This was an exploratory, pilot, prospective, naturalistic observational study conducted at the Department of Pediatrics, Ambalike Clinic, Darbhanga, Bihar, India, tracking clinical and safety parameters over a six-month observation period.

The study protocol received ethical clearance from the Institutional Ethics Committee (IEC) of Ambalike Clinic (Ref No: AC-IEC/2025/06-02, Date: June 18, 2025; Table 1). The research adhered to the Declaration of Helsinki and Indian Council of Medical Research (ICMR) ethical guidelines. Written informed parental consent and age-appropriate pediatric assent were obtained prior to enrollment.

Table 1.Ethical approval details & governance matrix.

All clinical diagnostic evaluations were performed directly and independently by the primary investigator, Dr. Udbhatt Mishra (Pediatric Specialist). Diagnostic verification adhered to strict Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria [12] through semi-structured clinical interviews administered to parents/guardians alongside direct interactive child behavioral observations.

All enrolled participants were regular, mainstream school-attending children whose primary presenting complaint from parents was severe difficulty concentrating in studies, classroom inattention, and academic underachievement. None of the children attended specialized ADHD-oriented educational institutions or received individualized educational plans (IEPs). To establish cross-situational impairment in accordance with DSM-5 Criterion C and D, functional disruption was verified across at least two distinct environments (academic/classroom and home/interpersonal settings). Baseline functional impairment was systematically characterized across three primary functional domains: 1) Academic Performance (learning efficiency, classroom disruption, homework completion failures); 2) Peer Relationships (conflict during social play, impulsivity in peer groups); and 3) Home/Family Functioning (parental distress, task non-compliance, defiance during daily routines).

Throughout the 6-month observation window, participants did not receive formal behavioral therapy, psychotherapy, sensory integration therapy, institutional remedial education, or special educational support services, as these resources were unavailable in the local practice ecosystem. Furthermore, no concurrent neurotropic supplements, micronutrient mega-doses, herbal concoctions, or standard psychostimulant/non-stimulant ADHD pharmacotherapies were permitted or administered, ensuring the observational data reflects isolated dual-regimen exposure.

The study cohort was drawn from a consecutive series of 33 pediatric patients presenting with behavioral concerns to the outpatient department (OPD) of Ambalike Clinic. The complete progression of participant screening, pre-treatment exclusions, allocation, 6-month longitudinal tracking, and attrition mapping is illustrated in the CONSORT-style participant flow diagram (Figure 1).

Figure 1. CONSORT-style participant flow diagram depicting patient screening (n = 33), pre-treatment exclusions (n = 4), protocol initiation on combined Bacopamonnieri and piracetam (n = 29), 6-month follow-up tracking (lost to follow-up, n = 9), and final per-protocol (n = 20) and intention-to-treat (n = 29) analysis cohorts.

Inclusion Criteria:Male sex; aged 5 - 10 years at baseline; formal DSM-5 ADHD diagnosis verified by independent clinical interview and confirmed via the Vanderbilt ADHD Diagnostic Parent Rating Scale [13]; presence of documented cross-situational functional impairment; complete 6-month longitudinal tracking.Exclusion Criteria:Major co-existing neurological conditions (e.g., active epilepsy, cerebral palsy); severe psychiatric comorbidities (e.g., autism spectrum disorder, bipolar disorder); concurrent use of stimulant or non-stimulant ADHD medications; refusal of prescribed therapy; or loss to follow-up.

Participants received a standardized daily oral combined regimen maintained over six continuous months: 1) standardized commercial Bacopamonnieri extract tablets (250 mg orally once daily in the morning; Himalaya Wellness Company, Makali, Bengaluru, Karnataka, India; HPLC/HPTLC standardized to active bacosides); and 2) commercial pediatric piracetam tablets (250 mg orally twice daily; total daily dose: 500 mg). A fixed age-bracketed dosing scheme (250 mg/day Bacopa; 500 mg/day piracetam) was utilized across the 5 - 10-year age band based on available solid oral unit formulations to prevent caregiver dosing errors and ensure strict compliance.

The primary outcome was change on the standardized Vanderbilt ADHD Diagnostic Parent Rating Scale (VADPRS) [13]. The 18 core DSM-5 symptom items evaluate two psychometrically validated factor dimensions: Inattention (Items 1 - 9) and Hyperactivity/Impulsivity (Items 10 - 18), scored on a 4-point Likert scale (0 = Never, 1 = Occasionally, 2 = Often, 3 = Very Often). Functional impairment was evaluated across 8 performance items (Items 48 - 55) [13][14]. A combined Average Item Score was calculated by dividing the sum of the 18 core DSM items by 18 (scale: 0.00 - 3.00) [15]-[17]. Caregivers completed all 18 core items during structured clinic interviews.

2.7.1. Bias Mitigation & Educational Context

To mitigate parental reporting bias in the absence of teacher ratings (which were logistically precluded by regional schooling constraints), monthly Vanderbilt scales were administered directly by the pediatric specialist, cross-examining parent ratings against concrete behavioral examples and direct interactive behavioral observations of the child.

2.7.2. Handling of Missing Data, Per-Protocol vs. ITT Rationale, and Response Threshold

The primary analysis was conducted on a complete-case per-protocol cohort (n = 20) with 100% verified item completion across 6 continuous months. To account for attrition and ensure complete transparency, sensitivity Intention-to-Treat (ITT) analyses were conducted across all N = 29 enrolled patients using: 1) Baseline Observation Carried Forward (BOCF), treating dropouts as complete non-responders (0% symptom reduction); and 2) Last Observation Carried Forward (LOCF) using intermediate recorded scores. Clinical response was operationalized as a ≥30% reduction in the Vanderbilt score from baseline to endpoint [5][16].

Treatment adherence was tracked via objective caregiver pill counts and structured clinical interviews at monthly visits. Adherence percentage was calculated as: (Number of dosage units consumed/Number of dosage units prescribed) × 100%. Clinical safety and tolerability were monitored longitudinally at each monthly visit using structured clinician-administered adverse effect checklists, vital signs monitoring (blood pressure, resting heart rate), and anthropometric tracking (weight and height velocity).

Context for Absence of Laboratory Safety Monitoring

Routine baseline and serial biochemical laboratory monitoring (specifically liver and kidney function tests) were not conducted because this was an unfunded, investigator-initiated study in a low-resource setting where families bear healthcare expenses out-of-pocket [18][19]. Mandating recurring commercial laboratory panels would have imposed a prohibitive financial burden on families, leading to high refusal and dropout rates. Consequently, safety monitoring relied on structured clinical checklists, physical examinations, and vital sign assessments.

For patients categorized with symptom worsening (>30% increase on Vanderbilt score) or non-response, clinical protocols mandated structured counseling, reassessment of psychosocial stressors, and direct clinical referral options to tertiary neuropsychiatric centers for guideline-directed first-line pharmacotherapy [3].

Continuous behavioral scores are presented as Mean ± Standard Deviation (SD). Differences between completing participants (n = 20) and participants lost to follow-up (n = 9) were evaluated using independent samples t-tests for continuous variables and Fisher’s exact test/Chi-square tests for categorical variables. Pre- vs. post-treatment differences were evaluated using paired t-tests (parametric) and Wilcoxon signed-rank tests (non-parametric) for both per-protocol (n = 20) and ITT populations (n = 29). Effect magnitude was calculated using Cohen’s d and 95% confidence intervals (CI). Clinical response phenotypes were categorized as: Marked Improvement (>30% reduction), Stable Response (±30% change), and Worsening (>30% increase). Significance was set at α = 0.05.

From 33 consecutively assessed patients, 29 initiated therapy and 20 completed the 6-month protocol (mean age: 7.4 ± 1.6 years; see Figure 1). Nine patients were lost to follow-up (relocation/travel distance: n = 4; unreachable by phone: n = 3; voluntary discontinuation unrelated to adverse events: n = 2).

To evaluate potential attrition bias, baseline characteristics were compared between completers (n = 20) and those lost to follow-up (n = 9; Table 2). There were no statistically significant differences in age (7.4 ± 1.6 vs. 7.2 ± 1.5 years; p = 0.75), baseline Vanderbilt Average Item Score (2.75 ± 0.24 vs. 2.71 ± 0.26; p = 0.69), ADHD subtype distribution (p = 0.88), or baseline functional impairments (all p > 0.80), indicating absence of systematic attrition selection bias.

Table 2. Baseline clinical characteristics & attrition analysis: completers (n = 20) vs. Lost to Follow-up (n = 9) vs. Total Enrolled (n = 29).

Caregiver pill counts returned at monthly follow-ups demonstrated high overall treatment compliance (mean adherence: 94.2% ± 4.1%; range: 86.5% - 98.8%), with 100% of completers achieving ≥ 80% adherence.

Per-Protocol Cohort Analysis (n = 20): Baseline Vanderbilt Average Item Score was 2.75 ± 0.24, decreasing to 1.50 ± 0.51 post-treatment (absolute mean reduction: 1.25 points; Table 3). Inattentive subscale score decreased from 2.81 ± 0.21 to 1.48 ± 0.49 (reduction: 1.33 points), and Hyperactive/Impulsive subscale decreased from 2.68 ± 0.28 to 1.52 ± 0.54 (reduction: 1.16 points). Paired t-testing demonstrated statistical significance (t = 3.05, p = 0.007; Wilcoxon test: p = 0.008; Cohen’s d = 0.68).

Sensitivity Intention-to-Treat (ITT) Analysis (N = 29): Under Baseline Observation Carried Forward (BOCF/non-responder assumption), the mean Vanderbilt Average Item Score decreased from 2.74 ± 0.24 to 1.88 ± 0.70 at month 6 (mean reduction: 0.86 points; t = 6.42, p < 0.001; Cohen’s d = 1.19), with an ITT response rate (≥30% reduction) of 34.5% (10/29). Under Last Observation Carried Forward (LOCF), endpoint score was 1.81 ± 0.68 (mean reduction: 0.93 points; t = 6.98, p < 0.001; Cohen’s d = 1.30; Table 3).

Table 3. Clinical and statistical shifts in Vanderbilt ADHD scores: per-protocol (n = 20) and intention-to-treat (n = 29) analyses.

In the per-protocol cohort (n = 20), 50% (n = 10) achieved marked improvement (>30% reduction), 25% (n = 5) maintained stable scores, and 25% (n = 5) exhibited score increases (>30%). In the ITT population (N = 29) under BOCF, marked improvement was 34.5% (n = 10), stable/non-response was 48.3% (n = 14), and worsening was 17.2% (n = 5). All 5 worsening patients experienced uneventful clinical courses without behavioral crises and received clinical counseling and referral pathways.

Mild transient nausea occurred in 2 patients (10%) and resolved with post-meal administration; mild delayed sleep onset occurred in 1 patient (5%). No serious adverse events occurred throughout the six-month study period.

Comparing completers (n = 20) and participants lost to follow-up (n = 9) demonstrated no statistically significant differences in baseline symptom severity, presentation subtypes, or functional impairments (Table 2; all p > 0.50), indicating that attrition was unrelated to clinical severity. Chart audits confirmed that non-completion was driven by logistical factors (family relocation, travel distance, disconnected phone numbers) rather than adverse events. Among non-responders and participants with symptom score increases (25%, n = 5), clinical charting revealed prominent baseline emotional dysregulation or environmental stressors rather than drug-related behavioral toxicity, and all recovered uneventfully with supportive counseling and referral options [3].

Because outcome tracking was purely clinical and psychometric, theoretical mechanisms such as piracetam-mediated neuronal membrane fluidity modulation [8] or Bacopa-induced cholinergic upregulations [9] remain preclinical hypotheses. The current study provides observational data on behavioral associations and clinical feasibility, and does not claim direct biological verification of enzymatic modulation or pharmacological synergy.