Research Advances in ADHD and Technology

Series ISSN: 2162-7258
CIBRIAN • ET AL
Series Editor: Ron Baecker, University of Toronto
Andrew Sixsmith, Simon Fraser University
Research Advances in ADHD and Technology

Franceli L. Cibrian, Chapman University
RESEARCH ADVANCES IN ADHD AND TECHNOLOGY

Gillian R. Hayes, University of California, Irvine
Kimberley D. Lakes, University of California, Irvine
Attention Deficit Hyperactivity Disorder (ADHD) is the most prevalent childhood psychiatric condition,
with estimates of more than 5% of children affected worldwide, and has a profound public health,
personal, and family impact. At the same time, a multitude of adults, both diagnosed and undiagnosed,
are living, coping, and thriving while experiencing ADHD. It can cost families raising a child with
ADHD as much as five times the amount of raising a child without ADHD (Zhao et al. 2019). Given the
chronic and pervasive challenges associated with ADHD, innovative approaches for supporting children,
adolescents, and adults have been engaged, including the use of both novel and off-the-shelf technologies.
A wide variety of connected and interactive technologies can enable new and different types of sociality,
education, and work, support a variety of clinical and educational interventions, and allow for the
possibility of educating the general population on issues of inclusion and varying models of disability.
This book provides a comprehensive review of the historical and state-of-the-art use of technology
by and for individuals with ADHD. Taking both a critical and constructive lens to this work, the book
notes where great strides have been made and where there are still open questions and considerations
for future work. This book provides background and lays foundation for a general understanding of
both ADHD and innovative technologies in this space. The authors encourage students, researchers, and
practitioners, both with and without ADHD diagnoses, to engage with this work, build upon it, and push
the field further.

About SYNTHESIS
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Research Advances in ADHD and
Technology
iii
Synthesis Lectures on
Assistive, Rehabilitative, and
Health-Preserving Technologies
Editors
Ronald M. Baecker, University of Toronto
Andrew Sixsmith, Simon Fraser University
Advances in medicine allow us to live longer, despite the assaults on our bodies from war, envi-
ronmental damage, and natural disasters. The result is that many of us survive for years or decades
with increasing difficulties in tasks such as seeing, hearing, moving, planning, remembering, and
communicating.
This series provides current state-of-the-art overviews of key topics in the burgeoning field
of assistive technologies. We take a broad view of this field, giving attention not only to prosthetics
that compensate for impaired capabilities, but to methods for rehabilitating or restoring function,
as well as protective interventions that enable individuals to be healthy for longer periods of time
throughout the lifespan. Our emphasis is in the role of information and communications technol-
ogies in prosthetics, rehabilitation, and disease prevention.

Franceli L. Cibrian, Gillian R. Hayes, and Kimberley D. Lakes
AgeTech, Cognitive Health, and Dementia

Andrew Sixsmith, Judith Sixsmith, Mei Lan Fang, and Becky Horst
Interactive Technologies and Autism, Second Edition

Julie A. Kientz, Gillian R. Hayes, Matthew S. Goodwin, Mirko Gelsomini, and Gregory D. Abowd
Zero-Effort Technologies: Considerations, Challenges, and Use in Health, Wellness, and Rehabil-
iation, Second Edition
Jennifer Boger, Victoria Young, Jesse Hoey, Tizneem Jiancaro, and Alex Mihailidis
Human Factors in Healthcare: A Field Guide to Continuous Improvement

Avi Parush, Debi Parush, and Roy Ilan
iv
Assistive Technology Design for Intelligence Augmentation

Stefan Carmien
Body Tracking in Healthcare

Kenton O’Hara, Cecily Morrison, Abigail Sellen, Nadia Bianchi-Berthouze, and Cathy Craig
Clear Speech: Technologies that Enable the Expression and Reception of Language
Frank Rudzicz
Designed Technologies for Healthy Aging

Claudia B. Rebola
Fieldwork for Healthcare: Guidance for Investigating Human Factors in Computing Systems
Dominic Furniss, Rebecca Randell, Aisling Ann O’Kane, Svetlena Taneva, Helena Mentis, and
Ann Blandford
Fieldwork for Healthcare: Case Studies Investigating Human Factors in Computing Systems
Dominic Furniss, Aisling Ann O’Kane, Rebecca Randell, Svetlena Taneva, Helena Mentis, and
Ann Blandford
Interactive Technologies for Autism

Julie A. Kientz, Matthew S. Goodwin, Gillian R. Hayes, and Gregory D. Abowd
Patient-Centered Design of Cognitive Assistive Technology for Traumatic Brain Injury Telereha-
bilitation
Elliot Cole
Zero Effort Technologies: Considerations, Challenges, and Use in Health,Wellness, and Rehabil-
itation
Alex Mihailidis, Jennifer Boger, Jesse Hoey, and Tizneem Jiancaro
Design and the Digital Divide: Insights from 40 Years in Computer Support for Older and Dis-
abled People
Alan F. Newell
Copyright © 2021 by Morgan and Claypool
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any form or by any means—electronic, mechanical, photocopy, recording, or any other except for brief quota-
tions in printed reviews, without the prior permission of the publisher.

Franceli L. Cibrian, Gillian R. Hayes, and Kimberley D. Lakes
www.morganclaypool.com
ISBN: 9781636390345 print

ISBN: 9781636390352 ebook
ISBN: 9781636390369 hardcover
DOI 10.2200/S01061ED1V01Y202011ARH015
A Publication in the Morgan and Claypool Publishers series

SYNTHESIS LECTURES ON ASSISTIVE, REHABILITATIVE, AND HEALTH-PRESERVING
TECHNOLOGIES
Lecture #15
Series Editors: Ron Baecker, University of Toronto and Andrew Sixsmith, Simon Fraser University and
AGE-WELL NCE
Series ISSN 2162-7258 Print 2162-7266 Electronic

Research Advances in ADHD and
Technology
Franceli L. Cibrian
Chapman University
Gillian R. Hayes
University of California, Irvine
Kimberley D. Lakes
University of California, Riverside
SYNTHESIS LECTURES ON ASSISTIVE, REHABILITATIVE, AND HEALTH-

PRESERVING TECHNOLOGIES #15
M
&C MORGAN & CLAYPOOL PUBLISHERS
viii
ABSTRACT
Attention Deficit Hyperactivity Disorder (ADHD) is the most prevalent childhood psychiatric
condition, with estimates of more than 5% of children affected worldwide, and has a profound
public health, personal, and family impact. At the same time, a multitude of adults, both diagnosed
and undiagnosed, are living, coping, and thriving while experiencing ADHD. It can cost families
raising a child with ADHD as much as five times the amount of raising a child without ADHD
(Zhao et al. 2019). Given the chronic and pervasive challenges associated with ADHD, innovative
approaches for supporting children, adolescents, and adults have been engaged, including the use of
both novel and off-the-shelf technologies. A wide variety of connected and interactive technologies
can enable new and different types of sociality, education, and work, support a variety of clinical
and educational interventions, and allow for the possibility of educating the general population on
issues of inclusion and varying models of disability.
This book provides a comprehensive review of the historical and state-of-the-art use of
technology by and for individuals with ADHD. Taking both a critical and constructive lens to this
work, the book notes where great strides have been made and where there are still open questions
and considerations for future work. This book provides background and lays foundation for a gen-
eral understanding of both ADHD and innovative technologies in this space. The authors encour-
age students, researchers, and practitioners, both with and without ADHD diagnoses, to engage
with this work, build upon it, and push the field further.
KEYWORDS
Attention Deficit Hyperactivity Disorder, ADHD, human-computer interaction, cognition,
social interaction, social skills, education, disability, human development, interactive technologies,
user experience, mobile computing, shared active surfaces, tabletop computing, virtual reality,
multi-sensory environments, augmented reality, sensors, wearable computing, robots, robotics,
natural user interfaces, natural input, tangible computing, tactile computing, eye tracking, behav-
ioral intervention
ix
Franceli L. Cibrian:
To Armando, Rome, and Francisco
Gillian R. Hayes:
To Steve, Warner, and William
Kimberley D. Lakes:
To Dr. Francis Crinella and James, Emma, Micah, and Elijah
xi
Contents
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ��1
1.1 The Evolution of ADHD as a Diagnostic Category . . . . . . . . . . . . . . . . . . . . . 2
1.2 The Evolution of “Technology” in Mental Health . . . . . . . . . . . . . . . . . . . . . . . 4
1.3 Other Relevant ADHD and Technology Reviews . . . . . . . . . . . . . . . . . . . . . . 6
1.4 Structure of This Book . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2 Methods and Classification Scheme. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ��9

2.1 Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.2 Classification Scheme . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2.2.1 Interactive Technology Platform . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2.2.2 Domain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.2.3 Goal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2.2.4 Target End User . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2.2.5 Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.3 Applying the Classification Scheme . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
3 Computationally Supported Diagnosis and Assessment . . . . . . . . . . . . . . . . . . . 21

3.1 ADHD Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
3.2 Computational Diagnostic and Assessment Approaches . . . . . . . . . . . . . . . . . 22
3.2.1 Computer and Mobile Phone-Based Assessments . . . . . . . . . . . . . . . 22
3.2.2 Virtual and Augmented Reality to Assess Attention . . . . . . . . . . . . . 23
3.2.3 Computationally Assessing Motor Skills . . . . . . . . . . . . . . . . . . . . . . 25
3.2.4 Diagnostic and Assessment Games . . . . . . . . . . . . . . . . . . . . . . . . . . 26
3.2.5 Visual Observational Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
3.2.6 Multimodal and Physical Interfaces . . . . . . . . . . . . . . . . . . . . . . . . . . 28
3.2.7 Wearable and Physiological Sensors . . . . . . . . . . . . . . . . . . . . . . . . . 29
3.3 Characterizing ADHD Through Technological Interactions . . . . . . . . . . . . . 34
3.4 Conclusions and Future Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
4 Attention and Other Cognitive Processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

4.1 Self-Regulation, Self-Control, and Executive Functioning . . . . . . . . . . . . . . . 37
xii
4.2 Computerized Cognitive Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

4.3 Neurofeedback Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
4.4 Virtual Reality Interventions and Serious Games Beyond Neurofeedback �� 41
5 Social and Emotional Development. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

5.1 Social and Emotional Development and ADHD . . . . . . . . . . . . . . . . . . . . . . 45
5.2 Social Skills Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
5.3 Technologies for Supporting Social and Emotional Development . . . . . . . . 47
5.4 Emotion Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
6 Behavior Management and Self-Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

6.1 Behavior Management, Self-Regulation, and ADHD . . . . . . . . . . . . . . . . . . . 55
6.2 Technology to Support Behavioral Training for Caregivers . . . . . . . . . . . . . . 56
6.3 Tracking, Prompting, and Reinforcing Behaviors . . . . . . . . . . . . . . . . . . . . . . 58
6.4 Technology-Based Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
6.5 Biofeedback and Neurofeedback . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
6.6 Conclusions and Future Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
7 Academic and Organizational Skills and Support. . . . . . . . . . . . . . . . . . . . . . . . . 65

7.1 Academic Support for Students with ADHD . . . . . . . . . . . . . . . . . . . . . . . . . 65
7.2 Technology Support for Academic Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
7.3 Transitioning to Postsecondary Institutions . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
7.4 Online Learning Environments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
8 Life and Vocational Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

8.1 Living with ADHD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
8.2 Career Readiness and Job Seeking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
8.3 Employment and Workplace Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
8.4 Mentoring and Coaching . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
9 Motor Control, Physical Accessibility, and Physical Activity . . . . . . . . . . . . . . . . 87

9.1 Motor Control and ADHD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
9.2 Technological Approaches to Supporting Motor Skill Development
and Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
9.2.1 Computerized Cognitive Training to Support Motor Skills . . . . . . . 88
xiii
9.2.2 Physical Interactions in Motor Skill Support and Assessment . . . . . 90

9.3 Physical Activity and ADHD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
9.4 Technological Interventions to Promote Physical Activity . . . . . . . . . . . . . . . 93
10 Discussion and Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

10.1 Multidisciplinary Research Agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
10.2 Inclusive and Engaged Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
10.3 Human Augmentation or Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
10.4 The Need for Translational Research and Systemic Change . . . . . . . . . . . . 101
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Authors’ Biographies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155

xv
Acknowledgments
We would like to thank the following people who provided input directly on the writing of this
manuscript, providing reviews, discussions, images, or comments on the content and writing: Sa-
brina E.B. Schuck, Mirko Gelsomini, Jeffrey Krichmar, Patrizia Marti, and Jesus A. Beltran. Addi-
tionally, Latoya Wilson has been an enormous help in organizing time and deadlines to ensure this
book actually got written. Finally, Gabriela Marcu and Paul Marshall provided extensive comments
and edits that improved the final version.
We wish to thank the following people for their influence on our thinking and informing
our understanding of the fields of ADHD, human-computer interaction, and health informatics
in significant ways: Sabrina E. B. Schuck, LouAnne Boyd, Julie Kientz, Nancy Donnelly, and the
children, parents, and teachers at The Children’s School in Irvine, California.
Finally, we wish to acknowledge the following funding sources that supported the authors
during the writing of this manuscript: National Institutes of Health (NIH), the Agency for Health-
care Research and Quality (AHRQ) under award number 1R21HS026058, and the Jacobs Founda-
tion Advanced Research Fellowship. The content is solely the responsibility of the authors and does
not necessarily represent the official views of the NIH, AHRQ, nor the Jacobs Foundation.
1
CHAPTER 1
Introduction
Attention Deficit Hyperactivity Disorder (ADHD) is the most prevalent childhood psychiatric
condition, with worldwide prevalence estimates of 5% and 7.2% (Polanczyk, et al., 2014; Thomas et
al., 2015), and profound public health, personal, and family impacts. In 2013, in a European setting
estimate that the average total ADHD-related costs ranged from €9,860 to €14,483 per patient and
annual national costs were between €1,041 and €1,529 million (M) (Le et al., 2014). In the U.S.
in 2000, a study estimated that the excess cost of ADHD was $31.6 billion (1.6 billion was for the
treatment; $14.2 billion for healthcare cost and $3.7 billion was for the work loss) (Birnbaum et
al., 2005; Doshi et al., 2012). In the Republic of Korea, the total economic burden of ADHD was
US$47.55 million, which accounted for approximately 0.004% of Korean gross domestic product
in 2012 (Hong et al., 2020). Given the international differences in the medical care system, it is
difficult to generalize a global cost and there is not a lot of data about the burdensome costs from
countries of the Global South; still, the burden may be similar or greater, although it may not be
recognized to the same extent.
At the same time, a multitude of adults are living, coping, and thriving while experiencing
ADHD, both diagnosed and undiagnosed. Given the chronic and pervasive challenges associated
with ADHD, innovative approaches for supporting people with ADHD across the lifespan have
been engaged, including the use of both novel and off-the-shelf technologies. A wide variety of
connected and interactive technologies can enable new and different types of sociality, education,
and work, support a variety of clinical and educational interventions, and allow for the possibility
of educating the general population on issues of inclusion and varying models of disability. These
technologies are used for traditional mental health care, such as diagnosis and assessment, as well
as addressing the primary mental health concerns of ADHD, including cognition and attention.
We intentionally engage a variety of technologies beyond this, however. Notably, we explore be-
haviors that can put people with ADHD in conflict with those without ADHD and discuss how
technologies can support self-regulation and management of behavior to fit cultural and societal
norms and social engagement with those without ADHD. We also explore technologies most con-
cerned with promoting the pragmatic outcomes of academic, work, and daily lives. Our goals are to
describe both a broad base of existing and emerging technological approaches as well as the large
scope of potential opportunities and challenges in the space of ADHD that future technologies
could address.
Since 2004, research papers describing potential applications of technology to ADHD
have increased dramatically; the ACM Digital Library (2019, https://dl.acm.org/) indicated that
2 1. INTRODUCTION
from 2004–2019 the numbers of publications focused on ADHD and technology increased expo-
nentially, with the fastest growth occurring in the last ten years. As scientific interest has grown,
commercial interest has developed even more rapidly. Many commercial products are currently
available on the market, advertising clinical benefits to individuals with ADHD and their families.
The efficacy of these products, however, is largely unknown.
Limited reviews of the scientific literature surrounding ADHD and technology use do
exist and are included in this book. Every day, people with ADHD and their families, co-workers,
friends, and teachers are adapting and adopting interactive technologies in novel ways not cata-
loged by any researchers. Thus, this review does not attempt to make clinical recommendations
nor provide a comprehensive examination of all technology use surrounding ADHD. Rather, this
volume focuses on describing current research—technological, social-behavioral, and medical—in
the broad spaces of ADHD assessment, diagnosis, treatment, and self-determination.
Each of the authors of this book has worked with and/or taught people with ADHD of
all ages for years. We come to this work as researchers, clinicians, educators, family members, and
friends of people with ADHD. Additionally, we have sought and incorporated feedback from peo-
ple with ADHD, including both children and adults, throughout our time working on this man-
uscript and are grateful for their lived experiences, which have informed this book. Our intention
with this book is to help readers understand ADHD as both a medical and sociological construct
and provide a broad review of the research literature that demonstrates the role technology has
served to this point. Finally, we hope through this work to identify some gaps, biases, and challenges
that we as a community have yet to overcome.
This book provides an overview of the historical and state-of-the-art use of technology by
and for individuals with ADHD with deep dives into a subset of research to further illustrate the
trends we see in the space. We take both a critical and constructive lens to this work, noting where
we have made great strides and where there are still open questions and considerations that must be
engaged. This book provides background and lays foundation for a general understanding of both
ADHD and innovative technologies in this space. We encourage students, researchers, and prac-
titioners, both with and without ADHD diagnoses, to engage with this work, build upon it, and
push the field ahead in order to support the needs of children, adolescents, and adults with ADHD.
1.1 THE EVOLUTION OF ADHD AS A DIAGNOSTIC

CATEGORY
The historic 1980 revision of the Diagnostic and Statistical Manual of the American Psychiatric
Association (DSM-III, 1980) introduced the diagnostic categories of Attention Deficit Disorder
without (ADD) or with Hyperactivity (ADDH). These categories replaced the prior diagnostic
category of hyperkinetic reaction of childhood (DSM-II, 1978). The DSM-III diagnostic criteria
1.1 THE EVOLUTION OF ADHD AS A DIAGNOSTIC CATEGORY 3
described symptoms of inattention, impulsivity, and hyperactivity. Subsequent revisions to the

manual (e.g., DSM-IIIR, DSM-IV 1994, DSM-5) expanded on these categories and symptoms.
Today, the DSM-5 diagnosis of ADHD falls within the broader grouping of Neurodevelopmental
Disorders, a grouping of conditions that emerge during early development. DSM-5 diagnostic
criteria are grouped as either inattention or hyperactivity-impulsivity symptoms. The earlier term
“ADD” is no longer applied; rather, the DSM-5 uses the diagnosis of ADHD, which can be spec-
ified as “Combined presentation” (six or more symptoms of inattention and six or more symptoms
of hyperactivity-impulsivity have been present for at least six months), “Predominantly inattentive
presentation” (sufficient inattention symptoms are present but hyperactivity-impulsivity symptoms
do not meet the threshold), or “Predominantly hyperactive/impulsive presentation” (symptoms of
hyperactivity-impulsivity meet the threshold, but symptoms of inattention do not).
The DSM-5 provides examples of how inattention and hyperactivity-impulsivity impair
daily functioning. Symptoms of inattention can include having difficulty focusing on a task, failing
to attend to details, demonstrating disorganization, lacking persistence, losing things, and forget-
ting to do things. Symptoms of hyperactivity often include fidgeting, having difficulty remaining
in place, and extreme restlessness. Impulsivity can be exhibited by acting without thinking, talking
excessively, interrupting others, and having difficulty waiting in line. The DSM-5 requires that
these difficulties interfere with functioning to meet the threshold for diagnosis and that alternative
explanations for these difficulties are considered and ruled out.
Researchers (e.g., Swanson, Wigal, and Lakes, 2009) have described attention and behavioral
control (the ability to regulate behavior and control one’s impulses) as occurring across a spectrum,
noting that individuals with ADHD fall at an “extreme” on the spectrum and exhibit impairment in
daily functioning. In other words, attention and self-regulation are exhibited to some degree in all
persons. Some demonstrate very strong abilities to pay attention and sustain attention over a long
period of time, while others struggle to do so. Likewise, some individuals display impressive levels
of self-control, while others appear to have very little self-control and frequently display impulsivity.
These cognitive and behavioral skills have been described as critical to success in life. In a rigorous
longitudinal study, Moffit et al. (2011) followed nearly 1,000 children from birth into adulthood
and concluded that self-control predicted physical health, substance dependence, personal finances,
and criminality, producing a gradient that indicated that as self-control improved, corresponding
outcomes improved as well. Their study continues to have important implications for society at
large, as well as individuals with ADHD who struggle with self-control: improving self-control can
improve outcomes across a wide range of domains (health, education, wealth, and citizenship). A
large body of evidence in the field of ADHD research similarly demonstrated that difficulties with
self-control are associated with poor educational, occupational, and social outcomes. Collectively,
this research highlights the importance of improving treatment and providing ongoing support
4 1. INTRODUCTION
for individuals with ADHD who struggle to control attention and behavior, as it suggests that the
long-term impact on outcomes can be meaningful and substantial.
Despite a wealth of research and attention, ADHD remains in many ways a misunderstood
condition, especially for women and girls. Researchers, clinicians, and the broader public have
shifted to some degree on the notion of ADHD as something that debilitates to something that
differentiates. Sabrina Park, writing in 2019, chronicled 11 women with ADHD whom she de-
scribed as “thriving:” including actress Emma Watson who also graduated from Brown University
and served as a United Nations Goodwill Ambassador, vocalist Solange Knowles who lamented
people’s perceptions of her before her diagnosis, Olympic gold medalist Simone Biles, and even
a YouTuber who created a “Hot to ADHD” informational channel (Park, 2019). Entrepreneur
magazine similarly chronicled ADHD success stories, such as JetBlue Airways founder Devid
Neeleman and Virgin Group founder Richard Branson (Belanger, 2017). That article references re-
search in which Wiklund et al. (2016) studied 14 entrepreneurs previously diagnosed with ADHD,
noting that impulsivity can be a major driver of entrepreneurial action, and hyper-focus can spur
such action to consequences. Regardless of these specific cases or potential benefits to ADHD, we
acknowledge that much of the western world is incompatible with the cognitive and behavioral
profile of ADHD. Thus, in this work, we explore technologies that seek to support people with
ADHD in learning to accommodate the environment around them as well as technologies that
seek to change the environment to accommodate them. As Harvey Blume (1998) noted, “Neurodi-
versity may be every bit as crucial for the human race as biodiversity is for life in general. Who can
say what form of wiring will prove best at any given moment?”
1.2 THE EVOLUTION OF “TECHNOLOGY” IN MENTAL

HEALTH
Although the vast majority of technology profiled in this book is more recent, it was worth under-
standing to some degree the origins of the notion of the use of technology in mental health. This
has, in many ways, tracked the use of technology in other parts of healthcare, but the trends are
distinct in interesting ways, with a much stronger emphasis on self-instruction and home care than
physical health trends.
In the 1970s, as hospitals and other health systems computerized, mental health also began
to include computerization. For example, Johnson and Williams (1975) described an “on-line com-
puter technology” for mental health admissions. This simple system collected psychological, social,
and physical information that could then be used for clinical decision-making. Other systems
would follow, and some have even been adopted and put into widespread clinical use. And yet, many
of our systems still rely on paper and pencil, particularly for smaller practices. A 1976 review of the
1.2 THE EVOLUTION OF “TECHNOLOGY” IN MENTAL HEALTH 5
state of the art in computers and mental health care delivery ( Johnson, Giannetti, and Williams,
1976) predominantly described large-scale data collection and clinical decision support systems.
As in other areas of healthcare, it would take the advent of personal computing to push
the notion of technology in mental health into more mainstream practice. An instructional book,
complete with included CD-ROM from the late 1990s, describes “practical advice” for even the
most “technophobic” clinicians and researchers (Rosen and Weil, 1997). Yet, even then, much of
the literature from this time period focuse on screening and assessment (e.g., Munizza et al., 2000;
Puskar et al., 1996; Stein and Milne, 1999) and computerized decision-support (e.g., Knight, 1995)
as opposed to using technology directly for treatment, which was still an emerging area of research
(e.g., Budman, 2000; Huang and Alessi, 1998; Riemer-Reiss, 2000). A focus, then as now, was on
the notion of treating patients and providing support services at a distance.
In more recent years, the notion of technology for mental health, and for ADHD in par-
ticular, has gained enough mainstream interest that a myriad of smartphone “apps;” games for
computers, phones, and even in Virtual Reality; and other approaches have become commonplace.
Some of this is driven by innovative clinicians, by people with ADHD themselves, and by friends
and family members of people with ADHD, making the effects disparate and hard to measure.
Several reviews of these technologies and their evidence exist (e.g., Batra et al., 2017; Grist, Porter,
and Stallard, 2017; Hansen, Broomfield, and Yap, 2019; Hollis et al., 2017; Michel, Slovak, and
Fitzpatrick, 2019; Torous et al., 2018). These explorations can point us toward a variety of future
directions with creative solutions and points to the need for more empirical research (e.g., Comer
and Myers, 2016; Firth et al., 2018; Ralston, Andrews, and Hope, 2019). Such research also high-
lights risks and obstacles to technological approaches (e.g., Bhuyan et al., 2017) but cannot yet, in
most cases, provide solid extensible guidance and recommendations.
Technology and ADHD have a complicated relationship. While researchers, clinicians, and
educators have sought to use technologically enabled approaches to support people with ADHD,
others have sought to detect a potential connection between the rise in use of computerized tech-
nologies and ADHD itself (e.g., Visser et al., 2014; Beyens et al., 2018). Despite the widespread
problematizing by the scientific community of claims that screen and media use cause a wide range
of psychiatric disorders (Odgers and Jensen, 2020; Stiglic and Viner, 2019), these myths continue
to be perpetuated by both the popular press and an increasingly limited number of researchers (e.g.,
Twenge et al., 2018). These claims are problematic in part due to their limited statistical power
but largely due to the implicit ableism and offensive nature of claims that assert technology has
“destroyed a generation” (Twenge, 2017) largely related to claims that this new generation has and
makes different choices than was true of prior generations, particularly in relation to independence
and social engagement. By asserting that ADHD is caused by screen time and media use (e.g.,
Tamana et al., 2019, Rosenblatt, 2019) and that, therefore, all children should have such screens re-
moved from their lives or have greatly reduced access (Twenge and Campbell, 2018), we implicitly
6 1. INTRODUCTION
assert that living with ADHD is worse than living without educational opportunities, connectivity
to remote social opportunities, and connection to the larger culture. We are writing this book at a
particular moment in time, during COVID-19 stay-at-home orders and subsequent social distanc-
ing, and this experience reinforces the deeply problematic nature of staking these claims that are
not backed in science and that contribute to bias and problematic policies.
Further challenging reviews and thoughts about Mental Health Technology, and specifically
those for use surrounding ADHD, is the use of the word “technology” itself by the interdisciplin-
ary mix of people working in this space. Some clinicians and mental health researchers use the
word technology to mean concepts, such as when Swift and Levin defined “empowerment” as an
emerging mental health technology (Swift and Levin, 1987). In this case, they were referring to the
feeling of power and competence as well as the modification of the structural conditions to invoke
these feelings. In this case, and others like it, the authors appear to be using the term technology
to describe any tool. Similarly, Byrnes, and Johnson (1981) use the term technology to describe a
new process. At the far other end of the spectrum, for many computer scientists and engineers,
technology is an evolving concept, and the term itself is difficult to pin down at times, describing
only digital or electrical solutions and at others more traditional tools, such as paper as technology.
This concept grows murkier when one considers the publication and funding realities of research
in the information and computer sciences, in which only new radically cutting-edge solutions are
considered worthy of scientific exploration. In this case, the word technology may often be preceded
by “novel” or “innovative.”
1.3 OTHER RELEVANT ADHD AND TECHNOLOGY REVIEWS

This book is not the first effort to catalog research related to ADHD and technology in some
form or another. However, prior reviews published in scientific journals have primarily focused a
specific form of technology and its impact on targeted outcomes in ADHD. For example, Powel et
al. (2017) focused on the ten most popular smartphone applications targeting children and young
people with ADHD or their caregivers and noted the lack of an evidence base for the applications,
as well as concerns about their utility and inadequate privacy/security features. They observed that
once an application had been purchased and downloaded, there was little opportunity for feedback
on utility; participants interviewed in their research identified a range of limitations in the available
products, suggesting that they had fallen short when it came to addressing patient, family, and cli-
nician needs. Powel et al. (2018) conducted a second review of 14 studies focused on technologies
designed to encourage and support self-management for individuals with ADHD. They noted
that although the research indicated some promise for technology to support self-management of
ADHD-related difficulties, research was limited by small sample sizes, weak outcome measures,
and limited integration of psychoeducation. As another example, in a recent preprint, Hussain
1.4 STRUCTURE OF THIS BOOK 7
(2020) catalogs the design methods, sample size, and specific subdomains of 27 papers from the
ACM Digital Library between 2007 and 2017 focused on technology for ADHD.
As we describe in Chapter 4, for example, hundreds of journal articles and several systematic
and meta-analytic reviews have been published addressing computerized cognitive training (e.g.,
attention training using a computer program designed to look like a video game) for individuals
with ADHD. These works have contributed to a growing understanding of how technology may or
may not ameliorate ADHD symptoms and improve outcomes. Our intent in this book is to take a
broader perspective and describe a wider range of technologies that have been addressed in prior in-
dividual reviews. When relevant to a particular chapter, we cite those other review articles and hope
that readers may engage with those works as they find them useful and relevant to their own work.
This book also is not meant to include every article ever written about ADHD in relation
to technology or technology in relation to ADHD. For one, the book would never be complete as
research is ongoing and growing in this space. More importantly, however, scientific journals are
the appropriate space for systematic reviews or structured meta-reviews and meta-analyses, such
as those described in the previous paragraph. This book is meant, instead, to lay out an intellectual
space. The hope of this approach, as has been in true in many volumes in this series, is three-fold.
First, we seek to educate and support scholars choosing to move into this area. Second, this book
should inspire others to build on, critique, and update the exciting advances we overview here. Fi-
nally, this book can serve as a resource for those in the industry looking to develop a new product
or modify an existing one to provide a better user experience for someone with ADHD, to enable
people with ADHD to make their own content and products or to develop new assessment, diag-
nostic, and therapeutic tools.
1.4 STRUCTURE OF THIS BOOK

This book is organized by functional domain within the broader context of living with ADHD.
While we do not focus on any particular age group, that organization means that some chapters are
more likely to focus on children while others may be more centered around the adult experience.
We begin in the next chapter with a description of our initial structured literature review and the
themes used to classify the literature in that review. This classification scheme runs throughout the
book and provides the backbone for the remaining chapters. Chapter 3 focuses on the diagnosis
and assessment of ADHD, a series of tools and approaches that cross many of these functional
domains. Chapter 4 focuses on cognition and attention and includes a discussion of tools developed
to train these skills in individuals with ADHD. In Chapter 5, we focus on social and emotional
skills, including the experiences of both children and adults. In Chapter 6, we review tools to sup-
port behavior management and self-regulation. Chapter 7 is dedicated to academic skills and so
is heavily tied to the experience of childhood schooling as well as higher education. By contrast,
8 1. INTRODUCTION
the next chapter, Chapter 8, highlights the role of technology in supporting everyday life skills and
employment and is thus more focused on the experiences of young adults and adults. Chapter 9
describes technologies to support and improve motor skills, physical access, and physical behaviors.
Finally, we conclude with a discussion of where we are headed as a field and what opportunities may
lie ahead. Of course, many projects overlap in categories and so can be found in multiple chapters.
Likewise, points from the discussion are relevant to detailed portions of the individual chapters as
well. Thus, readers may wish to begin with the discussion, read detailed chapters of interest, and
return to the final chapter again.
Within each chapter, we describe the background of the experience of ADHD as related
to the overall topic of that chapter. In these cases, we highlight both strengths and challenges,
indicating the ways in which technology can help people with ADHD to improve their life experi-
ences, ways that technology might help people without ADHD to be supportive and inclusive, and
ways in which the currently available technological solutions do not appear to be effective. Finally,
we close each chapter with some indication of the conclusions we can draw from inspecting this
literature together and the future directions the field might wish to pursue.
9
CHAPTER 2
Methods and Classification Scheme

In this chapter, we provide a description of the methods we used to identify and analyze interac-
tive technology research included in this book. Based on the existing work of Kientz et al. (2019)
in classifying papers in the broad space of interactive technologies for autism, we modified their
classification scheme to help categorize each technology approach. This approach is particularly
appealing in that it is both descriptive and explanatory. Using this framework, we have been able to
trace the history and evolution of this research within specific technology verticals. This approach
then provides a roadmap for future research by showing both where the field is headed and where
it perhaps could or should be with some appropriate intervention by researchers, practitioners,
product developers, or even funding bodies.
2.1 METHODS
Given the rapid growth rate in this area of research, the ambiguous definition of technology, and
the rapid changes in clinical and educational practice, as in the Kientz et al. volume that was fo-
cused on autism, we do not represent this work as a complete review of the literature but rather
an overview of the preponderance of evidence for and open questions about various technological
approaches. Notably, there are numerous off-the-shelf, open-source, and commercial products that
serve similar needs, either explicitly or through appropriation and adaptation. We intentionally
exclude applications from popular media, such as games for children with ADHD found in the
Apple App Store or on Google Play. These marketplaces are rich with different applications, but in
general, they are beyond the scope of this book unless they have been studied in the scientific liter-
ature. Given our focus on research, this book is limited to research projects and research-validated
products with some mention of other non-research products when particularly relevant.
We conducted our research for this book in two phases. In the first phase, we conducted a
structured literature review using searches in PubMed, ACM Digital Library, and IEEE Xplore
for articles published in English from 2004 to June 1, 2020. We witnessed an inflection point in
the ACM and IEEE articles, in particular around 2004 (see Figure 2.1). Search terms included:
“ADHD,” “Attention Deficit Hyperactivity Disorder,” “treatment,” “digital,” “intervention,” “as-
sistive technology,” “computer intervention,” “computer assisted,” “sensor,” “mobile,” “wearable,”
“smartphone,” “tablet,” “robot,” “virtual reality,” “augmented reality,” “neurofeedback,” “working
memory training,” “cognitive training,” “internet,” and “web.” We limited results to published
10 2. METHODS AND CLASSIFICATION SCHEME
peer-reviewed research papers, excluding research published solely as abstracts or extended ab-
stracts; these research abstracts were excluded during the first phase of screening (Figure 2.2).
Number of Relevant Papers Published

in ACM or IEEE Venues by Year
160
140
120
100
80
60
40
20
0
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Figure 2.1: Chart graphing publications in the ACM and IEEE digital libraries using “ADHD” as the
keyword starting in 1991 shows 2004 as a clear point after which the topic began to gain substantial
interest to technology and computing researchers. Notably, at time of publication, 2020 is still in prog-
ress, hence limiting the numbers of publications available for that year.
We included research articles that used consumer, clinical, and educational technologies.
To identify this initial set of literature for the book, we used the PRISMA process for identifying
appropriate articles for inclusion (see Figure 2.2, which demonstrates how we identified papers
focused on the application of technology to intervention and treatment only).
2.1 METHODS 11
Records Identified Through Additional Records Identified

Database Searching Through Database Searching
(n = 4347) (n = 10)
Records After Duplicates Removed

(n = 2189)
Identification
Cognitive Other Digital

Neurofeedback
Training Health Interventions
(n = 239)
(n = 772) (n = 772)
Screening
Records Records
Screened Excluded
(n = 1188) (n = 1112)
Eligibility
Full-text Articles Full-text Articles

Assessed for Elligibility Excluded, with
(n = 76) Reasons
Included
Studies Included in
Qualitative Synthesis
(n = 49)
Figure 2.2: Graphic depiction of the PRISMA process for initial meta-review.
Once this initial corpus was developed, we broadened our search to include additional con-
ferences and journals and additional topics in an iterative fashion. We checked the reference lists
in the papers in our initial corpus and used Google Scholar to scan the papers that cited them. We
then analyzed these papers using the classification scheme outlined below. Finally, when we identi-
fied holes in the literature through this analysis, we searched again, this time using Google Scholar
with the broad sets of terms outlined above but expanding to other databases, such as JSTOR and
EPIC that are indexed by Google. This process continued iteratively as we developed the text for
the book itself. Thus, while we do not compile a comprehensive view across all potential fields that
intersect ADHD and Technology, we are confident in our ability to detail the landscape of studies
to provide a foundation for scholars interested in expanding research in this area as well as practi-
tioners or developers looking to build on what already has been done.
2.2 CLASSIFICATION SCHEME

We adapted the framework developed by Kientz et al. (2019) to organize the existing literature. This
adapted framework consists of five dimensions along which projects can be categorized. Within
each dimension, we determined several labels within that dimension that could describe the work,
again derived in part from the Kientz et al. framework. Below we describe the five dimensions,
along with the associated labels within those dimensions and their operational definitions. In many
of these dimensions, it is possible that multiple sub-labels apply. For the purposes of the readabil-
ity of this book, we categorize them roughly in the most dominant sub-label, noting the overlap,
however in Table 2.1.
2.2.1 INTERACTIVE TECHNOLOGY PLATFORM

This category describes the primary platforms, form factors, or delivery mechanisms used by the
technology or application.
• Personal Computers and Web: Includes applications that use a traditional keyboard,
mouse, and monitor, and Internet-based applications that are primarily designed for
access via a desktop-based web browser. Can also include laptop-based technologies,
but the primary differentiator is those that are intended to be stationary and not
mobile.
• Mobile Devices and Tablets: Includes applications delivered on cell phones, PDAs,
tablets, or other mobile devices intended for personal use. Can be used in multiple
environments or anywhere the user goes.
• Sensor-Based and Wearable: Includes the use of sensors (e.g., accelerometers, heart
rate, microphones, brain-computer interfaces (BCI) etc.), both in the environment and
on the body, or computer vision to collect data or provide input.
• Virtual and Augmented Reality: Includes the use of virtual reality, augmented reality,
virtual worlds, and use of virtual avatars.
2.2 CLASSIFICATION SCHEME 13
• Robotics: Includes physical instantiations of digital interactions. Includes both hu-

manoid or anthropomorphic robots and general digital devices that carry out physical
tasks. Includes both autonomous robots and those operated remotely by humans.
• Natural User Interfaces: Includes the use of input devices beyond traditional mice
and keyboards, such as pens, gestures, speech, eye tracking, multi-touch interaction,
etc. Interacts with a system rather than just providing passive input. Although this is a
term of art for computing researchers, it is not without its critics, as the term “natural”
here largely means “not mouse and keyboard” rather than anything that is truly “natu-
ral” in the sense of not being artificial, synthetic, or learned.
2.2.2 DOMAIN
This category refers to the area of functioning within individuals with ADHD that the technology
targets, such as helping with the acquisition of certain skills or addressing particular deficits.
• Cognition and Attention: Includes applications designed to improve cognitive skills,
including attention, working memory, and other executive functions.
• Social and Emotional Skills: Includes technologies designed to improve social skills
and peer and family relationships and reduce emotional symptoms, such as anxiety
and depression.
• Behavior Management and Self-Regulation: Includes applications focused on sup-

porting self-regulation and behavioral approaches, such as technologies to track or
deliver token economies.
• Academic and Organizational Skills: Includes applications focused on time manage-

ment, organization, reading, mathematics, and other academic skills.
• Life and Vocational Skills: Includes applications or technologies designed to support

the development of independent living skills and other specific skills, such as training
to support safe driving behaviors.
• Motor Behaviors: Includes applications designed address hyperactivity and motor

coordination skills, such as tools to help improve fine motor coordination.
2.2.3 GOAL
This category refers to the primary goal of the technology itself. Some technologies related to
ADHD are intended to support a diagnostic process or to screen for symptoms of ADHD, whereas
others are intended to support or deliver interventions.
• Treatment/Intervention: Includes (1) applications that attempt to improve or pro-
duce a specific outcome in an individual with ADHD. May focus on teaching new
skills, maintaining or practicing new skills, or changing behaviors; and (2) applications
that provide support for caregivers, educators, clinicians, and other professionals to
further their understanding of ADHD and intervention strategies or improve their
skills as caregivers.
• Diagnosis/Assessment: Includes (1) applications that help either screen for ADHD
diagnosis in the general population or test for symptoms of ADHD in clinical set-
tings; (2) applications focused on the collection and review of data over time to assess
an individual’s learning, capability, or level of functioning. The data collected is in-
tended for end users and/or people caring directly for individuals with ADHD; and
(3) applications or projects that use technology in the collection and analysis of data
by researchers to understand more about ADHD and its features or characteristics.
Tools in this category generally are not yet available for or may not be appropriate or
feasible for home or community use.
2.2.4 TARGET END USER

This category focuses on the person or persons who will actually be interacting with the technology
itself and are considered the primary users. It does not refer to secondary stakeholders or those who
may benefit from the technology but do not actually interact with or use it.
• Child with ADHD
• Adolescent with ADHD
• Adult with ADHD
• Family Caregiver: Includes anyone who is not a professional who cares for or sup-
ports an individual with ADHD. May include parents, siblings, other family, friends,
volunteers, etc.
• Provider/Researcher: Includes a paid professional who works with individuals with

ADHD. May include teachers, medical professionals, doctors, occupational therapists,
2.3 APPLYING THE CLASSIFICATION SCHEME 15
physical therapists, speech therapists, applied behavior therapists, or other allied health
professionals. Also includes a person intending to collect data or conduct studies about
individuals with ADHD and publish something generalizable about the data. This
does not include researchers running a study about technology for an individual, only
when the researcher themselves is one of the technology’s primary users.
2.2.5 SETTING
The care of individuals with ADHD takes place in a number of different settings. This category
refers to the settings or locations in which the technology is primarily intended to be used.
• Home: The home or personal living space of a person with ADHD and/or their
family.
• School: A public or private place for educating individuals with ADHD. Includes
both schools that specialize in ADHD education as well as general, inclusive class-
rooms. Could include all levels from pre-school through postsecondary education.
• Research Lab: Technology intended for use in a research laboratory under careful
observation or that has been tested only in controlled settings.
• Clinic: A place of professional practice that is not intended for education, such as a
doctor’s office, therapist’s office, or a specialty service provider.
• Everyday Life: Including work, transportation, socialization, shopping, and other

daily activities.
2.3 APPLYING THE CLASSIFICATION SCHEME

To illustrate how we applied this framework, here we describe a single paper and how it was clas-
sified. Weisman et al. (2018) published a study evaluating the ICON smartphone application and
illustrated how innovative technologies could be applied to improve medication adherence, which
can be a substantial problem in ADHD treatment. We classified this work as a mobile device
(technological platform) that targets organizational skills (domain) in order to support interven-
tion and patient education (goals). The application targeted children and their caregivers (target
end users) and was developed for use at home (setting). Also, Table 2.1 includes 68 projects on
technologies reviewed for this book and their associated coding within the classification scheme.
We chose the 68 papers based on their diversity across specific areas to exemplify the use of the
classification scheme.
In the subsequent chapters, we use this framework to describe the approaches to interactive
technology research in the ADHD space. Although we adapted the Kientz et al. (2019) framework
for this analysis, we structure the rest of the book differently. Where they structured their review
based on the technological platform as the primary organizing principle, we instead focus on the
domain of concern that the design, technology, and/or research project was developed to address.
Subsequent chapters include Diagnosis and Assessment of ADHD Symptoms (Chapter 3), Cog-
nition and Attention (Chapter 4), Social and Emotional Skills (Chapter 5), Behavior Management
and Self-Regulation (Chapter 6), Academic and Organizational Skills and Support (Chapter 7),
Life and Vocational Skills and Support (Chapter 8), and Motor Behaviors and Physical Accessibil-
ity (Chapter 9). Some applications and technologies might fit into more than one of these catego-
ries, in which case they are mentioned in both relevant chapters and cross-referenced appropriately.
Within each chapter, we describe the challenges and opportunities of the specific domain as
well as the interventions and innovative technologies that have been developed in this space. We
describe solutions that have been developed or used by people with ADHD and the ways in which
these technologies themselves can be challenging or problematic. Finally, we close with potential
future opportunities in this area of research.
Any book will necessarily only provide a review that is a snapshot in time. Both our under-
standing of ADHD and the technologies we use to support our lives are ever-changing. We hope
this book provides a foundation upon which others may build. Additionally, we expect that others
can use the methods we outlined above to monitor additional literature as it is published and stay
up to date. Finally, we hope that people with ADHD themselves, whether researchers or not, will
take up this work, apply to it their lives, and inform our future work with their lived experiences.
Table 2.1: Coding of 70 projects used to test our classification scheme

Technology Target End
Domain Goal Setting
Platform User
Behavior Management/Self-Regulation
Adolescent with ADHD (13–19 years)

Motor Behaviors/Physical Activity
Academic/Organizational Skills
Virtual and Augmented Reality
Child with ADHD (<12 years)
Adult with ADHD (>20 years)

Personal Computers and Web
Caregivers (Parents/Teacher)
Mobile Devices or Tablets
Sensors/Wearables/EEG
Treatment/Intervention
Social/Emotional Skills
Assessment/Diagnosis
Providers/Researchers
Natural User Interface
Life/Vocational Skills
Cognition/Attention
Everyday Life
Research Lab
Robotics
School
Home
Clinic
Aase and Sagvolden,
* * * * *
2005, 2006
Adams et al., 2009 * * * * * *
Alchalabi et al., 2018;
* * * * *
Alchalcabi et al., 2017
Areces et al., 2018a,
* * * * *
2018b, 2019
Asiry et al., 2018 * * * * * *
Avila-Pesantez et al.,
* * * * * * *
2018
Babinski and Welkie,
* * * * * *
2019
Bashiri et al., 2018 * * * * *
Benzing et al., 2018;
Benzing and Schmidt, * * * * * *
2017, 2019
Breider et al., 2019 * * * * * * *
Bruce et al., 2017 * * * * * *
Bul et al., 2015, 2016,
* * * * * * *
2018
Chen et al., 2018 * * * * * * * *
Cibrian et al., 2020a * * * * * * * *
Clancey, Rucklidge, and
* * * * *
Owen (2006)
Clark-Turner and
* * * * * *
Begum, 2017
Corkum et al., 2019 * * * * * *
Davis, et al., 2018 * * * * *

Díaz-Orueta et al.,
* * * * * * *
2014; Iriarte et al., 2012
Dovis et al., 2015; Prins
* * * * *
et al., 2013
DuPaul et al., 2018 * * * * *
Eliasson et al., 2004 * * * *
Eom et al., 2019 * * * * * *
Faedda et al., 2016 * * * * * * *
Fang et al., 2019 * * * * * * *
Farran et al., 2019 * * * * * * * *
Fujiwara et al., 2017 * * * * * * *
García-Baos et al., 2019 * * * * * *
Garcia-Zapirain et al.,
* * * * *
2017
Hyun et al., 2018 * * * * *
Jaiswal et al., 2017 * * * * * *
Jimenez et al., 2016 * * * * *
Johnson et al., 2010 * * * * * *
Kam et al., 2010 * * * * *
Kanellos et al., 2019 * * * * * * *
Kim et al., 2020 * * * * *
Kollins et al., 2020 * * * * *
Lewis et al., 2010 * * * * *
Luna et al., 2018 * * * * * *
Matic et al., 2014 * * • * * * *
Mautone et al., 2005 * * * * *
Mock et al., 2018 * * * * * *
Muñoz-Organero et al.,
* * * * *
2018, 2019
Neguț et al., 2017 * * * * * *
Nolin et al., 2016 * * * * * *
Olthuis et al., 2018 * * * * * *
Palsbo and Hood-
* * * * *
Szivek, 2012
Park et al., 2009 * * * * * * * *
Parson et al., 2007 * * * * *
Pina et al., 2014 * * * * *
Pollak et al., 2009 * * * * *
Rijo et al., 2015 * * * *
Rodríguez et al., 2018 * * * * * * *
Ryan et al., 2015 * * * * *
Santos et al., 2011 * * * * * * *
Schuck et al., 2016 * * * * * *

Sehlin et al., 2018;
Söderqvist et al., 2017; * * * * * * * * * * *
Wentz et al., 2012
Shema-Shiratzky et al.,
* * * * * * *
2019
Shih, 2011; Shih et al.,
* * * * * *
2014, 2011
Sonne et al 2016a,
* * * * * * *
2016c
Sonne et al., 2015 * * * * * *
Sonne and Jensen, 2016;
* * * * *
Sonne et al., 2017
Spitale et al., 2019 * * * * *
Tam et al., 2017 * * * * *
Tan et al., 2019 * * * * * *
Thomas et al., 2010 * * * * * * * * *
Toshniwal et al., 2015 * * * * * *
Wills and Mason, 2014 * * * * * *
Wood et al., 2009 * * * * * *
Yeh et al., 2012 * * * * *
21
CHAPTER 3
Computationally Supported
Diagnosis and Assessment
ADHD is highly individualized, with each child, adolescent, and adult expressing symptoms in
different ways, with no clear physical test to diagnose the condition. Rather, diagnosis is typically
given in response to a series of behavioral observations and reports sometimes combined with
neuropsychological assessments and self-report of internal feelings. Many children and adults with
ADHD go years or even lifetimes without a formal diagnosis. At the same time, there is growing
interest in increasing the rigor of diagnostic procedures as well as the assessment of progress in
response to a variety of interventions. These kinds of tests, requiring intensive support from clinical
and educational resources, can be difficult to scale, but with the prevalence of ADHD such scale
is necessary. Thus, technology offers an opportunity to support human professionals and experts in
their diagnostic and assessment work. In this chapter, we first introduce the basics of ADHD diag-
noses, followed by the extensive literature on computational approaches to augmenting diagnostic
and assessment work.
3.1 ADHD DIAGNOSIS

No single diagnostic system or procedure for ADHD has been discovered or adopted yet, and a
rigorous evaluation process often involves hours of clinician time. Thus, technological tools have
been developed to glean diagnostic information useful to clinicians evaluating patients for ADHD.
On the one hand, research has often focused on classifying behaviors or physiological data between
individuals with ADHD and neurotypical peers. On the other hand, some research has focused on
finding patterns among the data to generate symptom profiles of ADHD.
For a number of years, computers have been used to test attention, yielding normative data
that can be useful as part of a comprehensive diagnostic evaluation for ADHD. One of the most
commonly used technological tools in clinics is the Conner’s Continuous Performance Test, cur-
rently in its 3rd edition (www.mhs.com/CPT3). This task-oriented computerized test of attention
allows the evaluation of an individual’s ability to maintain attention across a period of time and
produces standardized, normative scores that can help identify difficulties in attention that are sen-
sitive to development. Similarly, the Test of Variables of Attention (TOVA: www.tovatest.com) also
tests attention and produces informative scores. Both tests assess attention using an intentionally
boring “computer game” designed to evaluate how well an individual can regulate attention over
22 3. COMPUTATIONALLY SUPPORTED DIAGNOSIS AND ASSESSMENT
time. Neither claims to replace a comprehensive diagnosis, but both are widely thought to generate
useful information to inform a comprehensive diagnostic assessment.
As digital recording technologies become more pervasive, more robust, and less costly, it
should come as no surprise that they are increasingly used to support medical diagnoses of both
mental and physical health conditions. Mental health, in particular, has been traditionally difficult
to diagnose because few definitive tests exist for certain behavioral health conditions. Recent re-
search projects indicate that diagnoses of ADHD may be greatly enabled and streamlined through
automated sensing and monitoring of physical health and observable behaviors, in particular, as
they relate to potential co-occurring motor conditions. Additionally, the use of these tools has, in
some cases, enabled researchers to rule out such connections from conditions that only appear to
co-occur in clinical practice but such connections were not able to be tested rigorously previously.
In this section, we describe the extant research in using technology to understand and support the
diagnosis of ADHD, including studies that found use of such technologies to be promising as well
as those that demonstrated certain behaviors or symptoms either cannot be effectively measured or
are not predictive of diagnoses as expected.
3.2 COMPUTATIONAL DIAGNOSTIC AND ASSESSMENT

APPROACHES
Three primary approaches have been explored in research attempting to create non-biased diag-
nostic tests for ADHD. Computational techniques can be used to classify data from brain activity,
either EEG or fMRI. Data can also be collected from sensors (on the body, in the environment, or
inherent to computational tool use) used during everyday activities and then create computational
models that can classify unseen data instances. Finally, some approaches have been focused on de-
signing and developing serious games or environments where users can play and interact. The inter-
actions of the users with the game are analyzed to infer if the user has ADHD or related symptoms
3.2.1 COMPUTER AND MOBILE PHONE-BASED ASSESSMENTS

Given that ADHD is largely diagnosed by clinician observation and report, parental report, self-re-
port, and behavioral diagnostics, it should be no surprise that one role computation has taken in this
process is simply to document, support, and analyze such collected data. Clinical decision support
systems (CDSS) (Berner, 2007) can improve healthcare outcomes by facilitating evidence-based
medical practice. For example, Kemppinen et al. (2013) studied the implementation of a custom-
ized CDSS for adult diagnosis of ADHD, finding that implementation of such a system required
the establishment of a standard for the care of adult ADHD patients, enabling quick changes as
new information is incorporated into their processes.
3.2 COMPUTATIONAL DIAGNOSTIC AND ASSESSMENT APPROACHES 23
Some computerized tests support the patients directly, rather than as part of a clinical de-
cision support structure. For example, MATH-CPT uses an on-screen sequence of simple math-
ematical questions, which the authors hope can be used to diagnose participants with ADHD.
In a study of 303 participants (63 with ADHD), MATH-CPT correctly classified 91.6% of
participants, performing better in their study than the Test of Variables of Attention (TOVA)
(Rodríguez et al., 2018). QbTest, a computerized continuous performance test, has been shown to
reliably differentiate between children with ADHD and those without (Emser et al., 2018; Hult
et al, 2018) as well as adults (Bijlenga et al., 2019; Edebol, Helldin, and Norlander, 2013; Emser
et al., 2018; Hirsch and Christiansen, 2017; Lis et al., 2010). Similarly, QbCheck was built as an
online assessment tool for families who were not able to come into a clinic but wanted some initial
screening or assessment for ADHD. In a study with 142 adolescents and adults (69 with ADHD),
high convergent validity was observed between QbCheck at home and QbTest (Ulberstad, 2016)
in the clinic (Ulberstad et al., 2020). Despite the promise of these results for a notion of automated
diagnosis, many researchers have noted that there are just too many limitations inherent to claiming
to diagnose a clinical condition without a qualified clinician. Thus, many experts advocate for such
tools to provide useful information to the diagnostic process rather than replace it.
Finally, parents are sometimes the target of data collection as part of family and child assess-
ments. For example, Hsieh, Yen, and Chou (2019) examined the relationship between the Parental
Smartphone Use Management Scale (PSUMS) and ADHD symptoms, finding that PSUMS
accounted well for reactive management, proactive management, and monitoring in relation to
parental feelings of self-efficacy. Although PSUMS itself is not delivered via technology, it is a po-
tentially useful tool for clinical practice and parenting groups to understand parental management
and point to particular challenge areas around technology use for families. On the other hand, Li
and Lansford (2018) used smartphones in the form of ecological momentary assessment (Shiff-
man, Stone, and Hufford, 2008) to track parents of 184 kindergartners, with and without ADHD,
for one week, finding limited relationships between the stress of parenting and variability in harsh
parenting behaviors. Inclusion of assessment tools like this into other therapeutic or educational
applications for parents may be particularly valuable.
3.2.2 VIRTUAL AND AUGMENTED REALITY TO ASSESS ATTENTION

Virtual reality (VR) provides an option for creating dynamic, immersive three-dimensional envi-
ronments in which behaviors can be recorded and analyzed for later assessment more easily and in
more detail than in a traditional physical classroom. VR enables the presentation of cognitive tasks
that systematically target attention performance, which while only in VR may provide insights into
attention performance outside of this environment. Although there are several studies in virtual and
augmented reality to assess ADHD (e.g., Fang et al., 2019; Keshav et al., 2019; Knouse et al., 2005;
Silva and Frère, 2011), two main projects have been widely explored, the Virtual Reality Classroom
(then called ClinicalVR) and AULA.
The Virtual Reality Classroom has been used to assess the attention of children with ADHD
for the last two decades (Rizzo and Buckwalter, 1997; Rizzo et al., 2000, 2003, 2004, 2006). The
VR Classroom includes a standard rectangular classroom rendering containing three rows of desks,
a teacher’s desk at the front, a blackboard across the front wall, and a virtual teacher who presents
as a woman. On the left side, a large window looks out onto a playground with buildings, vehicles,
and people. As a tutorial, the virtual teacher instructs the participants to spend a minute looking
around the room and point, name observed objects, and then play a quick game. Following the
tutorial, participants can play two games, one focused on identifying letters on the blackboard, with
or without audio, visual, and 3D audio/visual distracters, and assessment of the virtual teacher’s ac-
curacy at identifying images drawn on the blackboard. The project was revised digital mediaworks,
inc. (http://www.dmw.ca/) and called ClinicalVR: Classroom-CPT (Nolin et al., 2016). The system
was then adapted to a Unity 3D version (Yeh et al., 2012; Tan et al., 2019).
Several studies have been conducted to test the efficacy and efficiency of the VR Classroom.
VR classroom measurements are consistently correlated with traditional measurements (Parson et
al., 2007; Pollak et al., 2009), making it a promising place for testing new interventions. However,
children with ADHD were more affected by distractions in the VR classroom than those without
ADHD (Adams et al., 2009). In the newest version, ClinicalVR, studies show that assessments
made by monitoring behaviors are reliable and unaffected by gender, while age is impacted (Nolin
et al., 2016). Although there are differences between performing these tests in the virtual environ-
ment from a more traditional computerized one, measurements were able to distinguish between
children with ADHD and neurotypical children (Negut et al., 2017), provide incremental validity
beyond that of teacher and parent report of behavior (Coleman et al., 2019), and add social cues to
the assessment (Eom et al., 2019).
Similarly, The AULA Nesplora or just AULA has also been used to assess ADHD in chil-
dren (Climent and Banterla, 2010). AULA is a virtual school classroom where children used a
head-mounted display with movement sensors, earphones, and a single-button switch to interact
in the environment. AULA had two main activities: a NO-X paradigm based exercise (i.e., “Press
the button when you DO NOT perceive the target stimulus”) and an X paradigm-based exercise
(i.e., “Press the button whenever you DO perceive the target stimulus”), that children can play for
20 minutes (Díaz-Orueta et al., 2014). This approach has also been explored using an aquarium
environment (Camacho-Conde and Climent, 2020).
Studies have been conducted with children to first correlate AULA measurements with more
common and standard Continuous Performance Tests (CPT), confirming the validity between the
tests (Díaz-Orueta et al., 2014). AULA was able to differentiate between children with ADHD
and without pharmacological treatment for a wide range of measures related to inattention, im-
pulsivity, processing speed, motor activity, and quality of attention focus (Díaz-Orueta et al., 2014;
Iriarte et al., 2016). The cognitive scales used in AULA take into account the virtual environment
to better characterize the difficulties encountered by people with ADHD (Areces et al., 2018a),
VR is able to classify the impulsive/hyperactive, inattentive behaviors, and combined symptoms
(Areces et al., 2018b). AULA predicts current and retrospective ADHD symptoms (Areces et al.,
2019), and better differentiates between ADHD and non-ADHD individuals in comparison with
the most commonly used CPT, the Test of Variables of Attention (TOVA) (Rodríguez et al., 2018).
These results show promise for improving the performance monitoring data collection that many
clinicians use to speed their screening, assessment, and even diagnostic work.
Augmented reality has also been explored to assess ADHD symptoms. For example, Em-
powered Brain is an augmented reality communication aid for children with ASD. In one study
of Empowered Brain, seven high school students diagnosed with ASD played Empowered Brain
for one week. In this study, Empowered Brain in-game performance correlated with ADHD
symptom severity in students with ASD. This was a relatively small sample but showed promise in
using tools designed to support children with ASD in simultaneously assessing them for ADHD
(Keshav et al., 2019).
3.2.3 COMPUTATIONALLY ASSESSING MOTOR SKILLS

Using systems that children already engage in within their daily lives that increasingly include
touchscreens and other computational tools, makes building assessment into the background ap-
pealing. For example, Mock et al. (2018) used touch trajectories during a multiple-choice format
math test to predict ADHD. For regression of overall ADHD scores, their mean squared error was
0.096 on a four-point scale (R² = 0.567). They demonstrated classification accuracy for increased
ADHD risk appropriate for use alongside other clinical diagnostics but not on its own (91.1%).
Although far from being ready to support ADHD clinical work, as of now it has not been tested
with people with ADHD, the Snappy App (Young et al., 2014) and its gaming “in the wild” coun-
terpart (Craven et al., 2014) show some promise in terms of measuring ADHD-related symptoms.
These approaches are novel and innovative and should be explored further with both children and
adults with ADHD diagnoses or who self-report ADHD symptoms and can be diagnosed as part
of a rigorous research study.
VR can be a particularly appealing platform for testing motor, spatial, and physical abilities
because it can represent a fully controlled large area in a relatively small physical space. Additionally,
data collected by wearable sensors and the VR environment itself provide vast amounts of data with
which to run diagnostic and research tests. For example, in a study that included 51 children with
ADHD, Farran et al. (2019) used a VR spatial navigation task to test hypotheses around co-occur-
ring motor impairment in people with ADHD. In this work, they found no relationship between
the motor and spatial domains and children with ADHD.
Despite the limits of existing work, VR may be particularly appealing as an assessment and
diagnostic approach because it can mimic the natural, physical world while still allowing for an
immense amount of control. It, in essence, becomes an experimentally controlled condition. VR
can, of course, be fun and engaging. It is not without its drawbacks, however. Even though VR has
become more accessible, less expensive, less heavy, and more tolerable (e.g., creates less nausea), it
is still not particularly intuitive for many people and may be totally out of reach for people with
certain kinds of sensory challenges, including small children and those with neurodevelopmental
disorders. As VR advances, we would expect these kinds of applications to improve, particularly to
support tools for assessment and long-term tracking of symptoms.
3.2.4 DIAGNOSTIC AND ASSESSMENT GAMES

Assessment and diagnosis of ADHD can be a tedious and repetitive process where children may be
easily distracted by a lack of motivation or engagement in the tasks. Those behaviors may be con-
fused with distractions and inattentiveness (i.e., executive dysfunction) associated with ADHD. To
create a more engaging platform for assessment, serious games have been proposed. The gameplay
dynamic of the serious game can be used to assess ADHD symptoms. For example, The Super-
market Game is a labyrinth that must be traversed while the players acquire items shown in his/
her shopping list (Andrade et al., 2006). The game used data mining algorithms to classify the data
produced by the game (e.g., points, time). Eighty students (39 with ADHD) played the game. A
Naïve Bayes algorithm was able to classify adolescents as with ADHD or without ADHD with a
sensitivity and specificity of 70% (Santos et al., 2011). Similarly, PANDAS, is a tablet-based game
that allows clinicians and researchers to collect data on gameplay, that is then fed to a linear binary
support vector machine (SVM) that was able to classify children with ADHD correctly 86.5% of
the time (Mwamba, Fourie, and Van den Heever, 2019). These approaches are promising but have
not yet rendered more traditional tests obsolete. Entrenched interests in traditional diagnostic ap-
proaches as well as a paucity of data backing up these new approaches combine to make it difficult
to make such approaches standard in clinical and educational practice.
To address the gaps in data collection merely on gameplay behavior, researchers have also ex-
amined serious games controlled with sensors that get data from the user. The data is then analyzed
to identify behaviors that may support the screening or assessment of ADHD symptoms. One ap-
proach is to create serious games controlled with commercial EEG (e.g., EMOTIV EPOC+, Neu-
rosky). Although commercial EEG usually has fewer electrodes than clinical units, the open-source
libraries attached to them make them appealing to develop serious games. The raw signals then can
be analyzed using machine learning techniques (similar to the techniques used in Section 3.2.2).
For example, Alchalabi et al. (2017) developed a serious game in which players collect yellow cubes
via mental commands of “push” as quickly as possible. The cubes are in a nature-theme environment
(e.g., forest) to enhance calm and relaxation. A pilot study with 4 neurotypical players and 4 with
ADHD suggesteded that machine learning models could classify EEG data of individuals with
ADHD with up to 96% accuracy (Alchalabi et al., 2018). These approaches require substantially
more work to move toward clinical use. First, clinical EEG systems should be opened up through
APIs to allow game makers to develop games using their platforms for increased electrical sensing
quality. Second, these studies must be conducted at much larger scales to test performance across
a wider variety of participants before they have any chance of being accepted as evidence-based
clinical tools.
Taken together, this research demonstrates the potential for using gameplay as an assess-
ment tool. In particular, the automated collection of data pertaining to game behaviors and sensors
can augment traditional clinical tests and may provide additional insights once enough evidence is
collected to support clinical use. The data collected can also be used to develop machine learning
models able to classify individuals most likely to be diagnosed with ADHD or to demonstrate
specific ADHD symptoms, which can indicate targets for intervention and greatly streamline
clinical workload.
3.2.5 VISUAL OBSERVATIONAL METHODS

Computer vision, computers understanding information from processing digital images or videos,
offers a promising approach to the diagnosis and monitoring of a wide variety of physical and men-
tal health challenges. Although concerns around undue capture or too much or inappropriate video
will likely deter most people from full-time video capture, a variety of less intrusive approaches
have been attempted. These are promising because vision sensors do not require the subject of the
analysis to do anything different than they might normally nor wear anything particular to cap-
ture the data. One example of such an approach uses RGBD (Color + Depth) sensors to gather
facial expression analysis and 3D behavior analysis ( Jaiswal et al., 2017). Their results indicated
classification rates as high as 96% for controls vs. condition in ADHD and Autism groups, which
are promising results as an early screener for either autism or ADHD prior to a clinical diagnosis.
This work builds on preliminary studies by Hernandez-Vela et al. (2011), who extracted a 3D
skeletal model of the human body using RGBD image sequences to find certain body gestures
that indicated ADHD in children. Although not as technologically advanced as these approaches,
QbTest is robust and commercially available. This system measures hyperactivity, inattention, and
impulsivity using head motion tracking alongside a computerized diagnostic instrument (Pelligrini
et al., 2020). This approach requires the subject to wear a head tracking headband and does not
include facial recognition.
Although not technically a computer vision approach, Lis et al. (2010) demonstrated that
infrared motion-tracking could be used to identify higher levels of motor activity in adults with
ADHD than those without. This objective measure of motor activity using a novel technological
approach was not extended to serve as a diagnostic but helps to understand more about the role of
hyperactivity in motor performance, particularly for adults with ADHD.
3.2.6 MULTIMODAL AND PHYSICAL INTERFACES

Mobile technology can allow researchers, educators, and clinicians to assess behaviors “any time”
“anywhere,” especially for adolescents and adults. In this sense, researchers have used tablets to
assess and screen adolescents and adults with ADHD (Hyun et al., 2018; Loskutova et al., 2019).
Hyun et al. (2018) successfully used a digital tablet to conduct the Rey-Osterrieth complex
figure test (ROCF), which is a neuropsychological assessment tool comprising of drawings than in-
dividuals need to copy and draw from memory (Rey, A., 1942) to assess visuospatial perceptual, vi-
sio-motor integration, and executive functions (Smith et al., 2007). Thirty adolescents with ADHD
and 30 neurotypical controls were asked to copy the drawing onto a Galaxy tablet screen using a
wireless pen. Results showed that using a tablet to do the ROCF assessment enabled researchers
to uncover different patterns of visuospatial working memory abilities in adolescents with ADHD
(Hyun et al., 2018).
Similarly, Loskutova et al. (2019) tested the feasibility of a two-step screening process for
adults with ADHD using computerized surveys on a tablet called Talking Survey™. The surveys
included a brief symptom checklist and an assessment of Quality of Life. A study with 711 adults
(181 screened positive) and 97 physicians showed that clinicians were willing to screen, diagnose,
and treat adults with ADHD using the Talking Survey, but they needed additional resources for a
full intervention.
A hybrid approach (wearable sensor, intelligent hardware, and mobile application) has also
been explored to create a system to support the assessment of the ADHD diagnosis items from
the DSM-5. Chen et al. (2018) develop COSA, a contextualized and Objective System to sup-
port ADHD diagnosis. COSA assesses ADHD symptoms using three Serious Games: Protect
Apple, Catch Butterfly, and Can’t Help Eating Candy. Physiological data, movement data, and
task-related data allow the assessment of inattention, hyperactivity, and impulsivity symptoms.
Clinicians, parents, and children found the use of COSA acceptable in evaluative questionnaires
(Chen et al., 2018).
Robotics, which can include a wide variety of human and self-controlled mechanical and
digital devices, have also been applied to the study of motor skills in individuals with ADHD.
CARBO (CAretakerRoBOt) was developed to address the fine motor skills and touch sensitiv-
ity differences that are sometimes observed in children with developmental disorders in order to
assist in delivering sensory integration therapy (Chou et al., 2015; Bucci et al., 2014). CARBO
is a socially assistive robot with a form factor that encourages users to rub or pet its surface. The
convex shell has 67 tactile sensors and LEDs to provide visual feedback to children. The sensors
and actuators allow the creation of interactive games at CARBO, such as ColorMe. ColorMe aims
for children to get a tactile response from CARBO (Krichmar and Chou, 2018). To win the game,
children need to rub the shell in a single direction at a constant speed. During this time, CARBO
gives auditory and motion feedback to the children. A deployment study was conducted with 19
children: 5 were diagnosed with ADHD, 13 had diagnoses of ADHD along with other disorders
such as depression or anxiety, and 1 was diagnosed with autism. Children played ColorMe using
CARBO, and all the tactile interactions were recorded and analyzed. Results showed that children
with only ADHD attempted to complete higher levels but had more errors and erratic movements.
Children with autism achieved lower levels and performed more slowly and smoothly. Children
with anxiety demonstrated more incorrect movements than others. These results indicate that
CARBO was sensitive to individual differences in behavior and the investigators anticipated that it
had the potential to provide potentially useful diagnostic information (Krichmar and Chou, 2018).
The results point to the potential for future research in robotics to help detect and address clinical
needs in individuals with ADHD.
Figure 3.1: CARBO on the left with children and on the right up close and illuminated. Images cour-
tesy of Jeffrey Krichmar.
3.2.7 WEARABLE AND PHYSIOLOGICAL SENSORS

Wearable sensors, while more intrusive than computer vision or infrared tracking, are increasingly
popular as diagnostic tools as their accuracy increases, the price reduces, and both battery life and
the comfort of wearing them improves. These tools can also be used to influence diagnostic tools
themselves, such as by demonstrating through wearable activity data that overactivity is indeed
one of the core features within ADHD combined subtype as clinically understood for years prior
(Wood et al., 2009). A wide variety of wearable sensor projects are focused on using a combination
of acceleration and velocity sensors to measure, describe, assess, and diagnose ADHD. In this sec-
tion, we describe those projects as well as those using a broader range of sensors.
Kam et al. (2010) analyzed data from actigraphs, small devices that record activity levels by
sensing physical movement, on the non-dominant wrists of 142 school-children (10 with ADHD)
for only 3 hours and used decision-tree algorithms to build 2 binary models (ADHD vs. Control)
using 2 sets of characteristics: (1) for the whole class and (2) just for the middle 14 minutes of the
class, respectively. They used decision-tree algorithms to check for accuracy (99.3% with 1 model
and 98.59% with the other), sensitivity (100% and 98.5%, respectively), and specificity (99.2% and
98.5%, respectively) in ADHD diagnoses. These findings indicate that a relatively short duration
of fitness tracker or smartwatch wearing can be sufficient in most cases to detect ADHD and cer-
tainly that such an approach can be used as a reliable screener. This work builds on other actigraphy
studies of children with ADHD that demonstrated discrimination between populations of children
with and without ADHD via wearable data is reliable (Porrino et al., 1983; Halperin et al., 1993).
More recently, in a study of 148 children (73 diagnosed with ADHD) wearable data resulted in
97.62% average sensitivity and 99.5% specificity using dominant hand actigraphs for 24 hours and
convolutional neural networks for analysis (Amado-Caballero et al., 2020). Open questions in this
space remain. Although researchers have attempted to identify ADHD sub-types using actigraphy
(Dabkowska, Pracka, and Pracki, 2007), they have not yet been able to find differences between
ADHD subtypes with movement data alone.
Using a more intensive approach, Muñoz-Organero et al. (2018) tested accelerometers, sen-
sors for measuring acceleration and movement, on the dominant wrist and non-dominant ankle of
22 children (11 with ADHD, 6 of whom were also medicated) during school hours. They converted
the sensor data into 2D acceleration images and trained a Convolutional Neural Network (CNN)
to recognize the differences between non-medicated ADHD children and their paired controls.
There were statistically significant differences in the way children with ADHD and those without
moved for the wrist accelerometer (t-test p-value <0.05), but only between non-medicated children
with ADHD and children without ADHD for the ankle accelerometer. This preliminary work
indicates that such an approach might provide automated detection of ADHD with an accuracy
of between 87.5% and 93.75%, high enough for a screener but not sufficient to indicate a truly
diagnostic tool. After this study, Muños-Organero et al. (2019) used a Recurrent Neural Network
(RNN) to improve their previous results, improving their screening tool in the process.
What is curious about these results is that a more intense period of data tracking than in
Kam et al.’s work produced weaker results. As researchers move to solidify these results, and clini-
cians and educators move to put them into practice, tools must be tested with larger populations,
and datasets should be open, combined, and compared.
Some researchers have gone beyond the use of accelerometry to include other sensor mea-
sures. For example, O’Mahony et al. (2014) used both accelerometers and gyroscopes, which
together make inertial measurement units (IMUs), in a proof-of-concept study with 43 children,
24 with an ADHD diagnosis. They used a support vector machine learning approach, testing two
algorithms: one with a linear kernel and one with a Gaussian kernel. The authors found that the
Gaussian may have overfitted, and their general approach (i.e., the linear SVM) produced accuracy
of 95.12%, sensitivity of 94.44%, and specificity of 95.65%, suggesting inertial sensors may be use-
ful for diagnosing ADHD. In another IMU-based study, Ricci et al. (2019) measured linear and
rotational movements of 37 school children, 17 with ADHD, finding similar rates of diagnosis
with slightly different configurations of sensors. Kaneko, Yamashita, and Iramina (2016) also used
acceleration and angular velocity sensors, this time on the backs of each hand and on the arm near
the elbow. In a test of 33 children and 25 adults doing both an imitative motor task and a maximal
effort task with one hand over 10 seconds, the researchers were able to quantifiably observe the
expected development in pronation and supination based on age but could not distinguish between
ADHD and typically developing individuals. The WEDA system, tested with 160 children ages
7–12, half with ADHD, attempted to discriminate between challenges in inattention from those
related to hyperactivity and impulsivity, finding that the tasks cover all symptoms but perform bet-
ter related to inattention ( Jiang et al 2020). The scores of the overall tests discriminating between
ADHD and typically developing children were highly sensitive and specific, but the system requires
the child to wear 6 motion sensors (on the head, both hands, both feet, and the waist) while con-
ducting 10 specific tasks, a setup that is unlikely to be used widely outside of research settings or
specialized clinics.
Figure 3.2: WeDA system including a touchscreen, 3D-printed physical devices, and motion sensors.
Image from Jiang et al. (2020), used with permission.
Electro Interstitial Scan (EIS) is a galvanic skin response device that measures the concen-
tration of free chloride ions in the interstitial fluid, the morphology of the interstitial fluid, and
electrical stimulation (Maarek, 2012). Chua et al. (2019) sought to use this technology to augment
other diagnostic work with children with ADHD. They collected EIS data from 182 Malaysian
school children (58 with ADHD), finding that the system detected significant differences between
the two groups. These results show promise as a complement to traditional diagnostic measures but
have not been tested prospectively.
Moving to directly sensing the brain, in 2011, the ADHD-200 Global Competition was held
to identify biomarkers of individuals with ADHD using resting-state functional magnetic reso-
nance imaging (rs-fMRI) and structural MRI (s-MRI) from 973 individuals (Milham et al., 2012).
Then, the Neuro Bureau prospectively collaborated with the competitors to preprocess the data and
share their results at the Neuroimaging Informatics Tools and Resources Clearinghouse (NITRC)
(http://www.nitrc.org/frs/?group_id=383). The repository was released and can be downloaded from
NITRC without data usage agreement, but user registration is needed for non-commercial research
purposes. From that time until now, several computer-based approaches have been explored, trying
to identify either biological markers or patterns using the fMRI Benchmark. Eloyan et al. (2012)
accomplish the best performance metric among the participants of the completion, but although
it was the best, there is still necessary to develop efficient algorithms that can distinguish ADHD
vs. neurotypicals. In the last five years, a variety of machine learning approaches have been used to
classify MRI/fMRI/sMRI data from ADHD (Biswas et al., 2020). Machine learning fits well into
behavioral science approaches as at its core, machine learning is about finding patterns in large-scale
datasets, something quantitative behavioral scientists already use statistical methods to do. Machine
learning, powered by extensive computational power, takes these methods to the next level. Once
patterns are found, they can be used for a variety of diagnostic or intervention approaches.
Machine-learning approaches that have been used for ADHD imaging include support
vector machines (SVM) (e.g., Sen et al., 2018; Riaz et al., 2018; Tan et al., 2017; Ghiassian et
al., 2016; Rangarajan et al., 2014), Convolutional Neural Network (3D-CCN) (e.g., Zou et al.,
2017; Ariyarathne et al., 2020; Wang et al., 2019), Extreme Learning Machine (ELM) (e.g., Peng
et al., 2013; Sachnev, 2015), Deep Belief Networks (DBN) (e.g., Kuang and He, 2014), k-Near-
est-Neighbor (Eslami et al., 2018), and multiple linear regressions (Miao et al., 2019). While these
approaches are outside of the scope of this review, machine learning advances continue to provide
new possibilities and should be monitored closely.
Important to consider for the future is the issue of comparing these approaches and actually
determining what might work best, a stable of clinical and translational science outside of the
broad areas of information technology. The style of computing articles, however, and the limited
requirements and interest in shared datasets, make such comparisons extraordinarily difficult. For
example, although these methods may use the same database, and even some of them the same
machine learning technique, the way they use the data (i.e., either the subset of data used or how
they partition the data to make the training and testing subgroups) makes it difficult to compare the
results. It is impossible, based on published material, to determine which is best, and it may not even
be possible with full replication was such replication possible with current approaches. Therefore,
in the future, to make a fair comparison the models could use the same performance estimation
method such as the same partition dataset method (e.g., k cross validation method) and same model
evaluation metrics. Funders and journal editors should make a point to address this reproducibility
crisis such that machine learning approaches can make safe, fair, and accurate advances alongside
pharmacological, physiological, and behavioral practices.
The analysis of brain source localization of the EEG signal of individuals with ADHD has
created new opportunities for the diagnosis and treatment of ADHD, starting more than 80 years
ago with Jasper et al. (1938) reporting a slowing of the EEG rhythms at front-central sensors.
This was one of the first indicators of a difference in the brain function of children described as
hyperactive and impulsive. Yet, there are still several methodological limitations from a clinical and
technological point of view (Cortese and Castellanos, 2012; Loo and Makeig., 2012).
Most of the research on the diagnosis of ADHD using EEG can be based on temporal,
spectral, and spatial features of the EEG signals. With the raw EEG data, the spectral components
can be obtained to compute the background state of brain activity. Alternatively, the EEG data can
be segmented around an event (Lenartowicz and Loo, 2014). Thus, the EEG data is a combination
of temporal, spectral special features that can be used individually or combined to assist diagnosis.
Several approaches are proposed based on EEG signal analysis in the literature for diagnosing
ADHD using machine learning approaches (e.g., Tenev et al., 2014; Muller et al., 2010), including
neural networks (Mohammadi et al., 2016), nonlinear analysis (Khoshnoud et al., 2018; Boroujeni
et al., 2019; Khoshnoud et al., 2015), decision support algorithms (Abibullaev and An, 2012), and
autoregressive models (e.g., Marcano et al., 2016). As with the approaches for MRI/fMRI/sMRI
data, these particular algorithms are outside of the scope of this review but should be followed and
integrated into clinical practice as possible. And as with the machine learning challenges described
above, replication and meta-analyses are likewise impossibly with existing analysis and publication
policies and norms.
Taken together, this research shows a substantial and growing interest in studying the brain
activity of people with ADHD. Unfortunately, brain activity is exceptionally complex, and to date
there is no conclusive diagnostic tool based on brain activity analysis.
3.3 CHARACTERIZING ADHD THROUGH TECHNOLOGICAL

INTERACTIONS
Although not strictly diagnostic in nature, in some cases, researchers were able to characterize
ADHD or better describe and understand it through technological assessments. These projects
speak to the potential for better discrimination among subtypes of ADHD, ongoing assessment of
progress related to therapeutic interventions, and the potential for automated responses based on
these detailed assessments.
Johnson et al. (2010) explored how accurate children with ADHD are when using a pen on
a digitizing tablet, finding that children with ADHD showed difficulties in movement accuracy on
the right side. These results suggest that there may exist a subtle spatial bias toward the right, which
could be adjusted using assistive technologies (ATs).
In work focused on understanding the impact of medication on posture, Sarafpour et al.
(2018) found that a mobile force platform to evaluate postural performance could accurately assess
patient balance. They were able to identify changes in the motor performance related to balance
among children with ADHD (38 children with ADHD, 23 who had current medication-based
treatments, and 25 children without ADHD), finding that those taking medication had similar
readings to those without ADHD and significantly different ratings from those with ADHD who
were not taking medication.
Similarly, Chatthong, Khemthong, and Wongsawat (2020) sought to measure the impact of
occupational therapy on school-aged children with ADHD. In a study of 305 school-aged children
in Thailand, they used brain mapping performance to measure differences between children with
and without ADHD, finding that the group with ADHD had higher emotional awareness and
language comprehension than the group without ADHD.
3.4 CONCLUSIONS AND FUTURE DIRECTIONS

The research published to date reflects substantial and innovative efforts to attempt to make diag-
nosis and assessment easier, more scalable, and more reliable through technological means. While a
wide variety of tools have been deployed against these challenges, many of them are making minor
tweaks to an already relatively proven technological approach. Accuracy levels are low in some cases,
but quite high in most, indicating strong promise for using such tools in both initial diagnoses and
long-term symptom monitoring. However, none of these approaches have been tested prospectively
at the scale required to make them truly diagnostic instruments. We suggest that in the case in which
an approach is already relatively successful (e.g., with the use of accelerometers and other sensors),
researchers should work with clinicians for large-scale validation rather than seek to tweak their al-
gorithms and sensors more for marginal improvements in the accuracy. Ultimately, a tool is unlikely
to be adopted and implemented in clinical settings without a strong evidence base for its utility.
3.4 CONCLUSIONS AND FUTURE DIRECTIONS 35
Also promising is the notion of embedding assessment into the everyday lives of children and
adults with ADHD. By incorporating assessment tracking into things like daily work applications,
gaming, or unobtrusive sensors, we may be able to study the effects of a wide variety of contex-
tual and environmental triggers on ADHD, understand how ADHD evolves over a lifetime, and
provide feedback to people with ADHD who may then be empowered to evaluate which coping
strategies are working well for them, experiment with new interventions, and generally take more
control of their experiences.
37
CHAPTER 4
Attention and Other Cognitive

Processes
Although ADHD is commonly thought of as relating to challenges with attention and other cog-
nitive processes in both children and adults, there is no single profile for these challenges. People
with ADHD have highly individualized experiences with their symptoms, at times, exacerbated
or accommodated by the context of the world around them. Although ADHD is highly hetero-
geneous, most people with ADHD describe similar challenges with attention and other cognitive
processes; concerns regarding self-regulation, self-control, and executive functioning in many ways
underly all other related experiences and symptoms but in differentiated ways. Thus, in practice,
clinicians, parents, teachers, and people with ADHD themselves often prefer a battery of psycho-
logical testing to assist with the diagnosis of ADHD as well as the profiling of the specific cognitive
needs of the person with ADHD. This is a particularly complex set of issues and procedures, far out
of the scope of a book focused on the intersection of technology research and ADHD. However,
in this chapter, we first provide some brief, but essential background on the cognitive elements of
the ADHD experience. We then discuss some of the ways in which technology has been applied
to support cognition in individuals with ADHD.
4.1 SELF-REGULATION, SELF-CONTROL, AND EXECUTIVE

FUNCTIONING
Self-regulation, self-control, and executive functioning all are umbrella constructs (e.g., Moffitt et
al., 2011; Zhou, Chen, and Main, 2012) that encompass processes involved in exerting control over
cognitive and behavioral processes. Davidson et al. (2006) described self-regulation as an ability that
reflects mature cognition from a developmental standpoint:
Mature cognition is characterized by abilities that include being able: (a) to hold information in
mind, including complicated representational structures, to mentally manipulate that informa-
tion and to act on the basis of it, (b) to act on the basis of choice rather than impulse, exercising
self-control (or self-regulation) by resisting inappropriate behaviors and responding appropri-
ately, and (c) to quickly and flexibly adapt behavior to changing situations. These abilities are
referred to respectively as working memory, inhibition, and cognitive flexibility. Together they
are key components of both “cognitive control” and “executive functions…” (p. 2037).
38 4. ATTENTION AND OTHER COGNITIVE PROCESSES
ADHD is characterized by difficulties in these cognitive abilities, although profiles for spe-
cific abilities may vary across individuals with ADHD. Generally, there has been a strong interest
in how to improve these cognitive skills—attention, working memory, inhibition, and cognitive
flexibility—using a variety of treatment methods. Some cognitive training programs have targeted
a specific ability (such as focusing and sustaining attention), while others have targeted multiple
abilities simultaneously (e.g., attention, working memory, inhibition). A large body of research has
examined how to improve these skills with different treatment approaches. We do not address
pharmaceutical treatments or other therapeutic programs here, as our focus is solely on approaches
that have applied technology in treatment.
A current systematic review of digital health interventions for individuals with ADHD
(Lakes et al., under review) identified more than 2,000 records that focused on ADHD treatment
delivered via a range of technologies [e.g., web-based intervention for teachers for students with
ADHD (Corkum et al., 2019); mobile devices (Davis et al., 2018); mixed-reality technology (Kim
et al., 2020)]; and reported research conducted with individuals with ADHD; among these, the
majority focused on cognitive training. These included 772 papers focused on cognitive training, in-
cluding attention and working memory (WM) training, and 239 records addressing neurofeedback.
Other less studied areas included serious games and virtual/augmented reality interventions. Given
the focus of this book, in this chapter, we emphasize interactive technologies in support of ADHD
and leave the reader to the systematic review for details outside that space.
4.2 COMPUTERIZED COGNITIVE TRAINING

Since not long after personal computers became widespread, computer interventions have been
designed to improve attention, working memory, and other executive functions. In the marketplace
and across the Internet, products claiming to remediate attention deficits or improve cognitive
functioning abound and have generated considerable enthusiasm and hope for accessible comput-
er-supported treatment options. Many commercial products are available on the market, advertising
clinical benefits to individuals with ADHD and their families. The efficacy of these products, how-
ever, is largely unknown. Recent news reports provide a relevant example. Lumosity (https://www.
lumosity.com/en/) markets computer games (“personalized brain training”), designed to improve
cognition, reported in 2015 that it had reached 70 million members. In January 2016, Lumo Labs,
the company behind Lumosity, was reported to have agreed to pay a 50-million-dollar settlement
to the Federal Trade Commission in response to claims regarding false advertising. The commission
found that Lumosity made claims about cognitive benefits without scientific evidence to support
those claims. The company was ordered not to make further claims of benefits for the disorders it
had targeted, including ADHD, without first gathering sufficient scientific evidence (Rusk, 2016).
4.2 COMPUTERIZED COGNITIVE TRAINING 39
Thus, although these products may be exciting and appealing, it is important to consider the current
evidence base, some of which we review in this section.
Rapport et al. (2013) conducted a review and meta-analysis of 25 programs designed to
train working memory, attention, and executive functions in children with ADHD. At the time,
they concluded that training, short-term memory appeared to produce a modest improvement in
short-term memory, but that training mixed executive functions or attention failed to significantly
improve those domains. Rapport et al. also pointed out that the positive effects of interventions did
not appear to generalize to real-life improvements in academic, behavioral, or cognitive functioning.
In other words, evidence for “far transfer effects” (e.g., a positive impact on a measure of function-
ing in real life versus performance on a trained task) was “nonsignificant or negligible.” As a result,
Rapport et al. concluded at the time that “Collectively, meta-analytic results indicate that claims
regarding the academic, behavioral, and cognitive benefits associated with extant cognitive training
programs are unsupported in ADHD” (p. 1237).
In the same year, Melby-Lervåg and Hulme (2013) reported results of a meta-analysis of
87 publications focused on working memory (WM) training and concluded, “working memory
training programs appear to produce short-term, specific training effects that do not generalize to
measures of ‘real-world’ cognitive skills.” Two years later, Cortese et al. (2015) published a review
and meta-analysis of 16 randomized, controlled trials examining cognitive training outcomes in
children with ADHD. These authors reported that there were significant improvements in total
ADHD symptoms, inattention, laboratory working memory tests, and parent ratings of executive
functions; however, they pointed out that when outcome measures were completed by blinded
raters, effects were weaker, suggesting potential expectancy effects. They, too, concluded that the ev-
idence “provided little support for cognitive training as a front-line ADHD treatment” (p. 171) but
stated that it may have a role as adjunctive treatment to treat certain neuropsychological impairments.
In the most up-to-date and extensive review of working memory training, Novick et al.
(2020) concluded:
“Unfortunately, the evidence now strongly, if not decisively, indicates that WM training does
not transfer to performance on nontrained tasks. The critics were right: WM training does not
lead to long-lasting generalizable improvements in cognitive functioning. We’re sure that this
conclusion will be disappointing to many readers of this book, as well as to the many individu-
als who have purchased commercial brain-training products. We’re sorry to offer such a gloomy
outlook on the state of the art, but sometimes science leads us where it leads us” (p. 542).
Thus, recent reports from systematic reviews and meta-analyses have produced broadly
consistent findings—the impact of cognitive training on ADHD symptoms and performance on
nontrained tasks appears to be minimal. Although improvements are usually noted in the trained
tasks (e.g., tasks involving computer testing of cognitive functions) and tasks similar to trained
tasks, there is a lack of compelling evidence indicating that these programs produce improvement
in cognitive functioning in other settings (school, work, home). Some researchers (e.g., Rapport et
al., 2013; Cortese et al., 2015) conceded that the evidence may be restricted due to methodological
limitations in the studies, but they and other clinical scientists have concluded that these products
cannot yet claim to be front-line treatments for ADHD.
However, research in this area continues to grow and is likely to continue to do so, using
both more advanced technological approaches to cognitive training as well as larger and more
rigorous clinical trials. In one of the most recent controlled trials, Kollins et al. (2020) randomized
348 children with ADHD to intervention (the STARS-ADHD digital intervention) or a digital
control condition. While they reported significant improvements on the primary outcome measure
(performance on a computerized test of attention), they reported no significant improvements
in ADHD symptoms or functional impairment; thus, their findings were consistent with prior
research, demonstrating that cognitive training programs may promote “near transfer” of training
effects (i.e., improvement in tasks similar to the trained tasks), but not “far transfer” (e.g., improve-
ments in clinical symptoms or school behaviors). However, given their rigorous trial design and
demonstrated impact on attention skills, this product, marketed as EndeavorRx, recently obtained
approval from the United States Food and Drug Administration (FDA) as a video game prescrip-
tion treatment for attention in children with ADHD (https://www.statnews.com/2020/06/15/
fda-akili-adhd-endeavorrx/). This work is likely to inspire future research to develop and study
such products. As brain-training approaches have not yet delivered compelling evidence of desired
improvements in ADHD symptoms in real-life settings, future work should examine how to gauge
the impact of training attention on real-life outcomes, which would clarify our understanding of
the potential clinical significance of this program and others like it.
4.3 NEUROFEEDBACK INTERVENTIONS

Another research area that has received considerable attention involves using computer programs
to evaluate brain activity with an electroencephalogram (EEG) and provide direct feedback to
patients. Neurofeedback interventions are intended to help patients learn to regulate their brain
activity in order to retrain underlying neural mechanisms involved in cognition and behavior (e.g.,
Enriquez-Geppert et al., 2019). In a review, Arns et al. (2014) discussed the history of attempts
to use neurofeedback to treat ADHD and described diverse results, concluding that specificity
is needed in the EEG parameters that are trained in order for interventions to be effective. They
described three “standard neurofeedback protocols” that are the basis for their subsequent review
(Arns et al., 2020) of the state of the evidence for neurofeedback interventions.
Arns et al. (2020) noted that a neurofeedback treatment regimen typically involves 30–40
sessions of training, and as mentioned above, there are standard protocols with specific targets that
4.4 VIRTUAL REALITY INTERVENTIONS AND SERIOUS GAMES 41
have some demonstrated efficacy. Providing a concise review of the current state of this field, Arns
et al. (2020) summarized results of prior meta-analyses (Van Doren et al., 2019; Cortese et al.,
2016) as well as individual trials and concluded that neurofeedback training using “standard neuro-
feedback protocols” appears to yield positive and sustained effects on parent and teacher ratings of
ADHD symptoms. They concluded that neurofeedback protocols for the treatment of ADHD “can
be concluded to be a well-established treatment, or ‘efficacious and specific’ in line with the APA
guidelines” (p. 45). This was consistent with the conclusions of Enriquez-Geppert and colleagues
(2019) who described neurofeedback as “a viable treatment alternative.”
Emerging research has described the development of video games that incorporate some
form of neurofeedback. For example, in a pilot study, Blandon et al. (2016) described a videogame
customized for neurofeedback (Harvest Challenge) that was developed to use children’s measured
attention levels to control the videogame. Other neurofeedback videogame interventions have been
compared directly to computerized cognitive training programs that also include a video game
approach. In a pilot trial, Steiner et al. (2014a, 2014b) compared standard computerized attention
training to neurofeedback. In the neurofeedback condition, children (ages 7–11 years) wore a bike
helmet with embedded EEG sensors while playing a computer game involving flying an airplane.
They were told that when they concentrated, the airplane would ascend and that if they did not
concentrate, the airplane would descend. The standard computer attention training program (Brain-
Train) included attention and working memory modules. Outcome measures were administered
to parents, teachers, and children themselves. Children in both groups were compared to a wait-
list control group; when compared to the wait-list control group, children in the neurofeedback
group demonstrated improvements in parent-rated ADHD symptoms. No significant differences
for either group were detected using teacher reports. Children in the standard attention training
condition self-reported improvements in attention, suggesting that they perceived their attention
as improved following attention training. This result is interesting but should be interpreted with
caution given the potential for expectancy effects and the lack of corresponding evidence from other
raters (teachers, parents).
4.4 VIRTUAL REALITY INTERVENTIONS AND SERIOUS

GAMES BEYOND NEUROFEEDBACK
A number of publications in recent years have described the development of VR interventions and
serious games to treat symptoms of ADHD. Many described projects in the early stages of devel-
opment with user feedback that had not yet been subjected to a randomized intervention study. For
example, Avila-Pesantez et al. (2018) described the design of an augmented reality serious game
designed to improve attention.
One randomized intervention study compared a virtual classroom cognitive remediation

program to either methylphenidate or a psychotherapy placebo condition (Bioulac et al., 2018).
Among 51 children with ADHD (ages 7–11 years old), significant improvements were reported
indicating that children in the virtual classroom condition demonstrated significant improvement
on virtual classroom tasks and performance on a computerized test of attention and that improve-
ment in these two areas was equivalent to improvements observed in the methylphenidate group.
The methylphenidate group also showed significant improvement in ADHD symptoms.
The REEFOCUS ADHD management gaming system was defined to train delay aversion,
inhibitory control, sustained and selective attention, motor coordination, and working memory
(Kanellos et al., 2019). REEFOCUS can be played at home on a smartphone or tablet device or in
a mixed reality mode in a clinical setting. The mixed reality mode has both tangible and augmented
reality elements. Parents, teachers, and clinicians can monitor engagement with the REEFOCUS
game, and the game is adapted both automatically in response to the child’s progress and response
to caregiver input. In a study with 75 children in Barcelona, the children who played the game
found REEFOCUS to be understandable and learnable, while most of them liked the story and en-
joyed playing the game. Parents mostly approved of the game. Although these results show promise,
the game’s effect on the areas it was intended to treat was not reported.
Although exergaming is discussed in more detail in Chapter 9 dedicated to motor behavioral
and physical access, it is worth considering briefly in relation to its potential impact on cognition
specifically. Exergaming has been used to simultaneously provide cognitive training and physical
training. In several studies, one research group (Benzing and Schmidt, 2017, 2019; Benzing, Chang,
and Schmidt, 2018) described how exergaming could serve as a support for executive functions,
including inhibition and switching. The exergaming intervention reported in their research required
attention, inhibition, switching, and speed of action. Other promising research has supported the
notion that physically and cognitively active videogames can have a positive impact on symptoms
in children with ADHD. In a randomized trial with 73 children (ages 6–13 years) comparing a
full-body-driven videogame to active control (an age-appropriate videogame), Weerdmeester et
al. (2016) reported that the full-body-driven videogame was associated with reductions in teach-
er-reported ADHD symptoms. Notably, the teachers were blind to experimental conditions in this
study. Shema-Shiratzky et al. (2019) also demonstrated promise with an intervention that involved
avoiding virtual obstacles while walking on a treadmill. While not technically an exergame, this
approach shares commonalities with those of exergames, and in this case, was associated with im-
provement in parent reports of children’s social interactions and problematic behaviors. Long-term
positive effects were maintained in both memory and executive function after system use.
Wearable technology has also been explored to provide real-time assistance regaining atten-
tion for children with ADHD. For example, CASTT (Child Activity Sensing and Training Tool)
uses a heart rate band, accelerometers on the arms and feet to sense movement, an EEG device,
and a smartphone. A preliminary evaluation with 20 children, with and without ADHD, found
that although using multiple wearable sensors was uncomfortable for children, and sometimes the
notifications were unnoticed, monitoring physical and physiological activities in real time could
potentially assist them (Sonne et al., 2015).
As our lives are increasingly lived in hybrid virtual/digital and physical spaces, and entertain-
ment is increasingly related to gaming and media consumption, engagement with these as tools for
therapeutic effect will remain widely appealing. Likewise, people increasingly have high-powered
computation in their homes in the form of gaming systems, which are often more powerful than
the laptops or Chromebooks used for educational and work purposes. Leveraging these platforms
to extend therapies will be essential for greater access and higher engagement with interventions.

Computer games or digital programs to train attention, working memory, and other executive
functions have been a popular area of research in psychiatry, psychology, education, and other spaces
related to ADHD. There are hundreds of studies describing such programs and their outcomes;
however, the underlying technologies are by and large the same for most of these studies. The ev-
idence to date indicates that cognitive training programs often can help improve performance on
trained tasks or similar types of computerized tasks, but that benefits do not appear to generalize
nor extend to performance in other settings. Some researchers have suggested that these tools may
be a useful adjunct to treatment in some cases (Cortese et al., 2015), but others have drawn con-
clusions that warrant caution in the prescription of such programs (e.g., Novick et al., 2020). For
developers and researchers interested in further pursuing technologically delivered cognitive train-
ing programs, work is needed to address how to enhance programs in a way that enables training
to produce improvements that will generalize to real-life settings. It may also be the case, and is
worth considering as a research community, that no technological approach to cognitive training
has—or will be able to have—long-term effects that transfer out of the specific tasks or contexts of
the cognitive training program.
On the other hand, scientific reviews of neurofeedback have been more positive, with Arns et
al. (2020) concluding that neurofeedback protocols for the treatment of ADHD “can be concluded
to be a well-established treatment, or ‘efficacious and specific’ in line with the APA guidelines” (p.
45). However, Enriquez-Geppert et al. (2019) noted that while neurofeedback may be a useful ad-
junct to treatment, in community settings there is a need for standardization of treatment protocols.
Thus, future work in this space should address how technology can be designed in a way that en-
ables practitioners to readily and consistently deliver evidence-based approaches to neurofeedback
intervention in their community settings.
Although more nascent as areas, serious games, exergaming, and mobile applications are
being applied in this space, there is room for much more work in these areas as technologies im-
prove and become more accessible for individuals with ADHD. This work deserves further inquiry
given the potential to support cognition using tools that are readily available and accessible through
devices people already own. However, randomized trials with blinded assessments are needed to
carefully evaluate the efficacy of products. Much has been learned in the past decade about how
to conduct a controlled study of this nature; moving forward, these lessons should be applied in
study designs, with careful attention to the study of generalizable effects to demonstrate that im-
provements detected using study measures actually translate into meaningful clinical outcomes.
Engagement with gaming companies, or at the very least the opening of their platforms further to
researchers, would accelerate this kind of development.
45
CHAPTER 5
Social and Emotional Development

In this chapter, we overview the technological approaches for supporting social and emotional skills
for people with ADHD. Technologies have been used to support training and therapeutic interven-
tions as well as real-time or in situ support.
There is a shift in the clinical, educational, and parenting approaches to supporting social
skills in particular right now, with a greater emphasis on helping people with ADHD cope with
environments that have not always been constructed with them in mind, rather than trying to
force people with ADHD to change themselves as the default position. However, a wide variety
of research in this space predates this shift. Notably, greater acceptance in schools, workplaces, and
communities of differences in social engagement will likely change the approaches taken, both in
technology-based interventions and those that do not use technology.
5.1 SOCIAL AND EMOTIONAL DEVELOPMENT AND ADHD

Social and emotional skills enable children to experience, regulate, and express their emotions in
socially and culturally “appropriate” ways (Yates et al., 2008; Halle and Darling-Churchill, 2016).
These skills help children get along with others, build relationships with peers and adults, and
support skills such as cooperation, following directions, regulating emotions, and paying attention
(Halle and Darling-Churchill, 2016). Social and emotional skills provide the foundation for chil-
dren to build healthier relationships, solve problems effectively, cope with life challenges (Parlakian,
2003), and attain academic achievement (Blair and Diamond, 2008; Konold and Pianta, 2005).
Unfortunately, social and emotional difficulties are common among individuals with ADHD
(e.g., Classi et al., 2012). Socially, children with ADHD often struggle to make friends (e.g., Mc-
Quade and Hoza, 2008) as they may have difficulty reading social cues and respecting the personal
space of other children and may tend to interrupt others or change topics in the middle of con-
versations (Uekermann et al., 2010). These and other social skills are dependent on attention and
impulse control. Impulsivity can contribute to a tendency to say or do something before thinking
it through, which can exacerbate difficult social situations. Emotionally, individuals with ADHD
often have difficulty tolerating frustration and regulating their emotions when facing a challenging
or otherwise stressful situation. Emotional difficulties associated with ADHD include poor emo-
tion regulation, aggression, and reduced empathy (Barkley, 2006; Anastopoulous et al., 2011).
Research has indicated that social difficulties are partially attributable to dysregulation of
emotion (Bunford et al., 2018). Stressful circumstances may deplete our resources for self-regu-
46 5. SOCIAL AND EMOTIONAL DEVELOPMENT
lation, such that any of us displays poorer self-regulation after an especially stressful day. This is
demonstrated in how adults may be terse or abrupt with family members after returning home
from a stressful day at work. Given their underlying difficulties with self-regulation, children with
ADHD may be more vulnerable to stress, pressure, and fatigue than their neurotypical peers, lead-
ing to poorer self-regulation and higher rates of aggressive behaviors and rule-breaking (Erhard
and Hinshaw, 1994; Hoza, 2007, 2005). Moreover, difficulties with emotion regulation coupled
with pervasive social challenges and daily stressors, can contribute to the development of comorbid
mood disorders. It has been estimated that up to 50% of children with ADHD exhibit depressive
and anxiety disorders (Gillberg et al., 2004; Elia et al., 2008), adversely impacting their education,
quality of life, healthcare, and wellness (Strine et al., 2006).
5.2 SOCIAL SKILLS TRAINING

Social and Emotional Learning is a subfield of educational psychology (Weissberg et al. 2015;
Mahoney, Drulak, and Weissberh 2018). Social skills do not develop naturally without any human
intervention in anyone. Children are coached to develop social skills by peers, siblings, parents,
other family members, and teachers. Thus, social and emotional development is an area of substan-
tial interest to both child development specialists and to those particularly focused on learning and
education in childhood. It has gained some traction in the human-computer interaction space in
the absence of ADHD (e.g., Littlefield et al., 2017; Slovak, Gilad-Bachrach, and Fitzpatrick 2015;
Slovak and Fitzpatrick 2015; Slovak et al., 2016; Tanaka et al., 2016). Taken together, this research
indicates that technology can be used effectively for social and emotional development, but as in
the ADHD focused papers we describe below, additional research is needed to demonstrate more
extensible outcomes from these promising practices.
One evidence-based non-pharmacological approach to supporting the development of
social-emotional skills in individuals with ADHD is social skills training. Social skills training
programs focus on teaching problem-solving, emotion regulation, impulse control, and verbal
and non-verbal communication (e.g., Storebø et al., 2019). For example, training may help chil-
dren learn to “read” common social cues, wait for their turns, recognize when the topic shifts in
a conversation, identify emotions in themselves and others (Fohlmann, 2009), learn social norms,
and understand societal “rules” (Liberman, 1988). Training programs go by various names, such as
social skills training, child life, attention skills treatment, behavioral therapy, social skills treatment,
psychosocial treatment, and cognitive behavioral therapy. These names of interventions also charac-
terize a wide range of treatments for issues other than ADHD. For example, Cognitive Behavioral
Therapy is one of the most extensively researched forms of psychotherapy (Butler et al., 2006;
Rothbaum et al., 2000) that emphasizes changing thinking patterns in the person engaging in
5.3 TECHNOLOGIES FOR SUPPORTING SOCIAL AND EMOTIONAL DEVELOPMENT 47
the therapy. Collectively, we use the term “social skills training” as a broad descriptor for programs
aiming to support the development of social and emotional skills.
Social skills training for children with ADHD tends to involve a variety of supports and
are frequently adapted and personalized by an individual teacher or social skills therapist or coach.
Thus, we do not provide extensive details of these approaches here. However, to help with under-
standing the potential landscape for technological design, we overview two popular approaches to
social skills training: role-playing and scripts. Role-playing typically involves defining the social
problem in enough detail to reenact or adapt it, acknowledging the negative feelings, discussing
alternate ways to respond, and finally practicing those alternate options by reenacting the negative
interaction. You do not have to have experienced a situation to practice social skills, however, and
so another popular approach involves generating and practicing scripts. In this case, rather than
reenact a negative experience, a person or a group might imagine a potential social situation. In
response to this imagined scenario, the group would then discuss potential approaches and likely
outcomes, sometimes going so far as to physically write a social script in response to the potential
scenario, such as in a collaborative classroom (Heemskerk et al., 2011). All people have sets of social
scripts ready at hand, and making them explicit is a way to simplify and make clear these scripts
for people with ADHD (Bye and Jussim, 1993) who might otherwise struggle to respond in the
moment (Bickett and Milch, 1987; Hubbard and Newcomb, 1991). Such scripts can be generated
using computationally-enhanced tools (Boujarwah et al., 2011), and other technological approaches
to social skills training have also been examined, as detailed in the following section.
5.3 TECHNOLOGIES FOR SUPPORTING SOCIAL AND

EMOTIONAL DEVELOPMENT
Technological applications have been developed with the goal of improving motivation, engage-
ment, and social interactions. For example, robots have been used to mimic social interactions and
provide opportunities for role-playing in a fun and non-threatening environment. Also, serious
games have been proposed to teach children social strategies, practice collaborative behaviors, and
follow societal rules, such as practicing taking turns or engaging in teamwork. Online coaching also
has been used to provide support and guidance through daily activities that may trigger emotional
challenges. In the following paragraphs, we explore some of the research in these and other areas.
Serious Games are interactive media experiences and games that support people in learning
new skills, thinking about difficult concepts, or accomplishing a variety of tasks (Michael and Chen,
2005). These games can be used for a variety of supports for people with ADHD. For example, Bul
et al. (2015) developed and studied “Plan-It Commander,” an Internet-based treatment for children
ages 8–12 years who have ADHD. Building on self-regulation theory (Barkley, 2006; Cameron
and Leventhal, 1995), Social Cognitive Theory (Bandura, 1986), and Learning Theory (Kato et al.,
2008) as conceptual models, the game teaches time management, planning and organizing, and
prosocial skills and can be played at home independently by children. The player takes on the role of
a space captain, gathering rare minerals throughout the universe for an interplanetary organization.
Individual assignments within the missions ask children to solve problems that specifically engage
the issues that are the subject of the intervention (time management, planning and organizing,
and social skills). The game included a social community in which children could interact with one
another. The game dynamic consists of three minigames: a labyrinth to learn how to manage time;
Explorobot, to learn planning; and space travel trainer, to learn to help their team and to develop
prosocial behavior. Bul et al. (2016) conducted a 20-week randomized controlled trial (RCT) with
182 children (ages 8–10 years) with ADHD from 4 mental health care clinics. The experimental
group played with the serious game and continued treatment as usual for 10 weeks. After that, the
experimental group continued with just treatment for another ten weeks. The control group re-
ceived the same, but in reverse: first treatment as usual, and then treatment as usual with the serious
game. The serious game (“Plan-It Commander”) was played for up to 65 minutes per day up to 3
times per week. Parents and teachers reported improvement in social skills surrounding gameplay
but planning and organizing skills were not significant between groups at either time period. The
authors note that future work should include more cooperative gameplay to improve social benefits
(Bul et al., 2016, 2018). Cooperative gameplay has been shown to have positive effects on social
skills for children with autism (e.g., Boyd et al., 2015; Piper et al., 2006). However, no similar stud-
ies were found for children with ADHD.
Research examining the benefit of serious games, such Plan-It Commander, suggests that
children with ADHD can learn and practice social skills in a virtual environment and that they can
be empowered to practice those skills with their peers using technological tools. On the one hand,
virtual environments create an immersive system where researchers or therapists can personalize
stimuli and facilitate interaction between children. On the other hand, tools that facilitate face-to-
face interactions may provide more ecological validity for developing certain social skills, but these
face-to-face interactions can cause anxiety in some children with ADHD and may be more difficult
to control. This trade-off between virtual socialization and face-to-face social engagement should
be explored further. Specifically, more research is needed to understand how skills developed in a
virtual environment can be transferred to support face-to-face social interactions.
In contrast to intervening in a virtual environment, other researchers have explored how to
support face-to-face social interactions, such as engagement with a therapist and participation in
therapy, using technology-based solutions. One therapy that has targeted socio-communicative
behaviors for children with neurodevelopmental disorders, including children with ADHD, is
music therapy (Crowe and Rio, 2004). In order to improve interactions between children and a
therapist and to increase attention during music therapy sessions, Lobo et al. (2019) co-designed
with therapists CHIMELIGHT, an Internet of Things (IoT) music therapy tool. CHIME-
LIGHT was designed to be used by children and their therapists during a hand chime activity.
Each device contained a microcontroller, Bluetooth, RGB LEDs, accelerometer, gyroscope, and
magnetometer. CHIMELIGHT monitors performance and provides visual rewards (e.g., static
blue light when the child is still and a filling yellow light when the child performs a hand chime
movement successfully). Therapists can add other feedback through a mobile app as well as ana-
lyze assessment data. A case series study, using an ABBAAB design, was conducted to evaluate
CHIMELIGHT. Three children with ADHD took music therapy sessions for six months using
CHIMELIGHT with and without feedback. Quantitative results and observations indicated
that when the device delivered visual feedback, children were more engaged (e.g., looked at the
chime) and exhibited fewer negative behaviors (e.g., looking away, non-imitative behaviors). This
preliminary yet promising research suggests that changes in socio-communicative behaviors, such
as synchronized musical play and looking at the therapist, were changed by augmenting music
therapy with technological-tools. Future work should look to scale such evaluation as well as to
understand whether and how such indicators of engagement with the other people in the musical
session translate to engagement in the social world or make such engagements less challenging
and/or more pleasant for people with ADHD.
Face-to-face approaches to improving social skills have also incorporated robots. Research-
ers in the human-robot interaction space have explored how robots may help facilitate social and
cognitive development for children with ADHD. For example, Lehmann et al. (2011) compared
the effectiveness of a humanoid social robot against a mobile robotic platform in supporting social
interaction through play scenarios. The humanoid robot, named Kaspar (Kinesics And Synchroni-
zation in Personal Assistant Robotics), was developed by the Adaptive Systems Research Group,
University of Hertfordshire (Dautenhahn et al., 2009), predominantly for children with autism.
Kaspar is a minimally expressive child-sized humanoid robot explicitly designed to promote com-
munication and social skills in children with special needs such as autism and ADHD. Kaspar has
a nose, eyes, and moth and can move the head, arms, and face while interacting with people. Kas-
par’s face is a mask used in CPR training with eyes that open and close and some minimal ability
to express emotions, including tilting of the head, smiling, and lowering lips to portray a sad face.
Kapsar has tactive sensing capabilities built into its cheeks, torso, arms, back, palsm of the hands,
and soles of the feet. These sensing capabilities allow Kapsar to appear to respond to a child’s touch,
which can be used to encourage or discourage particular behaviors. Children do not report being
unnerved by KASPAR’s humanoid appearance.
Figure 5.1: A pair of Kaspars, child-like robots from the University of Hertfordshire, plays with a
child during an imitation game. Image courtesy of Ben Robbins.
IROMEC (Marti et al., 2009; Marti, 2010) is a robotic platform developed as a social me-
diator for children with special needs. IROMEC has many tangible components that modify the
appearance and behavior of the robot. The robot can move in space autonomously and is remotely
controlled. It has a digital screen that displays graphical interface elements, like facial expressions.
A within-subjects study was conducted with ten children (nine boys) with neurodevelopmental
disorders, including ADHD. Children interacted with KASPAR or IROMEC in individual ses-
sions. Each session consisted of introducing the robot, followed by interaction scenarios, and ending
with time to say goodbye. Each session lasted 20 minutes. Children participated in three scenarios
during each session. These scenarios aimed to support cause and effect, imitation, and turn-taking.
For example, in the turn taking scenario, children seek to understand cause and effect through
engagement with the robot.
E
F
A
C
B
A. Mask
B. Luminescent Fabric
C. Lateral Add-On
D. Buttons
E. Pressure-Sensitive Textile
F. Interactive Fur
Figure 5.2: The IROMEC Robot; this nonhumanoid robot has a face displayed on its “head,” which
is a screen positioned to one side. In the image on the right, the authors describe the components, in-
cluding a mask, luminescent fabric, buttons, pressure sensate textiles, and interactive fur. Images cour-
tesy of Patrizia Marti.
In a study of children with autism using both robots, results indicated that imitation was
better supported with Kasper (the humanoid robot), as children were more willing to imitate the
robot’s movements (Iacono et al., 2011). However, this type of comparison has not been conducted
with children with ADHD.
Collectively, this research shows that technological interventions have the potential to sup-
port social skills interventions for children with ADHD, by providing opportunities to practice
behaviors and receive feedback in a safe environment. Technologically supported environments
have the potential, although are not guaranteed to provide such safe environments. For example,
for children who face barriers in access to traditional therapies, at home therapies enabled by
games, robotics, and so on can provide an important resource. Virtual simulations and serious
games can provide social engagement and skill building without any physical interaction. Robots
can provide some physical engagement, especially in cases in which therapists individualize the
robot-supported intervention by controlling stimuli and feedback. VR systems, particularly those
that do not require a full room, may be more readily accessible and affordable to families than
robots, but both should be explored in larger studies, given the likelihood of the technology to
become more affordable and consumer grade over time. At the same time, as the move to fully
remote engagement during the COVID-19 pandemic has reminded us, homes are not always the
safest place for children. Some children, especially those with ADHD, are at greater risk for abuse
in the home (Brisco-Smith and Hinshaw, 2006) and reliance on parents to implement or supervise
home-based therapies may increase the already-high burden on parents who are facing substantial
challenges associated with work, parenting, and other responsibilities. Thus, technological supports
for monitoring child safety and minimizing parent burden should also be considered, and any
solutions that remove outside engagement from teachers, therapists, and social workers in their
entirety should be examined skeptically.
5.4 EMOTION REGULATION

Emotion regulation difficulties are a key mechanism for the risk of depression in young people
with ADHD (Seymour et al., 2012; Steinberg and Drabick, 2015). Children and adolescents with
ADHD often exhibit difficulty modulating the intensity of their emotions (both positive and neg-
ative) and controlling emotions in frustrating situations (Cole, Martin, and Dennis, 2004). Emo-
tion regulation requires that an individual first recognize and monitor their emotional state, which
requires awareness and attention. It then requires self-evaluation, wherein the person can evaluate
this emotional state. If the state is undesirable (e.g., the person is experiencing sadness or anger),
the next step is to address this state using a learned strategy. For example, therapies for depression
often focus on teaching individuals to choose to engage in a pleasurable or mood-improving ac-
tivity (e.g., going for a walk, listening to music, gardening, playing a game, reaching out to a loved
one) when they begin to feel lethargic or depressed. Individuals with ADHD may have difficulty
modulating and controlling emotions because of insufficient self-monitoring, self-evaluation, and
self-correction skills. The development of these skills can be taught in therapy and could also be
supported using innovative technological tools.
Ecological momentary assessment (EMA), in which people report their behavior or attitudes
on a schedule or in response to a trigger (Shiffman, Stone, and Hufford, 2008), has been used as
an approach to study and intervene to support emotion regulation in children with ADHD (e.g.,
Rosen and Factor, 2015; Wen et al., 2017). Although EMA began as an approach to studying
people’s behaviors and perceptions in real time, ADHD researchers and providers have taken this
approach as an intervention as well as a data collection approach, mirroring to some degree the
notion of personal health informatics (Dishman, Matthews, and Dunbar-Jacob, 2004). One study
illustrated how self-monitoring can be achieved and may support emotion regulation in girls with
ADHD (Heron, et al., 2019). The assessment of emotion can be done more frequently than might
be possible using a self-report approach like EMA by using naturalistic real-time mobile technol-
ogy (Babinsky and Welkie, 2019). In a pilot study, 13 adolescents with ADHD and depression (ages
12–16 years old) and their mothers were provided with cellphones that triggered surveys at random
times during one week, without interfering with school time. Each phone survey captured negative
emotions and their intensity using six items [i.e., lonely, sad, worried, bored, hopeless, and in pain
(stomachaches, headaches, etc.)]. Each emotion was rated on a scale from 1 (very slightly or not at
5.4 EMOTION REGULATION 53
all) to 5 (very much). Both parents and girls rated their emotions on the phone. The study illustrated
how mobile applications provide a feasible method of monitoring emotions in individuals with
ADHD, and the significant correlation between child and parent scores provided some evidence for
the validity of self-reported emotion in youth with ADHD (Babinsky and Welkie, 2019).
Web-based coaching also has been used to promote emotion regulation among individuals
with ADHD. Coaching can provide effective strategies to help individuals respond to problems
and regulate emotions in everyday life in an accessible and acceptable manner (Goldstein, 2005;
Murphy et al., 2010; Parker and Boutelle, 2009). Researchers took a user-centered design approach
to develop a web-based chat intervention called SalutChat (Sehlin et al., 2018). Adolescents and
young adults with ADHD and/or autism and their parents were invited to design SalutChat to
connect with psychologists and therapists as coaches. During a six-month pilot study with ten
adolescents and young adults with autism and/or ADHD (15–26 years old), participants reported
improvements in self-esteem and perceptions of quality of life. These findings suggested that
web-based coaching may be a useful complement to other interventions for people with ADHD
(Wentz et al., 2012). Moreover, caregivers’ burdens decreased when the adolescents were using the
web-based intervention (Söderqvist et al., 2017), an important consideration in any intervention
aimed at helping youth with ADHD. Finally, after the conclusion of the pilot study, a qualitative
follow-up study was conducted to examine the overall experience of adolescents using SalutChat.
Results supported prior findings, indicating that web-based interventions could play a useful role
in supporting adolescents and young adults with ADHD and autism. Although not a replacement
for face-to-face therapies and other treatments, this approach could be a promising complement or
alternative to other support and treatment options (Sehlin et al., 2018).
Technological tools to support emotion regulation for youth and adults with ADHD have
the potential to have a meaningful impact on their quality of life and outcomes in a number of
domains. These tools can help individuals monitor and evaluate their emotional states and prompt
them to engage in behaviors that will help move them into more positive emotional states. As
illustrated above, this could be accomplished using mobile applications as well as web-based coach-
ing and support. In our work, we are exploring how smartwatches can be used as tools to support
emotion regulation in children and adolsecents with ADHD (Cibrian et al., 2020a). These mobile
applications have the advantage of being readily accessible as well as being delivered through de-
vices individuals already own and interact with on a daily basis. Given the growing technologies
that enable researchers to collect a variety of contextual data in an individual’s life using wearable
devices (e.g., sleep patterns, physical activity patterns, noise in the environment), our future research
aims to explore how this data could be used to predict potential situations that might deplete
self-regulation such that an application could pre-emptively deliver interventions (e.g., prompts to
engage in self-regulatory behaviors).

Living with ADHD as a child, adolescent, and an adult can require developing a wide range of
coping skills to deal with the social and emotional stress of the context in which you live, work,
and study while adapting personal experiences with ADHD. Socially, children with ADHD can
struggle to make and maintain friendships, while adults may enter or stay in unhealthy relationships
as a result of impulsivity or other challenges. The stress associated with these unhealthy or absent
relationships can interact with existing challenges around self-regulation to make for a social life
characterized by anxiety and fatigue. These same impacts occur in educational contexts, the work-
place, and within families. However, the research in technologies in this space shows much promise
for future interventions and supports.
In this chapter, we outlined the ways in which a variety of technologies can be used to
augment or replace human coaching and therapeutic interventions. From simple online telehealth
solutions to more elaborate gaming and robotics approaches, technologies can support, personalize,
and scale a wide variety of therapeutic approaches. For people whose lives are already very busy
and for whom the need for additional therapies informs how their lives must be structured, support
available at home, on demand, and/or customized to indivdiaul context can be invaluable. In partic-
ular, emotion regulation often requires support at exactly the time that a person with ADHD might
most struggle to reach out. Although most of these technologies have not been tested at scale nor
validated with the kind of clinical evidence we will ultimately need, there is promise for real-time,
contextualized support.
An individual’s lifetime trajectory of social and emotional development is inherently in-
teractive and collaborative, informed by the norms, communication standards, and engagement of
others in the communities in which individuals live and work. Thus, collaborative technologies must
be examined more carefully in this space, with an eye both toward making it easier and more enjoy-
able for people with ADHD to interact within the dominant culture and toward making it easier
and more enjoyable for those without ADHD to interact with people with ADHD, understand
their perspectives, and support their full inclusion.
55
CHAPTER 6
Behavior Management and

Self-Regulation
Behavioral interventions have been used to support the management of ADHD symptoms (hy-
peractivity, impulsiveness, and inattention) by teaching individuals with ADHD how to control
their behaviors (Friedman and Pfiffner, 2020; Reid, Trouth, and Schartz, 2005). Self-management
is important for all people, regardless of an ADHD diagnosis, and improved skills in these areas
tend to result in long-term success in education, work, and other areas of life.
6.1 BEHAVIOR MANAGEMENT, SELF-REGULATION, AND

ADHD
One common goal of behavioral interventions is to improve the control of attention and impulsivity
through the development of self-regulation skills (Reid, Trouth, and Schartz, 2005). Self-regulation
involves managing one’s behavior, emotions, and thoughts to pursue long-term goals. Self-regula-
tion requires self-monitoring, reflective thinking, goal setting, decision making, self-evaluation, and
management of emotions arising as a result of behavior change (Murray and Rosanbalm, 2017;
Reid, Trouth, and Schartz, 2005). As described in Chapter 4, self-regulation is critical to regulat-
ing emotions. Here we discuss how this construct is applied in understanding and intervening to
improve behavior.
Self-regulation is fundamental to adaptive developmental tasks at all stages of life (McClel-
land et al., 2018). Self-regulation first develops in early childhood (Bronson, 2000; Kochanska, Coy,
and Murray, 2001; McClelland and Cameron, 2012) and continues to develop throughout child-
hood and adolescence. Cultural context (Raver, 2004), parenting approaches (Bernier, Carlson, and
Whipple, 2010), and poverty and stress (Evans and Kim, 2013; Raver, 2004) all can influence the
development of self-regulation with challenges continuing into adulthood for many who struggle
as children. As noted in our introduction, longitudinal research following children from birth into
adulthood has documented the critical importance of self-regulation for a variety of health, eco-
nomic, and educational outcomes (Moffit et al., 2011).
Despite the continuing concerns into adulthood of challenges with self-regulation, and dif-
ficulties with impulsivity and inattention in particular, we found no research in our review focused
on using technology to support behavior management and self-regulation in adults with ADHD.
Thus, this chapter focuses on research describing the use of technologies for children, most com-
56 6. BEHAVIOR MANAGEMENT AND SELF-REGULATION
monly school-aged children. To support children who struggle with self-regulation, caregivers
(e.g., parents, teachers) often use motivational or emotional scaffolding. Motivational scaffolding
involves the caregivers’ efforts to initiate and sustain children’s enthusiasm for a task, using praise
and encouragement, redirection of the child’s attention, or restarting the task (Gulsrud, Jahromi,
and Kasari, 2010) [i.e., co-regulation (Ting and Weiss, 2017)]. When caregivers use co-regulation
strategies successfully, children with ADHD are better able to reduce problematic behaviors and
increase successful behaviors; these successes can lead to the development of greater feelings of
personal self-efficacy and confidence and also may improve parent-child interactions (Danforth
et al., 2006; Gisladottir and Svavarsdottir, 2017; Loren et al., 2015). Therefore, some technologic
interventions have focused on supporting parents by teaching them behavioral intervention and
co-regulation strategies.
To support behavior management and self-regulation skills for children with ADHD and
their caregivers, researchers have explored the use of web and mobile-based interventions to pro-
vide training and support. Research has examined mobile technology to support tracking children’s
behaviors and strategic prompting. Serious games and robot-based technologies have delivered
behavioral therapy, and sensor devices and EEG have been used to support bio- and neurofeedback
training with promising clinical results. Technologies have been tested in laboratory, home, and
school settings.
In this chapter, we overview the technological applications designed, developed, and tested to
support behavior management for individuals with ADHD, behavioral therapies, and the develop-
ment of self- and co-regulation skills (self-regulation of emotions is discussed in Chapter 5). In the
following sections, we explain these different approaches, providing examples from recent literature.
6.2 TECHNOLOGY TO SUPPORT BEHAVIORAL TRAINING

FOR CAREGIVERS
As a first step to understand behavior management and self-regulation, it is beneficial for caregiv-
ers and peers of individuals with ADHD to understand the challenges faced by individuals with
ADHD with the hopes of increasing empathic responses. Toward this aim, Goldman et al. (2014)
developed a videogame intended to recreate the experience of ADHD through game mechan-
ics. The game, called Drawn to Distractions, is a third-person 3D videogame that aims to cause
frustration and mental exhaustion in players (to mimic ADHD symptoms). Players need to help
a child-character to reach the school library in 10 minutes. The video moves very slowly to look
tedious, and there are bubbles and spaceships randomly appearing. If the players touch a spaceship,
the character is transported in a colorful and engaging mini-game (to mimic a rewarding activity
distracting from the main goal). The videogame was tested in three user studies: one included 7
caregivers, another included 13 undergraduate students who had friends with ADHD and the third
6.2 TECHNOLOGY TO SUPPORT BEHAVIORAL TRAINING FOR CAREGIVERS 57
included 8 undergraduate students and graduate students. The research indicated that it was feasi-
ble to use persuasive games to promote understanding of ADHD behaviors among caregivers and
friends of individuals with ADHD. Approaches such as these are novel approaches to increasing
empathy toward and understanding of individuals with ADHD, which could ultimately improve
the life experiences of those living with ADHD; however, more work is needed both to study and
disseminate such tools.
However, creating empathy and awareness alone is not enough, especially for caregivers who
want to promote self-regulation and improve behaviors in their children. Although treatment to
improve behaviors and self-regulation is highly recommended, fewer than half of families receive
this type of support, largely because face-to-face therapy can be perceived as expensive, inaccessible,
or unengaging (Chacko et al., 2016; McEwan et al., 2015; Kern et al., 2007). To address some of
these barriers to treatment, researchers have explored how to used web-based technology to support
parent behavioral training (Dupaul et al., 2018; Breider et al., 2019; Olthuis et al., 2018; Ryan et
al., 2015). For example, DuPaul et al. (2018) conducted a randomized controlled trial comparing
face to face behavioral training with online behavioral training. All families received ten sessions
of parental behavioral training. Both interventions had high attendance and improved the parent’s
knowledge of behavioral training, suggesting that web-based interventions can produce similar
clinical outcomes when compared to in-person interventions. This result is particularly reassuring
given the recent and sudden shift to telehealth treatment in response to COVID-19 pandemic
control measures. In early 2020, many mental health providers across the world (including one of
this books’ authors) rapidly transitioned from in-person therapies to telehealth therapies relying on
the support of a handful of video-conferencing web-based platforms. We anticipate that reports
examining telehealth treatment experiences and outcomes will increase rapidly in the next few years
as a result of this recent shift and hope that they will advance telehealth research and treatment.
Researchers and clinicians have long viewed telehealth as a promising means by which to reduce
barriers in access to treatment (e.g., geographic distance from providers, time constraints), but
barriers associated with health insurer reimbursement and other administrative factors had stifled
the growth of telehealth in spite of rapid growth in technological capabilities. Anectodal reports in
2020 have indicated that patients and families view telehealth as convenient and effective, with pa-
tients (including many in our clinics) and providers indicating that they would like to see increased
use of telehealth in the post-pandemic era.
In the last decade, technology research has shifted its focus from delivery of intervention
through personal computers to mobile devices. Mobile devices have added benefits due to porta-
bility as well as embedded sensors that allow for tracking behaviors and physiological data. Mobile
devices have added flexibility as they can be used for web- or app-based telehealth delivery as de-
scribed above, but also can be used to support treatment throughout the day, outside of traditional
appointments with providers. Mobile technologies may increasingly allow us to provide person-
alized intervention to children and their caregivers, delivering prompts in response to particular
individual indicators that intervention is needed. Among parents, mobile intervention provided in
tandem with wearables has shown the potential to reduce parental stress and increase adherence to
therapy (Pina et al., 2014). For example, ParentGuardian involved a system consisting of a mobile
phone, a peripheral display, and an electro-dermal wrist sensor that together gathered information
about parental stress and provided strategies to support behavioral improvements in children. A
two-week deployment study demonstrated that in situ cues can remind parents to implement
strategies in the moments when they are most needed, but automatically detecting stress using
the wrist band was still a work progress at that time as it is now. This particular area, while largely
unexplored to date, holds particular promise as technologies continue to improve, increasing the
potential impact of such tools.
6.3 TRACKING, PROMPTING, AND REINFORCING

BEHAVIORS
Technology is particularly promising when it comes to individualizing intervention, particularly
by tracking data, either automatically collected using a sensor or through direct input from users.
This tracking is then used to provide reinforcement or prompting to promote behavior change. This
approach has been studied with both children with ADHD and their caregivers.
Among children, Aase and Sagvolden (2005, 2006) conducted a study examining the impact
of reinforcement on behaviors. In a sample of 56 children with ADHD (from 6–12 years old) and
64 children without a diagnosis of ADHD, children were asked to play a very basic videogame
on a computer and to try to figure out how the game works. The game consisted of two squares
displayed on a computer screen. Every time the children clicked over the squares, they changed
colors as feedback, but when they clicked in the correct one (one of the squares), they received a re-
inforcement every 2 seconds (high density) or 20 seconds (low density). Results showed that when
reinforcement density was low (every 20 seconds), there were differences among children with and
without ADHD, but when it was higher, there were no differences in activity, impulsiveness, or
sustained attention. This research demonstrates how technology can track game-related behaviors
and suggests that children with ADHD can be supported with automated reinforcement and that
the timing of reinforcement may be important.
Another approach to tracking behaviors involves asking individuals with ADHD directly or
through their caregivers to input data. For example, Wills and Mason (2014) developed a self-mon-
itoring application to improve on-task behaviors. The application, called I-Connect, was piloted
with two adolescents with ADHD (ages 14 and 15 years). I-Connect sent scheduled prompts to
participants (e.g., “Are you on task?”) and provided an opportunity for data input (e.g., press “yes”
or “no”). After more than 20 sessions of use following an ABAB design methodology, researchers
6.3 TRACKING, PROMPTING, AND REINFORCING BEHAVIORS 59
found that both students improved their on-task behavior, suggesting that self-reflection using
prompting may increase awareness of one’s behaviors.
However, for younger children, rating one’s behavior may be more difficult, and self-moni-
toring may need to be learned in order to accurately assess one’s behavior. For example, Schuck et
al. (2016) develop the iSelfControl app, an iPad application, where every 30 minutes students with
ADHD and their teachers were prompted to rate children’s on-task behaviors. Twelve children
(ages 9–11 years old) and one teacher participated in the study in a school setting. For 13 days, both
students and teachers rated behaviors, including following directions, adhering to classroom rules,
staying on task, and getting along with peers. Results indicated that students initially demonstrated
a weak self-awareness (based on comparison of their self-ratings to ratings of their behavior pro-
vided by their teacher) that gradually improved over time, suggesting that self-monitoring can be
learned and can improve with the use of technological supports.
In primary school, in addition to learning to regulate their behaviors, children learn im-
portant social skills, like collaboration, empathy, and awareness of others, which can be essential
to long-term success in education, social interactions, and other key domains of daily life. Thus, to
engage these collaborative skills, particularly, Matic et al. (2014) developed and evaluated the use
of a shared classroom display in a school that was already using an intense individualized behavior
management program. Each child’s individual behaviors contributed to a portion of the shared dis-
play, with a rewarding image being shown at the end of the day in classrooms in which all children
succeeded in their behavior management goals for the day. In a study with 28 students with ADHD
(8–12 years) across multiple classrooms in the same school, students’ behaviors improved during
the intervention phase, but perhaps more importantly, students also began to support one another,
encouraging each other to do better and congratulating each other on successes.
Figure 6.1: Paper prototypes resulting from the co-design work in Cibrian et al. (2020a). On the left,
the smartwatch format used to engage the children with ADHD in design activities is shown. On the
right are examples of the ways in which the children imagined what their interfaces might say to sup-
port them in social interactions (Daily Goal: Help a friend), social well-being, and health (Challenge:
Be nice, Call Bro, Run for 20 minutes), and physical activities (walk, run, bike).
More recent research has explored how smartwatches can be used to support behavioral
therapies. Cibrian et al. (2020a) described design guidelines to develop self-regulation applications
for smartwatches. They asserted that using a hybrid approach to promote self- and co-regulation
using a smartwatch for children and a paired smartphone application for parents may be an espe-
cially promising approach to supporting behavioral intervention in the home. They highlighted the
advantages of smartwatches, such as their automatic tracking of behaviors, ability to deliver timely
prompts, and the potential to deliver intervention discretely, using a mainstream device to avoid
stigma among children and adolescents.
Some research has explored how to detect hyperactive behaviors in children with ADHD
automatically with the aim of delivering timely prompts. For example, Shih (2011) and Shih et al.
(2011, 2014) explored the use of input devices such as mouse and Nintendo Wii remote to detect
high-performance limb action to trigger prompting to the student when standing up arbitrarily
during class (a particular hyperactive behavior observed in children with ADHD). Three studies,
one with a mouse and two with the Nintendo Wii remote, showed that these input devices are
able to infer posture, and participants were able to maintain a static limb posture during the inter-
ventions. Overall, these research studies suggested that it is possible to infer behaviors of children
in order to help them to be more regulated. However, in practice, approaches to helping children
regulate hyperactivity should be balanced with accomodations that allow children to move when
necessary, for example, by allowing frequent activity breaks.
In summary, technologies can be used to promote self-regulation by increasing self-mon-
itoring (by tracking behaviors and providing a visual representation of behaviors), by supporting
self-evaluation or self-reflection (by prompting individuals to consider whether or not their be-
havior is appropriate for the situation), and self-correction (by delivering prompts and/or specific
strategies to promote positive behavior change).
6.4 TECHNOLOGY-BASED THERAPY

Technological support for mental health has been an area of interest for multiple decades (Lanyon,
1971). More recently, researchers have focused their efforts on approaches that leverage smart-
phones (e.g., Luxton et al., 2011; Kretzschmar et al., 2019), robotics (e.g., Fiske, Henningsen, and
Buyx, 2019; Riek, 2016; Tamura et al., 2003), and intelligent agents (e.g., Kretzschmar et al., 2019;
Vaidyam et al., 2019). These new technologies provide promise across a broad spectrum of mental
health approaches, though in this section, we are focused on technologically-enabled therapeutic
approaches for people with ADHD, specifically.
Particularly novel (and potentially controversial) in this area is the notion that robots or vir-
tual agents can act as the mental health professional themselves, initially augmenting but perhaps
one day replacing this role for a subset of mental health needs. The limited resources available for
6.4 TECHNOLOGY-BASED THERAPY 61
mental health support necessitate an approach that scales and technology-augmented therapy has
that potential. For example, Clark-Turner and Begum (2017) explored how to use reinforcement
learning to train a Nao-robot to deliver behavioral interventions for children with ADHD. Al-
though it was not empirically validated for use with children, the robot was successfully trained
using a model-free reinforcement learning algorithm (Q-learning) to create an intelligent model
to teach the social greeting steps (greeting command, prompt, and reward). A pilot study was
conducted with 11 students without ADHD to measure the success of the model when delivering
positive or negative prompts, given the greeting command. The accuracy of the model was 83.3%,
which indicates some potential for robot-led therapy that includes behavioral prompting.
Virtual environments also have been explored as tools to deliver therapy for individuals with
ADHD, by focusing on behaviors perceived to be negative or counterproductive by others, such as
impulsivity, and transforming them into positive behaviors, such as careful reasoned choices. For
example, Weerdmeester et al. (2016) compared an exergame called Dragon to the exergame ver-
sion of Angry Birds, examining the impact on teacher-rated ADHD symptoms. Dragon allowed
children to embody a small dragon to save its world through three levels: (1) “the forest,” focusing
mostly on attention and impulsivity; (2) “the water tower,” focusing on hyperactivity; and (3) “the
cave,” addressing impulsivity and motor skills. The game provided positive auditory feedback (e.g.,
“You’re doing great!”) for both successes and failures. After six 15-minute gameplay sessions, in a
study with 73 children (ages 6–13 years) with symptoms or diagnosis of ADHD, children who
played Dragon exhibited a marginally greater improvement in terms of teacher-reported ADHD
symptoms, such as impulsivity, than those who played Angry Birds.
Perhaps surprisingly or even counterintuitively, videogames also have been used to address
videogame addiction1 through the “positive” use of technology. For example, in a demonstration
study, Ruiz-Manrique et al. (2014) developed the Tajima Cognitive Method (TCM) as part of
a mobile/tablet application with exercises to train attention, memory, calculation, visual-motor
coordination, and perceptual reasoning. TCM is a cognitive training method that was designed to
enhance working memory, reasoning, and attention. The application, called “ADHD Trained,” was
used to treat a 10-year-old boy’s videogame addiction in tandem with pharmacological intervention.
This study results suggested that videogames could, at least in this case, increase the motivation of
children during therapy and reduce the behaviors perceived around their videogame use perceived
to be negative by parents, friends, and providers, such as perseveration on the game, hyperactivity,
and feelings of restlessness or irritability. As this was a single case study, far more work in this area
is needed to establish this approach as valid and clinically useful.
1
Videogame addiction, and the larger category of media addiction, are highly contested constructs at the time of
writing with some scholars, clinicians, and parents certain of its threat to child development and others certain
that no such addiction can exist. We make no comment as to the reality of media addiction specifically in this
work but note that scientific evidence has largely debunked many claims of risks of media use that fall short of
addiction in recent years (Odgers and Jensen, 2020; Stiglic and Viner, 2019).
Technological-based therapy approaches, including telehealth approaches discussed in the

previous section, are promising approaches to supporting behavioral therapy for individuals with
ADHD. While the telehealth approaches discussed previously had a modest level of evidence to
date, other approaches discussed in this section are still in the very early stages of testing in clinical
populations. As the current literature contains preliminary studies, more research is needed to cre-
ate prototypes robust enough to be used by multiple users at multiple times, and prototypes must
be both cost-effective and durable. Randomized controlled trials should be conducted with these
prototypes, using either a placebo control or an alternative behavioral therapy for comparison. Thus,
without this level of evidence, most research in this area can be described as still emerging. Much
more work is needed for these approaches to become a standard part of clinical care.
6.5 BIOFEEDBACK AND NEUROFEEDBACK

A widely studied strategy involves the practice of biofeedback (Basmajian, 1979; Schwartz and
Andrasik, 2017). Biofeedback approaches involve providing biological information to patients in
real time that would otherwise be unknown. This information can sometimes be referred to as
augmented or extrinsic feedback, that is the feedback that provides the user with additional infor-
mation, above and beyond the information that is naturally available to them, as opposed to the
sensory (or intrinsic) feedback that provides self-generated information to the user from various
intrinsic sensory receptors (Giggins, Persson, and Caulfield, 2013). For individuals with ADHD,
there have been two main approaches to support self-regulation with biofeedback: controlling
breathing and controlling brain activity, also known as neurofeedback.
Biofeedback, along with breathing exercises, can be used to slow down respiratory rates and
promote relaxation (Giggins, Persson, and Caulfield, 2013). For example, ChillFish (Sonne and
Jensen, 2016d) is a videogame controlled by a tangible thermistor sensor of exhalation. The game
aims to control a pufferfish (the players’ character) with a sensor, with the aim of collecting as many
starfish as possible. When the player breathes, the fish inflates and moves. A pilot study with 12
children with ADHD showed that the breathing sensor was not appropriate for children to blow,
and not all the children were able to use it, suggesting that more work is needed to understand how
this approach might be beneficial and for whom it might be beneficial. The research team then went
on to redesign ChillFish with a more robust sensor, but they had not yet evaluated this redesigned
tool with children with ADHD at the time of this publication (Sonne et al., 2017).
Another example is DEEP (Van Rooij et al., 2016), a VR biofeedback game that allows
players to explore an underwater fantasy world by using their breathing to control their movement
(Steiner et al., 2014a, 2014b). Players wear a belt with a stretch sensor to measure breathing to help
players relax. An ABAB design study was conducted with eight children from 12–16 years old with
ADHD. During this time, participants completed five or six DEEP sessions. Results demonstrated
6.5 BIOFEEDBACK AND NEUROFEEDBACK 63
a reduction in state-anxiety, but improvements in classrooms behaviors were only noted for half of
the participants. Given the size and preliminary nature of the study, additional investigation with a
larger sample size seems warranted and necessary.
Figure 6.2: One of the study authors, Mads Jensen, playing the Chill-Fish game from the Chillfish
commercial site, http://www.chillfish.dk/ where the authors include instructions for building your own
among other useful resources. Image courtesy of Mads Jensen.
On the other hand, neurofeedback training to support the self-regulation of brain activity
for individuals with ADHD has been widely used and is considered a non-invasive approach to
reducing ADHD symptoms (Arns et al., 2015; Steffert and Steffert, 2010; Marzbani, Marateb, and
Mansourian, 2016; Rossiter and La Vaque, 1995; Linden, Habib, and Radokevic, 1996; Maurizio et
al., 2014). It has been the subject of several meta-reviews (e.g., Sonuga-Barke et al., 2013; Cortese
et al., 2016; Loo and Makeig, 2012; Lofthouse et al., 2012; Arns et al., 2009; Micoulaud-Franchi
et al., 2014; Bussalb et al., 2019), and we addressed this work earlier in the book in a chapter on
cognition (Chapter 4).
Learning how to control biological signals is challenging, but there is some evidence that
technological interventions may help improve our ability to control our behaviors and minds.
Although there is much research on neurofeedback, other types of biofeedback have not been as
widely explored. Given that current technology can track physiological signals more easily than
technologies available in the prior decade (e.g., smartwatches can sense heart rate and provide
breathing training), there are ample opportunities to develop and study new intervention ap-
proaches. Indeed, although not the subject of our book, biofeedback has been considered for a
variety of other health concerns, such as asthma (Lehrer et al., 2004), constipation (Heymen et al.,
2003), headaches (Bunzynski et al., 1973), and psychiatric conditions (Glueck and Stroebel, 1975).

Emerging technologies have enormous and largely untapped potential for the improvement of in-
terventions to support behavioral management and self-regulation. New, more sophisticated track-
ing of physiological signals may allow researchers to infer and evaluate behaviors, which in turn can
help promote self-regulation. Researchers should envision more efficient and robust methods for
data collection in order to train models that support both the detection and evaluation of behaviors.
Additionally, prompting and behavioral interventions should be co-designed with clinicians,
caregivers, and individuals with ADHD. In particular, the absence of research regarding techno-
logical support for adults with ADHD in this area is notable and concerning. Much self-regulation
and behavior management develops in childhood. However, adults still struggle with impulsivity,
hyperactivity, and inattention. The fact that many adults living with ADHD are often undiagnosed
suggests that they have developed their own coping mechanisms, possibly with the support of main-
stream technologies, such as meditation apps, mobile organizers or calendars, and mobile mental
health support. On the other hand, it is possible that they continue to struggle, exert tremendous
effort, and do not have the coping mechanisms or supports needed to help them realize their full
potential. These areas should be a priority in future research, with an emphasis by researchers on
what we can learn from existing strategies, including strategies identified or developed by adults
with ADHD, and how we can augment or broaden the impact of these strategies for even greater
gains for adults with ADHD.
Finally, we must continue to explore novel technological approaches. Virtual environments
and robotic assistants may support behavioral therapies for individuals with ADHD in an engaging
manner, particularly as they become more common and less expensive. More work is needed to
explore how to co-design interventions using virtual reality environments so that distractions can
be controlled to improve ecological validity. In summary, there is an untapped potential for tech-
nologies to support individuals with ADHD by helping them to recognize and evaluate their be-
haviors—so they can reflect on them and make decisions accordingly. We hope that this potential,
as illustrated throughout this chapter, will inspire the current and future generations of computer
and clinical scientists to develop and bring into practice evidence-based tools to enhance the lives
of individuals with ADHD.
65
CHAPTER 7
Academic and Organizational Skills

and Support
Success in schooling and the workplace are often highly dependent upon high levels of organization
and self-regulation. Indeed, it is common for advertisements for jobs to emphasize organizational
skills and for workshops preparing students for postsecondary education to emphasize such skills,
whether for vocational school, two- or four-year colleges, or even graduate education. The sheer
volume of self-help books available on organization (e.g., Paul, 2003; Selk, Bartow, and Rudy,
2015; Mackenzie and Nickerson, 2009) indicates the importance of organization for success and
the challenges faced by many people. However, students and workers with ADHD may require
additional support (Pinsky, 2012; Knight, 2019), including the use of ATs (Voytecki et al., 2009) to
meet the expectations of instructors and employers. In Chapter 8, we focus on organizational skills
as they relate to daily life and employment. In this chapter, we focus specifically on support for the
academic environment.
7.1 ACADEMIC SUPPORT FOR STUDENTS WITH ADHD

Children with ADHD often need support in the classroom to address difficulties with executive
functions, particularly attention, working memory, organization, and self-regulation. These diffi-
culties can contribute to challenges in learning (including difficulty learning to read), organization
(such as misplacing homework), working memory (including trouble remembering and following
multiple-part directions), and classroom behavior (such as difficulty sitting still and paying atten-
tion). In the U.S., children with ADHD typically receive 80% or more of their instruction in a gen-
eral education setting; in these settings, individualized intervention, support, and accommodations
legally mandated by the U.S. Individuals with Disabilities in Education Act (IDEA) can often be
delivered sporadically (e.g., Harlacher, Roberts, and Merrell, 2006; Nowacek and Mamlin, 2007).
In other nations, this support can be more mixed (Agrawal et al., 2019), prompting the United Na-
tions Educational, Scientific, and Cultural Organization (UNESCO) to issue a report in 2017 that
children are less likely to complete primary or secondary school in many nations around the world if
they have disabilities (UNESCO, 2017). This report further suggests that many systems fall short of
living up to the UN Convention on the Rights of Persons with Disabilities (2006). Countries vary
in how they approach this concern, some creating guidelines or laws nationally while others rely on
efforts at a more local level. For example, in Canada, each Canadian province has its own policies to
66 7. ACADEMIC AND ORGANIZATIONAL SKILLS AND SUPPORT
ensure free public education rather than national law; in the UK, a specific law nationally governs
special education and identification processes; and in China, a law governs special education, but
services are not always provided and diagnostics are mixed (Agrawal et al., 2019).
Regardless of the nation in which services and education are provided, perceptions of indi-
vidualized support or intervention as impractical or time-consuming can be barriers to implemen-
tation (e.g., Harlacher et al., 2006). Additional barriers include variability in teachers’ understanding
of ADHD-related challenges and insufficient training in how to implement effective interventions
to address difficulties (e.g., Pavri, 2004). These and other instructional barriers could be addressed
in part using technologies designed to implement evidence-based school intervention strategies.
While most of the interventions reviewed in this chapter describe support for individuals
with ADHD, class-wide interventions also have been explored and are summarized by Harlacher,
Roberts, and Merrell (2006). They noted that supports can be provided for behavioral issues,
such as contingency management and self-monitoring, as well as for more classically academic
concerns, such as peer tutoring, instructional modification, and computer-assisted instruction. Un-
fortunately, research indicates that teachers in primary school may not provide sufficient accom-
modations for students with ADHD, and when they do, they are implemented in nonsystematic
ways (Nowacek and Mamlin, 2007). Technology can be an equalizer in this regard, as computing
systems tend to impose rigor and systemization in most contexts. The challenge then will be to
ensure that valuable personalization and customization are not lost in the push for greater consis-
tency. Likewise, such expanded access to accommodations, particularly those with technological
elements, must come with additional training for both teacher preparation programs (Pavri, 2004)
and continuing education.
Both practitioners and researchers have argued in support of the use of technology as part
of an overall intervention strategy for ADHD (e.g., Murphy, 2005). Additionally, the use of AT
has been shown to positively predict postsecondary educational attainment (Glynn, 2015). How-
ever, implementation in schools and universities has been mixed. For example, in a study involving
102 Swedish school children with ADHD and 940 without ADHD, Bolic et al. (2013) noted
that fewer than half of the students with ADHD had access to a computer in the classroom and
concluded that school staff should focus on enabling students with ADHD to use computers in
their educational activities at school. In a U.S.-based study of data collected in the early to mid-
2000s (Bouck et al., 2012), students with high-incidence disabilities like ADHD who received AT
in school had more positive postschool outcomes in terms of a paid job, wages, and participation
in postsecondary education. However, because AT was not a statistically significant predictor of
positive postschool outcomes, the exact relationship, and recommendations for use, are still unclear.
Notably, in this study, only 7.8% of participants reported receiving AT in high school, and only
1.1% after high school.
7.2 TECHNOLOGY SUPPORT FOR ACADEMIC SKILLS 67
Anecdotally, these rates appear to be increasing and certainly more youths are now using
smartphones and other technological tools in daily life. However, no comprehensive study has
been conducted globally, and even if it had, the numbers would likely change so rapidly in a post-
COVID-19 era as to make any study out of date nearly as soon as it was published. So, we are left
to consider not how quickly computation can be taken up in schools, but how best to do so. Ofiesh
et al. (2002) recommend use of AT devices for a broad range of postsecondary students with learn-
ing disabilities, including ADHD. Among these, they note that a strengths-based approach to AT
might give greater access to education, that the context of a specific course and classroom should be
considered, and that additional training is required as well periodic reviews with AT users.
Importantly, the idea that media use could precipitate ADHD-like symptoms has garnered
a worrisome amount of press and popular attention (Ra et al., 2018; e.g., McRae, 2018; Howard,
2018). These reports indicate poor attentional control in high media use contexts, leading to lower
reported well-being and diminished educational outcomes (Kushlev, Proulx, and Dunn, 2016;
Rosen et al., 2013). However, more recent studies have failed to replicate the finding that ADHD
and media multitasking are positively correlated, finding that the relationship did not approach
significance (Fisher, 2016). Interestingly, engagement with computerized tools has also been rec-
ommended to treat “video game addiction” (Ruiz-Manrique et al., 2014).
In the remainder of this chapter, we highlight some of the ways in which technological tools
have been developed to support the educational needs of students with ADHD. The majority of
studies that have focused on academic skills for people with ADHD are centered on the experi-
ences of primary school children. However, some recent studies have examined the relationship
between technology and academic skills for adolescents and young adults pursuing postsecondary
education. We discuss the current trends in developing and testing these tools and suggest direc-
tions for future work.
7.2 TECHNOLOGY SUPPORT FOR ACADEMIC SKILLS

Technological supports for academic intervention in children with ADHD include several tech-
niques developed to improve reading skills. In one study of 21 students aged 10–12 years, visual
coloring schemes improved reading through significant effects on attention span (Asiry et al.,
2018). In another study, 20 postsecondary students with primary diagnosis of ADHD used assistive
reading software for most of a semester (Hecker et al., 2002). Specifically, the software provided a
synchronized presentation of text with auditory cues and incorporated highlighting and note taking
features. The software improved reading speed by supporting the students in better attending to
their reading, reducing their distractibility, and enabling them to read for longer periods of time.
Despite these improvements, the use of the software had no effect on comprehension.
Technological interventions have also targeted the improvement of working memory, which
is critical to learning. A computerized training program called CogMed RoboMemo is perhaps the
most widespread tool used to try to improve working memory in children. One study randomized
60 youth (ages 12–17 years) with ADHD or learning disability (LD) into CogMed or another
computer-supported condition. Adolescents in the working memory training group showed greater
improvements than those in the other group, but there were no near or far measure effects (Gray et
al., 2012). In other words, although they improved on working memory tasks, there was no evidence
of improvement in academic settings. Nearly all of the 57 Swedish schoolchildren in another study
saw positive effects of working memory training, which in turn appeared to be beneficial to their
reading comprehension skills (Dahlin, 2011). In another study of RoboMemo with 67 children
with ADHD, improvements were shown in multiple areas, with those in reading still in place 8
months later (Egeland et al., 2013). Finally, in a study of CogMed (Chacko et al., 2014), which
was tested with 85 children with ADHD, researchers observed improvements in working memory
storage but no differences for other outcome measures. Given these somewhat inconsistent findings
and the large body of research on computerized working memory interventions, several meta-anal-
yses and reviews have been conducted to assess the state of the field, and these are discussed in
Chapter 4, which is focused on cognitive training.
More sophisticated and emergent tools are now being used to support literacy in children
with ADHD. For example, Luna et al. (2018) developed a prototype of an augmented reality sys-
tem to support literacy and vocabulary attainment in school-aged children. They pilot-tested this
prototype with 25 users, finding the system generally usable and promising for future work. As an-
other example, robots engaged in collaborative learning with children appear to have the potential
to improve engagement with reading over long periods of time ( Jimenez et al., 2016). Reflex is a
mobile training application that uses computer vision to support interaction with physical devices
(Spitale et al., 2019), building on the popular OSMO commercial platform (https://www.playosmo.
com/en/). With this approach, the applications can use the built-in camera on a mobile device cou-
pled with a mirror to point down at a table that holds physical objects. The application perceives
these objects and renders them digitally on the screen. These tools, while preliminary, show some
promise for academic learning. It is unclear what the mechanism is that underlies these successes.
However, the potential for engaging other sensory stimuli, such as tangible in the case of Reflex,
as well as the attention of a social agent—whether robotic and physical or digital and virtual—are
likely factors that would support learning. Using these tools, children who may struggle to learn
in one modality can use another while remaining engaged despite the potential for distractibility.
7.2 TECHNOLOGY SUPPORT FOR ACADEMIC SKILLS 69
Figure 7.1: A participant doing the Tangram activity on the Reflex platform. Image courtesy of Mirko
Gelsomini.
Despite these promising developments, there is limited evidence for the long-term efficacy
of such approaches. For example, Project CLASS (Rabiner et al., 2010), which reported results
from a randomized-controlled trial to study the impact of computer-assisted instruction (CAI)
on attention and academic performance in 77 American first graders (typically 6 or 7 years old),
there were demonstrated improvements through CAI in reading fluency and in teacher ratings
of academic performance. In this study, the authors used a commercially available tool, Captain’s
Log from Braintrain® (https://www.braintrain.com/), that provides structured activities to support
children training a variety of skills related to attention. Specifically, the authors chose to use ten
exercises that train the ability to sustain auditory and visual attention. An example they provide in
the publication requires children to press the space bar each time a symbol appears that matches
another symbol on-screen. However, the effects of this intervention were absent by second grade. In
this case, the control students also declined in attention problems by second grade, thereby erasing
the differences but leaving open the possibility that long-term effects may still be seen in future
years or with additional intervention.
Although improvement in reading is a well-studied area, there are also some efforts focused
on supporting mathematics education. In earlier research, researchers (DuPaul and Eckert, 1998;
DuPaul and Stoner, 2003) demonstrated that classroom-wide content could be broken into smaller
chunks to improve math performance and off-task behavior (Ota and DuPaul, 2002). As another
more recent example, Mautone et al. (2005) found that schoolchildren ages 10–12 years could im-
prove math skills through the use of CAI. Five years later, Lewis et al. (2010) found that accessible
digital math textbooks were preferable to print for both teachers and students. Additionally, the
use of these textbooks tended to correlate with higher test scores. As in reading skills, augmented
reality has shown some promise in supporting quantitative literacy. For example, Tobar-Munoz et
al. (2014) designed an inclusive augmented reality game supporting Logical Math Skills Learning.
They tested the game with a set of 20 students with diverse learning needs, including ADHD, sug-
gesting that an augmented reality game can support children with special needs in learning such
skills. However, this research is still in the early stages, and larger randomized trials are needed to
clarify the benefits for individuals with ADHD.
It can be difficult to disambiguate technologies that support academic skills more broadly.
Certainly, in the primary, secondary, and postsecondary markets, technology has an increasingly
outsized presence. This has been especially true during the COVID-19 pandemic, as many schools
have shifted toward delivering part or all of their education virtually, using a wide variety of tech-
nological tools. In this section, we focused only on those studies specific to academic support for
students with ADHD. However, students with ADHD almost certainly experience educational
technologies differently than those without ADHD; thus, in the section focused on online learning,
we also review those studies available that articulate some of these differences.
7.3 TRANSITIONING TO POSTSECONDARY INSTITUTIONS

Simple off the shelf technologies as well as those that are more advanced and innovative can
support adolescents and young adults as they transition to postsecondary education (Hayes et al.,
2013). In particular, transitioning to postsecondary education can mean a loss of both structure
and accommodations that students with ADHD have come to rely upon. Thus, a variety of experts
recommend using AT and other technological solutions to support these students (Connor, 2012;
Webb et al., 2008).
Given the challenges associated with organization, self-regulation, and time management
for students with ADHD, it is perhaps unsurprising that both commercial products and research
projects have examined solutions to supporting greater organization for college students. In one
such study, three students with learning disabilities (LD) and/or ADHD were studied in a case
study design; results indicated that students using a handheld computer, which we would now call a
mobile device, reported increased reliance on the device compared to the student using a traditional
paper planner, and that the digital approach was more proactive in supporting the student than the
reactive paper-based approach (Shrieber and Seifert, 2009). In more recent work, the authors of
this book (Cibrian et al., 2020a; Doan et al., 2020) found that smartwatches also could play this
role, with children and adolescents appreciating the organization and prompting that calendaring
and schedules in a smartwatch platform can provide. One might ask whether these tools could in
turn create dependence on such devices. However, students with ADHD should be treated in this
regard no differently than other busy students and professionals who regularly depend on planners,
digital calendars, and other supports to remember assignments and schedules.
7.4 ONLINE LEARNING ENVIRONMENTS 71
In their review of the literature for postsecondary transition, Mull and Sitlington (2003)
suggested that the transition processes must include a focus on funding. While funding for people
with disabilities has not necessarily improved in the intervening 17 years, technology prices have re-
duced dramatically and technological solutions have become more mainstream and accepted. Other
recommendations remain largely true today, such as their recommendations that the selection of the
specific ATs should address both student needs and environmental context and should providing
training opportunities for students to learn to use the technologies.
The transition process must also include a focus on assessment of the learning technology
needs of students prior to their attendance. In a survey of 142 students at a highly competitive
university, Parker and Banerjee (2007) found significant differences between the technology needs,
preferences, and fluency of undergraduates with and without disabilities. In particular, while all
students reported high levels of comfort and fluency with technologies overall, students with
disabilities indicated lower exposure to online and blended courses than their non-disabled peers.
These findings indicate that early assessment of the needs might enable postsecondary institutions
to provide access to and training with online learning environments prior to enrollment. The ad-
ditional opportunities and challenges of such online environments are discussed in more detail in
the following subsection.
7.4 ONLINE LEARNING ENVIRONMENTS

For the last 30 years, students with learning disabilities have been using AT more and more to
access a wide variety of services, including those provided by other mainstream or learning technol-
ogies (Bryant and Bryant, 1999). During the 2020 COVID-19 pandemic, the use of these online
learning environments and technologically enabled learning tools expanded massively and rapidly
all around the world. Although we anticipate an eventual return to in-person instruction for most
people, it is likely that increased reliance on such technologies, tools, and platforms is here to stay.
Understanding how students with ADHD perform in such environments, the unique challenges
they may face, and the opportunities these platforms afford will be essential to delivering equitable
education in the future. In particular, the COVID-19 era has demonstrated that reforms requested
by learners over the years focused on the challenges of traditional classrooms (e.g., Fovet, 2007) are
now possible to address with distance learning technologies and other related approaches.
In an effort to address the particular challenges for college students with ADHD with regard
to developing proficiency with technological tools used in postsecondary schools, such as learning
management systems, and the self-regulation required while processing information online, re-
searchers developed and piloted the Learning Technologies Management System (LiTMS). This
approach uses five components to deliver services.
• Universal Design for Instruction (Scott et al., 2001; Rose et al., 2006), which advo-
cates a design approach in which instructional technologies and instructional materials
are designed to be usable by all people, to the greatest extent possible.
• Authentic Learning Need, which intends to encourage students to think deeply, con-
sidering difficult questions and proactively raising them, to consider multiple forms of
evidence and recognize the nuances in them, and to navigate difficult problems.
• Preferences, which can include the ways in which students prefer to receive informa-
tion as well as behavioral aspects like study habits.
• Range of Learning Technologies, which includes consumer products, personal, and

ATs.
• Individualized Technology Design, which suits the unique needs and wants of the
people using the technologies.
Although this model has not been tested robustly, it is well-grounded theoretically and
matches the best practices for user experience design (Parker et al., 2009b).
Despite many schools, colleges, and universities making use of approaches like Universal De-
sign, challenges remain. For example, in a study of 14 first-year undergraduate students across the
Georgia state university system, all with learning disabilities and some with ADHD (exact number
unspecified by the authors), Wimberly et al. (2004) identified technical barriers (such as computer
malfunctions), design barriers (such as usability and readability), and intrapersonal barriers unique
to individual students as all preventing them from high-quality experiences with education-based
information technology. At the same time, even some well-designed strategies showed no effect
in practice. For example, Cho (2004) tested seven strategies for promoting student self-regulated
learning as described by Zimmerman and Martinez-Pons (1986). Although Zimmerman, Bonner,
and Kovach (1996) argued that students’ self-regulation can be taught and improved through stu-
dent effort, Cho’s technology-enabled interventions showed no effect.
Online education can be particularly difficult for people with attention disorders. The content
is delivered through an inherently distracting device, and few, if any, social and physical constraints
exist to encourage attention. Indeed, the authors observed in their own practices that following the
rapid switch to digital education due to COVID-19 quarantines or school facility closures, children
and adolescents with ADHD struggling to succeed in a virtual learning environment. VibRein
attempts to address these challenges through a mobile application that uses sensors to provide
“continuous supervision” and encourage attending to the video through haptic feedback (Toshniwal
et al., 2015). Surveillance through the camera tracking the student is required of an approach like
this. However, facial recognition in schools has become a hot ethical and practical question in recent
7.4 ONLINE LEARNING ENVIRONMENTS 73
years (Andrejevic and Selwyn, 2020; LoSardo, 2020). Similarly, as students and instructors are cop-
ing with the widespread use of this kind of visual surveillance for remote learning during COVID,
the challenges to ethical and equitable use of such technologies are becoming more evident (Doff-
man, 2020; Halaweh, 2020). Increasingly, both students and instructors are revolting against the
use of cameras in this way in educational environments (e.g., Hubler, 2020; Kelley, 2020; Swauger,
2020; Nicandro et al., 2020). This trend indicates that researchers and product designers will need
to develop new, less invasive approaches to provide the same kind of engagement or abandon these
types of prompting technologies altogether.
Limited effects and reported challenges may be due to the mismatch in some cases between
the ways in which most designers create learning technologies and the optimal learning context for
people with ADHD. In a case study of an individual student with diagnoses of both autism and
ADHD, three types of disorientation were identified-navigational, contextual, and procedural-
each of which required unique strategies for its mitigation (Meyers and Bagnall, 2015). Naviga-
tional disorientation refers to difficulty navigating what the authors call “hypermedia,” but which
we now identify as simply the way the modern web works. Interconnected links that may take us
down long paths that do not result in the answers we seek have long been a challenge of good
information architects. While Google’s original mission of “organizing the world’s information”
has increasingly become one of helping people to search the inherently disorganized information
of the world, this kind of information structure can be exceedingly disorienting to learners with
ADHD. Brown argued in 2009 that students with ADHD might become “lost in hyperspace”
due to the inherent challenges of this media approach (Brown, 2009). Contextual disorientation
involves difficultly placing the information found in this complex web within a larger context.
Learning management systems at universities as well as the instructor themselves, attempt to do
this work, but it can still be challenging for students. Finally, procedural disorientation refers to the
difficulty that students may have in understanding precisely what task they are meant to complete
next. Increasingly, learning management systems have attempted to address this challenge for all
learners by allowing instructors to group materials into “modules” or “units,” by making greater use
of calendaring across courses and other interventions. However, instructors often use these features
inconsistently, which can create an even more problematic learning environment for a student with
ADHD who needs consistent structure to be successful in an online learning environment.
At the same time, there is a strong indication that online learning environments have the
potential to improve the context of learning for some students with ADHD. Graves et al. (2011)
interviewed 11 students with ADHD and/or learning disabilities enrolled in STEM courses. Stu-
dents reported that using asynchronous online access enhanced their learning experiences according
to six themes: clarity, organization, asynchronous access, convenience, achievement, and disability
coping mechanism. This has been supported in the anecdotal experiences of students with ADHD
who transitioned to distance learning during COVID-19. While many have reported challenges,
as noted above, many of these individuals also report advantages. For some, the convenience of
learning at home was beneficial, as it allowed for more frequent breaks, more variety in physical
learning environments (such as being able to stand, walk, or change positions while “in class”), and
self-paced learning.
To date, research efforts indicate a variety of potential disjunctions between the character-
istics and properties of the learner’s online learning environment and the specific learning needs
and preferences of each individual learner. Thus, inclusive online learning environments in higher
education must take into account this need for personalization and adaptability. In a comprehensive
report from 2012, researchers at the Ontario College of Art and Design University set out to iden-
tify opportunities to use innovative technologies to support postsecondary education for students
with ADHD. This report focused on software but was informed by interviews and observations as
well as a comprehensive review of the literature. In their cataloging, they found a wide variety of
time management software—such as those we describe in Chapter 8—but a scarcity of mood- and
motivation-focused software. They also identified an emerging set of software focused on integrat-
ing with existing learning tools, which led them to conclude that “leveraging the features of stron-
ger software categories will strengthen weaker software categories, especially when these features
can be correlated with adult ADHD needs.” They went on to describe a set of tools they view as
particularly needed, including speech APIs for search, time visualization software, and smart goal
management tools. In the intervening eight years, some of these areas have certainly developed
more strongly, but the opportunities are currently unrealized in others.

Our review of the current literature indicated that the majority of technological tools that aim to
support academic skills were designed to be used by children, adolescents, and adults with ADHD
or their parents. Far fewer tools are available to support instructional staff, such as classroom teach-
ers and university professors. While some of these tools may be useful for students with ADHD in
the context of both classroom and online learning, much less attention has been paid to the notion
of holistic learning environments and support for multiple stakeholders.
There exist dozens of technological tools and mobile applications available to teachers that
aim to support general student success and classroom management, which may also benefit students
with ADHD, but the literature supporting the effectiveness of these tools for students with ADHD
is scant. Certain mobile applications for schools have been touted in the press as “promising prac-
tices” (The Zones of Regulation®; Katz, 2012). One tool, Class Dojo (https://www.classdojo.com/,
accessed February 17, 2020), which developers claim is implemented in 95% of schools in the U.S.,
includes a mobile application designed for teachers to manage classroom behavior and also aims to
improve communication between parents, teachers, and students. Much work has yet to be done
to determine if these technological supports are in fact, helpful when working with students with
ADHD and whether or not they contribute to meaningful outcomes. As communication between
home and the school remains a paramount challenge in managing symptoms of ADHD, research
should specifically address how these tools affect the quality and frequency of teacher and parent/
caregiver communication.
Additionally, education, both in the primary and secondary school as well as higher edu-
cation, is an industry in which adaptation and inclusion of tools are often done quickly and in
response to particular contexts at the level of an individual course or department. Thus, institutions
and researchers alike have limited insight into the efficacy of such tools and approaches at scale.
Ofiesh et al. (2002) argue that service-providers must collect and share data regarding effectiveness.
This approach would certainly enable much more large-scale naturalistic data collection and identi-
fication of trends in these data, though randomized controlled trials would provide greater potential
for identifying causal relationships. The current shift to online educational approaches that occurred
in response to COVID-19 presents endless opportunities to study at a widespread level what went
well and what did not. Collecting and sharing data across countries and the world could propel our
understanding of how to best employ technology in educational settings.
77
CHAPTER 8
Life and Vocational Skills

Adults with ADHD experience a variety of challenges when it comes to life skills, employment,
and other transition and post-transition needs, and their needs can be radically different from those
of children who tend to be more often the focus of research in this space (Ginsberg et al., 2014).
In particular, research has indicated that adults with ADHD are less likely to succeed in the work-
place than those without ADHD (Coetzer, 2016). The Multimodal Treatment Study of Children
with ADHD (MTA) followed children with ADHD (original N = 579 with 82% retention into
adulthood) and a local normative comparison group (original N = 258 with 93% retention into
adulthood). Early adulthood evaluations were conducted 16 years after enrollment in the study,
and participants were, on average, close to 25 years old. In early adulthood, there were significant
differences between individuals with ADHD and controls in impulsivity, mood (rapid exaggerated
changes in mood), educational attainment, occupational outcomes, and sexual behavior outcomes
(Hechtman et al., 2016). More specifically, there were significant differences in whether or not an
individual had obtained postsecondary education, the times he or she had quit or been fired from a
job, current income, and whether or not he or she was receiving public assistance (Hechtman et al.,
2016). This research points to the critical importance of developing and studying tools to support
positive outcomes in adulthood. In this chapter, we first provide background on the experiences of
adults living with ADHD, then review the technological systems that have been studied or sug-
gested for supporting people with ADHD. We begin that review with general life skills and then
move into the broad employment and vocational skills domain.
8.1 LIVING WITH ADHD

The concerning results from the long-term MTA follow-up studies point to the long-term negative
outcomes associated with ADHD, but also provide some hope for individuals with ADHD, their
families, and intervention or clinical service professionals. Among the participants diagnosed with
ADHD in childhood, by the time they reached adulthood, 50% (n = 226) had persistent ADHD
symptoms, but for 50% (n = 227), symptoms had desisted, no longer reaching the threshold for
ADHD. Those with persistent symptoms experienced greater challenges overall, but for those
whose symptoms had desisted, outcomes fell somewhere in-between the symptom-persistent group
and the local normative comparison group (individuals without ADHD who had been matched
on other variables) (Hechtman et al., 2016). This result highlights the importance of continuing to
78 8. LIFE AND VOCATIONAL SKILLS
develop tools to support individuals with ADHD while adjusting the context around them to better
accommodate their experiences in hopes of contributing to better long-term outcomes.
Although incredibly important to the success and long-term quality of life, few studies have
addressed life skills and technology engagement explicitly. Those research projects that do exist
address a range of domains, although pre-dominantly address issues of self-regulation and daily
management. Daily activities, in particular, can be a challenge for people who struggle with dis-
organization and impulsivity. Fujiwara et al. (2017) proposed an Internet of Things (IoT) solution
to help support the daily activities for adults with ADHD, focusing on helping them remember
activities and find lost objects. Although others have focused on computational systems for finding
lost objects (e.g., Peters et al., 2004; Nakada, Kanai, and Kunifuli, 2005), this project was focused
on supporting people with ADHD and involved an evaluation with professionals who work with
people with ADHD that showed some promise. Specifically, the authors presented the application
to four professionals who work in the field and followed up the demo with a questionnaire. The
results indicated that the professionals had some belief that the proposed solution would work
and be helpful, but how well would depend on the individual. These approaches can be useful for
initial evaluations of tools to reduce an unnecessary burden on a clinical population that is already
overburdened and can be difficult to recruit. However, such evaluations should not be considered
sufficient in lieu of direct engagement with people with ADHD before a tool is deployed or pro-
duced on a larger scale.
In another example of using promising approaches from other domains to support daily
activities, Bul et al. (2015) developed a serious game called “Plan-It Commander” to promote be-
havioral learning, time management, planning, and organization for children with ADHD. They
tested the game using a survey of 42 participants, finding general satisfaction and indicating a need
for greater research (Bul et al., 2018). Robotics are recently emerging as a promising approach to
the challenge of limited human resources for behavioral interventions; however, results are still
preliminary (Clark-Turner and Begum, 2017).
Pagers, a precursor to many of the mobile and wearable devices we now use, showed early
promise. For example, a fourth-grade boy with ADHD found success through custom paging to
support his daily routines (Epstein et al., 2000). Technology has advanced dramatically since the
time of pagers, and now smartwatches are a particularly promising platform for the delivery of
daily support in people with ADHD. Dibia (2016) developed Foqus, a smartwatch platform for
encouraging mindfulness and self-regulation in adults with ADHD. Cibrian et al. (2020a) found
that children with ADHD are interested in having support through smartwatch technology, and
in a related project, Doan et al. (2020) described a prototype tool called CoolCraig that translated
components of an existing evidence-based program (e.g., Lakes et al., 2009, 2011) into a smart-
watch format. This work is ongoing and focused on harnessing the potential of smartwatches in a
way that supports self-regulation and daily activities in individuals with ADHD.
8.1 LIVING WITH ADHD 79
Figure 8.1: Screenshots of Foqus demonstrating three different modes that the application can display,
including Pomodoro, Meditate, or general Health Tips. Image from ResearchGate, provided by Dibia
Victor.
Cognitive Assistive Technologies (CAT), such as those described by LoPresti, Mihailidis,

and Kirsch (2004) have shown particular promise in supporting people with a variety of life skills,
not simply related to ADHD. CAT (Mihaillidis and LoPresti, 2006) uses devices and tools to re-
habilitate and augment cognitive disabilities or to translate a challenge into a set of activities and
techniques that can better match the user’s strengths. Lindstedt and Umb-Carlsson (2013) studied
an intervention using 74 CATs over 15 months with adults with ADHD. Users valued weekly
schedules, watches, and weighted blankets the most. The authors note that CAT is most valuable
when individually tailored and structured to support the specific needs of the individuals, a set of
conditions most easily met by a combination of technologies that allow for personalization and the
involvement of trained professionals.
Patterns in AT use are difficult to discern and likely vary widely by geography, socioeconomic
status, and disability status (Sonne et al., 2016b). Using survey data from 163 postsecondary disabil-
ity service providers, the most commonly used assistive technologies in 2001 were voice recognition
systems, reading machines, frequency modulation systems, and text enlargement (Ofiesh et al.,
2002), with many of those systems most commonly being used by those with vision and hearing
impairments. Such surveys must be undertaken frequently with the ability to break down usage
precisely by a variety of categories, such as those listed above.
Beyond the executive function and self-management approaches developed to support
people with ADHD, some researchers have explored technologies for highly specific needs. In
some cases, parents are already using technologies in novel ways, such as a family who used loca-
tion-based services to monitor their child, who had dual diagnoses of ADHD and Asperger’s Syn-
drome (Thomas, Briggs, and Little, 2010). In most cases, however, the literature reports on specific
applications developed by or in conjunction with researchers. In one promising study, Bruce et al.
(2017) described a computer application (Drive Smart) to improve hazard detection in drivers with
ADHD. Preliminary results with 25 individuals with ADHD were promising, with improvements
in hazard detection noted after a single training session and maintained over a 6-week period.
Similarly, Clancey, Rucklidge, and Owen (2006) found that virtual reality may be useful to teach
adolescents about road-crossing safety, particularly given that in their study of 48 children aged
13–17 years (24 with ADHD), those with ADHD walked slower, showed lower margins of safety,
and in general demonstrated behaviors that put them at higher risk for collisions.
Moreover, medication adherence, long a target for technological support, can be improved
using a mHealth app, such as the one described by Weisman et al. (2018) and tested with 39 chil-
dren with ADHD. In this study, the authors found higher overall pill counts (a common measure
for medication adherence) in patients who used the app. Family daily routines are also an area of
ongoing struggle in families affected by ADHD. Sonne et al. (2016a, 2016c) developed a tool,
MOBERO, to support families living with at least one child with a diagnosis of ADHD during
the children’s morning and bedtime routines. They then conducted a follow-up study one month
later (Sonne et al., 2016a) after removing the AT from the homes of 13 children with ADHD.
Their study used technology to reduce parent frustration and conflict levels around morning and
bedtime routines, leading to improvements that lasted after the removal of the technology. These
studies provide examples of how novel technologies can address specific needs and support daily
functioning and life skills in individuals with ADHD and their families.
8.2 CAREER READINESS AND JOB SEEKING

A precursor to successful employment and engagement in the workplace for anyone is career read-
iness. Certainly, basic training on technologies, to be used in both job searches in general (e.g., job
search and resume websites) or those for a particular job (e.g., the Microsoft Office suite), should be
taught anyone with and without barriers to employment. However, in this section, we particularly
focus on those studies of technologies to support this kind of career readiness and job seeking for
people with ADHD.
In a one-year ethnographic study of job seekers with cognitive impairments, including
ADHD, in Norway, Michelsen, Slettebo, and Moser (2017) found that mandating the integration
of technology into career activities as well as the use of the students’ own technologies supported
the introduction of Cognitive Support Technologies (CST) for adults with ADHD and/or As-
perger’s. In this work, the researchers included a broad range of tools in their definition of CST,
such as tools used professionally in companies for productivity and communication as well as those
technologies that might help job seekers to improve their competitiveness or become more moti-
vated to cope with other life challenges, including smartphones and a variety of apps installed on
those phones for organization and communication. This particular project built on other research
8.3 EMPLOYMENT AND WORKPLACE SUPPORT 81
that shows CST for employees and students with cognitive disabilities, including autism, ADHD,
and other developmental disabilities, can be effective (e.g., Gentry et al., 2012; Hill et al., 2013);
however, the authors did not disambiguate which technologies were effective in which ways for
which students. In follow-up work, these authors (Michelsen, Slettebo, and Moser, 2019a, 2019b)
found that the introduction of ATs to the rehabilitation support process for adults with ADHD was
valuable both in terms of individual empowerment of participants and the long-term completion
of such programs.
Furthermore, in a promising examination of embedding technology instruction into exist-
ing curricula, Lombardi et al. (2017) added IT literacy modules into an existing online transition
curriculum for secondary education in the U.S. for students with disabilities, including ADHD. In
a quasi-experimental study across six secondary institutions, high schools in American parlance,
the intervention group improved IT literacy, and the control group made no such gains. These re-
sults show promise both for integrating such instruction into existing transition programs and for
teaching IT literacy using an online platform that by definition, requires some limited IT literacy
before beginning.
8.3 EMPLOYMENT AND WORKPLACE SUPPORT

Several reviews of the challenges of people with ADHD and employment already exist. Schaeffer,
Thomas, and Hersen (2004) described the literature alongside their own clinical experience in a
book focused on both learning disabilities and attention deficits in the workplace. Harris (2020)
described the documented challenges of adults with ADHD in the workplace in her doctoral dis-
sertation before delving into the findings of a small qualitative study. Shahin et al. (2020) reviewed
the literature on workplace participation for young adults (ages 18–35 years) with brain-based
disabilities, including ADHD, finding that environmental domains strongly influenced workplace
participation, with the majority of the studies focused on systems and organizations and other
studies referencing social support, physical access, and availability of assistive technology. In a more
practical guide, Honeybourne (2019) presented a mix of research literature and practical advice
aimed at helping employers build and maintain a neurodiversity-friendly workplace.
The search for employment itself relies on a level of organization and networking that is
difficult for anyone, regardless of an ADHD diagnosis. However, those with ADHD often report
feeling isolated, with challenges in interaction and communication with job coaches, career coun-
selors, therapists, and others (Adamou et al., 2013; Pitts, Mangle, and Asherson, 2015). Notably, in
a survey of 210 adults, 105 with ADHD, Pitts et al. (2015) found that respondents with ADHD
tended to become disengaged from the process and disaffected by the employment system overall,
in part due to the challenges of matching a job with their needs, abilities, and interests. Finally, job
searches increasingly are conducted online, as evidenced by the authors’ experience working on a
transition to work task force in education and clinical practice. However, in many cases, the support
structures that we have created in educational and clinical environments have not evolved as fast as
we might like with this change. Thus, there is an opportunity to develop approaches to using tech-
nologies effectively in the job search as also discussed in the previous section on career readiness.
Even if an appropriate position is found and an interview is secured, people with ADHD
often continue to struggle. Some studies have found that adults with ADHD are less accurate in
describing their past employment history than peers, resulting at times in an exaggeration of certain
skills or experiences (Cartwright, 2015; Steinau and Kandemir, 2013). As an added challenge, adults
with ADHD must also determine whether to disclose their condition at the time of interviews,
which could improve chances if the employer understands the condition and its treatment, but is
more likely to introduce a negative bias into the interview process (Adamou et al., 2013). Young
adults in one study even reported that requiring fewer physical accommodations seemed to increase
their success rate in acquiring a job (Toldrá and Santosb, 2013). As in employment searches, there is
an opportunity here to use technology to support the interview process, and some research projects
have begun to do this for populations other than ADHD (Hayes et al., 2015; Ulgado et al., 2013;
Ogbonnaya-Ogburu et al., 2018).
Once employed, there are opportunities to support people with ADHD as the challenges
associated with employment become sometimes more complex (Chang and Edwards, 2015; Ver-
heul et al., 2016). In a sample of 448 employees from across Puerto Rico, Rosario-Hernandez et
al. (2020) found that ADHD had a direct effect on both task performance and counterproductive
work behaviors. However, they saw no relationship between ADHD and organizational citizenship
behaviors. Well-designed and structured employment with appropriate support from supervisors
and managers combined with cognitive-behavioral and pharmaceutical treatments can mitigate
the challenges associated with ADHD symptoms in the workplace (Barkley, 2013; Biederman et
al., 2005; Chang and Edwards, 2015; Martinez-Raga et al., 2013; Seli et al., 2014). Adults with
ADHD often struggle with procrastination (Fletcher, 2013; Bozionelos and Bozionolis 2013),
time management, organization, and prioritization (Schafer et al. 2013). Similar observations have
been noted among young adults (ages 17–24 years old) as well as in the broader adult population
(Nguyen et al., 2013; Young et al., 2017). At the same time, a lack of understanding by those
without ADHD in the workplace can make it difficult for those with ADHD to work with their
colleagues in teams (Barkley, 2013; Fuermaier et al., 2013; Klein, Mannuzza, and Olazagasti, 2012;
Lopez et al., 2013; Surman et al., 2013; Morris et al., 2015) or to have the type of workplace friend-
ships that many people enjoy (Almasi, 2016). These challenges present opportunities for technolo-
gies to support those without ADHD in understanding those with the disorder as well as to help
those with ADHD increase their success in the workplace, as detailed in this chapter. In particular,
people with ADHD may demonstrate enhanced creativity and the ability to deal effectively with
complexity (Bozionelos and Bozionelos, 2013; Schnieders, Gerber, and Goldberg, 2015) as well as
8.4 MENTORING AND COACHING 83
resilience (Reid, et al., 2014), all of which can be leveraged with additional supports, such as inter-
active technologies, to improve workplace interactions for people with ADHD.
8.4 MENTORING AND COACHING

A key aspect to support for transition to employment for young adults with ADHD is coaching.
Thus, the notion of job coaches or employment support is embedded in the majority of transition
programs. Employment-focused coaching tends to be highly individualized, focusing on goal-set-
ting, organization, planning, and time management and workplace skills (Kubik, 2010; Prevatt et
al., 2011). Gerber, Ginsberg, and Reiff (1992) studied 71 successful adults with learning disabili-
ties, finding that coaches, mentors, and supportive coworkers were key to their eventual success in
the workplace.
Prevatt and Yelland (2013) studied a variety of aspects of the coaching process for people
with ADHD, including but not limited to coaching processes and structures and how they correlate
to success. In this work, ADHD coaching was conducted over a five year period with 148 college
students. Clients who received the 8-week intervention showed significant improvement in study-
ing and learning strategies as well as in their self-esteem and satisfaction with school work. Tuttle,
Ahmann, and Wright (2016) found that coaching supported beneficial client outcomes, particularly
when used in conjunction with CBT and/or medication. Tucha (2017) also found coaching to be
one of the nonpharmacological interventions that can be successful in the treatment and support
of people with ADHD, particularly as they transition into adulthood.
However, human coaching simply does not scale to the number and diversity of people
who can benefit from this kind of engagement. Thus, people have begun to examine options for
technologically enhanced supports that produce similar outcomes to human coaching. In one such
study, Burke et al. (2013) used VideoTote, a tablet-based video modeling and prompting tool to
support young adults in the workplace with autism, ADHD, and related conditions. In this study,
participants and parents both gave the software high ratings, and pre and post-tests indicated that
the prompting and modeling techniques were useful supports. Such studies should be expanded
and tested with people with ADHD without autism to understand the full potential for individ-
uals with ADHD. The VideoTote application was available for a time in the App Store for free.
However, it has since been removed, demonstrating the challenge with this kind of research. There
are many potential reasons for the loss of such a commercial product, including but not limited
to determining the market demand for such technologies. General execution should a commercial
approach be undertaken includes all of the challenges of launching a business (e.g., management
of the product lifecycle, marketing, sales, human resources, and finance). Finally, another challenge
may be the lack of desire by researchers to undertake a commercial or even non-profit product
enterprise. Steady streams of research revenue can sometimes help research teams to pick up the
challenge of maintaining tools shown to be effective. However, even this approach requires an in-
vestment on the part of the research team that may not be possible as the ability to publish the work
wanes over time, students and post-doctoral scholars move on, and so on. These challenges may be
best addressed by encouraging more collaboration between researchers and business communities
with interest in picking up and maintaining and updating products over time.
Figure 8.2: VideoTote user interface, showing the user selecting no stops, which allows for watching
the video from start to finish. The other option, “stops,” supports stopping the video automatically at
each step or chapter. Image from ResearchGate, uploaded by Keith D. Allen.

There is substantial evidence that people with ADHD can be successful in the workplace when
employers create “ADHD friendly” environments that allow their employees to use the behavioral
strategies they have developed to help them succeed (Fields, Johnson, and Hassig, 2017). Such
accommodations might include working from home, which has been found to be effective for
people with traumatic brain injuries (Roessler et al., 2017) as well as ADHD and other disabilities
(Solstad Vedeler and Schreuer, 2011). Of course, working from home requires the ability to suc-
cessfully use telework technologies, which many employers have declared impossible in the past.
The COVID-19 era has demonstrated that such accommodations are possible for a wide range of
employees and should be supported whenever possible; recent media outlets have included reports
from executives and researchers suggesting that expanded opportunities for telework are here to
stay and will fundamentally change the “workplace” for decades to come. This potential outcome
could benefit many individuals, including those with ADHD, who may especially benefit from
the flexibility to create a work environment conducive to their needs. Other technologically based
workplace accommodations might include the use of dictaphones, dual monitors, assistive devices
for communication, and computerized phones and alarms. Such tools have positively impacted
work satisfaction and work maintenance (Ripat and Woodgate, 2017; Morash-Macneil, Johnson,
and Ryan, 2018; Solstad Vedeler and Schreuer, 2011), and researchers have shown that a variety of
off the shelf technologies can be used to support adolescents with barriers to employment, includ-
ing ADHD (Hayes and Hosaflook, 2014; Hayes et al., 2013). In 2008, Lazarus (2008) described
how we might better incorporate people with disabilities in virtual workplaces. Such a study should
be undertaken again post-COVID-19 to understand how people with disabilities fared in the
workplace during this difficult time.
Time management and self-regulation are particular challenges that repeatedly emerge in
the literature as well as in self-reports from people with ADHD, making support essential to cre-
ating an ADHD-friendly work environment. Nadeau (2015) found that adults with ADHD who
used environmental modifications that limited internal and external distractions (e.g., a job that is
physically active or integrates exercise into the daily routine) benefit substantially in terms of their
ability to self-regulate and reduce feelings of restlessness and hyperactivity. Dipeolu, Hargrave, and
Storlie (2015) similarly found that people with ADHD could manage their symptoms using strict
schedules and minimizing distractions in their immediate work environments. These accommoda-
tions are all relatively straightforward to provide, particularly for office work. However, Morgen-
sterns et al. (2015) found that employers and coworkers rarely considered how crucially important
such accommodations are to employees with ADHD.
Technological tools for adolescents, young adults, and adults should be a high priority, es-
pecially as they are likely to need support in the transition into adulthood, making this a prime
period for the implementation of self-management and vocational success strategies. None of the
studies we reviewed that had clinical trial evidence addressed needs associated with the transition
from adolescence to adulthood. In spite of this, there are promising interventions in development
and early testing. Although some tools used highly innovative technological solutions, such as ro-
botics and VR, the vast majority of research in this space has been conducted on technologies that
could realistically scale with the off the shelf products currently available. Additionally, this space,
more so than the literature in any other chapter in this book, focuses on adults who are more able
to participate in large-scale, longitudinal research trials. Given the disparate adult vocational and
life outcomes documented for adults with ADHD (e.g., Hechtman et al., 2016), is it is imperative
that researchers prioritize the large-scale clinical trials necessary to demonstrate efficacy of life,
vocational, and post-transition supports. Such trials would make governmental funding in many
nations easier to obtain for these supports as well as insurance funding, for example, in the U.S.
87
CHAPTER 9
Motor Control, Physical

Accessibility, and Physical Activity
Although the majority of research surrounding ADHD focuses on issues of cognition, attention,
and working memory, the physical experience of ADHD for both children and adults is well worth
considering. It may be a motor or physical behavior that first suggests ADHD, an issue discussed
in more detail in Chapter 3 (Computationally Supported Diagnosis and Assessment). Likewise,
physical activity is increasingly considered as an intervention to address ADHD symptoms, in ear-
lier years as a strategy to reduce hyperactivity and more recently as a strategy to improve attention
and other executive functions. In this chapter, we describe the background in assessing and under-
standing motor control and ADHD and introduce some research on physical activity as it relates to
ADHD symptoms. We then move into the specific issues of technology related to motor behaviors
and physical accessibility, first by describing technologies that promote motor skill development
and motor control, specifically, and then describing work that promotes physical activity.
9.1 MOTOR CONTROL AND ADHD

Motor and cognitive development are fundamentally intertwined (Diamond, 2000). Therefore, it
is not surprising that difficulties in cognitive development are associated with difficulties in motor
development. Children with ADHD diagnoses often have different and slower trajectories related
to their motor control than their typically developing peers (Gilbert et al., 2011). They may not
meet developmental milestones involving timed repetitive and sequential movements, uninten-
tional movements accompanying voluntary tasks, and balance. Fine motor skills are often delayed,
and skills like producing neat handwriting can be especially difficult. Even much earlier research
in ADHD acknowledged differences in motor development, indicating that children with ADHD
tended to develop accurate rhythm later than their typically developing peers and showed immature
patterns of motor overflow later (Denckla and Rudel, 1978).
A variety of tests are available for evaluating motor control in all children and have been
used to assess children with ADHD. These include tests focused on motor control and move-
ment (Denckla, 1985) as well as those focused on manual dexterity and balance (Henderson and
Sudgen, 1992). This battery assesses the manual dexterity, ball skills, and balance of children.
Some tools are more typically used in schools and clinical settings (Deitz et al., 2007; Mancini
88 9. MOTOR CONTROL, PHYSICAL ACCESSIBILITY, AND PHYSICAL ACTIVITY
et al., 2020) while others require clinical intervention, such as Transcranial Magnetic Stimulation
(TMS) (Gilbert et al., 2011).
Challenges with motor control in people living with ADHD can present in a variety of ways
and have varied impacts on life experiences. The exact mechanisms by which motor challenges
manifest in some children with ADHD are unclear. Such challenges are inconsistent across the
population, leading to high variability in both life experiences and treatment. A variety of expla-
nations for the motor skills differences in children with ADHD and their peers without ADHD
can be given, including but not limited to comorbidity, inattention, or lack of inhibition (Kaiser et
al., 2015). Comorbid developmental coordination disorders may explain motor coordination diffi-
culties for some individuals. One study found that the motor skills of children with only ADHD
-and no other diagnoses-did not differ from a control group without ADHD. Indeed, in this
study, the presence of reading disabilities were better predictors of ADHD than motor impairment
of some kind (Kooistra et al., 2005). Likewise, a study including 84 children—20 with ADHD
only, 42 with ADHD and another co-occurring disability or illness, and 40 children with multiple
co-occurrences and ADHD—found that the presence of co-existing diagnoses had a significant
influence on both cognition and motor behavior in children with ADHD (Crawford et al., 2006).
A variety of treatments for motor control and physical accessibility challenges have been
studied and used for children and adults with ADHD for many years. These include both behavioral
and pharmaceutical treatments, but given the emphasis of this book on technological support and
behavioral augmentation through technologies, we here do not address pharmaceutical approaches.
9.2 TECHNOLOGICAL APPROACHES TO SUPPORTING

MOTOR SKILL DEVELOPMENT AND CONTROL
In addition to efforts to increase engagement and participation in physical activity, which may in
turn promote motor development and control, there is research describing a range of technological
tools designed to specifically support motor skills and motor control development. This work in-
cludes computerized cognitive training, robotics, and interfaces to support physical interventions.
We describe some of this work in subsequent subsections.
9.2.1 COMPUTERIZED COGNITIVE TRAINING TO SUPPORT MOTOR

SKILLS
Since the dawn of the personal computer, computers have been used to support a variety of
diagnostic and therapeutic goals. However, they are less frequently used specifically for motor
skills, given their limitations in input and output. Typing, using a mouse, and translation from a
three-dimensional world into a two-dimensional space are all difficult cognitive and motor skills,
particularly for children.
9.2 TECHNOLOGICAL APPROACHES TO SUPPORTING MOTOR SKILL DEVELOPMENT 89
Computers can, however, be used to support growth and skill development in the very
areas in which their use can be challenging. For example, Eliasson et al. (2004) demonstrated that
children with ADHD move the mouse more slowly, perform more jerky movements, and produce
more errors than children without ADHD. This type of finding can help develop models to detect
symptoms of ADHD that might otherwise be missed and design corrective assistive technologies
that can, for example, improve the performance of children with ADHD when mousing through,
smoothing the interaction experience dynamically in the background. Similarly, in a study testing
handdrawn movement, 62 children used an electronic pen on a digitizing tablet to join targets. The
results of this study indicated that children with ADHD showed no temporal difficulties in the
tasks but did demonstrate subtle spatial difficulties ( Johnson et al., 2010). In particular, they showed
a subtle spatial bias toward the right that the children without ADHD did not show, despite all
children both with and without ADHD being right-handed. This kind of subtle bias is an indicator
of the potential for accessibility features in computing systems that might support stylus and mouse
use with adaptive interactions that adjust for such subtle biases.
One of the longest available technologies to support motor control in people with ADHD
and others with related conditions is The Interactive Metronome® (IM). This training and assess-
ment tool was developed to improve cognition, attention, and focus, as well as motor and sensory
skills. The interactive metronome was developed in the early 1990s and included a “Main Station”
that connects to a computer and measures rhythm, auditory feedback delivered by headphones, and
one or more devices that the client uses to play the game—such as buttons to press or a mat to
tap with a foot. This digital program is used in homes, schools, and clinics for adult rehabilitation
(e.g., as related to brain injuries and neurological diseases) as well as pediatric practices focused on
ADHD, autism, sensory and learning disabilities, and speech and language delays. Clinicians use
IM to play digital interactive games alongside functional therapy interventions to explicitly target
the neural timing within and between the brain regions. The tool uses a game-like platform to in-
struct and engage the user while providing instant feedback and logging progress. The IM training
has been used successfully with boys with ADHD (Shaffer et al., 2001) to improve attention and
academic skills, but also for this chapter most notably motor control. In smaller studies, such as
one from Korea involving two boys with ADHD (Namgung et al., 2015), the IM was found to
facilitate timing, attention, and motor control in the boys who used it. In a similar study by Park
and Choi (2017), these results were replicated two years later with two other boys. A variety of
other studies have shown similar promise (Bartscherer et al., 2005; Gu et al., 2017; Park and Kim,
2018). However, to date, no comprehensive large-scale study of the IM for children or adults with
ADHD has been reported.
9.2.2 PHYSICAL INTERACTIONS IN MOTOR SKILL SUPPORT AND

ASSESSMENT
Teacher shortages, particularly for special education, have become a hallmark of the modern edu-
cational system. A wide variety of important skills, particularly in early childhood, require hand-
over-hand or other close one-on-one contact. However, very few children have the attention of a
teacher or an aid for the entire day. Furthermore, with the COVID-19 global pandemic remaking
schooling as we know it, this kind of close contact is even more difficult. Robotics offers a promising
alternative to these challenges. A social and physical assistant in the form of a robot can provide
one-on-one attention to augment that of a teacher or parent. For example, Palsbo and Hodd-Szivek
(2012) found that a 3D robot-assisted repetitive motion training system used for 10 hours of train-
ing improved handwriting fluidity for children with ADHD as well as speed for those referred for
slow writing speed.
Similar to a robotic approach, other tangible interactions can provide some of the benefits of
hands-on instruction without the need for another teacher or aide in the classroom. In a series of
studies, Shih et al. (2011) tested this approach using a gyrostatic mouse and a Nintendo Wii Remote
Control to detect hyperactivity and spontaneous standing (Shih et al., 2011, 2014; Shih, 2011). In
these cases, the researchers automatically detected the behavior and then used a gyroscopic mouse
or a Wii controller—devices that allow a user to control a piece of software by moving the device
through the air—to provide or remove vibrotactile feedback—used in this case as an aversive—when
the nonpreferred behavior was observed. In a small study, this approach appeared promising for sup-
porting individuals with ADHD in modifying their behavior to be considered more socially accept-
able for the context. Although the technologies used here may be effective in teaching the student
with ADHD to change their behaviors, researchers should also consider developing technologies
for such environments (e.g., classrooms) that help all students and teachers to feel more comfortable
when the student with ADHD needs to self-regulate through nonpreferred behaviors.
Beyond this kind of simple vibrotactile feedback, other researchers have explored notions
of other types of interaction more broadly. For example, Polipo, a tangible toy created for children
with neurodevelopmental disorders, enables a highly customizable experience with children and
therapists able to personalize its light, sound, and tactile stimuli (Tam, Gelsomini, and Garzotto,
2017). Other open-ended tangible environments have been shown to support children with dis-
abilities in learning, though the evidence remains limited (e.g., Bakker et al., 2011; Garzotto and
Gonella, 2011).
9.3 PHYSICAL ACTIVITY AND ADHD 91
Figure 9.1: A child plays with Polipo, on the left seated with a therapist, and on the right a view of the
child and Polipo alone. Images courtesy of Mirko Gelsomini.
Gesture-based interfaces—in which the software or device is controlled using specific

gestures, like scrolling, pinching or tapping—provide much of the same appeal as tactile systems,
allowing groups to customize and balance their interactions beyond what a traditional keyboard,
mouse, or even touchscreen might do. For example, Sharma et al. (2018) conducted a series of
studies using three gesture-based applications to support motor coordination (HOPE), joint at-
tention (Balloons), and life skills (Kirana). Although not empirically validated yet, their work is
particularly compelling as it considers a context under-represented in the research literature, living
with ADHD in India.
Finally, the last frontier in off-the-desktop interaction may be virtual and augmented reality.
These technologies can be combined with physical interventions to support improvement in motor
function. For example, Shema-Shiratzky et al. (2019) conducted a study with 14 non-medicated
children with ADHD during 18 training sessions over 6 weeks, in which the children walked on
a treadmill while avoiding virtual obstacles. Their results indicated that parents perceived children’s
behavior to improve meaningfully and that gait regularity significantly increased during dual-task
walking. Executive functions improved following training, but attention did not. These results, while
preliminary given the pilot nature of the study, suggest that further work in this area is warranted.
9.3 PHYSICAL ACTIVITY AND ADHD

Physical activity has long been considered important for motor development and physical health,
but in recent years, there has been growing body of evidence suggesting that physical activity can be
beneficial for cognition (e.g., Vazou et al., 2019; Diamond, 2015), which introduces the possibility
of physical activity producing multiple benefits—improved physical fitness, motor coordination,
and cognition—particularly for individuals with ADHD who may struggle in one or more of these
areas. For example, Verret et al. (2012) found that children with ADHD in a ten-week exercise
training program improved their muscular capacities and motor skills as well as performance on
information processing tests. Berwid and Halperin (2012) argued that there is evidence supporting
the hypothesis that physical activity impacts structural brain growth and functional neurocognitive
development, and this could have profound implications for intervention to alter the trajectory of
ADHD. They noted at the time that most physical activity research with children with ADHD had
been pilot research, with limitations including small sample sizes and unblind status of research-
ers or raters. In spite of these limitations, there appears to be growing evidence to suggest that a
variety of physical activity interventions could directly improve executive functions in children
with ADHD, but more research is needed before interventions become a recommended treatment
for ADHD. This interest physical activity interventions for children with ADHD, is particularly
relevant given that the risk of overweight and obesity is also associated with ADHD (e.g., Waring
and Lapane, 2008), and positive physical activity habits might maintain or improve physical health
while also reducing ADHD symptoms and promoting the development of motor skills.
As the benefits of physical activity for physical health and motor skill development are
generally widely known, here we focus on providing some background for the more recent work
on the relationship between physical activity and cognition, particularly as it may be relevant to
the development of technological tools to promote physical activity. As the relationship between
physical activity and the brain has received increasing attention, models have been proposed to ex-
plain the neurobiology of benefits to cognition. Best (2010) stated, “There are at least three general
pathways by which aerobic exercise may facilitate executive functions in children: (1) the cognitive
demands inherent in the structure of goal-directed and engaging exercise; (2) the cognitive en-
gagement required to execute complex motor movements; and (3) the physiological changes in the
brain induced by aerobic exercise.” However, the evidence indicates that not all forms of exercise
benefit executive functions equally (Diamond and Lee, 2011; Vazou et al., 2019; Diamond, 2015),
and that “the degree to which the exercise requires complex, controlled, and adaptive cognition and
movement may determine its impact on EF [executive functions]” (Best, 2010). Recent research
(e.g., Vazou et al., 2019; Pesce et al., 2020) has demonstrated that physical activity programs that
involve greater cognitive engagement (involving cognitive challenges or mindful components) pro-
duce stronger effects on executive functions than less cognitively engaging aerobic activities (such
as simply jogging). Diamond (2015) argued that moving without thought produces little sustained
change in executive functions and that practices that require both thought and movement—are
likely to have a stronger positive effect on executive functions and deserve further study.
It is worth briefly considering interventions that integrate physically active and mindful
components to target symptoms of ADHD, particularly as this may inform the development of
technologies that could support interventions with multiple components. Because mindfulness
9.4 TECHNOLOGICAL INTERVENTIONS TO PROMOTE PHYSICAL ACTIVITY 93
practice involves efforts to self-regulate attention, as awareness of this practice has grown, there has
naturally been an increasing interest in the potential of mindfulness training to improve executive
functions (particularly attention) in individuals with ADHD. Mitchell, Zylowska, and Kollins
(2015) concluded that while preliminary studies of mindfulness training for children and adoles-
cents with ADHD have produced promising results, the research to date has had methodological
limitations, including small sample sizes and lack of active control groups. Intervention combining
low-intensity physical activity with mindfulness training have been described in the literature; for
example, Zylowska et al. (2009) described how to train attention during sitting or walking medi-
tation by focusing attention on an anchor (such as breath), observing that distractions occur, and
letting go of them, and refocusing on the anchor. This work is interesting as Vazou et al. (2019),
demonstrated that in typically developing children, physical activities with a mindful component
(such as yoga or martial arts) produced stronger effects on cognition than less cognitively-engag-
ing forms of physical activity. However, to date, little research in the areas of physical activity and
mindfulness interventions has been conducted with individuals with ADHD.
In addition to studying physical activity as an intervention to promote physical and cog-
nitive outcomes, research has also examined the impact of movement on learning and classroom
performance. Results of a study conducted by Hartanto et al. (2015) showed that in children with
ADHD, performance on an executive function task was better when children were active during the
test, supporting the hypothesis that physical movement may function as a compensatory strategy to
increase arousal and attention in children with ADHD. Many years earlier, Etscheidt and Ayllon
(1987) reported that even five-minute bouts of exercise could reduce hyperactive behaviors during
classwork. Thus, a commonly recommended classroom accommodation for children with ADHD
has been allowing “physical activity breaks” to reduce restlessness and increase on-task behaviors. In
spite of these promising findings, there is no current data demonstrating how much or what type
of physical activity is required to have a meaningful impact on ADHD symptoms, but interest in
this line of research appears to have grown in the last decade.
9.4 TECHNOLOGICAL INTERVENTIONS TO PROMOTE

PHYSICAL ACTIVITY
Given the substantial interest in physical activity for individuals with ADHD, it is not surprising
that technological interventions are being developed and tested to assess potential benefits on
ADHD symptoms. As noted above, physical activity is associated with improved cognitive func-
tioning in a wide range of people and has been investigated specifically to support people with
ADHD. Technologies can broaden the potential for physical interventions by making such activity
more fun and engaging, allowing for home-based intervention, and producing positive outcomes
while tracking progress.
For example, Weerdmeester et al. (2016) demonstrated that a full-body-driven videogame

could reduce teacher-reported ADHD symptoms in 73 children with ADHD as well as influ-
ence positively both impulsivity and gross motor skills. Taken further, these types of whole-body
interactive games are often referenced collectively as “exergames,” and they provide a promising
approach for treatment and support of individuals with ADHD. Exergames have particular prom-
ise in potentially being able to target cognitive and physical processes at the same time. Benzing
et al. (2018) demonstrated improvement in reaction times in inhibition and switching with just 15
minutes of exergaming, in which children performed moderate intensity physical activity. In this
case, the exergame used was a commercial game called “Shape Up” from Ubisoft on a Microsoft
XBOX Kinect platform.
Benzing and Schmidt (2019) described and studied a cognitively and physically de-
manding exergaming intervention. The exergaming intervention was cognitively engaging (e.g.,
requiring attention, inhibition, switching, and speed of action) as well as physically challenging.
In a well-designed randomized controlled trial with 51 children (ages 8–12 years), Benzing and
Schmidt (2019) compared 8 weeks of home-based exergaming intervention to a waitlist control
and found significant improvements in executive functions (e.g., reaction time for inhibition and
switching), parent ratings of psychological difficulty (i.e., Conner’s 3 Global Index Scores), and
motor skills, although significant improvements in ADHD symptoms were not observed. Their
research uniquely highlights the potential benefits of integrating cognitively engaging and phys-
ically challenging exergames into daily routines for children and adolescents with ADHD that is
likely to inspire further research given a widespread focus on the potential of exercise to benefit
executive functions in general and for ADHD, in particular. However, they recommended the
need for customized exergames for this population in order to better target ADHD symptoms in
particular (Benzing and Schmidt, 2019).
Some researchers have begun to examine customizing exergames, in particular, in support
of children with autism, another neurodevelopmental disorder. For example, FroggyBobby, is an
exergame designed to support improved motor control and attention (Caro et al., 2017). In this
work, the authors focused on using a participatory design approach to support this custom design.
Although they did not test FroggyBobby with a large sample size, the teachers involved in this
work perceived that the exergame had some impact on motor functioning as well as other behaviors,
such as socialization and body awareness. Similarly, Caro et al. (2016) proposed a full room, tech-
nologically instrumented, to support exergaming: the ExerCaveRoom. This approach might provide
children with a wide variety of developmental disabilities the opportunity to practice customized
therapeutic interactions while being recorded for assessment toward progress.
Beyond these custom systems, a vast array of technologies and research studies have focused
on exergaming for children with autism (e.g., Caro et al., 2017; Peña et al., 2020; Cibrian et al.,
2017, 2020b). Although these technologies were not, in most cases, tested with children with
ADHD as well, it is worth quickly reviewing them for what they can provide us in thinking about
exergaming more broadly for children with a variety of disabilities, but particularly those that are
neurodevelopmental in nature. Certainly, this book, with its focus on ADHD, does not attempt
to fully review such approaches for other populations, such as individuals with autism. Notably,
some studies, such as Hilton et al. (2014, 2015), indicate substantial promise in improving work-
ing memory, metacognition, and the motor skills of strength and agility for children with autism.
Researchers should certainly take these positive results and not only replicate them with a broader
group of children with autism but also expand this work to both children and adults with ADHD.
In an attempt to make some sense of the many preliminary studies, Fang et al. (2019b)
produced a systematic review of exergaming for children with autism. In this review, they found
that children with autism showed significant improvements in physical fitness, executive function,
and self-perception, but there were minimal effects on emotional regulation and little to no effects
on motor development. These findings are somewhat in contrast to the studies cited above that do
show improvements in motor skills for children with ADHD. Whether these differences are due
to the preliminary nature of all of these studies or whether to differences between these clinical
groups has yet to be determined. Researchers should seek to both scale up these interventions and
to examine differences amongst various groups that are, in other ways, potentially related.
Children with ADHD might particularly benefit from exergame interventions that enable
them to play with other children with a variety of abilities, disabilities, and health conditions. In
a systematic review of exergames for children and adolescents who are not typically developing,
the authors found strong evidence that active video games improved balance, with more limited
evidence related to coordination, running, and jumping (Page et al., 2017). In one study, children
with cerebral palsy were more willing to engage in physical therapy, for example, when they were
able to play exergames with other children, both with and without cerebral palsy (de Greef et al.,
2013). Certainly, schools, that are inherently mixed ability venues, could benefit from these kinds
of approaches in their adaptive physical education programs.
Moreover, applications already embedded in mobile technologies (e.g., smartwatches, smart-
phones) could be used to help promote physical activity in individuals with ADHD. In our own
work with youth with ADHD, we are exploring how to promote physical activity with smart-
watches as part of a comprehensive parent-child system designed to support healthy behaviors, such
as physical activity and sleep, while also providing ADHD-specific behavioral intervention for both
parents and children (Cibrian et al. 2020a).

Although ADHD is most commonly associated with executive function difficulties, physical chal-
lenges, including difficulties with motor coordination, can be present and often have a negative
impact on day-to-day functioning. Motor control is, in fact, such a prevalent issue for children with
ADHD in particular that a battery of tests has been used to study motor control in children with
ADHD. The exact mechanisms for these challenges are unclear, but what is clear is the potential
for physical activity to simultaneously address motor and cognitive functioning. Thus, this chapter
outlined the growing rationale and evidence for technological interventions to promote physical
activity and simultaneously target motor and cognitive functioning.
This chapter points to several critical directions for future research. Exergames and other
approaches that influence and increase physical activity in children and adults with ADHD have
shown promising results in preliminary studies, and there is a growing scientific rationale for paying
more attention to how physical activity, motor functioning, and cognitive functioning are inter-
twined. In response to this promise, a wide range of technologies—from exergaming to robotics to
mobile applications—are being developed and studied. Likewise, other tools have been developed
to specifically focus on specific motor skills, including both simple desktop or web applications, as
well as augmented reality and wearables. In a period in which a worldwide pandemic and social
distancing have reduced opportunities for both physical activity and to some degree therapies fo-
cused on motor functioning, the potential for affordable, home-based technology to fill the gap is
especially important.
Although the work is promising, large-scale randomized controlled trials are very few, as is
often the case in the early stages of development. The range of technologies is inspiring, and their ap-
plication to critical challenges in ADHD is promising. We hope that now and in the future, greater
financial investment will yield the types of intervention studies needed to eventually bring these
technologies into the marketplace where they can directly benefit individuals with ADHD. Perhaps
in this current time of social distancing, studies could be undertaken using existing tools (such as
exergaming) both to promote opportunities for home-based physical activity and to propel the field
forward through widespread efforts to better understand the potential of existing technology.
97
CHAPTER 10
Discussion and Conclusion

ADHD is one of the most common neurodevelopmental disorders in childhood and often persists
into adulthood. It is commonly undiagnosed in adults and broadly considered as heritable (Khan
and Faraone, 2006), making the experience of ADHD in families particularly challenging. While
people living with ADHD are often successful, they may still struggle with a wide variety of symp-
toms and challenges. Additionally, as an invisible disability, it can be hard to seek and receive the
accommodations necessary for this success. Technological supports, particularly those that can be
built into everyday life or allow for personalized engagement at scale are particularly appealing
given that context and those, along with the wide variety of diagnostic and assessment tools, were
overviewed in this book.
10.1 MULTIDISCIPLINARY RESEARCH AGENDA

All of the authors of this book have been working in multidisciplinary research around the health
and wellness of children and adults with neurodevelopmental disorders for many years. Two have
been collaborating from these different worlds for a decade. The authors collectively have written
numerous literature reviews, including three on sub-topics covered in this book. Despite the years
of trust, engagement, and communication practices built in that time, reviewing this literature was
still an incredibly difficult task.
Multidisciplinary research in any field struggles with issues of how to conduct research,
where to publish, and what constitutes a contribution to the field. In the case of ADHD, the basic
science required to move the field forward includes the development and dissemination of clini-
cally relevant science, construction of robust theoretical and empirical models, and the design and
development of novel technologies. Likewise, true progress comes when evidence-based decisions
drawn on this research are the norm, and products in the marketplace have been rigorously tested
for efficacy. Translating the scholarship of this field into real-world practice requires the tech
transfer inherent to getting computer science research into the development pipeline as well as the
translation of behavioral and clinical research into policies, procedures, and practices.
Some simple but tractable challenges in this kind of scholarship include: publication venues,
keywords, style of research, and authorship. Clinical research must be indexed by PubMed to be
accessible to practitioners, medical and psychology students, and to be included in meta-reviews.
However, despite some progress—largely driven by leaders in the American Medical Informatics
Association, the Association for Computing Machinery, and the IEEE—many computing journals
98 10. DISCUSSION AND CONCLUSION
are still not indexed in this important reference site. Furthermore, even those that are can be nearly
impossible to find and understand, as computing articles tend not to use the standard abstract
presentation that many clinical venues do, making these articles functionally inaccessible, if not
physically inaccessible to clinicians and clinical researchers. On the other hand, clinical journals,
although they include randomized studies, often lack the technical descriptions needed to replicate
technological tools. Moreover, technological solutions are often designed from a clinical perspec-
tive, leaving aside the needs of the end-users, in this case, individuals with ADHD, something the
human computer interaction (HCI) field is trying to improve. This is only an example for U.S.-
based research. These issues are augmented when the multidisciplinary team research also includes
researchers from all over the world (not only from the “Global North”), as each country tends to
have its own policies on which publication venues are acceptable by their standards.
While more open tools like Google Scholar have improved this access, keywords still re-
main problematic. Simply put, computing researchers like to change keywords a lot with the new
technology trends and nearly never use the terms “technology” or “computer” that are too broad to
be useful in computing specific fields. Without these keywords, however, ADHD researchers and
practitioners are unlikely to stumble onto an article that invokes technical jargon for keywords like
“deep learning,” “Internet of Things,” or “wearables.” And yet, computing researchers need those in
other fields to pick up the work as it becomes unpublishable in computing venues around the time
it becomes eligible for a clinical trial and publication in a behavioral or medical context.
The notion of what is publishable brings us to the concern regarding publication style. This
book overviews a wide variety of papers in both content and structure. With such an enormous set
of publications available to read, people are always going to tend toward the ones that are structured
in familiar ways. However, a radically multidisciplinary space such as this should bring researchers
from computing, design, education, psychology, psychiatry, physiology, vocational rehabilitation,
and more. We, as scholars, must commit to reading in these fields even when uncomfortable as
well as learning to write in those styles. Finally, reviewers and editors must become more open to
norm-violating publications with scholarly merit.
Most academic researchers are keenly aware of the authorship norms in their own communi-
ties. However, these are highly differentiated across fields. Nowhere does this become more appar-
ent than when writing a major review in a field such as this. The authorship lists in the references
in this book vary from a single author to more than 20. As the field grows and as greater numbers
of technical contributions to work appear in the form of creation and maintenance of large-scale
datasets, code repositories, and algorithms, researchers will likely find themselves needing to address
authorship concerns in radically new ways. In our own collaborative work over the last decade, we
have learned to map out publications ahead of time, have uncomfortable but frank conversations
about authorship, and take any challenges that emerge with a generous and open spirit.
10.2 INCLUSIVE AND ENGAGED RESEARCH 99
Although this book does some of the work of addressing these multidisciplinary challenges
by going beyond a standard structured literature review, there is still work to do. Technological
venues allow for—in fact, demand—work that is innovative and new, which clinical journals rarely
allow, opting instead for a full randomized controlled trial (RCT) before publication. So, while
replication studies, studies at scale, and any long-term study that might demonstrate true efficacy
but has no technological innovation can be incredibly difficult to publish in a computing venue,
anything shy of a fully functioning product—which requires major investment—can be nearly
impossible to get in the hands of clinicians. These are not problems to be solved by single research
teams, no matter how excellent their interdisciplinary approach. These are major structural and
systemic issues that must be addressed for this field to truly advance.
10.2 INCLUSIVE AND ENGAGED RESEARCH

Due to the complexity and sheer number of people of all ages, gender identifications, and ethnic-
ities living with ADHD, a vast array of technologies are regularly brought to bear in support of
this community. At the same time, these technologies can be used to oppress, surveil, and dismiss
people with ADHD. This mix of power for opportunity and growth and risk for abuse and toxic-
ity is not unique to technologies in this space. However, the history of humankind’s responses to
people who think differently, live with mental health challenges, and cope with ADHD indicates
that special care should be taken in considering how the technologies we develop might be stud-
ied, received, and used.
One of the ways to deal with the challenges of ensuring access, inclusion, and equity in
our research is to include people with ADHD in our research teams and labs. The authors of this
book all make a practice of inclusion of people with a wide variety of disabilities into our research
programs. These individuals cannot be engaged simply as volunteers or community partners,
though those are valuable roles. They must also be invited into paid positions, studentships, and
full team memberships.
Beyond the good practices of individual research teams, given the power to both support and
harm individuals with ADHD and other mental health conditions, technological systems should
be subject to regulation. For the last several years, in the U.S., the Food and Drug Administration
(FDA) has been examining whether and how to regulate digital health applications (Shuren et
al., 2018). The outcome of this ultimate regulation will likely slow the development—particularly
commercial development—of some digital products in this space. However, the overall effect of
this slowdown will also likely be technologies with greater evidence of their efficacy before going
to market. One can hope that changing the speed of development may also increase the ability for
research labs and companies to create neurodiverse teams for the design, development, and testing
of these products.
To meet the high bar of the FDA and other regulatory agencies, the community will have to
develop higher quality standards for evaluation. Returning to the issues of interdisciplinarity from
the prior section, these standards will have to cross communities for them to be effective. As of now,
almost no standards reach across academic communities in this way. Even relatively standardized
concerns that have regulating bodies, such as the ethical treatment of human subjects, are still not
consistently managed. A true commitment to technological tools that are efficacious and ethical,
however, will demand such standards emerge, not just in technologies for mental health but across
the scope of computing. Moreover, researchers from all over the world should be acknowledged,
and, as researchers (in both clinical and computer fields), we cannot assume that technology that is
developed in one context may work for others that clearly have different resources and needs. So,
although the FDA is a well know regulatory agency in the U.S., we must look beyond those norms,
especially for developing countries.
Finally, computing researchers, especially those who work in the space of technologies for
health, will have to develop a more consumer-facing approach to their scholarship. Open-source
software communities offer one model for ensuring wide access to the products developed in gov-
ernment and university research labs. However, the use of such code repositories often still requires
heavy technical skills. A world must be developed in which research is accessible to people with
ADHD and those who care about them, whether through open access publishing, a notion of a
“generic” software intervention like generic prescription medication, or other mechanisms.
10.3 HUMAN AUGMENTATION OR REPLACEMENT

The world is simultaneously experiencing a surge in computational power and a highly limited
workforce in terms of people who can care for those with ADHD or other mental health chal-
lenges. In such a scenario, the temptation to replace humans with agent-based and other intelligent
support is enormous. However, recent seminal books on psychotherapy research have illustrated
the tremendous importance of a therapist-patient relationship as a common factor that predicts
psychotherapy outcomes above and beyond improvements attributed to specific therapeutic models
or strategies (Wampold and Imel, 2015). The importance of this human connection should not be
discarded in the race to deliver technologies to expand access to mental health intervention. We
see possibilities in a balanced approach in which computational elements support those things
that technology is best at supporting, and therapists, parents, friends, and educators continuing to
play key roles in supporting individuals with ADHD. An apt metaphor for this approach might
be the monitoring systems in a hospital that do the drudgery of checking the patient’s vital signs
frequently, recording progress, and ensuring no crisis is occurring, while clinicians do the high-level
work of monitoring these monitoring systems, responding if something changes that is problematic,
listening to patients, and providing direct treatment and patient education when needed. Likewise,
10.4 THE NEED FOR TRANSLATIONAL RESEARCH AND SYSTEMIC CHANGE 101
schools are already making use of intelligent tutor software programs to provide customized com-
puter-based instruction overseen by a teacher. We noted in some papers published in technological
scientific venues that programs were not described with this balance in mind. For future work, we
suggest that this balanced approach is taken; in striking this balance, researchers and developers
should acknowledge the strengths and limitations of technological approaches, which in turn may
increase the willingness of clinicians to adopt and use technologies, with the understanding that the
tools will support and extend their impact, rather than fully replace them. To achieve this balance,
multidisciplinary teams are especially important, as they simultaneously will draw from expertise in
clinical science/practice and computational science.
10.4 THE NEED FOR TRANSLATIONAL RESEARCH AND

SYSTEMIC CHANGE
In this book, we have frequently noted the gap in translation from design to adoption among
clinicians, families, and other systems (schools, workplaces). The computer science literature de-
scribes a wide variety of exciting, novel approaches to treatment and assessment. Most of these
papers describe development and feasibility or user testing with small sample sizes. In the clinical
sciences, the randomized clinical trial (often with a hundred or more patients) is considered the
gold standard for evaluating an intervention. Yet, few of the tools developed by computer scientists
have been studied at this level, as their goal is first to test prototypes to understand how the users
use them, how they can be improved, and discard those prototypes that have no potential from the
early stages, with the aim of only testing the efficacy of those prototypes with more possibilities
to success. This inevitably limits the uptake of products among clinicians, families, and individuals
with ADHD.
We noted that despite the innovative tools described in the literature, very few are com-
mercially available at this time. What is needed to move these ideas into the world so that they
can directly benefit individuals with ADHD and those around them? Certainly, we believe that
multidisciplinary and diverse teams are a necessary first step. Other systemic changes in the way
we conduct multidisciplinary science are also necessary. For example, there is a need to increase the
representation of these early-stage studies in clinical journals to increase awareness of the potential
value of technological tools and to inspire multidisciplinary research agendas, especially among clin-
ical scientists. This will require some adjustments and greater flexibility in journal editorial policies,
which we believe are possible to achieve without sacrificing scientific rigor. Another greatly needed
systemic change involves how we fund clinical trials once a prototype is available for this type of
testing. Clinical trials of sufficient size are extremely expensive to conduct, often costing several mil-
lion dollars over a few years. In the U.S., clinical scientists remain largely dependent on clinical trial
funding from the National Institutes of Health, yet this funding is extremely limited, competition
for funding is fierce, and it can take years to successfully obtain funding. Often, by the time funding
is received, substantial modifications to the study design are needed as technologies have advanced
in the interim. These modifications generally are a good thing, though, as they can help improve
the study design and product studied. Changes could include more NIH support for digital health
technology as well as bringing other investors and grant-making entities into this work.
We encourage investigators and the community at large to become engaged in advocating
for systemic changes that will decrease this substantial lag in the time from development to the
marketplace. Our current environment in the time of COVID-19 indicates that this is possible
when the demand and motivation is there. For example, telehealth capacity has existed for decades
in the “Global North,” and there have been a number of studies published over the last decade or
two that set the framework for how to conduct a telehealth practice ethically and safely. However,
clinician uptake of telehealth practices was extremely limited prior to March of 2020. Since that
time, many organizations and clinicians have rapidly engaged in telehealth practices. In our own
experiences at the University of California, we saw how rapidly departments were able to transition
to telehealth when the environment demanded it, and we are witnessing how effectively we are
able to deliver mental health services and reduce barriers to treatment using technologies that have
been available to us for at least the past decade. We hope that we will learn from this experience
and that it will fundamentally change for the better the way that we approach mental health care
and multidisciplinary work in the years to come, particularly as it relates to more rapid engagement
with technologies that can improve clinical care.
103
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155
Authors’ Biographies
Dr. Franceli L. Cibrian is an Assistant Professor at the Fowler School of
Engineering at Chapman University in Orange, California. She belongs to
the Nacional Science System from Mexico, given by Conacyt. She did her
postdoctoral training in the STAR lab of Dr. Gillian Hayes at UC Irvine.
She received her Ph.D. in Computer Science from the Center for Scien-
tific Research and Higher Education (CICESE) in Mexico, where she
worked under the supervision of Dr. Monica Tentori. She has a back-
ground in computer system engineering and a minor in software engineer-
ing. Her research interests focus on the design, development, and evalua-
tion of ubiquitous interactive technology to support the development of children, particularly
children with special needs. She has experience in human–computer interaction and interaction
design, with a specific focus on interactive surfaces and educational and therapeutic interventions
for children. She has also done research stays at the Design Lab at UC San Diego under the su-
pervision of Dr. Nadir Weibel and in the UCL Interaction Center at University College London
(UCL) under the supervision of Dr. Nadia Berthouze.
Dr. Gillian R. Hayes is the Robert A. and Barbara L. Kleist Professor of

Informatics at the University of California, Irvine, in the Department of
Informatics in the School of Information and Computer Sciences, in the
Department of Pediatrics in the School of Medicine, and in the School of
Education. Dr. Hayes is also the Vice Provost for Graduate Education and
Dean of the Graduate Division at the University of California, Irvine. She
is an alumna of Vanderbilt University and the Georgia Institute of Tech-
nology. For 15 years, her research has focused on designing, developing,
and evaluating technologies in support of vulnerable populations, including those with autism.
Building on a background in computer science and a consulting career before academia, she focuses
on methods for including people not traditionally represented in the design process or in research.
She received a CAREER award from the National Science Foundation in 2008 for her work on
mobile technologies for children and families coping with chronic illness and neurodevelopmental
disabilities. Her most recent work in this space has focused on wearables and augmented and virtual
reality in collaboration with former students and postdoctoral scholars, Dr. LouAnne Boyd, Dr.
Franceli Cibrian, Dr. Kathryn Ringland, and Dr. Monica Tentori. Dr. Hayes received the CHI
156 AUTHORS’ BIOGRAPHIES
Social Impact Award in 2019 for her work supporting community-based engaged research related
to technologies for neurodevelopmental disorders.
Dr. Kimberley D. Lakes is an Associate Professor of Psychiatry and Neu-

roscience at the University of California, Riverside. She is an alumna of
University of Wisconsin, Madison and completed a clinical child psychol-
ogy internship at the Children’s Hospital Los Angeles and a clinical psy-
chology postdoctoral fellowship at the Children’s Hospital of Orange
County and University of California, Irvine. She began her academic ca-
reer with a faculty appointment in the School of Medicine at the Univer-
sity of California, Irvine (UCI), and in 2018, left UCI and joined the fac-
ulty of the Department of Psychiatry and Neuroscience at the University of California Riverside
(UCR) School of Medicine. Dr. Lakes is a licensed psychologist who practices neuropsychology at
the university, with a specialty in child and adolescent neurodevelopmental disorders, particularly
ADHD. The central aim of her research is to contribute to scientific understanding of self-regula-
tion and executive functions in children and adolescents. In collaboration with Dr. Hayes and Dr.
Cibrian, she received funding from the Agency for Health Research and Quality and National
Institutes of Health to develop and study a digital health intervention for children and adolescents
with ADHD that includes intervention delivered through Apple Watches for children and a paired
iPhone application for parents. She has received a number of awards from the National Institutes
of Health for the impact of her work on youth who experience health disparities. Other awards for
her work include the Outstanding Recent Graduate Award from the School of Education at the
University of Wisconsin, Madison, Aspen Brain Forum Young Investigator Prize (awarded at the
international Aspen Brain Forum hosted by the New York Academy of Sciences, Aspen Brain
Foundation, and National Science Foundation), and a research fellowship to the University of Ox-
ford in the United Kingdom. www.drkimberleylakes.com.

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