Efficacy of cognitive training interventions in hyperactive children: A critical review

Clinical Psychology Review, Vol. 5, pp. 479-512, Printed in the USA. All rights reserved.

1985 Copyright

0272-7358185 $3.00 + .OO 0 1985 Pergamon Press Ltd.

EFFICACY OF COGNITIVE TRAINING INTERVENTIONS IN HYPERACTIVE CHILDREN:

Howard Abikoff Long Island Jewish-Hillside

Medical Center

ABSTRACT.

This article critically reviews the efficacy of cognitive training interventions in hyperactive (ADDH) children. The impact of training on cognitive, academic, and behavioralfunctioning is considered in medicated and unmedicated youngsters. The expectation that self-regulation skills facilitate generalization and maintenance effects has, in most cases, not been substantiated. Suggestions for enhancing transfer effects are presented. It is suggested that greater attention be given to individual differences, and the development of a poblemsolving assessment battery ti proposed. It is concluded that the clinical utility of cognitive training in the treatment of attention deficit disorders has not yet been established.

Hyperactivity (attention deficit disorder with hyperactivity, ADDH) is characterized by the primary symptoms of inattentiveness, impulsivity, and restlessness. Other features that are frequently associated with the disorder include poor school performance and inadequate interpersonal relationships. Information regarding the specific nature of these deficits has been steadily accumulating, and has been described extensively by Douglas (1980a, 1980b). Hyperactive children typically demonstrate an inability to modulate their behavior in response to situational demands. Instead, a careless, disorganized, nonreflective manner characterizes their cognitive and social functioning. This response style, coupled with difficulties in sustaining and directing attention, contribute to the inefficient search strategies (Douglas & Peters, 1980) and problem-solving skills (Tant & Douglas, 1982) displayed by these youngsters. Douglas’ (1980b) description of ADDH children as suffering from an inability to “Stop, Look, Listen, and Think,” succinctly captures the essence of the disorder. The most widely used treatment with ADDH children continues to be psychostimulant medication. The short-term clinical efficacy of these drugs (methylphenidate, dextroamphetamine, magnesium pemoline) has been well-documented (see Requests for reprints should be sent to Howard Abikoff, Department of Psychiatry, Long Island Jewish-Hillside Medical Center, PO. Box 38, Glen Oaks, NY 11004. 479

reviews by Barkley, 1977; Klein, Gittelman, Quitkin, 8c Rifkin, 1980; Whalen & Henker, 1976). With medication, a large proportion of ADDH youngsters (60%90%, Whalen & Henker, 1980) demonstrate substantial, improvement in the primary symptoms of the disorder. There are limitations associated with stimulant treatment, however. Medication appears to have little impact on molar aspects of cognitive ability such as reasoning, problem solving, and learning (Campbell, 1976). Although stimulants may increase academic productivity in some children, its impact on academic achievement has not been established (see Gadow, 1983). While tnedication diminishes disruptive classroom behavior, it does not enhance interpersonal skills (Pelham & Bender, 1982), or facilitate appropriate responses to provocative social demands (Hinshaw, Henker, & Whalen, 1984). Further, there is little evidence that long-term stimulant treatment substantially alters the eventual outcome of these children, because deficient social and learning skills and poor academic performance are still present in adolescence and young adulthood (Mendelson,Johnson, & Stewart, 197 1; Minde, Lewin, Weiss, Lavigueur, Douglas, & Sykes, 197 1; Weiss, Kruger, Danielson, & Elman, 1975). Moreover, the positive behavior changes associated with stimulants are invariably not maintained following termination of medication, necessitating the resumption of stimulant treatment in many cases (Gittelman-Klein, Klein, Katz, Saraf, & Pollack, 1976). Finally, a proportion of youngsters are nonresponders, demonstrating little or no benefit from medication. Given these limitations of stimulant treatment, there is considerable clinical importance attached to alternative and adjunctive ix~terventions that attempt to provide ADDH children with skills and tactics that enable them to cope more efficaciously. Over the past decade, there has been increasing interest in the use of cognitive training as an alternative or adjunct to stimulant treatment. This article critically reviews these cognitive training investigations in ADDH children. COGNIIIVE TRAINING RATIONALEAND PROCEDURES Like other therapeutic interventions, cognitive training has as its goals the reduction or elimination of maladaptive, inappr0priat.e behaviors, and the establishment of more efficient, adaptive modes of responding. Central to these goals is the development of self-control skills and reflective pr~)blem-solving strategies. It is assumed that the acquisition and internalization of these skills will provide the child with the means for regulating his own behavior, thereby facilitating generalization and maintenance effects (see Meichenbaum & Asarnow, 1979). Given the deficits characteristic of ADDH, the rationale and goals of cognitive training have made this approach especially attractive to those working with hyperactive children. A number of different treatment procedures and approaches, (e.g., self-instructional training, cognitive modeling, attentional training, self-regulation, cognitive problem-solving, strategy training, social problem-solving, cognitive behavior modification), all falling under the rubric of cognitive training, have been employed with hyperactive youngsters. The es~blishment of cognitive mediational skills has been emphasized in many cognitive training studies with ADDH children. The impetus for this focus stems in large part from the landmark study by Mcichenbaum and Goodman (1971). Influenced by Soviet work on the controlling effects of language and thought on behavior (e.g., Luria, 1961; Vygotsky. 1962), Meichenbaum and Goodman exam-

Cognitive

Training in Hyperactive

Children

481

ined the impact of cognitive training in behavior problem (Study I) and cognitively impulsive (Study II) children. These youngsters’ maladaptive behaviors and impulsive response styles were viewed as being related, in part, to three possible deficiencies: (a) poor comprehension of task or situational demands, (b) failure to produce task-appropriate cognitive mediators spontaneously, and (c) failure to use these mediators in a self-guiding fashion. It was hypothesized that training the children to use appropriate, task relevant, reflective cognitive strategies would result in positive behavior change. To this end, cognitive modeling and self-instructional techniques were employed with a variety of psychoeducational tasks (e.g., reproducing designs, following sequential instructions, concept problems). Compared to controls, the cognitively trained children demonstrated significant improvement on the WISC Picture arrangement and Coding subtests (Study I), and in error rate on the Matching Familiar Figures Test (Study II). Training followed a specific format. On each task, the child observed and “listened in” while the trainer verbalized reflective, sequential problem-solving statements which guided his task performance. These statements, and the corresponding modeled behaviors, emphasized the importance of defining the task problem, focusing attention, evaluating performance, and correcting errors. After this cognitive modeling, the child worked on the same task under the verbal direction of the trainer. Subsequently, the child performed the task on his or her own, first selfinstructing aloud, and then whispering the instructions. Finally, the child worked silently, using covert self-instructions to guide his or her performance. These procedures continue to be the model for much of the cognitive training work with ADDH youngsters. Hyperactive children typically perform in a cognitively impulsive manner on tasks, such as the Matching Familiar Figures test, which require care, organization, and attention to detail (Campbell, Douglas, & Morgenstern, 1971). Thus, it is not surprising that training procedures that are successful in modifying the perceptual search style of cognitively impulsive, nonhyperactive children have been incorporated into programs for ADDH youngsters. For example, the component attentional training approach employed by Egeland (1974) with normal, cognitively impulsive second graders, has also been used with hyperactive children (e.g., Douglas, Parry, Marton, & Garson, 1976). The procedures focus on reducing the inefficient visual search and scanning behaviors associated with impulsive cognitive response styles (see Drake, 1970; Siegelman, 1969). Modeling and self-instructional techniques are used to teach systematic search and scanning behaviors, methods for remembering essential features of stimulus arrays, and strategies for comparing stimuli for similarities and differences. Self-monitoring and self-reinforcement are frequently used in cognitive training with hyperactive youngsters. The rationale for employing these procedures with ADDH children has been detailed by Douglas (1980b). Briefly, self-monitoring is intended to reduce impulsive responding, because the youngsters are required to periodically stop and evaluate their performance. Self-monitoring also increases the children’s awareness of the problem-solving process as well as their attention to detail. Self-reinforcement avoids some of the problems associated with external reinforcement procedures in hyperactive youngsters (e.g., Firestone & Douglas, 1975; Parry 8c Douglas, 1983), while focusing the children’s attention on the contingencies being trained. Self-monitoring and self-reinforcement have been implemented in different

48.2

Howard Abikoff

ways in cognitive training regimens. Some investigators incorporate these procedures into the self-instructional process, using verbalizations to monitor and reinforce problem solving and task performance. In these cases, the trainer models self-statements having evaluative properties (e.g., “How am I doing?” “Am I following my plan?“) and reinforcing properties (e.g., “I did a good job”). The children are encouraged to monitor and reinforce their task performance similarly. In studies emphasizing cognitive-behavior modification techniques, self-monitoring and self-reinforcement are employed in a different fashion. Typically, at specified time intervals, the children evaluate their behavior on a self-monitoring sheet; evaluative self-verbalizations are not required. Accuracy of self-monitoring is frequently shaped using contingent reinforcement or response cost procedures. The children’s self-recorded checks are subsequently “cashed in” for previously selected back-up reinforcers. These procedures have been utilized mainly in classroom or group settings, where large response classes, such as prosocial and/or ontask behaviors have been targeted for self-monitoring and self-reinforcement. Interpersonal or social problem-solving training has been a treatment component in some studies (e.g., Abikoff & Gittelman, in press; Hinshaw et al., 1984). This approach employs sequential problem-solving techniques described by D’Zurilla and Goldfried (1971) and Shure and Spivack (1972). The focus is on teaching the child to recognize and define interpersonal problems when they arise; generate several alternative solutions to the problem; consider and evaluate the consequences of the various alternatives; consider the means by which the chosen solution can be implemented; and follow through on the chosen solution so as to verify the utility of the choice. Role-playing and modeling are often used to supplement the problem-solving procedures. REVIEWOF COGNITIVETRAINING STUDIES This article limits discussion to cognitive training studies with hyperactive children. Studies with non-ADDH behavior problem, or cognitively impulsive children are not presented, because this literature has been critically reviewed elsewhere (Abikoff, 1979; Hobbs, Moguin, Tyroler, & Lahey, 1980; O’Leary & Dubey, 1979; Roberts & Dick, 1980). Not unexpectedly, the investigations reviewed differ on a number of critical features, such as length of training, training procedures, outcome measures, and subject medication status. These and other study characteristics are summarized in Table 1. For ease of exposition, the studies are considered in terms of their impact on three major spheres of functioning: cognitive, academic, and behavioral. Each of these areas is discussed separately; however, individual studies are sometimes considered under more than one domain, when appropriate. In most instances, fairly standard clinical/research criteria for hyperactivity have been employed, (i.e., history consonant with a diagnosis of ADDH, cutoff scores on standardized teacher or parent rating scales). For purposes of brevity, diagnostic characteristics will be described only for studies employing less rigorous or atypical entry criteria.

Cognitive

Training in Hyperactive

Children

483

Training Effects on Cognitive Performance As noted previously, a major aim of cognitive training is to modify impulsive responding by providing self-statements that mediate reflective problem-solving behaviors. Systematic assessment of the internal validity (Mahoney, 1978) of treatment manipulations has been sorely lacking, as few, if any attempts have been made to determine whether the youngsters’ self-statements have been altered with training. Without such direct confirmation of the effects of treatment, the functional relationship between cognitive change and behavior change remains unclear (Kendall, 1981). Instead, research efforts with hyperactive, and other children, have relied extensively on psychological test performance as an indirect assessment of cognitive change. A number of investigations, most using self-instructional procedures, have attempted to alter the characteristic impulsive response style of ADDH youngsters. The earliest studies were those of Palkes and her colleagues. Palkes, Stewart, and Kahana (1968) examined the effects of self-directed verbal commands on the Porteus Maze performance of S- and g-year-old boys in psychiatric treatment for hyperactivity. No other diagnostic information was provided. Medication was discontinued during the study period. The 10 children in the experimental group were individually trained on visual discrimination and perceptual-motor tasks. Four visual aid cards, with prompts to Stop, Look, Listen, and Think, were placed before each child as he worked on a task. The child was required to verbalize the steps on each card at the proper time while working. The trainer reminded the child whenever he forgot to verbalize his self-commands. The children were reexposed to this same 30-minute training regimen the next day and were then immediately posttested on an alternate form of the mazes. Compared to an attention control group, the instructed youngsters significantly reduced their qualitative errors, performing in a less impulsive manner after training. In a subsequent study with 7- to 13-year-old boys, Palkes, Stewart, and Freedman (1972) examined whether verbalization of self-commands was crucial in improving performance, and evaluated maintenance effects as well. Diagnostic features and training procedures were identical to those of the earlier study. In addition to an attention control group, a third group of children was instructed to read silently, but not to verbalize the same training prompts given to the study children. The verbalization group significantly reduced its qualitative errors compared to the control groups, which did not differ significantly from each other. These findings are tempered, however, for two reasons. First, the differential treatment effects were not maintained at 2 weeks follow-up testing. Given the extremely brief training period, this lack of maintenance is not unexpected. Second, the verbally trained children did not verbalize during posttesting, which occurred immediately after the second training session. It is conceivable that these youngsters were using the self-command statements covertly to guide their performance, although this was not evaluated. Given this absence of verbalization, it is unclear why verbalizing rather than reading the self-commands during training led to superior test performance. Nevertheless, the results of these early studies were instrumental in suggesting the potential clinical efficacy of verbal mediation training with hyperactive children. The construct of reflection-impulsivity, or conceptual tempo, refers to an individual’s response style when presented with a problem-solving task consisting of

484

Howard

TABLE

1. Summary

of Cognitive

Training

Subjects

Abikoff

(1983)

Studies with Hyperactive Length

of

Abikoff

(Years)

Drug

Training

12

6-11

Yes

2 hr./wk.,

50

&

Other

Nh

CPS:

6-12

Yes

(T)

GrOUDS(S)

10 wks, tasks

2 hr./wk.,

16 wks.,

1 to 1,

Psychoeducational

(in press)

None

1 to 1,

Academic

CPS:

Gittelman

Children

and

Typic

Age Study

Abikoff

tasks;

SPS:

Drug

alone;

Drug

+ Attention

control

(Cl)

(C,)

groups

of 3; parent involvement

6

Barkley, Copeland, Sivage

7-10

No

2 hrs./ 4 x wk., 6 wks.;

&

CPS:

None

group;

SM and SR of on-

(1980)

task Brown

(1980a)

120

8; 13

% Yes,

Modeling

‘/2 No

(T,):

on MFFT

1 X, 7 min.

Direct

Instruction

on MFFT

(Ty);

untreated

control

(C)

Brown Study

(1980b,

Brown Study

(1980b,

Henker

24

10;

16

No

5th

No

Grade

2)

Bugental, Whalen,

23

1)

36 & (1977)

11

X,

Modeling

MFFT,

groups

1

Modeling, sessions

on

no. of

None

Untreated

controls

not

reported;

tasks not

reported;

1 to 1

% Yes,

1 hr.12

% No

wks.; Sl:

x wk., 6 1 to 1,

reinforcement

academic

tasks,

on-task

goal directed behavior

(T,)

Social (T2)

for

485

Cognitive Training in Hyperactive Children

Results’ Analysis

Cognitived

Academice

Behaviorair

Follow-uo

Pre-Post

NA

WRAT: Reading,* Spelling (n.r), Arithmetic (ns) SAT: Reading Comprehension,* Math Computation (ns), Math Apphcation (n.t), Skills Test*

NA

Not done

Between-groups

WISC-R: Performance IQ,* Block Design,* Object Assembly,* (2 5, T), all other tests (71s); PAT (ns); CPT (ns); Ravens (ns); MFFT; errors (11s). latency* (T > C,)

WRAT: Reading, Spelling, Arithmetic (all n.s); GOR (ns); SAT: Reading Comprehension, and Math Application, and, Math Computation (all n.5)

Teacher: HESBRS, CTRS, BRS (all 11s); Parent: BRS, WWPAS, PAT (all w)

1 month: all measures (7~)

ABAB Design

NA

NA

> On-task, < misbehaviors

Not done

Between-groups

MFFT: latency & errors (r2.s); WISC-R: coding* (T, + Drug & T, + Drug > C + Drug); copying task (m)

NA

NA

Not done

Pre-Posts

MFFT: errors,* latency (m)

NA

NA

Not done

Between-

MFFT: errors,* latency,* DTLA: sustained visual attention*

NA

NA

1 month: MFFT: errors,* latency* DTLA: Sustained visual attention (723)6 months:h

Porteus Mazes: Qualitative* (T,: High locus of control, and no

NA

CATRS:

groups, posttest only

Between-groups

drugs

best;

T2:

low locus of control, and drug best)

(ns)

Porteus Mazes (w); CATRS* (Ts < T,); locus of control* (T, ’

T2)

486

Howard

TABLE

1. Summary

Abikofj

of Cognitive

with Hyperactive

Children

Subjects iV

Study

Training

Studies

(continued) Length and Type< of Training (T)

Other Groups(s)

Age (Years)

Drug

8

No

‘12 hr.112 x ; CPS: 1 to 1, psychoeducational and math tasks; SM and SR on math tasks

None

5-6

Yes (see other

1 hr./2 x wk., 10 wks., CPS: 1 to 1 sensorimotor, cognitive, social tasks; parent and teacher involvement (T,: No drug)

CPS + Drug (T2), Drug alone (T,), Untreated controls

& (1980)

3

Cohen, Sullivan, Minde, Novak, & Helwig (1981)

24

Douglas, Parry, Marton, & Carson (1976)

29

6- 10

No

1 hr./24 X; CPS: 1 to 1, psychoeducational tasks; academic work; social interaction: groups of 2; parent and teacher involvement

Untreated

Eastman & Rasbury (1981)

11

1st grade

No

20 min.16 X; SI: 1 to 1: psychoeducational tasks; teacher involvement

Attention

controls

Friedling & O’Leary (1979)

8

6-8

No

90 min./ 1 X, 40 min/2 X; SI: 1 to 1; psychoeducational and reading tasks

Attention

Controls

Cameron Robinson

groups)

(T4)

controls

Cognitive

Training

in Hyperactive

487

Children

Resultsa Analysis

Cognitived

Academic<

Behavioralt

Follow-up

Time-series

NA

Math accuracy* (2 children improved)

On-task during math lesson (all children)*

1 week: Math accuracy* (all children); Selfcorrection of oral reading* (all children); On-task* (2 children)

Between-groups

Verbal IQ; PMFFT; Etch-ASketch; Selfconcept (all w)

NA

CTRS; CPRS; Richman-Graham (all 71.5)

1 year: Cognitive: (all ns) Behavioral: (all ns)

Between-groups

MFFT: errors,* latency *; Bender Gestalt: time,* errors (ns); DTAM: unrelated words (nr), related syllables (m); SCT: aggression,* realistic,* withdrawal (n.~); Porteus Mazes: test quotient (ns)

WRAT: Arithmetic (1~s);Durrell Reading: Oral reading (ns), Oral comprehension (m), Listening comprehension*

CATRS: (ns)

3 months: MFFT: errors,* latency*; Bender Gestalt; (1~s);DTAM: (1~s);SCT: aggression (m), realistic,* withdrawal*; Porteus Mazes: (m) WRAT: Arithmetic (n.s) Durrell Reading: Oral reading,* Oral comprehension,* Listening comprehension (ns); CATRS: (4

Between-groups

NA

Reading worksheets (n.s)

On-task (m)

Not done

Between groups

NA

Reading accuracy (RT); Reading quantity (nr) Reading: % skipped (71s)Math accuracy (7~)

On-task (ns)

Not done

TABLE

1. Summary

of Cognitive

with Hyperactive

Children

Subjects

Study

IV

Age (Years)

Hinshaw, Henker, & Whalen (1984, Study 1)

20

8-13

(Study

2)

Hinshaw, Henker, & Whalen (1983)

24

9-12

24

8-13

Drug */2Yes ‘/‘JNo

Yes (for 1st 2 wks., week 3: % Yes, L/2No)

Yes

Training

Studies

(continued) Length and Type< of Training (T) 2 hrs.15 x; groups of 3; CPS: 1 session, academic and finemotor tasks; SPS: 3 sessions; self-control strategies: I session (T1: training + drug; T,:training + no drug)

SO min./daily for 2 weeks; CPS: groups of 3, academic tasks, general problemsolving; 2 sessions in Week 3; stress inoculation to teasing; CPS: strategy rehearsal (?;: Week 3, no drug; T2:Week 3, on drug)

75 min./daily for 3 weeks, 2 days: SM & SR: groups of 4, cooperative & competitive playground events; Week 3, Days 3 & 4: % on drug, t/2on placebo; RSE on one day (T,), RA on one

Other Groups(s) None

Weeks 1 & 2 same as T, & r,, Week 3: perspective taking, empathy training, recognition of emotions (T,: Week 3, no drug; Ts: Week 3, on drug)

Normal comparisons

(N)

day (T2) Horn, Chatoor, & Conners (1983)

1

9

Yes

t/2hr.12 x week for 3 weeks; SI: 1 to 1, tasks not reported; SM and SR of Ontask. Training + drug (T,), Training + placebo (r,)

Drug only phase (T,)

Cognitive

Training

in Hyperactive

Children

489

Resultsa Analysis

Cognitived

Academicc

BehavioraIr

FoIIow-UD

Pre-post

NA

NA

Response to provocative teasing: > selfcontrol*; > purposeful alternative activities*; < Verbal retaliation*; no drug interaction

Not done

Between-groups

NA

NA

Response to provocative teasing: selfcontrol* (T, & T2

Not done

’ Ts & 7-4); purposeful alternative activity* (T, & T2 ’ G & 7-J; Coping strategies* (T, & TY > Ts & T4); Verbal retaliation (m) Between-groups

NA

NA

On playground: Negative social behaviors* (T, < T2) T, + drugs < N); Positive social behaviors* (T2 >

Not done

TY)

Single-case

CPT: errors* (improved with T3); MFFT: errors (ns), latency (ns)

Math accuracy (w); Spelling accuracy (4

Off-task* (reduced with T,); Gross motor, & vocalization & noise (results unclear); CATRS* improved with T,

2 days: Offtask*; Gross motor, 84 vocalization & noise (results unclear); other measure not assessed

490

Howard

Abikoff

TABLE 1. Summary of Cognitive Training Studies with Hyperactive Children (continued) Subjects Age (Years)

Drug

Length and Typec of Training (T)

Other Croups(s)

Study

Nb

Kirby & Horne (Note 3)

15

K-4th grade

No

32 hrs. over 6 weeks; CPS: increased from 1:l to 8:1, individualized tasks (not described); response cost; teacher training

Waiting list controls

Moore & Cole (1978)

14

8-12

No (on-going drug treatment for some, # not reported)

t/zhr./ 6 x ; CPS; 1 to 1, psychoeducational tasks, self-paced

Attention controls (C,); No treatment controls (C,)

Palkes, Stewart, & Freedman (1972)

30

7-13

No

% hr.12 x ; Selfdirected verbalizations: 1 to 1, psychoeducational tasks, visual prompts, (T,)

Silent reading (T?); Attention Controls

Palkes, Stewart, & Kahana (1968)

20

r/zhr./2 x ; Selfdirected verbalizations: 1 to 1, psychoeducational tasks, visual prompts

Attention

Varni & Henker (1979)

3

Watson & Hall (1977)

86

9

No

(C)

controls

(C)

8-10

No (2) Yes (1)

SI: L/2hr./ 3 X, 1 to 1, psychoeducational & reading tasks; SM: (# sessions varied), in clinic, on-task during reading; SM + SR: (# sessions varied), in clinic, in school, on-task during reading & math

None

4-6 grade

No

r/zhr./l2 X, CPS: 1 to 1, psychoeducational tasks; SPS: 1 to 1, hypothetical social problems; relaxation and biofeedback

Sensorimotor training (C,); No treatment controls (G)

Analysis

Cagnitivttd

Academicc

BehavioraIr

Ebllow-up

Between-groups

MFFT: erIYJr.s, latency; CPT; CEFT; Raveris CPM; WISC-R: Coding, Arithmetic, Mazes, Digit Span, (aU ~5s)

WRAT: Reading, Spelling, Arithmetic (all VE)

Parents: CPRS (?hh SCRS @.x1

Not done

CTRS

?+3c done

Between-gmlps

brteus

Within-subjects

NA

(muftipie baseline)

&fazes: NA Test Quotient* (T 1 C), Qualitative* (T x=+ C)

fnsj

NA

Nat done

NA

Not done

492

Howard Abikoff

TABLE

1. Summary

of Cognitive

with Hyperactive Subjects Study Weithorn & Kagen (1979)

N”

Age (Years)

Drug

94

5-7

No

(47 ADDH) (47 Low actives)

Children

Training

Studies

(continued) Length and Typec of Training (T) Length and # not reported; verbal self-direction: 1 to 1, perceptual discrimination task (ADDH: T,; Low actives; T2)

Other Groups(s) ADDH Attention controls (C,); Low actives attention controls (C,)

ZIn studies with more than two groups, only significant contrasts are reported. bTota1 sample size. CPS = cognitive problem-solving, includes selfGnstructiona1 training and cognitive modeling; SM = selfmonitoring; SR = self-reinforcement; RSE = reinforced self-evaluation; RA = reinforcement alone; SI = self-instructional training; SPS = social problem solving. dNA = not applicable; PAT = Paired Associates Test; CPT = Continuous Performance Test; MFFT = Matching Familiar Figures Test; DTLA = Detroit Test of Learning Aptitude; PMFFT = Preschool Matching Familiar Figures Test; DTAM = Detroit Test of Auditory Memory; SCT = Story Completion Test; CEFT = Children’s Embedded Figures Test; Ravens CPM = Ravens Colored Progressive Matrices; IAR= Intellectual Achievement Responsibility Questionnaire.

several highly similar solutions, only one of which is correct. In such situations, impulsive individuals tend to respond more quickly and less accurately than their reflective counterparts. The Matching Familiar Figures Test (MFFT) (Kagan, Rosman, Day, Albert, & Philips, 1964) is the instrument most frequently used to assess cognitive impulsivity. Test scores have been related to school performance (see review by Messer, 1976) and classroom behavior (Glenwich, 1976). In several cognitive training studies, performance on the MFFT has been the major, or sole, outcome measure. Weithorn and Kagen (1979) worked with first graders designated as showing “high-or-low activity level” on the basis of teacher ratings on a lo-item questionnaire adapted from the Abbreviated Conners Teacher Rating Scale. Children of both activity levels were assigned to training or attention control groups. The trained children were given explicit verbal instructions by the examiner on how to find the correct solution to multiple-choice perceptual discrimination problems similar in format to the MFFT. During training, children were required to verbalize aloud what they were searching for and whether their choice was right or wrong. Posttesting on the MFFT occurred immediately after training. The youngsters were instructed to use verbal self-instructions while working on the MFFT, and were reminded to do so if they failed to self-instruct. A significant interaction was found between activity level and training group. Trained children with high activity levels demonstrated a significant reduction in errors compared to their untrained counterparts. No differences emerged between the two low activity groups, due perhaps to ceiling effects. These findings are weakened by methodological problems. The similarity between the training and test materials suggests that the youngsters may have been taught a specific test taking skill rather than a generalized response strategy. Moreover, examiner prompts during posttesting further limit the assessment of transfer effects. A serendipitous finding of some interest in this study was the reported resistance

Cognitive

Training

in Hyperactive

493

Children

Results2 Analysis Between-groups

Cognitived

Academic<

Behavioralf

Follow-up

MFFT:

NA

NA

Not done

errors*

(T, < CJ

.

eWRAT = Wide Range Achievement Test; SAT = Stanford Achievement Test; GOR = Gray Oral Reading Test; PIAT = Peabody Individual Achievement Test. rHESBRS = Hahnemann Elementary School Behavior Rating Scale; CTRS = Conners Teacher Rating Scale; BRS = Behavior Rating Scale; WWPAS = Werry Weiss Peters Activity Scale; PAT-Parent Attitude Test; CATRS = Canners Abbreviated Teacher Rating Scale; CPRS = Canners Parent Rating Scale; SCRS = Self-Control Rating Scale. KPre- and posttesting occurred 1 month before, and after training, respectively. hBugenta1 et al. (1978). *Significent improvement.

to the training procedures among some of the low-activity level youngsters. These children made significantly fewer MFFT errors than the more active group at pretesting. As the authors suggest, the training strategies may have interfered with already established, efficient problem-solving skills in the low-activity group. The importance of matching training strategies with pre-existing problem-solving skills is discussed in more detail later in this article. Hyperactive children’s MFFT performance has reportedly been modified using cognitive modeling procedures, without exposure to self-instructional or verbal self-command training. Brown (1980b, Experiment 1) found that 5th- and lOthgrade hyperactive, cognitively impulsive boys in a residential treatment center, and cognitively impulsive normal 10th graders, showed significantly improved MFFT error rates 1 month after viewing videotapes of age-matched models engaging in reflective problem-solving strategies on the MFFT. The hyperactive and normal youngsters were not differentially influenced by the modeling procedure. These improvements would have been more meaningful if the MFFT was not used as the modeled training task. In Experiment 2, Brown (1980b) used more extensive modeling procedures with “hyperactive” fifth graders who were placed in learning disabilities classrooms because of severe impulsivity and attentional problems. These children viewed a series of puppet shows (the number and length of these sessions were not reported) which modeled the importance of planning ahead, stopping to think, and attending to details across a variety of problem situations (not detailed). The negative consequences of impulsive responding were modeled as well. The youngsters were required to reenact the puppet shows using the modeled reflective problem-solving strategies. During the training period, teachers emphasized the importance of working reflectively on classwork assignments. Compared to a no-treatment control group of hyperactive children, the cognitive

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modeling group demonstrated significant improvements in MFFT errors and latency and sustained visual attention on a subtest of the Detroit Test of Learning Aptitude 1 week after training. These significant differences on the MFFT were maintained 1 month later; the training group also tended to perform better than controls on the Detroit subtest. Unlike Experiment 1, the findings suggest a more generalized improvement in reflective problem-solving skills. Moreover, the treatment gains resulted from cognitive modeling alone, suggesting that modeling may be especially useful in cases where language delays or expressive language difficulties preclude or limit the use of verbal self-instruction procedures. It should be noted, however, that the study sample size of 24 was too small to ensure that randomization had resulted in equivalent groups at pretreatment. Therefore, it is not known to what extent the treatment effects were a function of pretreatment levels, because a posttest only design was employed. Cognitive training affects on a range of cognitive skills and abilities, including cognitive response style, were evaluated by Moore and Cole (1978). Fourteen 8- to 12-year-old hyperactive children from an educational residential treatment facility were randomized into either self-instructional training, attention control, or no treatment control groups stratified for age, IQ, and medication status. Subject selection criteria were based on diagnostic judgments of hyperkinesis by school personnel. The five cognitively trained children received six individual cognitive modeling, self-instructional training sessions, including social reinforcement and feedback. The training tasks were individually geared to skills level, and were selfrather than experimenter-paced. Training in the careful and selective planning of choice behaviors on mazes, finding hidden objects, and especially sequential dotto-dot tasks resulted in increases on MFFT latency and improved performance on the Children’s Embedded Figures Test and Picture Arrangement subtest of the WISC. Treatment differences were not found on the WISC Block Design and Coding subtests or MFFT errors. The pattern of findings indicates limited generalization, because differential treatment effects were obtained only when the task demands of the outcome measures resembled those of the training materials. Programs. Several investigations have employed not only multiple outcome measures, but multiple training procedures as well. The emphasis in these studies is on the utility of multi-push approaches, rather than on component analyses of training procedures. Kirby and Horne (1982) g ave school personnel (special education teachers and guidance counselors) 16 hours of preparatory exposure to cognitive behavior theory and training. Preparation included assigned reading of therapist training manuals, direct instruction, and modeling of cognitive training techniques. These personnel subsequently provided 32 hours of cognitive training to eight randomly assigned, hyperactive, nonconduct disordered children in kindergarten through fourth grade. Treatment procedures included self-instructional training, self-monitoring of cognitive and social problem-solving and attending behaviors, and response costs (loss of points) contingent upon failure to self-instruct, complete work or attend to directions, and talking out without permission. Individualized programs were implemented for each child. The training sessions were videotaped, and trainers were provided with weekly feedback and supervision. The child-teacher ratio progressed from 1: 1 to 8: 1, thus creating a situation resembling a regular classroom

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in which the children could practice their self-instructional and self-monitoring skills. The performance of Kirby and Horne’s (1982) study group was contrasted to a randomly assigned waiting list control group of seven children. Although the cognitively trained youngsters had higher gain scores than controls on 18 of 20 measures, no differential effects were obtained on any component of a cognitive test battery comprised of measures of conceptual ability, sustained attention, “freedom from distractibility,” attention to detail, and cognitive impulsivity. The modest impact of training was limited to significant gains on the Children’s Embedded Figures Test, the WISC-R coding subtest, and the “freedom from distractibility” measure. In contrast, there was no significant improvement in the controls on any cognitive measure. Given the comprehensive treatment package, the lack of differential treatment effects is noteworthy; although as noted by the authors, the small sample size may have resulted in insufficient power. Unfortunately, the training materials were not described, thus precluding speculation as to the possible impact of different aspects of the training tasks on the study results. Watson and Hall (1977) evaluated the efficacy of cognitive training in combination with relaxation and/or biofeedback training in fourth, fifth, and sixth graders designated hyperactive solely on the basis of scores on the Conners Abbreviated Teacher Rating Scale. The 26 children in the experimental group received 12 halfhour individual training sessions. The cognitive training component was adapted from the Think Aloud Program designed originally for use with aggressive first and second graders (see Camp, Blom, Hebert, 8c van Doorninck, 1977). This program relies extensively on Meichenbaum and Goodman’s (197 1) cognitive modeling and self-instructional procedures. The training content consists of visual and auditory cognitive tasks, as well as hypothetical interpersonal problem situations. The study group was compared to no-treatment controls and a placebo control group exposed to physical education activities that provided training in sensorimotor skills. The vague and incomplete data presentation make discussion of the findings difficult. However, there is no evidence that cognitive functioning, as measured by the MFFT, the WISC-R Digit Span, Mazes, and Coding subtests, and the Children’s Checking Task (a measure of auditory attention), was differentially improved in the experimental group. Douglas, based on her conceptualization of the attention deficits of hyperactive children (Douglas, 1975), developed a cognitive program comprised of selfinstructional, component attentional training, modeling, and role-playing techniques that focuses on teaching reflective problem-solving strategies and control of disruptive behavior. This program was evaluated by Douglas et al. (1976) in 18 6- to lo-year-old unmedicated hyperactive, cognitively impulsive boys. The 24session, S-month program emphasized reflective strategies for psychoeducational tasks (e.g., auditory sequencing tasks, match-to-sample tasks, block designs, puzzles). To a lesser extent, children were also trained to use cognitive strategies on teacher assigned academic work and in game and task situations involving dyadic peer interaction and cooperation. To help promote generalization, parents and teachers observed training sessions in order to implement the training techniques at home and at school. Teachers were also taught behavior modification techniques to help initiate task-relevant behavior in the classroom. Compared to untreated

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controls, similar in age, IQ, and degree of hyperactivity, the trained children demonstrated a more reflective cognitive response style on the MFFT (errors and latency), and significantly increased their drawing time on the Bender-Gestalt. A trend, in favor of the training group, was also found for Porteus Mazes performance and on a test for memory of unrelated words. The improvements in MFFT performance were maintained at 3 months follow-up, and a continuing trend in favor of the training group was also found for performance time on the Bender. This study is noteworthy for several reasons. The clinically meaningful (3-month) treatment regimen involved teachers and parents as well as professionals. Training materials were thoughtfully selected so as to maximize generalization effects. The change in cognitive response style was maintained 3 months after treatment termination. Further discussion of the study’s academic and behavioral impact is presented in the following sections. Trahing Plus Medication: Cognitive fffects. It has been suggested that the combination of cognitive training and psychostimulants may be especially advantageous, because the improved behavior and attention resulting from medication should facilitate the learning of problem-solving and self-control skills (Horn, Chatoor, & Conners, 1983). Several studies have examined the effects of this treatment combination on cognitive functioning. The additive effects of d-amphetamine (Dexedrine) and “self-control training” were evaluated in a single-case study design with a g-year-old psychiatric inpatient ADDH boy who also presented with an undersocialized conduct disorder and marked achievement deficits in math and spelling (Horn et. al., 1983). The authors posited that self-instructional training facilitates cognitive and academic performance, whereas behavioral self-reinforcement is effective in reducing disruptive behavior. Therefore, both training strategies were employed to maximize treatment gains across multiple response classes. The self-instructional training combined Meichenbaum and Goodman’s procedures with alternative problem-solving techniques, and occurred during two weekly half-hour sessions for 3 weeks. The training tasks were not described. Training had no beneficial effects on cognitive functioning. Performance on the Continuous Performance Test improved only with d-amphetamine treatment. Self-control training alone, or as an adjunct to medication, was ineffective in reducing errors on this vigilance task. Neither training nor medication improved performance on the MFFT. The absence of a medication effect on the MFFT is inconsistent with previous findings (see review by Barkley, 1977). The authors noted that the addition to the treatment regimen of token reinforcement for correct responses on the MFFT increased correct responses and response latencies. However, as there was no reversal procedure, and direct reinforcement of correct responses occurred after the self-control training, the effects of reinforcement are unclear. Brown (198Oa) randomly assigned 120 clinically medicated and unmedicated 9and 13-year-old cognitively impulsive, hyperactive children to three groups. A cognitive modeling group observed a ‘I-minute tape of a youngster modeling reflective behavioral cues while working on the MFFT. An instructed group was given specific directions regarding reflective performance on the MFFT and was also required to memorize a Stop, Look, Listen strategy. Untreated controls comprised the third group. The MFFT, WISC-R coding subtest, and a copying task were administered at pre- and 1 week posttreatment. A significant interaction between

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medication status and training was reported. In both training groups, only medicated youngsters reduced WISC-R Coding errors and time on the copying task. It was suggested that these improvements reflected a facilitative effect of training and medication, or were a function of more severe disturbance in the medicated than unmedicated youngsters. Interpretation of these findings is further clouded, because data analyses did not control for the significantly worse MFFT and copying task pretest scores among medicated than unmedicated children. The author’s suggestion that these pretest differences might be related to the detrimental cognitive effects of “high doses of stimulant drugs” (doses were not reported) is puzzling in light of the finding that these medicated youngsters apparently learned task strategies that enhanced their cognitive performance. Finally, the earlier report (Brown, 1980b) that modeling reduces cognitive impulsivity was not replicated, as MFFT performance was not differentially improved with training. Cohen, Sullivan, Minde, Novak, and Helwig (1981) examined the impact of cognitive behavioral modification, medication (methylphenidate, lo-30 mg/day), the combination of both treatments, and no treatment in 24 hyperactive 5- and 6year-old kindergarteners. The cognitive- behavior modification was a “total push” program incorporating many of Meichenbaum and Goodman’s (197 l), Douglas et al.‘s (1976) and Camp et al.‘s (1977) p rocedures. The 20 one-hour twice weekly training sessions used sensorimotor, cognitive, and social tasks. Planning, selfevaluation, copying, and awareness of consequences were focused on in training. Parents observed training sessions, and parents and teachers were encouraged to use similar strategies both at home and in school. All four groups showed significant improvements over time on most measures. There were no differential treatment effects at posttreatment, or 1 year follow-up, in Verbal IQ, Preschool MFFT and Etch-A-Sketch errors, or self-concept. Moreover, the cognitive performance of all groups was indistinguishable from normal control children, with the exception that the youngsters receiving the combined treatments made more errors than controls on the Preschool MFFT. The study is notable for employing a comprehensive cognitive treatment regimen in young ADDH children. The absence of differential treatment effects, along with significant improvement in the controls, suggest that maturational factors may have led to the reported gains. It should be noted, though, that the small group sizes (n = 4, 6, or 8) may not have permitted adequate treatment comparisons to be made (Ross & Ross, 1982, p. 217). Further, as noted by the authors and others (Loper, 1980), the immature cognitive development of 5and 6-year-olds may restrict the efficacy of cognitive training with this age group. Bugental, Whalen, & Henker (1977) evaluated the interaction of locus of control orientation, medication status, and type of behavioral treatment in 36 1 l-year-old hyperactive boys. Six weeks of 12 one-hour individual self-instructional training sessions emphasized academic skills, and to a lesser extent, goal-directed nondisruptive behavior. Significantly greater reduction on the Porteus Mazes qualitative error score was found for children who attributed school achievement to personal effort and for nonmedicated children. Social reinforcement, contingent upon appropriate and effective task attention, significantly improved maze performance for medicated children and children with low perceived control. Six-month followup data collected on 20 study children indicated that both groups maintained decreased qualitative error scores on the Mazes (Bugental, Collins, Collins, & Chaney, 1978). The posttreatment interaction effect was no longer significant at followup, although the trend was in the same direction. The results suggest treatment

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generalization, because improved Porteus Mazes performance resulted from cognitive training with academic rather than psychoeducational tasks. In addition, this is the only report of the interaction of subject and treatment variables in hyperactive children. Caution is necessary, though, in interpreting the obtained interaction effect. As noted by Mash and Dalby (1979), “It is possible that the medicated and nonmedicated groups were not equivalent, since teacher ratings, which have been shown to be sensitive to drug effects, did not differ for the two groups [prior to the study]” (p. 198). The efficacy of cognitive training as an adjunct to stimulant medication was evaluated by Abikoff and Gittelman (in press). Fifty hyperactive children, ages 6 to 12 years, undergoing maintenance stimuiant treatment, were randomly assigned to either cognitive training, attention control, or a medication alone group. The groups were stratified for age and degree of academic and behavioral difficulties on medication. The 16-week training program emphasized cognitive and interpersonal problem-solving skills. The first 8 weeks consisted of twice weekly individual l-hour training sessions at school in rooms set aside by the teachers. Self-instructional and cognitive modeling procedures were used to teach reflective problem-solving skills. The training materials consisted of psychoeducational tasks similar to those used by Douglas et al. (1976) and Moore and Cole (1978). Parents observed two training sessions and were instructed to encourage and praise their child’s use of a reflective approach to school assignments. During the final 8 weeks, the children were seen in small groups (N = 3) after school. These sessions emphasized social problem-solving skills. Parents were exposed to the problem-solving framework and were requested to engage their children in social problem solving at home. The combined treatment regimen did not differentially improve cognitive performance. No significant treatment effects were found for the Paired Associates Test, the Continuous Performance Test, the Ravens Progressive Matrices, or MFFT errors. The cognitively trained children increased their response latency on the MFFT relative to the medication alone group, but not to the attention controls, who were instructed to work slowly and carefully during training. (See note, p. 512). Cognitive training did not facilitate maintenance following stimulant termination, as the groups did not differ in cognitive performance at 1 month followup testing on placebo. Suck of Training fflects on Cognitive Perfomnce.The impact of training on cognitive performance has been equivocal. Qualitative improvement on the Porteus Mazes has been a fairly consistent finding, suggesting that training facilitates the planning and careful responding necessary for successful execution on this perceptual-motor task. On the other hand, training effects on cognitive impulsivity, as measured by the MFFT, have been less clear-cut. Several reports of increased reflectivity are not especially convincing, because the MFFT served as the training task in these studies. There are only two instances (Douglas et al., 1976; Moore & Cole, 1978) in which MFFT improvement suggested treatment generalization; and only Douglas et al. obtained increases in accuracy as well as response latency. Except for scattered instances of improved test performance (see Table l), there is no compelling evidence that cognitive training differentially enhances attentional (e.g., Continuous Performance Test), or memory (e.g., Paired Associates Test, Digit Span) processes. Also lacking are any indications of the adjunctive efficacy of training on the

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cognitive functioning of stimulant treated youngsters. However, the improvements in cognitive test performance with medication alone may create ceiling effects, thereby limiting the opportunity to detect any additive effects of training. The inclusion of measures less influenced by medication may increase the likelihood of detecting the impact of cognitive training in medicated youngsters. Training Effects on Academic Performance It is likely that the inefficient problem-solving skills and perceptual search strategies common in ADDH youngsters compound their academic difficulties, because these cognitive/perceptual functions are essential components of efficient learning and study skills. Moreover, the academic performance of hyperactive children also suffers because frequent, careless errors are a by-product of their impulsive response style. A number of studies have investigated the impact of cognitive training on academic productivity or achievement. Friedling and O’Leary (1979) compared the math and reading performance of four cognitively trained hyperactive second and third graders with a matched group of four attention control children. The initial session employed training tasks adapted from the Stanford Binet, the WISC, and the McCarthy Scales. The training tasks in the remaining two sessions were taken from the youngsters’ “hard” (i.e., gradelevel) reading workbook. No differential treatment effects were found for “hard” and “easy” (below grade level) reading or math tasks. The significant improvement in accuracy, after the first session, on “easy” math tasks, supported the authors’ suggestion that self-instructional training may be most effective with previously mastered skills that are not optimally performed. However, because of low accuracy initially, regression to the mean was also offered as an alternative explanation of this improvement. Eastman and Rasbury (198 1) also reported that academic productivity did not improve with self-instructional training. Six first graders with elevated Conners scores and “poor academic habits” received six 20-minute self-instructional training sessions. Subtests from the Primary Abilities and Metropolitan Readiness Tests served as training materials. During a selected classroom work period, reminder cards and directions from the teacher to “think out loud” served as prompts to self-instruct. Verbal approval for self-instructing was given by the teacher at the end of the period. Compared to a group of five attention control children matched for reading, Conners, and on-task scores, the cognitive training group showed no significant improvement in reading worksheet performance. The authors suggest that the brevity and narrow focus of the training program may have led to treatment failure. The relative cognitive immaturity of first graders may also have limited treatment efficacy. Varni and Henker (1979) conducted a component analysis of cognitive training procedures in three boys, ages 8 to 10 years, diagnosed hyperactive by their pediatricians, and nominated by their schools as management and attentional problems. The impact of self-instructional training, self-monitoring, and self-reinforcement on math and reading performance was evaluated in a within-subject multiple baseline across settings design. Self-instructional training was provided in three 30minute sessions, using Porteus Mazes, MFFT, and programmed grade-level reading texts as training material. The children subsequently self-monitored their time

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spent working on reading tasks. Point values, without back-up reinforcers, were associated with particular time spans. Finally, self-reinforcement was added to selfmonitoring by pairing prizes selected by the children with the points obtained for time spent working. Only the self-reinforcement procedures resulted in increased academic performance (number of problems attempted and number of correct solutions) in math and reading, with greater improvement obtained in the clinic than in the school setting. The effectiveness of self-instructional training appeared to be a function of the cueing properties of the trainer, because appropriate selfinstructions and academic performance occurred only in the trainer’s presence and dropped off as soon as the children were left alone. It should be emphasized that the self-instructional training on academic material was quite brief, totaling 30 minutes on three reading pages. Improved academic performance has been reported for three hyperactive, academically backward 8-year-olds provided with 12 half-hour cognitive training sessions (Cameron & Robinson, 1980). Using a multiple baseline across individuals design, the multi-component program trained the youngsters to self-instruct, and to self-monitor and self-reinforce accurate math performance. The training materials consisted largely of math problems within the children’s ability range, although psychoeducational tasks were also used to teach self-instructional strategies. Time series analyses indicated significant improvement in daily math accuracy for two youngsters during training, and for all three children during a follow-up phase. A significant increase was also obtained in the youngster’s self-correction rate of oral reading errors. This is the only study to report improvement in math performance in cognitively trained ADDH children. These gains appear to be a function of the program’s emphasis on the direct application of self-regulation skills to math tasks. The improvements in oral reading suggest some generalization of treatment effects. With training, the youngsters apparently monitored their reading performance more closely. The relative contribution of the study’s training components is unknown, although subsequent work indicated no clear support for cognitive training without reinforcement of correct responses (V. Robinson, personal communication, February 15, 1982). Finally, it is of interest that the youngster who demonstrated delayed improvement in math performance also required direct instruction in math skills, and was taught systematic strategies for completing math problems (M. Cameron, personal communication, February 15, 1982). Obviously, the direct instruction may have been instrumental in delayed gains. On the other hand, this youngster may have needed additional time to consolidate the effects of training (see Egeland, 1974). Several investigators have evaluated the effects of cognitive training on academic achievement rather than productivity. Three previously described studies with unmedicated children included standardized achievement tests as outcome measures. Kirby and Horne (1982) found no significant change or treatment effects on the Wide Range Achievement Test (WRAT) Reading, Arithmetic or Spelling subtests. It is not reported whether academic tasks were focused on in training. The absence of gains must also be considered in light of the l-month pre- posttesting interval. In view of the degree of measurement error on the WRAT, improvement in academic performance over a l-month period would have to be extremely large to reach statistical significance (Sprague & Berger, 1980). The test may therefore be inappropriate for detecting changes in achievement over brief time spans. Watson and Hall (1977) reported no differential treatment effects on the Math

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subtest of the Peabody Individual Achievement Test (PIAT). Compared to no treatment controls, the 6-week program of cognitive training plus relaxation resulted in significant improvement in PIAT reading comprehension. However, it is unclear whether the cognitively trained children’s reading scores differed significantly from the placebo-control group’s, because the appropriate data were not presented. Improvements in reading performance have also been reported by Douglas et the cognitive group’s Listening Comprehension al. (1976). At posttreatment, performance on the Durrell Analysis of Reading Difficulty Test was significantly better than the control’s; their Oral Comprehension grade scores tended to be higher than the controls as well. No differences were found in Oral Reading or Spelling on the Durrell, or in WRAT Arithmetic. At 3 months follow-up, significant differences in favor of the cognitive group were found in Oral Reading and Oral Comprehension. The reported improvements are weakened somewhat by certain group disparities. Group assignment was not random, and was based in part on a youngster’s geographical proximity to the treatment site (V. I. Douglas, personal communication, December 15, 1983). Although the groups were not significantly different in age, IQ, or degree of hyperactivity, the cognitive group’s average pretreatment reading scores were more than 1% years higher than the controls. Moreover, the absence of change in controls in Oral Reading and Oral Comprehension tends to overstate somewhat the differential treatment effects. It is important to note, however, that the major goal of this study was the reduction of hyperactivity and cognitive impulsivity, and not academic improvement per se (V. I. Douglas, personal communication, December 15, 1983). Douglas et al. (1976) emphasize that to effect change in academic performance, training in specific academic skills should be added to the cognitive training regimen. paining Plus Medication: Academic Effects. The impact of the combination of cognitive training and medication on academic performance has been reported in three studies. Horn et al. (1983), in their single-case study design, reported no improvements in math or spelling performance with self-control training, d-amphetamine, or the treatment combination. The authors suggest that direct reinforcement of academic performance be added to self-control training, as an increased trend in math and spelling accuracy was found when direct rewards were provided for correct responses. The only behavior targeted for self-reinforcement in this study, however, was on-task classroom behavior. Improved academic performance might have resulted if academic accuracy were self-reinforced (see above, Cameron & Robinson, 1980; Varni & Henker, 1979). Moreover, the math and spelling measures consisted of, respectively, 10 and 15 problems, ranging from just below to 1 year above the child’s tested grade placement. The youngster was 1 year below grade level in math and 2 years in spelling. Given the difficulty level and the small number of test items, along with the absence of any academic skills training, the lack of academic improvement in this youngster is not entirely unexpected. Abikoff and Gittelman (in press) evaluated a broad-based cognitive training program in stimulant treated hyperactive children. Training emphasized reflective social and cognitive problem-solving skills. Academic tasks and materials were not used in training, although the children were encouraged to use their self-instructional problem-solving strategies on schoolwork, and parents were instructed to praise their child’s attempts at reflective problem-solving on homework assign-

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ments. At the end of the l&week program, there were no group differences on the Gray Oral Reading Test, WRAT Spelling, Reading or Arithmetic subtests, or on the Stanford Achievement Test (SAT) Reading Comprehension, Math Computation, and Math Application subtests. Paralleling the results obtained on tests of cognitive functioning, no significant group differences were found in achievement at l-month follow-up testing on placebo. In a subsequent pilot study, Abikoff (1983) evaluated a IO-week cognitive training program in 12 hyperactive boys (ages 6- 11 years) treated with methylphenidate (mean daily dose = 42 mg, range = lo-65 mglday). Academic tasks and materials were used exclusively in the twice weekly, l-hour training sessions. Cognitive modeling and self-instructional training emphasized the importance of identifying the problem, planning “how to be careful” and following one’s plan (i.e., showing correspondence between verbalized strategies and subsequent behavior). The youngsters were taught to self-monitor and self-reinforce their verbalized problemsolving statements, as well as the correspondence between their self-instructions and performance. Accuracy checks, with response costs (loss of points) were used as well. Several children were provided with brief training in specific academic task strategies. Significant improvement was found in word recognition on the WRAT Reading and on the SAT Reading Comprehension subtests. No significant gains were obtained in WRAT Spelling or Arithmetic, or on the SAT Math Computation and Math Application subtests. The children also demonstrated significant improvement on a 40-item academic skills test comprised of task instructions more varied than those on standardized achievement tests. A comparison group of eight ADDH boys undergoing clinical stimulant treatment showed no significant improvement on this measure. The achievement test findings are weakened somewhat, because pretesting was done on placebo and posttesting on active medication. However, several studies have reported that stimulants alone have minimal effects 8c on reading achievement (e.g., Abikoff 8c Gittelman, in press; Gittelman-Klein Klein, 1976). Moreover, the training and comparison groups were pre- and posttested on the academic skills test while on active medication. Therefore, the cognitive group’s improvement on this test was not a function of medication status. Surnrndry of Trahhg Effects on Academic Performance. The studies reviewed differ on a variety of features, including training procedures, training tasks, length of training, outcome measures, and subjects’ achievement Ievels. There have been no systematic investigations of the effects of these factors, singly or in combination, on academic performance. It is not surprising, therefore, that the studies vary widely in their outcomes. Nevertheless, it is possible to speculate on the potential impact of several of these variables on academic functioning. It seems unlikely that youngsters functioning below grade-level will benefit from training programs that lack an academic skills component. These children must first develop some degree of academic competency before they can meaningfully apply reflective cognitive strategies to a content area. It has been suggested that self-instructional procedures may be particularly effective in developing initial skills competency by orienting the children’s self-guiding statements specifically to their particular deficits (Barling, 1980). Lloyd (1980) has presented evidence in support of this approach with non-ADDH children. In this context, it is important to consider whether direct remedial tutoring alone may be more effective than a cognitive

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training approach in facilitating academic achievement in academically backward hyperactive children. This possibility needs to be tested empirically. The findings from several studies suggest that cognitive training regimens lacking academic skills training can improve academic productivity. These improvements presumably result from the reduction of careless errors and the optimal use of academic skills already learned (see Parrish & Erickson, 1981 for a study with cognitively impulsive children). It also appears that increasing the children’s motivation and persistence through self-reinforcement procedures may be especially useful in improving academic productivity. Finally, an adequate test of cognitive training’s effectiveness in improving and maintaining academic performance requires the design of clinically meaningful studies. The length of training in some studies has been quite brief, often totalling 3 hours or less. Such brevity hardly constitutes a meaningful test of treatment efficacy. Training Effect3 on Behavior

The impact of cognitive training on the behavior of hyperactive children has been evaluated in a number of studies. The primary emphasis has been on school behavior. Teacher ratings, and observations of on-task behavior, misconduct, and social interactions have been used to assess treatment effects on school comportment. Changes in home behavior have been examined as well. Behavior. Several studies, using either the Conners Teacher Rating Scale (CTRS, Conners, 1969) or the abbreviated scale version (ACTRS, Conners, 1973), have reported no differential improvements in teacher ratings of classroom hyperactivity. The absence of behavioral improvement in these studies may have resulted from a lack of emphasis on behavioral skills. Douglas et al. (1976) focused primarily on cognitive problem-solving strategies. The behavioral training component was brief, and limited to dyadic social interaction skills. Although this program did not diminish teacher-rated hyperactivity, the cognitively trained children, compared to controls, significantly reduced their aggressive response choices and responded more realistically on the Story Completion Test, a paper and pencil measure of frustration coping. Moore and Cole (1978) trained children exclusively on cognitive problem-solving skills; there was no focus on improving classroom behavior. Teacher ratings indicated no treatment effect. Watson and Hall’s (1977) behavioral training component required youngsters to apply social problem-solving skills to six hypothetical situations describing classroom and schoolyard interpersonal conflicts. Both the training and placebo-control groups improved on the ACTRS relative to controls; however, there was no significant difference between the training and placebo groups on the scale. Moreover, no differential treatment effects were reported on classroom observations of appropriate, task-consistent behavior. Reports of cognitive training effects on on-task behavior have been inconsistent. Training regimens using self-instructional training alone have been relatively ineffective. Friedling and O’Leary (1979) found no improvement in on-task behavior with self-instructional training, thus failing to replicate the on-task improvements School

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reported by Bornstein and Quevillon (1976) with three 4-year-olds described as disruptive and overactive. However, Friedling and O’Leary subsequently found that when teacher reinforcement was used, on-task behavior improved significantly. Eastman and Rasbury (198 1) also failed to obtain significant increases in on-task behavior with self-instructional training on psychoeducational tasks. The emergence of an increasing trend in on-task behavior during the treatment period was noted though, and it was suggested that meaningful improvement might result with extended training. Effective medication in on-task classroom behavior has been reported in studies incorporating self-reinforcement procedures. Cameron and Robinson’s (1980) three study children self-reinforced their math performance during clinic training sessions and classroom math periods. Time series analyses of classroom observations during math periods indicated increased on-task behavior for all children. Two children maintained their gains during a brief follow-up phase. The reinforcement of math performance apparently provided an incentive for the youngsters to stay on-task more often. The absence of on-task assessments during other academic work periods limits the generality of the findings. Multiple baseline studies suggest that generalization frequently does not occur across non-targeted subject areas (e.g., Varni 8c Henker, 1979). Varni and Henker (1979) found that self-reinforcement of time on-task, but not self-instructional training, facilitated the self-regulation of hyperactive behaviors in three study children. Meaningful reductions were obtained at the clinic and school on a Hyperactivity Index, consisting of observed frequencies of gross motor and off-task behaviors. A self-control training program was evaluated in an experimental classroom with six 7- to lo-year-old hyperactive boys (Barkley, Copeland, & Sivage, 1980). An 8week within-subject ABAB design was used. Active treatment totaled 6 weeks. The children attended their regular schools in the morning and the experimental classroom for 2 hours in the afternoon, 4 days a week. A multicomponent program was used. Self-instructional training was provided in large groups for 20 minutes a day. Each youngster was presented with a series of problems (not described) and required to solve these using a four-step, self-instruction sequence, modeled previously by the teacher. During subsequent half-hour individual math and reading work periods, the children self-monitored and recorded their on-task behavior at signalled variable intervals. A poster card defining appropriate on-task behavior was present during the self-monitoring periods. Accuracy of self-monitoring was checked by observers, and points (tokens), subsequently exchanged for privileges, were awarded based on accuracy of recording. The study was not intended to do component analyses of the multiple treatment procedures. Nevertheless, the results point to the importance of self-monitoring and self-reinforcement, as reductions in misbehaviors and increases in time on-task were found only in individual work times. No improvements in misbehavior were found during the large group selfinstructional activity, presumably because reinforcement contingencies for appropriate behavior were not in effect at this time. The self-control skills did not transfer across settings, as there was no behavioral improvement in the regular classroom. The authors suggest that generalization should be programmed directly by implementing self-control procedures in the regular school setting.

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Home Behavior. Among unmedicated children, only Kirby and Horne (1982) have evaluated the effects of training on home behavior. The multi-push program included training by school personnel in self-control and self-regulation to improve interpersonal skills. There was no differential improvement in parent perceptions of hyperactivity and self-control as measured by the Conners Parent Questionnaire (Conners, 1973) and the Self-Control Rating Scale (Kendall 8c Wilcox, 1979). The absence of any parental involvement in the training program may have severely restricted generalization to home behavior. Training Plus Medication: Behavioral Effects. Comparisons of the singular and additive behavioral effects of cognitive training and stimulant medication have been reported. These studies examined treatment effects on social interaction, anger control, school and home behavior, and locus of control. The additive effects of medication and cognitive training were reported by Horn et al. (1983). The behavioral training component in this single-subject study was variable interval self-monitoring of quiet on-task behavior. The child’s self-recorded points were cashed in for previously chosen back-up reinforcers. Greater reductions in on-task behavior and teacher ratings of hyperactivity were found with the combination of d-amphetamine (10 mg, b.i.d.) and self-control training, than with either treatment alone. It should be noted, though, that the teacher and observers were not blind to the presence or absence of self-control training. In contrast to Horn et al. (1983), two comparative group studies found no evidence for the superiority of the combination of cognitive training and medication. Cohen et al. (198 1) obtained no differential behavioral effects in kindergarteners assigned to cognitive behavior modification, methylphenidate alone, the treatment combination, or no treatment. Paralleling their improvements in cognitive performance (described earlier), all four groups improved significantly on the Conners Teacher and Parent Rating Scales, and in parental perceptions of emotional and social adjustment. Although it improved, the children’s behavior was not normalized. The groups continued to be seen by parents and teachers as significantly more problematic than normal peers. Abikoff and Gittelman (in press) found that cognitive training did not differentially improve the behavior of ADDH children considered partial responders to stimulant medication. During the final 8 weeks of the 16-week cognitive training program, the children were trained in interpersonal problem-solving skills. Many of the training exercises were adapted from AWARE: Activities for Social Development (Elardo 8c Cooper, 1977). These exercises coupled role-playing and the recognition of feelings with Shure and Spivack’s interpersonal problem-solving methods. In addition, the children participated in cooperative tasks that were meant to produce conflict over role definitions and cooperative strategies. These situations provided opportunities for the youngsters to implement and evaluate their social problemsolving skills. As noted previously, brief parental training was also provided. The attention-controls were exposed to the same AWARE and cooperative task problems. Their group sessions emphasized problem identification, recognition of feelings, and general discussion. No social problem-solving training was provided. A medication alone group served as a control. At posttreatment, the groups did not differ significantly on any teacher (Hahnemann Elementary School Behavior Rating Scale, Conners Teacher Rating Scale) or parent (Behavior Rating Scale, Werry Weiss Peters

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Activity Scale, Parent Attitude Test) measures. Moreover, cognitive training did not facilitate behavioral maintenance. During the l-month placebo follow-up phase, the behavior of children in all groups deteriorated markedly, necessitating remedication in almost all cases. Bugental et al. (1977) reported no significant group differences in teacher rated hyperactivity in medicated and unmedicated hyperactive boys exposed to either a cognitive training or social reinforcement program. As noted previously, the training regimen emphasized self-instructional skills on academic tasks; less emphasis was placed on classroom behavior. Six-month follow-up on a partial study sample (Bugental et al., 1978) confirmed the prediction that the cognitively trained children would show greater attributional shifts in the direction of more perceived control over school success and failure. Contrary to prediction, the socially reinforced children improved more on teacher ratings at 6-month follow-up. The authors’ suggestion that the combination of cognitive training and social reinforcement might maximize treatment outcome needs to be tested empirically. Hinshaw, Henker, and Whalen (1983) evaluated the effects of reinforced selfevaluation procedures on the social behavior of 24 8- to 13-year-old ADDH boys attending a summer school research project. The four treatment conditions consisted of methylphenidate or placebo, combined with reinforced self-evaluation (RSE) or extrinsic reinforcement alone (RA). During 4 weeks of cooperative and competitive playground games, the boys were trained to monitor their behavior, compare it to a behavioral criterion, and estimate or match the trainer’s ratings of their behavior. Observations of the youngsters’ positive and negative social behaviors were subsequently collected over 2 days. Half the boys were assigned to RSE on Day 1 and RA on Day 2; the remaining half followed the reverse order. Medication status was kept constant during the 2 days. In rank ordering the treatment combinations, medication plus RSE was most effective in reducing negative and increasing positive social behaviors. Further, only this treatment combination reduced negative social behaviors below levels of normal controls. This study is exemplary for its careful selection of outcome measures and the assessment of social behaviors in a controlled “naturalistic” setting. Whether or not the adjunctive efficacy of self-evaluation procedures can be maintained over time and across settings requires further empirical study. The singular and additive effects of cognitive-behavioral training and methylphenidate in controlling anger and aggression have been investigated by Hinshaw, et al. (1984). Twenty-four positive medication responders, ages 9 to 12 years, received 2 weeks of training in problem-solving and self-instructional skills, and the application of these skills to academic tasks. In the third week, the children were assigned to medication or placebo, with half in each group assigned to cognitive behavior training (CBT) or a control condition. The CBT emphasized interpersonal problem-solving skills and stress inoculation procedures (Novaco, 1979). The latter included training in cue-recognition of anger eliciting events, and the use of self-control strategies to deal effectively with provocation. The control group received cognitive training in perspective-taking and social problem-solving, but not in stress inoculation or specific strategy usage and rehearsal. Pre- and posttreatment behavioral observations were collected during brief periods (45 seconds) of provocative teasing by peers. The CBT group received significantly higher selfcontrol ratings and demonstrated significantly more purposeful alternative strat-

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egies in response to taunting than controls. Verbal retaliation significantly decreased in all groups. Training conditions did not interact with medication status. These findings have potential clinical import, because problems in controlling anger and aggression frequently exacerbate hyperactive children’s difficulties. The authors correctly expressed caution, however, in interpreting the results, because generalization across time and setting was not evaluated, and the assessment of anger control was done “on cue.” It is not known how the youngsters would react to uncontrolled provocation in vivo. Summary ofTraining Effects on Behavior. Several studies have investigated the impact of task oriented cognitive problem-solving training on behavior (e.g., Eastman 8c Rasbury, 198 1; Friedling & O’Leary, 1979; Moore & Cole, 1978). Speculation that such training might result in behavioral gains derives from the assumption that cognitive and behavioral impulsivity are members of the same response class and therefore covariant. However, the findings provide no support for the hypothesis that cognitive strategies that guide reflective task performance can regulate nontask behavior as well. There is little evidence of behavioral improvement with social problem-solving training in either medicated (Abikoff & Gittelman, in press) or unmedicated hyperactive children (Douglas et al., 1976; Kirby & Horne, 1982). Despite early favorable reports (e.g. Spivack & Shure, 1974), subsequent studies have failed to document gains in behavior or adjustment with this approach alone (see Gesten & Weissberg, 1979). Although youngsters can be taught social problem-solving skills, there is little indication that they use these skills to mediate their social behavior in vivo. Stress inoculation procedures, with their emphasis on cue-recognition and strategy rehearsal, appear to have promise, and need to be explored in combination with social problem-solving training (e.g., Hinshaw et al., in press). Cognitive behavioral procedures, especially self-monitoring and self-reinforcement of appropriate behavior, have demonstrated effectiveness. These methods have proved most successful in improving classroom and playground behavior. However, for these procedures to achieve clinical utility, generalization of treatment effects needs to be demonstrated. Some studies fail to assess generalization at all (e.g., Cameron & Robinson, 1980), whereas others have reported no transfer of training effects (e.g., Barkley et al., 1980). To increase generalization to school and home, the significant others in these settings must be actively involved in cognitive training. Their involvement should include exposure to training rationale and procedures, as well as support, encouragement, and reinforcement of the youngsters’ attempts at self-control. CONCLUDING COMMENRi AND SUGGESTIONS The early expectations of the potential clinical utility of cognitive training in ADDH children have been tempered by almost a decade of research. It should be emphasized, though, that many of the methodological and treatment issues are not unique to studies with hyperactive youngsters, but are relevant to cognitive training with children in general (see Exceptional Educational Quarterly, 1, May 1980, entire issue).

The expectation that the development of internalized self-regulation skills would facilitate generalization and maintenance has not been realized. In studies where transfer effects have been evaluated, the results have usually been disappointing. To increase the generality of cognitive training effects in ADDH children, there are at least three issues that deserve greater consideration. First, the length of training has been far too brief in many studies. To expect meaningful change, the training regimen must be sufficiently long enough to ensure adequate exposure to a variety of task situations and to allow for the development of skills mastery. Second, generalization should not be expected when there is little or no overlap between training and outcome task demands. The failure to improve academic performance with cognitive training on nt)nacade~lic psychoeducational tasks points to this issue. Similarly, the exclusive emphasis in training on reflective, deliberate problem-solving strategies may diminish performance on speed tests (Abikoff & Gittelman, in press). Comprehensive task analyses of outcome measures are needed (Meichenbaum, 1977). Investigators must identify the skills necessary for adequate task performance, and use these analyses to guide their choice of training materials and procedures. Finally, greater attention needs to be given to the assessment of maintenance effects. This is especially important in light of the two reports of delayed treatment effects with cognitive training. Of the 23 studies reviewed, only 7 (30%) included follow-up phases, ranging from 2 days to 1 year. To demonstrate clinical utility, it is essential that the long- as well as short-term efficacy of cognitive training be established. To facilitate the likelih(~od of obtaining maintenance effects, greater emphasis should be placed on the use of “booster” sessions during the follow-up period. With few exceptions (e.g., Bugental et al., 1977; 1978), cognitive training interventions with hyperactive children have paid little attention to individual differences. Although invariant step-by-step treatment regimens have been avoided in most studies, there have been few, if any, attempts to systematically fashion training programs on the basis of individual subject differences. The failure to perform comprehensive skills assessments may, at times, be detrimental to the youngsters’ performances. For example, our clinical experience has shown that self-instructional training is difficult to implement in youngsters with expressive language problems, Self-instructional training can also interfere with the performance of children already proficient in the skill being trained (e.g., Weithorn & Kagan, 1979), and disrupt performance on tasks that require “automatic” processing (Hall, 1980). Hyperactive children exhibit a wide range of problem-solving and self-control deficits. Some youngsters perform poorly on academic tasks because they fail to systematically search for and read all the instructions, whereas the performance of others suffers because of a failure to follow task directions. Poor peer relationships for some children stem from deficient and immature social skills, whereas for others, an aggressive response style severely limits their social network. To individualize training programs, detailed evaluations of youngsters’ problem-solving skills are required. Although current technology may be sufficient for some assessments (e.g., social interaction observation codes), diagnostic problem-solving measures are lacking, and need to be developed. A colnprehensive assessment battery of the type proposed would include measures of cognitive, academic, and social problem-solving skills. Correspondence skills would also be evaluated, be-

cause some hyperactive youngsters show poor correspondence between their stated plans and intentions and their subsequent problem-solving behavior. If deficits are found, correspondence training (see Karlan & Rusch, 1982) could be added to the treatment regimen. Metacognitive skills and development must also be assessed (Loper, 1980). The evaluation of ADDH children’s degree of self-awareness may be especially helpful in individualizing a treatment regimen that facilitates generalization and maintenance effects (see Borkowski & Cavanaugh, 1979; Meichenbaum & Asarnow, 1979). Finally, greater attention needs to be given to the possible interaction of IQ and training format, because anecdotal evidence suggests that IQ may mediate response to treatment (e.g., Barkley et al., 1980; Cohen et al., 1981). It is common for clinical reviews in psychology to conclude with the caveat that additional research is required to elucidate the interaction of treatment procedures, subject variables, and outcome. This conclusion is especially applicable to cognitive training with ADDH children. It remains to be seen whether cognitive training will fulfill its early promise and become a fixture in the clinical armamentarium in the treatment of hyperactivity.

Acknowledgement-Preparation of this article was supported in part by National Institute of Mental Health Grant MH30822. The author would like to thank Salvatore Mannuzza for reading and commenting on an earlier draft of this article.

H. (1979). Cognitive training interventions in children: Review of a new approach. Journal of Learning Disabilities, 12, 123- 135. Abikoff, H. (1983, August). Acaukmic cognitive training and stimulants in hyperactivity: A pilot study. Paper

Abikoff,

presented at the annual meeting of the American Psychoiogical Association, Anaheim, CA. Abikoff, H., & Gittelman, R. (in press). Hyperactive children maintained on stimulants: Is cognitive training a useful adjunct? Archives of General Psychintry. Barkley, R. A. (1977). A review of stimuIant drug research with hyperactive children. Jou~l of Child P~c~lo~ and Psychiatry, 18, 137- 165. Barkley, R. A., Copeland, A., & Sivage, C. (1980). A self-control classroom for hyperactive children. Jountar of Au& and Developmental Disorders, 1, 75-89. Barling, J. (1980). A multistage multidependent variable assessment of children’s self-regulation of academic performance. Child Behavior Therapy, 2, 43 -54. Borkowski, J., & Cavanaugh, J. (1979). Maintenance and generalization of skills and strategies by the retarded. In N. Ellis (Ed.), Handbook of mental deficiency: Psychological theory and research (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum Associates. Bornstein, F!, & Quevillon, R. (1976). The effects of a self-instructional package with overactive preschool boys. Journal of Applied Behavior Analysis, 9, 179- 188. Brown, R. T. (1980a). Impulsivity and psychoeducational intervention in hyperactive children.Journol of Learning Disabilities, IS, 249-254. Brown, R. T. (1980b, September). ~~~~~g: A cognitive approach in ff~Z~o~a~~n~ impel in h~ff~~ve children. Paper presented at the annual meeting of the American Psycholo~cal Association, Montreal, Canada. Bugental, D. B., Collins, S., Collins, L., & Chaney, L. E (1978). Attributional and behavioral changes

following two behavior management interventions with hyperactive boys: A follow-up study. Chiid Dev&pment, 49, 247-250. Bugental, D. B., Whalen, C. K., & Henker, B. (1977). Casual attributions of hyperactive children and motivational assumptions of two behavior-change approaches: Evidence for an interaction& position, Child Development, 48, 874-884. Cameron, M. I., & Robinson, V. M. J. (1980). Effects of cognitive training on academic and on-task behavior of hyperactive children. Jounal of Abnormal Child Psychology, 8, 405-420. Camp, B. W., Blom, G. E., Hebert, E, & van Doorninck, W. J. (1977). “Think Aloud”: A program for developing self-control in young aggressive boys. Jownal of Abnomul Child Psychology, 5, 157- 169. Campbell, S. B. (1976). Hyperactivity: Course and treatment. In A. Davids (Ed.), Child personality and psych~aiho~o~: Cwrmt Topics (Vol. 3). New York: John Wiley & Sons. Campbell, S. B., Douglas, V. I., & Morgenstern, G. (1971). Cognitive styfes in hyperactive children and the effect of methylphenidate. Joint of Child Psycholo~ and Psychiatry, 14, 55-67. Cohen, N. J., Sullivan, J., Minde, K., Novak, C., & Helwig, C. (1981). Evaluation of the relative effectiveness of methylphenidate and cognitive behavior medication in the treatment of kindergartenaged hyperactive children. Journal of Abnormal Child Psychology, 9, 43-54. Conners, C. K. (1969). A teacher rating scale for use in drug studies with children. American Journal qf Psychiatry, 126, 884-888. Conners, C. K. (1973). Rating scales for use in drug studies with children. Psychopharmacology Bulletin [Special issue: Pharmacotherapy of children], 24-84. Douglas, V. I. (1975). Are drugs enough? To treat or train the hyperactive child. International Journal of Mental Health, 4, 199-212. Douglas, V. I. (1980a). Higher mental processes in hyperactive children: Implications for training. In R. Knights & D. Bakker (Eds.), Treatment of hyperactive and learning disordered children: Currentresearch (pp. 65-91). Baltimore: University Park Press. Douglas, V I. (1980b). Treatment and training approaches to hyperactivity: Establishing internal or external control. In C. Whalen & B. Henker (Eds.), ~~eyac~~~lechj~ye~~ The social ecology of~~tif~at~~ and tr~at~t (pp, 283-317). New York: Academic Press. Douglas, V. I., Parry, P., Marton, P., & Garson, C. (1976). Assessment of a cognitive training program for hyperactive children. Journal of Abnormal Child Psychology, 4, 389-410. Douglas, V. I., & Peters, IS. G. (1980). Toward a clearer definition of the attentional deficit of hyperactive children. In G. A. Hale & M. Lewis (Eds.), Attention and the development of cognitive skills (pp. 173247). New York: Plenum. Drake, D. (1970). Perceptual correlates of impulsive and reflective behavior. Developmental Psychology, 2, 202-214. D’Zurilla, T., & Goldfried, M. (1971). Problem solving and behavior modification. Journal of Abnormal Psychology, 78, 107 - 126. Eastman, B. G., & Rasbury, W. C. (1981). Cognitive self-instruction for the control of impulsive classroom behavior: Ensuring the treatment package. Journal ~~A~o~l Child Psychology, 9, 381-387. Egeland, B. (1974). Training impulsive children in the use of more efficient scanning techniques. Child D~e~~~f, 45, 165-171. Elardo, P., & Cooper, M. (1977). AWARE: Activities far social &elopment. Menlo Park, CA: AddisonWesley. Firestone, P., & Douglas, V. I. (1975). The effects of reward and punishment on reaction times and automatic activity in hyperactive and normal children. Jounal of Abnormal Child Psychology, 3, 201215. Friedling, C., & O’Leary, S. (1979). Effects of self-instructional training on second and third-grade hyperactive children: A failure to replicate. Journal of Applied Behavior Analysis, 12, 21 l-219. Gadow, K. D. (1983). Effects of stimulant drugs on academic performance in hyperactive and learning disabled children. Journal of Learning Disabilities, 5, 290-299. Gesten, E., & Weissberg, R. (1979, September). Social problem-solving training and prevention: Some good news and some bad new. Paper presented at the annual meeting of the American Psychological Association, New York City. Gittelman-Klein, R., Klein, D. E, Katz, S., Saraf, K., & Pollack, E. (1976). Comparative effects of methylphenidate and thioridarine in hyperkinetic children: I. Clinical results. Arch&es ofGenera1 Psychiatry, 33, 1217-1231. Gittleman-Klein, R., & Klein, D. F. (1976). Methylphenidate effects in learning disabilities. Psychometric changes. Archives of GeneralPsychiatry, 33, 655-664.

Cognitive

Training

in Hyperactive

Children

511

Glenwich, D. S. (1976). Some interpersonal correlates of cognitive impulsivity in fourth graders. journal of School Psychology, 14, 212-221. Hall, R.J. (1980). Cognitive behavior modification and information-processing skills of exceptional children. Exceptional Educalion Quarterly, 1, 9- 15. Hinshaw, S. I!, Henker, B., & Whalen, C. K. (1983, August). Cognitive-behavioral and pharmacologic inleruentions for hyperactive boys: Comparative and combined effects. Paper presented at the annual meeting of the American Psychological Association, Anaheim, CA. Hinshaw, S. P, Henker, B., & Whalen, C. K., (1984). Self-control in hyperactive boys in anger-inducing situations: Effects of cognitive-behavioral training and of methylphenidate. Journal of Abnormal Child Psychology, 12, 55-77. Hobbs, S. A., Moguin, L. E., Tyroler, M., & Lahey, B. B. (1980). Cognitive behavior therapy with children: Has clinical utility been demonstrated? Psychological Bulletin, 87, 147- 165. Horn, W. F., Chatoor, I., & Conners, C. K. (1983). Additive effects of Dexedrine and self-control training: A multiple assessment. Behuvior Modifications, 7, 383-402. Kagan, J., Rosman, B. L., Day, D., Albert, J., & Philips, W. (1964). Information processing in the child: Significance of analytic and reflective attitudes. Psychological Monograph, 78, (1, Whole No. 578). Karlan, G. R., & Rusch, E R. (1982). Correspondence between saying and doing: Some thoughts on defining correspondence and future directions for application. Journal of Applied Behavior Analysis, 15, 151-162. Kendall, P. C. (1981). Assessment and cognitive-behavioral interventions: Purposes, proposals, and problems. In. P. C. Kendall & S. D. Hollon (Eds.), Assessment strategies for cognitive-behavioral intervations. New York: Academic Press. Kendall, P. C., & Wilcox, L. E. (1979). Self-control in children: Development of a rating scale. Journal of Consulting and Clinical Psychology, 47, 1020- 1030. Kirby, E. A., & Horne, A. M. (1982). Cognitive-behavioral modification with hyperactive/attention deficit d&order chitiren. Paper presented at the annual meeting of the American Psychological Association, Washington, DC. Klein, D. E, Gittelman, R., Quitkin, F., & R&in, A. (1980). Diagnosti and drug treatment of psych&tic disorders: Adults and children (2nd ed.). Baltimore: Williams and Wilkins. Lloyd, J. (1980). Academic instruction and cognitive behavior modification: The need for attack strategy training. Exceptional Education Quarterly, 1, 53-63. Loper, A. B. (1980). Metacognitive development: Implications for cognitive training. Exceplional Education Quarterly, 1, l-8. Luria, A. (1961). Role of speech in the regulation of normal and abnormal behaviors. New York: Liveright. Mahoney, M. J. (1978). Experimental methods and outcome evaluations.journal of Consulting and Clinical Psychology [Special issue: Methodology in clinical research], 46, 660-672. Mash, E. J., & Dalby, J. T. (1979). Behavioral interventions for hyperactivity. In R. L. Trites (Ed.), Hyperactivity in children: Etiology, measurement, and treatment implications (pp. 161-216). Baltimore: University Park Press. Meichenbaum, D. H. (1977). Cognitive-behavior modification: An integrative approach. New York: Plenum Press. Meichenbaum, D. H., & Asarnow, J. (1979). Cognitive-behavioral modification and metacognitive development: Implications for the classroom. In P Kendall & S. Hollon (Eds.), Cognitive-behavioral interventions: Theory, research, and procedures (pp. 1 l-35). New York: Academic Press. Meichenbaum, D., & Goodman, J. (1971). Training impulsive children to talk to themselves: A means of developing self-control. Journal of Abnormal Psychology, 77, 115- 126. Mendelson, W., Johnson, N., & Stewart, M. A. (1971). Hyperactive children as teenagers: A follow-up study. Joumuzl of Nervous and Mental Disease, 153, 273-279. Messer, S. B. (1976). Reflection-impulsivity: A review. Psychological Bulletin, 83, 1026- 1052. Minde, K., Lewin, D., Weiss, G., Lavigueur, H., Douglas, V., & Sykes, E. (197 1). The hyperactive child in elementary school: A 5-year controlled, follow-up. Exceptional Children, 38, 2 15-22 1. Moore, S. E, & Cole, S. D. (1978). Cognitive self-mediation training with hyperkinetic children. Bulletin of le Psychonomic Society, 12, 18-20. Novaco, R. W. (1979). The cognitive regulation of anger and stress. In P C. Kendall & S. D. Hollon (Eds.), Cognitive-behavioral intervalions: Theo?, research, and procedures (pp. 24 l-285). New York: Academic Press. O’Leary, S. Cr., & Dubey, D. R. (1979). Applications of self-control procedures by children: A review. Journal of Applied Behavior Analysis, 12, 449-465.

512

Howard Abikoff

Palkes, H., Stewart, M., & Freedman, J. (1972). Improvement in maze performance of hyperactive boys as a function of verbal-training procedures. Journal ofSpecra1 Education, 5, 337-342. Palkes, H., Stewart, M., & Kahana, B. (1968). Porteus maze performance of hyperactive boys after training in self-directed verbal commands. Child Development, 39, 817-826. Parrish, J. M., & Erickson, M. T. (1981). A comparison of cognitive strategies in modifying the cognitive style of impulsive third-grade children. Cognitive Them@ and Research, 5, 71-84. Parry, P. A., & Douglas, V. I. (1983). Effects of reinforcement on concept identification in hyperactive children. Journal of Abnormal Child Psychology, 11, 327-340. Pelham, W. E., & Bender, M. E. (1982). Peer relationships in hyperactive children: Description and treatment. In K. Gadow & I. Bialer (Eds.), Advances in learning and behavioral dimbilzties (Vol. 1, pp. 365-436). Greenwich, CT: JAI Press. Roberts, R. N., & Dick, M. L. (1980). Self-control in the classroom: Theoretical issues and practical applications. In T. R. Kratochwill (Ed.), Advance.7 in school psychology (Vol. 2). Hillsdale, NJ: Erlbaum Assoc. Ross, D. M., & Ross, S. A. (1982). Hyperactivity; Current issues, research and theory (2nd ed.). New York: John Wiley & Sons. Shure, M. B., Spivack, G. (1972). Means-ends thinking, adjustment and social class among elementary school-aged children. Journal of Consulting and Clinical Psychology, 37, 389-394. Siegelman, E. (1969). Reflective and impulsive observing behavior. Child Development, 40, 12 13 - 1222. Spivack, G., & Shure, M. D. (1974). S ocial adjustment of young children. San Francisco: Jossey-Bass. Sprague, R. L. & Berger, B. D. (1980). Drug effects on learning performance: Relevance of animal research to pediatric psychopharmacology. In R. M. Knights & D. J. Bakker (Eds.), Treatment of hyperactive and learning disabled children: Current research (pp. 167- 183). Baltimore: University Park Press. Tant, J. L., & Douglas, V. I. (1982). Problem-solving in hyperactive, normal, and reading-disabled boys. Journal of Abnormal Child Psychology, 10, 285-306. Varni, J. W., & Henker, B. (1979). A self-regulation approach to the treatment of three hyperactive boys. Child Behavior Therapy, 1, 171- 192. Vygotsky, L. (1962). Thought and language. New York: John Wiley & Sons. Watson, D., & Hall, D. (1977). Self-control ofhyperactivity. Unpublished manuscript, LaMesa-Spring Valley School District, San Diego, CA. Weiss, G., Kruger, E., Danielson, V., & Elman, M. (1975). Effects of long-term treatment of hyperactive children with methylphenidate. Canadian Medical Association Journal, 112, 159- 165. Weithorn, C. J., & Kagen, E. (1979). Training first graders of high-activity level to improve performance through verbal self-direction. Jounal of Learning Disabilities, 12, 82-88. Whalen, C. K., & Henker, B. (1976). Psychostimulants and children: A review and analysis. Psychological Bulletin, 83, 1113-I 130. Whalen, C. K., & Henker, B. (1980). The social ecology of psychostimulant treatment: A model for conceptual and empirical analysis. In C.K. Whalen & B. Henker (Eds.) Hyperactive children: The social ecology of identafication and treatment (pp. 3 -5 1). New York: Academic Press.

Note: Since significantly the cognitive affected the

this article was written, it has been learned that the cognitive training group showed less improvement than the attention controls in WISC-R Performance IQ, due largely to group’s tests. Conceivably, cognitive training’s emphasis on reflectivity may have adversely youngster’s performance in situations requiring speed.