In this section we discuss our findings with respect to the research questions.
4.1.RQ1. What are the most common treatment modalities used in ADHD apps?
Among non-commercial video game apps, prevailing ADHD treatment modalities comprise cognitive training (34.62%), biofeedback (26.92%), and behavioral interventions (19.23%). Conversely, organization and social skills feature as the least common, with a presence of 3.85% each. CBT, social skills, and time management skills are not represented within this category. As for non-commercial non-video game apps, clinical diagnostic aid emerges as the most prevalent treatment modality, with a presence of 27.27%. Conversely, social skills and time management skills are the least common, each amounting for 9.09%. Behavioral interventions and biofeedback do not feature within this specific classification.
As for commercial apps, App Store apps predominantly embrace organization and clinical diagnostic aid as ADHD treatment modalities, with 50% and 20%, respectively. On the other hand, the Google Play Store favors organization as its primary modality, encompassing a usage rate of 50%, while cognitive training represents a staggering 83.33% of the treatment modalities found within commercial video game apps. Figure 5 summarizes this information and sheds light into the prevalent ADHD treatment modalities across all app types.
Table 10 below provides a global analysis of treatment modalities. As can be observed, cognitive training is the most prominent modality, followed by organization and clinical diagnostic aid. Such findings are consistent with the well-documented effectiveness of cognitive training in enhancing attention, memory, and executive functions, which are areas of concern for individuals with ADHD. Additionally, efforts have been made to develop ADHD apps that aid in clinical diagnosis, potentially assisting experts in expediting and improving the diagnostic process, given the substantial workload associated with this field.
Table 10
Distribution of Treatment Modalities in ADHD Apps
ADHD Treatment | % |
Cognitive training | 27% |
Organization | 17% |
Clinical diagnostic aid | 16% |
Biofeedback | 13% |
Behavioral | 11% |
Social skill | 5% |
Time management skills | 5% |
CBT | 3% |
Parent training | 3% |
Treatment modalities such as cognitive-behavioral therapy (CBT) and parent training are underrepresented in ADHD apps, yet CBT is widely recognized for its effectiveness in addressing ADHD symptoms by targeting behavioral patterns and equipping individuals with coping strategies [78]–[80]. Integrating CBT principles and exercises into mobile apps could extend therapeutic interventions beyond traditional settings, providing users with a comprehensive approach to managing their ADHD symptoms. Moreover, CBT has demonstrated benefits in enhancing self-regulation, addressing emotional difficulties, and developing coping strategies for individuals with ADHD. As for parent training, it is known to equip parents with skills and strategies to support their children with ADHD [81]–[83]. By integrating parent training components, developers could empower parents to better understand and manage their children’s challenges, fostering a supportive environment and improving treatment outcomes.
The distribution of treatment modalities in ADHD apps may be influenced by the adaptability of cognitive training and clinical diagnostic support to digital platforms. These modalities can be implemented through interactive exercises, assessments, and follow-up functions. In contrast, incorporating CBT or parent training may require more complex content and interactive components, posing challenges for developers. That is, the development of comprehensive CBT or parent training modules within apps would necessitate careful planning and collaboration with subject matter experts.
The use of biofeedback as a treatment modality differs significantly between commercial and non-commercial video game apps, as depicted in Fig. 5. Notably, biofeedback is completely absent in commercial video games, while it maintains a modest presence of at least 26.92% in non-commercial video games. The absence of biofeedback in commercial video games can be attributed to financial implications. Using biofeedback requires additional hardware and sensors, thus increasing production costs, whereas commercial game developers prioritize profitability and market demand, often overlooking biofeedback integration. This explains the concentration of 76.4783.33% of commercial video game apps on cognitive training. However, biofeedback has shown promise in alleviating ADHD symptoms by providing instantaneous feedback and promoting self-regulation [84]–[90]. Integrating biofeedback into commercial video games presents an opportunity to enhance therapeutic value.
In the domain of non-video game apps, both commercial and non-commercial, there are notable differences in the emphasis on treatment modalities. Non-commercial apps primarily focus on diagnostic support, CBT, cognitive training, and equipping parents with skills to support their children with ADHD. However, the biofeedback treatment modality is absent, likely due to its association with video games rather than traditional apps. Conversely, commercial apps demonstrate a different distribution of treatment modalities. Organizational apps represent the most prominent category, comprising 50% of those available on virtual app stores. This highlights the emphasis on assisting individuals with ADHD in effectively managing tasks and schedules. Clinical diagnostic aid follows closely behind, accounting for 20% overall, emphasizing the importance of providing resources for accurate diagnosis. These trends align with non-commercial apps as well.
The comparison between commercial and non-commercial ADHD apps, particularly non-video game apps, reveals distinct differences in treatment modality distribution. Non-commercial apps prioritize therapeutic interventions, parental support, social skills, and time management skills. In contrast, commercial apps prioritize organizational tools, clinical diagnostic support, and to a lesser extent, behavioral interventions and biofeedback (with minimal utilization). The absence of CBT and parental coaching modalities in commercial apps suggests potential opportunities for developers to integrate these effective approaches.
While market considerations may influence commercial apps, striking a balance between cost-effectiveness and comprehensive solutions for individuals with ADHD is crucial. Incorporating a broader range of evidence-based treatment modalities can enhance therapeutic value and contribute to improved outcomes for individuals with ADHD.
4.2. RQ2. Which treatment techniques are more common in ADHD apps?
Table 11 presents an overview of the distribution of treatment techniques employed in the context of ADHD apps. It is noteworthy that cognitive techniques exhibit a dominant presence within this domain, accounting for 15.5% of the total with a count of 20 apps. These methods are widely acknowledged for effectively tackling the unique challenges that individuals with ADHD confront. Following closely, executive functions (10.85%) and Focused Attention, Strategy Concentration, Sustained attention, techniques each account for 8.53%,, thus highlighting current efforts to address deficits in executive functioning and attention within app development. Prioritizing skill enhancement in areas such as planning, organization, task prioritization, and bolstering working memory capacity remains crucial.
Coordination, Memorial, Visual perception and survey/display information are represented at approximately 6–7%. Techniques such as Logical Exercise, Spatial attention, Spatial Reasoning, Anticipation, Auditory and Selective Attention receive even lower percentages, ranging from 3.10–3.88%. Such results may imply that there is tendency to prioritize techniques with broader applications and market demand. To address these discrepancies, app developers should adopt a more balanced approach by integrating techniques that cater to a broader range of cognitive abilities affected by ADHD.
It is well established that cognitive techniques are crucial in ADHD treatment, yet equal consideration should be given to techniques addressing auditory processing, selective attention, spatial reasoning, and anticipation skills, among others. Such an inclusive approach has the potential to provide comprehensive support to individuals with ADHD and can contribute to improved treatment outcomes. Collaboration with experts in the field of ADHD and cognitive development, along with thorough research and user feedback, can inform the app development process and guide decisions regarding the inclusion of specific techniques. Moreover, developers should explore the benefits of combining multiple techniques within a single app, thereby adopting a holistic approach that simultaneously addresses various cognitive domains. This approach has the potential to offer more comprehensive support and enhance the overall effectiveness of the app.
Table 11
Distribution of Treatment Techniques across ADHD Apps
Technique | % |
Cognitive | 15.50% |
Executive functions | 10.85% |
Focused Attention | 8.53% |
Strategy Concentration | 8.53% |
Sustained attention | 8.53% |
Coordination | 7.75% |
Memorial | 7.75% |
Visual perception | 6.98% |
Survey/display information | 6.20% |
Logical Exercise | 3.88% |
Spatial attention | 3.88% |
Spatial Reasoning | 3.88% |
Anticipation | 3.10% |
Auditory | 2.33% |
Selective Attention | 2.33% |
4.3. RQ3. Which ADHD apps support the most treatment techniques?
From an overall perspective, the app of [65] supports the greatest number of treatment techniques across all app types, which can be explained by the fact that it was reportedly developed in a meticulously scientific environment. It is a non-commercial video game app relying on six clearly identified treatment techniques, cognitive, coordination, visual perception, spatial attention, logical exercise and executive functions. On the other hand, [70] and [71] support the greatest number of treatment techniques in the non-commercial non-video game apps category, employing two techniques each, focused attention, memorial and cognitive, executive functions, respectively. Shimer: ADHD coaching (Google Play Store app) and ADHD Behavior Toolbox (App Store app),featured the largest number of treatment techniques in their respective categories. Specifically, Shimer: ADHD coaching showcased five techniques (auditory, cognitive, visual perception, executive functions and sustained attention), and ADHD Behavior Toolbox featured four techniques (strategy concentration, selective attention, focused attention and sustained attention) .
4.4. RQ4. Which ADHD apps are medically support?
Merely 24.32% of the non-commercial apps collaborate with health institutions, yet precise information on such collaborations is lacking. It is challenging to propose an explanation to such results; however, our findings do highlight an important gap to be addressed; that of developing more specialized apps with experiments validated by field experts. As for commercial apps, both Shimer: ADHD coaching and EndeavorRx are endorsed by field experts. The former claims to have originated from a collaborative effort involving ADHD coaches, psychiatrists, doctors, and engineers. Notably, the app emphasizes on the provision of a dedicated coach who assists and guides the user. On the other hand, EndeavorRx stands as the pioneering app to receive FDA approval for the treatment of some ADHD symptoms [91]. It is designed to be used as a part of a therapeutic regimen that includes clinician-directed therapy, medication, and educational programs to comprehensively address ADHD symptoms. Access to in-game treatment necessitates a prescription or an order from a qualified healthcare provider.
4.5. RQ5. Which are the most preferred ADHD apps?
We assessed app preference based on either the number of times an app has been downloaded from the app store (in the case of Google Play Store apps) or the better rated apps (App Store apps). As regards App Store non-video game apps, 63.5% of them cater to children, adolescents, and adults alike, with PiCal: Visual ADHD Day Planner being the best rated in this category. In contrast, 70% of the App Store apps are specifically designed for children, adolescents and adults, with ADHD Organizer, Planner: Focus with the highest number of ratings. Only one app is targeted at adults only and has 44 ratings. As regards Google Play Store non-video game apps, 50% of them are tailored to meet the needs of children, adolescents, and adults with ADHD. Among this category, the most frequently downloaded app is ADHD – causes, diagnosis, and treatment. In contrast, 30% of the Google apps are specifically developed for adolescents and adults, with the most downloaded option being RoutineFlow: Routine & ADHD. Apps designed exclusively for adults constitute 20% of the total apps retrieved from Google Play Store, with ADHD Monitor the most downloaded app.
In terms of video game apps, 64.7% of the reviewed apps are specifically developed for children, with Lumosity, Polygrams – Tangram Puzzles, Breathe, Think, Do with Sesame, and Jumpy Car ADHD being the most frequently downloaded options on Google Play Store. Furthermore, among the apps intended for children, adolescents, and adults alike, which constitute 23.5% of the total, the most popular video games are Spot it: Find the Difference and ADHD concentration games. Among the non-commercial apps, 51% were specifically designed for children, while 19% are aimed at both children and adolescents. In contrast, only 14% of the apps were designed for adults only. No apps were explicitly mentioned as having been tested on children, adolescents, and/or adults in this category.
4.6. RQ6. What is the predominant gamification element in ADHD apps?
Gamification refers to the application of game design principles and mechanics to non-game contexts, aiming at enhancing user engagement, motivation, and overall experience. At its core, gamification leverages psychological and motivational aspects found in games to influence human behavior, encourage participation, and drive desired outcomes. According to our findings, levels and statistics are the predominant gamification elements across all the apps, accounting for 16.96% each one. Similarly, Sensation is utilized in 11.61%% across all the app categories, while Objectives and Points are found in 10.71%% and 8.04%%, respectively. The remaining gamification elements have a lower global presence, with percentages ranging from 8.04–0.89%. Some techniques such as Chance, Novelty, Puzzle, Reputation, and Social Pressure are not implemented in any of the apps in scope.
In the case of non-commercial video game apps, Performance-related gamification, which includes points, progression, levels, statistics, and acknowledgment, seems to be the most prevalent among these applications, with levels being the most used element at 24.07%. This suggests that developers are interested in motivating users through clear objectives, progress tracking, and acknowledgment of their achievements. Points and progression, at 11.11% and 5.56% respectively, also play an important role in user engagement. Together, these elements make up 46.3% of the total gamification elements observed. Personal gamification elements make up 24.07% of the total elements, with sensation being the most prominent with 16.67%. Elements such as chance, imposed choice, economy, rarity, and time pressure were used less frequently in the apps, accounting for 18.52% of the total gamification elements. It could be that developers prioritized user experience and engagement over creating a sense of ecological realism. Fictional gamification, consisting of narrative and storytelling, also has a modest presence at 7.41%. Although not a primary element, it can add depth and context to the user experience and make applications more engaging and relatable. The social dimension of gamification is minimally represented among the apps reviewed, each with less than 2% of the total. Given the social nature of many ADHD-related difficulties, there may be room for improvement in encouraging social interactions and support within these apps.
Similarly, in the area of non-commercial applications, which are not video games, we observed a predominance of gamification elements related to performance. The most important element is statistics, with 27.78% of the total, followed by acknowledgment, with 16.67%, and levels and points, both with 11.11%. This implies that developers place importance on acknowledgment and motivating user progress, albeit with somewhat less emphasis. It is worth noting that Sensation and Objectives, categorized within personal gamification, together constitute 22.2%. Of note is the absence of gamification elements in the Ecological, Social, Personal, and Fiction dimensions. Elements such as chance, imposed choice, cooperation, social pressure, narrative and storytelling are totally absent. This omission limits the possibilities of offering a complete and engaging experience to users with ADHD. The paucity of elements such as competition, cooperation, narrative, and social pressure in ADHD apps could impede the development of a supportive community or opportunities for social interaction among users.
This trend is consistently observed among commercial video game apps, where the Performance dimension takes the lead with a prevalence of 66.67%. Notably, the key gamification elements that prominently feature in these commercial ADHD apps are Levels (33.33%), Progression (22.22%), and Acknowledgement (11.11%). Elements from the personal dimension, namely Sensations, and Objectives, each contribute 11.11% to the overall gamification. However, within the fictional dimension, only Storytelling is found, representing a mere 11.11% (i.e., present in a single app). Strikingly, gamification elements associated with the ecological and social dimensions are conspicuously absent in these commercial ADHD apps. This highlights a notable gap in the utilization of diverse gamification strategies within this category.
In the context of commercial non-video game apps, the Performance dimension takes the lead, representing 55% for the Apple App Store and a more pronounced 81.82% for the Google Play Store. In both cases, the standout element within this dimension is Statistics, accounting for 30% and a substantial 72.73%, respectively. However, it's worth noting that Google Play Store apps offer a more confined spectrum of gamification elements, with Objectives (9.09%) and Cooperation (9.09%) being the sole additional inclusions. Conversely, Apple's apps demonstrate a broader approach by incorporating elements from the Personal and Social dimensions. These include the noteworthy presence of Objectives (20.00%), Cooperation (10.00%), and Sensation (10.00%). This hints at a conscious effort to consider users' personal preferences and introduce limited social interaction elements within the apps. Remarkably, across both stores, there is a complete absence of gamification elements associated with the Fictional dimension. This absence signifies a missed opportunity to introduce narrative, storytelling, or fictional elements into these apps, which could potentially enhance engagement and immersion for individuals using them to manage ADHD.
4.7. Challenges and Trends
The growing body of research on ADHD raises some points for discussion with regards current trends and challenges to overcome. Overall, there is global scientific and commercial recognition of the importance of technology in providing support for people with ADHD and addressing their specific needs; however, the time lag between publications and their availability in virtual app stores raises some questions about the practical application and marketing of these apps. SmartCAT and ADHD Trainer, for example, were published in 2014, but were not commercially available until 2020 and 2017, respectively. This delay can be attributed to several factors, including the need for further development, rigorous testing, and obtaining regulatory approval. It also highlights the challenges of translating research and development into practical apps ready for public use.
Apps such as Peak, Inflow, and doBrain were published and made available in digital stores in the same year. This suggests a more agile process, possibly indicative of technological advances, greater efficiency in app development, or a greater emphasis on timely commercialization. It would be interesting to delve deeper into the factors that facilitated this simultaneous release and availability, as well as the implications for users and the app market. The case of ADHD Coping Card is also worth being discussed, the app has been available on App Store since 2021, despite being published in the literature in 2023. This raises questions about the reasons for the time gap and the motivations for releasing the app to the public earlier. One could speculate that the developers felt it was useful to make the app available to users earlier, perhaps to meet an immediate need or gather real-world feedback before finalizing the research and publishing the results. However, further research and more information from the developers would be needed to fully understand the reasoning behind this particular timing. As such, further exploration of the reasons behind these timelines and their implications may provide valuable information about the evolving landscape of ADHD app development and its impact on people with ADHD.
Furthermore, we observed a significant absence of clear information within the apps regarding the handling of patient data, especially in video game apps. It is crucial for developers to explicitly state how patient data is managed and the security measures in place to protect privacy and safeguard patient information. While the discussion of security and privacy falls beyond this work’s scope, this aspect warrants attention for the sake of transparency and user trust.
In the development of apps designed to support ADHD, several critical challenges need to be addressed:
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Defining the target population and determining appropriate gamification elements: It is imperative to customize the app to meet the unique needs and characteristics of individuals with ADHD, ensuring that the selected gamification elements are suitable and effective in enhancing engagement and therapeutic outcomes.
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Establishing communication and collaboration with specialists: This entails incorporating features within the app that allow users to consult or seek guidance from healthcare professionals. Additionally, securing medical support for the app's development and functionalities ensures credibility and expertise in the field.
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Exploring the integration of biofeedback mechanisms in commercial applications: By incorporating biofeedback technologies, the app can provide users with real-time information on physiological or cognitive measures. This facilitates self-regulation and enhances the effectiveness of intervention strategies.
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Prioritizing security and privacy of patient data: Due to the sensitive nature of health-related information, robust security measures must be implemented, adhering to relevant privacy regulations to safeguard patient data.
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Encouraging the availability of apps with scientific publications and accessibility in online stores: Emphasizing both scientific validation and availability in online stores ensures that evidence-based interventions reach a wider audience, promoting their adoption and impact in clinical settings and daily life.
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Incorporating psychometric properties within apps: By integrating validated assessments and measurement tools, apps can gather pertinent data to monitor progress, assess symptom severity, and provide personalized feedback to users. This inclusion of psychometric properties enhances the clinical utility of the app and contributes to evidence-based practice.