Executive Dysfunction-A Serious Game for Assessment in Real-Life Contexts: Development and Cross-Sectional Usability...

Traditional neuropsychological assessments often lack ecological validity and have limited sensitivity for detecting executive dysfunction (ED) in daily life. Although grounded in standardized tasks, they do not represent the complexity of real-world contexts. Serious games (SGs) have emerged as a promising approach by simulating ecologically valid environments involving dynamic, emotional, and socially embedded interactions.

This study aimed to (1) describe the development of a clinically oriented SG for assessing executive functioning in ecologically valid scenarios, and (2) evaluate its usability in clinical and healthy populations.

We conducted a cross-sectional usability study using a theory-driven SG set in a restaurant environment, developed through an iterative process based on neuropsychological theory and expert input. Participants assumed the role of a waiter and completed tasks targeting multiple executive domains (eg, planning, working memory, decision-making, contextual control, social cognition, prospective memory, and multitasking), with embedded emotional and social cues. A total of 181 participants (43 with traumatic brain injury [TBI], 49 post-COVID-19, and 89 healthy controls), aged 21 to 66 years, were recruited through convenience sampling from clinical and community settings. ED was classified based on standardized neuropsychological assessment and clinical consensus involving neurologists and neuropsychologists. Usability and perceived difficulty were assessed using the System Usability Scale and Perceived Difficulty Scale. Group differences were analyzed using Kruskal-Wallis tests with post hoc comparisons, and generalized linear and ordinal logistic regression models adjusted for age, sex, and education (α=.05).

A novel SG designed to support the assessment of executive functioning provides a more ecologically valid context than traditional neuropsychological tests. Usability was rated as good across groups, with mean System Usability Scale scores of 73.9 (SD 17.6) in TBI, 76.5 (SD 14.5) in post-COVID-19, and 81.7 (SD 13.5) in controls. Significant differences were observed across groups (χ²₂=9.18, P=.01), with lower usability in TBI compared to controls. Participants with ED (n=59) showed lower usability (mean difference -8.6, 95% CI -13.2 to -4.0; P<.001) and higher perceived difficulty (mean difference 1.3, 95% CI 0.5-2.1; P<.001), though these differences were no longer significant after adjusting for age and education. Age was associated with lower usability (β=-.27, 95% CI -0.45 to -0.09; P=.003) and higher difficulty (odds ratio 1.04, 95% CI 1.02-1.07; P<.001), while higher education was associated with better usability (β=.79, 95% CI 0.04-1.54; P=.04).

This study presents a novel SG integrating emotionally and socially embedded tasks to assess executive functioning in ecologically valid contexts, extending prior work through the inclusion of clinical populations and real-world demands. Findings indicate good usability and underscore the influence of demographic factors. This approach enhances the ecological relevance of neuropsychological assessment and supports its application in clinical and digital health settings. Further research should evaluate diagnostic accuracy, reliability, and real-world implementation.