title: Improving executive functioning in children with ADHD: training multiple executive functions within the context of a computer game. a randomized double-blind placebo controlled trial.
abstract: BACKGROUND
  Executive functions (EFs) training interventions aimed at ADHD-symptom reduction have yielded mixed results. Generally, these interventions focus on training a single cognitive domain (e.g., working memory [WM], inhibition, or cognitive-flexibility). However, evidence suggests that most children with ADHD show deficits on multiple EFs, and that these EFs are largely related to different brain regions. Therefore, training multiple EFs might be a potentially more effective strategy to reduce EF-related ADHD symptoms.
  
  
  METHODS
  Eighty-nine children with a clinical diagnosis of ADHD (aged 8-12) were randomized to either a full-active-condition where visuospatial WM, inhibition and cognitive-flexibility were trained, a partially-active-condition where inhibition and cognitive-flexibility were trained and the WM-training task was presented in placebo-mode, or to a full placebo-condition. Short-term and long-term (3-months) effects of this gamified, 25-session, home-based computer-training were evaluated on multiple outcome domains.
  
  
  RESULTS
  During training compliance was high (only 3% failed to meet compliance criteria). After training, only children in the full-active condition showed improvement on measures of visuospatial short-term-memory (STM) and WM. Inhibitory performance and interference control only improved in the full-active- and the partially-active condition. No Treatment-condition x Time interactions were found for cognitive-flexibility, verbal WM, complex-reasoning, nor for any parent-, teacher-, or child-rated ADHD behaviors, EF-behaviors, motivational behaviors, or general problem behaviors. Nonetheless, almost all measures showed main Time-effects, including the teacher-ratings.
  
  
  CONCLUSIONS
  Improvements on inhibition and visuospatial STM and WM were specifically related to the type of treatment received. However, transfer to untrained EFs and behaviors was mostly nonspecific (i.e., only interference control improved exclusively in the two EF training conditions). As such, in this multiple EF-training, mainly nonspecific treatment factors - as opposed to the specific effects of training EFs-seem related to far transfer effects found on EF and behavior.
  
  
  BACKGROUND
  trialregister.nl NTR2728. Registry name: improving executive functioning in children with ADHD: training executive functions within the context of a computer game; registry number: NTR2728.
authors.affiliation: Department of Developmental Psychology, University of Amsterdam, Amsterdam, The Netherlands; Addiction, Development, and Psychopathology (Adapt) Lab, Department of Psychology, University of Amsterdam, Amsterdam, The Netherlands; Cognitive Science Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Sebastiaan
authors.initials: S
authors.lastname: Dovis
authors.affiliation: Department of Developmental Psychology, University of Amsterdam, Amsterdam, The Netherlands; Cognitive Science Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands; Department of Clinical Psychology, Leuven University, Leuven, Belgium.
authors.forename: Saskia
authors.initials: S
authors.lastname: Van der Oord
authors.affiliation: Department of Developmental Psychology, University of Amsterdam, Amsterdam, The Netherlands; Addiction, Development, and Psychopathology (Adapt) Lab, Department of Psychology, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Reinout W
authors.initials: RW
authors.lastname: Wiers
authors.affiliation: Department of Developmental Psychology, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Pier J M
authors.initials: PJ
authors.lastname: Prins
mesh_terms: D001289:Attention Deficit Disorder with Hyperactivity / Q000503:physiopathology / Q000534:rehabilitation*; D002648:Child; D003194:Computer-Assisted Instruction / Q000379:methods*; D004311:Double-Blind Method; D056344:Executive Function / Q000502:physiology*; D005260:Female; D006801:Humans; D008297:Male; D010349:Patient Compliance / Q000706:statistics & numerical data; D016896:Treatment Outcome; D018910:Video Games
references.citation: Med Care. 2001 Aug;39(8):800-12
references.pmid: 11468499
references.citation: J Consult Clin Psychol. 1991 Feb;59(1):12-9
references.pmid: 2002127
references.citation: Neuropsychologia. 2008 Sep;46(11):2668-82
references.pmid: 18573510
references.citation: Biol Psychiatry. 2012 Mar 1;71(5):458-66
references.pmid: 22209640
references.citation: Hum Brain Mapp. 2010 Dec;31(12):1942-50
references.pmid: 20336653
references.citation: Transl Psychiatry. 2011 Nov 15;1:e53
references.pmid: 22833208
references.citation: J Atten Disord. 2009 Sep;13(2):137-43
references.pmid: 19429883
references.citation: J Atten Disord. 2006 Aug;10(1):44-53
references.pmid: 16840592
references.citation: J Abnorm Child Psychol. 2012 Jul;40(5):699-713
references.pmid: 22271141
references.citation: J Atten Disord. 2013 Nov;17(8):711-21
references.pmid: 22392551
references.citation: Biol Psychiatry. 2010 Apr 1;67(7):632-40
references.pmid: 20060961
references.citation: J Clin Exp Neuropsychol. 2002 Sep;24(6):781-91
references.pmid: 12424652
references.citation: Hum Brain Mapp. 2011 Oct;32(10):1741-9
references.pmid: 21365715
references.citation: J Am Acad Child Adolesc Psychiatry. 2000 Jan;39(1):28-38
references.pmid: 10638065
references.citation: J Abnorm Child Psychol. 2012 Jul;40(5):669-81
references.pmid: 22187093
references.citation: Am J Psychiatry. 2006 Jun;163(6):1044-51
references.pmid: 16741205
references.citation: Qual Life Res. 2004 Mar;13(2):489-95
references.pmid: 15085921
references.citation: J Atten Disord. 2005 Feb;8(3):109-20
references.pmid: 16009659
references.citation: J Pediatr Psychol. 2007 Jul;32(6):664-75
references.pmid: 17264086
references.citation: Proc Natl Acad Sci U S A. 2012 Apr 24;109(17):6769-74
references.pmid: 22474392
references.citation: J Abnorm Child Psychol. 2002 Dec;30(6):555-69
references.pmid: 12481971
references.citation: Appl Neuropsychol. 2000;7(4):252-8
references.pmid: 11296689
references.citation: Cyberpsychol Behav Soc Netw. 2011 Mar;14(3):115-22
references.pmid: 20649448
references.citation: J Abnorm Psychol. 2012 Nov;121(4):991-1010
references.pmid: 22612200
references.citation: J Abnorm Child Psychol. 2012 Oct;40(7):1193-207
references.pmid: 22477205
references.citation: Biol Psychiatry. 2011 Jun 15;69(12):1178-84
references.pmid: 20965496
references.citation: J Clin Child Adolesc Psychol. 2014;43(4):527-51
references.pmid: 24245813
references.citation: J Consult Clin Psychol. 2004 Oct;72(5):757-66
references.pmid: 15482034
references.citation: Assessment. 2008 Dec;15(4):426-34
references.pmid: 18483192
references.citation: Behav Brain Sci. 2005 Jun;28(3):397-419; discussion 419-68
references.pmid: 16209748
references.citation: J Abnorm Child Psychol. 2009 May;37(4):521-34
references.pmid: 19083090
references.citation: J Child Psychol Psychiatry. 2004 May;45(4):836-54
references.pmid: 15056314
references.citation: Nature. 2001 Sep 6;413(6851):67-70
references.pmid: 11544526
references.citation: BMJ. 2005 Apr 9;330(7495):843
references.pmid: 15817555
references.citation: J Abnorm Child Psychol. 2013 Apr;41(3):497-507
references.pmid: 23315233
references.citation: Dev Neuropsychol. 2011;36(2):181-98
references.pmid: 21347920
references.citation: J Child Psychol Psychiatry. 2015 May;56(5):566-76
references.pmid: 25256627
references.citation: Trends Cogn Sci. 2010 Jul;14(7):317-24
references.pmid: 20630350
references.citation: Games Health J. 2013 Feb;2(1):44-9
references.pmid: 26196554
references.citation: J Abnorm Child Psychol. 2012 Jan;40(1):145-57
references.pmid: 21789519
references.citation: Neurosci Biobehav Rev. 2010 Apr;34(5):744-54
references.pmid: 19944715
references.citation: Clin Psychol Rev. 2013 Dec;33(8):1237-52
references.pmid: 24120258
references.citation: Neurosci Biobehav Rev. 2003 Nov;27(7):593-604
references.pmid: 14624804
references.citation: Nature. 1998 May 21;393(6682):266-8
references.pmid: 9607763
references.citation: Neurotherapeutics. 2012 Jul;9(3):542-58
references.pmid: 22911054
references.citation: J Abnorm Child Psychol. 2010 Feb;38(2):149-61
references.pmid: 19787447
references.citation: PLoS One. 2013 May 22;8(5):e63614
references.pmid: 23717453
references.citation: J Atten Disord. 2014 Nov;18(8):699-712
references.pmid: 22879577
references.citation: J Am Acad Child Adolesc Psychiatry. 2005 Feb;44(2):177-86
references.pmid: 15689731
references.citation: J Clin Child Adolesc Psychol. 2015;44(5):859-74
references.pmid: 24766106
references.citation: Atten Defic Hyperact Disord. 2012 Mar;4(1):11-23
references.pmid: 22179720
references.citation: J Child Psychol Psychiatry. 2014 Mar;55(3):256-7
references.pmid: 24438534
references.citation: J Child Psychol Psychiatry. 2014 Mar;55(3):247-55
references.pmid: 24117656
references.citation: Atten Defic Hyperact Disord. 2010 Mar;2(1):31-42
references.pmid: 21432588
references.citation: J Pers Assess. 2004 Feb;82(1):50-9
references.pmid: 14979834
references.citation: Neurotherapeutics. 2012 Jul;9(3):639-48
references.pmid: 22752960
references.citation: Clin Psychol Rev. 2008 Jun;28(5):801-23
references.pmid: 18061324
references.citation: Neuron. 2003 Aug 14;39(4):713-26
references.pmid: 12925284
references.citation: Eat Behav. 2007 Jan;8(1):115-20
references.pmid: 17174859
references.citation: J Atten Disord. 2005 May;8(4):160-8
references.pmid: 16110046
references.citation: J Am Acad Child Adolesc Psychiatry. 1992 Mar;31(2):210-8
references.pmid: 1564021
references.citation: J Abnorm Child Psychol. 2004 Aug;32(4):435-51
references.pmid: 15305548
references.citation: PLoS One. 2013 Oct 04;8(10):e75660
references.pmid: 24124503
references.citation: Neuroimage. 2003 Sep;20(1):351-8
references.pmid: 14527595
references.citation: Front Hum Neurosci. 2012 Jan 03;5:180
references.pmid: 22291628
references.citation: J Clin Child Psychol. 2001 Mar;30(1):48-58
references.pmid: 11294077
references.citation: J Atten Disord. 2013 Aug;17(6):470-82
references.pmid: 22323120
references.citation: Psychol Bull. 2012 Jul;138(4):628-654
references.pmid: 22409508
references.citation: Psychol Res. 2014 Nov;78(6):852-68
references.pmid: 24389706
references.citation: J Abnorm Child Psychol. 2013 Aug;41(6):901-17
references.pmid: 23430155
references.citation: Clin Psychol Rev. 2005 Feb;25(2):183-213
references.pmid: 15642646
references.citation: Nature. 2003 May 29;423(6939):534-7
references.pmid: 12774121
references.citation: J Am Acad Child Adolesc Psychiatry. 1987 May;26(3):356-62
references.pmid: 3597291
references.citation: Multivariate Behav Res. 1981 Jan 1;16(1):105-23
references.pmid: 26800630
references.citation: J Child Psychol Psychiatry. 2011 Sep;52(9):917-8
references.pmid: 21793824
references.citation: J Clin Child Adolesc Psychol. 2013;42(6):769-83
references.pmid: 23668397