Novel Brain Training Game May Reduce Kids' ADHD Symptoms

Liam Davenport

March 03, 2016

A novel cognitive training computer game that uses a child's own brain waves to improve concentration may reduce symptoms of attention-deficit/hyperactivity disorder (ADHD), say US researchers.

Investigators used a novel feed-forward modeling (FFM) system, which employs a computer game to illustrate desired future behaviors or a path toward a goal via electroencephalogram-based adaptation, thus encouraging the restructuring of behaviors and actions.

They found it reduced ADHD symptoms by approximately one third and significantly improved the number of math problems that could be solved in a given period. These positive effects persisted for 3 months.

Lead author Ashley F. McDermott, PhD, of Atentiv LLC, Waltham, Massachusetts, which developed the FFM system, noted that although it was evaluated as a stand-alone treatment in the current study, it may have additional benefits if used with other therapies.

"We have not tested it alongside other treatments, but we're really going after a different skill and a different potential mechanism of action from, for instance, medication. So there's no reason to think you couldn't use both, because both are going after the problem from different angles," she said.

The research was published online January 28 in the Journal of Attention Disorders.

Symptom Reduction

The FFM system is based on a computer cognitive training game in which attention is required to move an avatar through the game. The game was calibrated using an electroencephalogram (EEG) headband with three frontal sensors to create a model of attention and inattention states.

With this "cognitive signature," the game was personalized so that the speed of the avatar would tally with the participants' attention level, allowing distraction and impulsivity to be recognized.

After an initial assessment, 46 children took part in the study. The FFM sessions were conducted at three clinical sites; 32 of the patients were boys; the median age of the patients was 9.57 years. The patients were randomly assigned to three or four 15- to 20-minute FFM sessions per week for 8 weeks or 8 weeks of standard nonpharmacologic interventions, which included cognitive- behavioral therapy, therapeutic training, or parent coaching sessions.

After the initial intervention period, the control group underwent FFM training for 8 weeks to allow comparison with the degree of improvement between the two groups.

The results indicated that the FFM group experienced a 36% reduction in ADHD symptoms on the clinician-rated ADHD–Rating Scale. This improvement was maintained at 3-month follow-up. There was a similar 31% reduction in symptoms reported by parents on the ADHD-RS Home Version, which was, again, maintained at 3-month follow-up.

The team also reports that there were improvements in scores on the Clinical Global Impression scale. There was a 26% increase in the number of math problems that could be completed in the time limit on the Permanent Product Measure of Performance, although this effect disappeared after 3 months.

The gains seen in the FFM group were largely mirrored by the control group after they had undergone the intervention.

However, patients in the FFM group had worse inattention scores on the Quotient ADHD system (Pearson Education, Inc., Westford, Massachussetts) after training, and they showed no significant improvements on the Woodcock–Johnson, Third Edition, test.

Although the current findings indicate that 8 weeks of FFM could be effective in ADHD patients, Dr McDermott is not sure that extending the intervention period any further would provide any additional benefit.

"In some of the early pilot studies, they went out to 10 weeks and saw similar improvements," she said. "Adding a few weeks at the end doesn't seem like it would necessarily make a difference."

The team is now looking at two avenues of research for the FFM system. "One is to continue on the clinical aspects, and we have a pivotal trial planned that would lead us to be able to apply to the FDA for clearance as a first-line treatment for ADHD," Dr McDermott explained.

"Given that we see these academic improvements, we also want to do further research in schools to see if this is a system that could be used beyond just kids with ADHD but with any struggling kids to see if they can improve academic performance by improving these cognitive skills."

Dr McDermott concluded that she is "really excited about the potential different applications this raises." Noting that attention and impulse control skills are "a foundation to life," she said that the FFM system could have benefits in "anything from older adults ― attention is really necessary to help support working memory ― to kids with learning difficulties."

Limitations

Commenting on the findings for Medscape Medical News, Pamelynn Esperanza, MD, assistant professor of psychiatry in the Division of Child and Adolescent Psychiatry at New York– Presbyterian Hospital and Weill Cornell Medical College, in New York City, pointed out that although the FFM system led to improvements, "the control group did not receive a single evidence-based treatment."

Although the treatment options used in the study are "ecologically valid," the choice of control therapies "makes it difficult to conclude whether the FFM is better than alternative treatment. At best, we can conclude that FFM is better than not receiving treatment," she said.

One rationale used by the study authors to explain the need for novel therapeutic options such as the FFM system is that stimulant medications may not only fail to improve performance on some measures but may also impair performance on some executive attention tasks.

Dr Esperanza believes that although stimulant medications may impair some laboratory-based computer measures of cognitive function, it is not clear whether such tests are critical measures of performance.

"I think that parents, teachers, and students are primarily interested in improving academics, and, as the article acknowledges, stimulants have been reliably shown to improve academic performance," she said.

"Thus, if stimulant treatment resulted in a given patient showing decreased performance in the laboratory but a large improvement in academics, I think most parents would be very pleased with that outcome," she added.

Dr Esperanza said it is too early to tell whether the FFM system will be incorporated into the clinician's repertoire. This is particularly the case inasmuch as few centers provide FFM, and "the time, effort, and commitment for this intervention may make it a lesser attractive treatment option for some families."

Moreover, the computer-based laboratory assessments used in the study may not be generalizable to home and school performance, she said, adding: "I think it will likely require further study to relate to real-world performance.

"I actually think that multimodal and tailored approaches are often necessary for children with ADHD, that a single treatment, especially psychosocial treatments, are probably not enough by themselves but rather as adjuncts to evidence-based ADHD treatments," she concluded.

The authors and Dr Esperanza have disclosed no relevant financial relationships.

J Atten Disord. Published online January 28, 2016. Abstract

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