Improving Executive Functioning in Children with ADHD: Training Multiple Executive Functions within the Context of a Computer Game. A Randomized Double-Blind Placebo Controlled Trial

Abstract

IntroductionExecutive functions (EFs) training interventions aimed at ADHD-symptom reduction have yielded mixed results. Generally, these interventions focus on training a single cognitive domain (e.g., working memory [WM], inhibition, or cognitive-flexibility). However, evidence suggests that most children with ADHD show deficits on multiple EFs, and that these EFs are largely related to different brain regions. Therefore, training multiple EFs might be a potentially more effective strategy to reduce EF-related ADHD symptoms.MethodsEighty-nine children with a clinical diagnosis of ADHD (aged 8–12) were randomized to either a full-active-condition where visuospatial WM, inhibition and cognitive-flexibility were trained, a partially-active-condition where inhibition and cognitive-flexibility were trained and the WM-training task was presented in placebo-mode, or to a full placebo-condition. Short-term and long-term (3-months) effects of this gamified, 25-session, home-based computer-training were evaluated on multiple outcome domains.ResultsDuring training compliance was high (only 3% failed to meet compliance criteria). After training, only children in the full-active condition showed improvement on measures of visuospatial short-term-memory (STM) and WM. Inhibitory performance and interference control only improved in the full-active- and the partially-active condition. No Treatment-condition x Time interactions were found for cognitive-flexibility, verbal WM, complex-reasoning, nor for any parent-, teacher-, or child-rated ADHD behaviors, EF-behaviors, motivational behaviors, or general problem behaviors. Nonetheless, almost all measures showed main Time-effects, including the teacher-ratings.ConclusionsImprovements on inhibition and visuospatial STM and WM were specifically related to the type of treatment received. However, transfer to untrained EFs and behaviors was mostly nonspecific (i.e., only interference control improved exclusively in the two EF training conditions). As such, in this multiple EF-training, mainly nonspecific treatment factors – as opposed to the specific effects of training EFs—seem related to far transfer effects found on EF and behavior.Trial Registrationtrialregister.nl NTR2728. Registry name: improving executive functioning in children with ADHD: training executive functions within the context of a computer game; registry number: NTR2728.

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

“…Of the fourteen included studies in this review, the interventions assessed include two tablet devices [59,60] two mobile applications [58,62], the use of a Wii remote control [61], computer software [51, 54] and computer games [34,52,53,[55][56][57]63]. Following exclusions, outcome measure assessment (Appendix 5) and quality assessment of the fourteen included studies was conducted (appendices 3 and 4).…”

“…One of the eight included RCTs, one was considered to be at overall high risk of bias [34], five RCTs were judged as being at overall low risk [51, 52,54,55,56] and two RCTs were considered to be at overall unclear risk of bias [53,57]. All included RCTs were considered to be at a low risk of bias for selective reporting [34,[51][52][53][54][55][56][57].…”

“…All included RCTs were considered to be at a low risk of bias for selective reporting [34,[51][52][53][54][55][56][57].…”

“…Ten of the fourteen included studies [34,[51][52][53][54][55][56][57][58]63] used ordinal scales of measurement all with established psychometric properties. Twelve of the included studies [34,51,[53][54][55][56][57][58][59][60][61][62] used scales of measurement that did not have established psychometric properties.…”

“…Twelve of the included studies [34,51,[53][54][55][56][57][58][59][60][61][62] used scales of measurement that did not have established psychometric properties. Four of the fourteen studies [58][59][60]63] did not perform any formal statistical analysis.…”