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17 May 2018

Muris P et al. Child Psychiatry Hum Dev 2018; Epub ahead of print

Many parents refuse pharmacotherapy with psychostimulant medications as an ADHD treatment for their child. There are a number of explanations for this; for example, the lack of a consistently clear-cut diagnostic test could mean that a parent does not fully recognise their child’s condition and thus reduces their willingness to accept a pharmacological intervention. Although some parents may accept their child’s ADHD diagnosis, they may have negative attitudes towards psychostimulants, with concerns of their long-term benefit and the risk of side effects and substance use. Alternatively, working memory training (WMT)* is a non-pharmacological intervention that has been suggested as a treatment for children and adolescents with ADHD. Specifically, Cogmed WMT has been shown to improve working memory in several studies, yet its impact on inducing a significant reduction in ADHD symptomatology is more mixed. This study aimed to look at the applicability of Cogmed WMT in the real-life setting in everyday clinical practice compared with a stimulant. In addition, since the patients and parents included in this study were given a choice between Cogmed WMT, stimulant pharmacotherapy, or a combination of both, this study also enabled evaluation of the underlying reasons surrounding treatment choice.

This naturalistic study took place between November 2012 and June 2015 at Lucertis Maastricht, The Netherlands, an outpatient facility for children and adolescents with mental health problems. Ninety children and adolescents aged 6–16 years (mean age, 10.8 years; 64.4% male) diagnosed with ADHD using the Diagnostic and Statistical Manual of Mental Disorders – 4th Edition (DSM-IV), and their parents, were provided with an information leaflet about the treatment options and were informed there would be a pre- and post-intervention assessment for the patient with ADHD (1 hour per session) and their parents (20 minutes per session). Parents and their children were then asked to choose a treatment option, give the motives driving that choice, and state their level of confidence in the selected treatment. The primary means of determining treatment efficacy was through the administration of a pre- and post-intervention ADHD questionnaire (ADHD-Q), comprising 18 items covering the DSM-defined ADHD symptoms in three domains: inattention, hyperactivity and impulsivity. Finally, 1 year post-initiation of treatment choice, parents were contacted to determine how they subsequently viewed their original treatment choice on reflection, the current symptom level of their child and current treatments being employed.

The findings of the study were as follows:

  • Stimulant medication was selected by 30 parents and children (33.3%). This choice was driven by both positive and negative reasons; 46.7% of participants who selected this option felt that it represented the most effective option, while the remaining 53.3% deemed the Cogmed WMT too demanding.
  • Cogmed WMT was selected by 35 parents and children (38.9%) and was driven predominantly by negative reasoning. Of those who chose this option, 36.7% reported being strongly against the use of medication (including fears of addiction and side effects) while 40.4% felt medication was too drastic a step for their child. Only 22.9% reported selecting Cogmed WMT based on a belief it would be effective.
  • Combination treatment was selected by 25 parents and children (27.8%). It was a choice which was entirely positively driven, with 100% of parents reporting they wanted the best treatment for their child, and 20% of those feeling that Cogmed WMT would positively contribute to treatment.
  • These findings were also apparent in participants’ confidence ratings of the different options, with medication and combination treatment expected to be more beneficial (M = 7.38, standard deviation [SD] 0.93 and M = 7.74, SD 0.88, respectively) when compared with Cogmed WMT alone (M = 6.63, SD 1.22; F(2,87) = 9.12, p<0.001).
  • All three treatment arms showed significant reduction in ADHD symptomatology (inattention, hyperactivity and impulsivity) post-intervention as per the ADHD-Q (all p<0.05). The effect sizes in the stimulant medication and combined treatment groups were in the medium to very large range (Cohen’s ds between 0.76 and 1.76), whereas the effect sizes in the Cogmed WMT were all in the small to medium range (Cohen’s ds between 0.30 and 0.54).
  • At the 1-year follow-up interview, parents indicated that pharmacotherapy alone or with Cogmed WMT had been more helpful and more effective in reducing ADHD symptoms and improving their child’s daily functioning when compared with Cogmed WMT alone. Almost half (46.4%) of children and adolescents who originally used Cogmed WMT started using a stimulant medication at 1-year follow-up.

It is important to note that this was a naturalistic study and not a randomised controlled clinical trial, and the effects of Cogmed WMT, pharmacotherapy and the combined intervention cannot be directly compared. As parents and patients with ADHD were allowed to select treatment options, groups were not comparable, particularly with regard to reported levels of symptomatology, associated interference, comorbid psychological symptoms and executive functioning pre-treatment. Moreover, the differences in motives for a particular intervention differed between parents and individuals with ADHD, and this led to differences in the confidence ratings across the three groups.

This study reported that some parents and their children chose a non-pharmacological treatment for ADHD, as they feared that medication was associated with side effects and addiction, or considered it too rigorous a step. However, following 1 year of Cogmed WMT, many parents and their children were willing to accept the use of medication as an intervention. This could be a result of the modest effect of Cogmed WMT and the need for additional treatment, or may have resulted from the parents gaining more awareness of their child’s condition through their involvement in administration of Cogmed WMT. The authors concluded that rather than suggesting Cogmed WMT is ineffective, it could be an appropriate intervention in clinical practice.

Read more about Cogmed WMT here

 

*WMT refers to the cognitive system that is responsible for holding information temporarily, allowing further processing and reflection of one’s responses during an activity, thus preventing the immediate sensory input by the environment
Cogmed WMT consists of visuospatial (remembering positions of objects on a grid) and verbal (remembering phonemes, letters or digits) working memory tasks, delivered via the official Pearson website. Participants were required to spend 45–60 minutes a day on the WMT, 5 days a week for 5 weeks. The Cogmed WMT is designed such that the difficulty level is adjusted to each individual child. Children were supervised by their parent/teacher during Cogmed WMT sessions

Muris P, Roodenrijs D, Kelgtermans L, et al. No medication for my child! A naturalistic study on the treatment preferences for and the effects of Cogmed working memory training versus psychostimulant medication in clinically referred youth with ADHD. Child Psychiatry Hum Dev 2018; Epub ahead of print.

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