Scientifically speaking, treatment options for students with attention deficits have long been limited. Outside of stimulant medication, and some behavior-modification strategies, few interventions have much of a research base to show that they can help.
That situation could change, though. Recent studies have shown that a computer-based training program developed in Sweden helps sharpen the “working memory” skills of children and teenagers with some form of attention deficit hyperactivity disorder, or ADHD. And, in the process, the studies show, the program can alleviate some of the problems they have with paying attention, controlling their impulses, and solving problems.
Working memory is the ability to keep information in mind and work with it at the same time. The brain calls on working memory, for example, when people solve mathematical problems or try to follow through on plans they’ve made.
Experts believe that working memory can be particularly difficult for many people with ADHD, a condition that afflicts an estimated 3 percent to 5 percent of school-age children, as well as for people who have suffered traumatic brain injuries or strokes.
Read the 2004 randomized study, posted by the Stockholm Brain Institute.
In a study published in 2004 in the peer-reviewed journal Nature Neuroscience, Dr. Torkel F. Klingberg and his colleagues at Stockholm’s Karolinska Institute gave the program to a group of attention-challenged Swedish adults, who used it for 30 minutes a day, five days a week, for five weeks. Brain scans taken before and after the training showed activity in the regions that control working memory had increased after the training period, suggesting that the training might have produced physical changes in the brains of those subjects.
Studies Under Way in U.S.
A second report, published a year later in the Journal of the American Academy of Child and Adolescent Psychiatry, which is also peer-reviewed, further bolstered the Swedish researchers’ case.
That study, a randomized experiment involving 53 Swedish students with the disorder from age 7 to age 12, showed that pupils who underwent the same five-week training outperformed their control-group peers on a variety of tasks meant to measure working memory, self-control, attention, and problem-solving. Such randomized experiments are often referred to as the “gold standard” for research evaluations of educational interventions.
Results reported in March from the first U.S. study of the program, a small-scale trial involving 12 adolescent students, suggest the same improvement pattern. More studies are under way in this country at Harvard University, the University of Notre Dame, and New York University.
“This is really different, because it does meet the gold standard, and the research has been replicated and there is ongoing research,” said Barbara D. Ingersoll, a Bethesda, Md.-based clinician and longtime ADHD expert.
The computer-based training program developed by the Swedish company Cogmed Inc. aims to sharpen the “working memory” skills of children and teenagers with attention deficit hyperactivity disorder.
While such results were enough to convince a veteran psychologist such as Ms. Ingersoll to get the training program for her clients, other clinicians remain unconvinced.
“I would not discourage a family from pursuing this on their own, but I would not recommend it as a first line of treatment,” said Dr. Andrew Adesman, the chief of developmental and behavioral pediatrics at Schneider Children’s Hospital in New Hyde Park, N.Y.
One big caution about the research so far, from his point of view: In the 2005 Swedish experiment, parents—but not teachers—reported seeing significant improvements in children’s behavior.
“I think improvement in the classroom is important,” Dr. Adesman added. “Kids are there five hours a day.”
Developed and marketed by a Stockholm-based company known as Cogmed Inc., the training consists of computer games that exercise visual and verbal working-memory skills. Its primary product is RoboMemo, which students use under the supervision of a trained coach.
“It’s like going to a gym and doing weight training,” said Dr. Klingberg, who founded Cogmed to market the program and now serves as a scientific adviser to the company. “Having a personal trainer might be more effective at helping you complete 25 days of training.”
The exercises get progressively harder as students’ skills increase. Users might, for example, have to repeat a pattern of lights that becomes longer and more complex as students become more adept. Pupils typically use the program at home for 30 to 40 minutes a day but keep in touch with their coaches by telephone or through the Internet. The cost for the entire package—coaching and clinical sessions, included—runs from $1,500 to $1,800, according to clinicians.
In Sweden, where the reported incidence of ADHD is slightly lower than it is in the United States, more than 1,400 children and adults have undergone the training. Dr. Klingberg said 80 percent of those users experienced improvements.
In his 2005 study, Dr. Klingberg also retested the participants three and six months later and found that most of the improvements had been sustained. In that group, 85 percent found that their working-memory skills and other associated improvements in attention, self-control, and complex reasoning had either held steady or increased over time, suggesting that the effects could even be self-perpetuating.
“If you give children this increase in working memory,” Dr. Klingberg said, “they may be more likely to do working-memory tasks at home and at school.”
The program was less successful, though, in curbing hyperactive behaviors in children with that problem—more than half the study group. Though most parents said their children had become less hyperactive, more objective measurements showed no differences between the control and treatment groups in the number of head movements children made during laboratory observations.
Dr. Klingberg said the smaller effect on hyperactivity may explain why teachers failed to see improvements in the classroom in the initial experiment.
“Paying attention may be more difficult to see if you have a class of 25 kids,” he said. In a subsequent experiment, the results of which have not yet been published, the positive classroom effects are more robust, and statistically significant, according to Dr. Klingberg.
Role for Medication
Still, the smaller impact on hyperactivity is one reason why Dr. Klingberg and other Cogmed proponents make no claims that their program will replace stimulant medication as a treatment for students with ADHD. While some students may be able to avoid using medication with the training, others may have to use both, and some may not benefit at all from the computer program.
“The effect sizes we get are in the same range as the effect sizes for medication,” Dr. Klingberg said, “but there will always be a need for medication for some kids.”
Questions also remain about which kinds of students are best helped by the intervention, how it works, and under what circumstances. For instance, in Sweden, fewer children take medication for ADHD. Much larger percentages of children in the ongoing U.S. studies are medicated, and experts wonder whether the training will be more or less effective with those children.
If the results hold up, though, schools could face some pressure from parents to incorporate the training into lesson plans for students struggling with attention deficits. The company this year opened a U.S. headquarters in Naperville, Ill., and has enlisted 20 clinics around the country to provide the training.
Because ADHD, in and of itself, does not qualify students for special services under federal special education law, it’s unclear whether schools will be able to make widespread use of the program, and some psychologists worry that students would not be as closely supervised in school settings as they might be at home.
However, Dr. Christopher P. Lucas, who is heading the NYU studies of the program, said he sees schools as “one of the better venues” for Cogmed’s training program.
“It offers a real chance of significant improvement in working memory, which underpins a lot of academic skills,” he said, “and that’s important.”
