Introduction: In spite of rapid advances in evidence-based treatments for attention deficit hyperactivity disorder (ADHD), community access to rigorous gold-standard diagnostic assessments has lagged far behind due to barriers such as the costs and limited availability of comprehensive diagnostic evaluations. Digital assessment of attention and behavior has the potential to lead to scalable approaches that could be used to screen large numbers of children and/or increase access to high-quality, scalable diagnostic evaluations, especially if designed using user-centered participatory and ability-based frameworks. Current research on assessment has begun to take a user-centered approach by actively involving participants to ensure the development of assessments that meet the needs of users (e.g., clinicians, teachers, patients).
Methods: The objective of this mapping review was to identify and categorize digital mental health assessments designed to aid in the initial diagnosis of ADHD as well as ongoing monitoring of symptoms following diagnosis.
Results: Results suggested that the assessment tools currently described in the literature target both cognition and motor behaviors. These assessments were conducted using a variety of technological platforms, including telemedicine, wearables/sensors, the web, virtual reality, serious games, robots, and computer applications/software.
Discussion: Although it is evident that there is growing interest in the design of digital assessment tools, research involving tools with the potential for widespread deployment is still in the early stages of development. As these and other tools are developed and evaluated, it is critical that researchers engage patients and key stakeholders early in the design process.
Attention Deficit Hyperactivity Disorder (ADHD) is the most widespread psychiatric condition among children, affecting approximately 11.4% of children aged 3–17 years old in the United States (1). The societal costs associated with ADHD were estimated at $19.4 billion among children ($6,799 per child) and $13.8 billion among adolescents ($8,349 per adolescent) in the United States (2).
A gold-standard diagnostic assessment of ADHD involves a comprehensive evaluation of symptoms related to inattention, hyperactivity, and impulsiveness (3). Inattention includes difficulty with focusing and maintaining attention, poor organizational skills, and forgetfulness. Behaviors often considered reflective of hyperactivity include: (1) movement behaviors (e.g., fidgeting, leaving seats when staying seated is expected, constant motion, restlessness) and (2) communication behaviors (e.g., talking nonstop, blurting out answers, interrupting others). Although gold-standard evaluations typically involve data from multiple sources (children, clinicians, parents, teachers) and multiple methods (standardized rating scales, structured and semi-structured clinical interviews, neuropsychological tests), in most parts of the world, these types of evaluations can often be difficult to obtain, are costly, and are not widely available.
In clinical practice, a diagnosis of ADHD is provided after a series of behavioral observations, combined with neuropsychological assessments and the completion of behavior rating scales by the individuals’ parent, guardian, or another informant. Self-reports of internal feelings and challenges experienced by the patient are also collected. Those reports can be influenced by factors intrinsic to the children themselves or extrinsic roles such as parents, the medical system, or school (4).
Unfortunately, scores derived using self-report, parent-, or teacher- report rating scales can be influenced by several factors (4), including rater bias, differences in behaviors across settings, and the relationship between the rater and the child (5). The limitations of rating scales have led to concerns about the validity of diagnoses, such as the potential for over-diagnosis, while barriers to gold-standard evaluations have raised concerns about under-recognition of ADHD. Failure to recognize and treat ADHD early on may adversely affect academic achievement (6), family and social relationships (7), employment (8), and functioning in other domains (4). Hence, there is a need to both increase the rigor and availability of diagnostic tools as well as the tools that could be used to assess progress in response to a variety of interventions. Given these challenges with assessment of ADHD symptoms, there is growing interest in increasing the rigor of diagnostic procedures as well as the assessment of progress in response to interventions using digital tools.
Currently, standardized assessment tools could go far to bolster the accuracy of diagnosis and the acceptance by families and others of the clinical diagnosis procedure, in which technology offers an opportunity to support human professionals and experts in their diagnostic and assessment work. Rapid technological advances in the last few decades have introduced tremendous opportunities to support professionals and experts in their diagnostic and assessment work. Despite these advances, only a handful of technology-supported assessment tools are used widely in practice. For example, the Continuous Performance Test (9) is one of the few computerized tests of attention that clinicians consistently use in their assessment battery during a neuropsychological evaluation.
On the other hand, research on digital tools has explored three main approaches to support the assessment and diagnosis of individuals with ADHD (10): (1) classify data from brain activity, either EEG or fMRI [e.g., (11–20)], (2) classify data 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 [e.g., (21–27)], and (3) design and employ serious games or environments where users can play and interact (the interactions of the users with the game are analyzed to infer if the user has ADHD or related symptoms) [e.g., (28, 29)]. While the first approach considers only the data from brain activity of ADHD individuals without their input; the second and third approaches involve end-users to some degree in certain stages of the development process for a given digital assessment tool.
Recently, there has been a tendency to use user-centered, participatory, and ability-based design (30–35) and similar types of frameworks to include the needs and consideration of the primary end users through the whole process of designing, developing and evaluating digital tools to assess symptoms and behaviors, including ADHD (36–38). In the case of ADHD diagnosis and assessment tools, there are two primary end users that should be considered: the clinicians (psychologist, psychiatrist, among others) who are conducting the assessment, and the individuals (patients) who are performing the activities requested by the clinicians. Therefore, research needs to find ways in which people with ADHD and experts might be empowered through technology and included in research teams to develop assessment tools.
Given the early stages of research in this area, our goal in this research was to conduct a mapping review of digital assessments with the potential to diagnose and measure ADHD symptoms. A mapping review has been defined as a “preliminary assessment of the potential size and scope of available research literature” that “aims to identify the nature and extent of research evidence,” including ongoing research (39). Scoping reviews typically do not include a formal quality assessment and typically provide tables of findings along with some narrative commentary. They are systematic and can provide preliminary evidence that indicates whether a full systematic review (with quality assessment) is warranted at a given time.