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{{Paper
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|title=Serious Games for ADHD: a narrative review
|pdfUrl=https://ceur-ws.org/Vol-3751/paper2.pdf
|volume=Vol-3751
|authors=Alessandro Aloisio,Giancarlo Marzano,Riccardo Bonanni,Maria Carla Ricci
|dblpUrl=https://dblp.org/rec/conf/dilend/AloisioMBR24
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==Serious Games for ADHD: a narrative review==
https://ceur-ws.org/Vol-3751/paper2.pdf
Serious Games for ADHD: a narrative review
Alessandro Aloisio1, Giancarlo Marzano2, Riccardo Bonanni2, Mariacarla Ricci3
1
Department of International Humanities and Social Sciences, Rome University of International Studies, Rome (Italy)
2
Walk-On Società Cooperativa Sociale, Via Aniello Falcone, 394, Napoli, 80127(Italy)
3
Fondazione Italiana dei Disordini dello Sviluppo – FINDS, Via Aniello Falcone, 394, Napoli 80127 (Italy)
Abstract
This article provides an overview of Attention Deficit Hyperactivity Disorder (ADHD) and the
effectiveness of Serious Games for ADHD (SGADs) as an intervention. ADHD is primarily characterized
by reduced attention and impulsivity, which significantly hinder normal development in children. These
core symptoms can affect various aspects of a child's life, including academic performance, social
interactions, and overall well-being. Literature data indicate that ADHD is highly prevalent among
children, affecting millions globally, and SGADs are emerging as a promising and effective intervention.
The interactive and engaging nature of these games offers a novel approach to managing ADHD
symptoms, making treatment more appealing to children who may otherwise resist traditional therapies.In
this article, a literature review will be presented on SGADs, focusing specifically on potential video games
and platforms useful for the diagnosis and treatment of ADHD in children. The review will examine
various studies and clinical trials that have explored the efficacy of SGADs, highlighting how these games
leverage technology to provide real-time feedback, personalized treatment, and engaging experiences. By
analyzing different video games and platforms, the review aims to identify key features that make these
tools effective for ADHD intervention. This includes the use of brain-computer interfaces, motion sensors,
and adaptive learning algorithms that adjust the game's difficulty based on the child's performance,
thereby maintaining an optimal level of challenge and engagement.Finally, there is a discussion with
potential suggestions for future research directions based on the current state of SGADs. This discussion
will explore gaps in the existing literature, such as the need for long-term studies to assess the sustained
impact of SGADs on ADHD symptoms. It will also consider the potential for developing new game-based
interventions that target specific cognitive and behavioral aspects of ADHD. Suggestions for future
research may include the integration of advanced technologies like virtual reality and augmented reality to
create more immersive and interactive therapeutic environments. Additionally, the discussion will address
the importance of tailoring these interventions to the individual needs of children, considering factors such
as age, gender, and the severity of symptoms. By proposing these directions, the article aims to pave the
way for more comprehensive and effective solutions for managing ADHD through serious games.
Keywords
ADHD, serious games, systematic review, diagnosis, treatment.
1
1. Attention Deficit Hyperactivity Disorder (ADHD)
Attention Deficit Hyperactivity Disorder (ADHD), also known as hyperactivity, is primarily
characterized by symptoms related to inattention, impulsivity, and hyperactivity. The prevalence of
ADHD generally stands at around 7.2%, although this may vary depending on different diagnostic
criteria [1]. ADHD is more prevalent in boys than girls, indicating that many children experience
this condition [2]. Children with ADHD struggle to focus, maintain attention, and resist distractions
due to attention deficits. Additionally, the hyperactivity disorder contributes to poor inhibition,
leading to challenges in emotion and behavior management, increasing the likelihood of
impulsivity. ADHD symptoms create significant disadvantages in children's daily lives, negatively
impacting academic performance, limited concentration in class, and a heightened risk of school
dropout [3]. Furthermore, obstacles in language expression and reading comprehension often
Proceedings of the Digital Innovations for Learning and Neurodevelopmental Disorders, May24–25, 2024, Rome, Italy
dott.giancarlomarzano@gmail.com (G. Marzano); bonannir@gmail.com(R. Bonanni);mariacarla.ricci1@gmail.com
(M.C. Ricci);alessandro.aloisio@unint.eu(A. Aloisio)
© 2023 Copyright for this paper by its authors.
Use permitted under Creative Commons License Attribution 4.0 International (CC BY 4.0).
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Proceedings
manifest, posing detrimental aspects to their normal growth [4, 5]. Other difficulties may arise in
social relationships, as children may exhibit extreme behaviors such as conflicts with family and
friends, and they may be more predisposed to developing other mental conditions, including
oppositional defiant disorder and depression [6].
The traditional approach to ADHD treatment through medication can lead to dependence and
generate side effects [7]. A new approach to ADHD treatment is provided by emerging
technologies: serious games, designed to blend entertainment and education, offering various
technological solutions and intervention methods [48].
In literature, with reference to Serious Games for ADHD (SGAD), games on consoles, computers,
and mobile devices have been explored. Somatosensory technology in console games facilitates
physical interaction, making exercise enjoyable for ADHD patients. Computer games, focused on
therapy, utilize Brain-Computer Interface (BCI) technology to detect EEG and facilitate attention
training. Sung has proposed a simplified framework for developing BCI-based serious games [8]. A
systematic review conducted by Zung et al. (2021) explores the crucial role of serious games in the
diagnosis and treatment of ADHD, recognizing them as a fundamental resource for managing the
condition and offering a promising perspective for addressing the disorder. While structured
questionnaires and interviews are commonly used for patient assessment, these methods can be
influenced by subjective opinions, compromising the reliability of the diagnosis [9]. In hospital
settings, children with ADHD may struggle to naturally exhibit symptoms, complicating diagnosis.
Serious games address this challenge by involving users in an immersive environment, using
interactive technology and multisensory experiences to enhance the effectiveness of assessment
[10]. In this sense, gamified assessment facilitates participant engagement, reducing energy
expenditure and dropout rates during the process, proving more appealing than traditional methods
[11]. Particularly in the treatment of ADHD with serious games, improvements are observed in the
development of daily and social skills, as well as in attention and impulse management. The use of
serious games as a complementary tool not only alleviates symptoms but also enhances executive
functions and provides cognitive training [12].
2. Serious games and ADHD
Serious games, defined as games with purposes beyond mere entertainment, have achieved notable
success in fields such as the military, education, and medicine due to their educational effectiveness
[13]. The constant stimulation and timely feedback provided by video games enable children with
ADHD to sustain attention for longer periods during play [14]. The therapeutic journey through
serious games allows ADHD patients to actively participate in the treatment process, completing
the educational path smoothly and efficiently. Video games create an engaging environment,
presenting stimulating challenges that significantly amplify players' enthusiasm [15]. In terms of
diagnosis and treatment, the systematic review conducted by Zheng et al. (2021) on Serious Games
for ADHD (SGAD) thoroughly examined the gaming mechanism and operational methods of each
game, providing an overview of the specific outcomes that such games can achieve. For instance,
console games allow for more natural interaction, enabling players to operate through body
movements rather than just buttons [48]. Some studies in the literature demonstrate that the use of
SGAD can increase the enthusiasm of children with ADHD to participate in treatment and improve
the effectiveness of executive function training [16]. Chuang's study on the effect of Wii console
games on children with ADHD highlighted an increase in fun and attention during gameplay.
Children with ADHD find SGAD to be an effective way to train specific deficits in executive
functions [17]. Benzing's experiment on the use of Shape UP and Beatmaster Training Quest, via the
Microsoft Xbox console, demonstrated that exercise games contribute to improving executive
function deficits, and more importantly, reduce inhibition and enhance readiness in patients with
ADHD [18]. Significant improvements in attention and daily skills in children with ADHD have
also been demonstrated by computer games. Specifically, a correlation between attention levels and
brain waves has been shown in the literature; in this regard, Brain-Computer Interface (BCI)
technology has been introduced in computer-based SGAD, allowing direct communication between
the brain and the computer. The EEG apparatus collects brain signals, integrating them directly into
computer activity and eliminating the need for traditional input devices such as a mouse or
keyboard [19]. A study conducted on children with ADHD confirmed the effectiveness of
neurofeedback in mitigating ADHD symptoms. Through the use of BCI devices, neurofeedback
monitors brain activities during video games, providing instant feedback and facilitating the
improvement of brain waves [20, 21, 22]. A meta-analysis demonstrated that various factors, such as
the depth of treatment, assessment reports, and the EEG equipment used, have been identified as
variables that can influence the effectiveness of neurofeedback therapy [23]. With the advancement
of technology, virtual reality has also made significant contributions in this field. Serious games
based on this technology can create an engaging environment, facilitating the transfer of learned
skills from training to real-life situations. Through a controllable reality environment, cognitive
exercises and timely feedback are offered, contributing to the improvement of ADHD symptoms,
enhancing players' responsiveness and sensitivity during gameplay, and facilitating proper
integration into the training environment [24, 25] (see Table 1).
Table 1.
Overview of Serious Games for ADHD
Field Details
Definition Serious games are games with purposes beyond mere entertainment,
achieving success in fields such as the military, education, and medicine.
Effect on children Provide constant stimulation and timely feedback, helping children with
with ADHD ADHD maintain attention for longer periods.
Therapeutic Serious games allow ADHD patients to actively participate in the
participation treatment process, completing the educational path smoothly and
efficiently.
Engagement and Create an engaging environment with stimulating challenges,
challenges significantly increasing players' enthusiasm.
Diagnosis and Zheng et al. (2021) examined the gaming mechanisms and operational
treatment methods of Serious Games for ADHD (SGAD). Console games allow for
natural interaction through body movements.
Effectiveness Studies show that SGAD can increase the enthusiasm of children with
ADHD for treatment and improve executive function training.
Wii console Chuang's study highlights an increase in fun and attention in children
with ADHD during gameplay.
Xbox (Shape UP Benzing's experiment demonstrates that exercise games improve
and Beatmaster) executive function deficits, reduce inhibition, and enhance readiness in
patients with ADHD.
Computer games Improve attention and daily skills in children with ADHD, correlating
attention levels with brain waves.
Brain-Computer BCI technology allows direct communication between the brain and
Interface (BCI) computer, using EEG to integrate brain signals into computer
activity.Studies confirm the effectiveness of neurofeedback in mitigating
ADHD symptoms.
Effectiveness Treatment depth, assessment reports, and EEG equipment can influence
variables the effectiveness of neurofeedback therapy.
Virtual Reality Serious games based on VR create an engaging environment that
(VR) facilitates the transfer of learned skills to real-life situations, improving
ADHD symptoms and integration into the training environment.
2.1 Serious Games: A tool for diagnosing ADHD
The systematic research conducted by Peñuelas-Calvo has clearly demonstrated the effectiveness of
assessment tools based on video games. These innovative tools have shown a remarkable ability to
successfully discriminate cases of ADHD from control groups, providing a reliable method for
distinguishing between different subtypes of ADHD. This precision in diagnosis is critical, as it
allows for more tailored and effective treatment plans. Additionally, video game-based therapies
have been positively received and proven effective in improving cognitive functions and reducing
ADHD symptoms [26]. This positive reception is crucial as it indicates that both children and their
caregivers find these therapies engaging and beneficial, enhancing adherence to treatment
protocols.
Gamifying the diagnostic process can make it less monotonous and more engaging and objective
since the outcome is based on the children's performance in the game [48]. By transforming what is
typically a tedious process into an enjoyable experience, children are more likely to participate
willingly and perform to the best of their abilities. This approach also reduces the potential for bias,
as the diagnostic outcomes are grounded in the objective measurement of performance metrics
within the game environment.
In this regard, Supermarket is an example of a game that uses data mining algorithms to
categorize data from children with ADHD and accurately distinguish between children with ADHD
and those without ADHD [27]. This game leverages sophisticated data analysis techniques to parse
through extensive datasets, identifying patterns and anomalies that correlate with ADHD. The use
of data mining algorithms enhances the accuracy of the diagnosis, ensuring that the assessment is
both comprehensive and precise.
Another example is the video game developed by Khaleghi [28] for the diagnosis and assessment
of ADHD, based on the DSM-IV as a reference diagnostic criterion. In this context, the diagnosis
result depends on the analysis of the number of mouse clicks on irrelevant responses, choices made,
and the time taken by players. This method provides a detailed behavioral profile of the player,
highlighting impulsivity, attention to detail, and decision-making processes, which are critical
markers of ADHD.
To assess executive functions, Timo's Adventure has been experimented with, a system
composed of six small games with different functions, each aimed at improving specific deficits in
executive function. The presence of ADHD is identified based on executive function deficiencies
highlighted during gameplay [29]. This multi-faceted approach ensures a comprehensive
assessment of various cognitive domains, allowing for a nuanced understanding of the child’s
executive functioning.
In this context, there are also Serious Games for ADHD (SGAD) based on mobile devices, with
an example being the mobile application developed by Nayra that integrates pre-diagnosis and
treatment functions for ADHD [30]. The convenience and accessibility of mobile applications make
them an excellent tool for ongoing assessment and treatment, providing continuous support and
monitoring outside the clinical setting.
Serious games based on brain-computer interaction technologies and virtual reality are
employed for ADHD diagnosis [31, 32, 33]. These advanced technologies create immersive
environments that engage multiple senses and cognitive functions, providing a rich dataset for
assessment. An example is an interactive video game that utilizes Kinect technology to identify
player actions, concluding the ADHD diagnosis by evaluating attention. This game allows the
player to control the gaming experience through body movement, and attention level is assessed
based on variables measured during interaction in the game [34]. The use of Kinect technology
enables a natural and intuitive interaction with the game, making the diagnostic process seamless
and less intrusive. The attention level is inferred from various metrics such as reaction times,
accuracy, and movement patterns, offering a holistic view of the child's attentional capabilities.
By integrating these diverse technologies and methodologies, serious games provide a
multifaceted approach to diagnosing and treating ADHD. This approach not only makes the
diagnostic process more engaging for children but also enhances the accuracy and effectiveness of
the treatment. As these technologies continue to evolve, they hold the potential to revolutionize the
way ADHD is diagnosed and managed, offering new avenues for research and innovation in this
field.
2.2 Serious Games: A tool for treating ADHD
The treatment of ADHD through serious games presents itself as a promising perspective,
addressing the shortcomings of other therapeutic modalities. Unlike traditional methods that may
rely heavily on medication or static forms of therapy, serious games provide dynamic, engaging,
and interactive ways to manage ADHD symptoms. By offering a more stimulating environment,
they cater to the need for constant engagement and immediate feedback, which are crucial for
individuals with ADHD. Through the combined use of various human-computer interaction
technologies, the range of interactive experiences is amplified, thereby contributing to improving
treatment effectiveness [48]. These technologies, including motion sensors, virtual reality, and
adaptive learning algorithms, create immersive experiences that keep the user engaged and
motivated. As a result, the therapeutic process becomes more enjoyable and potentially more
effective.
Serious games based on brain-computer interface (BCI) are progressively contributing to ADHD
treatment, aiming to enhance attention. By integrating EEG devices into the gameplay, these games
provide real-time feedback on the player's brain activity, enabling them to adjust their actions based
on their current mental state. Through the use of EEG devices, they provide real-time feedback
during the gaming experience (via displays or sounds) [35]. This immediate feedback loop helps
players become more aware of their attention levels and learn how to modulate them effectively.
The continuous monitoring and adjustment can lead to better self-regulation and improved focus
over time.
Algorithms, such as frequency analysis, are employed, and some titles incorporate fractal
dimension models [36, 37]. These advanced computational techniques allow for a detailed analysis
of brainwave patterns, enabling the games to adapt in real-time to the player's cognitive state. For
example, in "armis" [38], players use the keyboard to control characters and monitor their brain
state through a wireless EEG device. This visual experience allows them to assess the level of
attention and regulate it according to the game's requirements. By visualizing their brain activity,
players can see the direct impact of their concentration and adjust their strategies accordingly,
leading to more effective training sessions.
In another example, a BCI-based video game, set in a 3D virtual classroom, aims to train the
player's attention, seeking to transfer the effects of training from simulated situations in games to
reality [39]. This simulation of a classroom environment helps players practice focusing in a setting
that closely resembles their real-life experiences. By training in such a realistic scenario, players can
better apply the skills they develop during gameplay to their daily lives, potentially improving their
performance in actual classroom settings.
To exercise attention, patients with ADHD can leverage different types of video games. These
games are designed with specific objectives and mechanics that target various cognitive functions.
For instance, "Plan it Commander" is a typical serious game that, through three micro games,
enhances time management, organizational skills, and social competencies in children with ADHD,
demonstrating its utility in rehabilitation [40, 41]. By breaking down complex tasks into smaller,
manageable mini-games, "Plan it Commander" makes learning new skills fun and accessible. Each
micro game focuses on a different aspect of executive function, ensuring a comprehensive approach
to skill development.
Other games like "Braingame Brian" and "Antonyms" aim to improve attention and executive
function, contributing to the voluntary engagement of patients in treatment [42, 43]. These games
use a variety of techniques to capture and maintain the player's interest, such as rewarding progress
and offering increasingly challenging tasks. This not only helps improve cognitive functions but
also encourages children to participate actively in their treatment.
In relation to executive functions, Wro’nska has developed a serious game to improve reading
comprehension related to memory [44]. This game targets specific aspects of cognitive function that
are often challenging for individuals with ADHD. By focusing on reading comprehension and
memory, it helps players develop essential skills that are crucial for academic success.
Additionally, "The Secret Track of the Moon" offers a realistic chess-based gaming experience
and uses virtual reality to provide cognitive training to patients with ADHD [45]. By combining the
strategic elements of chess with the immersive nature of virtual reality, this game provides a unique
and engaging way to train cognitive functions. Players can practice critical thinking, problem-
solving, and planning in a highly interactive environment.
Finally, among the most innovative therapeutic approaches for children with ADHD, strategies
aimed at reducing stress and promoting emotional regulation through breathing exercises proposed
by "Chillfish" using LEGO respiratory sensors emerge [46]. These exercises help children learn how
to manage their stress and emotions, which can be particularly beneficial for those with ADHD. By
integrating these exercises into a playful and familiar context, "Chillfish" makes it easier for
children to adopt these techniques.
To improve attention and inhibit impulses, "ADDventurous Rhythmical Planet" uses musical
rhythm, also fostering cooperation between children with ADHD and other players [47]. The use of
music and rhythm in this game helps children develop better self-control and timing, while the
cooperative gameplay encourages social interaction and teamwork. This multifaceted approach
addresses both cognitive and social aspects of ADHD, providing a holistic treatment experience.
3. Conclusion
In conclusion, based on the meta-analyses examined, there appears to be a particular effectiveness
of Serious Games in the treatment of ADHD. These analyses suggest that serious games offer a
unique advantage over traditional methods by making the diagnosis and treatment process more
engaging for children. This engagement is crucial as it can significantly reduce ADHD symptoms,
thereby enhancing the overall quality of life for these children. The interactive and immersive
nature of serious games captivates children’s attention, which is often a challenge in conventional
therapy settings.
The use of various technologies, such as EEG detection and human-computer interaction, allows for
accurate assessment and adaptation of treatment to the specific needs of patients. EEG detection
enables real-time monitoring of brain activity, providing immediate feedback that helps tailor the
gaming experience to the player's current cognitive state. This precise feedback mechanism ensures
that the treatment is continually adjusted to meet the evolving needs of the patient, leading to more
effective outcomes. Human-computer interaction technologies, such as motion sensors and adaptive
algorithms, further enhance the customization of these games, ensuring that each child receives a
personalized therapeutic experience.
These games play a significant role in supporting children with ADHD in enhancing attention,
improving executive functions, and strengthening social communication skills. By providing
structured yet flexible environments, serious games help children practice and develop crucial
cognitive skills in a fun and motivating way. Enhancing attention through engaging gameplay helps
children stay focused on tasks for longer periods, a skill that can translate to better performance in
academic and daily activities. Improving executive functions, such as planning, organization, and
impulse control, prepares children to handle complex tasks more effectively. Furthermore, the social
aspects of many serious games encourage children to interact with peers, fostering better
communication and teamwork skills, which are vital for their social development.
However, they are not without critical aspects, such as the risk of video game addiction and the
need to customize approaches based on the individual characteristics of patients [48, 49, 50]. The
engaging nature of serious games, while beneficial, also poses the risk of excessive use or addiction,
which could negate the positive effects of the treatment. It is essential for caregivers and therapists
to monitor usage and ensure a balanced approach to gaming. Additionally, the effectiveness of
serious games can vary significantly based on individual differences among patients. Factors such as
age, severity of symptoms, and personal interests must be considered when designing and
implementing these games to maximize their therapeutic potential.
Finally, possible future directions for research on this topic are suggested. Future studies could
explore the long-term effects of serious games on ADHD symptoms to determine their
sustainability and potential for integration into standard treatment protocols. Research could also
investigate the development of new technologies and game mechanics that further enhance the
therapeutic benefits of serious games. Additionally, studies focusing on the prevention of video
game addiction and the creation of guidelines for safe and effective use are essential to ensure the
responsible implementation of these tools in clinical practice. By addressing these areas, the field
can continue to evolve, offering innovative and effective solutions for managing ADHD.
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