Running head: JOURNAL ARTICLE REVIEW

Journal Article Review: A Randomized Trial of Two Promising Computer-Based Interventions for Students with Attention Difficulties Jo Friesen University of Calgary

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In this article, Rabiner et al., (2009) investigate the effect of attentional training on classroom behavior and academic achievement. The foundation of the study was twofold. First, 16% of children (including the 3-10% who have Attention-Deficit/Hyperactivity Disorder (ADHD)) have attentional difficulties which significantly impact their classroom performance (Rabiner et al., 2009). These children are at a higher risk for reading difficulties, grade retention, special education placement and school drop-out, thereby demonstrating the need to offer interventions (Mayer et al., 2009; Rabiner et al., 2009). Second, existing empirically-based interventions mainly consist of either behavioral modification or mediation (Rabiner et al., 2009). While both types of these interventions have demonstrated efficacy and effectiveness when used with children with ADHD, they also have limitations, including parental unwillingness to medicate and the lack of availability of behavioral interventions due to the cost, intensity and training needed for effective implementation (Rabiner et al., 2009). Project CLASS, as the authors dubbed their randomized-controlled trial, was designed to investigate the impact that attentional training (computerized attention training (CAT) or computer-assisted instruction (CAI)) might have on childrens classroom attention, daily academic performance, and academic achievement (Rabiner et al., 2009). The dependent variables for this study were classroom behavior, primarily attention, and academic achievement. The authors operationalized these variables by using a number of assessment measures, including the Conners Teacher Ratings Scale-Revised (CTRS-R:L), the Woodcock Johnson III, Test of Achievement (WJ-III), the Dynamic Indicators of Basic Early Literacy Skills (DIBELS) and the Academic Performance Rating Scale (APRS). These assessment tools were used to assess the childs behavior and academic performance before the training began (T1), as soon as the 6-month training ended (T2) and 6 months following the end of training (T3). The Kaufman Brief Intelligence Test, Second Edition (KBIT-2) was used at T1 to estimate intellectual ability. The study focused on 77 first grade students, chosen from five public schools in the southeastern US. All participants had first been identified by their teacher has having attentional difficulties. Of the 136 initially identified, 33 did not receive consent to participate and 26 students were excluded due to either a lack of English language proficiency or having an IQ lower than 70. Of the 77 students in the trial, 16% had an existing ADHD diagnosis and 7% were currently on ADHD medication. Twenty-one percent of the students had repeated first grade, 69% were male and 67% qualified for the lunch subsidies. Other demographics (including race/ethnicity and family make-up) showed that this group was representative of the overall school populations (Rabiner et al., 2009). While careful measures were taken to select participants, it must be noted that no information is provided as to whether the children who did not receive consent were qualitatively different than those who did participate. This, along with the limited sample size, is important to consider when attempting to generalize results. The 77 children were randomly assigned within each school to one of three treatment groups. The Waitlist Control Group (WCG; n=25) were told they would have the opportunity for their children to be involved in the training program of their choice the next year. The CAT group (n=25) and the CAI group (n=27) participated in training for 75 minutes sessions two afternoons per week for 14 weeks, with at least 50-60 minutes dedicated to computer activities. These sessions were conducted in groups of 4-6 students and included both an individual and group incentive program. Average participation was 82% of sessions, with 5 students attending less than two-thirds of the session. Treatment integrity was monitored bi-weekly to ensure the staff was adhering to research protocol (Rabiner et al., 2009).

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The CAT group used a program called Captains Log (Braintrain), which includes a variety of cognitive training activities. Participants began at the easiest levels, which lasted three minutes. They received immediate feedback, and certain criterion (response time, correct/incorrect responses) was required to move to the next level. Each successive level increased in difficulty and lasted an additional minute. If the child did not pass a level, they discussed their performance with a research assistant before trying again. The CAI group used a program called Destination Reading and Math (Riverdeep), which has content closely matching curriculum. Students were allowed to work at their own pace and the activities were presented in small chunks which were repeated until the child had mastered the lesson. The program provided immediate feedback and featured unit tests which the child had to pass before moving to the next level. To determine the intervention effects, the researchers chose to compare groups based on the % of children in each particular group who showed a significant change, versus using group means. This allowed for the researchers to better determine how many children benefited from the interventions, a factor they believed was important in taking the intervention beyond efficacy and into effectiveness (Rabiner et al., 2009). Overall, the results showed that, on the CTRS-R:L measure of Inattention, 56% of CAI participants, and 44% of CAT participants demonstrated a statistically significant decrease in inattention between T1 and T2, compared with only 16% of the WCG. A significant difference was also found on the APRS Impulse Control Scale (WCG: 08%; CAT: 28%; CAI: 41%). On measures of academic achievement between T1 and T2, no significant effects were seen between groups when comparing WJ-III results, but there were significant effects found when comparing the DIBELS results, where 67% in the CAI group showed significant improvement (WCG: 40%; CAT: 44%). Therefore, while both the CAI and the CAT group showed significant intervention effects related to attention and impulse control, only the CAI group showed any significant intervention effects related to academic achievement. Strengths of this study include the research methodology, the ease of implementation in schools, the used of standardized rating scales with good validity and reliability, treatment integrity checks and positive short-term results of the children who received training. One of the limitations of this study was the number of differences (content, timing, nature of feedback, requirements for success) between the two program, making it difficult to determine what exactly was accounting for different results. A second limitation was the use of the incentive program. While the researchers felt it was necessary in order to keep the children motivated to participate, its inclusion introduces a significant confound, as the WCG did not have the opportunity to participate in a similar program. The researchers cannot be certain if it is the training, or the incentive program (or both) that accounted for the results. In moving forward with this area of research, the authors duly note that the modest effect of these results, coupled with the lack of long-term results (effects seen at T2 were not seen at T3 as the WCG had caught up with the other two groups) mean that additional research into both the general area of attentional training, and the specific use of computer based training is needed (Rabiner et al., 2009). However, the effects that were seen are promising and offer opportunities for expanding the field of research for effective ADHD interventions. Practically, these results offer good potential alternatives for school-based interventions; however, factors such as cost, which specific programs are effective, what input the school should have into the process and how computer based attention training could be used with other interventions still need to be considered. Overall, this research study offers good initial insight for schools and teachers as to potential intervention alternatives for children with ADHD and other attentional difficulties.

JOURNAL ARTICLE REVIEW References Mayer, J.M., Van Acker, R., Lochman, J.E., & Gresham, F.M. (Eds) (2009) Cognitive-behavioral interventions for emotional and behavioral disorders: School-based practice. NY: Guilford Press. Rabiner, D.L., Murray, D.W., Skinner, A.T., Malone, P.S. (2009). A randomized trial of two promising computer-based interventions for students with attention difficulties. Journal of Abnormal Child Psychology, 38, 131-142. doi: 10.1007/s10802-009-9353-x