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ADHD

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Symptoms

Inattention involves impairment in the ability to focus, maintain attention on a given task, and avoid distraction suitably for your Besides ADHD, other potential causes of inattention, include: developmental problems in particular brain regions, family situations, unreasonable expectations of a child by parents or teachers, a conscious effort to avoid humiliation, certain sleep disorders, chronic lack of sleep, insufficient breakfast, recurrent bullying, or specific learning disabilities in academic situations.[3]

Children with ADHD have problems with inattention in a variety of settings including those observed in school. This is caused by an inborn deficit in the brain for monitoring inhibition and self-control.[3] This impairment in self-regulation is neurologically based and affects brain function critical for focused and sustained attention; which is the main source of the difficulties they face.[3] This type of inattention is often called "primary inattention", in contrast to, the inattention caused by other factors mentioned above.

Besides inattention, the other major difficulties of ADHD are hyperactivity and impulsiveness.[3] Hyperactivity is characterized by difficulty controlling movements so that they are purposeful and goaloriented.[ 3] Impulsiveness involves a greater difficulty moderating behaviour and resisting temptation.[3] A term used to describe both hyperactivity and impulsiveness is disinhibition.[4]Disinhibition appears as problems with "fidgetiness", staying in one's seat, playing loudly, talking too much, interrupting, and more difficulty waiting in a line or taking turns.[4] Moreover issues with disinhibition arise at an earlier age, compared to problems with inattention.[4] Similarly difficulties in both disinhibition and inattention decline with age; however difficulties with inattention remains more stable, are constant for a longer period of time, and declines at an older age.[1][4] Meanwhile, disinhibition is related to a larger amount of difficulties in comparison with inattention.

Children with ADHD additionally experience difficulties in other areas, such as learning, behaviour, and emotional regulation.[3] Some other symptoms of children with ADHD include: being more active than other children, talking more, interrupting conversations of others, difficulty controlling motor overflow movements, problems stopping ongoing behaviour, and having more trouble turning down instant gratification or temptations.[4] Children with ADHD also show impaired encoding with regard to strategy and efficiency.[5]

In regards to research, ADHD is of fairly recent interest to scientists and psychologists. During 1957 to 1960 there were less than three dozen articles on the subject, compared to 20 years later during 1987- 1990 when there were over 7000 articles published.[3] Moreover much of the discussion involves children and educational situations.

Childhood Executive Function Inventory

Childhood Executive Function Inventory (CHEXI) is a newly developed and promising measure of identifying young children with ADHD.[6] Instead of classifying this disorder based on a specific set of several symptoms that must be present in the individual, like in the DSM-IV-TR, CHEXI focuses only on the inhibitory control, and the working memory of the individual.[6] Studies have found CHEXI has the ability to discriminate very well between children with ADHD and normally developing children.[6] Furthermore, the results indicated by CHEXI are highly similar to those classified by parent and teacher ratings. CHEXI is still in the early stages of development. Future researchers still must determine specific cut-offs, research CHEXI using longitudinal studies,[6] and compare CHEXI ratings with many more alternative measures of ADHD[7] if CHEXI is to be one day used in clinical practice.[6]

Working Memory

Working Memory Overview
Working Memory is a memory system used for keeping information in mind while carrying out a number of other cognitive tasks.[8] These tasks include the insertion of information into long term memory, and the retrieval of information from long term memory.[8] Working memory capacity allows for the retention and manipulation of information for short periods of time.[9] Working Memory is described through the three part model put forward by Alan Baddeley and Graham Hitch which includes the visuospatial sketchpad, the central executive, and the phonological loop.[8] The phonological loop has two components: short term storage for phonological information for a time period of seconds called the phonological store, and a second component to refresh this store called the articulatory process.

The visuo-spatial sketchpad involves keeping visual and spatial information in mind, and is more difficult to measure and study than the phonological loop.[8] The central executive is said to be the most important and complex part of Working Memory.[8] It is also the least understood.[8] The central executive has been proposed by Baddeley as conceptually equivalent to the supervisory attentional system of Norman and Shallice, and thus directly linked with attentional control.[8] Therefore, the study of working memory and the central executive are applicable to ADHD.

Working Memory and ADHD

Literature has cited a deficit in Working Memory in children and adults with ADHD,[10] due to frontal lobe impairment.[9] Moreover, because of the connection between attentional control and the central executive, impairments in Working Memory likely influence the difficulty with maintaining attention observed in those with ADHD.[8] It is suggested that no division exists between various features of attention and operation in the Working Memory, especially the central executive.[8] Furthermore, improvements in Working Memory are also linked with the ability of ADHD children to stay still for longer periods of time.

Children with ADHD have difficulties in the automatic processes needed to engage in tasks and to learn new skills without much conscious thought, which is related to working memory.[11]Specifically, something that is automatic for most individuals, such as packing last night's homework before school, children with ADHD must concentrate in order to focus on the task at hand, without becoming distracted. Another study failed to show problems with inhibition, with regard to, cognitive suppression in adolescents and adults with ADHD.[12] Nevertheless, the same study did recognize an impairment in controlling interference with working memory.

Working Memory Training

Working memory training is a method that focuses on the use of verbal and visuo-spatial tasks to improve the working memory capacity of individuals that possess poor working memory. Specifically there is a focus on improving the working memory capacity of children with ADHD and other intellectual disabilities; however it is not restricted to these groups. Working memory training is also used on a larger extent of the population. For example adult neuropsychological patients like those with multiple sclerosis,[13] or adults who have experienced a stroke,[14] and many more groups of individuals ranging from children to the elderly who possess a poor working memory. Strategies are taught to increase performance on the verbal and visuo-spatial tasks, and increased performances are hoped to produce transfer effects. Simply put, the overall goal and assumption of working memory training is that the resulting improvement in task performance will lead to improvement in everyday situations that rely specifically on working memory.[15] Working memory training may lead to this by strengthening working memory capacity, presenting strategies to assist working memory, or by developing voluntary control of attention.

Working Memory Training Tasks

Working memory tasks are conducted on computers and are often paired with positive reinforcement, feedback of the individualʼs performance,[16] and other motivational features such as displaying the individualʼs current score beside their personal best score.[14] Practicing these tasks demands numerous processes such as encoding, inhibition, maintenance, manipulation, shifting and controlling attention, and the ability to manage two tasks simultaneously or dividing attention.[17] Possible forms of the tasks include recalling a series of locations of items on the screen, recalling digits or letters in either the order presented or reverse order,[14] or recalling specifically where a particular number or digit was in a sequence.[16] Computers are additionally programmed to adjust the difficulty of the task to the individualʼs performance with each trial in order to maximize learning and overall improvement. If the individual does poorer on one trial, the difficulty will decrease. Similarly, if the individual excels on the next few trials, the difficulty will increase. Two ways of altering the difficulty is by adjusting the number of stimuli that is needed to be remembered, and adding visual distractions.

Strategies

Common strategies used in Working Memory Training include repetition of the tasks, giving feedback such as tips to improve oneʼs performance to both the parents and the individual, positive reinforcement from those conducting the study as well as parents through praise and rewarding,[16] and the gradual adjustment of the task difficulty from trial to trial. More explicitly used strategies by the individual include rehearsal of material, chunking, pairing mental images with the material, mnemonics, and other meta-cognitive strategies. The latter strategies have been learned and there is a conscious awareness of their use.

Training Set-up and Evaluation

Before training commences participants complete pre-training verbal and visuo-spatial tasks, which are additionally completed in the studyʼs follow-up as post-training tasks. Pre-training and post-training tasks vary, some studies use verbal and visuo-spatial tasks along with slightly different tasks; referred to as "nontrained tasks." Klingberg et al.[9] used visuo-spatial tasks, a Span board, theStroop task, Ravenʼs Coloured Progressive matrices, and a choice reaction time task, during pretraining and post-training. Holmes et al.[14] used a nonword recall task, mazes memory task, listening recall, and the "odd one-out" task. By using tasks that differ from ones in the study, laboratory results can demonstrate transfer effects if high scores are achieved, since these were not learned during training.

The training itself is set up in studies so that participants attend a set amount of sessions over a given period of time that widely varies between studies. This can vary anywhere from two weeks to a span of eight weeks. The time spent in sessions also ranges, with some studies being as short as fifteen minutes to other studies lasting forty minutes. Studies can take place in the lab, or even at home with researchers keeping in touch through weekly phone calls.[16] There is no universal way to set up the training schedule, since all schedules tended to vary to at least to some degree. The effects are tested immediately after training is completed and again a few months after, or even up to a year later, to see if the training outcomes are still in place. Testing and evaluation can be based on the measures of academic efficiency, ratings of the individualʼs symptoms from teachers and parents, comparing the experimental to the control groups of the study, and selfreport measures.

Transfer Effects

There are many possible transfer effects from working memory training. An increase in working memory capacity could make individuals more likely to take on tasks that have a higher working memory load, such as math and other challenging academics.[18] Holmes et al.[19] reported an improvement in mathematical reasoning, even six months after training was completed. Furthermore, there has been parent reported decreases of inattentive behaviours, hyperactivity, and impulsivity in children with ADHD,[18] in addition to, a decrease in motor activity.[9] However the majority of transfer effects are seen in lab-based nontrained tasks that are completed during follow-up and immediately after training is over. Findings from these results vary according which nontrained tasks the researcher chooses to use. The main general finding in these studies, confirm experimental groups improve on trained tasks in comparison to control groups, and that effects will need retraining to maintain.

Working Memory Training to Help with ADHD

Working memory training is said to improve general cognitive ability.[20] It can also show "transfer effects" which are improvements in areas other than Working Memory. This is relevant for children with ADHD since ADHD is associated with a deficit in Working Memory. Additionally, numerous transfer effects of this kind of training are relevant to ADHD such as: academic improvements, decrease in motor activity, improved reading comprehension, greater attentiveness, decreased hyperactivity, and so on. As such, there is hope that Working Memory training, through an improvement of Working Memory and other transfer effects, could improve the symptoms associated with ADHD.

Psychostimulant medication has been used as an effective remedy for Attention Deficit Hyperactivity Disorder symptoms for some time, but some studies claim that in medicating children we fail to address the root of the problem, and that effects diminish once patients are no longer medicated.[2] Because of this, researchers have been investigating non-pharmacological methods for improving ADHD symptoms. As mentioned previously, literature has shown that working memory plays a large part in a personʼs ability to maintain focus on a given task, such that one must retain information in either the phonological rehearsal loop, or the visuospatial-sketchpad, while using the central executive to direct current focus on the goal at hand.[21] An especially crucial part of this process is maintaining focus on goalrelevant information in the presence of distractors.[21] Since a primary symptom of ADHD is a deficit in attentional control, it may follow that by improving the working memory of individuals with ADHD, the severity of their symptoms of inattention may decrease as a result.

Effectiveness of Working Memory Training for Treating Children with ADHD Effects of Training on Working Memory and Short Term Memory in Children with ADHD

Recently, a computerized-training program has been developed that has been shown to improve working memory deficits as displayed by children with ADHD, as well as normally developing children and stroke patients.[14] In this method, patients complete 20-25 tasks that incorporate use of working memory and that increase in difficulty as the patientʼs working memory capacity and efficiency increases. A study by Holmes et al.[14] further investigated the effectiveness of this training program and compared it to the effectiveness of using psychostimulant medication alone. Participants were assessed for verbal short-term memory, visuo-spatial short-term memory, verbal working memory and visuo-spatial working memory while off medication for at least 24 hours, and then again once back on medication. A control group completed the tasks in the absence of the algorithm used to increase difficulty as the participantʼs performance improved, to control for improvements being made because of increasing familiarity with the activity. After completing these tasks over a period of 6-10 weeks they were assessed for improved working memory using the Automated Working Memory Assessment,[22] immediately following training and again 6 months later. Considerable improvements were seen in all four aspects of working memory, both after working memory training and by using stimulants alone.[14] The greatest improvement in working memory was observed after working memory training in children who were also taking stimulant medication, as compared to working memory training only.[14] Here, children all four components of working memory improved, and working memory proficiency increased from below-average levels to average or above-average levels for their age.[14] They also found that children who completed the tasks with increasing difficulty showed substantially more improvements in visuo-spatial working memory, nonverbal reasoning and response inhibition.[14] Improvements were still present at a followup assessment 6 months later, and children also showed classroom improvements in mathematical reasoning, suggesting that benefits of working memory training may extend to overall academic performance.[14] This study presented promising implications for the lasting effectiveness of working memory training, but was limited in that its participants may not have been representative of the ADHD community because researchers did not systematically diagnose children with ADHD prior to conducting the study. Rather, the studies relied on the opinions of the participant's pediatricians and child psychiatrists.

Effectiveness of Training on Specific Symptoms of ADHD

Several studies have found improvements in specific symptoms of ADHD following working memory training. Kerns and his colleagues administered an attention demanding task upon 14 children diagnosed with ADHD.[23] Prior to this, half of the children received working memory training specially designed to improve attentional control twice a week over a period of 8 weeks, and half received no training. There was no control group for which task difficulty did not increase to match participantsʼ developing working memory. Those that received training performed better on the attention-demanding task than those who did not, and also displayed better performance on other tasks not specific to aspects of working memory.[23] However, parent and teacher-reported symptoms of ADHD did not improve.

Klingberg conducted a similar study in which children with ADHD participated in 20-25 verbal and visuo-spatial working memory exercises, which included an experimental condition where task difficulty did not increase as the children progressed through training.[9] After training, most of the children who participated in the adaptive training condition showed improvements in mathematical reasoning, response inhibition and decreased hyperactivity, as well as a number of other ADHD symptoms according to parent reports.

Beck et al.[16] investigated whether improved working memory in children formally diagnosed with ADHD leads to decreased severity of specific ADHD symptoms, such as inattention, as indicated by parent and teacher ratings. Before training, parents and teachers filled out the Connorʼs Rating Scale, and were asked to report on the childrenʼs level of oppositional, cognitive problems, inattention, hyperactivity and a general ADHD index. Once children completed the 20-25 sessions of working memory training, parents and teachers filled out the Connorʼs Rating Scale a second time. Working memory training led to significant improvements in parent and teacher reports of all four subsets of ADHD symptoms indicating that working memory training may be a promising and lasting method for improving symptoms of ADHD.[16] These findings are meaningful in that they provide a hopeful alternative for the use of stimulant medication in young children and adolescents, a topic of much debate in the clinical field and society at large. Improving working memory appears to reach the basis of the problems underlying ADHD by altering children's capacity for retaining relevant information, while enhancing their ability to maintain focus and to avoid being side-tracked, which could help children become calm, attentive and successful members of the classroom and in many other areas as well.

Limitations and Directions for Future Research

Most research has its limitations, and working memory training is no exception. Probable confounding variables are a lack of comparison between experimental and control groups at the studyʼs follow-up, and parents and teachers not being blind to the study, therefore expectancy effects may influence their reports of changes in the participant.[16] A more complex problem involves the idea that, on the one hand, having lab based studies with short follow-ups create problems with its ecological validity; however trying to solve this by training outside laboratory setting creates possible issues with compliance over extended periods of time, and the lack of supervision that takes place causing enhanced negative effects on the results.

Future research directions include longer follow-ups, specifically examining the various subtypes of ADHD, more studies on the less researched populations such as individuals with brain injury, and trying to find more "clinically meaningful behaviour" in transfer effects as opposed to transfer effects seen in the lab.[16] More specific questions future research hopes to discover involve: optimal duration of training, correct spacing of training sessions to create durable improvements, the role of reward and motivation, and the influence of individual variables such as age.

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