J. Indian Assoc. Child Adolesc. Ment. Health 2017; 13(1): Original Article

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1 10 J. Indian Assoc. Child Adolesc. Ment. Health 2017; 13(1):10-25 Original Article Efficacy of a model Attention Training program for children with ADHD Susmita Halder, Akash Mahato Address for correspondence: Dr Akash Mahato, Institute of Mental Health, Sweekaar Academy of Rehabilitation Sciences, Secunderabad , akashmahatocp@gmail.com Abstract: Background: Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common neurobehavioral disorders of childhood. Children with ADHD have problems with attention span and tend to be very easily distracted. They have difficulty in paying and maintaining attention over prolonged periods of time, along with difficulty in focusing and screening the stimulus presented in their surrounding environment. Effective intervention may improve their attention span over time, helping them to be more productive in school and at home. Aim The present study aims to find out the efficacy of a 12- week attention training program for children with ADHD, aged 8-12 years, to improve attention of these children.

2 11 Method: Following purposive sampling, 15 children with ADHD were selected for attention training. Baseline assessment of inattention and hyperactivity symptoms of the subjects was done through parent reported rating scale. Attention training was delivered in individual session and included training module focussed on sustained, selective, alternative, and divided attention. Participants completed an outcome evaluation after 12 weeks of training program. Results: Post training there was improvement in attention and reduction in scores of severity in attention scale. Conclusion: Attention training for children with ADHD to improve attention span is effective and could be part of comprehensive management plan for children with ADHD. Keywords: ADHD, Attention training, Efficacy Introduction Attention Deficit Hyperactivity Disorder (ADHD) is a widely recognized childhood neurobehavioral disorders. It is also one of the best understood childhood disorder [1] but despite this understanding, clinicians may tend to over rely on pharmacological management, which though successful may not normalize attention functions [2] While ADHD diagnosed children can have either of inattention or hyperactive features or a combination of both; prevalence studies report relatively higher rate of inattention type (5.1%) compared to hyperactive type (2.9%) in children 6-12 years old, and 5.7% against 1.1% in children years old [3].

3 12 Studies [4] suggest that children with ADHD have poor cognitive functioning on verbal comprehension, perceptual reasoning, working memory and processing speed as compared to normal children. The primary deficit in attention manifests as difficulties in planning; failing to sustain on tasks, often causing difficulties and deterioration in academics for school going children with ADHD. It becomes difficult to decide for school going children, who mostly have inattention features and less of hyperactivity and even consultants refrain to prescribe pharmacotherapy as first line of treatment for these types of ADHD children. Pharmacotherapy often has its own side effects and can continue for long duration, thus creating a dilemma of opting for it. While treatment guidelines across the world focus on combination of pharmacotherapy, behavioural management and parental training [5, 6] A growing body of research suggests that working on the specific cognitive functions can strengthen mental faculties in ADHD children to cope with these difficulties, especially inattention [7]. Attention training programme could be highly beneficial for these children as attention skills are so important that they are the first critical step in more complex cognitive skills, especially memory. With impaired attention skills, the child may not pay attention to new information; leading to difficulty in retrieving it later. Intervention may improve their attention span over time, which could help them to be more productive across different conditions.

4 13 Worldwide researchers customise cognitive remedial programmes for specific clients or group of clients. In recent years, researchers have increasingly focussed on remedial programmes for inattention in ADHD, but such programmes need to be checked for their efficacy. With this background, the present study aimed to find out the efficacy of a twelve week attention training programme for children with ADHD. Methodology 15 children (9 males and 6 females), with Attention deficit hyperactive disorder, were selected from psychiatric clinics in Kolkata. School going children of both sexes, diagnosed with ADHD, in the age range of 8-12 years were included. Children with comorbid conditions like seizures, mental retardation, conduct disorder, autism or significant problem behaviour reported by parents were excluded. None of the subject was under medication for the reported symptoms. Tools: Malin s Intelligence Scale for Indian Children (MISIC)[8]: MISIC is a reliable IQ assessment tool consisting of verbal and performance scale and generate verbal quotient, performance quotient as well as full scale IQ score. It was primarily used to screen out mental retardation in the participants. ADHD Symptom Checklist-4 [9]: It is a 50 item checklist to assess ADHD symptoms divided into domains of inattention, hyperactivity/ impulsivity,

5 14 oppositional defiance and peer conflict. The peer conflict scale was not included in the present study as it is for younger children. Trail Making Test [10] (TMT): The TMT is a test for sustained and divided attention. Composed of 2 parts, A and B; part A consists of 25 circles printed on a sheet of paper. Each circle contains a number from 1 to 25. The subject s task is to connect the circles with a pencil line as quickly as possible, beginning with the number 1 and proceeding in numerical sequence. Part B consists of 25 circles numbered from 1 to 13 and lettered from A to L. The task in Part B is to connect the circles in a sequence, alternating between numbers and letters. The scores represent the time required to complete each part. Procedure: Informed consent was taken from parents of participant children. Selected sample were initially assessed on the Malin s Intelligence scale for Indian Children to rule out mental retardation. Base line assessment of Inattention and hyperactivity symptoms was done using parent reported rating scale (ADHD SC- 4). Subjects underwent individual attention training sessions spanned over 12 weeks. Training program included training on sustained, selective, alternative, and divided attention. Parents completed an outcome evaluation after 12 weeks of training program. In adjunct to attention training to subjects, parents of participating subjects were also given psychoeducation and counselled. None of the participating subjects received any pharmacotherapy. All participants completed the twelve week attention training programme without any drop out.

6 15 Module of the Attention Training Programme: Considering different facets of attention, a series of paper pencil tasks were compiled to to enhance the participant s abilities: To increase the span of attention To be able to sustain on a task To stay on task even when distraction is present. To attend to and handle two or more tasks at one time. Required for handling tasks quickly as well as handling complex tasks. The tasks spanned a total of 12 weeks. Participants had one session per week with the therapist, in which specific paper pencil tasks were explained and practiced. The tasks were also explained to parents in the session and participants practiced the tasks on provided proforma s daily at home. The practice at home was monitored by parents for recording time and regularity. The practiced proforma s at home formed the basis for subsequent task and setting of its difficulty level. The paper pencils tasks and similar activities were also given as homework assignments to participant subjects. Tasks included Considering the objectives, following drill and practice strategies were used in the training. Each task was initially demonstrated for participant to practice. Connecting Dots: Dots printed in random order on plain sheet was presented to participants with the task to connect all of them as fast as possible. The time taken

7 16 was noted to compare with next trials for improvement. The number of dots was increased gradually with successive trials. Number & Letter Cancellation: Participants were given sheets with numbers and letters printed in random order, with the task to locate and strike off specific number/ letter in increasing complexity. The cancellation tasks were in three modes: specific number only specific letter only Specific number and letter in combination. The task was initially kept simple by keeping target of one particular number/letter to be cancelled, and gradually increased up to five numbers/ letters in successive trials. The array of numbers/ letters also increased from initial 8x8 to 20x20.Homework practice was also assigned, even using newspapers columns. Improvement was assessed by gradually decreasing the time limit. The letter/ number cancellation task is an established measure of sustained attention 9 as well as motor skills. Letter Number sequencing: This task was similar to first task of connecting dots, but with difference of dots replaced by numbers (1-25) and letters (A Z), and the task of joining these letters and numbers in sequence in minimum time.

8 17 Letter Number and Letter- symbol substitution: Participants were presented with a list of random letters. Each letter had a preset substitute number printed on top of the sheet. The task was to substitute the letters with their respective numbers in minimum time. The trial was further repeated with letters to be substituted by symbols. Identifying repeated Designs/ letter/ number: The task was to identify the repeating in a given series. The task was given in three modes. o Designs: Participants were given a series of similar looking designs placed in rows of 6 and gradually progressing to 8 designs. Repeating design was required to strike off in minimum time. Complexity of designs too progressed from gross to minute difference. o Letter: List of letters in rows was presented, with the task of striking off the repeating letter. The complexity of the task increased by increasing the number of alphabets. o Numbers: List of numbers was presented, with the task of striking off the repeating number. The complexity of the task increased by increasing the number of digits from single to three digits. Trials were initially taken without time limit, then within time limit Position Coding: The participant was presented a list of 10 meaningful words. The task included replacing each letter of the word with its respective position in

9 18 the alphabet series. (For e.g., for word CAT, the correct code would be , where 3, 1, and 20 represent position of C, A and T in the alphabet series. The complexity of the task increased starting from 3 lettered to 5 lettered word. Homework assignment was integral to this training and training procedures were designed with simple tasks gradually increasing in difficulty level keeping in mind the individual capabilities of the participants. Results Table 1: Sociodemographic details of the sample Range Mean SD Age (In years) Sex N % Male Female IQ (Average) Taking into consideration the inclusion criteria of the sample, mean age of the intervened children was years. Majority of them were male (Table 1). This is consistent with higher prevalence of ADHD in males compared to females [11]. The IQ scores of the participants were within normal range.

10 19 Table 2: ADHD-SC-4 and TMT Measures at baseline and post intervention Domains Baseline Post Intervention ADHD-SC-4 Inattention (T Score) Hyperactivity/ Impulsivity Oppositional Defiance T MT (in sec) Part A Part B Post intervention parental rating of their children over domains of inattention, hyperactivity/ impulsivity and oppositional defiance showed improvement compared to baseline assessment (table 2). Scores on Trail making test (part A and part B) also showed improvement post intervention. Discussion Treatment of symptoms of ADHD remains a challenging task for clinicians. While pharmacotherapy and behavioural management are known interventions for ADHD; alternative approaches like neurofeedback [12], meditation [13], diet and sleep management, parent training interventions [14] too are reported by researchers with varying efficacy rates [15,16] Remedial training focussing on improving attention in adults [17] as well as children too have been reported [18], however most of these

11 20 programmes are computer based and have limited applicability in relatively lesser structured child psychiatry clinics in India. Compared to this, paper pencil techniques are widely applicable and easy to practise for children coming from different background. They are also economical on part of parents and can be used in addition to other psychotherapeutic techniques. The present study aimed to see the efficacy of 12 week attention training programme for ADHD children. Base line assessment of the participant children revealed significant deficits in domains of inattention more than hyperactivity. This was reflected in poorer task accuracy and resulted in academic deterioration of these children, despite these children having normal intellectual functioning. While ADHD is known to have several comorbidities19, 20] like mental retardation,learning disabilities, conduct disorder, anxiety, depression;the selected participants had no significant problem behaviour or other clinical condition, and the prime reason of these subjects being drug naive. The attention training programme in this study focussed at different levels of attention and resulted in improvements in concentration, evident by post intervention test scores as well as in improvement in academic performance reported by parents. The modules of the attention training programme were customised to address and improve sustained, selective and divided attention of the participants. Whilecognitive retraining has been advocated for improvement of attention [21, 22, 23] with researchers suggesting that the direct training of attention have a beneficial effect on both lower and higher levels of attention;researchers often question on generalisation of

12 21 the gains from these trainings to real world functioning. It could be difficult to establish statistically the impact of these trainings in real world functioning school going children. However, significant improvement in terms of improvement in attention and overall improvement in academic performance was reported by parents. Certain other intervening variables that could have played a role in positive outcome of the training programme was counselling of the parents as well as structuring of daily routine of the children that may have had a supportive impact. The fact that all the participants had average level of intelligence potentially helped them to better integrate the attention training. There were certain limitations too of this study. Considering the inclusion criteria, the sample size met was small, that limits the statistical strength of the study. The attention training spanned twelve weeks; however no assessment was done to see persistence of these gains in longitudinal course. Future Directions: The study findings imply the role of individual and parental counselling in addition to attention training for better outcome and a need of structured inclusion in the therapeutic packages for ADHD children. Future studies can be planned using the discussed attention training module on larger sample size, and also compare with different child clinical population. More cognitive tasks could be added to address all aspects of attention deficit. Conclusion The findings of the present study indicate that attention training programs facilitate attention in children with ADHD. The training programme is potentially

13 22 suitable for school going ADHD children with predominant inattention and normal intellectual functions. The study suggested that attention training can be efficiently done using paper pencil tools and not necessarily depend on computerized softwares. Addition of parental counselling, and certain behavioural measures do help in improving the overall outcome. The study findings stress on need of non pharmacological intervention for children with ADHD with certain customization to enhance attention function and improve academic performance and related functionality. References 1. Mccracken J T. Attention deficit disorders, in: Kaplan HI, Sadock B J, Sadock V A (ed), Comprehensive textbook of psychiatry, Seventh edition on CD ROM. Lippincott williams& Wilkins. Philadelphia Tucha O, Tucha L, Kaumann G, Konig S, Lange K M, Stasik D, et al. Training of attention functions in children with attention deficit hyperactivity disorder. AttenDeficHyperactDisord Sep; 3(3): Willcutt EG. The prevalence of DSM-IV attention-deficit/hyperactivity disorder: a meta-analytic review. Neurotherapeutics Jul; 9 (3): Kotnala S, Halder S. Working memory, verbal comprehension, perceptual reasoning and processing speed in ADHD and normal children: a comparative study. Unpublished dissertation. Amity University, Rajasthan

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16 19. U.S. Department of Education, Office of Special Education and Rehabilitative Services, Office of Special Education Programs. Identifying and Treating Attention Deficit Hyperactivity Disorder: A Resource for School and Home, Washington, D.C Halder S, Mahato A K, Mukherjee R. Profile of clinical comorbidities and emotional disturbances in adolescent ADHD. Journal of Rural & Community Psychiatry. 2 (4) Jul- Dec, 2015, Kerns K A, Eso K, Thomson J. Investigation of a direct intervention for improving attention in young children with ADHD. DevNeuropsychol. 1999; 16: Semrud-Clikeman M, Nielsen K H, Clinton A, Sylvester L H, Parle N, Connor R T. An intervention approach for children with teacher- and parent-identified attentional difficulties. Jr Learn Disabil. 1999; 32: Tamm L, Hughes C, Ames L, Pickering J, Silver C H, Stavinoha P, et al. Attention training for school-aged children with ADHD: Results of an open trial. J AttenDisord. 2010;14: Susmita Halder Associate Professor, Department of Clinical Psychology, Institute of Psychiatry, IPGME, Kolkata, Akash Mahato, Officiating Associate Professor in Clinical Psychology, Institute of Mental Health, Sweekaar Academy of Rehabilitation Sciences, Secunderabad. 25