JMIR Publications

ABSTRACT

Background:

Traditional neuropsychological assessments often lack ecological validity and are limited in detecting executive dysfunction (ED) as it occurs in daily life. These tools rely on structured tasks and fail to capture the complexity of real-world contexts involving dynamic, emotional, and socially embedded decision-making. There is growing demand for assessment tools that incorporate context-rich and emotionally salient situations to improve sensitivity and clinical relevance.

Objective:

This study presents the development and usability evaluation of a clinically oriented serious game (SG) designed to assess executive functioning in ecologically valid scenarios. The SG was tested in individuals with a history of traumatic brain injury (TBI) or COVID-19—two clinical populations frequently presenting ED—and in healthy controls.

Methods:

A theory-driven SG was created in a restaurant setting, with the player acting as a waiter. The game includes tasks targeting nine executive domains, including planning, working memory, decision-making, contextual control, social cognition, prospective memory, and multitasking. Emotional and social cues are embedded throughout gameplay. A total of 181 participants (TBI = 43; COVID = 49; healthy controls = 89) completed the game. Usability was assessed with the System Usability Scale (SUS) and Perceived Difficulty Scale (DP13-CL). ED was identified through neuropsychological testing and expert clinical consensus.

Results:

The SG effectively embedded real-life executive demands in a dynamic, interactive environment. Participants with ED reported lower usability and higher perceived difficulty than healthy controls, especially in tasks involving social and emotional adaptation (e.g., contextual control, social cognition). Age and education influenced usability ratings, partially accounting for group differences.

Conclusions:

The SG demonstrates strong ecological validity and good usability across groups. Its integration of emotionally and socially relevant tasks may enhance the detection of ED beyond what traditional tests can capture. Further studies are needed to validate its diagnostic accuracy.