Why Working Memory Matters & How Cogmed Improves it. Charles Shinaver, PhD Cogmed Consultant

Transcription

1 Why Working Memory Matters & How Cogmed Improves it. Charles Shinaver, PhD Cogmed Consultant

2 Agenda The Role of Working Memory in Speech Language Impairment. Working Memory s Affect on Academic Achievement. What is Cogmed Working Memory Training TM? A Brief Review of the Program and Research Highlights. Demonstration of Cogmed RM.

3 What is Working Memory? A system for temporary storage and manipulation of information, necessary for a wide range of cognitive tasks To keep information in your mind for a short period of time (seconds) & use in your thinking Processes all stimuli we encounter: Updating. Delegates to different parts of our brain to take action: Shifting. Inhibition: Allows us to block out unnecessary information Keeps us updated on what s happening & focused on what matters

4 Do you have any room left on your desk? Working Memory: The Mental Workspace working memory as a mental workspace in which products of ongoing processes can be stored and integrated during complex and demanding activities (Just & Carpenter, 1992).

5 Working Memory vs. Short-Term Memory Working Memory: (Dehn, 2008) WM actively and consciously processes information and stores it. WM capacity is less domain specific. WM retains products of various cognitive processes WM consciously directs retrieval of desired info from long term memory. STM can hold more items than you can process in WM WM & STM operate independently of one another Yet WM has some executive functions: inhibiting, shifting, updating WM operations rely heavily upon long term memory structures. WM has a stronger relationship with academic learning and with higher level cognitive functions.

6 Working Memory Operations (Dehn, 2008) Manipulation or recombination of memory items Encoding info into long term memory (LTM) Associating new info with existing long term items Transforming info Completing multiple-step computations Conducting conscious search for info in LTM Creating new memory representations Chunking related items into groups or categories

7 Neuropsychological Evidence of WM Research supports the following neuroanatomy of working memory:

8 Phonological Loop Stores and rehearses speech-based information and is necessary for the acquisition of native and secondlanguage vocabulary. Has the most research support. Loop=length of loop x speech rate. (Hulme &Mackenzie) normal phonological loop is 2 seconds. (Dehm, 2008). 1. Short-term phonological store: auditory memory traces subject to rapid decay: inner ear remembering speech sounds in their temporal order. 2. Articulatory rehearsal component sometimes called the articulatory loop. Acts as the inner voice and repeats the series of words on a loop to prevent them from decaying.

9 Working Memory and Specific Language Impairment. (Montgomery, et al., 2010) Children with specific language impairment (SLI) demonstrate significant impairments despite normal range hearing and nonverbal IQ. Many of these children also show marked deficits in working memory (WM) abilities. Over the past decade, the range of WM problems exhibited by children with SLI has broadened, and the evidence implicating an association between the WM and language difficulties in children with SLI has grown. CI users fall below age norms on auditory working memory (Pisoni & Cleary, 2003; Pisoni et al., 2008), visual memory spans and some visual sequencing skills (Cleary, et al., 2001; Conway et al., 2009; Pisoni & Cleary, 2004)

10 WM and Spoken Language Development (Montgomery, et al, 2010) Word Learning involves mapping sound to meaning. Using a variety of methods, robust associations between pstm and new word learning have been reported for preschool-age children through about age 8. The ability to hold novel speech material in pstm presumably permits children to establish stable, long-term phonological representations of new words in long-term memory. pstm may serve as the mediating or moderating mechanism for the process in which children initially learn whole phrases while later they learn underlying rules, categories, structures, etc. Adams and Gathercole (1995) reported that pstm predicts quantity and quality of spontaneous speech in 3-year-old children.

11 WM and Complex Sentence Comprehension (Montgomery, et al, 2010) WM has been linked to the comprehension of object relative clause forms in young children. Children with greater WM capacity show more accurate comprehension than lowcapacity children. Being able to reactivate a stored element and then integrate it into a developing local structure in a timely manner are other WMrelated skills underlying complex sentence comprehension. Montgomery, Magimairaj, and O Malley (2008) studied 6 to 12- year-old children s spoken comprehension of verbal be passives was associated with WM capacity and processing speed. At a more global level, children s comprehension of narrative is predicted by WM capacity and processing speed.

12 Sustained Auditory Attention & Sentence Comprehension (Montgomery, et al, 2010) SLI: 1. Poorer sustained attention, sentence processing & sentence comprehension. 2. Correlation between attention and comprehension. 3. Interpretation: immediate processing and comprehension of simple grammar involves significant mental effort by children with SLI but not age peers, suggesting that simple grammar is not yet processed automatically by children with SLI. Arguably they don t develop automaticity. Note: Based upon 2 studies: Montgomery, et al., 2008, & 2009.

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14 WM > Processing Speed in Standardized Language Performance (Montgomery, et al, 2010) Data shows the relative importance of STM over processing speed (Bayliss et al., 2005; Magimairaj et al., 2009). Leonard et al. (2007) samples of SLI and age-matched peers that significantly more variance in language was accounted for by WM capacity than processing speed, suggesting that WM plays a predominant role in children s standardized language functioning. Montgomery & Windsor (2007) found that pstm accounted for more variance than processing speed in both receptive and expressive scores in SLI children than control. For control neither pstm nor processing speed accounted for any unique variance suggesting that language measures fell within the limits of these children s pstm and processing speed.

15 Working Memory Predicts Achievement

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17 WM Predicts Language Comprehension Problems. Meta-analysis (Daneman & Merikle, 1996) 77 studies, with 6,179 Ss. Measures that tap the combined processing and storage capacity of working memory (e.g., reading span, listening span) are better predictors of comprehension than are measures that tap only the storage capacity (e.g., word span, digit span). Superior predictive power of the process plus storage measures is not limited to measures that involve the manipulation of words and sentences.

18 WM & difficult to reach kids. Low-income children: WM predicted in Pre-K predicted academic readiness in math and reading in kindergarten. Bilingual children at risk for reading disabilities: WM in both languages predicted Growth in literacy from ages 5 to 10. LD, children with learning difficulties : WM and processing speed predict these difficulties. Hearing-impaired: WM correlated with Reading achievement Intellectually disabled children: WM correlated with variance in reading and spelling.

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20 Why is working memory important from a student s point of view? Working memory is used for: Controlling attention Resisting distraction Organization Complex thinking Problem solving Remembering tasks

21 Why Working Memory is salient to Speech-Language Pathologists? 1 in 10 children have a WM impairment (Alloway) Of those in bottom 10% of WM over 80% have substantial problems in either reading or math or most commonly, in both (Gathercole & Alloway, 2008) Robust evidence indicates that WM supports the acquisition of complex academic skills and knowledge across a variety of languagebased literacy areas (Montgomery, et al., 2010) A separate literature shows that students with WM deficits exhibit various learning disabilities. (Montgomery et al., 2010). Individual differences in WM account for variation in academic achievement. (Montgomery, et al., 2010). Pisoni et al. (in press) found verbal WM in early childhood strongly predicted spoken word recognition, sentence repetition, vocabulary, reading, and nonword repetition, in children with CI s 8 years later.

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23 Core Training Paradigm: (Morrison & Chein, 2010) Core Training: Involve repetition of demanding WM tasks that are designed to target domain-general WM mechanisms. Core training designed to: 1)Limit the use of domain-specific strategies 2)Minimize automization 3) Tasks span multiple modalities 4) Require maintenance in the face of interference 5) Enforce rapid WM encoding and retrieval demands 6)Adapt to participants varying level of proficiency 7) Demand high cognitive workloads or high intensity cognitive engagement (though different studies place variable emphasis on these factors).

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26 1. Scientific designed by leading neuroscientists 2. Adaptive in real time 3. Intensive hard work 4. Sustained 25 sessions 5. Supported your coach will be there 6. Targeted wm only What is Cogmed? Software + Coaching

27 Adaptive vs. non-adaptive Cogmed training Rationale: Repeated recital of WM trials when difficulty level is not adapted typically leads to faster reaction times but not an increase in WM capacity - no generalization Non-adaptive training (placebo): items per span - same number of items per trial - not challenging WM capacity Adaptive training: - maintain multiple stimuli simultaneously - short delays while stimuli held in WM - unique sequencing order each trial - difficulty level adapts as function performance - correct trial: sub-level increase, more difficult span arrangement, more items per span -incorrect trial: almost right small decrease, not even close large decrease

28 Population Is Cogmed Evidence-based? 21 Peer-Reviewed Published studies & (* independent) (black font training done at a school) Normal Thorell et al., 2009 Nutley, et al., 2011 Klingberg et al., 2002 (exp. 2) Olesen et al., 2004, Westerberg & Klingberg, 2007 McNab et al., 2009 Brehmer et al.,2009 Bellander et al., 2011 Brehmer et al., 2011 ADHD/ low WM/ special needs Klingberg et al., 2002,2005 *Holmes et al., 2009, 2010 Mezzacappa et al., 2010 *Beck et al., 2010 *Dahlin, 2010 *Gibson, et al, 2011 Other: Deafness/ Low birth weight/ Acquired Brain injury/stroke *Kronenberger et al.,2010 *Lohaugen et al., 2010 *Lundqvist et al., 2010 Klingberg et al., 2007 Preschoolers Children/ Adolescents Adults Adults over 50

29 Research discovery: Working memory can be improved! Klingberg et al., 2002 Training of working memory in children with ADHD. Assessed: Trained visual spatial working memory. Non-trained working memory: Span Board. Selective Attention: Stroop Task. Non-verbal reasoning/general intelligence: Raven s matrices. Reaction Time: Choice Reaction time test. Inhibition/hyperactivity: Head movements. Experiment 1: n=7, 6 boys, 1 girl; between ages 7 and 15. Experiment 2: n=4 healthy adult males ages: 23,29,20, 22. Double blind, placebo controlled, randomized. Journal of clinical & Experimental Neuropsychology.

30 Summary Klingberg et al., 2002 Take home: Effects of Cogmed generalize to non-practiced tasks. Children with ADHD improve on neuropsychological evaluations after WM training. 1. The first published research on working memory training 2. Children with ADHD improved on neuropsychological tests (span board, Stroop test, Ravens progressive matrices) 3. Head movements reduced. 4. Samples of kids with ADHD (7) and healthy adults (4) 5. Limitations include the small sample size, the lack of behavioral measures, and no long-term follow-up Lg

31 Larger study confirms that Cogmed helps kids with ADHD Klingberg et al., 2005 Validation and expansion of the Klingberg et al., 2002 study, with multi-site format, 3- month follow up and rating scale data. Randomized, controlled, double-blind trial. n=53, ages 7-12, without Rx. Compliance (>20 training days) met by 44 subjects (22 tx, 22 control). Of those 42 evaluated at 3 months follow up. Journal of the American Academy of Child and Adolescent Psychiatry.

32 Results for Klingberg 2005 study. MAIN OUTCOME MEASURE: Span-board task ES=.93, follow up ES=.92 (99%) SECONDARY OUTCOME MEASURES: Digit span from WISC-III ES=.59, ES=.57 Stroop Interference task. ES=.34, ES=.35 Raven s Colored Progressive Matrices. ES=.45,.30 Motor activity: Infrared camera recording # of head movements in 15 minutes of performing a detection task. ADHD: DSM-IV 18 items were used as a rating scale. Conners Raging Scale for Parents & teachers.

33 1. Effects on parent ratings - blinded (Attention and Impulse control) Summary Klingberg et al., 2005 Take home: Replication and validation of Klingberg et al., Cogmed can improve WM capacity in children with ADHD. Included use of rating scales, 3 month follow up and no medication. 2. Effects on neuropsychological tests (span board, digit span, Raven s & Stroop faster and more accurate) 3. Improvement on complex problem solving. Ind

34 Children improve math, attention and following instructions after Cogmed Holmes, Gathercole, & Dunning, 2009 Skeptics and respected researchers connecting WM to Achievement scrutinize Cogmed and conclude: Adaptive training leads to sustained enhancement of poor working memory in children. =42 children, ages 8-11 screened for working memory deficits (at or below the 15 th percentile) were randomly assigned to high or low intensity training conditions. Assessments: Pre- and post-training Working memory (verbal STM, verbal WM, visuo-spatial STM and visuo-spatial WM (AWMA; Alloway, 2007) IQ (WASI; Wechsler, 1999) basic reading ( WORD; Wechsler, 1993) mathematical reasoning (WOND; Wechsler, 1996) following instructions (Gathercole et al., in press)

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36 Low WM Children improve attention and math up to six months after training Holmes et al., 2009 This study provides the first demonstration that these commonplace deficits and associated learning difficulties can be ameliorated, and possibly even overcome, by intensive adaptive training over a relatively short period: just 6 weeks, typically

37 From WM Deficit to Average Range WM (Holmes, 2009) Children with composite scores in excess of 95 (39 percentile) after training was calculated. Adaptive: 68%* Non-Adaptive: 25% Standard Score Gains at the end of training: 5 points Adaptive: 91%* Non-adaptive: 40% 10 points Adaptive: 77%* Non-adaptive: 15% 15 points Adaptive: 50%* Non-adaptive: 0% At 6 months follow only for the adaptive group: 5 points: 84% 10 points: 63% 15 points: 32%

38 Summary Holmes et al., 2009 Take home: Cogmed improves WM capacity, attention, following instructions and mathematics in school children with low WM. 1. Found academic improvements, shows the academic effect is not immediate, it emerges gradually (at 6 months in mathematics reasoning) 2. Following instructions was significantly improved at the end of training & at 6 months. 3. Training took place in school. Rx

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40 Impact of training and medication on WM of children with ADHD Holmes et al., 2010 Assessed 4 aspects of WM (verbal and visuo-spatial STM & verbal and visuo-spatial WM) in 25 children ages 8-11 years with clinical diagnosis of ADHD for 6 months or longer and receiving quick release stimulant medication (e.g. methylphenidate) T1 = Off medication, pre-training. 12 subtests of AWMA & IQ (WASI; Wechsler, 1999) T2 = On medication, pre-training. 8 WM tasks from AWMA & IQ T3 = On medication, post-training. 8 WM tasks from AWMA & IQ (WASI, 1999). T4 = On medication, 6 month follow-up. 4 WM tasks from AWMA & IQ

41 Slides courtesy of Dr. Joni Holmes

42 Summary Holmes et al., 2010 Take home: Children with ADHD show up to 6 months lasting effect of Cogmed WM training. Wider effect on executive functioning than stimulant medication alone. Significant gains in WM, no effect on IQ Rx intervention: Gains in visuo-spatial WM only reflects predominant influence of medication on right hemisphere structures associated with visuo-spatial WM (Bedard et al., 2004) Impact of medication on working memory deficits associated with poor academic progress may also be restricted in scope Behavioural intervention: Cogmed Significant gains in non-trained working memory tasks, which extended across all four aspects of working memory (low-average to average range) Pre-sch.

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44 Working Memory Training for Children with Cochlear Implants (Kronenberger, W., et al., 2011) Take home: Children significantly improved verbal and nonverbal WM, parent-reported WM, and Sentence repetition skills at program conclusion. Sentence repetition improvement maintained at 6 months. Pilot study. N=9 deaf children with cochlear implants (CIs). Ages Cogmed on a home computer over 5 weeks. Feasibility and acceptability were evaluated using parent report and measures of children s performance on training exercises. No problems with activities. The magnitude of improvement in WM decreased slightly at 1 month follow up and more substantially at 6- month follow up. However, marked improvement in sentence repetition was maintained at 6-month follow up. Conclusion: WM training may produce benefit for some memory and language skills for children with CI s, supporting the importance of conducting a large-scale randomized clinical trial with this population.

45 Working Memory Training for Children with Cochlear Implants (Kronenberger, W., et al., 2011) Feasibility and acceptance: Parents reported children had no difficulty hearing or understanding Cogmed exercises % reported it took significant effort especially during the final week. About half reported being satisfied with the program and would recommend it to others and believed it helped their child s attention and memory. Cogmed Performance: Improvement on all but one activity (Decoder). Working Memory Efficacy Measures: Digit Span Forward: post training & 1 month significantly higher Digit Span Backward: changes not significant Spatial Span Forward: post training Significantly higher Spatial Span Backward: post training significantly higher BRIEF WM ratings: Post training significantly higher Sentence Repetition: Post training & 6 months significantly higher

46 Cogmed most researched approach for improving working memory in school children (4 to 12). (Diamond & Lee, 2011) Cogmed improves working memory Cogmed has shown transfer to other executive functions but, this transfer is narrow Children with the poorest executive functions benefit most from training programs Executive function training has the potential to impact academic achievement in children Adaptive training is necessary because executive functions must be continually challenged in order to improve A key element to improving executive functions is the child s motivation that is; their willingness to devote time to the activity One benefit of computerized training over other approaches is that it can be done at home

47 Overview of Key Research Studies (I) Key learning Klingberg et al., 2002 Journal of Clinical and Experimental Neuropsychology Westerberg et al., 2004 Child Neuropsychology Olesen et al., 2004 Nature Neuroscience Klingberg et al., 2005 Journal of Am. Ac. of Child & Adolescent Psychiatry Westerberg & Klingberg, 2007 Physiology & Behavior Children with ADHD improve on neuropsychological tests (non-trained activities) after WM training. Working memory is a core deficit in ADHD. Increased activity in brain following Cogmed Working Memory Training (instead of less). Klingberg et al., 2002 data validated in larger, multi-site study adding three month follow-up and rating scale data from parents are significant Healthy adults show increased brain activity in pre-frontal cortex and improved WM capacity after Cogmed. Westerberg et al., 2007 Brain Injury Brehmer et al., 2007 Neuroscience Letters Adult victims of stroke self-report decreased cognitive problems in daily life and show far transfer after WM training. Dopamine transporter (DAT1) gene displays polymorphism with DAT 9/10 and DAT 10 variations. DAT 9/10 carriers have greater training related gains in visuo-spatial WM post Cogmed. Holmes et al., 2009 Developmental Science School setting, children with low WM improve WM, attention, better follow instructions and then improve in math six months after training. McNab et al., 2009 Science Thorell Developmental Science Healthy adults exhibit changes in dopamine D1 binding after Cogmed Working Memory Training. School setting, preschoolers improve WM w/ near and far transfer, to better attention; inhibitory training shows no result transfer

48 Overview of Key Research Studies (II) Key learning Holmes, 2010 Applied Cognitive Psychology School, on RX, 6 months lasting effects on WM in children with ADHD, wider effect on WM & executive functions than stimulant medication. Mezzacappa & Bruckner, 2010 School Mental Health School, Low SES Children improve WM and decrease teacher ratings of ADHD symptoms, improvement on measures of WM Dahlin, 2010 Reading and Writing Beck et al., 2010 Journal of Clinical Child & Adolescent Psychology School, Special needs children improve reading comprehension. 61% on Rx, Parents report improved on inattention, ADHD symptoms, initiation, planning/org. & WM, teachers reports approached significance on initiate scale. Kronenberger et al., 2010 Journal of Speech, Language, and Hearing Research Lundqvist et al., 2010 Brain Injury Cogmed is feasible intervention for hearing impaired. Transfer of WM improvement to language skills. Heterogeneous group of brain injured adults improve WM and selfrated occupational performance. Løhaugen et al., 2010 The Journal of Pediatrics Children born at extremely low birth weight improve WM with transfer to verbal learning ability. Gibson et al., 2011 Child Neuropsychology Bergman Nutley et al., 2011 Developmental Science WM is dissociated system consisting of SM and PM. ADHD children improve on parent reported behavioral symptoms after Cogmed. Preschoolers improve WM capacity after Cogmed. Gf improved by non-verbal reasoning training but not by WM training.

49 Why do this? Why now? It works. There is no time to waste. Why? Once you finish Cogmed it is now time to build skills. Yes, it is time to get to work Your student now finally has a workspace upon which there is enough room to actually work. Stuff will stick It s time to go to build some skills

50 Working memory training acts on underlying levels Skill/behavior Reading comprehension Math skills Language development On-task behavior Influences Rate of learning Manipulating information Remembering Instructions Concentration Executive function Working memory Planning Attention Task monitoring Organizing

51 How do I know this works: Case Study of 1: My son

52 Success stories Not only have they become engaged in class - staying on task, completing assignments, working independently, and understanding and following directions - but their behaviors outside of class have changed significantly. That is, they are able to accept responsibility for their actions, play appropriately with peers, play appropriately with toys, go to bed on time, sleep when they go to bed, and stay out of trouble. -Rob Budwig, Special Education Director Bridgeville, CA More user stories at

53 Success stories The student is much more focused. His ability to receive, retain, and recall has increased dramatically - as has his classroom confidence. He is also much more able to initiate an assignment, class work, or a project. Historically, he had no follow through- this is also an area of great improvement for him. -Teacher, Academy at Manayunk Philadelphia, PA More user stories at

54 Identifying Working Memory Deficits WISC IV/WAIS IV WISC IV Integrated BASC 2 Brown Consider BASC-2 POP (Portable Observation Program) to graph behavior changes Conners 3 Cogmed Checklist 1

55 Three products for Cogmed training