Q&A: Video game holds promise for future of ADHD treatment

Michael Kofler
Michael J. Kofler

More children in the U.S. were being treated for ADHD in 2011 compared with 2007, according to the most recent data from the CDC, with the percentage of children aged 4 to 17 years taking an ADHD medication increasing from 4.8% in 2007 to 6.1% in 2011.

Despite the well-documented benefits of treatment, many children with ADHD are nonadherent to medication and behavioral therapy, both of which are considered maintenance therapies without long-lasting effects.

As a result, researchers have begun studying alternative treatment methods with potentially long-lasting benefits that may not require patients to undergo daily therapy.

The NIH in January awarded $2 million to Michael J. Kofler, PhD, director of the Children’s Learning Clinic and an assistant professor at Florida State University, and colleagues to test the effects of a video game-based approach to treat children with ADHD.

Kofler spoke with Healio Psychiatry about their research, how the games work and how specifically designed video games could enhance treatment options. – by Ryan McDonald

Question: What led to the initial idea of this video game approach as a potential treatment option for ADHD?

Answer: It’s really the culmination of about 15 years of research that I have been doing on this, which started from the position of looking at current treatments. We have very effective current treatments that work really well when they are actively engaged. Medication works well for about 80% to 90% of children with ADHD, but it only works on the days a patient takes it. The patient doesn’t get any benefits on days they don’t take their medication. Our behavioral interventions can also be very effective, but they only work while parents and teachers are doing it. There's some evidence that the effects of behavioral interventions start to go away within minutes or hours of removing some of the contingencies. We don't have anything that keeps working after we stop doing it. There’s not a penicillin for ADHD where a patient takes it for 10 days and doesn’t need it anymore. All treatments are what we call maintenance therapies, which means patients have to keep using them to keep getting the benefits. My work and the work of my mentor, Mark D. Rapport, PhD, and some of our colleagues, has really been looking at the why of ADHD. We know that children with ADHD have attention problems, and we know that many of them show these hyperactivity or impulsivity symptoms, but that doesn’t tell us why. That’s where we are with ADHD as a clinical diagnosis. The diagnosis says a patient has more difficulties with attention or with impulse control than other children their age. But it doesn't tell us why.

We’ve been doing a series of studies to really try and understand that why, and we kept coming back to these brain abilities called executive functions. These are a set of related abilities that involve the frontal and prefrontal areas of the brain that help us to control our impulses and to guide our behavior. In study after study, we found that these abilities were related to the difficulties with attention, the hyperactivity symptoms, as well as the secondary symptoms of ADHD such as social and academic difficulties. When that evidence base really became apparent to us, the idea became, ‘Well, if this is what is underlying the ADHD symptoms for a lot of these children, let's see if we can improve these executive functions. If we can, we should see reductions in the overt behavioral symptoms of the disorder.’

Q: How did you develop the game, and how does it work?

A: We worked with a group of consultants with expertise in a lot of different areas. In addition to clinical psychologists with expertise in ADHD, we worked with cognitive psychologists to really help us define our treatment targets. We also worked with folks who do research in a field called human factors and a subpart of that called serious games research that looks at how gaming elements can affect motivation and can help to encourage children to keep playing these training games.

I’m sure you’ve played games that are too easy, and then quit because they were boring. Or, you might have quit because the game was too hard. There’s this sweet spot, what the developmental psychologists call the ‘zone of proximal development’, and what the serious games researchers call ‘flow state’. Difficulty level has to be right where it’s just difficult enough that we’re going to get some training benefits, but it can’t be too easy, and it can’t be too difficult. We also had to figure out how to adapt the game, so that as the children kept exercising, and these abilities start improving, then the games have to stay with them. So, they are always working at the level that is hopefully going to facilitate that growth.

That’s part of the reason why we’re still doing in-office sessions. We have folks that work with the children that we call executive function coaches, and they’re really like a personal trainer at the gym. They help with that encouragement, especially as things go on and the games get difficult. When a patient first comes in, it’s like the first time you go to the gym. You’re lifting lighter weights, and it’s easy until you figure out how much you can actually lift. The next time you go you know how much you can lift, so it’s fairly difficult right away and you need that extra encouragement. That’s why we’ve had the children coming into the office to have that one-on-one interaction.

Q: Do you foresee this treatment method moving out of the office and into a home setting?

A: We have designed this treatment to be online, with the idea that we could provide families with log-in information and a link that they could use. That works for some families, but it doesn’t work for others. In our pilot testing, one of the things that we found out is that there’s some children where the only treatment they’re getting is when they come into the office.

Q: What were some of the other preliminary results of the study?

A: In our first pilot study, we compared central executive training to the current gold standard nonmedication treatment for ADHD, which is behavioral management training, also commonly referred to as parent training. Parent training involves working with parents on how to work with their kids to provide structure and support while helping them learn self-management skills. That’s our current best option in terms of nonmedication options, so that’s what we wanted to compare it to.

We found that our central executive training worked just as well as the current gold standard in terms of parent reports of reductions in ADHD symptoms between pre- and posttreatment. And then we found it worked better than parent training on some of the other things that we looked at. Our central executive training did better than parent training in terms of improving children executive functions. That was expected, because our training is intentionally trying to improve executive functions and parent training is not. We also found that our treatment worked better in terms of some of our objective measures of ADHD symptoms. One of the things that we did was use actigraphs, which are similar to Fitbits, but are much more precise and take measurements 16 times per second recording how much children move. We used that to get a very objective measure of hyperactivity. When we looked at that, we found that children who received central executive training showed larger reductions in hyperactivity symptoms than children whose parents had gone through the parent training course.

Q: A concern with medication and parent training is the lack of long-lasting effect. How long do these treatment results last?

A: That’s one of the things we don’t know yet, and one of the things we’re going to look at in the current study. A few months after families complete the treatment, we’re going to bring them back in to retest them and see how much of those gains are still apparent.

Q: How long is the current treatment plan?

A: It’s a 12-week protocol. We bring the children in for 5 weeks to work with us for 1 hour a week and then the goal is that they'll do the training at home for 15 minutes two or three times a week. After those 5 weeks, we bring them in for a mid-testing appointment Then we do another 5 weeks of training, followed by our post-testing appointment. Families receive feedback in terms of how the children progressed and if there were any difficulties during the program. Then we discuss recommendations and what we think will be the next helpful steps for families. Finally, we bring the children back a couple months later to repeat some of the testing that and see how much their gains are still apparent.

Q: The NIH granted you and your team $2 million for further research. What will this grant allow you to do?

A: What the grant is going to allow us to do is to test this out on a much larger scale than we would otherwise be able to. We’re in the process of hiring staff and really expanding to see a lot more families than we have been able to in the past. We have provided over 100 no-cost evaluations to local families since we opened in 2015 — 100 families in about 2.5 years. We have to ramp up; we want to be able to see about 250 families in the next few years.

Q: This approach is an alternative to traditional treatment methods. How important is it for alternative methods to come to the forefront?

A: I think more important than the medication vs. nonmedication distinction, is the maintenance therapy vs. lasting benefits distinction. What we really need, whether it’s a medication or nonmedication treatment, are things that last beyond when we stop doing them. We need that penicillin where you can take it for 10 days and you don’t need to take it anymore. In terms of medication vs. nonmedication options, medication is currently our first-line and most effective treatment for ADHD. The evidence is clear that medications work better than any of the nonmedication options right now. There’s some evidence that combining medication with the behavioral approach might be more effective than just doing one alone. Medication is still our first-line treatment. I started in this field pretty anti-medication, but I’ve really had to change my tune because I have seen it be so helpful for so many children. We’re not trying to control behavior, what we’re trying to do is give them a tool to help them be their best self.

Despite medication being the most effective treatment, there are a lot of parents who are very hesitant and skeptical of medication, so being able to provide options that are acceptable and feasible for everyone is important. Hopefully we’re onto something that is going to be as successful or more successful than medication, so that it’s not a debate on whether to medicate or not, but a decision on what works better.

Michael Kofler
Michael J. Kofler

More children in the U.S. were being treated for ADHD in 2011 compared with 2007, according to the most recent data from the CDC, with the percentage of children aged 4 to 17 years taking an ADHD medication increasing from 4.8% in 2007 to 6.1% in 2011.

Despite the well-documented benefits of treatment, many children with ADHD are nonadherent to medication and behavioral therapy, both of which are considered maintenance therapies without long-lasting effects.

As a result, researchers have begun studying alternative treatment methods with potentially long-lasting benefits that may not require patients to undergo daily therapy.

The NIH in January awarded $2 million to Michael J. Kofler, PhD, director of the Children’s Learning Clinic and an assistant professor at Florida State University, and colleagues to test the effects of a video game-based approach to treat children with ADHD.

Kofler spoke with Healio Psychiatry about their research, how the games work and how specifically designed video games could enhance treatment options. – by Ryan McDonald

Question: What led to the initial idea of this video game approach as a potential treatment option for ADHD?

Answer: It’s really the culmination of about 15 years of research that I have been doing on this, which started from the position of looking at current treatments. We have very effective current treatments that work really well when they are actively engaged. Medication works well for about 80% to 90% of children with ADHD, but it only works on the days a patient takes it. The patient doesn’t get any benefits on days they don’t take their medication. Our behavioral interventions can also be very effective, but they only work while parents and teachers are doing it. There's some evidence that the effects of behavioral interventions start to go away within minutes or hours of removing some of the contingencies. We don't have anything that keeps working after we stop doing it. There’s not a penicillin for ADHD where a patient takes it for 10 days and doesn’t need it anymore. All treatments are what we call maintenance therapies, which means patients have to keep using them to keep getting the benefits. My work and the work of my mentor, Mark D. Rapport, PhD, and some of our colleagues, has really been looking at the why of ADHD. We know that children with ADHD have attention problems, and we know that many of them show these hyperactivity or impulsivity symptoms, but that doesn’t tell us why. That’s where we are with ADHD as a clinical diagnosis. The diagnosis says a patient has more difficulties with attention or with impulse control than other children their age. But it doesn't tell us why.

We’ve been doing a series of studies to really try and understand that why, and we kept coming back to these brain abilities called executive functions. These are a set of related abilities that involve the frontal and prefrontal areas of the brain that help us to control our impulses and to guide our behavior. In study after study, we found that these abilities were related to the difficulties with attention, the hyperactivity symptoms, as well as the secondary symptoms of ADHD such as social and academic difficulties. When that evidence base really became apparent to us, the idea became, ‘Well, if this is what is underlying the ADHD symptoms for a lot of these children, let's see if we can improve these executive functions. If we can, we should see reductions in the overt behavioral symptoms of the disorder.’

Q: How did you develop the game, and how does it work?

A: We worked with a group of consultants with expertise in a lot of different areas. In addition to clinical psychologists with expertise in ADHD, we worked with cognitive psychologists to really help us define our treatment targets. We also worked with folks who do research in a field called human factors and a subpart of that called serious games research that looks at how gaming elements can affect motivation and can help to encourage children to keep playing these training games.

I’m sure you’ve played games that are too easy, and then quit because they were boring. Or, you might have quit because the game was too hard. There’s this sweet spot, what the developmental psychologists call the ‘zone of proximal development’, and what the serious games researchers call ‘flow state’. Difficulty level has to be right where it’s just difficult enough that we’re going to get some training benefits, but it can’t be too easy, and it can’t be too difficult. We also had to figure out how to adapt the game, so that as the children kept exercising, and these abilities start improving, then the games have to stay with them. So, they are always working at the level that is hopefully going to facilitate that growth.

That’s part of the reason why we’re still doing in-office sessions. We have folks that work with the children that we call executive function coaches, and they’re really like a personal trainer at the gym. They help with that encouragement, especially as things go on and the games get difficult. When a patient first comes in, it’s like the first time you go to the gym. You’re lifting lighter weights, and it’s easy until you figure out how much you can actually lift. The next time you go you know how much you can lift, so it’s fairly difficult right away and you need that extra encouragement. That’s why we’ve had the children coming into the office to have that one-on-one interaction.

PAGE BREAK

Q: Do you foresee this treatment method moving out of the office and into a home setting?

A: We have designed this treatment to be online, with the idea that we could provide families with log-in information and a link that they could use. That works for some families, but it doesn’t work for others. In our pilot testing, one of the things that we found out is that there’s some children where the only treatment they’re getting is when they come into the office.

Q: What were some of the other preliminary results of the study?

A: In our first pilot study, we compared central executive training to the current gold standard nonmedication treatment for ADHD, which is behavioral management training, also commonly referred to as parent training. Parent training involves working with parents on how to work with their kids to provide structure and support while helping them learn self-management skills. That’s our current best option in terms of nonmedication options, so that’s what we wanted to compare it to.

We found that our central executive training worked just as well as the current gold standard in terms of parent reports of reductions in ADHD symptoms between pre- and posttreatment. And then we found it worked better than parent training on some of the other things that we looked at. Our central executive training did better than parent training in terms of improving children executive functions. That was expected, because our training is intentionally trying to improve executive functions and parent training is not. We also found that our treatment worked better in terms of some of our objective measures of ADHD symptoms. One of the things that we did was use actigraphs, which are similar to Fitbits, but are much more precise and take measurements 16 times per second recording how much children move. We used that to get a very objective measure of hyperactivity. When we looked at that, we found that children who received central executive training showed larger reductions in hyperactivity symptoms than children whose parents had gone through the parent training course.

Q: A concern with medication and parent training is the lack of long-lasting effect. How long do these treatment results last?

A: That’s one of the things we don’t know yet, and one of the things we’re going to look at in the current study. A few months after families complete the treatment, we’re going to bring them back in to retest them and see how much of those gains are still apparent.

PAGE BREAK

Q: How long is the current treatment plan?

A: It’s a 12-week protocol. We bring the children in for 5 weeks to work with us for 1 hour a week and then the goal is that they'll do the training at home for 15 minutes two or three times a week. After those 5 weeks, we bring them in for a mid-testing appointment Then we do another 5 weeks of training, followed by our post-testing appointment. Families receive feedback in terms of how the children progressed and if there were any difficulties during the program. Then we discuss recommendations and what we think will be the next helpful steps for families. Finally, we bring the children back a couple months later to repeat some of the testing that and see how much their gains are still apparent.

Q: The NIH granted you and your team $2 million for further research. What will this grant allow you to do?

A: What the grant is going to allow us to do is to test this out on a much larger scale than we would otherwise be able to. We’re in the process of hiring staff and really expanding to see a lot more families than we have been able to in the past. We have provided over 100 no-cost evaluations to local families since we opened in 2015 — 100 families in about 2.5 years. We have to ramp up; we want to be able to see about 250 families in the next few years.

Q: This approach is an alternative to traditional treatment methods. How important is it for alternative methods to come to the forefront?

A: I think more important than the medication vs. nonmedication distinction, is the maintenance therapy vs. lasting benefits distinction. What we really need, whether it’s a medication or nonmedication treatment, are things that last beyond when we stop doing them. We need that penicillin where you can take it for 10 days and you don’t need to take it anymore. In terms of medication vs. nonmedication options, medication is currently our first-line and most effective treatment for ADHD. The evidence is clear that medications work better than any of the nonmedication options right now. There’s some evidence that combining medication with the behavioral approach might be more effective than just doing one alone. Medication is still our first-line treatment. I started in this field pretty anti-medication, but I’ve really had to change my tune because I have seen it be so helpful for so many children. We’re not trying to control behavior, what we’re trying to do is give them a tool to help them be their best self.

Despite medication being the most effective treatment, there are a lot of parents who are very hesitant and skeptical of medication, so being able to provide options that are acceptable and feasible for everyone is important. Hopefully we’re onto something that is going to be as successful or more successful than medication, so that it’s not a debate on whether to medicate or not, but a decision on what works better.