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.

– 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