Systematic review of the effectiveness of innovative, gamified interventions for cognitive training in paediatric acquired brain injury

Figures & data

Table 1. Summary of study characteristics (level of function).

Authors	Design (methodology) & recorded time points	Participant characteristics	Intervention characteristics			Cognition at level of function
			Training (active/passive control)	Duration (sessions)	Setting	Cognitive domain	NPA
Carlson-Green et al. (2017)	Single-group (pilot; efficacy & feasibility) Pre-post (NI) 6 months	n = 21 Aetiology: BT Age (y): 8.0–18.0 Age of onset (y): m = 6.0, 1.0–14.0 range Sex: 12F/9M	Cogmed™ WM training (no control)	8–12 w (35)	Home; contacted 1/w by phone + emails (adherence, feedback, motivation, & support)	Academic capacity VWM Visual WM	WJ-III: Applied Problems Passage Comprehension AWMA: Backward Digit Recall Counting Recall Digit Recall Word Recall Dot Matrix Mr. X Spatial Span
Corti et al. (2020)	RCT (stepped-wedge; efficacy) Pre-post 2 months 6 months (NI)	n = 32 (E: 18, C: 14) Aetiology: CVA (E: 5, C: 4), encephalitis (E: 0, C: 1), HAI (E: 2, C: 0), TBI (E: 11, C: 9) Age (y): E: 13.83 ± 1.65 & C: 13.50 ± 1.99 Sex: E: 7F/12M & C: 3F/11M Time post-injury (y­): ≥1	Lumosity Cognitive Training™ (active)	5 × 20 mins pw, 8 w (40)	Home; contacted 1/w by phone (no feedback – adherence & motivation)	Academic capacity EF Visual WM	AC-MT: Arithmetic Calculation Problem-solving Wisconsin Card Sorting test Corsi Block-Tapping test
De Luca et al. (2020)	Case study (efficacy) Pre-post	n = 1 Aetiology: TBI Age (y): 15.0 Sex: 1M Time post-injury (y): ≥0.8	CAREN (active)	5 × 45 mins pw, 4 w (20)	Rehabilitation	Attention EF	Modified Bell Cancellation test WEIGL test
Eve et al. (2016)	Single-group, longitudinal (pilot; efficacy & feasibility) Pre-post 12 months	n = 7 (12 months: n = 5) Aetiology: AIS Age (y): 10.0–16.0 Age of onset (y): 1.0–10.0 Sex: 3F/4M	Cogmed™ WM training (no control)	30–40 mins, 5–7 w (25)	Home	Academic capacity Attention VWM Visual WM	WRAT-4: Mathematics TEA-Ch: Score! Score! DT Sky-Search Sky Search DT WMTB-C: Backward Digit Recall Digit Recall Listening Recall Non-word List Recall Word Listening Matching Word List Recall Block Recall
Phillips et al. (2016)	RCT (efficacy) Pre-post 3 months	n = 27 Aetiology: TBI Age (y): E: 12.75 & C: 11. 82 (median) Age of onset (y): E: 4.01 & C: 8.45 (median) Sex: NI	Cogmed™ WM training (active)	5 × 30–40 mins pw, 5 w (25)	Home	Academic capacity Attention VWM Visual WM	WIAT-II: Numerical Operations Reading Comprehension Word Reading TEA-Ch: Creature Counting Score! Sky Search Sky Search DT Walk/Don’t Walk AWMA: Counting Recall Digit Recall Dot Matrix Mr. X
Piovesana et al. (2017)	RCT (efficacy) Pre-post	n = 58 Aetiology: CVA (E: 12, C: 10), non-TBI (E: 9, C: 8), TBI (E: 8, C: 11) Age (y): E: 11.11 ± 2.60 & C: 11.10 ± 2.60 Age of onset (y): E: 5.20 ± 4.0 & C: 5.90 ± 3.50 Sex: E: 12F/17M & C:14F/15M	Mitii™ (passive)	6 × 30 mins pw, 20 w (120)	Home; frequently contacted by phone/email (feedback & support)	EF	D-KEFS: Colour-Word Inference TEA-Ch: Score! Sky Search Sky Search DT Tower of London-DX 2nd Edition Trail Making Test WISC-IV: Coding, Digit Span Backward, Symbol Search
Verhelst et al. (2017)	Case series, observational, longitudinal (pilot; feasibility) Pre-post 6 months	n = 5 Aetiology: TBI Age (y): 15.0–17.0 Sex: 1F/4M Time post-injury (y): 2.0–4.0	BrainGames (no control)	5 × pw, 8 w (40)	Home	Attention EF PSI VWM Visual WM	PEBL: Continuous Performance Test (reaction time) Flanker task CANTAB: Stockings of Cambridge Intra–Extradimensional Set Shift WISC-III-NL: Digit Symbol Coding Digit Span Backward Digit Span Forward Spatial Span

Abbreviations: AC-MT = Italian battery AC-MT; AIS = Arterial ischemic stroke; AWMA = Automated Working Memory Assessment; BT = Brain tumour; C = Control group; CANTAB = Cambridge Neuropsychological Test Automated Battery; CVA = Cerebrovascular accident; D-KEFS = Delis–Kaplan Executive Function System; E = Experimental group; EF = Executive functions; F = Female; HAI = Hypoxic-anoxic brain injury; M = Male; m = Mean; n = Number of participants; NI = No information; PEBL = Psychology Experiment Building Language; PSI = Information processing speed; pw = Per week; RCT = Randomised controlled trial; TBI = Traumatic brain injury; TEA-Ch = Test of Everyday Attention for Children; VWM = Verbal working memory; w = Week(s); WIAT-II = Wechsler Individual Achievement Tests, Second Edition Australian standardised edition; WISC-III-NL = Weschler Intelligence Scale for Children Third Edition (Dutch); WJ-III = Woodcock-Johnson Tests of Achievement, Third Edition; WM = Working memory; WMTB-C = Working Memory Test Battery for Children; WRAT-4= Wide Ranging Achievement Test 4; y = Year(s). Trailing Making Test: WISC-IV:, Coding, Digit Span Backward, Symbol Search.

Table 2. Summary of study characteristics (level of activities).

Authors	Design (methodology) & recorded time points	Participant characteristics	Intervention characteristics			Cognition at level of activities
			Training (active/passive control)	Duration (sessions)	Setting	Cognitive domain	Subjective: cognition in daily life
Carlson-Green et al. (2017)	Single-group (pilot; efficacy & feasibility) Pre-post (NI) 6 months	n = 21 Aetiology: BT Age (y): 8.0–18.0 Age of onset (y): m = 6.0, 1.0–14.0 range Sex: 12F/9M	Cogmed™ WM training (no control)	8–12 w (35)	Home; contacted 1/w by phone + emails (adherence, feedback, motivation, & support)	EF	BRIEF: Inhibit (parent-reported) Shift (parent-reported) Initiate (parent-reported) Emotional control (parent-reported) WM (parent-reported) Plan/organisation (parent-reported) organisation of materials (parent-reported) Monitor (parent-reported)
Piovesana et al. (2017)	RCT (efficacy) Pre-post	n = 58 Aetiology: CVA (E: 12, C: 10), non-TBI (E: 9, C: 8), TBI (E: 8, C: 11) Age (y): E: 11.11 ± 2.60 & C: 11.10 ± 2.60 Age of onset (y): E: 5.20 ± 4.0 & C: 5.90 ± 3.50 Sex: E: 12F/17M & C: 14F/15M	Mitii™ (passive)	6 × 30 mins pw, 20 w (120)	Home; frequently contacted by phone/email (feedback & support)	EF	BRIEF: BRI (parent-reported) MI (parent-reported) GEC (parent-reported)
Verhelst et al. (2017)	Case-series, observational, longitudinal (pilot; feasibility) Pre-post 6 months	n = 5 Aetiology: TBI Age (y): 15.0–17.0 Sex: 1F/4M Time post-injury (y): 2.0–4.0	BrainGames (no control)	5 × pw, 8 w (40)	Home	EF	BRIEF: BRI (self- & parent-reported) MI (self- & parent-reported) GEC (self- & parent-reported)

Abbreviations: BRIEF = Behaviour Rating Inventory of Executive Function; BT = Brain tumour; BRI = Behavioural Regulation Index (e.g., cognitive flexibility, inhibitory control, self-monitoring, shifting); C = Control group; EF = Executive functions; E = Experimental group; F = Female; GEC = Global Executive Composite; M = Male; MI = Metacognition Index (e.g., initiation, planning/organisation, task-monitoring, and working memory); m = Mean; n = Number of participants; NI = No information; pw = Per week; RCT = randomised controlled trial; TBI = Traumatic brain injury; w = Week(s); WM = Working memory; y = Year(s).

Figure 1. Flow diagram of study selection in accordance with the PRISMA statement (Moher et al., 2015).

Flow diagram portraying study selection (i.e., identification, screening, eligibility and included).

Table 3. Summary of findings (level of function).

Authors	Training completion (%)	NPA	Significance of comparisons between pre-training (t0), post-training (t1) & follow-up (t2)			Effect size (Cohen’s d, dppc2, r, SCS)			Comments
			t2-t1	t2-t0	t1-t0	t2-t1	t2-t0	t1-t0
Carlson-Green et al. (2017)	95.00	WJ-III:
		Applied Problems		+*	x
		Passage Comprehension		-	x
		AWMA:
		Backward Digit Recall		-	x
		Block Recall		+**	x
		Counting Recall		-	x
		Digit Recall		+**	x
		Dot Matrix		+**	x
		Mr. X		+*	x
		Spatial Span		+*	x
		Word Recall		+*	x
Corti et al. (2020)	98.30	AC-MT:							dppc2
		Arithmetic Calculation (accuracy)		-	-	-0.29	-0.06	0.24
		Arithmetic Calculation (speed)		-	+**	-0.33	-0.22	0.12
		Problem-solving		-	-	-0.02	0.13	0.15
		Wisconsin Card Sorting test		-	-	-0.40	-0.29	0.09
		Corsi Block-Tapping test		+**	+**	-0.47	0.32	0.92
De Luca et al. (2020)	100.00	Modified Bell Cancellation test			+*				RCI > 1.96
		WEIGL test			+*
Eve et al. (2016)	100.00	WRAT-4:							SCS
		Mathematics		-	-		-0.82	0.25
		TEA-Ch:
		Score!		-	-		0.03	0.17
		Score! DT		-	-		0.28	0.16
		Sky-Search		x	x		x	x
		Sky Search DT		-	-		0.28	0.16
		Walk/Don’t Walk		-	-		-0.82	0.25
		WMTB-C:
		Backward Digit Recall		-	-		0.03	0.48
		Digit Recall		-	+*		-0.15	0.46
		Listening Recall		-	-		0.03	0.48
		Non-word List Recall		-	+*		-0.15	0.46
		Word List Matching		-	+*		-0.15	0.46
		Word List Recall		-	+*		-0.15	0.46
		Block Recall		-	-		0.10	0.54
Phillips et al. (2016)	93.04	WIAT-II:							r
		Numerical Operations		-	-		-0.20	-0.15
		Reading Compreh.		-	+*		-0.10	-0.40
		Word Reading		+*	-		-0.46	-0.01
		TEA-Ch:
		Creature Counting		-	-		-0.07	-0.15
		Score!		-	-		-0.26	0.00
		Sky Search		-	-		-0.16	-0.14
		Sky Search DT		-	-		-0.07	-0.02
		Walk/Don’t Walk		-	-		0.00	-0.09
		AWMA:
		Counting Recall		-	-		-0.26	-0.07
		Digit Recall		-	-		-0.07	-0.21
		Dot Matrix		+*	+**		-0.41	-0.50
		Mr. X		-	-		-0.03	-0.34
Piovesana et al. (2017)	17.57	D-KEFS:							dppc2
		Colour Naming			-			-0.49
		Word Reading			-			-0.20
		TEA-Ch:
		Score!			-			-0.08
		Sky Search			-			-0.08
		Sky Search DT			-			-0.30
		Tower of London-DX 2nd Edition			-			0.54
		CTMT Trail 2			-			0.10
		CTMT Trail 3			-			0.25
		CTMT Trail 4			-			0.08
		CTMT Trail 5			-			0.12
		WISC-IV:
		Coding			-			0.18
		Digit Span Backward			-			-0.02
		Symbol Search			-			0.96
Verhelst et al. (2017)	92.13	PEBL:							Cohen’s d
		Continuous Performance Test (reaction time)					0.93	0.99
		Flanker task					0.98	3.18
		CANTAB:
		Stockings of Cambridge					1.89	1.26
		Intra–Extradimensional Set Shift					0.97	0.08
		WISC-III-NL:
		Digit Symbol Coding					0.35	0.30
		Digit Span Backward					1.98	0.55
		Digit Span Forward					1.07	0.48
		Spatial Span Backward					1.06	0.27
		Spatial Span Forward					1.73	0.78

Abbreviations: − = Not significant; +* = Significant at p ≤ .05; +** = Significant at p ≤ .01; AC-MT = Italian battery AC-MT; AWMA = Automated Working Memory Assessment; CANTAB = Cambridge Neuropsychological Test Automated Battery;?CTMT = Comprehensive Trail Making Test; D-KEFS = Delis–Kaplan Executive Function System; d_ppc2 =?Effect Size?d_ppc2?sensu Morris (2008) C.V.W calculated the effect size ‘d_ppc2’ (Morris, 2008), using an online calculator (Lenhard & Lenhard, 2016); n = Number of participants; PEBL = Psychology Experiment Building Language; TEA-Ch = Test of Everyday Attention for Children; WIAT-II = Wechsler Individual Achievement Tests; SCS =?Standardised change score;?Second Edition Australian standardised edition; WISC-III-NL = Weschler Intelligence Scale for Children Third Edition (Dutch); WJ-III = Woodcock-Johnson Tests of Achievement, Third Edition; WMTB-C = Working Memory Test Battery for Children; WRAT-4 = Wide Ranging Achievement Test 4

Table 4. Summary of findings (level of activities).

Authors	Training completion (%)	Subjective: cognition in daily life	Significance of comparisons between pre-training (t0), post-training (t1) & follow-up (t2)			Effect size (Cohen’s d, dppc2)			Comments
			t2-t1	t2-t0	t1-t0	t2-t1	t2-t0	t1-t0
Carlson-Green et al. (2017)	95.00	BRIEF:
		Inhibit (parent-reported)		+**
		Shift (parent-reported)		+*
		Initiate (parent-reported)		+*
		Emotional control (parent-reported)		-
		WM (parent-reported)		+**
		Plan/organisation (parent-reported)		+*
		Organisation of materials (parent-reported)		-
		Monitor (parent-reported)		+**
Piovesana et al. (2017)	17.57	BRIEF:							dppc2
		BRI (parent-reported)			-			-0.11
		MI (parent-reported)			-			-0.12
		GEC (parent-reported)			-			-0.09
Verhelst et al. (2017)	92.13	BRIEF:							Cohen’s d
		BRI
		(self-reported)					0.84	0.27
		(parent-reported)					-0.70	-0.24
		MI
		(self-reported)					0.50	0.25
		(parent-reported)					0.73	0.30
		GEC
		(self-reported)					1.00	0.34
		(parent-reported)					0.64	0.14

Abbreviations: − = Not significant; +* = Significant at p ≤ .05; +** = Significant at p ≤ .01; BRIEF: = Behaviour Rating Inventory of Executive Function; BRI = Behavioural Regulation Index (e.g., cognitive flexibility, inhibitory control, self-monitoring, shifting); GEC = Global Executive Composite; MI = Metacognition Index (e.g., initiation, planning/organisation, task-monitoring, and working memory); WM = Working memory.

Figure 2. Overview of risk of bias for the randomised controlled trials (ROB 2).

Note: D2 (Bias due to deviations from the intended intervention) – intervention effect of interest to the review author was the effect of assignment to the intervention at baseline (i.e., the “intention-to-treat effect”).

A 7 × 4 table portraying the risk of bias for the three randomized controlled trials. Risk of bias rated as some concerns.

Figure 3. Overview of risk of bias for the non-randomised controlled trials (ROBINS).

Note: D3 (Bias in classification of interventions) not included due to single condition; D4 (Bias due to deviations from the intended intervention) – intervention effect of interest to the review author was the effect of assignment to the intervention at baseline (i.e., the “intention-to-treat effect”).

A 9 × 5 table portraying the risk of bias for the four non-randomized controlled trials. Three studies rated the risk of bias rated as serious. One study rated the risk of bias as moderate.

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