TEAMS ADHD Treatment – Training Executive, Attention, and Motor Skills

[Bill]

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ATTENTION RESEARCH UPDATE – April 2012

TEAMS: A New ADHD Treatment for Preschoolers

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Dear Colleague,

I hope that you are doing well and that 2012.

In this month’s issue of Attention Research Update I review a recently published study that examined a new intervention for preschool children with ADHD called TEAMS – Training Executive, Attention, and Motor Skills. The premise of this interesting and important study is that through regular parent-child engagement in games designed to exercise important neurocognitive skills, it may be possible to affect enduring reductions in core ADHD symptoms. Thus, in contrast to current evidence-based interventions like medication treatment and behavior therapy, the goal of TEAMS is to produce more fundamental and enduring change. I think this is very important work for the field and I believe you will find this to be an interesting study.

Sincerely,

David Rabiner, Ph.D.

Associate Research Professor

Dept. of Psychology & Neuroscience

Duke University

Durham, NC 27708

P.S. Please feel free to forward this newsletter to others you know who may be interested – you’ll find a “Forward to a Friend” link at the end of this message. If this has been forwarded to you, and you would like to receive Attention Research Update on a regular basis, just visit http://www.helpforadd.com to subscribe.

** TEAMS: A New ADHD Treatment for Preschoolers **

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Although medication treatment and behavior therapy provide short-term symptomatic relief for children with ADHD, such gains rarely persist after treatment ends. Because these treatments are infrequently sustained over extended periods (most children on medication do not even remain on it for a year), few individuals with ADHD receive effective treatment over the long-term. This may explain why current treatments provide only limited long-term benefits and why many individuals with ADHD have poor adolescent and young adult outcomes even if they were effectively treated in childhood. Clearly, treatments that can provide enduring benefits are needed.

As knowledge of the underlying neural and neurocognitive contributors to ADHD has grown, and knowledge that brain development is highly responsive to environmental influences has accumulated, a compelling theoretical framework for the development of more enduring ADHD interventions has emerged. Specifically, it has been hypothesized that particular kinds of experience can ameliorate – or at least diminish – some of the underlying neural factors that contribute to the development and expression of ADHD.

In fact, this possibility has already been demonstrated in several studies. For example, work in the neurofeedback domain has demonstrated changes in neural activity in individuals with ADHD following treatment. Similarly, significant changes in neural activity have been shown to occur in individuals following working memory training.

Neurofeedback, working memory training, and other forms of computerized cognitive training are distinctly different activities from typical daily experience and are not particularly social in nature. However, it may also be possible to provide children with environmental stimulation that can enhance neural and cognitive functioning within the context of the parent-child relationship. And, because such activities can be inherently enjoyable, and promote positive relations between parents and children, they may be sustained over time and thus provide children with ongoing experience that can enhance their neural functioning. In theory, such an intervention could produce enduring treatment gains in children with ADHD, particularly if introduced when children are young and neuroplasticity may be greatest.

This was the premise underlying an extremely interesting and important study recently published online in the Journal of Attention Disorders [Halperin et al., (2012). Training executive attention and motor skills: A proof-of-concept study in preschool children with ADHD. Journal of Attention Disorders, published online March 5, 2012. DOI: 10.1177/1087054711435681.]. To be candid, I found this to be one of the most interesting studies I have read during the past 10 years.

Participants were 29 four- and five-year old ethnically diverse children diagnosed with ADHD and their parents. Children and parents participated in a novel intervention called TEAMS – Training Executive, Attention, and Motor Skills.’ As discussed below, TEAMS was designed to “…apply frequent and enduring positive environmental stimulation to underlying neurodevelopmental processes in children with ADHD.” Specifically, parents learned to engage in specific game-like activities with their child that placed increasingly challenging demands on a variety of neurocognitive and motor skills. The theory behind TEAMS was that this would promote underlying changes in neural functioning that would lead to enduring improvements in ADHD symptoms.

The authors describe this as a ‘proof of concept’ study. Thus the goals were to learn whether parents would have positive feelings about the treatment experience, whether they would engage regularly with their child in the prescribed activities, and whether there was any preliminary evidence of positive effects. As such, there was no control group and no randomization to condition. Thus, even were favorable results to be found, this was a preliminary study that could not establish the efficacy of the new treatment.

TEAMS Intervention Specifics

The TEAMS intervention was conducted in a 90-minute group format (between 5 and 10 group meetings were held) that included 3-5 families per group. In each group, children and parents were introduced to a predetermined set of games chosen to target an array of neurocognitive skills. For example, to target inhibitory control, i.e., the ability to refrain from responding impulsively, games would include variations of “Simon Says” and ‘freeze dance’. To develop working memory skills, games would include things like remembering shopping lists or the locations of ‘hidden treasures’ under cups. Other targeted cognitive skills were visual-spatial abilities, planning and organization, and sustained attention. Games to develop motor skills were also included as was an aerobic exercise component.

Between group meetings, parents were instructed to spend at 30-45 minutes each day playing these games with their child. The goal was to provide sufficient stimulation of the underlying neural processes targeted by the games so that these processes were repeatedly exercised and strengthened.

A focus in group meetings was working with parents to identify and overcome difficulties they had experienced consistently implementing the games with their child during the prior week. Parents also learned new games, discussed the cognitive skills being targeted, and were taught how to gradually increase the difficulty level so that children’s cognitive skills were continually challenged. The importance of regular aerobic exercise was also stressed as there is emerging evidence that this can improve cognitive functioning.

Measures

To assess the impact of the TEAMS program, ratings of core ADHD symptoms and of children’s impairment from symptoms were collected from parents and teachers. Ratings were obtained before treatment began, immediately after the groups ended, and at a 1- and 3-month follow-up. These latter measurement points enabled the researchers to learn whether any gains that were initially evident endured.

In addition, parents completed ratings of how often they engaged in the prescribed games each week and how long they engaged in these games with their child.

Results

Parental acceptance – Only one of the 29 families withdrew during the active treatment phase and this was because of transportation issues. Overall, parents attended 93% of scheduled sessions and nearly 70% attended all sessions. Satisfaction with the intervention was rated very highly.

Engagement in TEAMS activitie – For TEAMS to be effective, children must engage in the prescribed games with considerable frequency. Throughout the intervention period, parents indicated that they engaged in the games nearly every day for an average of 35 minutes. One month after treatment ended they were still playing the games nearly 3 times a week for 30 minutes. At the 3-month followup, this had declined to an average of 20 minutes/day two days per week. Thus, despite the drop-off from the active treatment period, parents and children continued to regularly engage in the games for at least 3 months after treatment ended.

ADHD symptom severity – Significant reductions in parent and teacher ratings of ADHD symptoms were evident from pre- to post-treatment. Furthermore, these reductions remained evident at the 1- and 3-month followups. Equivalent reductions were found for inattentive and hyperactive-impulsive symptoms. The magnitude of the reductions were in a range that would be considered large for parents and moderate for teachers.

Impairment from symptoms – Ratings of impairment from symptoms declined significantly for both parents and teachers. Interestingly, these declines were not significant immediately following treatment, but became evident at the 1-month follow-up for parents and at the 3-month follow-up for teachers. The magnitude of the decline was in a range that would be considered moderate.

Summary and Implications

The premise of TEAMS is that consistently engaging children with ADHD in activities that challenge and exercise particular neurocognitive functions can strengthen the underlying neural activity that support these functions and thereby diminish ADHD symptoms. This premise is consistent with the rationale underlying neurofeedback treatment, working memory training, and other approaches to computerized cognitive training. What is unique about the TEAMS approach, however, is the idea that such stimulation can occur in the context game like activities between parents and children that are inherently enjoyable and that also promote positive parent-child interactions.

In my view, this is a very exciting study and the kind of work the field really needs. For years, evidence that ADHD is strongly influenced by genetic factors may have undermined efforts to examine whether experiential factors – particularly the ways that parents interact with their child – could play an important role in addressing core ADHD symptoms. What these researchers have suggested, and provided preliminary evidence of, is that this may be possible.

Note that their approach is very different from using behavioral principles to manage ADHD symptoms and encourage desired behavior. While behavioral management approaches are important and helpful, the focus is on symptom management and not on changing children’s underlying capacities. Here, in contrast, the idea is that parents can provide ongoing opportunities to help children exercise neurocognitive functions that can lead to enduring benefits.

Also note that the TEAMS approach in no way implies that parents are somehow responsible for their child’s development of ADHD. Instead, TEAMS strives to teach parents how to provide children with experiences that may lead to enduring reductions in ADHD symptoms over time.

While I found this to be an exciting study, it is important to emphasize that this is only an initial ‘proof of concept’ of the approach. As the authors note, the absence of any control group makes it impossible to determine why children seemed to improve. Although the theory underlying TEAMS is that the children’s ongoing involvement in the prescribed games and exercise program alters their underlying neural functioning, no such assessments were conducted. The sample size was also relatively small.

These limitations not withstanding, this initial effort demonstrated that TEAMS was experienced positively by parents who continued to engage regularly in the treatment exercises up to 3 months after treatment ended. And, beneficial effects as rated by parents and teachers remained evident after 3 months. The authors conclude by noting that a larger randomized trial is planned so that the potential benefits of TEAMS can be better understood. This is important work and I look forward to reviewing it for you Attention Research Update when it becomes available.

Thanks again for your ongoing interest in the newsletter. I hope you enjoyed the above article and found it to be useful to you.

Sincerely,

David Rabiner, Ph.D.

Associate Research Professor

Dept. of Psychology & Neuroscience

Duke University

Durham, NC 27708

(c) 2012 David Rabiner, Ph.D.

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[ashockley55]

Ooo! I live near Durham!

Am neither preschooler nor parent, but still. Cool to see they are doing something major near me.

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[Scattybird]

Bill – this is really interesting – thanks for posting it.

I don’t have kids and I am not one – but on Sunday I did something that was completely exhilarating and different and new and I didn’t need my meds yesterday or today. I reckon it was just because my brain had been exercised in a different way and was firing positively.

But the reality of normality is kicking in again now. But there must be something in altering our neural activity even just for short term gain?

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[JimC.]

@Scattybird…OK can’t stand it, what did you do Sunday that was helpful for you?

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[ashockley55]

right, JimC? That’s what I want to know!

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[Anonymous]

Thank you for this!!

My son is 2.5 and he is 100% a mini me, which has me convinced he’s an ADDer too. I really hope this is going to be available if we need it soon..

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[Robbo]

Thanks a bumch Bill, Great article!. Totally worth reading, n re-reading.

This is great stuff. Not just for kids I might add. We’re grown up kids, and our brains do still have the ability to re-wire themselves.

<<” In theory, such an intervention could produce enduring treatment gains in children with ADHD, particularly if introduced when children are young and neuroplasticity may be greatest. “>>

Neuroplasticity “may be greatest” when we’re little, but we keep our ability to create new neuro-pathways for life. All of this is still possible for us. It’s not likely my parents are going to want to fly a few states over just to play some romper room games with me, but you guys get the picture right? We can work with friends or counselors, support groups. And do tons of different mental exercises. I have called this web site “TEAM totallyadd in previous posts. It’s a cool thing to remember that. Just that little bit of medication gave me the edge to really read and digest this entire article. Mostly I’m doing better at reading and writing because I have been reading and writing tons and tons. I’m paralyzed from my sternum down, so maybe I’ve got a bunch of extra brain capacity at my disposal because it’s not controlling most of my body. My doctor was real happy to hear how well I’m doing, and all the new community involvement I’m into as well.

<<” Parental acceptance – Only one of the 29 families withdrew during the active treatment phase and this was because of transportation issues. Overall, parents attended 93% of scheduled sessions and nearly 70% attended all sessions. Satisfaction with the intervention was rated very highly.

Engagement in TEAMS activitie – For TEAMS to be effective, children must engage in the prescribed games with considerable frequency. “>>

Again, this applies to us grown up kids too. I prefer to be called child-like, rather than childish. But heck, my neighbor is one of the best friends I got, she’s ADD, and calls me “Kiddo” I wonder why? She’s only 6 years older than me.

So many of us have such great creativity that we can invent all kinds of new memory training tricks, and brain exercises. I’ve got a few bookmarked, just gotta hunt em down in my history cuz I may have forgotten to bookmark em. We get ideas from all over the Internet. Tons of links to mental workouts are all over this web site. “A good artist copy’s, A great artist steals” I dunno who said that, but it’s true about music, and all the silly sit coms some of us used to watch endless re-runs of. Remember when Peter made the volcano that blew mud all over the place (Brady Bunch). Tons of other shows about family’s have entertained us over the years. Most of em copy the Waltons, or Beverly Hillbillys. Huh?

Fortunately I haven’t eaten much yet today, I will/am. I remembered to take my 5mg of methylphenidate (generic ritalin). So it kicked in enough to help me read through this article without much struggle. I got lucky in that it’s working well enough for me. I was on time for my doctors appointment yesterday and he was happy to hear about how well I’m doing. And especially how healthy I’m looking, my labs came out excellent!. That’s diet and exercise. Education, and forcing myself to live different. I have learned tons of names over the last couple months. I add a visual connection to the person, and an experience I had with the person. So the memory gets stored on a few different neuro-pathways. I even came up with a visualization of a “spark” with the new name/face bursting out from one spot inside my head into a bunch of different memory centers, current smells, temp, environment, I jus get creative.

<<” Engagement in TEAMS activitie – For TEAMS to be effective, children must engage in the prescribed games with considerable frequency. Throughout the intervention period, parents indicated that they engaged in the games nearly every day for an average of 35 minutes. “>>

We can be our own parents, and our family n friends can help us with the exercises too. I read those Howie Mandel articles from this thread http://totallyadd.com/forum/topic.php?id=2526. He talked about how his family has been in therapy to deal with having him for a Dad/husband. But he’s been able to stay married for 30 years. He said “I’d never say that ADD/ADHD is a gift or a blessing. And if someone says it is a gift, I’d love to return it.” Here http://www.additudemag.com/adhd/article/8615.html It’s a great article you guys. I hope ya have the patience to read through all this.

Some work pays better than others. I’m glad I took the time to read it.

Peace n happiness you guys. Good luck remembering to…. that list is endless huh?

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[Scattybird]

Ah Jim and ashockley. Sorry – I didn’t mean to sound so secretive – well, I did a bit. It was my birthday and one I wanted to forget about so as a distraction I booked myself a whole days worth of helicopter flying lessons.

I was being secretive because (1) it seems wrong to jump around saying what I did because it was stupidly expensive and I know money is really tight for lots of us here; (2) I blew a significant amount of my house repair savings on one day of pleasure and it took a while to save up – probably not sensible; (3) as a result it’s going to take longer to fix the house and it’s getting in a desperate state.

Not things I really want to think about!

So all in all I didn’t want to admit to it really BUT I have no regrets! The house can wait – it was a completely wonderful experience!!!!!

Who needs a functioning house that isn’t subsiding when you can have a day in a helicopter instead?! Mmm – that’s rhetorical!

Problem is now I want to have lessons proper and they are unaffordable plus I don’t think they like ADHD and I’d have to declare it if I did it again. Think it’s the meds they don’t like.

Anyway, I didn’t take my Ritalin that day in case they asked if I was taking any medication and I really didn’t need it. The adrenalin was more than enough! I have never concentrated so hard for so long in ages.

Yesterday I was still buzzing so much I did 4 hours of gardening after work!!

Unfortunately Ritalin is cheaper than heli lessons so guess I’m grounded now.

If anyone wants to impulsively blow some money I’d recommend flying lessons as a way to do it.

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[JimC.]

@Scattybird: I can relate sort of, glad you had a great experience! As a mountain biker on the Nor-shore of Vancouver, it takes all your focus to stay on your bike and not get seriously injured, which I think is a fun way to spend the day (not in injured, but focused) Post ride there’s a bit of blissful faint endorphin action, so I do it over and over and over. Adderall helps. next time I’d try the Ritalin, just don’t go under any bridges!

Enjoy the ride with me on this link: http://www.pinkbike.com/video/5179/whofaved/ , I’m not in this video, but live below this trail and helped build in about 10 years back. Sometimes I think all of us doing this are ADD or similar.

Helicopter flying, far out

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[Scattybird]

Thanks Jim – I will check out your video in a while – am using the BB at the moment and it’s hopeless for videos. It can be my bed time viewing!

I would imagine you get a fantastic adrenalin rush from that kind of biking. If I wasn’t such a coward (and a lazy being!) I’d love to try it. But I saw a horrible biking accident a while ago and it put me off. A guy didn’t manage to stop on time and he and his bike went over a ‘cliff’. Anyway……

I suppose when you’re doing it you’re concentrating so much that any thoughts of danger are secondary.

Maybe I should give it a go. I want to experience that buzz again – I can see why you do it over and over again.

Odd you should say you think mountain bikers are ADD because the only ones I know actually are!

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[JimC.]

@Scattybird: I also do road riding and it is strangely meditative and calming; all new sports aside, just getting on a bike makes me a kid again and it’s just plain fun. Not for all, but if it works for you, then go for it!?! if you’r interested I can try to help get you started, and it’s less $ than learning to fly helicopters.

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[Scattybird]

OMG Jim! You are one BRAVE man doing that!! Great video – thanks for posting it. You must have fantastic balance as well.

When I was younger I used to cycle everywhere but I gave it up – not actively gave it up – it just happened. I bought a motor bike and liked the speed!

But it would be great to take it up. Actually I have no excuse really because I could cycle to work some days, but keeping it for pleasure would be better.

So…I have a bike in the garage which is very heavy but I could make a start. Thank you for your offer of help Jim – that would be great! If nothing else, having an interested party on board would be lovely.

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[Bill]

Hey Scattybird – A party on board a bike would be fun indeed!

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[Scattybird]

that’s funny Bill! It’s a shame we don’t all live closer or it would be doable – kind of.

I was feeling bad about putting your thread off topic but I realised you mentioned ‘motor’ skills in the title so with some lateral thought it might be perceived as sort of related.

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[JimC.]

@scattybird: you can e me here jcampbll at telus dot net. and I’m happy to get you back on a bike! Don’t correct my last name, there’s an ‘e’ missing.

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[Author]

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