A randomized controlled trial of central executive training (CET) versus inhibitory control training (ICT) for ADHD.

Abstract

Objective: Executive function deficits are well-established in ADHD. Unfortunately, replicated evidence indicates that executive function training for ADHD has been largely unsuccessful. We hypothesized that this may reflect insufficient targeting, such that extant protocols do not sufficiently and specifically target the neurocognitive systems associated with phenotypic ADHD behaviors/impairments. Method: Children with ADHD ages 8–12 (M = 10.41, SD = 1.46; 12 girls; 74% Caucasian/Non-Hispanic) were randomized with allocation concealment to either central executive training (CET; n = 25) or newly developed inhibitory control training (ICT; n = 29). Detailed data analytic plans were preregistered. Results: Both treatments were feasible/acceptable based on training duration, child-reported ease of use, and parent-reported high satisfaction. CET was superior to ICT for improving its primary intervention targets: phonological and visuospatial working memory (d = 0.70–0.84). CET was also superior to ICT for improving go/no-go (d = 0.84) but not stop-signal inhibition. Mechanisms of change analyses indicated that CET-related working memory improvements produced significant reductions in the primary clinical endpoints (objectively assessed hyperactivity) during working memory and inhibition testing (indirect effects: β ≥ −.11; 95% CIs exclude 0.0). CET was also superior to ICT on 3 of 4 secondary clinical endpoints (blinded teacher-rated ADHD symptoms; d = 0.46–0.70 vs. 0.16–0.42) and 2 of 4 feasibility/acceptability clinical endpoints (parent-reported ADHD symptoms; d = 0.96–1.42 vs. 0.45–0.65). CET-related gains were maintained at 2–4 month follow-up; ICT-related gains were maintained for attention problems but not hyperactivity/impulsivity per parent report. Conclusions: Results support the use of CET for treating executive function deficits and targeting ADHD behavioral symptoms in children with ADHD. Findings for ICT were mixed at best and indicate the need for continued development/study.

Central executive training for ADHD: Effects on academic achievement, productivity, and success in the classroom.

“…Studies of neurocognitive heterogeneity in pediatric ADHD indicate that 89% of children with ADHD exhibit deficits in at least one executive function, with approximately 62%−85% of children exhibiting working memory deficits and 21%−46% of children exhibiting inhibitory control deficits (for review see Kofler et al, 2017). Growing cross-sectional, experimental, and intervention-based evidence supports the notion that deficits in these higher-order executive functions may reflect core mechanisms underlying ADHD behavioral symptoms and many if not most associated functional impairments, including academic functioning, for a majority of children with ADHD (for reviews see Kofler et al, , 2020Rapport et al, 2013).…”

“…The Academic Productivity scale contains 12 items that assess academic efficiency (e.g., percentage of classwork completed correctly) and consistency, following group instructions, and timely completing work. Teachers were masked to treatment allocation; masking maintenance was excellent (Kofler et al, 2020). 2 Raw scores were selected a priori as recommended for research purposes (Achenbach, 1991).…”

“…As recommended in the K-SADS, oppositional-defiant disorder (ODD) was diagnosed only with evidence of multiinformant/multisetting symptoms. ODD comorbidity is 39% based on parent-reported symptom counts, and 48% based on meeting parent or teacher-reported symptom counts(Kofler et al, , 2020.4 SINGH, GAYE, COLE, CHAN, AND KOFLER…”

Increasing Effectiveness of Cognitive Behavioral Therapy for Conduct Problems in Children and Adolescents: What Can We Learn from Neuroimaging Studies?

“…Impaired response inhibition may also affect these children's and adolescents' social problem solving such as generating solutions and making decisions. An efficacy study can test the hypothesis whether enhancing response inhibition through training programs (see further Kofler et al, 2018Kofler et al, , 2020 affects social problem solving in everyday life and ultimately results in a reduction of conduct problems, especially in those children and adolescents with either comorbid ADHD or associated ADHD symptoms. Likewise, an efficacy study can test the hypothesis whether enhancing response inhibition by psychostimulants in children and adolescents with conduct problems and ADHD comorbidity affects social problem solving in everyday life and ultimately results in a reduction of conduct problems.…”

“…In line with a conceptual framework for combined neurocognitive and skill-based treatment approaches for youth with ADHD (Chacko et al, 2014), we suggest that executive function training programs are included in the treatment of children and adolescents with conduct problems and poor response inhibition associated with ADHD. While training programs targeting working memory and response inhibition have been less successful than initially anticipated, results of recent studies on central executive training targeting working memory, with effects on response inhibition and hyperactivity, are promising (Kofler et al, 2018(Kofler et al, , 2020. In a review of interventions and approaches for improving executive functions, Diamond and Ling (2016) suggest that while challenging of executive functions is necessary for improving them, benefits of improving executive functions will be greater if children's and adolescents' emotional, social, and physical needs are also addressed.…”