Neural mechanisms of guided internet-based cognitive behavioral therapy for children with attention-deficit/hyperactivity disorder: a protocol for a prospective multimodal MRI study

Abstract

Introduction Attention-deficit/hyperactivity disorder (ADHD), a common neurodevelopmental disorder in childhood, is associated with academic, social, and emotional difficulties. Although pharmacotherapy is widely used for treating ADHD, functional impairments often remain. Cognitive behavioral therapy (CBT) has demonstrated benefits in children with ADHD, and internet-based CBT (ICBT) may improve treatment accessibility. However, the neurobiological mechanisms underlying ICBT remain unclear, and neural markers predicting treatment responses have not been well established, particularly in children with ADHD. Neuroimaging may aid in the exploration of changes in the brain structure and function that are associated with interventions and provide insights into predictors of treatment response. Methods and analysis This multimodal neuroimaging study aims to examine intervention-related neural changes in children with ADHD using pre- and post-intervention MRI assessments. Participants will be drawn from a cohort of participants of an ongoing randomized, sham-controlled ICBT clinical trial and will thus belong to an ICBT or sham control group. Approximately 60 children with ADHD will undergo multimodal magnetic resonance imaging (MRI), including structural MRI, resting-state functional MRI, and diffusion tensor imaging before and after an 11-week intervention. MRI data from typically developing (TD) children will be obtained from an ongoing neuroimaging database for baseline cross-sectional comparisons and as a reference for interpreting post-intervention neural changes in the ADHD group. Analyses will explore intervention-related changes in brain structure and function, as well as associations between baseline MRI markers and clinical treatment response. Ethics and dissemination This study was approved by the Research Ethics Committee of the University of Fukui Hospital in February 2026 (ethics approval number: 20250238). Participant recruitment commenced in March 2026. The study findings will be disseminated through peer-reviewed journals and scientific conferences.