Serious Games in the new era of digital-health interventions: A narrative review of their therapeutic applications to manage neurobehavior in neurodevelopmental disorders

Discriminative Power of the Serious Game Attention Slackline in Children and Adolescents With and Without Attention-Deficit/Hyperactivity Disorder: Validation Study

Background

Attention-deficit/hyperactivity disorder (ADHD) is a prevalent neurodevelopmental condition characterized by inattention, hyperactivity, and impulsivity, significantly impacting the psychological, social, and academic well-being of affected children and adolescents. Traditional ADHD diagnostic methods often rely on subjective reports, which can be biased. Recent advancements in serious games offer the potential for objective assessment tools.

Objective

This study aimed to evaluate the discriminative power and concurrent validity of the serious game Attention Slackline in distinguishing children and adolescents with ADHD from those without the condition and in correlating game performance with standardized ADHD assessment scales.

Methods

A sample of 32 children and adolescents diagnosed with ADHD and 39 healthy controls participated in the study. Participants were divided into 2 age groups: children (aged 6-11 years) and adolescents (aged 12-17 years). The serious game Attention Slackline was administered alongside established ADHD assessment scales, including the Child and Adolescent Assessment System and the ADHD Rating Scale IV. Group differences were analyzed using multivariate analysis of covariance, and effect sizes were reported using Cohen d. Correlations between game performance and ADHD symptoms were calculated using Pearson r.

Results

Children with ADHD demonstrated significantly worse performance in Attention Slackline than the controls (t65=-2.26; P=.03; |d|=0.901), whereas no significant differences were observed in adolescents (t65=0.75; P=.73; |d|=0.191). Task performance was negatively correlated with family-reported hyperactivity/impulsivity symptoms in children across both tests (r=-0.43 and r=-0.51), but no significant correlations were observed in adolescents.

Conclusions

The findings support the validity of Attention Slackline for assessing hyperactivity/impulsivity symptoms in children with ADHD. However, its efficacy decreases in adolescents, potentially due to developmental factors, such as compensatory strategies and ceiling effects in task performance. The gamified nature of the tool enhances engagement, which is crucial for young populations, while maintaining its diagnostic utility in measuring impulsivity. The age-dependent validity aligns with previous research indicating that continuous performance test paradigms are less effective in older populations due to developmental maturation. Attention Slackline shows potential as a complementary tool for ADHD diagnosis in children, offering an engaging and objective assessment of hyperactivity/impulsivity. Future research should aim to establish clinical cutoff points and refine the task's complexity to align with individual characteristics.

Effectiveness of Serious Games as Digital Therapeutics for Enhancing the Abilities of Children With Attention-Deficit/Hyperactivity Disorder (ADHD): Systematic Literature Review

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that often begins in childhood and requires long-term treatment and management. Given the potential adverse effects of pharmacological interventions in children, interest in alternative treatments has increased. Among alternative therapies, serious games have emerged as a promising digital therapeutic approach and are increasingly recognized as an important intervention for children with ADHD.

OBJECTIVE

This systematic review aims to evaluate the effectiveness of serious games as digital therapeutics for children with ADHD. It focuses on assessing therapeutic outcomes, including improvements in attention, hyperactivity-impulsivity, social skills, motor skills, executive functions, and enjoyment.

METHODS

The review was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A comprehensive literature search was performed across 5 databases: PubMed, Web of Science, Scopus, IEEE Xplore, and ACM Digital Library, covering English studies published from January 2010 to January 2024. Eligibility criteria were established based on the PICOS (Participants, Intervention, Comparison, Outcomes, Study design) framework, with digital therapeutics guidelines pragmatically applied to inform inclusion criteria, exclusion criteria, and quality assessment. Standardized tools including the Cochrane Risk of Bias Tool for randomized controlled trials, the Cochrane Risk of Bias Tool for Non-Randomized Studies of Interventions (ROBINS-I) for nonrandomized controlled trial studies, and the Critical Appraisal Skills Program checklists were used to evaluate risk of bias. Data on study design, targeted abilities, game software and hardware, and intervention parameters (duration, frequency, and length) were extracted and synthesized descriptively.

RESULTS

Of the 35 studies identified (1408 participants), gender data were available for 22 studies (888 participants), comprising 660 male and 228 female participants. Analysis revealed multiple abilities focused across many studies: 80% (28/35) assessed attention, 29% (10/35) addressed hyperactivity-impulsivity, 17% (6/35) explored improvements in social skills, 20% (7/35) evaluated motor skills, and 43% (15/35) investigated executive functions. Furthermore, in 89% (31/35) of the trials, children exhibited a positive attitude toward game interventions. Evidence suggests that serious games may contribute to improvements in attention, hyperactivity-impulsivity, social skills, and executive functions in children with ADHD. Although findings on motor skills were inconclusive, interventions incorporating somatosensory inputs demonstrated benefits for hand-eye coordination.

CONCLUSIONS

The findings support the potential of serious games as a digital therapeutic modality for children with ADHD, offering benefits in core symptoms and associated impairments while promoting engagement.

TRIAL REGISTRATION

PROSPERO CRD420250509693; https://www.crd.york.ac.uk/PROSPERO/view/CRD420250509693.

Polydatin reactivates mitochondrial bioenergetics and mitophagy while preventing premature senescence by modulating microRNA-155 and its direct targets in human fibroblasts with trisomy 21

Mitochondrial dysfunction and redox dyshomeostasis are considered crucial factors causally linked to the pathogenesis of Down syndrome (DS), a human genetic anomaly currently lacking a cure, associated with neurodevelopmental deficits in children and early onset symptoms of aging in adults. Several natural plant-derived polyphenolic compounds, known for their neurostimulator, antioxidant and anti-inflammatory activities, have been proposed as dietary supplements to manage DS-linked phenotypic alterations. However, the poor bioavailability and rapid metabolism of these compounds have limited conclusive evidence regarding their clinical efficacy in individuals with DS. Polydatin (PLD), a natural polyphenolic glucoside precursor of resveratrol derived from Polygonum cuspidatum, is instead highly bioavailable and resistant to enzymatic oxidation. PLD supplementation has shown many therapeutic efficacies in several human diseases without side effects. In this study, we used fetal trisomy 21 human skin fibroblasts (DS-HSFs) to investigate, from a mechanistic point of view, whether PLD supplementation could prevent or counteract critical cellular alterations linked to both neurodevelopmental deficits and early aging in DS. Our findings demonstrate that PLD reactivates mitochondrial bioenergetics, reduces oxygen radical overproduction and prevents oxidative stress (OS)-induced cellular senescence and DNA damage in DS-HSF. Notably, we identified a novel mechanism of PLD action involving the chromosome-21-encoded microRNA-155 (miR-155) and its direct target genes casitas B-lineage lymphoma (CBL), BAG Cochaperone 5 (BAG5) and mitochondrial transcription factor A (TFAM). These proteins play pivotal roles in regulating mitochondrial bioenergetics, biogenesis and mitophagy. Given that the deregulation of miR-155/CBL axis is also implicated in acute leukemias, which frequently occur in children with DS, PLD emerges as a promising candidate for translational application. Its ability to enhance mitochondrial bioenergetics and address critical DS-associated phenotypic alterations highlights its therapeutic potential.

Virtual environments as a novel and promising approach in (neuro)diagnosis and (neuro)therapy: a perspective on the example of autism spectrum disorder

Over the last three decades, dynamically evolving research using novel technologies, including virtual environments (VEs), has presented promising solutions for neuroscience and neuropsychology. This article explores the known and potential benefits and drawbacks of employing modern technologies for diagnosing and treating developmental disorders, exemplified by autism spectrum disorder (ASD). ASD's complex nature is ideal for illustrating the advantages and disadvantages of the digital world. While VEs' possibilities remain under-explored, they offer enhanced diagnostics and treatment options for ASD, augmenting traditional approaches. Unlike real-world obstacles primarily rooted in social challenges and overwhelming environments, these novel technologies provide unique compensatory opportunities for ASD-related deficits. From our perspective in addition to other recent work, digital technologies should be adapted to suit the specific needs of individuals with ASD.

Cultural applicability and desirability of 'Broodles': The first serious game intervention for siblings of children with disabilities

Objective

Serious games can serve as easily accessible interventions to support siblings of children with disabilities, who are at risk of developing mental health problems. The Dutch serious game 'Broodles' was developed for siblings aged 6-9 years. The current study aims to assess the cultural applicability, desirability, feasibility, and acceptability of 'Broodles' in Norway.

Methods

Norwegian siblings (N = 16) aged 6-13 years and parents (N = 12) of children with intellectual disabilities assessed the game. Their feedback data from interviews and questionnaires were sorted using a model of engagement factors in serious games.

Results

At pre-use, participants showed interest in the game, and after initial use the participants were overall positive about the format, content and objectives, including validation of emotions and recognition. The participants had suggestions for improved engagement and feasibility.

Conclusion

The game was found to be culturally applicable, desirable and acceptable, although Norwegian translation is necessary for further evaluation. Recommendations to enhance engagement were provided, including suggestions to play the game with parents or in a group.

Innovation

This initial assessment of the serious game Broodles in a non-Dutch setting shows promise for an innovative way of supporting siblings of children with disabilities.

Automated Detection of Neurodevelopmental Disorders Using Face-to-Face Mobile Technology Among Typically Developing Greek Children: Randomized Controlled Trial

BACKGROUND

Neurodevelopmental disorders (NDs) are characterized by heterogeneity, complexity, and interactions among multiple domains with long-lasting effects in adulthood. Early and accurate identification of children at risk for NDs is crucial for timely intervention, yet many cases remain undiagnosed, leading to missed opportunities for effective interventions. Digital tools can help clinicians assist and identify NDs. The concept of using serious games to enhance health care has gained attention among a growing group of scientists, entrepreneurs, and clinicians.

OBJECTIVE

This study aims to explore the core principles of automated mobile detection of NDs in typically developing Greek children, using a serious game developed within the SmartSpeech project, designed to evaluate multiple developmental domains through principal component analysis (PCA).

METHODS

A total of 229 typically developing children aged 4 to 12 years participated in the study. The recruitment process involved open calls through public and private health and educational institutions across Greece. Parents were thoroughly informed about the study's objectives and procedures, and written consent was obtained. Children engaged under the clinician's face-to-face supervision with the serious game "Apsou," which assesses 18 developmental domains, including speech, language, psychomotor, cognitive, psychoemotional, and hearing abilities. Data from the children's interactions were analyzed using PCA to identify key components and underlying principles of ND detection.

RESULTS

A sample of 229 typically developing preschoolers and early school-aged children played the Apsou mobile serious game for automated detection of NDs. Performing a PCA, the findings identified 5 main components accounting for about 80% of the data variability that potentially have significant prognostic implications for a safe diagnosis of NDs. Varimax rotation explained 61.44% of the total variance. The results underscore key theoretical principles crucial for the automated detection of NDs. These principles encompass communication skills, speech and language development, vocal processing, cognitive skills and sensory functions, and visual-spatial skills. These components align with the theoretical principles of child development and provide a robust framework for automated ND detection.

CONCLUSIONS

The study highlights the feasibility and effectiveness of using serious games for early ND detection in children. The identified principal components offer valuable insights into critical developmental domains, paving the way for the development of advanced machine learning applications to support highly accurate predictions and classifications for automated screening, diagnosis, prognosis, or intervention planning in ND clinical decision-making. Future research should focus on validating these findings across diverse populations integrating additional features such as biometric data and longitudinal tracking to enhance the accuracy and reliability of automated detection systems.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06633874; https://clinicaltrials.gov/study/NCT06633874.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-https://doi.org/10.3390/signals4020021.

Impact of VR-Based Cognitive Training on Working Memory and Inhibitory Control in IDD Young Adults

BACKGROUND

Young people with intellectual developmental disabilities have a persistent delay in the development of executive functions. Virtual reality (VR) is increasingly being used as a cognitive intervention tool, with significant effectiveness demonstrated in different types of populations.

METHODS

This pilot study aims to investigate the impact of a cognitive training program utilizing VR on young adults diagnosed with intellectual developmental disabilities (IDDs). The participants (N = 15) served as their own control group and were assessed three times: weeks 0, 8, and 16, with a rest period (0-8 weeks) and an intervention period (8-16 weeks). The assessments included measures of cognitive function provided by E-Prime® (Version 3).

RESULTS

Overall, an improvement in working memory and inhibitory control was found after the intervention, but not in sustained attention.

CONCLUSIONS

These findings suggest that VR-based cognitive training holds promise as an effective intervention for enhancing cognitive abilities in young adults with intellectual developmental disabilities. This study provides a foundation for future investigations into VR's role in cognitive rehabilitation and its potential to support daily living skills and overall quality of life for individuals with IDDs. Further research is needed to explore the long-term effects and broader applicability of VR interventions.

Transcranial Direct Current Stimulation in neurogenetic syndromes: new treatment perspectives for Down syndrome?

This perspective review aims to explore the potential neurobiological mechanisms involved in the application of transcranial Direct Current Stimulation (tDCS) for Down syndrome (DS), the leading cause of genetically-based intellectual disability. The neural mechanisms underlying tDCS interventions in genetic disorders, typically characterized by cognitive deficits, are grounded in the concept of brain plasticity. We initially present the neurobiological and functional effects elicited by tDCS applications in enhancing neuroplasticity and in regulating the excitatory/inhibitory balance, both associated with cognitive improvement in the general population. The review begins with evidence on tDCS applications in five neurogenetic disorders, including Rett, Prader-Willi, Phelan-McDermid, and Neurofibromatosis 1 syndromes, as well as DS. Available evidence supports tDCS as a potential intervention tool and underscores the importance of advancing neurobiological research into the mechanisms of tDCS action in these conditions. We then discuss the potential of tDCS as a promising non-invasive strategy to mitigate deficits in plasticity and promote fine-tuning of the excitatory/inhibitory balance in DS, exploring implications for cognitive treatment perspectives in this population.

Co-Design of a Virtual Reality Multiplayer Adventure Game for Adolescents With Autism Spectrum Disorder: Mixed Methods Study

BACKGROUND

Virtual reality (VR) adventure games can offer ideal technological solutions for training social skills in adolescents with autism spectrum disorder (ASD), leveraging their support for multisensory and multiplayer interactions over distance, which may lower barriers to training access and increase user motivation. However, the design of VR-based game environments for social skills training is still understudied and deserves the deployment of an inclusive design approach to ensure its acceptability by target users.

OBJECTIVE

We aimed to present the inclusive design process that we had followed to develop the Zentastic VR adventure game to foster social skills training in adolescents with ASD and to investigate its feasibility as a training environment for adolescents.

METHODS

The VR game supports multiplayer training sessions involving small groups of adolescents and their therapists, who act as facilitators. Adolescents with ASD and their therapists were involved in the design and in an explorative acceptability study of an initial prototype of the gaming environment, as well as in a later feasibility multisession evaluation of the VR game final release.

RESULTS

The feasibility study demonstrated good acceptability of the VR game by adolescents and an enhancement of their social skills from baseline to posttraining.

CONCLUSIONS

The findings provide preliminary evidence of the benefits that VR-based games can bring to the training of adolescents with ASD and, potentially, other neurodevelopmental disorders.

Effect of Cognitive Training Programs Based on Computer Systems on Executive Functions in Children With ADHD: A Systematic Review

BACKGROUND

The purpose of this systematic review is to synthesize the existing literature reporting the effects of computerized cognitive trainings on the executive functions of children with ADHD.

METHOD

A systematic review was carried out following the PRISMA statement; the primary sources used were five electronic databases (Scopus, Science Direct, Pubmed, Springer, Taylor & Francis).

RESULTS

20 articles met the eligibility criteria, data on the training characteristics and the effects on executive functions were extracted, followed by an analysis of bias and the methodological quality of the studies. The results of the studies were widely heterogeneous, largely associated with the variety of training programs and the measurement instruments used. The most studied executive functions were working memory and inhibitory control. Some of the studies reported that the intervention led to significant effects on working memory and attention (N = 7), and improvements in inhibitory control (N = 5) and planning (N = 4) were also reported. At the same time, others did not report the effects of the intervention on these processes. The assessment of the quality of the evidence showed important risk biases among the reviewed studies.

CONCLUSION

Some training based on computer systems showed positive effects on the executive functions of working memory, attention, and inhibitory control in children with ADHD. However, other training sessions did not show significant effects. In general, the evidence shows mixed results, a high diversity of measurement instruments, and high risks of bias between the studies. Therefore, the evidence has not been consistent about the general benefits of computerized training on the executive functions of children with ADHD.

Brain Mitochondrial Bioenergetics in Genetic Neurodevelopmental Disorders: Focus on Down, Rett and Fragile X Syndromes

Mitochondria, far beyond their prominent role as cellular powerhouses, are complex cellular organelles active as central metabolic hubs that are capable of integrating and controlling several signaling pathways essential for neurological processes, including neurogenesis and neuroplasticity. On the other hand, mitochondria are themselves regulated from a series of signaling proteins to achieve the best efficiency in producing energy, in establishing a network and in performing their own de novo synthesis or clearance. Dysfunctions in signaling processes that control mitochondrial biogenesis, dynamics and bioenergetics are increasingly associated with impairment in brain development and involved in a wide variety of neurodevelopmental disorders. Here, we review recent evidence proving the emerging role of mitochondria as master regulators of brain bioenergetics, highlighting their control skills in brain neurodevelopment and cognition. We analyze, from a mechanistic point of view, mitochondrial bioenergetic dysfunction as causally interrelated to the origins of typical genetic intellectual disability-related neurodevelopmental disorders, such as Down, Rett and Fragile X syndromes. Finally, we discuss whether mitochondria can become therapeutic targets to improve brain development and function from a holistic perspective.