The Effects of Exergaming on Attention in Children With Attention Deficit/Hyperactivity Disorder: Randomized Controlled Trial

Background Despite growing evidence showing the effects of exercise and cognitive trainings on enhancing attention, little is known about the combined effects of exergame on attention in children with attention deficit/hyperactivity disorder (ADHD). Exergame, a form of exercise using a video game, has both cognitive stimulation and physical activity components and has been shown to improve cognitive function in children. Objective The purpose of this study was to investigate the effect of exergaming on attention and to compare the effect induced by exergaming with the effect of aerobic exercise on attention in children with ADHD. Methods In all, 30 children with ADHD, aged 8-12 years, were randomly divided into an exergaming group (EXG; n=16) or a bicycle exercise group (BEG; n=14). Before and after the 4-week intervention, the Frankfurter Aufmerksamkeits-Inventar (FAIR; Frankfurt Attention Inventory) test was administrated, and event-related potentials during the Go/No-go task was measured to assess attention. Results After intervention, both the EXG and BEG had significantly increased selective attention and continuous attention (all P<.001), as well as self-control on the FAIR test (EXG: P=.02 and BEG: P=.005). Similarly, both the EXG and BEG had significantly reduced response time on the Go/No-go test (all P<.001). For the Go response, the N2 amplitude (frontocentral maximal negativity) was significantly increased in Fz (midfrontal line) in the EXG (P=.003) but was not changed in the BEG (P=.97). Importantly, the N2 amplitude in Fz was significantly greater in the EXG compared to the BEG (Go: P=.001 and No-go: P=.008). Conclusions Exergaming has the comparable effects to bicycle exercise to enhance attention in children with ADHD, suggesting that exergaming can be used as an alternative treatment for children with ADHD. Trial Registration Clinical Research Information Service KCT0008239; https://tinyurl.com/57e4jtnb

The CONSORT-EHEALTH checklist is intended for authors of randomized trials evaluating web-based and Internet-based applications/interventions, including mobile interventions, electronic games (incl multiplayer games), social media, certain telehealth applications, and other interactive and/or networked electronic applications. Some of the items (e.g. all subitems under item 5 -description of the intervention) may also be applicable for other study designs.
The goal of the CONSORT EHEALTH checklist and guideline is to be a) a guide for reporting for authors of RCTs, b) to form a basis for appraisal of an ehealth trial (in terms of validity) CONSORT-EHEALTH items/subitems are MANDATORY reporting items for studies published in the Journal of Medical Internet Research and other journals / scientific societies endorsing the checklist.
As the CONSORT-EHEALTH checklist is still considered in a formative stage, we would ask that you also RATE ON A SCALE OF 1-5 how important/useful you feel each item is FOR THE PURPOSE OF THE CHECKLIST and reporting guideline (optional).
Mandatory reporting items are marked with a red *. In the textboxes, either copy & paste the relevant sections from your manuscript into this form -please include any quotes from your manuscript in QUOTATION MARKS, or answer directly by providing additional information not in the manuscript, or elaborating on why the item was not relevant for this study. yes: all primary outcomes were significantly better in intervention group vs control partly: SOME primary outcomes were significantly better in intervention group vs control no statistically significant difference between control and intervention potentially harmful: control was significantly better than intervention in one or more outcomes inconclusive: more research is needed 其他: not submitted yet -in early draft status not submitted yet -in late draft status, just before submission submitted to a journal but not reviewed yet submitted to a journal and after receiving initial reviewer comments submitted to a journal and accepted, but not published yet published 其他: not submitted yet / unclear where I will submit this Identify the mode of delivery. Preferably use "web-based" and/or "mobile" and/or "electronic game" in the title. Avoid ambiguous terms like "online", "virtual", "interactive". Use "Internet-based" only if Intervention includes non-web-based Internet components (e.g. email), use "computer-based" or "electronic" only if offline products are used. Use "virtual" only in the context of "virtual reality" (3-D worlds). Use "online" only in the context of "online support groups". Complement or substitute product names with broader terms for the class of products (such as "mobile" or "smart phone" instead of "iphone"), especially if the application runs on different platforms.  e  a  t  u  r  e  s  /  f  u  n  c  t  i  o  n  a  l  i  t  i  e  s  /  c  o  m  p  o  n  e  n  t  s  o  f  t  h  e  i  n  t  e  r  v  e  n  t  i  o  n  a  n  d  c  o  m  p  a  r  a  t  o  r  i  n  t  h  e  M  E  T  H  O  D  S  s  e  c  t  i  o  n  o  f  t  h  e  A  B  S  T  R  A  C  T Mention key features/functionalities/components of the intervention and comparator in the abstract. If possible, also mention theories and principles used for designing the site. Keep in mind the needs of systematic reviewers and indexers by including important synonyms.

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Clarify the level of human involvement in the abstract, e.g., use phrases like "fully automated" vs. "therapist/nurse/care provider/physician-assisted" (mention number and expertise of providers involved, if any).  t  o  -f  a  c  e  a  s  s  e  s  s  m  e  n  t  s  i  n  t  h  e  M  E  T  H  O  D  S  s  e  c  t  i  o  n  o  f  t  h  e  A  B  S  T  R  A  C  T Mention how participants were recruited (online vs. offline), e.g., from an open access website or from a clinic or a closed online user group (closed usergroup trial), and clarify if this was a purely web-based trial, or there were face-to-face components (as part of the intervention or for assessment). Clearly say if outcomes were self-assessed through questionnaires (as common in web-based trials Copy and paste relevant sections from the manuscript abstract (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Methods: Thirty children with ADHD, aged between 8 and 12 years old, were randomly divided into an Exergame group (EXG, n=16) or a bicycle exercise group (BEG, n=14). Before and after the 4-week intervention, the Frankfurter Aufmerksamkeits-Inventar (FAIR) test was administrated and event-related potentials (ERP) during the Go/No-go task was measured to assess attention.  I  N  T  R  O  D  U  C  T  I  O  N   2  a  )  I  n  I  N  T  R  O  D  U  C  T  I  O  N  :  S  c  i  e  n  t  i  f  i  c  b  a  c  k  g  r  o  u  n  d  a  n  d  e  x  p  l  a  n  a  t  i  o  n  o  f  r  a  t  i  o  n  a  l  e   D  o  e  s  y  o  u  r  p  a  p  e  r  a  d  d  r  e  s  s  s  u  b  i  t  e  m  1  b  -i  v  ? Copy and paste relevant sections from the manuscript abstract (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Results: After intervention, both EXG and BEG significantly increased selective attention and continuous attention, and self-control on the FAIR test. Similarly, both EXG and BEG significantly reduced RT on the Go/No-go test. To the Go response, the N2 amplitude was significantly increased in Fz in EXG, but not changed in BEG. Importantly, the N2 amplitude in Fz was significantly greater in the EXG compared to BEG. Copy and paste relevant sections from the manuscript abstract (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Conclusions: Exergame has the comparable effects to cycling exercise to enhance attention in children with ADHD, suggesting that Exergaming can be used as an alternative treatment for children with ADHD. Our results showed that both Exergame and bicycle exercise training enhanced the attention in children with ADHD, but the benefits induced by Exergame may be somewhat greater than bicycle exercise. These findings suggest that, through complex and stimulating environment during the training, Exergame may stimulate the frontal lobes of the brain and has a significant impact on attention, processing speed, and cognitive control function, thereby improving attention in children with ADHD symptoms. Therefore, the present study may hold an important public health implication that Exergame could be used as a new exercise therapy for ADHD children in the future.
? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder that is characterized by inattention and/or hyperactivity and impulsivity [1]. Approximately 3 to 5% of the school age population is living with ADHD [2, 3]. Among symptoms of ADHD, hyperactivity tends to improve during adolescence, but carelessness and impulsiveness may persist into adulthood [4]. The impaired attention and executive function in children with ADHD lead to reduced inhibitory ability, working memory, and task shift due to an imbalance of neurotransmitters such as dopamine and norepinephrine [5][6][7]. The abnormal neuropsychological activities caused by these symptoms may disrupt the patients' learning ability, daily activities, professional activities and social functions [8,9]. Each exercise session consisted of 10 min of warm-up, 30 min of main exercise, and 10 min of cool down. Exercise interventions were conducted in two separate child mental health care facilities so that the groups were not aware of the exercise program they were performing with each other. Participants who did not complete more than 80% of the exercise sessions were excluded from the final analysis.The Frankfurter Aufmerksamkeits-Inventar (FAIR) test was administrated and reaction time (RT) and electrophysiological signal from the frontal (Fz) cortex were collected during a Go/No-go task twice, pre-and post-exercise training. Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Children with mild to moderate ADHD were recruited from Children's Mental Health Medical Center in Busan, Republic of Korea. Participants who met the following criteria were included in the study: Korean Attention-Deficit/Hyperactivity Disorder Diagnostic Scale (K-ADHDDS) between 70-110, indicating lack of attention; absence of children with diseases other than ADHD; right-hand dominance; normal or corrected-to-normal vision; absence of physical impairment to perform exercise. Written informed consent was obtained from both the children and their parents/legal guardians. Forty-two children (8 to 12 years old) with mild to moderate ADHD were recruited and then randomly assigned to either Exergame group (EXG; n = 21) or the bicycle exercise group (BEG; n = 21). Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Open vs. closed, web-based vs. face-to-face assessments: Mention how participants were recruited (online vs. offline), e.g., from an open access website or from a clinic, and clarify if this was a purely webbased trial, or there were face-to-face components (as part of the intervention or for assessment), i.e., to what degree got the study team to know the participant. In online-only trials, clarify if participants were quasi-anonymous and whether having multiple identities was possible or whether technical or logistical measures (e.g., cookies, email confirmation, phone calls) were used to detect/prevent these. Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Exercise session for both EXG and BEG were consist of 3 days/week, 50 min/day, 60% to 80% of heart rate reserve (HRR) for 4 weeks. Exercise intensity was determined by using the Karvonen target HR method: [exercise intensity × (HRmax -resting HR)] + resting HR [36]. Each exercise session consisted of 10 min of warm-up, 30 min of main exercise, and 10 min of cool down. Exercise interventions were conducted in two separate child mental health care facilities so that the groups were not aware of the exercise program they were performing with each other. Participants who did not complete more than 80% of the exercise sessions were excluded from the final analysis.The Frankfurter Aufmerksamkeits-Inventar (FAIR) test was administrated and reaction time (RT) and electrophysiological signal from the frontal (Fz) cortex were collected during a Go/No-go task twice, pre-and post-exercise training.
Information given during recruitment. Specify how participants were briefed for recruitment and in the informed consent procedures (e.g., publish the informed consent documentation as appendix, see also item X26), as this information may have an effect on user self-selection, user expectation and may also bias results.

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Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study All subjects were required to complete a written informed consent approved by the Institutional Review Board of Pusan National University. Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study The Frankfurter Aufmerksamkeits-Inventar (FAIR) test was administrated and reaction time (RT) and electrophysiological signal from the frontal (Fz) cortex were collected during a Go/No-go task twice, pre-and post-exercise training. Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study The Frankfurter Aufmerksamkeits-Inventar (FAIR) test was administrated and reaction time (RT) and electrophysiological signal from the frontal (Fz) cortex were collected during a Go/No-go task twice, pre-and post-exercise training.  Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Describe the history/development process of the application and previous formative evaluations (e.g., focus groups, usability testing), as these will have an impact on adoption/use rates and help with interpreting results. Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Revisions and updating. Clearly mention the date and/or version number of the application/intervention (and comparator, if applicable) evaluated, or describe whether the intervention underwent major changes during the evaluation process, or whether the development and/or content was "frozen" during the trial.
Describe dynamic components such as news feeds or changing content which may have an impact on the replicability of the intervention (for unexpected events see item 3b).
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Digital preservation: Provide the URL of the application, but as the intervention is likely to change or disappear over the course of the years; also make sure the intervention is archived (Internet Archive, webcitation.org, and/or publishing the source code or screenshots/videos alongside the article). As pages behind login screens cannot be archived, consider creating demo pages which are accessible without login. Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study EXG was administered using ExerHeart® devices (D&J Humancare, Busan, South Korea), which consisted of a running/jumping board (730 width × 730 depth × 130 height) and a screen connected to the board ( Figure 1A). The exercise program called "Alchemist's Treasure" (D&J Humancare, Busan, South Korea) was used for EXG. In this game, participants run or jump in place with their avatars, using front, back, left, and right sensors on the mat to avoid obstacles and acquire items ( Figure 1B). The BEG performed stationary bike exercise using commercial Fit Elite-Whole body exerciser 1000 (Seoul, South Korea), with resistance of 0.5~3 kp. Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Clarify the level of human involvement (care providers or health professionals, also technical assistance) in the e-intervention or as co-intervention (detail number and expertise of professionals involved, if any, as well as "type of assistance offered, the timing and frequency of the support, how it is initiated, and the medium by which the assistance is delivered". It may be necessary to distinguish between the level of human involvement required for the trial, and the level of human involvement required for a routine application outside of a RCT setting (discuss under item 21 -generalizability).  Figure 1A). The exercise program called "Alchemist's Treasure" (D&J Humancare, Busan, South Korea) was used for EXG. In this game, participants run or jump in place with their avatars, using front, back, left, and right sensors on the mat to avoid obstacles and acquire items ( Figure 1B). The BEG performed stationary bike exercise using commercial Fit Elite-Whole body exerciser 1000 (Seoul, South Korea), with resistance of 0.5~3 kp.  Figure 1A). The exercise program called "Alchemist's Treasure" (D&J Humancare, Busan, South Korea) was used for EXG. In this game, participants run or jump in place with their avatars, using front, back, left, and right sensors on the mat to avoid obstacles and acquire items ( Figure 1B). The BEG performed stationary bike exercise using commercial Fit Elite-Whole body exerciser 1000 (Seoul, South Korea), with resistance of 0.5~3 kp. Exercise session for both EXG and BEG were consist of 3 days/week, 50 min/day, 60% to 80% of heart rate reserve (HRR) for 4 weeks. We monitored individual exercise intensity using HR monitor (Polar RS400sd, Finland). Exercise intensity was determined by using the Karvonen target HR method: [exercise intensity × (HRmax -resting HR)] + resting HR [36]. Each exercise session consisted of 10 min of warm-up, 30 min of main exercise, and 10 min of cool down. Exercise interventions were conducted in two separate child mental health care facilities so that the groups were not aware of the exercise program they were performing with each other. Participants who did not complete more than 80% of the exercise sessions were excluded from the final analysis. For both EXG and BEG, all subjects' heart rates (HR) during exercise were monitored using HR monitors (polar RS400sd, Madison Height, Michigan, USA) to confirm that the value was within the target HR range. Informed consent procedures (4a-ii) can create biases and certain expectations -discuss e.g., whether participants knew which intervention was the "intervention of interest" and which one was the "comparator". Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Normality of Go/No-Go test performance was also tested using the Shapiro-Wilk test. Repeated measures ANOVA were used to compute the main effects of Time (i.e., before vs after intervention), Group (i.e., EXG vs BEG), and Group × Time interaction on the behavioral performance (i.e., accuracy rate and reaction time), ERP (i.e., N2 amplitude), and FAIR (i.e., P, Q, and C). If an interaction was identified, paired sample t-test was used to verify the direction of the interaction. Significance level was set at 0.05 for all analyses, effect sizes were assessed using partial eta squared (η2p), and all statistical analyses were performed using SPSS 24. Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study There was no significant Group × Time interaction on the changes in RT in response to Go and No-go stimulation before and after exercise intervention. However, both groups significantly reduced RT for Go and No-go stimulation after exercise intervention (Fig 2). For Go stimulation, RT was significantly reduced in EXG from 846.13±126.43 ms to 764.56±107.05 ms (p=0.001, η2p=0.969) and BEG from 873.79±123.31 ms to 780.79±96.41 ms (p=0.001, η2p=1.267) (Fig 2 A) (Fig 2 B).
There was a significant Group × Time interaction on the Go and No-go N2 amplitude in the Fz region before and after exercise intervention (Table 3). EXG significantly increased Go N2 amplitude on Fz after intervention, while BEG showed no significant changes. None of the groups showed changes in No-go stimulus after intervention. In the between-group comparison, EXG consistently demonstrated greater N2 amplitudes on both Go and No-go stimulation. The waveforms of Go and No-go N2 amplitudes Fz for EXG and BEG before and after exercise are shown in Figure 3. There was no significant Group × Time interaction on the ability index P (selective attention) before and after exercise intervention. However, both groups significantly increased ability index P after exercise intervention. Similarly, although there was no significant interaction between EXG and BEG on the on the changes in ability index Q (self-control), both EXG and BEG significantly increased control index Q following intervention. Lastly, there was also no significant interaction between EXG and BEG on the on the changes in ability index C (persistent attention), but both groups significantly increased index C in response to exercise intervention (Table 4). Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Report multiple "denominators" and provide definitions: Report N's (and effect sizes) "across a range of study participation [and use] thresholds" [1], e.g., N exposed, N consented, N used more than x times, N used more than y weeks, N participants "used" the intervention/comparator at specific pre-defined time points of interest (in absolute and relative numbers per group). Always clearly define "use" of the intervention. Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study the analysis was by original assigned groups Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Table 3 Results of changes in Go/No-go N2 amplitude in Fz and Table 4 Results of changes in Frankfurter Aufmerksamkeits-Inventar (FAIR). In addition to primary/secondary (clinical) outcomes, the presentation of process outcomes such as metrics of use and intensity of use (dose, exposure) and their operational definitions is critical. This does not only refer to metrics of attrition (13-b) (often a binary variable), but also to more continuous exposure metrics such as "average session length". These must be accompanied by a technical description how a metric like a "session" is defined (e.g., timeout after idle time) [ Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study There was no significant Group × Time interaction on the changes in RT in response to Go and No-go stimulation before and after exercise intervention. However, both groups significantly reduced RT for Go and No-go stimulation after exercise intervention (Fig 2). For Go stimulation, RT was significantly reduced in EXG from 846.13±126.43 ms to 764.56±107.05 ms (p=0.001, η2p=0.969) and BEG from 873.79±123.31 ms to 780.79±96.41 ms (p=0.001, η2p=1.267) (Fig 2 A) (Fig 2 B).
There was a significant Group × Time interaction on the Go and No-go N2 amplitude in the Fz region before and after exercise intervention (Table 3). EXG significantly increased Go N2 amplitude on Fz after intervention, while BEG showed no significant changes. None of the groups showed changes in No-go stimulus after intervention. In the between-group comparison, EXG consistently demonstrated greater N2 amplitudes on both Go and No-go stimulation. The waveforms of Go and No-go N2 amplitudes Fz for EXG and BEG before and after exercise are shown in Figure 3. There was no significant Group × Time interaction on the ability index P (selective attention) before and after exercise intervention. However, both groups significantly increased ability index P after exercise intervention. Similarly, although there was no significant interaction between EXG and BEG on the on the changes in ability index Q (self-control), both EXG and BEG significantly increased control index Q following intervention. Lastly, there was also no significant interaction between EXG and BEG on the on the changes in ability index C (persistent attention), but both groups significantly increased index C in response to exercise intervention ( The purpose of the present study was to examine the effects of Exergame on attention in children with ADHD and if these effects were driven by games or exercise by comparing the effects of Exergame and cycling exercise. Through an examination of the behavioral performance and event-related potential during the Go/No-go task and FAIR test, our results may suggest that both Exergame and bicycle exercise elicited shorter RT during the Go/Nogo task, improved selective attention, self-control, and persistent attention. Notably, larger N2 amplitudes were observed following Exergame compared to the bicycle exercise. Our results are in agreement with prior findings that showed improved processing speed in ADHD children after exercise. For example, acute aerobic exercise engendered significantly faster processing speed during the Stroop and flanker task compared to the control group [40]. In another study, an 8-week yoga enhanced attention and processing speed in children with ADHD [41]. Research shows that exercise facilitates the upregulation of cerebral blood flow (CBF) [42] and exercise-induced increase in CBF promotes information processing speed [43]. Further, a possible neurophysiological mechanism underpinning the beneficial effects of exercise training on attention in ADHD children was exercise-induced secretion of catecholamine [44]. Therefore, in the present study, it may be that both Exergame and cycling exercise stimulate CBF increase and catecholamine secretion, thereby promoting the allocation of attention resources and improvement of processing speed in children with ADHD. However, since the present study did not measure CBF and catecholamines levels, this interpretation should be viewed with caution and the potential neurophysiological mechanism underpinning the Exergame and attention should be further investigated in the future.
Novel to the present investigation is that there was an interaction effect of exercise modes on changes in the N2 amplitude during the Go/No-go task after intervention, such that the improvements in the N2 amplitude were only manifested in Exergame, while the intervention effects were not observed in the bicycle exercise. The N2 components provide important information through the amplitude and latent phase because it is an indicative of attentional assignment of the anterior cingulate cortex ( subitem not at all important 1 2 3 4 5 essential ay a e bee educed due to ess e gag g e e c se e o e t c e ge de ed o beneficial effect on attention after bicycle exercise. This may also be associated with the fact that all participants who dropped out from the BEG (n=7) was due to lost interest while all participants who dropped out from the EXG (n=5) was due to conflicting schedule. This obvious discrepancy between the groups in the drop-out reasons occurred even the interventions were administered in two separate child mental health care facilities, which was intended to avoid environmental factors that could influence the participants' motivation. Thus, the ACC is likely to be more actively stimulated during complex exercise that involves multiple aspects of environment (e.g., Exergame) than monotonous exercise environment (e.g., cycling). Performing Exergame requires a process of directional judgment (e.g., front or back, left or right); thus, attention and cognitive control ability needs to be executed to successfully perform the task. However, further translational evidence is needed to clarify this hypothesis. For the FAIR results, we found improved selective attention, self-control, and persistent attention following Exergame and bicycle exercise. The results of Medina et al. [52] showed that physical activity increases the release of serotonin, dopamine and norepinephrine, and it is assumed that the attention of the participants with ADHD is improved because of the release of these neurotransmitters. According to a previous investigation, Tai Chi training was conducted to investigate the attentional in children and adolescents with ADHD [53]. The results showed that continuous Tai Chi performance at a stable speed significantly enhanced the ability of selective attention and continuous attention. Studies in adolescents with ADHD have shown that exercise based game intervention confers maximal benefits for selective attention, self-control, and persistent attention [54,55]. We surmise that three components of executive function (i.e., selective attention, self-control, and persistent attention) have been facilitated during Exergame performance. First, elective attention is the process of stimulating specific consciousness. During Exergame, participants had to quickly avoid the obstacles appear on the screen; thus, participants had to maintain their selective attention throughout the game. Second component is cognitive control, which is necessary to complete tasks within a certain period of time and is expected to be facilitated while pressing the displayed number on the screen quickly and accurately during Exergame. Lastly, sustained attention is the duration of concentration related to the duration of correct concentration. In the present study, Exergame characters were controlled by the user's movement. To control the game character's movement accurately and quickly, participants had to maintain their attention throughout the game. Therefore, because Exergame contains general aerobic exercise elements as well as additional components to stimulate selective attention, self-control, and continuous attention, it may have had significant impacts on the attention and attention of ADHD children. Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Our study is not without limitations. First, the present study is subject to the limitation of lacking a non-exercise (or active) control group, warranting some caution in interpreting the results until they can be replicated in a larger randomized controlled trial. Second, the present study is also limited by a relatively small sample size (n = 30) and homogeneous characteristics of participants (i.e., all Asians and 86.6% were male) so may not be generalizable to the entire ADHD children. Third, only one type of game device was used in the present study; thus, future studies also need to examine the effects of multiple Exergame devices and games on ADHD attention. Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study The authors have no competing interests to report.