Category — Cognitive Therapy

A study published in the June 14 edition of the Journal of Developmental and Behavioral Pediatrics has sparked controversy regarding ADHD medication and the brain’s power to regulate itself.

The study was funded by the National Institutes of Health and conducted by Dr. Adrian Sandler, a developmental-behavioral pediatrician and medical director of the Olson Huff Center for Child Development at Mission Children’s Hospital in Asheville, North Carolina.  The research was performed over the course of eight years using 99 patients from Western North Carolina.

Sandler found that children with ADHD can do just as well on half their medication when the medication is combined with a placebo. They performed as well even when parents and children had full knowledge they were taking a placebo.

[Placebo --  A substance containing no medication and prescribed or given to reinforce a patient's expectation to get well. The placebo in this research was akin to a harmless inert pill].

Previous studies have shown that common stimulant medication causes side-effects like tics, weight loss, stunted growth, and even heart complications in some instances. This often causes trepidation in parents afraid of the possible side-effects on their children.

Sandler compared fully medicated children, children on reduced medication, and children on reduced medication with a known placebo. The results were quite intriguing.  Both the fully medicated and reduced medication groups had increased side-effects while the reduced medication with placebo demonstrated decreased side-effects. Furthermore, the reduced medication group reported decreased control of their ADHD symptoms. However, the control of ADHD symptoms was no different in the reduced medication with placebo group than in the full dose group, i.e. the reduced medication with placebo performed as well as the fully medicated group with less side-effects as well.

“I’ve been getting a lot of calls and e-mails,” said Sandler,, who conducted the research with James Bodfish, a professor in the departments of psychiatry and pediatrics at UNC Chapel Hill School of Medicine, and study coordinator Corrine Glesne.

“Medications work,” Bodfish said in a statement. “The question is whether we always need to use them at the highest dose. Many parents are concerned about placing their child on medication. Some choose not to treat their child because of concerns about side effects.”

While the research doesn’t address it, the obvious question is, Why? Parents and children in this study knew they were taking a placebo. Why then did they perform as well as their peers without the side-effects — at essentially half the dose as their peers? While the placebo effect has been studied widely, the exact mechanisms are unknown. We do know that the mechanism is governed by the brain. This clearly tells us that having ADHD or not, our brain is still a powerful weapon in our arsenal.

We also cannot exclude the influence of the parents during this research. Did they expect their child to do better? The authors suggest that this was so. This dynamic cannot be overlooked in your family either.

The bottom line is that we likely have far more control over our behaviors and cognitive processes than we are given credit for. Modern medicine, as this research suggests, is just beginning to understand the brain’s role in shaping our lives. We’ve known this for years at Play Attention. Cognitive training. Memory training. Motor skills. Attention training. Behavioral shaping. It’s time to take control over our lives. We’ve all got the power to do it. It lies right behind our eyes.

A Nottingham University research team in the United Kingdom found that the brains of children with ADHD appear to respond to immediate rewards in the same way as they do to medication. Their research was published in the journal Biological Psychiatry.

“Our study suggests that both types of intervention [medicine and immediate reward/reinforcement] may have much in common in terms of their effect on the brain,” said Professor Chris Hollis, the lead investigator of  the study.

The research team used an EEG (electroencephalograph) to measure the brain activity of children as they played a computer game that provided extra points for less impulsive behavior.

The researchers devised a computer space game which rewarded the ADHD children when they caught aliens of specific colors  while avoiding aliens of designated colors. The game design actually tested the children’s ability to resist the impulse to grab the wrong colored aliens.

To test whether immediate reward/reinforcement made a difference, one iteration of the game rewarded the children fivefold for catching the right alien and penalized them fivefold for catching the wrong one.  All of this was done while activity in different parts of their brains was monitored with an EEG.

Hollis found that the immediate rewards helped the children perform better at the game. This was verified by the EEG which  revealed that both medication and immediate reward/reinforcement were "normalizing" brain activity in the same regions.

Many parents of ADHD children are aware that giving a reward to an ADHD child a week after their good behavior is insignificant to that child. ADHD children respond better to immediate reward, not delayed reward.

"Although medication and behavior therapy appear to be two very different approaches of treating ADHD, our study suggests that both types of intervention may have much in common in terms of their effect on the brain. Both help normalize similar components of brain function and improve performance,"  said Hollis.

"We know that children with ADHD respond disproportionately less well to delayed rewards – this could mean that in the ‘real world’ of the classroom or home, the neural effects of behavioral approaches using reinforcement and rewards may be less effective."

It’s obvious that providing immediate rewards/reinforcement 24 hours a day and 7 days a week would be impractical and impossible. But what does this research tell us? It tells us that if we are to train an ADHD student, feedback, reward, and reinforcement need to be immediate if we are to get their brain to rewire.

We at Play Attention have known this for many years. This is why we integrated immediate feedback/reinforcement for attention training, cognitive training, memory training, and behavioral shaping by using feedback technology. We patented this method years ago because of its inherent strength. While we knew this was the best way to achieve success, we feel research like this rather reinforces our approach. It’s about time the world caught up!

Virtually anyone that knows, teaches, counsels, or works with an ADHD person is aware that ADHD is not a simple matter of attention deficit. That’s just the tip of a very large iceberg.

As a matter of fact, the term ‘attention deficit’ is actually a misnomer of sorts. ADHD people have diffused attention, not a deficit or lack of attention. Ask them. I often asked ADHD students what was happening in my classroom. They could tell me about the bird outside the window, the cobwebs in the corner of the room, a little about my lesson, a little about the whispering around them, and a little about when the air conditioner was turning on and off. That’s actually a great amount of attention. It’s just scattered or diffused over a wide area all day long.

A true hallmark of ADHD is the brain’s inability to direct attention for long periods without becoming distracted. So, it’s not a deficit at all; ADHD is an inability to direct attention. But there’s more.

ADHD is also a matter of difficulty in multiple domains of cognition. These domains are also labeled “Executive Functions.” Aside from diffused attention, ADHD also encompasses difficulty in organization of thought and tasks; sustaining effort while filtering out distractions; memory (both short-term and working memory); managing behavior/emotion; and visually directing attention and actions.

How does one cope with all these areas? It seems a monumental task. Of course, the primary medical intervention is medication. Does medication actually address all of these cognitive domains? No, it does not. Medication has limitations. That’s a fact. That’s why many parents do not see academic, behavioral, or social improvements [see the MTA study] over time. Another fact is that many of these cognitive domains can be strengthened by direct instruction.

Several small and large software companies have introduced themselves recently into the brain fitness category. Each company tends to address a specific domain like memory or focus. So, to satisfy the cognitive and behavioral needs of an ADHD person, one would need to purchase many of these games.

As the original pioneer and developer back in the late 1980s,  I saw that there was a vast gap in the needs of the ADHD person and what was being delivered. By 1994, I developed Play Attention to teach sustained attention, visual tracking with attention (like watching a teacher move about the classroom), organizing and finishing tasks, memory, filtering out distractions, and motor skills. I even included behavioral shaping. Later this year we’ll deliver social skills, more working memory & short-term memory modules, and more.  We’ve received 3 patents for this pioneering effort.

Play Attention is a careful collaboration between you, the Play Attention software, and the Play Attention professional support staff. It’s provided us with a 92% satisfaction rating.

Of course, to get results, you need to use it. Next week I’ll address how Play Attention transcends being useful to being compelling.

In late 2009, the University of Hertfordshire in the United Kingdom performed a study on Play Attention. Children in the school system near the university used Play Attention 3 days per week for twelve weeks.  Also see: http://www.sciencedaily.com/releases/2010/01/100107083904.htm

We’ll discuss this study at our free webinar on January 13th. Please register here to attend.

These students were compared to a control group of students who did not use the system.  Play Attention students showed significant improvement in behavior and attention. One of the authors of the study said:

“Children with a diagnosis of ADHD find it hard to control their impulses and inhibit inappropriate behaviour,” said Professor Pine, “This can lead to educational and behavioural difficulties. The Play Attention method may prevent long-term problems by helping the children to be less impulsive and more self-controlled.”

The study will be published in a peer reviewed journal shortly.  The full press release from the University of Hertfordshire:

New Treatment for Hyperactivity in Children

07 January 2010 Hertfordshire, University of

A new thought-operated computer system which can reduce the symptoms of Attention Deficit Hyperactivity Disorder (ADHD) in children will be rolled out across the UK this month.

Professor Karen Pine at the University of Hertfordshire’s School of Psychology and assistant Farjana Nasrin investigated the effects of EEG (Electroencephalography) biofeedback, a learning strategy that detects brain waves, on ten children with an attention deficit from Hertfordshire schools

They used a system called Play Attention, supplied by not-for-profit community interest company, Games for Life, three times a week for twelve weeks.

The system involves the child playing a fun educational computer game whilst wearing a helmet similar to a bicycle helmet. The helmet picks up their brain activity in the form of EEG waves related to attention. As long as the child concentrates they control the games, but as soon as their attention waivers the game stops.

The researchers found at the end of the study that the children’s impulsive behaviour was reduced, compared to a control group who had not used the system.

“Children with a diagnosis of ADHD find it hard to control their impulses and inhibit inappropriate behaviour,” said Professor Pine, “This can lead to educational and behavioural difficulties. The Play Attention method may prevent long-term problems by helping the children to be less impulsive and more self-controlled.”

Professor Pine and Dr Rob Sharp a senior specialist educational psychologist are continuing to work on futuristic projects with Ian Glasscock, Managing Director of Games for Life. A means of assessing learning in children with
severe communication and physical difficulties by a thought-controlled computer game method is likely to have considerable potential for these children who cannot operate a computer manually.

“Attention-related difficulties including ADHD affects many children, young people and adults and has a significant impact on their lives,” said Mr Glasscock. "Mind-controlled educational computer games technology is the only intervention shown to reduce the core symptoms of ADHD, historically medication may have been prescribed for the child.”

Games for Life plans to roll out this new system across the UK this month.

PRE-SCHOOL PROGRAM SHOWN TO IMPROVE KEY COGNITIVE FUNCTIONS, SELF-CONTROL

The following press release from the University of British Columbia maintains that a research study has demonstrated that cognitive training can improve attentional control, impulse control, and other executive functions.

Furthermore, the study’s authors cite that practice of cognitive skills in early development years may decrease incidence of ADHD. I have insisted that this was possible for nearly a decade.

Complicating this matter is the No Child Left Behind act (“NCLB”). It is my belief that the NCLB has added to the ADHD problem due in part to the program’s rigid adherence to test scores based on a watered down curriculum that forces teachers to teach the test. Subjects are taught quickly requiring rote memorization rather than significant reasoning or logical application. Additionally, teachers seldom have time to individualize curriculum or nurture students with learning disabilities like ADHD. Thus, rather than encouraging cognitive skills and the development of attention, NCLB has helped promote diffused attention while simultaneously discouraging the development of cognitive skills.

NCLB has also decreased recess time, children’s access to the arts like music and drama, and even physical education. Research has clearly demonstrated increased abilities in mathematics and other academic subjects when students are involved in music and the arts.

The press release:

Program Promises Improvement in Academic Achievement for Children of Poor Families

An innovative curriculum for preschoolers may improve academic performance, reduce diagnoses of attention deficient hyperactivity disorder (ADHD), and close the achievement gap between children from poor families and those from wealthier homes, according to research led by a Vancouver neuroscientist who is an expert on the development of the cognitive functions that depend on the prefrontal cortex area of the brain, called executive functions (EFs).

University of British Columbia Psychiatry Prof. Adele Diamond, who is Canada Research Chair in Developmental Cognitive Neuroscience, led the first evaluation of a curriculum called Tools of the Mind (Tools) that focuses on EFs. These functions include resisting distraction, giving a more considered response instead of your first impulse, working with information you are holding in mind, and the mental flexibility to think “outside the box.”

The program was developed over the last 12 years by educational psychologists Deborah Leong and Elena Bodrova and has been used in several U.S. states. Its value in improving EFs has not been determined until now.

The study is published in this week’s issue of Science.

“EFs are critical for success in school and life. These skills are rarely taught, but can be, even to preschoolers. It could make a huge difference, especially for disadvantaged children,” says Diamond, who is a member of the Brain Research Centre at UBC Hospital; the Child and Adolescent Psychiatry Dept. at BC Children’s Hospital; the Child & Family Research Institute (CFRI); and the Human Early Learning Partnership (HELP). Her work is also supported by Vancouver Coastal Health Research Institute and BC Mental Health and Addiction Services.

“The recent explosion in diagnoses of ADHD may be partly due to some children never learning to exercise attentional control and self-discipline,” says Diamond.

“Although some children are strongly biologically predisposed to hyperactivity and wouldn’t benefit from training, others may be misdiagnosed because what they actually need are skills in self-regulation.”

Previous research has shown that EFs are stronger predictors of academic performance than IQ, she adds. Children from lower-income families enter school with disproportionately poor EF skills and fall progressively farther behind in school each year – facts which Diamond says are related and correctible.

“Helping at-risk children improve EF skills early might be critical to closing the achievement gap and reducing societal inequalities. We showed EFs can be improved in preschoolers without fancy equipment and by regular teachers in regular public school classrooms.”

Most interventions target consequences of poor self-control rather than seeking prevention at an early age, as does Tools. “Early intervention – heading off problems before they develop – costs far less and achieves far better results than trying to correct problems once they have developed,” Diamond says.

“If throughout the school-day EFs are supported and progressively challenged, benefits generalize and transfer to new activities. Daily EF ‘exercise’ appears to enhance and accelerate brain development much as physical exercise improves our bodies,” she adds.

The research team, which includes investigators from the National Institute for Early Education Research at Rutgers University in New Jersey, evaluated 147 five-year-olds in a low-income, urban U.S. school district. Researchers compared Tools with a balanced literacy curriculum (dBL) that covered the same academic content as Tools but without a focus on EF.

Both programs were new, instituted at the same time and used identical resources. Children and teachers in Tools and dBL were randomly assigned and teachers had equivalent levels of education and teaching experience. The children in both curricula were from the same neighborhood and ethnic group, and from families with very similar levels of income and parental education. Children received either Tools or dBL for one to two years.

Evaluation involved two computerized tests that measured EF. These tasks were different from anything any of the children had done before. Better performance by children in Tools shows that they were able to generalize and transfer their EF skills to new situations.

Tools encourages out-loud self-instruction and dramatic play. “Preschool teachers are under pressure to limit play and spend more time on instruction but social pretend play may be more critical to academic success,” says Diamond.

I have written for years that only by redefining ADHD can we address the problem through education and training. Finally, the movement is approaching mainstream as indicated in the article from Scientific American entitled, Training the Brain, Cognitive Therapy As An Alternative To ADHD Drugs.

It is interesting to note that the techniques mentioned in the article have been incorporated in the Play Attention cognitive tools for about ten years.

“Recent studies support the notion that many children with ADHD have cognitive deficits, specifically in working memory–the ability to hold in mind information that guides behavior. The cognitive problem manifests behaviorally as inattention and contributes to poor academic performance. Such research not only questions the value of medicating ADHD children, it also is redefining the disorder and leading to more meaningful treatment that includes cognitive training.”

Salient issues raised by the author include:

1. The difficult decision by parents “To medicate or not? Millions of parents must decide when their child is diagnosed with attention-deficit hyperactivity disorder (ADHD)–a decision made tougher by controversy.”
2. While medication may calm a student’s outward behavior, research shows that it does not increase cognitive ability manifesting in improved academic performance, social relationships, or defiant behavior over the long-term.
3. This has led scientists to research effective means of cognitive training as a substitute.

This is really a shift in our understanding of this disorder from behavioral to biological,” states Rosemary Tannock, professor of psychiatry at the University of Toronto. Tannock has shown that although stimulant medication improves working memory, the effect is small, she says, “suggesting that medication isn’t going to be sufficient.” So she and others, such as Susan Gathercole of the University of Durham in England, now work with schools to introduce teaching methods that train working memory. In fact, working-memory deficits may underlie several disabilities, not just ADHD, highlighting the heterogeneity of the disorder.”

The article focuses on Dr. Torkel Klingberg of the Karolinska Institute in Sweden who trained around 40 kids with ADHD with a software program that addressed “working memory.” After more than 20 days of training parents reported that their children had greatly improved attention and lessened hyperactivity.

Klingberg essentially proved that cognitive retraining improved neurobiological function. This work has been underway with Play Attention since 1994. It’s good to see the paradigm shift beginning to happen.