Working memory training in children with neurodevelopmental disorders and intellectual disabilities, the role of coaching: A double-blind randomised controlled trial.

BACKGROUND: Working memory training (WMT) can offer therapeutic benefits to patients with neurodevelopmental disorders (NDD) and mild to borderline intellectual disability (MBID). However, consistent evidence for treatment benefits of WMT over placebo training is missing. So far, participants in double-blind research designs did receive non-specific coaching, whereas active coaching based on individual training results might increase the efficacy of WMT. Furthermore, the intensity and duration of WMT is often too stressful for these children. This study therefore investigated whether a less intensive but more prolonged WMT, with active personalised coaching and feedback, would reduce behavioural symptoms and improve neurocognitive functioning and academic achievements in children with NDD and MBID. METHOD: A double-blind randomised controlled trial in children (aged 10;0-13;11) with MBID (60 < IQ < 85) and ADHD and/or ASD evaluated the effects of a less intensive but prolonged version of the original Cogmed WMT (30 min a day, 4 days a week, 8 weeks in total). Eighteen participants received active, personalised coaching and feedback, based on their actual individual performance during training. Twenty-two received general non-personalised coaching for the same amount of time. Executive functioning, academic achievements and several behavioural measurements were administered, before and after training, with a 6-months follow-up. RESULTS: We observed a significant effect of time on both primary and secondary outcome measures, indicating that all children improved in working memory performance and other neurocognitive and academic outcomes. The interaction between time and group was not significant. DISCUSSION: This study was unable to document superior effects of active personalised coaching and feedback compared with general non-personalised coaching and no feedback in an adaptive WMT in children with MBID and NDD. The objectively documented changes over time suggest that for these vulnerable children, a regular, structured and structural contact with a coach and adapted exercises is enough to develop therapy fidelity, boost motivation and improve neurodevelopmental task performance. Further research is needed to examine which possible subgroups within this heterogenic group of children profit more from WMT compared with other subgroups.

Neurocognitive functioning of children with mild to borderline intellectual disabilities and psychiatric disorders: profile characteristics and predictors of behavioural problems.

BACKGROUND: The aim of the current study was twofold: first, to uncover a neurocognitive profile of normative and relative strengths and weaknesses that characterises an extremely vulnerable group of children with mild to borderline intellectual disabilities (MBID) and co-morbid psychiatric disorders, and second, to investigate the relevance of these neurocognitive functions explaining internalising and externalising symptoms. METHOD: We recruited 45 children (Mage  = 9.5, SDage  = 1.7; range 6-13 years) with MBID (Full-Scale IQ 50-85) and at least one psychiatric disorder. Neurocognitive functioning was examined utilising the Wechsler Intelligence Scale for Children - Fifth Edition (WISC-V) indices and the Cognitive Task Application (COTAPP), a comprehensive computerised self-paced task designed in such a manner that 'g' (an overall tendency of children with MBID to execute tasks with a slower reaction time and a higher error rate) has been corrected for in the administration of the task (i.e. completely self-paced) and in the operationalisation of outcome measures. Behavioural problems were measured using the CBCL and TRF. One-sample t-tests and binomial tests were carried out to compare performance with normative data. Regression analyses were used to examine the relationship between neurocognitive parameters and mental health. RESULTS: Compared with normative data, very small to very large effect sizes were found, indicating clear heterogeneity amongst neurocognitive domains relevant for children with MBID. Two prominent neurocognitive weaknesses emerged: processing speed - characterised by slowness and unstableness combined with a high drift rate and delayed processing of the previous trial, particularly under higher cognitive demands - and working memory - in terms of a weaker central executive and 'slave' systems to temporarily store information. Both domains were not clearly predictive of internalising or externalising problems. CONCLUSION: Children with MBID and psychiatric disorders are hampered by a strongly diminished processing speed and working memory capacity, together resulting in an overall limited processing capacity that may underlie the general developmental delays on domains that depend on fast and parallel processing of information (i.e. language, reading, mathematics and more complex forms of social cognition). Neurocognitive vulnerabilities are neither necessary nor sufficient to explain internalising and externalising problems; rather, a mismatch between the support needs and adaptations these children need, arising from their diminished processing capacity, and the inadequacy of the environment to compensate for this vulnerability may be of relevance.

Working memory training in children with borderline intellectual functioning and neuropsychiatric disorders: a triple-blind randomised controlled trial.

BACKGROUND: Poor working memory, lower IQ and maladaptive behaviour form a triple disability known to have negative effects on the academic and social development of children with borderline intellectual functioning (BIF; IQ: 70 < IQ < 85) and neuropsychiatric disorders [attention-deficit hyperactivity disorder (ADHD) and/or autism spectrum disorder (ASD)]. Treatment possibilities for these children are scarce and hardly evidence based. This study primarily investigated whether adaptive computerised working memory training (WMT) may lead to significantly more improvement on a non-trained visuospatial WM task compared with a non-adaptive control WMT (placebo) in children with BIF and neuropsychiatric disorders. As secondary outcome measures, we used the scores on several non-trained neuropsychological near-transfer and far-transfer tasks as well as behavioural measures. METHOD: We conducted a triple-blind placebo-controlled randomised clinical trial in 72 children (aged 10;0-13;11 years, 53 boys, 19 girls) with BIF and comorbid neuropsychiatric disorders (ADHD = 37, ASD = 21, both = 14) that were referred to child and adolescent psychiatry care, between May 2012 and March 2019. Children completed the Dutch version of Cogmed WMT, either the adaptive training version or the non-adaptive placebo version, 25 sessions (30-45 min a day), for 5 weeks. The primary outcome measure was the score on a non-trained visuospatial working memory task. The primary outcome was measured before and directly after 5 weeks of WMT and again 6 months after training. RESULTS: A total of 375 children were screened for eligibility and 72 were randomised. No significantly higher levels of improvement over time were found on our primary outcome measure in the experimental WMT group compared with the placebo control WMT, nor in the secondary (near-transfer and far-transfer tasks) or tertiary (behavioural measures) outcome measures. However, this study did show changes over time for these measurements for both the experimental and placebo conditions. CONCLUSIONS: This study was unable to document superior training effects over time of an adaptive WMT in children with BIF and neuropsychiatric disorders, compared with a placebo (non-adaptive) WMT. The objectively documented changes over time in the non-adaptive WMT arm suggest that these children with persistent impairments in WM may benefit from a structured learning environment that is associated with improvement of neurocognitive functioning and coping strategies. Further research is needed to examine which elements of cognitive training may be useful for which specific patients and to study long-term effects of training.