Computer games for user engagement in attention deficit hyperactivity disorder (ADHD) monitoring and therapy

State-of-the-art computer games and psychological tests for symptom monitoring and therapy in Attention Deficit Hyperactivity Disorder (ADHD) are explored and reviewed. Three foci for research studies are identified: task (human performance) focus; educational focus; medical/clinical focus. It is found that game designs in the literature include a variety of tests of cognition mostly dependent on attention and executive functions (inhibitory motor control, working memory, interference suppression) which involve reactions to stimuli on computer (or mobile phone) screens. In addition, based on the measurement of neural pathways that can be accessed by Brain Computer Interfaces, there are several applications of games that employ biofeedback and demand the user to control aspects of their brain activity to play them, with the aim of improving function. A number of games have been used in clinical studies for self-monitoring and therapy, some of these controlled with comparators such as treatment as usual or cognitive therapies, or with the individual as their own control, where efficacy is evaluated by measuring behavioural and functional outcomes on measurement instruments such as ADHD or behavioural trait questionnaires or other cognitive tests. Other applications of games include education and raising awareness of mental health conditions to reduce stigma. The paper then presents and proposes designs of new games that are based on psychological tests or tasks that aim to monitor or improve attention, inhibitory and/or motor activity including Continuous Performance Tests, Go/No-go and Stop-signal tasks

Computer games for user engagement in attention deficit hyperactivity disorder (ADHD) monitoring and therapy

State-of-the-art computer games and psychological tests for symptom monitoring and therapy in Attention Deficit Hyperactivity Disorder (ADHD) are explored and reviewed. Three foci for research studies are identified: task (human performance) focus; educational focus; medical/clinical focus. It is found that game designs in the literature include a variety of tests of cognition mostly dependent on attention and executive functions (inhibitory motor control, working memory, interference suppression) which involve reactions to stimuli on computer (or mobile phone) screens. In addition, based on the measurement of neural pathways that can be accessed by Brain Computer Interfaces, there are several applications of games that employ biofeedback and demand the user to control aspects of their brain activity to play them, with the aim of improving function. A number of games have been used in clinical studies for self-monitoring and therapy, some of these controlled with comparators such as treatment as usual or cognitive therapies, or with the individual as their own control, where efficacy is evaluated by measuring behavioural and functional outcomes on measurement instruments such as ADHD or behavioural trait questionnaires or other cognitive tests. Other applications of games include education and raising awareness of mental health conditions to reduce stigma. The paper then presents and proposes designs of new games that are based on psychological tests or tasks that aim to monitor or improve attention, inhibitory and/or motor activity including Continuous Performance Tests, Go/No-go and Stop-signal tasks

A systematic review evaluating the implementation of technologies to assess, monitor and treat neurodevelopmental disorders: A map of the current evidence

Technology-based interventions provide an attractive option for improving service provision for neurodevelopmental disorders (NDD), for example, widening access to interventions, objective assessment, and monitoring; however, it is unclear whether there is sufficient evidence to support their use in clinical settings. This review provides an evidence map describing how technology is implemented in the assessment/diagnosis and monitoring/ treatment of NDD (Prospero CRD42018091156). Using predefined search terms in six databases, 7982 articles were identified, 808 full-texts were screened, resulting in 47 included papers. These studies were appraised and synthesised according to the following outcomes of interest: effectiveness (clinical effectiveness/ service delivery efficiencies), economic impact, and user impact (acceptability/ feasibility). The findings describe how technology is currently being utilised clinically, highlights gaps in knowledge, and discusses future research needs. Technology has been used to facilitate assessment and treatment across multiple NDD, especially Autism Spectrum (ASD) and attention-deficit/hyperactivity (ADHD) disorders. Technologies include mobile apps/tablets, robots, gaming, computerised tests, videos, and virtual reality. The outcomes presented largely focus on the clinical effectiveness of the technology, with approximately half the papers demonstrating some degree of effectiveness, however, the methodological quality of many studies is limited. Further research should focus on randomised controlled trial designs with longer follow-up periods, incorporating an economic evaluation, as well as qualitative studies including process evaluations and user impact

A comparison of simultaneous and sequential visuo-spatial memory in children born very preterm

Research suggests that children born very preterm (≤32weeks’ gestation) are at greater risk of impairments in information processing (particularly when information is presented simultaneously rather than sequentially) and visuo-spatial short-term and working memory relative to children born at term. This study compared the performance of children born very preterm with their term-born peers to elucidate the nature of group differences in these areas. 113 children (65 very preterm; 48 term-born) aged 8-to-11years completed four visuo-spatial recall tasks. Tasks varied by presentation type (simultaneous or sequential) and memory type (short-term or working memory). Both groups recalled more locations in simultaneous than sequential tasks, and in short-term than working memory tasks. In short-term memory tasks, children born at term recalled more locations than children born very preterm for the sequential task, but groups did not differ on the simultaneous task. The opposite pattern was observed in the working memory tasks, with no group differences on the sequential task, but better performance on the simultaneous task for children born at term. Our findings indicate that simultaneous processing may not be impaired in children born very preterm per se, with poorer performance observed only under high cognitive demand. This interaction suggests very preterm birth may affect the level of cognitive resources available during feature integration, the consequences of which become apparent when resources are already stretched. The impact of interactions with cognitive demand in this population should be an important consideration for educational support strategies, and for assessment in research and clinic

Is autonomic nervous system function atypical in attention deficit hyperactivity disorder (ADHD)? A systematic review of the evidence

Although arousal mechanisms have frequently been found to be atypical in ADHD, these findings usually emerged from indirect behavioural measures which give only a limited understanding of arousal dysregulation in this condition. To assess the hypothesis that functioning of the autonomic nervous system (ANS), one component of arousal, is atypical in ADHD, we carried out a systematic review of the literature on 55 studies investigating electro-dermal, heart rate and pupillometry measures under different experimental conditions (resting-state, cognitive tasks and in response to reinforcers or socio-emotional stimuli). Our literature review identified ANS dysfunction in individuals with ADHD, more often in the direction of hypo-arousal than hyper-arousal, particularly at rest and during tasks requiring response regulation and sustained attention. Almost half of the reported findings were null. Stimulant medications increased ANS activity and, in some studies, reinforcers and rewards produced a similar effect, suggesting that ANS function can be modified in ADHD. Further research is needed to assess the influence of comorbid symptoms and to explore methodological parameters that may influence findings

Task-related default mode network modulation and inhibitory control in ADHD: effects of motivation and methylphenidate

Background: Deficits characteristic of Attention Deficit/Hyperactivity Disorder (ADHD), including poor attention and inhibitory control, are at least partially alleviated by factors that increase engagement of attention, suggesting a hypodopaminergic reward deficit. Lapses of attention are associated with attenuated deactivation of the Default Mode Network (DMN), a distributed brain system normally deactivated during tasks requiring attention to the external world. Task-related DMN deactivation has been shown to be attenuated in ADHD relative to controls. We hypothesised that motivational incentives to balance speed against restraint would increase task engagement during an inhibitory control task, enhancing DMN deactivation in ADHD. We also hypothesised that methylphenidate, an indirect dopamine agonist, would tend to normalise abnormal patterns of DMN deactivation. Method: We obtained functional magnetic resonance images from eighteen methylphenidate-responsive children with ADHD (DSM-IV combined subtype) and 18 pairwise-matched typically developing children aged 9-15 years while they performed a paced Go/No-go task. We manipulated motivational incentive to balance response speed against inhibitory control, and tested children with ADHD both on and off methylphenidate. Results: When children with ADHD were off-methylphenidate and task incentive was low, event-related DMN deactivation was significantly attenuated compared to controls, but the two groups did not differ under high motivational incentives. The modulation of DMN deactivation by incentive in the children with ADHD, off- methylphenidate, was statistically significant, and significantly greater than in typically developing children. When children with ADHD were on-methylphenidate, motivational modulation of event-related DMN deactivation was abolished, and no attenuation relative to their typically developing peers was apparent in either motivational condition. Conclusions: During an inhibitory control task, children with ADHD exhibit a raised motivational threshold at which task-relevant stimuli become sufficiently salient to deactivate the DMN. Treatment with methylphenidate normalises this threshold, rendering their pattern of task-related DMN deactivation indistinguishable from that of typically developing children

Visuomotor learning and unlearning in children and adolescents with Tourette syndrome

Tourette syndrome (TS) is a childhood-onset neurological condition characterised by an evolving repertoire of chronic motor tics and one or more phonic tics. Tics, like habits, are inflexible and repetitive behaviours that are acquired over a period of time. It has been proposed that tics arise in TS as a result of increased habit learning: which may bias the child to acquire automatic behaviours (i.e. tics) more readily than is normal and make it harder to unlearn maladaptive habits once they have been acquired. Using a well-established visuomotor adaptation task, we investigated motor learning in a group of children and adolescents with a clinical diagnosis of TS relative to a group of age and gender matched typically developing individuals. In particular, we quantified differences in the strength and quality of motor learning and unlearning in TS, and the consolidation of motor learning over a 24 hour washout period. We demonstrated that there was a marginally significant decrease in learning rate in the individuals with TS relative to age and gender matched typically developing controls. However, this effect was not associated with tic severity and could be entirely accounted for by the severity of co-occurring ADHD symptoms. Thus, once ADHD symptoms had been accounted for, there were no between group differences in learning rate or the degree of learning observed. By contrast, and more importantly, we found that following learning the rate of forgetting (unlearning) was significantly negatively associated with motor tic severity, such that individuals with more severe tics took longer to unlearn previously learnt motor patterns of behavior. This finding is consistent with the proposal that TS is associated with alterations in the striatal habit learning system and with the view that TS may make it harder to unlearn maladaptive motor habits once they have been acquired

Indices of heart rate variability and performance during a response-conflict task are differently associated with ADHD and autism

Objective. We investigated autonomic arousal, attention and response conflict, in ADHD and autism. Method. Heart rate variability (HRV), and behavioural and electrophysiological indices of performance, were recorded during a task with low and high levels of response conflict in 78 children/adolescents (7-15 years old) with ADHD, autism, comorbid ADHD+autism, or neurotypical. ANOVA models were used to investigate effects of ADHD and autism, while a mediation model was tested to clarify the relationship between ADHD and slower performance. Results. Slower and less accurate performance characterised ADHD and autism; however, atypical electrophysiological indices differently characterised these conditions. The relationship between ADHD and slower task performance was mediated by reduced HRV in response to the cue stimulus. Conclusions. Autonomic hypo-arousal and difficulties in mobilising energetic resources in response to sensory information (associated with ADHD), and atypical electrophysiological indices of information processing (associated with autism), might negatively affect cognitive performance in those with ADHD+autism

Developing mHealth remote monitoring technology for attention deficit hyperactivity disorder: a qualitative study eliciting user priorities and needs

Background: Guidelines in the United Kingdom recommend that medication titration for attention deficit hyperactivity disorder (ADHD) should be completed within 4-6 weeks and include regular reviews. However, most clinicians think that weekly clinic contact is infeasible, and audits have shown that this timeline is rarely achieved. Thus, a more effective monitoring and review system is needed; remote monitoring technology (RMT) may be one way to improve current practice. However, little is known about whether patients with ADHD, their families, and clinicians would be interested in using RMT. Objective: To explore patients’, parents’, and health care professionals’ views and attitudes toward using digital technology for remote monitoring during titration for ADHD. Methods: This was a qualitative study, and data were collected through 11 focus groups with adults and young people with ADHD, parents of children with ADHD, and health care professionals (N=59). Results: All participant groups were positive about using RMT in the treatment of ADHD, but they were also aware of barriers to its use, especially around access to technology and integrating RMT into clinical care. They identified that RMT had the most potential for use in the ongoing management and support of ADHD, rather than during the distinct titration period. Participants identified features of RMT that could improve the quality of consultations and support greater self-management. Conclusions: RMT has the potential to augment support and care for ADHD, but it needs to go beyond the titration period and offer more to patients and families than monitoring through outcome measures. Developing and evaluating an mHealth app that incorporates the key features identified by end users is required

Visuomotor learning and unlearning in children and adolescents with Tourette syndrome

Tourette syndrome (TS) is a childhood-onset neurological condition characterised by an evolving repertoire of chronic motor tics and one or more phonic tics. Tics, like habits, are inflexible and repetitive behaviours that are acquired over a period of time. It has been proposed that tics arise in TS as a result of increased habit learning: which may bias the child to acquire automatic behaviours (i.e. tics) more readily than is normal and make it harder to unlearn maladaptive habits once they have been acquired. Using a well-established visuomotor adaptation task, we investigated motor learning in a group of children and adolescents with a clinical diagnosis of TS relative to a group of age and gender matched typically developing individuals. In particular, we quantified differences in the strength and quality of motor learning and unlearning in TS, and the consolidation of motor learning over a 24 hour washout period. We demonstrated that there was a marginally significant decrease in learning rate in the individuals with TS relative to age and gender matched typically developing controls. However, this effect was not associated with tic severity and could be entirely accounted for by the severity of co-occurring ADHD symptoms. Thus, once ADHD symptoms had been accounted for, there were no between group differences in learning rate or the degree of learning observed. By contrast, and more importantly, we found that following learning the rate of forgetting (unlearning) was significantly negatively associated with motor tic severity, such that individuals with more severe tics took longer to unlearn previously learnt motor patterns of behavior. This finding is consistent with the proposal that TS is associated with alterations in the striatal habit learning system and with the view that TS may make it harder to unlearn maladaptive motor habits once they have been acquired