Sharp Brains: Brain Fitness and Cognitive Health News

Neuroplasticity, Brain Fitness and Cognitive Health News

Icon

Promising Cognitive Training Studies for ADHD

As not­ed in our Mar­ket Report, we expect the field of cog­ni­tive train­ing (or “brain fit­ness”) soft­ware to grow in a vari­ety of edu­ca­tion and health-relat­ed areas over the next years. One of the most promis­ing areas in our view: help­ing chil­dren and adults with atten­tion deficits improve brain func­tion to reduce ADHD symp­toms.

I am glad to present this in-depth dis­cus­sion on the results of two recent high-qual­i­ty sci­en­tif­ic stud­ies. Let me start with Dr. Rabin­er’s con­clu­sion:

Results from these two cog­ni­tive train­ing stud­ies high­light that cog­ni­tive train­ing inter­ven­tions may pro­vide an impor­tant com­ple­ment to tra­di­tion­al med­ica­tion treat­ment and behav­ior ther­a­py. Both stud­ies includ­ed appro­pri­ate con­trol groups, employed ran­dom assign­ment, and had out­come mea­sures pro­vid­ed by indi­vid­u­als who were “blind” to which con­di­tion chil­dren were assigned to. They are thus well-designed stud­ies from which sci­en­tif­i­cal­ly sound con­clu­sions can be drawn. They add to the grow­ing research base that inten­sive prac­tice and train­ing focused of key cog­ni­tive skills can have pos­i­tive effects that extend beyond the train­ing sit­u­a­tion itself.”

With­out futher ado…enjoy the arti­cle!

- Alvaro

——————

Two New Cog­ni­tive Train­ing Stud­ies for ADHD Yield Promis­ing Find­ings

– By Dr. David Rabin­er

Although med­ica­tion treat­ment is effec­tive for many chil­dren with ADHD, there remains an impor­tant need to explore and devel­op inter­ven­tions that can com­ple­ment or even sub­sti­tute for med­ica­tion. This is true for a vari­ety of rea­sons includ­ing:

1) Not all indi­vid­u­als with ADHD ben­e­fit from med­ica­tion.
2) Among those who ben­e­fit, many have resid­ual dif­fi­cul­ties that need to be addressed via oth­er means.
3) Some indi­vid­u­als expe­ri­ence adverse effects that pre­vent them from remain­ing on med­ica­tion.
4) Med­ica­tion treat­ment does not result in ben­e­fits that extend beyond when med­ica­tion is being tak­en.

Except for #3 above, the same lim­i­ta­tions hold for behav­ior ther­a­py, which is the oth­er inter­ven­tion for ADHD that is wide­ly con­sid­ered to have a strong evi­dence base at this time.

Because of these lim­i­ta­tions, some researchers have pur­sued cog­ni­tive train­ing as an alter­na­tive method of treat­ment. The basic idea behind cog­ni­tive train­ing is that impor­tant cog­ni­tive skills such as atten­tion and work­ing mem­o­ry can — like any oth­er skill — be strength­ened and enhanced with inten­sive and focused prac­tice. Fur­ther­more, when an indi­vid­ual builds these skills the ben­e­fits may endure beyond the time when the actu­al train­ing is pro­vid­ed.

Although this is a log­i­cal and com­pelling idea, the research base as it applies to indi­vid­u­als with ADHD is rather lim­it­ed and the idea that atten­tion is a skill that could be strength­ened by focused train­ing has not been care­ful­ly stud­ied. In fact, when I was prepar­ing a grant appli­ca­tion sev­er­al years ago for an atten­tion train­ing study, I was sur­prised to locate few­er than 5 stud­ies of this issue. Fur­ther­more, these were gen­er­al­ly small pre­lim­i­nary stud­ies that would be con­sid­ered pilot inves­ti­ga­tions.

In recent years, how­ev­er, researchers in the ADHD field have devot­ed greater atten­tion to exam­in­ing the poten­tial ben­e­fits of cog­ni­tive train­ing for ADHD. Below, I review 2 recent stud­ies that high­light the poten­tial val­ue of train­ing ori­ent­ed approach­es.

- Study 1: Com­put­er­ized Pro­gres­sive Atten­tion­al Train­ing for Chil­dren with ADHD —

This study was con­duct­ed with 36 6–13-year-old chil­dren in Israel who were diag­nosed with ADHD. Results from this study were pub­lished last year in Child Neu­rospsy­chol­o­gy [Shalev, Tsal, & Mevo­rach (2007). Com­put­er­ized pro­gres­sive atten­tion­al train­ing: Effec­tive direct inter­ven­tion for chil­dren with ADHD. Child Neu­ropsy­chol­o­gy, 13, 382–388.]

Par­tic­i­pants were ran­dom­ly assigned to receive 8 weeks of com­put­er­ized atten­tion train­ing (one hour ses­sions two times per week) or to a con­trol group. The basic premise of com­put­er­ized atten­tion train­ing is sim­ple: the pro­gram requires chil­dren to attend to a vari­ety of com­put­er exer­cis­es and to make dif­fer­ent respons­es depend­ing on the stim­uli pre­sent­ed. For exam­ple, a par­tic­u­lar­ly sim­ple task would require the child to press the space bar each time the num­ber 2 was flashed but to refrain from respond­ing when any oth­er num­ber is flashed. To per­form well, the child must sus­tain their atten­tion and refrain from respond­ing impul­sive­ly.

Although oth­er tasks may be far more com­pli­cat­ed, and place demands on both prob­lem solv­ing skills and work­ing mem­o­ry, all tasks require sus­tained atten­tion to do well. They also become more dif­fi­cult and longer as the child moves through the train­ing pro­gram. Thus, the child receives repeat­ed prac­tice in sus­tain­ing atten­tion to increas­ing­ly chal­leng­ing tasks that last for longer time peri­ods. Ide­al­ly, the dif­fi­cul­ty lev­el adjusts to match the child’s ongo­ing per­for­mance so that the child is con­stant­ly chal­lenged to per­form at their best pos­si­ble lev­el — not too easy but not too hard.

By suc­ceed­ing in the pro­gram, the child is demon­strat­ing an increas­ing abil­i­ty to sus­tain their atten­tion to chal­leng­ing cog­ni­tive activ­i­ties. Although chil­dren may get bet­ter at attend­ing to the actu­al com­put­er exer­cis­es, how­ev­er, the impor­tant ques­tion is whether this gen­er­al­izes to the class­room and oth­er set­tings where focused atten­tion is crit­i­cal for suc­cess. If not, become bet­ter at attend­ing to the atten­tion train­ing exer­cis­es would be of lit­tle val­ue.

The atten­tion train­ing pro­gram test­ed in this study was designed to train 4 dif­fer­ent aspects of atten­tion: sus­tained atten­tion (the abil­i­ty to main­tain atten­tion and per­sist on task until com­ple­tion), selec­tive atten­tion (the abil­i­ty to main­tain a spe­cif­ic cog­ni­tive set in the face of com­pet­ing dis­trac­tions), ori­ent­ing atten­tion (direct­ing one’s atten­tion to crit­i­cal stim­uli), and exec­u­tive atten­tion (allo­cat­ing atten­tion­al resources between com­pet­ing demands and choos­ing what to attend to). Dur­ing each ses­sion chil­dren were trained on these dif­fer­ent types of atten­tion and the tasks become more dif­fi­cult as chil­dren’s per­for­mance improved.

Chil­dren in the con­trol group played com­put­er games — rather then receiv­ing atten­tion train­ing — for the same amount of time. These games also required chil­dren to sus­tain their atten­tion to suc­ceed and became more dif­fi­cult as chil­dren pro­gressed. Thus, the amount of time chil­dren spent under adult super­vi­sion work­ing on com­put­er activ­i­ties that became more dif­fi­cult as they pro­gressed was the same for each group. Unlike chil­dren ran­dom­ly assigned to the atten­tion train­ing group, how­ev­er, chil­dren in the video game con­trol con­di­tion were not exposed to activ­i­ties that focused on train­ing spe­cif­ic com­po­nents of atten­tion.

Before and imme­di­ate­ly fol­low­ing train­ing, par­ents rat­ed their child’s ADHD symp­toms using a stan­dard­ized behav­ior rat­ing scale (the authors report that par­ents were blind to which group their child was in). In addi­tion, aca­d­e­m­ic per­for­mance was test­ed pre- and post-train­ing using math prob­lems, read­ing com­pre­hen­sion prob­lems, and pas­sage copy­ing prob­lems tak­en direct­ly from chil­dren’s school books. Stan­dard achieve­ment tests were not used because such tests are not avail­able in Hebrew. Infor­ma­tion about whether any chil­dren were on med­ica­tion dur­ing the train­ing or dur­ing test­ing was not pro­vid­ed.

- Results -

Encour­ag­ing results were obtained. Par­ents of chil­dren in the atten­tion train­ing group report­ed a sig­nif­i­cant decline in their child’s inat­ten­tive symp­toms com­pared to par­ents of chil­dren in the con­trol group. The change in hyper­ac­tive-impul­sive symp­toms was in the same direc­tion but was not sig­nif­i­cant.

After con­trol­ling for aca­d­e­m­ic per­for­mance before train­ing, chil­dren who received atten­tion train­ing did sig­nif­i­cant­ly bet­ter than con­trols in read­ing com­pre­hen­sion and in their speed of copy­ing pas­sages. Math per­for­mance was in the same direc­tion but was not sig­nif­i­cant.

- Sum­ma­ry and Impli­ca­tions -

The authors con­clude that their atten­tion train­ing pro­gram pro­duced sig­nif­i­cant improve­ments in par­ents’ rat­ings of inat­ten­tive symp­toms and on aca­d­e­m­ic tests. This is the first demon­stra­tion I am aware of that sug­gests atten­tion train­ing may improve aca­d­e­m­ic per­for­mance.

The authors note sev­er­al impor­tant lim­i­ta­tions to their study. First, the sam­ple is rel­a­tive­ly small. Sec­ond, no behav­ioral data was obtained from chil­dren’s teach­ers. Third, there was no extend­ed fol­low-up so the dura­tion of the ben­e­fits observed at post-test is unknown. To these con­cerns I would add that the aca­d­e­m­ic results would be stronger if a stan­dard­ized achieve­ment mea­sure had been used. Final­ly, I won­der if par­ents tru­ly remained blind to whether their child was receiv­ing atten­tion train­ing or was in the video game con­trol group.

These lim­i­ta­tions not with­stand­ing, these are promis­ing results that high­light the poten­tial of atten­tion train­ing pro­ce­dures for chil­dren with ADHD. A larg­er con­trolled tri­al that address­es the lim­i­ta­tions of the cur­rent work is cer­tain­ly war­rant­ed.

Note — To my knowl­edge, this atten­tion train­ing pro­gram is not cur­rent­ly avail­able out­side of Israel.

- Study 2: The impact of dif­fer­ent types of work­ing mem­o­ry train­ing for chil­dren with ADHD —

Work­ing mem­o­ry is a key cog­ni­tive func­tion that allows indi­vid­u­als to hold infor­ma­tion in mind for brief peri­ods of time. This abil­i­ty plays an impor­tant role in count­less dai­ly tasks includ­ing fol­low­ing direc­tions, accu­rate­ly track­ing con­ver­sa­tions, read­ing com­pre­hen­sion, solv­ing com­plex math prob­lems, and stay­ing focused on a project. Cur­rent the­o­ries of ADHD that empha­size the crit­i­cal role of exec­u­tive func­tions high­light work­ing mem­o­ry deficits as an impor­tant aspect of the dis­or­der; in fact, research has shown that many indi­vid­u­als with ADHD have poor work­ing mem­o­ry com­pared to same age peers with­out the dis­or­der.

A study pub­lished sev­er­al years ago report­ed evi­dence that work­ing mem­o­ry is a skill that can be improved with inten­sive train­ing. In a ran­dom­ized con­trolled tri­al con­duct­ed with 53 chil­dren diag­nosed with ADHD, work­ing mem­o­ry train­ing was found to yield sig­nif­i­cant gains in non-trained work­ing mem­o­ry tasks and a reduc­tion in ADHD symp­toms as report­ed by par­ents (you can find a review of this study Here). Addi­tion­al con­trolled stud­ies of work­ing mem­o­ry train­ing have report­ed pos­i­tive results in oth­er groups includ­ing younger and old­er adults with­out ADHD, typ­i­cal­ly devel­op­ing preschool­ers, and stroke vic­tims. Until recent­ly, how­ev­er, addi­tion­al con­trolled stud­ies doc­u­ment­ing pos­i­tive effects in chil­dren with ADHD have not been report­ed.

At the May 2008 recent meet­ing of the Amer­i­can Psy­chi­atric Asso­ci­a­tion, Dr. Christo­pher Lucas and his col­leagues at NYU Med­ical School pre­sent­ed new data on the use of work­ing mem­o­ry train­ing in chil­dren diag­nosed with ADHD. Their study report­ed on the results of 2 dif­fer­ent types of work­ing mem­o­ry train­ing — audi­to­ry train­ing or visu­al-spa­tial train­ing — con­duct­ed with 46 chil­dren aged 7–12 who were par­tic­i­pat­ing in an inten­sive sum­mer treat­ment pro­gram for ADHD.

Par­tic­i­pants were ran­dom­ly assigned to received either audi­to­ry or visu­al spa­tial work­ing mem­o­ry train­ing using the com­put­er­ized train­ing pro­gram devel­oped by Cogmed. The idea behind assign­ing chil­dren to these dif­fer­ent types of train­ing was to see whether one was more effec­tive then the oth­er; the researchers had hypoth­e­sized that chil­dren who received visu­al-spa­tial train­ing would achieve bet­ter results.

A typ­i­cal audi­to­ry train­ing exer­cise would involve the com­put­er pre­sent­ing the child with a string of dig­its, and the child had to sub­se­quent­ly indi­cate the cor­rect order — either for­ward or back­ward — via the key­board. In a typ­i­cal visu­al spa­tial work­ing mem­o­ry train­ing task, the child would be required to recall the loca­tion of dif­fer­ent objects that lit up on the screen. You can view actu­al exam­ples of the work­ing mem­o­ry train­ing tasks Here.

Train­ing took place for 30–35 min­utes per day, 4 days per week, over a 6‑week peri­od so that a tar­get of 25 train­ing days could be pro­vid­ed. Both audi­to­ry and visu­al-spa­tial train­ing pro­to­cols auto­mat­i­cal­ly increased the dif­fi­cul­ty lev­el of the work­ing mem­o­ry tasks depend­ing on how well the child is per­form­ing, becom­ing more dif­fi­cult when the child is suc­cess­ful and eas­i­er when the child is strug­gling. These adjust­ments are made on near­ly a tri­al by tri­al basis by increas­ing or decreas­ing the num­ber of items to recall. As a result, the child is con­sis­tent­ly chal­lenged to work at their max­i­mum per­for­mance lev­el with­out the task becom­ing so dif­fi­cult that they become frus­trat­ed and give up.

The researchers were inter­est­ed in 2 basic ques­tions. First, did chil­dren who received visu­al-spa­tial train­ing show greater gains in work­ing mem­o­ry per­for­mance on non-trained tasks than chil­dren who received the audi­to­ry work­ing mem­o­ry train­ing? This was assessed by hav­ing chil­dren com­plete a com­pre­hen­sive work­ing mem­o­ry assess­ment before and after train­ing using tasks that dif­fered from what they were actu­al­ly trained with. It is impor­tant to eval­u­ate train­ing using tasks that dif­fer from train­ing activ­i­ties to see whether train­ing improve­ments extend to non-trained activ­i­ties.

The sec­ond ques­tion was whether visu­al-spa­tial work­ing mem­o­ry train­ing was also asso­ci­at­ed with behav­ioral improve­ments. To answer this ques­tion, the researchers exam­ined the num­ber of pos­i­tive behav­ior points, i.e., points award­ed for behav­ing appro­pri­ate­ly and fol­low­ing camp rules, that chil­dren in both groups received from camp coun­selors between weeks 4 and 6 of the train­ing. The coun­selors who award­ed points were not aware of which train­ing con­di­tion chil­dren had been assigned to.

This rep­re­sents a strin­gent test of work­ing mem­o­ry train­ing on behav­ior for sev­er­al rea­sons. First, the rat­ings were being made by blind observers. Sec­ond, most chil­dren were being treat­ed with med­ica­tion, and their behav­ior would already have improved because of this. Third, all chil­dren were involved in an inten­sive behav­ioral ther­a­py pro­gram designed to pro­mote pos­i­tive behav­ior. Thus, any improve­ment from work­ing mem­o­ry train­ing would be above and beyond gains achieved from treat­ments that were already in place.

- Results -

Before and after the train­ing, chil­dren were test­ed on sev­er­al non-trained mea­sures of work­ing mem­o­ry. Con­sis­tent with the researchers’ pre­dic­tion, chil­dren who received visu­al-spa­tial train­ing per­formed sig­nif­i­cant­ly bet­ter on sev­er­al of these tasks than chil­dren who received audi­to­ry work­ing mem­o­ry train­ing.

Of par­tic­u­lar inter­est is that chil­dren who received visu­al-spa­tial work­ing mem­o­ry train­ing earned sig­nif­i­cant­ly more pos­i­tive behav­ior points from the camp coun­selors. Thus, these chil­dren were rat­ed as doing a bet­ter job of con­sis­tent­ly fol­low­ing camp rules and behav­ing appro­pri­ate­ly.

- Sum­ma­ry and Impli­ca­tions —

Results from this study sup­port the ben­e­fits of work­ing mem­o­ry train­ing for chil­dren with ADHD and indi­cate that train­ing of visu­al-spa­tial work­ing mem­o­ry is espe­cial­ly impor­tant. The fact that this train­ing was asso­ci­at­ed with an increase in pos­i­tive behav­ior above and beyond med­ica­tion and behav­ior treat­ments already in place is a very encour­ag­ing result.

As with Study 1, this study has sev­er­al lim­i­ta­tions to con­sid­er. Although the behav­ior improve­ments not­ed by camp coun­selors is impor­tant, it would also be impor­tant to doc­u­ment that such behav­ioral gains were also observed by par­ents and teach­ers. This, how­ev­er, was not exam­ined in the study. As with Study 1, there was no extend­ed fol­low-up so the dura­tion of train­ing ben­e­fits can not be deter­mined.

- Over­all Sum­ma­ry -

Results from these two cog­ni­tive train­ing stud­ies high­light that cog­ni­tive train­ing inter­ven­tions may pro­vide an impor­tant com­ple­ment to tra­di­tion­al med­ica­tion treat­ment and behav­ior ther­a­py. Both stud­ies includ­ed appro­pri­ate con­trol groups, employed ran­dom assign­ment, and had out­come mea­sures pro­vid­ed by indi­vid­u­als who were “blind” to which con­di­tion chil­dren were assigned to. They are thus well-designed stud­ies from which sci­en­tif­i­cal­ly sound con­clu­sions can be drawn. They add to the grow­ing research base that inten­sive prac­tice and train­ing focused of key cog­ni­tive skills can have pos­i­tive effects that extend beyond the train­ing sit­u­a­tion itself.

As not­ed above, how­ev­er, each study has lim­i­ta­tions that should be addressed in sub­se­quent work. It is encour­ag­ing to see the momen­tum for such work build­ing and I look for­ward to review­ing oth­er stud­ies in this impor­tant area as they become avail­able.

Rabiner_David– Dr. David Rabin­er is a child clin­i­cal psy­chol­o­gist and Direc­tor of Under­grad­u­ate Stud­ies in the Depart­ment of Psy­chol­ogy and Neu­ro­science at Duke Uni­ver­sity. He pub­lishes Atten­tion Research Update, an online newslet­ter that helps par­ents, pro­fes­sion­als, and edu­ca­tors keep up with the lat­est research on ADHD, and teach­es the online course  How to Nav­i­gate Con­ven­tion­al and Com­ple­men­tary ADHD Treat­ments for Healthy Brain Devel­op­ment.

For relat­ed read­ing, you may enjoy:

- Mind­ful­ness Med­i­ta­tion for Adults & Teens with ADHD

- Work­ing Mem­o­ry Train­ing: Inter­view with Dr. Torkel Kling­berg

Leave a Reply...

Loading Facebook Comments ...

3 Responses

  1. Robert P. O'Reilly Ph. d. says:

    Work­ing from home in my semi-retire­ment with ADHD chil­dren and dyslex­i­cs I am now look­ing for soft­ware of the type you describe that might be imple­ment­ed on a lapt­top. Much of my approach involves orig­i­nal mat­er­al that cen­ter on the speech sci­ences.
    ROR

  2. Betsy Hill says:

    You might con­sid­er Brain­Ware Safari, an engag­ing soft­ware pro­gram that devel­ops cog­ni­tive skills includ­ing atten­tion, mem­o­ry, audi­to­ry and visu­al pro­cess­ing and sen­so­ry inte­gra­tion. Results in stud­ies con­duct­ed to date have shown dra­mat­ic improve­ment.

  3. Alvaro says:

    Robert: Cogmed (men­tioned in Dr. Rabin­er’s arti­cle) offers the only pro­gram with high-qual­i­ty pub­lished results for kids with ADHD. Same for Sci­en­tif­ic Learn­ing for kids with dyslex­ia.

    Best­sy: please feel free to share with us the spe­cif­ic ref­er­ences of pub­lished tri­als that show how your pro­gram helps kids with ADHD or dyslex­ia. We haven’t found them. Thank you.

Leave a Reply

Categories: Attention and ADD/ADHD, Cognitive Neuroscience, Education & Lifelong Learning, Health & Wellness

Tags: , , , , , , , , , , , , , , , , , , , , , , , ,

About SharpBrains

As seen in The New York Times, The Wall Street Journal, BBC News, CNN, Reuters,  SharpBrains is an independent market research firm tracking how brain science can improve our health and our lives.

Search in our archives

Follow us and Engage via…

twitter_logo_header
RSS Feed

Watch All Recordings Now (40+ Speakers, 12+ Hours)