Cognitive Training for Attention-Deficit/Hyperactivity Disorder: Meta-Analysis of Clinical and Neuropsychological Outcomes From Randomized Controlled Trials

Samuele Cortese, MD, PhD, Maite Ferrin, MD, PhD, Daniel Brandeis, PhD, Jan Buitelaar, MD, PhD, David Daley, PhD, Ralf W. Dittmann, MD, PhD, Martin Holtmann, MD, Paramala Santosh, MD, PhD, Jim Stevenson, PhD, Argyris Stringaris, MD, PhD, MRCPsych, Alessandro Zuddas, MD, Edmund J.S. Sonuga-Barke, PhD, on behalf of the European ADHD Guidelines Group (EAGG)

Objective: The authors performed meta-analyses of randomized controlled trials to examine the effects of cognitive training on attention-deficit/hyperactivity disorder (ADHD) symptoms, neuropsychological deficits, and academic skills in children/adolescents with ADHD. Method: The authors searched Pubmed, Ovid, Web of Science, ERIC, and CINAHAL databases through May 18, 2014. Data were aggregated using random-effects models. Studies were evaluated with the Cochrane risk of bias tool. Results: Sixteen of 695 nonduplicate records were analyzed (759 children with ADHD). When all types of training were considered together, there were significant effects on total ADHD (standardized mean difference [SMD] ¼ 0.37, 95% CI ¼ 0.09–0.66) and inattentive symptoms (SMD ¼ 0.47, 95% CI ¼ 0.14–0.80) for reports by raters most proximal to the treatment setting (i.e., typically unblinded). These figures decreased substantially when the outcomes were provided by probably blinded raters (ADHD total: SMD ¼ 0.20, 95% CI ¼ 0.01– 0.40; inattention: SMD ¼ 0.32, 95% CI ¼ 0.01 to 0.66). Effects on hyperactivity/impulsivity symptoms were not significant. There were significant effects on laboratory tests of working memory (verbal: SMD ¼ 0.52, 95% CI ¼ 0.24–0.80; visual: SMD ¼ 0.47, 95% CI ¼ 0.23–0.70) and parent ratings of executive function (SMD ¼ 0.35, 95% CI ¼ 0.08–0.61). Effects on academic performance were not statistically significant. There were no effects of working memory training, specifically on ADHD symptoms. Interventions targeting multiple neuropsychological deficits had large effects on ADHD symptoms rated by most proximal assessors (SMD ¼ 0.79, 95% CI ¼ 0.46–1.12). Conclusion: Despite improving working memory performance, cognitive training had limited effects on ADHD symptoms according to assessments based on blinded measures. Approaches targeting multiple neuropsychological processes may optimize the transfer r of effects from cognitive deficits to clinical symptoms.

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A Randomized Trial of Two Promising Computer-Based Interventions for Students with Attention Difficulties

Journal of Abnormal Child Psychology Journal of Abnormal Child Psychology January 2010, Volume 38, Issue 1, pp 131–142

Few studies have examined whether attention can be improved with training, even though attention difficulties adversely affect academic achievement. The present study was a randomized-controlled trial evaluating the impact of Computerized Attention Training (CAT) and Computer Assisted Instruction (CAI) on attention and academic performance in 77 inattentive first graders. Students receiving either intervention were more likely than controls to show a moderate decline in teacher rated attention problems in first grade. Students receiving CAI also showed gains in reading fluency and in teacher ratings of academic performance. Intervention effects for attention were absent by second grade largely because attention problems declined in all groups. However, post hoc analyses indicated potential longer-term benefits for children with 6 or more inattentive symptoms at baseline. Persistent attention problems were associated with poorer academic performance in multiple domains. Results provide initial evidence that CAT and CAI can improve children’s attention in the classroom - and support additional studies to determine whether more clinically significant benefits are attainable.

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What's New — What Is Cognitive Remediation in Psychiatric Practice and Why Do We Need It?

John is now 23 years old. At 17, he developed schizophrenia, a serious and persistent mental illness that typically interferes with a person’s ability to function in school, work and in the family. At first, his symptoms were very obvious and troubling: He was paranoid, heard voices telling him bad things about himself, and isolated himself from family and friends, often behaving oddly. Over time, with medication and supportive care, these symptoms improved but his problems with memory, attention, processing and organizing information kept him from making a life like we all want — with relationships, work and purpose.

Amelie is 42 and has had a serious mental illness for over a decade, sometimes identified as bipolar disorder, sometimes as schizoaffective disorder (where psychotic and mood symptoms both appear). While her moods are considerably helped by medications and psychotherapy she has had trouble functioning in her job in a restaurant or meeting the many responsibilities that come with being a wife and mother of two. It is difficult to maintain social relationships when you cannot pay attention to or remember what someone has said to you. Work and independent living tasks can become insurmountable when a person cannot process, remember and organize information.

However, we now have treatments, really more like training programs, to improve the cognitive deficits associated with serious mental illnesses. Cognitive remediation (CR) is an example of such an innovative treatment in psychiatry, and if you are ill or have a loved one with a mental illness you want to know about it, and see if it can help.

The principal goal of CR is to reduce cognitive difficulties, which are different from the symptoms of psychosis or severe mood swings. Other treatments, including medication and certain forms of psychotherapy, only partially reduce symptoms, often not touching difficulties in concentrating or distractibility. CR is focused on reducing the disability caused by impaired attention, memory, and planning abilities.

We define CR as a training intervention that targets cognitive deficits using scientific principles of learning. Its goal is to improve the functioning of those people with deficits. Its primary methods are drill and practicestrategy coachingand developingways to compensate or work around limitations.

CR can be done using different — and now available — programs. These programs consist of repetitive practice sessions, some of which can actually be fun (like computer games) (1). People who engage in CR actually like doing it. In addition to the programmed mental exercises, CR can help people develop better strategies for solving the complex, or multistep, problems we encounter everyday in going from one place to another, when shopping, or attending school or at our jobs. In addition, CR programs often give patients greater confidence — in themselves as well as in their cognitive capabilities.

It is important that the cognitive improvements achieved in a program’s sessions be transferred into the tasks of everyday life. Indeed, the gains of CR can enable individuals to better use psychological rehabilitation programs specifically aimed to help them stay in school, return to school, get jobs or retain the jobs they have (2,3).

An important benefit of CR is how it can improve a person’s capacities to interact in social situations, including participating in a conversation and appreciating the intentions and emotions of other people; sometimes this is called “emotional intelligence,” which is associated with success for all people, not just those with serious mental conditions. Moreover, CR can help individuals with mental illness who underestimate the degree of their disability to better appreciate their problems — and their consequences for their personal and work lives.

A CR program is recommended to a patient, and family, by a mental health team after a thorough evaluation. CR is only recommended after patients have stabilized clinically from an acute episode of illness, and when they agree to participate. Mental health clinicians can increase patient motivation by offering programs that answer to the wishes of the people they treat — like wanting friends, good pay, and a social life (4).

We also know that CR programs work better when they are integrated into rehabilitation goals and programs (5,6). CR programs generally last three to six months, and are best done when the program has a coach or facilitator, which requires investment. That investment is worth the cost when CR provides a stepping stone to improved functioning. Ideally, thus, each CR program should be connected to a rehabilitation program that offers skills training to help someone return to work, school or to live independently (7). What this means is that with a CR program, and rehabilitation, a person improves their chances of functioning independently, and meeting their goals of finishing school, working, socializing and managing their home life.

While CR is now especially focused on people with schizophrenia and related psychotic illnesses, there are programs for bipolar patients who suffer with cognitive disabilities. In Europe and the US, work is also underway for young adolescents suffering from rare metabolic or genetic diseases that produce cognitive symptoms (e.g., Velocardiofacial Syndrome) or for the cognitive problems seen in anorexia nervosa (8). In child psychiatry, CR programs have been developed for children with “dysexecutive” problems (similar to the executive cognitive problems described above) that occur with Attention Deficit Hyperactivity Disorder (ADHD), youth with higher functioning autism spectrum disorders, and serious learning disabilities.

The benefits of CR can also be seen in clinical and neurological ways. Clinically, depressive symptoms can be reduced, possibly through a gain in self-esteem or self-confidence. Even when cognitive improvements per se are modest, the improvement in depressive symptoms can be robust and have been replicated in a number of studies (9). Cerebral imaging studies also demonstrate that: Crucial brain structures located in the frontal lobe, which showed hypoactivation (decreased activity) before CR had increased activation after the program, paralleling an improvement in working memory (10), and loss of cerebral grey matter (brain cells) was observed to have been arrested, even two years after treatment with a cognitive behavioral therapy program that included CR (11).

CR is relatively new to psychiatry and mental health. But its scientific roots are not: It derives from the explosion of new knowledge from cognitive neuroscience. It is time for psychiatric programs to include CR as a standard part of the array of services needed for the comprehensive and quality treatment of persons with serious mental illnesses, especially schizophrenia and schizoaffective disorders. This will require first incubation in innovative and leadership clinical programs and then dissemination throughout a system of care on the basis of what is learned about how to best engage patients (and families) and train staff to deliver CR in mental health settings.

Cognitive remediation can remarkably change the lives of people who were previously disabled, or may become so, because of mental diseases. We owe this opportunity to them and their families.


Isabelle Amado, M.D., Ph.D. Psychiatrist; Director, Reference Center for Cognitive Remediation and Rehabilitation (C3RP), Sainte Anne Hospital, Paris

Lloyd I. Sederer, MD Medical editor, mental health for The Huffington Post