What is Brain Training and will it help my child?

What is Brain Training and will it help my child? Professor Peter Anderson Monash Institute of Cognitive and Clinical Neurosciences School of Psychological Sciences Monash University Group Leader, VIBeS Murdoch Childrens Research Institute

Outline What is brain training Cogmed working memory training Evidence for Cogmed Memory Meastros Cogmed & preterm children Norwegian studies IMPRINT Future directions & conclusions Questions

Brain Training Often referred to as cognitive training Intervention to improve specific cognitive skill(s) Based on premise that: Specific cognitive skills can be improved Most interventions involve repetitive training Vary according to length of training sessions, number of training sessions, and training exercises

TRAIN YOUR BRAIN

Big Business Digital-brain-health market 2005 - $210 mil 2009 - $600 mil 2013 - $1.3 bil ($715m software) 2020 - $6.15 bil ($3.38bil software) Lumosity > 70 million members End users only 20% are <18 years

Adaptive cognitive training Exercises are practiced intensely (ie. repeatedly) Training commences at the individual s ability level Performance continuously monitored Complexity level adapted to keep student challenged but not frustrated Multiple exercises are trained. Cross-training is thought to increase likelihood that real-life improvements will be achieved, as well as sustained benefits Inbuilt rewards to maximise motivation Safe learning environment to encourage individuals to try alternative strategies and make mistakes Content is age appropriate, engaging and fun Computer-games

Cogmed Program Designed by Torkel Klingberg at Karolinska Institute Utilises cognitive training principles to improve working memory Training is intensive (40-50 mins, 5 days per week, for 5 weeks) Training commences at the child s ability level Complexity constantly adapts to child s increasing performance Activities designed to be engaging and fun Rewards system Training is based on implicit learning rather than explicit learning

Cogmed Started as a experimental intervention for ADHD children Small trials demonstrated short- and moderate-term benefits Start-up company formed, Cogmed Inc Selected individuals were accredited to be Cogmed coaches June 2010 Cogmed purchased by Pearsons

Cogmed Process Clients needs to be referred to a certified Cogmed Coach Certified coaches are usually health or educational professionals Completed accredited Cogmed training program Family attend a start-up session Introduction to training (practice session) Planning sessions, coach calls, reward structures, training environment, role of training aide Ensure program working on device and synching Monitoring of training coach calls, training web Wrap-up meeting

Eligibility The first responsibility of the Cogmed coach is to determine eligibility for training - its built into the protocol - salience/readiness to train is integral to the success of the program.

Cogmed JM (Preschool) Cogmed RM (School age) Cogmed QM (Adolescent & Adult)

Cogmed RM

Asteroids

Data Room

Rotating Data Link

Rotating Dots

Input Module

Robo-racing

Online Coach Training Web

How to assess whether Brain Training works? Performance gains on trained exercises Expected result and not sufficient Gains in non-trained cognitive tests Eg. Better performance of tests of working memory Gains in everyday activities Eg. Better reading or maths Eg. Improved behaviour

Level of Evidence What level of evidence is needed to support individual brain training programs? Real-life benefits Magnitude of effect Duration of effect Cost effectiveness

Published research (Pearson s website) ADHD samples (20 studies) Typical / healthy samples (16 studies) Brain injury eg. Stroke, ABI (6 studies) Cancer (2 studies) Low WM / Academics / Classroom behaviour (6 studies) Hearing impaired (2 studies) Preterm birth (3 studies) Downs Syndrome (1 study) PTSD (1 study) Intelligence impairment (1 study) Language impairment (1 study) Chronic Fatigue (1 study) Mild cognitive impairment (1 study)

Klingberg et al (2005), J Am Acad Child Adolesc Psychiatry, 44, 177-186 TRAIN I N G OF WORKING M EM ORY TABLE 1 Subject Characteristics a Comparison Treatment Total Boys 22/20 22/16 44/36 Girls 4/4 5/4 9/8 ADHD combined 16/15 22/15 38/30 ADHD inattentive 10/9 5/5 15/14 Age, yr, mean (SD) 9.8 (1.3)/9.7 (1.3) 9.9 (1.3)/9.8 (1.4) 9.8 (1.3)/9.8 (1.3) Note: ADHD = attention-deficit/hyperactivity disorder. a Data given for all randomized subjects (n = 53)/subjects that complied (n = 44). See Fig. 1. participating sites. Written informed consent wasobtained from all participating families. version) (Conners, 2001). Symptomswerescored by assigning aseverity estimate for each symptom on a4-point scale, from 0 (not at all) to 3 (very much). Because there are no updated Swedish norms

Klingberg et al (2005), J Am Acad Child Adolesc Psychiatry, 44, 177-186

Holmes et al, (2009), Developmental Science, 12, F9-15 Adaptive 22 children with low WM Non-adaptive 20 children with low WM 10yr-olds Not randomised

Does Cogmed result in immediate benefits in working memory? No. of studies (k) Effect size (d) Heterogeneity I 2 Immediate Verbal WM 4 1.18 83% Immediate Visuo-spatial WM 8 0.86 24% Melby-Lervag & Hulme (2013), Developmental Psychology, 49, 270-291

Does Cogmed result in immediate benefits in working memory? YES No. of studies (k) Effect size (d) Heterogeneity I 2 Immediate Verbal WM 4 1.18 83% Immediate Visuo-spatial WM 8 0.86 24% Melby-Lervag & Hulme (2013), Developmental Psychology, 49, 270-291

Does Cogmed result in benefits in reasoning ability? Hulme & Melby-Lervag (2012), J Appl Res Mem Cogn, 1, 197-200

Does Cogmed result in benefits in reasoning ability? NO Hulme & Melby-Lervag (2012), J Appl Res Mem Cogn, 1, 197-200

Does Cogmed result in benefits in impulse control? Hulme & Melby-Lervag (2012), J Appl Res Mem Cogn, 1, 197-200

Does Cogmed result in benefits in impulse control? Unlikely Hulme & Melby-Lervag (2012), J Appl Res Mem Cogn, 1, 197-200

Does Cogmed result in immediate benefits in everyday attention (as reported by parents)? Spencer-Smith & Klingberg (2015), PLOS One, 10(3)

Does Cogmed result in immediate benefits in everyday attention (as reported by parents)? Probably Spencer-Smith & Klingberg (2015), PLOS One, 10(3)

Does Cogmed result in ongoing benefits in everyday attention (as reported by parents)? Spencer-Smith & Klingberg (2015), PLOS One, 10(3)

Does Cogmed result in immediate benefits in everyday attention (as reported by parents)? Maybe Spencer-Smith & Klingberg (2015), PLOS One, 10(3)

Design Issues Summary Small samples Limited long-term follow-up (up to 6 months) Different clinical/non-clinical groups Benefits Working memory Parent-reported attention Sustained effects (1 year and longer) unknown

Memory Maestros Can Cogmed have a sustained impact on (a) literacy and numeracy and (b) working memory skills in children with low working memory?

6-month working memory outcomes

12-month working memory outcomes

24-month working memory outcomes

12-month outcomes

24-month outcomes

Cogmed intervention: Conclusions Benefits in some working memory measures at 6 and 12 months No working memory benefit at 24 months No benefits in academic achievement at 12 or 24 months

Will Cogmed work for very preterm children?

Attention & Working Memory Deficits Fundamental cognitive skills Needed for more complex cognitive skills & new learning Considered core deficits in preterm children

Cogmed training ELBW & Term adolescents (14-16 yrs) Lohaugen et al., 2011, J Pediatr, 158, 555-561.

Working memory tasks across 2 time-points: (1) baseline and (2) immediately after training.

Cogmed training VLBW preschoolers (5-6yrs) Working Memory Training Improves Cognitive Function in VLBW Preschoolers Kristine Hermansen Grunewaldt, Gro Christine Christiansen Løhaugen, Dordi Austeng, Ann-Mari Brubakk and Jon Skranes Pediatrics 2013;131;e747; originally published online February 11, 2013; DOI: 10.1542/peds.2012-1965

IMPRINT Improving Memory in a Preterm Randomised Intervention Trial Evaluate the efficacy of Cogmed in EP/ELBW 7 yr-olds compared to a placebo program Primary outcome: academic functioning at 24 mths post intervention

Design Double-blinded, placebo-controlled RCT of EP children aged 7-8 years All EP and/or ELBW (<1000g) children born in Victoria in 2005 who survived to age 2 Children with a severe intellectual/sensory/physical impairment that affects their capacity to attend mainstream school and families unable to support their child were excluded

July 2012 April 2014 n=172 Recruited n = 91 (60% participation) Baseline assessment Randomisation Placebo training n = 46 Cogmed training n = 45 2-week follow-up n = 45 2-week follow-up n = 43 1-yr follow-up n = 41 1-yr follow-up n = 39 2-yr follow-up n =?? 2-yr follow-up n =??

July 2012 April 2014 n=172 Recruited n = 91 (60% participation) 21 ineligible 49 declined Baseline assessment Randomisation Placebo training n = 46 Cogmed training n = 45 2-week follow-up n = 45 2-week follow-up n = 43 1-yr follow-up n = 41 1-yr follow-up n = 39 2-yr follow-up n =?? 2-yr follow-up n =??

July 2012 April 2014 n=172 Recruited n = 91 (60% participation) Baseline assessment Randomisation Stratified according to: 1) multiple, 2) low working memory Placebo training n = 46 Cogmed training n = 45 2-week follow-up n = 45 2-week follow-up n = 43 1-yr follow-up n = 41 1-yr follow-up n = 39 2-yr follow-up n =?? 2-yr follow-up n =??

Adjusted between group differences on attention and working memory measures post-intervention 4 3 2 1 0-1 -2-3 -4 Regressions adjusted for baseline performance. Error bars represent 95% confidence interval of adjusted mean differences.

Adjusted between group differences on attention and working memory measures post-intervention 4 3 2 1 0-1 -2-3 -4

Change in attention and working memory measures from baseline to post-intervention 5 4 3 2 1 0-1 -2-3 -4-5 Cogmed Placebo

Summary No differences between Cogmed and placebo groups post training in working memory or attention. Slight improvements in working memory were observed in Cogmed and placebo groups. Need to determine which children benefited from program Compliance was not great Program was too difficult Too demanding: time & effort

Who is most likely to benefit? Specific cognitive profiles? Working memory deficits Attention deficits Specific clinical populations? ADHD Learning disability Mild cognitive impairment

Duration Structure of Training Length of training (15, 20, 30 sessions) Intensity 10, 15, 20, 30, 40 mins per day Frequency 2, 3, 5, 7 days per week Content & mode of delivery Implicit only, introduce some explicit strategies

Cogmed Plus Cogmed administered in conjunction with another intervention Prior Concurrently Post Combined programs Maths, literacy, inhibition, strategy based learning, anxiety,

Multiple domain programs Suite of modules focusing on specific cognitive domains Programs targeted to individual needs

Booster programs / sessions Benefits diminish with time Booster sessions required Frequency? Duration? Timing? Structure?

What we know Cogmed is a popular intervention Marketed heavily Immediate gains in working memory Initial benefits weaken with time Gains in real-life outcomes, such as academics, are unlikely Not suitable for individuals with severe impairments

What we don t know Which individuals benefit from training Whether modification of training structure would make it more effective Duration, intensity, frequency Implicit, explicit, repetition & strategy teaching Updating activities Whether combining it / integrating with other interventions would make it more effective

Conclusions Cognitive training may help to enhance core deficits in very preterm children Research evidence with Cogmed is mixed Cogmed & Placebo programs resulted in improved performance More research with Cogmed is needed Which families are suited to Cogmed? Which children will benefit? Do benefits persist long-term? Does improved working memory translate into better academic functioning and behaviour?

Questions Have any studies been done on brain training being used in conjunction with dietary supplements (eg Omega 3)? If so, how do results differ from studies done with brain training, without the use of supplements?

Questions Interested in brain training for children with ADHD

Questions What is the optimal age range for CogMed to address attention issues?