The Efficacy of Working Memory Training for Children and Adolescents with Attention-

Transcription

1 The Efficacy of Working Memory Training for Children and Adolescents with Attention- Deficit/Hyperactivity Disorder- Combined type compared to Children and Adolescents with Attention-Deficit/Hyperactivity Disorder- Primarily Inattentive type Thesis Presented in Partial Fulfillment of the Requirements for the Degree Master of Arts in the Graduate School of The Ohio State University By Synthia Sandoval Puffenberger B.A. Graduate Program in Psychology The Ohio State University 2011 Thesis Committee: Steven J. Beck, Advisor Michael Vasey Cynthia Gerhardt ii

2 Copyright by Synthia Sandoval Puffenberger 2011

3 Abstract This study investigated the efficacy of a computer based working memory training program for 51 children and adolescence between the ages of 7 and 17. All participants involved in the study were classified as having ADHD, with either the primarily inattentive or combined type. Parents and teachers provided ratings of executive function and ADHD symptoms of participants before treatment, one month and four months following treatment. Data in this study were analyzed by ADHD subtype to better determine if any differences could be found by subtype population. At post treatment parents rated the DSM Inattentive group as improving on measures of both executive function and ADHD symptoms. Parent reported changes appeared to persist at four month follow up for this group. Teachers also reported change from pre to post treatment for the DSM Inattentive group on the BRIEF Initiate scale. There were no reported significant changes for the DSM combined group by either parent or teacher report from pre to post treatment. Regression analysis using the Conners scales of inattention, hyperactivity, and oppositional at pre treatment as predictors for change at post treatment and four month follow up found that by parent report for the DSM Combined group, ratings of hyperactivity and opposition at pre treatment were negatively related to change post treatment. However, according to teacher report, opposition, hyperactivity, and inattention were positively related to reported change post treatment for both the Inattentive and Combined subtypes ii

4 of ADHD. This data suggest that this training may be beneficial as an adjunct treatment for children with ADHD to focus on executive functioning deficits. This training may be more beneficial for those diagnosed with the Inattentive type of ADHD, possibly due to the detrimental or interfering behaviors of hyperactive and impulsive symptoms found in the Combined type population. However, more research is necessary to determine the validity of the treatment effects found, as well as if these findings are enduring. It is also necessary to determine if these findings go beyond 3 rd party report and if they can also be found through objective measures of the participants, (i.e. using the Automated Working Memory Assessment or the Tower of London). iii

5 Vita June Sinagua High School May 2007.B.A. Psychology, University of Nevada Las Vegas Sep 2007-June 2008.Psychology Department Fellowship June 2008-Sep 2008 AGEP-SBES Summer Graduate Research Award Sep 2008-June Graduate Teaching Associate, Department of Psychology, The Ohio State University June 2009-Sep AGEP-SBES Summer Graduate Research Award Sep 2009-June2010 Graduate Teaching Associate, Department of Psychology, The Ohio State University Sep 2010-present...Graduate Teaching Associate, Department of Psychology, The Ohio State University Publications Beck, S.J., Hanson, C.A., Puffenberger, S.S., Benninger, K.l., Benninger, W.B. (2010). A Controlled Trial of Working Memory Training for Children and Adolescents with ADHD. Journal of Clinical Child and Adolescent Psychology, 39, Major Field: Psychology Minor Fields: Child Clinical Psychology Fields of Study iv

6 Table of Contents Abstract... ii Vita..iv List of Tables. vi Chapter 1: Introduction 1 Chapter 2: Methods...11 Chapter 3: Results..21 Chapter 4: Discussion 33 References.. 44 v

7 List of Tables Table 1: Demographic differences by subtype.. 47 Table 2: Parent Subscales Pre-Post Treatment Outcomes.48 Table 3: Teacher Subscales Pre-Post Treatment Outcomes..49 Table 4: Parent Subscales Post-Follow up Treatment Outcomes..50 Table 5: Teacher Subscales Post-Follow up Treatment Outcomes...51 Table 6: Parent Subscales Pre-Follow up Treatment Outcomes 52 Table 7: Teacher Subscales Pre-Follow up Treatment Outcomes.53 Table 8: Parent Regression Pre-Post.. 54 Table 9: Parent Regression Post - Follow up 55 Table 10: Parent Regression Pre-Follow Up.56 Table 11: Teacher Regression Pre-Post.57 Table 12: Teacher Regression Post-Follow Up.58 Table 13: Teacher Regression Pre-Follow Up...59 vi

8 Chapter 1: Introduction Attention-Deficit/Hyperactivity Disorder Attention-Deficit/Hyperactivity Disorder (ADHD) is a prevalent, chronic, and impairing disorder occurring in 3% to 7% of school aged children (American Psychiatric Association, 2000; Goldman, Genel, Bezman & Slanetz, 1998). ADHD has been found to cause significant impairments in nearly every domain of daily functioning including school performance, as well as family, and peer interactions (Mash & Barkley, 2006). With this level of potential impairment in mind, it is important to note that there has been recent discussion that the subtypes of ADHD, ADHD Primarily inattentive type and ADHD-Combined type, may actually be two separate and distinct diagnoses (e.g, Milich, Balentine, & Lynam, 2001). With this heterogeneity in mind, treatment outcomes by subtype should be examined further. Attention-deficit Hyperactivity Disorder Subtypes Currently, the diagnosis of ADHD can be categorized into three subtypes according to the DSM-IV (1994) criteria. The current subtypes are as follows, Predominantly Inattentive type, Predominantly Hyperactive-Impulsive type, and the Combined type. The predominantly inattentive type consists of symptoms such as difficulty sustaining attention, difficulty attending to details, difficulty with planning and organization, and easily distracted or forgetful (DSM, 1994). The hyperactive/impulsive subtype consists of the symptoms of being fidgety, difficulty remaining seated, described 1

9 as being on the go, blurting out answers or waiting for their turn, or interrupting others. Lastly, the combined subtype, consists of both the hyperactive/impulsive and the inattentive symptoms (4th ed; DSM-IV; American Psychiatric Association, 1994). Each subtype can be thought of as distinctively different from one another, and perhaps different subtypes may need differential treatment recommendations (Milich et al, 2001). Milich et al (2001) articulates that the two predominantly diagnosed subtypes of ADHD, Inattentive type and Combined type, may be better thought of as two distinct disorders; children with both hyperactive and inattentive problems and those children that can be characterized as having only inattentive symptoms with little to no symptoms of hyperactivity. In a review of Lahey et al., (1997), Milich refers to several factor analyses in which the symptoms associated with ADHD appear to load onto two different dimensions that appear to coincide with the two main subtypes of ADHD. This finding appears to suggest that there may in fact be distinct and separate disorders of ADHD. Milich et al., (2005) emphasizes the idea that future ADHD studies should examine the potential differences between the ADHD subtypes. By conceptualizing and analyzing data in this manner, we may be better able to determine if these distinct disorders deserve varying treatment recommendations better tailored to the specific deficits experienced by these children. Using the current diagnostic criteria for differentiating between the combined and inattentive types of ADHD in the DSM-IV, Nigg et al., (2005) speculates that the hyperactive and inattentive criteria may currently be too stringent leading to a less accurate differentiation between the groups (Nigg, Wilcutt, Doyle, & Sonuga-Barke, 2005). Currently, to meet DSM-IV criteria for the combined type of ADHD a child or 2

10 adolescent must display at least 6 inattentive symptoms and at least 6 hyperactive/impulsive symptoms. To meet criteria for the primarily inattentive type (PIT) of ADHD a child or adolescent must have a minimum of 6 inattentive symptoms and less than 6 hyperactive/impulsive symptoms. Based on these criteria it may be possible for a child to meet criteria for the PIT while consequently having 5 symptoms of hyperactivity/impulsivity. It is also widely recognized that current hyperactive/impulsive symptoms as listed in the DSM IV are more characteristic of behaviors associated with childhood and are less apparent in adolescents, making it more difficult to meet full criteria for the combined type of ADHD with age (Barkley, 2005). Barkley (2005) also emphasizes that girls may be less likely to meet full criteria for the combined type of ADHD since they tend to express less hyperactive/impulsive symptoms. Since it is possible for children to fall just short of meeting criteria for the combined type of ADHD (i.e., by having less than 6 hyperactive/impulsive symptoms), the current diagnostic differentiation may be somewhat indistinct and arbitrary making it important to investigate more stringent guidelines for classification. Symptom variation continues to be a concern in the literature for the diagnosis of ADHD. Barkley (2005) emphasizes the idea that if in fact these are distinct disorders, we need to find better methods in which to differentiate them. With overlapping symptoms confounding the complete differentiation of the two groups, conceptualization of how they differ needs to be investigated further. Currently it is believed that some of the symptoms that may be uniquely associated with the predominantly inattentive type are behaviors such as frequent daydreaming, staring off into space, appearing to be often confused, hypoactivity, and slow sluggish cognitive tempo (Barkley, 2005). It has been 3

11 suggested that these children may also be less likely to be diagnosed with a comorbid externalizing disorder which is distinctly different from the comorbidity profile typical of those children with the combined type of ADHD (Barkley, 2001). Treatment outcomes for children with varying types of ADHD must also be examined further. Current treatment research often compares children with ADHD as compared to those without ADHD. In a randomized double blind control trial of methylphenidate, Grizenko, Paci, & Joober (2010) compared 371 children diagnosed with either ADHD inattentive type or ADHD combined/hyperactive type and found significant differences between the two groups post treatment. Children diagnosed with ADHD Combined/Hyperactive type were found to be better responders to the medication than those diagnosed with ADHD inattentive type. Grizenko et al. (2010) also found that the Combined/Hyperactive group had a comorbid conduct disorder more often then the Inattentive group. Further differentiation in the treatment literature may help treatment providers to determine if some children may benefit more from specific treatments than others. ADHD and Executive Functioning, specifically working memory Executive functioning is thought to be one of the core domains of deficit in those diagnosed with ADHD (Nigg et al., 2005). Executive functioning is thought to consist of a variety of cognitive functions including goal setting, task persistence, organization, planning, and working memory (WM). It is thought that deficits in this area contribute to many of the difficulties in school that children with ADHD often experience. In fact, 4

12 executive functioning may be one of the most studied areas of ADHD deficits due to its impact on school functioning (Nigg et al., 2005). Previous research on the trainability of working memory has been abundant in the literature over the last decade (Klingberg et al., 2005, Holmes et al., 2009). Working memory can be thought of as holding something in mind long enough to remember it, while also experiencing some type of interference (Westerberg et al., 2007). WM is thought of as a core deficit in ADHD due to the large impact it has on everyday functioning, especially in the academic arena. As an example, WM is vital in reading comprehension since one must be able to not only remember what one has just read but retain the information while reading something new and merging the two. If one is unable to remember the previous information while incorporating the new information one will not be able to comprehend the story as a whole. Until recently, WM was thought to be resistant to modification with little to no plasticity to change. In the last several years, however, research has begun to focus on the trainability of WM. Current studies of the executive functioning deficits associated with ADHD focus mainly on children that have been diagnosed with combined type of ADHD vs. normal controls (Nigg, 2005). With the current literature on the differentiation between the subtypes emphasizing the slow cognitive functioning of children diagnosed with PIT, ADHD studies examining executive functioning should be looking at both those diagnosed with the combined type of ADHD, as well as those diagnosed with the PIT of ADHD to further evaluate any differences between the two groups. To date, no studies have been found that examined executive functioning differences between ADHD combined and predominantly inattentive types. 5

13 Treatment for working memory deficits in ADHD Working memory training has been found to lead to increased activation in prefrontal and parietal activity in the brain when engaging in both tasks trained over time and novel untrained tasks of working memory in normal healthy adults (Olesen et al., 2004). These changes in brain activation following training display the plasticity of working memory, once thought to be fixed, and the potential gains of working memory training for those subgroups with executive functioning deficits. Klingberg et al (2002) used a variation on a working memory training activity to evaluate the necessary components needed to create benefits from WM training. Specifically, a computerized training program both with and without an algorithm, a mechanism used in the training program that allowed the training program to change in difficulty as the trainee either answered questions correctly or incorrectly, allowing for the trainee to work at their maximum working memory ability throughout the training. Klingberg et al. (2002) examined if benefits from working memory training were found due to practiced attention or due to the program equipped with an algorithm. Fourteen children and adolescents between the ages of 7 and 15 with a diagnosis of either subtype of ADHD, made by a referring physician, were assigned to either receive a computerized WM training program equipped with an algorithm allowing the participant to work at their maximum WM ability or a computerized WM training program that did not have an algorithm but instead used a set number of trials in each activity. Using measures similar to those used in the WM training, such as visuo-spatial WM tasks and span board, as well as the Stroop task, Raven s colored progressive matrices, a choice reaction time task, 6

14 and a measure of head movements, (a measure described as being associated with a hyperactivity,) the authors found significant changes following WM training when using the algorithm. Specifically, Klingberg et al., (2000) found significant treatment effects for the practiced visuo-spatial WM and Span board tasks, as well as on Raven s colored progressive matrices, and the Stroop task. They also found a significant decrease in the number of head movements following training for the experimental group. This study found that WM training equipped with an algorithm can result in treatment effects on measures of WM. Further research on the efficacy of WM training investigating treatment effects for children with ADHD found similar results at post treatment (Klingberg et al., 2005). Fifty-three children diagnosed with ADHD, either combined or predominantly inattentive type by a referring physician, between the ages of 7 and 12 with access to a computer either at school or at home were included in a preliminary study. Measures used in the Kingberg., (2000) study were also used in the study including Span board, Digit-Span, the Stroop task, and Raven s colored progressive matrices, as well as an infrared camera to measure number of head movements to measure motor activity. Klingberg et al. also included Conners parent and teacher report forms, and the DSM-IV criteria for ADHD to measure ADHD symptoms as supplementary outcome measures. Using a double-blind procedure. children were assigned to either the WM training program with or without the algorithm for the duration of the training. Similar to previous findings, Klingberg et al. found significant changes at post treatment for all measures (the Stroop task, digit span, Raven s colored progressive matrices and Span board) of executive functioning that appeared to persist at a 3 month follow-up. Parent s also rated significant changes on the 7

15 measures of inattention, and hyperactivity/impulsivity but no significant findings were found for teachers. One potential limitation to this study may have been their exclusion of children being treated with stimulant medication, or meeting criteria for Oppositional Defiant Disorder, both of which are common for children diagnosed with ADHD (Barkley, 2001). In an attempt to look at other populations with potential WM and other executive functioning difficulties, Westerberg et al., (2007) investigated the efficacy of WM training in a pilot study of adults following diagnosis and treatment of a stroke. Strokes have been found to often lead to deficits in working memory and attention, similar to those deficits found in children with Predominantly Inattentive type of ADHD. Participants for this study were 18 men and women that were randomly assigned to either receive the WM training as treatment or to serve as a control and receive no treatment at all. Using similar neuropsychological measures as Klingberg et al., 2005, as well as the Cognitive Functioning Questionnaire (CFQ), a self rating scale of cognitive failures in daily life, Westerberg et al. found a variety of significant changes over time. Specifically, they found that WM training led to significant improvements in both WM and attention following stroke on cognitive tasks, as well as on the CFQ. Holmes, Gathercole, Place, Dunning, Hilton, & Elliott (2009) investigated possible gains in working memory for 25 children, ages 8-11, with ADHD combined type following either working memory training or stimulant medication. Using untrained WM tasks, Holmes et al. found that while stimulant medication lead to improvements in the area of visuo-spatial WM, training led to gains in all components of WM that were assessed. By comparing WM gains following both computerized training and stimulant 8

16 medication, this study adds evidence to the literature for the efficacy of WM training as an adjunct treatment for children and adolescents with ADHD. Beck, Hanson, Puffenberger, Benninger, and Benninger (2010) evaluated the efficacy of WM training for a U.S. population of 52 children and adolescents ages 7-17 with a diagnosis of ADHD. Using both parent and teacher reported paper and pencil measures of working memory, executive functioning, and ADHD symptoms, significant results were found for parent report on a number of subscales both post-treatment and at 4-month follow up. Specifically, Beck et al. found that at post-treatment, parents rated their children and adolescents lower, that is displaying fewer symptoms or fewer difficulties, on scales of inattention, initiation, planning/organization, and working memory. Parent s also reported an overall decrease in the number of inattentive ADHD symptoms displayed by their child or adolescent following treatment. At 4 month followup, these results appeared to be maintained and showed continued improvement from post-treatment to 4 month follow-up on the parent rated scale of WM. Teacher reports appeared to approach significance both at post treatment and at 4 month follow up but did not reach statistical significance. The Present Study The present study assesses differences in the efficacy of working memory training for children and adolescents with ADHD based on their subtype. Specifically this study aims to determine if working memory training is efficacious for both subtypes of ADHD when examined separately. We employed an intensive working memory training task to children and adolescents diagnosed with either ADHD Combined type or ADHD 9

17 Inattentive type using two different diagnostic criteria. The present study used parent and teacher ratings of ADHD symptoms and executive functioning as outcome measures. We hypothesized that based on the symptoms associated with the Predominantly Inattentive type of ADHD that children and adolescents with this type may be better treatment responders then those with the combined type. Since the current study used the data set from the Beck et al. (2010) study that found WM training to lead to improved scores on the BRIEF scales of WM, Initiate, and Plan/Organize as well as on the Conners scale of Inattention, we hypothesized that we would find similar results for these scales for the Inattentive subtype group. 10

18 Chapter 2: Methods Participants Participants were 51 predominantly Caucasian (96%) children and adolescents between the ages of 7 and 17 (mean=12.17, SD=2.68, 16 females). While all participants met DSM-IV criteria for ADHD, the majority (n=36), 71%, met criteria for ADHD- Predominantly Inattentive type, while the remaining (n=15) 29% met criteria for ADHD- Combined type. Children with co-occurring diagnosis were also eligible for the study, including 46% with either ODD or CD, 39% with anxiety disorders, and 8% with mood disorders. Twenty-nine percent of the participants met diagnostic criteria for one comorbid diagnosis, 17 % with two, and 17% with three or more co-morbid diagnoses. According to parent report, 61% of participants were concurrently taking stimulant medication. Procedures Participants were recruited from a private school in a large Midwestern City. The private school specialized in teaching children and adolescents with learning and other health disabilities, including ADHD, who had a history of poor performance in customary school settings. School officials were asked to send home flyers to parents with 11

19 information about the current study, as well as an invitation to attend an informational meeting about the working memory training. Parents that attended the meeting were educated about the connection between ADHD and working memory, as well as the possibility for their child to participate in the current study investigating working memory training. The working memory training protocol, as well as expectations for participation in the study was explained to parents. If parents were interested in having their child participate, they then completed consent forms for both themselves and their child to participate, and they also completed prescreening measures. The prescreening measures used for inclusion in the study included the working memory subscale of the Behavior Rating Inventory of Executive Function (BRIEF) Parent Form (Gioia et al., 2000) and a checklist of inattentive symptoms from the DSM-IV Inattentive symptoms for ADHD (4th ed; DSM-IV; American Psychiatric Association, 1994). To be included in the study, parent prescreening measures were required to have a T-score greater than 64 on the BRIEF Working Memory scale or endorse 6 or more inattentive symptoms. Sixty parents filled out the prescreening measures following the initial meeting, all 60 parents reported that their child met the eligibility requirements necessary to be included in the study and were asked to participate. All parents were then asked to complete a phone administered structured clinical interview for psychological diagnosis with a member of the research team before active participation in the study could begin. Following the interview, 52 children met DSM-IV (1994) diagnostic criteria for ADHD and were included in this study. Researchers then went to the school and completed assent forms with all children and adolescents whose parents completed pre-screening and consent forms. 12

20 If participants met the criteria to participate in the study and completed both parental consent, as well as participant assent, they were then assigned to either the experimental or the waitlist control group. The 52 participants that met eligibility criteria were alphabetized by last name and assigned every other participant to the experimental group. The remaining participants were assigned to the waitlist control group. The waitlist control group completed the working memory training intervention one month following the experimental group s completion of their training. Following the assignment to treatment group, one parent of each participant completed outcome measures including items from the DSM-IV-TR inattention scale (American Psychiatric Association, 2000), the BRIEF Parent Form, and the Conners' Parent Rating Scale-Revised: Short Form (CPRS-R:S) (Connors, Sitarenios, Parker, & Epstein, 1998b). Parents were asked to complete these measures before treatment began, 1 month after, and 4 months after their child received the intervention. Teachers of participants were also asked to fill out the Conners Teacher Rating Scale-Revised: Short Form (CTRS-R:S) (Connors, Sitarenios, Parker, & Epstein, 1998a ) and the BRIEF Teacher Form before treatment and 1 month after the intervention. Teachers of participants in the experimental group were asked to fill out measures 4 months following treatment, however, teachers of participants in the waitlist control group were not asked to fill out measures 4 months following their treatment due to summer break and a change in teachers for each participant. Research staff that had been trained in monitoring and administering the working memory intervention trained the parents of the participants actively receiving the treatment on how to use the program. Parents were also trained on how their children 13

21 should be supervised during their training, ways to encourage their child to continue training, and finally how to implement and adjust a reward system tailored for their child. While actively receiving treatment, participants and their parents were given weekly minute phone calls by trained research staff coaches. While the experimental group was actively receiving treatment, the control group did not receive anything until the experimental group completed training. For data analysis, groups were then split by ADHD diagnostic criteria into two groups, ADHD-Combined type or ADHD- Predominantly Inattentive type (DSM-IV- TR). The groups were split using two separate procedures, first they were split using the DSM-IV diagnostic criteria that was obtained by the P-ChIPS interview. Using the DSM- IV criteria the groups were comprised of 15 participants meeting criteria for ADHD-C and 36 participants meeting criteria for ADHD-PIT. The second procedure used for differentiating groups is based on a more stringent criteria designed to eliminate overlap between the two populations by using scales from the parent version of the Conners Rating Scale-Revised, Short Form (Nigg personal communication, 2009). The groups were split with the criteria of having a T-score < 50 on the Hyperactive scale and T-score > 65 on the Inattention to be classified as purely inattentive, and a T-score >65 on the Inattention scale as well as T-score >65 on the Hyperactivity scale to be classified as combined. The criteria for classification using the Conners scores are based on the individual scaled scores rated by parents at pre-treatment which were then compared to norms of appropriate age and gender to create standard scores, T-scores. T-scores are based on a mean of 50 and a standard deviation of 10 with standard practice being that a T-score of one and a half standard deviations above the mean (T=65) as a cut off for 14

22 detecting clinical symptoms of ADHD (Sleaton & Von Neumann, 1974; Sprague, Cohen, & Werry, 1974; Trites, Dugas, Lynch, & Ferguson, 1979). Since T-scores of 50 are average, T-scores less than 50 on the Hyperactivity scale were used as criteria for inclusion in the purely inattentive group to avoid any sub-threshold levels of hyperactivity symptoms, and are by definition below average for children and adolescents without ADHD. The Conners manual classification groups were comprised of sixteen participants meeting criteria for Combined type and only six participants meeting criteria for the Purely Inattentive. Due to these small sample sizes, especially for the purely inattentive type, it was inappropriate to further evaluate these groups. Working Memory Training The working memory training program used in the current study was a computer based training program, Cogmed Working Memory Training (Cogmed America, Inc., 2007). The computer program was completed in the home of the participant under the supervision of one parent. The working memory training consists of 25 daily sessions that were to be done 5 days a week for 5 weeks, with most participants completing training in about 6 weeks. Each session averaged minutes in length and consisted of fifteen trials on eight of twelve working memory exercises. Previous studies examining the length of training have found that a minimum of 30 minutes of active training is necessary to reach maximum efficacy of training. If participants took less than 30 minutes during their daily training, research staff were able to adjust any participants training in order to increase the number trials per exercise in order to meet a minimum of 30 minutes of active training. The training program is equipped with an algorithm that 15

23 increased or decreased the difficulty of each individual exercise according to the participant s performance on each exercise individually. The algorithm allowed for each participant to work at their own individual working memory capacity. Each participant s progress was monitored through an online viewing capability allowed by the WM training software weekly by a trained member of the research staff to ensure each participant was working at their maximum capability, and to later offer tips over the phone to parents to help their child complete training. Weekly minute phone calls made to parents and participants were designed to offer parent s suggestions for helping their child get through their daily training, which often included altering the order of exercises the child completed and offering positive reinforcement to the participant for continuing their training. While actively participating in the training, participants were given individual rewards from their parents for completing daily training. Rewards varied by participant and were decided upon by the participant and their parent before the training began. Parents gave rewards ranging from desert choice following dinner to small monetary rewards for each session completed to larger rewards at the end of each week of training. The only incentive given to families for completing the training was the software provided for training, which is valued at $1500 for 25 training sessions. Measures Structured Clinical Interview The structured clinical interview used in the current study was a phone administered P-ChIPS to determine each participant s diagnoses on 20 Axis I disorders as well as psychosocial stressors (Weller, Weller, Rooney, & Fristad, 1999). The P-ChIPS is 16

24 based on the criteria from the DSM-IV and has been found to have a moderate correlation with the child version of the measure (Fristad, Teare, Weller, Weller, & Salmon, 1998). The child version or the ChIPS asks the same symptom-based questions as the adult version but the wording is altered to fit the appropriate reporter (i.e. Are there times when you is changed to Are there times when your child ) and has been shown to be both a reliable and valid diagnostic tool for children and adolescents ages 6-18 years (Fristad, Glickman, Verducci, Teare, Weller, & Weller, 1998; Fristad, Cummins, Verducci, Teare, Weller, & Weller, 1998; Teare, Fristad, Weller, Weller, & Salmon, 1998a, 1998b). Average sensitivity and specificity of the P-ChIPS has been found to be 87% and 76% (Fristad, Teare, et al., 1998), and for ADHD diagnosis in particular, the sensitivity was found to be 100% and specificity 44%. Correlations with clinician diagnosis have been found to be 76% for ADHD (Fristad, Teare, et al., 1998). Measures of ADHD Symptoms Measures of ADHD symptoms were found using parent and teacher report and not self-report in the current study due to the findings of Garcia, Hinshaw, & Zupan (1996) and Pelham et al (2002) which suggest that children with a diagnosis of ADHD are inaccurate reporters of their symptoms. Both parent and teacher versions of the Conners Rating Scale-Revised, Short Form, (CPRS-R: S) were used in the current study. Both versions of the Conners are made up of four subscales: Oppositional, Cognitive Problems/Inattention, Hyperactivity, and an ADHD index. The Connors scales have been found to have good internal consistency, with Cronbach s alpha ranging from The test-retest reliability over a period ranging from 6-8 weeks was.62 for 17

25 Oppositional,.73 for Cognitive Problems/Inattention, 0.85 for Hyperactivity, and.72 for the ADHD Index for a sample of 49 children and adolescents with a mean age of (Conners, 2000). However, correlations between the parent and the teacher version of the Conners rating scales have been found to be low, ranging from for males and.18 to.52 for females (Conners, 2000). Parents were also given a list of DSM-IV symptoms for ADHD that they were asked to endorse for their child. Measures of Executive Functioning The parent and teacher forms of the Behavior Rating Inventory of Executive Function (BRIEF, Gioia, Isquith, Guy, & Kenworth, 2000a) were used as a measure of executive functioning. The BRIEF is an 86 item questionnaire for either a parent or a teacher; the BRIEF asks reporters to rate whether the child or adolescent never, sometimes, or often displays behaviors related to executive functioning. The BRIEF is designed to measure executive functioning in children and adolescents from 5-18 years of age. In its entirety, The BRIEF is made up of eight subscales; Emotional Control, Inhibit, Initiate, Monitor, Organization of Materials, Plan/Organize, Shift, and Working Memory. For this study, Monitor, Organization of Materials, Plan/Organize, and Working Memory were the only subscales used. These scores can also be used to comprise an index score which combine various subscales into one scale. The subscales of Initiate, Working Memory, Plan/Organize, Organization of Materials, and Monitor are combined to make up the Metacognition Index which will also be used in this study. The BRIEF has shown high internal consistency, with Cronbach s alpha between.80 and.98 and test-retest reliability ranging from over a two-week period (Gioia, Isquith, Guy, & 18

26 Kenworth, 2000b). Convergent validity has been established with other measures of inattention, impulsivity, and learning skills in clinical ADHD populations (Gioia, et al., 2000b). Data Analysis Preliminary analysis were conducted to determine if the ADHD Primarily Inattentive group and the ADHD Combined type group differed at pre-treatment on any of the baseline measures, as well as on other demographic variables such as age, gender, and number of diagnosis (see Table 1). The first set of analysis were a series of 2 x 2 repeated measures ANOVA with condition (experimental vs. wait-list control group) as a between subjects factor and time (pre treatment vs. post treatment) as a within subjects factor be for each subtype population of ADHD using both classifications described previously. Initial analyses looked specifically at the outcome measures of Initiate, WM, and Plan/Organize from the BRIEF and the Inattention scale from the CPRS-R: S. The remaining outcome measures from the BRIEF and Conners were evaluated on an exploratory basis. Groups were looked at as separate populations due to the discrepancies in sample size for each classification. For example, in the DSM diagnostic classification there were more than two times as many participants meeting criteria for Inattentive type (N=36) than the Combined type (N=15) making it inappropriate to compare the two samples in analysis. Analyses were also completed in this manner in an effort to treat each subtype as a distinct population. Next, we conducted regression analysis on change scores from pre-treatment to post-treatment, post-treatment to 4 month follow-up, and pre-treatment to 4 month follow 19

27 up. Regression analysis were conducted for all treatment completers to determine if outcomes were predicted by inattention, hyperactivity/impulsivity, opposition, or the interaction between inattention and hyperactivity/impulsivity (as measured by the Conner s scale at pre-treatment). Effect sizes (Cohen s d) for the baseline to post treatment, baseline to follow up, and post treatment to follow-up changes were analyzed using the following formula to calculate the effect sizes: d = change in experimental group change in control group pooled baseline standard deviation Four month follow-up analyses were also conducted for both parents and teachers using changes between baseline and follow-up data, as well as changes from posttreatment to follow-up for outcome measures using t-tests. Follow-up analysis were conducted after combining treatment groups (experimental and waitlist control) for parent data as the waitlist control group began treatment before 4 month follow data was collected for the experimental group leaving a lack of control data to compare results. The teacher 4 month follow up data were reported for the experimental group only as we were not able to collect the waitlist control group 4 month follow up data following summer break and a change in teachers. Follow-up analysis compared changes both from pre-treatment to 4 month follow-up, as well as from post-treatment to 4 month follow-up to determine if additional treatment gains were being made following treatment. Exploratory analysis completed on the data set also included 2x2 repeated measures ANOVA for all treatment completers with condition (Primarily Inattentive type vs. Combined type ) as a between subjects factor and time (pre treatment vs. post treatment) as a within subjects factor using diagnostic criteria for all outcome measures. 20

28 Chapter 3: Results Preliminary Analysis Multiple Comparisons Since the preliminary hypothesis based on the literature were that WM training would lead to improvements on the BRIEF scales of WM, Initiate, and Plan/Organize as well as on the Conners Inattention scale all other exploratory analyses had an adjusted p- value. Due to the exploratory nature of these additional analyses we used a family wise alpha level of.10 to calculate the significance level for each test. The exploratory analyses consisted of 6 subscales from the BRIEF parent and teacher forms (excluding the WM, Initiate, and Plan/Organize subscale) and 6 subscales from the parent and teacher Conners rating scales (excluding the Cognitive Problems/Inattention Subscale). The Sidak-Bonferroni correction with α FW being the familywise error rate and c being the number of comparisons is (Keppel & Wickens, 2004): α = 1 (1 - α FW)1/c Having 6 comparisons for the BRIEF scales as well as the Conners scales and a familywise alpha of.10, the alpha level is.017 for both scales. Since much of the analyses are exploratory, as well as the small N, all analyses that are less then.05 will be described further in the text. Analysis Comparing Experimental and Waiting-list Control group at Post-Treatment by ADHD Subtype 21

29 For these analyses 51 participant s data were analyzed as one child from the control group did not return their post-treatment measures and were excluded from the pre to post-treatment analyses. All participants in the Experimental group completed the WM training and returned post-treatment measures. All outcome measure changes from baseline to post-treatment were analyzed for each ADHD subtype classification described earlier (i.e., those meeting DSM diagnostic criteria for either ADHD Primarily Inattentive type or Combined type.). In an attempt to give the reader greater ease in reading the results, the data analyses for the DSM Inattentive groups will be presented before the DSM Combined groups. Parent Ratings DSM Diagnostic Criteria Analyses As hypothesized, the repeated measures ANOVA displayed a significant interaction between time (pre and post-treatment) and group (Experimental and Waiting list Control) for the parent rated BRIEF subscales of Initiate F(1,34)= 9.546, p=.004, d=.94, and Plan Organize F(1,34)=6.164, p=.018, d=1.09 for the ADHD Inattentive type group. Specifically, at post treatment those in the experimental group were rated lower (experiencing fewer difficulties). The WM scale of the BRIEF which was hypothesized to show a change at post only approached significance with p=.074, d=77, and the Inattention scale from the Conners also failed to show significant change at post treatment. However, the non hypothesized scales of the BRIEF MetaCognitive scale and the DSM Inattentive scale also had a p value less than.05 at post treatment 22

30 F(1,34)=4.285, p=.046, d=.85 and F(1,34)= 5.396, p=.026, d=1.58 for the ADHD Inattentive type. Also as hypothesized, the ADHD Combined type group did not have any significant interactions on the scales of initiate, plan/organize, working memory, or the inattention scale from the Conners. However, the Conner s scale of hyperactivity was less than.05 at post F(1,13)=5.55, p=.035, d=.83 with the experimental group displaying less hyperactive symptoms post treatment that then control group. No other significant interactions were found (see Table 2). Teacher Ratings DSM Diagnostic Criteria Analyses At post treatment teachers reported a significant interaction between time (pre to post) and group (control vs experimental) on the BRIEF subscale of Initiate for the DSM- IV Inattentive subtype. On the Initiate scale teachers reported the experimental group as displaying less difficulty with initiation at post compared to the control group F(1,34)=4.428, p=.04 d=.48. No other significant interactions were found for teachers for either the inattentive or combined subtypes of ADHD. (See Table 3). Changes at 4 month follow-up by ADHD Subtype for all treatment completers Of the 51 participants with an ADHD diagnosis that were included in the initial analyses, 49 completed the WM training either as the experimental group or as the waiting list control group. Those that completed treatment were then asked to complete 4 month follow-up measures, at this time 31 (63%) of participants returned follow-up 23

31 measures. Of the 31 participants whom returned measures, 28 were classified as the DSM Inattentive subtype and only 3 were participants classified as the DSM Combined subtype. For all follow- up analyses the control group and experimental group were combined to make one group as the wait list control group had completed training at the time of data collection for the experimental group and were no longer able to serve as a comparison group for data analyses. Follow-up analysis for teachers reports include only reports for the experimental group as the control group completed treatment at the end of the school year and subsequently had new teachers at the time of follow-up data collection (N=16 for the DSM Inattentive group and N=7 for the DSM Combined group). Parent Post to Follow-up DSM Diagnostic Criteria Analyses A significant decrease in T-score from post treatment to follow-up was found on the MetaCognitive index, t (28) = 2.10, p <.05, d = 0.28, for the DSM Inattentive group. There were no significant decreases in T-score from post treatment to follow-up for the DSM Combined subtype on either the BRIEF or Conners scales (see Table 4). Teacher Post to Follow-up DSM Diagnostic Criteria Analyses There were no significant differences from post to follow-up on any of the subscales of either the BRIEF or the Conners measures for either of the DSM subtypes (see Table 5). 24

32 Parent Pre to Follow-up DSM Diagnostic Criteria Analyses Significant decreases in T-scores from pre treatment to follow-up were found for all subscales of the Parent BRIEF for the DSM Inattentive group. Effect sizes ranged from 0.46 to 0.91 (see Table 9). Improvement from pre treatment to follow-up were also found to be significant for all subscales of the Conners scales, except the Oppositional scale, with effect sizes ranging from 0.65 to There were also significant decreases from pre to follow-up for the BRIEF Parent scales of the MetaCognitive Index, (d=.34) and WM (d=.74) for the DSM Combined group. No other significant findings were found for this group (see Table 6). Teacher Pre-Follow-up DSM Diagnostic Criteria Analyses A significant difference from pre treatment to follow-up was reported by teachers for the DSM Inattentive group on the Conners subscale of Hyperactivity, t(10)=2.23, p<.05, d=.49). No other significant changes from pre to follow-up were reported by teachers for either DSM group (see Table 7). Exploratory Analyses Regression Analyses for all treatment completers by parent report Regression analyses were completed for all treatment completers to determine if inattentive, hyperactive, or oppositional symptoms at pre treatment were related to change scores in outcomes from pre to post treatment, post to follow-up treatment, or pre to follow-up treatment. Regression analysis was also completed using an interaction 25

33 variable between inattentive and hyperactivity symptoms, but this interaction term did not significantly relate to change scores and was subsequently removed from analyses. Regression analyses were completed for both parent and teacher reported outcome measures. Parent Reported Pre to post treatment by diagnostic criteria DSM Diagnostic Criteria Analyses For the DSM Inattentive group a significant relationship between Inattention at pre and the change score from pre to post on the Conners subscale of ADHD symptoms was found, in that higher levels of inattention at pre negatively predicted a change in ADHD symptoms at post treatment, = -.364, t(30) = , p <.05. No other significant relationships were found for this group (see Table 8). For the DSM Combined group there were several significant relationships found for a variety of subscales. On the BRIEF MetaCognitive scale, hyperactivity negatively predicted strength of change score from pre to post treatment in that higher reported levels of hyperactivity at pre were associated with smaller reported change after treatment, = -.798, t(9) = , p <.05. On the BRIEF Initiate scale, inattention positively predicted change while hyperactivity and oppositional negatively predicted change, =.855, t(10) = 2.597, p <.05; = -.956, t(10) = , p <.01; and = -.564, t(10) = , p <.05 respectively. And lastly, on the BRIEF WM subscale inattention was also positively related to change while hyperactivity and oppositional were negatively related to change =.922, t(10) = 2.849, p <.05; = -.936, t(10) = , p 26

34 <.01; and = -.606, t(10) = , p <.05 respectively. No other significant relationships were found for this group (see Table 8). Post to follow-up treatment by diagnostic criteria DSM Diagnostic Criteria Analyses Analysis completed from post to follow up for the DSM Inattentive group revealed a positive predictive change for the subscale of Hyperactivity as it relates to opposition at pre, =.530, t(24) = 2.745, p <.01. No other significant relationships were found for this group (see Table 9). Due to a very small N of 3 for the DSM Combined group at follow up, regression was not possible to complete for this group. Pre to Follow-up treatment by diagnostic criteria DSM Diagnostic Criteria Analyses From pre treatment to follow up the DSM Inattentive group there were several significant relationships found on the BRIEF subscales of MetaCognitive Index, WM, and Planning/Organization as well as on the Conners subscales of ADHD, Hyperactivity, and Inattention. On the BRIEF MetaCognitive scale inattention positively predicted change from pre treatment to follow up while opposition negatively predicted change, =.421, t(24) = 2.477, p <.05; and = -.370, t(24) = , p <.05. On the BRIEF WM scale opposition at pre treatment negatively predicted change at follow-up = -.497, t(24) = , p <.01. On the BRIEF Plan/Organize subscale inattention positively predicted change from pre treatment to follow-up =.370, t(24) = 2.059, p= 27

35 .05. On the Conners ADHD subscale inattention positively predicted change =.395, t(24) = 2.276, p <.05. On the Conners Hyperactivity subscale hyperactivity positively predicted change =.815, t(24) = 5.816, p <.01. On the Conners Inattention subscale inattention positively predicted change and opposition negatively predicted change =.481, t(24) = 2.895, p <.01 and = -.354, t(24) = , p <.05. No other significant relationships were found for this group (see Table 10). Due to a very small sample size the DSM Combined group at follow up, regression was not possible to complete for this group. Teacher Reported Pre to post treatment by diagnostic criteria DSM Diagnostic Criteria Analyses For the DSM Inattentive group there were several significant relationships between Inattention, Hyperactivity and Opposition at pre and the change score from pre to post on the Conners subscales and on the BRIEF. Specifically, Opposition was positively related to the BRIEF scales of Initiate, and the MetaCognitive Index as well as the Conners scale of Opposition. Positive relationships found for the teacher rated scores, or higher levels of Opposition, Hyperactivity, or Inattention were related to greater change scores at post were also found on the Conners scales of ASHD and Hyperactivity as they related to Hyperactivity rating at pre. Lastly Inattention at pre was also positively related to change in Conners Inattention scale at post. No other significant relationships were found for this group (see Table 11). 28