February 24, 2020

expert reaction to study looking at a video game-like digital intervention in children with ADHD

Research, published in the Lancet Digital Health, reports that video game-like intervention may show promise in improving attention in children with ADHD. 

Prof Philip Asherson, Professor of Molecular Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, said:

“This is an interesting study of 8-12 year old children with ADHD.  The paper finds statistically significant effects of cognitive training using a digital game-like interface on improved performance on an objective test of attention.  The cognitive training asked children to engage in a computer game in which they had to practice two aspects of ‘cortical control’ – inhibitory control and sustained attention.  Then using an objective test of attention (TOVA), that is known to be associated with ADHD, they found significant improvements when compared to a control condition.  The authors point out that the TOVA is a task requiring sustained attention which mimics one component of the classroom situation, in which children are required to remain seated and engaged in a tedious, repetitive task.  Such situations are particularly difficult for children with ADHD.

“The main limitation is that the authors did not find statistically significant effects on the clinical symptoms and impairments of ADHD.  The authors point to improvements in ADHD symptoms in exploratory subgroup analyses – in particular the sub-group that had recently been on medication for ADHD – raising the possibility that there are clinically meaningful effects on ADHD symptoms in a subgroup of children with ADHD.  This is interesting and warrants further research.

“Another limitation is the short period of training of 4 weeks.  It is feasible that more time is needed to see the impact of improved cognitive skills transfer over to improved attention, and self-regulation of behaviour in daily life.

“The authors also did not include a large group of children with ADHD who did not show significant deficits on the TOVA, indicating that not all children with ADHD show deficits of attention on the TOVA.

“Overall the findings are similar to that reported for other forms of cognitive training in children with ADHD.  For example, in the meta-analysis of cognitive training on working memory (another cognitive performance function associated with ADHD) there were significant effects on working memory performance, but no significant effects on ADHD (Cortese et al., J Am Acad Child Adolesc Psychiatry 2015;54(3):164–174.).  The current findings are in keeping with this.

“Overall these studies show that performance on computerized tests of attention can be improved following cognitive training in children with ADHD.  What is less certain is whether this leads to improvements in ADHD symptoms such as inattention and restlessness in daily life, and educational settings.

“It is feasible that the cognitive functions that improve following this training have no direct impact on function in daily life – this has yet to be demonstrated for any cognitive training in children with ADHD.  It remains uncertain whether the cognitive functions that improve reflect core cognitive problems leading to ADHD (inattention in daily life), or whether they are better viewed as co-occurring neurodisabilities that are commonly but not always seen in children with ADHD.  The clinical meaning of improvements in TOVA scores has yet to be determined and has not been demonstrated here.

“Future studies need to evaluate cognitive training, and impact on behavioural and functional outcomes over longer periods of time.”

Dr Elizabeth Liddle, Associate Professor in Translational Mental Health, Division of Psychiatry and Applied Psychology, University of Nottingham, said:

“There is a lot of interest in developing computer games that could help children with ADHD to improve their attention.  Usually the children get better at actually playing the games.  However, there is little evidence so far that any improvements transfer to real-life situations.  This study of the STARS program doesn’t show that either, but then it didn’t try to.  Instead, it set out to first make really sure that STARS has a real impact on the attention-paying skills it is supposed to help, and the results are very promising.  It will be interesting to see whether further studies show real-life and long-term benefits.”

Dr Louise Theodosiou of the Child and Adolescent Faculty at the Royal College of Psychiatrists, said:

“We welcome research that may increase the range of treatment options available to children and young people with ADHD.  However, the improvements reported in this study must be considered cautiously given that parents and clinicians did not report a notable improvement in overactivity.  ADHD has a significant impact on family, social and educational environments, so any viable treatments need to demonstrate improvement across all of these areas.”

Dr Bruno Bonnechère, Department of Psychiatry, University of Cambridge, said:

Is this good quality research?  Are the conclusions backed up by solid data?

“This is excellent quality research:

– Large sample size (348 patients) based on prior power analysis;

– Multicentric studies (20 centers);

– Double-blind: the patients and their parents were not aware if they are in the intervention or control (placebo) group.  The assessments were done by researchers that were not aware of the intervention (no risk of bias);

– Statistical analysis in intention-to-treat (more powerful) adjusting for multiple testing.  The different tests have been done based on a plan written before the study.

How does this work fit with the existing evidence?

“There is currently a lack of strong evidence supporting the use of digital intervention with ADHD patients.  The available studies have a small sample size, most of the time no control or not randomized: there is therefore a high risk of bias.  There are a few meta-analyses highlighting this lack of high-quality studies and suggesting a small but significant effect of the digital intervention.

“In this study, the authors reported a statistically significant improvement in attention and inhibition control in the intervention group compared to the placebo.  This is consistent with the literature and previous pilot studies.

Have the authors accounted for confounders?  Are there important limitations to be aware of?

“This is a high-quality study and the risk of bias is low.  However, due to the fairly strict exclusion criteria, the authors analyzed a very homogeneous population: patients with severe attention deficit, no medication, and no psychiatric comorbidity.  This sample did represent only part of the patients (they evaluated 900 patients but included only 348).

“Besides this point, there are two important limitations of this work:

“The first one is that the post-test evaluation has been performed directly after the last session of training (day 28).  We do not know if the improvements are sustained over time.

“The second limitation is that it is a relatively short-term intervention (25min/day, 5 days/week during 4 weeks).  During this period the participation was high (83%, usually we accepted participation of 80% in this kind of intervention).  But we know that at the beginning patients like new interventions and novelty in the treatment but it is important to know whether the motivation will be maintained over a longer period of time.

What are the implications in the real world?  Is there any overspeculation?  

“The authors are rather cautious about their conclusions.  We already discussed the specific group of patients that have been tested so the results can not be generalised to all kinds of ADHD patients (e.g. patients under medication).

“When assessing a new treatment it is important to define both the efficacy and the safety of the intervention.

“Concerning the safety, there were only a few light adverse events (frustration and headache) indicating that the intervention is safe.

“Concerning the efficacy, the authors did find differences in the primary outcome (TOPA API score) in favour of the intervention but they did not find significant differences in the secondary outcome (assessing different functions).  The intervention is focusing on attention and inhibition, two functions assessed by the TOPA API, it seems that there is no transfer to the other functions (again this is not specific to ADHD it is well documented that the benefit of a training intervention is rather specific).  Interestingly, while the authors find a difference between the two groups, the children’s perception of improvement is not different in the two groups, and the parents’ perception is only slightly higher.  This is something important to highlight because from a patient’s perspective it is important to have improvements in the real-world (activities of daily living) rather than on clinical evaluation.  From this point of view, this study does not make it possible to highlight the superior efficacy of the intervention compared to the control.  It must be stressed, however, that this is not a study comparing and intervention versus placebo but rather comparing a specific solution (developed for ADHD patients and focusing on attention and inhibition function) versus a non-specific solution (activities challenging different cognitive functions).  This can also explain the absence of difference for the secondary outcome.

“To summarise, this study provide evidence of the safety and efficacy of a novel specific training program for ADHD children with severe attentional deficit.  In the context of the high availability of smartphones and tablets, such a kind of intervention could be used as a complement to conventional care to motivate patients.  This kind of intervention could also be used to partially compensate for the lack of health care professionals – it could be used as a complement to the existing treatment; a mixed approach between conventional sessions and exercises and at-home training would be probably be the best option.”

‘A novel digital intervention for actively reducing severity of paediatric ADHD (STARS-ADHD): a randomised controlled trial’ by Scott H Kollins et al. was published in the Lancet Digital Health at 23:30 UK time on Monday 24 February 2020.

DOI: 10.1016/S2589-7500(20)30017-0

Declared interests

Dr Bruno Bonnechère: “The author declares no conflict of interest.”

None others received.