Mobile Devices and Systems in ADHD Treatment

Renato Montaleão Brum Alves, Mônica Ferreira da Silva, Eber Assis Schmitz

and Antonio Juarez Alencar

Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil

Keywords: ADHD, Mobile, Neurofeedback, Serious Games, Treatment.

Abstract: Attention Deficit Hyperactivity Disorder (ADHD) is a neurobiological condition that appears during an

individual’s childhood and may follow her/him for life. Even though it is not a new disorder, ADHD treatment

is limited to the use of drugs and behavioral therapy, even for children. The objective of this research was to

investigate the technological possibilities of mobile devices and web-based information systems, as well as

other computer technologies, to support the ADHD treatment phase. Results show the potential of these

approaches as alternatives for long-term treatment, as well as the difficulties and limitations that persist today.

Besides, the research also highlighted that the use of computer technology could provide persistent long-term

results.

1 INTRODUCTION

Attention Deficit Hyperactivity Disorder (ADHD) is

one of the most common neurobiological conditions

that affects children. Faraone, Biederman, & Mick

(2006) found out that, in 65% of the cases, ADHD

persists into adolescence and adulthood.

The current treatment for this

neurodevelopmental disorder includes a combination

of medication and psychotherapy. Despite the relative

success of pharmaceutical therapies in ADHD, there

are essential reasons to identify alternative non-

invasive methods. First, the list of side effects

includes headaches, mood swings, nausea and

dizziness. Besides, prescribing drugs to young

children involves risks not yet thoroughly and surely

studied. Lastly, medicine is not equally effective for

ADHD subgroups.

The treatment phase of ADHD offers a vast field

for research, and computer technologies play a

promising role in this regard. Systems have been used

for such purpose since 1985, through the software

CAPTAIN (Gomez & Carro, 2014). Since then,

technology has evolved, especially in the mobile

segment.

This work aimed to investigate the technological

advances of web-based information systems, as well

as other computer technologies, to support the ADHD

treatment phase. Through this research work, it was

possible to verify which are the leading

computational technologies today. The results show

the potential of these approaches as alternatives for

long-term treatment for patients in childhood or

adulthood, indicating that the use of some

technologies produces lasting effects, even when

application is interrupted. Also, the difficulties and

limitations emerged from the analyses carried out.

2 USE OF MOBILE AND WEB

COMPUTER TECHNOLOGY

FOR ADHD TREATMENT

In some locations, access to psychotherapeutic

treatment is practically impossible due to distance or

mobility issues. For this reason, mobile technology

associated with web resources may be the only form

of treatment for some patients. IT Systems have been

used to treat ADHD since 1985 (Gomez & Carro,

2014). In our research, we used literature systematic

review techniques to identify several published

papers in recent years, dealing with the use of

technology as a means of non-invasive treatment.

Among the most used technologies, we can highlight

Neurofeedback, followed by Serious Games, and the

combined use of both approaches. Also,

approximately 15% of scientific research reported the

use of web remote assistance technology by video

conferencing or data monitoring capabilities.

Alves, R., Ferreira da Silva, M., Schmitz, E. and Alencar, A.

Mobile Devices and Systems in ADHD Treatment.

DOI: 10.5220/0010148201410146

In Proceedings of the 16th International Conference on Web Information Systems and Technologies (WEBIST 2020), pages 141-146

ISBN: 978-989-758-478-7

141

2.1 Neurofeedback

Neurofeedback is a neural self-regulation technique

that allows individuals to modulate their brain

frequencies using visual, auditory reinforcements, or

both, usually displayed on the screen of a computing

device. The training based on such technique,

designed to change an individual’s brain activity, has

been in use for nearly four decades and accounting for

one of the first applications of brain-computer

interfaces. Most studies are based on

electroencephalogram (EEG) recordings and apply

neurofeedback in clinical contexts, exploring its

potential as a treatment for psychopathological

syndromes.

Cowley et al., (2016) carried out a controlled

clinical trial of neurofeedback therapeutic

intervention in ADHD for adults. The EEG device

used was Enobio from the company Neuroelectrics

SL. The software developed was based on the

OpenViBE

signal acquisition framework with Qt

frontend, and it is available as an open source. As a

result, the technique improved self-reported ADHD

symptoms.

Another study using the same technique analyzed

the differences between inattentive and hyperactive

subtypes using the BrainMaster software. The results

indicated that the predominantly inattentive group

showed relevant differences on the control scale and

the attention scale. The predominantly hyperactive

group showed improvement in the control scale. The

control group showed no significant difference in

either scale. Findings suggest that neurofeedback

training using the theta/beta protocol was more

effective in the predominantly inattentive subset of

individuals (Duarte Hernández, González Marqués,

& M. Alvarado, 2017).

A variation of such an approach by Azman,

Mansor & Lee (2018) evaluated the use of a physical

race car game to treat children. Wireless data

transmission to transfer brain signal data was used to

move and stop the car. A program installed on the

microcontroller was used to control the car’s motion.

NeuroSky MindWave Mobile EEG was connected to

the Arduino UNO and Toys”R”Us Fastlane Slot Car

via Bluetooth. As the NeuroSky MindWave receives

the user’s brain signal, the car is activated if the user

concentrates and gives it full attention. Arduino UNO

was used as a controller to detect the level of attention

embedded in the brain signal and activate the

Toys”R”Us Fastlane Slot Car.

http://openvibe.inria.fr/

In another variation, experimented by Shin et al.

(2016), a tablet was used to verify whether the

neurofeedback technique could improve brain

executive functions. Forty children participated in the

experiment using the equipment connected to a

mobile brainwave monitor. Several

neuropsychological tests were carried out after

training with the devices, and the conclusion was that

there was an improvement in the cognitive function.

The good results remained during the follow-up

period.

Two other surveys also verified the permanence

of the training effect months after it ended. One of

them performed experiments with adolescents using

real-time functional magnetic resonance imaging

neurofeedback (rtfMRI-NF). Results showed

significant increases in linear activation in the target

regions, and a reduction in ADHD symptoms during

the 11 months of follow-up (Alegria et al., 2017).

The second survey analyzed aimed at assessing

sustained improvements after six months of applying

neurofeedback to children. One hundred and four

children received cognitive training, neurofeedback

treatment, or were placed in the control status. The

neurofeedback system used was Play Attention

, from

the company Unique Logic and Technology.

Brainwaves were measured by an EEG sensor built in

a bicycle helmet, centrally located at the top of the

skull, and two others bilaterally located EEG sensors.

Individuals who used neurofeedback had more

significant improvements in ADHD symptoms as

compared to those in the control group or undergoing

cognitive treatment and maintained them during the

6-month follow-up period (Steiner et al., 2014).

On the other hand, Bink et al. (2015) reported an

experiment with negative results concerning the

superior effectiveness of neurofeedback approach.

The EEG signal was sent to the computer using

Brainquiry PET and the training conducted with

EEGer software. The combination of usual treatment

with neurofeedback was not more effective than

applying the standard therapy alone. However, the

software interface does not seem to encourage its use

and, without the aid of a serious game, engagement of

individuals with attention-deficit may have been

jeopardized.

Lastly, an unsuccessful use of neurofeedback

software: a study investigated the effect of a system

called ACTIVATE™ that targets a wide range of

cognitive functions. Seventy children with ADHD

participated in the experience. The intervention group

used ACTIVATE™ for 8 weeks. Both groups were

http://www.playattention.com/

WEBIST 2020 - 16th International Conference on Web Information Systems and Technologies

142

evaluated regarding cognitive functions, symptoms,

behavioral and functional outcomes after 8, 12 and 24

weeks. The clinical trial found no significant effect on

cognitive training (Bikic et al., 2018).

2.2 Serious Games

Attention-training games based on Brain-Computer

Interface (BCI) have proved positive in the treatment

of children with ADHD, specifically with inattentive

symptoms. Five research papers analyzed used

neurofeedback techniques combined with serious

games. Rohani, Sorensen & Puthusserypady (2014),

for example, introduced a system aimed at treating

children with ADHD. To do so, a virtual classroom

environment was developed using Unity3D game

engine with SDK, BLENDER 3D modeling software,

and Microsoft Kinect.

Other three studies also used the Unity3D SDK

platform. Ochi et al. (2017) developed a serious game

with neurofeedback for attention training in adults

with ADHD. The game Armis was generated using

the Unity platform. The results suggested that this

type of therapy may be effective as an alternative

treatment since the high-risk group achieved

significant improvement.

Chen et al. (2018) used the same development

platform and the same EGG mobile monitor,

NeuroSky MindWave, to detect brainwaves and then

apply them to the game. Finally, using the Conners’

Continuous Performance Test / Conners Kiddie

Continuous Performance Test (CPT / KCPT), a

significant improvement was observed in the

attention and focus of children who participated in the

study.

Alchalcabi, Eddin & Shirmohammadi (2017)

designed a virtual reality serious game, also using the

Unity SDK, with the EGG device called EMOTIV

EPOC+. The goal was to improve the focused

capacity in individuals with ADHD and ADD.

Preliminary experiments with healthy individuals

showed an average improvement of 10% in

engagement and 8% in focus for persons who used

the EEG-controlled game, compared to those who

used the same game but controlling it by the

keyboard.

The third study examined the topological changes

of the brain functional networks induced by the 8-

week BCI-based attention intervention. The attention

training game consisted of a head arc with EEG

sensors that sent brainwave readings to the computer.

The tested group showed a reduction in inattention

symptoms followed by differential brain network

reorganization after the training (Qian et al., 2018).

On the other hand, we have serious games-

focused studies used without neurofeedback. Dovis et

al. (2015) trained several executive roles of children

with ADHD through a software called Braingame

Brian. It is a computer-based executive function

training, turned into a serious game. The results

suggested the beneficial effects of treatment

perceived using technology.

In another study, authors carried out a case study

with a 10-year-old patient. The child was treated

using medication along with a new video game-based

cognitive training method called the TCT method.

The cognitive areas in which improvement was

observed were the spatial working memory and fine

motor skills. The technique improves cognitive skills

such as attention, working memory, processing speed,

calculating ability, and reasoning, as well as visual-

motor coordination. As a result, the researchers

highlighted that regular computer-based cognitive

training can improve some of the cognitive ADHD

symptoms and still be useful to treat video game

addiction. (Ruiz-Manrique, Tajima-Pozo &

Montañes-Rada, 2015).

In 2015, a group of researchers developed a

serious game called Plan-It Commander, designed to

promote behavioral learning and strategy use in

everyday life situations known to be problematic for

children with ADHD. The game content and

approach are based on the psychological principles of

the Self-Regulation Model, the Social Cognitive

Theory, and the Learning Theory. A survey was

carried out with 42 children with ADHD, in order to

gather user feedback on a prototype of the game.

Children guardians also participated and reported a

significant improvement of children in time

management, planning and frustration tolerance

issues (Bul et al., 2015).

In 2018, the same researchers tried to identify

which subgroups of children with ADHD benefited

most from treatment using a serious game. As a

conclusion, the study found two groups that benefited

most from the intervention: girls in general and boys

with lower scores on hyperactivity and higher scores

with Conduct Disorder symptoms. (Bul et al., 2018).

2.3 Remote Web Treatment

There are still many barriers to access personalized

therapeutic content, either due to the distance

between patients and large urban centers, or even

because of displacement difficulties. That is the

reason why the use of remote technology for

treatment has been arousing interest and may become

a promising manner to offer behavioral interventions

to parents and children with ADHD.

Mobile Devices and Systems in ADHD Treatment

143

Sibley, Comer & Gonzalez (2017) investigated

the therapy for parents and children in the

videoconferencing format. A Cisco platform, called

Webex

, was used in the study. The families reported

a high level of satisfaction with the experience.

Therapists observed improvement for 50% of

families. Teachers and parents observed reductions in

ADHD symptoms, in the organization, time

management, and planning issues.

In another study, videoconferencing was

evaluated to provide behavioral interventions to the

families of individuals with ADHD. The product used

was the Catalyst Common View. Parents reported

results comparable to conventional assistance (Tse,

McCarty, Stoep, & Myers, 2015).

Simons et al. (2016) tried to explore the opinions

and behavior of patients, parents and health

professionals as regards the use of a remote

monitoring system. A prototype was developed by the

company QbTech and consisted of automated

messages via SMS with an invitation to fill in Web

forms on routine outcome measures, to monitor

symptoms and side effects of medication prescribed.

2.4 Other Mobile and Web Computer

Technologies

Using a touch screen desk, Gomez & Carro (2014)

introduced the AdaptADHD, an app to support

adaptive training and assessment for children and

adolescents with ADHD during their therapies. The

application aims to assist patients in improving their

skills regarding concentration and impulse control.

Besides, it supports the work of therapists in enabling

patient monitoring.

Another software analyzed in the survey was the

Drive Smart

. The authors believe that the risk of

young drivers with ADHD is increased by correlation

with the impaired ability to perceive risk. The study

carried out aimed to verify the changes in the ability

to sense danger in young drivers with ADHD, who

received training through Drive Smart. The risk

perception skills of respondents improved

significantly after the training, and with some gain

maintenance, found within 6 weeks of follow-up,

after using the software. (Bruce et al., 2017).

iPads were also analyzed in the context of ADHD

treatment. Schuck et al. (2016) evaluated the

usefulness of a web-based application called

iSelfControl. The system was designed to support

classroom behavior management. The iSelfControl

required that each student performed a self-

http://www.webex.com

assessment at predefined periods. Simultaneously,

the teacher evaluated each student on a separate iPad.

The app collected assessment discrepancies between

teachers and students, as well as significant variations

throughout the day.

In the context of social networks and wearables,

Schoenfelder et al. (2017) used a device called Fitbit

Flex: a smart wristband that allows physical

monitoring information. They also used a social

network to create an engagement group with weekly

goals. Such technologies were used due to their

interactivity features, which are promising for

adolescents, a public with a higher risk of abandoning

treatments. The results indicated improvement in

adolescents’ inattentive symptoms, as reported by

their parents.

In another web technology evaluation, authors

sought to verify the effect of an educational site on

parental perceptions and knowledge levels. A total of

172 parents, whose children had ADHD, were

recruited. After taking a 30-item basic knowledge

test, parents were directed to an educational site on

ADHD. Then they were contacted again for the

follow-up test. 85.5% of the respondents regarded the

use as relevant and would use it again. As an overall

result, authors found that parents showed more

significant knowledge of ADHD after using the site

(Ryan, Haroon, & Melvin, 2015).

3 CONCLUSIONS AND FUTURE

WORK

Non-invasive treatments for ADHD are as urgent as

feasible through the web and mobile technology that

exist today, revealing increasingly promising results.

The use of technology also allows continuous

treatment to be offered even to those who reside far

from urban centers. In this article, we highlighted the

current trends, main findings and some limitations of

using mobile and web technology in the treatment

phase of ADHD.

As shown in literature, mobile EEG technology

combined with serious games has been effective in

the treatment of ADHD. Our next step will be to

evaluate the adoption of a prototype that allows the

use of a domestic neurofeedback device in

conjunction with a gamification strategy and a web

system, to enable remote treatment and the support by

health professionals.

The objective is to verify which human or

technological factors impact the adoption of these

http://drivesmart.vic.gov.au

WEBIST 2020 - 16th International Conference on Web Information Systems and Technologies

144

tools, and which facilitators can drive the use of

technology. For this purpose, we will verify such

aspects under the perspective of Technology

Acceptance Model (TAM) (Davis, 1989).

Another expected contribution of the research is

to verify if the solution applies equally to all subtypes

of ADHD. Still, as a future work of this research

group, there is the objective of evaluating the

possibilities of using computer technologies to assist

in the diagnosis stage of ADHD disorder.

REFERENCES

Alchalcabi, A. E., Eddin, A. N., & Shirmohammadi, S.

(2017). More attention, less deficit: Wearable EEG-

based serious game for focus improvement. 2017 IEEE

5th International Conference on Serious Games and

Applications for Health, SeGAH 2017.

https://doi.org/10.1109/SeGAH.2017.7939288.

Alegria, A. A., Wulff, M., Brinson, H., Barker, G. J.,

Norman, L. J., Brandeis, D., … Rubia, K. (2017). Real-

time fMRI neurofeedback in adolescents with attention

deficit hyperactivity disorder. Human Brain Mapping,

38(6), 3190–3209. https://doi.org/10.1002/hbm.23584.

Azman, N. H., Mansor, W., & Lee, K. Y. (2018). Neuro

based racing car for cognitive training. IEEE Student

Conference on Research and Development: Inspiring

Technology for Humanity, SCOReD 2017 -

Proceedings, 2018-Janua, 473–476.

https://doi.org/10.1109/SCORED.2017.8305437.

Bikic, A., Leckman, J. F., Christensen, T., Bilenberg, N., &

Dalsgaard, S. (2018). Attention and executive functions

computer training for attention-deficit/hyperactivity

disorder (ADHD): results from a randomized, controlled

trial. European Child and Adolescent Psychiatry, 27(12),

1563–1574. https://doi.org/10.1007/s00787-018-1151-y

Bink, M., van Nieuwenhuizen, C., Popma, A., Bongers, I.

L., & van Boxtel, G. J. M. (2015). Behavioral effects of

neurofeedback in adolescents with ADHD: a

randomized controlled trial. European Child and

Adolescent Psychiatry, 24(9), 1035–1048.

https://doi.org/10.1007/s00787-014-0655-3.

Bruce, C. R., Unsworth, C. A., Dillon, M. P., Tay, R.,

Falkmer, T., Bird, P., & Carey, L. M. (2017). Hazard

perception skills of young drivers with Attention

Deficit Hyperactivity Disorder (ADHD) can be

improved with computer based driver training: An

exploratory randomised controlled trial. Accident

Analysis & Prevention, 109, 70–77.

https://doi.org/https://doi.org/10.1016/j.aap.2017.10.00

Bul, K. C. M., Doove, L. L., Franken, I. H. A., Van Der

Oord, S., Kato, P. M., & Maras, A. (2018). A serious

game for children with Attention Deficit Hyperactivity

Disorder: Who benefits the most? PLoS ONE, 13(3), 1–

18. https://doi.org/10.1371/journal.pone.0193681.

Bul, K. C. M., Franken, I. H. A., Van der Oord, S., Kato, P.

M., Danckaerts, M., Vreeke, L. J., … Maras, A. (2015).

Development and User Satisfaction of “Plan-It

Commander,” a Serious Game for Children with

ADHD. Games for Health Journal, 4(6), 502–512.

https://doi.org/10.1089/g4h.2015.0021.

Chen, C. L., Tang, Y. W., Zhang, N. Q., & Shin, J. (2018).

Neurofeedback based attention training for children

with ADHD. Proceedings - 2017 IEEE 8th

International Conference on Awareness Science and

Technology, ICAST 2017, 2018-

Janua(iCAST), 93–97.

https://doi.org/10.1109/ICAwST.2017.8256530.

Cowley, B., Holmström, É., Juurmaa, K., Kovarskis, L., &

Krause, C. M. (2016). Computer Enabled

Neuroplasticity Treatment: A Clinical Trial of a Novel

Design for Neurofeedback Therapy in Adult ADHD.

Frontiers in Human Neuroscience, 10(May), 1–13.

https://doi.org/10.3389/fnhum.2016.00205.

Davis, F. D. (1989). Perceived Usefulness, Perceived Ease

of Use, and User Acceptance of Information

Technology. MIS Quarterly, 13(3), 319.

https://doi.org/10.2307/249008.

Dovis, S., Van Der Oord, S., Wiers, R. W., & Prins, P. J.

M. (2015). Improving executive functioning in children

with ADHD: Training multiple executive functions

within the context of a computer game. A randomized

double-blind placebo controlled trial. PLoS ONE,

10(4), 1–30. https://doi.org/10.1371/journal.

pone.0121651.

Duarte Hernández, E., González Marqués, J., & M.

Alvarado, J. (2017). Effect of the theta-beta

neurofeedback protocol as a function of subtype in

children diagnosed with attention deficit hyperactivity

disorder. Spanish Journal of Psychology, 19(2016), 1–

10. https://doi.org/10.1017/sjp.2016.31.

Faraone, S. V., Biederman, J., & Mick, E. (2006). The age-

dependent decline of attention deficit hyperactivity

disorder: A meta-analysis of follow-up studies.

Psychological Medicine.

https://doi.org/10.1017/S003329170500471X.

Gomez, L., & Carro, R. M. (2014). Adaptive training of

children with attention deficit hyperactivity disorder

through multi-touch surfaces. Proceedings - IEEE 14th

International Conference on Advanced Learning

Technologies, ICALT 2014, 561–563.

https://doi.org/10.1109/ICALT.2014.164.

Ochi, Y., Laksanasopin, T., Kaewkamnerdpong, B., &

Thanasuan, K. (2017). Neurofeedback game for attention

training in adults. BMEiCON 2017 - 10th Biomedical

Engineering International Conference, 2017-Janua, 1–5.

https://doi.org/10.1109/BMEiCON.2017.8229113.

Qian, X., Loo, B. R. Y., Castellanos, F. X., Liu, S., Koh, H.

L., Poh, X. W. W., … Zhou, J. (2018). Brain-computer-

interface-based intervention re-normalizes brain

functional network topology in children with attention

deficit/hyperactivity disorder. Translational

Psychiatry, 8(1). https://doi.org/10.1038/s41398-018-

0213-8.

Rohani, D. A., Sorensen, H. B. D., & Puthusserypady, S.

(2014). Brain-computer interface using P300 and

Mobile Devices and Systems in ADHD Treatment

145

virtual reality: A gaming approach for treating ADHD.

2014 36th Annual International Conference of the IEEE

Engineering in Medicine and Biology Society, EMBC

2014, 3606–3609. https://doi.org/10.1109/EMBC.

2014.6944403

Ruiz-Manrique, G., Tajima-Pozo, K., & Montañes-Rada, F.

(2015). Case Report: “ADHD Trainer”: the mobile

application that enhances cognitive skills in ADHD

patients. F1000Research, 3, 283.

https://doi.org/10.12688/f1000research.5689.3.

Ryan, G. S., Haroon, M., & Melvin, G. (2015). Evaluation

of an educational website for parents of children with

ADHD. International Journal of Medical Informatics,

84(11), 974–981. https://doi.org/10.1016/j.ijmedinf.

2015.07.008.

Schoenfelder, E., Moreno, M., Wilner, M., Whitlock, K. B.,

& Mendoza, J. A. (2017). Piloting a mobile health

intervention to increase physical activity for adolescents

with ADHD. Preventive Medicine Reports, 6, 210–213.

https://doi.org/https://doi.org/10.1016/j.pmedr.2017.03.

003.

Schuck, S., Emmerson, N., Ziv, H., Collins, P., Arastoo, S.,

Warschauer, M., … Lakes, K. (2016). Designing an

iPad app to monitor and improve classroom behavior

for children with ADHD: ISelfControl feasibility and

pilot studies. PLoS ONE, 11(10), 1–13.

https://doi.org/10.1371/journal.pone.0164229.

Shin, M. S., Jeon, H., Kim, M., Hwang, T., Oh, S. J.,

Hwangbo, M., & Kim, K. J. (2016). Effects of smart-

tablet-based neurofeedback training on cognitive

function in children with attention problems. Journal of

Child Neurology, 31(6), 750–760.

https://doi.org/10.1177/0883073815620677.

Sibley, M. H., Comer, J. S., & Gonzalez, J. (2017).

Delivering Parent-Teen Therapy for ADHD through

Videoconferencing: a Preliminary Investigation. Journal

of Psychopathology and Behavioral Assessment, 39(3),

467–485. https://doi.org/10.1007/s10862-017-9598-6.

Simons, L., Valentine, A. Z., Falconer, C. J., Groom, M.,

Daley, D., Craven, M. P., … Hollis, C. (2016).

Developing mHealth Remote Monitoring Technology

for Attention Deficit Hyperactivity Disorder: A

Qualitative Study Eliciting User Priorities and Needs.

JMIR MHealth and UHealth, 4(1), e31.

https://doi.org/10.2196/mhealth.5009.

Steiner, N. J., Frenette, E. C., Rene, K. M., Brennan, R. T.,

& Perrin, E. C. (2014). In-School Neurofeedback

Training for ADHD: Sustained Improvements From a

Randomized Control Trial. Pediatrics, 133(3), 483–

492. https://doi.org/10.1542/peds.2013-2059.

Tse, Y. J., McCarty, C. A., Stoep, A. Vander, & Myers, K.

M. (2015). Teletherapy Delivery of Caregiver Behavior

Training for Children with Attention-Deficit

Hyperactivity Disorder. Telemedicine and e-Health,

21(6), 451–458. https://doi.org/10.1089/tmj.2014.0132.

WEBIST 2020 - 16th International Conference on Web Information Systems and Technologies

146