Computer-Based Cognitive Training Programme For ADHD And Other Disorders: Are They Effective?

It is an intriguing thought to consider that we may be able to improve the cognitive and executive function difficulties associated with disorders such as ADHD without using medication. Over the last seven to ten years a number of commercially available cognitive training programmes are now available to the public. In Hong Kong there are several psychology clinics that promote these interventions. The programmes are marketed as having research evidence documenting their effectiveness for children. They involve “brain training” in systematic and repetitive game style activities that target some specific cognitive domain such as attention or working memory. These skills are sometimes referred to as “Executive Functions” of the brain. Executive function is a term that is becoming more and more familiar to parents and educators. This refers to persons’ internal capacity to regulate their attention, working memory, organisational skills and emotions. Research has clearly shown that these skills are impaired in children with ADHD, Autism/Asperger Syndrome and Dyslexia. Computer based cognitive training programmes make claims that they can increase or improve a child’s abilities related to executive function.

These programmes can be quite attractive to parents and even schools as they seem a low risk, less invasive treatment versus medication or traditional behavioural intervention that requires a lot of increased adult involvement in a child’s life. The theoretical background for development of these programmes comes from the increasing body of evidence from neuroscience that environmental experiences and interventions can alter brain development. But do these programmes really work? Is there enough solid research evidence such that professionals working in mental health and education should be recommending these as an evidence based treatment for attention or other cognitive difficulties?

There are several commercially based cognitive training programmes that have some research published on their effectiveness including: Cogmed, Jungle Memory, Captain’s Log and Brain Fitness Pro-Junior. Cogmed which utilises computer games that are targeted at increasing working memory has the largest number of studies in the research literature. The problem is that in many of these studies the research methodology is somewhat lacking making it difficult to draw specific conclusions about the programme’s effectiveness. What some studies do show is that computerised cognitive training programmes result in short term performance improvements on the tasks that are involved in the programme and can also increase working memory and attention if the tasks are similar to those that are used in the training programme. Providers of these commercial training programmes suggest that this indicates that there are changes in brain structuring as a result of the programme. Therefore this increases the efficiency of a participant’s working memory and attentional systems. That should then transfer to related abilities such as attention and organisational skills in the classroom, regulating behaviour and increased academic performance.

The best study to date that document the effectiveness of cognitive training programmes on working memory is by Dr M Melby and will be published in the Journal of Developmental Psychology. This is a meta-analysis which means thirty studies that met crucial research criteria such as inclusion of a control group and randomised assignment were analysed. Results suggested that there were some immediate training effects for verbal and visual spatial working memory tasks. The evidence was strongest for children that were 10 years old or younger but overall there were no long term benefits after implementation of the programme. They found some small effects and generalisation to related reasoning tasks but the effects disappeared when a control group or randomised design was utilised. There were no improvements on verbal reasoning, word reading or arithmetic and it was concluded that the evidence does not support the notion that working memory, computer based cognitive training programmes produced significant positive outcomes on related tasks that typically involve working memory.

There were only a handful of studies attempting to document the effectiveness of computer based training programmes on core ADHD symptoms. These are studies that included control groups and had random assignment. One study included thirty six 6 to 13 year olds with ADHD and utilized a combination of non commercial attention training tasks The outcome suggested that those in the treatment group had increased reading comprehension and passage copying skills and parent’s ratings indicated a reduction in attention problems. The intervention took place for eight weeks but there was no follow up data or teacher ratings or measures of school performance included as measurement criteria.

In the second study utilising Captain’s Log, 6 and 7 year old children who were rated as inattentive by their teachers were randomly assigned to a computerised training programme, a computerised academic intervention or a waitlist. Results suggested that the children participating in the computerised training programme significantly reduced their inattentive behaviour based on teacher ratings. However, positive gains in their attentional skills did not sustain at follow up.

In another study, forty one middle school age students with ADHD were assigned one of three conditions (Neuro Feedback, Captain’s Log Computer Training or Wait List). There were various rating scales used as outcome measures. Children in both the Neuro Feedback and Computer Training Programme a lot of evidenced improvement in their behaviour based on parent’s ratings but this was also the case for the Wait List control group. However, teacher’s ratings suggested that there were no significant improvements for any of the three groups before and after the interventions.

The pattern appears to be same for studies on the outcome of improving attention as it is for working memory. Short term immediate effects on some measures of similar tasks are noted but there is not solid evidence for long term improvement. Evidence for overall improvement in academic functioning was only noted in one study.

Putting all of these results together, it appears that computerised cognitive training programmes can produce some changes in attention and overall executive functioning in the short term but to say that they are reliable and valid and there is evidence of transfer to improved school functioning does not appear to be the case at present. This is in marked contrast to the claims of the vendors of commercial cognitive training programmes. Overall, there are many questions that remain about the clinical utility of these programmes. The problems with the studies that are put forward as evidence by the marketers of these programmes is that they have methodological flaws such as lack of control groups, single measures of cognitive constructs and inconsistent transfer to tasks across studies. Researchers question whether the short term benefits of cognitive training programmes are really evidence of underlying changes in brain function as opposed to something as simple as a practise effect with certain tasks.
In looking at the working memory tasks that are included in many of these programmes they are relatively simple. Researchers question how potent they can really be given that executive function and related cognitive skills are quite complex and involve many components of our nervous system. Intuitively it can be hard to accept that a relatively simple cognitive task could have a significant overall impact on a complex system such as executive function and lead to significant changes in a person’s day to day ability to focus, attend, block out distraction, regulate behaviour and perform academically.

Perhaps computerised cognitive training programmes could someday help remediate cognitive and behavioural deficits associated with ADHD, Autism and other related disorders and continued development of research in this area should be encouraged. Unfortunately, at present the existing research with properly designed peer reviewed studies is limited. Parents and professionals should therefore be careful in recommending commercially available computer based cognitive training programmes and consider the costs versus the potential benefits before making a decision in utilising them for treatment of their children’s difficulties.

References:

Melby-Lervåg, M., & Hulme, C. (2012). Is working memory training effective? A meta analytic review. Developmental Psychology. Advance online publication. Doi: 10.1037/a0028228
http://www.apa.org/pubs/journals/releases/dev-49-2-270.pdf

Shalev, L., Tsai, Y., & Mevorach, C. (2007). Computerized Progressive Attentional Training (CPAT) program: effective direct intervention for children with ADHD. Child Neuropsychology: A Journal on Normal and Abnormal Development in Childhood and Adolescence, 13,382-388
http://www.ncbi.nlm.nih.gov/pubmed/17564853?log$=activity