Executive Functioning and ADHD in Children

ADHD has been increasingly identified as a disorder of executive functioning (brain-based self-management skills such as working memory, flexibility, organization and self-control) by experts such as Russell Barkley, Ph.D., and Thomas Brown, Ph.D. These observations are consistent with many of the difficulties that children with ADHD experience, such as forgetfulness (working memory), losing things (organization), and impulsive behavior (response inhibition). In addition, many children who don’t quite meet the criteria for a formal diagnosis of ADHD exhibit executive functioning deficits such as difficulty with planning and foresight, poor time- management skills, and inflexible problem solving. While problems with executive functioning and ADHD are not exactly the same disorder, they share many characteristics and treatments.

One of the more promising approaches to treating problems with executive functions and ADHD is the use of technology. Video games and other digital tools have been demonstrated to improve a variety of executive functions in children with ADHD. For example, a study in Germany by Oliver Tucha and colleagues utilized a computer training program called AIXTENT to train four different components of attention: alertness, vigilance, and selective and divided attention. They found that there was generalized effectiveness in training on attention skills such as vigilance, divided attention, and flexibility. A study conducted in Japan by Rui Nouchi and colleagues, using the video games Brain Age and Tetris, revealed that brain-training games can improve executive functioning skills like working memory and processing speed in young adults. Puzzle games (in this case, Tetris) were observed to improve attention and visuospatial ability compared to playing the brain-training game.

There is additional evidence that technologies like video games can improve working-memory skills, which are frequently identified as the single most important deficit observed in children with ADHD and are often a significant area of weakness for children with autism spectrum disorder. A series of studies conducted with Cogmed Working Memory Training — which utilizes a series of short, memory-based video games — has been demonstrated to result in real-world improvement and generalization of working-memory skills. Research from the Karolinska Institute in Sweden, led by Torkel Klingberg, suggests that this type of training leads to structural changes in the brain that directly result in improvement of the symptoms of Attention Deficit/Hyperactivity Disorder. Studies using Cogmed Working Memory Training have shown that consistently playing a series of short, adaptive (i.e., they get harder as the player improves) video games with intensity and sustained focus can improve both verbal working memory and visuospatial working memory. A study conducted by Joni Holmes and colleagues in 2009 found that treatment with Cogmed Working Memory Training resulted in enhanced concentration, but also improved a variety of academic skills, including reading and math. This study also suggested that working-memory training could improve self-awareness and strategic thinking, both considered to be executive skills. An additional study from the Karolinska Institute in Sweden led by Sissela Bergman Nutley found that video-game based working memory training can improve fluid intelligence skills, which are strongly related to executive functions such as cognitive flexibility, planning, and problem solving.

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Another series of studies undertaken in the Netherlands by S. van der Oord described the use of a video game called Braingame Brian, which consists of 25 training sessions of about 40 minutes each to train visuospatial working memory, inhibition, and cognitive flexibility. This game was structured so that the difficulty level was automatically adjusted to the child’s level of performance. To make it more game-like and enhance motivation, good scores led to the main character receiving extra “powers.” The study found that children with ADHD showed improvement in executive functions compared to a control group and to children treated with medication. More noteworthy, is that the effects were maintained in follow-up assessments, suggesting the children truly improved executive functioning skills while playing Braingame Brian.

The staff at LearningWorks for Kids conducted a pilot study of our executive functioning training program Playing Smarter in 2011 with a group of 10 children diagnosed with ADHD. This study demonstrated that children can improve their capacity to recognize where and when to apply executive-functioning skills. Video games such as Learn to Fly, Chuzzle, and Red Remover — all of which demonstrate multiple concrete examples of a particular executive function — were played for 30 to 60 minutes so that participants could become familiar with game mechanics and experience how they were using an executive-functioning skill. These popular short-form games were accompanied by classroom discussions and other activities to help promote generalization of the skill. At the conclusion of the study participants scored higher on a post-test, indicating that they were able to identify more examples of how each game-based executive function was applied in real-world activities than before the testing.

While research on the use of video games to improve executive functioning and ADHD is in its infancy, there are some common themes in the current studies. First, working memory training via video-game play holds great promise. Secondly, video game play needs to be adaptive, getting more challenging in order to achieve cognitive gains. Third, making the games engaging, fun, and motivating appears to contribute to the development of executive functioning skills. And finally, building in opportunities to generalize the game-based skills to real-world activities improves the likelihood of long-term effects.

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