Task Difficulty Levels of Game-Based Digital Therapeutics Regulate ADHD Symptom Improvement in Children with ADHD : Pilot Study (Preprint)

BACKGROUND Recent advances in digital therapeutics (DTx) have led to the development of game-based interventions that provide engaging treatment options for individuals with attention-deficit/hyperactivity disorder (ADHD). Previous studies have mainly examined DTx usage patterns (eg, frequency and duration), however, the impact of in-game performance metrics on ADHD symptoms has not been investigated. OBJECTIVE We aimed to examine whether task difficulty levels affect ADHD symptom improvement using game-based digital therapeutics in pediatric ADHD. METHODS We analyzed data from 35 children with ADHD who participated and engaged in five cognitive digital tasks in 25-minute sessions, five times weekly for four weeks. All sessions were conducted at home using Neuro-World, an adaptive DTx platform that dynamically adjusted task difficulty based on individual performance in real time. Performance data were collected from all five cognitive tasks to derive three key indicators of task difficulty: average task difficulty (ATD), task difficulty variability (TDV), and task difficulty slope (TDS). In addition, ADHD symptom improvements were assessed using the Korean version of the ADHD Rating Scale (K-ARS) and the Korean Child Behavior Checklist (K-CBCL), administered before and after the intervention. RESULTS We found that task difficulty in game-based DTx was associated with symptom improvement in children with ADHD. Specifically, one of the five tasks, Cognitive Digital Task 1 (requiring recognition of common features among animal figures), was significantly correlated with ADHD symptom improvements. Specifically, children who performed higher levels of average task difficulty (ATD) or lower task difficulty variability (TDV) exhibited greater reductions in internalizing symptoms (K-CBCL) of ADHD. Moreover, children who progressively performed easier tasks (negative task difficulty slope [TDS]) showed more consistent improvement in hyperactivity and impulsive symptoms (K-ARS) of ADHD. CONCLUSIONS These results suggest that DTx task difficulty (ATD, TDV, TDS) differentially regulates ADHD symptoms in children with ADHD. Consequently, the consistency and quality of task performance might be critical predictors of DTx effectiveness, and task performance metrics could inform personalized intervention strategies for ADHD. CLINICALTRIAL The Korea Clinical Research Information Service KCT0009326; https://cris.nih.go.kr/cris/search/detailSearch.do?seq=26799