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).
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.
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.