What is ADHD and its cognitive stimulation

Attention deficit hyperactivity disorder (ADHD) is a neurobiological disorder that starts during childhood and manifests through attention issues, hyperactivity and/or impulsivity. These deficits affect several areas of the child’s life, especially in academics, but how can we help them improve their cognitive capabilities so that academic performance is also improved?

Knowledge on the causes and most recent available treatments, such as the different types of cognitive rehabilitation, is fundamental to offer children with ADHD useful tools that help them obtain improvements in the altered functions, such as working memory and sustained attention.

What is ADHD?

Attention deficit hyperactivity disorder or ADHD is a neurobiological disorder that presents patterns of attention deficit, hyperactivity and/or impulsivity and, many times, is associated with learning disorders.According to the Spanish Pediatric Association, the prevalence of ADHD was estimated as being between 4 and 6%. 

However, these figures have been revised throughout the years and prevalence is currently situated between 10 and 20%, depending strongly on the assessment tests employed. Symptoms, or signs of ADHD, start to manifest before the age of seven and are present in two or more development contexts of the child (for example, at home, at the school, etc.). 

Different studies have remarked that between 50 and 80% of kids with ADHD continue to show symptoms during adolescence and approximately 50-65% during adult life. Diagnosis is much more frequent in boys than in girls and has been associated with low income or adverse psychosocial situations.

What are the causes of ADHD?

There is no single factor that explains ADHD entirely, with several causes being associated with the same disorder. The factors related to its development can be grouped in the following categories:

• Genetics: genetics plays an important role in the development of ADHD. Studies carried out with twins, families and adopted children demonstrate that close relatives of the people who suffer from ADHD have a higher probability of presenting the disorder, than people with no family history.

• Neurotransmitters: neurotransmitters are biomolecules that enable the transmission of information from one neuron to another, by synapses. Of all neurotransmitters found in the brain, dopamine is the most related to ADHD. A maladjustment in dopamine has been associated with poor cognitive and executive functioning.

• Electrophysiology: children with ADHD present alterations in their electroencephalogram (EEG), more specifically an increase of theta waves in the frontal lobe of the brain. There is also a different ratio of theta and beta poweer, with an excess of theta and lack of beta. The following picture shows the QEEG of a specific ADHD case.

• Psychosocial factors: ADHD has been associated with different adverse variables such as stress, maternal anxiety, marital disagreements, emotional disconnection, criticism of parents towards the child, inadequate parenting, psychopathological disorders of the parents, etc.

What are the types of ADHD and what are the main symptoms? 

There are three types of ADHD: with a predominance of attention deficit, with a predominance of hyperactivity/impulsivity, and the combined type. The main characteristics of each type are described next.

Inattentive type

In the inattentive type, the children present behavior that is characterized by attention deficit without or with very mild hyperactivity/impulsivity symptoms. This is more common in older girls with academic problems. Some of the characteristics of the inattentive type ADHD include:

• Show problems on paying attention to details and commits careless mistakes in school assignments or at work.
• Has difficulties in sustaining attention, including during ludic activities.
• Seems not to listen when someone is talking to them.
• Does not follow instructions or complete chores.
• Has a hard time organizing tasks and activities.
• Avoids or does not like tasks that required sustained mental effort. 
• Frequently loses objects necessary for tasks and activities.
• Is easily distracted by irrelevant stimuli.
• Neglects daily activities.

Hyperactive-impulsive type

Is the most conflictive type because the symptoms are more evident and striking, putting the child in the spotlight. Some of the symptoms are: 

• Excessive movements of hands and feet, is squirmish and fidgety.
• Acts out of turn.
• Runs and jumps excessively in inadequate situations and in inappropriate times.
• Has trouble engaging in quiet activities.
• Is constantly “on the go”.
• Talks constantly.
• Blurts out answers before questions are completely formulated.
• Has a hard time waiting for his/her turn.
• Interrupts other people and disrupts the activities of others.

Combination type

In this group, the children manifest symptoms of both previous types and present, generally, higher deterioration and higher comorbidity rates with other disorders. This type is more frequent in boys than in girls.

What other problems are presented by ADHD children? 

Besides the aforementioned symptoms, children with ADHD mental disorder present educational issues and learning disorders due to the challenges associated with the defective cognitive processes. 

Usually, they show slightly lower performance in general intelligence tests, worse school performance and completing their homework can turn into a titanic task due to their  inability to focus. 

Other difficulties are social and behavior issues arising from the way other people judge and interact with children with ADHD. Since they can be often a nuisance, disobedient, noisy and even aggressive, other people may reject or avoid them in their daily life activities.

When children start to be conscious about their difficulties and problems, both at academic and interpersonal levels, they can feel guilt and uselessness. Many time this occurs due to the several reprimands received as a consequence of their lack of attention or impulsive behavior. These children can even suffer depressive and anxiety-related symptoms (more information on depression and its cognitive rehabilitation). These emotional symptoms and personal dissatisfaction can worsen the symptoms of ADHD and affect more areas of their life, with repercussions on close relatives.

ADHD therapy: How to treat a child with ADHD?

There are currently different ADHD treatments that have been tested and proved effective to minimize and control the symptoms and their impact. As this disorder affects different aspects of life, it is important to plan an integral, individualized multidisciplinary intervention that is adapted to each particular case and tackles the different cognitive, behavior, emotional, educational and family-related aspects. 

In this way, the objective of the behavior therapy is oriented to controlling and improving the main symptoms of attention deficit and hyperactivity/impulsivity, as well as tackling the previously mentioned associated issues (school performance with special educational approaches, improve interpersonal relationships by involving family and school, etc.).

ADHD most common treatment is pharmacological, mainly based on the use of stimulants or nootropics such as methylphenidate and dexamphetamine. These drugs reduce impulsivity, improving impulse control, and excessive activity, aggressive and defiant behavior, and improves attention. Nevertheless, not all people benefit from these treatments and side effects can appear. Also, when the medication is stopped, the symptoms reappear.

Psychological interventions are another option. They are based on the use of different strategies and techniques, such as behavior changing, social ability training, psychoeducation or contingence management techniques, among others. The objective is to intervene on those cognitive capabilities that are altered, attention and concentration, while simultaneously working on other aspects such as emotional, behavioral or relationship issues. The most positive results recently obtained for ADHD combined medication and psychological interventions.

Family interventions are oriented to help address and solve conflicts in the family environment with all the family members, especially for the parents who many times are lost and feel guilty. The main objective is to give them adequate educative and behavior changing guidelines for their relationship with the children, without them feeling “special” and judged beforehand.

When addressing ADHD, educative interventions are also fundamental to improve school performance that is usually low due to the difficulties in executive functions, cognitive capabilities and behavior problems. Informing and training the teachers on the possible manifestations of ADHD, as well as establishing strategies and action protocols, enable to carry out curricular adaptations that ease learning and improve results at academic levels.

Cognitive stimulation for ADHD 

In addition to the previously described treatments to treat the nuclear symptoms of ADHD, there are also other strategies that can help in the neuropsychological rehabilitation of affected executive functions and cognitive capabilities (sustained attention, concentration, memory, planning, problem solving, etc.).

A classic cognitive rehabilitation approach are cognitive stimulation exercise workbooks that work on capabilities such as memory, attention, orientation, etc. These cognitive stimulation workbooks are available at different difficulty levels, so they can be employed with children and adolescents of different ages, and even adults. These workbooks are easy to find in bookstores and on the internet. Although very utilized, their use is complicated because these workbooks are not appealing to people with ADHD, presenting in many cases boring activities that require extra effort to complete.

The well-known “mental training” or “brain training” games are another option for cognitive stimulation, which is more entertaining and motivating for people with ADHD. These include games such as labyrinths, mazes, reasoning problems, search for symbols, mental calculations, etc. that work on the cognitive rehabilitation of the affected capabilities. 

Although many of these computer games offer the possibility of adapting the difficulty levels to each user, there is limited evidence on the transference of the learning to cognitively close tasks and daily life activities. However, these video games are widely used as cognitive rehabilitation exercises because they are easily accessible and can be employed practically anywhere and anytime.

Another type of cognitive rehabilitation is neurotechnology, which registers individual brain activity, especially the theta/beta pattern of people with ADHD, and adapts necessary interventions. Changes in brain neuroplasticity are produced, related to rehabilitation and improvement of the cognitive capabilities such as sustained attention, memory and processing speed. Elevvo Medical, developed by the Bitbrain neurotechnology company, is a tool utilized for cognitive rehabilitation of people that suffer pathologies or disorders that include cognitive deterioration or decline, such as ADHD.

Neurotechnology for cognitive rehabilitation in ADHD 

Attention deficits are a key symptom in people that suffer from ADHD. Rehabilitation of these deficits, as well as of other executive functions and cognitive capabilities that are altered, can be essential to improve the clinical aspects of the specific disorder and provide general personal and emotional wellbeing. One of the ways to address these cognitive deficits is the use of cognitive rehabilitations programs such as  Elevvo.

Elevvo is a scientifically-validated cognitive rehabilitation program, employed in several populations and utilized to complement other conventional treatments. Bitbrain, in collaboration with the Hospital Miguel Servet, the Instituto Aragonés de Ciencias de la Salud (IACS) and the Universidad de Zaragoza, carried out an exploratory study in children with ADHD (Escolano, 2014). 

The study investigated the effect of 18 Elevvo sessions, obtaining remarkable results at cognitive level (16% and 10% improvements in the correct answers of Letter-Number Digit and Sequencing tests, (WISC-IV), respectively), indicating improvements in working memory and sustained attention. The parents reported improvements in attention and hyperactivity/impulsivity, approximately 9 points for each variable in Conners’ Parent Rating Scales (CPRS-R).

The Elevvo cognitive stimulation programs are applied by professionals that help the child carry out a series of simple cognitive training programs. The program includes several rehabilitation sessions, along with two evaluation sessions (before and after the rehabilitation sessions). The program provides comparative results evaluating neuroplastic changes (which are the neurophysiological support of cognitive improvement) and cognitive changes.

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