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Accepted November 5, 2012.Address correspondence to Dr. Evian Gordon, Brain Resource Inc., 1000 Sansome Street, Suite 200, San Francisco, CA 94111, USA. Tel: 415-499-7990; Fax: 415-852-5198; E-mail: eviang@brainresource.com

Technology and Innovation, Vol. 15, pp. 53–62, 2013 1949-8241/13 $90.00 + .00Printed in the USA. All rights reserved. DOI: http://dx.doi.org/10.3727/194982413X13608676060574Copyright 2013 Cognizant Comm. Corp. E-ISSN 1949-825X www.cognizantcommunication.com

optimal cognitive function and emotional well- being. The unique ability for these online self-guided technologies to be readily disseminated without the requirement of face-to-face visits with health profes-sionals means that their potential is high for broadly benefiting individuals at an affordable cost. As such, advancing the science of cognitive brain training has become a global priority agenda endorsed by the National Institute of Mental Health (NIMH), with the first international workshop held in April 2012 in Bethesda, USA, for leaders in the field.

ONLINE COGNITIVE BRAIN TRAINING ASSOCIATED WITH MEASURABLE IMPROVEMENTS IN

COGNITION AND EMOTIONAL WELL-BEING

Evian Gordon,* Donna M. Palmer,*† Helen Liu,* William Rekshan,* and Savannah DeVarney*

*Brain Resource Inc., San Francisco, CA, USA†Brain Dynamics Center, Westmead Millennium Institute and University of Sydney Medical School at

Westmead Hospital, Sydney, New South Wales, Australia

The extent to which brain training is beneficial for both cognition and emotional well-being is explored in a naturalistic study design capturing users of the online brain training program MyBrainSolutions over a 2.5-year period. A total of 2,752 users trained to a minimum required level and completed a validated assessment battery of cognitive and emotional states before and after training, which com-pared their performance to a large database of healthy norms. Both the games and the assessment were designed to tap both cognitive (thinking) and emotional domains, with emotional functioning broken out into nonconscious reactions (emotion), conscious experience (feeling), and conscious regulation (self-regulation). The relationships between game play and improvement in assessment scores were established using linear regression models. Games within the domains of thinking, emotion, feeling, and self-regulation were found to have beneficial effects in improving measured scores on the assess-ment within these same domains. The most significant benefits were found for games training positivity to improve scores within anxiety, stress, and depression (feeling scores). In addition, training in self-regulation was found to be beneficial in terms of improved memory, attention, and executive function and reduction in anxiety, stress, and depression levels. While follow-up studies are needed to further elucidate these findings, initial results from a snapshot of naturalistic use indicate a beneficial effect of brain training on cognitive skills and emotional well-being. Furthermore, results suggest a synergistic effect of cognitive and emotional training.

Key words: Brain training; Cognition; Cognitive training; Emotional well-being; Stress

INTRODUCTION

As Internet accessibility and web 2.0 interactive technologies have scaled and the financial and social burden of disease has escalated, there has been an explosion in online technologies developed to pre-vent disease and promote wellness in the physical and behavioral health areas. Similar to our understanding that we maintain physical health through proactive exercise and dietary strategies, it is increasingly being recognized that mental health can be maintained and/or improved through training the brain to develop

54 GORDON ET AL.

and body cues), “feeling” (bodily experience of the emotion via heart rate, breathing, and sweat rate changes), and “self-regulation” (positivity, resilience, and social capacity, which additionally act to regulate thinking, emotion, and feeling). This interconnected design means that training in one specific skill would be expected to not only improve that skill itself (such as training working memory to improve memory skills) but will have flow on effects to other aspects of brain function (such as reduced anxiety, improving attention, and, consequently, improving memory).

In this study, we evaluate the benefits of brain train-ing within each of these four core domains of think-ing, emotion, feeling, and self-regulation, within a naturalistic use of a brain training program designed to target these skill areas. By employing a validated online assessment battery of cognitive and emotional function to assess the level of capacity within these domains, both before and after several weeks of training with games specifically designed to improve these same capacities, we evaluate both the direct benefit of training games on capacities within each domain (e.g., thinking games on thinking skills) as well as the extent to which this integrated approach to brain training provides additional indirect benefits of training in one domain on capacities in a different domain (e.g., emotion games on thinking skills).

METHODS

Study Design

The current study employs a naturalistic design in capturing data from individuals normally using the brain training website MyBrainSolutions within the period from January 2010 to August 2012. This design approach was taken so as to capture as close as possible the amount of benefit that would be derived from training in a typical real-world situa-tion, and from as broad a subject pool as possible. However, there are also substantial limitations to this approach in regard to participant self-selection factors and the absence of a comparative control group. The intention of this approach here is there-fore to provide initial data indicating the extent of benefit that is derived from these games in a real-world situation, and further studies employing a more rigorous and controlled study design will be needed to further elucidate these relationships.

Research to date provides early evidence that online training is efficacious in boosting core cogni-tive capacities such as working memory and atten-tion (2,6,9) as well emotional well-being (3). The majority of evidence to date has been shown for the separate training of specific cognitive skills, partic-ularly the ability to improve working memory (6), with a smaller amount of evidence pointing to simi-lar improvements in other skills such as memory recall, attention, and executive functions (1,10,12).

To date, cognitive training programs have been developed to target core capacities of general cogni-tion that have a basis in functioning of brain circuitry. For example, working memory is a core capacity that has been linked to the functioning of the frontal brain circuits and their connection with parietal attention circuits. In this sense, cognitive training can also be thought of as “brain training.” Cognitive capacities are important to train because they are needed to perform everyday tasks in our occupational and social worlds. For example, to perform even the simple task of mak-ing a telephone call at work, we rely on working mem-ory; the capacity to hold a name or telephone number in our mind for a short time while we transfer it to the keypad or use it to do a contact search. The comple-mentary importance of “social” and “emotional” cognition is increasingly recognized. The effective interaction of occupational and social functions, for instance, arguably relies on the effective interplay of both general and emotional cognitions. To date, cognitive (or brain) training programs have not, however, incorporated training for these social and emotional aspects of cognition.

The online brain training program MyBrainSolu-tions (www.mybrainsolutions.com) is particularly tar-geted toward strengthening skills across the breadth of cognitive and emotional functioning domains, with a goal of achieving overall brain health. Stemming from the theoretical context that the brain is a highly interconnected system, particularly in the interplay between traditional cognitive and emotional func-tioning systems, the games of MyBrainSolutions are designed to train both cognitive and emotional func-tioning domains, using the contextual framework of the INTEGRATE model (4,5,15), in which traditional cognition is conceptualized as a “thinking” domain (conscious rational processing of memory, attention, and planning) and emotional functioning is broken out into “emotion” (nonconscious awareness of face

COGNITIVE BRAIN TRAINING 55

This minimum level of proficiency for each game was based on the score on that game, which for all games reflects a combination of accuracy and speed of game performance. By normalizing the range of each user’s scores to their own performance and then averaging for each trial point over all users, a progress function was established for each indi-vidual game that reflects the average trajectory of improvement at that game over time (Fig. 1). For most games, this consists of initial rapid improve-ment, which slows over time. Each curve was then fitted to a logarithmic function, y = A + b[log(x)], where x is the number of trials of the game played and y is the normalized score, and the minimum level of proficiency is defined as the “elbow” point of the curve or the point where improvement rate is beginning to slow its increase, and the elbow point is calculated by maximizing the distance between the line connecting the first trial point and the last point of the minimum number of trials to reach a near-linear asymptote.

A small number of the training games are designed as exercises to be completed a certain number of times a week, and points are awarded for each completion rather than speed or accuracy of responses. For these games, the minimum level of proficiency could not be calculated using the above method, and was instead defined as complet-ing the task at the minimum recommended train-ing level of once every 2 weeks. These games were E-Self Regulate, Relaxation Room, My Calm Beat, Thought Challenger, and Positive Affirmations.

Cognitive Assessment Battery

The WebNeuro assessment battery (13) takes approximately 30 min to complete and includes tests of general cognition and emotional cognition and questionnaires on emotional well-being and social functioning. Across the individual tests of general and emotional cognition, PCA analyses have previ-ously revealed a smaller number of core capacities that are assessed, including thinking domain capaci-ties of memory, attention and executive functioning, and emotion domain capacities of emotion identifica-tion, emotion recognition, and automatic reactions (8,11). Similarly, the DASS questionnaire provides an assessment of feeling domain functioning of depression, anxiety, and stress states (7), and the

Brain Training Program

Users of the MyBrainSolutions program have access to 22 brain training games within the web-site, each designed to train skills within one of the four key domains of thinking, emotion, feeling, and self-regulation (Table 1). Users are provided information about the skills trained by each game and are free to utilize each game as they wish. The MyBrainSolutions training program also offers access to the cognitive assessment battery WebNeuro (13). This assessment battery, commonly used in clinical applications, has been adapted and embedded within the MyBrainSolutions program to report on the rec-ommend games to users that will best train areas of weakness and enable the tracking of improvement over time. As such, users are encouraged to complete the assessment when they first begin the program as a method of guiding their training regime.

Participants

Within the time frame considered in this study, a total of 60,607 people were registered users of MyBrainSolutions, the majority participating as part of embedding with employee health programs of cor-porate organizations and a smaller proportion as self- referred individuals from the general community. From these, a subset were selected who met the criteria of having taken the cognitive assessment battery twice, having completed no brain training prior to the first assessment, having a minimum of 2 weeks between the first and second assessment, having trained to a min- imum proficiency level on at least one game (details described below), and being over 18 years of age. A total of 2,752 users met these criteria and were con-sidered for inclusion in this study (1,696 females; age range, 18–78 years; mean, 42.7 ± 11.3; median time between assessments, 6 months). All individuals included in the current study had provided consent for their data to be used for research purposes.

Minimum Required Brain Training

For each game, a level was set, which was consid-ered to be a minimum level of proficiency required to have a beneficial impact on the cognitive skill being targeted. Assessment outcomes were then compared between those who did and did not train to this minimum level on each game.

56 GORDON ET AL.

Table 1. Overview of Games Included Within the MyBrainSolutions Program

Times Description Skills Trained

Thinking domain

e-Think Simon Says Remember an increasingly difficult string of colors and direc-tions. Performance measured by maximum span of working memory.

Memory and attention

e-Think Memory Find the matching cards and flip them over. Performance mea-sured by speed and number of matches found.

Memory

e-Think Focus Balance a virtual ball on a pointer while ignoring distractions. Performance measured by success time.

Attention

e-Think On Target Adjust the aim of a virtual bow and arrow for distance and wind factors. Performance measured by accuracy of arrow with the target.

Executive function

e-Think Balance Balance a ball on a beam while ignoring distractions. Performance measured by success time.

Attention

e-Think Executive Remember an increasingly long hidden path through a maze. Performance measured by maximum length of path remembered.

Executive function

Emotion domain

e-Motion Expressions Identify and match facial expressions. Performance measured by response speed and accuracy.

Emotion cues

e-Motion Happy Pick out the happy face among an increasing matrix of negative faces. Performance measured by response speed and accuracy.

Positivity (facial cues)

e-Motion Faces Identify nonverbal facial expressions. Performance measured by response speed and accuracy.

Emotion cues

e-Motion Body Language Identify and train the perception of body language cues. Performance measured by speed and accuracy of response.

Emotion cues

e-Motion Well-being Pick out the happy face in a moving train full of negative faces. Performance measured by true positives and negatives selected.

Positivity (facial cues)

Feeling domain

e-Positive Spin Visual positivity training, matching words with pictures. Performance measured by speed and accuracy.

Positivity

Positive Affirmations Develop positive self-talk to reinforce positive feelings and break cycles of stress. Performance not measured by any metric.

Positivity

e-Catch the Feeling Pop bubbles with positive words only, similar to a go-no go task. Performance measured by true positives and negatives.

Positivity

e-Find the Feeling Timed crossword puzzle with positively biased words. Performance measured by number of correct words found.

Positivity

Self-regulation domain

My Calm Beat Monitor breathing and heart rate variability. Performance not measured.

Conscious regulation

e-Faces and Names Remember an increasing string of faces and names. Performance measured by speed and accuracy.

Social memory

e-Tree of Life Answer a series of questions about hypothetical real-life prob-lems. Performance measured by correctness of response.

Conscious regulation

Thought Challenger Write about a current adverse situation and identify nega-tive thinking patterns while building constructive thoughts. Performance not measured.

Conscious regulation

e-Self Regulate Associate a positive feeling with a positive visual. Performance not measured.

Conscious regulation

Thought Challenger Write about a current adverse situation and identify nega-tive thinking patterns while building constructive thoughts. Performance not measured.

Conscious regulation

e-Positivity Puzzle Solve a puzzle of a positive picture. Performance measured by puzzle-solving speed.

Positivity

COGNITIVE BRAIN TRAINING 57

on games within the same domain area, with the exception of three capacities that improved at trend level only, but with more highly significant effects at the individual game level (Table 2). The additional exception to this was the memory capacity, which did not improve overall but did show significant relationships with a few specific games (Table 3).

The regression coefficients for the individual games revealed that not all games contributed equally, but rather that some games had a significant beneficial effect where others did not.

For the thinking domain, games within this domain that showed a direct benefit for thinking capacities included the game E-Think improving memory skills, the memory and attention game E-Think Simon Says improving attention capacity, and the attention game E-Think Focus improving executive function capacity (although with no direct influence on the measured attention capacity score) (Fig. 2). The executive function games within the think-ing domain were not found to improve measured executive function capacity (E-Think on Target and E-Think Executive), but had a trend-level beneficial influence within the emotion domain on emotion recognition skills (Fig. 3)

In addition, training within the different domains of self-regulation was found to have widespread ben-efit for thinking capacities (Fig. 3). The game E-Self

BRISC questionnaire provides subscales reflecting core self-regulation capacities of positivity bias, resilience, and social skills (14). Assessment scores are provided as normalized z scores in comparison to the WebNeuro normative database. Improvement between assessment 1 and posttraining assessment 2 is measured here as changes in these capacity level z scores for each domain.

Data Analysis

The relationship between training on games and improvement on assessment scores was explored using a linear regression approach. For each domain area of thinking, emotion, feeling, and self-regulation, separate linear regressions were conducted to deter-mine whether training on games (comparing users who trained below and above proficiency levels) improved assessment capacity scores within the same domain and, subsequently, whether all games contributed equally or some were more beneficial others. In order to assess whether similar benefits are also observed from training on games from dif-ferent domains, a second set of linear regressions were conducted including games from across all domain categories.

RESULTS

Most capacity scores from the assessment improved significantly as a result of brain training

Figure 1. Modeled progress function reflecting the average trajectory of improvement at each game over time. The “elbow point” was selected as the minimum training required to achieve proficiency at each game.

Table 2. Regression Model Summary for All Capacities, From Regressions Assessing the Influence of Games Within the Same Domain to Improve Capacity Scores

Regression Model

Capacity Change F

Thinking domainAttention 0.209 1.54a

Memory n.s.Executive function 0.463 1.76b

Emotion domainAutomatic reactions 0.081 1.54a

Emotion recognition 0.762 1.71b

Emotion identification 0.342 1.83b

Feeling domainStress 0.164 2.79b

Depression 0.202 1.92c

Anxiety 0.159 4.85d

Self-regulation domainPositivity bias 0.173 4.84d

Resilience 0.173 2.01c

Social skills 0.194 1.41a

ap < 0.1, bp < 0.05, cp < 0.01, dp < 0.001.

58 GORDON ET AL.

For the emotion domain, games within this domain improved all three measured aspects of emotion capacity (Fig. 2). Emotion identification capacity was improved by the Emotion domain games E-Motion Expressions and E-Motion Happy, which both spe-cifically train both automatic and controlled aspects of facial expression identification. In addition, the game E-Motion Expressions improved emotion rec- ognition capacity, and the game E-Motion Faces was highly significant in improving automatic reac-tion bias capacity level. The E-Motion Faces game also had a strong influence on improving the feeling domain anxiety levels (Fig. 3).

Within the feeling domain, the positivity train-ing game Positive Affirmations produced a highly significant improvement across the spectrum of feeling capacities of depression, anxiety and stress (Fig. 2). The similar positivity game of E-Positive Spin also showed a similar pattern, indicating a gen-eral benefit of positivity training for these aspects of emotional well-being. Training on the feeling domain games also had an influence on self- regulation capacities, with the Positive Affirmations game strongly improving positivity bias and the E-Catch the Feeling having a trend-level influence on improving social skills (Fig. 3).

Within the self-regulation domain, training on most games led to a widespread improvement in these capacities (Fig. 2). The positivity bias capacity was improved by training on the self-regulation games MyCalmBeat, E-Faces and Names, E-Tree of Life, and Thought Challenger. Resilience was improved by training on Thought Challenger and E-Self Regulate, and social skills were improved by training on MyCalmBeat. In addition, training in self-regulation had widespread benefits across most other domain capacities (Fig. 3).

DISCUSSION

Brain training on games aimed to build skills within the four domains of thinking, emotion, feel- ing, and self-regulation were found overall to improve these capacity levels on an independent cognitive assessment and questionnaire battery. The strongest direct benefits were observed for games training positivity to improve levels of experienced depres-sion, anxiety, and stress falling within the feeling domain of emotional well-being. These effects of

Regulate improved attention capacity. Memory capacity was significantly improved by the game E-Tree of Life, with an additional trend-level indi-cation of improvement from the positivity emotion domain game E-Motion Happy and also a trend-level indication of executive function capacity improv-ing from the positivity self-regulation domain game E-Positivity Puzzle.

Table 3. Regression Coefficient Summary for All Games and Capacities, From Regressions Assessing the Influence of All Across Different Domains Games on Capacity Scores

Capacity Game

Estimated Regression Coefficient

Thinking domainAttention e-Think Simon Says 0.226a

e-Self Regulate 0.316a

Memory e-Think Memory 0.119a

e-Tree of Life 0.142a

Executive function e-Think Focus 0.077a

e-Positivity Puzzle 0.076b

Emotion domainEmotion identification e-Motion Expressions 0.506a

e-Motion Happy 0.116c

e-Positive Spin 0.144d

Emotion recognition e-Motion Expressions 0.402a

e-Think Executive 0.079b

Reaction bias e-Motion Faces 0.179d

e-Think Memory 0.112a

e-Tree of Life 0.121a

Feeling domainAnxiety e-Positive Spin 0.134c

Positive Affirmations 0.358d

e-Motion Faces 0.168d

My Calm Beat 0.137a

e-Faces and Names 0.144a

Thought Challenger 0.711d

Relaxation Room 0.460c

Depression e-Positive Spin 0.128a

Positive Affirmations 0.283d

Thought Challenger 0.581a

Stress Positive Affirmations 0.283d

Thought Challenger 0.440c

Self-regulation domainSocial skills My Calm Beat 0.119a

e-Catch the Feeling 0.068b

Positivity bias My Calm Beat 0.171c

e-Faces and Names 0.120a

e-Tree of Life 0.092b

Thought Challenger 0.676a

e-Positive Spin 0.079a

Positive Affirmations 0.227d

Resilience Thought Challenger 0.328a

e-Self Regulate 0.096a

e-Motion Happy 0.074a

ap < 0.05, bp < 0.1, cp < 0.01, dp < 0.001.

COGNITIVE BRAIN TRAINING 59

Figure 2. Relationships between cognitive brain training and measured improvements in capacity scores for games and capacities with the same core domain area.

60 GORDON ET AL.

Figure 3. Relationships between cognitive brain training and measured improvements in capacity scores for games and capacities across different core domain areas.

COGNITIVE BRAIN TRAINING 61

games across multiple domain areas, making it diffi-cult to determine precise relationships between game training and specific measurable capacity outcomes. Future more targeted study designs may benefit from a stricter employment of controlled methods.

The current results provide support for a benefit of brain training across both cognitive and emotional functioning domains, with a goal of achieving over-all brain health. The key interconnected processes of thinking, emotion, feeling, and self-regulation clearly show benefits of training games specifically target-ing each of these skills, as well as the benefits of harnessing the interconnectedness of this system and training across different domains, such as self-regulation training benefits for thinking and feeling capacities. Furthermore, these results indicate that not only can the benefits of cognitive brain train-ing be objectively measured across a breadth of domains, but that the science of brain training itself may further elucidate the nature of these intercon-nected cognition–emotion brain systems.

ACKNOWLEDGMENTS: E.G., D.M.P., H.L., W.R., and S.D. all receive income from Brain Resource Ltd., which has developed the cognitive training program, MyBrainSolutions. MyBrainSolutions is offered as a for-profit product with finan-cial interest for E.G., D.M.P., and S.D. as stockholders.

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