Intervention program to improve attention and working memory for schoolaged children with behavioral- and learning problems

Attention- and working memory deficits are common deficits for the population
of clinically referred school age children seen at the Department of Child
Psychiatry and Learning disabilities of the Academic Center of Child and
Adolescent Psychiatry, the Bascule in the Netherlands. These children suffer
mostly from academic problems combined with child psychiatric comorbidity such
as Attention Deficit Hyperactivity Disorder, Pervasive Developmental Disorder,
Anxiety disorders or other common child psychiatric problems.
Studies show that children with Attention Deficit Hyperactivity Disorder (ADHD)
often suffer from deficits in executive functions, such as attentional control,
inhibition and working memory (Barkley, 1997; Willcutt et al., 2005). It is
known that these executive functions play an important role in academic
performances (Bull and Scerif, 2001). Especially working memory skills are
associated with problems in learning and poor classroom behaviour (Aronen et
al., 2005; Gathercole et al., 2000). Individuals with poor working memory
function are at risk of poor educational progress, meaning that over 85% of
children with poor working memory have problems in reading or mathematics
(Gathercole & Alloway, 2008). They suggest these children often suffer from
working memory overload during learning tasks.
Recently, studies have shown that the Cogmed Working memory Training not only
has positive outcomes on working memory deficits, but also showed better
performance on related executive function tasks such as logic reasoning and
response inhibition and still continued to show effects after 3 months
(Klingberg et al., 2002; 2005).
Interestingly, Holmes and colleagues (2009) showed with there study that
academic achievement improved as well in children with working memory deficits
that followed this training. These effects remaind consistent after 6 months.
Some studies so far that paid attention to education were promosing (Holmes
e.a., 2009; Mezzacappa e.a., 2010), but paid little attention to academic
achievenment. More research to study the effects of classroom behaviour and
academic achievement is needed. So far, other studies only used teacher
ratings, left out academic achievement, or had a sample size that was to small.
But recent research showed that measures for effectively spent learningtime,
on-task behavior and teacher-student relationship are important indicators for
improving academic achievement and classroom behaviour. In this study we want
to integrate all these measures. Finally, from clinical practice we know that
improving working memory has positive outcomes on functioning in everyday life
and that this is scarcely investigated in past research. So this study want's
to investigate the effects on everyday life.

The aim of study I is to compare the two working memory interventions, Cogmed
and the intervention developed by the Bascule, in a sample of 100 children with
ADHD and working memory deficits, aged between 8 and 12 years old. Effects on
working memory, effectively spent learningtime, on-task behavior and effects on
everyday life are being studied.

The aim of study II is to find traits that determine the response or
non-response to the intervention developed by the Bascule. This way we can get
insight in the efficiency of both interventions, taking individual traits,
severity of the problem and cost into consideration (stepped-care-approach). In
this study, 175 children (50 included from study I) between the age of 8 and 12
who get the intervention developed by the Bascule will be followed for a year.
Effects on working memory, effectively spent learningtime, on-task behavior and
effects on everyday life are being studied.

Study I is a Radomised Controlled Trial (RCT) in which children will be
randomly assigned to the Cogmed working memory training (n = 50), or the
intervention developed by the Bascule (n = 50). Effectiveness of both
interventions is being measured with primary outcomes academic achievement and
neuropsychological functioning and as secondary outcomes teacher/student
relationship, behavior problems and quality of life.

Study II determines the traits that predict the effectiveness of the
intervention developed by the Bascule (n = 175), in which the non-responders
get the Cogmed intervention after 6 months follow-up to investigate these
effects.

Both interventions are an individual treatment, the duration is the same and
both interventions are being administered at school.

Children that follow the Cogmed working memory training, receive a training
protocol of 5 weeks, 5 days, 45 minutes and getting support from a trained
Cogmed-coach, in which the working memory is being trained and the coach
directs the teacher.

The duration of the intervention developed by the Bascule is the same as
Cogmed. This intervention is less specifically aimed on only working memory,
but also aim*s at targeted behavior and is contextual. Memory interventions
based on theory(Dehn, 2008; Gathercole & Alloway, 2008)are being offered to the
child, in which a assignment book helps.

Both Cogmed and the intervention developed by the Bascule are being offered as
treatment within the Bascule with as goal to improve working memory deficits.
We expect that children will have enough benefit from the intervention
developed by the Bascule. If children do not benefit sufficiently, Cogmed can
be given as well. Possible risk of the intervention: premature failure of
children in the experimental groups. Careful guidance and information for the
family should limit this. Weekly appointments advance motivation of the
trainers and ensure that correction is possible.

Within study I, the strain for children consists of the 3 measures that are
being accomplished (neuropsychological research and academic performance) that
each take about 2 hours.
Within study II, the strain for children consists of the 4, and at
insufficiently respond 5, measures that are being accomplished
(neuropsychological research and academic performance) that each take about 2
hours.