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30 Apr 2019

Powell L et al. J Med Internet Res 2019; 21: e12831

Pharmacological and non-pharmacological treatments for children and adolescents with ADHD typically involve others helping them manage their ADHD, instead of learning self-management strategies. Although technology has been harnessed as an intervention to facilitate the self-management of ADHD in children and adolescents, there are no guidelines based on theories or evidence to underpin the development of this technology. The aim of this study was to create evidence-based guidelines with key stakeholders who will provide recommendations for the development of future technological interventions that will facilitate self-management of ADHD.

A realist evaluation* was used over five phases. Phase 1 involved identifying propositions/hypotheses outlining what could potentially work for a technological intervention. Phase 2 involved identifying existing mid-range theories of behaviour to underpin the propositions/hypotheses. Phase 3 included the identification and development of content mechanism outcome configurations which state which element of the intervention could be affected by which contexts and the consequent outcomes. Phase 4 included the validation and refinement of the propositions from Phase 1 via interviews with key stakeholders. Finally, Phase 5 involved using the information gathered from Phases 1–4 to develop the guidelines.

Overall, 21 participants were involved in the study from July to October 2018. This included seven children or adolescents (age range: 8–11 years; female: n=2) with ADHD, most of who were receiving medication for ADHD (n=5), eight parents and six specialist clinicians (consultant community paediatrician: n=2; consultant paediatrician: n=1; nurse clinical specialist: n=1; nurse prescriber: n=1; and registrar psychiatrist: n=1).

Seven key themes for technological interventions were identified in this study. These included:

  • Positive rewarding feedback:
    • All participants thought that an immediate positive reward should be used when the user selects a correct response as this would allow the user to engage with the technological intervention.
    • Some participants (n=12) felt that this reward could be personalised, and 11 participants stated that the reward could be given by providing different gaming levels.
    • However, two children/adolescents with ADHD, one parent and two clinicians believed that the levels shouldn’t be too challenging as this could cause demotivation or frustration and then stop the user’s engagement with the intervention.
  • Downloadable gaming resources:
    • The participants wanted downloadable resources to make the technological intervention more accessible. This would allow the child or adolescent with ADHD to be able to use the intervention even if they have to share a device with their siblings, have limited screen time or are away from home.
    • Some participants (children/adolescents with ADHD, n=5; parents, n=3; clinicians, n=2) also wanted the downloadable resources to have a gaming component including colouring in, crosswords, mazes, quizzes, origami activities or word searches.
  • Personalisable and adaptable components:
    • Most participants (children/adolescents with ADHD, n=5; parents, n=4; clinicians, n=6) wanted the technology to be personalisable with adaptable avatars so the hair/eye colour, gender, clothing and skin colour could be adapted as the child or adolescent wished.
    • Some participants emphasised the importance of the user having the correct amount of stimulation such that users were neither over- nor under-stimulated.
  • Psychoeducation component:
    • Several participants (children/adolescents with ADHD, n=5; parents, n=5; clinicians, n=6) felt it was important that the intervention allowed users to have a good understanding of their ADHD, and two clinicians thought the positive aspects of ADHD should be highlighted through examples of others who have ADHD (e.g. celebrities).
    • However, five clinicians stated that these interventions should not ‘gloss over’ some of the difficulties associated with ADHD.
    • Overall, 11 participants (children/adolescents with ADHD, n=3; parents, n=4; clinicians, n=4) emphasised that it was important that the intervention helped the user to understand their ADHD so they can explain it to their friends.
  • Integration of self-management strategies:
    • Most participants (children/adolescents with ADHD, n=5; parents, n=4; clinicians, n=6) believed that the technological intervention should include strategies that help the child or adolescent with ADHD self-manage their ADHD (e.g. anger-management strategies).
    • Use of animated social scenarios were also discussed where the user could choose alternate endings to help them understand what is and is not acceptable behaviour in social situations. This idea was favoured by three children/adolescents with ADHD, three parents and five clinicians.
  • Goal setting:
    • Six parents liked the idea of short-term goal setting within an intervention. As the working memory of some children/adolescents with ADHD can be poor, they felt that longer-term goals may be challenging.
  • Context (environmental and personal):
    • Personal contexts: since some children and adolescents with ADHD also have dyslexia, one parent and one clinician stated that some users may struggle to read text, and if any text was to be included then this should be on a background colour that is adaptable. Moreover, one parent and six clinicians believed that the information presented should be developmental and age-appropriate so that the user can understand the material provided.
    • Environmental contexts: in total, 13 participants (children/adolescents with ADHD, n=3; parents, n=4; clinicians, n=6) agreed that children or adolescents with ADHD would be more motivated to engage in a technological intervention if they were supported and encouraged by their close friends and relatives.

The qualitative nature of this study was validated and refined by only a small number of participants which is a limitation of this study. In addition, as ADHD is a complex disorder, one intervention will not suit all children and adolescents with ADHD or their families, and future technological interventions will need to account for this. This study was also limited by the views and opinions of the study participants, and game designers and platform developers were not consulted on these guidelines; however, this was outside the aims and objectives of this study.

The authors conclude that the guidelines outlined in this study could be of use for future development of technologies that aim to facilitate self-management of ADHD in children and adolescents.

Read more about guidelines for the development of technological interventions for self-managing ADHD in children and adolescents here

 

*Realist evaluation is an effective framework for evaluating complex healthcare interventions and aims to explore how a mechanism may cause a different outcome when in different contexts.

Powell L, Parker J, Harpin V, et al. Guideline development for technological interventions for children and young people to self-manage attention-deficit hyperactivity disorder: realist evaluation. J Med Internet Res 2019; 21: e12831.

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