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Published on in Vol 15 (2026)

Preprints (earlier versions) of this paper are available at https://preprints.jmir.org/preprint/95139, first published .
Young man uses a mobile app with a futuristic landscape theme for a learning session.

A Metacognitive Intervention for Children and Adolescents in Neuropediatric Care (Mio-Training): Protocol for a Randomized Controlled Trial

A Metacognitive Intervention for Children and Adolescents in Neuropediatric Care (Mio-Training): Protocol for a Randomized Controlled Trial

Authors of this article:

Saskia Salzmann1, 2 Author Orcid Image ;   Valentin Benzing3 Author Orcid Image ;   Sebastian Grunt1 Author Orcid Image ;   Rhoikos Furtwängler4 Author Orcid Image ;   Regula Everts1 Author Orcid Image
Article Authors Cited by Tweetations Metrics

    1Division of Neuropaediatrics, Development and Rehabilitation, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 15, Bern, Switzerland

    2Graduate School for Health Sciences, University of Bern, Switzerland

    3Institute of Sport Science, University of Bern, Bern, Switzerland

    4Division of Pediatric Hematology and Oncology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Switzerland

    Corresponding Author:

    Regula Everts, Prof Dr phil


    Background: Diseases during childhood and adolescence such as cancer or attention-deficit/hyperactivity disorder (ADHD) can have an impact on brain development and place children and adolescents at increased risk for cognitive long-term problems. Most cognitive trainings currently available have limited efficacy and show limited transfer to nontrained tasks and everyday functioning. We developed a novel intervention (Mio-Training) aiming to increase metacognitive abilities at the intersection between exercise psychology and cognitive science to strengthen the cognitive development of pediatric patients with atypical brain development in the long term.

    Objective: The study assesses the efficacy of the Mio-Training on the primary (metacognitive abilities) and secondary outcomes (executive functions, processing speed, and memory) before the training, immediately after the training, and at a 3-month follow-up in patients with atypical development and healthy controls.

    Methods: The Mio-Training stimulates metacognition through 38 digital games, which playfully teach mnemonic strategies (ie, rehearsal, chaining, and associations), present intensive verbal and visual working memory training, and motor coordination tasks. The training group will train for 5 weeks, 3 times per week, for 20 minutes. The waiting control group will receive the training after completion of the study procedure. We will evaluate the efficacy of the Mio-Training on metacognitive abilities and cognitive performance in a randomized controlled clinical trial. We expect a long-term increase in metacognitive abilities associated with an increase in subjective and objective cognitive performance. The efficacy of the Mio-Training will be investigated in 3 subgroups (patients with cancer, ADHD, and healthy controls; each group n=40; all aged 8‐16 years) using pre-intervention and post-intervention assessments. All participants will be randomly assigned to the Mio-Training or the waiting control group, stratified by age and sex.

    Results: This study protocol describes the study design of the randomized controlled trial evaluating the efficacy of the Mio-Training. The project is funded from October 2024 to December 2027. Recruitment for healthy controls has been completed (n=40; October 2024-August 2025), recruitment for childhood cancer survivors (n=10, 25% participants recruited) is scheduled from August 2025 to December 2027, and recruitment for participants with ADHD (n=39, 97.5% recruited) is scheduled from October 2025 to September 2026. Data analyses have not yet commenced; first results from the ADHD subgroup are expected in early 2027, with findings from the cancer survivor subgroup anticipated in early 2028 following completion of recruitment.

    Conclusions: To strengthen cognitive development in young patients with atypical development, it is necessary to address the current lack of effective treatment options. The combination of cognitive and motor training with metacognitive abilities may support patients’ cognitive maturation trajectories and will enable transfer of the training effect to everyday and school situations.

    Trial Registration: ClinicalTrials.gov NCT06464237; https://clinicaltrials.gov/study/NCT06464237 and NCT07162831; https://clinicaltrials.gov/study/NCT07162831

    International Registered Report Identifier (IRRID): DERR1-10.2196/95139

    JMIR Res Protoc 2026;15:e95139

    doi:10.2196/95139

    Keywords

    cognitive training; metacognitive abilities; childhood; pediatric cancer; attention-deficit/hyperactivity disorder; ADHD; mnemonic strategies; motor coordination; working memory training 


    Many diseases during childhood and adolescence such as cancer or attention-deficit/hyperactivity disorder (ADHD) have an impact on the development of the brain and place children and adolescents at increased risk for cognitive long-term impairments [1-4]. These cognitive impairments can lead to difficulties in everyday and school life, decreased quality of life, and may interfere with the achievement of developmental milestones [5-8]. Through pruning and myelination, there is a rapid increase in white matter and a decrease in gray matter in the child’s brain [9]. Childhood is a maturation period that comes with high cerebral plasticity, and there is evidence that cognitive training during childhood and adolescence entails rapid neural changes [10]. On the basis of the abovementioned knowledge, we developed a cognitive training that supports this sensitive phase of brain development in healthy children and adolescents as well as in patients with cancer or ADHD.

    Most cognitive trainings currently available for children and adolescents have only limited efficacy and show limited transfer to nontrained tasks, particularly everyday functioning [11-14]. Intensive training programs often focus on a specific cognitive function (ie, working memory), and different meta-analyses show that intensive training of isolated cognitive functions improves the trained function immediately after the training but shows limited transfer to nontrained tasks, and long-term effects are lacking [11,13].

    There is a close relationship between cognitive functions and motor abilities (eg, motor coordination) due to shared cognitive and neural mechanisms between cognitive processes and motor abilities [15]. Studies with pediatric cancer survivors, children and adolescents with ADHD, and healthy children and adolescents show that physical activities can have a positive effect on cognition and even on quality of life [16-19]. However, recent empirical evidence indicates that the type of physical exercise matters to obtain the largest benefits for cognitive functions [20-22]. Pure endurance exercise is thought to be less suitable for promoting cognitive development [23-25]. Instead, physical exercises that include both cognitive and physical demands are more likely to touch upon and thus improve cognition, such as executive functions [21,26-29]. Meta-analyses show that physical activities with cognitive engagement or thoughtful reflections (ie, metacognitive abilities) support the development of executive functions (ie, the ability to inhibit interference, routine thoughts, and impulsive behaviors) [21,26].

    Besides intensive training of isolated functions and motor training, the acquisition of mnemonic strategies can enhance cognitive functions. Teaching mnemonic strategies not only leads to improvements in memory functions but also in untrained cognitive domains such as reading and attention in the short and long term [30-33]. Mnemonic strategies are often used in adult neurorehabilitation to enhance learning and recall after brain injury [34]. During and after the acquisition of mnemonic strategies, individuals are thought to develop metacognitive abilities, namely, the ability to supervise, manage, and monitor cognitive processes and to use this knowledge to regulate behavior, cognition, and motor abilities [35,36].

    Metacognition refers to the awareness and knowledge an individual has of their own cognitive processes (also referred to as “thinking about thinking”). Metacognitive abilities are a cross-functional set of skills that has a positive effect on school success, social behavior, and a variety of everyday situations [35,37]. An improvement of metacognitive abilities comes along with increased awareness and knowledge of one’s own cognitive and motor performance. Metacognition is the knowledge that allows individuals to use cognitive and motor resources to best plan, monitor, and evaluate behavior, cognition, and motor abilities. Interventions focusing on metacognitive abilities in children showed positive effects on metacognitive abilities, self-efficacy, executive functions, and academic skills [38]. Various models exist to describe applications of metacognitive abilities, all of them sharing the importance of engaging in a variety of processes to plan, monitor, and evaluate performance [39-41].

    A recent review demonstrates the positive effects of serious games as an intervention for pediatric patients with cancer [42] because they may help in a playful manner to increase compliance by being intrinsically motivating, highly engaging, and easily accessible at any time, regardless of age and gender [43]. In patients with ADHD, digital health interventions presented via a serious game showed positive effects on cognitive outcomes [44]. A meta-analysis comparing serious games versus conventional instruction methods (ie, lectures, reading, drill, and practice) revealed stronger effects of serious games on learning and retention than conventional instruction methods [45]. Interventions that do not require additional visits to a facility reduce participants’ burden, yield higher compliance rates, and are highly attractive to children and adolescents with cancer and ADHD and their families due to the autonomous handling [46].

    On the basis of the background above, we developed the Mio-Training, an easily accessible, playful, multicomponent digital intervention that stimulates metacognitive abilities through the combination of motor coordination and cognitive training in a serious game. We evaluate the efficacy of the Mio-Training in a randomized controlled trial (RCT) in 3 groups of children and adolescents, namely children and adolescents with cancer, children and adolescents with ADHD, and healthy controls. We include healthy children and adolescents to evaluate the feasibility of the Mio-Training and to compare their data with those of the children and adolescents with cancer and ADHD.

    The primary objective of this study is to investigate the short- and long-term efficacy of the Mio-Training on metacognitive abilities assessed with the Junior Metacognitive Awareness Inventory (Jr.MAI; primary outcome) [47]. Furthermore, we will investigate the efficacy of the Mio-Training on executive functions, processing speed, and memory (secondary outcomes). Additionally, the feasibility of the Mio-Training will be assessed (ie, usability, enjoyment, level of autonomy, and perceived impact).

    We hypothesize that 5 weeks of Mio-Training will lead to improved metacognitive abilities in the short and long term (primary outcome) in children and adolescents with cancer and ADHD. Furthermore, an increase in metacognitive abilities will be associated with an increase in objective performance in executive functions, processing speed, and memory in the short term and with an increase in subjective performance in executive functions in the long term (secondary outcomes). In addition, we hypothesize that the Mio-Training will be perceived as feasible by the healthy children and adolescents and the patients with cancer and ADHD.


    Design and Setting of the Study

    The study is an investigator-initiated RCT including 2 experimental groups (Mio-Training and a waiting control group). We will investigate the efficacy of the Mio-Training using the same study design in three subgroups, namely (1) healthy children and adolescents, (2) children and adolescents with cancer, and (3) children and adolescents with ADHD.

    Participants will be screened for eligibility according to the inclusion and exclusion criteria by a study investigator (for details, see participants section [cancer survivors, children and adolescents with ADHD and healthy controls]). After the screening, 3 study visits will take place at the Division of Neuropediatrics, Development and Rehabilitation at the Inselspital in Bern or at the participants’ home. Cognitive and motor assessments will be performed before the intervention and the waiting period (baseline assessment; T1) and will be repeated after 5 weeks at immediate follow-up (T2). The questionnaires will be completed again at a 3-month follow-up (T3; Figure 1).

    ‎
    Figure 1. Study flow chart. T0: screening; T1: first assessment (before intervention or waiting period); T2: second assessment (immediately after intervention or waiting period); T3: third assessment (12 weeks after intervention or waiting period).

    Participants

    Overview

    In total, 120 German- or French-speaking children and adolescents aged 8 to 16 years will be included in the study. In each subgroup (cancer, ADHD, and healthy controls), 40 (33.3%) participants will be randomly allocated to either the Mio-Training (n=20) or the waiting control group (n=20), with age (8 to <12 years vs 12 to 16 years) and sex (male vs female) as stratification factors (1:1 allocation ratio). The randomization sequence will be generated by an independent statistician and implemented in REDCap (Research Electronic Data Capture; Vanderbilt University) to ensure concealment of allocation. Randomization will be performed at the study site (Children’s University Hospital Bern).

    Cancer Survivors

    Forty children and adolescents with a previous diagnosis of cancer with or without central nervous system involvement who are between 3 months before and 10 years after termination of treatment (chemotherapy, and/or radiotherapy, and/or surgery) will be included. The following exclusion criteria will be applied: (1) unstable neurological condition (eg, epilepsy), (2) a severe psychiatric disease (eg, eating disorder) or severe learning disability, (3) known or suspected noncompliance, (4) inability to follow the procedures of the study, (5) IQ <85, or (6) a history of cancer without central nervous system involvement and only surgical removal of the tumor without subsequent radiation and/or chemotherapy. Cancer survivors will be recruited at the Division of Neuropediatrics, Development and Rehabilitation at the Inselspital in Bern and other children’s hospitals in Switzerland through flyers.

    Children and Adolescents With ADHD

    Forty children and adolescents with ADHD will be included in the study. All types of ADHD will be included (inattentive, hyperactive, and combined type). The following exclusion criteria will be applied: (1) unstable neurological condition (eg, epilepsy), (2) severe psychiatric disease (eg, eating disorder) or severe learning disability influencing the development, (3) known or suspected noncompliance, (4) inability to follow the procedures of the study, or (5) IQ <85. Patients with ADHD will be recruited at the Division of Neuropediatrics, Development and Rehabilitation at the Inselspital in Bern and at other institutions in Switzerland through flyers.

    Healthy Controls

    Forty healthy children and adolescents will be included. The following exclusion criteria will be applied: (1) known neurological, (2) psychiatric, (3) other chronic disease influencing the cognitive development, or (4) IQ <85.

    Ethical Considerations

    The study with the healthy children and adolescents was approved by the ethics committee of the University of Bern (2023-12-05). The study with the children and adolescents with cancer (2023‐01196) and the study with the children and adolescents with ADHD (2023‐01189) were approved by the cantonal ethics committee of Bern. The study will be conducted in accordance with the current version of the World Medical Association Declaration of Helsinki [48], the International Council for Harmonisation Good Clinical Practice guidelines, and the local legally applicable requirements. All participants and/or one parent or legal guardian will sign a written informed consent.

    The studies were registered at ClinicalTrials.gov (cancer and healthy controls: NCT06464237; ADHD: NCT07162831).

    Intervention

    The intervention consists of the Mio-Training (Figure 2), a training app developed by a multidisciplinary team of experts at the Division of Neuropediatrics, Development and Rehabilitation at the Inselspital in Bern in collaboration with the software development company Pioneo GmbH. The Mio-Training stimulates metacognitive abilities in a playful manner using a serious game, a journey through space. The Mio-Training is a multicomponent training program, and each session includes intensive visual and verbal working memory training, the teaching and practicing of 5 mnemonic strategies and memory tasks, a motor coordination exercise, and metacognitive questions that stimulate reflection on cognitive processes through a chatbot. The content of the Mio-Training is based on the knowledge and experience from previous cognitive training and motor intervention studies [23,25,32,33,49-51]. Children and adolescents are encouraged to train 3 times per week for 15 to 20 minutes per training session, resulting in 15 training sessions in total (approximately 300 min of training).

    ‎
    Figure 2. Prototype of the Mio-Training app.

    To maximize adherence to the Mio-Training, a user-friendly design that includes reward elements and elements of gamification in the framework of a chatbot was incorporated. To monitor adherence to the Mio-Training, minimal usage data, including length, frequency, compliance, retention rates, chosen difficulty levels, and within-training performance levels will be recorded during the use of this training. These data will be used to monitor compliance. A study investigator will have insight into the usage data on a regular basis, and the participant will be contacted if noncompliance is observed.

    Outcome Measures

    Baseline characteristics (age, sex, and socioeconomic factors) and clinical characteristics will be assessed through clinical chart review and questionnaires.

    Primary Outcome

    The primary end point will be the change score in metacognitive abilities, as measured by the Jr.MAI [47] calculated based on the change between baseline and the 3-month follow-up assessment. The score summarizes 18 items and evaluates metacognitive abilities, focusing on metacognitive knowledge and regulation. The score ranges between 18 and 90, with higher values indicating better metacognitive abilities. Research findings confirmed the validity of the Jr.MAI and demonstrated the reliability of the overall score with a Cronbach α of 0.87 [52]. The Jr.MAI will be assessed in all subgroups and both experimental groups (Mio-Training vs waiting control) before and after the training and waiting period and at 3-month follow-up.

    Secondary and Additional Outcomes

    The secondary end points evaluate changes in cognitive functions between T1, T2, and T3 with different standardized tests.

    The neuropsychological assessment will be performed at T1 and T2 (Figure 1 and Table 1) by trained psychology students and neuropsychologists. All children and adolescents will undergo an assessment of general intelligence (short form of the Wechsler Intelligence Scale for Children–Fifth Edition [WISC-V]) [53], which will be performed only at T1. The following executive functions will be assessed: working memory (Working Memory Index; WISC-V) [53], cognitive flexibility and inhibition (Color-Word Interference Test; Delis-Kaplan Executive Function System [D-KEFS]) [54], and planning (Tower of Hanoi; D-KEFS) [54]. Furthermore, processing speed (Processing Speed Index; WISC-V) [53], verbal short- and long-term memory (Verbal Learning and Memory Test; VLMT) [55] and visuospatial short- and long-term memory (Battery for Assessment in Children–Merk- und Lernfähigkeitstest; Basic-MLT) [56] will be assessed. In the ADHD group, selective attention and divided attention (Go/Nogo, divided attention; Test of Attentional Performance; TAP) [57] will also be assessed.

    Table 1. Detailed information about neuropsychological and motor assessment and questionnaires.
    AssessmentInstrumentTime pointsPopulationsReference
    Neuropsychological assessment
    IQShort version WISC-VaT1bHealthy, cancer, and ADHDc[53]
    Executive functions
     Working memoryWorking memory index (WISC-V)T1 and T2dHealthy, cancer, and ADHD[53]
     InhibitionColor-Word Interference Test (D-KEFSe)T1 and T2Healthy, cancer, and ADHD[54]
     Cognitive flexibilityColor-Word Interference Test (D-KEFS)T1 and T2Healthy, cancer, and ADHD[54]
     PlanningTower of Hanoi (D-KEFS)T1 and T2Healthy, cancer, and ADHD[54]
    Processing speedProcessing speed index (WISC-V)T1 and T2Healthy, cancer, and ADHD[53]
    Attention
     Selective attentionGo/Nogo (TAPf)T1 and T2ADHD[57]
     Divided attentionDivided attention (TAP)T1 and T2ADHD[57]
    Memory
     Verbal short- and long-term memoryVLMTgT1 and T2Healthy, cancer, and ADHD[55]
     Visual short- and long-term memoryPattern learning (Basic-MLT)hT1 and T2Healthy, cancer, and ADHD[56]
    Motor assessment[58]
    BalancingDMTiT1 and T2Healthy, cancer, and ADHD 
    Jumping back and forth sidewaysDMTT1 and T2Healthy, cancer, and ADHD 
    Torso bendDMTT1 and T2Healthy 
    Push-upsDMTT1 and T2Healthy 
    Sit-upsDMTT1 and T2Healthy 
    Standing long jumpDMTT1 and T2Healthy 
    Questionnaires
    Metacognitive abilitiesJr.MAIjT1, T2, and T3kHealthy, cancer, and ADHDl[47,52]
    Executive functionsBRIEFmT1, T2, and T3Healthy, cancer, and ADHDn[59]
    ADHD symptomsConners 3oT1, T2, and T3ADHDp[60]
    ResourcesFRKJqT1, T2, and T3Healthy, cancer, and ADHDl[61]
    FatiguePedsQLrT1, T2, and T3Healthy and cancern[62]
    Physical self-conceptPSDQ-SsT1, T2, and T3Healthy, cancer, and ADHDl[63]

    aWISC-V: Wechsler Intelligence Scale for Children–Fifth Edition.

    bT1: first assessment (before intervention or waiting period).

    cADHD: attention-deficit/hyperactivity disorder.

    dT2: second assessment (immediately after intervention or waiting period).

    eD-KEFS: Delis-Kaplan Executive Function System.

    fTAP: Test of Attentional Performance.

    gVLMT: Verbal Learning and Memory Test.

    hBasic-MLT: Battery for Assessment in Children–Merk- und Lernfähigkeitstest.

    iDMT: German Motor Test.

    jJr.MAI: Junior Metacognitive Awareness Inventory.

    kT3: Third Assessment (12 weeks after intervention or waiting period).

    lSelf-rating.

    mBRIEF: Behavior Rating Inventory of Executive Function.

    nParent and Self-rating.

    oConners 3: Conners, Third Edition.

    pParent Rating.

    qFRKJ: Questionnaire on Resources in Childhood and Adolescence.

    rPedsQL: Multidimensional Fatigue Scale.

    sPSDQ-S: physical self-description questionnaire–short version.

    The motor assessment will be performed at T1 and T2 (Figure 1 and Table 1). The following subtests of the German motor performance test will be performed: balancing, jumping back and forth sideways, torso bend, push-ups, sit-ups, and standing long jump [58].

    The participants and parents will fill out questionnaires using a REDCap survey at T1, T2, and T3 (German and French versions; Figure 1 and Table 1). Questionnaires will be used to assess metacognitive abilities (Jr.MAI) [47], executive functions and metacognition (Behavior Rating Inventory of Executive Function) [59], personal and social resources (Questionnaire on resources in childhood and adolescence) [61], fatigue (Multidimensional Fatigue Scale) [62], physical self-concept (physical self-description questionnaire–short version) [63] and feasibility of the Mio-Training (self-made questionnaire). Additionally, for children with ADHD, the intensity of ADHD symptoms will be assessed (Conners, Third Edition) [60] at T1.

    Statistical Analysis

    The sample size was calculated for the primary outcome measure (Jr.MAI total score) using G*Power 3: repeated measures ANOVA (within-between subjects interaction); small effect size (Cohen f2=0.25); α=.05, power=0.8; retest correlation=0.5. The resulting minimal sample size is 14 participants per experimental group (Mio-Training vs waiting control group), corresponding to n=28 per subgroup (healthy controls, children and adolescents with cancer, and children and adolescents with ADHD). To compensate for losses and dropouts, the sample size was defined as 40 participants per subgroup, with a total sample size across all 3 subgroups of 120.

    Statistical analyses will be conducted using RStudio (Posit PBC). The planned statistical analyses were developed in consultation with an experienced statistician. The level of significance is set at α=.05. Data will be tested for normal distribution. The primary analysis will follow an intention-to-treat approach using linear mixed-effects models to calculate 2-sided 95% CIs for the primary outcome (Jr.MAI total score). The mixed-effects model will contain the total score of the Jr.MAI, the time points (ie, baseline, 5-week follow-up, or 3-month follow-up, as a categorical variable), treatment allocation (ie, Mio-Training vs waiting control group), the baseline score of the Jr.MAI (to adjust for individual differences in baseline functioning and to improve statistical precision), and stratification factors as fixed effects. The primary effect of interest is the treatment allocation-by-time point interaction. Participant ID will be included as a random intercept. Secondary end points will be analyzed using the same method. A per-protocol analysis will be conducted as a sensitivity analysis using the same model structure restricted to adherent participants (≥80% intervention compliance). Additional sensitivity analyses will examine differences in slopes over time between groups. Subgroup analyses will investigate potential effect modification by sex and age via interaction terms (treatment×sex and treatment×age), with stratified results reported where appropriate. Missing data exceeding 5% will be handled using multiple imputation by chained equations (50 datasets), incorporating all baseline and outcome variables at all time points as predictors. Rubin’s rules [64] will be used for pooling estimates. Variables with more than 50% missing values will not be used for the imputation model. To address multiplicity arising from secondary and subgroup analyses, a false discovery rate correction will be applied where appropriate. The primary analysis will not be adjusted for multiplicity, as it is prespecified and confirmatory. Secondary and exploratory subgroup analyses (including sex and age interactions) will be interpreted with false discovery rate–adjusted P values to control for type I error inflation arising from multiple comparisons.

    Safety and Monitoring

    Although the intervention is considered low risk, safety monitoring procedures were implemented for all subgroups. Potential adverse events include tiredness, frustration, distress, muscle soreness, or overexertion during or after the training sessions. Adverse events are monitored throughout the study via participant self-report, caregiver feedback, and study team observations during assessments. All reported events are documented and reviewed by the study team on an ongoing basis. In case of any adverse reactions, training sessions are paused or discontinued as appropriate, and participants are referred for clinical evaluation if necessary.

    Data Management

    The case report forms will be stored in a dedicated electronic data capture system (REDCap [65]) hosted by the Clinical Trials Unit Bern of the Faculty of Medicine of the University of Bern and the Inselspital, Bern University Hospital, Switzerland.

    Data Monitoring

    On-site monitoring will be part of the quality control activities implemented. Data will be monitored on a regular basis, including a quality check of the data performed by the principal investigator or his designees.


    The project is funded from October 2024 to December 2027. Data collection for the study with the healthy controls started in October 2024 and ended in August 2025. Data collection for the study with the cancer survivors started in August 2025 and is expected to continue until the end of 2027, while the study with the children with ADHD began in October 2025 and is projected to end in September 2026.

    Forty participants have been recruited and assessed in the healthy control group, 10 (25%) participants in the cancer survivor group, and 39 (97.5%) participants in the ADHD group. In total, 40 participants per subgroup will be recruited. Data analyses have not yet commenced. First results from the ADHD study are expected to be published in late 2026 or early 2027. The healthy control data will not be published as a separate study, except for the feasibility results, but will be analyzed in comparison with the ADHD and cancer survivor groups. As recruitment for the cancer survivor study is more challenging and is expected to continue until the end of 2027, the ADHD study will be analyzed and published first. Publications from the cancer survivor study are anticipated for early 2028.


    The Mio-Training is a newly developed multicomponent digital intervention designed to address a critical gap in the field, namely, the lack of multimodal, transferable, and accessible training approaches for children and adolescents with cancer and ADHD that focus on everyday functioning rather than isolated cognitive functions. By stimulating metacognitive abilities through the combination of intensive working memory training, mnemonic strategies, and motor coordination within a serious game, the Mio-Training aims to strengthen cognitive development in children and adolescents with atypical brain development. We anticipate that 5 weeks of Mio-Training will lead to improvements in metacognitive abilities, with associated gains in executive functions, processing speed, and memory that transfer beyond trained tasks and persist over time. To evaluate its feasibility and efficacy, we conduct a RCT including 3 pediatric subgroups (ADHD, cancer, and controls).

    The development of the Mio-Training is grounded in evidence suggesting that isolated cognitive or motor training often yields only modest and domain-specific improvements, with limited transfer to everyday and school functioning [11]. Meta-analyses and longitudinal studies have shown that while cognitive training programs—particularly intensive working memory or attention training—can produce short-term gains, these effects lack generalization and sustainability in the long term [66]. Similarly, motor-based interventions, though beneficial for motor coordination and certain aspects of executive functioning, rarely lead to long-term improvements when implemented in isolation [67]. Hence, the Mio-Training stimulates metacognitive abilities during the acquisition of mnemonic strategies, the performance of intensive working memory training, and motor coordination tasks. The multimodal approach presented in the Mio-Training emphasizes the interactive and complementary nature of cognitive development and addresses the limitations of unimodal interventions.

    Integrating metacognitive abilities into cognitive training is a critical factor in enhancing training efficacy, particularly in pediatric populations where introspection, self-reflection, and thinking about cognitive self-optimization are still absent or only emerging [35-41,68]. Metacognitive abilities—such as reflecting on one’s own thinking, learning and mnemonic strategies, and task performance—promote self-regulated learning and deeper cognitive engagement. Research has shown that metacognitive abilities (ie, planning, monitoring, and evaluating one’s own cognitive processes) are strongly associated with academic achievement, problem-solving abilities, and long-term school outcomes [69]. In children, especially those with atypical development, metacognitive abilities can encourage active participation in their learning, which can enhance motivation, persistence, and self-efficacy and, through this, support the transfer of trained skills (ie, the application of mnemonic strategies) to school and everyday life [35-41,68]. Thus, metacognitive abilities do not merely supplement cognitive training but rather enhance its relevance and long-term efficacy. Strong metacognitive abilities can give individuals a sense of agency over their rehabilitation journey [40].

    Increasing evidence from developmental neuroscience suggests that motor coordination and cognitive functions, particularly executive functions and working memory, share overlapping neural networks, including the cerebellum, prefrontal cortex, and parietal regions [70,71]. Coordinative motor activities require goal-directed behavior, inhibition, and attentional control—all core components of executive functioning. Incorporating motor coordination exercises into cognitive training can therefore support the development of higher-order cognitive skills. Coordination tasks can thus enhance cognitive processes through embodied learning mechanisms [72]. Moreover, coordination tasks are often of a playful nature and hence increase motivation, engagement, and the experience of self-efficacy. The multimodal stimulation may be particularly beneficial for children and adolescents with atypical development [73], such as those with ADHD or pediatric cancer, whose neural systems may require multisensory and integrative stimulation to strengthen cognitive, everyday, and school performance.

    To evaluate the efficacy of the Mio-Training scientifically, the implementation of an RCT is essential before its possible application in clinical practice. As the gold standard in intervention research, RCTs minimize bias, control for confounding variables through random allocation, and enable the detection of intervention effects by comparing outcomes between the intervention and control groups. Moreover, evaluating the Mio-Training not only in clinical populations (namely children with ADHD or pediatric cancer) but also in a healthy control sample allows for the assessment of differential responsiveness to the training across groups. This will allow insight into whether the training has specific benefits for populations with atypical development or whether its effects generalize to typically developing children.

    The Mio-Training is presented in a well-designed, visually appealing, and intuitively navigable serious game—a journey through space—with a rewarding and immersive environment that can ease the use of the training program. All of these factors are particularly critical in pediatric populations to balance therapeutic attempts with user-centered design to enhance motivation, repeated use, engagement, and adherence and, through this, hopefully the acceptability and efficacy of the training.

    In light of increasing economic constraints and staff shortages in educational and clinical settings, there is an urgent need for cognitive interventions that are both effective and easy to implement in environments where resources are limited. The low-threshold, user-friendly Mio-Training offers a promising tool to address both the needs of children and adolescents with atypical development and these systemic challenges.

    Presenting the efficacy of a multimodal training program—the Mio-Training—is of high relevance to both clinical and scientific staff. For clinicians, the Mio-Training offers a training protocol that strengthens cognitive development in patients without much staff support; for researchers, it provides a framework to investigate different driving modes and their effects on neuroplasticity in vulnerable developmental populations.

    Several limitations warrant consideration. As a protocol paper, all findings are anticipated rather than empirically established. The sample sizes within each subgroup are relatively small, which may limit statistical power and the generalizability of findings. Both clinical subgroups (children with cancer and children with ADHD) are inherently heterogeneous with respect to diagnosis, treatment history, and disease severity, which may introduce considerable variability in training response and complicate between-group comparisons. Blinding of participants is not possible given the nature of the intervention, and differential effects based on prior gaming experience or digital access cannot be excluded.

    Future studies could use factorial trial designs to disentangle the relative contributions of the individual training components (motor coordination, working memory training, mnemonic strategies, and metacognitive strategy acquisition) to better understand which elements drive observed effects and for whom. Longer follow-up periods and neuroimaging studies could further clarify the durability and neural correlates of training-induced changes.

    Findings will be published in open-access peer-reviewed journals and presented at relevant conferences in pediatric oncology and neuropsychology. Results will also be communicated to patient advocacy groups and clinical networks to support translation into practice.

    Acknowledgments

    The authors thank Pioneo GmbH for the technical development of the Mio-Training app. The authors also thank all the children and adolescents who will participate in the study, as well as their parents. The Mio-Training was developed in collaboration with Pioneo GmbH under a service agreement. The development partner holds no ownership, intellectual property, licensing, or commercialization rights related to the app. Ownership and intellectual property rights remain with the research team and institution.

    The authors declare the use of generative artificial intelligence (GenAI) in the research and writing process. According to the Generative AI Delegation Taxonomy (2025) [74], the following tasks were delegated to GenAI tools (ChatGPT; OpenAI) under full human supervision: literature search, code generation, code optimization, and proofreading and editing. Responsibility for the final manuscript lies entirely with the authors.

    Funding

    The study is financially supported by the Swiss Cancer Research Foundation, the Cancer Foundation of Thun-Berner Oberland, the Zoé4Life Foundation, the Kinderinsel Foundation, the Johanna Dürmüller-Bol Foundation, the R and V Draksler Foundation, and the Marie-Lou Ringgenberg Foundation.

    Data Availability

    Data sharing is not applicable to this article as no data sets were generated or analyzed during this study.

    Authors' Contributions

    The conception and design of the study were developed by SS and RE. The Mio-Training was conceptualized and developed by SS and RE. SS and RE drafted and revised the initial manuscript. All authors contributed to the refinement of the study protocol and were involved in revising, editing, and providing feedback on the final draft. RE is the sponsor and principal investigator of the study. All authors approved the final manuscript.

    Conflicts of Interest

    None declared.

    Checklist 1

    SPIRIT 2025 checklist.

    PDF File, 278 KB

    Peer Review Report 1

    Peer Review Report by the Swiss Cancer Research Foundation.

    PDF File, 5853 KB
    1. Krull KR, Hardy KK, Kahalley LS, Schuitema I, Kesler SR. Neurocognitive outcomes and interventions in long-term survivors of childhood cancer. J Clin Oncol. Jul 20, 2018;36(21):2181-2189. [CrossRef] [Medline]
    2. Hardy SJ, Krull KR, Wefel JS, Janelsins M. Cognitive changes in cancer survivors. Am Soc Clin Oncol Educ Book. May 23, 2018;38:795-806. [CrossRef] [Medline]
    3. Biederman J, Monuteaux MC, Doyle AE, et al. Impact of executive function deficits and attention-deficit/hyperactivity disorder (ADHD) on academic outcomes in children. J Consult Clin Psychol. Oct 2004;72(5):757-766. [CrossRef] [Medline]
    4. da Silva BS, Grevet EH, Silva LCF, Ramos JKN, Rovaris DL, Bau CHD. An overview on neurobiology and therapeutics of attention-deficit/hyperactivity disorder. Discov Ment Health. Jan 5, 2023;3(1):2. [CrossRef] [Medline]
    5. Schwörer MC, Reinelt T, Petermann F, Petermann U. Influence of executive functions on the self-reported health-related quality of life of children with ADHD. Qual Life Res. May 2020;29(5):1183-1192. [CrossRef] [Medline]
    6. Siegwart V, Benzing V, Spitzhuettl J, et al. Cognition, psychosocial functioning, and health-related quality of life among childhood cancer survivors. Neuropsychol Rehabil. Jul 2022;32(6):922-945. [CrossRef] [Medline]
    7. Mulhern RK, Butler RW. Neurocognitive sequelae of childhood cancers and their treatment. Pediatr Rehabil. 2004;7(1):1-14. [CrossRef] [Medline]
    8. Trapani JA, Murdaugh DL. Processing efficiency in pediatric cancer survivors: a review and operationalization for outcomes research and clinical utility. Brain Behav. Dec 2022;12(12):e2809. [CrossRef] [Medline]
    9. Konrad K, Firk C, Uhlhaas PJ. Brain development during adolescence: neuroscientific insights into this developmental period. Dtsch Arztebl Int. Jun 2013;110(25):425-431. [CrossRef] [Medline]
    10. Tymofiyeva O, Gaschler R. Training-induced neural plasticity in youth: a systematic review of structural and functional MRI studies. Front Hum Neurosci. 2020;14:497245. [CrossRef] [Medline]
    11. Sala G, Gobet F. Working memory training in typically developing children: a multilevel meta-analysis. Psychon Bull Rev. Jun 2020;27(3):423-434. [CrossRef] [Medline]
    12. Melby-Lervåg M, Hulme C. Is working memory training effective? A meta-analytic review. Dev Psychol. Feb 2013;49(2):270-291. [CrossRef] [Medline]
    13. Melby-Lervåg M, Redick TS, Hulme C. Working memory training does not improve performance on measures of intelligence or other measures of “far transfer”: evidence from a meta-analytic review. Perspect Psychol Sci. Jul 2016;11(4):512-534. [CrossRef] [Medline]
    14. Spitzhuettl J, Roebers CM. Neuropsychological, physical activity and psychological interventions for pediatric cancer survivors: a review and synthesis. J Clin Dev Psychol. 2020;2(1). [CrossRef]
    15. Roebers CM, Kauer M. Motor and cognitive control in a normative sample of 7-year-olds. Dev Sci. Jan 2009;12(1):175-181. [CrossRef] [Medline]
    16. Braam KI, van Dijk-Lokkart EM, Kaspers GJ, et al. Cardiorespiratory fitness and physical activity in children with cancer. Support Care Cancer. May 2016;24(5):2259-2268. [CrossRef] [Medline]
    17. Christiansen L, Beck MM, Bilenberg N, Wienecke J, Astrup A, Lundbye-Jensen J. Effects of exercise on cognitive performance in children and adolescents with ADHD: potential mechanisms and evidence-based recommendations. J Clin Med. Jun 12, 2019;8(6):841. [CrossRef] [Medline]
    18. Liu S, Yu Q, Li Z, et al. Effects of acute and chronic exercises on executive function in children and adolescents: a systemic review and meta-analysis. Front Psychol. 2020;11:554915. [CrossRef] [Medline]
    19. Benzing V, Schmidt M. The effect of exergaming on executive functions in children with ADHD: a randomized clinical trial. Scand J Med Sci Sports. Aug 2019;29(8):1243-1253. [CrossRef] [Medline]
    20. Ludyga S, Gerber M, Kamijo K. Exercise types and working memory components during development. Trends Cogn Sci. Mar 2022;26(3):191-203. [CrossRef] [Medline]
    21. Vazou S, Pesce C, Lakes K, Smiley-Oyen A. More than one road leads to Rome: a narrative review and meta-analysis of physical activity intervention effects on cognition in youth. Int J Sport Exerc Psychol. 2019;17(2):153-178. [CrossRef] [Medline]
    22. Mavilidi MF, Vazou S, Lubans DR, et al. How physical activity context relates to cognition across the lifespan: a systematic review and meta-analysis. Psychol Bull. May 2025;151(5):544-579. [CrossRef] [Medline]
    23. Benzing V, Chang YK, Schmidt M. Acute physical activity enhances executive functions in children with ADHD. Sci Rep. Aug 17, 2018;8(1):12382. [CrossRef] [Medline]
    24. Diamond A, Ling DS. Aerobic-exercise and resistance-training interventions have been among the least effective ways to improve executive functions of any method tried thus far. Dev Cogn Neurosci. Jun 2019;37:100572. [CrossRef] [Medline]
    25. Egger F, Benzing V, Conzelmann A, Schmidt M. Boost your brain, while having a break! The effects of long-term cognitively engaging physical activity breaks on children’s executive functions and academic achievement. PLoS One. 2019;14(3):e0212482. [CrossRef] [Medline]
    26. Álvarez-Bueno C, Pesce C, Cavero-Redondo I, Sánchez-López M, Martínez-Hortelano JA, Martínez-Vizcaíno V. The effect of physical activity interventions on children’s cognition and metacognition: a systematic review and meta-analysis. J Am Acad Child Adolesc Psychiatry. Sep 2017;56(9):729-738. [CrossRef] [Medline]
    27. Pesce C. Shifting the focus from quantitative to qualitative exercise characteristics in exercise and cognition research. J Sport Exerc Psychol. Dec 2012;34(6):766-786. [CrossRef] [Medline]
    28. Schmidt M, Benzing V, Kamer M. Classroom-based physical activity breaks and children’s attention: cognitive engagement works! Front Psychol. 2016;7:1474. [CrossRef] [Medline]
    29. Tomporowski PD, Pesce C. Exercise, sports, and performance arts benefit cognition via a common process. Psychol Bull. Sep 2019;145(9):929-951. [CrossRef] [Medline]
    30. Brehmer Y, Li SC, Müller V, von Oertzen T, Lindenberger U. Memory plasticity across the life span: uncovering children’s latent potential. Dev Psychol. Mar 2007;43(2):465-478. [CrossRef] [Medline]
    31. Turley-Ames KJ, Whitfield MM. Strategy training and working memory task performance. J Mem Lang. Nov 2003;49(4):446-468. [CrossRef]
    32. Everts R, Ritter B. Das Memo-Training. Memo, der vergessliche Elefant - Mit Gedächtnistraining spielerisch zum Lernerfolg. Hogrefe; 2022. [CrossRef]
    33. Everts R, Wapp M, Ritter BC, Perrig W, Steinlin M. Effects of two different memory training approaches in very preterm-born children. Adv Ped Res. 2015;2(13). URL: https:/​/boris-portal.​unibe.ch/​server/​api/​core/​bitstreams/​4a8f3257-0534-47a8-856b-02b254885daa/​content [Accessed 2026-06-24] [CrossRef]
    34. Thöne-Otto A, Ackermann H, Benke T, et al. Diagnostik und therapie von gedächtnisstörungen bei neurologischen erkrankungen, S2e- leitlinie. In: Leitlinien Für Diagnostik Und Therapie in Der Neurologie. Deutsche Gesellschaft für Neurologie; 2020. URL: https:/​/dnvp9c1uo2095.​cloudfront.net/​wp-content/​uploads/​2020/​03/​030124_LL_Gedaechtnisstoerungen_2020.​pdf [Accessed 2026-06-16]
    35. Lai ER. Metacognition: a literature review: research report. Pearson; 2011. URL: https://nuovoeutile.it/wp-content/uploads/2015/11/Metacognition_Literature_Review_Final.pdf [Accessed 2026-06-16]
    36. Tomporowski PD, McCullick B, Pendleton DM, Pesce C. Exercise and children’s cognition: the role of exercise characteristics and a place for metacognition. J Sport Health Sci. Mar 2015;4(1):47-55. [CrossRef]
    37. Veenman MV, Kok R, Blöte AW. The relation between intellectual and metacognitive skills in early adolescence. Instr Sci. May 2005;33:193-211. [CrossRef]
    38. Eberhart J, Ingendahl F, Bryce D. Are metacognition interventions in young children effective? Evidence from a series of meta-analyses. Metacognition Learn. Dec 2024;20:7. [CrossRef]
    39. Ambrose SA, Bridges MW, DiPietro M, Lovett MC, Norman MK. How Learning Works: Seven Research-Based Principles for Smart Teaching. John Wiley & Sons; 2010.
    40. Flavell JH. Metacognition and cognitive monitoring: a new area of cognitive–developmental inquiry. Am Psychol. 1979;34(10):906-911. [CrossRef]
    41. Brown A. Metacognition, executive control, self-regulation, and other more mysterious mechanisms. In: Weinert FE, Kluwe RH, editors. Metacognition, Motivation, and Understanding. Routledge; 1987. [CrossRef]
    42. Majid ES, Garcia JA, Nordin AI, Raffe WL. Staying motivated during difficult times: a snapshot of serious games for paediatric cancer patients. IEEE Trans Games. 2020;12(4):367-375. [CrossRef]
    43. DeSmet A, Van Ryckeghem D, Compernolle S, et al. A meta-analysis of serious digital games for healthy lifestyle promotion. Prev Med. Dec 2014;69:95-107. [CrossRef] [Medline]
    44. Lakes KD, Cibrian FL, Schuck SE, Nelson M, Hayes GR. Digital health interventions for youth with ADHD: a mapping review. Comput Hum Behav Rep. May 2022;6:100174. [CrossRef]
    45. Wouters P, van Nimwegen C, van Oostendorp H, van der Spek ED. A meta-analysis of the cognitive and motivational effects of serious games. J Educ Psychol. 2013;105(2):249-265. [CrossRef]
    46. Brier MJ, Schwartz LA, Kazak AE. Psychosocial, health-promotion, and neurocognitive interventions for survivors of childhood cancer: a systematic review. Health Psychol. 2015;34(2):130-148. [CrossRef]
    47. Sperling RA, Howard BC, Miller LA, Murphy C. Measures of children’s knowledge and regulation of cognition. Contemp Educ Psychol. Jan 2002;27(1):51-79. [CrossRef]
    48. World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. Nov 27, 2013;310(20):2191-2194. [CrossRef] [Medline]
    49. Benzing V, Spitzhüttl J, Siegwart V, et al. Effects of cognitive training and exergaming in pediatric cancer survivors-a randomized clinical trial. Med Sci Sports Exerc. Nov 2020;52(11):2293-2302. [CrossRef] [Medline]
    50. Benzing V, Schmidt M. Exergaming for children and adolescents: strengths, weaknesses, opportunities and threats. J Clin Med. Nov 8, 2018;7(11):422. [CrossRef] [Medline]
    51. Cicerone KD, Langenbahn DM, Braden C, et al. Evidence-based cognitive rehabilitation: updated review of the literature from 2003 through 2008. Arch Phys Med Rehabil. Apr 2011;92(4):519-530. [CrossRef] [Medline]
    52. Sperling RA, Richmond AS, Ramsay CM, Klapp M. The measurement and predictive ability of metacognition in middle school learners. J Educ Res. 2012;105(1):1-7. [CrossRef]
    53. Wechsler D. Wechsler Intelligence Scale for Children. 5th ed. Hogrefe; 2017.
    54. Delis DC, Kaplan E, Kramer JH. Delis-Kaplan Executive Function System: D-KEFS. Pearson. 2001. URL: https://www.pearsonclinical.co.uk/en-gb/delis/Delis-Kaplan-Executive-Function-System/p/P100009078 [Accessed 2026-06-16]
    55. Helmstaedter C, Lendt M, Lux S. Verbaler Lern- Und Merkfähigkeitstest. Beltz Test; 2001.
    56. Lepach AC, Petermann F. Merk- und Lernfähigkeitstest Für 6- Bis 16-Jährige. Hogrefe; 2008.
    57. Zimmermann P, Fimm B. TAP – testbatterie zur aufmerksamkeitsprüfung. Psytest. URL: https://www.psytest.net/de/testbatterien/tap/tests [Accessed 2026-06-21]
    58. Bös K, Schlenker L, Büsch D, et al. Deutscher Motorik-Test 6-18 (DMT 6-18). Feldhaus; 2009.
    59. Drechsler R, Steinhausen HC. Verhaltensinventar Zur Beurteilung Exekutiver Funktionen: Deutschsprachige Adaptation Des Behavior Rating Inventory of Executive Function: BRIEF. Hogrefe & Huber Publishers; 2013.
    60. Lidzba K, Christiansen H, Drechsler R. Conners 3: Conners Skalen Zur Aufmerksamkeit Und Verhalten-3: Deutschsprachige Adaptation Der Conners 3rd Edition (Conners 3) von C Keith Conners: Manual. Huber; 2013.
    61. Lohaus A, Nussbeck FW. Fragebogen Zu Ressourcen Im Kindes- Und Jugendalter. Hogrefe; 2016.
    62. Varni JW, Burwinkle TM, Katz ER, Meeske K, Dickinson P. The PedsQL in pediatric cancer: reliability and validity of the Pediatric Quality of Life Inventory Generic Core Scales, Multidimensional Fatigue Scale, and Cancer Module. Cancer. Apr 1, 2002;94(7):2090-2106. [CrossRef] [Medline]
    63. Marsh HW, Martin AJ, Jackson S. Introducing a short version of the Physical Self Description Questionnaire: new strategies, short-form evaluative criteria, and applications of factor analyses. J Sport Exerc Psychol. Aug 2010;32(4):438-482. [CrossRef] [Medline]
    64. Rubin DB. Multiple Imputation for Nonresponse in Surveys. John Wiley & Sons; 1987. [CrossRef]
    65. REDCap. URL: https://www.projectredcap.org/ [Accessed 2026-06-22]
    66. Bharadwaj SV, Yeatts P, Headley J. Efficacy of Cogmed Working Memory Training program in improving working memory in school-age children with and without neurological insults or disorders: a meta-analysis. Appl Neuropsychol Child. 2022;11(4):891-903. [CrossRef] [Medline]
    67. Singh AS, Saliasi E, van den Berg V, et al. Effects of physical activity interventions on cognitive and academic performance in children and adolescents: a novel combination of a systematic review and recommendations from an expert panel. Br J Sports Med. May 2019;53(10):640-647. [CrossRef] [Medline]
    68. Carruthers G. A metacognitive model of the sense of agency over thoughts. Cogn Neuropsychiatry. 2012;17(4):291-314. [CrossRef] [Medline]
    69. Fleur DS, Bredeweg B, van den Bos W. Metacognition: ideas and insights from neuro- and educational sciences. NPJ Sci Learn. Jun 8, 2021;6(1):13. [CrossRef] [Medline]
    70. Henschke JU, Pakan JM. Engaging distributed cortical and cerebellar networks through motor execution, observation, and imagery. Front Syst Neurosci. 2023;17:1165307. [CrossRef] [Medline]
    71. Leisman G, Moustafa AA, Shafir T. Thinking, walking, talking: integratory motor and cognitive brain function. Front Public Health. 2016;4:94. [CrossRef] [Medline]
    72. Skulmowski A, Rey GD. Embodied learning: introducing a taxonomy based on bodily engagement and task integration. Cogn Res Princ Implic. 2018;3(1):6. [CrossRef] [Medline]
    73. Klupp S, Möhring W, Lemola S, Grob A. Relations between fine motor skills and intelligence in typically developing children and children with attention deficit hyperactivity disorder. Res Dev Disabil. Mar 2021;110:103855. [CrossRef] [Medline]
    74. Suchikova Y, Tsybuliak N, Teixeira da Silva JA, Nazarovets S. GAIDeT (Generative AI Delegation Taxonomy): a taxonomy for humans to delegate tasks to generative artificial intelligence in scientific research and publishing. Account Res. Apr 2026;33(3):2544331. [CrossRef] [Medline]

    ‎
    ADHD: attention-deficit/hyperactivity disorder
    D-KEFS: Delis-Kaplan Executive Function System
    Jr.MAI: Junior Metacognitive Awareness Inventory
    RCT: randomized controlled trial
    REDCap: Research Electronic Data Capture
    WISC-V: Wechsler Intelligence Scale for Children–Fifth Edition

    Edited by Javad Sarvestan; The proposal for this study was externally peer-reviewed by the Swiss Cancer Research Foundation. See the Peer Review Report; submitted 12.Mar.2026; accepted 15.May.2026; published 26.Jun.2026.

    Copyright

    © Saskia Salzmann, Valentin Benzing, Sebastian Grunt, Rhoikos Furtwängler, Regula Everts. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 26.Jun.2026.

    This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Research Protocols, is properly cited. The complete bibliographic information, a link to the original publication on https://www.researchprotocols.org, as well as this copyright and license information must be included.