It’s easy to forget that we are part of nature. But, we are living, breathing organisms. We are walking biomes. This season, Dr. Sanjay Gupta explores the science of YOU by traversing the boundary between our bodies and the world around us. Discover why we feel refreshed after visiting the ocean, how our gut helps us maintain homeostasis, and the evolutionary root of bad dreams. Listen each week as Dr. Gupta helps listeners uncover what mindful, healthy living really means.
What if instead of pills to cure your ailments, you were prescribed a video game? At Akili Interactive, researchers are trying to do just that. EndeavorRX is the first FDA-cleared video game for medical treatment, in this case ADHD in children. We dive into the science behind the treatment and how video games have the potential to be used for other cognitive dysfunctions, including autism, depression and multiple sclerosis.
You hear the sound of a video game called Endeavor RX. Read also : This new Netflix show just beat out Stranger Things. And 13-year-old Owain is a big fan.
The whole point of the game is to catch these little creatures and bring them back to your little home base. And when you achieve those goals, you’ll be rewarded.
But here’s the thing, Endeavor RX isn’t just any video game.
I was shocked there is a real video game that could help with ADHD.
That’s correct! It’s a game that doctors prescribe to treat two types of Attention Deficit Hyperactivity Disorder – ADHD – in children. Ever since he was very young, Owain says he’s struggled to do things that come easily to others.
I would switch off at times when I really just wasn’t interested in class or any work, but I wouldn’t just switch off. I would imagine it as my own little paradise, my reality. And I would just be there for a very long time and not know what’s going on.
Before school, we would have to wake him up about an hour and a half before school.
And he just stared at a blank wall for like five or ten minutes before he did anything. And then you’d have to go, hey, focus, mate, put your pants on. And an hour and a half, and he was still running out of the house with the shoes barely on his feet.
At first they tried therapy and medication.
That’s when we found out he had pediatric migraines that made him vomit.
Owain just couldn’t take the drugs, and Kelcey felt they were out of options. Until she heard about this video game.
I mean it was incredible. I mean it really gave us a very different life than what we had.
Now you’re probably thinking that video games get a pretty bad rap. Some of them can become violent and as a parent I know they can be very addictive for children… Even adults I’ll admit it! Well, it turns out games can be good too. So in this episode we’re going to explore a brand new form of medicine, one that you can download onto your iPad… One that not only treats the symptoms of ADHD, but also seeks to remodel the underlying brain circuitry that is at the core of it problems. i am dr Sanjay Gupta, CNN’s Chief Medical Correspondent… Pick up your video game controller. It’s time to chase life.
It’s an incredibly exciting moment for us to be taking a video game through this FDA process, for the first time ever, that took place during COVID. For me it was the silver lining of a really challenging time.
This is Doctor Adam Gazzaley. He’s a neuroscientist. He is also co-founder of Akili Interactive. This is the company that developed Endeavor RX, the prescription video game that received FDA market approval back in June 2020. It is designed as a treatment for children between the ages of 8 and 12 with ADHD. Adam also runs a lab called Neuroscape at the University of California, San Francisco. There he and his team are researching how technology can be used to improve cognitive functions…processes like attention, memory, perception and more. I visited Adam’s lab in 2016 and saw her work first hand. Adam and I recently had the opportunity to meet again.
You know it’s interesting. I think I mentioned that to you when I first saw you in your lab a few years ago. Me, I tend to get very addicted to things, video games. In fact my wife bought me a PlayStation many years ago and I had to return it Adam because I realized what was happening. I played for a whole weekend.
I sympathize with that. I’m also quite addicted to video games.
Did you, I mean did you grow up playing games in some way? Are you still playing?
I did. I think we’re about the same age. I grew up with Atari and all those early games like Asteroids and Space Invaders, the beginnings of the genre. And then, yes, I played, I stopped playing during med school and residency because I was too busy. But I, you know, then when mobile devices came out, I liked to play the little, you know, games on my iPhone. So yeah, I’ve played video games for most of my life.
That’s not the focus of this podcast, but as you know, actually a lot of people still do, and I and I still do that sometimes, you know, pull out my phone when I’ve got any idle time, on a flight or so wait and play. Good idea? Bad idea? Helpful? Not helpful?
Challenge and our brain really are best friends. Our brain doesn’t like passivity. The idea of just retiring and doing nothing is not good for your brain. And obviously, too much stress can have harmful effects. But the question will be, do you know what are the benefits? Do the benefits make sense? Are you persistent? And, you know, there’s research literature showing that even consumer video games have cognition benefits. And that was an inspiration to me, because if a game designed just to have fun can show cognitive benefits, how much better could we do if we made a game that relied on neural networks with adaptive algorithms that try to improve cognition?
So that’s what Adam did with basic neuroscience at heart.
The core principle is that our brains have this phenomenon known as neuroplasticity, and that it can change itself, changing its function, its structure, even its chemistry in response to experiences. And it is in many ways the oldest medicine for the mind. Things like meditation and mindfulness have been used to bring relief from mental suffering for thousands of years. And what we’ve done both in my research at UCSF and now at Akili Interactive is pushing that concept of what I consider experiential medicine – experience as medicine to improve brain function. And having the ability to use technology to create very personalized experiences where the challenges and rewards are geared towards that person. And then to be able to do very thorough, randomized, controlled testing, much like pharmaceuticals and drugs do. And so you have all these advantages of modern technology, and then you combine it with this ancient experiential practice as medicine, and you end up with a new kind of treatment with a video game as medicine.
I think I think when I was back at your lab in California I played some of the games and I remember having to multitask. And and and that wasn’t easy. I mean I felt like it was a challenge. Was this the forerunner of what eventually became Endeavor RX today?
So you know that the first version of this game was back in 2009 and it was called NeuroRacer. And the research on this became the subject of a scientific paper published in Nature, showing it could be beneficial for older adults and their attentional skills. And eventually it became what we now call Endeavor RX, a much better game from an art, music, story, interactivity point of view, the game that a 12 year old could really enjoy. What is interesting, however, is that the core mechanics of the game have remained the same since 2009. This is the active ingredient of our medicine. So the cool thing is that we can build all the elements around that core that make it more fun and cater to different audiences.
You know, I’m wondering when you started thinking about it, how did you initially think about it? You know, if you’re thinking of taking a cholesterol-lowering drug, for example, it might do something to lower the amount of cholesterol your liver makes, or it might pull cholesterol out of your gastrointestinal tract. So you have some sense that the mechanism may or may not work, but you have an idea of what you’re trying to do when it comes to looking at these technologies as video technologies, as therapeutics. How did you first think about it?
Like 14 years ago, as you know, I was studying the aging of the aging brain, and I had been studying attention. And we have shown, and many others have shown, that when you engage in a particular experience, the networks in your brain are activated in a very selective way. That’s the underlying principle of how the brain works, something we’ve never achieved with the drug before is this kind of selective activation of brain networks. So we know that interacting with the environment can selectively activate the brain. And since we know the brain is plastic and responsive and optimizing its function, you get the selective network activation when you create an environmental interaction. And then, by challenging at higher and higher levels as the brain continues to optimize its function, you can continue to develop and hone your skills. And that was really the hypothesis that because an experience activates brain networks selectively, we would get a lot fewer side effects than our current treatments for the brain, which activate the brain quite blatantly without the selectivity. And because the brain has this trait of learning over time, we would see improvements as a person engaged over a period of time.
All in all, Endeavor RX’s closed-loop system is key. This is a technical term. This means that the game adapts to the player’s abilities in real-time as the player plays.
This is a very important part of our video games that differentiates them from consumer games. And then you improve over time. But if you don’t get better outside of the game, which we call transfer, then you can’t really consider it as something that would fall under the medical category. And so the hypothesis, based on our research and many other labs, was that we’ve shown that there are common brain networks that exist between things like attention and things like short-term memory and multitasking, task switching. So if you can improve any of these skills through a very high level in-game challenge, the hypothesis was that you would see benefits in using your brain outside of the game. And that’s what we’ve shown and continue to show over the years, and that’s the key point that takes it beyond entertainment to something that we could imagine as medicine.
So you’re not just getting better at the game. You have these things, which are then transferrable.
After several studies totaling more than 600 children, Adam and Akili’s team submitted their game to the U.S. Food and Drug Administration to treat ADHD. A little over two years ago, the FDA approved the video game, and it’s now available by prescription as part of a comprehensive treatment program for children ages eight to 12. How exactly would the process work for a concerned parent who has a child with ADHD?
I hear it all the time when a friend says their kid is ten years old and doesn’t respond to medication or they don’t want, you know, they want something else, it’s doctor prescribed and available as medication, just like is a stimulant for the same condition. And it would be something that can be downloaded to their own device. I think that’s really important because it helps with accessibility, you know, we don’t have to ship devices to everyone in need, most people have a phone or a tablet. And then they would be given a path of engagement where they would play 30, about 30 minutes a day, five days a week for a month. And that’s one dose of this drug. And they would receive the challenges and rewards the game offers them, which put pressure on the neural networks involved in attentional control. And as our data and many different studies have shown, even in this population, their ability to focus their attention in boring environments, rather than the gaming environment, improves.
Is there a way to describe to the non-neuro audience what happens in the brain with this type of therapy?
Yes. So how our brain works when it comes to paying attention is that the front part of our brain, the prefrontal cortex, which is the most developed part of the human brain, makes connections with the other areas of the brain. We call these neural networks. So when you look at something, there is a network between your prefrontal cortex and the visual area. And these networks are involved in focusing your attention and interfering with the world around you based on your goals. What we see after the gameplay, a month of gameplay, is that the network strength is increased. So the ability of you to activate your brain in that way, to focus attention, is at a higher level, you know, not quite the same as going to the gym and, you know, using a weight and seeing how Your muscles will get bigger, but not dissimilar. That you use that muscle in your brain every day and you know you have the best personal trainer built into the game, constantly pushing you to the limit of your abilities. So if it’s too easy, just push it a little bit harder. And after all that, you have this stronger muscle, your brain, and you can focus your attention more effectively.
Now, understandably, there are critics who said they didn’t think the game’s perks would translate to real-life skill improvements. But people like Kelcey, the mother of Owain Sihanourath, were desperate for new opportunities.
As soon as it was approved, I sat down with my husband and I was like, hey, you know, the FDA says this is approved and we should try it. And I showed them a little ad about it, and he said it’s a game. i thought i know But it’s like, well, let’s just try. What have we got to lose? It’s not like it makes him any worse.
So Kelcey quickly arranged for Owain to get a prescription for Endeavor RX from her pediatrician. Akili Interactive connected us with them for this episode.
So we sat down with Owain and we talked about, you know, hey mate, that’s what’s the matter with you. Instead of going from point A to point B, you go from point A to Z to the number four. And if at some point someone reminds you to go to B, you get there. And he says okay. This game will help your brain learn how to get from A to B. It will take practice and it will be something to work towards. But it’s a video game, you know, he’ll like that.
Together, Kelcey and Owain made a list of tasks for Owain to attempt to complete as his alertness improved. Things like…
Don’t forget your water bottle at school. And then I had a list of, I think one of my things to do was empty the dishwasher in less than an hour.
Owain played the game five days a week, 25 minutes every day for several weeks. He then paused before continuing with another round of treatment.
So at first it was ok, but then we got into the second and third levels where it’s like you have to click on multiple creatures and they have different shapes and colors this time while you have to dodge like potholes and hit certain power zones. Very difficult.
There were days when he wanted to give up. He wanted to stop playing because it was so hard.
I tried glitch liking the system. I was actually trying to find glitches to skip certain levels so I didn’t have to keep playing.
But with his mother’s support, he continued. And after just a month, Owain was already showing real-world progress outside of the game.
I still remember the day I realized it worked. We sat on the couch waiting for the bus and we had about 30 minutes for the bus to get there which I noticed. I thought, Wow, we’re not running out the door. And I looked over and my son had his shoes tied. I mean even now it brings tears to my eyes to think of how that boy was, he didn’t, he wouldn’t even put his shoes on his right foot most mornings. And here it is, 30 minutes before we have to leave. And he already tied his shoes, you know, like, oh my god, it was such a big, big moment. And when I try to explain it to people, most people say, well, okay, he should be able to do that anyway. And I think he should, but he couldn’t and now he can. And that’s like, it’s life changing.
Owain is now 13 so he is no longer eligible to play the game but is still fine.
I’m so proud of him. This is a kid who flunked third grade and didn’t do well the second time. And now he’s AB Honor Roll. And you know, it’s not like Endeavor made my kid any smarter. Endeavor helped my child have the tools to facilitate their own learning.
The irony is that video games have always been thought to be the only thing kids with ADHD can focus on, often to the detriment of everything else. But now one of Owain’s favorite things to do is also what has helped him control his attention span.
I didn’t really notice it at first. As if I thought everything was still the same. But at some point I realized that I’m not like that, forgot to get my pens during class or left my lunchbox behind. I mean, I forgot my pencils the whole time. This was such a big deal because I was only going to bring a pen to school. These little bugs were very frustrating. Now that I remember keeping up with my stuff, that was really cool. I was very, very proud of myself.
When we come back, Adam and I will be discussing how video games could help even more of us in the future.
In ten years we’ll have another whole new industry like pharmaceuticals apart from video games as medicine.
But first, speaking of games, I want to help with something. We have an upcoming episode all about gaming and we’d like to hear your thoughts on it. What ways have you found to keep the concept of play from your childhood alive in your adult life? Record a voice note and email it to AskSanjay@cnn.com…or call us at 470-396-0832 and leave a message. And now back to Chasing Life.
Yes, this is our treatment software that we will demonstrate to you.
I do not think so. This adapts to everyone, so over time it adapts to your abilities.
In 2016 I caught up with Adam and the team at Akili to try out this new game they were developing… A prototype for what would eventually become Endeavor RX.
I gotta tell you, between piloting the ship and catching the characters, the game wasn’t exactly easy, but it was fun. And I wondered what’s next?
Well, Akili’s immediate path, which probably won’t come as much of a surprise to a listener, is to expand the age range. Right. Because ADHD is not limited to 8 to 12 year olds. There are many adults who suffer from ADHD, including the elderly. And then there are other conditions that have attention deficit disorder, even though they may not have it in the name, like ADHD, for example, depression, autism, multiple sclerosis. These are all conditions for which we already have data on the benefits of attention with Endeavor RX in these populations. Therefore, we will expand the indication to other populations of individuals and inform you of greater and broader applicability of this treatment.
What about the healthy brain? How about the idea of thinking of this as a supplement or as an optimization tool?
Who Needs Better Attention Skills? Who doesn’t want to remember or meet things better, you know, and even go beyond that, make better decisions, feel more empathy, regulate their emotions better, you know, more effectively. And can this be a preventive measure? Can it be the kind of things you would ingest as you get older to keep your brain healthy? I believe all of this is possible. And we have data to support that. And that’s one direction we’re very interested in expanding these offerings.
You know, it’s interesting that you specified the nature of the background and what inspired some of your earliest work. You know, when you’re talking about a therapeutic specifically, and in this case for kids with ADHD, that’s pretty incredible. I mean, it seems like there’s a tremendous need there, but there’s also medicine. Have you tried to solve an unmet need? Have you been frustrated with existing therapies or have you been driven by something else?
Yes, I’m really glad you said that. You know, the two main inspirations in the early days when I started this work was one that I saw that there was a way to use technology and use neuroplasticity to lead to benefits. But the other was the tremendous need that exists in just about every neurological and psychiatric disease that affects the mind. Whether we’re talking about memory, cognition, attention, emotion regulation, stress regulation, or even moving outside the, you know, clear medical realm of things like empathy and compassion and decision making. All of these skills are missing and unoptimized in my opinion. I call this a realization crisis that what I think we’re in is global. And I was very frustrated and still am frustrated that the main paradigm in medicine for the mind today is that somewhere out there is this magic brain pill that will just fix the problem and we just have to find it but , but it is there. And you know, we’ve been doing this for 70 years, right? Trying to find something and schizophrenia is gone, autism is gone, depression is gone, alzheimer’s is gone. We didn’t succeed. But the time has come for us to explore other avenues to improve brain function.
In the meantime. To be clear, Adam doesn’t think video games will completely replace pills or other drugs.
You know, I think it’s going to happen that the drugs that we use today to treat everything from depression to anxiety and so on to Alzheimer’s disease will be used in lower doses so they have fewer side effects, but they are not used in isolation. They are used to activate these neurotransmitter receptor systems but without the specificity. And then experiential medicine, that is, I would say a video game treatment is a version of it, is used to put pressure on these selective neural networks so that these drugs can actually be used better and more selectively. I think they would work well together.
Of course, it is always difficult to predict what will actually happen in ten, five or even a year. But it’s encouraging to know that some of our brightest minds are working on this issue, minds like Adam Gazzaley. And that one day maybe we can all benefit from this research in some way. Let us know what you think of this episode. Did you learn something new? I definitely have. Record your thoughts as a voice memo and email them to AskSanjay@CNN.com or call us at 470-396-0832 and leave a message. You can also tweet me @drsanjaygupta. this is dr spells DR We may even include your responses in an upcoming episode of the podcast. We’ll be back next Tuesday. Thanks for listening. Chasing Life is a CNN Audio Production. Megan Marcus is our executive producer. Our podcast is produced by Emily Liu, Andrea Kane, Xavier Lopez, Isoke Samuel, Grace Walker and Allison Park. Tommy Bazarian is our engineer and special thanks to CNN Health’s Ben Tinker, Amanda Sealy, Carolyn Sung and Nadia Kounang, and CNN Audio’s Rafeena Ahmad, Lindsay Abrams and Courtney Coupe.
