Inattention significantly impacts children's lives, affecting their performance at home and school. While stimulant medication is the most common treatment for ADHD, it has several side effects. Cognitive training and physical exercise are promising non-pharmaceutical alternatives, and combined approaches (exergames) have shown some benefits. However, research validating these combined approaches, particularly their real-world impact, neural correlates, and long-term effects, is limited. This study aimed to assess the feasibility of implementing an integrated cognitive-physical videogame, BBT, as an after-school program and evaluate its impact on attention abilities in children with a range of attention abilities. The "all-comers" approach allowed exploration of the intervention's benefits across the spectrum of attention abilities, rather than focusing solely on clinically diagnosed ADHD cases. The study aimed to demonstrate the intervention's impact on objective cognitive and neural measures of attention, as well as on real-world function as reported by parents. Finally, it sought to determine the persistence of benefits beyond the initial intervention period.

Existing research demonstrates the individual benefits of cognitive training and physical exercise in improving attention in children. Studies have shown improvements in cognitive control abilities (attention, working memory, and cognitive flexibility) following targeted attention interventions and fitness-based interventions. The combined approach of exergames has also demonstrated some success in enhancing executive function. However, these studies often lack comprehensive evaluations, including parental perceptions, neural mechanisms, and long-term effects. There is a clear need for research that comprehensively assesses the effectiveness of combined cognitive-physical interventions, considering the diversity of children's attention abilities.

Twenty-seven children (7-12 years old) were recruited through school postings and word of mouth. After screening, 22 children (6 female) completed the 8-week intervention (24 sessions, 30 min/day). The BBT intervention integrates full-body motion capture technology (Kinect 2™) with cardiac and cognitive adaptive algorithms into a 3D video game. It comprises three modules targeting attention, working memory, and cognitive flexibility. The game uses closed-loop adaptivity, adjusting difficulty based on real-time performance and heart rate (monitored using an Apple Watch™). Outcome measures included the Vanderbilt ADHD Parent Rating Scale (parent-reported inattention), the Test of Variables of Attention (TOVA; objective measure of sustained attention and impulsivity), and EEG recordings (inter-trial coherence (ITC) as a neural correlate of attention). Secondary measures included the NeuroRacer multitasking assessment, a delayed recognition working memory task, and physical fitness tests (Curl-Up, Push-Up, Trunk Lift, PACER run). Data were collected at baseline, post-intervention, and 1-year follow-up. Paired samples t-tests and repeated measures ANOVAs were used to analyze the data, comparing pre-to post-training, post-training to 1-year follow-up, and pre-training to 1-year follow-up performance. Correlations between changes in primary measures were also calculated. Comparisons to historical control data from previous studies were also conducted using repeated measures ANOVAs.

The study demonstrated a 95.8% compliance rate. Participants showed significant improvements in parent-reported inattention (average change = 3.72 points, p = 0.002), comparable to previous studies with children diagnosed with ADHD. Improvements were also observed on the TOVA task, specifically in response time variability (RTV) for both sustained (p = 0.024) and impulsive (p = 0.001) conditions. These improvements persisted for at least 12 months. EEG analysis revealed increased midline frontal theta ITC following the intervention for both sustained (p = 0.05) and impulsive conditions. Changes in ITC correlated with both parent-reported inattention and RTV improvements. Secondary outcome measures also showed improvements: multitasking performance improved (p = 0.001), there was a trend toward improvement in working memory accuracy (p = 0.07), and improvements in physical fitness measures (Curl-Up, max HR). There was no significant correlation between baseline inattention scores and the extent of improvement on the primary outcome measures, suggesting the intervention benefits children across a spectrum of attention abilities.

The findings provide preliminary evidence that BBT is a feasible and effective non-pharmaceutical intervention for improving attention in children. The high compliance rate and observed improvements in both subjective (parent reports) and objective (cognitive and neural) measures suggest the intervention's potential for real-world applications. The lack of correlation between baseline inattention and improvement suggests that BBT benefits children regardless of their initial level of attention difficulties. The observed neural changes further support the effectiveness of the intervention and provide insight into the underlying mechanisms. The persistence of benefits for one year highlights the potential long-term impact of BBT.

This pilot study provides encouraging evidence for the feasibility and effectiveness of the BBT videogame in enhancing attention in children with varying attention abilities. The observed improvements across multiple measures, including parent-reported inattention, objective cognitive tasks, neural activity, and even physical fitness, suggest a comprehensive benefit. The long-term persistence of improvements highlights the potential for sustainable impact. Future research with larger samples and control groups is needed to confirm these findings and explore the mechanisms of action.

The single-arm design limits the ability to draw definitive conclusions about BBT's efficacy compared to other interventions or control groups. The relatively small sample size may limit the generalizability of the findings. The heterogeneous sample, while reflecting real-world diversity, makes it challenging to isolate effects for specific populations (e.g., children with ADHD). Some correlations reported didn't survive correction for multiple comparisons. Further research needs to address these limitations.