Although medication treatment and behavior therapy provide
short-term symptomatic relief for children with ADHD, such gains rarely persist
after treatment ends. Because these treatments are infrequently sustained
over extended periods (most children on medication do not even remain on it
for a year), few individuals with ADHD receive effective treatment over the
long-term. This may explain why current treatments provide only limited long-term
benefits and why many individuals with ADHD have poor adolescent and young
adult outcomes even if they were effectively treated in childhood. Clearly,
treatments that can provide enduring benefits are needed.
As knowledge of the underlying neural and neurocognitive contributors to
ADHD has grown, and knowledge that brain development is highly responsive
to environmental influences has accumulated, a compelling theoretical framework
for the development of more enduring ADHD interventions has emerged. Specifically,
it has been hypothesized that particular kinds of experience can ameliorate
- or at least diminish - some of the underlying neural factors that contribute
to the development and expression of ADHD.
In fact, this possibility has already been demonstrated in several studies.
For example, work in the neurofeedback domain has demonstrated changes in
neural activity in individuals with ADHD following treatment. Similarly,
significant changes in neural activity have been shown to occur in individuals
following working memory training.
Neurofeedback, working memory training, and other forms of computerized
cognitive training are distinctly different activities from typical daily
experience and are not particularly social in nature. However, it may
also be possible to provide children with environmental stimulation that
can enhance neural and cognitive functioning within the context of the parent-child
relationship. And, because such activities can be inherently enjoyable,
and promote positive relations between parents and children, they may be
sustained over time and thus provide children with ongoing experience that
can enhance their neural functioning. In theory, such an intervention
could produce enduring treatment gains in children with ADHD, particularly
if introduced when children are young and neuroplasticity may be greatest.
This was the premise underlying an extremely interesting and important study
recently published online in the Journal of Attention Disorders [Halperin
et al., (2012). Training executive attention and motor skills: A proof-of-concept
study in preschool children with ADHD. Journal of Attention Disorders,
published online March 5, 2012. DOI: 10.1177/1087054711435681.]. To
be candid, I found this to be one of the most interesting studies I have read
during the past 10 years.
Participants were 29 four- and five-year old ethnically diverse children
diagnosed with ADHD and their parents. Children and parents participated
in a novel intervention called TEAMS - Training Executive, Attention, and
Motor Skills.' As discussed below, TEAMS was designed to "...apply frequent
and enduring positive environmental stimulation to underlying neurodevelopmental
processes in children with ADHD." Specifically, parents learned to engage
in specific game-like activities with their child that placed increasingly
challenging demands on a variety of neurocognitive and motor skills.
The theory behind TEAMS was that this would promote underlying changes in
neural functioning that would lead to enduring improvements in ADHD symptoms.
The authors describe this as a 'proof of concept' study. Thus the
goals were to learn whether parents would have positive feelings about the
treatment experience, whether they would engage regularly with their child
in the prescribed activities, and whether there was any preliminary evidence
of positive effects. As such, there was no control group and no randomization
to condition. Thus, even were favorable results to be found, this was
a preliminary study that could not establish the efficacy of the new treatment.
TEAMS Intervention Specifics
The TEAMS intervention was conducted in a 90-minute group format (between
5 and 10 group meetings were held) that included 3-5 families per group.
In each group, children and parents were introduced to a predetermined set
of games chosen to target an array of neurocognitive skills. For example,
to target inhibitory control, i.e., the ability to refrain from responding
impulsively, games would include variations of "Simon Says" and 'freeze dance'.
To develop working memory skills, games would include things like remembering
shopping lists or the locations of 'hidden treasures' under cups. Other
targeted cognitive skills were visual-spatial abilities, planning and organization,
and sustained attention. Games to develop motor skills were also included
as was an aerobic exercise component.
Between group meetings, parents were instructed to spend at 30-45 minutes
each day playing these games with their child. The goal was to provide
sufficient stimulation of the underlying neural processes targeted by the
games so that these processes were repeatedly exercised and strengthened.
A focus in group meetings was working with parents to identify and overcome
difficulties they had experienced consistently implementing the games with
their child during the prior week. Parents also learned new games, discussed
the cognitive skills being targeted, and were taught how to gradually increase
the difficulty level so that children's cognitive skills were continually
challenged. The importance of regular aerobic exercise was also stressed as
there is emerging evidence that this can improve cognitive functioning.
To assess the impact of the TEAMS program, ratings of core ADHD symptoms
and of children's impairment from symptoms were collected from parents and
teachers. Ratings were obtained before treatment began, immediately
after the groups ended, and at a 1- and 3-month follow-up. These latter
measurement points enabled the researchers to learn whether any gains that
were initially evident endured.
In addition, parents completed ratings of how often they engaged in the
prescribed games each week and how long they engaged in these games with
Parental acceptance - Only one of the 29 families withdrew during
the active treatment phase and this was because of transportation issues.
Overall, parents attended 93% of scheduled sessions and nearly 70% attended
all sessions. Satisfaction with the intervention was rated very highly.
Engagement in TEAMS activities - For TEAMS to be effective, children
must engage in the prescribed games with considerable frequency. Throughout
the intervention period, parents indicated that they engaged in the games
nearly every day for an average of 35 minutes. One month after treatment
ended they were still playing the games nearly 3 times a week for 30 minutes.
At the 3-month followup, this had declined to an average of 20 minutes/day
two days per week. Thus, despite the drop-off from the active treatment
period, parents and children continued to regularly engage in the games for
at least 3 months after treatment ended.
ADHD symptom severity - Significant reductions in parent and teacher
ratings of ADHD symptoms were evident from pre- to post-treatment. Furthermore,
these reductions remained evident at the 1- and 3-month followups. Equivalent
reductions were found for inattentive and hyperactive-impulsive symptoms.
The magnitude of the reductions were in a range that would be considered
large for parents and moderate for teachers.
Impairment from symptoms - Ratings of impairment from symptoms declined
significantly for both parents and teachers. Interestingly, these declines
were not significant immediately following treatment, but became evident at
the 1-month follow-up for parents and at the 3-month follow-up for teachers.
The magnitude of the decline was in a range that would be considered moderate.
Summary and Implications
The premise of TEAMS is that consistently engaging children with ADHD in
activities that challenge and exercise particular neurocognitive functions
can strengthen the underlying neural activity that support these functions
and thereby diminish ADHD symptoms. This premise is consistent with
the rationale underlying neurofeedback treatment, working memory training,
and other approaches to computerized cognitive training. What is unique
about the TEAMS approach, however, is the idea that such stimulation can occur
in the context game like activities between parents and children that are
inherently enjoyable and that also promote positive parent-child interactions.
In my view, this is a very exciting study and the kind of work the field
really needs. For years, evidence that ADHD is strongly influenced by
genetic factors may have undermined efforts to examine whether experiential
factors - particularly the ways that parents interact with their child - could
play an important role in addressing core ADHD symptoms. What these
researchers have suggested, and provided preliminary evidence of, is that
this may be possible.
Note that their approach is very different from using behavioral principles
to manage ADHD symptoms and encourage desired behavior. While behavioral
management approaches are important and helpful, the focus is on symptom management
and not on changing children's underlying capacities. Here, in contrast,
the idea is that parents can provide ongoing opportunities to help children
exercise neurocognitive functions that can lead to enduring benefits.
Also note that the TEAMS approach in no way implies that parents are somehow
responsible for their child's development of ADHD. Instead, TEAMS strives
to teach parents how to provide children with experiences that may lead to
enduring reductions in ADHD symptoms over time.
While I found this to be an exciting study, it is important to emphasize
that this is only an initial 'proof of concept' of the approach. As
the authors note, the absence of any control group makes it impossible to
determine why children seemed to improve. Although the theory underlying
TEAMS is that the children's ongoing involvement in the prescribed games and
exercise program alters their underlying neural functioning, no such assessments
were conducted. The sample size was also relatively small.
These limitations not withstanding, this initial effort demonstrated that
TEAMS was experienced positively by parents who continued to engage regularly
in the treatment exercises up to 3 months after treatment ended. And,
beneficial effects as rated by parents and teachers remained evident after
3 months. The authors conclude by noting that a larger randomized trial
is planned so that the potential benefits of TEAMS can be better understood.
This is important work and I look forward to reviewing it for you Attention
Research Update when it becomes available.
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Attention Research Update is for informational purposes only, and is not
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Copyright © 2012 by David Rabiner