Cogmed in ADHD 6/27/2016. Introduction. Introduction. Introduction. WM is commonly impaired in individuals with ADHD

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1 Introduction Cogmed in ADHD WM is commonly impaired in individuals with ADHD It is estimated that 81% of children with ADHD have deficits in the working component of WM (e.g. the attentional control center or central executive) (Rapport et al., 2013). WM functioning is dependent on dopamine (Williams & Goldman- Rakic, 1995), which is consistent with the association of ADHD with atypical dopaminergic transmission (Cook et al., 1995). Introduction Groups with ADHD have demonstrated gains in WM capacity post Cogmed training Over 30% of the peer-reviewed, published Cogmed research focuses on children and adolescents with ADHD. 14 out of 15 papers reveal that participants with ADHD improve after Cogmed training on measures of WM not previously practiced. Introduction Improvements in symptoms of inattention have been shown after Cogmed training in groups with ADHD The effect of training has been observed on improved parental ratings of inattention in ADHD children both immediately post Cogmed and at follow-up three months later (Klingberg et al. 2005). Data from 769 children, pre and post-cogmed at 3 practices in Singapore, the Netherlands and Canada showed that on average, Cogmed End-Users improved inattentive symptoms (DSM-IV Parent Rating Scale), by 30% from baseline to post-test. Children, mostly with ADHD, improved on the Inattention score of the Disruptive Behaviors Rating Scale by 33% at post-test, 42% at 6 months, and 40% at 12 months post-training. 1

2 Agenda What is working memory? Working memory in ADHD What is Cogmed? Is it clinically relevant for children and adolescents with ADHD? Research Evidence Clinical practice insights Cogmed Plus Information to help you recommend Cogmed or become a coach A system for temporary storage and manipulation of information, necessary for wide range of cognitive tasks The ability to keep information active in your mind for a short period of time (seconds) keeping it available for further processing Working memory is an essential function in every day life Processes all stimuli we encounter Alan Baddeley s Working Memory Metaphor Central Executive Delegates it to the different parts of our brain that can take action Allows us to block out unnecessary information It keeps us updated on what s happening and keeps us focused on what matters Phonological Loop Episodic Buffer Visuo-Spatial Sketch Pad 2

3 Holmes, Gathercole Dunning 2010 Poor Working Memory: Impact and Interventions in Joni Holmes, editor, Advances in Child Development and Behavior, Vol 39 Academic Press 2010 pp1-43 Working Memory impairments are associated with a wide range of developmental disorders of learning Verbal STM Visualspatial STM Verbal WM Visualspatial WM Dr Torkel Klingberg on ADHD ADHD includes severe problems of attention, impulsivity and hyperactivity. Key component is working memory Affects 3-5% of children between 6-16 years, Hyperactivity decreases with age, but problems of inattention remain strong genetic component, with heritability estimated around 70%. Deficits in working memory explain many cognitive and behavioral problems in ADHD (Barkley, 1997; Castellanos and Tannock, 2002; Rapport et al., 2000; Westerberg et al., 2004). A meta-analysis of 46 studies (Martinussen et al., 2005) confirmed the WM deficits in ADHD, and that deficits are most pronounced in Visuo-spatial domain. DYSCALCULIA DYSLEXIA ADHD SLI 10 Presentation Title runs here l 00/00/00 The Development of Working Memory in ADHD Correct Working Memory 5 7,5 8,5 9,5 10,5 11,5 12,5 13,5 14,5 15,5 Age Westerberg et al. (2004), Visuo-spatial working memory: a sensitive measurement of cognitive deficits in ADHD. Child Neuropsychology 10 (3) Control ADHD Profile of a child with ADHD Unfocused Always interrupting Not listening to a word I say 12 3

4 ADHD: DSM-IV symptoms of inattention At least 6 out of 9 of the following: i. Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities ii. Often has trouble keeping attention on tasks or play activities iii. Often does not seem to listen when spoken to directly iv. Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace v. Often has trouble organising activities vi. Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time vii. Often loses things needed for tasks and activities viii.is often easily distracted ix. Is often forgetful in daily activities Symptoms displayed by individuals with poor Working Memory i. Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities ii. Often has trouble keeping attention on tasks or play activities iii. Often does not seem to listen when spoken to directly iv. Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace v. Often has trouble organising activities vi. Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time vii. Often loses things needed for tasks and activities viii.is often easily distracted ix. Is often forgetful in daily activities Ref: Gathercole & Alloway (2008), Gathercole, Alloway, Elliott, & Kirkwood (2008)..now let s look for the overlap with poor WM Ref: Gathercole & Alloway (2008), Gathercole, Alloway, Elliott, & Kirkwood (2008)..7 out of 9 Inattentive Symptoms overlap with poor WM Do you observe these behaviours? Working memory impact is life long Is easily distracted when doing something not highly interesting Has trouble waiting his/her turn Struggles with getting started and completing a task. Watches and depends on friends to remind them of the current task Difficulty organising something with multiple steps frequently stops, frequently loses their place Often seems restless and on the go Fails to progress despite working hard Age Challenge Fitting in Learning to Getting into Graduating Promotion Achieving read University goals 4

5 Why is working memory important? How does ADHD affect learning? Working memory is used for: Controlling attention Resisting distraction Complex thinking Organisation Problem solving Remembering tasks Gathercole & Alloway 2008 POOR WORKING MEMORY: IMPACT AND INTERVENTIONS Holmes et al: 3 strategies Children with poor working memory make characteristic errors in their classroom work: failing to keep track of their place in demanding and complex activities Mistakes in writing and counting Failing to self-correct 1. Change the environment 2. Teach strategies for coping 3. Intensive training on WM tasks to strengthen working memory capacity Over time these frequent missed learning opportunities amount to slow educational progress and poor academic attainment Book: Advances in Child Development and Behavior, Vol. 39 Joni Holmes, Susan Gathercole, Darren Dunning Academic Press, 2010, pp

6 How is ADHD managed now? Education Coaching Sleep Nutrition Physical exercise Mindfulness training Medication Working memory training Interventions Shown to Aid Executive Function Development in Children 4 to 12 years old Adele Diamond and Kathleen Lee, Science 333, 959 (2011); Diverse activities have been shown to improve children s executive functions: computerized training, games, aerobics, martial arts, yoga, mindfulness, and school curricula All successful programs involve repeated practice and progressive increase of the challenge to executive functions. Children with worse executive functions benefit most from these activities importance of early intervention To improve executive functions, focusing narrowly on them may not be as effective as also addressing emotional, social and physical development (shown by positive effects of aerobics, martial arts and yoga). Can working memory be improved? In clinical trials, CWMT has been shown to improve attentional problems in many with ADHD: a) as evident in rating scales Klingberg 2005, Beck et al 2010, Gropper et al 2014, Bigorra et al 2015) a) or measured with objective measures Green et al 2012, Bigorra et al 2015) 6

7 Research discovers working memory can be improved Replication Klingberg replicates first study in placebo controlled, multicenter trial - drawing attention to WM training (Klingberg et al., 2005) Led by neuroscientist T.Klingberg, MD, PhD The findings challenged for the first time the long-held assumption that working memory is a fixed characteristic, unable to be changed. Computerized training of working memory in children with ADHD: a randomized, controlled trial Klingberg et al., 2005 Computerized training of working memory in children with ADHD: a randomized, controlled trial Klingberg et al., 2005 Population: N = 53 children with ADHD (combined & inattentive), ages 7-12 years, no stimulant medication n = 24 in adaptive Cogmed training group n = 26 in non-adaptive (placebo) Cogmed training group n = 3 withdrew Design: Multi-site, randomized, placebo controlled, double-blinded, test-retest T1= Baseline, T2 = Post-test, T3 = 3 month follow up Results: Treatment group improved significantly over active control on outcomes measures: 1) Non practiced visuo-spatial WM task (Span Board; WAIS-RNI) 2) Non practiced verbal WM task (Digit Span; WISC-III) 7

8 Summary Klingberg et al., 2005 This study shows that WM can be improved by training. In addition, we saw effects on reasoning, response inhibition, and a decrease in parentrated symptoms of ADHD. Neuroplasticity makes working memory training possible 1. Expands on Klingberg et al.,2002 replication 2. Placebo condition (low dose training) 3. Multi-site, Randomized, Double -blinded, Placebo controlled 4. Published in leading peer-reviewed journal (JAACAP) 5. Shows results remain after 3 months 6. Shows effects on parent ratings (blinded) 7. Shows effects on neuropsychological tests (attention and impulse control) 8. Shows improvement on complex problem solving 9. Does not show significant effects on teacher ratings or head movement The brain can physically change in response to focused, repeated, intensive activity - training Brain Function and Neuroplasticity Use it or lose it You have to train (or simulate). You are the product of what you DO and THINK Use it and improve it It has to be challenging Specificity Neurons that fire together, wire together Repetition matters Lots of practice is needed Intensity matters It must be effortful Time matters it takes time related to effort Salience matters it must be meaningful, authentic Age matters we are more malleable at an early age, but change/learning is possible at any age Transference and Interference Your brain is highly interconnected, changes in one area will affect others What is Cogmed? Kleim JA, Jones TA. Principles of experience-dependent neural plasticity: implications for rehabilitation after brain damage. J Speech Lang Hear Res 2008 Feb;51(1):S

9 Cogmed Working Memory Training An evidence-based intervention for working memory Highly structured, highly supported program Research-based -Cogmed emerged out of research on the plasticity of working memory and backed up by peer reviewed, published, and fully independent studies Specific working memory exercises, 3000 tasks, lots of practice Adaptively Challenging the program automatically keeps the task within the zone of proximal development Intensive choose from flexible protocols 15, 25 or 35 minutes, 3, 4, 5 times a week for 5-10 weeks Meaningful and supported always provided through a coach, personalised goals and rewards. Feedback - supervised by training aide, progress monitored by Coach. Weekly one-to-one review. Strategies are noticed and practiced How does Cogmed meet the criteria for ideal cognitive training? Three products for Cogmed training Principles Training Challenge is necessary for change Specificity Repetition Need to practice Intensity Salience Feedback Cogmed Engaging exercises Adaptive algorithm Only wm exercises multiple trials for each task, overlapping areas of WM Structured protocol, typically completed in 5-10 weeks Don t start until motivation and goals established Professional support Cogmed JM Cogmed RM Cogmed QM Preschoolers School-age Adults All the products share the same underlying design the only difference is in the user interface >> engagement and rewards 9

10 Demo at mycogmed.com Visual-spatial working memory Cogmed is a highly structured, supportive process Visual-spatial working memory Visual-spatial STM Verbal working memory 1. Structured interview 2. Start-up session training sessions, weekly coach calls 4. Wrap-up session 5. Extension training (optional) Variable Protocols Adaptively Challenging # Session Length Days per Week Number of Sessions Number of Exercises per Session TOTAL TIME Rationale: Repeated recital of WM trials when difficulty level is not adapted typically leads to faster reaction times but not an increase in WM capacity - no generalization 1 50 mins weeks 2 50 mins weeks, 1 day 3 50 mins weeks, 1 day 4 35 mins weeks 5 35 mins weeks, 2 days 6 35 mins weeks 7 25 mins weeks 8 25 mins weeks 10

11 Rewarding e.g. RoboRacing: Cogmed RM Supporting Resources Involves racing against other robots on different tracks The more you win, the more options you have The right and left arrows control the direction of the robot; the space bar to jump With the extra energy that the child has earned from Cogmed RM, they can get extra speed by pressing the CTRL button. Cogmed Coaching Centre Training Details 11

12 Cogmed Progress Indicator (CPI) Monitoring progress: Questionnaire Protocol Shape up, Listen up, Add up tasks Embedded in program Math challenge (auto/manual removal) CPI has cognitive load Best performance out of Days 1 and 2 used as Baseline Measure Occurs on 6 sessions (occurrence depends on training protocol selected) Day 1 & Captures users perspective of their Attention in everyday life Expectations for CWMT, Areas they would like to improve Purpose Provides quantitative measure of training effect Assess with non-trained working memory tasks Track cognitive change as it occurs Sources: yo: DSM-IV ADHD (attention) scale - Intrinsic Motivation Inventory (IMI) Pre: Prior to Day 1 CPI and Training, during Start-Up Session with Coach Post: Available to complete after 80% of training has been completed; Is Cogmed clinically relevant for children and adolescents with ADHD? Children w/ ADHD show 6 months lasting effect of training. Wider effect on executive functioning than stimulant medication alone (Holmes et al., 2010) Cogmed Slide Library

13 Pre-training off medication vs. on medication Holmes et al., 2010 Post-training on medication Holmes et al., Off meds On meds, pre-training Post-training Follow-up Off meds On meds, pre-training Post-training Cogmed Slide Library l 2014 Slides courtesy of Dr. Joni Holmes Verbal STM Visuo-spatial STM Verbal WM Visuo-spatial WM Cogmed Slide Library l 2014 Slides courtesy of Dr. Joni Holmes Verbal STM Visuo-spatial STM Verbal WM Visuo-spatial WM 6 month follow up post-training Holmes et al., 2010 ADHD children achieve significant gains on four WM tests postintervention Holmes et al., Off meds On meds, pre-training Post-training Follow-up By far the most dramatic gains in WM function were observed with WM training. Significant and substantial improvements were found in all assessed aspects of WM, in each case taking the group from a level below average to one within the average range of scores for children of their age Verbal STM Visuo-spatial STM Verbal WM Visuo-spatial WM Cogmed Slide Library l 2014 Slides courtesy of Dr. Joni Holmes Cogmed Slide Library

14 Working memory deficits can be overcome: Impacts of training and medication on working memory in children with ADHD Holmes et al., 2010 Results: 1) Significant gains in all four WM areas at T2 T3 (post training) 2) Training gains remain significant for verbal & visuo-spatial WM and visuo-spatial STM at T4 (6 months) 3) No effect on standardized measure of IQ 4) Training led to greater gains than medication alone Consistent with Cogmed standpoint that WM training is complementary to pharmacological intervention Will working memory training generalize to improve off-task behavior in children with Attention-Deficit/ Hyperactivity Disorder? Green et al Restricted Academic Situations Task (RAST) 5 categories of behavior associated with ADHD scored at 30 sec intervals Given toys to play with for 5 minutes; examiner puts toys to the side, participants asked to complete easy math packet for 15 minutes while videotaped Good indicator of behavioral responses to ADHD stimulant medication Consistent with externalizing teacher ratings and actometer measures of ADHD Objective measure and sensitive to moment-to-moment changes in off-task behavior Children with ADHD show up to 6 months lasting effect of Cogmed WM training. Wider effect on executive functioning than stimulant medication alone. Cogmed Slide Library 2014 Green et al 2012 Publication: Neurotherapeutics Institution: University of California, Davis Investigator(s): Chloe T. Green, Debra L. Long, David Green, Ana-Maria Iosif, J. Faye Dixon, Meghan R. Miller, Catherine Fassbender, Julie B. Schweitzer Randomized, placebo controlled, double-blinded study of 26 children with ADHD first known research to demonstrate the impact of WM training on an ecologically valid measure of observable ADHD-associated behaviours - RAST Children who trained with the standard Cogmed program (adaptive WM training) improved significantly over children in the placebo group (nonadaptive WM training) on non-trained, widely used, standardized measures of WM (Digit Span and Letter-Number Sequencing; WISC) and on measures of the Restricted Academic Setting Task (RAST) that related to attention. 14

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16 Cogmed does not claim to be a treatment for ADHD Dr Michael McDowell Dr Michael McDowell is a Developmental Paediatrician and works at the Child Development Network, a private multidisciplinary service in Brisbane. He has an Associate Professor position at the University of Queensland and is the Foundation President of the NBPSA, a national Society for Neurodevelopmental Paediatricians Clinical Practice Poor attention, impulsive Anxious, easily upset Parents separated Impaired learning Impaired social skills Poor self concept Cogmed Plus Cogmed 'creates an opportunity for change' but the ultimate benefit depends on how that opportunity is used - e.g. to build literacy, social skills, lifestyle habits, resilience and so on. The extent to which it works cannot be separated from the support, the rewards, the matching content that the school and coaching environment can provide. The intervention itself works. It isn t whether the intervention is good or bad, but how it is used 16

17 Focus Time Child Family Future School / Child s world Before Training After Dr Ed Hallowell Recommend Cogmed 17

18 Become a Coach As a Cogmed Qualified Coach you can: Differentiate your clinical practice by offering an effective, evidence-based intervention Provide a well-structured solution for individuals you have assessed with working memory difficulties Support and encourage users to complete the program with your coaching skills and your expertise in working memory and cognitive rehabilitation Make a real difference in people s lives - improvements to working memory have an impact on core, everyday living skills Monique Ryan s Story Mother, Wife, Coach Two sons, one husband with ADHD Desperate to get change value for money VERY challenging needed daily rewards, angry at the voice Three very different training experiences husband got worse before he got better hyperactiive at end but at 1 month mark everything came together Little one improved visibly, immediately, continued to make steady improvement Older child improved very slowly with gains highly visible at the 6 month follow up. Life changing experience Learn more about Cogmed Try the demonstration: Try Out Cogmed See: Download the Resource Kit for Schools Learn more about becoming a Clinical Coach Contact: Mimma Mason at Pearson info@cogmed.com.au or your closest Cogmed Coach 18