Interventions Matter: Supporting Academic Achievements While Minimizing Stress

Transcription

1 Interventions Matter: Supporting Academic Achievements While Minimizing Stress Tony J. Simon & Ingrid N. Leckliter Cognitive Analysis and Brain Imaging Lab Funding: NIH 2R01HD04269 (Simon), K99MH (Beaton), UC Davis CEDD, UC Davis T32 MCRTP (Stoddard/Angkustsiri) 1 What is the problem? Outline of Talk Mismatches between abilities and demands - Poor calibration What are the solutions? bringing the child s abilities closer to the worlds demands bringing the world s demands closer to the child s abilities How well does it work? 2

2 What is the problem? Outline of Talk Mismatches between abilities and demands - Poor calibration What are the solutions? bringing the child s abilities closer to the worlds demands bringing the world s demands closer to the child s abilities How well does it work? 3 Our Working Hypothesis Cognitive impairments limit competence IQ of 75 means operating as a 9-year-old in a 12-year-old s world mental representation impairments limit development in domains like space, time, number Executive Function impairments limit behavior/emotional regulation Impaired cognition (borderline IQ) creates/interacts with increased stress/anxiety to further modulate/challenge development stress/anxiety increase inattention and decrease cognitive control Family/School/Community supports further modulate above interaction & influence coper/struggler trajectory strugglers might experience higher allostatic load & psychosis risk If so, we can target cognitive, emotional and environmental factors for intervention to improve academics, mental health, family dynamics 4 4

3 Everyday Demands Cognitive Abilities Stimulation Coping Resources 5 Anxiety & Functional Abilities N=91, r=0.02; Adaptive function NOT related to overall IQ. Unlike TD/most other NDDs Adaptive function IS related to anxiety levels Angkustsiri et al., submitted Anxiety levels related to stress hormone level, maybe psychosis risk Beaton et al., submitted; Beaton & Simon,

4 Anxiety and Attention Prelim data from Hot Cognition tasks Dot Probe Threat Bias (Perez-Edgar, 11; Roy, Pine, Lissek..) Emotional Attentional Blink (Lim/Pessoah, 09) 500ms or 10ms/image 90ms ISI 500ms Lag = 1 or Lag = ms Lag = Anxiety and Attention Dot probe RTs suggest 22q group drawn to angry faces (threat bias) positive scores indicate vigilance for angry faces some evidence of relation to the one fear anxiety index checked so far 8 8

5 Anxiety and Attention What does this actually look like? How distracting is threat? Movie #1 a typical child with no emotion bias Movie #2 a child with 22q11 with a strong threat (i.e. angry face bias) 9 9 Arousal, Anxiety & Inattention Color Key ADHD and Anxiety Anxiety and ADHD (Venn-Euler Diagram) Value Anxiety+ADHD ADHD Anxiety Neither q11.2DS participants ADHD ANXIETY ETY Anxiety DHD ADHD Michelle Y Deng, Ph.D. 10

6 What is the problem? Outline of Talk Mismatches between abilities and demands - Poor calibration What are the solutions? bringing the child s abilities closer to the worlds demands bringing the world s demands closer to the child s abilities How well does it work? 11 What is working memory? The ability to keep information in your mind for a short period of time (seconds) and be able to use the information in your thinking A system for temporary storage and manipulation of information, necessary for wide range of cognitive tasks Working memory is the search engine of the brain Cogmed America 2011 Center for Excellence in Developmental Disabilities UCDAVIS MIND Institute 12

7 Prospects for Intervention One program might help with issues related to Executive Function/ADHD Cogmed: limited to key Exec. Function domain costly & not unlimited access well validated, not yet with 22q11.2DS BUT, buyer beware. Now purchased by Pearson Testing Inc. starting to morph into wider product range possibly beyond evidence base this was what happened with Fast ForWord 13 Prospects for Intervention How on earth can you know what works, and for whom? Sharp Brains: neuroscience based community likely to prioritize evidence base BUT, buyer beware. This IS a PRO brain training group NB: I have no affiliation with either of these 14

8 Prospects for Intervention How on earth can you know what works, and for whom? Sharp Brains: neuroscience based community likely to prioritize evidence base BUT, buyer beware. This IS a PRO brain training group NB: I have no affiliation with either of these 15 Stress/Anxiety Intervention Evidence Based Behavioral Approaches Cognitive Behavioral Therapy (CBT) high linguistic/conceptual demands Biofeedback, Meditation, Exercise Work with (any) good clinician Pharmacological Approaches SSRI - Selective Serotonin Reuptake Inhibitors Stimulants - ADHD medications reasonable concerns but safe & effective Work with pediatrician/psychiatrist 16

9 Computer Assisted Cognitive Behavior Therapy for Anxiety! Developed from Coping Cat; Individual Cognitive Behavior Therapy (Kendall & Hedtke, 2006)! Camp Cope-A-Lot! 12 sessions, Interactive CD ROM! 7-13 year old youths with anxiety! First 6-sessions self-guided! Last 6-sessions therapist coached! Center for Excellence in Developmental Disabilities UCDAVIS MIND Institute 17 Stress/Anxiety Intervention Less Evidence Based but research supported anxiety program Turnaround Anxiety Therapy Work with family member NB: we don t have experience with this AND adult/parental involvement will modulate success. BUT does seem to be based on sound CBT principles 18

10 Strong evidence based for Social Skills Training as effective with: children & adults a range of disorders ASD, Schizophrenia, others Michelle Garcia-Winner is a leader in this work Many medical centers, universities, other organizations offer evidencebased social skills group training Social Skills Training 19 What is the problem? Outline of Talk Mismatches between abilities and demands - Poor calibration What are the solutions? bringing the child s abilities closer to the worlds demands bringing the world s demands closer to the child s abilities How well does it work? 20

11 What is the problem? Outline of Talk Mismatches between abilities and demands - Poor calibration What are the solutions? bringing the child s abilities closer to the worlds demands bringing the world s demands closer to the child s abilities How well does it work? 21 Effect sizes (d) for Cogmed studies with Control Groups: Nontrained Behaviors STUDY CONTROL GROUP SAMPLE d After Cogmed d Four to 6- months f/u Klingberg et al (2005) Swedish Nonadaptive Training 7-12 years, ADHD Parent report Inattn= 1.21 Hyp/Imp= 0.42 > = Parent report Inattn= 0.67 Hyp/Imp= 0.42 Holmes et al (2009) English Nonadaptive Training 8-11 years, WM< 15 th percentile Classroom Inst. Task= 0.83 Math Rsng= 0.11 > < Classroom Inst. Task= 0.52 Math Rsng= 0.49 Dahlin (2010) Swedish SpEd as usual 9-12 years, ADHD & LD Reading Comp= 0.88 = Reading Comp= 0.91 Beck et al (2010) American Wait List 7-17 years, ADHD + (ODD, Anx., Mood Dis. & on meds.) Parent report DSM-IV Inatt= 1.49 BRIEF MetaCog= 0.91 Plan/Org= 0.92 > = > Parent report DSM-IV Inatt= 1.03 BRIEF MetaCog= 0.83 Plan/Org= 0.72 Center for Excellence in Developmental Disabilities UCDAVIS MIND Institute 22

12 How Well Does WM Training Work? Developmental Psychology 2012 American Psychological Association 2012, Vol., No., /12/$12.00 DOI: /a Is Working Memory Training Effective? A Meta-Analytic Review Monica Melby-Lervåg University of Oslo Keywords: working memory training, ADHD, attention, learning disabilities Charles Hulme University College London and University of Oslo Twenty-three studies with 30 group comparisons met the criteria for inclusion. The studies included involved clinical samples and It hassamples been suggested of that working typically memory training developing programs are effective children both as treatments and for adults. Meta-analyses attention-deficit/hyperactivity disorder (ADHD) and other cognitive disorders in children and as a tool to indicated that the programs produced improve cognitive reliable ability and scholastic short-term attainment in typically improvements developing children and inadults. working However, memory skills. For effects across studies appear to be variable, and a systematic meta-analytic review was undertaken. To verbal working memory, these be included near-transfer in the review, studies effects had to be randomized were controlled nottrials sustained or quasi-experiments atwithout follow-up, whereas for randomization, have a treatment, and have either a treated group or an untreated control group. visuospatial working memory, Twenty-three limitedstudies evidence with 30 groupsuggested comparisons met the that criteriasuch for inclusion. effects The studies might included be maintained. More involved clinical samples and samples of typically developing children and adults. Meta-analyses importantly, there was no convincing indicated that the evidence programs produced of the reliablegeneralization short-term improvements inof working working memory skills. memory For training to other verbal working memory, these near-transfer effects were not sustained at follow-up, whereas for skills (nonverbal and verbal ability, visuospatial inhibitory working memory, processes limited evidence suggested in attention, that such effectsword might be maintained. decoding, More and arithmetic). The importantly, there was no convincing evidence of the generalization of working memory training to other authors conclude that memory training programs appear to produce short-term, specific training effects skills (nonverbal and verbal ability, inhibitory processes in attention, word decoding, and arithmetic). The authors conclude that memory training programs appear to produce short-term, specific training effects that do not generalize. Possible limitations of the review (including age differences in the samples and that do not generalize. Possible limitations of the review (including age differences in the samples and the variety of different clinical conditions included) are current findings cast doubt on the variety of different clinical conditions included) are noted. However, current findings cast doubt on both the clinical relevance of working memory training programs and their utility as methods of enhancing cognitive functioning in typically developing children and healthy adults. both the clinical relevance of working memory training programs and their utility as methods of Review of 23 working memory training studies with control groups no sustained verbal WM effects, some lasting visuospatial effects no convincing evidence of generalization... to other skills 23 How Well Does EF Training Work? REVIEW Interventions Shown to Aid Executive Function Development in Children 4 to 12 Years Old Adele Diamond 1 * and Kathleen Lee 1 To be successful takes creativity, flexibility, self-control, and discipline. Central to all those are executive functions, including mentally playing with ideas, giving a considered rather than an impulsive response, and staying focused. Diverse activities have been shown to improve children s executive functions: computerized training, noncomputerized games, aerobics, martial arts, yoga, mindfulness, and school curricula. All successful programs involve repeated practice and progressively increase the challenge to executive functions. Children with worse executive functions benefit most from these activities; thus, early executive-function training may avert widening achievement gaps later. To improve executive functions, focusing narrowly on them may not be as effective as also addressing emotional and social development (as do curricula that improve executive functions) and physical development (shown by positive effects of aerobics, martial arts, and yoga). W hat will children need to be successful? What programs are successfully helping children develop those skills in the earliest school years? What do those programs have in common? Four of the qualities that will probably be key to success are creativity, flexibility, self-control, and discipline. Children will need to think creatively to devise solutions never considered before. They will need working memory to mentally work with masses of data and see new connections among elements, flexibility to appreciate different perspectives and take advantage of serendipity, and self-control to resist temptations and avoid doing something they would regret. Tomorrow s leaderswillneedthedisciplineto stay focused, seeing tasks through to completion. All of those qualities are executive functions (EFs), the cognitive control functions needed when you have to concentrate and think, when acting on your initial impulse might be ill-advised. EFs depend on a neural circuit in which the prefrontal cortex is central. Core EFs are cognitive flexibility, inhibition (self-control, self-regulation), and working memory (1). More complex EFs include problem-solving, reasoning, and planning. EFs are more important for school readiness than is intelligence quotient (IQ) (2). They continue to predict math and reading competence throughout all school years [e.g., (3)]. Clearly, to improve school readiness and academic success, targeting EFs is crucial. EFs remain critical for success throughout life [in career (4) andmar- riage (5)] and for positive mental and physical health (6, 7). Children with worse self-control (less persistence, more impulsivity, and poorer attention regulation) at ages 3 to 11 tend to have worse health, earn less, and commit more crimes 30 years later than those with better self-control as children, controlling for IQ, gender, social class, and more (8). Since self-control s effects follow a [linear] gradient, interventions that achieve even small improvements in self-control for individuals could shift the entire distribution of outcomes in a salutary direction and yield large improvements in health, wealth, and crime rate for a nation (8). What Programs Have Been Shown to Help Young Children Develop These Skills? There is scientific evidence supporting six approaches for improving EFs in the early school years. Tables S1 and S2 provide details on each intervention and their outcomes. Computerized training. The most researched approach, and one repeatedly found successful, is CogMed (Pearson Education, Upper Saddle River, NJ) computerized working-memory training (9 13), which uses computer games that progressively increase working-memory demands. Youngsters improve on games they practice (Fig. 1), and this transfers to other working-memory tasks. Groups studied have been typically developing children (12) andthosewithattentiondeficithyperactivity disorder (ADHD) (10, 13) or poor working-memory spans (9). Benefits usually do not generalize to unpracticed EF skills (14). Three studies (9 11)includedcontrols whoplayed the same training games without increasing difficulty; those controls did not show the same gains. Two studies looked 6 months later and found EF benefits remained (9, 13). For math, gains were Review of 6 different approaches to executive function training. Diverse activities have been shown to improve children s executive functions: computerized training, noncomputerized games, aerobics, martial arts, yoga, mindfulness, and school curricula. All successful programs involve repeated practice and progressively increase the challenge to executive functions. Children with worse executive functions benefit most from these activities; thus, early executive-function training may avert widening achievement gaps later. To improve executive functions, focusing narrowly on them may not be as effective as also addressing emotional and social development and physical development. 1 University of British Columbia and Children s Hospital, Vancouver, BC V6T 2A1, Canada. *To whom correspondence should be addressed. adele.diamond@ubc.ca Fig. 1. A teen working at a CogMed game. [Photo courtesy of CogMed] SCIENCE VOL AUGUST

13 Randomized, controlled comparison (Khanna & Kendall, 2010)! 49 children with anxiety disorders ages 7 to 13-years! Random assignment! Evaluators blind to treatment condition! Computer-assisted CBT vs Individual CBT vs Computer-linked education, support and attention condition (CESA) CA-CBT (Camp Cope-A-Lot) 81% principal anxiety diagnosis no longer present at posttreatment Child and parent more satisfied than with CESA; CA-CBT = I-CBT I-CBT (Coping Cat) 70% principal anxiety diagnosis no longer present Child and parent more satisfied than with CESA I-CBT = CA-CBT CESA (attention/ education control) 19% principal anxiety diagnosis no longer present Child and parent satisfaction CESA< CA-CBT and I-CBT Center for Excellence in Developmental Disabilities UCDAVIS MIND Institute 25 CBT & medication yields substantial improvement (Walkup, Albano, Piacentini et al. 2008)! 488 Children 7 to 17-years with anxiety disorders! Random assignment! evaluators blind to all treatment assignments! 12-weeks, multi-site trials Sertraline only (N analyzed= 133) Cognitive Behavioral Therapy (CBT) only (N=139) Sertraline & CBT combined (N=140) Placebo drug (N=76) 55% very much to much improved 60% very much to much improved 81% very much to much improved 24% very much to much improved 0.45 effect size 0.31 effect size 0.86 effect size Center for Excellence in Developmental Disabilities UCDAVIS MIND Institute 26

14 Conclusions We do now understand a lot about what needs to be fixed huge amount can be done without stem cells/brain surgery instead, well validated methods, with skilled providers are widely available and don t require 22q11.2DS expertise Much energy is going into novel, technological interventions these are works in progress trying to translate basic neuroscience into effective treatments any of these might work for your child, but no evidence yet for wide ranging, long-lasting effects few Random Controlled Trials - the gold standard Decades of training studies show above pattern so the big Q: Will Brain Training be different? More studies and time will tell 27