Child Neuropsychology

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Computerized Progressive Attentional Training (CPAT) Program: Effective Direct Intervention for Children with ADHD Lilach Shalev a; Yehoshua Tsal b; Carmel Mevorach c a Department of Education and Psychology, Open University of Israel, b Department of Psychology, Tel Aviv University, c School of Psychology, University of Birmingham,

Online Publication Date: 01 July 2007 To cite this Article: Shalev, Lilach, Tsal, Yehoshua and Mevorach, Carmel (2007) 'Computerized Progressive Attentional Training (CPAT) Program: Effective Direct Intervention for Children with ADHD', Child Neuropsychology, 13:4, 382 - 388 To link to this article: DOI: 10.1080/09297040600770787 URL: http://dx.doi.org/10.1080/09297040600770787

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Child Neuropsychology, 13: 382–388, 2007 http://www.psypress.com/childneuropsych ISSN: 0929-7049 print / 1744-4136 online DOI: 10.1080/09297040600770787

COMPUTERIZED PROGRESSIVE ATTENTIONAL TRAINING (CPAT) PROGRAM: EFFECTIVE DIRECT INTERVENTION FOR CHILDREN WITH ADHD Lilach Shalev,1 Yehoshua Tsal,2 and Carmel Mevorach3 1

Department of Education and Psychology, Open University of Israel, 2Department of Psychology, Tel Aviv University, and 3School of Psychology, University of Birmingham

We tested the efficacy of a pioneering intervention program grounded in a contemporary theoretical framework of attention and designed to directly improve the various attentional functions of children with ADHD. The computerized progressive attentional training (CPAT) program is composed of four sets of structured tasks that uniquely activate sustained attention, selective attention, orienting of attention, and executive attention. Performance was driven by tight schedules of feedback and participants automatically advanced in ordered levels of difficulty contingent upon performance. Twenty 6- to 13-yearold children with ADHD were assigned to the experimental group and received the CPAT sessions twice a week over an 8-week period. Sixteen age-matched control children with ADHD were assigned to the control group and participated in sessions of the same frequency, length, and format except that instead of performing the training tasks they played various computer games during the session. The experimental participants showed a significant improvement in nontrained measures of reading comprehension, and passage copying as well as a significant reduction of parents’ reports of inattentiveness. No significant improvements were observed in the control group. We thus concluded that the above academic and attentional improvements were primarily due to the CPAT.

INTRODUCTION Attention deficit/hyperactivity disorder (ADHD) is a chronic mental health disorder of childhood onset characterized by inattention, impulsiveness, and hyperactivity (Diagnostic and Statistical Manual of mental disorders, 4th edition [DSM-IV]; APA, 1994). Given the high prevalence of ADHD and its impact on many aspects of development and every day functioning, extensive effort has been focused on various treatments to lessen symptoms. Since this study reports a novel cognitive nonpharmacological treatment, we will briefly review the recent developments in the field of nonpharmacological treatments for children with ADHD. Cognitive Treatment Many different types of cognitive-behavioral treatments have been applied to children with ADHD, including verbal self-instructions, problem-solving strategies, cognitive

Address correspondence to Lilach Shalev, Behavioral Brain Sciences Centre, School of Psychology, University of Birmingham, Edgbaston, B15 2TT, Birmingham, UK. E-mail: [email protected] © 2007 Psychology Press, an imprint of the Taylor & Francis Group, an Informa business


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modeling, self-monitoring, self-evaluation, and self-reinforcement among others. These interventions are focused on improvement of self-controlled behavior through the enrichment of problem-solving strategies. Unfortunately, many studies (Abikoff & Gittelman, 1985; Abikoff, 1991; Bloomquist, August, & Ostrander, 1991) showed that cognitivebehavioral treatments do not provide significant improvements in the behavior and academic performance of children with ADHD. More recently, Kerns, Eso, and Thomson (1999) argued that repeated activation and stimulation of attentional systems can facilitate changes in cognitive capacity that presumably reflects underlying changes in neuronal activity. They tested the efficacy of a new set of child-oriented direct intervention materials and found that children with ADHD receiving this direct intervention did significantly better than a control group on a number of untrained measures of attention and academic performance. No significant improvement in parent and teacher rating scales was obtained. A recently developed training method (Klingberg et al., 2005; Klingberg, Forssberg, & Westerberg, 2002) demonstrated that intensive computerized training of working memory (WM) gradually increased the amount of information that children with ADHD can keep in WM. Posner and Rothbart (2005) demonstrated that normal 4-year-old children benefited from five days attentional training. Their EEG data suggested that the training altered activity in the anterior cingulate. They concluded that attentional training could change the underlying network in ways that might lead to extensive generalization. Theoretical Framework of the Present Study The present research is based on Posner and Petersen’s (1990) influential theory of attention networks and its recent application to ADHD research (Tsal, Shalev, & Mevorach, 2005). Posner and Petersen (1990) proposed that the attentional system can be broken down into three networks represented in distinct anatomical areas: (a) The vigilance network, responsible for maintaining a state of alertness (right frontal and parietal regions); (b) the visual orienting network, which controls the selection of information from sensory input (superior parietal lobe, temporal parietal junction); and (c) the executive attention network, responsible for resolving conflicts among responses (midline frontal areas and lateral prefrontal cortex). The present study was designed to test the hypothesis that attention deficits of children with ADHD can be ameliorated by a systematic individualized training program involving a direct intensive exercising of the attentional networks. Studies examining the academic achievements of children with ADHD indicate that many of them receive low grades in academic subjects and low scores on standard measures of reading, math, spelling, or written language (Anderson, Williams, McGee, & Silva, 1987; Barkley, Fischer, Edelbrock, & Smallish, 1990; Zentall, 1993). Thus, our aim was to demonstrate that attentional training in children with ADHD can primarily improve academic performance. A computerized progressive attentional training (CPAT) program was developed on the basis of leading theories and commonly used methodologies in the visual attention literature. The program was specifically designed for use with children (aged 6 years and above) who cope with attentional difficulties. The program includes four sets of tasks each designed to extensively train one of the four attentional networks: sustained attention, selective attention, orienting of attention, and executive attention. The rationale for improvement in training was based on the gradual progress across difficulty levels driven by tight schedules of feedback and accumulation of points.


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METHOD Participants. Participants were diagnosed by a qualified psychiatrist, neurologist or psychologist according to DSM-IV criteria. The participants were randomly assigned to either the experimental group or the control group, and group identity was known neither to participants nor to their parents. Written parental consent was a prerequisite for participation in the study. The experimental group included 20 children (17 males and 3 females) and the control group included 16 children (13 males and 3 females) all with ADHD. The experimental group had a mean age of 9.1 years (range 6–13 years); the mean age of the control group was 9.2 years (range 6–13 years). There was no significant difference between ages (p = .88) and intelligence (p = .41) between the two groups. The majority of the participants met the DSM-IV criteria for ADHD combined subtype (15/20 in the experimental group and 13/16 in the control group). The other participants met the DSM-IV criteria for ADHD inattentive subtype (DuPaul et al., 1998). The training tasks. The four comprehensive training tasks are based on expansions and modifications of various tasks that have extensively been investigated in the attention literature and are known to uniquely reflect the various attentional functions. The four training tasks included the Computerized Continunuous Performance Task (CCPT; based on Rosvold, Mirsky, Sarason, Bransome, & Beck, 1956), which was designed to improve the function of Sustained Attention, the Conjunctive Search Task (based on Treisman & Gelade, 1980), which was designed to improve the function of Selective Attention, the Combined Orinenting and Flanker Task (based on Eriksen & Eriksen, 1974 and Posner, Snyder, & Davidson, 1980), which was designed to improve the function of Orienting Attention and the Shift Stroop-like Task (based on Navon, 1977), which was designed to improve the function of Executive Attention. Procedure. On the average each session included eight blocks from four different tasks. Number of blocks varied across participants primarily due to age differences. Every block contained 40 trials, except for blocks in the CCPT that consisted of either 80 trials or 160 trials depending on the level of difficulty. Participants advanced in levels of difficulty according to prespecified criteria based on fixed-accuracy and individually adjusted reaction time (RT). Participants received an auditory feedback (beep) when an error was committed and visual feedbacks on RT performance. These feedbacks were translated into points that were presented on the screen at the end of each block. The training program. The training program was carried out over a period of eight weeks consisting of two one-hour sessions per week. Each participant was supervised by a research assistant during the entire session. During each session participants performed a selection of tasks and within each task participants advanced in the levels of difficulty according to their gradual progress, expressed in speed and accuracy performance. In order to evaluate the success of our program participants were tested on several criteria before and after training. Improvement on these tasks (relative to natural progress of control participants served as an indication for the success of the CPAT. The control group consisted of children with ADHD who participated in sessions of the same frequency, length, and format except that instead of performing the training tasks they played various computer games and were involved in various paper and pencil activities during the session. These computer games contained inherent scoring and feedback mechanisms. These games also included multiple levels of difficulty.

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The training evaluation tests. Pre- and posttreatment measures were administered prior to beginning the intervention and within 2 weeks of completing the treatment. The corresponding pretests and posttests were different but of equal difficulty levels. Since there are no standard academic tests in Hebrew, the academic tests for each participant were taken from school-books of the relevant grade. The research assistants who administered both the pre- and posttests were randomly assigned to avoid any consistent bias. Participants were presented with the following tests: passage copying, math exercises, reading comprehension, and parents’ rating scale (DuPaul et al., 1998). RESULTS AND DISCUSSION Figure 1 presents the pre- and posttraining scores of the three academic measures for experimental and control participants. The figure suggests a clear distinction between the experimental and control groups in reading comprehension and passage copying. That is, on these two measures training produced a substantial improvement and no effect was obtained for the control participants. Statistical analyses indeed confirmed these observations.These data were subjected to ANCOVA (Analysis of covariance) in order to remove the extraneous variability that derives from preexisting individual differences. These analyses revealed that in both reading comprehension, F(1, 31) = 4.89, p < .05; η2 = .12, and speed of copying, F(1, 31) = 6.11, p < .05; η2 = .17, the significant improvements that were obtained in the experimental group are attributed to the type of treatment and are not due to preexisting individual differences. However, the analysis also revealed that the improvement of experimental participants relative to control participants in mathematical performance could not be fully attributed to training, F(1, 32) = 1.2, p < .30. Figure 2 presents the pre- and posttraining scores of parents’ ratings (DuPaul et al., 1998) of both inattention and hyperactive symptoms. The figure shows a substantial reduction in inattention symptoms for the experimental participants and no change in the control participants. The figure also shows a reduction in hyperactive symptoms for children in both groups. An ANCOVA carried out on these data indicated that while the

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reduction in inattention symptoms could be attributed to training, F(1, 24) = 8.37, p < .01; η2 = .29, the reduction in hyperactive symptoms could possibly be attributed to extraneous influence, F(1, 24) = 2.34, p = .14. The results clearly show that a relatively short-term computerized progressive attentional training (CPAT) that operates on attentional networks produced significant improvements in both academic tests and parents’ behavioral ratings. It should be noted that in both groups children were treated very positively and were semantically rewarded for being consistent and cooperating throughout the 16-session intervention. Alternative explanations such as spontaneous development or a general supportive atmosphere can be ruled out since no systematic changes on these measures were observed for the control group. While the program also significantly improved mathematical performance and reduced behavioral symptoms, the present analyses could not rule out the possibility that these effects were due to extraneous variability deriving from preexisting individual differences. The present findings lend support to the proposition (Kerns et al., 1999) that process specific interventions that directly stimulate and exercise attentional systems improve cognitive capacity as they presumably reflect underlying changes in neuronal activity. In considering the manner in which the CPAT could affect academic performance it is important to keep in mind that every academic task requires the efficient functioning of attentional systems and that attention deficit is the primary cause for poor academic performance in children with ADHD (Zentall, 1993). Thus, for example, effective copying performance requires orienting to the location of the momentarily relevant word (orienting of attention) while ignoring other adjacent words (selective attention), avoiding lapses of attention during this prolonged process (sustained attention), and regulating the entire task in the presence of potential interference (executive attention). Hence, it is possible that systematic improvement in these four attentional functions may generalize to academic tasks by virtue of improving the mediating attention processes.



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While it is generally hard to identify the specific cause of changes in treatmentoriented investigations (Kerns et al., 1999), it is worth noting two unique characteristics of feedback in CPAT that distinguishes this program from other activities and are likely to contribute to its success. First, feedbacks provided in other forms of treatment and daily activities are rather general and vague in the sense that they are not reinforcing the specific desired response. In the present training the attentional components of the tasks were isolated and, thus, those processes mediating attentional control were immediately and directly linked to the feedback. The second distinctive characteristic of CPAT was the advancement in difficulty levels in a systematic fashion under highly structured conditions. Structured training procedures with defined “working rules” have been shown to facilitate self-regulation and control. For example, Reid and Borkowski (1987) found that attention of impulsive children could be brought under some degree of voluntary control by self-instructional procedures. In addition to its positive cognitive aspects, this gradual learning process also had a significant motivational influence. Given that within each difficulty level effective responses were within reach, it is likely that children experience a gain in self-esteem and sense of control as they improve on treatment tasks. It was clear that the number of points presented at the end of each block served as a tremendous source of fulfillment and satisfaction. There are three major limitations in the present study. The first limitation of the present study is that we did not include in our evaluation battery any objective attentional measure assessing attentional difficulties before and after training. Future studies evaluating the mechanisms that underlie the effects of the CPAT should include attentional measures in order to investigate the extent to which improvements in academic performance are associated with improvements in the various attentional measures. The second limitation is that without any long-term follow-up study, it is not possible to determine whether the improvement observed in the present study is time limited or whether it represents an enduring change in underlying ability. A longer term investigation is warranted to more adequately address this question. The third limitation is the absence of teachers’ evaluations regarding the children’s classroom functioning and academic performance. Future research should enlarge the tools that assess the effectiveness and generalization effects of the attentional training, including teachers’ evaluations. Original manuscript received November 9, 2005 Revised manuscript accepted April 21, 2006 First published online October 20, 2006

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