Computers in Human Behavior 29 (2013) 1318–1324

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Computers in Human Behavior

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Video game training to improve selective visual attention in older adults

Patrícia Belchior a,⇑, Michael Marsiske b,⇑, Shannon M. Sisco b, Anna Yam b, Daphne Bavelier c,
Karlene Ball d, William C. Mann e
a
School of Physical and Occupational Therapy, McGill University, Canada
b
Department of Clinical and Health Psychology, University of Florida, United States
c
Department of Brain and Cognitive Sciences, University of Rochester, United States
d
Department of Psychology, University of Alabama-Birmingham, United States
e
Department of Occupational Therapy, University of Florida, United States

a r t i c l e i n f o a b s t r a c t

Article history: The current study investigated the effect of video game training on older adult’s useful field of view per-
Available online 1 March 2013 formance (the UFOVÒ test). Fifty-eight older adult participants were randomized to receive practice with
the target action game (Medal of Honor), a placebo control arcade game (Tetris), a clinically validated
Keywords: UFOV training program, or into a no contact control group. Examining pretest–posttest change in selec-
Aging tive visual attention, the UFOV improved significantly more than the game groups; all three intervention
Visual attention groups improved significantly more than no-contact controls. There was a lack of difference between the
Training
two game conditions, differing from findings with younger adults. Discussion considers whether games
Videogames
Older adults
posing less challenge might still be effective interventions for elders, and whether optimal training dos-
ages should be higher.
Ó 2013 Elsevier Ltd. All rights reserved.

1. Introduction cessing speed/efficiency by which central and peripheral targets

The focus of the current study was to examine whether off-the-
shelf video games, particularly so-called first person action video
games, could boost useful field of view (UFOV, a widely studied
measure of speed of processing and visual attention) in older
adults. UFOV yields an estimate of the size of the visual area within
which targets can capture attention during a brief inspection per-
iod, and has been shown to be negatively related to age (Ball,
Beard, Roenker, Miller, & Griggs, 1988; Sekuler, Bennett, & Mamel-
ak, 2000). The deterioration of the UFOV is characterized by a de-
crease in the efficiency with which individuals can extract
information from a cluttered scene, rather than by a shrinking of
the field of view per se. Furthermore, the decrease in efficiency is
increased when conditions require the division of attention be-
tween central and peripheral tasks (Sekuler et al., 2000). When
there is training, the primary goal of the UFOV is to improve pro-
⇑ Corresponding authors. Addresses: School of Physical and Occupational Ther-
apy, McGill University, Hosmer House, 3654 Promenade Sir William Osler, Montreal
(QC), Canada H3G 1Y5. Tel.: +1 514 398 4400x00675; fax: +1 514 398 8193 (P.
Belchior), Department of Clinical and Health Psychology, University of Florida, PO
Box 100165, Gainesville, FL 32610-0165, United States. Tel.: +1 352 273 5097; fax:
+1 352 720 5897 (M. Marsiske).
E-mail addresses: Patricia.belchior@mcgill.ca (P. Belchior), marsiske@phhp.u-
fl.edu (M. Marsiske), ssisco@phhp.ufl.edu (S.M. Sisco), ayam@phhp.ufl.edu (A. Yam),
daphne@bcs.rochester.edu (D. Bavelier), kball@uab.edu (K. Ball), wmann@phhp.u-
fl.edu (W.C. Mann).
can be identified (Ball, Edwards, & Ross, 2007).
UFOV performance appears to have practical implications:
Better UFOV has been associated with better driving (De Raedt
& Ponjaert-Kristoffersen, 2000; Roenker, Cissell, Ball, Wadley, &
Edwards, 2003) and everyday task performance (Ball et al.,
2007), and UFOV testing has been integrated into some elder
driving assessment contexts (Clay et al., 2005; Myers, Ball, Kali-
na, Roth, & Goode, 2000). It follows that UFOV improvements
are expected to be related to maintained mobility and everyday
functioning.
The UFOV test is comprised of three subtasks: speed of process-
ing, divided attention and selective attention, which build on top of
each other in complexity. Several training studies have found that
UFOV can be improved with fairly brief computer-based instruc-
tion on the criterion task (Edwards et al., 2005). Training is usually
adaptive, beginning at the lowest level of skill in which the partic-
ipant shows performance below a defined criterion. Training goals
are to increase speed of processing as well as the peripheral eccen-
tricity of detected targets. In ACTIVE, a multi-site clinical trial of
adults aged 65 years and older, initial UFOV intervention effects
were maintained up to 5 years post-intervention (Ball et al.,
2002; Willis et al., 2006).
The rationale for examining video games as an alternative ap-
proach to training UFOV-related visual attention stems from prior
research with younger adults and from practical considerations.
Studies by Green and Bavelier (2003, 2006a) and colleagues

0747-5632/$ - see front matter Ó 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.chb.2013.01.034
 P. Belchior et al. / Computers in Human Behavior 29 (2013) 1318–1324
(Achtman, Green, & Bavelier, 2008) have shown that the training of
young adult non-gamers in action video games (Medal of Honor,
Unreal Tournament) improves UFOV, as well as other aspects of
attention including attention to objects, attention in time, and
more basic aspects of vision such as reduced crowding and greater
contrast sensitivity. From a practical point of view, video game
consoles are widely available at low cost and most older adults al-
ready own a television set. Training at home, and in the context of
leisure play, might facilitate intervention compliance and increase
training dosage (Hertzog, Kramer, Wilson, & Lindenberger, 2009).
This would address challenges inherent in prior laboratory based
research. When interventions require travel to centralized facilities
during defined office hours, only more persistent or committed
participants are likely to remain compliant. Furthermore, ‘‘busi-
ness’’ hours limit the exposure time to the training program. In
addition, Park, Gutchess, Meade, and Stine-Morrow (2007) have ar-
gued that active leisure (‘‘productive engagement’’) which encour-
ages the formation of new schema will be more likely than
‘‘receptive engagement’’ (e.g., reading, listening to music) to lead
to the development of improved cognition. Furthermore, recent
work employing strategy-based video games with older adults,
has documented improvements in executive skills such as the abil-
ity to switch between task sets (Basak, Boot, Voss, & Kramer, 2008).
The mechanisms by which action video games impact visual
and cognitive skills are still unknown. It has been posited that ac-
tion video game play facilitates a general speed of processing
improvement, presumably by (a) the game demands for fast and
frequent decisions (Green, Pouget, & Bavelier, 2010), (b) the use
of a dynamic display and a rich environment to explore, (c) the
need for divided attention at all times, and (d) the rapid pace
requiring non-stop decision making (Achtman et al., 2008). In addi-
tion, Clark, Fleck, and Mitroff (2011) found that video game players
(VGPs) and non-video game players (NVGPs) use different search
patterns when exploring a visual scene. VGP are more likely to
search the visual scene broadly while NVGP are more likely to per-
severe in a given region. Furthermore, VGP require fewer expo-
sures to the change stimulus to detect its presence. It can be the
case that VGP are able to capitalize on their visual processing abil-
ities and explore larger areas of the image or alternatively they
might use a different strategy to employ a broad search strategy.
Another study found that video game playing can alter funda-
mental characteristics of the visual system such as the spatial res-
olution of visual processing across the visual field (Green &
Bavelier, 2007). The spatial resolution of visual attention was mea-
sured by the smallest distance a distracter could be from a target
without compromising target identification. Results showed that,
compared with a non-video game player, an action video game
player could tolerate smaller target-distracter distances.
Prior work employing video game interventions also suggests
that video games, due to their multimodal engagement of re-
sources, might facilitate enhancement of processing components
with more widespread consequences, which as Hertzog et al.
(2008) argue, might be particularly appropriate for individuals
with better-preserved latent cognitive potential.
The current study sought to augment the video game literature
by (a) extending a previously employed video game training ap-
proach to older adults (i.e. Medal of Honor, Green & Bavelier,
2003), (b) including a no-contact control group, and (c) including
a clinically validated training condition (UFOV training), which
has been shown to effectively enhance UFOV skills in prior studies
(Ball et al., 2002). This clinically validated group could serve as a
benchmark for gauging video game training effect sizes. This study
was also intended as a feasibility/pilot study to investigate the use
of video games to train visual attention in a group of older adults.
As such, beyond the goal of finding statistically significant training
group differences (as reported in this paper), we also sought to
1319
achieve effect size determination (as also reported in the paper)
to permit the powering of future larger scale trials.
2. Materials and methods
2.1. Ethics statement
All research was approved by the Institutional review board
(IRB02, FWA00005790, DHHS Institutional Profile Code: 513806,
Federal Entity Identification Number: 1596002052A1) of the Uni-
versity of Florida. Informed consent was obtained for all partici-
pants, and the investigation was conducted according to the
principles expressed in the Declaration of Helsinki.
2.2. Sample
As is typical for almost all studies in this field of research, the
sample was a community-solicited volunteer group from the com-
munity surrounding University of Florida. Participants’ characteris-
tics were reflective of the local community. Fifty-eight non-gamers
completed the entire study; they were generally young-old (mean
age = 74.5 years, SD = 6.7, range = 65–91), college-educated (mean
education = 16 years, SD = 2.4, high school to doctorate), and all
were White. There were 30 women and 28 men. Participants were
recruited by phone calls, by mail, and through flyers that were dis-
tributed in the community.
Three randomized participants (one from each intervention
group – MOH, UFOV, Tetris) dropped out prior to the onset of train-
ing and were not included in the analysis. No participant dropped
out after the training had initiated. Given the small sample size, it
is not surprising that there were no differences between dropout
and completing participants in age, years of education, gender,
MMSE, or visual acuity (p > .05).
As described in greater detail below, participants were random-
ized into four groups (Medal of Honor n = 14; Useful Field of View
n = 16; Tetris n = 15; Control n = 13). With an average group size of
14.5, this design was powered to detect an omnibus effect size Co-
hen’s f or 0.45 at power = 0.80. This corresponds to an eta-squared
of 0.17.
2.3. Inclusion and exclusion criteria
Included participants were (a) 65 years or older, (b) had very lit-
tle or preferably no video game usage in the past 6 months (same
criteria used by Green & Bavelier, 2003), (c) scored 24 or higher on
the Mini Mental State Examination (MMSE), (d) were willing to
participate in 6 training sessions, and (e) had visual acuity of 20/
70. Visual acuity tests were used because eye sensory function
plays an important role in UFOV test performance and training ef-
fects could be compromised by a lack of visual acuity. Participants
with composite scores of 200 (combined scores from speed, di-
vided and selective attention tasks) or lower on the UFOV were ex-
cluded from the study because of limited room for improvement
(i.e., their baseline performance already exceeded the established
criterion for training). With regard to participants’ status as novice
gamers, no participants reported playing any of console games
prior to this study. The only game that a subset of participants re-
ported playing was solitaire on a computer; those participants
were not excluded, since there was no clear association between
that game and the demands of the console game. It should be fur-
ther noted that fewer than five of 58 participants reported playing
even these simple computer games.
1320 P. Belchior et al. / Computers in Human Behavior 29 (2013) 1318–1324
2.4. Measures
Three subtasks from the UFOVÒ test were included as depen-
dent measures (same as in Ball et al., 2002). Each subtask pre-
sented stimuli at speeds ranging from 16 to 500 ms. For each
subtask, a double staircase method determined an individual’s
threshold of 75% correct performance. This value, assessed in mil-
liseconds, was the individual’s score on the task. UFOV training fo-
cus on increasing speed of processing and speed of responding is
not important. The subtasks (see Fig. 1), in order of incremental
difficulty, were:
2.4.1. Speed
This subtask required accurate identification of a centrally-pre-
sented object (two-dimensional line drawing of a car or truck).
2.4.2. Divided attention
This subtask required both accurate object identification and
simultaneous accurate localization of a peripherally-presented car.
2.4.3. Selective attention
This subtask was similar to Divided Attention, but added visual
clutter (multiple equilateral triangles that filled most of the blank
areas of the screen), requiring rapid visual search to localize the
peripheral target.
The analysis was conducted using each subscore as a separate
within-person level of a task factor. The score for each subtask
could range from 16 ms (the minimum frame rate the computer
could detect) to 500 ms (a maximum time-out criterion). Lower
scores indicated better speed of processing skills. Specifically, the
score assigned to each subtask reflected the presentation time
needed to achieve at least 75% accuracy on the central task (for
Speed) and on the peripheral task as well (for Divided and Selective
Attention).
To permit comparisons with the ACTIVE study (Ball et al., 2002),
we used the identical UFOV presentation platform as the ACTIVE
study, which was a DOS based platform, with no chin rest. The
training procedure was identical to that reported in Ball et al.
The UFOV testing and training were conducted in a darkened room,
following standardized instructions associated with that training
program.
2.5. Design and procedure
Participants were randomized to one of four groups: (1) Medal
of Honor training (MOH; target intervention for this study,
n = 14); (2) clinically validated UFOV training (Ball et al., 2002,
n = 16); (3) Tetris (placebo control) training (Green & Bavelier,
Fig. 1. Useful field of view subtasks.
2003, n = 15); or (4) no-contact control (pre- and posttest only,
n = 13). Pre- and post assessments were completed within 1 week
of interventions.
The two video game training conditions (MOH and Tetris) em-
ployed a Sony PlayStation 2 (PS2), console model 97060 and a dual
shock 2 analog controller, model 97026. The games were presented
on a 1900 TV monitor. The UFOV training was administered via a
desktop computer. A CPU was connected to a 2100 ELO touch screen.
For the three training conditions, training consisted of six 90-
min sessions administered over 2–3 weeks. Training was sched-
uled according to participants’ preferred time of day. For consis-
tency, to control time-of-day effects within subject, participants
were trained at the same time of day for all subsequent sessions.
Trainers were undergraduate student assistants who had extensive
self-reported experience with action video games. All trainers re-
ceived instruction in the implementation of the training protocol,
which was manualized. Manuals with step by step instructions
on game play were developed for both video game conditions.
For the UFOV condition, a training manual previously used in the
ACTIVE (Ball et al., 2002) study was used. Trainings were provided
individually or in groups of 2. Training is summarized below, and
full copies of the training manual are available from the authors
upon request.
For both video game conditions (Medal of Honor, Tetris), the
trainer played the game for about 10 min in order to model game
play and the requisite skills. Next, the trainer demonstrated use
of the controller to the participants.
2.5.1. Medal of Honor training
In this training, participants played the ‘‘first person shooter’’
video game Medal of Honor – Rising Sun, first with guidance from
a student trainer and then more independently. The MoH training
was conducted in a lighted room with normal office (fluorescent)
lighting, using low-glare television screens.
The MOH game is quite challenging for novice elders, so diffi-
culty level was made manageable by use of step by step instruc-
tions on how to play the game, which were presented by an
experienced trainer/coach, using a Microsoft Power Point presenta-
tion on a computer that was placed next to the participants. Train-
ing broke the game into missions, and manualized all the steps
needed to successfully solve a mission. The experienced coach/
interventionist first modeled successful game play, talking aloud
as they progressed through the mission. The coach then had partic-
ipants execute all the manualized steps themselves, starting and
stopping as much as needed, until they had successfully completed
a mission. Finally, participants played through the mission from
beginning to end, and continued to play until they had successfully
completed the mission. This shaping by steps ensured that all
 P. Belchior et al. / Computers in Human Behavior 29 (2013) 1318–1324 1321

participants could experience some progress. Trainers were avail-
able to offer guidance and support throughout game play. Once
participants had mastered a mission on their own (achieving all
mission objectives, as detailed in the training manual), they could
‘‘graduate’’ to the next mission. All trained participants experi-
enced progress in game play: 21% completed missions 1–3, 50%
completed missions 1–4, and 29% completed missions 1–5.
measure and with peripheral targets close to the center of the
screen. As participants mastered performance at that level, periph-
eral eccentricity was gradually increased to maximum, then pre-
sentation time was decreased by 40 ms, and the localization
ladder from central-to-peripheral was repeated until the training
criterion was reached.

3. Results and discussion

2.5.2. Tetris training
In this placebo training condition, participants played the video
game Tetris (Tetris Worlds for PS2, arcade mode). In the game,
which is a classic 1980s arcade game, seven randomly rendered
tetrominoes – shapes composed of four blocks each – fall down
the playing field. The object of the game is to manipulate these
tetrominoes to create a horizontal line of blocks without gaps.
When such a line is created, it disappears, and the blocks above
(if any) fall. As the game progresses, the tetrominoes fall faster,
and the game ends when the stack of tetrominoes reaches the
top of the playing field. Unlike MOH, the Tetris game scenario did
not change over the course of the following sessions. The partici-
pants had to repeat the same task over and over again; however
as game play improved, the speed of tetramino dropping increased.
It should also be noted that participants had to visually process the
tetramino at the top of the screen, while simultaneously determin-
ing the optimal position for its placement at the bottom of the
screen. Thus, Tetris required continual visual scanning and spatial
manipulation, although tetraminos were usually presented more
in the central and less in the peripheral fixation region.
2.5.3. Useful field of view (UFOV) training
For this training, a manual previously employed in ACTIVE (Ball
et al., 2002) was used. In the initial assessment, participants re-
ceived a preliminary score on the each of the three UFOV subtasks.
Participants were considered not in need of further training on a
subtask if they were scoring 30 ms or better on Speed, 40 ms or
better on Divided Attention, or 80 ms or better on Selective Atten-
tion. Training began at participants’ current skill level, starting at
the most challenging level (speed followed by Divided Attention
followed by selective attention) at which the participant was per-
forming worse than the pre-specified training criterion. Within a
given task, training started at roughly the presentation time at
which they performed with high accuracy (75%) on the screening
3.1. Assessment of baseline differences between treatment groups
An analysis of variance was conducted to determine whether
there were differences between the four intervention groups in
demographic status, age, years of education, gender, race, cognitive
status (MMSE), and visual acuity. The omnibus test revealed that
there were no significant differences between the four groups, sug-
gesting that randomization had distributed participant characteris-
tics similarly across the groups. Table 1 shows the characteristics
of the sample on the variables assessed, both for the total group
and by intervention subgroup. P-values shown reflect the absence
of a significant overall difference between groups.
3.2. Training effect on visual attention
In UFOV training, goal performance on the Speed subtask is
630 ms and on the Divided Attention subtask 640 ms. Preliminary
analyses revealed that the majority of participants were perform-
ing at or better than this criterion on the Speed (93%) and Divided
Attention (53% at 640 ms) subtasks at baseline. In contrast only
one participant (1.7%) was at or below the 680 ms training goal
for Selective Attention. This applied to all groups, and meant re-
duced sensitivity to change for these first two outcomes.
A 3  2  4 ANOVA was conducted with two within-persons
factors (UFOVÒ Task: Speed, Divided Attention, Selective Attention
and Test: Pretest, Posttest) and one between-person factor (Train-
ing Group: Medal of Honor, UFOV, Tetris, no-contact). A significant
main effect was revealed for Test (prepost), F(1, 54) = 23.49,
p < .001, g2 = .30, Cohen’s f = 0.65 and UFOVÒ task,
F(2, 108) = 178.36, p < .001, g2 = .77, Cohen’s f = 1.83 but no signifi-
cant main effect was found for Group, F(3, 54) = 1.27, p = .294,
g2 = .07, Cohen’s f = 0.27. A significant two-way interaction effect

Table 1
Sample characteristics both for the total group and by intervention subgroup.

Total sample (N = 58) MOH group (N = 14) UFOV group (N = 16) Tetris group (N = 15) Non contact (N = 13) p-Values
Age .81
M 74.7 74.8 73.7 75.8 73.7
(SD) (6.4) (6.3) (6.2) (8.5) (5.3)
Education .72
M 16.0 15.8 15.6 16.5 16.3
(SD) (2.4) (2.5) (2.6) (2.6) (1.7)
Sex .33
Male
N 28 9 5 7 7
(%) (48.3) (64.3) (31.2) (46.6) (53.8)
Female
N 30 5 11 8 6
(%) (51.7) (35.7) (68.8) (53.4) (46.2)
MMSE .42
M 29.8 29.2 29.2 29.4 29.0
(SD) (5.2) (.97) (1.5) (.91) (1.2)
Vision .26
M 85.2 87.2 86.8 86.3 79.6
(SD) (11.5) (5.9) (3.9) (5.1) (22.3)
Snellen equivalent
20/18 20/17 20/17 20/17 20/20

Note: MOH = Medal of Honor; UFOV = useful field of view; MMSE = Mini Mental State Examination.
1322 P. Belchior et al. / Computers in Human Behavior 29 (2013) 1318–1324

Table 2
ANOVA summary tables for three visual attention outcomes.

Source df Speed Divided Attention Selective Attention

2 1 2
F g /f F g /f F g2/f
Between-subjects
Group (G) 3 0.75 0.04 /0.20 1.77 0.09 /0.31 0.94 0.05/0.23
Error 54 198.84 7020.19 21436.67
Within subjects
Test (T) 1 2.74 0.05 /0.23 5.93* 0.10 /0.33 26.49*** .33/0.70
Group  Test 3 1.45 0.08 /0.29 1.05 0.06 /0.25 4.49** .20/0.50
Error 54 183.64 2255.33 2881.05

Note: values enclosed in parentheses represent mean square errors. g2 = partial eta squared, f = Cohen’s f, estimate of effect size.
*
p < .05.
**
p < .01.
***
p < .001.

Table 3
Change of useful field of view performance by group from pretest to posttest.

Measure Training group

UFOV (n = 16) Medal of Honor (n = 14) Tetris (n = 15) No-contact (n = 13)
Pretest Posttest Pretest Posttest Pretest Posttest Pretest Posttest
UFOV speed
M 19.88 16.94 18.29 19.43 20.13 18.53 30.15 16.85
SD 5.48 2.11 3.27 4.22 8.92 3.62 39.17 2.15
UFOV divided
M 41.69 24.56 85.36 43.43 95.73 66.67 61.92 63.92
SD 20.52 11.55 86.24 37.96 100.61 70.68 72.98 92.01
UFOV selected
M 209.00 118.63 225.64 172.64 256.93 185.33 209.54 218.69
SD 54.44 72.71 114.76 108.39 131.91 119.85 114.22 148.38

Note: Lower scores represent faster (better) performance. M = mean, SD = standard deviation, UFOV = useful field of view.

was revealed for Test  UFOVÒ task, F(2, 108) = 11.44, p < .001
g2 = .18, Cohen’s f = 0.47, but no significant interaction effects were
revealed for UFOVÒ task  Group, F(6, 108) = .945, p = .467, g2 = .05,
Cohen’s f = 0.23 or Test  Group, F(3, 54) = 2.37, p = .081, g2 = .12
Cohen’s f = 0.37. All lower order effects were qualified by a signif-
icant three-way interaction: Test  UFOVÒ task  Group effect,
F(6, 108) = 3.40, p < .004, g2 = .16, Cohen’s f = 0.44.
Followup univariate ANOVAs were conducted for each UFOVÒ
task (Speed, Divided Attention, Selective Attention). Main effects
and interaction of Test (2: pretest, posttest) and Group (4: Medal
of Honor, UFOV, Tetris, no-contact) were examined, as summarized
in Table 2. As Table 2 and the means/standard deviations in Table 3
show, for Divided Attention and Selective Attention, faster posttest
performance for all groups produced the Test main effect.
To decompose the Test-  -Group interaction for the Selective
Attention task, a simple effects post-hoc analysis compared pre-
post change by group; results showed greater improvement for
(1) UFOV-trained participants than controls, t(54) = 3.51, p = .001,
g2 = .19, Cohen’s f = 0.48, Cohen’s d = .99, (2) Medal of Honor-
trained participants than controls, t(54) = 2.13, p = .038, g2 = .08,
Cohen’s f = 0.29, Cohen’s d = 0.59 and (3) Tetris-trained participants
than controls, t(54) = 2.81, p = .007, g2 = .13, Cohen’s f = 0.39, Co-
hen’s d = 0.77. None of the three intervention groups differed from
one another (all ps > .05). Table 3 demonstrates that UFOV-trained
participants gained about 90.34 ms in Selective Attention, while
Medal of Honor and Tetris gained about 53.00 and 71.60 ms respec-
tively. Control participants, on the other hand, performed about
9.15 ms slower at posttest than at pretest. If Bonferroni corrections
had been used to keep family-wise error rates below .05, only tests
with p-values of .008 and lower would be judged significant, mean-
ing that the Medal of Honor effect would not be judged significantly
greater than controls.
4. Conclusion
The current study findings are promising but should be inter-
preted with caution due to low sample size, minimal training dos-
age and the lack of racial/ethnic diversity in the sample. Clearly,
generalizability of the current findings to a larger and more diverse
population of elders is a necessary goal for future research. This
study, which employed action video games to train older adults’ vi-
sual attention skills, partially replicated previous findings with
younger adults (Green & Bavelier, 2003), in that playing a first-per-
son shooter game was associated with significant improvement in
selective visual attention relative to no contact controls. Unlike in
the younger adults from the Green and Bavelier (2003) study, Tetris
play (an arcade puzzle game utilized as a placebo control condi-
tion) also improved selective attention in our older adult sample.
All participants were novice players; thus, no participant reported
playing any of console games prior to this study.
The UFOV training program produced marginally (but not sig-
nificantly) greater improvement than the video games, which
was expected given high isomorphy between the training condi-
tions and the tests used to evaluate change. Unfortunately, the
low sample size in this study compromised the power to detect dif-
ferences among the training conditions. The biggest surprise in this
study was the apparent effect of Tetris play on selective visual
attention, which was not observed in the Green and Bavelier
(2003) study with younger adults. Speculatively, given that Tetris
appears to demand whole-screen scanning and mental rotation
which, for non-gamer older adults, may have been sufficiently
 P. Belchior et al. / Computers in Human Behavior 29 (2013) 1318–1324
challenging to produce the observed selective attention
improvements.
Anecdotally, Tetris may also have inadvertently conferred a
higher training dosage than Medal of Honor. Trainers observed that
Tetris was easier for elders to learn, such that participants may
have spent less time learning the game mechanism and engaged
in more active play than in Medal of Honor. Similar findings have
been reported in adults with amblyopia; both Medal of Honor and
the non-action game Sim City improved visual attention and acuity
(Li et al., 2008). Also, it is possible that participants were more en-
gaged in the Tetris game, which is a puzzle-like game that might be
more appealing to an older adult population than a first person
shooter game.
A special question emerging from the current investigation is
why the Tetris condition might have produced UFOV improvement
in older adults, when it did not in younger adults (Green & Bavelier,
2003)? The answer likely includes the idea that our participants
were older and were gaming novices. For novice older adults
(who play Tetris against a backdrop of declining speed and percep-
tual abilities), Tetris likely offered a much higher level of percep-
tual, cognitive and motor challenge than it would for younger
adults. The perceptual and motor demands of making relatively
fast responses to falling blocks (novel stimuli requiring mental
rotation), the need to divide attention between the falling object
and the receptor site (located at different vertical ends of the
game), the need to predict where the falling object would best
fit, and the game-delivered feedback of decisions (‘‘clearing a
row’’ or failing to do so) likely all contributed to making Tetris
much more of an ‘‘action’’ video game for older adults than it
would have been for younger participants.
As a preliminary study with relatively few participants, the
current investigation can offer relatively little insight into the
mechanisms or mediators of our video game training effects on
UFOV. The growing literature in this area, however, suggests sev-
eral speculative reasons regarding why video games might be
effective. These include: (1) improvement in basic speed of pro-
cessing (video games demand rapid and accurate response to
transient objects with fast velocity; as participants increase
speed in game play, this may generalize to speed in other tasks
(Edwards et al., 2005; Roenker et al., 2003 & Dye, Green, & Bave-
lier, 2009a); (2) improvement in executive control (video games
require balancing among a large number of concurrent demands,
including fast response, high cognitive/perceptual/motor loads,
peripheral and central visual field processing, predicting what
may happen next, maintaining items in short-term memory, ra-
pid task switching, and reasoning); practice with coordination
may then generalize to the coordinative demands of UFOV
(Green et al., 2010; Scalf et al., 2007 & Anderson-Hanley et al.,
2012); in general, ‘‘gamification’’ increases the need to engage
high-level planning and spatial working memory (Green & Bave-
lier, 2012). (3) improvements in attentional control, including
improvements in both the spatial and temporal operation of
attention (Donohue, Woldorff, & Mitroff, 2010; Dye, Green, &
Bavelier, 2009b; Green & Bavelier, 2006b; Hubert-Wallander,
Green, & Bavelier, 2011); (4) improvements in the ability to
quickly perceive the relations between multiple objects and
events, since video games require differential response to differ-
ent virtual objects; this may generalize to the simultaneous per-
ceptual identification and object localization demands of the
UFOV selective attention task (Green et al., 2006a; Basak et al.,
2008); (5) an fMRI study suggests that UFOV practice may in-
creases activation in the right inferior frontal gyrus and right
precentral gyrus; this raises the question of whether video game
play might also increase activation in brain regions associated
with the ability to recruit and re-orient stimulus-driven atten-
tion to novel and unpredictable target locations outside the cur-
1323
rent focus of attention (Mishra, Zinni, Bavelier, & Hillyard, 2011;
Scalf et al., 2007; West, Stevens, Pun, & Pratt, 2008); (6) practice
in the specific skills needed for UFOV performance (fast re-
sponse, whole field visual search, feature matching)—this argu-
ment suggests that video games share enough processing
feature with UFOV that transfer would be expected based on
the law of identical elements (Thorndike, 1913); and (7) motiva-
tion/arousal/engagement/reward/feedback/enjoyment
(Csikszentmihalyi, 2008) (for example, in another study, we
found that Tetris and Medal of Honor play were associated with
increases in perceived flow (Belchior, Marsiske, Sisco, Yam, &
Mann, 2012) throughout the period of training, something that
was not true for traditional UFOV training; might this suggest
that high levels of engagement and effort mean that games
encourage older players to ‘stick with it’ and ‘try harder’, and
that these factors contribute to the training potential of games?
This motivational interpretation is consistent with recent work
by Anderson-Hanley et al. (2012), who showed that video-game
based exercycling was more effective than traditional cycling in
boosting executive function in older adults. The authors argued
that the enjoyment and motivational value of games, including
visual stimulation and personal challenge to beat previous per-
formance levels, may make them particularly potent intervention
tools. If the games maximize engagement, individuals may exert
maximal effort.
While the present study used a randomized experimental design
with more control conditions than previous research (i.e., Tetris as
control game, gold-standard training condition, and no-contact con-
trols), given our sample of healthy, educated, White older adults,
many of whom were performing quite well at baseline, the general-
izability of findings is limited. Other studies using participants with
slower baseline processing have found much larger training effects
(Edwards et al., 2005). The modal intervention dosage of 6–9 h
was brief, especially for the MOH condition, in which necessary
‘‘game learning’’ reduced time spent actively playing the game.
Future research can expand on the current findings in several
key ways: (a) recruitment of a more ability-diverse sample with
fewer high performers at baseline; (b) increase of exposure dosage
or additional dose-response studies to determine optimal amount
of game play needed to produce larger and broader visual attention
training effects; and (c) expansion of the outcome battery to exam-
ine possible transfer effects and game differences in transfer to
other measures of visual attention, spatial cognition, and everyday
function. In addition, more work aimed at identifying the processes
by which games improve visual attention and other cognitive skills
are necessary. The present study contributes to the growing body
of intervention work, termed ‘‘third generation’’ by Hertzog et al.
(2009), aimed at capitalizing on neural plasticity and boosting
underlying cognitive-behavioral processes that might generalize
to novel environments. Findings suggest that ‘‘off-the-shelf’’ video-
games may be one accessible vehicle for achieving cognitive per-
formance improvements in older adults.
Funding
This research was supported by the National Institute on Dis-
ability and Rehabilitation Research Grant H133E010106 awarded
to W.C.M. Patricia Belchior’s work on the manuscript was also sup-
ported by a Supplement to Enhance Diversity Grant U01-AG-
014276-S1 to M.M. Anna Yam was supported, in part, by Robert
Wood Johnson Foundation Grant 64441 to P.B. Additional study
support in the form of discounted software licenses was provided
by Systems Technology Inc. (http://www.stisimdrive.com/) of
Hawthorne, CA. The funding sources had no involvement in re-
search design, data collection or data analysis.
1324 P. Belchior et al. / Computers in Human Behavior 29 (2013) 1318–1324
Acknowledgments
We acknowledge the support of undergraduate colleagues at
the University of Florida who assisted with data collection and
training activities. These include Jason Bendezu, Eric Gonzalez-
Mule, Brian Huei, Matt Mustard, Sean Weisbrot, Emily Ricketts,
and Claudia Ramirez. We also thank Jason Rogers for technical
and IT-related support with this Project.
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