Working memory and cognitive flexibility-training for children with an autism spectrum disorder: a randomized controlled trial

Current Status of Cognitive Remediation for Psychiatric Disorders: A Review

Cognition is an important factor that affects daily functioning and quality of life. Impairment in cognitive function is a common symptom present in various psychological disorders, which hinders patients from functioning normally. Given that cognitive impairment has devastating effects, enhancing this in patients should lead to improvements in compromised quality of life and functioning, including vocational functioning. Over the past 50 years, several attempts have been made to improve impaired cognition, and empirical evidence for cognitive remediation (CR) has accumulated that supports its efficacy for treating schizophrenia. More recently, CR has been successfully applied in the treatment of depressive disorders, bipolar disorders, attention deficit/hyperactivity disorder, and anorexia nervosa. This study critically reviews recent CR studies and suggests their future direction. This study aimed to provide a modern definition of CR, and examine the current status of empirical evidence and representative CR programs that are widely used around the world.

Executive function predicts the visuospatial working memory in autism spectrum disorder and attention-deficit/hyperactivity disorder

Children with autism spectrum disorder (ASD) and those with attention deficit/hyperactivity disorder (ADHD) always show working memory deficits. However, research findings on the factors that affected the working memory in ASD and ADHD were inconsistent. Thus, we developed the present study to investigate the association of executive function (EF) with the visuospatial working memory (VSWM) in ASD and ADHD. Three groups of participants were examined: 21 children with ASD, 28 children with ADHD and 28 typically developing (TD) children as the controls. All participants completed two tests: the Wisconsin Card Sorting Test (WCST) and the Corsi Block Tapping Test for measuring EF and VSWM, respectively. The WCST included four domains: categories achieved (CA), perseverative errors (PE), failures to maintain set (FMS), and total errors (TE). The findings indicated that (1) the ASD group showed poorer performance in VSWM than the ADHD and TD groups; (2) for the ASD group, VSWM was positively correlated with CA, and was negatively correlated with PE and TE; (3) for the ADHD group, FMS showed a negative relationship with VSWM; and (4) TE predicted the performance of VSWM in ASD group, while FMS predicted VSWM in ADHD group. The study results suggested that VSWM was impaired in ASD but not in ADHD. Also, the EF domains were differently correlated with the VSWM performance in ASD and ADHD. Our study suggests that we should consider different intervention targets of working memory and EF contributions in improving the cognitive capacity of ASD and ADHD. Autism Res 2018, 11: 1148-1156. © 2018 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: The present study compared the visuospatial working memory (VSWM) in three groups of children: autism (ASD), attention deficit/hyperactivity disorder (ADHD), and typically developed children (TD). The ASD group showed poorer VSWM than the ADHD and TD groups. The total error of executive function predicted the performance of VSWM in ASD, while failures to maintain set predicted VSWM in ADHD . These findings suggested that we should consider the different working memory and executive function training targets to increase cognitive capacity of ASD and ADHD.

Computerized Cognitive Training in Children With Autism and Intellectual Disabilities: Feasibility and Satisfaction Study

BACKGROUND

Researchers are increasingly interested in testing and developing computerized cognitive training interventions for individuals with autism spectrum disorder due to the limited accessibility of treatments for this disorder. Understanding the feasibility of testing cognitive interventions for this population is critical, especially for individuals with ASD who have low to moderate intellectual ability.

OBJECTIVE

The aim of the study was to evaluate the feasibility of computerized cognitive training as measured by attrition rate and a parent satisfaction survey.

METHODS

A total of 26 participants aged 8-17 years with an autism spectrum disorder diagnosis and significant intellectual impairment were enrolled (mean age 11.1 years). They were instructed to complete 25 sessions of Cogmed Working Memory Training in 5 to 6 weeks with coach assistance. Attrition rate and parent satisfaction surveys were measured after the completion of training.

RESULTS

Most participants (96%, 25/26) completed the training and indicated high satisfaction (>88%). However, among the participants who completed the training, 5 participants (19%) were unable to finish in 6 weeks, the recommended training period by Cogmed. Parents noted various positive (eg, voice-overs) and negative (eg, particular graphic and sounds associated with a stimulus) features of the game that they thought affected their child's response.

CONCLUSIONS

Children with autism spectrum disorder and intellectual impairments can successfully participate in computerized cognitive training interventions but may require additional weeks to complete the training beyond the time needed for children without intellectual impairments. The overall completion rate, with extended time to complete the training, was high. Developers of cognitive training programs for this population should take into account potential issues regarding the noise level of stimuli and characteristics of the visual graphics.

Functional changes during visuo-spatial working memory in autism spectrum disorder: 2-year longitudinal functional magnetic resonance imaging study

This study examined functional changes longitudinally over 2 years in neural correlates associated with working memory in youth with and without autism spectrum disorder, and the impact of increasing cognitive load. We used functional magnetic resonance imaging and a visuo-spatial 1-back task with four levels of difficulty. A total of 14 children with autism spectrum disorder and 15 typically developing children (ages 7-13) were included at baseline and followed up approximately 2 years later. Despite similar task performance between groups, differences were evident in the developmental trajectories of neural responses. Typically developing children showed greater load-dependent activation which intensified over time in the frontal, parietal and occipital lobes and the right fusiform gyrus, compared to those with autism spectrum disorder. Children with autism spectrum disorder showed minimal age-related changes in load-dependent activation, but greater longitudinal load-dependent deactivation in default mode network compared to typically developing children. Results suggest inadequate modulation of neural activity with increasing cognitive demands in children with autism spectrum disorder, which does not mature into adolescence, unlike their typically developing peers. Diminished ability for children with autism spectrum disorder to modulate neural activity during this period of maturation suggests that they may be more vulnerable to the increasing complexity of social and academic demands as they progress through adolescence than their peers.

Cognitive enhancement therapy for adult autism spectrum disorder: Results of an 18-month randomized clinical trial

Cognitive remediation is a promising approach to treating core cognitive deficits in adults with autism, but rigorously controlled trials of comprehensive interventions that target both social and non-social cognition over a sufficient period of time to impact functioning are lacking. This study examined the efficacy of cognitive enhancement therapy (CET) for improving core cognitive and employment outcomes in adult autism. Verbal adult outpatients with autism spectrum disorder (N = 54) were randomized to an 18-month, single-blind trial of CET, a cognitive remediation approach that integrates computer-based neurocognitive training with group-based training in social cognition, or an active enriched supportive therapy (EST) comparison focused on psychoeducation and condition management. Primary outcomes were composite indexes of neurocognitive and social-cognitive change. Competitive employment was a secondary outcome. Intent-to-treat analyses indicated that CET produced significant differential increases in neurocognitive function relative to EST (d = .46, P = .013). Both CET and EST were associated with large social-cognitive improvements, with CET demonstrating an advantage at 9 (d = .58, P = 0.020), but not 18 months (d = .27, P = 0.298). Effects on employment indicated that participants treated with CET were significantly more likely to gain competitive employment than those in EST, OR = 6.21, P = 0.023, which was mediated by cognitive improvement. CET is a feasible and potentially effective treatment for core cognitive deficits in adult autism spectrum disorder. The treatment of cognitive impairments in this population can contribute to meaningful improvements in adult outcomes. Autism Res 2018, 11: 519-530. © 2017 International Society for Autism Research, Wiley Periodicals, Inc.

LAY SUMMARY

Cognitive enhancement therapy (CET), an 18-month cognitive remediation intervention designed to improve thinking and social understanding, was found to be more effective than supportive therapy at improving mental quickness, attention, and employment in adults living with autism. Social understanding was equally improved in CET and supportive therapy. Cognitive remediation interventions are feasible and may confer significant functional benefits to adults with autism.

Formal Thought Disorder and Executive Functioning in Children and Adolescents with Autism Spectrum Disorder: Old Leads and New Avenues

Formal thought disorder (FTD) is a disruption in the flow of thought and a common feature in psychotic disorders and autism spectrum disorder (ASD). Executive dysfunction has often been associated with FTD, yet for ASD convincing evidence is lacking. This study investigated FTD and three core executive functions in 50 young children and adolescents with high-functioning ASD and 56 matched controls. Higher overall levels of FTD marked ASD compared to controls. Furthermore, in ASD decreased performance on verbal working memory was correlated with increased FTD ratings and explained a significant amount of variance of objective and subjective FTD. Verbal working memory is currently the most promising target executive function for understanding the development of idiosyncratic thought disorders in ASD.

Effectiveness of the BOOST-A™ online transition planning program for adolescents on the autism spectrum: a quasi-randomized controlled trial

BACKGROUND

The majority of existing transition planning programs are focused on people with a disability in general and may not meet the specific need of adolescents on the autism spectrum. In addition, these interventions focus on specific skills (e.g. job readiness or self-determination) rather than the overall transition planning process and there are methodological limitations to many of the studies determining their effectiveness. The Better OutcOmes & Successful Transitions for Autism (BOOST-A™) is an online program that supports adolescents on the autism spectrum to prepare for leaving school. This study aimed to determine the effectiveness of the BOOST-A™ in enhancing self-determination.

METHODS

A quasi-randomized controlled trial was conducted with adolescents on the autism spectrum enrolled in years 8 to 11 in Australian schools (N = 94). Participants had to have basic computer skills and the ability to write at a year 5 reading level. Participants were allocated to a control (n = 45) or intervention (n = 49) group and participants were blinded to the trial hypothesis. The intervention group used the BOOST-A™ for 12 months, while the control group participated in regular practice. Outcomes included self-determination, career planning and exploration, quality of life, environmental support and domain specific self-determination. Data were collected from parents and adolescents.

RESULTS

There were no significant differences in overall self-determination between groups. Results indicated significant differences in favor of the intervention group in three areas: opportunity for self-determination at home as reported by parents; career exploration as reported by parents and adolescents; and transition-specific self-determination as reported by parents.

CONCLUSIONS

Results provide preliminary evidence that the BOOST-A™ can enhance some career-readiness outcomes. Lack of significant outcomes related to self-determination at school and career planning may be due to the lack of face-to-face training and parents being the primary contacts in the study. Further research is needed to determine effectiveness of the BOOST-A™ related to post-secondary education and employment. Trial registration #ACTRN12615000119594.

Balanced bifrontal transcranial direct current stimulation enhances working memory in adults with high-functioning autism: a sham-controlled crossover study

Background

Working memory (WM) often is impaired in autism spectrum disorder (ASD). Such impairment may underlie core deficits in cognition and social functioning. Transcranial direct current stimulation (tDCS) has been shown to enhance WM in both healthy adults and clinical populations, but its efficacy in ASD is unknown. We predicted that bifrontal tDCS would improve WM performances of adults with high-functioning autism during active stimulation compared to sham stimulation and that such enhancement would generalize to an untrained task.

Methods

Twelve adults with high-functioning ASD engaged in a battery of WM tasks that included backward spatial span, backward digit span, spatial n-back and letter n-back. While engaged, 40 min of 1.5 mA bifrontal stimulation was applied over the left and the right dorsolateral prefrontal cortices (DLPFC). Using a single-blind crossover design, each participant received left anodal/right cathodal stimulation, right anodal/left cathodal stimulation, or sham stimulation, in randomized counterbalanced order on three separate days. Following tDCS, participants again engaged in letter and spatial n-back tasks before taking the Brief Test of Attention (BTA). We used repeated-measures ANOVA to compare overall performance on the WM battery as measured by a composite of z-scores for all five measures. Post hoc ANOVAs, t tests, Friedman’s tests, and Wilcoxon signed-rank tests were used to measure the online and offline effects of tDCS and to assess performances on individual measures.

Results

Compared to sham stimulation, both left DLPFC anodal stimulation (t₁₁ = 5.4, p = 0.0002) and right DLPFC anodal stimulation (t₁₁ = 3.57, p = 0.004) improved overall WM performance. Left anodal stimulation (t₁₁ = 3.9, p = 0.003) and right anodal stimulation (t₁₁ = 2.7, p = 0.019) enhanced performances during stimulation. Enhancement transferred to an untrained task 50 min after right anodal stimulation (z₁₁ = 2.263, p = 0.024). The tasks that showed the largest effects of active stimulation were spatial span backward (z₁₁ = 2.39, p = 0.017) and BTA (z₁₁ = 2.263, p = 0.024).

Conclusions

In adults with high-functioning ASD, active bifrontal tDCS given during WM tasks appears to improve performance. TDCS benefits also transferred to an untrained task completed shortly after stimulation. These results suggest that tDCS can improve WM task performance and could reduce some core deficits of autism.

Trial registration

NCT01602263

Cognitive flexibility training intervention among children with autism: a longitudinal study

Autism is defined by persistent deficits in social communication and social interaction in multiple contexts as well as restricted and repetitive patterns of behavior. There are also reported difficulties in the dynamic activation and modification of cognitive processes in response to changes in tasks' demands. Such difficulties are believed to be due to poor flexible cognition. This research aimed to assess and intervene in cognitive flexibility in subjects with autism.Ten subjects diagnosed with autism by psychiatrists, aged 5 years to 13 years and 5 months, were assessed in non-verbal intelligence through Raven's Progressive Matrices in pretest. They were also assessed in cognitive flexibility through Wisconsin Card Sorting Test (WCST) and in patterns of social interactions, behaviors, and communication through Autism Diagnostic Interview-Revised (ADI-R). An intervention program of 14 to 21 sessions was established to enhance cognitive flexibility. In posttest, they were assessed in WCST and ADI-R.All measures of cognitive flexibility improved in posttest except for failure to maintain set. Among the measures improved in posttest, perseverative errors and responses improved in posttest with statistical significance as well as categories completed. Total scores on ADI-R were lower in posttest as well as scores on communication abilities.The qualitative improvement showed by the individuals of this research concerning cognitive flexibility and also patterns of restricted behavior, social interaction, and communication abilities suggests that individuals with autism can benefit from the development of strategies for the enhancement of cognitive flexibility. Nevertheless, more research is suggested with a larger sample among subjects on the autism spectrum.

Annual Research Review: Digital health interventions for children and young people with mental health problems - a systematic and meta-review

BACKGROUND

Digital health interventions (DHIs), including computer-assisted therapy, smartphone apps and wearable technologies, are heralded as having enormous potential to improve uptake and accessibility, efficiency, clinical effectiveness and personalisation of mental health interventions. It is generally assumed that DHIs will be preferred by children and young people (CYP) given their ubiquitous digital activity. However, it remains uncertain whether: DHIs for CYP are clinically and cost-effective, CYP prefer DHIs to traditional services, DHIs widen access and how they should be evaluated and adopted by mental health services. This review evaluates the evidence-base for DHIs and considers the key research questions and approaches to evaluation and implementation.

METHODS

We conducted a meta-review of scoping, narrative, systematic or meta-analytical reviews investigating the effectiveness of DHIs for mental health problems in CYP. We also updated a systematic review of randomised controlled trials (RCTs) of DHIs for CYP published in the last 3 years.

RESULTS

Twenty-one reviews were included in the meta-review. The findings provide some support for the clinical benefit of DHIs, particularly computerised cognitive behavioural therapy (cCBT), for depression and anxiety in adolescents and young adults. The systematic review identified 30 new RCTs evaluating DHIs for attention deficit/hyperactivity disorder (ADHD), autism, anxiety, depression, psychosis, eating disorders and PTSD. The benefits of DHIs in managing ADHD, autism, psychosis and eating disorders are uncertain, and evidence is lacking regarding the cost-effectiveness of DHIs.

CONCLUSIONS

Key methodological limitations make it difficult to draw definitive conclusions from existing clinical trials of DHIs. Issues include variable uptake and engagement with DHIs, lack of an agreed typology/taxonomy for DHIs, small sample sizes, lack of blinded outcome assessment, combining different comparators, short-term follow-up and poor specification of the level of human support. Research and practice recommendations are presented that address the key research questions and methodological issues for the evaluation and clinical implementation of DHIs for CYP.

Effectiveness and Retention of Teaching Memory Strategy Use to Children With Autism Spectrum Disorder

Although low levels of memory strategy use have been found in children with autism spectrum disorders (ASDs), few studies have explored the effectiveness of interventions for improving strategy use with this population. In two studies, we examined the short- and longer term effectiveness of rehearsal strategy training. In Study 1, children with ASD made strong gains during a focused teaching session, but rehearsal strategy use was not well maintained after training. In Study 2, we increased training with multiple individualized sessions. Longer term maintenance of gains occurred, demonstrating the possibility of successfully teaching and generalizing of strategy use, findings that have important implications for classroom and intervention contexts with children with ASD.

Exploring the Moderating Effects of Cognitive Abilities on Social Competence Intervention Outcomes

Many populations served by special education, including those identified with autism, emotional impairments, or students identified as not ready to learn, experience social competence deficits. The Social Competence Intervention-Adolescents’ (SCI-A) methods, content, and materials were designed to be maximally pertinent and applicable to the social competence needs of early adolescents (i.e., age 11-14 years) identified as having scholastic potential but experiencing significant social competence deficits. Given the importance of establishing intervention efficacy, the current paper highlights the results from a four-year cluster randomized trial (CRT) to examine the efficacy of SCI-A (n = 146 students) relative to Business As Usual (n = 123 students) school-based programming. Educational personnel delivered all programming including both intervention and BAU conditions. Student functioning was assessed across multiple time points, including pre-, mid-, and post-intervention. Outcomes of interest included social competence behaviors, which were assessed via both systematic direct observation and teacher behavior rating scales. Data were analyzed using multilevel models, with students nested within schools. Results suggested after controlling for baseline behavior and student IQ, BAU and SCI students differed to a statistically significant degree across multiple indicators of social performance. Further consideration of standardized mean difference effect sizes revealed these between-group differences to be representative of medium effects (d > .50). Such outcomes pertained to student (a) awareness of social cues and information, and (b) capacity to appropriately interact with teachers and peers. The need for additional power and the investigation of potential moderators and mediators of social competence effectiveness are explored.

Exploring possible predictors and moderators of an executive function training for children with an autism spectrum disorder

Previously, a total of 121 children with an autism spectrum disorder (ASD) performed an adaptive working memory (WM)-training, an adaptive flexibility-training, or a non-adaptive control (mock)-training. Despite overall improvement, there were minor differences between the adaptive and mock-training conditions. Moreover, dropout was relatively high (26%). In the current study we explored potential predicting and moderating factors to clarify these findings. The effects of intelligence, autism traits, WM, flexibility, reward sensitivity and Theory of Mind on dropout, improvement during training, and improvement in everyday executive functioning (EF), ASD-like behavior, and Quality of Life (QoL) were studied. None of the predictors influenced dropout or training improvement. However, 1) more pre-training autism traits related to less improvement in EF and QoL, and 2) higher reward sensitivity was related to more improvement in QoL and ASD-like behavior. These findings suggest that these EF-training procedures may be beneficial for children with fewer autism traits and higher reward sensitivity. However, the exploratory nature of the analyses warrant further research before applying the findings clinically.

Executive functioning and local-global visual processing: candidate endophenotypes for autism spectrum disorder?

BACKGROUND

Heterogeneity within autism spectrum disorder (ASD) hampers insight in the etiology and stimulates the search for endophenotypes. Endophenotypes should meet several criteria, the most important being the association with ASD and the higher occurrence rate in unaffected ASD relatives than in the general population. We evaluated these criteria for executive functioning (EF) and local-global (L-G) visual processing.

METHODS

By administering an extensive cognitive battery which increases the validity of the measures, we examined which of the cognitive anomalies shown by ASD probands also occur in their unaffected relatives (n = 113) compared to typically developing (TD) controls (n = 100). Microarrays were performed, so we could exclude relatives from probands with a de novo mutation in a known ASD susceptibility copy number variant, thus increasing the probability that genetic risk variants are shared by the ASD relatives. An overview of studies investigating EF and L-G processing in ASD relatives was also provided.

RESULTS

For EF, ASD relatives - like ASD probands - showed impairments in response inhibition, cognitive flexibility and generativity (specifically, ideational fluency), and EF impairments in daily life. For L-G visual processing, the ASD relatives showed no anomalies on the tasks, but they reported more attention to detail in daily life. Group differences were similar for siblings and for parents of ASD probands, and yielded larger effect sizes in a multiplex subsample. The group effect sizes for the comparison between ASD probands and TD individuals were generally larger than those of the ASD relatives compared to TD individuals.

CONCLUSIONS

Impaired cognitive flexibility, ideational fluency and response inhibition are strong candidate endophenotypes for ASD. They could help to delineate etiologically more homogeneous subgroups, which is clinically important to allow assigning ASD probands to different, more targeted, interventions.

Impact of Attention Training on Academic Achievement, Executive Functioning, and Behavior: A Randomized Controlled Trial

Children with intellectual and developmental disabilities (IDD) experience significant difficulties in attention, learning, executive functions, and behavioral regulation. Emerging evidence suggests that computerized cognitive training may remediate these impairments. In a double blind controlled trial, 76 children with IDD (4-11 years) were randomized to either an attention training (n = 38) or control program (n = 38). Both programs were completed at home over a 5-week period. Outcome measures assessed literacy, numeracy, executive functioning, and behavioral/emotional problems, and were conducted at baseline, post-training, and 3-month follow-up. No training effects were observed at post-training; however, children in the training group showed greater improvements in numeracy skills at the 3-month follow-up. These results suggest that attention training may be beneficial for children with IDD; however, the modest nature of the intervention effects indicate that caution should be taken when interpreting clinical significance.

Evaluation of the effectiveness of an online transition planning program for adolescents on the autism spectrum: trial protocol

BACKGROUND

The transition from high school to post-secondary education and work is difficult for adolescents on the autism spectrum. Transition planning can be an effective way of supporting adolescents on the autism spectrum to prepare for leaving school and to succeed in obtaining employment; however, there is a need for an autism-specific transition planning program with proven effectiveness. This paper describes a trial protocol for evaluating the Better OutcOmes & Successful Transitions for Autism (BOOST-A™); an online interactive program that empowers adolescents on the autism spectrum to plan their transition from school to further study, training, or employment.

METHODS

The trial will involve adolescents on the autism spectrum in high school and their parents, who will be alternately assigned to a control group (regular practice) or an intervention group (using the BOOST-A™). The BOOST-A™ was developed using the PRECEDE-PROCEED model, and is based on the self-determination model, and the strengths- and technology-based approaches. It involves participants completing a series of online modules. The primary outcome will be self-determination, because high self-determination has been linked to successful transition to employment among adolescents on the autism spectrum. Secondary outcomes will include domain-specific self-determination, career planning and exploration, quality of life, and environmental support. Data will be obtained from questionnaires completed by the adolescent on the autism spectrum and their parent/s. Data collection will take place at baseline (Time point 1) and 12 months later (Time point 2).

DISCUSSION AND CONCLUSIONS

This trial will provide evidence of the effectiveness of the BOOST-A™ to assist adolescents on the autism spectrum to successfully transition from school. Trial registration #ACTRN12615000119594.

Computerised attention training for children with intellectual and developmental disabilities: a randomised controlled trial

BACKGROUND

Children with intellectual and developmental disabilities (IDD) experience heightened attention difficulties which have been linked to poorer cognitive, academic and social outcomes. Although, increasing research has focused on the potential of computerised cognitive training in reducing attention problems, limited studies have assessed whether this intervention could be utilised for those with IDD. This study aimed to assess the efficacy of a computerised attention training programme in children with IDD.

METHODS

In a double-blind randomised controlled trial, children (n = 76; IQ < 75) aged 4-11 years were assigned to an adaptive attention training condition or a nonadaptive control condition. Both conditions were completed at home over a 5-week period and consisted of 25 sessions, each of 20-min duration. Outcome measures (baseline, posttraining and 3-month follow-up) assessed core attention skills (selective attention, sustained attention and attentional control) and inattentive/hyperactive behaviour.

RESULTS

Children in the attention training condition showed greater improvement in selective attention performance compared to children in the control condition (SMD = 0.24, 95% CI 0.02, 0.45). These improvements were maintained 3 months after training had ceased (SMD = 0.26, 95% CI 0.04, 0.48). The attention training programme was not effective in promoting improvements in sustained attention, attentional control or inattentive/hyperactive behaviours.

CONCLUSIONS

The findings suggest that attention training may enhance some aspects of attention (selective attention) in children with IDD, but the small to medium effect sizes indicate that further refinement of the training programme is needed to promote larger, more global improvements.

Gamification of Cognitive Assessment and Cognitive Training: A Systematic Review of Applications and Efficacy

Background

Cognitive tasks are typically viewed as effortful, frustrating, and repetitive, which often leads to participant disengagement. This, in turn, may negatively impact data quality and/or reduce intervention effects. However, gamification may provide a possible solution. If game design features can be incorporated into cognitive tasks without undermining their scientific value, then data quality, intervention effects, and participant engagement may be improved.

Objectives

This systematic review aims to explore and evaluate the ways in which gamification has already been used for cognitive training and assessment purposes. We hope to answer 3 questions: (1) Why have researchers opted to use gamification? (2) What domains has gamification been applied in? (3) How successful has gamification been in cognitive research thus far?

Methods

We systematically searched several Web-based databases, searching the titles, abstracts, and keywords of database entries using the search strategy (gamif* OR game OR games) AND (cognit* OR engag* OR behavi* OR health* OR attention OR motiv*). Searches included papers published in English between January 2007 and October 2015.

Results

Our review identified 33 relevant studies, covering 31 gamified cognitive tasks used across a range of disorders and cognitive domains. We identified 7 reasons for researchers opting to gamify their cognitive training and testing. We found that working memory and general executive functions were common targets for both gamified assessment and training. Gamified tests were typically validated successfully, although mixed-domain measurement was a problem. Gamified training appears to be highly engaging and does boost participant motivation, but mixed effects of gamification on task performance were reported.

Conclusions

Heterogeneous study designs and typically small sample sizes highlight the need for further research in both gamified training and testing. Nevertheless, careful application of gamification can provide a way to develop engaging and yet scientifically valid cognitive assessments, and it is likely worthwhile to continue to develop gamified cognitive tasks in the future.

The set-shifting profiles of anorexia nervosa and autism spectrum disorder using the Wisconsin Card Sorting Test: a systematic review and meta-analysis

Difficulties in set-shifting are commonly reported in both autism spectrum disorder (ASD) and anorexia nervosa (AN) populations. Despite this, it is not known whether this cognitive profile persists across different ages, or whether the profiles seen in ASD and AN are comparable. This systematic review and meta-analyses aimed to compare the set-shifting profiles, as measured by the Wisconsin Card Sorting Test (WCST) in adults and younger people with either ASD or AN, relative to healthy controls (HCs) and to statistically compare performance on the WCST between ASD and AN. In all, 24 studies on ASD and 22 studies on AN were identified. In ASD, there were significant differences between the clinical group and HCs, with the ASD group making significantly more perseverative errors, indicating greater difficulty in set-shifting [pooled effect size of d = 0.67, 95% confidence interval (CI) 0.53-0.81, p ⩽ 0.001]. This effect was consistent across the age span. For AN studies, there was a significant difference between adults with AN and HCs (d = 0.52, 95% CI 0.36-0.68, p ⩽ 0.001) but a non-significant effect in child studies (d = 0.25, 95% CI -0.05 to 0.55, z = 1.66, p = 0.096). Meta-regression indicated no effect of diagnosis (AN or ASD) on performance in adult studies but there was a non-significant trend (p = 0.053) towards children with ASD performing worse than children with AN. While difficulties with set-shifting appear to be stable in ASD, there may be differences between children and adults with AN, which warrant further investigation.

Discrepancies between direct and indirect measures of interpersonal and neurocognitive skills in autism spectrum disorder children

BACKGROUND

Subjects with autistic spectrum disorders (ASD) show persistent deficits in social interaction. In order to explore the scope of their deficits, it is of great interest to compare the different interpersonal skills and executive functions of ASD subjects to those of children with typical development. Assessing these skills usually involves a large variety of informants (parents, teachers, other family members) and of measures, with frequent discrepancies between direct performance measures and indirect measures (third-party report). Different explanations of this mismatch between measures have been addressed in previous studies.

OBJECTIVES

We wish to analyze whether there are differences between children with ASD and children with typical development on several direct performance measures of interpersonal and neurocognitive skills and one third-party report on real-life performance of interpersonal skills; we also want to look at whether discrepancies appear between the two types of measurements in the two groups of participants.

METHOD

A total of 68 Spanish children between the ages of 7 and 12 years participated; 34 were children with ASD, and 34 showed typical development. All participants were tested for recognition of emotions, solving interpersonal conflicts, and executive function.

RESULTS

Significant differences between the two groups were not found on most of the direct performance measures, but they did appear in the report by third parties, in favor of the group with typical development. There was also a significant association between neurocognitive and social variables in the latter group.

CONCLUSIONS

There were intergroup differences and discrepancies between the direct performance and indirect measures in children with ASD, and these must be explained. For this reason, future studies could seek to explain the cause of these discrepancies with a greater number of measures for each of the skills.

Touchscreen learning deficits and normal social approach behavior in the Shank3B model of Phelan-McDermid Syndrome and autism

SHANK3 is a synaptic scaffolding protein localized in the postsynaptic density and has a crucial role in synaptogenesis and neural physiology. Deletions and point mutations in SHANK3 cause Phelan-McDermid Syndrome (PMS), and have also been implicated in autism spectrum disorder (ASD) and intellectual disabilities, leading to the hypothesis that reduced SHANK3 expression impairs basic brain functions that are important for social communication and cognition. Several mouse models of Shank3 deletions have been generated, varying in the specific domain deleted. Here we report impairments in cognitive function in mice heterozygous for exon 13-16 (coding for the PDZ domain) deletion. The touchscreen pairwise discrimination task was chosen by virtue of its: (a) conceptual and technical similarities to the Cambridge Neuropsychological Test Automated Battery (CANTAB) and NIH Toolbox Cognition Battery used for testing cognitive functions in humans, (b) minimal demand on motor abilities, and (c) capability to measure many aspects of learning and memory and complex cognitive functions, including cognitive flexibility. The similarity between our mouse tasks and human cognitive assays means a high translational validity in future intervention studies using preclinical models. Our study revealed that Shank3B heterozygous mice (+/-) were slower to reach criterion in the pairwise visual discrimination task, and exhibited trends toward making more errors (first trial errors) and more correction errors than wildtype mice (+/+). Open field activity was normal in +/-, ruling out hypo- or hyperactivity as potential confounds in the touchscreen test. Sociability in the three chamber test was also normal in both +/+ and +/-. These results indicate a deficit in discrimination learning in the Shank3B model of PMS and ASD, suggesting that this mouse model is a useful preclinical tool for studying neurobiological mechanisms behind cognitive impairments in PMS and ASD. The current findings are the starting point for our future research in which we will investigate multiple domains of cognition and explore pharmacological interventions.

Influence of Autism Traits and Executive Functioning on Quality of Life in Children with an Autism Spectrum Disorder

Children with Autism Spectrum Disorders (ASDs) often experience a low Quality of Life (QoL). We studied if IQ, early language development, current autism traits, and daily Executive Functions (EFs) are related to QoL in children (aged 8–12 years) with ASD (N = 120) and typically developing (TD) children (N = 76). Children with ASD showed a lower QoL than TD children. This lower QoL was related to higher levels of autism traits and EF deficits. Moreover, specific autism traits and EFs were related to specific QoL subdomains. The low QoL and the aggravating effects of autism traits and EF deficits indicate a potential to identify and target such factors in treatment to improve QoL.

An update on the comorbidity of ADHD and ASD: a focus on clinical management

Attention deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) commonly co-occur. With the DSM-5, clinicians are permitted to make an ASD diagnosis in the context of ADHD. In earlier versions of the DSM, this was not acceptable. Both ASD and ADHD are reported to have had substantial increases in prevalence within the past 10 years. As a function of both the increased prevalence of both disorders as well as the ability to make an ASD diagnosis in ADHD, there has been a significant amount of research focusing on the comorbidity between ADHD and ASD in the past few years. Here, we provide an update on the biological, cognitive and behavioral overlap/distinctiveness between the two neurodevelopmental disorders with a focus on data published in the last four years. Treatment strategies for the comorbid condition as well as future areas of research and clinical need are discussed.

Improving executive functioning in children with ADHD: training multiple executive functions within the context of a computer game. a randomized double-blind placebo controlled trial

INTRODUCTION

Executive functions (EFs) training interventions aimed at ADHD-symptom reduction have yielded mixed results. Generally, these interventions focus on training a single cognitive domain (e.g., working memory [WM], inhibition, or cognitive-flexibility). However, evidence suggests that most children with ADHD show deficits on multiple EFs, and that these EFs are largely related to different brain regions. Therefore, training multiple EFs might be a potentially more effective strategy to reduce EF-related ADHD symptoms.

METHODS

Eighty-nine children with a clinical diagnosis of ADHD (aged 8-12) were randomized to either a full-active-condition where visuospatial WM, inhibition and cognitive-flexibility were trained, a partially-active-condition where inhibition and cognitive-flexibility were trained and the WM-training task was presented in placebo-mode, or to a full placebo-condition. Short-term and long-term (3-months) effects of this gamified, 25-session, home-based computer-training were evaluated on multiple outcome domains.

RESULTS

During training compliance was high (only 3% failed to meet compliance criteria). After training, only children in the full-active condition showed improvement on measures of visuospatial short-term-memory (STM) and WM. Inhibitory performance and interference control only improved in the full-active- and the partially-active condition. No Treatment-condition x Time interactions were found for cognitive-flexibility, verbal WM, complex-reasoning, nor for any parent-, teacher-, or child-rated ADHD behaviors, EF-behaviors, motivational behaviors, or general problem behaviors. Nonetheless, almost all measures showed main Time-effects, including the teacher-ratings.

CONCLUSIONS

Improvements on inhibition and visuospatial STM and WM were specifically related to the type of treatment received. However, transfer to untrained EFs and behaviors was mostly nonspecific (i.e., only interference control improved exclusively in the two EF training conditions). As such, in this multiple EF-training, mainly nonspecific treatment factors - as opposed to the specific effects of training EFs-seem related to far transfer effects found on EF and behavior.

TRIAL REGISTRATION

trialregister.nl NTR2728. Registry name: improving executive functioning in children with ADHD: training executive functions within the context of a computer game; registry number: NTR2728.