. 2021 Nov 4;21:490. doi: 10.1186/s12887-021-02916-5

Table 1.

Summary of Included Sources

Source	Study design	Population	Intervention	Outcomes (incl. outcome measures)
Bartscherer & Dole (2005) [78]	Case report	Boy with attention and motor coordination difficulties (n = 1; no formal ADHD diagnosis) Age: 9 Medication: no	Interactive Metronome training: Variety of upper and lower limb tasks performed with metronome beat Schedule: 7-week program Sessions 3x/week (60–90 min each) 4 pre-sessions, 15 sessions	Bruininks-Oseretsky Test of Motor Proficiency (BOTMP): Improvements in gross and fine motor skills: ∙ Largest improvements in balance, response speed, visual-motor control, upper limb speed, dexterity ∙ Smaller changes in bilateral coordination, strength ∙ No change in running speed, agility ∙ Decline in upper limb coordination Interactive Metronome long-form test (IM LFT): Improvements in timing accuracy Parent reports: Behavior changes More cooperative, less resistance & fighting, self-confidence (willingness to take risks), faster at solving math problems, improvements in handwriting
Dahan et al. (2018) [20]	Review	ADHD subjects	Neurofeedback (NF) interventions: Theta/beta frequency training and SCP neurofeedback EMG-Biofeedback (EMG-BF) interventions: Feedback on motor activity Physical activity and motor interventions: Several weeks training program or single intervention (e.g. running on treadmill, ball handling and balance exercises, general exercise)	NF: Improvements in behavioral self-regulation; reduction of ADHD symptoms (mixed findings); increase in response speed; no differences between the different NF approaches EMG-BF: Improvements in motor coordination and regulation, visuo-motor precision, flexibility, fine motor control, muscle relaxation; reduction of ADHD symptoms Physical activity and motor interventions: Improvements in executive functioning, social behavior, response preparation, working memory, motor performance; reduction of ADHD symptoms; regardless of type of physical activity Follow-up: Evidence for persisting changes
Duda et al. (2019) [79]	Case-control study	Children and adolescents with ADHD (n = 16) Control group: Children and adolescents without ADHD (n = 16) Age: 9–15 Medication: no	Graphomotor learning task: Practicing a novel grapheme on a digitizing tablet 30 x Schedule: One single session Note: Not a training for fine motor skills but to investigate graphomotor procedural learning	WACOM Cintiq 21UX digitizing tablet & MovAlyzeR software ADHD group: No improvements in graphomotor fluency and automaticity Control group: Improvement in graphomotor fluency and automaticity
Gharebaghy et al. (2015) [80]	Single case experimental design (multiple baselines)	Children with ADHD (n = 6) Age: 7–12 Medication: yes	Cognitive Orientation to daily Occupational Performance (CO-OP): Use of cognitive strategies to reach self-selected goals regarding motor performance in daily living activities (e.g. handwriting, dressing) Schedule: 12-week program 12 sessions (45–60 min each)	Bruininks-Oseretsky Test of Motor Proficiency and Performance (BOTMP): Improvements in motor performance Canadian Occupational Performance Measure (COPM): Perceived improvements in chosen goals (satisfaction and performance) reported by all children and parents Goal Attainment Scaling: 17/18 goals attained or exceeded
Halperin et al. (2013) [81]	Proof-of-concept study	Preschool children with ADHD (n = 29; all subtypes) Age: 4–5 Medication: no	TEAMS Intervention (Training Executive, Attention, and Motor Skills): Games designed to enhance inhibitory control, working memory, attention, visuo-spatial abilities, planning, and motor skills (e.g. games with balls, puzzles, jump rope) + additional aerobic exercises (e.g. jumping jacks) Schedule: Therapist sessions for children (90 min each) Parent sessions (20 min each): Psychoeducation & support Group A: 5 weeks, 1x/week Group B: 8 weeks, 1x/week Group C: 5 weeks, 2x/week A, B, C: Additional daily training sessions at home (30–45 min each)	ADHD-RS-IV (parent & teacher ratings): Improvement in ADHD symptoms; reductions in impairment No differences on outcomes among groups Parent Satisfaction Questionnaire (PSQ): Satisfaction with program and treatment compliance Follow-up (1 month & 3 months): Improvements in ADHD symptoms maintained
Molsberger et al. (2014) [82]	Case report	Boy with ADHD (n = 1) Age: 9 Medication: yes	Complementary medical intervention: Applied kinesiology (AK), acupuncture, respiratory exercises Schedule: 10 months 18 sessions Week 1: 2 sessions Week 2 to end: sessions every 2–4+ weeks First 3 sessions: respiratory exercises (10–15 min each) + acupuncture (permanent needles for 2 days each time) Respiratory exercises at home (2 min/day)	Coachman’s test: Normalized muscle function Parent reports: Improvements in sleep behavior and handwriting; increased effectiveness of medication after acupuncture Follow-up (15 months): Improvements maintained
Palsbo & Hood-Szivek (2012) [83]	Non-randomized uncontrolled pretest-posttest design	Children with learning impairments, neuromotor and/or handwriting deficits (n = 18): ASD (n = 5), ADD or ADHD (n = 2), Pervasive developmental delay (n = 1), Intellectual disability (n = 2), Auditory processing disorder or deafness (n = 2), no disability (n = 6) Age: 5–11	Robotic-assisted three-dimensional repetitive motion training: Use of a haptic computer-user interface to improve handwriting through a program of active therapy (e.g. proprioception exercises, robot-assisted glyph formation) with multisensory feedback Schedule: 4–6/8 weeks 15–20 sessions 3-5x/week or daily sessions (25–30 min each)	Beery-Buktenica Developmental Test of Visual-Motor Integration (Motor Coordination Subtest): Improvements in fine motor skills & motor control (children with learning disabilities and ≥ 9 years) No improvements (children with CP or < 9 years) Test of Handwriting Skills-Revised (THS-R; random number and uppercase letter order subtests) & Print Tool (random lowercase letter order subtest): Improvements in consistency of glyph formation (10/14 children) and writing size (all children with ASD) Evaluation Tool of Children’s Handwriting (ETCH; copy subtest): Improvements in handwriting fluidity (writing speed) while maintaining legibility (all children with ASD or ADHD/ADD)
Ruiz-Manrique et al. (2014) [84]	Case report	Boy with ADHD and comorbid video game addiction (n = 1) Age: 10 Medication: yes	“ADHD Trainer”: Mobile/tablet application designed to treat ADHD using a cognitive training method to enhance cognitive skills (attention, working memory, processing speed, calculation ability, reasoning, visuo-motor coordination) Schedule: 2 months (within study), 6 months (total training reported by parents) 1st month: 10 min-4 h/day (average: 1 h/day) 2nd month: min. 10 min/day	Conners’ Parent and Teacher Rating Scales & Barkley School Situations Questionnaire: ∙ Behavioral improvements ∙ Academic improvements ∙ Improvement of cognitive areas: visuo-spatial working memory, fine motor skills Parent report: Reduction of videogame abuse (playing time)
Shaffer et al. (2001) [85]	Randomized controlled pretest-posttest design (blinded)	Boys with ADHD (n = 56) Age: 6–12	Interactive Metronome training: Variety of upper and lower limb tasks performed with metronome beat Schedule: Treatment group: 3–5 weeks Interactive Metronome training 15 sessions (60 min each) Control group A: No intervention Control group B: 3–5 weeks video game training (incl. eye-hand coordination, advanced mental planning, multiple task sequencing) 15 sessions (60 min each)	Treatment group: Improvements in attention: ∙ Tests of Variables of Attention (TOVA): Reduction of errors and distractibility, consistency of reaction time, improved overall attention ∙ Conners’ Rating Scales-Revised (CRS-R) Teacher & Parent versions: Improvements in aggression control ∙ Wechsler Intelligence Test for Children-Third Edition ∙ Achenbach Child Behavior Checklist Improvements in motor control: ∙ Conners’ Rating Scales-Revised (CRS-R) Teacher & Parent versions ∙ Achenbach Child Behavior Checklist ∙ The Sensory Profile ∙ Bruininks-Oseretsky Test for Motor Proficiency (selected subtests) Improvements in academic achievements: ∙ Wide Range Achievement Test (WRAT 3; reading & writing): Improvements in reading ∙ Language Processing Test: Improvements in language processing Differences between groups: Improved performance in treatment group; decreased performance in control group and video game group
Tucha & Lange (2005) [86]	Study 1: Experimental design (randomized) Study 2: Experimental design (randomized) Study 3: Case report	Study1: Neurotypical students (n = 26) Age: 20–35 Study 2: Children with ADHD/combined type (n = 12; no fine motor problems) Age: 9–12 Medication: Depending on experimental condition Study 3: Boy with ADHD/combined type (n = 1) Age: 10 Medication: yes	Study 1: Examination of handwriting movements of neurotypical students under different conditions (normal/neat/blind writing, visually/mentally tracking the pen) Schedule: 1 single session Note: Not included in review (not ADHD) Study 2: Examination of handwriting movements of children with ADHD under medication vs. placebo condition Medication condition: different instructions (repetitive hand movements, fluent circle drawing, blind/fast writing) Schedule: 2 sessions in 5–7 days Note: Not included in review (no training) Study 3: Training of automated handwriting movements (copying short texts) aided by simple instructions to direct attention away from accuracy and legibility of handwriting Schedule: ~ 3 weeks 6 sessions	WACOM IV Digitizing Tablet & specific pen: Study 1 (Tablet): Automated handwriting movements under different conditions Study 2 (Tablet): Reduced handwriting fluency on medication; automated handwriting movements on medication through instructions Study 3: ∙ Tablet: Automated and perfectly smooth handwriting movements (on tablet and homework) through instructions and feedback; reduced number of false starts ∙ Parent and teacher reports: Increased writing speed; legible handwriting but irregular alignment; better grades; higher motivation Follow-up (4 weeks): Improvements of handwriting movements maintained
Weerdmeester et al. (2016) [87]	Feasibility study (randomized controlled pretest-posttest design)	Children with ADHD (n = 47) or elevated ADHD symptoms (n = 26) Age: 6–13	“Dragon”: Full-body videogame intervention with ADHD-focused training components Intervention condition: “Dragon” Control condition: “Angry Birds Trilogy” (comparable full-body videogame not targeting ADHD symptoms) Schedule: 6 sessions (15 min each)	ADHD VragenLijst (AVL; teacher-ratings): Greater improvement of ADHD symptoms in intervention vs. control group Go/no-go task: Reduction in number of hits (sustained attention) in both groups; greater increase in false alarms (impulsivity) in intervention vs. control group Movement Assessment Battery for Children (MABC-2-NL): Improvements in fine motor skills (both groups); no improvement in gross motor skills Evaluative questions about “Dragon”: Satisfaction with game
Yazd et al. (2015) [88]	Experimental design (randomized)	Children with ADHD (n = 36) Age: 6–12 Medication: Depending on experimental condition	Group A: Perceptual-motor training (incl. spatial/temporal/directional/body awareness, balance, coordination) Group B: Combination of perceptual-motor training and drug therapy Group C: Drug therapy (Methylphenidate, Risperidone) Schedule: 6-week treatment/training Group B & C: 18 training sessions	Bruininks-Oseretsky Test of Motor Proficiency: ∙ Group A: Improvements in gross and fine motor skills ∙ Group B: Improvement in gross and fine motor skills ∙ Group C: No improvement in motor performance

Source

Study design

Population

Intervention

Outcomes (incl. outcome measures)

Bartscherer & Dole (2005) [78]

Case report

Boy with attention and motor coordination difficulties (n = 1; no formal ADHD diagnosis)

Age: 9

Medication: no

Interactive Metronome training: Variety of upper and lower limb tasks performed with metronome beat

Schedule:

7-week program

Sessions 3x/week (60–90 min each)

4 pre-sessions, 15 sessions

Bruininks-Oseretsky Test of Motor Proficiency (BOTMP): Improvements in gross and fine motor skills:

∙ Largest improvements in balance, response speed, visual-motor control, upper limb speed, dexterity

∙ Smaller changes in bilateral coordination, strength

∙ No change in running speed, agility

∙ Decline in upper limb coordination

Interactive Metronome long-form test (IM LFT): Improvements in timing accuracy

Parent reports:

Behavior changes

More cooperative, less resistance & fighting, self-confidence (willingness to take risks), faster at solving math problems, improvements in handwriting

Dahan et al. (2018) [20]

Review

ADHD subjects

Neurofeedback (NF) interventions: Theta/beta frequency training and SCP neurofeedback

EMG-Biofeedback (EMG-BF) interventions: Feedback on motor activity

Physical activity and motor interventions: Several weeks training program or single intervention (e.g. running on treadmill, ball handling and balance exercises, general exercise)

NF: Improvements in behavioral self-regulation; reduction of ADHD symptoms (mixed findings); increase in response speed; no differences between the different NF approaches

EMG-BF: Improvements in motor coordination and regulation, visuo-motor precision, flexibility, fine motor control, muscle relaxation; reduction of ADHD symptoms

Physical activity and motor interventions: Improvements in executive functioning, social behavior, response preparation, working memory, motor performance; reduction of ADHD symptoms; regardless of type of physical activity

Follow-up: Evidence for persisting changes

Duda et al. (2019) [79]

Case-control study

Children and adolescents with ADHD (n = 16)

Control group: Children and adolescents without ADHD (n = 16)

Age: 9–15

Medication: no

Graphomotor learning task: Practicing a novel grapheme on a digitizing tablet 30 x

Schedule: One single session

Note: Not a training for fine motor skills but to investigate graphomotor procedural learning

WACOM Cintiq 21UX digitizing tablet & MovAlyzeR software

ADHD group: No improvements in graphomotor fluency and automaticity

Control group: Improvement in graphomotor fluency and automaticity

Gharebaghy et al. (2015) [80]

Single case experimental design (multiple baselines)

Children with ADHD (n = 6)

Age: 7–12

Medication: yes

Cognitive Orientation to daily Occupational Performance (CO-OP): Use of cognitive strategies to reach self-selected goals regarding motor performance in daily living activities (e.g. handwriting, dressing)

Schedule:

12-week program

12 sessions (45–60 min each)

Bruininks-Oseretsky Test of Motor Proficiency and Performance (BOTMP): Improvements in motor performance

Canadian Occupational Performance Measure (COPM): Perceived improvements in chosen goals (satisfaction and performance) reported by all children and parents

Goal Attainment Scaling: 17/18 goals attained or exceeded

Halperin et al. (2013) [81]

Proof-of-concept study

Preschool children with ADHD (n = 29; all subtypes)

Age: 4–5

Medication: no

TEAMS Intervention (Training Executive, Attention, and Motor Skills): Games designed to enhance inhibitory control, working memory, attention, visuo-spatial abilities, planning, and motor skills (e.g. games with balls, puzzles, jump rope) + additional aerobic exercises (e.g. jumping jacks)

Schedule:

Therapist sessions for children (90 min each)

Parent sessions (20 min each): Psychoeducation & support

Group A: 5 weeks, 1x/week

Group B: 8 weeks, 1x/week

Group C: 5 weeks, 2x/week

A, B, C: Additional daily training sessions at home (30–45 min each)

ADHD-RS-IV (parent & teacher ratings):

Improvement in ADHD symptoms; reductions in impairment

No differences on outcomes among groups

Parent Satisfaction Questionnaire (PSQ): Satisfaction with program and treatment compliance

Follow-up (1 month & 3 months): Improvements in ADHD symptoms maintained

Molsberger et al. (2014) [82]

Case report

Boy with ADHD (n = 1)

Age: 9

Medication: yes

Complementary medical intervention: Applied kinesiology (AK), acupuncture, respiratory exercises

Schedule:

10 months

18 sessions

Week 1: 2 sessions

Week 2 to end: sessions every 2–4+ weeks

First 3 sessions: respiratory exercises (10–15 min each) + acupuncture (permanent needles for 2 days each time)

Respiratory exercises at home (2 min/day)

Coachman’s test: Normalized muscle function

Parent reports: Improvements in sleep behavior and handwriting; increased effectiveness of medication after acupuncture

Follow-up (15 months): Improvements maintained

Palsbo & Hood-Szivek (2012) [83]

Non-randomized uncontrolled pretest-posttest design

Children with learning impairments, neuromotor and/or handwriting deficits (n = 18): ASD (n = 5), ADD or ADHD (n = 2), Pervasive developmental delay (n = 1), Intellectual disability (n = 2), Auditory processing disorder or deafness (n = 2), no disability (n = 6)

Age: 5–11

Robotic-assisted three-dimensional repetitive motion training: Use of a haptic computer-user interface to improve handwriting through a program of active therapy (e.g. proprioception exercises, robot-assisted glyph formation) with multisensory feedback

Schedule:

4–6/8 weeks

15–20 sessions

3-5x/week or daily sessions (25–30 min each)

Beery-Buktenica Developmental Test of Visual-Motor Integration (Motor Coordination Subtest):

Improvements in fine motor skills & motor control (children with learning disabilities and ≥ 9 years)

No improvements (children with CP or < 9 years)

Test of Handwriting Skills-Revised (THS-R; random number and uppercase letter order subtests) & Print Tool (random lowercase letter order subtest): Improvements in consistency of glyph formation (10/14 children) and writing size (all children with ASD)

Evaluation Tool of Children’s Handwriting (ETCH; copy subtest): Improvements in handwriting fluidity (writing speed) while maintaining legibility (all children with ASD or ADHD/ADD)

Ruiz-Manrique et al. (2014) [84]

Case report

Boy with ADHD and comorbid video game addiction (n = 1)

Age: 10

Medication: yes

“ADHD Trainer”: Mobile/tablet application designed to treat ADHD using a cognitive training method to enhance cognitive skills (attention, working memory, processing speed, calculation ability, reasoning, visuo-motor coordination)

Schedule:

2 months (within study), 6 months (total training reported by parents)

1st month: 10 min-4 h/day (average: 1 h/day)

2nd month: min. 10 min/day

Conners’ Parent and Teacher Rating Scales & Barkley School Situations Questionnaire:

∙ Behavioral improvements

∙ Academic improvements

∙ Improvement of cognitive areas: visuo-spatial working memory, fine motor skills

Parent report: Reduction of videogame abuse (playing time)

Shaffer et al. (2001) [85]

Randomized controlled pretest-posttest design (blinded)

Boys with ADHD (n = 56)

Age: 6–12

Interactive Metronome training: Variety of upper and lower limb tasks performed with metronome beat

Schedule:

Treatment group:

3–5 weeks Interactive Metronome training

15 sessions (60 min each)

Control group A: No intervention

Control group B:

3–5 weeks video game training (incl. eye-hand coordination, advanced mental planning, multiple task sequencing)

15 sessions (60 min each)

Treatment group: Improvements in attention:

∙ Tests of Variables of Attention (TOVA): Reduction of errors and distractibility, consistency of reaction time, improved overall attention

∙ Conners’ Rating Scales-Revised (CRS-R) Teacher & Parent versions: Improvements in aggression control

∙ Wechsler Intelligence Test for Children-Third Edition

∙ Achenbach Child Behavior Checklist

Improvements in motor control:

∙ Conners’ Rating Scales-Revised (CRS-R) Teacher & Parent versions

∙ Achenbach Child Behavior Checklist

∙ The Sensory Profile

∙ Bruininks-Oseretsky Test for Motor Proficiency (selected subtests)

Improvements in academic achievements:

∙ Wide Range Achievement Test (WRAT 3; reading & writing): Improvements in reading

∙ Language Processing Test: Improvements in language processing

Differences between groups: Improved performance in treatment group; decreased performance in control group and video game group

Tucha & Lange (2005) [86]

Study 1: Experimental design (randomized)

Study 2: Experimental design (randomized)

Study 3: Case report

Study1: Neurotypical students (n = 26)

Age: 20–35

Study 2: Children with ADHD/combined type (n = 12; no fine motor problems)

Age: 9–12

Medication: Depending on experimental condition

Study 3: Boy with ADHD/combined type (n = 1)

Age: 10

Medication: yes

Study 1: Examination of handwriting movements of neurotypical students under different conditions (normal/neat/blind writing, visually/mentally tracking the pen)

Schedule: 1 single session

Note: Not included in review (not ADHD)

Study 2: Examination of handwriting movements of children with ADHD under medication vs. placebo condition

Medication condition: different instructions (repetitive hand movements, fluent circle drawing, blind/fast writing)

Schedule: 2 sessions in 5–7 days

Note: Not included in review (no training)

Study 3: Training of automated handwriting movements (copying short texts) aided by simple instructions to direct attention away from accuracy and legibility of handwriting

Schedule:

~ 3 weeks

6 sessions

WACOM IV Digitizing Tablet & specific pen:

Study 1 (Tablet): Automated handwriting movements under different conditions

Study 2 (Tablet): Reduced handwriting fluency on medication; automated handwriting movements on medication through instructions

Study 3:

∙ Tablet: Automated and perfectly smooth handwriting movements (on tablet and homework) through instructions and feedback; reduced number of false starts

∙ Parent and teacher reports: Increased writing speed; legible handwriting but irregular alignment; better grades; higher motivation

Follow-up (4 weeks): Improvements of handwriting movements maintained

Weerdmeester et al. (2016) [87]

Feasibility study (randomized controlled pretest-posttest design)

Children with ADHD (n = 47) or elevated ADHD symptoms (n = 26)

Age: 6–13

“Dragon”: Full-body videogame intervention with ADHD-focused training components

Intervention condition: “Dragon”

Control condition: “Angry Birds Trilogy” (comparable full-body videogame not targeting ADHD symptoms)

Schedule: 6 sessions (15 min each)

ADHD VragenLijst (AVL; teacher-ratings): Greater improvement of ADHD symptoms in intervention vs. control group

Go/no-go task: Reduction in number of hits (sustained attention) in both groups; greater increase in false alarms (impulsivity) in intervention vs. control group

Movement Assessment Battery for Children (MABC-2-NL): Improvements in fine motor skills (both groups); no improvement in gross motor skills

Evaluative questions about “Dragon”: Satisfaction with game

Yazd et al. (2015) [88]

Experimental design (randomized)

Children with ADHD (n = 36)

Age: 6–12

Medication: Depending on experimental condition

Group A: Perceptual-motor training (incl. spatial/temporal/directional/body awareness, balance, coordination)

Group B: Combination of perceptual-motor training and drug therapy

Group C: Drug therapy (Methylphenidate, Risperidone)

Schedule: 6-week treatment/training

Group B & C: 18 training sessions

Bruininks-Oseretsky Test of Motor Proficiency:

∙ Group A: Improvements in gross and fine motor skills

∙ Group B: Improvement in gross and fine motor skills

∙ Group C: No improvement in motor performance