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Can ADHD Be Prevented?

04/16/14 | by Training Games | Categories: Play

A game-style intervention for preschoolers might prevent ADHD from developing, reducing reliance on medications

Mar 1, 2014 |By Emily Laber-Warren

Games such as freeze dance coach kids to abruptly stop what they are doing.

Pay Attention
By addressing signs of attention-deficit hyperactivity disorder very early, some psychologists hope they can prevent the problem from arising.

Treatments under development involve teaching children and their parents a wide variety of games designed to strengthen focus, planning ability, memory and impulse control.

The brains of very young children are furiously sprouting new connections, creating a window of opportunity for learning that slows after age five.

From the start, Tzippora Gold was a smart and loving little girl, with a strong independent streak and tons of energy. During infancy and toddlerhood, her family noticed nothing amiss. But when Tzippora entered preschool, she did not listen to the teacher or sit in a circle. “I had never in my life thought that a three-year-old could get sent to the principal's office,” recalls her mother, Sara Gold of New York City, a graphic designer. “But she was. I pulled her out in the middle of the year because they couldn't handle her. And this was supposed to be a top-of-the-line preschool.”

A few months later Gold began seeing flyers posted by psychologists at nearby Queens College. The researchers were seeking unusually distractible, talkative and active children for a study. Gold signed up Tzippora. She had just turned four.

Plenty of four- and five-year-olds zoom around and have trouble paying attention, but those who qualified for the Queens College study, like Tzippora, were at the extremes. These youngsters showed early signs of attention-deficit hyperactivity disorder (ADHD), a condition associated with a variety of challenges, including trouble with attention, impulsivity and poor school performance.

ADHD affects around 10 percent of children in the U.S., according to the Centers for Disease Control and Prevention. It is typically diagnosed at age seven or eight, when a child's inability to sit still and focus conflicts with the increasingly academic demands of elementary school. Pediatricians and psychiatrists often prescribe drugs such as Adderall and Ritalin, which can dramatically increase productivity and motivation. Yet the drugs have side effects, such as insomnia and loss of appetite, and many parents are uncomfortable medicating their children so they will do better in school.

The Queens College psychologists are exploring a different treatment paradigm. They hope that by addressing signs of ADHD early—before the disorder has even been diagnosed—it may be possible to change kids' brains so that they never get ADHD or, if they do, are less seriously afflicted. The treatment is a five-week series of games designed to strengthen focus, planning ability, memory and impulse control. It draws from growing evidence that the brains of very young children are furiously sprouting new connections, creating a window of opportunity for learning that slows after age five. Two such programs are in development in the U.S.: the one at Queens College and another at Cincinnati Children's Hospital Medical Center. A similar intervention, the New Forest Parenting Program, is already in use in the U.K. and attracting interest from psychologists and educators in Brazil, France, Hong Kong and Japan. “We're trying to capitalize on the fact that the brain is changing rapidly and forming and laying down those connections early on,” says psychologist Leanne Tamm, who is developing the Cincinnati early intervention program.

ADHD brain-training programs are deceptively simple, many of them involving variations on Simon says, I spy, Jenga and freeze dance. Parents and children learn them during weekly laboratory visits, but the real work happens at home, where everyone is expected to repeat the activities on a near-daily basis. (In the U.K. program, trainings also take place in families' homes.) The approach seems to work: recent results from small early trials were impressive enough that the National Institute of Mental Health is underwriting larger ones. “The idea of early intervention is building,” says Jeffrey M. Halperin, the psychologist leading the Queens College study. “The hope is that we can change the long-term trajectory of the disorder.”

Outgrowing ADHD
ADHD runs in families, and evidence suggests a strong genetic component. “Very few, at this point, think that bad parenting or bad teachers cause ADHD,” Halperin says. “It really is a brain disorder. There is compelling evidence for that.” But about half of children with ADHD eventually outgrow it, although no one knows why. In a 2008 study Halperin and his colleagues tried to understand what differentiates individuals whose ADHD persists from those who get better. They tracked down 98 adolescents and young adults who had ADHD as children and gave them tests of verbal, reasoning and math skills, among other mental abilities.

To the researchers' surprise, they found that those who had recovered from ADHD and those who had not had many similar brain impairments. For example, both groups had trouble consistently focusing during 15 minutes of computer-based exercises. Yet those who overcame the disorder had developed especially strong higher-level thinking skills and mental control, abilities that seemed to compensate for their deficits. These skills reside in the prefrontal cortex, a brain area that because it continues to develop throughout childhood offers the potential for change.

That study inspired Halperin to create a preschool brain-training program. His thinking was that if for some children the natural course of brain development counteracts ADHD, exercises specifically designed to promote that growth might help people shed the symptoms—if not the underlying biology—of the disorder.

Child's Play
Five children watch while a young woman puts six plastic cups upside down on a table. Underneath each she places an M&M. “We are going to take turns lifting a cup,” she tells the children. “If you find a piece of candy, you may eat it.” And so begins a memory game called remember the treasure, in which candy rewards serve as motivation. Children must watch carefully as their peers make their moves, endeavoring to recall which cups have been lifted, so that when their turn comes they will choose a cup that still conceals an M&M.

The children are gathered in a cheerful blue room at Queens College decorated with decals of monkeys and vines, birds and leaves. As they become more adept, the game intensifies. The leader next instructs the children to save the M&Ms they find rather than eating them. Whenever they err by choosing an empty cup, they must forfeit one of their hoarded sweets, placing it under the cup.

Kids with ADHD often have trouble holding in mind several pieces of information, an ability known as working memory that is related to attention and is essential to effective reasoning, planning and problem solving. Games such as remember the treasure enhance working memory because children have to keep track of which cups have been lifted. Another working memory exercise is a list game, in which one person recounts several things, such as activities he did that day or places she has gone on vacation. Players then must name one of the things on the list or, as the game intensifies, repeat all of them in order or, harder still, backward.

Children with ADHD also struggle with impulsivity, so delaying gratification is built into some of the games. The instruction to save the M&Ms is one example. Another activity, used in the Cincinnati program, involves giving children a banana and asking them to notice as much as they can—what it smells like, whether the skin is smooth or rough, what shape it is—before eating it. The programs also use variations on games such as freeze dance and Simon says to help kids learn to abruptly terminate an activity or train of thought. Picture puzzles such as the ones in Highlights magazine, where unexpected items are hidden in the background, help children hone their ability to concentrate and attend to details. In addition, because kids with ADHD can get wound up and have trouble regulating their emotions, some of the early intervention programs also include meditation and relaxation and sensory awareness exercises.

Here in the U.S., Tzippora Gold is one of a very few children who have experienced the experimental play-based approach. One of the first changes her mother noticed after Tzippora began participating in the Queens College study was at bedtime. Every night at seven o'clock Sara Gold would put her daughter to bed after a calming routine of a warm bath and stories, but Tzippora would spend the next two hours bouncing, singing to herself or knocking on the window to get the attention of passersby. The early intervention program taught Tzippora how to focus on her breathing and relax her muscles. Soon she was falling asleep within 20 minutes.

When walking with her daughter, Sara began playing upbeat songs on her cell phone and practicing the freeze dance game. Eventually Tzippora began stopping when her mother called out, and Sara no longer feared she would dart into the street.

At her new preschool, Tzippora received occupational therapy and was assigned an aide who coached her on proper classroom behavior. Last fall, when Tzippora entered kindergarten, she no longer needed an aide. “She's a different kid in the classroom, like a new person,” her mother said. “There's a kid in her class she comes home telling me stories about, saying that he's a troublemaker and he doesn't listen. Last year she was that kid.”

This article was originally published with the title "Concentrate."

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