Cognitive Control, Brain Exercise and ADHD: Here we go again!
June 1, 2014
A recent article in the New York Times, which has been circulating among therapists suggests the benefits of “exercising the mind” to treat ADHD. While this idea is tremendously appealing, if only we could strengthen the brain rather than rely on drugs to treat ADHD, the evidence continues to be remarkably lacking to support these approaches.
In his recent New York Times article, “Exercising the Mind to Treat Attention Deficits” Daniel Coleman, suggests that there now is: “a growing stream of research [which] suggests that that strengthening this mental muscle [the brain] ………may help children and adults cope with ADHD.” Unfortunately this is not true. There is no real evidence to support the conclusion that brain training or mental exercises can help with ADHD.
A close examination of Coleman’s articles suggests that there really is no solid evidence to support his hopefulness/enthusiasm for braining training. First, Coleman discusses research which identifies how adolescents with ADHD in Finland are far less likely to be treated with medication. While interesting, this shows only that there are differences in treatment approaches and medication use, nothing about the relative benefit or utility of any type of treatment. Second, he goes on to site a study suggesting the limited benefit of ADHD medication, in addition to quoting several professionals who further comment on the limits of medication treatment. However, noting the limits of medication treatment (for the record, nearly all medication treatment of nearly all disorders has limitations) does not mean it is of no value or that cognitive exercises are beneficial. Third, the article sites a study in the on-line journal Clinical Neurophysiology which purports that adults with ADD benefited from mindfulness combined with cognitive therapy. An examination of this article, clearly reveals that this research does not show the benefits of mindfulness for ADHD: the type of treatment used with a combined cognitive therapy and mindfulness approach so what the key ingredient of the treatment that helped (if it indeed had any benefit) is unclear, e.g., mindfulness exercises or CBT components (there is research by Solanto, Ramsey and others that does show the benefits of CBT in adults with ADHD); the treatment was compared to a waiting list control group so it is unclear if the benefit of being in treatment was all that had any impact; and most importantly the only benefits shown from the study where in terms of neuropsychological measures of braining function so it is unclear if there is any real world value to this treatment. A final point while, Coleman suggests that this study showed that benefits of the mindfulness training were similar to medication, there is no examination of medication treatment in this article. Fourth, Coleman sites research in the Frontiers in Human Neuroscience, an on-line open access journal, and suggests that the study in question supports how mindfulness may strengthen the ability to attend. However, this is quite a leap of faith. The article in Frontiers focused on adult “meditators” and did not examine persons with ADHD. Thus, while the findings might be of interest in understanding the role meditation in brain functioning, it is a great leap to suggest that looked at brain functioning in 14 healthy adults (who meditated regularly) means that meditation is going to help change ADHD symptoms.
Overall, the NY Times article raises an intriguing idea: maybe some type of cognitive exercise might help ameliorate deficits associated with ADHD and other disorders. However, the evidence that cognitive exercises are of any value for persons with ADHD continues to lack any real evidence to support its use. In fact, there seems to be a dearth of evidence to support the use of brain training type programs (despite their being marketed with an increased vigorousness – anyone who is on line for any time is sure to have viewed the ad from Lumosity). Specifically, an analysis of 23 of the best studies on brain training, by the researcher Monica Melby-Lervag, concluded that while players do get better, the increase in skill hasn’t been shown to transfer to other tasks.
It would be nice if there was evidence to support the use of non-invasive side-effect free interventions in the treatment of ADHD, and other disorder. However, the absence of evidence continues to suggest that these activities are likely nothing more than a pleasant way to spend time (if you enjoy this type of activity).
Exercising the Mind to Treat Attention Deficits. By DANIEL GOLEMAN, May 12, 2014
Effects of mindfulness-based cognitive therapy on neurophysiological correlates of performance monitoring in adult attention-deficit/hyperactivity disorder. Clinical Neurophysiology, Volume 125, Issue 7 , Pages 1407-1416, July 2014
Cognitive-Behavioral Therapy for Adult ADHD: An Integrative Psychosocial and Medical Approach by J. Russell Ramsay , Anthony L. Rostain
Cognitive-Behavioral Therapy for Adult ADHD: Targeting Executive Dysfunction by Mary V. Solanto PhD
Effects of meditation experience on functional connectivity of distributed brain networks. Front. Hum. Neurosci., 01 March 2012 | doi: 10.3389/fnhum.2012.00038
Monica Melby-Lervag, sited in a N.Y. Times article: http://well.blogs.nytimes.com/2014/03/10/do-brain-workouts-work-science-isntsure/?_php=true&_type=blogs&_php=true&_type=blogs&emc=edit_tnt_20140310&nlid=21288644&tntemail0=y&_r=1
Does anything but medication help with ADHD symptoms?
March 8, 2013
Unfortunately, the answer appears to be, “not really.” Several sources of data suggest that there is not strong evidence to support the use of non-pharmacological interventions to treat core ADHD symptoms. Core symptoms refers to the central problems of impulse control (including low frustration tolerance and impatience) and inattention (including difficulties with distractibility, task completion, sustained focus and forgetfulness).
A recent meta-analysis* examining the effectiveness of non-medication based treatment found that there was no strong evidence indicating that treatments other than medication are helpful in alleviating core ADHD symptoms. This study examined a wide range of interventions, from behavioral to dietary. The authors carefully examined the findings of the study and distinguished findings based on more and less stringent criteria. Specifically, the authors noted when findings were based on blind evaluators (evaluators who did not know what intervention a child received) versus when finding were based on not-blind evaluators (evaluators who were aware of the intervention the child was receiving and possibly had an investment finding that the intervention was helpful). When more stringent criteria was used, blind evaluators, the authors concluded that there was little evidence to support non-pharmacological interventions. Specifically, the authors concluded that, “Most notably, the standardized mean differences for all psychological interventions dropped considerably, to non-significant levels, when analyses were restricted to trials with probably blinded assessments.” In other words, there is no clear evidence to support non-pharmacological interventions as helpful in reducing core ADHD symptoms.
A second source of data questioning the value of non-pharmacological interventions was a recent meta-analysis** of Working Memory. This analysis found that interventions based on efforts to strengthen working memory, e.g., CogMed, showed no real benefit. This study is discussed in detail in two previous posts in this Blog.
However, these findings do not mean that medication is the only intervention to consider for children with ADHD. First, the findings of these meta-analyses focused on core ADHD symptoms. Many children with ADHD present with multiple problems and symptoms ranging from oppositional behavior to anxiety and low self-esteem. These problems are far more amenable to psychological interventions. Second, families with ADHD often do not fully understand the implications of the diagnosis of the child with ADHD, and are stressed by the child’s behavioral difficulties. Thus, psychological interventions, include parent education and training, are often quite useful for children and families with ADHD.
“Nonpharmacological Interventions for ADHD: Systematic Review and Meta-Analyses of Randomized Controlled Trials of Dietary and Psychological Treatments.” American Journal of Psychiatry. Volume 170, No. 3. March, 2013. by Edmund J.S. Sonuga-Barke, Ph.D.; Daniel Brandeis, Ph.D.; Samuele Cortese, M.D., Ph.D.; David Daley, Ph.D.; Maite Ferrin, M.D., Ph.D.; Martin Holtmann, M.D.; Jim Stevenson, Ph.D.; Marina Danckaerts, M.D., Ph.D.; Saskia van der Oord, Ph.D.; Manfred Dopfner, Ph.D.; Ralf W. Dittmann, M.D., Ph.D.; Emily Simonoff, M.D.; Alessandro Zuddas, M.D.; Tobias Banaschewski, M.D., Ph.D.; Jan Buitelaar, M.D., Ph.D.; David Coghill, M.D.; Chris Hollis, M.D.; Eric Konofal, M.D., Ph.D.; Michel Lecendreux, M.D.; Ian C.K. Wong, Ph.D.; Joseph Sergeant, Ph.D.; European ADHD Guidelines Group.
** Melby-Lervag M, & Hulme, C. “Is working memory training effective? A meta-analytic review.” Developmental Psychology. Advance online publication. (May 21, 2012.
More on Why Working Memory Training is Not an Effective Treatment for ADHD!
January 19, 2013
Introduction: For those who like more detail, this entry delves deeper into the meta-analysis of Melby-Lervag and Hulme (2012) and examines their finding that there is no solid evidence that working memory training is of benefit for those with ADHD. Please see the entry of 1/13/2013 for an overview of their meta-analysis which clearly shows that there is no evidence that Working Memory Training programs, such as Cogmed, are effective in treating ADHD.
Methodological Issues, or why the quality of the research matters: One of the problems in trying to ascertain whether a given approach is helpful, is the quality of the research. Poorly designed studies can show support for a treatment approach. However, the problem is that these the flaws in design, or the lack of robust research design, may account for the positive findings. A simple example: if researchers are testing the benefits of working memory training by comparing it to a no treatment group, the fact that participants are receiving some intervention (an expectancy or placebo affect) may account for positive results rather than the intervention itself. This is but one example of how flawed research can claim to support an intervention when in reality the findings more likely reflect design flaws.
Generalizability or Transfer of Gains: A key issue in demonstrating the clinical value of an intervention, whether it really makes a difference, is whether the purported benefits of an intervention carry over to how study participants function in the real world. For example, we would expect that those receiving training on working memory tasks would do better when tested on similar types of tasks, a practice effect. The relevant question is: can working memory training show positive changes in areas that participants have not been trained in. For example, working memory training showed show benefits in theoretically related areas such as attention (sustained focus) and verbal ability.
Results of the Meta-Analysis on Working Memory Training: The findings are quite consistent, working memory training does not show any significant benefit for participants other than improved ability to perform working memory tasks after receiving training. Working memory training does not appear to generalize, lead to benefits in other related areas of functioning. Moreover, at follow up (re-evaluation several months or more after receiving training) working memory training showed no benefit for ADHD related symptoms.
In conclusion: One cannot say that working memory training absolutely does not work. Perhaps the dose (the amount of training received) or the type of training could be modified/improved and benefit might be found. However, the current review strongly suggests that there is a need for solid evidence that working memory training works before it is utilized as a treatment approach for ADHD, or other disorders for that matter.
* Melby-Lervag M, & Hulme, C. “Is working memory training effective? A meta-analytic review.” Developmental Psychology. Advance online publication. (May 21, 2012.
Does Working Memory Training Work?
What is working memory?: For those unfamiliar with the concept working memory is a higher order, or more complex cognitive ability, involving the capacity to hold ideas or concepts or facts in mind, in the face of distractions and/or competing tasks. Put more simply, working memory refers to the ability to remember what you are planning to do or thinking about, even after you are distracted or have had to complete other tasks. Russell Barkley, PhD has focused on deficits in working memory as a key feature of ADHD. Specifically, Barkley hypothesizes that deficits in working memory result in individuals with ADHD being more likely to respond to immediate stimuli, i.e., have more difficulty with self-control or self-regulation, as well has having more difficulty planning and working towards longer term goals.
What is working memory training? The most widely known program for strengthening working memory is CogMed, a computer based working memory training program. Other programs include Cognifit and JungleMemory. These programs seek to strengthen working memory skills by having participants practice memory tasks, that are increasingly more demanding. Melby-Lervag and Hulme (2012) have compared this type of training to strength training where muscles are strengthened by repeated use.
How can one tell if working memory training helps? There have been a number of studies, and even a few reviews of studies, regarding the benefits of working memory training. The findings are quite variable, most likely due to the fact that the methodology (quality) of the studies was variable, ranging from case studies to well controlled research. Recently, Melby-Lervag and Hulme (2012) published a detailed review of the research on working memory training, a meta-analysis which compares and evaluates the findings of many studies. They evaluated both the quality and findings of these studies.
Does working memory training work for ADHD?: The answer appears to be no. Melby-Lervag and Hulme (2012) conclude that “when we focus on studies using robust design with treated controls and randomization, the effect is zero.” They go on to note that for attention problems there is “a small to moderate effect immediately after training but the effect is reduced to zero at follow-up.” They conclude that “working memory training procedures cannot, based on the evidence to date, be recommended as suitable treatment” for ADHD.
What are the implications of these findings?: The most reasoned conclusion one can draw is that for treating ADHD, the approaches that work best are medication and behaviorally oriented parent training approaches, for children and teens, and medication and Cognitive Behavior Therapy, for adults.
* Melby-Lervag M, & Hulme, C. “Is working memory training effective? A meta-analytic review.” Developmental Psychology. Advance online publication. (May 21, 2012)
Sunday, January 15th, 2012
This month (January 2012) Consumer Reports posted an article on their website “Is fish oil right for you?”. In this article the authors suggest that “Although the evidence isn’t overwhelming, the supplements may modestly …… improve the symptoms of ADHD ….. in children.”. Before we jump on the fish oil supplement bandwagon it is important to keep in mind that this finding is based on parent reports (survey data). While such data can be useful it is important to remember that survey data lacks the scientific soundness of controlled research. Therefore, we should not assume that fish oil supplements are a magic bullet for the treatment of ADHD. In fact, Consumer Reports survey data on ADHD treatments found that 67% of parents who gave their children medication rated medication as “helping a lot.” This is in stark contrast to parent ratings on fish oil supplements; only 12% of those who gave such supplements rated them as helping a lot. Finally, it is important to keep in mind that research has consistently shown that medication (primarily stimulant medication) based treatment helps 70-80% of children diagnosed with ADHD.
Sunday, June 6th, 2010
Intuvin: A new ADHD medication
Intuvin is a new medication for ADHD, that is being marketed by Shire. Intuvin is an extended release guanfacine. Guanfacine is an anti-hypertensive agent. Shire is touting the benefits of Intuvin and appears to be placing particular emphasis on the fact that it is a non-stimulant and also is offered in extended release form.* However, there are several important things to keep in mind when considering a new ADHD medication such as Intuvin:
1. Limited data on the benefits of Intuvin
The benefits of Intuvin were established based on only two studies (ref. 1), that lasted 8 and 9 weeks respectively.
These studies compared the benefits of Intuvin to placebo. While Intuvin was found to be far more effective than a placebo in reducing ADHD symptoms there is no evidence that Intuvin is more or less effective than other ADHD medications.
There have been other studies of guanfacine (Tenex) in non-extended release form. Three out of four of these studies showed some improvement in ADHD symptoms. However, three of these studies were on small samples (under 20 subjects) and had no control groups. The one study using a control group found benefits for guanfacine relative to placebo (ref. 2.). However, these studies only support the claim that guanfacine is more effective than placebo.
2. How Intuvin (guanfacine) is supposed to work
As Shire notes on their website it is not certain how Intuvin works. The theoretical model suggests that it should increase receptiveness to Norepinephrine in the prefrontal cortext. Coincidently, this is the same neurotransmitter that Strattera (atomoxetine) is hypothesized to increase (albeit in a different manner (ref. 2).