Computer-based attention training in the schools for children with attention deficit/hyperactivity disorder: a preliminary trial

Research Review: Pharmacological and non-pharmacological treatments for adolescents with attention deficit/hyperactivity disorder - a systematic review of the literature

BACKGROUND

Attention Deficit/Hyperactivity Disorder (ADHD) demonstrates unique developmental manifestations in adolescence with implications for optimized, age-appropriate treatment. This 10-year update is the third in a series of systematic reviews examining the efficacy and safety of adolescent ADHD treatments. We broadly examined efficacy on ADHD symptoms, impairments, and other reported outcomes. Acute and long-term efficacy, and treatment moderators, were considered.

METHOD

We performed PubMed, EMBASE, and PsycINFO searches for articles published or in press from 2013 to 2024, integrated with hand search and randomized controlled trials (RCTs) identified in this series' earlier reviews. RCTs examining the safety or efficacy of interventions delivered to adolescents (ages 10.0-19.9) with a diagnosis of ADHD were included. Study characteristics were extracted and reviewed, quality of evidence was assessed using GRADE, and effect sizes were calculated for individual studies and illustrated using forest plots.

RESULTS

Sixty-three RCTs were identified. Quality of evidence ranged from high (medication; k = 29) to very low (nutrient supplementation, neurofeedback, occupational therapy; k = 1 each). Medications demonstrated consistent strong impact on ADHD symptoms and inconsistent impact on impairment. Diverse cognitive/behavioral treatments (C/BTs) demonstrated inconsistent impact on ADHD symptoms but strong and consistent impact on impairment and executive function skills, plus moderate benefits on internalizing symptoms. No interventions demonstrated significant safety concerns. Long-term maintenance (up to 3 years post-treatment) was demonstrated for C/BTs, though moderate quality of evidence was noted because participants cannot be fully blinded to receipt of treatment.

CONCLUSIONS

The effects of C/BTs and medication appear complementary, not duplicative. Combining medication and C/BT is advised at treatment outset to maximize engagement, maintenance, and response breadth (i.e. improving both ADHD symptoms/cognitive performance and coping skills/functional impairments). Engagement strategies (e.g. motivational interviewing) may facilitate uptake. Novel treatments do not yet demonstrate effects on ADHD symptoms or impairments in adolescents but remain a promising area for research.

Improvement in Math Ability and Cognitive Processing in Children with Low Attention: An Intervention Based on PASS Theory

This study investigates the effects of math training on math and cognitive performance among 8-9 year-old students with low attention. Fifty-six students with low attention were randomly assigned to a training group (n = 24) and a passive control group (n = 32). They completed math problem-solving, calculation fluency and PASS cognitive processing tests both before and after training. The children in the training group received 3 days of training per week for a total of 21 days using the math modules of The Children's Mathematics and Cognition Training Manual in Chinese. The results showed that the training group's math problem-solving performance improved significantly. Moreover, the cognitive performance on the CAS-2 in the planning and simultaneous processing tests for the training group was enhanced. The implications of these findings are discussed with consideration of the interpretability being constrained by the fact that no active control condition was applied.

The wide world of technological telerehabilitation for pediatric neurologic and neurodevelopmental disorders - a systematic review

Introduction

The use of Information and Communication Technology (ICT) for assessing and treating cognitive and motor disorders is promoting home-based telerehabilitation. This approach involves ongoing monitoring within a motivating context to help patients generalize their skills. It can also reduce healthcare costs and geographic barriers by minimizing hospitalization. This systematic review focuses on investigating key aspects of telerehabilitation protocols for children with neurodevelopmental or neurological disorders, including technology used, outcomes, caregiver involvement, and dosage, to guide clinical practice and future research.

Method

This systematic review adhered to PRISMA guidelines and was registered in PROSPERO. The PICO framework was followed to define the search strategy for technology-based telerehabilitation interventions targeting the pediatric population (aged 0-18) with neurological or neurodevelopmental disorders. The search encompassed Medline/PubMed, EMBASE, and Web of Science databases. Independent reviewers were responsible for selecting relevant papers and extracting data, while data harmonization and analysis were conducted centrally.

Results

A heterogeneous and evolving situation emerged from our data. Our findings reported that most of the technologies adopted for telerehabilitation are commercial devices; however, research prototypes and clinical software were also employed with a high potential for personalization and treatment efficacy. The efficacy of these protocols on health or health-related domains was also explored by categorizing the outcome measures according to the International Classification of Functioning, Disability, and Health (ICF). Most studies targeted motor and neuropsychological functions, while only a minority of papers explored language or multi-domain protocols. Finally, although caregivers were rarely the direct target of intervention, their role was diffusely highlighted as a critical element of the home-based rehabilitation setting.

Discussion

This systematic review offers insights into the integration of technological devices into telerehabilitation programs for pediatric neurologic and neurodevelopmental disorders. It highlights factors contributing to the effectiveness of these interventions and suggests the need for further development, particularly in creating dynamic and multi-domain rehabilitation protocols. Additionally, it emphasizes the importance of promoting home-based and family-centered care, which could involve caregivers more actively in the treatment, potentially leading to improved clinical outcomes for children with neurological or neurodevelopmental conditions.

Systematic review registration

PROSPERO (CRD42020210663).

Neuropsychological Stimulation Program for Children from Low Socioeconomic Backgrounds: Study Protocol for a Randomized Controlled Trial

BACKGROUND

Guatemala remains one of the poorest countries in Central America and suffers from high rates of social inequality and violence. In addition to the negative impact that two years without attending school has had on Guatemalan children due to the consequences of the COVID-19 pandemic, this unfavourable socioeconomic context poses a risk to children's emotional and cognitive development. This work presents a protocol for implementing a cognitive and emotional stimulation program aimed at increasing the academic performance of these children and consequently improving their quality of life.

METHODS

The protocol proposes the implementation of a randomized controlled trial to assess the efficacy of a 24-session-long stimulation program. It targets the cognitive functions of attention, language, executive functions, and social cognition, using the digital neurorehabilitation platform NeuronUP. The participants (n = 480) will be randomly assigned to an Experimental or Control group. Pre- and post-intervention assessments will be carried out, together with a follow-up in the next academic year, in which both groups will change roles. Results will be compared for the first and second years, looking for differences in academic and cognitive performance between groups.

DISCUSSION

Mid- and long-term outcomes are still unknown, but effective interventions based on this protocol are expected to facilitate the following benefits for participants: (1) improved cognitive and emotional development; (2) improved academic performance; (3) improved well-being. We expect to create a validated neuropsychological stimulation program that could be applied in similar socioeconomically disadvantaged contexts around the world to help these children improve their life chances.

Treating Executive Function in Youth With Attention Deficit Hyperactivity Disorder: A Review of Pharmacological and Non-Pharmacological Interventions

INTRODUCTION

Executive function (EF) deficits are common in youth with ADHD and pose significant functional impairments. The extent and effect of interventions addressing EF in youth with ADHD remain unclear.

METHODS

We conducted a systematic literature review using PRISMA guidelines. Included studies were randomized controlled trials of interventions to treat EF in youth with ADHD.

RESULTS

Our search returned 136 studies representing 11,443 study participants. We identified six intervention categories: nonstimulant pharmacological (N = 3,576 participants), neurological (N = 1,935), psychological (N = 2,387), digital (N = 2,416), physiological (N = 680), and combination (N = 366). The bulk of the evidence supported pharmacological interventions as most effective in mitigating EF, followed by psychological and digital interventions.

CONCLUSION

A breadth of treatments exists for EF in youth with ADHD. Pharmacological, psychotherapeutic, and digital interventions had the most favorable, replicable outcomes. A lack of outcome standardization across studies limited treatment comparison. More data on the persistence of intervention effects are necessary.

Effectiveness of applied and casual games for young people's mental health: A systematic review of randomised controlled studies

Many youth experience mental health problems and digital games hold potential as mental health interventions. This systematic review provides an overview of randomised controlled studies assessing the effectiveness of digital applied and casual games for improving mental health in youth aged 6-24 years. A systematic search of PsycINFO, Web of Science and Pubmed yielded 145 eligible studies. Studies on (sub)clinical participant samples (n = 75) most often focused on attention-deficit/hyperactivity disorder (ADHD), autism and anxiety. Applied games were found most effective for improving social skills, verbal memory and anxiety, whereas casual games were found most effective for improving depression, anxiety and ADHD. Studies involving healthy youth (n = 70) were grouped into papers examining anxiety in medical settings, momentary effects on positive and negative affect, and papers employing a longitudinal design measuring mental health trait outcomes. Promising results were found for the use of games as distraction tools in medical settings, and for applied and casual games for improving momentary affect. Overall, our findings demonstrate the potential of digital games for improving mental health. Implications and recommendations for future research are discussed, such as developing evaluation guidelines, clearly defining applied games, harmonising outcome measures, including positive outcomes, and examining nonspecific factors that may influence symptom improvement as well.

The effect of cognitive training on children with attention deficit and hyperactivity disorder: A meta-analysis

OBJECTIVE

This document is a meta-analysis of randomized controlled trials that evaluated the effect of cognitive training interventions on attention deficit and hyperactivity disorder (ADHD) symptoms.

METHODS

A systematic literature search was conducted using databases such as PubMed, Web of Science, and Embase from the inception of each database to April 28, 2022. Data were analyzed using Stata 15 software. The risk of bias assessment was conducted using five domains from the Cochrane Collaborations tool.

RESULTS

A total of 10 studies with 446 children with ADHD were included. The results showed that cognitive training was effective in improving attention symptoms [SMD= -0.78 (95% CI: -1.46, -0.1)] and executive function [SMD = -0.3 (95% CI: -0.56, -0.05)] in children with ADHD compared to controls. No significant difference in the degree of improvement in hyperactivity/impulsivity with cognitive training compared to the control group [SMD = -0.65 (95% CI: -1.35, 0.05)]. In addition, subgroup analyses also found that cognitive training significantly improved attention in children with ADHD <10 years of age [SMD = -1.3 (95% CI: -2.58, -0.02)] and children with ADHD with length of training >30 days [SMD = -0.94 (95% CI: -1.81, -0.07)] compared to controls.

CONCLUSION

This meta-analysis found that the beneficial effects of cognitive training on attention (particularly for children with ADHD <10 years old and >30 days of training) and executive function in children with ADHD, but not on hyperactivity/impulsivity.

Meta-analysis of the efficacy of digital therapies in children with attention-deficit hyperactivity disorder

Background

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder that commonly occurs in childhood. The aim of this meta-analysis was to summarize the available evidence for the efficacy of digital therapeutics in children and adolescents with ADHD.

Methods

We searched the MEDLINE, EMBASE, Cochrane Library (Cochrane Database of Systematic Reviews), and Web of Science (science and social science citation index) databases for relevant studies and used Stata 15.0 software to carry out the meta-analysis.

Results

A total of 31 studies involving 2169 participants (1665 boys and 504 girls) aged 4-17 years old were included in the final analysis. The meta-analysis results showed that digital interventions improved the symptoms of inattention with an effect value of -0.20 (95% confidence interval [CI] -0.36, -0.04) and decreased the continuous performance task (CPT) reaction time (effect, -0.40, 95% CI -0.73, -0.07) in ADHD patients. The score for impulsive hyperactivity was slightly decreased (effect, -0.07, 95% CI -0.23, 0.09). Moreover, executive function was improved (effect, 0.71, 95% CI 0.37, 1.04). The capability of working memory appeared to be increased (effect, 0.48, 95% CI 0.21, 0.76) between the two groups. Visual appraisal of the sensitivity analysis suggested the absence of heterogeneity, and no obvious publication bias was detected.

Discussion

Based on the existing literature evidence, we conclude that digital therapy can be a promising therapeutic strategy for ADHD patients.

The Influence of Extrovert-Introvert Personality on Children's Cortical Activation with Attention Training Systems

Extrovert-Introvert personality can take an active role in affecting people's attitudes, tastes, and behaviors in education. However, little research has been conducted to study whether and how Extrovert-Introvert personality may influence children's interaction with the attention training system. In this manuscript, we present the results of a user study that not only measured the influence of children's Extrovert-Introvert personality on their perception of two typical types of attention training systems (i.e., computer-based and neurofeedback-based) but also employed functional near-infrared spectroscopy (fNIRS) to investigate how the personality may influence cortical activation in children. Our results show that, for extroverted children, the neurofeedback-based attention training system elicited significantly more activation in the prefrontal cortex and posterior parietal cortex, and was more likely to be preferred. The findings could be useful for developing more effective attention training systems based on user personality.

Surface electroencephalographic neurofeedback improves sustained attention in ADHD: a meta-analysis of randomized controlled trials

BACKGROUND

The efficacy of surface electroencephalographic neurofeedback (EEG-NF) for improving attentional performance assessed by laboratory measures in patients with attention-deficit/hyperactivity disorder (ADHD) remains unclear.

METHODS

Following the PRISMA guidelines, the PubMed, Embase, ClinicalKey, Cochrane CENTRAL, ScienceDirect, Web of Science, and ClinicalTrials.gov databases were systematically searched for randomized controlled trials on the efficacy of surface EEG-NF against ADHD focusing on attentional performance evaluated by laboratory measures from inception to January 2022.

RESULTS

Fourteen eligible studies were analyzed. Of the 718 participants involved, 429 diagnosed with ADHD received EEG-NF treatment. Significant improvement in attentional performance in ADHD subjects receiving EEG-NF was noted compared to their comparators (p < 0.01). Besides, there was a significant EEG-NF-associated beneficial effect on sustained attention (Hedges' g = 0.32, p < 0.01), whereas the impact on selective attention (p = 0.57) and working memory (p = 0.59) was limited. Moreover, protocol including beta wave enhancement was superior to that only focusing on reducing theta/beta ratio or modulation of slow cortical potential. Subgroup analyses showed that three sessions per week of EEG-NF produced the best effect, while the efficacy of surface EEG-NF was much poorer (Hedges' g = 0.05) when only studies that blinded their participants from knowledge of treatment allocation were included. No significant difference was noted in the improvement of attentional performance 6-12 months after EEG-NF intervention (n = 3, p = 0.42).

CONCLUSIONS

Our results demonstrated the satisfactory effectiveness of surface EEG-NF for improving sustained attention, especially when beta wave enhancement was included, despite its failure to sustain a long-term effect. Further large-scale trials are warranted to support our findings.

Effectiveness of Virtual Reality on Attention Training for Elementary School Students

This study is aimed at investigating the effectiveness of virtual reality (VR) on attention training for elementary school students. A pre-test and post-test design of the quasi-experimental method was adopted and 66 third and fourth graders from an elementary school in Hsinchu, Taiwan were used as experimental subjects, divided into a control group and experimental group. The former used the computerized Attention Process Training (APT) system and the latter used the proposed VR system for attention training, both for two weeks. The attention scale for elementary school children was used to evaluate the participant’s attention before and after training, including the dimensions of focused attention, sustained attention, selective attention, alternating attention, and divided attention. A questionnaire survey was conducted to measure the learning anxiety and cognitive load during the training process. The experimental results indicated: (1) The overall attention was significantly improved after the training process for both groups, and the VR system was more effective than the computerized APT in improving children’s attention. (2) The questionnaire results showed that the experimental group had lower learning anxiety and cognitive load than the control group. According to the experimental results, VR training is more effective in improving the attention of participants while reducing their learning anxiety and cognitive load. Therefore, it is a useful tool for attention training in elementary schools.

A pilot meta-analysis on self-reported efficacy of neurofeedback for adolescents and adults with ADHD

Self-reported effectiveness of electroencephalogram-based neurofeedback (EEG-NF) against the core symptoms of attention-deficit hyperactivity disorder (ADHD) in adolescents/adults remains unclear. We searched PubMed, Embase, ClinicalKey, Cochrane CENTRAL, ScienceDirect, Web of Science, and ClinicalTrials.gov from inception to August 2021 for randomized clinical trials (RCTs) of EEG-NF with self-reported ADHD symptom ratings. Comparators included participants on waitlist/treatment as usual (TAU) or receiving other interventions. Of the 279 participants (mean age = 23.48; range: 6-60) in five eligible RCTs, 183 received EEG-NF treatment. Forest plot demonstrated no difference in inattention (SMD = -0.11, 95% CI -0.39-0.18, p = 0.46), total score (SMD = -0.08, 95% CI -0.36-0.2, p = 0.56), and hyperactivity/impulsivity (SMD = 0.01, 95% CI -0.23-0.25, p = 0.91) between EEG-NF and comparison groups. Nevertheless, compared with waitlist/TAU, EEG-NF showed better improvement in inattention (SMD = -0.48, 95% CI -0.9--0.06, p = 0.03) but not hyperactivity/impulsivity (SMD = -0.03, 95% CI -0.45-0.38, p = 0.87). Follow-up 6-12 months demonstrated no difference in inattention (SMD = -0.01, 95% CI -0.41-0.38, p = 0.94), total score (SMD = 0.22, 95% CI -0.08-0.52, p = 0.15), and hyperactivity/impulsivity (SMD = -0.01, 95% CI -0.27-0.26, p = 0.96) between the two groups. Dropout rate also showed no difference (RR = 1.05, 95% CI 0.82-1.33, p = 0.72). Our results support EEG-NF for improving inattention in adolescents/young adults, although its effectiveness against hyperactivity/impulsivity remains inconclusive.

Results of Neurofeedback in Treatment of Children with ADHD: A Systematic Review of Randomized Controlled Trials

Attention-deficit/hyperactivity disorder (ADHD) is one of the most prevalent disorders in children and adolescents. Neurofeedback, a nonpharmaceutical treatment, has shown promising results. To review the evidence of efficacy of neurofeedback as a treatment for children and adolescents with ADHD. A systematic review of the specific scientific studies published in 1995-2021, identifying and analyzing randomized controlled trials (RCT). A total of 1636 articles were identified and 165 met inclusion criteria, of which 67 were RCTs. Neurofeedback training was associated with significant long-term reduction in symptoms of ADHD. Though limitations exist regarding conclusions about the specific effects of neurofeedback, the review documents improvements in school, social, and family environments.

Meta-analysis of effectiveness of electroencephalogram monitoring of sustained attention for improving online learning achievement

The conclusions of previous studies have not been consistent regarding the effects of the use of electroencephalogram (EEG) monitoring technology to improve the sustained attention and online learning achievement of students. Therefore, we performed a meta-analysis of the results of nine experimental studies. Results indicate that the combined effect of EEG monitoring during periods of sustained attention was moderately positive in improving students' online learning achievement (value of combined effect in the studies = .52). The greatest impact of EEG monitoring of sustained attention regarding students' online learning achievement was found for an openended design challenge of immersive virtual reality (reminder feedback). No significant difference was found according to education level.

Control interventions in randomised trials among people with mental health disorders

BACKGROUND

Control interventions in randomised trials provide a frame of reference for the experimental interventions and enable estimations of causality. In the case of randomised trials assessing patients with mental health disorders, many different control interventions are used, and the choice of control intervention may have considerable impact on the estimated effects of the treatments being evaluated.

OBJECTIVES

To assess the benefits and harms of typical control interventions in randomised trials with patients with mental health disorders. The difference in effects between control interventions translates directly to the impact a control group has on the estimated effect of an experimental intervention. We aimed primarily to assess the difference in effects between (i) wait-list versus no-treatment, (ii) usual care versus wait-list or no-treatment, and (iii) placebo interventions (all placebo interventions combined or psychological, pharmacological, and physical placebos individually) versus wait-list or no-treatment. Wait-list patients are offered the experimental intervention by the researchers after the trial has been finalised if it offers more benefits than harms, while no-treatment participants are not offered the experimental intervention by the researchers.

SEARCH METHODS

In March 2018, we searched MEDLINE, PsycInfo, Embase, CENTRAL, and seven other databases and six trials registers.

SELECTION CRITERIA

We included randomised trials assessing patients with a mental health disorder that compared wait-list, usual care, or placebo interventions with wait-list or no-treatment .

DATA COLLECTION AND ANALYSIS

Titles, abstracts, and full texts were reviewed for eligibility. Review authors independently extracted data and assessed risk of bias using Cochrane's risk of bias tool. GRADE was used to assess the quality of the evidence. We contacted researchers working in the field to ask for data from additional published and unpublished trials. A pre-planned decision hierarchy was used to select one benefit and one harm outcome from each trial. For the assessment of benefits, we summarised continuous data as standardised mean differences (SMDs) and dichotomous data as risk ratios (RRs). We used risk differences (RDs) for the assessment of adverse events. We used random-effects models for all statistical analyses. We used subgroup analysis to explore potential causes for heterogeneity (e.g. type of placebo) and sensitivity analyses to explore the robustness of the primary analyses (e.g. fixed-effect model).

MAIN RESULTS

We included 96 randomised trials (4200 participants), ranging from 8 to 393 participants in each trial. 83 trials (3614 participants) provided usable data. The trials included 15 different mental health disorders, the most common being anxiety (25 trials), depression (16 trials), and sleep-wake disorders (11 trials). All 96 trials were assessed as high risk of bias partly because of the inability to blind participants and personnel in trials with two control interventions. The quality of evidence was rated low to very low, mostly due to risk of bias, imprecision in estimates, and heterogeneity. Only one trial compared wait-list versus no-treatment directly but the authors were not able to provide us with any usable data on the comparison. Five trials compared usual care versus wait-list or no-treatment and found a SMD -0.33 (95% CI -0.83 to 0.16, I² = 86%, 523 participants) on benefits. The difference between all placebo interventions combined versus wait-list or no-treatment was SMD -0.37 (95% CI -0.49 to -0.25, I² = 41%, 65 trials, 2446 participants) on benefits. There was evidence of some asymmetry in the funnel plot (Egger's test P value of 0.087). Almost all the trials were small. Subgroup analysis found a moderate effect in favour of psychological placebos SMD -0.49 (95% CI -0.64 to -0.30; I² = 53%, 39 trials, 1656 participants). The effect of pharmacological placebos versus wait-list or no-treatment on benefits was SMD -0.14 (95% CI -0.39 to 0.11, 9 trials, 279 participants) and the effect of physical placebos was SMD -0.21 (95% CI -0.35 to -0.08, I² = 0%, 17 trials, 896 participants). We found large variations in effect sizes in the psychological and pharmacological placebo comparisons. For specific mental health disorders, we found significant differences in favour of all placebos for sleep-wake disorders, major depressive disorder, and anxiety disorders, but the analyses were imprecise due to sparse data. We found no significant differences in harms for any of the comparisons but the analyses suffered from sparse data. When using a fixed-effect model in a sensitivity analysis on the comparison for usual care versus wait-list and no-treatment, the results were significant with an SMD of -0.46 (95 % CI -0.64 to -0.28). We reported an alternative risk of bias model where we excluded the blinding domains seeing how issues with blinding may be seen as part of the review investigation itself. However, this did not markedly change the overall risk of bias profile as most of the trials still included one or more unclear bias domains.

AUTHORS' CONCLUSIONS

We found marked variations in effects between placebo versus no-treatment and wait-list and between subtypes of placebo with the same comparisons. Almost all the trials were small with considerable methodological and clinical variability in factors such as mental health population, contents of the included control interventions, and outcome domains. All trials were assessed as high risk of bias and the evidence quality was low to very low. When researchers decide to use placebos or usual care control interventions in trials with people with mental health disorders it will often lead to lower estimated effects of the experimental intervention than when using wait-list or no-treatment controls. The choice of a control intervention therefore has considerable impact on how effective a mental health treatment appears to be. Methodological guideline development is needed to reach a consensus on future standards for the design and reporting of control interventions in mental health intervention research.

Which Factor Is More Relevant to the Effectiveness of the Cognitive Intervention? A Meta-Analysis of Randomized Controlled Trials of Cognitive Training on Symptoms and Executive Function Behaviors of Children With Attention Deficit Hyperactivity Disorder

Objective: Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by developmentally inappropriate inattention, hyperactivity, and impulsivity. Multiple cognitive training appeared to be more effective than working memory training, but the evidence remains insufficient, particularly for the subgroup symptoms and executive function behaviors at home. Further analysis of the impact of factors on the effectiveness would facilitate the development of cognitive training.

Methods: We searched PubMed, Cochrane Library, Psyche, Embase, Chinese Biomedical Literature Database, CNKI, and Weifang Database, and included randomized controlled trials (RCTs) of children with ADHD undergoing cognitive intervention. Metaanalysis and univariate metaregression were performed by STATE. The risk of bias was assessed with the Cochrane risk of bias tool 2.0 by the two investigators separately. This study was registered with INPLASY, number INPLASY202140065.

Results: We included 17 RCTs in the systematic review, with a combined 1,075 participants. For metaanalyses of both subgroups of ADHD symptoms and the executive function behaviors, the test of published bias failed to reach the p < 0.05 level. When all of the training are considered together, cognitive training can improve the presentation of inattention symptoms [SMD = −0.390, 95%CI (−0.675, −0.104)] and executive function behaviors (SMD = −0.319, 95%CI (−0.527, −0.111)]. In the subgroup analysis, the effects of working memory training on both presentations were not statistically significant. In contrast, the multiple cognitive training had significant effects on the presentation of inattention symptoms [SMD = −0.507, 95% CI (−0.722, −0.292)], hyperactivity/impulsivity [SMD = −0.305, 95% CI (−0.518, −0.09)], and the executive function behaviors [SMD = −0.499, 95%CI (−0.707, −0.290)]. In addition, metaregression analysis showed that only training frequency did significantly impact the symptoms of ADHD and the executive function behaviors.

Conclusion: This study showed that improvements in symptoms and executive function behaviors were related to the domains of cognitive intervention. The findings suggest that multiple domains of cognitive training and moderate training frequency may have wider clinical benefits. All the above results highlight further research in refining the executive functions of children with ADHD and developing individually tailored cognitive intervention on homes based for children with vulnerable executive functions.

Systematic Review Registration: [http://inplasy.com/], [INPLASY202140065].

The Effect of the ‘Touch Screen-Based Cognitive Training’ for Children with Severe Cognitive Impairment in Special Education

Traditional education in special schools have some limitations. We aimed to investigate if the ‘touch screen-based cognitive training’ is feasible and effective for children with severe cognitive impairment (developmental age 18–36 months) in special education. In this case, 29 children were randomly allocated to intervention (n = 17, ‘touch screen-based cognitive training’, 30 min/session, 3 times/week, 12 weeks) and control (n = 12, traditional education) groups. Psychoeducational Profile-Revised (PEP-R), Early Childhood Behavior Questionnaire (ECBQ), Sequenced Language Scale for Infants (SELSI), Pediatric Evaluation of Disability Inventory (PEDI), and Goal Attainment Scale (GAS) were measured before and after 12 weeks of education. The ‘touch screen-based cognitive training’ was applicable in special education. When repeated measures analysis of variance (ANOVA) was used, significant groupⅹtime effect was found for GAS, and significant group effect was found for ECBQ (attentional shifting) and GAS. When adjusting for pre-education measurements, the intervention had a significant effect on the post-education measurements of ECBQ (attentional shifting) and GAS (p < 0.05). No relationship existed between the degree of improvements and the severeness of developmental delay in the measurements. ‘Touch screen-based cognitive training’ in special school was feasible and it improved cognition in children with severe cognitive impairment (developmental age 18–36 months), irrespective of the severeness of the developmental delay.

Gamified Attention Training in the Primary School Classroom: A Cluster-Randomized Controlled Trial

Objective: This randomized controlled trial evaluated the efficacy of attention training delivered in class on cognitive attention processes, inattention, hyperactivity, working memory, and numeracy in primary school children. Method: Eight classes (n = 98 children; 5-9 years) were cluster randomized to gamified attention training, a placebo program, or a no-contact control condition. Assessments were conducted at baseline, immediately after the 5-week intervention (posttraining), and 6 months later (follow-up). Results: Posttraining, attention training was associated with reduced inattention and hyperactivity within the classroom compared with controls, and reduced hyperactivity at home compared with the no-contact control. At follow-up, reduced hyperactivity within the classroom compared with the no-contact control persisted. No effects of training on cognitive attention processes, working memory, and numeracy were observed posttraining. Conclusion: Classroom-based attention training has select benefits in reducing inattention and hyperactivity, but may not promote gains in cognitive or academic skills in primary school children.

Sustained benefits of cognitive training in children with inattention, three-year follow-up

The goal of this study was to test for long-term benefits three years after the completion of a cognitive training intervention (Project: EVO™) in a subset of children with Sensory Processing Dysfunction (SPD). Our initial findings revealed that children with SPD who also met research criteria for Attention Deficit Hyperactivity Disorder (SPD+IA) showed a significant decrease in parent-observed inattentive behaviors, which remained stable in a nine-month follow-up assessment. Forty nine caregivers of participants who completed the Project: EVO™ training were contacted to be included in this follow up study. Each was emailed an invitation to complete the Vanderbilt ADHD Diagnostic Parent Rating Scale, which yielded a completion rate of 39/49 (80%). A Generalized Estimating Equations analysis was used to assess changes in symptoms over time, specifically to determine whether the initial improvements were retained. The SPD+IA cohort continued to show sustained benefits on their parent-reported scores of inattention, with 54% of SPD+IA individuals no longer meeting criteria for ADHD three years following intervention. These findings provide initial insights into the potential long-term benefits of a digital health intervention for children with attention-based issues.

Effect of Neurocognitive Training for Children With ADHD at Improving Academic Engagement in Two Learning Settings

Objective: This preliminary study investigated effectiveness of neurocognitive training on academic engagement (AET) for children with ADHD. The training approach targeted working memory, inhibitory control, and attention/relaxation (via brain electrical activity). Method: A reversal design with a 2-week follow-up was used to assess the effectiveness of the treatment on two children with diagnosed ADHD in two learning settings. Direct observation was used to collect academic-related behavior. Results: Improvements in on-task expected behavior (ONT-EX) and general AET, as well as reductions in off-task motor activity (OFF-MA) and off-task passive behavior (OFF-PB) were observed for both students over baselines and across the settings. Moreover, differences in behavioral change were found between participants and settings. Conclusion: These findings support using the treatment for improving academic performance of children with ADHD. Future studies may investigate influences of contextual differences, nontreatment variables, or adult's feedback during the training session on treatment effectiveness.

High Trait Attention Promotes Resilience and Reduces Binge Drinking Among College Students With a Family History of Alcohol Use Disorder

Binge patterns of alcohol use among post-high school emerging adults are associated with both immediate negative consequences and increased risk of long-term drinking problems, particularly among individuals with a family history (FH) of alcohol use disorder (AUD). Therefore, the developmental time period of emerging adulthood, paired with the high-risk environment of college campuses, represents an important target for interventions. Attentional ability has recently emerged as a mediator of resilience to stress-related psychopathology and offers a potential neurocognitive target for interventions. We tested the hypothesis that attentional ability promotes resilience to binge drinking in a sample of 464 college students with (n = 221) or without (n = 243) familial risk for AUD. Two-way analyses of covariance (ANCOVA) tested effects of FH and self-reported binge drinking on attention scores from the Barratt Impulsiveness Scale (BIS). In addition, mediation analyses tested whether BIS attention scores mediated the relationship between Conner-Davidson Resilience Scale scores and binge drinking. ANCOVA results indicated a significant FH-by-binge drinking interaction (p = 0.008) in which FH positive subjects who did not binge drink had the fewest attention problems, consistent with a marker of resilience. Furthermore, BIS attention scores significantly mediated the effect of Conner-Davidson Resilience Scale scores on binge drinking, with stronger effects in FH positive subjects (p < 0.001) than FH negative subjects (p = 0.49). The findings suggest that attention promotes resilience to binge drinking in individuals with familial risk for AUD. Interventions targeting attentional ability in this high-risk population, particularly FH positive individuals with attention deficits, may serve to reduce binge drinking and its consequences.

Computer-based inhibitory control training in children with Attention-Deficit/Hyperactivity Disorder (ADHD): Evidence for behavioral and neural impact

Attention-deficit hyperactivity disorder (ADHD) is the most commonly diagnosed psychological disorder of childhood. Medication and cognitive behavioral therapy are effective treatments for many children; however, adherence to medication and therapy regimens is low. Thus, identifying effective adjunct treatments is imperative. Previous studies exploring computerized training programs as supplementary treatments have targeted working memory or attention. However, many lines of research suggest inhibitory control (IC) plays a central role in ADHD pathophysiology, which makes IC a potential intervention target. In this randomized control trial (NCT03363568), we target IC using a modified stop-signal task (SST) training designed by NeuroScouting, LLC in 40 children with ADHD, aged 8 to 11 years. Children were randomly assigned to adaptive treatment (n = 20) or non-adaptive control (n = 20) with identical stimuli and task goals. Children trained at home for at least 5 days a week (about 15m/day) for 4-weeks. Relative to the control group, the treatment group showed decreased relative theta power in resting EEG and trending improvements in parent ratings of attention (i.e. decreases in inattentive behaviors). Both groups showed improved SST performance. There was not evidence for treatment effects on hyperactivity or teacher ratings of symptoms. Results suggest training IC alone has potential to positively impact symptoms of ADHD and provide evidence for neural underpinnings of this impact (change in theta power; change in N200 latency). This shows promising initial results for the use of computerized training of IC in children with ADHD as a potential adjunct treatment option for children with ADHD.

Using the NIH Toolbox to Assess Cognition in Adolescents and Young Adults with Autism Spectrum Disorders

Despite the clinically significant impact of executive dysfunction on the outcomes of adolescents and young adults with autism spectrum disorders (ASD), we lack a clear understanding of its prevalence, profile, and development. To address this gap, we administered the NIH Toolbox Cognition Battery to a cross-sectional Intelligence Quotient (IQ) case-matched cohort with ASD (n = 66) and typical development (TD; n = 66) ages 12-22. We used a general linear model framework to examine group differences in task performance and their associations with age. Latent profile analysis (LPA) was used to identify subgroups of individuals with similar cognitive profiles. Compared to IQ case-matched controls, ASD demonstrated poorer performance on inhibitory control (P < 0.001), cognitive flexibility (P < 0.001), episodic memory (P < 0.02), and processing speed (P < 0.001) (components of Fluid Cognition), but not on vocabulary or word reading (components of Crystallized Cognition). There was a significant positive association between age and Crystallized and Fluid Cognition in both groups. For Fluid (but not Crystallized) Cognition, ASD performed more poorly than TD at all ages. A four-group LPA model based on subtest scores best fit the data. Eighty percent of ASD belonged to two groups that exhibited relatively stronger Crystallized versus Fluid Cognition. Attention deficits were not associated with Toolbox subtest scores, but were lowest in the group with the lowest proportion of autistic participants. Adaptive functioning was poorer in the groups with the greatest proportion of autistic participants. Autistic persons are especially impaired on Fluid Cognition, and this more flexible form of thinking remains poorer in the ASD group through adolescence. LAY SUMMARY: A set of brief tests of cognitive functioning called the NIH Toolbox Cognition Battery was administered to adolescents and young adults with autism spectrum disorders (ASD; n = 66) and typical development (TD; n = 66) ages 12-22 years. Compared to TD, ASD showed poorer performance in inhibiting responses, acting flexibly, memorizing events, and processing information quickly (Fluid Cognition). Groups did not differ on vocabulary or word reading (Crystallized Cognition). Crystallized and Fluid Cognition increased with age in both groups, but the ASD group showed lower Fluid, but not Crystallized, Cognition than TD at all ages. A categorization analysis including all participants showed that most participants with ASD fell into one of two categories: a group characterized by poor performance across all tasks, or a group characterized by relatively stronger Crystallized compared to Fluid Cognition. Adaptive functioning was poorer for participants in these groups, which consisted of mostly individuals with ASD, while ADHD symptoms were lowest in the group with the greatest proportion of TD participants.

A Novel Feed-Forward Modeling System Leads to Sustained Improvements in Attention and Academic Performance

Objective: This study tested a novel feed-forward modeling (FFM) system as a nonpharmacological intervention for the treatment of ADHD children and the training of cognitive skills that improve academic performance. Method: This study implemented a randomized, controlled, parallel design comparing this FFM with a nonpharmacological community care intervention. Improvements were measured on parent- and clinician-rated scales of ADHD symptomatology and on academic performance tests completed by the participant. Participants were followed for 3 months after training. Results: Participants in the FFM training group showed significant improvements in ADHD symptomatology and academic performance, while the control group did not. Improvements from FFM were sustained 3 months later. Conclusion: The FFM appeared to be an effective intervention for the treatment of ADHD and improving academic performance. This FFM training intervention shows promise as a first-line treatment for ADHD while improving academic performance.

Effectiveness of Cognitive Training for School-Aged Children and Adolescents With Attention Deficit/Hyperactivity Disorder: A Systematic Review

Problems with executive functions (EF) are hallmark characteristics of Attention Deficit/Hyperactivity Disorder (ADHD). Therefore, this review analyzed the efficacy of cognitive training for EF in reducing ADHD symptomatology and improving educational, interpersonal, and occupational outcomes in children and adolescents with this disorder. A systematic search, using a PICO (population/participant, intervention/indicator, comparator/control, outcome) framework was carried out. From 2008 to 2018, resorting to EBSCOhost, the following databases were searched: Academic Search Complete, ERIC, MEDLINE with Full Text, PsycARTICLES, PsycINFO, and Psychology and Behavioral Sciences Collection. Twenty-two studies were included in this review. Of the 18 studies that reported performance-based measures of EF, 13 found improvements and five did not. Overall, 17 studies showed positive transfer effects on ADHD symptomatology, EF, academic improvement, reduced off-task behavior, and/or enhanced social skills. Of the nine studies that performed follow-up sessions, seven concluded that the treatment effects were maintained over time. In sum, results showed that cognitive training can be an effective intervention for children and adolescents with ADHD and might be a complementary treatment option for this disorder.

Non-pharmacological interventions for cognitive difficulties in ADHD: A systematic review and meta-analysis

Attention deficit hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder in children and is associated with significant risk of educational failure, interpersonal problems, mental illness, and delinquency. Despite a number of comparative and comprehensive reviews on the effects of ADHD treatments on ADHD core symptoms, evidence synthesizing the effects of ADHD interventions on cognitive difficulties is limited. In this meta-analysis, the neuropsychological effects of non-pharmacological interventions for ADHD were examined across studies published between 1980 and 2017. Data were extracted from studies that used objective cognitive measures (either computerized or pencil-and-paper), and multiple meta-analyses were conducted to compare the effectiveness across these interventions. Publication bias was assessed, as well as quality of the evidence, using Cochrane risk of bias tool for randomized control trials studies. Our final meta-analysis included 18 studies with interventions that were categorized into four categories: neurofeedback, cognitive-behavioral therapy, cognitive training, and physical exercises. Physical exercises demonstrated the highest average effect size (Morris d = 0.93). A further evaluation of cognitive functions yielded 49 effect sizes for the five categories, including attention, inhibition, flexibility, and working memory. Analyses demonstrated a homogenous, medium to large, effect size of improvement across interventions, with inhibition demonstrating the largest average effect size (Morris d = 0.685). This study highlights the positive effect of psychological interventions on ADHD cognitive symptomology and supports the inclusion of non-pharmacological interventions in conjunction with the commonly used pharmacological treatments.

A Large-Scale, Cross-Sectional Investigation Into the Efficacy of Brain Training

Brain training is a large and expanding industry, and yet there is a recurrent and ongoing debate concerning its scientific basis or evidence for efficacy. Much of evidence for the efficacy of brain training within this debate is from small-scale studies that do not assess the type of “brain training,” the specificity of transfer effects, or the length of training required to achieve a generalized effect. To explore these factors, we analyze cross-sectional data from two large Internet-cohort studies (total N = 60,222) to determine whether cognition differs at the population level for individuals who report that they brain train on different devices, and across different timeframes, with programs in common use circa 2010–2013. Examining scores for an assessment of working-memory, reasoning and verbal abilities shows no cognitive advantages for individuals who brain train. This contrasts unfavorably with significant advantages for individuals who regularly undertake other cognitive pursuits such as computer, board and card games. However, finer grained analyses reveal a more complex relationship between brain training and cognitive performance. Specifically, individuals who have just begun to brain train start from a low cognitive baseline compared to individuals who have never engaged in brain training, whereas those who have trained for a year or more have higher working-memory and verbal scores compared to those who have just started, thus suggesting an efficacy for brain training over an extended period of time. The advantages in global function, working memory, and verbal memory after several months of training are plausible and of clinically relevant scale. However, this relationship is not evident for reasoning performance or self-report measures of everyday function (e.g., employment status and problems with attention). These results accord with the view that although brain training programs can produce benefits, these might extend to tasks that are operationally similar to the training regime. Furthermore, the duration of training regime required for effective enhancement of cognitive performance is longer than that applied in most previous studies.

Clinical and Experimental Factors Influencing the Efficacy of Neurofeedback in ADHD: A Meta-Analysis

Meta-analyses have been extensively used to evaluate the efficacy of neurofeedback (NFB) treatment for Attention Deficit/Hyperactivity Disorder (ADHD) in children and adolescents. However, each meta-analysis published in the past decade has contradicted the methods and results from the previous one, thus making it difficult to determine a consensus of opinion on the effectiveness of NFB. This works brings continuity to the field by extending and discussing the last and much controversial meta-analysis by Cortese et al. (1). The extension comprises an update of that work including the latest control trials, which have since been published and, most importantly, offers a novel methodology. Specifically, NFB literature is characterized by a high technical and methodological heterogeneity, which partly explains the current lack of consensus on the efficacy of NFB. This work takes advantage of this by performing a Systematic Analysis of Biases (SAOB) in studies included in the previous meta-analysis. Our extended meta-analysis (k = 16 studies) confirmed the previously obtained results of effect sizes in favor of NFB efficacy as being significant when clinical scales of ADHD are rated by parents (non-blind, p-value = 0.0014), but not when they are rated by teachers (probably blind, p-value = 0.27). The effect size is significant according to both raters for the subset of studies meeting the definition of "standard NFB protocols" (parents' p-value = 0.0054; teachers' p-value = 0.043, k = 4). Following this, the SAOB performed on k = 33 trials identified three main factors that have an impact on NFB efficacy: first, a more intensive treatment, but not treatment duration, is associated with higher efficacy; second, teachers report a lower improvement compared to parents; third, using high-quality EEG equipment improves the effectiveness of the NFB treatment. The identification of biases relating to an appropriate technical implementation of NFB certainly supports the efficacy of NFB as an intervention. The data presented also suggest that the probably blind assessment of teachers may not be considered a good proxy for blind assessments, therefore stressing the need for studies with placebo-controlled intervention as well as carefully reported neuromarker changes in relation to clinical response.

What is the level of evidence for the use of currently available technologies in facilitating the self-management of difficulties associated with ADHD in children and young people? A systematic review

A number of technologies to help self-manage attention deficit hyperactivity disorder (ADHD) in children and young people (YP) have been developed. This review will assess the level of evidence for the use of such technologies. The review was undertaken in accordance with the general principles recommended in the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. 7545 studies were screened. Fourteen studies of technology that aim to self-manage difficulties associated with ADHD in children and YP were included. Primary outcome measures were measures that assessed difficulties related to ADHD. Databases searched were MEDLINE, Web of Science (Core collection), CINAHL, the Cochrane Library, ProQuest ASSIA, PsycINFO and Scopus. The methodological quality of the studies was assessed. This review highlights the potential for the use of technology in paediatric ADHD management. However, it also demonstrates that current research lacks robustness; using small sample sizes, non-validated outcome measures and little psychoeducation component. Future research is required to investigate the value of technology in supporting children and YP with ADHD and a focus psychoeducation is needed.

Brain Training in Children and Adolescents: Is It Scientifically Valid?

Background: Brain training products are becoming increasingly popular for children and adolescents. Despite the marketing aimed at their use in the general population, these products may provide more benefits for specific neurologically impaired populations. A review of Brain Training (BT) products analyzing their efficacy while considering the methodological limitations of supporting research is required for practical applications. Method: searches were made of the PubMed database (until March 2017) for studies including: (1) empirical data on the use of brain training for children or adolescents and any effects on near transfer (NT) and/or far transfer (FT) and/or neuroplasticity, (2) use of brain training for cognitive training purposes, (3) commercially available training applications, (4) computer-based programs for children developed since the 1990s, and (5) relevant printed and peer-reviewed material. Results: Database searches yielded a total of 16,402 references, of which 70 met the inclusion criteria for the review. We classified programs in terms of neuroplasticity, near and far transfer, and long-term effects and their applied methodology. Regarding efficacy, only 10 studies (14.2%) have been found that support neuroplasticity, and the majority of brain training platforms claimed to be based on such concepts without providing any supporting scientific data. Thirty-six studies (51.4%) have shown far transfer (7 of them are non-independent) and only 11 (15.7%) maintained far transfer at follow-up. Considering the methodology, 40 studies (68.2%) were not randomized and controlled; for those randomized, only 9 studies (12.9%) were double-blind, and only 13 studies (18.6%) included active controls in their trials. Conclusion: Overall, few independent studies have found far transfer and long-term effects. The majority of independent results found only near transfer. There is a lack of double-blind randomized trials which include an active control group as well as a passive control to properly control for contaminant variables. Based on our results, Brain Training Programs as commercially available products are not as effective as first expected or as they promise in their advertisements.

Interdisciplinary Ugandan perspectives on computerized intervention implementation for child survivors of severe malaria: A qualitative analysis

PURPOSE

Severe malaria (SM) is the leading cause of pediatric cognitive impairment in sub-Saharan Africa. Computerized Cognitive Rehabilitation Therapy (CCRT), a promising intervention for children suffering from SM related cognitive delay, targets areas impacted by the disease (memory, attention, and executive function), but has yet to be implemented for daily use. This paper explores the perspectives of Ugandan professionals regarding CCRT implementation in the academic setting of Uganda.

METHODS

A qualitative descriptive approach was taken to conduct interviews with Ugandan professionals directly or indirectly aware of an ongoing CCRT intervention trial. Eight individuals were consented and interviewed. Responses were analyzed thematically. Question topics included knowledge of malaria and CCRT, perspectives on implementation feasibility, and experience engaging in a global collaborative research endeavor.

RESULTS

Facilitators included perceived value and environment. Potential barriers were geography and resource availability. Perceived value is seen, expected, and/or hoped for outcomes by adults involved in the child's development. Environment speaks to the internal environment of the CCRT program as well as the external environment of the school setting. Geography presents as a barrier due to the difficulty of accessing CCRT in rural settings. Resource availability was a consistently identified barrier to implementation including aspects of technological, financial, and understanding deficits leading to difficulties in CCRT dissemination.

CONCLUSION

Results demonstrate optimism and hope of Ugandan professionals for CCRT in children who have survived SM. Professionals identify and prioritize needs for implementation uniquely, pointing to the value in interdisciplinary collaboration to ensure effective implementation of CCRT.

Clinician-delivered cognitive training for children with attention problems: effects on cognition and behavior from the ThinkRx randomized controlled trial

PURPOSE

The impact of attention problems on academic and social functioning coupled with the large number of children failing to respond to stimulant medication or behavioral therapy makes adjunctive therapies such as cognitive training appealing for families and clinicians of children with attention difficulties or childhood attention deficit hyperactivity disorder. However, the results of cognitive training studies have failed to find far transfer effects with this population. This study examined the quantitative cognitive effects and parent-reported behavioral effects of a clinician-delivered cognitive training program with children who have attention problems.

PATIENTS AND METHODS

Using a randomized controlled study design, we examined the impact of a clinician-delivered cognitive training program on processing speed, fluid reasoning, memory, visual processing, auditory processing, attention, overall intelligence quotient score, and behavior of students (n=13) aged 8-14 years with attention problems. Participants were randomly assigned to either a waitlist control group or a treatment group for 60 hours of cognitive training with ThinkRx, a clinician-delivered intervention that targets multiple cognitive skills with game-like, but rigorous mental tasks in 60-90-minute training sessions at least 3 days per week.

RESULTS

Results included greater mean pretest to posttest change scores on all variables for the treatment group versus the control group with statistically significant differences noted in working memory, long-term memory, logic and reasoning, auditory processing, and intelligence quotient score. Qualitative outcomes included parent-reported changes in confidence, cooperation, and self-discipline.

CONCLUSION

Children with attention problems who completed 60 hours of clinician-delivered ThinkRx cognitive training realized both cognitive and behavioral improvements.

"When the Prescription Pad Is Not Enough": Attention-Deficit Hyperactivity Disorder Management 2.0

Jose is a 13-year-old boy who presents to his primary care provider after struggling in school for many years. When he was in the first grade, he was diagnosed at a tertiary center with attention-deficit hyperactivity disorder. Multiple medication trials have produced few benefits and many side effects including poor sleep, morbid thoughts, lack of motivation, and, according to his parents, "he seemed like a robot."He comes now for his annual physical in April, and the parents tell you that the school is threatening that he be retained in the seventh grade. Parents are very adamant they do not want to try another medication. They have brought you their own and his advisor's Vanderbilt's, which each endorse 7 of 9 inattentive symptoms including trouble organizing, poor attention to detail, and easily distracted and forgetful in daily activities.His birth history and developmental history before beginning formal schooling are unremarkable. His first language was English whereas his parents speak Spanish to each other but not the children. He is healthy and without a history of head trauma, seizures, meningitis, or lead poisoning. An aunt has "learning problems."Jose's family lives in a crowded section of a large urban area. They share an apartment with another family, and both parents are employed full time with his father holding 2 full time jobs working double shifts. Their annual income is at the poverty line. There are 4 children in the family aged between 6 and 13 years.His school has been deemed a "recovery school" because of performing below standard on district-wide achievement tests. His classroom has 27 students, many of whom are English language learners, and he is not on an individualized education plan or 504 accommodations.The family is very concerned about the possibility of retention but have decided that "medicine does not help," and they look to you for other recommendations. Where do you go next?

Cognitive remediation in pediatric chronic kidney disease and end-stage kidney disease: rationale, candidate interventions, and applicability

The purpose of this paper is to address the potential use of cognitive remediation interventions for children and adolescents with chronic kidney disease (CKD) and end-stage kidney disease (ESKD). The prevalence and risk for neurocognitive dysfunction in children with this condition remains high, but, to date, interventions targeting these challenges have not been attempted either individually or as part of a larger treatment program. This is the next logical step in addressing the neurocognitive dysfunction that can be present in pediatric CKD/ESKD, with the field needing to determine the efficacy of cognitive remediation approaches for this population. To our knowledge, this paper is the first to raise this possibility by identifying candidate treatments addressing the neurocognitive challenges observed in children and adolescents with CKD/ESKD. Initially, we present the rationale for the importance of addressing the cognitive difficulties in this population, including an overview of the literature documenting the neurocognitive deficits associated with pediatric-onset CKD/ESKD. This is followed by a review of five candidate cognitive remediation programs that may be applicable to patients with this condition, and associated factors that could affect such treatment. The paper concludes with suggestions for both clinical and research initiatives that could be implemented to examine cognitive remediation as potential components of a larger treatment program for children and adolescents with CKD/ESKD.

A double-blind randomized pilot trial comparing computerized cognitive exercises to Tetris in adolescents with attention-deficit/hyperactivity disorder

BACKGROUND

The purpose of this trial was to examine the feasibility and efficacy of computerized cognitive exercises from Scientific Brain Training (SBT), compared to the computer game Tetris as an active placebo, in a pilot study of adolescents with attention-deficit/hyperactivity disorder (ADHD).

METHOD

Eighteen adolescents with ADHD were randomized to treatment or control intervention for 7 weeks. Outcome measures were cognitive test, symptom, and motivation questionnaires.

RESULTS

SBT and Tetris were feasible as home-based interventions, and participants' compliance was high, but participants perceived both interventions as not very interesting or helpful. There were no significant group differences on cognitive and ADHD-symptom measures after intervention. Pre-post intra-group measurement showed that the SBT had a significant beneficial effect on sustained attention, while the active placebo had significant beneficial effects on working memory, both with large effect sizes.

CONCLUSION

Although no significant differences were found between groups on any measure, there were significant intra-group changes for each group.

Computerized cognitive training in children and adolescents with attention deficit/hyperactivity disorder as add-on treatment to stimulants: feasibility study and protocol description

Abstract Background Cognitive training has received increasing attention as a non-pharmacological approach for the treatment of attention deficit/hyperactivity disorder (ADHD) in children and adolescents. Few studies have assessed cognitive training as add-on treatment to medication in randomized placebo controlled trials. The purpose of this preliminary study was to explore the feasibility of implementing a computerized cognitive training program for ADHD in our environment, describe its main characteristics and potential efficacy in a small pilot study. Methods Six ADHD patients aged 10-12-years old receiving stimulants and presenting residual symptoms were enrolled in a randomized clinical trial to either a standard cognitive training program or a controlled placebo condition for 12 weeks. The primary outcome was core ADHD symptoms measured using the Swanson, Nolan and Pelham Questionnaire (SNAP-IV scale). Results We faced higher resistance than expected to patient enrollment due to logistic issues to attend face-to-face sessions in the hospital and to fill the requirement of medication status and absence of some comorbidities. Both groups showed decrease in parent reported ADHD symptoms without statistical difference between them. In addition, improvements on neuropsychological tests were observed in both groups – mainly on trained tasks. Conclusions This protocol revealed the need for new strategies to better assess the effectiveness of cognitive training such as the need to implement the intervention in a school environment to have an assessment with more external validity. Given the small sample size of this pilot study, definitive conclusions on the effects of cognitive training as add-on treatment to stimulants would be premature.

A pilot study to determine the feasibility of enhancing cognitive abilities in children with sensory processing dysfunction

Children with Sensory Processing Dysfunction (SPD) experience incoming information in atypical, distracting ways. Qualitative challenges with attention have been reported in these children, but such difficulties have not been quantified using either behavioral or functional neuroimaging methods. Furthermore, the efficacy of evidence-based cognitive control interventions aimed at enhancing attention in this group has not been tested. Here we present work aimed at characterizing and enhancing attentional abilities for children with SPD. A sample of 38 SPD and 25 typically developing children were tested on behavioral, neural, and parental measures of attention before and after a 4-week iPad-based at-home cognitive remediation program. At baseline, 54% of children with SPD met or exceeded criteria on a parent report measure for inattention/hyperactivity. Significant deficits involving sustained attention, selective attention and goal management were observed only in the subset of SPD children with parent-reported inattention. This subset of children also showed reduced midline frontal theta activity, an electroencephalographic measure of attention. Following the cognitive intervention, only the SPD children with inattention/hyperactivity showed both improvements in midline frontal theta activity and on a parental report of inattention. Notably, 33% of these individuals no longer met the clinical cut-off for inattention, with the parent-reported improvements persisting for 9 months. These findings support the benefit of a targeted attention intervention for a subset of children with SPD, while simultaneously highlighting the importance of having a multifaceted assessment for individuals with neurodevelopmental conditions to optimally personalize treatment.

An RCT into the effects of neurofeedback on neurocognitive functioning compared to stimulant medication and physical activity in children with ADHD

Neurofeedback (NFB) is a potential alternative treatment for children with ADHD that aims to optimize brain activity. Whereas most studies into NFB have investigated behavioral effects, less attention has been paid to the effects on neurocognitive functioning. The present randomized controlled trial (RCT) compared neurocognitive effects of NFB to (1) optimally titrated methylphenidate (MPH) and (2) a semi-active control intervention, physical activity (PA), to control for non-specific effects. Using a multicentre three-way parallel group RCT design, children with ADHD, aged 7-13, were randomly allocated to NFB (n = 39), MPH (n = 36) or PA (n = 37) over a period of 10-12 weeks. NFB comprised theta/beta training at CZ. The PA intervention was matched in frequency and duration to NFB. MPH was titrated using a double-blind placebo controlled procedure to determine the optimal dose. Neurocognitive functioning was assessed using parameters derived from the auditory oddball-, stop-signal- and visual spatial working memory task. Data collection took place between September 2010 and March 2014. Intention-to-treat analyses showed improved attention for MPH compared to NFB and PA, as reflected by decreased response speed during the oddball task [η p2  = 0.21, p < 0.001], as well as improved inhibition, impulsivity and attention, as reflected by faster stop signal reaction times, lower commission and omission error rates during the stop-signal task (range η p2  = 0.09-0.18, p values <0.008). Working memory improved over time, irrespective of received treatment (η p2  = 0.17, p < 0.001). Overall, stimulant medication showed superior effects over NFB to improve neurocognitive functioning. Hence, the findings do not support theta/beta training applied as a stand-alone treatment in children with ADHD.

The Efficacy of Computerized Cognitive Training in Adults With ADHD: A Randomized Controlled Trial

OBJECTIVE

This is a randomized control trial examining the efficiency of computerized cognitive training (CCT) for adults with ADHD, comparing two training conditions with graded levels of executive cognitive demands.

METHOD

Adults with ADHD (n = 60) were randomized into study (n = 34) and control (n = 26) groups. Training was conducted with the computerized AttenFocus program. Control group received a simple, non-hierarchical version with less executive demands.

RESULTS

Significant positive changes in symptoms ratings, ecological measures of executive functions, and occupational performance were found in both groups. No significant changes were found in variables of neurocognitive performance battery and quality of life. No significant time by group interaction effects were found.

CONCLUSION

No benefits of the intervention were found relative to the control. Lack of interaction effects may be due to insufficient power, non-specific cognitive training or placebo effects. Results demonstrate some positive findings for general CCT, yet do not support the inclusion of specific higher level executive training.

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.

A pilot randomized controlled trial comparing computer-assisted cognitive rehabilitation, stimulant medication, and an active control in the treatment of ADHD

BACKGROUND

This research aimed to compare computer-assisted cognitive rehabilitation (CACR) psychostimulants (MED) and placebo CACR (PCACR) in the treatment of ADHD using a multiarm parallel design.

METHODS

Thirty-four boys with ADHD, aged 7-12, were randomly assigned to either CACR (n = 12), MED (n = 11), or PCACR (n = 11). However, the study was not blinded and medication doses might be suboptimal given the lack of titration. Continuous performance test, Tower-of-London, forward/backward digit span, span board, Raven's progressive matrices, and SNAP-IV were completed at baseline, posttest, and follow-up.

RESULTS

Computer-assisted cognitive rehabilitation outperformed both MED and PCACR on backward digit span at posttest and PCACR at follow-up. CACR outperformed PCACR and MED on forward digit span at posttest and PCACR at follow-up. CACR outperformed MED on span board at posttest. CACR outperformed PCACR and MED on Raven's matrices at posttest. CACR and PCACR scored lower than MED on ADHD-PHI at posttest. CACR scored lower than MED on ADHD-C at posttest.

CONCLUSIONS

Immediately after interventions, CACR improved certain simple executive functions (EFs) as much as active stimulant medication. On complex EFs, CACR was superior to active stimulant medication and PCACR. CACR reduced behavioral symptoms of ADHD more than active stimulant medication. However, at 3-month follow-up, maintenance of the CACR gains was weak.

Nonpharmacological Interventions for Children with Attention Deficit Hyperactivity Disorder in India: A Comprehensive and Comparative Research Update

The nonpharmacological treatments for children with attention deficit hyperactivity disorder (ADHD) have witnessed a sea change from a rudimentary and haphazard psychosocial to cognitive interventions to social and behavioral skills to body oriented interventions to more sophisticated neurocognitive interventions. As the objective of each treatment varied, the method or procedure of each treatment also differed across studies. Indian research although not very rigorous, did witness changes emphasizing on exploring interventions in reducing symptoms and improving overall behavior. The research literature between 2005 and 2015 was searched using PubMed, Google Scholar, IndMED, MedIND, ResearchGate, and other indexed databases. Results of 110 studies were organized into five broad categories of themes of interventions such as psychosocial, body-focused, cognitive/neuro-cognitive, and cognitive behavioral. Effects of ADHD on cognitive, academic, and behavioral outcomes were also highlighted before the themes of intervention to establish linkage with discussion. However, a limited number (n = 9) of reported Indian studies focusing either on the impact of ADHD on the function of children or on interventions were found, suggesting a huge gap between global and Indian research in the area of children with ADHD. It also highlights the need for development and efficacy testing of indigenous intervention program in different areas of intervention for research and clinical practice.

Neurofeedback Therapy for Enhancing Visual Attention: State-of-the-Art and Challenges

We have witnessed a rapid development of brain-computer interfaces (BCIs) linking the brain to external devices. BCIs can be utilized to treat neurological conditions and even to augment brain functions. BCIs offer a promising treatment for mental disorders, including disorders of attention. Here we review the current state of the art and challenges of attention-based BCIs, with a focus on visual attention. Attention-based BCIs utilize electroencephalograms (EEGs) or other recording techniques to generate neurofeedback, which patients use to improve their attention, a complex cognitive function. Although progress has been made in the studies of neural mechanisms of attention, extraction of attention-related neural signals needed for BCI operations is a difficult problem. To attain good BCI performance, it is important to select the features of neural activity that represent attentional signals. BCI decoding of attention-related activity may be hindered by the presence of different neural signals. Therefore, BCI accuracy can be improved by signal processing algorithms that dissociate signals of interest from irrelevant activities. Notwithstanding recent progress, optimal processing of attentional neural signals remains a fundamental challenge for the development of efficient therapies for disorders of attention.