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Case Report
Revised

Case Report: "ADHD Trainer": the mobile application that enhances cognitive skills in ADHD patients

[version 5; peer review: 2 approved, 1 approved with reservations]
PUBLISHED 26 Oct 2015
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Abstract

We report the case of a 10 year old patient diagnosed with attention deficit hyperactivity disorder (ADHD) and comorbid video game addiction, who was treated with medication combined with a novel cognitive training method based on video games called TCT method. A great risk of developing video game or internet addiction has been reported in children, especially in children with ADHD. Despite this risk, we hypothesize that the good use of these new technologies might be useful to develop new methods of cognitive training. The cognitive areas in which a greater improvement was observed through the use of video games were visuospatial working memory and fine motor skills. TCT method is a cognitive training method that enhances cognitive skills such as attention, working memory, processing speed, calculation ability, reasoning, and visuomotor coordination. The purpose of reviewing this case is to highlight that regular cognitive computerized training in ADHD patients may improve some of their cognitive symptoms and might be helpful for treating video game addiction.

Keywords

ADHD; mobile app; TCT method; working memory

Revised Amendments from Version 4

We have included a direct link to download the app according to the reviewers comments, and also introduced some modifications in the discussion.

See the authors' detailed response to the review by Kevin J. Black
See the authors' detailed response to the review by Aviv Weinstein

Introduction

Attention deficit hyperactivity disorder (ADHD) is the most commonly diagnosed neurodevelopmental disorder in childhood, which affects 3% to 7% of the population worldwide1. ADHD is characterized by distractibility, hyperactivity and impulsivity. The standard treatment for ADHD includes mainly medication, psychosocial and behavioral treatment, and cognitive training exercises.

Cognitive training exercises are especially useful when cognitive impairment is observed and when a regular and personalized cognitive training is performed2. Studies in participants with cognitive impairment have shown that regular and daily cognitive training can improve some of their cognitive symptoms3,4. In addition, recent studies have demonstrated that computerized working memory and executive function training programs lead to better results than ordinary cognitive training methods in children with ADHD57.

Children’s use of electronic devices, Internet and video games, has noticeably increased in the last 10 years. Since the first case of Internet addiction was described in 1996 by Young6, several other pathologies have been proposed including pathological gambling and dependence7. Despite extensive research literature available, the prevalence and proper diagnostic criteria for pathological gaming are still debated among the scientific community8. Gaming addiction represents part of the postulated construct of Internet addiction, and is the most widely studied specific form of Internet addiction to date9. Prevalence estimates range from 2%10 to 15%11, depending on the respective socio-cultural context, sample, and assessment criteria utilized. A great risk of developing video game or Internet addiction has been reported in children, and especially in those with ADHD8. Despite this risk, we hypothesize that good use of these new technologies can be useful in developing new methods of cognitive training.

Case report

This case study involves a 10 year old child born in Madrid (Spain) who received treatment in a childhood psychiatry unit for 2 years due to behavioral disorders and ADHD. No other previous medical history was reported. His mother, aged 35, received psychological treatment for anxiety 3 years ago. His father, aged 36, works as an engineer and presented no relevant medical history. The patient was their only son. The parents described a great addiction to video games in the last year, referring to 4 hours per day of video game playing. This affected his social interaction, causing a lack of imaginative play and poor academic scores. Teachers at the school reported deterioration in his academic performance over the past year. At that time, the child was treated with methylphenidate 40 mg per day. The patient’s parents reported that the only significant change from the previous year was a major addiction to a war videogame.

To reduce the exposure to video games, we used a novel technique, based on the Tajima Cognitive Method (TCT) called “ADHD Trainer”. It consists in a cognitive stimulation program with a mobile/tablet application designed specifically to treat ADHD. This app can be purchased at Google play and iTunes. https://itunes.apple.com/us/app/adhd-trainer/id687869470?l=us&ls=1&mt=8 and https://play.google.com/store/apps/details?id=com.tktbrainsolutions.adhdtrainer&hl=es

Behavioral and academic improvements were rated on the Conners Parent and Teacher Rating Scales (brief version) and Barkley School Situations Questionnaire.

ADHD diagnosis was made according to DSM V criteria9,10. Attention was rated with CPT Conners Continuous Performance Test.

Differential diagnosis between oppositional defiant disorder and ADHD disorder was considered, because most of the symptoms were observed at home; however angry or irritable mood was not observed.

The patient was treated with a combination of methylphenidate and cognitive training method based in the TCT method. The patient received daily treatment with 40 mg of methylphenidate, and at least 10 minutes of daily cognitive training with the “ADHD Trainer” app.

The TCT is a type of computer adaptive test (CAT), as it adapts to the individual’s cognitive strengths and weaknesses, based on his own scores over time, as well as those of his peers. Users receive separate scores in different cognitive areas, including simple calculation, attention, perceptual reasoning, and visuomotor coordination (Figure 1). The goal of the daily training is to reach a pre-set individualized score in different cognitive domains, in order to complete a week of successful training.

afd754f8-61f4-49f1-81b2-9d50908b209c_figure1.gif

Figure 1. The cognitive areas treated with ADHD Trainer.

During the first month of cognitive training therapy, the patient was only allowed to play with specific games based on the TCT Method, using the “ADHD Trainer” (Figure 2). The patient and their families also received cognitive behavioral therapy in order to modify the routines at home, especially to treat the video gaming addiction.

The patient had to use the application every day at the same time, provided that in addition targets that were assigned in therapy (such as the progressive reduction in the number of hours to play other games and just being able to play with them once a week) were met. During the first month, he was allowed to play this game a maximum range of 4 hours per day. No addiction symptoms to this video game were observed during the first month (tolerance, withdrawal or functional impairment). The average number of hours that the child played the video game was 1 hour a day. In the following months the objective was to play the game at least 10 minutes per day.

afd754f8-61f4-49f1-81b2-9d50908b209c_figure2.gif

Figure 2. Capture of one of the games based in Trail Making Test.

In less than two months video game abuse was substantially reduced, limiting its use to weekends, and always for periods not exceeding 4 hours in total. Although 4 hours a day might seem an important amount of time for a single day, the global reduction of the time wasted in videogames and its limitation to the weekend means a significant improvement in this particular case.

Behavioral and academic improvement was rated on the Conners Parent and Teacher Rating Scales and Barkley School Situations Questionnaire. The initial score of the Conners was 19 for the teachers and 20 for the parents, and after the cognitive training the scores were 15 for the teachers and 16 for the parents. The main severity score for the Barklay School Situations Questionnaire was 70 before starting the training, and 66 after the cognitive training.

Both the school and the family reported a significant improvement in the patient after 6 months of TCT cognitive training, which included important improvements for both academic and behavioral outcomes.

Examples of exercises that are practiced in one daily session are shown in Figure 2.

Discussion

Most of the studies reported so far the emphasize the potential addictive risk of new technologies and the influence they have on children’s interpersonal development, by reducing the time children spend outside home and increasing the time they spend alone playing in front of a television or a computer screen12. It is also known that new technologies may affect children's academic performance by reducing the number of hours that they dedicate to studying.

There are few studies which focus on the positive aspects of new technologies and the opportunities that they offer for professionals and users to interact as well as the development of new therapeutic methods, that are capable of reaching the young.

New technologies, in particular video games, can be used as therapeutic tools to train executive functions6,7. As they generate greater motivation in children and adolescents they will increase the frequency of performing cognitive tasks oriented to enhance executive functions, especially the working memory.

We consider that a combined therapy of behavioral and cognitive training therapy could improve ADHD symptoms especially in childhood population. There are key advantages for children practicing the TCT Method relative to traditional cognitive training therapies which include.

1) Increased motivation in children for completing cognitive training therapy. This increase in motivation comes from: entertainment value (these games are designed to be similar to regular video games that children enjoy) and feedback on performances relative to own and peer scores (which improves children’s sense of agency and self-efficacy, as demonstrated by documented research on motivation and learning)11,12.

2) Ease of accessing the application. Children can play the games at any place or any time, day and night.

Conclusion

ADHD patients are especially vulnerable to develop video gaming addition. ADHD patients often suffer from working memory and executive function dysfunctions, but we have observed that very few cognitive training techniques have been developed for ADHD patients in the last years. Poor completion rates of cognitive training in children with ADHD have been observed. We suggest that a daily cognitive computerized training in ADHD patients may improve some of their cognitive symptoms, and might be helpful for treating the video gaming addition.

Consent

Written informed consent to publish this report was obtained by the patient’s parents.

Comments on this article Comments (3)

Version 5
VERSION 5 PUBLISHED 26 Oct 2015
Revised
Version 1
VERSION 1 PUBLISHED 18 Nov 2014
Discussion is closed on this version, please comment on the latest version above.
  • Author Response 14 Apr 2015
    Kazuhiro Tajima-Pozo, Department of Psychiatry, Hospital Universitario Fundacion Alcorcon, Alcorcon, 28922, Spain
    14 Apr 2015
    Author Response
    Thanks for your comments Mr Black! best regards
    Competing Interests: No competing interests were disclosed.
  • Reader Comment (F1000Research Advisory Board Member) 20 Nov 2014
    Kevin J Black, Washington University in St Louis, St. Louis, USA
    20 Nov 2014
    Reader Comment F1000Research Advisory Board Member
    This is a trivial comment, just FYI, but the phrase "integrated by medical doctors and engineers" in the Competing Interests section sounds great in Spanish, but would be better rendered ... Continue reading
  • Discussion is closed on this version, please comment on the latest version above.
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Ruiz-Manrique G, Tajima-Pozo K and Montañes-Rada F. Case Report: "ADHD Trainer": the mobile application that enhances cognitive skills in ADHD patients [version 5; peer review: 2 approved, 1 approved with reservations]. F1000Research 2015, 3:283 (https://doi.org/10.12688/f1000research.5689.5)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Key to Reviewer Statuses VIEW
ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
Version 5
VERSION 5
PUBLISHED 26 Oct 2015
Revised
Views
15
Cite
Reviewer Report 23 Feb 2016
Gabriele Duccio Papanti, Division of Psychiatry, University of Trieste, Trieste, Italy 
Approved
VIEWS 15
A very interesting paper indeed, I am glad to provide a review. The title seems appropriate, however I would suggest to limiting it to “Case Report: "ADHD Trainer": the mobile application that enhances cognitive skills in ADHD”. The conclusions seems ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Papanti GD. Reviewer Report For: Case Report: "ADHD Trainer": the mobile application that enhances cognitive skills in ADHD patients [version 5; peer review: 2 approved, 1 approved with reservations]. F1000Research 2015, 3:283 (https://doi.org/10.5256/f1000research.7805.r12578)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
Version 4
VERSION 4
PUBLISHED 10 Sep 2015
Revised
Views
23
Cite
Reviewer Report 30 Sep 2015
Kevin J. Black, Department of Psychiatry, Washington University in St. Louis, St Louis, MO, USA 
Approved with Reservations
VIEWS 23
The authors have satisfactorily addressed most of the concerns listed ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Black KJ. Reviewer Report For: Case Report: "ADHD Trainer": the mobile application that enhances cognitive skills in ADHD patients [version 5; peer review: 2 approved, 1 approved with reservations]. F1000Research 2015, 3:283 (https://doi.org/10.5256/f1000research.7375.r10258)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
Version 3
VERSION 3
PUBLISHED 23 Jun 2015
Revised
Views
30
Cite
Reviewer Report 26 Jun 2015
Kevin J. Black, Department of Psychiatry, Washington University in St. Louis, St Louis, MO, USA 
Approved with Reservations
VIEWS 30
The authors have addressed points #1 and 4 from my previous review, but the following issues remain.
 
2. The paper still needs copy editing to reflect standard written English. The last 2 sentences of the Introduction provide an example.
  • Comma placement:  Do
... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Black KJ. Reviewer Report For: Case Report: "ADHD Trainer": the mobile application that enhances cognitive skills in ADHD patients [version 5; peer review: 2 approved, 1 approved with reservations]. F1000Research 2015, 3:283 (https://doi.org/10.5256/f1000research.7195.r9143)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
Version 2
VERSION 2
PUBLISHED 07 May 2015
Revised
Views
32
Cite
Reviewer Report 15 Jun 2015
Kevin J. Black, Department of Psychiatry, Washington University in St. Louis, St Louis, MO, USA 
Approved with Reservations
VIEWS 32
This is an interesting and encouraging report, but I have the following reservations.
  1. One case provides very limited evidence for efficacy and even less for safety. In this light, a couple of statements, including the following, are too enthusiastic and need
... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Black KJ. Reviewer Report For: Case Report: "ADHD Trainer": the mobile application that enhances cognitive skills in ADHD patients [version 5; peer review: 2 approved, 1 approved with reservations]. F1000Research 2015, 3:283 (https://doi.org/10.5256/f1000research.6850.r8915)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 23 Jun 2015
    Kazuhiro Tajima-Pozo, Department of Psychiatry, Hospital Universitario Fundacion Alcorcon, Alcorcon, 28922, Spain
    23 Jun 2015
    Author Response
    According to the reviewer comments
    We have included a table showing the cognitive training areas that are trained everyday.
    We have made a overall review of the grammar.
    We have included the scores ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 23 Jun 2015
    Kazuhiro Tajima-Pozo, Department of Psychiatry, Hospital Universitario Fundacion Alcorcon, Alcorcon, 28922, Spain
    23 Jun 2015
    Author Response
    According to the reviewer comments
    We have included a table showing the cognitive training areas that are trained everyday.
    We have made a overall review of the grammar.
    We have included the scores ... Continue reading
Views
23
Cite
Reviewer Report 18 May 2015
Aviv Weinstein, Department of Behavioural Sciences, Ariel University, Ariel, Israel 
Approved
VIEWS 23
The authors have revised the ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Weinstein A. Reviewer Report For: Case Report: "ADHD Trainer": the mobile application that enhances cognitive skills in ADHD patients [version 5; peer review: 2 approved, 1 approved with reservations]. F1000Research 2015, 3:283 (https://doi.org/10.5256/f1000research.6850.r8583)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 19 May 2015
    Kazuhiro Tajima-Pozo, Department of Psychiatry, Hospital Universitario Fundacion Alcorcon, Alcorcon, 28922, Spain
    19 May 2015
    Author Response
    Thanks for your comments and your review. Best regards.
    Competing Interests: Dr. Kazuhiro Tajima-Pozo, have participated in the development of “ADHD Trainer” , and other brain training applications as consultant psychiatrist.
COMMENTS ON THIS REPORT
  • Author Response 19 May 2015
    Kazuhiro Tajima-Pozo, Department of Psychiatry, Hospital Universitario Fundacion Alcorcon, Alcorcon, 28922, Spain
    19 May 2015
    Author Response
    Thanks for your comments and your review. Best regards.
    Competing Interests: Dr. Kazuhiro Tajima-Pozo, have participated in the development of “ADHD Trainer” , and other brain training applications as consultant psychiatrist.
Version 1
VERSION 1
PUBLISHED 18 Nov 2014
Views
46
Cite
Reviewer Report 25 Nov 2014
Aviv Weinstein, Department of Behavioural Sciences, Ariel University, Ariel, Israel 
Approved with Reservations
VIEWS 46
This is an interesting case report on the usefulness of cognitive computer training for a child who is diagnosed with ADHD and concurrent videogame addiction. The rationale for the study, methods and findings are fine but I would like to ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Weinstein A. Reviewer Report For: Case Report: "ADHD Trainer": the mobile application that enhances cognitive skills in ADHD patients [version 5; peer review: 2 approved, 1 approved with reservations]. F1000Research 2015, 3:283 (https://doi.org/10.5256/f1000research.6082.r6739)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 07 May 2015
    Kazuhiro Tajima-Pozo, Department of Psychiatry, Hospital Universitario Fundacion Alcorcon, Alcorcon, 28922, Spain
    07 May 2015
    Author Response
    We have included the following new references and made the changes according to the reviewer comments.  
     
    Mishra J, Merzenich MM, Sagar R. Accessible online neuroplasticity-targeted training for children with ADHD. ... Continue reading
  • Author Response 07 May 2015
    Kazuhiro Tajima-Pozo, Department of Psychiatry, Hospital Universitario Fundacion Alcorcon, Alcorcon, 28922, Spain
    07 May 2015
    Author Response
    We have included the following new references and made the changes according to the reviewer comments.  
     
    Mishra J, Merzenich MM, Sagar R. Accessible online neuroplasticity-targeted training for children with ADHD. ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 07 May 2015
    Kazuhiro Tajima-Pozo, Department of Psychiatry, Hospital Universitario Fundacion Alcorcon, Alcorcon, 28922, Spain
    07 May 2015
    Author Response
    We have included the following new references and made the changes according to the reviewer comments.  
     
    Mishra J, Merzenich MM, Sagar R. Accessible online neuroplasticity-targeted training for children with ADHD. ... Continue reading
  • Author Response 07 May 2015
    Kazuhiro Tajima-Pozo, Department of Psychiatry, Hospital Universitario Fundacion Alcorcon, Alcorcon, 28922, Spain
    07 May 2015
    Author Response
    We have included the following new references and made the changes according to the reviewer comments.  
     
    Mishra J, Merzenich MM, Sagar R. Accessible online neuroplasticity-targeted training for children with ADHD. ... Continue reading

Comments on this article Comments (3)

Version 5
VERSION 5 PUBLISHED 26 Oct 2015
Revised
Version 1
VERSION 1 PUBLISHED 18 Nov 2014
Discussion is closed on this version, please comment on the latest version above.
  • Author Response 14 Apr 2015
    Kazuhiro Tajima-Pozo, Department of Psychiatry, Hospital Universitario Fundacion Alcorcon, Alcorcon, 28922, Spain
    14 Apr 2015
    Author Response
    Thanks for your comments Mr Black! best regards
    Competing Interests: No competing interests were disclosed.
  • Reader Comment (F1000Research Advisory Board Member) 20 Nov 2014
    Kevin J Black, Washington University in St Louis, St. Louis, USA
    20 Nov 2014
    Reader Comment F1000Research Advisory Board Member
    This is a trivial comment, just FYI, but the phrase "integrated by medical doctors and engineers" in the Competing Interests section sounds great in Spanish, but would be better rendered ... Continue reading
  • Discussion is closed on this version, please comment on the latest version above.
Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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