Do Working Memory Deficits Underlie Reading Problems in Attention-Deficit/Hyperactivity Disorder (ADHD)?

Reading problems are common in children with ADHD and show strong covariation with these children's underdeveloped working memory abilities. In contrast, working memory training does not appear to improve reading performance for children with ADHD or neurotypical children. The current study bridges the gap between these conflicting findings, and combines dual-task methodology with Bayesian modeling to examine the role of working memory for explaining ADHD-related reading problems. Children ages 8-13 (M = 10.50, SD = 1.59) with and without ADHD (N = 78; 29 girls; 63% Caucasian/Non-Hispanic) completed a counterbalanced series of reading tasks that systematically manipulated concurrent working memory demands. Adding working memory demands produced disproportionate decrements in reading comprehension for children with ADHD (d = -0.67) relative to Non-ADHD children (d = -0.18); comprehension was significantly reduced in both groups when working memory demands were increased. These effects were robust to controls for foundational reading skills (decoding, sight word vocabulary) and comorbid reading disability. Concurrent working memory demands did not slow reading speed for either group. The ADHD group showed lower comprehension (d = 1.02) and speed (d = 0.69) even before adding working memory demands beyond those inherently required for reading. Exploratory conditional effects analyses indicated that underdeveloped working memory overlapped with 41% (comprehension) and 85% (speed) of these between-group differences. Reading problems in ADHD appear attributable, at least in part, to their underdeveloped working memory abilities. Combined with prior cross-sectional and longitudinal findings, the current experimental evidence positions working memory as a potential causal mechanism that is necessary but not sufficient for effectively understanding written language.

Can working memory training work for ADHD? Development of central executive training and comparison with behavioral parent training.

OBJECTIVE: Working memory deficits have been linked experimentally and developmentally with attention-deficit/hyperactivity disorder (ADHD)-related symptoms/impairments. Unfortunately, substantial evidence indicates that extant working memory training programs fail to improve these symptoms/impairments. We hypothesized that this discrepancy may reflect insufficient targeting, such that extant protocols do not adequately engage the specific working memory components linked with the disorder's behavioral/functional impairments. METHOD: The current study describes the development, empirical basis, and initial testing of central executive training (CET) relative to gold-standard behavioral parent training (BPT). Children with ADHD ages 8-13 (M = 10.43, SD = 1.59; 21 girls; 76% Caucasian/non-Hispanic) were treated using BPT (n = 27) or CET (n = 27). Detailed data analytic plans for the pre/post design were preregistered. Primary outcomes included phonological and visuospatial working memory, and secondary outcomes included actigraphy during working memory testing and two distal far-transfer tasks. Multiple feasibility/acceptability measures were included. RESULTS: The BPT and CET samples did not differ on any pretreatment characteristics. CET was rated as highly acceptable by children and was equivalent to BPT in terms of feasibility/acceptability as evidenced by parent-reported high satisfaction, low barriers to participation, and large ADHD symptom reductions. CET was superior to BPT for improving working memory (Group × Time d = 1.06) as hypothesized. CET was also superior to BPT for reducing actigraph-measured hyperactivity during visuospatial working memory testing and both distal far-transfer tasks (Group × Time d = 0.74). CONCLUSIONS: Results provide strong support for continued testing of CET and, if replicated, would support recent hypotheses that next-generation ADHD cognitive training protocols may overcome current limitations via improved targeting. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Have Phobias, Will Travel: Addressing One Barrier to the Delivery of an Evidence-Based Treatment.

Although a host of evidence-based treatments exist for youth with anxiety disorders, less than 30% of youth and their families receive these treatments. One of the main barriers to receiving these treatments is the lack of access to care, due largely to the absence of mental health professionals who have expertise in the delivery of these treatments in certain geographic locales. The current study examined whether a brief intensive treatment for specific phobias (SPs), Augmented One-Session Treatment (OST-A), would result in comparable treatment gains for families who traveled a considerable distance to receive this treatment when compared to families who resided in our local community. Participants included 76 youth with a clinically confirmed diagnosis of SP (38 local families and an age- and sex-matched sample of 38 nonlocal families). Although SP severity at pretreatment was significantly greater for the nonlocal youth than the local youth, both nonlocal and local youth showed commensurate improvement and maintenance of treatment gains over a 6-month period across several clinical outcome measures. Findings from this study show that OST-A is effective when families choose to travel for treatment, addressing at least one of the barriers to use of this evidence-based treatment.

Neurocognitive and behavioral predictors of social problems in ADHD: A Bayesian framework.

OBJECTIVE: Social problems are a key area of functional impairment for children with attention deficit hyperactivity disorder (ADHD), and converging evidence points to executive dysfunction as a potential mechanism underlying ADHD-related social dysfunction. The evidence is mixed, however, with regard to which neurocognitive abilities account for these relations. METHOD: A well-characterized group of 117 children ages 8-13 (M = 10.45, SD = 1.53; 43 girls; 69.5% Caucasian/Non-Hispanic) with ADHD (n = 77) and without ADHD (n = 40) were administered multiple, counterbalanced tests of neurocognitive functioning and assessed for social skills via multi-informant reports. RESULTS: Bayesian linear regressions revealed strong support for working memory and cross-informant interfering behaviors (inattention, hyperactivity/impulsivity) as predictors of parent- and teacher-reported social problems. Working memory was also implicated in social skills acquisition deficits, performance deficits, and strengths based on parent and/or teacher report; inattention and/or hyperactivity showed strong correspondence with cross-informant social problems in all models. There was no evidence for, and in most models strong evidence against, effects of inhibitory control and processing speed. The ADHD group was impaired relative to the non-ADHD group on social skills (d = 0.82-0.88), visuospatial working memory (d = 0.89), and phonological working memory (d = 0.58). In contrast, the Bayesian ANOVAs indicated that the ADHD and non-ADHD groups were equivalent on processing speed, IQ, age, gender, and socioeconomic status (SES). There was no support for or against group differences in inhibition. CONCLUSIONS: These findings confirm that ADHD is associated with impaired social performance, and implicate working memory and core ADHD symptoms in the acquisition and performance of socially skilled behavior. (PsycINFO Database Record

Are Episodic Buffer Processes Intact in ADHD? Experimental Evidence and Linkage with Hyperactive Behavior.

Working memory deficits are present in a substantial proportion of children with ADHD, and converging evidence links these deficits with ADHD-related behavioral and functional impairments. At the same time, working memory is not a unitary construct, and evidence is lacking regarding the role of several components of this system in ADHD. Preclinical behavioral studies are needed to fractionate the multicomponent working memory system, determine which specific subcomponent(s) are impaired in ADHD, and more importantly link these subcomponent(s) with specific ADHD-related behavioral symptoms/functional impairments. The current study reflects one piece of that puzzle, and focuses on the episodic buffer component of working memory. Across multiple testing days, a well-characterized sample of 86 children ages 8-13 (M=10.52, SD=1.54; 34 girls; 64% Caucasian/Non-Hispanic) with ADHD (n=49) and without ADHD (n=37) completed three counterbalanced working memory tests that were identical in all aspects except the key subcomponent process (phonological, visuospatial, episodic buffer). Gross motor movement during these and control tasks were measured using 4 high-precision actigraphs. There was no evidence of group differences in gender, age, SES, or IQ. Bayesian mixed-model ANOVAs indicated that the ADHD group performed significantly worse on all three working memory tests (d=1.17-1.44) and was significantly more hyperactive than controls (d=0.66-1.05) during the visuospatial and episodic buffer tests. In contrast, the ADHD and Non-ADHD groups were equivalent with regard to effects of episodic buffer demands on performance and hyperactive behavior. The most parsimonious conclusion is that the episodic buffer is likely intact in ADHD, and unrelated to ADHD hyperactivity symptoms.

Parent Management Training and Collaborative & Proactive Solutions: A Randomized Control Trial for Oppositional Youth.

This study examined the efficacy of Collaborative & Proactive Solutions (CPS) in treating oppositional defiant disorder (ODD) in youth by comparing this novel treatment to Parent Management Training (PMT), a well-established treatment, and a waitlist control (WLC) group. One hundred thirty-four youth (ages 7-14, 61.9% male, 83.6% White) who fulfilled Diagnostic and Statistical Manual of Mental Disorders (4th ed.) criteria for ODD were randomized to CPS, PMT, or WLC groups. ODD was assessed with semistructured diagnostic interviews, clinical global severity and improvement ratings, and parent report measures. Assessments were completed pretreatment, posttreatment, and at 6 months following treatment. Responder and remitter analyses were undertaken using intent-to-treat mixed-models analyses. Chronological age, gender, and socioeconomic status as well as the presence of comorbid attention deficit/hyperactivity and anxiety disorders were examined as predictors of treatment outcome. Both treatment conditions were superior to the WLC condition but did not differ from one another in either our responder or remitter analyses. Approximately 50% of youth in both active treatments were diagnosis free and were judged to be much or very much improved at posttreatment, compared to 0% in the waitlist condition. Younger age and presence of an anxiety disorder predicted better treatment outcomes for both PMT and CPS. Treatment gains were maintained at 6-month follow-up. CPS proved to be equivalent to PMT and can be considered an evidence-based, alternative treatment for youth with ODD and their families.

Synchrony-desynchrony in the tripartite model of fear: Predicting treatment outcome in clinically phobic children.

The tripartite model of fear posits that the fear response entails three loosely coupled components: subjective distress, behavioral avoidance, and physiological arousal. The concept of synchrony vs. desynchrony describes the degree to which changes in the activation of these components vary together (synchrony), independently, or inversely (both forms of desynchrony) over time. The present study assessed synchrony-desynchrony and its relationship to treatment outcome in a sample of 98 children with specific phobias both prior to and 1 week after receiving one-session treatment, a 3 h cognitive-behavioral intervention. The results suggest an overall pattern of desynchronous change whereby youth improved on behavioral avoidance and subjective distress following treatment, but their level of cardiovascular reactivity remained stable. However, we found evidence that synchronous change on the behavioral avoidance and subjective distress components was related to better treatment outcome, whereas desynchronous change on these components was related to poorer treatment outcome. These findings suggest that a fuller understanding of the three response systems and their interrelations in phobic youth may assist us in the assessment and treatment of these disorders, potentially leading to a more person-centered approach and eventually to enhanced treatment outcomes.

Specific phobias in youth: a randomized controlled trial comparing one-session treatment to a parent-augmented one-session treatment.

OBJECTIVE: Examine the efficacy of a parent-augmented One-Session Treatment (A-OST) in treating specific phobias (SP) in youth by comparing this novel treatment to child-focused OST, a well-established treatment. METHOD: A total of 97 youth (ages 6-15, 51.5% female, 84.5% White) who fulfilled diagnostic criteria for SP were randomized to either A-OST or OST. SPs were assessed with semistructured diagnostic interviews, clinician improvement ratings, and parent and child improvement ratings. In addition, measures of treatment satisfaction and parental self-efficacy were obtained. Blind assessments were completed pretreatment, posttreatment, and 1month and 6months following treatment. Analyses were undertaken using mixed models. In addition, gender, age, internalizing/externalizing problems, parent overprotection, and parent anxiety were examined as potential predictors and moderators of treatment outcome. RESULTS: Both treatment conditions produced similar outcomes with approximately 50% of youth in both treatments diagnosis free and judged to be much or very much improved at posttreatment and 1-month follow-up. At 6-month follow-up, however, the treatments diverged with OST resulting in marginally superior outcomes to A-OST, contrary to predictions. Only age of child predicted treatment outcome across the two treatments (older children did better); unexpectedly, none of the variables moderated treatment outcomes. CONCLUSIONS: Parent augmentation of OST produced no appreciable gains in treatment outcomes. Directions for future research are highlighted.