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Scientific American on Alternative Therapies for ADHD


Training the Brain

Cognitive therapy as an alternative to ADHD drugs

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. Studies increasingly show that while medication may calm a child’s behavior, it does not improve grades, peer relationships or defiant behavior over the long term.

Consequently, researchers have focused attention on the disorder’s neurobiology. 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.

“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.

“Working memory is a bottleneck for everyday functioning independent of what category you fit into,” comments Torkel Klingberg, a neuroscientist at the Karolinska Institute in Stockholm. Based on Klingberg’s research, Karolinska founded Cogmed–a biotech company that has developed a software program to train working memory. In a recent paper in the Journal of the American Academy of Child and Adolescent Psychiatry, Klingberg reported that 60 percent of 20 unmedicated ADHD children no longer met the clinical criteria for ADHD after five weeks of training. The company has already rolled out its training service in Sweden and Germany, and Karolinska is collaborating with New York University to launch a clinical trial with ADHD kids later this year.

“It’s intriguing data,” Tannock remarks. “The emphasis is on visual-spatial memory, which is where we find the strongest link to inattention and ADHD. But they have to go further. You want to show that training improves ability on a range of tasks, not just holding information.”

That ADHD children would respond to cognitive training does not surprise experts such as Lawrence H. Diller, a child psychiatrist and author of Running on Ritalin. “Hyperactivity and inattention are bell-shaped spectrum disorders,” he says. “The majority of kids who are getting medication are borderline normal versus abnormal.” In Diller’s experience, the former benefit the most from nonpharmaceutical training approaches. Medication has been overemphasized by a pharmaceutical and medical industry “that has changed people’s view of themselves,” he continues. “Personal responsibility has taken a backseat to lifelong disorders.”

Moreover, because there is no industry to back it, behavioral therapy has been grossly underrated, Diller and others opine. Unpublished data from the Multimodal Treatment Study–the largest U.S. long-term study of ADHD treatment in children–show that after two years, kids treated with behavioral therapy only (parent training, school intervention and a special summer camp program) functioned just as well as kids on high-dose medication, says lead researcher William Pelham of the University at Buffalo. Also, only an additional 8 percent of the children in the behavioral arm were medicated at the end of the second year, indicating that most parents in this group were satisfied with behavioral therapy.

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Additude article about Cogmed

Programmed for Success?

The training consists of eight simple, memory-tuning exercises. The software prompts you, for instance, to listen to a string of numbers and recite them backwards, or to watch sections of a grid light up in sequence, and then copy the pattern. It’s not exactly scintillating stuff, but over time, I found myself enjoying and getting better at the drills. I suspect my son shared this experience. The program provides graphs that chart your progress, and both of us watched our lines go steadily upward. Tuckman kept telling my son how much better he was doing than I was — another powerful motivator for him.

The obvious question for consumers is how this proficiency translates into real-world skills. Cogmed representatives say 80 percent of those who complete the training experience “significant change.” I looked for signs of improvement, both in Buzz and me, and didn’t see anything dramatic. At the start of Week 3, I forgot my purse when I went out to dinner. On the other hand, after only a couple of weeks, it seemed that my son was making more eye contact, and having fewer and less intense temper tantrums. Amid one of our most difficult summers ever, full of cabin fever and conflict, we had some unusually calm conversations. Furthermore, after Buzz hacked into my Facebook account, sending goofy messages to my friends — alas, not unusual behavior for him — he apologized, which wasn’t exactly on par with teaching himself Farsi, but, for him, was extraordinary.

Results Over Time

Tuckman tells me that the changes often take time to appear — sometimes several months after the training is completed — so I’m staying hopeful.

Meanwhile, I’m pondering two questions: 1) Might it be that anything else that was going on in our lives this summer — from family therapy to the fact that my son was out of school for a couple of months—helped improve his behavior? This is something only a controlled study could tell us, and I had only my anecdotal experience. 2) What role did our expectations play in the improvements we saw?

LA great deal of research has been done on the placebo effect, all of it suggesting that expectations matter mightily. It’s also a no-brainer that when a parent directs intense, positive attention toward a child — from closely monitoring his diet to schlepping her to violin lessons — it’s bound to have a positive effect.

Might it be that my son was being perceptibly nicer because I’d been sending him my own “You Rock!” signals every time he completed a day of Cogmed training? I’ll probably never know, but I am convinced it didn’t hurt.


This article appears in the Winter 2011 issue of ADDitude.
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