Tracy Packiam Alloway, PhD

The topic of medicating individuals with ADHD is still controversial. That is why I am always interested when research on this topic is published. I was recently asked to write a commentary on one such article that will appear in ‘Developmental Medicine and Child Neurology’.

Children with ADHD exhibit deficits in both cognitive and behavioral domains. In particular, response inhibition has been proposed as a core element of individuals with ADHD that can impact both these types of functioning. Given the widespread prevalence of ADHD, with some reports as high as 16% of children receiving this diagnosis, treatment is a priority.

Stimulant medication, such as methylphenidate, is considered to improve certain cognitive functions in children with ADHD. The suggestion is that methylphenidate acts to increase levels of dopamine and norepinephrine, which are associated with attention and focus.

However, most research in this area has focused primarily on immediate-release stimulant medication. Clinical studies in continued-release of stimulant medication have produced mixed results and it is as yet unclear which cognitive and behavioral functions associated with response inhibition can be improved as a result of stimulant medication.

Thus, the authors—Blum et al—sought to investigate this issue. Children aged 6 to 12 participated in a double-blind placebo controlled crossover trial, using the individual’s most effective dose of OROS- methylphenidate. The benefit of this approach is that neither the person administering the medication, nor the child taking it was aware of whether they were receiving the medication or the placebo. The conditions were then switched, so the Medication group took the placebo, and the Placebo group took the medication.

The findings indicated that hyperactive and inattentive behaviors (measured by both parent and teacher ratings) improved when the child was receiving their optimal dose of OROS- methylphenidate. Cognitive functions also improved in some cases, but not all. For example, the students were no better at tasks involving motor inhibition and working memory.

Studies like this one by Blum et al. are very valuable because they raise the issue of the efficacy in using this approach for individuals with ADHD. Amidst increasing concerns regarding side effects and the potential for abuse, some parents and clinicians are seeking alternative methods to ameliorate the cognitive and behavioral deficits associated with ADHD.

One promising alternative is adaptive working memory training, where the intensity and difficulty of working memory sessions are individually customized to the aptitude of the child. Traditionally, working memory was viewed as genetically fixed, and thus unable to be modified by an individual’s environmental experiences or opportunities. However, an increasing body of recent studies has challenged this notion, demonstrating that considerable cerebral plasticity exists within the developing brain and that working memory capacity may potentially be improved by environmental intervention and support.

Such findings highlight important opportunities for improving the learning, behavioral and social opportunities of the large number of children with working memory problems. Working memory impairments are widely reported in students with ADHD, and several studies have found that adaptive working memory training can improve behavior ratings by parents (Klingberg et al., 2005), as well as IQ and attainment scores (Alloway, 2009).

Research like Blum et al.’s illustrates the limited impact of continued-release of stimulant medication and highlight the need to consider alternative forms of intervention. When such measures prove to be insufficient, then the option to prescribe stimulant medication can be discussed with a physician who is aware of the severity of the individual’s symptoms. Care should also be taken when considered the type of stimulant medication—immediate vs. continuous release; as well as the optimal dose for the individual.

References

Alloway TP. Cognitive Training: Improvements in Academic Attainments. Professional Association for Teachers of Students with Specific Learning Difficulties 2009; 22: 57-61.

Klingberg T, Fernell E, Olesen PJ, Johnson M, Gustafsson P, Dahlstrom K. et al. Computerised training of working memory in children with ADHD -a randomized, controlled trial. J of the Am Acad of Child and Adolescent Psychiatry 2005; 44: 177-186.

Students with ADHD often have average or even high IQ. Yet they struggle with learning. I was quite puzzled by this for some time. Then I noticed a similar pattern of behavior problems, such as fidgeting, highly distractible, and lacking motivation, coupled with high IQ in an entirely different group—gifted students. Although their behavioral profile is similar between these two groups, they are driven by different reasons. The ADHD student has difficulty controlling their behavior and inhibiting inappropriate actions, while gifted students ‘act up’ out of boredom or being insufficiently challenged. )
Here is a case study of a boy from my research collaboration with the National Association of Gifted Children in the UK.

Joseph was very articulate and our assessment with him took longer than usual as he asked questions frequently. He loves English and History and tried to begin many debates and discussions with us during the assessment. His mother says that he spends hours and hours researching topics that he finds interesting – these might not be related to school. However, his pattern of behavior on the Conners Rating Scale indicated a very high ADHD. When asked about his motivation levels, he was very apathetic and negative about his school and learning in general.

These two groups of students—ADHD and gifted ones—had similar behavioral patterns and IQ scores. Yet they had very different learning outcomes. Why? When I looked more closely at their scores, I found their working memory profiles were very different. As you would expect, the gifted students had excellent working memory, which was linked to their above average academic outcomes. In contrast, the ADHD students’ poor working memory was linked to low achievement. Average IQ does not suggest average grades. If a student has a working memory problem, they will struggle academically even though they have average IQ ability.

EXCERPT FROM Improving Working Memory

Did you every play Marco Polo as a child? I used to love closing my eyes and spinning around faster and faster when I was ‘It’. Now imagine playing that game in the middle of a busy intersection. Cars are honking, dogs are barking, siren sounds get closer, and people are yelling. You are ‘It’ and are trying to listen to the where ‘Polo’ is coming from. For a student that is hypersensitive to sound, touch, and light, the world is a chaotic place. As a result, new surroundings can be very disorienting for them. Some label such sensory hypersensitivity as sensory integration dysfunction (SID).

The label of sensory integration disorder may come as a welcome relief to some parents who want an explanation for why their child has not reached certain milestones, like walking or talking. As parents, it is instinctive to worry that something may be wrong with our child. We view Bobby obsessively lining up cars in a row as a symptom of Autistic Spectrum, and Daisy mixing up words as dyslexic. Yet, does a label like SID actually help parents? Although it is a ‘condition’ identified by some health practitioners, there are many psychologists and neurologists who think that the label of SID is actually doing a disservice to parents. I will outline several reasons for why this is the case. The first issue is that the difficulties associated with SID reflect a neurodevelopmental immaturity, rather than a distinct disorder. The absence of adults receiving a diagnosis of SID begs the question of whether in some cases, the child might outgrow the symptoms naturally without the need for expensive and unproven treatments. The next point is related to this issue as sensory hypersensitivity is a symptom of other disorders such as dyspraxia, ADHD, and Autistic Spectrum. A label of SID might falsely lead to parent to feel comforted that their child is receiving support, when more serious problems might be going undiagnosed, and as a result, untreated or supported. Finally, there are very few published clinical trials on either the diagnosis of SID or the treatment of it. Those that are published have been criticized as flawed research, due to small samples and heterogeneous samples (ie, including students with ADHD, ASD, in the sample). It appears then while the symptoms of SID are indeed real, they can point to more serious disorders which merit diagnosis and treatment.

The WISC is a standardized assessment of cognitive abilities in children aged 6 to 16 years and revised versions include the Working Memory Index.

DIGIT SPAN

The Digit Span test is a highly validated method of measuring aspects of working memory capacity, and is fast and reliable to administer. However, the method of combining forward digit span with backward digit span scores conflates verbal short-term memory and verbal working memory. This can artificially raise a student’s working memory score as they may do well on the forward digit span subtest, yet struggle in the backward digit span subtest.

LETTER-NUMBER SEQUENCING

This subtest draws heavily on the student’s knowledge of basic number skills and the alphabet. Students may perform poorly on this subtest, not because they have working memory problems, but because they struggle in remembering the alphabet or numbers in the correct sequence.

ARITHMETIC

The supplementary test, arithmetic, can also be calculated into the Working Memory Index. However, it is not clear that this test genuinely provides a direct measure of working memory measure, although it certainly would be expected that children with poor working memory would be slow to develop the necessary mathematical knowledge to support good levels of performance on this test. It is therefore not recommended that arithmetic test scores are interpreted as direct assessments of working memory.

There are other limitations to the Working Memory Index. One practical drawback is that the WISC-IV is cannot be used with children below 6 years. Another is the heavy reliance on verbal information. This raises the possibility that a student who has particular problems in handling verbal information mentally may perform at low levels on these tests simply because of the format of the material, and not because of working memory problems. For example, students who fail to develop language struggle greatly on these kinds of memory test that involve spoken language, but perform at entirely normal levels when the information that is being remembered is non-verbal - such as remembering a pattern in a grid or the location of an object on a screen. So although these children have substantial working memory problems, they are probably secondary rather than primary in nature, and they also have working memory strengths that would be undetected by administration of the WISC-IV.

Read more in Working memory and learning: A practical guide

The typical characteristics of students with poor working memory are as follows. They have normal social relationships with their peers, but are reserved in group situations in the classroom, in which they tend not to participate actively.  Their academic progress is very slow, particularly in reading and maths. They struggle to meet the working memory demands of many classroom activities, and have particularly problems in remembering and following instructions, in coping with tasks that involve combining the storage of information with demanding mental processing, and in keeping track of their progress in complex tasks.

Teachers view the students as having poor attention span and being highly distractible, features that we suggest are consequences of the loss of information that is relevant to the ongoing task from working memory, resulting in task failure and loss of focus.

While these characteristics typify the majority of students with working memory problems, they are not on their own sufficient for a definitive ‘diagnosis’. Reduced working memory capacity is not the only cause of many of these classroom difficulties, although there is growing evidence that it is the most common one.

Some students can have a broader constellation of cognitive problems of which reduced working memory capacity is only one. Several relatively common developmental disorders in which working memory is impaired, including language impairment, dyslexia, ADHD, and developmental coordination disorder (dyspraxia). Importantly, these disorders have distinct working memory strengths and weaknesses that impact academic attainment.

Clear identification of working memory problems and their underlying causes is therefore a priority, and a range of methods has now been developed to support the assessment of working memory in children. I will discuss different assessments in next week’s blog.

Excerpt taken from Working memory and learning: A practical guide.

I was recently invited to write a blog for SharpBrains on a paper I published on this topic. Here is a copy of the blog post.

Working memory is our ability to store and manipulate information for a brief time. It is typically measured by dual-tasks, where the individual has to remember an item while simultaneously processing a sometimes unrelated piece of information. A widely used working memory task is the reading span task where the individual reads a sentence, verifies it, and the recalls the final word. Individual differences in working memory performance are closely related to a range of academic skills such as reading, spelling, comprehension, and mathematics. Crucially, there is emerging research that working memory predicts learning outcomes independently of IQ. One explanation for the importance of working memory in academic attainment is that because it appears to be relatively unaffected by environmental influences, such as parental educational level and financial background, it measures a student’s capacity to acquire knowledge rather than what they have already learned.

However little is known about the consequences of low working memory capacity per se, independent of other associated learning difficulties. In particular, it is not known either what proportion of students with low working memory capacities has significant learning difficulties or what their behavioral characteristics are. The aim of a recent study was to provide the first systematic large-scale examination of the cognitive and behavioral characteristics of school-aged students who have been identified solely on the basis of very low working memory scores.

In screening of over 3000 school-aged students in mainstream schools, 1 in 10 was identified as having working memory difficulties. There were several key findings regarding their cognitive skills. The first is that the majority of them performed below age-expected levels in reading and mathematics. This suggests that low working memory skills constitute a high risk factor for educational underachievement for students. This corresponds with evidence that working memory impacts all areas of learning from kindergarten to college. It is a basic cognitive skill that we need to perform a variety of activities, and we use it in core subjects like reading and maths, as well as general topics like Art and Music. Crucially, this pattern of poor performance in learning outcomes remains even when students’ IQ is statistically accounted. This fits well with evidence suggesting that working memory is even more important to learning than other cognitive skills such as IQ. For example, in typically developing students, I found that their working memory skills, rather than IQ, at 5 years old were the best predictor of predictor of reading, spelling, and math outcomes six years later.

The next major finding from the studies of students with working memory difficulties is that teachers typically judged the students to be highly inattentive, and have short poor attention spans and high levels of distractibility. They were also commonly described as forgetting what they are currently doing and things they have learned, failing to remember instructions, and failing to complete tasks. In everyday classroom activities, they often made careless mistakes, particularly in writing, and had difficulty in solving problems. In contrast, relatively few of the students were judged to exhibit the high levels of hyperactive and impulsive behaviors.

The final key finding is that students with working memory difficulties take a much longer time to process information. They are unable to cope with timed activities and fast presentation of information. As a result, they often end up abandoning the activities all together out of frustration. One way to overcome this difficulty is to provide them with a shorter activity and to allow for more time during tests.

Studies such as these demonstrate that students with working memory difficulties have an extremely high risk of making poor academic progress and are relatively common in the classroom - they represent approximately 10% of their age group in mainstream schooling. Without early intervention, working memory deficits cannot be made up over time and will continue to compromise a child’s likelihood of academic success. How can we support students’ learning? The first crucial step in supporting students with working memory impairments is proper diagnosis, which can be conducted by a school psychologist. However, at present working memory problems often go undetected in students or are misdiagnosed as attentional problems. There are several test batteries that can be used to assess working memory, including the Working Memory Index in the WISC. However, most assessment instruments that are currently available require considerable experience in the administration, scoring and interpretation of cognitive tests. One useful tool to identify and support students with working memory impairments is the Automated Working Memory Assessment (AWMA; Alloway, 2007 published by Pearson) . The benefit of the AWMA is that it is designed to provide a practical and convenient way for non-expert assessors such as teachers to screen their pupils for significant working memory problems, with a user-friendly interface. The automated presentation and scoring of tasks provide consistency in presentation of stimuli across participants, thus reducing experimenter error. The AWMA was used in the study described here, as well as in numerous peer-reviewed journal articles on the role of working memory in learning, anxiety, and development in typical and clinical populations.

The main goal of this article was to explore the link between working memory and academic performance. On the basis of a large-scale screening study of over 3000 student, 10% were found to have working memory impairments that jeopardize their chance of academic success. The majority perform below age-expected levels in all areas of learning and struggle to follow simple instructions in the classroom. These difficulties highlight the need for early assessment to identify those at risk. In a future article, I will discuss ways to help students with working memory problems, inc luding clinical trials demonstrating successful transfer of cognitive training to academic attainments.

REFERENCE:  Alloway et al. (2009). The cognitive and behavioral characteristics of children with low working memory.  Child Development, 80 , 606-621.

READ IT AT SHARPBRAINS

YOU CAN ALSO READ IT HERE AT SCIENTIA PRO PUBLICA (under ‘Psychology’)

What’s the difference between having ADHD and poor working memory? Children with ADHD not only have trouble sitting still and are often acting out, teachers usually comment that their classroom performance is poor and they often forget vital information, such as instructions, the right books for their classes, where they need to be. Do they have poor working memory?

Yes. One of the most consistent findings in scientific studies is that children with ADHD have very poor working memory, particularly when they have to remember visual information, such as graphs or images. As part of a government-funded project that I lead, I found that children with ADHD were 4x more likely to have working memory problems compared to their peers without attention problems. This has serious impacts on their learning. As a result of their working memory problems, they will struggle in the classroom.

This doesn’t mean that all children with poor working memory have ADHD. In fact, as part of a different government-funded project, I found that children with poor working memory (that don’t have ADHD) are actually NOT impulsive or hyperactive. They aren’t disrupting the class, they aren’t bouncing off the walls. As a result, the teacher doesn’t notice there is a problem. At least not until it’s too late. Not until they start failing because they haven’t grasped key concepts in the lesson or can’t understand what to do and how to do it.

Ultimately, both students with ADHD and those with poor working memory need our help. Addressing their behavior won’t bring lasting change to learning.  Supporting their working memory is the only way to help make sense of what goes on in the classroom. Find out more about testing and supporting working memory.

As a parent of a 10 year old who is struggling in school, even with an Individualized Education Program, what hope is there to catch up our child?  He’s realizing that he is not able, and is now suffering with self-confidence.  In the US this is not well known, what tools are available?

-Cheryl, AZ

The term ‘working memory’ refers to the capacity to store and manipulate information for brief periods of time. It provides a mental workspace that is used in many important activities in learning. Working memory is a pure measure of a child’s learning potential. As it is not influenced by the child’s prior experiences such as pre-school education, or their socio-economic background, it tells us about a child’s capacity to learn. In contrast, school-based assessments or even IQ tests measure knowledge that the child has already learned.

Behaviors in the classroom characteristic of children with working memory impairments include: failing to obey instructions, not listening, being in a world of his own, and not being able to copy sentences from the board. It is very common that students with poor working memory begin to lose their confidence. They feel unmotivated as every time they try, they can’t remember what they are supposed to do.

There are a few options available to you.
1. The first option is to receive a professional psychological report on your child’s working memory profile, ways in which it will impact their learning, and suggested strategies that the classroom teacher can use, as well as additional activities that you can use at home. This professional report will also take into account any other psychological assessments to provide you with a complete picture of your child’s cognitive skills and the link to working memory. This is suitable for 5 to 16 year olds. More details are available here, click on Expert Consultation. This is an online assessment and has been used by parents in the USA and the UK, as well as around the world. Feedback from other parents is available HERE.

3. The next option is a cognitive training program that we are using in schools across the UK, USA, and Australia. In a recent scientific study, JungleMemory© was found to improve not only working memory but IQ, Reading, and Math. The students who used the program increased their grades from a C to a B, and from a B to an A in just 8 weeks. This is very exciting, as other programs have not demonstrated such an improvement. This is suitable for 6 to 16 year olds and is endorsed by the Psychological Corporation.

For more information, go to the homepage and click on each bullet point. You can also try a free demo and watch a short video presentation HERE.