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Applied Neuropsychology: Child

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/hapc20

Inhibitory control stimulation in elementary


school children through digital games: A
systematic mapping study

Bernardo Benites Cerqueira , Débora Nice Ferrari Barbosa , João Batista


Mossmann , Caroline de Oliveira Cardoso & Jorge Luis Victória Barbosa

To cite this article: Bernardo Benites Cerqueira , Débora Nice Ferrari Barbosa , João Batista
Mossmann , Caroline de Oliveira Cardoso & Jorge Luis Victória Barbosa (2020): Inhibitory control
stimulation in elementary school children through digital games: A systematic mapping study,
Applied Neuropsychology: Child, DOI: 10.1080/21622965.2020.1843040

To link to this article: https://doi.org/10.1080/21622965.2020.1843040

Published online: 09 Nov 2020.

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APPLIED NEUROPSYCHOLOGY: CHILD
https://doi.org/10.1080/21622965.2020.1843040

Inhibitory control stimulation in elementary school children through digital


games: A systematic mapping study
Bernardo Benites Cerqueiraa , De bora Nice Ferrari Barbosaa , Jo~ao Batista Mossmannb , Caroline de
Oliveira Cardoso c
ria Barbosad
, and Jorge Luis Victo
a
Cultural Diversity and Social Inclusion Graduate Program, Feevale University, Novo Hamburgo, Brazil; bCreative and Technological Sciences
Institute, Feevale University, Novo Hamburgo, Brazil; cPsychology Graduate Program, Feevale University, Novo Hamburgo, Brazil; dApplied
Computing Graduate Program, University of Vale do Rio dos Sinos, S~ao Leopoldo, Brazil

ABSTRACT KEYWORDS
The inhibitory control is a component of the executive functions that allows the individual to Children; digital games;
inhibit inadequate behaviors, resist distractions and select a relevant stimulus when executing inhibitory control;
activities. In the neuropsychology field, evidences of stimulation and improvement of the inhibi- neuropsychological inter-
vention; school intervention
tory control through school interventions is sought by using computerized software, such as
digital games. These research studies constitute an important investigation area within the execu-
tive functions in ecological approaches. This paper presents a systematic mapping study on inhibi-
tory control stimulation in elementary school children with the use of digital games. The
investigation encompassed an automated database search with further backward snowballing pro-
cedure with the final selection for additional publications as research strategy. The automated
search considered six databases: SCOPUS, PubMed, IEEE Explore Digital Library, ACM Library,
Springer Link, and Scielo. The initial database search found 641 works published between 2014
and 2019. After the exclusion and inclusion criteria were considered, three publications related to
digital games or mobile applications were found and selected for analysis, which focused on
inhibitory control or correlated processes stimulation in school-based interventions with elemen-
tary school children. Results indicated that investigations within the field are incipient, pointing to
an emerging research area.

Introduction development, but also for their professional and academic


lives (Diamond, 2013; Tourinho et al., 2016).
Individuals are asked from an early age to control their
Several theoretical models seek to clarify the structure of
behavior and the way they express their emotions, to think the executive functions (Diamond, 2013; Fisk & Sharp, 2004;
of alternatives to solve problems, for example, during a Miyake et al., 2000). For Diamond (2013), the inhibitory
game or in their social interactions. In the early years of for- control, working memory and cognitive flexibility are the
mal schooling, they are asked to work independently to main components that allow children to manage daily activ-
complete projects, and must organize and plan to meet ities. Based on this core, more complex cognitive skills are
goals. In addition, academic or social success will depend on formed, such as reasoning, problem solving and planning.
how easily they can organize, prioritize, memorize and Research studies demonstrated that the maturation of the
manipulate information or inhibit inappropriate behavior. executive functions occurs since the early years of life
That is, as childhood is a highly sensitive period, it is essen- (Bernier et al., 2010), and strengthens significantly during
tial that children can develop or improve such skills (Center childhood (Best & Miller, 2010).
on the Developing Child at Harvard University, 2011; The present study focuses on the inhibitory control,
which allows individuals to inhibit inappropriate or irrele-
Hughes, 2011, Meltzer, 2014). These essential skills are
vant behaviors, resist distractions and select the relevant
called “Executive Functions,” which is an interrelated group
stimulus during the execution of activities. Also, the compo-
of cognitive skills that serves to regulate and control human nent can be divided into response inhibition and interfer-
behavior, in order to achieve specific goals. Other authors ence control. The first is characterized by inhibiting
define them as an umbrella term for functions that are inappropriate behavior or resisting to the initial response or
essential for managing goals and tasks (Chan et al., 2008; the first response impulse; also known as self-control, or the
M€ uller et al., 2008). These skills are essential in several ability to resist the dominant temptation/desire/response.
aspects, not only for individual’s mental health and cognitive The latter refers to inhibiting thoughts or memories

CONTACT Bernardo Benites Cerqueira bernardobenites@hotmail.com Feevale University, 2755 075, RS-239 – Vila Nova, Novo Hamburgo, RS93525-
075, Brazil.
ß 2020 Taylor & Francis Group, LLC
2 B. B. CERQUEIRA ET AL.

(cognitive inhibition) and to the interference or environ- et al., 2011). Thus, the players are proactively involved in
mental distractors control (selective or focused attention) the learning process through the digital game, and may
(Diamond, 2013). interact with the information (Lieberman, 2006).
Moreover, the inhibitory control relates to the individu- Furthermore, cognitive stimulation through technology and
als’ ability to wait and respond thoughtfully rather than digital games qualify the classrooms as ecologically valid
reactively or impulsively, which may lead to uncomfortable environments in search for evidence and innovative pro-
social situations, therefore resisting to the temptation of posals within the research fields addressed.
behaving inappropriately (Diamond & Ling, 2016). Most computer programs available in the literature work
Impairments or deficits in this executive component are with the category of working memory stimulation (Cardoso
known to be correlated to Attention Deficit Hyperactivity et al., 2018). Interventions that aim at stimulating the inhibi-
Disorder (ADHD) (Fosco et al., 2019) and Autism Spectrum tory control through digital games in school-based interven-
Disorder (ASD) (Christ et al., 2007). tions are still introductory, as most of this type of
Researchers have been interested in understanding and intervention are focused on the working memory compo-
proposing interventions that promote and improve executive nent (Cardoso et al., 2018; Diamond & Ling, 2016). This
functions during childhood (Barnett et al., 2008; Cardoso article proposes a systematic mapping study, to characterize
et al., 2019; Dias & Seabra, 2015; Klingberg et al., 2005; empirical studies on school-based computerized interven-
Mackey et al., 2011; Thorell et al., 2009). The proposed tions that aim to stimulate the inhibitory control in elemen-
interventions occurred in different contexts and involved tary school children, as well as their designs, methods and
several methods, including computerized cognitive training, main outcomes.
computerized and non-computerized games, aerobic exer- Systematic mapping studies observe emerging research
cises, martial arts and mindfulness activities, curricular and areas and specific topics within a wider area (Perryman,
complementary programs (Diamond & Lee, 2011). 2016) with purpose of answering specific research questions
The use of computerized programs, in which digital raised prior to the search process. The publications are
games are included, have shown that such programs are selected considering inclusion and exclusion criteria and fur-
effective for children with ADHD (Klingberg et al., 2005) ther analyzed. Systematic mapping studies are often used in
and for preschoolers with typical development (Thorell other fields, such as information systems or software engin-
et al., 2009). A meta-analysis by Takacs & Kassai (2019) eering (Jalali & Wohlin, 2010), medical and related health
sought to synthesize available empirical evidences regarding research (Fernandez et al., 2015; Fernandez-Sotos et al.,
the effectiveness of different intervention types in children’s 2019). This research seeks to map recent publications
executive functions, which included different approaches. focused in the inhibitory control stimulation involving
Although the authors found evidences that it was possible to digital games or mobile applications in school-based inter-
train children’s executive function skills, further follow-up ventions with elementary school children, from 5 to 11 years
assessments did not find convincing evidence that the bene- old. Hence, our objective is to indicate gaps, provide insights
fits from the interventions were sustained over time. on this area of study, and raise suggestions for future work.
Regarding computerized working memory programs, No recent systematic mapping study has been found within
Melby-Lervåg & Hulme (2013) and Melby-Lervåg et al. the scope proposed here. Finally, systematic mapping studies
(2016) found out that training with CogmedV had immedi-
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differs from other literature reviews or meta-analysis types
ate significative effects in verbal and visuospatial working (Perryman, 2016). They are closer to scoping reviews,
memory in children. However, the benefits of interventions although much broader than the latter.
with computerized programs, specifically in regards of trans- The present study investigated the following hypothesis:
ference effects and generalization gains still have to be estab- that the use of digital games in the context of a neuro-
lished (Diamond & Ling, 2016; Melby-Lervåg & Hulme, psychological intervention program in the school environ-
2013). Melby-Lervåg & Hulme (2013) showed that working ment can contribute to the stimulation of the inhibitory
memory training did not improve inhibitory control in chil- control of elementary school children and may transfer to
dren, while Melby-Lervåg et al.(2016) did not find evidences untrained skills. In terms of effectiveness it is expected that
of long-term benefits in verbal working memory, but only most interventions would prove to have positive outcomes
significative effect in visuospatial working memory in a fol- in the participating children such as improved cognitive and
low-up assessment. academic development, both within the stimulation group
Computer programs are attractive because they reduce (intragroup analysis) and in the comparison between the
the need for additional human resources and motivate the stimulation and control groups (intergroup analysis).
participants (Cruz et al., 2013). In addition, some may auto-
matically adapt to the children’s performance throughout
Background
the training in regards to the difficulty level of each task, for
instance (Cardoso et al., 2018; Klingberg et al., 2005). The inhibitory control is responsible for many aspects of an
Besides promoting the development of cognitive aspects, individual’s life, along with the other components of the
digital games enable the players themselves to actively par- executive functions. Diamond and Ling (2020) promotes the
ticipate in the learning process. As a result, a more enjoy- importance of stimulating and improving the executive
able, interesting and motivating process takes place (Prins functions, linking them to aspects such as temptation
APPLIED NEUROPSYCHOLOGY: CHILD 3

resisting in order to complete tasks, avoid saying or doing 2020). However, regarding the inhibitory control, the inves-
later regrettable actions, presence of mind to wait before tigations do not clarify whether or not inhibitory control
speaking or acting, being able to resist impulsive reactions, skills are possible to train and stimulate, having transfer
creative problem solving and seizing unexpected effects to untrained skills. Another recent meta-analysis by
opportunities. Takacs and Kassai (2019) investigated different types of
The executive functions are critical for school readiness, interventions with children, such as computerized and non-
academic performance, career success, socio affective func-
computerized training, cognitively engaging physical
tioning, marital harmony, good health and quality of life
activities, mindfulness meditation and curricula involving
(Diamond & Ling, 2020). However, an investigation by
executive skills, art activities, biofeedback-enhanced relax-
Miller et al. (2011) found out that youths which had poorer
development of the executive functions, specifically the ation and strategy teaching interventions. According to the
inhibitory control, were exponentially more likely to suffer authors, the explicit executive function training results were
from adverse health conditions, while other longitudinal similar when using computerized and non-computerized
study (Moffitt et al., 2011) demonstrated that adults that training. The studies with computerized training in the
had poorer inhibitory control in childhood were more likely meta-analysis included Cogmed, Braingame Brian, Memory
to experience drug addiction, single parenthood and to com- Booster, Jungle Memory, Mate Marote and LocuTour
mit more crimes than those with better inhibitory control as Multimedia Cognitive Rehabilitation. Significative effects in
children. According to Diamond and Ling (2020), research working memory were found in comparison with inhibitory
suggests that early executive function gains can reduce control and cognitive flexibility, although the authors high-
aforementioned issues, as well as antisocial or inappropriate light that it was due to the fact that most of the studies
behaviors, and that enhancing executive development early sought explicit training working memory using Cogmed.
in life is critical to children’s trajectory. Besides, the effects on working memory were maintained
Although, there are controversies regarding the effective-
over time. Another interesting result is that explicit training
ness of the stimulation through computerized programs, as
was significantly lower for atypical development children
well as in the methodologies employed (Alves & Silva, 2017)
group, when compared to the typical development children.
and in the reproduction of the results in other studies
In regards of the use of computerized training in the
(Holmes et al., 2009). The authors indicate that such contra-
dictions are evidenced in the adaptive issues that are over- school context, a literature review by Cardoso et al. (2018)
looked in the cognitive stimulation programs. One of the demonstrated that most of the computer programs used in
aspects that maintains the statement above is the transfer school-based interventions with children available aimed for
effect. In other words, benefits attained from stimulating a stimulating the working memory (Cardoso et al., 2018).
Besides CogmedV, another noncommercial computerized
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skill in a certain scenario must also be observable elsewhere.


A behavioral investigation before and after the execution of game that was reported in investigations is called Braingame
the proposed task should be conducted and the skill gains Brian, which is aimed for stimulating the executive functions
should also appear in the performance of other untrained in children with ADHD and cognitive control problems. No
daily tasks. The development of such stimulation programs transfer effect to untrained domains was found in the stud-
should be aligned with the promotion of the adaptive func- ies with these computerized games.
tioning of the individuals as a whole, and not only applied Thus, it is observed that the effects of interventions
to the activities practiced and evaluated (Diamond & focused exclusively on the inhibitory component would
Ling, 2016). benefit from a specific observation, in order to seek for the
A meta-analysis by Kassai et al. (2019) investigate the evidences and impacts available in recent studies in school-
topic of near and far transfer effect in neuropsychological based intervention programs.
interventions with children, although no strong evidences
were found that training a specific executive function would
transfer to untrained executive components. Moreover, Method
results from investigations by Melby-Lervåg and Hulme
(2013) and Sala and Gobet (2017) have found no significant This paper proposes a systematic mapping study through an
transfer effect from working memory training to inhibitory automated database search with complementary backward
control in children participants, while Volckaert and No€el snowballing technique on the final sample. The guidelines
(2015) have shown preliminary results of marginal transfer for systematic mapping studies proposed by Petersen, et al.
effect between inhibitory control and cognitive flexibility. (2015), were followed: (1) definition of research questions;
Kassai et al. (2019) highlighted that the latter investigation (2) delimitation of the search process; (3) definition of
results could have been impacted due to the similarity exclusion criteria; (4) analysis of the results. The final sam-
between the outcome measures and the game activities prac- ple of this process, after the exclusion criteria was applied,
ticed by the children participants. was used in a variation of the backward snowballing proced-
The possibilities of stimulation of the executive functions ure (Wohlin, 2014). This complementary procedure was
through computerized programs, including digital games, used to track publications that could have been missed dur-
have been reported previously (Diamond & Ling, 2016, ing the initial database search.
4 B. B. CERQUEIRA ET AL.

Table 1. Research questions.


Id Question Category
GQ1 How the digital games for cognitive stimulation were applied to children in the school context? Intervention
GQ2 What kind of platforms were used in stimulation applications? Platform
GQ3 Were digital games developed in the academic research context? Development
GQ4 What strategies were used to measure the intended results? Psychometry
FQ1 Do these applications focus on stimulating the inhibitory control? Cognitive skill
FQ2 Have the digital games been validated by specialists before being used in applications aimed at cognitive stimulation? Validation
EQ1 What are the stimulation outcomes in the publications? Evidence

Figure 1. Graph representing the data-filtering process applied to the results from the automated database search.

Research questions group; and specific cognitive component. Based on this pro-
cess, the following search string was created:
The research process was based on three groups of questions:
((“video game” OR “videogame” OR “mobile game” OR
General Questions (GQ), Focal Questions (FQ), and Evidence
“mobile application”) AND (school OR intervention OR
Questions (EQ), which were categorized as per Table 1. application OR “school intervention” OR “school program”
OR “school curriculum” OR “neuropsychological inter-
Eligibility criteria vention”) AND (child OR children OR childhood) AND
Studies were considered eligible when the following criteria (“cognitive stimulation” OR “cognitive stimuli” OR
was met: (1) the study included computerized games or “inhibitory control” OR inhibition))
mobile applications in their interventions for stimulation or The string was applied across six databases: SCOPUS1,
training; (2) focused on the inhibitory control or correlated PubMed2, IEEE Explore Digital Library3, ACM Digital
cognitive processes for stimulation and assessment, being Library4, Springer Link5, and Scielo6. The results included
this the main cognitive interest in the research; (3) the pro- publications from 2014 to 2019. PubMed is the database
posed method had at least one quantitative psychometric that stands out as a literary base in the health context,
strategy used to verify and measure the results and cognitive whereas the other databases were considered due to their
relevance in the technology field.
outcomes, rather than only qualitative-focused interviews;
(4) the study had performed school-based interventions to
train or stimulate the inhibitory control or correlated cogni- Result filters
tive processes; (5) involved elementary school children from The following inclusion criteria (IC) were used to filter the
5 to 11 years old as participants, in line with the Brazilian results: IC1 – work published between 2014 and 2019; IC2 –
elementary school system (this study authors’ country). work involving digital games or mobile applications; IC3 –
Studies that had participants in different ages, but involved text published in the full version; IC4– article published in a
children within the elementary school age range, were con- conference, workshop or journal.
sidered for inclusion; (6) the study was empirical, with at In addition, the following exclusion criteria (EC) were used
least two groups for comparison, designed as randomized as a second filter: EC1 – duplicated works; EC2 – works that
controlled trial (RCT) or quasi-experimental pretest-posttest did not address inhibitory control nor correlated cognitive
study and (7) the study was peer reviewed; processes; EC3 – works that did not use quantitative psycho-
metric strategies to verify the results; EC4 – works that did not
Search process 1
SCOPUS – Retrieved from: https://www.scopus.com/
The search string used in this research was based on specific
2
PubMed – Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/
3
IEEE Explore Digital Library – Retrieved from: https://ieeexplore.ieee.org/
keywords separated according to their interest groups. The 4
ACM Digital Library – Retrieved from: https://dl.acm.org/
following groups were defined: technological product type; 5
Springer Link Base – Retrieved from: https://link.springer.com/
application or scholar intervention type; desired target age 6
Scielo Base – Retrieved from: https://www.scielo.org/
APPLIED NEUROPSYCHOLOGY: CHILD 5

carry out school–based applications; EC5 – works that did not database search was used as the initial papers set for the
involve children between five and eleven years old. backward snowballing. In the procedure adopted, the refer-
Figure 1 shows the filtering process, with the initial ences from a starting set of papers were used to search add-
results and after the application of the exclusion criteria. itional publications, which might have been missed during
The search string was applied to the title, abstract, and the database search. In the procedure, every reference found
keywords of publications within each database. Singular and from the starting set list that matches the inclusion criteria
plural variations of the keywords were used in the search specified is then added to a new set, and a new iteration is
string, producing the initial results. Figure 1 synthesizes and made in order to find any references that should be
depicts the database search process, which took place as fol- included for the subsequent iteration. This process may go
lows: after the initial search was performed, filters EC1 and on until the inclusion and exclusion criteria are met, and in
EC2 were applied in order to address works that carried out the case of this work, publications prior to 2014
investigations in inhibitory control and correlated cognitive were discarded.
processes. Subsequently, Keshav’s (2007) three-step tech- The process considered the references from the final sam-
nique was adopted: (1) reading the title, abstract and intro- ple of papers, including a verification of publication year,
duction, going through sections and subsections titles, title and type verification. The abstracts of potential candi-
mathematical elements (if any) and conclusions. During this dates were considered, and if inconclusive for inclusion to
first step, the other exclusion criteria (EC3, EC4, and EC5) the new set of papers, the paper was read in full. The same
were applied. After the first step, the other two were carried inclusion and exclusion criteria defined previously for the
out: (2) analysis of figures, diagrams or illustrations analysis; automated database search were used in the backward snow-
and (3) reading the remaining articles in full. balling procedure for the papers to the next iteration inclu-
sion. The iterations resulting of this procedure are further
Study selection described in the next section.

The research questions and the eligibility criteria of this


study were formulated in consensus among all authors. The Results
first author performed the automated database search and Search strategy results
filtered the articles, and the three first authors determined
the inclusion eligibility, and, in case of doubt, consulted the Automated database search
other authors. The full reading of the elected papers was The initial automated database search found a total of 641
performed by the first author, and the final decision was publications. From these, pre-selection included 63 publica-
discussed by the first three authors. tions within the thematic area, among which the final selec-
tion encompassed three after all filters were applied. Table 2
shows the final sample resulting from the automated search
Data extraction carried out in the databases.
The data extraction from each paper was done by one
author, and further discussed by the authors for inclusion. Backward snowballing
Once a consensus was reached, they were included in the The first iteration of the backward snowballing used the
study. The data collected from the final selection was then final sample of the automated search as the starting set of
summarized in order to answer the research questions papers. This procedure used the same eligibility, exclusion
defined prior to the database search. The following data and inclusion criteria as the automated search process.
were extracted: Figure 2 depicts the search strategy with the results from
each step for filtering the results.
 Abstract and bibliographic information The publication from Li et al. (2018) included 26 biblio-
 Focused cognitive process and objective graphic references, of which three publications were candi-
 Intervention approach (e.g. randomized controlled trial dates for inclusion based on their title, type and publication
or quasi-experimental) year. A total of 16 references were excluded based on their
 Application strategy (e.g. duration, frequency, number publication year. Another eight were discarded based on
of sessions) their title and publication types. The remaining two referen-
 Psychometric strategies/instruments used ces were identified as candidates, but their title and context
 Digital platform used for stimulation had insufficient information to determine their inclusion in
 Validity of the digital games/application the next iteration round. Thus, after reading their abstracts,
 Quantitative intervention outcomes one reference was discarded, while one full paper evaluation
was done mainly to examine if it included the school space
and digital games within the investigation procedure.
Backward snowballing procedure
Finally, references from Li et al (2018) failed the eligibility
The backward snowballing procedure (Wohlin, 2014) was evaluation and were excluded from the next iteration round.
used in this study as a complementary step to the automated The publication from Ramos and Melo (2019) had a total
database search. The final sample from the automated of 52 references, of which eight references were considered
6 B. B. CERQUEIRA ET AL.

for inclusion after checking the title, type and publication

n ¼ 71 (Train group ¼

¼ 8; Control Group
n ¼ 15 (CPAT Training
Video condition=?)

30; Control group


year. A total of 37 references were excluded based on their

Participants

condition=?;
publication year, and another seven were discarded based on

n ¼ 161 (Game
their title and publication types. The remaining eight refer-

¼ 41)

¼ 7)
ences were identified as candidates, but their title and refer-
ence context had insufficient information to determine their
inclusion in the subsequent iteration round. After reading
their abstracts or summaries, six references were discarded,
Approx 11 min

and two were selected for full reading. These two papers
Session

were subsequently discarded as their experiments included


15 min

45 min
only clinical settings.
In the Spaniol et al. (2018) publication, there were 87
references, from which eight were candidates for the next
iteration after checking the title, type and publication year.
A total of 72 references were discarded based on their publi-
Daily for six weeks
Single application

Twice a week for


Application

cation year. Another seven references were discarded based


two months

on the title and publication types. From the remaining eight


references, two were excluded after reading the abstract. The
last six references were then discarded after full text reading,
as they did not propose school-based interventions, as well
as not using digital games, or had no control group.
Finally, given the publications eligibility criteria discon-
Raven Matrices; CARS;

sidered articles published before 2014, no further iterations


Go-No-Go Task and
Functional near-

Attention Test: D2
Psychometric
instruments

mathematics,

were done, as none of the references cited in the starting set


spectroscopy

reading and
copy tests;

of papers met the eligibility criteria proposed in this study.


infrared

(fNIRS)

The research questions raised in this work are further


discussed in the following sections.

General question 1 – how the digital games for


Intervention methodology

cognitive stimulation were applied to children in the


Experimental and Active
Quasi-experimental  2
randomized groups;

randomized groups;

randomized groups;
Single application  3
experiments with 2

school context?
Control  2

Li et al. (2018) conducted a study with single application


groups for two days, using the digital game Dr. Panda in
Space for mobile devices, such as tablets, with an experi-
mental group. Results were compared with a control group
that saw the digital game recorded in video format on lap-
tops the following day. The participants in the second day
Inhibitory control

would only watch the video, which showed the digital game
scenes in story format, since they could not interact
Focus

Attention

Attention

with them.
A total of 161 children, divided into three different
experiments, participated in the investigation (Li et al.,
2018). These experiments varied in participants number,
with 72, 19, and 72 children, respectively, with ages between
Laptop and Tablet

four and six years. The children were randomized to video


Platform

viewers condition or game players condition. Each experi-


Table 2. Final selection of the results.

ment contained small method variations used by the


Tablet

Data not informed by the authors.

authors, alternating between time spent using laptops and


PC

type of digital game activities played (fantastic or more real-


istic narrative events). Participants in this study (Li et al.,
2018) performed pre and post-neuropsychological tests while
Ramos & Melo (2019)

Spaniol et al. (2018)

wearing a functional near-infrared spectroscopy (fNIRS)


Author and year
Li et al. (2018)

device on brain regions during the second and third experi-


ments to read neural activities and being assisted by the
researchers. The pre and post-tests were done before and
after a single application with the participant.
APPLIED NEUROPSYCHOLOGY: CHILD 7

Figure 2. Graph representing the search strategy process for filtering the results.

Ramos and Melo (2019) carried out a daily quasi-experi- the applications. Li et al. (2018) opted for two platforms,
mental study with 15 minutes of duration for six weeks. In tablets and laptops, to carry out the interventions in two dif-
their study, 71 participants were separated into an experi- ferent variations: laptops only (video watching) and tablets
mental group (n ¼ 30) which used the training platform only (touch screen interaction). Finally, Spaniol et al. (2018)
with digital games from Escola do CerebroV (Brain School),
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used only computers, which was an application protocol
and a control group (n ¼ 41) which continued their daily used in previous studies.
tasks normally in their classroom. Students, who were in the
second and third school years, were between seven and nine
years old. Before being assigned to the experimental or the General question 3 – were digital games developed in
control group, the participants went through pre and post- the academic research context?
intervention neuropsychological attention tests. During the Among the articles found, two of them used digital games
intervention, researchers assisted the participants who developed by the research team for the cognitive stimulation
belonged to the experimental group. purpose. Ramos and Melo (2019) used the cognitive training
Spaniol et al. (2018) investigated experimental and active software package with digital games called Escola do
control groups for eight weeks, twice a week, 45 minutes per CerebroV (Brain School), developed at the Santa Catarina
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session. Fifteen children from two different schools, aged Federal University (UFSC) by the research group. In a cog-
between seven and ten years old participated in the study. nitive training platform format with five digital games, the
Participants performed pre-intervention tests and then were program provides feedback to the players on their perform-
matched according to their chronological and cognitive ages, ance. Escola do CerebroV records player’s time, speed, stabil-
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gender, and intelligence. Subsequently, the participants were ity, and accuracy to calculate performance on three
randomly assigned to an experimental group (n ¼ 8), which cognitive skills: attention, problem solving, and working
used a computerized training program with digital games— memory. The research (Ramos & Melo, 2019) took place in
Computerized Progressive Attentional Training (CPAT)—or the school context with children between seven and nine
an active control group (n ¼ 7), which used the computer years with typical development.
games “Plants vs. Zombies,” “Bejeweled 3,” and “Pacman” for Spaniol et al. (2018) used a program called Computerized
the same period. Participants were assisted throughout the Progressive Attentional Training (CPAT), developed by one
program by the researchers. After the intervention, neuro- of the authors (Shalev et al., 2007). It is a training program
psychological post-tests were conducted. that presents activities through digital games proposed for
Finally, even though the investigations (Li et al., 2018; children with typical development. The objective was to find
Ramos & Melo, 2019; Spaniol et al., 2018) versed on inhibi- out if CPAT could be used as a training program in children
tory control studies or correlated cognitive processes, and with ASD as well as to measure its transfer effect for
corroborated the application locus, their application meth- untrained skills and cognition. The digital games in this
ods differed. Other investigations (Alves & Silva, 2017; training software have three activity types in mini-game for-
Diamond & Ling, 2016) have also indicated the existence of mat focusing on sustained attention, selective-spatial atten-
methodological variability in stimulation programs, espe- tion or executive attention. Each activity is based on
cially with the use of computerized games. Further studies neuropsychological tasks, which were adapted to the digital
are required for the definition of an optimal application games in 2D format esthetics aimed for children between six
strategy and psychometric measurement to verify the effect- and thirteen years old.
iveness of the results. Finally, Li et al. (2018) used an digital game called Dr.
Panda in Space. Developed by a Chinese company, Dr.
Panda in Space is a commercial mobile game with a fantasy
General question 2 – what kind of platforms were used
theme for children. It is not related to the academic context,
in the stimulation applications?
and the mobile application is currently available for sale in
The work of Ramos and Melo (2019) used exclusively mobile application stores. This digital game is set in a fan-
mobile platforms (tablets) for the game’s execution during tastic spatial theme in which the player interacts with several
8 B. B. CERQUEIRA ET AL.

animals in 3 D scenes and goes on adventures focused on following a specific a protocol. Ramos and Melo (2019) used
the child’s interaction through activities in a storytelling for- a digital game validated only by the target audience (chil-
mat. This digital game has no time limits, rules or score and dren), whereas Li et al. (2018) used a commercial educa-
its purpose is to allow children to venture into stories and tional digital game which presented no scientific evidence
interact with the narrative and characters to finish the sto- on their cognitive stimulation capacity prior to the study
ries in the form of mini chapters. Although the digital game carried out by researchers.
has not been developed within the academic research con- The next subsection approaches the evidence questions
text, this investigation used the game for the neuropsycho- (EQ), which has been defined previously in
logical intervention which was carried out within a school “Search questions.”
context with typical development children with the objective
of seeking for stimulation evidence.
Evidence question 1 – what are the stimulation
outcomes in the publications?
General question 4 – what strategies were used to
measure the intended results? The investigation by Li et al. (2018) performed three differ-
ent experiments, as mentioned in GQ1: small duration
Regarding the strategies for the psychometric measurement application variations (in minutes) and digital game activity
of the investigation’s participants, the studies presented dif- types played or viewed (fantastical or more realistic narrative
ferent approaches: Li et al. (2018) carried out an investiga- events). Experiment 1 (n ¼ 72) found that children in the
tion with a dual strategy for measuring the intervention viewing condition performed worse in sensitivity response
results, applying the Go-No-Go Task (Wiebe et al., 2012) as between the pre and post Go-No-Go tasks after viewing fan-
pre and post-test, along with a fNIRS multichannel equip- tastical events than children in the game condition. The lat-
ment/system (LABNIRS, Shimadzu), focusing on functional ter group perceived the same activities as more realistic due
near-infrared spectroscopy on brain regions. to interacting with the events. This experiment was per-
Spaniol et al. (2018) used various pre and post-tests, formed in within school context.
which included an intelligence test—Computerized Experiment 2 (n ¼ 17) (Li et al., 2018) had the same find-
Progressive Matrices (CPM) (Raven et al., 2008)—, mathem- ings as experiment 1, that is, worse sensitivity response for
atics, reading, and copying academic tests as well as the the viewing condition. The second experiment had a small-
Child Autism Rating Scale (CARS) test (Schopler et al., time variation (from eleven to five minutes long video),
1980). In addition, semi-structured interviews were con- changes in the Go-No-Go task (from 64 trials to 40 trials)
ducted with teachers and teacher assistants to obtain their and the use of the multichannel fNIRS system in the partici-
readings on the participant’s performance. pants during the experiment. Data from the fNIRS suggested
Finally, Ramos and Melo (2019) opted for a specific test that the sensitivity response was significantly lower after
aimed at measuring the participants’ attention, the Attention children viewed fantastical events due to a higher processing
Test: D2 (Ara ujo, 2016), in which the subjects need to that fantasy cognitive demanded in comparison to the inter-
observe a page with several target stimuli and distractors action via touch-screen with the same events in the game
and only mark the first type. condition. This experiment occurred in a laboratory setting.
The next subsection approaches the research focal ques- Experiment 3 (n ¼ 72) (Li et al., 2018) used the same
tions (FQ), which were defined previously in planning as the previous experiment, except for the viewing
“Research questions.” condition time variation (from five to eleven minutes long
video), and that the events chosen by the researchers were
Focal question 1 – do these applications focus on considered more real events compared to the experiment 2.
stimulating inhibitory control? Outcomes from both groups suggested an increase in the
inhibitory control on the post-test. The authors did not
The study proposed by Li et al. (2018) looked exclusively at mention if this experiment was done within a school or
the participants’ inhibitory control stimulation/training. laboratory setting.
Spaniol et al. (2018) and Ramos and Melo (2019) investi- Therefore, the investigation by Li et al. (2018) suggested
gated the effects on attention training, focusing on the that viewing fantastical events may have produced more
related cognitive processes. Although the inhibitory control negative effects in the inhibitory control than the interaction
was indirectly assessed, the focus was not the compo- with a mobile platform with the same events in the
nent itself. game condition.
The study by Ramos and Melo (2019) found that the
Training Group (n ¼ 30) showed greater improvement in
Focal question 2 – have the digital games been
pre and posttest (D2 raw score and total score) when com-
validated by specialists before being used in
pared with the Control Group (n ¼ 41). However, there
applications aimed at cognitive stimulation?
were no significant effects on the other variables of the D2:
Among the studies found, only the study by Spaniol et al. Attention Test.
(2018) used a game that was validated by specialists, since it Finally, the investigation by Spaniol et al. (2018) found
is a cognitive stimulation program that must be applied by improvements for untrained skills in the CPAT training
APPLIED NEUROPSYCHOLOGY: CHILD 9

group’s academic tests, such as time-limited math, reading Spaniol et al. (2018) and Ramos and Melo (2019) also
comprehension and copying speed tests. Also, the non-ver- stated that further investigations should be made within the
bal cognitive assessment (Raven CPM) improved for the school setting context. Both studies indicate the existence of
training group. According to the authors, these findings a gap within the stimulation field for attentional aspects of
were either significant or approaching significant at the the executive functions, within a context that relates to the
ANOVA level. Moreover, all results were significant at the participants’ daily lives.
simple effect level, and the Reliable Change Indices (RCI) Regarding the final selection, the filtered investigations
analysis also shown improvement for most participants in addressed children with typical development (Li et al., 2018;
the training group. Ramos & Melo, 2019), as well as on the autistic spectrum
(Spaniol et al., 2018). Both publications took place within
school contexts and highlighted the possibilities of cognitive
Discussion stimulation through digital games.
This work searched for recent investigations, which used Within the research questions, FQ2 presented an issue
digital games or mobile applications that aimed at stimulat- regarding the validation of the digital games or mobile
ing children’s inhibitory control in school-based interven- applications. Namely, it refers to the validation and evalu-
tions, published within a period of six years (between 2014 ation by specialists in the neuropsychology field, regarding
and 2019). Additionally, this work evaluated the proposed stimulation activities proposed by the games or applications.
methodologies and the measures of the neuropsychological The validation with specialists occurred in one digital game
effects in school interventions. The search was conducted only (Spaniol et al., 2018) out of the three reported in the
across six recognized databases in the academic context and mapping study. Ramos and Melo (2019) used a validated
the outcomes pointed to a low number of current research and evaluated game with the target audience, whereas Li
studies that look for evidence of inhibitory control stimula- et al. (2018) used a commercial game that had not been vali-
tion within a school context, that is, with ecological validity. dated in the academic research context.
Out of 641 articles found in the initial search, with the Two questions arise from this outcome. First, from the
previously defined search string, only three fit within all the software development processes point of view, as is the case
criteria established a priori. A variation of the backward with digital games or mobile applications, the interaction
snowballing technique was used as a complementary search between the tool, or digital game, and the target audience is
strategy in order to track any possibly missed publications especially important. This user-centered development type
within the automated database search. In any case, no add- can bring up issues with the potential to directly interfere
itional publications were found. One could infer that this with the player’s experience and engagement, and may,
investigation obtained a low result range due to the final therefore, directly affect the results.
sample of three publications. However, two recent studies in The second is the tool, or digital game evaluation, by
the field indicate otherwise: experts in the field in which the investigation is proposed to
The investigation from Cardoso et al. (2018), for take place. The evaluation ensures more reliable and safe
example, sought for the effectiveness of neuropsychological tools are selected for the research, as well as for its partici-
stimulation programs in children with typical development. pants. This subject is addressed by the Institute of Digital
Eight out of 19 studies used computerized programs, includ- Media and Child Development Working Group on Games
ing games. However, the studies aimed for different execu- for Health (Baranowski et al., 2016), in which a group of
tive functions other than the inhibitory control or correlated researchers, from different areas consider the need and call
cognitive processes, thus not fitting the parameters within for greater collaboration between game designers and health
this research. This investigation (Cardoso et al., 2018) con- and behavioral professionals, so that evidence-based behav-
sidered publications from 2000 to early 2016, included pre- ioral changes in applications are guaranteed. For example,
schoolers and focused on the effectiveness of executive has the digital game or application been validated by neuro-
function programs in general. psychology experts from the area which the tool is designed
A wider recent systematic literature review conducted by to train? Is the digital game or computerized program suit-
Diamond and Ling (2020) aimed at executive functions pro- able for the cognitive stimulation of the proposed tar-
grams with neuropsychological effectivity evidences in gen- get groups?
eral found 179 studies. Although the review did not focus Furthermore, regarding the intervention outcomes,
specifically on children, neither on digital games, the authors Spaniol et al. (2018) reported near and far-transfer effects
reported nine studies for this age range and context. The from inhibitory control training to untrained skills, such as
authors have not reported any studies with computerized academic and non-verbal cognitive performance for the par-
programs considering the more restrictive parameters used ticipant children in both groups—training and active con-
in the present investigation, such as digital games focused trol. Although, Li et al. (2018) and Ramos & Melo (2019)
on the inhibitory control or correlated processes with chil- did not report transference effects in post-intervention tests.
dren (5–11 years of age) in school-based interventions. It Since the investigation by Spaniol et al. (2018) focused spe-
also indicated a specificity in the neuropsychology field, and, cifically on ASD diagnosed participants and used a larger set
furthermore, brought to the discussion an emerging research of psychometric tests, the difference between studies’ results
area (Diamond & Ling, 2016). should be taken into consideration. Although, it was not
10 B. B. CERQUEIRA ET AL.

possible to draw conclusions on the possibility of far-trans- and Technological Development – CNPq/Brazil (http://www.cnpq.br)
fer effect to untrained abilities through inhibitory control for providing financial support for this study, process number 313311/
2019-6 and 306395/2017-7. Moreover, we extend our thanks to the
stimulation within the investigations found in this mapping
Editors and anonymous reviewers for their valuable comments, which
study, as most of these studies did not mention far-trans- helped improve the paper. Finally, we would like to thank Feevale
fer effect. University (http://www.feevale.br) and Vale do Rio dos Sinos
The present research presents limitations related to: (a) the University (Unisinos - http://www.unisinos.br) for supporting
search string selection in different research fields, and (b) publi- this research.
cations that addressed digital games still under research or
development have not been included. The search string used in
this search, with keywords variations in singular and plural
Funding
forms in the six databases, was created generically, and it does
not fit each thematic area specifically. This aspect may have This work was supported by the Brazilian Coordination for the
interfered with the results found in specific areas indexes, Improvement of Higher Education Personnel (CAPES) under the
finance code 001 and by the Brazilian Council for Scientific and
namely, keywords generally used in the physical education field
Technological Development (CNPq) process number 313311/2019-6.
for cognitive stimulation programs.
Concerning the games addressed, because of the specifi-
city of this investigation, publications that described digital
games with research still under development have not been ORCID
selected, as they would not have a post intervention phase
Bernardo Benites Cerqueira http://orcid.org/0000-0001-5362-4624
described. Thus, an investigation approaching games aimed Debora Nice Ferrari Barbosa http://orcid.org/0000-0001-8107-8675
at the inhibitory control stimulation in a general context Jo~ao Batista Mossmann http://orcid.org/0000-0003-4605-1738
should be considered in regards to their conception proc- Caroline de Oliveira Cardoso http://orcid.org/0000-0002-3720-0845
esses, development and evaluation by specialists. Games Jorge Luis Vict
oria Barbosa http://orcid.org/0000-0002-0358-2056
aimed for research may take several years to be developed
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