There is little doubt that drinking that morning cup of coffee will likely increase alertness, but the main questions that research is trying to answer go beyond that. Basically: is there a sustained, lifetime, benefit or harm from drinking coffee regularly?

The answer, so far, contains good news and bad news. The good news for coffee drinkers is that most of the long-term results are directionally more positive than negative, so no clear harm seems to occur. The bad news is that it is not clear so far whether caffeine has beneficial effects on general brain functions, either short-term or long-term (aged-related decline or risks of dementia).

It is important to note that many of the studies showing an effect of coffee consumption on brain functions or risks of dementia report a correlation or association (they are not randomized clinical trials). As you know, correlation doesn’t prove causation: coffee drinkers may seem to do well in a number in these long-term studies, but there may be other reasons why coffee drinkers do better.

Q: How does caffeine affect my brain?
A: Caffeine is a stimulant.

It belongs to a chemical group called xanthine. Adenosine is a naturally occurring xanthine in the brain that slows down the activity of brain cells (neurons). To a neuron, caffeine looks like adenosine. It is therefore used by some neurons in place of adenosine. The result is that these neurons speed up instead of slowing down.

This increased neuronal activity triggers the release of the adrenaline hormone, which will affect your body in several ways: your heartbeat increases, your blood pressure rises, your breathing tubes open up, sugar is released in the bloodstream for extra energy.

In moderate doses (a few cups a day) caffeine can increase alertness but also reduce fine motor coordination, cause insomnia, cause headaches and nervousness.

Q: Does caffeine boost brain functions?

A: To date 3 studies suggest that the answer is “maybe”.

In one study of over 7000 people, results showed a correlation between current caffeine intake and better performance on 4 tests. This was more pronounced in older individuals than in younger ones (Martin, 1993).

Another study showed that in 1500 people over 65, life-time consumption of coffee was associated with increased performance in 6 out 12 tests. Current intake was related to better performance in only 2 out 12 tests (Johnson-Kozlow, et al., 2002).

The third study showed for a group of 1875 adults aged 24 to 81, current intake of coffee was associated with better performance in 2 tests but not in 4 others. (Hameleers et al., 2000)

Thus, caffeine consumption may be associated with better performance but 1) there are only very few studies so far, 2) this effect seems limited to some tasks only.

Q: Does caffeine protect against age-related cognitive decline?

A: Two studies say “yes” and 3 studies say “no”.

Van Gelder et al. (2007) followed 676 elderly men over 10 years and found that those who drank more coffee showed less decline in the Mini-Mental Test. The least decline was observed with 3 cups a day.

Ritchie et al. (2007) showed that over 4 years, women over 65 (but not men) who drank more than 3 cups a day showed less decline than women who drank one cup or less. This was observed only in a task of verbal memory.

Van Boxtel et al. (2003) followed 1376 individuals aged 24 to 81 for 6 years and found that caffeine intake had a very small impact on a motor task but no effect on verbal memory tasks.

Hameleers et al. (2000) found no evidence that caffeine intake counteracts cognitive age-related decline in a group of 1875 people aged 24 to 81.

The most recent study of 2606 people showed that over 28 years coffee drinking was not related to better performance (Laitala et al., 2009).

As you can see results are mixed. The evidence showing that caffeine reduces age-related cognitive decline is limited: very few studies and very few tasks.

Q: Does caffeine protect against dementia?

A: Three studies say “yes” and 2 studies say “no”.

Maia et al. (2002) studied 54 Alzheimer’s patients and their non-affected relatives (Controls): Higher daily caffeine intake during the 20 years prior diagnosis was found to be associated with lower risk of Alzheimer’s Disease, suggesting that coffee may be protective.

Eskelinen et al. (2009) followed 1409 individuals aged 65 to 79 for 21 years and found that those who drank coffee had less risk of developing dementia than those who didn’t. The lowest risk was in people drinking 3-5 cups a day.

Lindsay et al (2002) studied 4615 individuals over 5 years and found that coffee consumption was associated with a reduced risk of Alzheimer’s Disease.

Ritchie et al. (2007) studied 7017 individuals aged 65 and over and showed that, over 4 years, caffeine consumption did not reduce dementia risk.

The most recent study to date showed that over 28 years, coffee drinking did not affect the risk of mild cognitive impairment or dementia (Laitala et al., 2009).

Here again the evidence is mixed. Based on the few studies, it is not possible at this time to say that coffee consumption indeed decreases the risks of dementia.

– Pascale Michelon, Ph. D., is SharpBrains’ Research Manager for Educational Projects. Dr. Michelon has a Ph.D. in Cognitive Psychology and has worked as a Research Scientist at Washington University in Saint Louis, in the Psychology Department. She conducted several research projects to understand how the brain makes use of visual information and memorizes facts. She is now an Adjunct Faculty at Washington University.

We recently run an online survey among subscribers of our monthly eNewsletter, and over 500 people said we have helped them make better personal or professional decisions on how to maintain and improve brain fitness. Most gave very illuminating examples, which we are reading and enjoying as we speak.

Respondents also had many good questions to ask, so I have selected 15 common ones, paraphrased/ synthesized them below, and answered them by linking to our most relevant posts and resources. I hope you enjoy the FAQ session.

Q: I teach a brain fitness class at my library/ senior center/ school, using much of your info. Can you share some of your presentations?
A: Yes, we have just decided to share, using a Creative Commons Attribution No Derivatives License, the full presentation of my recent book talk at New York Public Library. As long as you give credit to SharpBrains and don’t modify it, you are free to use the presentation you can see and download HERE. The talk was videotaped, and will be available online soon, so please keep tuned.

Q: What exactly does neuroplasticity mean, and why is it so important for education and health?
A: Start by reading how learning changes your brain.

Q. Is this only relevant for older adults? Can I also apply it in the workplace (I am 47)
A. I strongly suspect you do have a human brain, so you may benefit from these Ten Habits of Highly Effective Brains. Further, HR departments would do well to start paying more attention to Cognitive Fitness and the Mature Workforce trends.

Q. I read so many conflicting things I don’t know where to start.
A. You are not alone. We should all be aware that It is Not Only Cars That Deserve Good Maintenance: Brain Care 101.

Q. How can my organization deliver brain fitness activities as a community service?
A. These articles will provide good guidelines and ideas: Retooling Use It or Lose It , and Public Libraries: Community-Based Health Clubs for the Brain.

Q. Everyone seems obsessed with brain games. What about meditation?
A. Check out Yes, You Can Build Willpower, and Mindfulness Meditation in Schools.

Q. Are software-based cognitive interventions effective?
A. As a category, it certainly seems so, as long as we ask the right questions, For Whom, For What?. For example, did you see this Science paper on how Cognitive Training Can Influence Dopamine System?.

Q. What about the trade-off between time invested vs benefits realized.
A. Efficiency and replicability of cognitive and brain-based outcomes seem to be, in fact, the strongest points of structured cognitive interventions. They seem to maximize the Cognitive Value of your Mental Workout.

Q. It sometimes looks like the whole field came out of nowhere, due to Nintendo Brain Age’s success, so we can’t be talking about something serious.
A: Nintendo did indeed create consumer awareness (for a product with little evidence) but “brain training” has solid roots in neuropsychology and cognitive neuroscience, as you can read in our interview with Elkhonon Goldberg.

Q. What about neurofeedback?
A. After years of much clinical use and little solid evidence, several important trials have been published in 2009, showing how neurofeedback can help diagnose and treat ADHD patients.

Q. How can one improve memory?
A. Well, the answer deserves a whole book, but we can offer some Tips to Improve Memory including Sleep, Practice and Testing.

Q. How can I choose one among the number of products making memory and brain claims?
A. We suggest you use this Evaluation checklist, and consider reading our consumer guide/ book.

Q. Any general tips for educators and lifelong learners?
A. Indeed, here you have these 10 Brain Tips to Teach and Learn.

Q. How can I keep track of all the new trends, companies and products? Our health system/ insurer/ senior community/ venture firm/ company needs to make good decisions.
A. Well, that’s why we publish market research, such as the one summarized in this Infographic: State of the Market 2009 and also recently launched a professional Network for Brain Fitness Innovation. You can also Save the Date for the upcoming SharpBrains Summit.

Q: Thank you for all the information you provide…but what I want more of is… brain teasers!
A. Understood. We will make sure to offer more, but you can try, right now, these Top 50 Brain Teasers and continue with more recent puzzles and brain games.

A simple example illustrates the importance of WM for particular academic tasks. Try adding 3 and 9 in your head. That was probably easy for you. Now trying adding 33 and 99. That was probably more difficult. Finally, try adding 333 and 999. This is quite challenging for most adults even though each calculation required is trivially easy. The challenge occurred because you need to store information – the sum of 3+9 in the one’s column and then ten’s column – as you process the remaining part of the problem, i.e., 3+9 in the hundred’s column, and this taxed your WM. If your WM capacity was exceeded, you could not complete the problem successfully.

This simple problem also illustrates the difference between short-term memory (STM) and WM. Short-term memory simply involves retaining information in mind for short periods of time, e.g., remembering that the problem you need to solve is 333+999. Working memory, in contrast, involves mentally manipulating – or ‘working’ with – retained information and comes into play in a wide range of learning activities. For example, to answer questions about a science chapter, a child not only has to correctly retain factual information but must mentally work with that information to answer questions about it. Thus, when a child’s WM capacity is low relative to peers, academic performance is likely to be compromised in multiple areas.

Because WM deficits play an important role in the struggles experienced by many individuals with ADHD, it is important to consider how different interventions address this aspect of the disorder. In this study, the authors were interested in comparing the impact of Working Memory Training and stimulant medication treatment on the WM performance of children diagnosed with ADHD.

Participants were 25 8-11 year-old children with ADHD (21 boy and 4 girls) who were being treated with stimulant medication. Children’s memory performance was assessed on 4 occasions using the Automated Working Memory Assessment (AWMA), a computerized test that measures verbal short-term memory, verbal working memory, visuo-spatial short-term memory, and visuo-spatial working memory.

At time 1, the assessment was conducted when children had been off medication for at least 24 hours. The second assessment occurred an average of 5 months later and when children were on medication. The third assessment occurred after children had completed 5 weeks of Cogmed Working Memory Training using the standard training protocol (see below). The final assessment occurred approximately 6 months after training had ended. This design enabled the researchers to make the following comparisons:

- WM performance on medication vs. off medication (T1 vs T2)
- WM performance on medication vs. after training (T2 vs. T3)
- WM performance immediately after training ended vs. 6 months following training (T3 vs. T4)

This final comparison provided information on whether any benefits provided by the training had endured.

In addition to measuring STM and WM at each time point, measures of IQ were collected at times 1, 2, and 3.

- Working Memory Training -

WM training was conducted using the standard Cogmed training protocol with each child completing 20-25 training sessions within a 25 day period. The training requires the storage and manipulation of sequences of verbal, e.g., repeating back a sequence of digits in reverse order, and/or visuo-spatial information, e.g., recalling the location of objects on different portions of the computer screen.

Difficulty level is calibrated on a trial by trial basis so the child is always working at a level that closely matches their performance. For example, if a child successfully recalled three digits in reverse order, on the next trial he had to recall four. When a trial was failed, the next trial was made easier by reducing the number of items to be recalled. This method of ‘adaptive training’ is thought to be a key element because it requires the child to ’stretch’ their WM capacity to move through the program.

- Results -

- Impact of Short-Term Memory and Working Memory -

Medication vs. no medication – When tested on medication, children showed better visuo-spatial WM relative to when they were tested off medication. However, no improvement was found for verbal STM, verbal WM, or visuo-spatial STM.

Performance on medication vs. performance after WM training – Cogmed WM Training led to significant gains in all four memory scores. Thus, there was evidence that WM training led to greater gains in WM that medication treatment alone. On all areas of memory assessed, the average score of participants had moved from below average to within the average range.

Performance 6 months after training ended – Training gains in 3 of the 4 memory components – all but visuo-spatial STM – remained significant 6 months after training had ended and there was little indication of any decline in children’s performance. Thus, the benefits evident immediately following training had largely persisted.

- Impact on IQ -

IQ results on and off medication were equivalent. Likewise, there was no indication that WM training was associated with any increase in children’s IQ results. Thus, the benefits of training were restricted to children’s performance on the memory tasks.

- Summary and Implications -

Results from this study indicate that WM training yields greater benefits in WM for children with ADHD than are provided by stimulant medication treatment. Furthermore, memory gains following training persist for a significant period. Because adequate WM functioning is critically important for children’s academic success, these are encouraging findings as they suggest that intensive training can ameliorate deficits in this important executive function. The absence of training benefits on IQ suggests that the benefits of training may be limited to WM specifically, although it should be noted that other WM training studies have reported benefits on particular aspects of intelligence. Thus, the impact of WM training on IQ requires further study.

However, it is important not to over interpret the results from this study. While it is tempting to regard this as a comparison of medication treatment and WM training for ADHD, and to view the results as indicating the superiority of the latter, this would be an erroneous interpretation. The constellation of difficulties that comprise ADHD for many children extend significantly beyond WM deficits, and this study did not examine a number of other important outcomes.

For example, it provides no information on the relative benefits of medication and WM training on children’s attention, hyperactivity, other behavior problems, and academic performance. Even though other studies of WM training have found benefits in several of these areas, adding assessments of these critical outcomes to the current study would have strengthened it. This criticism is not intended to discount the important results obtained, but to instead provide an appropriate context for evaluating these interesting findings and it would not be surprising if medication treatment were to have greater impact in other important areas.

It is also the case that the study was limited by restricting the assessment of WM to computerized measures of this capacity, even though validated parent and teacher rating scale measures of WM are available. Incorporating such measures into the study would have provided a more comprehensive of children’s memory functioning at each assessment point.

Although these represent important study limitations, the results provide additional evidence that intensive WM training can yield enduring benefits in this key executive function. Because the benefits providing by training enhance those provided by medication, it also suggests that WM training may be a useful complement to existing evidence-based interventions for ADHD, particularly for children whose WM functioning is limited to begin with.

– Dr. David Rabiner is a child clinical psychologist and Director of Undergraduate Studies in the Department of Psychology and Neuroscience at Duke University. His research focuses on various issues related to ADHD, the impact of attention problems on academic achievement, and attention training. He also publishes Attention Research Update, a complimentary online newsletter that helps parents, professionals, and educators keep up with the latest research on ADHD.

Related articles by Dr. Rabiner

- Neurofeedback/ Quantitative EEG for ADHD diagnosis

- Promising Cognitive Training Studies for ADHD

- Mindfulness Meditation for Adults & Teens with ADHD

- Self-Regulation and Barkley’s Theory of ADHD

Introduction

• Basak, C. et al. (2008). Can training in a real-time strategy video game attenuate cognitive decline in older adults? Psychology and Aging.
• Begley, S. (2007). Train your mind, change your brain: How a new science reveals our extraordinary potential to transform ourselves. Ballantine Books.
• DeKosky, S. T., et al. (2008). Ginkgo biloba for prevention of dementia: a randomized controlled trial. Journal of the American Medical Association, 300, 2253-2262.
• Doidge, N. (2007). The Brain that changes itself: Stories of personal triumph from the frontiers of brain science. Viking Adult.

Chapter 1. The Brain and Brain Fitness 101

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• David Kolb, D. (1983). Experiential learning: Experience as the source of learning and development. FT Press.
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• Gage, F. H., Kempermann, G., & Song, H. (2007). Adult Neurogenesis. Cold Spring Harbor Laboratory Press, NY.
• Gardner, H. (1983). Frames of Mind: The theory of multiple intelligences. New York: Basic Books.
• Gaser, C. & Schlaug, G. (2003). Brain structures differ between musicians and non-musicians. The Journal of Neuroscience, 23, 9240-9245.
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• Klingberg, T., Fernell, E., Olesen, P. J., Johnson, M., Gustafsson, P., Dahlström, K., Gillberg, C. G., Forssberg, H., & Westerberg, H. (2005). Computerized Training of Working Memory in Children With ADHDA Randomized, Controlled Trial. J American Academy of Child and Adolescent Psychiatry, 44(2), 177-186.
• Maguire, E. A., Woollett, K., & Spiers, H. J. (2006). London taxi drivers and bus drivers: A structural MRI and neuropsychological analysis. Hippocampus, 16, 1091-1101.
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• Parsons, L. M. (2001). Exploring the functional neuroanatomy of music performance, perception, and comprehension. Annals Of The New York Academy Of Sciences, 930, 211-31.
• Roenker, D., Cissell, G., Ball, K., Wadley, V., & Edwards, J. (2003). Speed of processing and driving simulator training result in improved driving performance. Human Factors, 45, 218-233.
• Rueda, M. R., Posner, M. I., & Rothbart, M. K. (2005) The development of executive attention: contributions to the emergence of self-regulation. Developmental Neuropsychology, 28, 573-594.
• Rueda, M. R., Rothbart, M. K.., Saccamanno, L., & Posner, M. I. (2005) Training,maturation and genetic influences on the development of executive attention. Proceedings of the National Academy of Sciences, 102, 14931-14936.
• Stern, Y. (2002). What is cognitive reserve? Theory and research application of the reserve concept. Journal of Int. Neuropsych. Soc., 8, 448-460.
• Sylwester, R. (2007). The adolescent brain: Reaching for autonomy. Corwin Press.
• Tang, Y., Ma, Y., Wang, J., Fan, Y., Feng, S., Lu, Q., et al. (2007). Short-term meditation training improves attention and self-regulation. Proceedings of the National Academy of Sciences, 104(43), 17152-17156.
• Woodruff, L., & Woodruff, B. (2007). In an instant: A Family‘s journey of love and healing. Random House.
• Zull, J. E. (2002). The art of changing the brain: Enriching the practice of teaching by exploring the biology of learning. Stylus Publishing.

Chapter 2. The 4 Pillars of Brain Maintenance

• Ball, K., Berch, D. B., Helmers, K. F., Jobe, J. B., Leveck, M. D., Marsiske, M., Morris, J. N., Rebok, G. W., Smith, D. M., Tennstedt, S. L., Unverzagt, F. W., & Willis, S. L. (2002). Effects of cognitive training interventions with older adults. Journal of the American Medical Association, 288, 2271-2281.
• Basak, C. et al. (2008). Can training in a real-time strategy video game attenuate cognitive decline in older adults? Psychology and Aging.
• Brooks, J. O., Friedman, L., Pearman, A. M., Gray, C., & Yesavage, J. A. (1999). Mnemonic training in older adults: Effect of age, length of training, and type of cognitive pretraining. International Psychogeriatrics, 11, 75-84.
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• Colcombe, S., & Kramer, A. F. (2003). Fitness effects on the cognitive function of older adults: A Meta-Analytic study. Psychological Science, 14 (2) , 125–130.
• DeKosky, S. T., et al. (2008). Ginkgo biloba for prevention of dementia: a randomized controlled trial. Journal of the American Medical Association, 300, 2253-2262.
• Derwinger, A., Neely, A. S., Persson, M., Hill, R. D., & Backman, L. (2003). Remembering numbers in old age: Mnemonic training versus self-generated strategy training. Aging Neuropsychology and Cognition, 10, 202-214.
• Elsabagh, S., Hartley, D. E., Ali, O., Williamson, E. M., & File, S. E. (2005). Differential cognitive effects of Ginkgo biloba after acute and chronic treatment in healthy young volunteers. Psychopharmacology, 179(2), 437-46
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• Gage, F. H., Kempermann, G., & Song, H. (2007). Adult Neurogenesis. Cold Spring Harbor Laboratory Press, NY.
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• Heyn, P., Abreu, B. C., & Ottenbacher, K. J. (2004). The effects of exercise training on elderly persons with cognitive impairment and dementia: a meta-analysis. Archives of Physical Medicine and Rehabilitation, 85(10), 1694-704.
• Hillman, C. H., Erickson, K. I., & Kramer, A. F. (2008). Be smart, exercise your heart: exercise effects on brain and cognition. Nature Reviews Neuroscience 9 (1), 58-65.
• Katzman, R., Aronson, M., Fuld, P., Kawas, C., Brown, T., Morgenstern, H., Frishman, W., Gidez, L., Eder, H., & Ooi, W.L. (1989). Development of dementing illnesses in an 80-year-old volunteer cohort. Annals of Neurology, 25, 317–324.
• McCleary, L. (2007).The Brain Trust Program: A scientifically based three-part plan to improve memory, elevate mood, enhance attention, alleviate migraine and menopausal symptoms, and boost mental energy. Perigee Trade.
• McCraty, R., Barrios-Choplin, B., Rozman, D., Atkinson, M., & Watkins, A. D. (1998). The impact of a new emotional self-management program on stress, emotions, heart rate variability, DHEA and cortisol. Integr. Physiol. Behav. Sci., 33(2), 151-70.
• Nair, K. S., Rizza, R. A., O’Brien, P., Dhatariya, K., Short, K. R., Nehra, A., Vittone, J. L., et al. (2006). DHEA in elderly women and DHEA or testosterone in elderly men. The New England Journal of Medicine, 355(16), 1647-59.
• Piscitelli, S. C, Burstein, A. H., Chaitt, D., Alfaro, R. M., Falloon, J. (2001). Indinavir concentrations and St John’s wort. Lancet, 357, 1210.
• Roenker, D., Cissell, G., Ball, K., Wadley, V., & Edwards, J. (2003). Speed of processing and driving simulator training result in improved driving performance. Human Factors, 45, 218-233.
• Sapolsky, R. M. (2004). Why zebras don’t get ulcers. Owl Books.
• Scarmeas, N., Levy, G., Tang, M. X., Manly, J., & Stern, Y. (2001). Influence of leisure activity on the incidence of Alzheimer’s disease. Neurology, 57, 2236-2242.
• Snowdon, D. A., Ostwald, S. K., Kane, R. L., & Keenan, N. L. (1989). Years of life with good and poor mental and physical function in the elderly. Journal of Clinical Epidemiology, 42, 1055-1066.
• Solomon, P. R, Adams, F., Silver, A., Zimmer, J., & DeVeaux, R. (2002). Ginkgo for memory enhancement: a randomized controlled trial. JAMA, 288(7), 835-40.
• Stern, Y. (2002). What is cognitive reserve? Theory and research application of the reserve concept. Journal of Int. Neuropsych. Soc., 8, 448-460.
• Verhaeghen, P., Marcoen, A., & Goosens, L. (1992). Improving memory performance in the aged through mnemonic training: A meta-analytic study. Psychology and Aging, 7, 242-251.
• Willis, S. L., Tennstedt, S. L., Marsiske, M., Ball, K., Elias, J., Koepke, K. M., Morris, J. N., Rebok, G. W. Unverzagt, F. W. Stoddard, A. M., & Wright, E. (2006). Long-term effects of cognitive training on everyday functional outcomes in older adults. Journal of the American Medical Association, 296(23), 2805-2814.
• Wilson, R.S., Bennett, D.A., Bienias, J.L., Aggarwal, N.T., Mendes de Leon, C.F., Morris, M.C., Schneider, J. A., & Evans, D. A. (2002). Cognitive activity and incident AD in a population-based sample of older persons. Neurology, 59, 1910-1914.
• Zelinski et al. (on-going). The IMPACT Study: A randomized controlled trial of a brain plasticity-based training program for age-related decline.
• Zelinski, E. M., & Burnight, K. P. (1997). Sixteen-year longitudinal and time lag changes in memory and cognition in older adults. Psychology and Aging, 12(3), 503-513.
• Zull, J. E. (2002). The Art of changing the brain: Enriching the practice of teaching by exploring the biology of learning. Stylus Publishing: Sterling, VA.

Chapter 3. Mental Exercise vs. Mental Activity

• American Society on Aging (2006). ASA-Metlife Foundation Attitudes and Awareness of Brain Health Poll.
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• Beck, J. S. (2007). The Beck diet solution: Train your brain to think like a thin person. Oxmoor House.
• Ericsson, K. A., & Delaney, P. F. (1998). Working Memory and Expert Performance. In R. H. Logie & K. J. Gilhooly (Eds.), Working Memory and Thinking, pp. 93-114. Hillsdale, NJ: Erlbaum.
• Gaab, N, Gabrieli, J. D. E., Deutsch, G. K., & Temple, E. (2007). Neural correlates of rapid auditory processing are disrupted in children with developmental dyslexia and ameliorated with training: An fMRI study. Restorative Neurology and Neuroscience, 25, 295-310.
• Gopher, D., Weil, M., & Baraket, T. (1994). Transfer of skill from a computer game trainer to flight. Human Factors, 36, 387-405.
• Hambrick, D. Z., Sathouse, T. A., & Meinz, E. J. (1999). Predictors of crossword puzzle proficiency and moderators of age-cognition relations. Journal of Experimental Psychology: General, 128, 131-164.
• Hillman, C. H., Erickson, K. I., & Kramer, A. F. (2008). Be smart, exercise your heart: exercise effects on brain and cognition. Nature Reviews Neuroscience 9 (1), 58-65.
• Jaeggi, S. M., Buschkuehl, M., Jonides, J., & Perrig, W. J. (2008). Improving fluid intelligence with training on working memory. Proceedings of the National Academy of Sciences of the United States of America, 105(19), 6829-6833.
• Jobe, J. B., Smith, D. M., Ball, K., Tennstedt, S. L., Marsiske, M., Willis, S. L., Rebok, G. W., Morris, J. N., Helmers, K. F., Leveck, M. D., Kleinman, K. (2001). ACTIVE: A cognitive intervention trail to promote independence in older adults. Control Clinical Trials, 22(4), 453-479.
• Kawashima, R. (2005). Train your brain: 60 days to a better brain. Kumon Publishing North America.
• Klingberg, T., Fernell, E., Olesen, P. J., Johnson, M., Gustafsson, P., Dahlström, K., Gillberg, C. G., Forssberg, H., & Westerberg, H. (2005). Computerized training of working memory in children with ADHDA randomized, controlled trial. J. American Academy of Child and Adolescent Psychiatry, 44(2), 177-186.
• Lavin, A., & Glaser, S. (2006). Who’s boss: Moving families from conflict to collaboration. Collaboration Press.
• Lavin, A., & Glaser, S. (2007). Baby and toddler sleep solutions for dummies. Wiley.
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• Mahncke, H. W., Connor, B. B., Appelman, J., Ahsanuddin, O. N., Hardy, J. L., Wood, R. A., Joyce, N. M., Boniske, T., Atkins, S. M., & Merzenich, M. M. (2006). Memory enhancement in healthy older adults using a brain plasticity-based training program: A randomized, controlled study. PNAS, 103(33), 12523-12528.
• Davidson, R. J., Kabat-Zinn, J., Schumacher, J., Rosenkranz, M., Muller, D., Santorelli, S. F., Urbanowski, F., Harrington, A., Bonus, K. and Sheridan, J. F. (2003). Alterations in brain and immune function produced by mindfulness meditation. Psychosomatic Medicine, 65, 564-570.
• Newberg, A., D’Aquili, E., & Rause, V. (2001). Why God won’t go away: Brain science and the biology of belief. Ballantine Books.
• Newberg, A. & Waldman, M. R. (2006). Why we believe what we believe: Uncovering our biological need for meaning, spirituality, and truth. Free Press.
• Paquette, V., Levesque, J., Mensour, B., Leroux, J. M., Beaudoin, G., Bourgouin, P., et al. (2003). Effects of cognitive-behavioral therapy on the neural correlates of spider phobia. Neuroimage, 18, 401-409.
• Roenker, D., Cissell, G., Ball, K., Wadley, V., & Edwards, J. (2003). Speed of processing and driving simulator training result in improved driving performance. Human Factors, 45: 218-233.
• Scarmeas, N., Levy, G., Tang, M. X., Manly, J., & Stern, Y. (2001). Influence of leisure activity on the incidence of Alzheimer’s disease. Neurology, 57, 2236-2242.
• Stahre, L., Tärnell, B., HÃ¥kanson, C.-.E., & Hällström, T. (2007). A randomized controlled trial of two weight-reducing short-term group treatment programs for obesity with an 18-month follow-up. International Journal of Behavioral Medicine, 14(1), 48-55
• Steenbarger, B, N. (2006). Enhancing Trader Performance: Proven Strategies From the Cutting Edge of Trading Psychology. Wiley.
• Steenbarger, B. N. (2003). The Psychology of Trading: Tools and Techniques for Minding the Markets. Wiley.
• Tang, Y., Ma, Y., Wang, J., Fan, Y., Feng, S., Lu, Q., et al. (2007). Short-term meditation training improves attention and self-regulation. Proceedings of the National Academy of Sciences, 104(43), 17152-17156.
• Temple, E., Deutsch, G. K., Poldrack, R. A., Miller, S. L., Tallal, P.,Merzenich, M. M., & Gabrieli, J. D. E. (2003). Neural deficits in children with dyslexia ameliorated by behavioral remediation: Evidence from functional MRI. Proc. Natl. Acad. Sci. USA, 100, 2860-2865.
• Willis, S. L., Tennstedt, S. L., Marsiske, M., Ball, K., Elias, J., Koepke, K. M., Morris, J. N., Rebok, G. W. Unverzagt, F. W. Stoddard, A. M., & Wright, E. (2006). Long-term effects of cognitive training on everyday functional outcomes in older adults. Journal of the American Medical Association, 296(23), 2805-2814.
• Woodruff, L., & Woodruff, B. (2007). In an Instant: A Family’s journey of love and healing. Random House.
• Zelinski et al. (on-going). The IMPACT Study: A randomized controlled trial of a brain plasticity-based training program for age-related decline.

Chapter 4. Brain Training Software: Profiles, Evaluation Criteria and 21 Quick Picks

• Baril, L., Nicolas, L., Croisile, B., Crozier, P., Hessler, C., Sassolas, A., McCormick, J. B., & Trannoy, E. (2004). Immune response to Abetapeptides in peripheral blood from patients with Alzheimer’s disease and control subjects. Neurosci. Lett., 355(3), 226-30
• Gopher, D., Weil, M., & Bareket, T. (1994). Transfer of skill from a computer game trainer to flight. Human Factors, 36, 1-19.
• Kawashima, R. (2005).Train your brain: 60 days to a better brain. Kumon Publishing North America.
• Klingberg, T., Fernell, E., Olesen, P. J., Johnson, M., Gustafsson, P., Dahlström, K., Gillberg, C. G., Forssberg, H., & Westerberg, H. (2005). Computerized training of working memory in children with ADHDA randomized, controlled trial. J. American Academy of Child and Adolescent Psychiatry, 44(2), 177-186.
• Mahncke, H. W., Connor, B. B., Appelman, J., Ahsanuddin, O. N., Hardy, J. L., Wood, R. A., Joyce, N. M., Boniske, T., Atkins, S. M., & Merzenich, M. M. (2006). Memory enhancement in healthy older adults using a brain plasticity-based training program: A randomized, controlled study. PNAS, 103(33), 12523-12528.
• Nussbaum, P. (2007). Your brain health lifestyle. Word Association.
• Small, G. (2005). The memory prescription: Dr. Gary Small’s 14-day plan to keep your brain and body young. Hyperion.
• Steenbarger, B, N. (2006). Enhancing trader performance: Proven strategies from the cutting edge of trading psychology. Wiley.

Chapter 5. A Growing Range of Applications

• Barkley, R. A. (1997). Attention-deficit/hyperactivity disorder, selfregulation, and time: Toward a more comprehensive theory. Journal of Developmental & Behavioral Pediatrics, 18(4), 271-279.
• Centers for Disease Control and Prevention and the Alzheimer’s Association. (2007). The Healthy Brain Initiative: A National Public Health Road Map to Maintaining Cognitive Health.
• Cicerone, K. D., Dahlberg, C., Kalmar, K., Langenbahn, D. M., Malec, J. F., Bergquist, T. F., Felicetti, T., Giacino, J. T., Harley, J. P., Harrington, D. E., Herzog, J., Kneipp, S., Laatsch, L., & Morse P. A. (2000). Evidencebased cognitive rehabilitation: recommendations for clinical practice. Arch. Phys. Med. Rehabil., 81, 1596-615.
• Cicerone, K. D., Dahlberg, C., Malec, J. F., Langenbahn, D. M., Felicetti, T., Kneipp, S., Ellmo, W., Kalmar, K., Giacino, J. T., Harley, J. P., Laatsch, L., Morse, P. A., & Catanese, J. (2005). Evidence-based cognitive rehabilitation: Updated review of the literature from 1998 through 2002. Arch. Phys. Med. Rehabil., 86, 1681-92.
• Goldstein, S., & Ingersoll, B. (1993). Controversial treatments for children with ADHD and impulse disorders. In L. F., Koziol C. E. Stout, and D. Ruben, (Eds.). Handbook of childhood impulse disorders and ADHD: Theory and practice. Charles C Thomas, Publisher, pp. 144-160
• Gopher, D., Weil, M., & Baraket, T. (1994). Transfer of skill from a computer game trainer to flight. Human Factors, 36, 387-405.
• Kasten, E., Wuest, S., Behrens-Bamann, W., & Sabel, B. A. (1998). Computer-based training for the treatment of partial blindness. Nature Medicine, 4, 1083–1087.
• Klingberg, T., Fernell, E., Olesen, P. J., Johnson, M., Gustafsson, P., Dahlström, K., Gillberg, C. G., Forssberg, H., & Westerberg, H. (2005). Computerized training of working memory in children with ADHDA randomized, controlled trial. J. American Academy of Child and Adolescent Psychiatry, 44(2), 177-186.
• Mark Katz, M. (1997). On playing a poor hand well. W.W. Norton and Company.
• Olesen, P. J., Westerberg, H., & Klingberg, T. (2004). Increased prefrontal and parietal brain activity after training of working memory. Nature Neuroscience, 7(1), 75-79.
• Rabiner, D., & Coie, J. D. (2000). Early attention problems and children’s reading achievement: A longitudinal investigation. Journal of the American Academy of Child & Adolescent Psychiatry, 39(7), 859-867.
• Roenker, D., Cissell, G., Ball, K., Wadley, V., & Edwards, J. (2003). Speed of processing and driving simulator training result in improved driving performance. Human Factors, 45, 218-233.
• Shebilske, W. L., Volz, R. A., Gildea, K. M., Workman, J. W., Nanjanath, M., Cao, S,, & Whetzel, J. (2005). Revised Space Fortress: A validation study. Behavior Research Methods, 37, 591-601.
• Willis, S. L., Tennstedt, S. L., Marsiske, M., Ball, K., Elias, J., Koepke, K. M., Morris, J. N., Rebok, G. W. Unverzagt, F. W. Stoddard, A. M., & Wright, E. (2006). Long-term effects of cognitive training on everyday functional outcomes in older adults. Journal of the American Medical Association, 296(23), 2805-2814.

Chapter 6. Ready for the Future?

• Whalen, C., Liden, L., Ingersoll, B., Dallaire, E., & Liden, S. (2006). Positive behavioral changes associated with the use of computerassisted instruction for young children. Journal of Speech and Language Pathology and Applied Behavior Analysis, 1(1), 11-25.
• Vance, D. E., Webb, N. M., Marceaux, J. C., Viamonte, S. M., Foote, A. W., & Ball, K. K. (2008). Mental stimulation, neural plasticity, and aging: directions for nursing research and practice. Journal of Neuroscience Nursing, 40(4), 241-9.

Chapter 7. Opening the Debate

• Ybarra, O., Burnstein, E., Winkielman, P., Keller, M. C., Manis, M., Chan, E., & Rodriguez, J. (2008). Mental exercising through simple socializing: Social interaction promotes general cognitive functioning. Personality and Social Psychology Bulletin, 34, 248-259.

For more information on the book, please visit The SharpBrains Guide to Brain Fitness.

However little is known about the consequences of low working memory capacity per se, independent of other associated learning difficulties. In particular, it is not known either what proportion of students with low working memory capacities has significant learning difficulties or what their behavioral characteristics are. The aim of a recent study published in Child Development (reference below) was to provide the first systematic large-scale examination of the cognitive and behavioral characteristics of school-aged students who have been identified solely on the basis of very low working memory scores.

In screening of over 3000 school-aged students in mainstream schools, 1 in 10 was identified as having working memory difficulties. There were several key findings regarding their cognitive skills. The first is that the majority of them performed below age-expected levels in reading and mathematics. This suggests that low working memory skills constitute a high risk factor for educational underachievement for students. This corresponds with evidence that working memory impacts all areas of learning from kindergarten to college. It is a basic cognitive skill that we need to perform a variety of activities, and we use it in core subjects like reading and maths, as well as general topics like Art and Music. Crucially, this pattern of poor performance in learning outcomes remains even when students’ IQ is statistically accounted.

This fits well with evidence suggesting that working memory is even more important to learning than other cognitive skills such as IQ. For example, in typically developing students, I found that their working memory skills, rather than IQ, at 5 years old were the best predictor of predictor of reading, spelling, and math outcomes six years later.

The next major finding from the studies of students with working memory difficulties is that teachers typically judged the students to be highly inattentive, and have short poor attention spans and high levels of distractibility. They were also commonly described as forgetting what they are currently doing and things they have learned, failing to remember instructions, and failing to complete tasks. In everyday classroom activities, they often made careless mistakes, particularly in writing, and had difficulty in solving problems. In contrast, relatively few of the students were judged to exhibit the high levels of hyperactive and impulsive behaviors.

The final key finding is that students with working memory difficulties take a much longer time to process information. They are unable to cope with timed activities and fast presentation of information. As a result, they often end up abandoning the activities all together out of frustration. One way to overcome this difficulty is to provide them with a shorter activity and to allow for more time during tests.

Studies such as these demonstrate that students with working memory difficulties have an extremely high risk of making poor academic progress and are relatively common in the classroom – they represent approximately 10% of their age group in mainstream schooling. Without early intervention, working memory deficits cannot be made up over time and will continue to compromise a child’s likelihood of academic success.

How can we support students’ learning? The first crucial step in supporting students with working memory impairments is proper diagnosis, which can be conducted by a school psychologist. However, at present working memory problems often go undetected in students or are misdiagnosed as attentional problems. There are several test batteries that can be used to assess working memory, including the Working Memory Index in the WISC. However, most assessment instruments that are currently available require considerable experience in the administration, scoring and interpretation of cognitive tests. One useful tool to identify and support students with working memory impairments is the Automated Working Memory Assessment (AWMA; Alloway, 2007 published by Pearson). The benefit of the AWMA is that it is designed to provide a practical and convenient way for non-expert assessors such as teachers to screen their pupils for significant working memory problems, with a user-friendly interface. The automated presentation and scoring of tasks provide consistency in presentation of stimuli across participants, thus reducing experimenter error. The AWMA was used in the study described here, as well as in numerous peer-reviewed journal articles on the role of working memory in learning, anxiety, and development in typical and clinical populations.

The main goal of this article was to explore the link between working memory and academic performance. On the basis of a large-scale screening study of over 3000 student, 10% were found to have working memory impairments that jeopardize their chance of academic success. The majority perform below age-expected levels in all areas of learning and struggle to follow simple instructions in the classroom. These difficulties highlight the need for early assessment to identify those at risk. In a future article, I will discuss ways to help students with working memory problems, including clinical trials demonstrating successful transfer of cognitive training to academic attainments.

Reference: Alloway et al. (2009). The cognitive and behavioural characteristics of children with low working memory. Child Development, 80, 606-621.

Tracy Packiam Alloway, PhD, is the Director of the Center for Memory and Learning in the Lifespan at the University of Stirling, UK. She was recently awarded the prestigious Joseph Lister Award by the British Science Association for her contribution to science and has developed the world’s first standardized working-memory tests for educators published by Pearson. To date, it has been translated into 15 languages and used to screen for working memory problems in students with dyslexia, motor dyspraxia (Developmental Coordination Disorder), ADHD and Autistic Spectrum Disorder. She provides consultancy to the World Bank and her research has received widespread international coverage in hundreds of media outlets, including Scientific American, the BBC, and Reuters.

Let me introduce and quote some of the top Brain Health Studies, Articles and Resources published in March:

1) Cognitive Decline Begins In Late 20s, Study Suggests (Science Daily)

- “These patterns suggest that some types of mental flexibility decrease relatively early in adulthood, but that how much knowledge one has, and the effectiveness of integrating it with one’s abilities, may increase throughout all of adulthood if there are no pathological diseases,” Salthouse said.

- However, Salthouse points out that there is a great deal of variance from person to person

2) Cerebrum 2009: Emerging Ideas in Brain Science – new book by the Dana Foundation that “explores the cutting edge of brain research and its implications in our everyday lives, in language understandable to the general reader.”

A couple of excellent chapters of direct relevance to everyone’s brain health are:
- Chapter 4: A Road Paved by Reason, by Elizabeth Norton Lasley

- Chapter 10: Neural Health: Is It Facilitated by Work Force Participation?, by Denise Park, Ph.D

3) Staying Sharp DVD Program: “Dr. Jordan Grafman, chief of the Cognitive Neuroscience Section at the National Institute of Neurological Disorders and Stroke outside of Washington, DC, and a member of the Dana Alliance for Brain Initiatives, is your guide as we cover what to expect from the aging brain and what we can do to ’stay sharp.’

For a free DVD of this program you can contact stayingsharp@dana.org. (they say free in their website, I don’t know if that includes shipping & handling)

4) Drivers to be tested on cognitive ability starting at age 75 (Japan Times)

The outline of a cognitive test that drivers aged 75 or over will be required to take from June when renewing their licenses was released Thursday…The test is intended to reduce the number of traffic accidents involving elderly drivers by measuring their cognitive level.

5) Physical Fitness Improves Spatial Memory, Increases Size Of Brain Structure (Science Daily)

- “Now researchers have found that elderly adults who are more physically fit tend to have bigger hippocampi and better spatial memory than those who are less fit.”

6) Brain Trainers: A Workout for the Mind (Scientific American Mind)

“I recently tried out eight of the latest brain fitness programs, training with each for a week. The programs ranged widely in focus, quality and how fun they were to use. “Like physical exercise equipment, a brain exercise program doesn’t do you any good if you don’t use it,” says Andrew J. Carle, director of the Program in Assisted Living/Senior Housing Administration at George Mason University. And people tend not to use boring equipment. “I remember when NordicTrack was the biggest thing out there. Everyone ran out and bought one, and 90 percent of them ended up as a clothes rack in the back of your bedroom.”

The reporter used: Posit Science’s Brain Fitness Program Classic, HappyNeuron, Nintendo BrainAge, CogniFit’s MindFit/ CogniFit Personal Coach, Lumosity, MyBrainTrainer, BrainTwister, Cogmed Working Memory Training.

7) The Latest in Mental Health: Working Out at the ‘Brain Gym’ (Wall Street Journal)

- “Marshall Kahn, an 82-year-old family doctor in Fullerton, Calif., says he got such a boost from brain exercises he started doing at a “Nifty after Fifty” club that he decided to start seeing patients again part-time. “Doing all the mental exercise,” he says, “I realized I’ve still got it.”

Debate Over Drugs For ADHD Reignites (Washington Post)

- “New data from a large federal study have reignited a debate over the effectiveness of long-term drug treatment of children with hyperactivity or attention-deficit disorder, and have drawn accusations that some members of the research team have sought to play down evidence that medications do little good beyond 24 months.”

- “The study also indicated that long-term use of the drugs can stunt children’s growth.”

Adaptive training leads to sustained enhancement of poor working memory in children (Developmental Science)

Abstract: Working memory plays a crucial role in supporting learning, with poor progress in reading and mathematics characterizing children with low memory skills. This study investigated whether these problems can be overcome by a training program designed to boost working memory. Children with low working memory skills were assessed on measures of working memory, IQ and academic attainment before and after training on either adaptive or non-adaptive versions of the program. Adaptive training that taxed working memory to its limits was associated with substantial and sustained gains in working memory, with age-appropriate levels achieved by the majority of children. Mathematical ability also improved significantly 6 months following adaptive training. These findings indicate that common impairments in working memory and associated learning difficulties may be overcome with this behavioral treatment.

9) Brain cortex thinning linked to inherited depression (Los Angeles Times)

- “On average, people with a family history of depression appear to have brains that are 28% thinner in the right cortex — the outermost layer of the brain — than those with no known family history of the disease. That cortical thinning, said the researchers, is on a scale similar to that seen in patients with Alzheimer’s disease or schizophrenia.”

You can read part 1 here.

Q – In your Harvard Management Update interview, you said that “When what we pay attention to is driven by the last email we received, the trivial and the crucial occupy the same plane.” As well, it seems to be that a problem is our culture’s over-idealization of “always on” and “road warrior” habits, which distract from the importance of executive functions such as paying attention to one’s environment, setting up goals and plans, executing on them, measuring results, and internalizing learning. How can companies better equip their employees for future success? Can you offer some examples of companies who have positive cultures that encourage and reward employees fully put their frontal lobes into good use?

A – As I mentioned above, we are working and living in ways that undermine our ability to strategize, focus, reflect, innovate. Skimming, multitasking and speed all have a place in 21st-century life. But we can’t let go of deeper skills of focus and thinking and relating, or we’ll create a society of misunderstanding and shallow thinking.

To create workplaces that foster strategic thinking, deep social connection and innovation, we need to take three steps:

First, question the values that venerate McThinking and undermine attention. Recently, my morning paper carried a front-page story about efforts “in an age of impatience” to create a quick-boot computer. “It’s ridiculous to ask people to wait a couple of minutes to start up their computer,” explained one tech executive. The first hand up in the classroom, the hyper business-man or –woman who can’t sit still, much less listen – these are icons of success in American society. Still, many of us are beginning to question our adoration of instant gratification and hyper-mobility.

Second, we need to set the stage for focus individually and collectively by rewriting our climate of distraction and inattention. To help, some companies and business leaders are experimenting with “white space” – the creation of physical spaces or times on the calendar for uninterrupted, unwired thinking and connection. Executives are scheduling “quiet time” in their calendars to recapture space for reflection. One architect’s design for a major new government laboratory specifically creates spaces for focus, as well as collaboration. IBM’s global practice of “ThinkFridays” began three years ago when software engineers decided to limit email, conference calls and meetings one day a week in order to focus on their creative, patent work. Now, different teams and departments interpret “ThinkFridays” in varied ways. This pioneering initiative is fluid, flexible and workable – more so than the rigid, top-down policies that ban email one day a week.

Finally, if there’s just one action we can take to spark a “renaissance of attention,” it should be to give the gift of our attention to others. Parents and leaders, in particular, need to role model attention. As contemplative scholar Alan Wallace says, “When we give another person our attention, we don’t get it back. We’re giving our attention to what seems worthy of our life from moment to moment. Attention, the cultivation of attention, is absolutely core.”

Q – Some essential skills to thrive in the Cognitive Age seem to be attention, emotional self-regulation, working memory. These capacities are today understood to be less immutable than once thought, with emerging research opening the way for training programs that, for example, perhaps Fortune 500 companies will want too offer in the future as part of their corporate training and leadership programs, Your view?

A – Remarkably, scientists are now beginning to understand the mysteries and workings of attention and its sister skills of working memory and self-regulation. They are also discovering that attention can be trained, a finding that should revolutionize parenting, education and workplace training. In just five days of computer-based training, the brains of 6-year-olds begin to act like adults on measures of executive attention, one study by Michael Posner found. Torkel Klingberg’s work has shown that boosting short-term memory seems to improve children’s ability to stay on task. We don’t yet know how long-lasting the gains are, but practices such as meditation, computer-based exercises and behavioral therapies are proven to boost focus, awareness, working memory and executive attention. The philosopher/psychologist Williams James thought that attention could not be highly trained by “drill or discipline,” but he was wrong.

Still, there are important caveats to keep in mind. Some researchers question computer-based efforts as too narrow in scope, arguing that people must be taught attention holistically, as a life skill. No brief training regime is likely to be a magic bullet. “Part of the problem in today’s society is that people are looking for extremely quick fixes that have no vision. People are looking to lose 20 pounds for the wedding next week,” neuroscientist Amir Raz of McGill University once told me. “But attention training is a slow process.” As well, machine-based training will not be the only way to strengthen attention. Certainly, technology truly augments the human mind, and our gadgets will evolve to better help us focus and think. Yet it’s a mistake to believe that computers, or pharmaceuticals for that matter, can replace the hard, difficult work that we all face in “upgrading” ourselves.

Q – Neuroscientist Torkel Klinkgerg recently told our readers that “modern life itself may help make us more cognitively able. And emerging tools may enhance our abilities and better prepare us for the demands of the Information Age.” What are the opportunities and the risks you see ahead of us?

A – We now have easy access to reams of data, ever-expanding social networks, and limitless experiences across the planet and in the new frontier of cyberspace. The potential for learning, connection, fulfillment is great. But at the moment, we are not realizing this potential. Despite our scientific and technical achievements, we are squandering our chances to create a high-tech, yet reflective and caring society. And yet I am optimistic. In this time of flux, uncertainty, mistrust and collapse, we may nevertheless be shaken enough to reconsider our taken-for-granted ways of thinking and being. We may be ready to effect change. The task before us – to spark a renaissance of attention – is monumental, and yet it’s as crucial as greening the planet or rebuilding our financial system. For we can only meet the challenges of our day by strengthening, not undermining, our powers of attention.

Maggie, thank you very much for your time and attention.

My pleasure!

—
Maggie’s Book: Distracted: The Erosion of Attention and the Coming Dark Age

—
Related articles and resources:

- Part 1 of the interview with Maggie Jackson

- The Overflowing Brain: Most Important Book of 2008

- Top 10 Brain Fitness Books

Neurofeedback treatment for ADHD has been controversial in the field for many years and remains so today. Although a number of published studies have reported positive results many prominent ADHD researchers believe that problems with the design of these studies preclude concluding that neurofeedback is an effective treatment. These limitations have included the absence of random assignment, the lack of appropriate control groups, raters who are not ‘blind’ to children’s treatment status, and small samples. For additional background, you can find a recent review I wrote on existing research support for neurofeedback treatment of ADHD – along with links to extensive reviews of several recently published studies -: How Strong is the Research Support for Neurofeedback in Attention Deficits?

- Results from a New Study of Neurofeedback -

Recently, a study of neurofeedback treatment for ADHD was published that addresses several limitations that have undermined prior research [Gevensleben, et al., (2009). Is neurofeedback an efficacious treatment for ADHD? A randomized controlled clinical trial. Journal of Child Psychology and Psychiatry.]

The study was conducted in Germany and began with 102 children aged 8 to 12. All had been carefully diagnosed with ADHD and approximately over 90% had never received medication treatment. About 80% were boys. Children were randomly assigned to one of two treatment conditions: 36 sessions of neurofeedback training or 36 sessions of computerized attention training. The computerized attention training task was intended to serve as the control intervention. Training was conducted in two 50-minute blocks per sessions, with a short break in-between; children in both groups participated in two to three such training sessions per week.

- Description of Training -

Neurofeedback Training – As noted above, neurofeedback entails providing children with real-time feedback on their EEG state so that they become able to learn how to create and maintain a state that is consistent with focused attention. This is done by linking their ability to control what appears on the computer screen to their ability to produce and maintain the EEG state being trained. Technical details of the training protocols are not summarized here but were based on research findings suggesting the specific EEG differences between children with and without ADHD that training should address. For example, one part of training focused on teaching children to elevate their production of higher frequency beta waves and supress the production of lower frequency theta waves. This is based on prior findings that individuals with ADHD tend to have an elevated ratio of theta to beta activity relative (see Neurofeedback/ Quantitative EEG for ADHD diagnosis).

Computerized Attention Training – This treatment was based on a program called ‘Skillies’, described as award-winning German learning software that provides systematic exercises in visual and auditory perception, vigilance, sustained attention, and reactivity. It was considered the ‘control’ condition to which the results of neurofeedback training was compared.

Performing well on the program requires children to sustain their attention to a variety of game-like tasks that become increasingly challenging and that provide children with frequent feedback about their performance. Children thus receive extended practice in ‘paying attention’ for increasing periods to tasks that become increasingly demanding and need to learn to sustain their attention in order to do well. Unlike neurofeedback treatment,however, no direct feedback on EEG state is provided.

- Experimental Controls -

As noted above, children were randomly assigned to treatment condition, which is essential when comparing different interventions. Efforts were also made to make the intervention experience as similar as possible, except for the critical difference as to whether children received direct training in managing their EEG state. Thus, treatment for both groups entailed computer-game like tasks that demanded attention. In both conditions, children were encouraged to develop strategies to focus attention and to practice these strategies at home and school. They also received similar amounts of attention and praise for doing so.

By equalizing as many aspects of the training experience as possible, the researchers could attribute any outcome differences that emerged to critical differences in the programs themselves, i.e., whether feedback on EEG state was provided, as opposed to some extraneous factor such as attention from the experimenters, time spent on a demanding computer task, etc.

In addition to these important controls, efforts were made to keep parents and teachers ‘blind’ to the type of training children received. Thus, parents were only told that their child would receive either of two promising computer-based treatments for ADHD. They also did not accompany their child into the treatment room to observe. Children’s teachers were also not informed about the child’s treatment. Although a number of parents became aware of which treatment their child received, and perhaps some teachers did as well, it is not possible to keep everyone truly ‘blind’ in a study like this.

- Measuring Treatment Outcomes -

The main outcome measure used were parent and teacher ratings of children’s ADHD symptoms. In addition to ratings of core inattentive and hyperactive-impulsive symptoms, ratings were collected on a variety of other behaviors, e.g., oppositional behavior, conduct problems, emotional problems, and social problems. These rating scales were obtained before and after treatment.

To rule out placebo effects as an explanation for any treatment differences found, the researchers also asked parents about their attitudes towards treatment, how motivated they thought their children were, and how satisified they were with their child’s treatment.

- Results -

Preliminary analyses revealed no group differences in parents’ attitudes towards, or satisfaction with, their child’s treatment or in how motivated they felt their child was. These factors thus should not have influenced parents’ ratings of core symptoms.

Results of the parent and teacher behavior ratings indicated the following:

1. Parents of children treated with neurofeedback reported significantly greater reductions in inattentive and hyperactive-impulsive symptoms than parents of control children, i.e,. those who received computerized attention training. The size of the group difference was in a range that would be considered moderate, i.e., about .5 standard deviations.

2. Teachers of children treated with neurofeedback reported significantly greater reductions in inattentive and hyperactive-impulsive symptoms than teachers of control children. The size of the group difference was similar in magnitude to that found for parents, about .5 standard deviations.

3. Apart from these differences in core ADHD symptoms, few group differences were found. However, neurofeedback was associated with greater reductions in parents’ ratings of oppositional and aggressive behavior. Teacher ratings for the two groups did not differ on any of the remaining behavioral measures.

The results summarized above reflect average differences between the groups. The authors also examined the percentage of children in each group that were judged to derive significant benefit where this was defined as at least a 25% reduction in core ADHD symptoms. Fifty-one percent of children in the neurofeedback group met this threshold compared to only 26% of children in the attention training control group. This difference was statistically significant as well.

- Summary and Implications -

This was a well-designed study of neurofeedback treatment for ADHD that used random assignment, blind raters, and included an appropriate control group. Results indicate that neurofeedback treatment yielded significantly greater reductions in parent and teacher ratings of core ADHD symptoms than the comparison treatment. Furthermore, the magnitude of the reductions appear large enough to be clinically meaningful. Although the impact of neurofeedback treatment on other aspects of children’s functioning was less pronounced, significant reductions in parents’ ratings of oppositional behavior were also found.

Overall, these findings add to the research support for neurofeedback as a treatment for ADHD. However, despite the many strengths of this study, there are concerns to note and reasons why some researchers will find a basis for criticizing it. The main concerns – and my own take on them – include the following:

1. Without getting too technical, some researchers will argue that the statistical tests used in this study were not ideal and may have overestimated the advantages of neurofeedback treatment. My sense from examining the data is that the primary findings would hold up even if more conservative statistical tests were employed. However, it would be really nice to see that done.

2. Neurofeedback is supposed to work by teaching children to transform their EEG state to one that is characteristic of children without ADHD. However, there were no EEG measures taken in this study. Thus, there is no way to know whether neurofeedback actually resulted in these hypothesized changes in EEG. While this is certainly true, this has more to do with documenting the mechanism by which neurofeedback led to reductions in ADHD symptoms and has nothing to do with whether those reductions actually occurred.

I believe that some neurofeedback practitioners would argue that this may have also diminished the benefits provided by neurofeedback treatment. The reason for this is that training was not matched to the specific EEG parameters that needed to be altered for each individual and that additional benefits would have accrued had this been done. Whether this is actually the case, however, would require additional research to determine.

3. No measures of children’s academic functioning were collected. Because improving academic performance is a critical treatment target for most children with ADHD, the absence of this data is an important study limitation. There is no arguing with this and it is unfortunate that measures of academic performance in the classroom were not collected.

4. No long-term follow up was conducted. There is thus no basis for knowing whether neurofeedback treatment resulted in any enduring benefits. While this is certainly a limitation, it should be noted that neither medication treatment nor behavioral treatment have been shown to have enduring benefits after treatment ends. However, one of the reputed advantages of neurofeedback is that it may result in enduring gains. Thus, adding a long-term follow up to this study would have been an important addition.

5. It is important to remember that when improvement was defined as at least a 25% reduction in core ADHD symptoms, about 50% of children treated with neurofeedback did not meet this threshold. Thus, many children did not derive significant benefit from this treatment even though the benefits averaged across all children were statistically significant.

This is not surprising as no treatment – including medication – will help everyone. However, the rate of non-responders is less than what is typically found in controlled studies of medication treatment and this is important to remain aware of.

Despite these limitations and concerns, my take on this study is that it represents an important addition to the research literature on neurofeedback treatment for ADHD. In the context of other positive findings that have been reported for neurofeedback, it provides additional basis for regarding this as an extremely promising treatment approach for some children with ADHD.

– Dr. David Rabiner is a child clinical psychologist and Director of Undergraduate Studies in the Department of Psychology and Neuroscience at Duke University. His research focuses on various issues related to ADHD, the impact of attention problems on academic achievement, and attention training. He also publishes Attention Research Update, a complimentary online newsletter that helps parents, professionals, and educators keep up with the latest research on ADHD.

Related articles by Dr. Rabiner

- Neurofeedback/ Quantitative EEG for ADHD diagnosis

- Promising Cognitive Training Studies for ADHD

- Mindfulness Meditation for Adults & Teens with ADHD

- How Strong is the Research Support for Neurofeedback in Attention Deficits?

- Self-Regulation and Barkley’s Theory of ADHD

This is a 2-part interview conducted via e-mail: we will publish the continuation on Thursday March 12th.

Alvaro Fernandez: New York Times columnist David Brooks said last year that we live in a Cognitive Age, and encouraged readers to be aware of this change and try and adapt to the new reality. Can you explain the cognitive demands of today’s workplaces that weren’t there 30-40 years ago?

Maggie Jackson: Our workplaces have changed enormously in recent decades, and it’s easy to point to the Blackberry or the laptop as the sources of our culture of speed and overload and distraction. But it’s important to note first that our 24/7, fragmented work culture has deeper roots. With the first high-tech inventions, such as the cinema, phonograph, telegraph, rail, and car, came radical changes in human experience of time and space. Distance was shattered – long before email and red-eye flights. Telegraph operators – not online daters – experienced the first virtual love affairs, as evidenced by the 1890s novel Wired Love. Now, we wrestle with the effects of changes seeded long ago.

Today, the cognitive and physical demands on workers are steep. Consider 24/7 living. At great cost to our health, we operate in a sleepless, hurried world, ignoring cues of sun and season, the Industrial Age inventions of the weekend and vacation, and the rhythms of biology. We try to break the fetters of time – and live like perpetual motion machines. That’s one reason why we feel overloaded and stressed – conditions that are corrosive to problem-solving and clear thinking.

At the same time, our technologies allow us access to millions of information bites – producing an abundance of data that is both wondrous and dangerous. Unless we have the will, discipline and frameworks for turning this information into wisdom, we remain stuck on the surface of the “knowledge economy.” Today, half of college students can’t judge the objectivity of a website, and just 30 percent of college graduates can read a document as simple as a food label proficiently. A third of workers say they are often so busy and interrupted that they don’t have time to reflect on the work they do. I worry that we are creating new forms of ignorance, based not on a lack of information but on a lack of will or ability to wrest knowledge from the oceans of information surrounding us. Google isn’t making us stupid. And yet, are we using Google wisely?

Finally, we have developed a highly fragmented workstyle, thanks in part to the enormous influence of Frederick W. Taylor. Taylor was an efficiency guru who taught workers to chop up tasks so that each part of a project could be made to go faster. His theories, according to management guru Peter Drucker, have influenced the world as much as those of Marx or Freud. Today, the average office worker switches tasks every three minutes all day long, and nearly half of such interruptions – both external and internal – are self-imposed. Such a workstyle is correlated with stress, frustration and even lower creativity.

In this new world, we can revel in our ability to move freely across the globe, connect with millions of others instantly and tap newfound sources of potential knowledge. Yet too often, our new ways of working undermine our powers of attention, a tripartite set of skills related to awareness or wakefulness; focus or the spotlight of the mind; and executive attention, a package of higher-order skills related to judgment and planning. Our split-focus, frenetic, diffused lives undermine our powers of attention, leaving us detached, unfocused and scattered.

Q – What may the role of spending hours per day in front of a TV?

A – Today, we are exposed to far more than television everyday. YouTube, movies, animated billboards, laptops, Muzak, iPods and other devices envelop us by choice and by default in streams of visual and aural distractions, information and ads. The average American child is exposed to nearly six hours of non-print media a day. So determining the specific impact of just one type of media is difficult in this new mediated world. Still, it’s certain that this environment shapes us, and molds our incredibly plastic brains, in ways we can only begin to fathom. According to work by Daniel Anderson at the University of Massachusetts/Amherst, toddlers exposed to “background television” – tv running in the background of family life – are more likely to show attention deficiencies. They play more briefly with toys, show less focus with their play, and interact less with parents.

As humans, we are born interrupt-driven. In order to survive, we need to focus on new stimuli in our environment and stay vigilant to changes around us. This is why we are prey to and delighted by quick-moving, enticing, complex media – at home and at work. In the office especially, if we’re constantly reacting to the new, new thing, we wind up doing nothing more than putting out fires and keeping our email inbox empty. We are less inclined to wrestle with the bigger, messy, problems of the day. Today, we must place ourselves back in the driver’s seat of our attention. We need to take charge of our environment and our attentional skills, and recapture time for reflection, deep problem-solving and creativity. As one top executive once told me, “thinking can’t be done in sound bites.”

Q – In your Harvard Management Update interview, you said that “When what we pay attention to is driven by the last email we received, the trivial and the crucial occupy the same plane.” As well, it seems to be that a problem is our culture’s over-idealization of “always on” and “road warrior” habits, which distract from the importance of executive functions such as paying attention to one’s environment, setting up goals and plans, executing on them, measuring results, and internalizing learning. How can companies better equip their employees for future success? Can you offer some examples of companies who have positive cultures that encourage and reward employees fully put their frontal lobes into good use?

A – As I mentioned above, we are working and living in ways that undermine our ability to strategize, focus, reflect, innovate. Skimming, multitasking and speed all have a place in 21st-century life. But we can’t let go of deeper skills of focus and thinking and relating, or we’ll create a society of misunderstanding and shallow thinking.

To create workplaces that foster strategic thinking, deep social connection and innovation, we need to take three steps:

First, question the values that venerate McThinking and undermine attention. Recently, my morning paper carried a front-page story about efforts “in an age of impatience” to create a quick-boot computer. “It’s ridiculous to ask people to wait a couple of minutes to start up their computer,” explained one tech executive. The first hand up in the classroom, the hyper business-man or –woman who can’t sit still, much less listen – these are icons of success in American society. Still, many of us are beginning to question our adoration of instant gratification and hyper-mobility.

To Be Continued…

Please remember: we will publish the continuation of this interview on Thursday March 12th. (yes, you can consider this a test of your executive functions and/ or your memory).

Book: Distracted: The Erosion of Attention and the Coming Dark Age.

Related articles and resources:

- The Overflowing Brain: Most Important Book of 2008

- Top 10 Brain Fitness Books

The study was led by Dr. Torkel Klingberg and his colleagues from the Karolinska Institute in Sweden. The goal was to learn whether Working Memory Training is associated with changes in brain biochemistry, thus suggesting a mechanism by which training may lead to enhanced working memory capacity and a reduction in attention problems. Thus, although Working Memory Training has previously shown promising results as a treatment for working memory and attention difficulties, this was a basic science study rather than a treatment study.

The major finding was that increased working memory capacity following training was associated with changes in brain biochemistry. Specifically, the researchers found changes in the density and binding potential of cortical D1 dopamine receptors in brain regions that are activated during working memory tasks.

Results from this study suggest a biological basis for the improvement in working memory capacity and reductions in attention problems that have been demonstrated in several randomized controlled trials of Working Memory Training. In addition to this possible treatment implication, this is the first demonstration that cognitive training modifies basic aspects of brain biochemistry at the level of receptor cells. Thus, it is an especially interesting basic science finding in that it shows that brain biochemistry can be modified by experience.

You can listen to an interview with Dr. Klingberg in which he lays out the findings from this study in a clear and accessible manner. The interview can be accessed Here.

You can also access the entire article online at Here (opens PDF).

Let me note that the article is quite technical and that I found listening to Dr. Klingberg’s interview before reading it to be quite helpful.

– Dr. David Rabiner is a child clinical psychologist and Director of Undergraduate Studies in the Department of Psychology and Neuroscience at Duke University. His research focuses on various issues related to ADHD, the impact of attention problems on academic achievement, and attention training. He also publishes Attention Research Update, a complimentary online newsletter that helps parents, professionals, and educators keep up with the latest research on ADHD.

Related articles:

- Article written by Torkel Klingberg on The Overflowing Brain & Information Overload

- His recent book, which was The SharpBrains Most Important Book of 2008: The Overflowing Brain: Information Overload and the Limits of Working Memory

- 2006 Interview with Dr. Klingberg: Working Memory Training and Cogmed: Interview with Dr. Torkel Klingberg