Video Games and Exercise as Alternative Therapies for ADHD

Preliminary findings suggest that certain domains of attention-deficit/hyperactivity disorder (ADHD) can be improved with at-home computer interventions and other nonpharmacologic modalities such as physical activity.¹ This comes as welcome news to children, who adapt easily to mobile devices and exercise, and to parents who seek alternatives to drugs that have limited efficacy and adverse effects. Even if a certain therapy is effective, 50% of patients will stop taking it despite the severity of their symptoms.^2,3

Video games to improve attention

In a proof-of-concept study, Davis and colleagues at Duke University sought to determine how attention, working memory, and inhibition in children with ADHD could be improved with home computer games.¹ The multisite study included 40 children with psychiatrist-diagnosed ADHD (mean age, 10.3 years) and 40 without any psychiatric disorder (mean age, 10.5 years) who were given a mobile-device-based game to use for 28 days.¹

The intervention was a home video game, NeuroRacer, in which participants had to complete driving tasks. The mean time for participation was 10.9 hours (or 30-45 minutes per day, 5 days per week). Participants were assessed on the basis of their attention and spatial working memory, as measured by the Mini International Neuropsychiatric Interview for Children and Adolescents, ADHD Rating Scale, Columbia Suicide Severity Rating Scale, Test of Variables of Attention, Behavior Rating Inventory of Executive Function-Parent Form, and Cambridge Neuropsychological Test Automated Battery.¹

Researchers noted significant improvement in attention (P =.033), and especially in the subset of patients with high severity ADHD (P =.003).¹ Reaction time also improved significantly in the ADHD group (P =.006), but working memory just reached statistical significance (P <.05). Participants in the control group did not show improvements in any of the tested domains.¹ Despite the time-consuming regimen, no participants dropped out of the study, and researchers noted a high compliance rate: 81% in the ADHD group, 86% in the severe ADHD group, and 87% in the control group. Standard pharmacologic studies have dropout rates of >10%.¹

Just after the proof-of-study review was published, the same Duke University researchers released preliminary data on STARS-ADHD, a multisite pivotal study of 348 children with ADHD (ages 8-12 years) who were randomly assigned to a similar electronic intervention, code named AKL-T01, on tablet devices. The only differences were the reward and stimuli of the active comparator game.⁴ The 4-week study sought to determine the improvement in the children’s attention, memory, and impulsivity. The mobile intervention, AKL-T01, achieved significant improvement compared with the control group in the primary end point, Attention Performance Index, a composite score from the Test of Variables of Attention (P =.006).⁴

“This innovative study represents, to my knowledge, the largest and most rigorous evaluation of a digital medicine,” Scott Kollins, PhD, professor of psychiatry, director of the ADHD program at Duke University School of Medicine, Durham, North Carolina, and principal investigator of the study said in a news release. “The objective improvements of attention observed in the study suggest that AKL-T01 addresses a key deficiency in ADHD that is not directly targeted by standard treatments. Since the active control group in this study also played an engaging video game, we are encouraged that the statistically significant group differences were driven by the therapeutically active component in AKL-T01 and not just the video game experience.”⁴

“We are very motivated to conduct more studies like this one in younger age groups. We often conduct studies we have performed in older adults in younger populations,” said NeuroRacer inventor Adam Gazzaley, MD, PhD, professor of neurology, physiology, and psychiatry at the University of California, San Francisco, in an interview with Psychiatry Advisor. “We are interested in advancing experimental treatments, often delivered through video game technologies, as interventions for attentional deficits.”

Serious video games have demonstrated prior efficacy, albeit in different ADHD domains. A Dutch study of 170 children aged 8 to 12 years discovered that games improved children’s time management, responsibility, and working memory.³

The 20-week crossover trial employed Plan-It Commander, a computer game designed to improve children’s activities of daily living abilities as an adjunct to medication or behavior therapy. Children with ADHD were randomly assigned to 2 groups: the first group received the game intervention, whereas the second group was given treatment as usual. At the midpoint of the trial (week 10), the second group was given the game intervention. Children in both groups maintained their medication regimens during the study.³

At week 10, participants in the first intervention group achieved significant improvement, as reported by their parents, in time management skills (P =.004), social skill of responsibility (P =.04), and working memory (P =.02). The first intervention group maintained or improved these skills at week 20 of the study.³

Overall, children in the first group had greater improvements in time perception than did children in the second group (P =.09). Teachers, as well as parents, reported more improvement in time management and working memory in the first group vs the second group, although the observation did not reach statistical significance.³

Exercise for ADHD

Another nonpharmacologic intervention being tested on executive function and motor performance in ADHD is “exergaming,” which uses a commercially available video game that combines full-body exercise and cognitive tasks.⁵ In a study of 66 boys and girls aged 8 to 12 years with ADHD, the children were randomly assigned either to use Kinect for 30 minutes at least 3 times per week for 8 weeks or to a waiting-list control group.⁵ Benzing and colleagues have preliminary evidence that such a modality might be effective in adolescents with ADHD.

“The [kids with ADHD] from the intervention group profited in terms of their executive function performance compared [with] the control group,” coauthor Mirko Schmidt, PhD, assistant professor of sports science at the University of Bern in Switzerland, told Psychiatry Advisor. “They also have benefitted in their motor performance after the intervention. Evidence is showing that physical activity is a viable tool to help children with ADHD to deal with their daily hassles.”

References

1. Davis NO, Bower J, Kollins SH. Proof-of-concept study of an at-home, engaging, digital intervention for pediatric ADHD. PLoS One. 2018;13(1):e0189749.
2. Pappadopulos E, Jensen PS, Chait AR, et al. Medication adherence in the MTA: saliva methylphenidate samples versus parent report and mediating effect of concomitant behavioral treatment. J Am Acad Child Adolesc Psychiatry. 2009;48(5):501-510.
3. Bul KC, Franken IH, Van der Oord S, et al. Development and user satisfaction of “Plan-It Commander,” a serious game for children with ADHD. Games Health J. 2015;4(6):502-512.
4. Akili achieves primary efficacy endpoint in pediatric ADHD pivotal trial [press release]. Boston, MA: Akili. https://www.akiliinteractive.com/news-collection/akili-achieves-primary-efficacy-endpoint-in-pediatric-adhd-pivotal-trial. Published December 4, 2017. Accessed March 26, 2018.
5. Benzing V, Schmidt M. Cognitively and physically demanding exergaming to improve executive functions of children with attention deficit hyperactivity disorder: a randomised clinical trial. BMC Pediatr. 2017;17:8.