Study: Promising New Neurocognitive Intervention for Preschoolers with ADHD (TEAMS)

Although med­ica­tion treat­ment and behav­ior ther­a­py pro­vide short-term symp­to­matic relief for chil­dren with ADHD, such gains rarely per­sist after treat­ment ends. Because these treat­ments are infre­quent­ly sus­tained over extend­ed peri­ods (most chil­dren on med­ica­tion do not even remain on it for a year), few indi­vid­u­als with ADHD receive effec­tive treat­ment over the long-term. This may explain why cur­rent treat­ments pro­vide only lim­it­ed long-term ben­e­fits and why many indi­vid­u­als with ADHD have poor ado­les­cent and young adult out­comes even if they were effec­tive­ly treat­ed in child­hood. Clear­ly, treat­ments that can pro­vide endur­ing ben­e­fits are needed.

As knowl­edge of the under­ly­ing neur­al and neu­rocog­ni­tive con­trib­u­tors to ADHD has grown, and knowl­edge that brain devel­op­ment is high­ly respon­sive to envi­ron­men­tal influ­ences has accu­mu­lat­ed, a com­pelling the­o­ret­i­cal frame­work for the devel­op­ment of more endur­ing ADHD inter­ven­tions has emerged. Specif­i­cal­ly, it has been hypoth­e­sized that par­tic­u­lar kinds of expe­ri­ence can ame­lio­rate — or at least dimin­ish — some of the under­ly­ing neur­al fac­tors that con­tribute to the devel­op­ment and expres­sion of ADHD.

In fact, this pos­si­bil­i­ty has already been demon­strat­ed in sev­er­al stud­ies. For exam­ple, work in the neu­ro­feed­back domain has demon­strat­ed changes in neur­al activ­i­ty in indi­vid­u­als with ADHD fol­low­ing treat­ment. Sim­i­lar­ly, sig­nif­i­cant changes in neur­al activ­i­ty have been shown to occur in indi­vid­u­als fol­low­ing work­ing mem­o­ry training.

Neu­ro­feed­back, work­ing mem­o­ry train­ing, and oth­er forms of com­put­er­ized cog­ni­tive train­ing are dis­tinct­ly dif­fer­ent activ­i­ties from typ­i­cal dai­ly expe­ri­ence and are not par­tic­u­lar­ly social in nature. How­ev­er, it may also be pos­si­ble to pro­vide chil­dren with envi­ron­men­tal stim­u­la­tion that can enhance neur­al and cog­ni­tive func­tion­ing with­in the con­text of the par­ent-child rela­tion­ship. And, because such activ­i­ties can be inher­ent­ly enjoy­able, and pro­mote pos­i­tive rela­tions between par­ents and chil­dren, they may be sus­tained over time and thus pro­vide chil­dren with ongo­ing expe­ri­ence that can enhance their neur­al func­tion­ing. In the­o­ry, such an inter­ven­tion could pro­duce endur­ing treat­ment gains in chil­dren with ADHD, par­tic­u­lar­ly if intro­duced when chil­dren are young and neu­ro­plas­tic­i­ty may be greatest.

This was the premise under­ly­ing an extreme­ly inter­est­ing and impor­tant study recent­ly pub­lished online in the Jour­nal of Atten­tion Dis­or­ders [Halperin et al., (2012). Train­ing exec­u­tive atten­tion and motor skills: A proof-of-con­cept study in preschool chil­dren with ADHD. Jour­nal of Atten­tion Dis­or­ders, pub­lished online March 5, 2012. DOI: 10.1177/1087054711435681.]. To be can­did, I found this to be one of the most inter­est­ing stud­ies I have read dur­ing the past 10 years.

Par­tic­i­pants were 29 four- and five-year old eth­ni­cal­ly diverse chil­dren diag­nosed with ADHD and their par­ents. Chil­dren and par­ents par­tic­i­pat­ed in a nov­el inter­ven­tion called TEAMS — Train­ing Exec­u­tive, Atten­tion, and Motor Skills.’ As dis­cussed below, TEAMS was designed to “…apply fre­quent and endur­ing pos­i­tive envi­ron­men­tal stim­u­la­tion to under­ly­ing neu­rode­vel­op­men­tal process­es in chil­dren with ADHD.” Specif­i­cal­ly, par­ents learned to engage in spe­cif­ic game-like activ­i­ties with their child that placed increas­ing­ly chal­leng­ing demands on a vari­ety of neu­rocog­ni­tive and motor skills. The the­o­ry behind TEAMS was that this would pro­mote under­ly­ing changes in neur­al func­tion­ing that would lead to endur­ing improve­ments in ADHD symptoms.

The authors describe this as a ‘proof of con­cept’ study. Thus the goals were to learn whether par­ents would have pos­i­tive feel­ings about the treat­ment expe­ri­ence, whether they would engage reg­u­lar­ly with their child in the pre­scribed activ­i­ties, and whether there was any pre­lim­i­nary evi­dence of pos­i­tive effects. As such, there was no con­trol group and no ran­dom­iza­tion to con­di­tion. Thus, even were favor­able results to be found, this was a pre­lim­i­nary study that could not estab­lish the effi­ca­cy of the new treatment.

TEAMS Inter­ven­tion Specifics

The TEAMS inter­ven­tion was con­duct­ed in a 90-minute group for­mat (between 5 and 10 group meet­ings were held) that includ­ed 3–5 fam­i­lies per group. In each group, chil­dren and par­ents were intro­duced to a pre­de­ter­mined set of games cho­sen to tar­get an array of neu­rocog­ni­tive skills. For exam­ple, to tar­get inhibito­ry con­trol, i.e., the abil­i­ty to refrain from respond­ing impul­sive­ly, games would include vari­a­tions of “Simon Says” and ‘freeze dance’. To devel­op work­ing mem­o­ry skills, games would include things like remem­ber­ing shop­ping lists or the loca­tions of ‘hid­den trea­sures’ under cups. Oth­er tar­get­ed cog­ni­tive skills were visu­al-spa­tial abil­i­ties, plan­ning and orga­ni­za­tion, and sus­tained atten­tion. Games to devel­op motor skills were also includ­ed as was an aer­o­bic exer­cise component.

Between group meet­ings, par­ents were instruct­ed to spend at 30–45 min­utes each day play­ing these games with their child. The goal was to pro­vide suf­fi­cient stim­u­la­tion of the under­ly­ing neur­al process­es tar­get­ed by the games so that these process­es were repeat­ed­ly exer­cised and strengthened.

A focus in group meet­ings was work­ing with par­ents to iden­ti­fy and over­come dif­fi­cul­ties they had expe­ri­enced con­sis­tent­ly imple­ment­ing the games with their child dur­ing the pri­or week. Par­ents also learned new games, dis­cussed the cog­ni­tive skills being tar­get­ed, and were taught how to grad­u­al­ly increase the dif­fi­cul­ty lev­el so that chil­dren’s cog­ni­tive skills were con­tin­u­al­ly chal­lenged. The impor­tance of reg­u­lar aer­o­bic exer­cise was also stressed as there is emerg­ing evi­dence that this can improve cog­ni­tive functioning.

Mea­sures

To assess the impact of the TEAMS pro­gram, rat­ings of core ADHD symp­toms and of chil­dren’s impair­ment from symp­toms were col­lect­ed from par­ents and teach­ers. Rat­ings were obtained before treat­ment began, imme­di­ate­ly after the groups end­ed, and at a 1- and 3‑month fol­low-up. These lat­ter mea­sure­ment points enabled the researchers to learn whether any gains that were ini­tial­ly evi­dent endured.

In addi­tion, par­ents com­plet­ed rat­ings of how often they engaged in the pre­scribed games each week and how long they engaged in these games with their child.

Results

Parental accep­tance — Only one of the 29 fam­i­lies with­drew dur­ing the active treat­ment phase and this was because of trans­porta­tion issues. Over­all, par­ents attend­ed 93% of sched­uled ses­sions and near­ly 70% attend­ed all ses­sions. Sat­is­fac­tion with the inter­ven­tion was rat­ed very highly.

Engage­ment in TEAMS activ­i­ties — For TEAMS to be effec­tive, chil­dren must engage in the pre­scribed games with con­sid­er­able fre­quen­cy. Through­out the inter­ven­tion peri­od, par­ents indi­cat­ed that they engaged in the games near­ly every day for an aver­age of 35 min­utes. One month after treat­ment end­ed they were still play­ing the games near­ly 3 times a week for 30 min­utes. At the 3‑month fol­lowup, this had declined to an aver­age of 20 minutes/day two days per week. Thus, despite the drop-off from the active treat­ment peri­od, par­ents and chil­dren con­tin­ued to reg­u­lar­ly engage in the games for at least 3 months after treat­ment ended.

ADHD symp­tom sever­i­ty — Sig­nif­i­cant reduc­tions in par­ent and teacher rat­ings of ADHD symp­toms were evi­dent from pre- to post-treat­ment. Fur­ther­more, these reduc­tions remained evi­dent at the 1- and 3‑month fol­lowups. Equiv­a­lent reduc­tions were found for inat­ten­tive and hyper­ac­tive-impul­sive symp­toms. The mag­ni­tude of the reduc­tions were in a range that would be con­sid­ered large for par­ents and mod­er­ate for teachers.

Impair­ment from symp­toms — Rat­ings of impair­ment from symp­toms declined sig­nif­i­cant­ly for both par­ents and teach­ers. Inter­est­ing­ly, these declines were not sig­nif­i­cant imme­di­ate­ly fol­low­ing treat­ment, but became evi­dent at the 1‑month fol­low-up for par­ents and at the 3‑month fol­low-up for teach­ers. The mag­ni­tude of the decline was in a range that would be con­sid­ered moderate.

Sum­ma­ry and Implications

The premise of TEAMS is that con­sis­tent­ly engag­ing chil­dren with ADHD in activ­i­ties that chal­lenge and exer­cise par­tic­u­lar neu­rocog­ni­tive func­tions can strength­en the under­ly­ing neur­al activ­i­ty that sup­port these func­tions and there­by dimin­ish ADHD symp­toms. This premise is con­sis­tent with the ratio­nale under­ly­ing neu­ro­feed­back treat­ment, work­ing mem­o­ry train­ing, and oth­er approach­es to com­put­er­ized cog­ni­tive train­ing. What is unique about the TEAMS approach, how­ev­er, is the idea that such stim­u­la­tion can occur in the con­text game like activ­i­ties between par­ents and chil­dren that are inher­ent­ly enjoy­able and that also pro­mote pos­i­tive par­ent-child interactions.

In my view, this is a very excit­ing study and the kind of work the field real­ly needs. For years, evi­dence that ADHD is strong­ly influ­enced by genet­ic fac­tors may have under­mined efforts to exam­ine whether expe­ri­en­tial fac­tors — par­tic­u­lar­ly the ways that par­ents inter­act with their child — could play an impor­tant role in address­ing core ADHD symp­toms. What these researchers have sug­gest­ed, and pro­vid­ed pre­lim­i­nary evi­dence of, is that this may be possible.

Note that their approach is very dif­fer­ent from using behav­ioral prin­ci­ples to man­age ADHD symp­toms and encour­age desired behav­ior. While behav­ioral man­age­ment approach­es are impor­tant and help­ful, the focus is on symp­tom man­age­ment and not on chang­ing chil­dren’s under­ly­ing capac­i­ties. Here, in con­trast, the idea is that par­ents can pro­vide ongo­ing oppor­tu­ni­ties to help chil­dren exer­cise neu­rocog­ni­tive func­tions that can lead to endur­ing benefits.

Also note that the TEAMS approach in no way implies that par­ents are some­how respon­si­ble for their child’s devel­op­ment of ADHD. Instead, TEAMS strives to teach par­ents how to pro­vide chil­dren with expe­ri­ences that may lead to endur­ing reduc­tions in ADHD symp­toms over time.

While I found this to be an excit­ing study, it is impor­tant to empha­size that this is only an ini­tial ‘proof of con­cept’ of the approach. As the authors note, the absence of any con­trol group makes it impos­si­ble to deter­mine why chil­dren seemed to improve. Although the the­o­ry under­ly­ing TEAMS is that the chil­dren’s ongo­ing involve­ment in the pre­scribed games and exer­cise pro­gram alters their under­ly­ing neur­al func­tion­ing, no such assess­ments were con­duct­ed. The sam­ple size was also rel­a­tive­ly small.

These lim­i­ta­tions not with­stand­ing, this ini­tial effort demon­strat­ed that TEAMS was expe­ri­enced pos­i­tive­ly by par­ents who con­tin­ued to engage reg­u­lar­ly in the treat­ment exer­cis­es up to 3 months after treat­ment end­ed. And, ben­e­fi­cial effects as rat­ed by par­ents and teach­ers remained evi­dent after 3 months. The authors con­clude by not­ing that a larg­er ran­dom­ized tri­al is planned so that the poten­tial ben­e­fits of TEAMS can be bet­ter under­stood. This is impor­tant work and I look for­ward to review­ing it for you Atten­tion Research Update when it becomes 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.

Pre­vi­ous arti­cles by Dr. Rabin­er:

• Neurofeedback/ Quan­ti­ta­tive EEG for ADHD diagnosis
• Self-Reg­u­la­tion and Barkley’s The­ory of ADHD