The presence of attention deficit/hyperactivity disorder (ADHD) symptoms in children with autism spectrum disorder (ASD) is associated with worse cognitive control. Children with ASD and ADHD often respond poorly to medications, thus we need alternative treatments. We examined the feasibility, acceptability, and preliminary efficacy of Project Evo—a digital treatment. Nineteen children with ASD and co-occurring ADHD symptoms completed this app-based treatment that targets multi-tasking through gameplay versus a comparison educational treatment. Children had a high engagement with both treatments, and parents and children reported high acceptability. Within-group analyses suggest the multi-tasking but not the educational treatment may improve cognitive control. This multi-tasking treatment is feasible, acceptable, and possibly efficacious for cognitive control impairments in children with ASD and ADHD.
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American Psychiatric Association, & DSM-5 Task Force. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Arlington: American Psychiatric Association.
Anguera, J. A., Boccanfuso, J., Rintoul, J. L., Al-Hashimi, O., Faraji, F., Janowich, J., et al. (2013). Video game training enhances cognitive control in older adults. Nature, 501(7465), 97–101. https://doi.org/10.1038/nature12486.
Anguera, J. A., Brandes-Aitken, A. N., Antovich, A. D., Rolle, C. E., Desai, S. S., & Marco, E. J. (2017a). A pilot study to determine the feasibility of enhancing cognitive abilities in children with sensory processing dysfunction. PLoS ONE, 12(4), e0172616. https://doi.org/10.1371/journal.pone.0172616.
Anguera, J. A., Gunning, F. M., & Areán, P. A. (2017b). Improving late life depression and cognitive control through the use of therapeutic video game technology: A proof-of-concept randomized trial. Depression and Anxiety, 34(6), 508–517. https://doi.org/10.1002/da.22588.
Botvinick, M. M., Braver, T. S., Barch, D. M., Carter, C. S., & Cohen, J. D. (2001). Conflict monitoring and cognitive control. Psychological Review, 108(3), 624–652.
Cambridge Cognition. (1996). CANTAB. Cambridge: Cambridge Cognition Ltd.
Clapp, W. C., Rubens, M. T., Sabharwal, J., & Gazzaley, A. (2011). Deficit in switching between functional brain networks underlies the impact of multitasking on working memory in older adults. Proceedings of the National Academy of Sciences, 108(17), 7212–7217. https://doi.org/10.1073/pnas.1015297108.
Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Erlbaum Associates.
Corbett, B. A., Constantine, L. J., Hendren, R., Rocke, D., & Ozonoff, S. (2009). Examining executive functioning in children with autism spectrum disorder, attention deficit hyperactivity disorder and typical development. Psychiatry Research, 166(2–3), 210–222. https://doi.org/10.1016/j.psychres.2008.02.005.
Davis, N. O., Bower, J., & Kollins, S. H. (2018). Proof-of-concept study of an at-home, engaging, digital intervention for pediatric ADHD. PLoS ONE, 13(1), e0189749. https://doi.org/10.1371/journal.pone.0189749.
de Vries, M., Prins, P. J. M., Schmand, B. A., & Geurts, H. M. (2015). Working memory and cognitive flexibility-training for children with an autism spectrum disorder: A randomized controlled trial. Journal of Child Psychology and Psychiatry, 56(5), 566–576. https://doi.org/10.1111/jcpp.12324.
DuPaul, G. J., Power, T. J., Anastopoulos, A. D., & Reid, R. (1998). ADHD Rating Scale-IV: Checklists, norms, and clinical interpretation. New York: Guilford Press.
Elliott, C. D. (2007). Differential Ability Scales-II (DAS-II). San Antonio: Pearson Assessments.
Gazzaley, A., Cooney, J. W., Rissman, J., & D’Esposito, M. (2005). Top-down suppression deficit underlies working memory impairment in normal aging. Nature neuroscience, 8(10), 1298–1300. https://doi.org/10.1038/nn1543.
Geurts, H. M., van den Bergh, S. F. W. M., & Ruzzano, L. (2014). Prepotent response inhibition and interference control in autism spectrum disorders: Two meta-analyses. Autism Research, 7(4), 407–420. https://doi.org/10.1002/aur.1369.
Geurts, H. M., Verté, S., Oosterlaan, J., Roeyers, H., & Sergeant, J. A. (2004). How specific are executive functioning deficits in attention deficit hyperactivity disorder and autism? Journal of Child Psychology and Psychiatry, 45(4), 836–854. https://doi.org/10.1111/j.1469-7610.2004.00276.x.
Gilotty, L., Kenworthy, L., Sirian, L., Black, D. O., & Wagner, A. E. (2002). Adaptive skills and executive function in autism spectrum disorders. Child Neuropsychology, 8(4), 241–248.
Gioia, G. A., Isquith, P. K., Guy, S., & Kenworthy, L. (2015). Behavior Rating Inventory of Executive Function, second edition (BRIEF-2). Odessa: Psychological Assessment Resources.
Greenberg, L. M. (1996). Test of variables of attention. Los Alamitos: University Attention Disorder Inc.
Gresham, F., & Elliott, S. N. (2008). Social Skills Improvement System (SSIS) Rating Scales. Lutz: Psychological Assessment Resources.
Hedges, L. V. (1981). Distribution theory for Glass’s estimator of effect size and related estimators. Journal of Educational Statistics, 6(2), 107–128. https://doi.org/10.3102/10769986006002107.
Hill, E. L. (2004). Evaluating the theory of executive dysfunction in autism. Developmental Review, 24(2), 189–233.
Johnson, K. A., Robertson, I. H., Kelly, S. P., Silk, T. J., Barry, E., Dáibhis, A., et al. (2007). Dissociation in performance of children with ADHD and high-functioning autism on a task of sustained attention. Neuropsychologia, 45(10), 2234–2245. https://doi.org/10.1016/j.neuropsychologia.2007.02.019.
Jones, R. M., Caroline, C., Hamo, A., & Lord, C. (2017). Placebo-like response in absence of treatment in children with Autism. Autism Research, 10(9), 1567–1572. https://doi.org/10.1002/aur.1798.
Karalunas, S. L., Hawkey, E., Gustafsson, H., Miller, M., Langhorst, M., Cordova, M., et al. (2018). Overlapping and distinct cognitive impairments in attention-deficit/hyperactivity and autism spectrum disorder without intellectual disability. Journal of Abnormal Child Psychology. https://doi.org/10.1007/s10802-017-0394-2.
Kenworthy, L., Yerys, B. E., Anthony, L. G., & Wallace, G. L. (2008). Understanding executive control in autism spectrum disorders in the lab and in the real world. Neuropsychology Review, 18(4), 320–338. https://doi.org/10.1007/s11065-008-9077-7.
Klingberg, T., Fernell, E., Olesen, P. J., Johnson, M., Gustafsson, P., Dahlström, K., et al. (2005). Computerized training of working memory in children with ADHD—A randomized, controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 44(2), 177–186. https://doi.org/10.1097/00004583-200502000-00010.
Kraemer, H. C., Mintz, J., Noda, A., Tinklenberg, J., & Yesavage, J. A. (2006). Caution regarding the use of pilot studies to guide power calculations for study proposals. Archives of General Psychiatry, 63(5), 484–489. https://doi.org/10.1001/archpsyc.63.5.484.
Lai, C. L. E., Lau, Z., Lui, S. S. Y., Lok, E., Tam, V., Chan, Q., et al. (2017). Meta-analysis of neuropsychological measures of executive functioning in children and adolescents with high-functioning autism spectrum disorder. Autism Research, 10(5), 911–939. https://doi.org/10.1002/aur.1723.
Lord, C., Rutter, M., DiLavore, P. C., Risi, S., Gotham, K., & Bishop, S. (2012). Autism Diagnostic Observation Schedule, second edition (ADOS-2) manual (part I): Modules 1–4. Torrance: Western Psychological Services.
O’Hearn, K., Asato, M., Ordaz, S., & Luna, B. (2008). Neurodevelopment and executive function in autism. Development and Psychopathology, 20(4), 1103–1132. https://doi.org/10.1017/S0954579408000527.
Pennington, B. F., & Ozonoff, S. (1996). Executive functions and developmental psychopathology. Journal of Child Psychology and Psychiatry, 37(1), 51–87.
Pugliese, C. E., Anthony, L., Strang, J. F., Dudley, K., Wallace, G. L., & Kenworthy, L. (2015). Increasing adaptive behavior skill deficits from childhood to adolescence in autism spectrum disorder: Role of executive function. Journal of Autism and Developmental Disorders, 45(6), 1579–1587. https://doi.org/10.1007/s10803-014-2309-1.
Pugliese, C. E., Anthony, L. G., Strang, J. F., Dudley, K., Wallace, G. L., Naiman, D. Q., et al. (2016). Longitudinal examination of adaptive behavior in autism spectrum disorders: Influence of executive function. Journal of Autism and Developmental Disorders, 46(2), 467–477. https://doi.org/10.1007/s10803-015-2584-5.
Rao, P., & Landa, R. J. (2014). Association between severity of behavioral phenotype and comorbid attention deficit hyperactivity disorder symptoms in children with autism spectrum disorders. Autism, 18(3), 272–280.
Research Units on Pediatric Psychopharmacology (RUPP). (2005). Randomized, controlled, crossover trial of methylphenidate in pervasive developmental disorders with hyperactivity. Archives of General Psychiatry, 62(11), 1266–1274. https://doi.org/10.1001/archpsyc.62.11.1266.
Russo, N., Flanagan, T., Iarocci, G., Berringer, D., Zelazo, P. D., & Burack, J. A. (2007). Deconstructing executive deficits among persons with autism: Implications for cognitive neuroscience. Brain and Cognition, 65(1), 77–86. https://doi.org/10.1016/j.bandc.2006.04.007.
Rutter, M., Bailey, A., & Lord, C. (2003). Social Communication Questionnaire (SCQ). Los Angeles: Westerm Psychological Services.
Scahill, L., McCracken, J. T., Rockhill, C., Shah, B., Politte, L., Sanders, R., et al. (2015). Extended-release guanfacine for hyperactivity in children with autism spectrum disorder. American Journal of Psychiatry, 172, 1197–1206.
Sikora, D. M., Vora, P., Coury, D. L., & Rosenberg, D. (2012). Attention-deficit/hyperactivity disorder symptoms, adaptive functioning, and quality of life in children with autism spectrum disorder. Pediatrics, 130(Suppl 2), S91–S97. https://doi.org/10.1542/peds.2012-0900G.
Sinzig, J., Bruning, N., Morsch, D., & Lehmkuhl, G. (2008a). Attention profiles in autistic children with and without comorbid hyperactivity and attention problems. Acta Neuropsychiatrica, 20(4), 207–215. https://doi.org/10.1111/j.1601-5215.2008.00292.x.
Sinzig, J., Morsch, D., Bruning, N., Schmidt, M. H., & Lehmkuhl, G. (2008b). Inhibition, flexibility, working memory and planning in autism spectrum disorders with and without comorbid ADHD-symptoms. Child and Adolescent Psychiatry and Mental Health, 2(1), 4. https://doi.org/10.1186/1753-2000-2-4.
Wallace, G. L., Kenworthy, L., Pugliese, C. E., Popal, H. S., White, E. I., Brodsky, E., et al. (2016a). Real-world executive functions in adults with autism spectrum disorder: Profiles of impairment and associations with adaptive functioning and co-morbid anxiety and depression. Journal of Autism and Developmental Disorders, 46(3), 1071–1083. https://doi.org/10.1007/s10803-015-2655-7.
Wallace, G. L., Yerys, B. E., Peng, C., Dlugi, E., Anthony, L. G., & Kenworthy, L. (2016b). Assessment and treatment of executive function impairments in autism spectrum disorder: An update. In International review of research in developmental disabilities (Vol. 51, pp. 85–122). San Diego: Elsevier.
Yerys, B. E., Kenworthy, L., Jankowski, K. F., Strang, J., & Wallace, G. L. (2013). Separate components of emotional Go/No-Go performance relate to autism versus attention symptoms in children with autism. Neuropsychology, 27(5), 537–545. https://doi.org/10.1037/a0033615.
Yerys, B. E., Wallace, G. L., Sokoloff, J. L., Shook, D. A., James, J. D., & Kenworthy, L. (2009). Attention deficit/hyperactivity disorder symptoms moderate cognition and behavior in children with autism spectrum disorders. Autism Research, 2(6), 322–333. https://doi.org/10.1002/aur.103.
We would like to thank the youth and family members who gave their time and energy to participate in this study. The study was sponsored by Akili Interactive Labs (Akili). As part of the sponsored clinical study conducted with Children’s Hospital of Philadelphia.
This study was sponsored by Akili Interactive Labs (Akili).
Conflict of interest
Authors GD and RTS served as consultants to Akili Interactive Labs in the design of the study reported on here. Author RTS holds stock options for consulting work to Akili Interactive Labs Inc. Author GD is on the Scientific Advisory Boards of Janssen Research and Development, Akili Interactive Labs, Inc., LabCorp, and Roche Pharmaceutical Company, has received grant funding from Janssen Research and Development, L.L.C. and PerkinElmer, speaker fees from ViaCord, and receives royalties from Guilford Press and Oxford University Press. Author BEY and JRB received partial salary support from Akili to carry out the study reported on here. Akili participated in the design of the study, but did not participate in the data analysis and interpretation, manuscript preparation, or decision to publish.
All procedures performed in this study with human participants were in accordance with the ethical standards of the institutional research board committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This included obtaining informed parental consent and child assent for all participants.
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Yerys, B.E., Bertollo, J.R., Kenworthy, L. et al. Brief Report: Pilot Study of a Novel Interactive Digital Treatment to Improve Cognitive Control in Children with Autism Spectrum Disorder and Co-occurring ADHD Symptoms. J Autism Dev Disord 49, 1727–1737 (2019). https://doi.org/10.1007/s10803-018-3856-7
- Neurodevelopmental disorder
- Attention deficit/hyperactivity disorder
- Executive function