Digital Intervention for ADHD

A four-week randomized regulated trial of 348 children aged 8-12 years, published in the journal The Lancet Digital Health, recommends that a digital intervention for pediatric attention deficit hyperactivity disorder (ADHD) might improve inattention with minimal adverse effects. Further analysis is needed to confirm the observed changes’ clinical meaningfulness, but the intervention’s digital nature could improve some patients’ access.

Replacing conventional care with digital alternatives

ADHD is a childhood-onset disorder considered to affect around 5% of people globally. It involves persistent impaired attention, hyperactivity, or impulsivity. Prescribed treatments include both medication and evidence-based behavior therapy, but both have shortcomings. A lack of adequately trained pediatric mental health specialists and services’ availability limits access to behavioral interventions. For some patients, medication may not be suitable due to caregiver preferences or concerns about misuse, abuse, and diversion.

Moreover, while highly effective for treating ADHD symptoms, medication may not be as useful at addressing day-to-day cognitive and functional impairments encountered by patients. Several areas of impairment for children with ADHD, such as social and academic functioning, need more complicated skill acquisition over time, and treatments that only cure symptoms might not directly improve these kinds of difficulties. Digital alternatives to conventional care have shown promise and could help tackle these issues.

Video game-like intervention

Researchers studied whether a video game-like intervention designed to target attention and cognitive control could improve a validated score related to engagement (Test of Variables of Attention (TOVA) Attention Performance Index (API)). Between July 2016 and November 2017, the researchers randomly assigned 348 children to undergo the digital therapy (n=180) or a control therapy (n=168), designed to match the intervention as a challenging and engaging digital word game.

Patients retreated from any medication for three days to measure a baseline attention score before the intervention or control, compared with the same test results at the trial’s end. Throughout the trial process, the participants did not take their ADHD medication. The researchers directed the patients to use the control or intervention for 25 minutes every day for five days every week. The study monitored the compliance electronically, and the researchers notified the parents by email if patients used no intervention in 48 hours.

Professor Scott Kollins of the Duke University Medical Centre, USA, says: “Our trial is one of only rare randomized controlled investigations into digital interventions for children with ADHD. The improvement noted in attentional functioning in patients who received the active intervention was remarkable. However, additional studies are required to examine the full clinical meaningfulness of the findings. We do not yet know whether to consider this intervention as an alternative to current treatments.”

Trials’ result

On average, patients in the intervention group finished 83 of 100 sessions in the four weeks, and the control group 96 of 100 sessions. More patients significantly improved their scores on the attention score in the intervention group. Concerning secondary outcomes, including symptom ratings, both the treatment and control groups improved, but there were no differences.

There were no severe adverse events or discontinuations on trial. Only 12 children in the intervention group and three in the control group experienced any treatment-related adverse events, the most prevalent of which were frustration (five in the intervention group) and headaches (three in the intervention group).

The authors selected the TOVA API attention score as a primary endpoint in this trial to design the intervention specifically to target cognitive control and attention. This result is different from symptom rating scales routinely used as primary outcomes in pharmacological treatment studies of ADHD. The authors used these symptom rating scales as secondary outcomes in the present study with no differences between the intervention and control groups.

A reliable and easy-to-access arbitration

Co-author Doctor Elena Cañadas who works at Akili Interactive Labs, USA, says: “These conclusions confirm the evidence of digital therapy being a reliable and easy-to-access arbitration that could deal with issues concerning delivery of treatment for many patients with ADHD. Further work should investigate the impact of different scheduling and time involved in the treatment sessions as well as looking longer term at optimal benefits.”

The authors recognize several limitations. Four weeks of treatment is relatively small, and future work should look at a more extensive intervention and test different video game-like therapy regimens. The results may not generalize for the whole population of children with ADHD. It is because of not including milder cases that did not record below a particular attention score, as were children with significant psychiatric comorbidities. Children could not take their regular medication during the trial, which indicates the result may not generalize to those on medication.

The study did not accumulate EEG data, which could help clarify the mechanism for the findings. Further work should explore secondary outcomes around behavioral improvements in a more rational way and the mechanism underlying the effect.

Further research is needed.

Dr. Catalá López, a scientist at Institute of Health Carlos III, Spain, says: “The results of Kollins and colleagues’ study are impressive and highlight how further to develop digital health interventions for children with ADHD. We need to establish long-term efficacy in future studies besides short-term trials because of the chronic course of ADHD. Thus, we need further research to analyze ways of sustaining treatment effects over the long-term, in the wider population of children with ADHD, including those who have comorbidities and receive evidence-based therapies.”

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