Warning: This is an author submission that is not peer-reviewed or edited. Preprints - unless they show as "accepted" - should not be relied on to guide clinical practice or health-related behavior and should not be reported in news media as established information.
Gamified Digital Interventions for Children and Adolescents with Attention-deficit/hyperactivity Disorder: A Systematic Review and Meta-Analysis of Game Design Features
ABSTRACT
Background:
Gamified digital interventions (GDIs) address executive dysfunction and altered reinforcement sensitivity in children and adolescents with attention-deficit/hyperactivity disorder (ADHD). However, it remains unclear how specific game features and latent design dimensions contribute to specific therapeutic outcomes.
Objective:
This study aimed to evaluate the efficacy of GDIs on core clinical symptoms and executive functions in youth with ADHD, and to investigate how specific game types, structural features, and overarching design dimensions moderate these therapeutic effects.
Methods:
Two systematic literature searches were conducted in March and December 2025 to identify eligible randomized controlled trials (RCTs) involving children or adolescents (aged 6–18 years) with a formal ADHD diagnosis. Eligible interventions were digital software incorporating game mechanics into therapeutic or training contexts. Effect sizes (Hedges' g) on ADHD symptoms and executive functions were pooled using random-effects models. Game features were coded for subgroup analyses, and meta-regression was conducted on latent design dimensions derived from exploratory factor analysis.
Results:
The final analysis included 24 RCTs comprising 1,948 participants (1,539 male, 409 female). Compared to non-gamified controls, GDIs significantly improved overall ADHD symptoms (k=21, g=.52, 95% CI .33–.71; P<.001; I²=62.2%), with consistent effects across inattention (g=.52, 95% CI .24–.80) and hyperactivity/impulsivity (g=.54, 95% CI .21–.86). Executive functioning showed small-to-moderate improvements (k=18, g=.42, 95% CI .31–.53; P<.001; I²=0%), specifically in metacognition (g=.53, 95% CI .28–.77) and working memory (g=.42, 95% CI .21–.63), but planning improvements were not significant (g=.23, 95% CI -.02 to .48; P=.070). Adventure and Action World games produced the most stable improvements across domains. Feature-level analyses indicated that embodiment attenuated treatment effects for total ADHD (Δg=-.38) and inattention (Δg=-.44), while self-competition reduced effect sizes for several executive domains, including planning (Δg=-.30). Meta-regression revealed that the latent design dimension of Experiential Richness positively predicted working memory improvements (β=.13, P=.031), while Performance System mechanics negatively predicted gains in metacognition (β=-.16, P=.013) and planning (β=-.18, P=.010).
Conclusions:
GDIs are effective adjunctive treatments that improve ADHD symptoms and core executive functions. Therapeutic benefits appear more dependent on core cognitive demands than surface-level gamification. Furthermore, highly performance-regulating systems and excessive algorithmic scaffolding may inadvertently hinder the learner's internalization of autonomous self-regulation. Clinical Trial: The review was registered with PROSPERO (CRD420251016458).
Citation
Request queued. Please wait while the file is being generated. It may take some time.
Copyright
© The authors. All rights reserved. This is a privileged document currently under peer-review/community review (or an accepted/rejected manuscript). Authors have provided JMIR Publications with an exclusive license to publish this preprint on it's website for review and ahead-of-print citation purposes only. While the final peer-reviewed paper may be licensed under a cc-by license on publication, at this stage authors and publisher expressively prohibit redistribution of this draft paper other than for review purposes.