There are several cognitive training approaches that can be used as interventions for children and young people. They can potentially impact on conditions such as ADHD, anxiety and depression, as well as learning disabilities. Here we look at three interventions; working memory training, cognitive bias modification and attentional bias modification.

Working memory training

Working memory allows people to store information in their minds for a short period of time and use it in their current thinking. Think of it as a kind of mental workspace, which is used for things like reading, writing, maths, comprehension, planning and problem solving. Low working memory capacity can make it more difficult for children to filter out irrelevant distractions (Conway et al.,2001). It’s also been suggested that working memory is the most important factor in determining someone’s general intellectual ability (SüB et al., 2002).

For some children working memory doesn’t follow a typical pattern of development. Deficits are common in children and young people with developmental disorders and learning difficulties, such as ADHD (Martinussen, 2005) and specific language impairments (Gathercole et al. 2005).

If working memory is not functioning properly it causes significant problems in the classroom and can lead to poor academic performance (Gathercole et al., 2005). Children with working memory problems may be easily distracted and inattentive, have difficulty following and remembering instructions, be unable to finish work and make slow progress with step by step tasks that need an accumulation of knowledge.

Research on working memory initially focused on verbal working memory, but evidence shows that there is a separate working memory capacity for visuospatial material that is also important for learning. Visuospatial memory scores are strongly linked with performance in mathematics and science (Gathercole, 2005).

While there is evidence that working memory problems might be one of the core deficits in ADHD, LD and learning problems, there is now a significant amount of research showing that working memory capacity may be plastic and trainable (Constantinidis and Klingberg, 2016).

There are two main approaches to tackling poor working memory:

• A classroom-based approach where teachers adapt the way they teach, to reduce the memory load on a child. The downside of this approach is that children do not learn to internalise the strategies they need to improve memory
• Improving working memory by training, ie practicing working memory tasks.

Working memory training is computer-based training, where a child or a young person trains intensively on specific tasks for a continued period. The training programmes are adaptive: after successful performances, the difficulty of the tasks increases. There are several commercial, computer-based, working memory training programs; the most well-known is probably CogMed which is widely used in schools and clinics. It is based on eight different exercises involving both visuospatial and verbal working memory tasks.

Cognitive Bias Modification (CBM)

CBM is a cognitive training exercise whereby common distortions in thinking are changed using a series of basic computerised selection tasks (for example, by attuning to positive images instead of negative ones) (Christea 2015).  It is largely used as an intervention for treating anxiety or depression and its potential lies in its ability to be delivered anywhere, without the need for a psychological therapist.

There are a number of cognitive biases, including attentional and interpretation bias. Biases are essentially habits of thinking, such as seeing a glass half empty or half full. People who are anxious pay more attention to things that are frightening or threatening; this is an attentional bias. People who are depressed tend to see themselves and the world as negative, which makes them biased towards seeing the negative rather than the positive side of things. This is a negative interpretation bias.

The theory is that if cognitive biases could be eliminated or reversed this may reduce anxiety. This type of cognitive training is usually delivered with a computer programme which teaches participants to either shift their attention away from something threatening, or to interpret ambiguous situations in a positive or benign manner. One of the main methods of doing this is by using Attentional Bias Modification.

Attentional Bias Modification

Attention Bias Modification Treatment (ABMT) is a relatively new approach which involves computer-based treatment that targets threat-related attention in people who are anxious. The programmes are usually repetitive tasks designed to train attention away from images that might provoke anxiety and more towards neutral images. This way, people learn to focus their attention away from negative images.

Working memory training

Ongoing research is exploring whether improvements in memory translate to other abilities, such as academic and reasoning ability (Constantinidis and Klingberg, 2016). However, there are several studies that show a reduction in inattentive behaviour in day to day life after working memory training (Constantinidis and Klingberg, 2016). This includes improvements for children with ADHD (Klingberg et al., 2005, Green et al. 2012, Bigorra et al. 2016).

Training that includes both verbal and visuospatial components appears to have the most impact, compared to training that focuses on one area alone (Danielsson, 2015).

In children and young people with learning disabilities, working memory training appears to give reliable short-term improvements in verbal and visuospatial working memory, and word decoding (Janneke 2016).

The evidence for the benefits of working memory training for children and young people with ADHD is currently mixed. A 2015 meta-analysis by Cortese showed that working memory training has a moderate to large effect on the symptoms of inattention (an effect of 0.3-0.5). A meta-analysis of Cogmed WM training on inattentive symptoms in daily life found a similar average effect size (Spencer-Smith and Klingberg, 2015). That is roughly equivalent to the effect of some antidepressant medications of around 0.3 or less (Kirsch 2008).

A randomised controlled trial by Chacko in 2014 found that computerised working memory training has effects on certain aspects of working memory in children with ADHD but doesn’t appear to impact on ADHD symptoms, objective measures of attention, hyperactivity and impulsivity, or academic achievement. Half of the children in the study also had Oppositional Defiant Disorder and were largely from the same social economic group. More research is needed to test whether working memory training is less effective for these groups.

Cognitive bias modification

We know that cognitive bias exists, and that when people are anxious or depressed they selectively tune in to anxiety-provoking stimuli or focus on negative information.

The quality of research on cognitive bias modification is generally poor. Initially promising results from studies in adults haven’t been reflected in studies with children and young people and the drop-out rate from interventions is high (Lau, 2015).

Cognitive bias modification interventions for children and adolescents appear to have no effect on mental health generally, or anxiety or depression (Christea, 2015). However, these interventions do appear to influence cognitive biases (Christea, 2015).

Attention Bias Modification (ABM)

It is well established that one of the hallmarks of anxiety is an attention bias towards threatening information (Bar-Haim, 2010).

Much of the research in this area has been done in adults and, as yet, there is little high quality evidence in children and young people. What evidence there is suggests that generally ABM works as a treatment for anxiety in children and young people (Lowther 2014).

Working memory training

We don’t really know what the most effective type of working memory training is, and what aspects are important in their design. It’s also unclear if, and how, short-term effects from memory training remain over time and can be transferred to everyday activities (Danielsson, 2015).

Although the benefits for working memory training are unclear, we don’t know whether cognitive training has little potential per se, or whether it’s the way that working memory training is approached and delivered that isn’t yet right (Gathercole 2014).

Cognitive Bias Modification

We don’t know whether, despite the impact it has on biases, cognitive bias modification leads to any significant improvement in symptoms (Christea, 2015).

We also don’t know what impact CBM has on healthy young people, and therefore its potential to prevent anxiety and depression. (Lothmann, 2010, Chan, 2014).

Attention Bias Modification (ABM)

The research isn’t clear whether AMB would work for different types of anxiety disorder, whether it can be used as a standalone treatment, or whether it needs to be used alongside other interventions.

Cognitive bias modification research is still in a transition from laboratory to real-world clinical settings. Addressing questions such as ‘how can we translate training in a laboratory to the real-world?’ may give us a clearer idea of how well these interventions work in a clinical context. Furthermore, as more rigorous studies are conducted, a clearer idea of the efficacy of CBM will hopefully begin to emerge.

Attention bias modification seems to be a hot topic at the moment. There are several ongoing clinical trials exploring attention bias modification in young people with anxiety, social anxiety and depression including those who haven’t responded to CBT.

Useful Resources

Understanding working memory, a classroom guide
Professor Susan E. Gathercole and Dr Tracy Packiam Alloway
https://www.mrc-cbu.cam.ac.uk/wp-content/uploads/2013/01/WM-classroom-guide.pdf

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