Co-Principal Investigators: Ellen C. Perrin and R. Christopher Sheldrick

Purpose: Clinically significant attention problems in children can present a considerable obstacle to learning in school. Because of concerns over medication, many parents and school systems are increasingly turning to alternative forms of treatment for Attention-Deficit/Hyperactivity Disorder (ADHD), including computer-based attention training systems. The aim of this project is to evaluate the efficacy of two computer-based attention training systems in schools. One program uses EEG biofeedback to train children with ADHD to focus on a task, and the other uses a standard computer format for cognitive retraining. Both systems have received increasing attention from parents, school administrators, and the general public. This research study, which focuses on the efficacy and adaptation of computer-based attention training systems for use in schools, is of direct relevance to educators and to families of children with ADHD.

Project Activities: Using a randomized clinical trial with a wait-list control, the research team is comparing changes in ADHD symptoms, academic achievement, and classroom behavior of children in three conditions: (1) attention training with EEG biofeedback, (2) attention training with standard computer format, and (3) wait-list control. Children in the wait-list control condition will be randomly assigned to receive one of the two interventions during the following school year. This protocol will be repeated twice over 4 years. Both interventions consist of 45-minute sessions conducted three times a week for a total of 40 sessions, to be completed over approximately 5 months. Children's exhibited ADHD symptoms, academic achievement, and classroom behavior will be measured in all conditions at multiple time points during the year of intervention and at a 6-month follow-up assessment.

Products: Products from this project include published reports on the efficacy of two widely used computer-based attention training systems for students with ADHD.

Structured Abstract

Setting: This study will take place in 16 elementary schools in the greater Boston area.

Population: Participants will include 144 children with ADHD in 2nd and 4th grades, who will be enrolled over 2 years, from a total of 5,000 students entering these grades in all 16 schools during the first 2-year enrollment period.

Intervention: This study includes two interventions. (1) The first intervention uses EEG biofeedback to train children with ADHD to focus on a task. (2) The second intervention uses a standard computer format for the training. Both interventions are administered by coaches and consist of 45-minute sessions conducted three times a week. Each intervention coach supervises two students at a time, teaches relaxation techniques, graphs attention-related behaviors, reviews the session with each student, and establishes a specific "attention goal" to work on until the next session. Sessions are scheduled in close collaboration with teachers so that key classroom instruction is not affected. Participants will complete a total of 40 sessions over the course of approximately 5 months.

Research Methods: After the initial assessment, students are randomly assigned to the EEG biofeedback intervention, the standard computer format intervention, or a wait-list control group. Two waves of data collection, each following identical enrollment and randomization procedures, commence at the beginning of two consecutive school years. Each year, the researchers enroll incoming 2nd and 4th graders with diagnoses of ADHD, so that children who are in 1st and 3rd grades during the first year of the study have the opportunity to enroll when they advance to 2nd and 4th grades in the second year of the study. One year after the initial intervention in each wave, children assigned to the wait-list control group are randomly assigned to complete one of the same two interventions.

Control Condition: The research team is using a wait-list control. During the evaluation year, children in the control condition receive whatever intervention strategies the school typically provides to help students with ADHD and standard community medical treatment, which might include medication for ADHD. In addition, the wait-list control group will receive an equivalent amount of relaxation training consolidated into five sessions. In the subsequent year, children in the control condition are randomly assigned to either the EEG biofeedback or the standard computer format condition.

Key Measures: Parents, teachers, and children of the immediate intervention group complete a systematic assessment at three time points (before the intervention, immediately after the intervention, and 6 months later). The wait-list control group completes assessments at the same time points, with additional assessments immediately after their intervention and 6 months later. Primary outcome assessments include measures of: (a) ADHD symptoms (Conners' Rating Scales-Revised; Behavioral Rating Inventory of Executive Functioning; Test of Variables of Attention); (b) academic achievement (AIMSweb assessment of basic skills, including reading, early literacy, early numeracy, mathematics, and spelling; and the Permanent Product Measure of Performance math test); and (c) classroom behavior (Swanson, Kotkin, Agler, M-Flynn & Pelham Rating Scale for teacher behavior; and the Classroom Observation Code of children's ADHD-related behaviors).

Data Analytic Strategy: Factor scores serve as the outcome variable in hierarchical growth curve models to assess changes between groups over time. Data are analyzed separately using repeated-measures ANOVA. Tukey post hoc tests are used for pairwise comparisons. Means, standard deviations, and effect sizes will be reported to facilitate comparison to other studies. Exploratory analyses include regression models to explore whether baseline child and demographic variables act as predictors of outcome or moderators of intervention. Univariate analyses are used to determine child characteristics that are associated with participation. Hierarchical growth curve models are used to assess the association between each intervention, clinical outcomes, and child and family characteristics across the multiple longitudinal measurements.

Project Website: http://www.drnaomisteiner.com/

Products and Publications

Journal article, monograph, or newsletter

Steiner, N.J., Frenette, E.C., Hynes, C., Pisarik, E., Tomasetti, K., and Perrin, E.C. (2014). A Pilot Feasibility Study of a Neurofeedback Intervention for Children With Autism. Applied Psychophysiology and Biofeedback, 39(2): 99–107.

Steiner, N.J., Sheldrick, R.C., Frenette, E.C., Rene, K.M., and Perrin, E.C. (2014). Classroom Behavior of Participants With ADHD Compared With Peers: Influence of Teaching Format and Grade Level. Journal of Applied School Psychology, 30(3): 209–222.

Steiner, N.J., Sheldrick, R.C., Gotthelf, D., and Perrin, E.C. (2011). Computer-Based Attention Training in the Schools for Children With Attention Deficit/Hyperactivity Disorder: A Preliminary Trial. Clinical Pediatrics, 50(7): 615–622.

Steiner, N.J., Sidhu, T., Rene, K., Tomasetti, K., Frenette, E., and Brennan, R.T. (2013). Development and Testing of a Direct Observation Code Training Protocol for Elementary Aged Students With Attention Deficit/Hyperactivity Disorder. Educational Assessment, Evaluation and Accountability, 25(4): 281–302.

Steiner, N.S., Frenette, E.C., Rene, K.M., Brennan, R.T., and Perrin, E.C. (2014). In-School Neurofeedback Training for ADHD: Sustained Improvements From a Randomized Control Trial. Pediatrics.

Steiner, N.S., Frenette, E.C., Rene, K.R., Brennan, R.T., and Perrin, E.C. (2014). Neurofeedback and Cognitive Attention Training for Children With Attention-Deficit Hyperactivity Disorder in Schools. Journal of Developmental and Behavioral Pediatrics, 35(1): 18–27.