METHOD OF INVESTIGATION

Transcription

1 129 C HAPTER IV METHOD OF INVESTIGATION

2 130 Chapter IV Method of Investigation In this chapter a detailed description of nature of research, the research design, nature of sampling, sampling procedure used for the neurocognitive intervention program and the procedure followed in conducting the intervention program is presented. The present study was executed in two phases. The first phase had the objective of assessing the executive function levels among children with ADHD and children without ADHD. The second phase of the study examined the impact of neurocognitive intervention on the executive function of children with ADHD. The research proposal was reviewed by the doctoral committee who are experts in the subjects and also were internal ethical committee and they gave clearance for the research. Initially, an extensive review of literature was conducted by the researcher. Based on the review of available literature, the variables were selected. A pilot study was conducted on a sample of 30 children with ADHD and 30 children without ADHD, during which the researcher administered the test and checked the feasibility of tools selected for the study. The reliability of the selected tools was established. After the pilot study, the researcher found it feasible to administer the tool and study the domains of executive functions i.e., attention (sustained attention and focused attention), fluency (verbal fluency and design fluency), working memory (verbal working memory and visuospatial working memory), planning and set shifting ability among children with ADHD and children without ADHD.

3 131 A focussed group discussion (FGD) was conducted for the parents of children with ADHD to understand the problems and challenges faced by their children. The responses from FGD were analysed based on the EF subtypes. As the objective of the phase II consisted of intervention, the researcher designed and developed a neurocognitive program for the purpose of intervention. Apart from the impact of the neurocognitive intervention program on executive functions, the behavioural problems of children at home, school and severity of ADHD symptoms were also selected as outcome variables of the study. Phase I Research Design In the first phase, an ex-post facto survey with case (ADHD) control (Non-ADHD) design was used. Ex-post facto research is a systematic empirical inquiry in which the scientist does not have direct control of independent variables because the manifestations have already occurred or because they are inherently not manipulatable (Kerlinger, 1973). Children with ADHD and children without ADHD were assessed using Standardized test to screen for the presence of executive function difficulties. Independent and Dependent Variables The following independent and dependent variable were selected for the study Independent variable The independent variable is Attention Deficit Hyperactivity Disorder (ADHD).

4 132 Dependent variable The dependent variable is the executive functions of children with ADHD and without ADHD. The executive functions selected are attention (sustained attention and focused attention), fluency (verbal fluency and design fluency), working memory (verbal working memory and visuospatial working memory), planning and set shifting ability Operational Definitions The following are the operational definitions of all the variables in the present study. Attention Deficit Hyperactivity Disorder (ADHD) Hyperactivity is, according to the DSM-IV, characterized by symptoms such as the following: restlessness, fidgeting, running around or climbing excessively in situations in which it is inappropriate, having problems playing or engaging in leisure activities quietly, and talking excessively. Impulsivity is characterised by an individual blurting out answers before the questions have been completed, having difficulty awaiting one s turn, and interrupting or intruding on others. Inattention, includes symptoms such as failing to give close attention to details or making careless mistakes, having difficulties sustaining attention, being easily distracted by extraneous stimuli and being forgetful in daily activities. ADHD is usually characterized by a pattern of increased impulsivity, high levels of motor activity, and attentional problems that impair functioning at home, school and social settings (APA, 1994). Comorbidity Comorbidity relates to the co-occurrence of several different disorders in one individual.

5 133 Executive Functions Welsh and Pennington (1988) defined executive functions as a broad range of abilities, serving the purpose of maintaining an appropriate problem-solving set for attainment of a future goal. Executive functions includes functions such as planning, persistence, mental flexibility, working memory and inhibition (Barkley, 1997a; Lezak, 1995; Welsh, 1991). In this study, executive function includes attention (sustained attention and focussed attention), fluency (verbal and design fluency), working memory (verbal working memory and visuospatial working memory), planning and set shifting ability.si g fluency), working memory (verbal working memory and Attention Attention has been defined as a cognitive brain mechanism that enables one to process relevant inputs, thoughts, or actions while ignoring irrelevant or distracting stimuli (Gazzaniga, Ivry&Mangun, 2002). With regard to the present study, attention is defined in terms of sustained attention and focused attention measured by colour cancellation test (Kapur,1974), and colour trails test (D Elia,Satz,Utchiyama&White,1996) Fluency Fluency refers to intrinsic generation of responses or alternatives, typically within a set of constituents and can be assessed by measures of verbal and nonverbal fluency (Spreen and Strauss, 1998).With regard to this study Fluency is defined in terms of Verbal Fluency and

6 134 Design Fluency measure by FAS Phonemic Fluency Test (Lezak, 1995) and Design Fluency Test (Jones-Gotman& Millner, 1977). Working memory Working memory refers to the system involved in the short-term maintenance and manipulation of information necessary for the performance of complex cognitive tasks (Baddeley& Hitch, 1974).With regardto this study working memory is defined in terms of verbal working memory and visuospatial working memory by using N back test (Smith &Jonides,1995) and Visuospatial Working Memory Span task (Milner,1971) respectively. Planning Planning is defined as the identification and organization of the steps and elements needed to carry out an intention or achieve a goal (Lezak, 1995). In this study planning is measured through Porteus Maze Test (Porteus,1965). Set shifting It refers to the ability of the individual to change from current sorting principle to number of other sorting principles or set. It is the ability that requires cognitive flexibility to shift mental set depending upon various environmental contingencies (Spreen et al., 1998). In this study set shifting is measured by Wisconsin Card sorting test (Heaton,Chetune,Talley,Kay &Curtis,1993) Non ADHD: With regard to the present study, non-adhd is a term used to refer to children without Attention Deficit Hyperactive Disorder and without any psychiatric or physical illness.

7 135 Sample Size Estimation One of the earlier studies conducted by Indian Council of Medical Research Bangalore (1984) found the prevalence rate to be 9%. Gada (1987) reported a prevalence rate of 8.1% in primary school children. Bhatia, Nigam, Bohra and Mallik (1991) found high prevalence rates (29%) of ADHD among 11 to 12 year old school-going children. In another study, the estimated ratio of prevalence of ADHD was 10 to 20% (Singhi & Malhi 1998; Bhatia, Chowdry, Sidhana; 1999). In recent years, Suvarna and Kamath (2010) estimated the prevalence rate of preschool children with ADHD to be 12.2% in one region of Bombay (India). Venkata and Panicker (2013) conducted a cross sectional study in four different schools in Coimbatore district to identify the prevalence of ADHD in preschool children and reported a prevalence rate of 11.32%, with a higher prevalence rate among boys (66.7%). The sample for the first phase of the study was estimated based on the calculation using the approximate target population required with a precision level of 95% of confidence and an error margin of 5%. Understanding from the literature that ADHD occurrences was a finite 12 cases in 1000, it was estimated to include 200 cases. Keeping the feasibility of time and research deadline, a sample of 100 children were selected to gather evidence for executive function. Sample Design Purposive sampling was used to select children from three special schools and one normal school in Chennai, Tamil Nadu, India. Two groups of children were selected for the study based on inclusion and exclusion criteria. The first group consisted of 50 boys with

8 136 ADHD from a special school. The second group consisted of 50 boys without ADHD from a regular school. Therefore the total sample size included in Phase I of this study was 100. Selection Criteria Inclusion criteria for ADHD group Age ranging from 8 years 12 years Diagnosed as ADHD with comorbid LD according to the DSM-IV TR IQ 90% 96% percentile Family income Rs.20,000-30,000 per month Children living with parents Exclusion criteria for ADHD group Presence of any psychiatric problems. ADHD children who are under medical intervention IQ less than 90% Uncorrected vision and hearing. Pervasive developmental disorder, mental retardation, Tourette s syndrome, seizure disorder and autism. Inclusion criteria for Non ADHD Children diagnosed with no ADHD and LD

9 137 Age ranging from 8 years 12 years IQ 90% - 96% percentile Family income Rs.20,000-40,000 per month Children living with parents Exclusion criteria for Non ADHD group Presence of any psychiatric problems Any long acting psychotropic medication Uncorrected vision and hearing IQ less than 90% Pervasive developmental disorder, mental retardation, Tourette s syndrome, seizure disorder, autism and brain damage. Procedure The sample was selected from three special schools and one normal school in Chennai, Tamil Nadu, India, based on the inclusion criteria and exclusion criteria. A total of 140 children (70 children with ADHD and 70 children without ADHD) were screened for for the study. Out of which 120 children were found eligible and their parents were contacted for consent. Consent was received from 107 parents (52 parents of children with ADHD and 55 parents of children without ADHD), yielding a response rate of 89.1%. Two groups of children participated in the study. The first group consisted of 52 children with ADHD from a special school, out of which two children dropped out of the study. The selected children

10 138 (n = 50) were assessed using the criteria of DSM IV TR for Attention Deficit Hyperactivity Disorder (ADHD). Malin s Intelligence Scale for Indian children (Indian adaption of WISC) was administered to children with ADHD and children without ADHD. Those children who scored 90% - 96% percentile only were selected for the study. Conners Abbreviated Rating Scale (Conners, 1973) rated by parents and teachers was also used to identify attention problems. Interviews with parents and teachers were conducted to further concur that the children had attention disorder. In addition a socio demographic data sheet (Appendix P) was filled by the parents. The second group consisted of 55 children without ADHD from a regular school, out of which 5 students dropped out of the study due to a long leave of absence. The children (n = 50) were further screened using DSM IV TR criteria and Conners Abbreviated Rating Scale (CARS) (Conners, 1973) to ascertain that they did not have any attention disorder. None of these children were on medication. The scores of these children without ADHD in CARS were found to be less than 15. The neuropsychological test used in the present study has been taken from the NIMHANS Neuropsychological battery for children (Kar, Rao, Chandramouli, Thennarasu,2004) and the following subdomains were measured 1. Attention a) sustained attention-colour cancellation test (Kapoor,1974) b) Focussed attention-colour trails test, Trail A and B (D Elia, Satz, Uchiyama &White,1996),2) Fluency a) verbal Fluency-Phonemic Fluency (Lezak,1995) b) Design Fluency -Design Fluency (Jones-Gotman&Milner,1977) 3)Working memory a)verbal Working memory-n Back Test (Smith & Jonides,1995) b)visuo spatical working memory

11 138A VSWM Span Task(Milner,1971) 4) Planning - Porteus Maze (Porteus,1965) 5) Set shifting - Wisconsin card sorting. After explaining the need and importance of the study, the investigator sought permission from the school authorities to conduct the survey. Before administration of the tools, a written consent (attached as Appendix B) was obtained from parents seeking their permission to allow their wards to participate in the study. Another informed consent form was obtained prior to the intervention to allow the wards to participate in the intervention (Appendix B1)

12 139 Children with ADHD Special Schools School A (n = 10) School B (n = 10) School C (n = 32) Total N - 52 Matched for Age, Gender, I.Q., SES & Location Children without ADHD Normal School N = 55 Screening Screening DSM IV TR DSM IV TR Conners Rating Scale Conners Rating Scale N = 52 N = 55 During the course of assessment, 2 children were dropped N = 50 During the course of assessment, 5 children were dropped N = 50 Figure 6. Flowchart showing the sample selection procedure in Phase I

13 140 Sample Characteristics Out of 100 boys (N = 100) selected for phase I of the study, 50 of them were children with ADHD selected from a special school (Group I), and 50 of them were children without ADHD from a normal school (Group II). The first group consisted of 50 boys diagnosed with ADHD between the age group of 8 years to 12 years (mean = 10.1). Among the 50 students with ADHD, 64% of the sample had one or two siblings while 36% were only children. 96% of the children were from a nuclear family while 4% were from a joint family. The profile of the parents of children with ADHD revealed that 16% of them were from a low socioeconomic background (salary between 20,000 and 5,000), 34% were from a medium socioeconomic background (salary between 26,000 and 31,000) and 50% were from a high socioeconomic background (salary between 32,000 and 40,000). 40% of both fathers and mothers were graduates (under graduate and post graduate) while 60% were non graduate (10 th, 12 th pass and diploma holders). The second group consisted of 50 boys without ADHD selected from a matriculation school in Chennai. Only boys were selected to match the sample in the first group. The age group of the children was 8 years to 12 years with a mean age of 10.3 years. Among the 50 students, 70% of the sample had one or two siblings and 96% of the sample came from a nuclear family. The demographic profile of the parents of children without ADHD, 24% were from a low socioeconomic status (salary between 20,000 and 25,000), 36% were from a medium socioeconomic background (salary between 26,000 and 31,000) and 40% were from a high socioeconomic background (salary between 32,000 and 40,000). 42% of fathers and 50% of mothers were graduates (under graduate and post graduate) while 58% of fathers and 50% of mothers were non graduate (10 th,12 th pass and diploma holders).the demographic details reveals an identical profile of the family

14 141 background of the children (ADHD and Non ADHD), except for a marginal difference in the socio economic status between both groups. More non ADHD children come from the low income and medium income groups than ADHD children.

15 142 Table 1 Demographic details of ADHD group and Non ADHD group Demographic Variables Total N = 100 ADHD Non ADHD N % N % Father s Education Mother s Education Socioeconomic status Graduate % 20 42% Non Graduate % 30 58% Graduate % 25 50% Non Graduate % 25 50% Low % 12 24% Medium % 18 36% High % 20 40% Siblings Family Type Siblings % 35 70% No Siblings % 15 30% Nuclear % 48 96% Joint 4 2 4% 2 4%

16 143 Tools Used A brief description of each test and its rationale is presented below. Table 2 Table representing the tools used for assessing children with ADHD Functions Domains Sub-domains Name of Tool Author Screening tool for ADHD Malin s Intelligence Scale Malin, 1969 DSM IV TR American Psychiatric Association, 2000 Conners Abbreviated Rating Scale for Conners, 1973 Parents and Teachers (CARS) Sustained Attention Colour Cancellation Kapur, 1974 Attention Focused Attention Colour Trails Test, D Elia, Satz, Uchiyama Trail A & B & White, 1996 Verbal Fluency Phonemic Fluency Lezak, 1995 Executive Functions Fluency Jones-Gotman& Milner, Design Fluency Design Fluency 1977 Verbal Working N Back Task-verbal Smith &Jonides, 1995 Working Memory Memory Visuospatial VSWM Span Task Milner, 1971 Working Memory Planning Planning Porteus Maze Porteus, 1965 Set Wisconsin Card Heaton, Chelune, Talley, Set Shifting Shifting Sorting test Kay & Curtis, 1993

17 144 Assessment Procedure All the executive function assessment tools were performance based as this was administered individually by the investigator. Special effort was taken to make the assessment area devoid of distraction, as the characteristic features of the participants were inattention, hyperactivity, and impulsivity. Since the participants were children with ADHD and there were multiple tests used, the assessment procedure was spread over three days for each child. The measures were administered in English as the children were studying in an English medium school. Conners Abbreviated Rating Scale (CARS) (Conners, 1973) Rationale CARS picks up both hyperkinetic and conduct problems, as there is a heavy overlap of items loaded on these two scales. Therefore, it can be used as a screening instrument to detect the problem of hyperactivity and conduct disorder and it has a high sensitivity and specificity (Luk and Leung, 1989). The instrument has been found to be useful for cross-cultural comparison. The scale has been used as an effective screening tool in several Indian studies (Agarwal & Rao, 1997; Oberoi &Kapur, 1995). Materials 10 items from the 39-item scale of Conners Teacher s Rating Scale (Attached as Appendix C)

18 145 Description Conners Abbreviated Rating Scale (CARS) consists of ten overlapping parent and teacher items from the 39-item scale of Conners Teacher s Rating Scale. The items are rated on a four point scale with the following categories: Not at all (score = 0), Just a little (score = 1), Pretty much (score = 2) and very much (score = 3). Barkley (1981) recommended that the cut-off should be at 2 SD above the mean (score - 20). However, Trites, Dugas, Lynch and Ferguson (1979) and Oommen (1987, 1990) from India all agree that a mean item rating of 1.5 or a total score of 15 for the ten items is satisfactory for classifying a child as hyperactive. The children who got a score of 15 or above were included in the present study. Reliability and validity of this scale has been found to be fairly good and useful for crosscultural comparison. Normative data was established in a sample of 383 children in the age group of 3 to 17 years. The test-retest reliabilities over one week interval were found to be 0.91 to 0.98 (Milich, Roberts, Loney and Caputo, 1980) and 0.89 over two week intervals (Zentall and Barack, 1979). Gomez, Harvey, Quick, Scharer and Harris (1999) reported the concurrent validity of the scale by the correlation between the teacher ratings of the inattentive and hyperactive items with the DSM IV ADHD Rating Scale which were 0.77 and 0.86 respectively. Significant relationship between teacher ratings of impulsivity, laboratory tests of impulse control and distractibility (Brown and Wynne, 1984) were found. Teacher records of aggression and hyperactivity, clinic playroom observations of child behaviours and other rating scales of hyperactivity validates the scale (Arnold, Barnebey and Smeltzer, 1981).

19 146 Scoring The items are rated on a four point scale with the following categories: Not at all (score = 0), Just a little (score = 1), Pretty much (score = 2) and very much (score = 3).The maximum possible score is 30 and minimum possible score is 0. Cut off of 15 and above is considered as a condition of ADHD. Tools used to measure executive functions Sustained Attentation : Colour Cancellation Test ( Kapur, 1974 ) Rationale Colour Cancellation Test is a measure of sustained attention. It is also a measure of accurate visual scanning as well as activation and inhabitation of a rapid response. More number if omissions reflects poor visual scanning and poor sensitive attention. More number of commissions reflects problems in inhibition of a rapid response. Material Colour cancellation sheet, pencil and stopwatch. Description The subject is presented with a sheet having 150 circles in 5 different colours i.e. red, yellow, blue, black and gray. Subject is required to cancel only the red and yellow circles

20 147 as fast as possible. Time taken to complete the test is recorded and errors of omissions and commissions are noted. Instructions This is a sheet having circles in 5 different colours. I want you to cancel only the red and yellow circles in the whole sheet as fast as you can. Scoring Time taken in seconds and errors of omission and commission comprise the score. In Indian sample (NIMHANS Neuropsychological battery for children) it is observed the score range between minimum of 80 to maximum of 123 seconds or the cut off score for 8, 9, 10, 11, 12 years is 123, 108, 97, 88, 80 seconds respectively Focused Attention: Colour Trails Test, Trial A & B (D Elia, Satz, Uchiyama and White, 1996) Rationale Colour Trails Test is as measure of focused attention. It is also a measure of mental or conceptual tracking and cognitive flexibility. Trail Making Test has been found to be highly sensitive to brain damage (O Donnel, 1983). Larger than normal differences between part A and B of this test have been interpreted as an indication of left lateralized lesions (Wheeler & Reitan, 1963).

21 148 Material Colour trail sample sheets, colour trails A and B, stopwatch. Description Colour trails test has been included in the present assessment tools due to its wider applicability. This test is designed to minimize the influence of language and covers a wide age range from childhood to adulthood. It has two parts, Part A and Part B. On Trail A, circles numbered 1 to 25 are in two colours yellow and pink. All odd numbered circles are in pink and even numbered circles are in yellow. The subject is required to serially connect the numbers 1 to 25, irrespective of the colours. Trail B shows all numbers from 1 to 25 twice once in pink and once in yellow. The subject is required to connect the numbers serially from 1 to 25 alternating between pink and yellow circles and disregarding the numbers in circles of the alternate colour. Time taken for both trail A and B are noted separately. Errors are also recorded. The test-retest reliability of Colour Trails Test is reported as.64 for Trail A and.78 for Trail B (D Elia et al., 1996). This test is loaded on rapid visual search and visuo-spatial sequencing factor as well as cognitive set shifting. Normative data for colour trails was based on the performance of adults aged 18 years to 89 years. In children aged 5 years 11 months to 16 years, a steady age progression was noted. Girls were found to complete Colour Trails B more quickly than boys (Spreen & Strauss, 1998).

22 149 Scoring Time taken in seconds and errors of omissions and commissions for Trail A and Trail B separately comprise the score for this test. In Indian sample (NIMHANS Neuropsychological battery for children) it is observed the score for Trail A has a cut off score of 193 for 8, 9, 10, 11, 12, and 174, 157, 142, 128 seconds respectively. For Trail B, the cut off score for 8, 9, 10, 11, 12 years is 193, 174,157,142,128 seconds respectively Verbal Fluency: FAS Phonemic Fluency Test (Lezak, 1995) Rationale FAS Phonemic Fluency Test is a measure of verbal fluency. This test evaluates spontaneous production of words beginning with a given letter within a limited time. Deficits in verbal fluency have been found to be more in left frontal damage (70%) compared to right frontal damage (38%) (Benton 1968). An fmri study of brain activity during a verbal fluency task, i.e. FAS Phonemic Fluency Test, showed activation in left prefrontal and right cerebellar areas (Schlosser et al., 1998). The test-retest reliability of the FAS test in 8 year old children is reported to be.54. Concurrent validity has also been established indicating better validity for letter fluency than for category fluency (Lezak, 1995). Description The subject is asked to produce orally as many words as possible beginning with a given letter F, A, and then S. The subject should not give proper nouns. One minute is given for each letter. Words produced for each letter are noted on the record form. In regional

23 150 languages, a letter can be given as suggested by NIMHANS Neuro psychological battery for children Ka, Pa and Ma For children studying in English medium F,A, S (John, 2000) can be given instead of Ka, Pa and Ma. Instructions I will say a letter. I want you to give me as many words that begin with that letter as quickly as you can. You have one minute for this. Do not give the same word again with a different ending i.e., someone, somewhere etc. Do not give numbers, names of places and people. Likewise I will be giving three letters one by one. Begin as I say the first letter. The first letter is F. Go ahead. One minute is allowed for each letter. Words produced are noted down in the order produced. Wrong words, variations of the same word, names, and repetitions are not counted (Lezak, 1995). Scoring A sum of all admissible words for the three letters comprises the score. Design Fluency: Design Fluency Test (Jones-Gotman & Milner, 1977) Rationale Design Fluency Test is a measure of the subject s ability to produce/ generate/invent novel abstract designs. It is a nonverbal analogue of verbal fluency test. Creating novel designs is a complex task and involves cognitive processes like cognitive flexibility, creativity and

24 151 constructional abilities. Jones-Gotman and Milner (1977) and Jones-Gotman (1991) showed that patients with right frontal or central damage had difficulty on design fluency test. Material A4 size sheets, pencil, eraser and stopwatch Description Design Fluency Test requires the subject to generate as many different meaningless designs as possible. The test is composed of a free-response condition lasting for 5 minutes and a fixed response condition lasting for 4 minutes. In the fixed condition, the subject is required to draw meaningless designs using only four lines. The free response condition does not have such restriction except a few which are mentioned in the instructions. The reliability coefficient of the test was found to be.74. Good to fair interrater reliability was reported for novel responses (r =.69) (Spreen & Strauss, 1998). Instructions The subject is presented with a sheet of paper and pencil and the following instructions are given. I want you to draw some meaningless design, which you make up in your mind. Do not make drawings that represent something. Do not draw anything you have seen before. Do not make drawings, which anyone could name. Each design should be different from the other. It should be a design and not scribbling. Start drawing when I

25 152 say start. Make as many different designs as you can in 5 minutes. Start. The examiner can give a few examples before starting the test. These examples should be removed from the subject s view once the test commences. It is important on the part of the examiner to watch while the subject is drawing, particularly in the case of young children. This is to ensure that they have understood the instruction and to check and prompt if they continue to draw meaningful drawings (Spreen & Strauss, 1998). Scoring Design fluency test obtains two scores. One basic score is the novel output score (NOS). This is defined as the total output minus the sum of all perseverative responses and meaningful drawing. Second is the perseverative error score (PES). This signifies the sum of drawings, which are rotations, mirror image versions of previous drawings, variations of the same designs and drawings that differ from the previous drawings in small details. In Indian sample (NIMHANS Neuropsychological battery for children) the cut off score for 8, 9, 10, 11, 12 years is 3, 3, 4, 4, 5 respectively. Verbal Working Memory: N Back Task (Smith &Jonides, 1995) Rationale N Back Task (verbal) is a measure of verbal working memory. Development of working memory proceeds dimensionally, starting with refinement of basic perceptual and sensory motor functions and culminating with the physiological maturation of widespread neural networks that integrate complex processing demands inherent to working memory tasks.

26 153 PET studies have revealed two major sites of activation in the N Back Task particularly the 2 back verbal working memory task. Activation is observed in the posterior parietal cortex in the left hemisphere which is thought to be responsible for storage of verbal material. The other sites of activations are a trio of locations in the prefrontal cortex: these activations primarily mediate the production of internal speech code required for rehearsal (Smith & Jonides, 1995). Material List of phonemes and record form Description Verbal working memory has three important components i.e. storage, manipulation of information and rehearsal. N back Task is based on the theoretical premise that two variables can affect verbal working memory i.e. word length and phonemic similarity. It consists of a 1 back task and a 2 back task. The 1 back task consists of a list of phonemes which is kept out of the subject s view. Each phoneme is presented at the rate of one phoneme per second. The subject is required to respond in terms of Yes or No for phonetically similar and dissimilar sounds respectively. The subject has to say Yes for each consecutively repeated sound and for the other sounds the response is No. In the 2 back task as each is presented the subject has to decide whether or not it matched the sound that appeared two items back in the sequence and if so the subject has to respond in terms of Yes or No. In this condition, the subject must always maintain representations of the two most recent sounds in memory to compare with the current one.

27 154 Instructions 1 Back Task - I will be reading out a list of sounds such as ga, na, ja. As each sound appears, you have to decide whether or not it matched the sound that appeared just before the present sound. If so, I want you to say Yes otherwise say No. Listen carefully. 2 Back Task - Again, I will be reading out sounds such as ga, ma, pa. As each sound appears you have to decide whether it matched the sound that appeared two items or sounds back in the sequence. I want you to say Yes if it is so, otherwise say No. Scoring The N Back Task (Verbal) obtains 2 score. One score is called a hit that is the number of correct responses. The other score is called misses and is scored when the subject has missed a correct target and said no for a phoneme when he should have said yes. Each of the two scores are obtained separately for the 1 back and 2 back tasks. In Indian sample, it is observed that the cut off score for N Back test (I Back) 8,9,10,11,12 years is 7, 8,8,8,8 respectively and (2 Back) 9,10,11,11,12 respectively.

28 155 Visuospatial Working Memory Two tests are taken as measure of visuospatial working memory: visuospatial working memory span task and the N back Task (Visual). Visuospatial Working Memory Span Task (Milner, 1971) Rationale This test is a measure of visuospatial working memory span. Material 5 wooden cubes (1 in size). Description The Visuospatial Working Memory Span Task consists of 4 cubes/blocks arranged in a row. The examiner taps these four cubes with a fifth cube. The tapping is performed in different sequences as given below. The subject is required to repeat the sequence of four taps tapped by the examiner. Five trials of forward and five trials of reverse sequence are given. Number of taps remains the same for all the forward and reverse sequences but each sequence is different from the other. The five sequences are as follows: a b c d e

29 156 The numbers mentioned in the sequences signify the serial position of the blocks to be tapped. The same sequences are given for both reverse sequences. Instructions Instructions for the forward sequence: Here are four blocks. I will be tapping on these blocks in a predetermined sequence. I want you to look carefully and repeat the same sequence. Five different sequences will be given. Now, look carefully for the first one and repeat it after I finish. Instructions for reverse sequence: Again I will be tapping on these four blocks in a predetermined sequence. I want you to tap the same sequence in reverse order. Watch carefully. Scoring Number of the correct sequences tapped by the subject for both the forward and reverse condition together comprises the total score for this test. In Indian sample, it is observed that the cut off score for 8, 9, 10, 11, 12 years is 5, 5, 5, 6, 6 respectively. Planning: Porteus Maze Test (Porteus, 1965) Rationale Porteus Maze Test is a measure of planning and foresight i.e., choosing, trying, rejecting and adopting alternative courses of conduct or thought. Porteus maze test can be quite sensitive to the effects of brain damage as reported in a study on the psychological consequences of brain lesions and ablations (Klebanoff, Singer, &Wilensky, 1954).

30 157 Material 10 mazes and a pencil Description Porteus Maze Test, Children s Version was included in the battery of tests. It consists of 12 different mazes of increasing difficulty level for children between the ages of 3 years to 12 years, children of 14 years and adults. The mazes are printed on sheets of paper. This is not a timed test. The subject is required to trace the maze from the starting point to the goal without entering the blind alley and without lifting the hand. In the present battery this test is not administered for the 5 to 7 years age group but is given to children aged 8 years and above because of the delayed maturation of planning in children. In the present battery, the maze designed for the 5 year age level is given first. The child is allowed two trials on each maze from 5 through 9 year mazes and four trials on each of the 12 and 14 year mazes and also on the adult maze. If the child makes an error on all the trials given, he/she is considered as having failed that maze. The test is discontinued when the child succeeds in two successive mazes above the 8 year maze. The test is also discontinued when the child fails on mazes for any three successive ages. Adult maze is not given under following conditions i.e., if the subject is under twelve years of age, if the subject has taken more than one trial on mazes below the 9 year maze and also if the trials taken on mazes 12 year and 14 year levels are more than three in number. Instructions The subject is presented with the first maze and a pencil. The following instructions are given. I want you to imagine that all the lines in this drawing are walls with spaces

31 158 between them. A rat came along and found this hole and ran through until he found this piece of bread. Now, I want you to draw a line of the rat finding his way from the starting point to the bread. You should not lift your pencil from the paper until you have finished and found your way out. For further mazes, 6 to 14 years and adult form, the examiner says; Start at this point and find your way out here. Scoring The basal age is assumed to be 4 years on this test, as the present battery starts from the 5 year age level. Two trials per year in terms of age are allowed on the 5 to 11 year mazes. At each of the mazes, success on the first trial gets an addition of one year, while success in the second trial gets an addition of half year to the basal age of 4 years. Four trials are allowed per age on the 12 and 14 year mazes. If these are passed, the numbers of trials given in each test are added together and additional credit is given, as follows (Porteus, 1965): Table 3 Scoring for planning test. Sum of trials of 12 and 14 year Mazes Credit added to the score (test age) already obtained in mazes below 2 trials 4 years 3 trials 3½ years 4 trials 3 years 5 trials 2½ years 6 trials 2 years 7 trials 1 ½ years 8 trials ½ years

32 159 If the 12 year age level maze is failed and 14 year age level maze is passed then credit is given as follows: Table 4 Scoring for planning test. No. of trials in 14 year maze Credit to be added to the score already obtained 1 trial 2 years 2 trials 1 ½ years 3 trials 1 year 4 trials ½ year The maximum score in terms of test age, obtained when the subject passes all the tests before adult test on the first trial and the adult test in one or two trials is 17 years. In Indian sample, it is observed that the cut off score for 8,9,10,11,12 years is 8,8,8,9,10 respectively. Set Shifting: Wisconsin Card Sorting Test (Heaton, Chelune, Talley, Kay, &Curts, 1993) Rationale Wisconsin Card Sorting Test (WCST) is a measure of the ability to form abstract concepts, to shift and maintain set, ability to utilize feedback and inhibitory control of interference (Spreen & Strauss, 1998). These functions are primarily mediated by the dorsolateral prefrontal cortex (Fuster, 1997). A SPECT study reported that WSCT produced a left

33 160 dorsolateral prefrontal activation (Rezai, 1993). Evidence of inability of patients with dorsolateral frontal lobe lesions to shift from one sorting principle to another due to perseverative interference of previous models of response has been reported (Milner, 1963). Material Four stimulus cards, 128 response cards and record form. Description This test was originally developed to assess abstraction ability and the ability to shift cognitive strategies in response to changing environmental contingencies. It is considered as a sensitive measure of executive function. The test consists of four stimulus cards, first with a red triangle, second with two green stars, third with 3 yellow crosses and fourth with 4 blue circles. The subject is given two packs of cards, each containing 64 response cards, which have designs similar to those on the stimulus cards, varying in colour, geometric form and number. The subject is required to match each of the cards in the deck to one of the 4 stimulus cards. Feedback is given in terms of right and wrong. The examiner should never give any indication of the sorting principles (categories) or the nature of shifts from one category to the other. The first correct sorting category is Colour. As the subject begins to sort the cards, the examiner responds correct/wrong for each match made according to colour. This process continues until the subject has produced 10 consecutive colour responses. Without comment or any other indication, the examiner changes the sorting category to Form. It is important that the examiner makes

34 161 an undetectable transition between two sorting categories. Form remains the correct category until consecutive correct responses. Then the examiner changes the correct sorting category to Number. After 10 consecutive correct responses to number the examiner has to switch back to Colour as correct sorting category, then to Form and then to Number. The test continues until the subject has successfully completed six categories or until both decks of response cards have been used. There is no time limit to this test (Heaton, Chelune, Talley, Kay & Curtis, 1993). Instructions Four stimulus cards are placed on the table in a row in front of the subject. The order in which the stimulus cards are placed on the table is as follows: card with the red triangle, card with two green stars next to it, card with 3 yellow crosses and then a card with 4 blue circles. Response card decks (128 cards) are kept on the left side of the subject. The examiner should be ready with the record sheet to record each response. The following instructions are given, I am not allowed to tell much about how to do the test. Here are 4 stimulus cards and this is a set of cards I have placed on your left. You are required to match each of the cards in these decks to one of the four stimulus card. You must take the card on top from the deck and place it below the stimulus card you think it would match. Take one card at a time. I will tell you each time whether you are right or wrong. If you are wrong, leave the card where you have placed and try to get the next card correct. Do not take the card back to the deck after you have matched it wrong or right. There is no time limit for this test. Let s begin. Responses are recorded on the record sheet each time the subject responds.

35 162 Scoring Performance on WCST is scored in different ways. WCST obtains following scores (Heaton et al.,1993): 1. Number of trials administered. 2. Total number of correct responses 3. Total number of errors 4. Percentage of errors. 5. Perseverative responses are scored when the subject persists in responding to a stimulus characteristic that is incorrect. The response is said to match the perseverated to principle and is scored as perseverative error. Perseverative errors are perseverative responses. 6. Percent perseverative errors are the percentage of the total number of perseverative errors and reflect the concentration of perseverative errors in relation to overall test performance. 7. Non- perseverative errors. 8. Percentage of non- perseverative errors. 9. Conceptual level responses (consecutive correct responses occurring in runs of three or more). It gives an insight into correct sorting principle. 10. Percentage of conceptual level responses.

36 Number of categories completed during the test, which can range from 0 6 (a category is a sequence of 10 consecutive correct matches to the criterion sorting principle). 12. Number of trials taken to complete first category. This score gives an indication of initial conceptualization before a shift of set. 13. Failure to maintain set is the number of times the subject makes five or more correct responses in a row and then makes an error before successfully achieving a category. This indicates the inability to continue using a strategy that has been successful. 14. Learning to learn score reflects the subject s average change in conceptual efficiency across the successive stages of WCST. Pilot study A pilot study was conducted with the aim of familiarising the researcher with the administration of the tool, study the feasibility, reliability, time taken for administration and also to establish the variability between the groups. Using purposive sampling, 30 children without ADHD were selected from a normal school. They were assessed with DSM IV TR criteria along with Conners Abbreviated Rating Scale to ascertain that they did not have any attention disorders. 30 children with ADHD & LD (Comorbid) from special schools who were already diagnosed by a qualified psychologist were selected and they were further screened using (1) a DSM-IV-TR diagnosis of Attention Deficit Hyperactivity Disorder (APA, 1994); (2) Conners Abbreviated Rating Scale (Conners, 1973) to ascertain the presence of attention problem. Both the groups were compared using NIMHANS Neuropsychological Battery for Children (Kar, Rao, Chandramouli, Thennarasu, 2004) for the level of executive functions.

37 164 The result of the pilot study showed a significant difference between children with ADHD and children without ADHD. The pilot study helped the researcher understand the practical difficulty in administering the tools, establish the feasibility and reliability of the tool. It also became evident that there was significant difference between children with ADHD and children without ADHD in their levels of executive functions. The average time taken for test administration for children with ADHD was two and half hours in contrast to two hours for children without ADHD, this helped the researcher plan the test allotment schedules. Based on the results of the pilot study and review of literature, the following modifications were made. N Back Verbal Working Memory Test was used in Phase I and II instead of N Back Visual Working Memory Test as it was time consuming and also did not hold the attention of the children. Few items were modified in Barkley s Home Situation Questionnaire to make it culturally suitable. For eg. Item no 13 While in the car was modified as while in the car / auto rickshaw / bus; item no 14 when with a babysitter was modified as when with a baby sitter/grandparents/relatives. In order to find out the effectiveness of intervention, the researcher decided to include Barkley s Home Situations Questionnaire and School Situations Questionnaire rated by parents and teachers. It was also decided to use ADHD Rating Scale (DuPaul, 1971) to assess the severity of the ADHD symptoms rated by parents and teachers.

38 165 The following table shows the reliability values of all the tools used in the pilot study. Table 5 Test retest Reliability Values of all the Tools used in the Pilot Study S. No. Functions Test Correlation Coefficient 1 Sustained Attention Colour Cancellation Test Focused Attention Colour Trails Test, Trail A 0.82 Colour Trails Test, Trail B Verbal Fluency Phonemic Fluency Design Fluency Design Fluency Test Visuospatial Working Memory VSWM Span Task Verbal Working Memory N Back (Verbal) 1 Back Verbal Working Memory 2 Back N Back (Verbal) 2 Back Planning Poteus Maze Test Set Shifting Wisconsin Card Sorting Test 0.79 The researcher once again established the reliability of the tool using test-retest reliability method for the study. The researcher incorporated all the above mentioned modifications in the main protocol of the study. The following two tables depict the time taken to administer each tool to both groups of children.

39 166 Table 6 Average Time Taken to Administer each Tool on Children with ADHD Serial Number Name of Test Avg Time taken for each Child (n = 1) 1 Colour Cancellation 5 minutes 2 Colour Trails Test, Trail A and Trail B 8 minutes 3 Phonemic Fluency 7 minutes 4 Design Fluency 9 minutes 5 N Back Test Verbal 9 minutes 6 Visuospatial Working Memory Span Task 7 minutes 7 Porteus Maze 10 minutes 8 Wisconsin Card Sorting Test 50 minutes 9 Misc (IQ test) 45 minutes Total Time 150 minutes (2 hrs 30 min)

40 167 Table 7 Average Time Taken to Administer each Tool on Children without ADHD Serial Number Name of Test Avg Time taken for each Child (n = 1) 1 Colour Cancellation 3 minutes 2 Colour Trails Test, Trail A and Trail B 6 minutes 3 Phonemic Fluency 5 minutes 4 Design Fluency 7 minutes 5 N Back Test Verbal 6 minutes 6 Visuospatial Working Memory Span Task 5 minutes 7 Porteus Maze 8 minutes 8 Wisconsin Card Sorting Test 40 minutes 9 Misc (IQ test) 40 minutes Total Time 120 minutes (2 hours) The time assigned to administer the tests on both the ADHD group and the Non ADHD group were different.

41 168 Phase II Phase II of the study consisted of Pre assessment stage, Intervention stage and Post assessment stage. Children who were pre assessed were randomly assigned to the experimental and control groups. The data obtained from Phase I of the study was used as a base line data of the phase II of the study along with children s behavioural problems in home and school situations and severity symptoms of children with ADHD. Indian norms were used to interpret the result. Research Design Quasi experimental design using randomly assigned experimental control group was used in phase II of the study to find the effect of NCIP. In this phase both qualitative and quantitative research methods were used. Focused group discussion was conducted to obtain detailed information about the problems and challenges faced by the parents of children with ADHD. This information was very vital in developing a neuro cognitive intervention program. The assessment included executive function domains of attention (sustained attention and focused attention), fluency (verbal fluency and design fluency), working memory (verbal working memory and visuospatial working memory), planning, set shifting ability and children s behavioural problems in home, school situations and their severity of symptoms. For the intervention purpose, students from a single special school were selected so as to reduce inter school variability in environment, to reduce the experimenter bias during intervention and also having enough sample size to allocate for 2 conditions.

42 169 Sampling design Random assignment was used to allocate children with ADHD into the experimental group and the control group using block randomization. Before randomizing the participants the homogeneity was established by verifying the mean value and SD. Sample Description 32 children (N = 32) with ADHD who were identified with difficulties in executive functions in Phase I, were selected for Phase II of the study. These participants were divided equally into experimental group (n = 16) and control group (n = 16) using block randomization procedure. Participants in the experimental group received the neurocognitive intervention while participants in the control group did not receive any training. Two subjects in the experimental group were not able to complete the intervention. One participant s parents were transferred to another city and another participant met with an accident and was absent for a long period of time and therefore was excluded from the study. Hence, 14 participants from the experimental group and 16 participants from the control group completed the intervention program. The study was single blinded where the assessment was carried out by another assistant who was blind to intervention. Tools used and their Description The following tools were used in the Neurocognitive Intervention Program to train children with ADHD in the experimental group. These tools were used in addition to the tools used in Phase I of the present study.