The Effectiveness of Story- and Quiz-Based Games in Digital Interventions for ADHD: A Comparative Approach

Abstract

The content in digital intervention therapies for children with attention deficit hyperactivity disorder (ADHD) requires various technical elements to interest and motivate the children. Their structure is often quiz-based, which allows easy access to quantitative assessments. However, in this study, I verify the effectiveness of digital intervention therapy by implementing story-based game content with active participation. In this study, 48 children aged 6 to 13 years diagnosed with ADHD were recruited and assigned to experimental (story-based content) and control (quiz-based content) groups; their attention improvements were compared. The improvement in attention was assessed by comparing the change rate of the Comprehension Attention Test (CAT) and Korean ADHD Rating Scale (K-ARS) scores before and after the intervention. At 4 weeks, the CAT score change rate was significantly different between the groups (p = 0.039, p = 0.040); the CAT score change rate before and after the intervention was significantly greater in the experimental than in the control group (p = 0.038). After adjusting for the baseline, the experimental group showed a significantly greater reduction in the K-ARS impulsivity and total K-ARS scores compared with the control group (p = 0.018, p = 0.012). Therefore, story-based content is more effective than quiz-based content in digital intervention therapy for children with ADHD.

1. Introduction

Recent advancements in information and communications technology have had a rapid impact on the transformation of social media [1]. Consequently, the ways in which learners access information in the educational field have become increasingly diverse [2]. A learner-centered approach, in which information search functions are emphasized, has become a growing trend, and interactive methods are becoming increasingly common [3]. However, the crucial element of learner engagement and attention is recognized as a particularly distinct factor due to fast-paced changes in media [4].

Learners’ fundamental attitudes toward learning are directly related to their ability to concentrate in various environments. When attention deficits occur, learners may exhibit symptoms associated with attention deficit hyperactivity disorder (ADHD) [5]. Therefore, elements of attentional focus involve learners being intrinsically motivated, which helps regulate their learning behavior and fosters autonomous learning skills, leading to academic achievement [6]. Significant therapeutic and training interventions are required for learners who fail to develop these abilities. In particular, when the learner is a young child, careful consideration is necessary regarding treatment methods [7].

Recently, various studies have been conducted on digital therapeutic interventions that provide adjunctive therapeutic effects, along with pharmacological treatments [8]. Digital therapeutic interventions, also referred to as digital therapeutics (DTx), involve direct participation in virtual activities through video content and stimulating and training sensory behaviors through the content [9]. Particularly for children, the use of familiar visuals and engaging game-based content enhances their subjective motivation during the training process, fostering a sense of an active challenge. This approach increases the immersion in a task and contributes to improved attention [10].

Although numerous previous studies have demonstrated the effectiveness of digital therapeutic interventions in improving attention in children with ADHD [11,12,13], the influence of game-based content, specifically the structure and progression of content targeting children, has not been extensively reported. The game-based content used in digital therapeutic interventions represents a step forward from simple quiz formats to incorporating learning objectives and performance tasks that record or challenge learners to achieve quantitative target scores [14].

This study aimed to move beyond repetitive learning methods that require simple quantitative proficiency and develop a creative, story-based content approach integrated with game elements, comparing its effectiveness in digital therapeutic interventions.

Traditional quiz game content can improve learners’ quantitative outcomes through repeated practice and is typically structured in a step-by-step level-up format that requires repetitive single actions from the learner. In contrast, story-based game content adopts a problem-solving approach that relies on character immersion. This approach requires children to make numerous decisions and recall memories during the process, forming patterns based on the situational context, resulting in a greater number of scenarios. Consequently, compared with quiz formats, story-based content demands the development of a wider range of situation-specific content.

The content used in digital therapeutic interventions is fundamentally designed with a level-based difficulty tailored to the abilities of the target individual [15]. Problem-solving abilities are evaluated based on criteria such as accuracy rates or the time required to complete tasks, and progression to the next level is determined accordingly. Therefore, during the development process, content levels are established by designing components to improve memory, attention, and focus. These components are evaluated in relation to the performer’s outcomes, and their information-processing abilities are assessed to determine progression [16].

The participating children continuously track spatial changes using their visuoperceptual senses to maintain the ability to follow changes in content, such as the positions and behaviors of characters, through memory. This training method can stimulate and improve memory abilities, enhance rapid information-processing skills during the task, and is expected to improve visuoperceptual memory [17]. Although continuous repetitive learning may enhance step-by-step processing abilities, the repetition of identical actions and patterns could occasionally lead to a lack of motivation, resulting in apathy due to routine resistance in the targeted children.

This study implemented story-based game content to address these challenges and examined its therapeutic adjunct effects based on the information-processing abilities of the targeted children. Story-based game content is designed to enhance memory and attention through character-driven engagements. Starting from a simple, sequential entertainment format, it evolved into scenarios in which the character (protagonist) undertakes tasks, such as journeys or adventures, integrating fun and immersion to train selective attention, sustained attention, and visuoperceptual memory, thereby enhancing information-processing abilities. Thus, this study aimed to compare and evaluate the effectiveness of digital therapeutic interventions comparing quiz-based problem-solving with story-based game content in children with ADHD aged 6 to 13 years.

Through this study, I propose a novel approach to the design of digital therapeutic content, wherein the targeted children actively participate as protagonists of the game and perform tasks within a framework based on an engaging and appropriate storyline. This study was conducted to test the hypothesis that incorporating an appropriate storyline into the training process can enhance user attention when using game-based content. The aim is to demonstrate that story-based content is more effective than traditional quiz-based formats in improving the attention of children with ADHD.

2. Materials and Methods

2.1. Study Participants

The participants of this study were 48 children aged 6 to 13 years who were diagnosed with ADHD at the Department of Psychiatry of a university hospital [18,19]. Included were children diagnosed with ADHD by a specialist and excluded were those with medical conditions other than ADHD; those with significant motor impairments, including episodic disorders; those who had difficulty using digital therapeutic devices (e.g., physical deformities of the hands or arms, prosthetics); individuals with color blindness; those suspected or confirmed to have substance abuse or dependence within six months of screening; children who had participated in another ADHD-related study within 90 days of screening; and those with family members enrolled or participating in the same study [20].

To calculate the sample size, the difference in scores from the assessment tools was evaluated using a two-sample t-test; if normality was not satisfied, the Mann–Whitney U test was applied [21]. The existing pharmacological treatment was continued, while the experimental group (story-based content) and the control group (quiz-based content) for the adjunctive digital therapeutic treatment were assigned at a 1:1 ratio. With a two-sided significance level of 0.05 and a power of 0.90, the minimum number of subjects required to demonstrate the superiority of the experimental group compared with the control group was set at 20 participants per group, considering a dropout rate of 10%, resulting in a total of 48 participants.

A total of 48 clinical trial participants were randomly assigned to the control and experimental groups. Of the 48 participants, 8 dropped out or withdrew prior to the group assignment. The remaining 40 participants completed the intervention (Figure 1) [22]. The clinical trial was prospectively conducted for a total of four months, from 7 October 2024 to 30 December 2024, in the Department of Psychiatry at K University Hospital. It was approved by the Institutional Review Board of K University Hospital (IRB No. 2024-08-049, CRIS KCT0009862), and written informed consent was obtained from all patients (see Supplementary Materials, Document S1). All methods were performed in accordance with the relevant guidelines and regulations.

In this study, participants were allowed to continue taking their previously prescribed ADHD medications, while the initiation of any new medications during the intervention period was not permitted. The medications permitted for continued use included methylphenidate-based and atomoxetine-based treatments. These medications were maintained within the prescribed range prior to study participation and were not altered during the intervention.

In addition, there was no significant difference in the baseline severity of ADHD symptoms between the two groups. Symptom severity prior to the intervention was assessed using the Clinical Global Impression-Severity (CGI-S) scale, an observer-rated measure used to describe the overall severity, treatment response, and course of illness. Both the intervention and control groups showed statistically comparable CGI-S scores at baseline.

Furthermore, the two groups shared similar demographic and clinical characteristics, excluding age and gender distribution, including baseline symptom severity.

2.2. Experimental Methods

To test the effectiveness of the digital therapeutic intervention using game-based content, both the experimental and control groups underwent pre- and post-assessments of attention to evaluate the hypothesis. The assessment tools used to measure attention improvement were the Comprehension Attention Test (CAT) and Korean ADHD Rating Scale (K-ARS).

First, the CAT was used to measure attention in children with ADHD through pre- and posttests. This tool consists of six subtests: a visual selective attention task, auditory selective attention task, flanker task (interference selective attention), sustained attention-to-response task (inhibitory sustained attention), divided attention task, and spatial working memory task [23]. All subtests were completed by the children.

Depending on the child’s age, the tests were administered in three to six areas. Four items were measured to evaluate selective attention: visual selective attention, auditory selective attention, sustained attention-to-response tasks, and flanker tasks. This study compared the sensitivity index and rate of change in the sensitivity index as indicators of the ability to distinguish between target and nontarget stimuli during a participant’s task performance process. A sensitivity index score of two or higher indicates effective differentiation between the target and nontarget stimuli [24]. The reliability of the tool at the time of development had an average correlation coefficient of 0.79, and in this study, it was 0.81 [25].

The second assessment tool used in this study was the K-ARS, which was used to evaluate improvements in attention. Given that the assessment is designed for parents or teachers, it was completed by the parents in this study. The assessment tool consists of 18 items across two domains: attention deficits and hyperactivity–impulsivity. It is primarily used to measure attention-deficit and hyperactivity-impulsivity symptoms in children diagnosed with ADHD. Each item is rated on a 0–3 Likert scale, with 0 = “Not at all” or “None”, 1 = “Occasionally”, 2 = “Frequently”, and 3 = “Very frequently”, based on the frequency of problem behaviors in the child. If an item receives a score of two or higher, it is considered abnormal for the child’s developmental stage. The total score ranges from 0 to 54. Although there may be age-related variations, a higher score indicates more severe attention-deficit symptoms [26]. In this study, the K-ARS scores and the rate of change in the K-ARS scores were compared. The rate of change in the K-ARS score was calculated as follows: {(Baseline K-ARS) − (Follow-up 4 weeks K-ARS)}/(Baseline K-ARS) × 100. Several studies have demonstrated the reliability and validity of this assessment tool [27]. This clinical trial combined traditional pharmacological treatment with DTx. The experimental group received story-based game content DTx, whereas the control group received quiz-based content DTx. Both groups were evaluated.

2.3. Duration of Study

Participants receiving a combined treatment with existing pharmacotherapy and DTx used a digital therapeutic application for 30 min per session, five times a week, over a four-week period, alongside their usual medication. Pretreatment assessments were conducted, and posttreatment assessments were performed after four weeks of digital intervention to compare the results. During the trial period, treatment adherence was monitored at each visit to assess its potential impact on the clinical trial outcomes. To evaluate the primary efficacy, the change in the total CAT score from baseline to the four-week mark was recorded. The CAT symptom assessment was conducted for six subcategories, with evaluations at both baseline and at the four-week time point. Additionally, as a secondary efficacy measure, the total score change in the K-ARS was measured at both the baseline and the four-week mark.

The pre-assessment was conducted individually in the testing room, with each child’s schedule coordinated after enrollment. It was conducted from 10 September 2024 to 10 November 2024, with a testing duration of approximately 30 min for children aged 6 to 8 years and approximately 40–50 min for those aged 9 to 13 years. Additionally, the CAT and K-ARS test were administered individually at the clinic, with schedules coordinated for the participating children. The post-assessment was conducted four weeks after the pre-assessment, with the CAT and K-ARS test administered in the testing room based on the schedule. The post-assessment took place from 7 October 2024 to 16 December 2024, and similarly to the pre-assessment, the CAT and K-ARS test were administered individually in the clinic.

2.4. Types of Digital Therapeutic Tools

The digital therapeutic tools used in this clinical trial included the quiz-based game content EYAS-Focus (2024, Indeotec Co., Ltd., Daegu, Republic of Korea) and story-based game content NeuroWorld (2022, WooriSoft Co., Ltd., Daegu, Republic of Korea). The representative screens of these products are illustrated in Figure 2 and Figure 3.

The digital content employed for therapeutic interventions was designed to operate on mobile devices to ensure ease of use for participants. The quiz-based game content, shown in Figure 2, involves participants identifying correct answers by matching the shapes and patterns presented in the tasks. The story-based game content, depicted in Figure 3, requires participants to follow a character’s narrative and solve problems presented along the way, with performance assessed based on accuracy. Unlike tasks that require only momentary judgment, story-based game content involves decision-making based on a contextual understanding of the scenario and recall of prior information. Consequently, participants were required to maintain continuous focus throughout the training process.

2.5. Data Analysis

Data collected during the study were analyzed using SPSS Ver. 23.0 program (SPSS Inc., Chicago, IL, USA) with a two-sided test at a statistical significance level of 0.05 [28]. Efficacy evaluations were conducted using both modified intention-to-treat (ITT) and per-protocol analyses, with the final determination of clinical trial results based primarily on the modified ITT analysis [29]. The modified ITT analysis population included participants who were randomized, provided with an investigational digital device, and had post-baseline data available for primary efficacy evaluation variables. The per-protocol analysis population was derived from the modified ITT group and included participants without major protocol violations (e.g., early withdrawal, violation of the inclusion/exclusion criteria, or randomization errors). The participants were also required to have a treatment adherence rate of at least 80%.

For participants with missing data for efficacy evaluation variables due to dropouts or other reasons prior to the conclusion of the clinical trial, the last observation carried forward method was employed to replace missing values with the most recently recorded data (i.e., from the last visit) [30]. Missing data handling was applied only to the modified ITT population, whereas the other items were analyzed using the available dataset without imputing missing values. A safety evaluation was conducted for all participants who were enrolled in the clinical trial and received at least one application of the investigational medical device.

The general characteristics of the participants were analyzed using frequencies and percentages, as well as means and standard deviations. A homogeneity test for the general characteristics of the experimental and control groups was performed using Fisher’s exact test. For the homogeneity test of the dependent variables, t-tests were used if the data followed a normal distribution, and the Mann–Whitney U test was applied if the data did not follow a normal distribution [31]. The differences between groups and changes over time for dependent variables that followed a normal distribution were analyzed using repeated measures analysis of variance [32]. For dependent variables that did not follow a normal distribution, the effect of the intervention was examined using generalized estimating equations [33]. The changes before and after the intervention in the experimental and control groups were analyzed using paired t-tests, whereas differences in the changes between the groups were analyzed using independent t-tests. If normality was not satisfied, the Wilcoxon signed-rank test or Mann–Whitney U test was used. Additionally, to evaluate the differences in the changes between the groups before and after the intervention, an analysis of covariance was conducted by setting the baseline score as a covariate and comparing the changes in scores at four weeks after the intervention. This was performed to adjust for potential baseline differences between the groups and accurately assess the intervention effect.

Effect sizes were reported in addition to statistical significance. For the paired t-tests, Cohen’s d values were calculated, with interpretation thresholds set at 0.2 (small), 0.5 (medium), and 0.8 (large). For ANCOVA with baseline adjustment, partial eta squared (η²) values were reported, where 0.01, 0.06, and 0.14 were interpreted as small, medium, and large effects, respectively [34].

3. Results

3.1. Participant Information

This study included 40 children who were randomly assigned to either the experimental group (20 participants) or the control group (20 participants) using a lottery-based random sampling method (

Table 1. Information on participating children.

		Experimental Group (N = 20)		Control Group (N = 20)		p-Value
		Mean or N	SD or %	N	%
Gender						0.024 *
	Boy	16	80	11	55
	Girl	4	20	9	45
Age						0.838 *
	6–7	2	10	2	10
	8–9	10	50	12	60
	10–11	4	20	4	20
	12–13	4	20	2	10
		9.3	2.67	8.85	2.58	0.59 **

* Chi-squared test and ** independent t-test.

). The experimental group consisted of sixteen boys (80%) and four girls (20%), and the control group consisted of eleven boys (55%) and nine girls (45%). Both groups had a higher proportion of boys, and a statistically significant difference was observed between the groups based on gender (χ² = 5.1, p = 0.024). The mean ages of the experimental and control groups were 9.3 ± 2.67 years and 8.85 ± 2.58 years, respectively. There was no significant difference in age between the two groups (t = 0.848, p > 0.05), and the mean age difference was also not statistically significant (t = 0.541, p > 0.05).

3.2. Attention Assessment

After two weeks of digital intervention, the change rate in attention (total CAT score) was significantly different between the experimental group (story-based content group) and the control group (quiz-based content group), with the experimental group showing a change rate of 40.2 ± 10.4 and the control group showing 34.0 ± 17.2 (p = 0.038), as shown in

Table 2. Results of correlation analysis by level of engagement.

		Experimental Group (N = 20)		Control Group (N = 20)		p-Value	Effect Size
		Mean	SD	Mean	SD
Simple selection (visual)	Baseline	3.07	0.81	3.05	0.49	0.165 *
	Four weeks	3.59	0.57	3.40	0.33	0.849 *
	p-value	0.024 **		0.520 **		0.039 ***	0.042 ##
	Effect size	0.667 #		0.742 #
	Change rate	−16.94	29.63	−11.48	32.65	0.028 *
Simple selection (auditory)	Baseline	1.10	0.58	1.78	1.27	0.097 *
	Four weeks	1.25	1.16	1.54	0.63	0.880 *
	p-value	0.749 **		0.410 **		0.146 ***	0.025 ##
	Effect size	0.269 #		0.196 #
	Change rate	−13.64	−100	13.48	50.39	0.112 *
Sustained inhibition	Baseline	2.05	1.08	2.38	0.75	0.475 *
	Four weeks	2.31	0.54	2.46	1.02	0.514 *
	p-value	0.679 **		0.157 **		0.040 **	0.009 ##
	Effect size	0.250 #		0.111 #
	Change rate	−12.68	50	−3.36	−36	0.014 *
Interference selection	Baseline	0.62	0.76	0.57	0.36	0.498 *
	Four weeks	0.80	0.50	0.84	0.45	0.106 *
	p-value	0.064 **		0.077 **		0.043 ***	0.002 ##
	Effect size	0.246 #		0.780 #
	Change rate	−29.03	34.21	−47.37	−25	0.579 *
Total CAT score	Change rate	40.2	10.4	34.0	17.2	0.038 *	0. 436 #

* Independent t-test, ** paired t-test (Baseline vs. 4 weeks), *** analysis of covariance (ANCOVA) adjusted for baseline, ^# Cohen’s d, and ^## η². CAT: Comprehensive Attention Test.

.

Additionally, for each subtest, the sensitivity coefficients for attention were above two points in both the experimental and control groups for simple selection (visual) and sustained inhibition, with the exception of simple selection (auditory) and interference selection. Specifically, the experimental group showed a significant increase in the simple selection (visual) test from baseline to the four-week point (3.07 ± 0.81 vs. 3.59 ± 0.57, p = 0.024). Additionally, after adjusting for the baseline, a statistically significant difference was found in the scores between the experimental and control groups at the four-week time point for both the simple selection (visual) and sustained inhibition tests (p = 0.039 and p = 0.040, respectively). Both tests showed greater changes in scores in the experimental group compared with the control group.

In the interference selection test, after adjusting for the impact of the baseline on the sensitivity coefficients, a significant difference was found between the experimental and control groups after the four-week intervention (p = 0.043), although the actual score difference was minimal.

Among the sensitivity coefficients, the experimental group showed a greater rate of change in both simple selection (visual) and sustained inhibition than the control group, and this difference was statistically significant (p = 0.028 and p = 0.014, respectively). Furthermore, the rate of change in the total CAT score after the intervention was significantly greater in the experimental group than in the control group (p = 0.038).

As an indicator of the response style in the CAT, a score of one is the baseline. Scores above one indicate inattention, whereas scores below one indicate impulsivity. The results are summarized in

Table 3. The change rate of the attention response style index.

			Experimental Group (N = 20)		Control Group (N = 20)		p-Value
			Mean	SD	Mean	SD
Simple selection (visual)	Baseline		0.28	0.38	0.36	0.31	0.491 *
	Four weeks		0.87	0.38	0.36	0.31	0.754 *
	p-value		0.151 **		0.110 **		0.044 ***
	Change rate		−141.67	−393.55	−35.71	−28.95	0.028 *
			N	%	N	%
		Deterioration	8	40.0	5	25.0	0.854 ***
	Pre-post change	No change	0	0.0	1	5.0
		Improvement	12	60.0	14	70.0
Simple selection (auditory)	Baseline		0.72	0.54	0.47	0.20	0.084 *
	Four weeks		0.86	0.74	0.62	0.32	0.490 *
	p-value		0.460 **		0.140 **		0.579 ***
	Change rate		−19.44	−64.44	−31.91	−60.00	0.549 *
			N	%	N	%
		Deterioration	2	10	6	30	0.451 ****
	Pre-post change	No change	3	15	0	0
		Improvement	15	75	14	70
Interference selection	Baseline		0.70	0.08	0.77	0.21	0.742 *
	Four weeks		0.67	0.15	0.57	0.27	0.212 *
	p-value		0.620 **		0.001 **		0.143 ***
	Change rate		4.29	−87.50	25.97	−28.57	0.026 *
			N	%	N	%
		Deterioration	10	50	10	50	0.025 ****
	Pre-post change	No change	2	10	7	35
		Improvement	8	40	3	15
Sustained inhibition	Baseline		0.42	0.30	0.45	0.15	0.880 *
	Four weeks		0.70	0.27	0.64	0.04	0.214 *
	p-value		0.423 **		0.118 **		0.016 ***
	Change rate		−66.67	10.00	−42.22	73.33	0.042 *
			N	%	N	%
		Deterioration	11	55	12	60	0.280 ****
	Pre-post change	No change	0	0	0	0
		Improvement	9	45	8	40

* Independent t-test, ** paired t-test (baseline vs. 4 weeks), *** analysis of covariance (ANCOVA) adjusted for baseline, and **** chi-square test.

. For simple selection (visual) and sustained inhibition, the results of the analysis of covariance adjusted for baseline indicated that the index values and changes were significantly higher in the experimental group than in the control group (p = 0.044 and p = 0.016, respectively). Furthermore, the change rates for simple selection (visual) and sustained inhibition were significantly higher in the experimental group than in the control group (p = 0.028 and p = 0.042, respectively). Regarding interference selection, the control group showed a significantly greater rate of change than the experimental group (p = 0.026). Additionally, when analyzing the change in ADHD symptoms before and after the intervention using a chi-squared test, the data for each participant were categorized as follows: 1 for improvement (closer to 1 compared with baseline after 28 days), −1 for deterioration (further from 1), and 0 for no change. A chi-squared test was performed to analyze changes in ADHD symptoms before and after the intervention. The results show that, in interference selection, the experimental group using the story-based intervention had a significantly higher rate of symptom improvement than the control group using the short-answer intervention (p = 0.025) (Table 3).

The total K-ARS score, inattention, and hyperactivity–impulsivity scores and their respective rates of change are presented in

Table 4. The change rate of the K-ARS total score.

		Experimental Group (N = 20)		Control Group (N = 20)		p-Value
		Mean	SD	Mean	SD
K-ARS Inattention	Baseline	10.48	0.48	9.18	0.18	0.108 *
	Four weeks	7.18	1.10	7.10	2.48	0.908 *
	p-value	0.008 **		0.346 **		0.498 ***
	Change rate	31.49	−129.17	22.66	−1277.78	0.670 *
K-ARS Hyperactivity–Impulsivity	Baseline	9.08	1.05	6.48	2.58	0.242 *
	Four weeks	5.01	5.18	5.24	4.03	0.729 *
	p-value	0.010 **		0.102 **		0.18 ***
	Change rate	44.82	−393.33	20.99	−56.20	0.002 *
K-ARS Total Score	Baseline	15.77	6.18	16.04	4.28	0.108 *
	Four weeks	12.15	8.29	12.58	9.15	0.910 *
	p-value	0.026 **		0.580 **		0.012 ***
	Change rate	22.95	−34.14	21.57	−133.79	0.025 *

* Independent t-test, ** paired t-test (baseline vs. 4 weeks), and *** repeated measures ANOVA. K-ARS: Korean ADHD Rating Scale.

. The rate of change in K-ARS scores was calculated using the following formula:

$$\mathrm{C}\mathrm{h}\mathrm{a}\mathrm{n}\mathrm{g}\mathrm{e} \mathrm{r}\mathrm{a}\mathrm{t}\mathrm{e}={\displaystyle \frac{(\mathrm{B}\mathrm{a}\mathrm{s}\mathrm{e}\mathrm{l}\mathrm{i}\mathrm{n}\mathrm{e} \mathrm{K}-\mathrm{A}\mathrm{R}\mathrm{S})-(4 \mathrm{w}\mathrm{e}\mathrm{e}\mathrm{k}\mathrm{s} \mathrm{K}-\mathrm{A}\mathrm{R}\mathrm{S})}{\mathrm{B}\mathrm{a}\mathrm{s}\mathrm{e}\mathrm{l}\mathrm{i}\mathrm{n}\mathrm{e} \mathrm{K}-\mathrm{A}\mathrm{R}\mathrm{S}}}\times 100$$

A significant reduction in scores was observed in the experimental group using NeuroWorld DTx for the K-ARS inattention, K-ARS hyperactivity-impulsivity, and K-ARS total scores after four weeks (p = 0.008, p = 0.010, and p = 0.026, respectively), whereas no significant differences were noted in the control group (p > 0.05).

After adjusting for baseline effects, the experimental group that received the story-based intervention showed a significantly greater reduction in K-ARS hyperactivity–impulsivity and K-ARS total scores than the control group at the four-week follow-up (p = 0.018 and p = 0.012, respectively). Furthermore, the change rates for the K-ARS hyperactivity–impulsivity and K-ARS total scores were significantly higher in the experimental group (p = 0.002 and p = 0.025, respectively; Figure 4).

4. Discussion

This study analyzed whether game-based digital therapeutic content is effective in improving the cognitive abilities of children with ADHD. This study aimed to determine whether the effects of digital therapeutic interventions differ based on the type of content used. Recently, digital content aimed at increasing accessibility and motivation for the treatment and training of children with ADHD has been developed, primarily in the form of games [35]. For game-based content, incorporating an appropriate storyline into the execution process to engage users in the training program should be effective. This study confirmed this hypothesis.

There is a digital therapeutic program for ADHD called EndeavorRx, a game software developed in the United States for children aged 8 to 12 years with ADHD [36]. EndeavorRx was approved by the Food and Drug Administration and demonstrated that game-based digital interventions can enhance cognitive function in the targeted children. Recently, functional games using digital media have been developed as adjunct therapies for mental health treatment [37]. Similar products include the autism treatment video game AKL-T01 (Akili Interactive) and an AI-based customized behavioral therapy program for children with developmental disorders, Autism Therapeutic (Cognoa) [38]. Functional game content enhances interest in learning, motivates learning engagement, and leads to improvements in learning abilities [39].

This study confirmed the effectiveness of using story-based digital media over traditional quiz content derived from conventional classroom methods in a group of children undergoing ADHD digital intervention therapy. In particular, story-based content in game-type media has shown a superior effect in enhancing focus and improving learning attitudes, thereby contributing to an increased learning effectivity in children.

The effectiveness of story-based content is thought to stem from its ability to foster the prediction of upcoming events. The interest in and enjoyment of content are driven by a sequence of continuous events, and engagement arises during the anticipation of what will happen within those events. Simple quiz-based formats are less predictable and tend to follow a fixed path determined by the creator’s intent. By contrast, story-based content allows for variability based on the user’s role and decisions.

Game-based content used in digital interventions for children with ADHD has a positive effect [23]. The game format effectively captures the child’s attention, enhances motivation during treatment and learning (training) processes, and encourages the active and enjoyable participation of the child [40]. However, overly flashy characters and screen designs intended solely for motivation may cause excessive excitement. Therefore, maintaining balance is crucial. This balance requires designing content in alignment with the difficulty level and the intended outcome to ensure positive effects. Furthermore, children with ADHD often struggle to maintain sustained attention, making the role of observers (therapists and caregivers) essential. However, game-based content can offer benefits by allowing children to directly interact with the content through appropriate rewards (e.g., scores, items, and leveling up) [41].

Therefore, adding a story to game-based content not only enhances the sense of challenge according to the difficulty level but also allows for behavioral adjustments through predictive exercises. The continuous motivation provided by the story-driven problem-solving approach can improve self-regulation abilities. This signifies the positive effect of reducing stress and resistance during the performance process [42]. The story-based game content presented in this study not only increases the child’s engagement but also allows for the introduction of various characters throughout the performance process, enabling diverse educational opportunities. Hence, future research on social behaviors that align with the learning objectives of story-driven content is required.

The types of content used in the digital intervention and training process for children with ADHD begin with temporary motivation through enjoyment and immersion and can be enhanced by adding various contents to improve intervention effectiveness. In particular, based on the findings of this study, story-based themes for improving attention and concentration are believed to have the potential to develop into content based on individual life themes.

This study has several limitations. First, the sample size was small, as the research was conducted with only 40 patients with ADHD over a four-week period, with content-based studies for each group. Although statistical effects on ADHD symptoms were confirmed in these 40 participants, I plan to conduct a larger-scale study in the future to assess the overall effectiveness of the ADHD treatment over a longer duration. Second, the number of boy participants was higher than the number of girl participants. According to research on ADHD and neurodevelopmental disorders, the boy-to-girl ratio in children aged 6 to 13 years is approximately 2:1, with a higher incidence of ADHD in boys owing to biological and sociocultural factors [43]. Additional research addressing this limitation should be pursued in future studies. In future research, I plan to expand the participant pool and develop content based on stories from fairy tales to enhance accessibility and motivation for the target children. This is because the user motivation to actively engage in activities is a critical factor for effectiveness in ADHD-related interventions.

The story-based approach added to game content can be reconstructed and created by analyzing the learner’s issues during the development process, with the expectation that it will help modify the learner’s behavior through the learning experience. Thus, game-based content used in digital therapeutic interventions can play an important role as a therapeutic element tailored to the individual characteristics of children, beyond simply serving as a motivational tool based on entertainment.

5. Conclusions

The effectiveness of story-based digital content in improving the treatment outcomes of children with ADHD was evaluated using digital therapeutic interventions. The game-based digital content was compared in two formats—quiz- and story-based—to analyze the impact on attention improvement in the target children. The change in the overall attention (CAT total score) showed statistically significant differences between the experimental and control groups after four weeks, when baseline adjustments were made for simple selection (visual) and sustained inhibition. Additionally, the change in the total CAT score before and after the intervention was significantly greater in the experimental group than in the control group (p = 0.038). Furthermore, after adjusting for baseline influences, the scores for K-ARS hyperactivity and the K-ARS total score at four weeks were significantly reduced in the experimental group using story-based digital intervention content compared with the control group, with a significantly greater score change in the experimental group than in the control group (p = 0.018 and p = 0.012, respectively). Therefore, in the case of game-based content, story-based content can be considered more effective than quiz-based content for the digital intervention treatment of children with ADHD.