Enhancing Attention, Memory, and Self-Awareness: A Review of Cognitive-Based and Mindfulness Interventions in ADHD Saoud, W., Rizeq, J., Basile, A. G., Casaluce, D., Edwards, A., & Toplak, M. E. Clinical-Developmental Program, Department of Psychology LaMarsh Centre for Child and Youth Research, York University Table 1 Cognitive and Mindfulness Interventions based on developmental level ABSTRACT CONCLUSIONS Difficulties with attention, impulsivity, and hyperactivity are characteristic of Attention-Deficit/Hyperactivity Disorder (ADHD). Symptoms emerge in childhood, and lead to significant impairments across settings (DSM-IV-TR, 2000). Evidence-based interventions rely on pharmacological and/or behavioural treatments; although these are effective, costs are high and treatment gains do not always last or transfer. This review examined the status of cognitive-based programs, which include cognitive training and cognitive-behavioural therapy (CBT), and mindfulness training in ADHD. A developmental lens was used to evaluate effects across age. Young Children (4 – 7 years) Middle Childhood (8-12 years) Adolescence (13 -17 years) Adulthood (ages 18+) Cognitive-Behavioral Therapy Fehlings et al. (1991) x● (parent) Barkley et al. (2001) ● (parent) Hesslinger et al. (2002)●●(self-report) Hall & Kataria (1992) ● (w/ meds) Stevenson et al. (2002) ●(self-report) Semrud-Clikeman et al. (1999) ● Vita et al. (2010) ●(self-report) Abikoff et al. (1988) x x Cognitive Training Rapport et al. (1996) no analyses Karatekin (2006) x Gibson et al. (2011) ●●(parent, teacher) White & Shah (2006) x Halperin et al. (2012) ●(parent; teacher) Klingberg et al.(2005) ●● (parent) Gray et al. (2012) ●● (parent) Virta et al. (2010) ● Klingberg et al. (2002) ● O’Connell et al. (2006) ● Green et al. (2012) ●● (parent) Hoekzema et al. (2010) ● Holmes et al. (2012) ● Lim et al. (2012) ● (parent) Oord et al. (2012)● (parent; teacher) Shaffer et al. (2000)●● (parent) Shalev et al. (2012) ●● (parent) Tamm et al. (2010) ●● (parent) Tamm et al. (2012) ●● (parent, not teacher) Mindfulness Training Jensen & Kenny (2004) ●(parent, not teacher) Haydicky et al. (2012) ● (parent) Mehta et al. (2011)● (parent; teacher) Weijer-Bergsma et al. (2012) ● (self, parent, not teacher) Oord et al. (2012) ●(parent; teacher) ●There is considerable variability in the methods of cognitive-based and mindfulness studies in ADHD, including number of sessions (ranging from 1 session to 25-30 sessions), child/adolescent and/or parent involvement, medication status, and nature of control groups (comparison to an alternative treatment group versus waitlist controls). ● Results suggest that a developmental lens is critical for understanding treatment effects in ADHD. ● Most cognitive training studies were conducted with children during middle childhood (7-12 years) which is consistent with the development of several executive functions during this period (Diamond, 2013). Based on the studies included in this review, cognitive training programs have shown significant effects on both cognitive performance-based measures and behavioural ratings (particularly by parents) during this period of development. ● Few studies pertain to young children (ages 4-7). Play-based programs have shown some promise, with maintenance of effects after 3 months (Halperin et al., 2012). ● CBT has been regarded as ineffective for ADHD treatment (Abikoff, 1991). Effects have been mixed in childhood on both cognitive and behavioural ratings. However, studies on adults have indicated that CBT approaches are effective on cognitive measures and self-reported behaviours. Some evidence suggests that CBT is actually more beneficial for adults with ADHD than cognitive training (Virta et al., 2010). This idea is consistent with others who have suggested that the degree of maturity required for interventions that involve higher order functioning and self management make CBT more viable for adults with ADHD than younger samples (Rutledge et al., 2012) ●Few studies have examined the effectiveness of mindfulness training in ADHD, and the results thus far have been mixed. Consistent with other reviews, there is insufficient evidence at this time regarding the effectiveness of mindfulness treatments for ADHD (Krisanaprakornkit et al., 2010). However, physical-based meditation has been found to show more promising effects than mind-based meditation. The former focuses on yoga-based strategies to achieve behavioural control, whereas the latter focuses on training selective deployment of attention. ● Some cognitive-based studies have shown maintenance of effects after 3 months (Klingberg et al., 2005), however it will be critical for these programs to show transfer of training effects and predicting real-world outcomes (e.g., academic achievement). INTRODUCTION ● ADHD is characterized by symptoms of impulsivity, inattention, and hyperactivity (DSM-IV-TR, 2000). It affects approximately 9% of school-aged children (Pastor & Reuben, 2008). Symptoms affect academic, social, and occupational functioning (DSM-IV-TR, 2000) and usually persist into adulthood (e.g., Barkley, 2006). ● The most widely used interventions rely on evidence-based, pharmacologic treatments (MTA Cooperative Group, 1999) and behavioural training (Chronis, Jones, & Raggi, 2006). Stimulants and behavioral therapy are effective, but their effects rarely endure beyond treatment termination (e.g., Chronis et al., 2004). ● Poor self-regulation is considered particularly characteristic of the problems associated with ADHD (e.g., Barkley, 1997). Models of ADHD are characterized by cognitive and executive function deficits (e.g., Sonuga-Barke, 2002). ● What is the status of cognitive-based interventions for ADHD? Cognitive studies include direct training of cognitive skills, such as attention. Cognitive-behavioral studies include metacognitive and strategy training (Toplak et al., 2008). A recent paper conducted a meta-analyses of nonpharmacologic treatments that included dietary and cognitive-based studies (Sonuga-Barke, et al., 2013) .The literature indicates that treatments produced significant effects when outcome measures were based on assessments by raters closest to the therapeutic setting. However, when blinded assessment was used, effects remained significant for some dietary interventions but were substantially reduced to nonsignificance for psychological treatments. ● Mindfulness training programs were also included in this poster. Mindfulness training focuses on improving self-regulation through enhanced awareness, self-control, and attentional focus. This is thought to be accomplished through body scan, meditation, and breathing exercises, which have been shown to result in improved executive performance and behavioral outcomes (e.g., van de Weijer-Bergsma, 2012). ● The purpose of this poster was to provide an updated review, examining cognitive-based and mindfulness treatments from a developmental view. Table 2 Effect sizes with behavioural effects collapsed across studies Treatment Type and Outcome Measure (Number of Studies) Effect Size Ranges Cognitive Behavioural Training Parent – Attention (1) 0.46 Parent - ADHD Behaviour (2) 0.47 – 0.64 Parent – Oppositional (2) 0.25 – 0.38 Teacher - Attention 0.86 Self- Attention (1) 0.29 Self Memory (1) 0.26 Self- Overall ADHD and Symptoms (2) 0.26 – 2.18 Cognitive Training Parent – Inattention (6) 0.35 – 1.49 Parent – Hyperactivity (4) 0.36 – 1.10 Parent – Oppositional (1) Parent – Children’s Problems Checklist (2) 0.57 – 0.58 Parent – Overall ADHD (3) 0.29 – 0.76 Teacher – Inattention (3) 0.22 – 0.27 Teacher – Hyperactivity (2) 0.26 – 0.55 Teacher – Oppositional (1) 0.13 Teacher – Children’s Problems Checklist (1) 0.60 Teacher –Overall ADHD (2) 0.17 – 0.55 Mindfulness Training Parent – Inattention (2) 0.36 – 0.80 Parent – Hyperactivity (3) 0.48 – 0.73 0.77 Parent – Emotional (1) 0.79 Parent – Overall ADHD (1) Teacher – Overall ADHD (1) 2.33 ● Since 2010, there has been an increase in the number of studies examining cognitive training (13/19 studies) and mindfulness training (4/5 studies) in ADHD, but not in CBT (0/8 studies). Jjj Type of Effect Symbol Behavioural Rating Effects ● No Behavioural Rating Effects x Cognitive Effects No Cognitive Effects Change in Neural Activity METHODS A review of 32 studies including cognitive-based or mindfulness treatments for ADHD were included from 1981 to 2012. Developmental periods included: early childhood (4-7 years), middle childhood (8-12 years), adolescence (13-17 years), and adulthood (18+). Cognitive and behavioural rating dependent measures were examined. Given the variability in methods/samples, meta-analytic methods could not be computed. Effect sizes were calculated for individual studies, thus ranges of effect sizes are reported across studies. Cohen’s D is reported for pre-post effects, and Glass’s Δ is reported for group differences. Table 3 Effect sizes with cognitive effects collapsed across studies Treatment Type and Outcome Measure (Number of Studies) Effect Size Ranges Cognitive Training Verbal Working Memory (5) 0.42 – 1.02 Nonverbal Working Memory (5) 0.15 – 2.08 Inhibition-Stroop (2) 0.44 – 0.67 Inhibition/Switching (2) 0.60 – 0.87 Choice Reaction Time (1) 0.13 – 0.41 Intellectual Ability (4) 0.84 – 1.07 Cognitive-Behavioural Training Sustained Attention (2) 0.90 – 1.13 Matching Familiar Figures Test – Errors (1) 0.67 Continuous Performance Test (CT+ Med vs. Med Only) 1.74 Key References Sonuga-Barke, E. J., Brandeis, D., Cortese, S., Daley, D., Ferrin, M., Holtmann, M., ... & Sergeant, J. (2013). Nonpharmacological interventions for ADHD: systematic review and meta-analyses of randomized controlled trials of dietary and psychological treatments. American Journal of Psychiatry. Toplak, M. E., Connors, L., Shuster, J., Knezevic, B., & Parks, S. (2008). Review of cognitive, cognitive- behavioral, and neural-based interventions for Attention Deficit/Hyperactivity Disorder (ADHD). Clinical Psychology Review, 28(5), 801-823. RESULTS Eight studies used CBT interventions for ADHD: 4 using child samples, 1 using adolescents, and 2 using adults. Twenty studies used cognitive training for ADHD: 2 using young child samples, 13 using middle childhood samples, 2 using adolescents, and 2 using adults. Five studies used mindfulness training for ADHD: 3 using middle childhood samples, and 2 using adolescents. For more information contact: Wafa Saoud (wafa29@yorku.ca) or Maggie Toplak (mtoplak@yorku.ca), Department of Psychology, Faculty of Health, York University, Toronto, Ontario ·  Barkley, R.A. (2006). Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment. (3rd Edition). New York: Guilford Press. Kline, R. B. (2004). Beyond significance testing: Reforming data analysis methods in behavioural research. Washington, D. 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