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Cognitive Neuroscience and ADD/ADHD Today

Some days ago we men­tioned atten­tion deficits and exec­u­tive func­tions, as part of a review of Cog­ni­tive Neu­ro­science and Edu­ca­tion. Let me explore that in more depth now, hav­ing just met a num­ber of very inter­est­ing researchers, doc­tors and experts at CHADD con­fer­ence, and wit­nessed the first baby steps of a com­ing rev­o­lu­tion.

First, 3 clar­i­fi­ca­tions are in order:

- CHADD is the main con­fer­ence for pro­fes­sion­als involved in ADD/ADHD work. Our part­ners in Cogmed and I attended it last week

- “Atten­tion” and exec­u­tive func­tion­ing are rel­e­vant to every human being. They are not binary (either I have good atten­tion, or I have an atten­tion deficit), but a skill, a mus­cle, that can be more or less devel­oped, and that is sub­ject to devel­op­ment and training.

- ADD/ADHD (atten­tion deficit dis­or­der) is diag­nosed accord­ing to lists of symp­toms that med­ical pro­fes­sion­als eval­u­ate. It is a neu­ro­bi­o­log­i­cal prob­lem, with well-researched frontal lobe and exec­u­tive func­tion­ing impli­ca­tions, but the assess­ment today only takes into account rat­ing scales of symptoms.

A num­ber of par­tic­i­pants in CHADD con­fer­ence last week dis­cussed how we could feel the first steps of a rev­o­lu­tion in the under­stand­ing and treat­ment of ADD/ADHD and, by exten­sion, in the main­stream under­stand­ing of what the Frontal Lobes of our brains are, and why, and how, each of us could take care of them thanks to well-designed Brain Fit­ness Pro­grams. A chronol­ogy of events in the con­fer­ence to share that feeling:

- Wednes­day: Cogmed orga­nized a pri­vate meet­ing with the 15 US-based clin­i­cians (from pedi­a­tri­cians to neu­ropsy­chol­o­gists and child psy­chi­a­trists) who have started to offer RoboMemo to their patients with work­ing mem­ory deficits-a con­di­tion in many kids and adults with ADD/ADHD. We heard incred­i­ble tes­ti­mo­ni­als from peo­ple like Dr. Bar­bara Inger­soll, Dr. Arthur Lavin, and oth­ers. Not only that, but Dr. Torkel Kling­berg pre­sented some pre­lim­i­nary data com­ing from the work in the Karolin­ska Insti­tute and a repli­ca­tion study done in by Bradley Gib­son at NotreDame Uni­ver­sity (he and his team are doing very inter­est­ing work on cog­ni­tive train­ing of exec­u­tive functions).

- Thurs­day: Mark Katz won a well-deserved award and talked about his inter­est in resilience and emo­tional endurance. Emo­tional man­age­ment and self-motivation being key areas, Mark Katz and I later had a great con­ver­sa­tion on resiliency and emo­tional endurance. In short, he is writ­ing a new book on the impor­tance of “turn­ing points” that enable all of us, includ­ing peo­ple brought up in dif­fi­cult con­texts (with many risk fac­tors, such as ADD/ADHD), over­come life dif­fi­cul­ties by attach­ing new mean­ings to our expe­ri­ences and our lives, devel­op­ing a sense of mas­tery, and find­ing at least one area in our lives where we can suc­ceed and build self-confidence around.

- Also on Thurs­day, Dr. Rus­sel Barkley, Research Pro­fes­sor of Psy­chi­a­try at the SUNY Med­ical Uni­ver­sity and Clin­i­cal Pro­fes­sor of Psy­chi­a­try at the Med­ical Uni­ver­sity of South Car­olina, gave the open­ing keynote speech in which he showed pre­lim­i­nary find­ings from his research on adults with ADD/ADHD and con­cluded that most rel­e­vant symp­toms to diag­nose an adult with ADD/ADHD involve exec­u­tive func­tion­ing and frontal lobe prob­lems. We have talked about this ear­lier, but in short: exec­u­tive func­tions reside in our brain’s frontal lobes (behind our fore­head), and deal with abil­i­ties such as inhi­bi­tion, work­ing mem­ory, orga­ni­za­tion to time and future events, emo­tional man­age­ment, self-motivation, and plan­ning.

- Fri­day: 2 great pre­sen­ta­tions by Dr. Torkel Kling­berg on Cogmed’s work­ing mem­ory train­ing pro­gram, RoboMemo, were very well received by a large audi­ence. Torkel intro­duced us to exist­ing research on the effects of work­ing mem­ory train­ing not only in the ADD/ADHD field (includ­ing the effect on dopamine cre­ation and recep­tor den­sity), but also in stroke reha­bil­i­ta­tion, and nor­mal chil­dren and adult devel­op­ment and aging.

- Sat­ur­day: Mark Katz and a good num­ber of other peo­ple were very inter­ested in watch­ing an amaz­ing video on atten­tion (if you have 2 min­utes, please try it)

As I left the con­fer­ence I was think­ing about how to best sum­ma­rize these new find­ings and their impli­ca­tions, and for­tu­nately came across an Edi­to­r­ial titled The Role of Intel­lec­tual Processes in the DSM-V Diag­no­sis of ADHD, writ­ten by Jour­nal of Atten­tion Dis­or­ders Editor-in-Chief and neu­rop­shy­chol­o­gist Dr. Sam Gold­stein and Jack A. Naglieri (August 2006).

High­lights

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1. There are two types of ADD/ADHD, and they are very dif­fer­ent in nature, diag­no­sis and intervention

A) ADHD-Combined: which Dr. Gold­stein calls a “self-regulation deficit”, because the main prob­lem lies in exec­u­tive func­tions. This can be con­cep­tu­al­ized as “a fail­ure of self-control within the con­text of pre­frontal lobe func­tions” (Dr. Elkhonon Gold­berg, 2001), and the main prob­lem seems to lay on poor behav­ioral inhi­bi­tion (Barkley, 1997). “poor plan­ning and antic­i­pa­tion; reduced sen­si­tiv­ity to errors; poor orga­ni­za­tion; impaired ver­bal problem-solving and self-directed speech; poor rule-governed behav­ior; poor self-regulation of emo­tions; prob­lems devel­op­ing, using and mon­i­tor­ing orga­ni­za­tional strate­gies; and self-regulation and inhi­bi­tion prob­lems (Barkley 2003). Gold­berg suc­cinctly sum­ma­rizes this frontal lobe dys­func­tion, based on his men­tor Alexan­der Luria’s work, as “poor plan­ning and fore­sight, com­bined with dimin­ished impulse con­trol and exag­ger­ated affec­tive volatil­ity (p.179 of Exec­u­tive Brain)

B) ADHD-Inattentive: kids and adults with selec­tive atten­tion prob­lems. This would be the true “atten­tion deficit”

2. Sug­gested impli­ca­tions for diag­no­sis and inter­ven­tion: espe­cially for kids and adults with ADHD-Combined, Dr. Gold­stein writes that “chil­dren who are poor in plan­ning and poor in math cal­cu­la­tion improved con­sid­er­ably when pro­vided an inter­ven­tion that helped them bet­ter use their plan­ning processes and be less com­pul­sive and more thought­ful and reflec­tive when com­plet­ing aca­d­e­mic work.

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This is part of where Brain Fit­ness pro­grams such as Cogmed work­ing mem­ory train­ing help, hav­ing been shown to gen­er­al­ize to other cog­ni­tive areas such as prob­lem solv­ing (Ravens) and response inhi­bi­tion (Stroop test-see below). For bet­ter con­text, you can read my con­ver­sa­tion with Pro­fes­sor David Rabiner on cog­ni­tive train­ing.

Through­out this post, we have been using 2 con­cepts, plan­ning and inhi­bi­tion, that you can try your­self in 2 fun games based on neu­ropsy­cho­log­i­cal assessments:

- Plan­ning: Tow­ers of Hanoi

- Inhi­bi­tion: Stroop Test

Finally, let me men­tion some promis­ing areas of research.

- The so-called “Dopamine effect”: whether dopamine recep­tor den­sity can be influ­enced by cog­ni­tive training.

- Objec­tive assess­ments for ADD/ADHD, such as cog­ni­tive bat­ter­ies (which need to be psychometrically-sound assess­ments), and/ or EEG biofeed­back. Specif­i­cally, cog­ni­tive bat­ter­ies should help iden­tify kids and adults with spe­cific weak­ness (for instance, say­ing that “my Man­darin flu­ency is not that good) ver­sus hav­ing a seri­ous deficit or “bot­tle­neck” (say­ing “not speak­ing Man­darin flu­ency is pre­cisely my main prob­lem, if I could solve it first, then many good things good follow).

- Larger repli­ca­tion stud­ies for work­ing mem­ory training.

- Bet­ter assess­ment and inter­ven­tions designed specif­i­cally for adults.

For more infor­ma­tion on Exec­u­tive func­tions, you can check the excel­lent review in the Amer­i­can Jour­nal of Psy­chi­a­try, of Dr. Elkhonon Goldberg’s book The Exec­u­tive Brain

That’s it for now. Am par­tic­i­pat­ing today and tomor­row at the Seri­ous Games Sum­mit in DC, so will write from a dif­fer­ent per­spec­tive for the rest of the week.

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