Can Video Games Help Treat ADHD? Reviewing the Evidence
Last week, video games made headlines for positive reasons as the Food and Drugs Administration (FDA) approved its first video game treatment for a medical condition. This treatment is EndeavorRx, a video game designed to help those diagnosed with ADHD. As news articles commonly don’t refer to or cite research, this left people with a lot of questions. What is EndeavorRx? Is it effective? Why and how does it improve symptoms of ADHD?
I made a short Twitter thread providing links to research citing the effectiveness of EndeavorRx. However, I appreciate that terms like randomised controlled trials aren’t going to be understood by many people. Because of this, I will be explaining these research studies (in order of publication date) using language that is easy to understand. Before diving into these studies, I’ll quickly explain two things that seem to be on everyone’s mind – why ADHD, and why video games?
As usual, there will be a summary at the bottom if you do not wish to read everything. Now, let’s begin!
Contents
Why ADHD?
Attention Deficit/Hyperactivity Disorder (ADHD) is a complex neurodevelopmental disorder which can lead to difficulties in paying attention, impulsive behaviour, and hyperactivity (APA, 2013). It is also possible for those with ADHD to have difficulties processing and filtering incoming information, alongside poor working memory (think of having to write down a long number after it has been read out to you; Friedman & Rapoport, 2015; Konrad & Eickhoff, 2010).
Common treatment options for ADHD include a combination of talking therapies and medication (Wolraich et al., 2011; Pelham & Fabiano, 2008). However, there are four potential problems with ADHD treatment that are relevant to the current discussion:
- Medication can have harmful side effects for some users (Pliszka, 2007).
- Medication can be ineffective for symptoms of ADHD such as difficulties filtering incoming information (Pietrzak et al., 2006; Biederman et al., 2015).
- While talking therapies can be beneficial for ADHD, there may be limited opportunities to apply the contents of the therapy outside of the office. For example, clinicians may give homework tasks that the young person ignores due to boredom. Young people need to be engaged in their therapy in a way that’s entertaining and makes them want to continue.
- A shortage of trained clinicians can mean that young people aren’t receiving adequate care while waiting to be seen by a specialist (Bussing et al., 2003; Abdel-Kader et al., 2016).
To summarise, current ADHD treatments can have adverse side effects, may not target all aspects of ADHD, may be boring, and may have barriers to access such as waiting lists. So how can video games help with this?
Why Video Games?
In previous articles, I pointed out how video games are a great way to remedy low adherence rates for boring treatments such as physical rehabilitation. For example, attaching a video game to strength and balance training programmes can increase adherence from below 50% to up to 100%. Not only are people more likely to keep playing these health-promoting video games, but they have little to no side effects and can be delivered safely from home. These findings suggest that video games are a great way to counteract limitations of ADHD treatments such as medication side effects and boring homework tasks. The ability to receive safe treatment from home is especially important in the current pandemic.
Let’s introduce EndeavorRx as a treatment option before diving into the research evaluating it. EndeavorRx is a colourful iOS game that encourages players to focus on specific targets while ignoring others. This exercise can help those with ADHD to filter out unnecessary information and can train maintaining attention on a task.
The research papers below mention two benefits that EndeavorRx can have as a treatment option. Firstly, EndeavorRx adapts itself to the pace of the user depending on their scores in previous rounds. This ensures that EndeavorRx remains a healthy balance of challenging the user while not overly frustrating them. Secondly, the user feedback loop means that users are praised and rewarded for maintaining focus on the task. Technology allows these young people to feel positive about themselves and feel that they are making progress at a pace that is tailored for them.
Study One
The first study exploring EndeavorRx in young people was published in 2017 by Anguera et al. This paper is still very much in the experimental stages of EndeavorRx and utilises brain-scanning techniques to observe the influence of EndeavorRx in 57 young people aged between 8-12.
Rather than targeting young people with a diagnosis of ADHD, this study explored young people exhibiting Sensory Processing Dysfunction (SPD – no, not Zangief’s Spinning Piledriver). SPD involves difficulties in filtering and processing information, frequently leading to loss of attention and inability to focus (Miller et al., 2007). Recent neurological research finds that SPD is associated with structural differences in white matter tracks in the brain, potentially explaining the inability to sustain attention (Owen et al., 2013).
This study was a two-stage process. They first set out to establish that young people experiencing SPD symptoms do indeed have difficulties paying attention and maintaining attention. This was achieved with a combination of a brain-scanning technique known as EEG along with computerised tests of attention, alongside parental ratings of their child’s attention levels. The second stage involved administering EndeavorRx for four weeks, then re-assessing scores on attention tests and regathering parental assessments of attention.
Attention tests, brain scans, and parental reports provided evidence that children experiencing SPD have a slower response to attention tests and show weaker neural responses to measures of attention than non-SPD children. Both the SPD and non-SPD groups had faster response times to attention tests after playing EndeavorRx. However, only the SPD group showed improved neurological engagement and lower parental reports of SPD symptoms; these parental reports continued to be lower nine months after playing EndeavorRx.
These findings suggest that EndeavorRx can be used to train children to both pay attention to and maintain attention on what they are currently focusing on. It is also important to note that the benefits of playing EndeavorRx for four weeks could still be observed nine months later.
Study Two
The second study, published in 2018 by Davis et al., moves away from children exhibiting SPD symptoms and begins testing the effectiveness of EndeavorRx on children with a confirmed diagnosis of ADHD. This study included a total sample of 80 children aged between 8-12, with an even divide of ADHD and non-ADHD children.
This study did not use the same brain scanning techniques as the previous study. Instead, two computer-based tests of factors such as attention and working memory were given to participants before and after four weeks of EndeavorRx for 30-45 minutes per day, five days a week. Similar to the previous study, parents were also asked to rate the severity of their child’s ADHD symptoms using a questionnaire. Additional information was recorded on how often the children played EndeavorRx (the ‘adherence rate’ of the treatment) and whether there were any adverse side effects.
The study found that the ADHD group showed significant improvements in tests of attention, while the non-ADHD group did not show significant improvements. For participants experiencing a high level of ADHD severity, playing EndeavorRx led to improvements in their working memory. However, parents’ ratings of their child’s ADHD symptoms did not significantly change after the intervention. Participants found EndeavorRx to be enjoyable and no adverse side effects deemed to be related to the game were found. No participants from the ADHD group stopped playing the game and adherence to the treatment was high – 86% of the ADHD group and 87% for the non-ADHD group.
Similar to the previous study, support was found for the effectiveness of EndeavorRx using tests of attention. As attention improved more so for ADHD children than non-ADHD children, this suggests that EndeavorRx is effective at targeting and improving attentional difficulties associated with ADHD.
Study Three
The third study, published in 2018 by Yerys et al., is where things start to get a little more experimental with EndeavorRx research. In the first and second study, participants were excluded from the study if they had an additional mental health diagnosis such as Bipolar Disorder or Autism Spectrum Disorder (ASD). This is understandable as the preliminary research papers wanted to test the effectiveness of EndeavorRx on specific conditions such as SPD and ADHD.
This study uses a sample of young people aged between 9-15 who have a diagnosis of both ADHD and ASD. This is important to explore as research suggests that attention span is especially inhibited in those with both diagnoses (Yerys et al., 2013; Rao & Landa, 2014). A total of 19 participants were recruited for a research procedure similar to what we’ve seen before: tests of attention, parental ratings of ADHD and enjoyment before EndeavorRx, playing EndeavorRx for four weeks, then tests and ratings after playing.
Different from previous studies, not all participants played EndeavorRx. While 11 participants did indeed play EndeavorRx, 8 played an educational game where participants created a word based on an array of letters. This group was used as a comparison group for the effectiveness of EndeavorRx.
For the results, I’m going to give you all of the information and allow you to come to your own conclusions. Parents of young people who played EndeavorRx reported significantly fewer overt ADHD symptoms and behavioural problems than before their child’s time with the game. When it comes to more objective measures like the computerised attention tests, that’s where things get a bit more debatable. It’s common in research to be unable to say that something is significantly different or significantly related if the p-value of the analysis is greater than 0.05. When scores from attention tests are compared before and after playing EndeavorRx, there is a medium-to-large change in scores for the better (d = 0.72), but with a p-value of 0.12, we cannot say it is a significant difference. Similar to the previous study, enjoyment of EndeavorRx was high and there was a high adherence rate to the treatment.
In a small sample of young people with a diagnosis of both ASD and ADHD, EndeavorRx was an enjoyable treatment that they stuck with. While parents reported fewer ADHD and behavioural symptoms in their child, more objective measures like reaction and attention tests produced medium-to-large, but non-significant changes in scores.
Study Four
I feel that it is fair to say that we have saved the best for last.
The fourth paper, published in 2020 by Kollins et al., is a randomised controlled trial exploring the effectiveness of EndeavorRx for young people aged 8-12 with a confirmed diagnosis for ADHD. Randomised controlled trials are considered to be the gold standard of research due to the strict levels of control they involve. I won’t weigh this section down by talking too much about it, but as the paper is available for everyone to read, you can see for yourself how much is registered, disclosed and pre-emptively controlled for in advance – it’s a delightful read.
This study incorporates aspects from other studies discussed above, but uses them in a larger and more tightly controlled study. The same measurements of attention, working memory, enjoyment, and parental reports of symptoms are included from above. Additional measures were added such as asking participants themselves to report their levels of attention. 180 participants played EndeavorRx for four weeks, while 168 played the word game outlined in Study Three.
Minimal adverse effects associated with EndeavorRx were reported in this study, including five accounts of frustration and three headaches. Adherence to EndeavorRx was also high, with an average of 83% of sessions completed.
The diagram above represents the change in attention scores before and after EndeavorRx when compared with the word game. However, subjective reports were a bit more varied: while young people didn’t report a significant change in their attention abilities before and after EndeavorRx, their parents felt that they had indeed observed a significant change.
Concerns
After reviewing four studies exploring the effectiveness of EndeavorRx, it’s time to look at some concerns people may have about this.
“You can’t just treat ADHD with video games”
Yes, you’re completely right. EndeavorRx is not designed to be the primary treatment for ADHD. Instead, you can think of it as a companion treatment that is aimed to improve aspects of ADHD related to initiating and maintaining attention. You are still fully entitled to treatment such as mental health practitioners and medication, this is just something on the side.
“A video game won’t help ADHD sufferers in real life”
This is a point which I am conflicted on. Factors such as attention were consistently measured using computerised tests such as the TOVA test. Study One mentions that future research could consider factors such as teachers’ ratings of whether the young person is concentrating in class. While this would involve moving from objective measures (e.g. reaction times) to subjective measures (e.g. personal reports), it could be a better reflection on whether EndeavorRx is helping the young person in a realistic setting.
However, Study Four argues that measures such as the TOVA test can actually reflect real-life struggles for young people with ADHD:
The TOVA setting has been described as mimicking “one component of the classroom situation in which children are required to remain seated and engaged in a tedious, repetitive task”.
– Kollins et al. (2020)
I currently feel that both arguments make a valid point, but further research may be needed to see if this is the case. Which brings us to our final argument…
“There’s not enough research”
Dr Hagan of the American Academy of Paediatrics has criticised the decision to allow EndeavorRx to be prescribed:
I wish the numbers were 6,000-plus and not 600-plus. I’m not going to recommend it to my families because I don’t think it’s ready for prime time. I think it deserves additional study.
– Hagan (2020)
This is another point which I am conflicted on. Here’s why.
The authors of these papers make it no secret that they wish for more research into this. A section of Study Four is dedicated to dismantling the current research base on video games and ADHD, criticising it for suffering from methodological flaws. Each study also concludes with a description of where future research avenues can go, such as testing whether EndeavorRx can be useful for shorter periods than four weeks. More research could also allow us to pinpoint why exactly self-report measures seem to differ in reports between studies.
However, we are currently living in a world where: a) there are barriers to face-to-face care for ADHD due to the current pandemic, and b) barriers to face-to-face care for ADHD exist irrespective of COVID-19. In fact, reports suggest that EndeavorRx is being made free to families without the need for a prescription during the current COVID-19 pandemic. I feel that an intervention which is enjoyable and has minimal adverse effects has the capacity for positive change at a time of great difficulty.
You could also say that I’m burdened with the knowledge of knowing what is currently going on in other research fields. For example, we still don’t know how exactly Gaming Disorder is going to be treated. EndeavorRx is a companion treatment for ADHD, and so far it has used brain scanning techniques, nine-month follow-up periods, and a randomised controlled trial. It would be nice if these same research standards were applied to other research fields, but I completely understand the desire for more research with larger sample sizes.
In conclusion, research exploring the effectiveness of EndeavorRx includes an interesting mixture of brain scanning techniques, following up on participants for many months after playing EndeavorRx, and randomised controlled trials which represent a gold standard for research. EndeavorRx appears to be effective at improving objective measures of attention such as reaction time tests, while subjective reports of ADHD symptom improvement seem a bit more varied. While our knowledge of EndeavorRx could benefit from more research, it seems to be a safe and enjoyable treatment option for ADHD during a time when face-to-face treatment is challenging.
Summary
- The FDA recently approved a video game called EndeavorRx as a treatment for ADHD. This article attempts to explain the research and logic behind this decision.
- ADHD is an ideal candidate for a video game treatment as current treatment plans can have adverse health effects, can involve boring homework tasks, and may involve long waits for treatment. Previous research shows that video game treatments are enjoyable, encourage engagement with treatment, have minimal adverse effects, and can be enjoyed from home.
- Please note that for all studies, EndeavorRx is played for a four-week period for five days per week. Assessments such as attention and memory are taken before and after this four-week period.
- In Study One, EndeavorRx was played by 57 children (aged 8-12). Playing EndeavorRx improved performance in attention tasks for all children, but the children with pre-identified attention problems showed improved neurological engagement (via brain scans) and lower parental reports of SPD symptoms; these parental reports continued to be lower nine months after playing EndeavorRx.
- Study Two compared the effectiveness of EndeavorRx in 80 children (aged 8-12) with and without a diagnosis of ADHD. Improved attention scores were found only for the ADHD group. For those with severe ADHD, playing EndeavorRx also improved their working memory. Participants found EndeavorRx to be fun, engagement in EndeavorRx was high, and no adverse effects of playing EndeavorRx were found. However, parental reports of ADHD symptoms did not significantly change before and after playing EndeavorRx.
- Study Three examined the effectiveness of EndeavorRx in 19 young people (aged 9-15) with a diagnosis of both ADHD and Autism Spectrum Disorder (ASD). The effects of EndeavorRx were compared against a word play game. While parents reported fewer ADHD and behavioural symptoms in their child, more objective measures like reaction and attention tests produced medium-to-large, but non-significant changes in scores. EndeavorRx was enjoyable and safe for young people, and 95% of players played throughout the test period.
- Study Four used a randomised controlled trial (the gold standard in research due to its high levels of control) to assess the effectiveness of EndeavorRx in a total sample of 348 participants (aged 8-12) compared to the word game described above. Playing EndeavorRx resulted in a significant improvement in attention scores, and parents reported that they felt their child had shown improvements too. While EndeavorRx was enjoyable with minimal adverse effects, young people themselves didn’t report significant changes in their ability to pay attention.
- It is important to note that EndeavorRx is a companion treatment for ADHD and is not going to be the only ADHD treatment a young person receives.
- Paediatricians report concerns that more research should be conducted before prescribing EndeavorRx. While more research would definitely be beneficial, the current research base involves an interesting mixture of brain scans, assessing participants nine months after research, and randomised controlled trials which represent a gold standard for research. Future research could also explore aspects such as whether teachers feel EndeavorRx has improved performance and concentration in the classroom.
- While our knowledge of EndeavorRx could benefit from more research, it seems to be a safe and enjoyable treatment option for ADHD during a time when face-to-face treatment is challenging.
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