The effect of Ecological Executive Skills training on emotional problems in children with attention-deficit hyperactivity disorder

Abstract

Background

Emotional problems represents a prevalent clinical manifestation in pediatric populations with attention-deficit/hyperactivity disorder (ADHD), exacerbating functional impairments and complicating treatment outcomes. While pharmacological and behavioral interventions target core ADHD symptoms, structured approaches addressing emotional dysregulation through executive function training remain underexplored. Ecological executive skills training (EEST) has emerged as a promising intervention. This study systematically evaluates the multidimensional impact of EEST by integrating behavioral, cognitive, and emotional metrics to establish an evidence-based framework.

Methods

A total of 65 primary school children diagnosed with ADHD for the first time were recruited for this study. Children with ADHD were evaluated by Achenbach Child Behavior Checklist (CBCL), Strengths and Difficulties Questionnaire(SDQ), Conner’s Parent Symptom Questionnaire (PSQ), Vanderbilt ADHD Diagnostic Parent Rating Scale (VADPRS), Behavior Rating Inventory of Executive Function(BRIEF) and Weiss Functional Impairment Rating Scales-Parent Report (WFIRSP). Statistical analysis was conducted using SPSS software (version 19.0). Categorical variables were presented as counts (n) and percentages (%). Improvements in Inattention were analyzed using Generalized Estimating Equations (GEE) with robust standard error estimators.

Results

1.Efficacy of Mood Regulation: After three months of treatment, the experimental group exhibited significantly greater improvement than the control group in anxiety and depression subscales of the CBCL, SDQ teacher emotional symptom ratings, PSQ (Anxiety), VADPRS and VADTRS anxiety/depression items, and the BRIEF Emotion Regulation Index. 2. Core Symptom Severity: The experimental group demonstrated significantly greater reductions in inattention and hyperactivity/impulsivity symptoms compared to controls, as measured by the VADPRS and VADTRS. 3.Executive Functioning Improvements: The experimental group showed significantly greater enhancements (P < 0.05) across all BRIEF executive function domains, with particularly significant improvements observed in working memory. 4. EEST can improve Social Functioning Outcomes.

Conclusions

EEST significantly alleviates emotional probloms in children with ADHD, including symptoms of anxiety, depression, and impaired emotional control. Furthermore, this intervention demonstrates measurable improvements in core ADHD symptoms, executive functioning, and social competency.

Clinical trial registry

The Chinese Clinical Trial Registry (ChiCTR). Trial Registration Number:2,200,062,513​.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12888-025-07748-6.

Introduction

Attention-deficit/hyperactivity disorder (ADHD) is among the most prevalent neuro-developmental conditions affecting school-age children, characterized by persistent hyperactivity, impulsivity, and inattention [1, 2]. Globally, it impacts an estimated 2–7% of pediatric populations [3, 4], with higher diagnostic rates in males than females. Core ADHD symptoms significantly impair academic performance, executive functioning, and social adaptation in affected children [5]. Notably, 30–50% of cases persist into adulthood, exacerbating long-term challenges for individuals, families, and societal systems [5]. Beyond core symptoms, comorbid emotional dysregulation poses substantial challenges. Studies report emotional problems in 24–50% of youth with ADHD [6], encompassing anxiety, depression, and mood instability. While severe cases meet diagnostic criteria for anxiety disorders, depression, or bipolar spectrum disorders, subthreshold emotional dysregulation—manifesting as low frustration tolerance, irritability, temper outbursts, and rapid mood fluctuations—also disrupts daily functioning, academic engagement, and peer relationships [7]. Collectively, emotional comorbidities compound ADHD’s clinical complexity, complicating treatment planning and necessitating integrated intervention strategies.

School-age children with ADHD exhibit pronounced executive function impairments [8]. Studies indicate that 89% of children with ADHD demonstrate objectively-defined impairment on at least one executive function [9], and these deficits contribute to emotional and behavioral challenges in daily life, such as difficulties with impulse control and instruction adherence in academic settings.

Executive function constitutes a higher-order cognitive domain essential for self-regulation and goal-directed behavior, and is composed of multiple interrelated components [10]. Drawing upon established models [11], some researchers explicitly mention that core deficits in ADHD often involve inhibitory control (leading to impulsivity), working memory (underlying difficulties in following instructions and planning), and cognitive flexibility/set-shifting (contributing to rigid behaviors and poor adaptation to change) [12]. These components do not operate in isolation but interact dynamically. Enhanced inhibitory control enables individuals to resist impulsive reactions during heightened emotional states [13], while robust working memory facilitates processing of emotionally salient information, promoting adaptive emotional management. Greater cognitive flexibility supports emotional adaptability, allowing individuals to navigate situational demands and stressors more effectively [14]. Collectively, stronger executive function equips individuals with greater capacity to employ proactive strategies for managing emotional challenges [15, 16], underscoring its pivotal role in mitigating ADHD related difficulties.

Non-pharmacological interventions for ADHD, such as behavioral therapy and cognitive training, are increasingly favored by families due to their accessibility and holistic benefits. Ecological Executive Skills Training (EEST) has demonstrated efficacy in alleviating ADHD core symptoms while enhancing executive functions [17], with high acceptability among families. EEST is an intervention program grounded in the work of Dawson and Guare (2010), designed to enhance the everyday executive functioning of children with ADHD. It incorporates culturally adapted components within a cognitive-behavioral therapy framework to ensure the concepts’ applicability and acceptability for Chinese children [18]. EEST represents a compensatory approach to addressing core executive function (EF) deficits in ADHD, distinguishing itself from facilitative intervention training (FIT) through its superior ecological validity. While FIT often relies on computer-based drills that may improve isolated cognitive metrics like working memory, its effects frequently fail to transfer to real-world behaviors, academic performance, or broader neuropsychological functioning. In contrast, EEST grounded in a combination of cognitive training and behavioral therapy is specifically designed to enhance EF within children’s daily lives, thereby enabling meaningful generalization of skills and offering a more sustainable and functionally relevant non-pharmacological intervention.

Traditional ADHD management primarily targets core symptoms, yet limited research investigates executive function training’s impact on emotional dysregulation in affected children. According to the ecological systems theory [19], an individual’s psychological characteristics (including emotion regulation) and environmental factors (such as peers and family), exert a substantial influence on their psychological well-being. Furthermore, studies suggest that peer relationships [20], social competence [21], and family functioning [22] also play significant roles in the development and progression of anxiety and depressive symptoms in individuals with ADHD. This study aims to investigate whether EEST can ameliorate emotional difficulties experienced by school-age children with ADHD. Therefore, the purpose of this study is to explore whether EEST, which aim to improve daily executive skills in children with ADHD, will improve emotional problems in school-age children with ADHD.

Methods

Participants

In this study, 65 participants were children with ADHD recruited from Department of Developmental-Behavioral Pediatrics, First Hospital of Jilin University.

The inclusion criteria were as follows: (1) All children were aged 6–12 years (primary school period). (2) They all met the ADHD diagnosis criteria of DSM-5 and were assessed for core symptoms using Vanderbilt ADHD Diagnostic Parent Rating Scale (VADPRS) with/without Vanderbilt ADHD Diagnostic Teacher Rating Scale (VADTRS) [23, 24]. (3) Wechsler Intelligence Scale FIQ ≥ 70. Exclusion criteria were: (1) children with severe physical disabilities and/or uncontrolled epilepsy, (2) children who have been diagnosed with anxiety disorder and Major Depressive Disorder (MDD) in the past with/without drug therapy at the same time, (3) children whose parents did not agree with other additional questionnaires. Five participants (3 in the EEST group and 2 in the control group) had been maintained on a steady dosage of either methylphenidate or atomoxetine for more than six months, and this dosage remained unchanged throughout the entire study period. A strict protocol was enforced whereby initiating new medications or other Psychosocial Treatments was not permitted during the study. The implementation situation of the intervention is shown in Fig. 1.

Fig. 1.

Flowchart of participant enrollment

Study design

This study adopts a single-blind controlled design and implements a blinding scheme for the assessors. Certified assessors include those with at least 10 years of clinical experience and the corresponding assessment qualifications. All assessors demonstrated maintenance of group allocation concealment throughout the evaluation period, with no prior involvement in intervention protocol development or participant recruitment. The research cohort included 65 children who met the DSM-5 criteria for ADHD, and they were assigned to the EEST group and the control group on a voluntary basis. Participants in the EEST group received the implementation of EEST once a week under clinical supervision and also received a structured ADHD psychoeducation module. The control group, on the other hand, only received the parent psychoeducation program.

The intervention was jointly provided by a senior developmental behavioral pediatrician and a trained psychotherapist, with all training principles and procedures documented in a manual to ensure treatment fidelity. To monitor implementation and engagement, parents were provided with simple logs to track their child’s participation in prescribed home-based activities, which served both as a measure of homework compliance and an indicator of the intervention’s penetration into the home environment, supplemented by brief weekly feedback meetings to assess child engagement and protocol-related challenges.

The Ecological Executive Skills Training (EEST)

The Ecological Executive Skills Training (EEST), an innovative systematic intervention framework developed by Peking University Sixth Hospital’s Child Psychiatry Research Team, demonstrates empirical efficacy in enhancing neurocognitive executive functions among school‑aged children with ADHD [17, 18]. This training program structured seven core modules targeting key dimensions of executive functioning (EF): Response inhibition, Planning, Time management, Sustained attention, Organization, Cognitive flexibility, Working memory. The intervention incorporates concurrent parental involvement components, to help their children finish the homework outlined in the handbook between sessions. The training program included 8 weekly 1-h sessions in a clinical setting and was applied in groups of 4 to 6 families. Further details are described in Supplementary Material 1.

The parent psychoeducation program

The Parent Psychoeducation Program constitutes a structured psychoeducation curriculum delivered by certified clinicians, comprising three evidence-based components: (1) Neurobiological education module elucidating ADHD’s etiological frameworks, symptom phenomenology, and functional consequences; (2) Parent-child interaction training system incorporating behavioral activation strategies and contingency management techniques; (3) Bibliotherapy component utilizing empirically validated ADHD resource materials.

A comprehensive multidimensional assessment battery was administered to all ADHD at baseline (pre-intervention) and at 3-month follow-up. The evaluation protocol included: (1) Achenbach Child Behavior Checklist (CBCL), (2) Strengths and Difficulties Questionnaire (SDQ), (3) Conner’s Parent Symptom Questionnaire (PSQ), (4) Vanderbilt ADHD Diagnostic Parent Rating Scale (VADPRS), Vanderbilt ADHD Diagnostic Teacher Rating Scale (VADTRS), (5) Behavior Rating Inventory of Executive Function (BRIEF), and (6) Weiss Functional Impairment Rating Scales-Parent Report (WFIRS-P) .

Measures

Achenbach Child Behavior Checklist (CBCL) is used to screen children for social skills and behavioral problems and to identify and evaluate children at high risk for behavioral and emotional problems. The scale has good internal consistency with a Cronbach’s coefficient between0.71-0.96 [25].

The Strengths and Difficulties Questionnaire (SDQ) is a brief screening questionnaire to assess behavioral problems and emotional problems in children. It consists of five factors that assess emotional symptoms, conduct problems, hyperactivity-inattention, peer problems, and pro-social behavior. The Cronbach’s coefficient for each factor and the total score of the questionnaire was 0.84, which is a good internal consistency [26]. There is good support for convergent validity in China, and it can be used as a tool to evaluate the mental health status of Chinese children and adolescents [27].

The Conner’s Parent Symptom Questionnaire (PSQ) is a set of scales that assesses common behavioral problems in children and consists of six factors: behavioral problems, learning problems, psychosomatic disorders, impulsive\hyperactivity, anxiety, and hyperactivity index. The scale has good reliability and validity, with a Cronbach’s coefficient of 0.93 and a test-retest reliability of 0.59 [28].

The Vanderbilt ADHD Diagnostic Parent Rating Scale (VADPRS) and the Vanderbilt ADHD Diagnostic Teacher Rating Scale (VADTRS) were developed based on the DSM-IV ADHD diagnostic criteria [29, 30]. The scale is used to assess symptoms, functional impairment, and treatment outcomes in school-aged children with ADHD. They all include 18 ADHD core symptoms rated on a 4-point scale that indicates how frequently each ADHD symptom occurs (0 = never, 1 = occasionally, 2 = often, 3 = very often). In addition, the VADPRS includes 8 items of ODD, 14 items of CD, and 7 items of anxiety/depression comorbidity screening scales. Also, it has two sets of performance items that assess functional impairment of academic and social domains rated on a 5-point scale (1 = excellent performance, 5 = problematic performance). It consists of 55 items and the scale includes both behavioral and performance sections. The scale has been internally implemented with Cronbach’s coefficient ≥ 0.9 and internal consistency ≥ 0.93 [24]. The ODD and CD items of VADTRS are not the same as those in VADPRS, with an abbreviated 10-item screen for ODD and CD. In China, its sensitivity, specificity, and positive predictive values have not been outstanding for diagnosing ADHD by VADPRS [31]. VADPRS is helpful in the clinical diagnosis of ADHD, but it cannot replace the interview and judgment of professionals. We used it for assessing ADHD core symptoms with the help of a teacher rating scale at the same time.

The Behavior Rating Inventory of Executive Function (BRIEF) parent form is a comprehensive questionnaire utilized to assess and evaluate various executive function behaviors exhibited in everyday life environments. It has undergone translation into Chinese and demonstrates favorable psychometric properties and clinical discrimination. It exhibits a test-retest reliability of 0.68 to 0.89 and a Cronbach’s coefficient of 0.74 to 0.96 [32].

The Weiss Functional Impairment Rating Scale-Parent Report (WFIRS-P), developed by Margaret D. Weiss in 2007, assesses the extent to which symptoms and the patient’s behavioral or emotional problems impact clinically relevant domains of functioning. The scale consists of 50 items encompassing six functional domains: Family, Learning and School, Life Skills, Self-Concept, Social Activities, and Risky Activities. Each item is rated on a 4-point scale from 0 to 3: 0 (Never), 1 (Occasionally/Sometimes), 2 (Often), 3 (Very Often/Always). Cronbach’s alpha coefficient exceeded 0.7 for all domains and test-retest reliability exceeded 0.7 for all but Risky Activities [33].

Statistical analysis

Statistical analysis was conducted using SPSS software (version 19.0). Categorical variables were presented as counts (n) and percentages (%). Improvements in Inattention were analyzed using Generalized Estimating Equations (GEE) with robust standard error estimators. GEE is a regression-based method used for analyzing longitudinal data where observations across time are not independent [34]. Since Inattention is a continuous variable, we selected Gaussian distribution with identity link function. The main goal of this study was to determine whether children in the EEST intervention group sustained the improvements observed after training. Thus, the first GEE model assessed changes over time within the EEST intervention group with baseline as the reference. Additionally, the interaction of Group and Time was assessed in a separate model with EEST intervention group as the reference for the Group variable and baseline scores as the reference of time.

Result

This study enrolled 65 children with ADHD (EEST intervention group: n = 35, 31 boys/4 girls; control group: n = 30, 27 boys/3 girls). Participants’ mean ages were 97.03 ± 16.54 months (EEST intervention) and 105.4 ± 27.13 months (control). Baseline demographic characteristics demonstrated statistical comparability between groups, with no significant differences in gender distribution, chronological age, parental education, marital status, employment status and parental history of ADHD (P < 0.05). Detailed demographic data are presented in Table 1.

Table 1.

Demographic and clinical characteristics of the children with ADHD in this study

Characteristics	EEST intervention group (n = 35)	control group (n = 30)	/t
Gender, n (%)			0.340	0.853
Female	31(88.6)	27(90.0)
Male	4(11.4)	3(10.0)
Age (months), mean ± SD	97.03 ± 16.54	105.40 ± 27.13	-1.525	0.132
Parental literacy(Father, %)			0.619	0.431
High school and below	20(57.1)	20(66.7)
University and above	15(42.9)	10(33.3)
Parental literacy(Mother, %)			0.136	0.713
High school and below	23(65.7)	21(70.0)
University and above	12(34.3)	9(30.0)
Parental relations (%)			0.395	0.530
Harmonious	33(94.3)	26(86.7)
Unharmonious	2(5.7)	4(13.3)
Parental history of ADHD (%)	8 (22.8)	10 (33.3)	0.885	0.347
Employment status(Father, %)			0.458	0.498
Employed	34(97.1)	27(90.0)
Unemployed	1(2.9)	3(10.0)
Employment status(Mother, %)			0.126	0.722
Employed	27(77.1)	22(73.3)
Unemployed	8(22.9)	8(26.7)

Baseline comparisons demonstrated no significant between-group differences across all outcome measures (all p > 0.05). Specifically, the VADPRS total scores showed equivalence, with similar non-significant findings for VADTRS. Comparable baseline status was observed for CBCL total problems (male, p = 0.528), SDQ (P/T) difficulty scores (p = 0.305/0.089), BRIEF global executive composite (p = 0.857), PSQ total scores (p = 0.197) and Weiss total scores (p = 0.396). Complete statistical parameters are presented in Table 2.

Table 2.

Comparing baseline data of all outcome measures in two groups

	EEST intervention group(n = 35)	Control group(n = 30)	X2/t	P
VADPRS
Total score of Inattentive symptoms	19.94 ± 3.16	18.97 ± 5.86	0.817 a	0.419
Total score of Hyperactive/impulsive symptoms	15.37 ± 5.84	14.33 ± 6.75	0.665 a	0.509
VADTRS
Total score of Inattentive symptoms	18.60 ± 5.17	18.17 ± 6.09	0.310 a	0.757
Total score of Hyperactive/impulsive symptoms	12.00(8.00, 21.00)	8.0(2.75,16.00)	− 1.760b	0.078
The severity of ADHD			1.038c	0.595
Mild[N(%)]	13(37. 1)	11(36.7)
Moderate[N(%)]	15(42.9)	10(33.3)
Severe[N(%)]	7(20.0)	9(30.0)
CBCL1
Total score (male)	47(31, 57)	45(25, 58)	-0.631b	0.528
SDQ (Parent)
Total score	18.09 ± 5.37	16.70 ± 5.40	1.035 a	0.305
SDQ (Teacher)
Total score	17.06 ± 5.23	14.90 ± 4.76	1.728 a	0.089
PSQ
Total score	43(29, 58)	38(27, 48)	− 1.290b	0.197
BRIEF
Total score	154.17 ± 18.60	153.2 ± 24.68	0.181a	0.857
WFIRS-P
Total score	0.78(0.60, 0.94)	0.67(0.47, 0.98)	-0.849b	0.396

Note 1. For the total score of CBCL (male), the number of cases in the experimental group was 31, and that in the control group was 27. a: t-test; b: rank sum test; c: chi-square test

The influence of EEST on the core symptoms of children with ADHD

To assess the short-term effects of the EEST intervention on ADHD symptoms and related impairments, we compared the Vanderbilt ADHD Diagnostic Rating Scale scores from both parent (VADPRS) and teacher (VADTRS) reports at baseline and 3 months post-treatment between the EEST intervention group (n = 35) and the control group (n = 30). Median scores and interquartile ranges for all subscales are presented in Table 3.

Table 3.

Comparison of the VADPRS and VADTRS between the two groups at baseline and 3 months after treatment

		EEST intervention group (n = 35)		Control group(n = 30)		B	SE	P
		Before	After	Before	After
VAPRS / VATRS	Inattentive symptoms (P/T)	8.00(7.00, 9.00)/ 7.00(6.00, 9.00)	3.00(1.00, 6.00)/ 3.00(1.00, 5.00)	8.00(6.00, 9.00)/ 7.00(4.75, 9.00)	6.00(3.00, 8.00)/ 5.00(2.75, 7.00)	-2.424/-2.319	0.7594/0.7404	0.001*/0.002*
	Total score	20.00(17.00, 22.00)/ 19.00(17.00, 22.00)	11.00(8.00, 16.00)/ 11.00(8.00, 14.00)	19.50(13.75, 24.00)/ 18.50(14.25, 22.5)	16.50(12.00, 20.00)/ 14.00(9.75, 19.00)	-5.200/-3.205	1.5203/1.5942	0.001*/0.044*
	Hyperactive/impulsive symptoms (P/T)	6.00(2.00, 8.00)/ 5.00(2.00, 8.00)	1.00(0.00, 3.00)/ 1.00(0.00, 3.00)	5.00(2.00, 7.00)/ 2.00(0.00, 6.00)	3.00(2.00, 5.25)/ 1.50(0.00, 4.25)	-2.510/-1.684	0.6496/0.7864	<0.001*/0.036*
	Total score	15.00(10.00, 20.00)/ 12.00(8.00, 21.00)	8.00(3.00, 11.00)/ 5.00(2.00, 10.00)	14.50(9.75, 20.00)/ 8.00(2.75, 16.00)	11.50(9.75, 14.25)/ 9.50(3.75, 13.5)	-5.724/-4.133	1.4665/1.8645	<0.001*/0.027*
	Oppositional defiant	3.00(1.00, 5.00)/ 1.00(0.00, 4.00)	1.00(0.00, 2.00)/ 0.00(0.00, 1.00)	2.50(0.00, 4.00)/ 1.00(0.00, 4.00)	2.00(1.00, 3.25)/ 0.00(0.00, 2.00)	-1.729/-0.800	0.5787/0.5525	0.003*/0.148
	Conduct disorder	0.00(0.00, 1.00)	0.00(0.00, 0.00)	0.00(0.00, 1.00)	0.00(0.00, 0.00)	-0.295	0.1960	0.132
	Anxiety/depression	1.00(0.00, 3.00)/ 0.00(0.00, 2.00)	0.00(0.00, 1.00)/ 0.00(0.00, 0.00)	1.00(0.00, 2.00)/ 1.00(0.00, 2.25)	1.00(0.00, 2.00)/ 0.50(0.00, 2.00)	-1.100/-1.233	0.3281/0.4524	0.001*/0.006*
	Academic impairment	2.00(1.00, 3.00)/ 1.00(0.00, 2.00)	0.00(0.00, 2.00)/ 0.00(0.00, 2.00)	1.50(0.00, 3.25)/ 1.00(0.00, 3.00)	2.00(0.00, 4.00)/ 1.50(0.00, 3.00)	-0.914/-0.895	0.3226/0.2915	0.005*/0.002*
	Impaired performance in social relationships and group activities.	0.00(0.00, 1.00)/ 2.00(1.00, 3.00)	0.00(0.00, 0.00)/ 1.00(0.00, 2.00)	0.00(0.00, 1.00)/ 2.00(1.00, 3.25)	0.00(0.00, 1.00)/ 2.00(0.00, 2.25)	-0.410/-0.529	0.2368/0.4182	0.084/0.206

Note: * P < 0.05

Generalized Estimating Equations (GEE) models were employed to analyze the longitudinal data. An exchangeable correlation structure was used as the working correlation matrix, which was deemed appropriate for the study design. The results of the GEE analysis (Table 3) demonstrated that the intervention group showed significant improvements compared to the control group across multiple domains, as reported by both informants. Parents in the intervention group reported significant reductions in core ADHD symptoms, including Inattention (p = 0.001) and Hyperactivity/Impulsivity (p < 0.001). Corresponding total scores were also significantly improved. Furthermore, significant improvements were observed in comorbid symptoms of Oppositional Defiant disorder (p = 0.003) and Anxiety/Depression (p = 0.001), as well as in Academic Impairment (p = 0.005). Teacher reports corroborated the positive effects of the intervention on the core ADHD symptom domains. Significant improvements were noted for Inattention (p = 0.002) and Hyperactivity/Impulsivity (p = 0.036), along with their total scores. Teachers also reported a significant reduction in Anxiety/Depression symptoms (p = 0.006) and Academic Impairment (p = 0.002). However, teacher-reported scores for Oppositional Defiant symptoms showed a non-significant trend (p = 0.148).

Notably, symptoms of Conduct Disorder and impairments in Social Relationships did not show statistically significant changes between groups from either parent or teacher perspectives.

To evaluate the impact of the EEST intervention on daily-life executive function, we analyzed the BRIEF scores between two groups at baseline and 3 months post-treatment. GEE with an exchangeable correlation matrix were used to assess group differences over time. The results are summarized in Table 4. Analysis of the result revealed significant improvements in the intervention group compared to controls. Significant group-by-time interaction effects were observed for Inhibition (SE = 1.154, p = 0.024), Shifting/Cognitive Flexibility (SE = 0.760, p = 0.031), and Emotional Control (SE = 1.105, p = 0.017). Additionally, the composite Behavioral Management Index showed a highly significant improvement (SE = 2.242, p = 0.002). Other subdomains showed positive trends that did not reach conventional levels of significance, including Initiation (SE = 2.977, p = 0.128), Planning (SE = 1.022, p = 0.064), and Monitoring (SE = 0.719, p = 0.097). In the metacognition domain, significant improvements were observed for Working Memory (SE = 0.938, p = 0.013) and Organization (SE = 0.698, p = 0.086). However, the overall Metacognition Index did not show a statistically significant difference between groups (SE = 4.523, p = 0.424). Most importantly, the total score demonstrated a highly significant improvement in the intervention group compared to controls (SE = 4.311, p < 0.001), indicating substantial enhancement in overall executive functioning.

Table 4.

Comparison of the BRIEF scale between the two groups at baseline and 3 months after treatment

Group	Variable	Baseline	3 months after treatment	B	SE	P
Experimental group	Inhibition	20.00 (17.00, 24.00)	15.00 (13.00, 17.00)	-2.595	1.1537	0.024*
Control group		18.00 (15.00, 24.50)	16.00 (13.75, 19.50)
Experimental group	Switching	14.00 (12.00, 17.00)	11.00 (9.00, 12.00)	-1.643	0.7600	0.031*
Control group		14.00 (11.75, 16.00)	13.00 (11.00, 15.00)
Experimental group	Emotional control	18.00 (13.00, 22.00)	13.00 (11.00, 17.00)	-2.633	1.1052	0.017*
Control group		16.50 (13.00, 22.00)	16.00 (12.00, 18.00)
Experimental group	Initiation	15.00 (14.00, 17.00)	13.00 (10.00, 14.00)	-4.529	2.9767	0.128
Control group		16.00 (12.00, 18.00)	15.00 (13.00, 17.00)
Experimental group	Working memory	23.00 (22.00, 26.00)	19.00 (16.00, 21.00)	-2.324	0.9382	0.013*
Control group		23.00 (22.00, 27.00)	22.00 (18.75, 25.00)
Experimental group	Planning	28.00 (25.00, 30.00)	23.00 (19.00, 27.00)	-1.890	1.0215	0.064
Control group		29.00 (24.00, 31.25)	26.00 (21.00, 29.00)
Experimental group	Organization	15.00 (13.00, 17.00)	12.00 (10.00, 14.00)	-1.200	0.6984	0.086
Control group		14.00(12.00,17.00)	13.00 (10.00, 16.00)
Experimental group	Monitoring	19.00 (18.00, 22.00)	16.00 (14.00, 18.00)	-1.195	0.7194	0.097
Control group		20.00 (18.00, 23.25)	17.50 (14.75, 21.00)
Experimental group	Behavioral management Index	54.00 (44.00, 62.00)	39.00 (33.00, 46.00)	-6.871	2.2418	0.002*
Control group		49.00 (40.75, 57.25)	45.00 (39.00, 52.00)
Experimental group	Metacognition Index	101.00 (93.00,106.00)	81.00 (72.00, 95.00)	-3.614	4.5232	0.424
Control group		102.50 (86.00,111.00)	91.00 (76.00,104.25)
Experimental group	Total score	155.00 (143.00,166.00)	124.00 (109.00,136.00)	-15.152	4.3107	<0.001*
Control group		149.00 (134.50,170.50)	135.50 (120.00,159.00)

Note: * P < 0.05

The impact of EEST on emotional problems in children with ADHD

Analysis using GEE revealed significant improvements in emotional functioning following the EEST intervention compared to the control group at the 3-month follow-up assessment. As shown in Table 5, the intervention group demonstrated statistically significant reductions across multiple standardized measures of emotional problems.

Table 5.

Comparison of emotional problems between the two groups at 3 months post-intervention

		B	SE	95% CI
CBCL	Anxious	-1.753***	0.4825	0.807	2.698
	Depression	-2.178**	0.8248	0.561	3.795
PSQ	Anxiety	-1.500***	0.4407	0.636	2.364
BRIEF	Emotional control	-2.633*	1.1052	0.467	4.800
SDQ-P	Emotional problem	-0.752	0.4041	-0.040	1.544
SDQ-T	Emotional problem	-1.200*	0.5117	0.197	2.203
VADPRS	Anxiety/depression	-1.100***	0.3281	0.457	1.743
VADTRS	Anxiety/depression	-1.233**	0.4524	0.347	2.120

Note: B,Regression Coefficient; SE, Standard error; CI, Confidence interval

*p < 0.05, **p < 0.01, ***p < 0.001

On the CBCL, significant group differences emerged for both anxious symptoms (SE = 0.483, 95% CI: 0.807–2.698, p < 0.001) and depressive symptoms (SE = 0.825, 95% CI: 0.561–3.795, p = 0.002), indicating substantial improvement in core emotional domains. Parallel findings were observed on the PSQ anxiety subscale (SE = 0.441, 95% CI: 0.636–2.364, p < 0.001) and the BRIEF emotional control subscale (SE = 1.105, 95% CI: 0.467-4.800, p = 0.017).

Multi-informant reports provided converging evidence, with both parent-rated (VADPRS: SE = 0.328, 95% CI: 0.457–1.743, p < 0.001) and teacher-rated (VADTRS: SE = 0.452, 95% CI: 0.347–2.120, p = 0.003) measures showing significant improvements in anxiety/depression symptoms. Teacher reports on the SDQ also indicated significant emotional problem reduction (SE = 0.512, 95% CI: 0.197–2.203, p = 0.019), though parent reports on the SDQ emotional problems scale did not reach statistical significance (SE = 0.404, 95% CI: -0.040-1.544, p = 0.063).

The influence of EEST training on the social function of children with ADHD

The impact of the EEST intervention on functional impairment was assessed using the parent-reported WFIRS-P. GEE analysis with an exchangeable correlation matrix revealed a significant group-by-time interaction effect for the total impairment score (p = 0.006), indicating that the intervention group experienced a significantly greater reduction in overall functional impairment compared to the control group at the 3-month follow-up.

As detailed in Table 6, analysis of specific domains showed numerical improvements in the intervention group across several areas of daily life, although these did not reach statistical significance. These included the Family domain (p = 0.66), Learning and School domain (p = 0.871), Life Skills domain (p = 0.191), Self Management domain (p = 0.205), Social Activities domain (p = 0.173), and Adventurous Activities domain (p = 0.775).

Table 6.

Comparison of the scores of the parent version of the Weiss functional impairment rating scale between the two groups at baseline and 3 months after treatment

Group	Variable	Baseline	3 months after treatment	B	SE	P
Experimental group	Family	0.70 (0.40, 1.20)	0.40 (0.30, 0.70)	-0.198	0.1076	0.66
Control group		0.55 (0.37, 1.13)	0.65 (0.30, 0.90)
Experimental group	Learning and School	0.90 (0.50, 1.30)	0.40 (0.20, 0.70)	-0.041	0.2510	0.871
Control group		0.80 (0.48, 1.00)	0.70 (0.28, 0.90)
Experimental group	Life Skills	0.90 (0.60, 1.20)	0.60 (0.30, 0.80)	-0.132	0.1012	0.191
Control group		1.00 (0.60, 1.23)	0.85 (0.40, 1.20)
Experimental group	Self Management	0.67 (0.00, 1.33)	0.33 (0.00, 0.67)	-0.176	0.1390	0.205
Control group		0.84 (0.33, 1.33)	0.67 (0.33, 1.00)
Experimental group	Social Activities	0.86 (0.57, 1.14)	0.57 (0.29, 0.14)	-0.125	0.0916	0.173
Control group		0.86 (0.57, 1.33)	0.79 (0.5, 1.04)
Experimental group	AdventurousActivities	0.30 (0.20, 0.40)	0.20 (0.10, 1.00)	-0.017	0.0584	0.775
Control group		0.20 (0.10, 0.425)	0.20 (0.10, 0.40)
Experimental group	Total score	0.78 (0.60, 0.94)	0.50 (0.32, 0.60)	-0.158	0.0575	0.006*
Control group		0.67 (0.47, 0.98)	0.63 (0.36, 0.89)

Note: * P < 0.05

Despite the lack of statistically significant findings in the individual domains, the significant improvement in the total score suggests that the EEST intervention led to a meaningful overall reduction in functional impairment as reported by parents, with benefits sustained at the 3-month assessment (p = 0.006).

Discussion

The EEST employed in this study represents a novel non-pharmacological intervention specifically developed for children with ADHD. Building on core executive function training frameworks, it integrates training components targeting key skills—including emotion management, response inhibition, sustained attention, cognitive shifting, task initiation, and working memory. Delivered through a combination of child group sessions and parent training programs, this intervention aims to: (1) address core executive function deficits in children with ADHD; (2) adjust parental cognitions and modify parent-child interaction patterns; (3) strengthen parent-child relationships; and (4) ultimately improve core ADHD symptoms and associated impairments in social functioning. Notably, this study marks the first investigation in China to explore the impact of EEST on emotional problems in children with ADHD. The findings demonstrate that this intervention effectively alleviates emotional difficulties, reduces core ADHD symptoms, enhances executive function performance, and improves social functioning in affected children.

Impact of EEST on emotional problems in children with ADHD

The comprehensive review establishes that emotion dysregulation is not merely a comorbid feature but is intrinsically linked to EF deficits in ADHD, representing a core component of the disorder’s pathophysiology, which is further substantiated by structural and developmental anomalies in key neural substrates. The relationship is characterized by a bidirectional interplay where deficits in core EF processes—particularly inhibitory control, attentional allocation, cognitive flexibility, and working memory—directly impair the ability to modulate emotional responses, a difficulty exacerbated by the relatively reduced surface area of the cerebral cortex, smaller subcortical structures [35], and immature prefrontal development observed in children with ADHD [36, 37]. Consequently, individuals exhibit profound difficulties with emotional lability, irritability, poor emotional recognition, and a failure to adaptively regulate emotional states in goal-oriented contexts, manifesting as heightened frustration, excitability, and emotional fluctuations. Crucially, this interplay is underpinned by dysfunctional prefrontal-limbic circuitry, where deficient top-down cognitive control from the underdeveloped prefrontal cortex fails to regulate bottom-up emotional impulses generated by hyperreactive limbic structures. Such emotional dysregulation profoundly impacts multiple life domains, including academic performance, social interactions, and family relationships, with the severity often surpassing that of core ADHD symptoms and culminating in poorer long-term prognoses [38]. This integrated perspective, incorporating both neurocognitive deficits and structural immaturities, challenges purely behavior-based diagnostic schemas and underscores the necessity of evaluating both EF and emotional dimensions to grasp the holistic clinical profile of ADHD.

The findings robustly demonstrate that enhanced working memory capacity uniquely predicts improved emotion regulation in children with ADHD, both directly and indirectly via reductions in core ADHD symptoms, highlighting its central role in the neurocognitive architecture of emotion dysregulation in this population [39], [40]. Building upon prior research establishing the efficacy of EEST for improving executive functions, the current study not only confirms significant gains in overall executive function-particularly in working memory—but also reveals improvements in emotional regulation, leading to the proposition that the effect of EEST on emotion may operate through its enhancement of working memory. In contrast to executive function training targeting primarily cold cognitive processes, EEST demonstrates significant potential in enhancing working memory capacities that are intrinsically linked to emotional regulation, problem-solving, and learning. By strengthening these capacities, the training facilitates the integration of positive emotions into working memory, thereby displacing negative emotional states and alleviating emotional difficulties. Furthermore, EEST improves cognitive flexibility within executive functions, which helps modulate emotional reactivity intensity and enhances the adaptability of emotion regulation processes, while also bolstering response inhibition abilities that strengthen the suppression of negative stimuli and improve overall emotion regulation capacity. Nonetheless, the neural mechanisms underlying these effects, particularly how training induces measurable changes in brain function, require further exploration and validation through advanced neuroimaging or indirect neurophysiological assessments.

Concurrently, within EEST, group-based support facilitates children’s gradual development of a sense of belonging, along with the perception of being accepted and attended to by peers. Through experience-sharing sessions, children more readily recognize that others share similar personal experiences and encounter comparable challenges in emotional management. Furthermore, the group context provides enhanced opportunities to encourage behavioral change, motivating children to abandon maladaptive cognitions and actions, while also fostering observational learning of positive behavioral models. Notably, the reinforcement of prosocial behaviors in this setting arises not solely from the group leader but also from dynamic interactions among peers. This multi-source social reinforcement mechanism may yield more robust intervention outcomes compared to individual-based approaches alone.

Impact of ecological executive skills training on the core symptoms of children with ADHD

Evidence indicates that the EEST significantly alleviates core symptoms of ADHD in children, with moderate to large effect sizes observed in reducing both inattentive and hyperactive-impulsive behaviors. The improvement in core symptoms—a key indicator of intervention efficacy—was evaluated using multi-contextual assessments (VADTRS and VADPRS) across different settings. Results indicated that the EEST group exhibited more substantial symptomatic improvement compared to the control group, a outcome consistent with previous randomized trials and meta-analyses showing that executive function training, particularly ecologically valid compensatory approaches, can lead to meaningful reductions in ADHD symptomatology [41] .

Notably, symptom improvements were observed across multiple assessment modalities, including both parent-reported scales (e.g., ADHD-RS-IV) and performance-based tasks (e.g., Stroop test, Trail-Making Test). However, the effect sizes were generally larger for informant ratings than for objective cognitive measures, suggesting that the intervention’s benefits may be more readily detectable in everyday contexts than in laboratory settings [17, 42]. This pattern underscores the ecological validity of EEST and its functional relevance to real-world symptoms.

The effectiveness of EEST can be attributed to its comprehensive, multi-component structure, which integrates targeted executive function training with systemic support from parents and classroom-like scenarios. The program directly addresses common EF deficits in children with ADHD—such as inhibition, working memory, and planning—while also involving parents through education sessions and real-time feedback during child sessions. Furthermore, the use of in-situ behavioral rehearsal and regular homework assignments facilitates the transfer of trained skills into daily routines. This process helps bridge the gap between abstract executive functions and practical executive skills, enabling sustained application in natural environments. By contextualizing ADHD-related challenges within the family system and reinforcing positive behaviors through repeated practice, EEST promotes not only symptom reduction but also meaningful functional improvement. These outcomes highlight the value of ecological and family-involved intervention approaches for achieving durable gains in ADHD treatment.

Impact of EEST on the executive function of children with ADHD

In 1997, Berkley proposed the inhibition model [43], suggesting that the primary deficit in inhibitory control is the core deficit of ADHD. This primary deficit gives rise to secondary deficits in four aspects: emotional regulation, non-verbal working memory, language internalization, and behavioral reorganization, thus leading to the occurrence of a series of ADHD symptoms. This hypothesis has been supported by genetic and imaging studies. The executive function deficits closely associated with ADHD and the core symptoms of ADHD are regulated by the same genes [44]. In children with ADHD, the cortical volume of the dorsolateral prefrontal cortex and its projection areas (caudate nucleus, globus pallidus, anterior cingulate gyrus, and cerebellum) is significantly reduced [45]. These regions coincide with the brain areas critically involved in executive function regulation. Historically, most executive function interventions have relied on computer-based games, predominantly targeting isolated components of executive function [46], such as working memory and response inhibition. Tailored to children’s ability levels, training difficulty parameters are adjusted dynamically within these programs. Via sustained training with structured feedback, these interventions have been shown to yield long-term improvements in children’s executive function capacity and neural plasticity [47].

However, the scope of these interventions remains overly narrow. Empirical evidence demonstrates that computerized training programs, despite improving working memory within controlled laboratory environments, exert limited effects on ADHD core symptoms and broader learning-related functions [48] . Studies have shown that improvements in EF, particularly those gauged by laboratory-based assessments, do not necessarily translate into enhanced performance in daily life activities [49]. This discrepancy may be attributable to the limited ecological validity of traditional, decontextualized EF training paradigms. Therefore, enhancing ecological validity has become a critical focus of our intervention approach. The EEST adopted in the present study was designed to address this gap by integrating targeted cognitive-behavioral therapy. This approach not only teaches children with executive deficits specific strategies and skills but also holistically trains a comprehensive set of abilities embedded within executive function, such as response inhibition, task initiation, working memory, emotional control, and planning/organization [50]. We propose that this training methodology, by emphasizing the practical application and internalization of learned skills in realistic contexts, facilitates a more effective transfer of gains. Thereby, it promotes a more generalized and substantial enhancement of executive function in children with ADHD, consequently improving the ecological validity of the training.

In this study, pre-versus post-treatment comparisons of factor scores and total scores on the BRIEF scale revealed that the experimental group exhibited significantly greater improvements compared with the control group. These findings align with prior research evidence on the efficacy of EEST in improving executive function among children with ADHD [18], reinforcing the conclusion that such training effectively enhances executive function in this population. Furthermore, to some degree, EEST can also address critical limitations of pharmacological interventions, including suboptimal medication adherence and high attrition rates [51] .

Impact of EEST on the social function of children with ADHD

The social functioning of children with ADHD is closely linked to their EF capacity. Evidence suggests that deficits in core EF domains—such as inhibition, cognitive flexibility, emotional control, initiation, and self-monitoring—are associated with increased social difficulties [52]. In line with this, the present study found that the EEST group showed significantly greater improvement in the total score of the WFIRS-P compared to the control group, indicating a beneficial effect of the intervention on overall functional impairment.

The EEST program is designed to enhance EF through a structured approach that integrates traditional executive function training with real-world executive skill application. This is achieved via simulated daily scenarios—such as interpersonal conflicts or emotional outbursts—using role-playing exercises. These activities help identify individual-specific challenges and provide opportunities for targeted cognitive and behavioral remediation. By fostering competencies such as pausing before reacting, communicating needs effectively, practicing empathy, and utilizing time management strategies, EEST supports transfer of training gains to everyday contexts.

It is noteworthy that, although the WFIRS-P total score improved significantly, no significant changes were observed in its individual subscales. This pattern may be attributable to the relatively short intervention or follow-up period, which might have been insufficient for treatment effects to fully manifest within discrete functional domains. Nevertheless, the total score improvement suggests that EEST facilitated initial generalized gains across several areas. These broad-based benefits likely stem from the training’s emphasis on foundational EF processes that underpin performance in multiple settings—such as family interactions, school activities, and self-management. Thus, while the generalized effect was captured by the total score, longer-term training or follow-up may be necessary for significant and domain-specific improvements to become clearly measurable.

Limitations and future directions

This study has several limitations that should be acknowledged. A primary limitation of this study is its non-randomized design, wherein group assignment was based on parental self-selection. Although the strict application of predefined inclusion and exclusion criteria ensured no significant differences in baseline characteristics between groups, this design may still introduce potential selection bias. The influence of unmeasured confounders, potentially related to differing levels of parental motivation or engagement, cannot be ruled out. Consequently, future research should employ randomized controlled trials to establish definitive causality regarding the intervention’s efficacy. Second, the relatively small sample size and the lack of long-term follow-up data limit the ability to evaluate the sustained efficacy of EEST and generalize the findings.

Integrating EEST with pharmacotherapy and nutritional strategies represents a paradigm shift from siloed interventions to multimodal, personalized care for ADHD. While EEST alone targets EF deficits ecologically, its combination with medications addresses immediate symptom relief, and nutritional support may underlying neural health. Future research must focus on interactive effects through rigorous designs, ultimately advancing tailored strategies that maximize functional outcomes for individuals with ADHD. This approach aligns with the transdiagnostic nature of EF deficits, potentially extending benefits to other mental disorders (e.g. anxiety, autism spectrum disorders).

Adverse events

During the process of this study, no adverse events related to the intervention occurred, indicating that the EEST is safe.

Conclusion

EEST significantly alleviates emotional dysregulation in children with ADHD, including symptoms of anxiety, depression, and impaired emotional control. Furthermore, this intervention demonstrates measurable improvements in core ADHD symptoms, executive functioning, and social competency. As a non-pharmacological treatment modality, EEST enhances multiple clinical outcomes, warranting broader implementation and integration into therapeutic protocols for pediatric ADHD populations.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

ADHD

Attention-Deficit/Hyperactivity Disorder

EEST

Ecological Executive Skills Training

VADPRS

Vanderbilt ADHD Diagnostic Parent Rating Scale

VADTRS

Vanderbilt ADHD Diagnostic Teacher Rating Scale

CBCL

Achenbach Child Behavior Checklist

SDQ

Strengths and Difficulties Questionnaire

PSQ

Conner’s Parent Symptom Questionnaire

BRIEF

Behavior Rating Inventory of Executive Function

WFIRS-P

The Weiss Functional Impairment Rating Scale - Parent Report

Author contributions

LL W, F-Y J, and L D significantly contribute to concept and design, data acquisition, and data analysis and interpretation. XY P , WY Z, GY L and C M collected data and arranged graphs and tables. L D critically revises articles and provides important intellectual content. All authors contributed to and have approved the final manuscript.

Funding

This work was supported by the health science and technology ability improvement project of Jilin Province (Grant number: 2023LC005).

Data availability

Deidentified individual participant data (including data dictionaries) will be made available, in addition to study protocols, the statistical analysis plan, and the informed consent form. The data will be made available upon publication to researchers who provide a methodologically sound proposal for use in achieving the goals of the approved proposal. Proposals should be submitted to du\_lin@jlu.edu.cn; or jidawanglili@163.com.

Declarations

Ethics approval and consent to participate

All procedures were performed in accordance with ethical standards of the Ethics Committee of the First Hospital of Jilin University (Ethics NO.22K031-001), according to the principles of the Declaration of Helsinki (1964) and its later reforms. Written informed consent was provided by the parents or caregivers of the children.

Competing interests

The authors declare no competing interests.