Intervention for executive functions in attention deficit and
                    hyperactivity disorder

Menezes, Amanda; Dias, Natália Martins; Trevisan, Bruna Tonietti; Carreiro, Luiz Renato R.; Seabra, Alessandra Gotuzo

doi:10.1590/0004-282X20140225

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ARTICLES • Arq. Neuro-Psiquiatr. 73 (3) • Mar 2015 • https://doi.org/10.1590/0004-282X20140225 copy

Intervention for executive functions in attention deficit and hyperactivity disorder

Intervenção para funções executivas no transtorno do déficit de atenção e hiperatividade

Authorship SCIMAGO INSTITUTIONS RANKINGS

This study aimed to investigate if an executive functions (EF) intervention could promote these skills in individuals with attention deficit and hyperactivity disorder (ADHD). Eighteen children and adolescents, 7-13 years old, divided into experimental (EG, N = 8) and control (CG, N = 10) groups, were assessed in the Block Design and Vocabulary subtests of the WISC III and seven tests of EF. Parents answered two scales, measuring EF and inattention and hyperactivity signs. EG children participated in a program to promote EF in twice-weekly group sessions of one hour each. After 8 months of intervention, groups were assessed again. ANCOVA, controlling for age, intelligence quotient and pretest performance, revealed gains in attention/inhibition and auditory working memory measures for the EG. No effect was found for scales or measures of more complex EF. Results are not conclusive, but they illustrate some promising data about EF interventions in children and adolescents with ADHD.

regulation; intervention; executive function; inattention

Control Group					Experimental Group
Gender	Age	Grade	School	Methylphenidate	Gender	Age	Grade	School	Methylphenidate
M	10	4	Private	Yes	M	13	8	Public	Yes
M	13	7	Private	No	M	8	4	Private	Yes
M	11	6	Public	No	F	10	5	Private	No
M	10	3	Public	No	M	8	4	Public	No
F	8	2	Public	No	M	10	5	Private	No
M	8	2	Public	No	F	10	6	Private	Yes
M	7	2	Public	No	M	10	6	Private	No
M	10	5	Public	Yes	M	8	3	Private	No
M	13	7	Public	Yes
M	13	6	Public	Yes

		Pretest results		Posttest results corrected after ANCOVA
Variable	Group	M	SD	M	SE	F	p
*Stroop* *Score in part 2*	CG	0.97	0.03	0.99	0.01	*4.66*	*0.06*
*Stroop* *Score in part 2*	EG	0.96	0.05	1	0.01
Stroop RT in part 2	CG	0.60	0.12	0.64	0.03	0.04	0.84
Stroop RT in part 2	EG	0.62	0.14	0.65	0.03
Stroop Score in part 3	CG	0.79	0.22	0.86	0.03	6.79	0.03
Stroop Score in part 3	EG	0.85	0.09	0.98	0.03
Stroop RT in part 3	CG	1.18	0.25	1.19	0.05	0.36	0.56
Stroop RT in part 3	EG	1.42	0.68	1.14	0.05
*Stroop* *interference score*	CG	-0.19	0.22	-0.12	0.03	*4.72*	*0.06*
*Stroop* *interference score*	EG	-0.10	0.09	-0.03	0.03
Stroop interference RT	CG	0.58	0.26	0.56	0.06	0.46	0.52
Stroop interference RT	EG	0.80	0.59	0.49	0.07
CAT number of hits	CG	62.80	21.10	76.08	3.81	0.00	0.98
CAT number of hits	EG	79.25	14.05	76.28	4.42
TMT – sequences in part B	CG	9.00	5.207	9.34	1.62	2.36	0.15
TMT – sequences in part B	EG	14.00	3.162	13.8	2.03
WCST – hits	CG	37.00	11.16	40.15	2.59	1.83	0.20
WCST – hits	EG	46.50	10.49	46.19	2.99
WCST – errors	CG	25.40	13.74	23.95	2.48	2.20	0.16
WCST – errors	EG	17.50	10.49	17.69	2.85
WCST Perseverative responses	CG	19.30	17.17	15.56	3.16	0.03	0.87
WCST Perseverative responses	EG	10.50	8.30	14.67	3.63
WCST Perseverative errors	CG	16.70	12.53	13.6	2.47	0.25	0.63
WCST Perseverative errors	EG	8.75	5.99	11.51	2.84
WCST – completed categories	CG	1.70	1.25	2.68	0.35	1.49	0.24
WCST – completed categories	EG	3.13	1.46	3.4	0.4
WCST – failure to maintain set	CG	1.70	2.00	0.3	0.3	1.34	0.27
WCST – failure to maintain set	EG	0.75	1.16	0.88	0.34
AWM	CG	5.20	2.94	5.26	0.92	4.72	0.05
AWM	EG	8.43	3.55	8.91	1.16
VWM	CG	5.30	3.92	7.15	0.71	0.93	0.35
VWM	EG	6.71	3.64	8.36	0.88
Fluency FAS	CG	14.10	6.87	20.26	2.85	0.07	0.80
Fluency FAS	EG	23.57	11.19	18.91	3.61
Fluency Animals	CG	10.60	4.06	10.86	1.41	0.35	0.57
Fluency Animals	EG	11.71	3.45	12.34	1.75
CHEXI total score	CG	83.57	19.77	83.77	7.61	0.00	0.99
CHEXI total score	EG	94.25	11.49	83.63	3.95
CHEXI working memory	CG	28.57	9.39	27.55	2.32	0.15	0.71
CHEXI working memory	EG	30.63	4.47	26.48	1.2
CHEXI planning	CG	13.00	3.32	14.42	2.27	0.72	0.42
CHEXI planning	EG	14.75	1.75	12.08	1.18
CHEXI self-regulation	CG	16.14	5.76	19.56	1.31	0.93	0.37
CHEXI self-regulation	EG	20.63	3.38	18.04	0.69
CHEXI inhibitory control	CG	19.29	3.45	19.59	2.46	0.40	0.55
CHEXI inhibitory control	EG	22.13	4.22	21.47	1.27
MTA-SNAP-IV inattention	CG	14.00	7.23	17.32	2.63	0.95	0.36
MTA-SNAP-IV inattention	EG	16.25	4.56	14.23	1.37
MTA-SNAP-IV hyperactivity	CG	11.29	7.16	14.14	2.52	0.29	0.61
MTA-SNAP-IV hyperactivity	EG	14.38	6.09	12.51	1.32

PIAFEx Modules	Activities	Activity name	Description of the original activity	Adaptation
M1 - Organization of materials/routine and time management	1	Daily schedule	In this task, the mediator sets the day's tasks in the form of routine. With every task performed, the routine is updated.	Used with no adaptation - used to organize the daily activities.
	2	-	Not used	-
	3	-	Not used	-
	4	Time management	The activity proposes visual aids to help participants deal with the notion of time and organize their behavior according to the time available for each task.	Used with no adaptation - used to support time management during activities.
M2 - Organization of ideas, goal-setting and planning: Strategies for the day-to-day	1	Calendar	A monthly calendar is used to mark commitments and important dates to help in organization and planning.	Used with no adaptation. Calendar was made on the first day of each month. Children were encouraged to mark appointments, tests, and important dates. Calendar was consulted every session.
	2	Graphic organizers	A tool to help children to deal with multi-step tasks and objectives.	Used with no adaptation - used to help to plan complex tasks.
	3	Check-lists	A list to help checking, planning, or organization of materials.	Used with no adaptation - used to help remember things to do or materials needed for some activity.
	4	-	Not used	-
	5	-	Not used	-
M3 - Organization of ideas, goal-setting and planning: Stimulation activities	1	-	Not used	-
	2	-	Not used	-
	3	Main idea x Details	A card with a set of pictures is presented. Children are encouraged to think about the general idea and its specificities.	Used with no adaptation - used to discuss different perspectives. Discussion could be in depth in relation to the activity conducted with preschoolers.
	4	Linking figures 1	Children should link some pictures according to specific criteria. After, the activity is repeated, but with new criteria.	Used with adaptation - activities 4 and 5 were combined. Discussion was encouraged after the activity.
	5	Linking figures 2	Children should link some pictures according to specific criteria. After, the activity is repeated, but children should alternate between criteria.
M4 - EF in Physical/Motor Activities	1	-	Not used (space limitations in the clinical context)	-
	2	Simon says	A child or the mediator plays “Simon.” Children need to make movements according to Simon’s orders.	Used with no adaptation
	3	-	Not used (space limitations in the clinical context)	-
	4	-	Not used (space limitations in the clinical context)	-
	5	-	Not used (space limitations in the clinical context)	-
	6	-	Not used (space limitations in the clinical context)	-
	7	-	Not used (space limitations in the clinical context)	-
	8	-	Not used (space limitations in the clinical context)	-
	9	-	Not used (space limitations in the clinical context)	-
	10	-	Not used (space limitations in the clinical context)	-
	11	Hit cards 1	This is a card game. There is a target stimulus (for example, the picture of a cat) and each child receives a number of cards. One at a time, children must discard a card on the table. If the discarded card is the target stimulus, all must hit the deck. The latest to hit takes all of the cards. The child who discards their hand first is the winner.	Used with adaptations - the rules were the same, but cards contained distractor stimuli to increase the complexity of the task (e.g., while in the original task children should hit if the card of the cat is shown, in the adapted task, they should hit the card with a white cat only if the cat has a red tie around its neck).
	12	Hit cards 2	The same as Hit cards 1, but stimuli are letters and numbers.
	13	Hit cards 3	The same as Hit cards 1, but there is a new rule. Some cards are red in the back. Even if the card has the target stimulus, children cannot hit the red cards.
M5 - Communication and Conflict Management	1	Time for dialogue	This task is used at the end of the week to discuss events and problems in the classroom and to discuss and model more adaptive ways to deal with and solve problems with peers.	Used with adaptation - children could discuss personal events during the week. Adaptive ways of solving problems were discussed and modeled.
	2	-	Not used	-
	3	-	Not used	-
M6 - Regulating emotions	1	Dealing with emotions	This is a four-step technique to help children to recognize and deal with their emotions. The steps are: 1) recognize your feeling; 2) Stop and think; 3) reflect and breathe deeply three times; 4) Now, think of a solution.	Used with no adaptation. Steps to recognize and control emotions were modeled and simulated.
	2	-	Not used	-
	3	-	Not used	-
M7 - Working with colleagues - Opportunities for exercising hetero- and self-regulation	1	Reading with pictures	Activity is conducted with peers. Children have different roles and should coordinate them to achieve a common goal. One child should tell a story based on pictures. The other must maintain his/ her role and just listen to the story.	Used with adaptation - instead of using pictures, children can read the story to their colleagues. Comic books can also be used.
	2	Storyteller	The structure is similar to the previous activity. Children take the books home and parents read for them. The next day, children should tell the story to their colleague. Children assume roles again.	Used with adaptation – children themselves read the stories.
	3	-	Not used	-
	4	-	Not used	-
	5	-	Not used	-
	6	Blocks design	Children assume roles (the engineer or the builder). The engineer should plan the construction, and the builder must set up blocks according to the plan.	Used with no adaptation - the complexity of projects were enhanced in relation to the work with young children; the task was the same.
	NEW	Planning projects	-	New activity designed from the objectives and structure of Module 7. In Planning projects, children should think broadly about building a project that has several steps to completion (e.g., building a game).
M8 - Playing with the meanings of words	1	Working with ambiguities 1	This task uses ambiguous words to show children that a word can have more than one meaning.	Used with no adaptation - discussion/reflection could be more profound in relation to work with young children.
M8 - Playing with the meanings of words	2	Working with ambiguities 2	This task uses ambiguous phrases and folk sayings.
M9 - Talking about the activities	1	Talking about the activities	This task uses questions to stimulate children’s thinking about how they perform tasks. It promotes metacognition.	Used with adaptations - this activity was conducted in the context of other tasks, for example during games as puzzles or a memory game. Children were encouraged to think about strategies used and evaluate their effectiveness.
M10 - The Planned Play	1	The Planned Play	It is an imaginative play that can be conducted in groups. Children should plan the play before its implementation. They should think about roles, scenarios, and materials. After, they must act according to the initial plan.	Used with some adaptations - the objective and structure were the same. More complex plans (with more details) and scenarios (e.g., interchange in a different country) were stimulated.
Supplementary Module: Nina’s Diary	-	Nina’s Diary	This is a narrative with 10 chapters. In the story, the protagonist Nina faces situations in which she needs to learn how to control her emotions and behavior, plan and organize, and solve problems. After each chapter, there are activities to help children exercise the strategies modeled by Nina.	Used with some adaptations - children themselves read the chapters during the session. Afterwards, all participated in the discussion and activities. The discussion could be enhanced in relation to the activity conducted with preschoolers.

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[1] Correspondence: Natália M. Dias; Centro Universitário FIEO; Programa de Pós-Graduação Stricto Sensu - Psicologia Educacional; Avenida Franz Voegeli, 300 / Bloco Prata (1° andar), Parque Continental; 06020-190 Osasco SP, Brasil; E-mail: natalia.dias@unifieo.br