The Effects of Exergaming on Executive Functions in Children with

ADHD: A Protocol of Systematic Review and Meta-Analysis

Febryansah Gilang Aris Pradana

, Rakhmat Ari Wibowo

and Graham Baker

Physical Activity for Health Department, The University of Edinburgh, Edinburgh, Scotland, U.K.

Keywords: Exergaming, Executive Functions, Children, ADHD.

Abstract: Background: Attention-deficit/hyperactivity disorder (ADHD) is one of the most common

neurodevelopmental disorders that affect children. Symptoms of ADHD have been associated with reduced

executive functions (EFs). Physical activity (PA) was suggested as an optional treatment; however, adherence

to PA in children with ADHD is low. Exergaming has shown the beneficial effects on EFs; however, the

evidence-base results were varied. This study will review primary studies investigating the effects of

exergaming to increase EFs. Methods: This protocol of systematic review and meta-analysis is developed

following the PRISMA guidelines. The study protocol has been registered in PROSPERO

(CRD42024549395). Studies from eleven databases, published articles from the same authors, forward and

backward, and co-citing and co-cited citation searches will be screened by two researchers based on inclusion

and exclusion criteria. Two researchers will assess the risk of bias using The Cochrane Risk of Bias 2.

Narrative synthesis will be presented, and meta-analyses will be performed on EF outcomes using random-

effect meta-analyses. GRADE will be used to assess the quality of evidence by two researchers. Conclusion:

This study will be the first systematic review and meta-analysis which offer insights on the effects of

exergaming on EFs and adherence to PA in children with ADHD.

1 INTRODUCTION

Attention deficit/hyperactivity disorder (ADHD) is

one of the most common neurodevelopmental

disorders in children (Salari et al., 2023). The key

symptoms of ADHD are inattention,

hyperactivity/impulsivity, or combined presentation

and mostly arise during school-age children

(American Psychiatric Association, 2022; Colomer et

al., 2017). Those symptoms have been associated

with the reduction in executive functions (EFs) (Nigg

et al., 2002; Willcutt et al., 2005).

EFs are meta-cognitive functions that are

essential for goal orientation, behaviour flexibility,

and adaptation because they control fundamental

cognitive processes (Diamond, 2013). According to

Biederman et al. (2004), EFs consist of three main

processes which are inhibition, working memory, and

cognitive flexibility. Those three processes are highly

associated with learning and academic achievement

https://orcid.org/0009-0005-2929-4772

https://orcid.org/0000-0002-3643-4164

https://orcid.org/0000-0002-9547-6778

in children. Therefore, children with ADHD usually

experience low performance and poor academic

achievement due to problems with their EFs (Arnold

et al., 2020).

Engaging in physical activity (PA) could be one

of the options to deal with reducing EFs. There are

substantial evidence-based studies indicating that PA

has positive impacts on EFs (Welsch et al., 2021;

Chan et al., 2022). However, although the positive

impacts of doing PA for children with ADHD are

known, children with ADHD engage in less PA

(Mercurio et al., 2021). Boman & Bernhardsson

(2023); Ogrodnik et al. (2023) found that one of the

barriers for children with ADHD to engage in PA is

low motivation and forgetfulness since PA is often

perceived as fatiguing and uninteresting.

Therefore, there is a need for another approach as

adjunct or independent treatment for children with

ADHD. Halperin & Healey (2011) argued that

combining PA with cognitive challenges might be a

Pradana, F., Wibowo, R. and Baker, G.

The Effects of Exergaming on Executive Functions in Children with ADHD: A Protocol of Systematic Review and Meta-Analysis.

DOI: 10.5220/0013064800003828

Paper published under CC license (CC BY-NC-ND 4.0)

In Proceedings of the 12th International Conference on Sport Sciences Research and Technology Support (icSPORTS 2024), pages 251-256

ISBN: 978-989-758-719-1; ISSN: 2184-3201

251

good treatment to deal with EF problems and low

adherence in PA to children with ADHD. This

combination approach could be implemented through

exergaming.

Exergaming is an innovation that combines

exercise with gaming; therefore, players should make

body movements that appear on the digital games to

play exergaming; by doing so, the players will get the

benefits of doing PA (Wijffelaars & Markopoulos,

2023). Using game field approaches, exergaming

could be fun exercises that can increase motivation,

EFs, and adherence to PA in children (Staiano &

Calvert, 2011; Primack et al., 2012).

There are growing numbers of studies that

examine the effects of exergaming on the EFs in

children with ADHD and found the beneficial effects

(Chang et al., 2022; Benzing & Schmidt, 2019).

However, the effects of the outcomes of those studies

are varied from moderate effects (Benzing &

Schmidt, 2019) to large effects (Chang et al., 2022).

Therefore, it could be suggested to conduct a

systematic review to solve the gaps in understanding

the effects of exergaming to increase EFs in children

with ADHD.

To the best of our knowledge, this will be the first

systematic review and meta-analysis exploring the

effects of exergaming on EFs in children with ADHD.

This systematic review and meta-analysis aim to

review primary studies that have investigated the

effects of exergaming on EFs in children with ADHD

and to summarise their findings.

1.1 Research Questions

1. What is the effectiveness of exergaming on

executive functions in children with ADHD

compared with the control group?

2. What is the adherence of children with ADHD

in exergaming interventions?

2 METHODS

A systematic review will be conducted to answer the

research questions. The review protocol was written

based on the Preferred Reporting Items for

Systematic Review and Meta-Analysis Protocols

(PRISMA-P) statement (Moher et al., 2015;

Shamseer et al., 2015) and the Cochrane Handbook

(Higgins et al., 2023). The protocol has been

registered in the International Prospective Registers

of Systematic Reviews (PROSPERO)

(CRD42024549395; Pradana et al., 2024).

2.1 Eligibility Criteria

Studies will be selected based on the following

inclusion and exclusion criteria using Population,

Intervention, Control, Outcomes, and Study design

(PICOS) framework: (1) Population: children aged 4

– 12 years of age who have been diagnosed as having

ADHD symptoms using the standardised diagnostic

tool, for instance the International Classification of

Diseases (ICD) criteria or the Diagnostic and

Statistical Manual of Mental Disorder (DSM); (2)

Intervention: studies that used exergaming as at least

one of their interventions. All exergaming domains,

structured or semi-structured, and indoors or outdoors

will be included. However, studies using single-bout

interventions will be excluded.; (3) Control: control

groups with no treatment or using waiting list or using

non-active treatment, such as usual care and cognitive

training; (4) Outcomes: EFs (inhibition, working

memory, and cognitive flexibility) and the adherence

on exergaming interventions; (5) study design:

Randomized Controlled Trials (RCTs). Only English-

language published articles with no date and location

restriction will be included to identify relevant studies

(Lefebvre et al., 2023).

2.2 Information Sources

A systematic search will be conducted on the 11

electronic databases to identify published literature

which will be included in the review: MEDLINE

(Ovid); CINAHL (EBSCO); CENTRAL; Embase

(Ovid); SPORTDiscus (EBSCO); PsycINFO (Ovid);

Scopus (Elsevier); Web of Science (Clarivate); ACM

Digital Library; IEEE Xplore Digital Library; and

Sport Medicine & Education Index.

2.3 Search Strategy

The search strategy will be developed based on 5

categories from the PICOS (Table 1). The search

strategy for the MEDLINE database is provided in

Table 1 and will be adapted for other databases.

Moreover, the researchers will search for additional

papers by the same author and perform forward and

backward, and co-cited and co-citing citation

searches of all eligible studies.

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Table 1: Search strategies.

Cate

ories Terms

Children child* OR kid* OR

outh OR

ediatric

ADHD ADHD OR “attention deficit

hyperactivity disorder” OR “attention

deficit disorder” OR “attention deficit-

hyperactivity disorder” OR “attention-

deficit/hyperactivity disorder” OR

“hyperactivity disorder” OR

“hyperkinetic syndrome” OR “minimal

brain damage” OR “minimal brain

dysfunction” OR “neurodevelopmental

disorder”

Exergame exergam* OR video gam* OR game*

OR gaming OR “active video games”

OR “computer games” OR “online

gam*” OR “internet gam*” OR “virtual

reality” OR vr OR “augmented reality”

OR “immersive virtual reality” OR

“immersive vr” OR ivr OR wii OR

“nintendo wii” OR “wii gam*” OR “wii

fit” OR “virtual cycl*” OR “xbox

kinect” OR “physical action gam*” OR

“serious

ame”

Executive

functions

“executive function*” OR “executive

dysfunction” OR “cognitive function*”

OR “executive abilit*” OR “cognitive

ability*” OR “cognitive control” OR

“executive process*” OR cognit* OR

memor* OR vigilance OR distractibility

OR “cognitive flexibility” OR impulsiv*

OR inhibit* OR “dual task” OR

“inhibitory control” OR “working

memory” OR “short term memory” OR

“interference control” OR “speed

reaction” OR “processing speed” OR

“cognitive dysfunction” OR “cognition

disorders”

RCTs “randomized controlled trial” OR rct OR

“randomised controlled trial

2.4 Data Management

The researchers will use the Covidence tool

(https://www.covidence.org/) to automatically

remove duplicates and to improve efficiency in time.

Moreover, the PRISMA diagram will be used to

manage records of every process (Page et al., 2021).

2.5 Selection Process

Two researchers will independently screen articles

based on the eligibility criteria. Firstly, the reviewers

will conduct an initial search followed by two-step

screening processes which are screening the titles and

the abstracts to exclude studies that do not meet the

eligibility criteria. The reviewers will choose ‘yes’ to

the eligible study and “no” to the study which is not

meet a particular criterion. If the reviewers are unsure

about the decision, the reviewers will follow through

to the next step which is screening the full text.

Secondly, the reviewers will screen the full text of

selected studies to identify the final eligible studies to

be included in the synthesis. If there are

disagreements during abstract and full-text screening,

they will be resolved through discussion. If there are

any disagreements that cannot be resolved, the arbiter

from the third author will mediate the discussion of

the discrepancies.

2.6 Data Collection Process and Data

Items

The data collection process will be performed by two

independent researchers who will collect the data of

following study characteristics in the Excel: the

reference, study location, participant characteristics

(age, gender, type of ADHD), intervention details

(type of exergame, exergame features, dose, setting,

delivery mode, theoretical frameworks), and

outcomes (measurement tool, unit of measurement,

EFs domains, adherence) from included studies based

on the Consolidated Standards of Reporting Trial-

EHEALTH checklist (Eysenbach & CONSORT-

EHEALTH Group, 2011) and the Consensus on

Exercise Reporting Template (CERT) (Slade et al.,

2016). The author will contact the study authors if

there are missing or unclear data. Discussion will be

conducted to resolve discrepancies between

reviewers. If conflicts cannot be resolved, the third

author will conduct mediation.

2.7 Outcomes and Prioritization

The primary outcome of this study is EFs (inhibition,

working memory, and cognitive flexibility). Studies

exploring changes in EFs between baseline and the

end of interventions which used standardized

outcome measures assessing either EFs or any

specific domain of EFs as a continuous outcome will

be included. For instance, Chang et al. (2022) used

The Wisconsin Card Sorting Test, while Benzing &

Schmidt (2019) used computer-based tests using E-

Prime Software.

The secondary outcome of this systematic review

and meta-analysis is the adherence to the exergaming

interventions which will be measured through the

drop-out rate.

The Effects of Exergaming on Executive Functions in Children with ADHD: A Protocol of Systematic Review and Meta-Analysis

253

2.8 Risk of Bias in Individual Studies

The risk of bias (RoB) in the included studies will be

independently assessed by two researchers using the

Cochrane RoB 2 tool for RCT. The authors will

present RoB table for all included studies. Conflicts

between reviewers will be resolved through

discussion. The third author will conduct mediation if

there are discrepancies that cannot be resolved.

The researchers will assess RCTs on the allocation

concealments, sequence generation, blinding of

outcome assessments, incomplete outcome data,

reporting bias, and validity of outcome measures

(Higgins et al., 2011). Blinding of participants and

personnel to the group allocation will not be assessed

since this would not be suitable for the exergaming

intervention study. Rating as “low” or “some

concerns” or “high” risk of bias will be used.

2.9 Data Synthesis

A narrative synthesis of the results in EFs outcome

will be presented. A meta-analysis will be conducted

where possible by pooling the appropriate data using

Review Manager 2014. The authors will use random-

effects meta-analysis since high variance of the unit

of measurement and intervention design. The authors

will use outcome data which reported using the

change from baseline to calculate the standardised

mean difference (SMD) and 95% confidence

intervals (CIs). The authors will conduct imputation

on p-value to obtain the standard deviation (SD) of

the change from baseline if the studies did not report

using change from baseline (Deeks et al., 2019).

The authors will calculate the I

statistics to assess

heterogeneity (Higgins, 2002) and will be depicted as

part of the forest plots in Review Manager. Where

possible, the authors will independently perform

subgroup analyses on the type of ADHD and

exergame, the measurement methods between

studies, and male versus female. Moreover, the

authors will perform sensitivity analyses.

2.10 Publication Bias

The authors will utilize a funnel plot when the meta-

analysis contains at least 10 studies.

2.11 Confidence in Cumulative Evidence

Two reviewers will use the Grading of

Recommendation, Assessment, Development and

Evaluation (GRADE) tool by Higgins & Green

(2008) to independently assess the quality of

evidence. Disagreements between reviewers will be

solved through discussion. If discrepancies cannot be

resolved, the third author will conduct mediation.

3 DISCUSSION

The needs of optional approaches to treat executive

dysfunctions in children with ADHD are crucial.

Exergaming has shown beneficial effects to increase

EFs in children with ADHD (Chang et al., 2022;

Benzing & Schmidt, 2019). As far as authors

concerned, this will be the first systematic review and

meta-analysis investigating and summarising the

evidence on the effects of exergaming on EFs in

children with ADHD.

This proposed systematic review and meta-

analysis may introduce some limitations. Since our

topic is specific and the exergaming interventions to

treat EFs in children with ADHD is relatively new,

the results of eligible studies may be limited. Those

can affect the possibility to conduct meta-analysis,

sub-group analysis, and sensitivity analysis (Higgins

et al., 2023). However, to address those limitations,

the authors will use 11 databases and comprehensive

search strategies which have been consulted with an

academic librarian. Another potential limitation is the

possibility of bias in the included studies; therefore,

the authors will use the RoB 2 tool to assess the risk

of bias of eligible studies.

On the other hand, there are some potential

strengths of our study. Two reviewers and one arbiter

will involve in the screening, data extraction, and

RoB and GRADE assessments. Those approaches can

minimize the selection bias (Stoll et al., 2019).

Moreover, the authors will adhere to the PRISMA

guideline to implement robust and rigorous

systematic review and meta-analysis (Page et al.,

2021).

4 CONCLUSION

This study will be the first systematic review and

meta-analysis which will synthesis primary studies

and summarise their findings on the effects of

exergaming on EFs and adherence to PA in children

with ADHD.

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ACKNOWLEDGEMENTS

The authors would like to acknowledge the Indonesia

Endowment Fund for Education Agency (LPDP RI)

who funded this research under a master’s degree

scholarship for the primary author (FGAP)

(202308122023612). Additionally, the authors would

like to acknowledge Ishbel Leggat, an academic

librarian at The University of Edinburgh, who

assisted the development of the search strategy.

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