Cognitive training for attention-deficit/hyperactivity disorder: meta-analysis of clinical and neuropsychological outcomes from randomized controlled trials

Samuele Cortese, Maite Ferrin, Daniel Brandeis, Jan Buitelaar, David Daley, Ralf W Dittmann, Martin Holtmann, Paramala Santosh, Jim Stevenson, Argyris Stringaris, Alessandro Zuddas, Edmund J S Sonuga-Barke, European ADHD Guidelines Group (EAGG), T Banaschewski, D Brandeis, J Buitelaar, D Coghill, S Cortese, D Daley, M Danckaerts, R W Dittmann, M Dopfner, M Ferrin, C Hollis, M Holtmann, E Konofal, M Lecendreux, A Rothenberger, P Santosh, J A Sergeant, E Simonoff, E J Sonuga-Barke, C Soutullo, H-Ch Steinhausen, J Stevenson, A Stringaris, E Taylor, S van der Oord, I Wong, A Zuddas, Samuele Cortese, Maite Ferrin, Daniel Brandeis, Jan Buitelaar, David Daley, Ralf W Dittmann, Martin Holtmann, Paramala Santosh, Jim Stevenson, Argyris Stringaris, Alessandro Zuddas, Edmund J S Sonuga-Barke, European ADHD Guidelines Group (EAGG), T Banaschewski, D Brandeis, J Buitelaar, D Coghill, S Cortese, D Daley, M Danckaerts, R W Dittmann, M Dopfner, M Ferrin, C Hollis, M Holtmann, E Konofal, M Lecendreux, A Rothenberger, P Santosh, J A Sergeant, E Simonoff, E J Sonuga-Barke, C Soutullo, H-Ch Steinhausen, J Stevenson, A Stringaris, E Taylor, S van der Oord, I Wong, A Zuddas

Abstract

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] = 0.37, 95% CI = 0.09-0.66) and inattentive symptoms (SMD = 0.47, 95% CI = 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 = 0.20, 95% CI = 0.01-0.40; inattention: SMD = 0.32, 95% CI = -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 = 0.52, 95% CI = 0.24-0.80; visual: SMD = 0.47, 95% CI = 0.23-0.70) and parent ratings of executive function (SMD = 0.35, 95% CI = 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 = 0.79, 95% CI = 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 of effects from cognitive deficits to clinical symptoms.

Keywords: ADHD; evidence-based psychiatry; executive functions; nonpharmacological; working memory.

Copyright © 2015 American Academy of Child and Adolescent Psychiatry. Published by Elsevier Inc. All rights reserved.

Figures

Figure 1
Figure 1
Preferred Reporting Items in Systematic Reviews and Meta-Analyses (PRISMA) flow diagram of selection of studies (last search updated May 18, 2014). Note: aA total of 259 studies were not on attention-deficit/hyperactivity disorder (ADHD); 342 were not on cognitive training; 7 were not randomized controlled trials (RCTs); 47 were reviews; 3 were studies in adults; and 1 was a study protocol. bReasons for exclusion of each study are reported in Table S2, available online. cEgeland et al. and Hovik et al. refer to the same study.
Figure 2
Figure 2
Forest plots for meta-analysis of effects on attention-deficit/hyperactivity disorder (ADHD) core symptoms assessed by the most proximal and probably blinded raters. Note: Cogn = cognitive; std = standard.
Figure 3
Figure 3
Forest plots for meta-analysis of effects on neuropsychological and academic outcomes. Note: Cogn = cognitive; std = standard.

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Source: PubMed

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