Thomas is feeding virtual bananas to virtual monkeys. If the banana is yellow, he presses the computer’s arrow key to feed it to the monkey. If it’s brown, he’s supposed to just wait for the next banana. “Good job, you really watched carefully,” says Susan Faja, PhD, who’s coaching him through the task.
In the next round, Thomas has to throw bananas in the trash—but only the brown ones. “Oops, I threw a good banana away!” Thomas exclaims. “No worries,” Faja reassures him, “let’s try and remember the new rule on the next one.”
Being able to inhibit impulses—even small ones—is one aspect of what’s called executive function, a set of cognitive skills that allow us to manage complex or conflicting information, solve more nuanced problems and fine-tune our behavior. Executive function also includes the ability to plan, hold information in mind, and shift flexibly between different rules in different situations. And Faja thinks that strengthening executive function could help children with autism spectrum disorder (ASD) function better socially.
Studies suggest that more than half of children with ASD have impaired executive control, even when their IQ is in the normal range or higher, says Faja, a clinical psychologist at Boston Children’s Hospital’s Laboratories of Cognitive Neuroscience.
Currently, there are virtually no interventions to enhance executive function in ASD. But earlier this year, Faja launched Gaming for Autism to Mold Executive Skills, better known as the GAMES Project, that attempts to sharpen executive function with a series of computer games—which many kids with ASD enjoy.
Gaming for autism
Executive function training through computer games isn’t new; it’s been used in typically developing children and in children with ADHD. But this is the first study to test its effects in children with ASD and examine both brain and behavioral changes.
“We think executive function and social skills are pretty closely intertwined,” says Faja. “For example, executive function helps you understand the perspective of other people, which is often challenging for children with autism. You have to hold in mind someone else’s perspective, and you may have to stop yourself from thinking about your own perspective to understand where the other person is coming from.”
As they play the games, coaches help the children think about how they’re playing, how to improve their game and how they might use their developing skills in other settings, like at school.
“As you become better at controlling your behavior, for example, you may be able to stop yourself from doing things that are off-putting to other people and instead do something that would be more appropriate in that social situation,” says Faja.
The actual training exercises—which progressively increase in difficulty—were developed by M. Rosario Rueda and Maria Teresa Bajo of the Cognitive Training Program PEC-UGR (University of Granada, Spain). The games ask children to do tasks that challenge executive function—like shifting between two different rules, withholding responses in certain situations, avoiding distracting details on the screen and holding information in mind from one screen to the next. All these activities are thought to challenge the executive function system. Coaches also work with children to develop the skills to be successful as the games become more challenging—including staying calm.
The Pirates game, for example, asks players to select the bag with the most gold coins—even if that bag is smaller. In the second phase, kids have to avoid accumulating silver coins, which are fakes, and select the smaller amount even when that bag is larger.
The Ocean Game asks children to match animals that appear in the aquarium with the identical animal at the bottom of the screen. If there’s no exact match, children must click on the animal that’s most different (in both shape and color). At higher levels, the game goes faster, and more pictures are added at the bottom to increase the amount of interfering information.
Before play, children put on a hat with dozens of EEG sensors that pick up electrophysiologic activity across the brain, including the frontal lobe areas involved in executive function. (Encouragement and practice wearing the hat, coupled with short cartoons, help kids get used to the odd sensation.) The children also have standardized behavioral assessments before and after training, and parents and teachers are asked to fill out questionnaires.
Faja hopes to enroll sixty 7- to 11-year-olds with ASD and IQs of 85 or higher in her study. Thirty children will be randomly assigned to executive function training and 30 to a waiting list. Children assigned to training will make five to ten 1-hour training visits over a six- to ten-week period. If results show the training to be beneficial, it will be offered to everyone on the waiting list after the study concludes.
“Families are really excited about what we’re doing,” says Faja. “There’s a need for developing really specific skills in children with autism that hasn’t been met yet. I think what people are responding to is that we are doing something meaningful.”