of Child and Adolescent Psychiatry 48, 501510.
Pascual-Leone, A, Amedi, A, Fregni, F, Merabet, LB (2005). The plastic human brain cortex. Annual Review of Neuroscience 28, 377401.
Pietrzak, RH, Maruff, P, Mayes, LC, Roman, SA, Sosa, JA, Snyder, PJ (2008). An examination of the construct validity and factor structure of the Groton Maze Learning Test, a new measure of spatial working memory, learning efficiency, and error monitoring. Archives of Clinical Neuropsychology 23, 433445.
Poldrack, RA (2000). Imaging brain plasticity: conceptual and methodological issues–a theoretical review. Neuroimage 12, 113.
Rabiner, DL, Coie, JD, CPPRG (2000). Early attention problems and children's reading achievement: a longitudinal investigation. Journal of the American Academy of Child and Adolescent Psychiatry 39, 859867.
Rabiner, DL, Malone, PS, CPPRG (2004). The impact of tutoring on early reading achievement for children with and without attention problems. Journal of Abnormal Child Psychology 32, 273284.
Rabiner, DL, Murray, DW, Skinner, AT, Malone, PS (2010). A randomized trial of two promising computer-based interventions for students with attention difficulties. Journal of Abnormal Child Psychology 38, 131142.
Rajani, N, Rekola, J, Mielonen, T (2003). Free as in Education: Significance of the Free/Libre and Open Source Software for Developing Countries. OneWorld Finland and KEPA: Helsinki.
Sandlund, M, McDonough, S, Hager-Ross, C (2009). Interactive computer play in rehabilitation of children with sensorimotor disorders: a systematic review. Developmental Medicine and Child Neurology 51, 173179.
Schumann, R, Kende, M (2013). Lifting Barriers to Internet Development in Africa: Suggestions for Improving Connectivity. Analysys Mason Limited: London.
Snow, RW, Guerra, CA, Noor, AM, Myint, HY, Hay, SI (1995). The global distribution of clinical episodes of Plasmodium falciparum malaria. Nature 434, 214217.
Story, A (2004). Intellectual Property and Computer Software: a Battle of Competing Use and Access Visions for Countries of the South. International Centre for Trade and Sustainable Development (ICTSD) and United Nations Conference on Trade and Development (UNCTAD), Chavanod, France.
Tardieu, M, Mayaux, M-J, Seibel, N, Brentano, IF, Straub, E, Teglas, J-P, Blanche, S (1995). Cognitive assessment of school-age children infected with maternally transmitted human immunodeficiency virus type 1. The Journal of Pediatrics 126, 375379.
Vinogradov, S, Fisher, M, deVillers-Sidani, E (2012). Cognitive training for impaired neural systems in neuropsychiatric illness. Neuropsychopharmacology Reviews 32, 4376.
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