Turning Off-The-Shelf Games into Biofeedback Games
Regan L. Mandryk, Michael Kalyn, Yichen Dang, Andre Doucette, Brett Taylor, Shane Dielschneider · 2012 · Proceedings of the 14th International ACM SIGACCESS Conference on Computers and Accessibility (ASSETS 2012) · doi:10.1145/2384916.2384952
Summary
This demonstration paper presents two systems that convert existing commercial off-the-shelf games into biofeedback (BF) training games for people with cognitive impairments. Biofeedback training — particularly neurofeedback using EEG — has been shown effective for helping children with ADHD and fetal alcohol spectrum disorder (FASD) learn to self-regulate brain function. However, purpose-built BF games have critical limitations: they are expensive to create, tend to be simplistic "toy applications" that fail to hold user interest over the long-term repeated sessions required for training effectiveness, they offer limited game genre choices, and users cannot select which physiological system to train independently from their game choice. The key innovation is decoupling BF sensing from gameplay by overlaying feedback on top of any existing game. The desktop system applies texture-based graphical overlays (such as frost, web, or grime patterns) that progressively obscure the game screen when the user is not in the desired physiological state — maintaining the desired state keeps the view clear. The mobile system uses an iPhone companion device to provide audio or vibration feedback about physiological state while the user plays any game on a separate screen. Both approaches use EEG sensing hardware to monitor brain activity.
Key findings
The two systems demonstrate that biofeedback training can be effectively decoupled from game design, allowing users to train with any game they find engaging. The desktop overlay approach provides intuitive visual feedback — as users achieve the desired mental state (e.g., relaxation or focus), the overlay clears and they can see the game better, creating a natural reward loop. Multiple overlay textures can be customized per game to maintain visual coherence (e.g., frost for Portal, dirt/grime for Nail'd). The mobile approach enables multimodal BF feedback without modifying the game at all, using a separate device for audio or vibration cues. Both systems allow users to choose which physiological state to train (relaxation, focus, etc.) independently of the game, addressing the limitation of purpose-built BF games where the training target is hard-coded. BF training has been used to help people with Asperger's Syndrome, reduce seizure frequency in epilepsy patients, and treat ADHD in children with FASD — the most prevalent cause of intellectual impairment in the western world, affecting an estimated 3-10 per 1000 live births.
Relevance
This paper addresses an important intersection of gaming, assistive technology, and cognitive rehabilitation. For accessibility practitioners, it demonstrates a generalizable design pattern: rather than building specialized accessible applications from scratch, overlay or companion approaches can add therapeutic or accessibility features to existing mainstream technology. This mirrors the broader accessibility principle of augmenting rather than replacing mainstream experiences. The work is particularly relevant for children with FASD and ADHD, populations that need sustained engagement with therapeutic interventions — leveraging games they already enjoy solves the motivation problem that plagues purpose-built therapeutic tools. The decoupling of physiological training from gameplay also supports personalization, allowing clinicians or caregivers to prescribe specific training targets while letting users choose their own entertainment. As consumer EEG devices have become more affordable and accessible since 2012, the practical feasibility of this approach has only increased.
Tags: biofeedback · neurofeedback · EEG · cognitive impairment · ADHD · fetal alcohol spectrum disorder · FASD · self-regulation · game accessibility · serious games