Exergaming intervention to foster executive functions in children with attention deficit hyperactivity disorder: Results from a randomized con- trolled trial

Benzing, Valentin Johannes; Schmidt, Mirko (8 February 2018). Exergaming intervention to foster executive functions in children with attention deficit hyperactivity disorder: Results from a randomized con- trolled trial. In: 10. Jahrestagung der Sportwissenschaftlichen Gesellschaft der Schweiz (SGS). Magglingen. 08.-09.02.18.

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Introduction Attention deficit hyperactivity disorder (ADHD) is one of the most frequent disorders in child- hood. The key symptoms of ADHD – impaired attention, hyperactivity and impulsivity – are associated with an increased risk of long-term academic and social impairments (1). Since pronounced ADHD symptoms are frequently associated with executive functions (EFs), an explanation for the development of these symptoms is seen in a primary deficit in the EFs (2). Although deficits can be reduced through medication, possible side effects, low compliance and unknown long-term sequelae call for alternatives to improve EF deficits. Exercise is known to have a positive effect on EFs. This has frequently been demonstrated with healthy children (3). However, in children with ADHD there is limited empirical evidence. The existing intervention studies mostly detected positive effects on cognitive performance (4), with mixed physical exercises (including several different activities such as running, coordina- tion tasks and ball games) having the highest efficacy and broad transfer effects. Although based on only few studies, this underlines the importance of cognitively challenging physical exercise. The level of cognitive challenge included in physical exercise is important with regard to ben- efits for EFs (5). This notion is based on the theoretical assumption that, cognitively challeng- ing PA such as coordinative exercise pre-activates brain regions used to control higher-order cognitive processes, leading to a better performance after PA (5). Considering that children with ADHD frequently drop out of traditional sports programs (6) and often display deficient motor skills/control in addition to a functional deficit in their EFs (7), physical exercise charac- teristics targeting motor learning, might be even more important for this population. Therefore, the aim of this randomized controlled trial (RCT) was to examine the effects of an exergame intervention (characterized by both high physical and high cognitive demands) on EFs in children with ADHD. Exergaming is a portmanteau of “exercise” and “gaming”, extend- ing the gaming experience to the entire body. Exergaming helps to combine physical and cog- nitive challenges in a gamified fashion. Initial investigations have yielded promising Results (8), suggesting that exergaming could serve as an intervention for promoting health- related outcomes such as EFs. Methods Using a parallel pre-post study design, 51 children between 8-12 years were randomly as- signed to an exergaming or a waiting-list control group [for more information see (9)]. Seven children (six from the exergaming group) discontinued the study and did not participate in the post-test, resulting in 44 remaining participants. The exergame intervention was carried out using the Xbox Kinect. For 8 weeks, children were supposed to train three times a week for at least 30 minutes with “Shape UP” (Ubisoft, Montreal, Canada), which has been shown to be cognitively and physically challenging [cf. (8)]. The training program was introduced in a su- pervised first training session, and data on physical exertion and perceived cognitive challenge [8] were gathered. As primary outcome, the core EFs were measured using computer-based tests before and immediately after the interventional period. Updating performance was meas- ured using the color span backwards task; inhibition and shifting using an adapted Flanker and Simon Task (10). In addition, as secondary outcome, the sport motor performance was as- sessed using the “Deutscher Motorik Test 6-18 (DMT)”(11). As revealed by independent t- tests, Background variables [age, gender, ADHD symptoms and BMI] and pre-test values of dependent variables did not differ between groups (ps > .05). ANCOVAs (using the pre-test values as covariates) were used to compare EFs and sport motor performance between groups. Results According to diaries, participants in the exergaming group trained on average 2.43 times (for in total about 90 minutes) per week. The mean heart rate during the supervised first training session was M = 143.46 bpm (SD = 10.84) and children rated exergaming to be more cogni- tively challenging than video watching (t = 3.48, p = .001). Regarding EF performance after the interventional period, the exergaming group showed faster reaction times in the Flanker task in congruent (F (2, 41) = 4.10, p = .049, η2p = .091) and shifting trials (F (2, 41) = 4.48, p = .040, η2p = .099) than control. In the Simon task, the exergaming group showed faster con- gruent trials (F (2, 41) = 5.57, p = .023, η2p = .120) and overall task performance (F (2, 41) = 4.71, p = .036, η2p = .103). No significant effects were detected on other trials of cognitive tasks, nor on updating or accuracy (ps > .05). Regarding sport motor performance, the exer- gaming group showed a significantly better performance than control (F (2, 41) = 8.21, p = .007, η2p = .167) after the interventional period. Discussion This is the first study to investigate the effects of cognitively and physically demanding exer- gaming on EFs in children with ADHD. Results show that exergaming is able to enhance EFs with regard to inhibition and shifting performance. In addition, a positive effect on sport motor performance could be observed. Regarding the main Results, it seems evident that exergaming can improve EFs. This is in line with the limited empirical evidence on beneficial effects of traditional physical exercise for cog- nitive performance in children with ADHD (12) and with the larger evidence on healthy children (3). Exergaming therefore seems to be a promising approach to foster EFs in children with ADHD and might serve as an adjunct to future treatment. However, it remains unclear whether physically and cognitively challenging exergaming is superior to cognitive or physical exercise training alone. Comparing all three might be an interesting issue for future studies. In the current RCT, improvements in inhibition and shifting but no effects on updating were found. These Results are partly in line with a recent meta-analytic review of physical exercise in ADHD (12). The authors indicated that the most consistent effects of physical exercise seem to be on inhibition and updating, and Results are unclear with regard to shifting. Correspond- ingly, in the current study inhibition improved. However, non-correspondingly shifting was en- hanced and no significant effect could be detected on updating. These Results might be ex- plained by the characteristics of the used exergame: For successful task execution, fast reac- tions and focused attention are necessary, whereas updating is needed to a smaller extent. An improvement in sport motor performance could be detected in the current study. This might be particularly important for children with ADHD because (a) children with ADHD have difficul- ties taking part in traditional sports programs and not dropping out of these (6); (b) they spend more time playing sedentary video games (13); and (c) the majority has deficits in EFs and in motor skills (7). New Methods are therefore needed to place the focus on health promotion through sports, and in particular to encourage children and adolescents who are overtaxed by traditional programs.In Conclusion, these are first encouraging Results indicating that exergaming might in future serve as tool to enhance EFs in children with ADHD. In particular, it could be a safe environ- ment for clinical patients suffering from cognitive deficits (e.g., ADHD, pediatric cancer survi- vors) to increase their physical activity level and replace sedentary screen time. However, with regard to drop-out rate, customized exergames including improvements in child appropriate- ness, cognitive as well as physical challenge seem warranted. References 1. Johnston C, Park JL. Interventions for Attention-Deficit Hyperactivity Disorder: A year in review. Curr Dev Disord Reports. 2015;2(1):38–45. 2. Willcutt EG, Doyle AE, Nigg JT, Faraone S V, Pennington BF. Validity of the executive function theory of Attention-Deficit/Hyperactivity Disorder: A meta-analytic review. Biol Psychi- atry. 2005;57(11):1336–46. 3. Donnelly JE, Hillman CH, Castelli D, Etnier JL, Lee S, Tomporowski P, et al. Physical activ- ity, fitness, cognitive function, and academic achievement in children. Med Sci Sport Exerc. 2016;48(6):1197–222. 4. Neudecker C, Mewes N, Reimers AK, Woll A. Exercise interventions in children and ado- lescents with ADHD: A systematic review. J Atten Disord. 2015;11:1-18. 5. Pesce C. Shifting the focus from quantitative to qualitative exercise characteristics in exer- cise and cognition research. J Sport Exerc Psychol. 2012;34(6):766–86. 6. Lee H, Dunn JC, Holt NL. Youth sport experiences of individuals with Attention Deficit/Hy- peractivity Disorder. Adapt Phys Act Q. 2014;31(4):343–61. 7. Kaiser ML, Schoemaker MM, Albaret JM, Geuze RH. What is the evidence of impaired motor skills and motor control among children with attention deficit hyperactivity disorder (ADHD)? Systematic review of the Literature. Res Dev Disabil. 2015;36:338–57. 8. Benzing V, Heinks T, Eggenberger N, Schmidt M. Acute cognitively engaging exergame- based physical activity enhances executive functions in adolescents. PLoS One. 2016;11(12). 9. Benzing V, Schmidt M. Cognitively and physically demanding exergaming to improve exec- utive functions of children with attention deficit hyperactivity disorder: a randomised clinical trial. BMC Pediatr. 2017;17(1). 10. Roebers CM, Kauer M. Motor and cognitive control in a normative sample of 7-year-olds. Dev Sci. 2009;12(1):175–81. 11. Bös K, Schlenker L, Büsch D, Lämmle L, Müller H, Oberger J, et al. Deutscher Motorik- Test 6-18 (DMT 6-18). Hamburg: Feldhaus Verlag; 2009. 12. Tan BWZ, Pooley JA, Speelman CP. A meta-analytic review of the efficacy of physical exercise interventions on cognition in individuals with Autism Spectrum Disorder and ADHD. J Autism Dev Disord. 2016;46(9):3126–43. 13. Weiss MD, Baer S, Allan BA, Saran K, Schibuk H. The screens culture: impact on ADHD. ADHD Atten Deficit Hyperact Disord. 2011;3(4):327–34.

Item Type:

Conference or Workshop Item (Paper)


07 Faculty of Human Sciences > Institute of Sport Science (ISPW)
07 Faculty of Human Sciences > Institute of Sport Science (ISPW) > Sport Science I

UniBE Contributor:

Benzing, Valentin Johannes and Schmidt, Mirko


100 Philosophy > 150 Psychology
700 Arts > 790 Sports, games & entertainment


Valentin Johannes Benzing

Date Deposited:

20 Feb 2018 09:48

Last Modified:

20 Feb 2018 09:48



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