Exploring the Impact of Multimodal Training on Sensory,Motor and Cognitive Function Among Children with Attention Deficit Hyperactivity Disorder: A FOCUS Protocol of Randomised Controlled Trial

Abstract

Background

Attention deficit hyperactivity disorder (ADHD) is a prevalent neurodevelopmental disorder characterised primarily by inattention, hyperactivity, and impulsiveness with associated impairments related to sensory processing and motor coordination, and attributed to abnormalities in the brain areas responsible for sensory-motor integration and cognitive control. The symptoms may persist until adulthood, impacting various aspects of life. Traditional treatment and pharmacological approaches chiefly target behavioural aspects, highlighting the need to address sensory, motor, and cognitive issues via an integrative approach.

Purpose

This study aims to determine the effect of a multi-modal exercise programme on improving cognitive, sensory, and motor function among children with ADHD.

Methods

The study will be a randomised controlled trial involving 60 children diagnosed with ADHD, aged 6–12 years. Children will be randomly allocated to either the intervention group or the control group. Both groups will be subjected to a 45-minute therapy session four times a week for eight weeks. The intervention group will receive sensory, motor and cognitive training, and the control group will receive standard care. Outcomes Paediatric Balance Scale (PBS), Short Sensory Profile (SSP), Trail Making Test, and Developmental Coordination Disorder Questionnaire 2007 will be analysed at baseline, two weeks, four weeks, and at the end of the eight-week training programme.

Results

It is anticipated that an integrative training approach among the intervention group, will concurrently address the underlying neurodevelopmental deficits and improve sensory, motor, and cognitive functions instead of focusing solely on symptom management among children with ADHD.

Conclusion

Incorporating sensory, motor, and cognitive training offers a promising supplementary approach in ADHD management. The multimodal stimulation of neural circuits will serve to improve core functions and promote more adaptive behaviours.

Trial Registration

This prospective trial has been successfully registered with the Clinical Trial Registry of India with registration number (CTRI/2025/05/086742).

Introduction

Attention deficit hyperactivity disorder (ADHD), a condition marked by inattention, hyperactivity, and impulsivity, affects 5%–8% of children worldwide. ¹ Children with ADHD often face challenges with motor coordination and sensory processing, making it harder for them to learn and carry out motor-related activities effectively, which can affect their balance, coordination, fine and gross motor skills, and ability to perform everyday tasks. These difficulties can have lasting effects on their personal lives, social interactions, and academic performance.^{2, 3}

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, defines ADHD as a condition where the symptoms persist for at least six months and are severe enough to interfere with daily activities, academic performance, or social interactions. ⁴ Importantly, research shows that about 50% of children with developmental coordination disorder also meet the criteria for ADHD. ⁵

Neuroimaging studies have revealed differences in the structure and function of certain parts of the brain in people with ADHD compared to people without the disorder. Specifically, abnormalities were found to be related to the cerebellum, activity and connectivity of the prefrontal cortex, and differences in the size and shape of the basal ganglia.^6–8 There is a favourable association between somatosensory discrimination and motor planning, motor learning, and motor abilities, as demonstrated by the various studies that have shown the sensory processing differences in children with ADHD. ⁹ It has been demonstrated that reduced cognitive functioning is associated with delayed acquisition of motor skills and movements needed for activities of daily living (ADLs). ¹⁰ In addition, compromised sensory integration affects the ability to process and respond appropriately to sensory stimuli. Given the complex nature of ADHD and its wide-ranging effects, early detection and targeted treatments are crucial. ¹¹ Pharmacological interventions mostly aim to target the core symptoms associated with symptom reduction and behaviour compliance. However, their long-term use is associated with side effects, including potential cardiovascular risks, and does not address the functional limitations associated with the disorder. ¹²

Investigation on how children with ADHD’s motor skills link to their social and cognitive abilities suggests that issues with cognition obstruct the development of motor skills. ¹³ This connection between cognitive deficits and motor impairments underscores the interconnectedness of these areas, highlighting the importance of a comprehensive understanding of the disorder and the development of evidence-based interventions for children with ADHD. ¹⁴ Interrelatability in deficiencies related to perception, motor control, and attention requires a multimodal approach that addresses cognitive, sensory, and motor challenges in a coordinated way to improve both functional abilities and quality of life for children with ADHD. Early detection and intervention using such a treatment strategy will allow for more personalised, effective treatment that supports children’s development from an early stage and helps prevent long-term negative outcomes. Despite the growing body of research, there remains a gap in standardised protocols and robust evidence regarding the combined impact of such interventions. This study seeks to contribute to the evolving understanding of multimodal interventions and their role in reshaping clinical practice and educational support for children living with this complex condition. Given this context, the present study aims to explore the need for and efficacy of an integrative training approach that concurrently targets sensory, motor, and cognitive domains in children with ADHD. By addressing the underlying neurodevelopmental deficits rather than merely managing symptoms, such an approach may offer a more holistic and sustainable strategy for enhancing the functional outcomes and quality of life for individuals with ADHD.

Methods

Ethical Approval

This study is a two-group, pretest-posttest design, randomised controlled trial targeting children with ADHD. The study protocol was approved by the Research Ethics Committee of the School of Allied Health Sciences, Galgotias University (Ref. no. SEC/SAHS/PHD/24/10). This prospective trial has been successfully registered with the Clinical Trial Registry of India (acknowledgement number REF/2025/04/103647) and obtained trial registration number (CTRI/2025/05/086742) on 13 May 2025. The study will be conducted per the ethical principles for medical research involving human subjects outlined in the Declaration of Helsinki (revised 2013) and the Indian Council of Medical Research National Ethical Guidelines for Biomedical and Health Research Involving Human Participants (2017).^{15, 16} This FOCUS protocol document is identified as version 1.0, dated 9 January 2025, reflecting all amendments and updates as of this date. Any further updates will be systematically documented with new version numbers and dates, as required.

Compliance with Ethical Standards

The protocol is prepared following the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) 2013 guidelines, which offer an evidence-based framework to ensure that all essential scientific, ethical, and methodological aspects of the trial are thoroughly addressed. ¹⁷ Additionally, this protocol has been formally submitted for registration with the Copyright Office, Government of India, with a unique diary number 11478/2025-CO/L (https://copyright.gov.in/Reports/frmPrintAckLetter.aspx).

Study Setting and Design

To evaluate the effect of the FOCUS protocol trial, this study will adopt a two-group, pre-test-post-test design and will be conducted in a teaching hospital with a physiotherapy outpatient department located in Dehradun, Uttarakhand, India and equipped with standardised facilities and appropriate infrastructure to carry out the trial effectively. The children will be randomly assigned to either the intervention group or the control group. Baseline assessments (pretest) will be conducted for all children before the intervention, followed by post-intervention assessments (posttest), enabling within-group and between-group comparisons to evaluate the proposed outcomes and assess the effect of the intervention.

Eligibility Criteria

The inclusion criteria are as follows: Girls and boys aged 6–12 years with a clinical diagnosis of ADHD; cooperation in understanding and performing tasks as determined by the Modified Mini-Mental Scale for Cognitive Function in Children. Inclusion will be based on obtaining informed consent from both the parent or guardian and the child participant. The following will be excluded from the study: Children who have undergone recent surgical procedures; those with visual or auditory impairments; associated birth defects and congenital anomalies; diagnosed neurological disorders and systemic diseases other than ADHD; and any physical deficits leading to motor disorders.

Randomisation, Allocation and Blinding

Children will be randomised to the sensory, motor and cognitive training group and the standard care group. A computer-generated random number table employing the block randomisation method will be administered. To ensure allocation concealment, sequentially numbered, sealed, opaque envelopes will be used. Children will be randomly assigned to either the intervention or control group based on the generated sequence. Both children and outcome assessors will be blinded to group allocation to minimise performance and detection bias. The physiotherapist administering the intervention will not be blinded; however, they will not be involved in outcome assessments. Unblinding will be permitted only in cases involving medical emergencies or adverse events, only after consulting the principal investigator. The schematic Consolidated Standards of Reporting Trials flow chart for the study protocol is displayed in Figure 1.

Figure 1.

Proposed Consolidated Standards of Reporting Trials (CONSORT) Flow Chart for Non-pharmacological Intervention. ²⁹

Sample Size Estimation

The sample size was calculated using the Systat 13.2 Software, and was 60 (30 in each group). https://grafiti.com/product/systat-v13-2/ The expected mean difference (effect size) was 15 with an alpha level of 0.05, 90% statistical power (beta = 0.90), and a population variance of 16.

Recruitment, Enrolment, and Baseline Measurements

Eligible children who meet the selection criteria will be included in the study after obtaining informed consent. The enrolment will be conducted over 10 months, ensuring adequate time to complete the assessment. Baseline characteristics of each patient will be determined through a standardised assessment proforma, including demographic details. Children in both groups will participate in an eight-week training programme.

Patient participation schedules for the trial will be determined as per Table 1.

Table 1.

SPIRIT Flow Diagram (Schedule of Enrolment, Interventions, and Assessments).

Time Point	Study Period
	Enrolment	Allocation	Post-allocation
	Baseline (T0)	Baseline (T0)	T0 (Baseline)	T1 (Week 2)	T2 (Week 4)	T3 (Week 8)
Eligibility screen	×
Informed consent	×
Evaluation based on inclusion and exclusion criteria	×
Allocation		×
Intervention
Sensory, motor and cognitive training			×________________________×
Standard care			×________________________×
Assessment
Demographic data			×
Paediatric balance scale			×	×	×	×
Short sensory profile			×	×	×	×
Trail making test			×	×	×	×
Developmental Coordination Disorder Questionnaire, 2007			×	×	×	×

Source: Drafted by authors as per the SPIRIT Checklist. ¹⁷

Procedure

After meeting the selection criteria and obtaining baseline measures, children will be randomly assigned to the intervention group and the control group. The therapy will be administered as four sessions per week over eight weeks, with each session lasting approximately 45 minutes.

Intervention Group (Sensory, Motor and Cognitive Training Group)

Children in this group will receive a self-designed, structured therapy programme based on a multimodal approach incorporating sensory, motor, and cognitive therapeutic components to address different aspects of the needs of children with ADHD. Each component of the intervention will follow a planned progression schedule, with modifications implemented once every two weeks. Table 2 illustrates the intervention group (sensory, motor and cognitive) training protocol.

Table 2.

Protocol for Sensory-motor and Cognitive Training.

Sensory Training							Weeks 1 and 2
Activity	Description	Position of Child	Therapist Position	Frequency	Repetitions per Session	Duration of Exercise per Session
Swinging	Swings on a soft-padded swing	Sitting	Standing beside the swing for assistance and safety	Four times/week	10 swings forward and back	Three minutes
Crawling	Crawls over a soft-textured mattress	Moving on hands and knees, with body outstretched	Standing near the cushion for guidance	Four times/week	Three passes across the mattress	Three minutes
Identifies textured objects in a container	Identifies textured objects from a container	Sitting with height adjusted to access the container easily	Sitting or standing beside the child	Four times/week	10 objects placed in a container	Three minutes
Aiming at a target	Throwing an object onto a target	Standing or sitting	Stands beside the child	Four times/week	10 tosses	Three minutes
Bubble blowing	Blowing bubbles and popping them	Sitting in a comfortable position	Stands/sits beside the child	Four times/week	15 bubbles	Three minutes
Weeks 3 and 4
Activity	Description	Position of Child	Therapist Position	Frequency	Repetitions per Session	Duration of Exercise per Session
Midline crossing on swing	The child reaches out across midline and touches different textured objects placed on either side	Sitting on a swing with feet unsupported	Stands beside the swing and assists if needed	Four times/week	10 repetitions	Three minutes
Weeks 3 and 4
Activity	Description	Position of Child	Therapist Position	Frequency	Repetitions per Session	Duration of Exercise per Session
Pushing an object to reach a designated target	The child pushes an object to a designated target and returns to the starting position	Kneels and pushes the object	Sitting/standing facing the child	Four times/week	One repetition	Three minutes
Sorting textured items from the box	The child picks textured items, as instructed, and places them in a container placed adjacent to it	Standing beside the target box	Standing next to or behind the child	Four times/week	10 objects explored and sorted	Three minutes
Catching a ball while seated on an exercise ball	The child catches and returns a ball to the therapist.Note: A soft ball should be used to avoid injury	Sits on a therapy ball	Stands straight in front of the child	Four times/week	10 catches	Three minutes
Hopping over a textured mat with auditory feedback	Child hops over a textured mat, matching the auditory signals	Standing followed by hopping	Stands beside the child	Four times/week	10 hops	Three minutes
Weeks 5 and 6
Activity	Description	Position of Child	Therapist Position	Frequency	Repetitions per Session	Duration of Exercise per Session
Hopping over the textured mat to quick auditory prompts	Children hop, matching the cues to augment sensory processing further	Stands at one end and hops over to reach the opposite end	Stands beside the child, ensuring safety	Four times/week	10 hops per set; Two sets	Five minutes
Push balls in pairs while standing on a foam mattress	Each pair pushes an exercise ball back and forth while standing on a foam mattress	Standing, facing each other	Stands next to the ball/between pairs	Four times/week	10 ball pushes per set; Two sets	Five minutes
Mirror movements	Children mirror movements as the therapist performs them	Standing, facing the therapist	Observes movements and guides children	Four times/week	Three rounds of one minute each	Three minutes
Carrying objects while crossing a textured path	Children walk through a textured path while carrying an object in their hands	Walks over a textured path	Alongside the path, monitoring the child	Four times/week	Two circuits of the path	Two minutes
Weeks 7 and 8
Activity	Description	Position of Child	Therapist Position	Frequency	Repetitions per Session	Duration of Exercise per Session
Search Items in a sensory-rich setting within a stipulated time	Children locate hidden items from a box with sensory (touch, tactile) stimuli as instructed	Standing or sitting	Stands by the box and guides the child	Four times/week	Three sets of five items each	Three minutes
Weeks 7 and 8
Activity	Description	Position of Child	Therapist Position	Frequency	Repetitions per Session	Duration of Exercise per Session
Complete an obstacle course on a sensory mat	Child navigates a hurdle course and walks through the mat	Standing or walking	Observing and assisting as needed	Four times/week	Three obstacle courses	Five minutes
Copying the design using blocks	A child forms a pre-defined block structure within a given time	Sitting	Stands next to the child and prompts to facilitate the activity	Four times/week	Build two structures	Six minutes
High-five on auditory prompts	Children perform synchronised high-fives with another person	Standing or sitting facing each other	Stands next to the child	Four times/week	–	One minute
Cognitive Training							Weeks 1 and 2
Activity	Description	Position of Child	Therapist Position	Frequency	Repetitions per Session	Duration of Exercise per Session
Spotting differences between Images	Identify subtle differences between pictures	Seated with pictures kept on a table in front	Stands nearby to guide	Four times/week	Two rounds	Four minutes
Recalling a sequence of pictures	The child is instructed to recall and arrange a sequence of images shown to them in order	Seated with pictures kept on a table in front	Walks around/stands to assist	Four times/week	Two sequences of five pictures	Four minutes
Categorise cards based on said features	The child categorises cards based on size or shape into assigned boxes	Seated with cards kept on a table in front	Stands nearby to guide	Four times/week	Two rounds with 10 items each	Four minutes
Solve a time-bound Puzzle	The child solves an assigned puzzle (complete pieces of a picture) in a given time	Seated	Stands nearby to supervise the activity	Four times/week	One puzzle	Three minutes
Weeks 3 and 4
Activity	Description	Position of Child	Therapist Position	Frequency	Repetitions per Session	Duration of Exercise per Session
Memory recall with added distractions	Recall the shown items after a thorough observation, with continuous music playing throughout the activity	Sitting	Standing near the child	Four times/week	Three rounds	Three minutes
Complete a random number sequence	Fill missing numbers in a visual sequence	Sitting	Stands beside or behind to supervise	Four times/week	Two sequences per session	Four minutes
Matching words with colour	Match the font colour to the written name of a colour	Sitting	Stands and monitors performance	Four times/week	10 cards per session	Four minutes
Weeks 3 and 4
Activity	Description	Position of Child	Therapist Position	Frequency	Repetitions per Session	Duration of Exercise per Session
Tower building using blocks	The child works to build a stable tower using blocks	Sitting around the blocks	Stands and monitors performance	Four times/week	Two tasks per session	Four minutes
Weeks 5 and 6
Activity	Description	Position of Child	Therapist Position	Frequency	Repetitions per Session	Duration of Exercise per Session
Catch and recall words	The child throws a soft ball to the therapist and recalls a word from a category (such as colours)	Sitting or standing, facing each other	Stands within or adjacent to the circle	Four times/week	Two rounds	Five minutes
Sort the cards and make piles	Cards with various categories (like shapes) are sorted by the child into designated piles	Sitting	Stands next to the table and provides instructions	Four times/week	One round with 20 cards	Two minutes
Organise objects as per the given criteria	A child arranges objects by size first, followed by shape, then weight	Sitting	Standing or sitting nearby	Four times/week	One round	Four minutes
Build a paper model with verbal cues	The child assembles a simple paper model simultaneously with the provided instructions	Sitting	Standing or sitting nearby, providing instructions	Four times/week	Two models	Four minutes
Weeks 7 and 8
Activity	Description	Position of Child	Therapist Position	Frequency	Repetitions per Session	Duration of Exercise per Session
Organise objects as per the given instruction manual/list	The child arranges the objects in the correct order based on the list within a set time frame	Sitting	Stands nearby, providing verbal cues if necessary	Four times/week	Three rounds	Three minutes
Multi-step task with associated distractions	The child attempts to complete a multi-step task with sound in the background	Sitting/Standing	Stands nearby, providing verbal cues if necessary	Four times/week	Three tasks	Three minutes
Timed walking task	Instruct the child to walk for said time	Standing in an open area	Walking alongside or timing the steps, providing corrections as needed	Four times/week	Four rounds of 20 steps each	Four minutes
Play a story together	Engage the child in acting out a short story where he/she is assigned a role to enhance	Standing/ Sitting	Facilitating the activity by narrating the story	Four times/week	–	Five minutes
Motor Training							Weeks 1 and 2
Activity	Description	Position of Child	Therapist Position	Frequency	Repetitions per Session	Duration of Exercise per Session
Limb movements with count	Children perform limb movements while counting	Standing	Standing and counting with children	Four times/week	10 repetitions/task	Three minutes
Target a ball at a place	Throw a small ball to hit a marked target placed at varying distances	Standing at a marked spot	Stands next to the child and provides feedback	Four times/week	Five trials	Four minutes
Tandem walk	Walk in a straight line while focusing on a distant point	Standing	Walking alongside to monitor	Four times/week	Three rounds	Four minutes
Breathe with hand movements	Combine deep breathing with synchronised hand movements	Sitting on a chair	Standing and guiding movement	Four times/week	Five cycles	Four minutes
Weeks 3 and 4
Activity	Description	Position of Child	Therapist Position	Frequency	Repetitions per Session	Duration of Exercise per Session
Cross-body movements	Child performs slow and focused movement (e.g., touch right leg with left arm)	Standing	Stands and provides cues	Four times/week	10 repetitions/side	Three minutes
Start and stop verbal commands with added variations in actions	Child performs actions when instructed via cues (e.g., hop). Note: Includes variations like changing action on cue (e.g., walk)	Standing in an open space	Gives verbal commands and monitors responses	Four times/week	2–3 rounds/task	Four minutes
Walk on a changing path	A child walks along a designated path that changes directions	Stands and walks along a traced path	Walks alongside	Four times/week	Two rounds/path	Four minutes
Rolling movements of the neck	Child perform gentle neck rolls in circular movements	Sitting comfortably on a chair	Sitting and guiding pace	Four times/week	Five repetitions/direction	Four minutes
Weeks 5 and 6
Activity	Description	Position of Child	Therapist Position	Frequency	Repetitions per Session	Duration of Exercise per Session
Rhythmic progressive claps	Child performs clapping sequences, starting with simple patterns and progressing to complex ones	Sitting	Stands, demonstrating and cueing the activity	Four times/week	Three rounds of 10 claps	Three minutes
Weeks 5 and 6
Activity	Description	Position of Child	Therapist Position	Frequency	Repetitions per Session	Duration of Exercise per Session
Rhythmic and progressive foot movements	Children perform rhythmic tapping of feet, alternating left and right, while following a count	Sitting or standing in place	Standing or moving around to observe	Four times/week	Three rounds of 15 steps	Three minutes
Throw and catch while moving	Throw and catch a ball with another moving therapist across a designated area	Standing in pairs, facing each other	Stands observing and assisting, as needed	Four times/week	Five rounds	Five minutes
Relay activity	The child hops to a designated point while holding an object, and passes it to the next person	Standing in a line or circle	Stands observing and assisting, as needed	Four times/week	Two rounds	Four minutes
Weeks 7and 8
Activity	Description	Patient Position	Therapist Position	Frequency	Repetitions per Session	Duration of Exercise per Session
Clearing a multistep obstacle	Child navigates an obstacle course (stepping over cones)	Standing at the starting point	Stands, guiding, and providing cues	Four times/week	Two rounds	Five minutes
Jogging to music beats	Jog on the spot in sync with the changing music beats	Standing in the designated space	Stands, adjusting music, and encouraging participation	Four times/week	Three rounds of 10 jogs each	Three minutes
Dribble the ball around a series of cones	Child dribbles a soft ball using their hands or feet around cones placed in a zigzag pattern	Standing at the starting line	Stands, guiding, and providing cues	Four times/week	Two rounds	Four minutes
Reaching out activities	Children reach out to grab objects placed at varying heights and distances	Standing	Adjusting object placement and supervising	Four times/week	15 reaches	Three minutes

Control Group (Standard Care Group)

The standard care provided to participants will include: Range of motion exercises, aerobic training, strength and balance training, along with relaxation techniques, administered for the same duration.

Protocol Adherence and Discontinuation

The intervention will be performed under the supervision of a skilled physiotherapist. To enhance adherence to the intervention protocol, strategies such as scheduling sessions at similar timings and educating parents or guardians on the benefits of completing all scheduled sessions to maximise therapeutic effect will be incorporated. Adherence to the intervention will be monitored through structured attendance logs and a checklist to document the completion of prescribed activities during every session. Any missed sessions from the protocol will be recorded systematically. Rest periods will be allowed, as required, to ensure sustained engagement of the child throughout the session and prevent feelings of being overwhelmed. In case of adverse events, involving exercise-induced cardiovascular symptoms or worsening of behavioural symptoms, intervention will be subject to discontinuation. The emergence of any psychiatric conditions that are contradictory to exercise participation, repeated non-compliance with therapy sessions despite reminders, will also necessitate discontinuation from the therapy. Parents or guardians can withdraw their consent at any stage during the therapy. Participation in any other structured training or consumption of unprescribed cognitive-enhancing supplements will be prohibited to avoid confounding effects.

Outcome Assessment

Following a baseline assessmnt, follow-up assessments for the outcome measures will be repeated after two weeks, four weeks, and at the end of the training programme (eighth week), to determine both short and long-term impact. The assessors will be trained physiotherapists, acquainted with the use of the included outcome measures tools. All the assessments will involve blinded assessors, not involved in the delivery of intervention throughout the therapy, and will have no access to the intervention data. Any accidental unblinding will be immediately reported to the principal investigator and reassigned to another unblinded assessor.

Outcome Measures

Scoring sheets specific to the outcome measures and data entry forms will be used for documentation. Secured folders specifically assigned for documentation will be used to maintain assessment records.

Paediatric Balance Scale

The Paediatric Balance Scale (PBS) is used to assess the functional balance skills of school-aged children. It has a maximum score of 56 points and consists of 14 items, with scores ranging from 0 (least functional) to 4 (most functional). PBS’s validity is supported by its high test–retest and interrater reliability (ICC = 0.998 and 0.997, respectively), as well as its strong correlation with other motor function assessments, including the Paediatric Evaluation of Disability Inventory and the Gross Motor Function Measure. ¹⁸

Short Sensory Profile

The Short Sensory Profile (SSP) is a questionnaire used to assess a child’s low energy, tactile sensitivity, taste sensitivity, movement sensation, desire sensation, auditory filtering, and visual sensitivity. The SSP has shown good content validity and high test–retest reliability (r = 0.76–0.90), enabling it to distinguish between children with and without sensory processing issues. ¹⁹

Trail Making Test

The test has Part A and Part B. In Part A, the participant must make as many accurate and timely connections between numbered circles (1, 2, 3, etc.) in order, while in Part B, the participant switches between letters and numbers in ascending order, such as 1-A-2-B-3-C, and so on. Inter-rater reliability is very high, often exceeding 0.95, and shows a strong correlation with other executive functioning tests. ²⁰

Developmental Coordination Disorder Questionnaire 2007

It has 15 items that are divided into three categories: General coordination, fine motor and handwriting skills, and control during movement. Concurrent validity exhibits a moderate to strong range of correlation coefficients (r = 0.50–0.70), while studies have demonstrated strong test–retest reliability with correlation values (r) greater than 0.90. ²¹

Statistical Analysis

The collected data will be analysed by the principal investigator. Descriptive statistics will be employed to present the baseline characteristics of eligible participants. The Kolmogorov–Smirnov test is applied to establish the normality of the collected data for a sample size >50, and for the sample size < 50, the Shapiro–Wilk test will be applied. Descriptive statistics will be expressed as mean ± standard deviation or median and interquartile range. Depending on the normality of data, within-group comparisons and between-groups comparisons will be conducted using the Statistical Package for the Social Sciences (SPSS) version 16 software (SPSS Inc., Chicago, IL, USA). The analysis will follow the intention-to-treat approach.

Data Management

Data will be entered into an electronic database and will be password-protected to help prevent unauthorised data access. Discrepancies, if any, will be cross-verified and corrected via double data entry. Each participant will be allotted a unique identification code to maintain data confidentiality. Regular data monitoring will be conducted to detect missing or erroneous entries. To ensure the confidentiality of the data, access will be restricted to the principal investigator only.

Discussion

ADHD, a complex neurodevelopmental condition, often involves issues with attention regulation, overactivity, and impulsiveness. Currently, research highlights multi-factorial treatments tailored to individual profiles, whereas traditional models primarily emphasised medication. While medications remain an essential component, non-medical options have gained prominence as understanding of this multifaceted disorder continues to grow.

Multimodal training enhances neuroplasticity, aiming to strengthen functional connections across brain regions associated with ADHD. Specifically, irregularities in tactile, auditory, and vestibular modalities can worsen inattentiveness and behavioural regulation issues. ²² Structural and functional imaging research shows that children with ADHD often exhibit altered activity in the areas of the brain involved in sensorimotor integration and executive function. ²³ Therefore, incorporating sensory integration into ADHD treatments addresses these sensory modulation challenges and boosts attentional control. By combining cognitive and sensory-motor-based techniques, multimodal training has the potential to offer more comprehensive support for children facing multiple challenges.

Sensorimotor activities that involve coordination and balance stimulate the cerebellum’s connections to the cortex in ways that are underdeveloped in those with ADHD. Studies have shown that balance training and rhythmic movement therapies improve behaviour and focus by promoting cerebellar development, which, in turn, strengthens motor planning and impulse control. ²⁴ For instance, programmes that incorporate rhythmic entrainment, such as Interactive Metronome training, have shown improvements in timing, attention, and academic performance. Rhythmic activities challenge the cerebellum to regulate movements and attention over time better, leading to improved coordination between thoughts and actions. Diverse sensorimotor routines engaging the cerebellum’s role in cognition show promise for reducing ADHD’s impact on executive functions. ²⁵ Cognitive interventions centring around working memory, inhibitory control, and processing speed display reasonable efficacy in mitigating fundamental ADHD signs, specifically when adapted to singular shortcomings. Studies imply programmes such as Cogmed have exhibited improvements in executive performance and lessened unfocused behaviours. ²⁶ However, when paired with sensory and motor facets, such as in neurocognitive coaching routines, the synergistic impact appears more robust. Findings from the investigation have demonstrated that these trainings might strengthen connectivity between prefrontal and parietal regions. ²⁷

While medication remains an important treatment option for many, the incorporation of alternative therapies can provide symptom relief without dependence or undesirable side effects. This multi-pronged nature of integrative interventions aids neuroplastic adaptation through repeated exposure across domains. Sensory stimulation refines cortical maps, motor skills support synaptic pruning and coordination, and cognitive exercises augment dopamine and norepinephrine along prefrontal circuits, key neurotransmitters in ADHD. Baseline evaluations inform individualised programmes targeting sensory sensitivities, motor function, and executive control to optimise neuroplasticity through a personalised approach. Enhanced neuroplasticity may then support compensatory skill development. ²⁸

Conclusion

In conclusion, integrative sensory, motor, and cognitive training represents a promising adjunctive intervention in ADHD management. The multimodal stimulation of neural circuits enhances core functions and facilitates more adaptive behaviours. This approach aligns with current guidelines emphasising non-drug strategies for ADHD, engaging the individual, and applying skills in real-world contexts. Moreover, such techniques tend to gain broader applicability when deployed in educational or community environments, optimising academic performance and quality of life over the long-term.