DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY ORIGINAL ARTICLE

Computerized working memory training has positive long-term

effect in very low birthweight preschool children
KRISTINE HERMANSEN GRUNEWALDT 1,2 | JON SKRANES 1,3 | ANN-MARI BRUBAKK 1,2 | GRO C C LHAUGEN 1,3
1 Department of Laboratory Medicine, Childrens and Womens Health, Norwegian University of Science and Technology, Trondheim; 2 Department of Pediatrics,
St. Olav University Hospital, Trondheim; 3 Department of Pediatrics, Srlandet Hospital, Arendal, Norway.
Correspondence to Kristine Hermansen Grunewaldt at Department of Laboratory Medicine, Childrens and Womens Health, Norwegian University of Science and Technology,
7489 Trondheim, Norway. E-mail: kristine.grunewaldt@ntnu.no

This article is commented on by Wolke on pages 120121 of this issue.

PUBLICATION DATA AIM Working memory deficits are frequently found in children born preterm and have been
Accepted for publication 5th June 2015. linked to learning disabilities, and cognitive and behavioural problems. Our aim was to
Published online 3rd July 2015. evaluate if a computerized working memory training program has long-term positive effects
on memory, learning, and behaviour in very-low-birthweight (VLBW) children at age 5 to
ABBREVIATIONS 6 years.
CWMT Computerized working memory METHOD This prospective, intervention study included 20 VLBW preschool children in the
training intervention group and 17 age-matched, non-training VLBW children in the comparison
VABS Vineland Adaptive Behavior group. The intervention group trained with the Cogmed JM working memory training
Scales program daily for 5 weeks (25 training sessions). Extensive neuropsychological assessment
VLBW Very low birthweight and parental questionnaires were performed 4 weeks after intervention and at follow-up
7 months later. For most of the statistical analyses, general linear models were applied.
RESULTS At follow-up, higher scores and increased or equal performance gain were found in
the intervention group than the comparison group on memory for faces (p=0.012), narrative
memory (p=0.002), and spatial span (p=0.003). No group differences in performance gain
were found for attention and behaviour.
INTERPRETATION Computerized working memory training seems to have positive and
persisting effects on working memory, and visual and verbal learning, at 7-month follow-up
in VLBW preschool children. We speculate that such training is beneficial by improving the
ability to learn from the teaching at school and for further cognitive development.

Owing to improvements in pre- and postnatal treatment in
recent decades, the survival rate of children born preterm
has increased dramatically, especially for the most premature
children.1 Still, the risk of brain pathology and neuroimpair-
ments is high compared with peers born at term2,3 and even
in the preterm children without signs of severe brain injury,
follow-up studies report cognitive and behavioural deficits as
well as reduced attention and executive function.4,5
Working memory has been defined as our skill to hold
on to and manipulate information temporarily over a short
period and is considered a precondition for executive func-
tions like reasoning and planning.6 Impairment in working
memory, which is often reported in children born pre-
term,7,8 has been linked to learning disabilities with
academic consequences in childhood, during adolescence,
and into adulthood.8,9 In recent years several commer-
cially available computerized working memory training
(CWMT) programs have been developed to improve
working memory.10,11 In very-low-birthweight (VLBW)
preschool children, we have previously reported that a
CWMT program designed for preschool children
(Cogmed JM) had positive short-term effects on trained
and non-trained working memory tasks and a generalizing
effect on memory and learning.12 However, no study has
investigated whether such training has long-term positive
effects on higher-order cognitive functions in children
born preterm.
The aim of the present study was to investigate
whether CWMT has persisting positive effects on working
memory as well as transfer effects on verbal and visual
memory, attention, and behaviour in VLBW preschool chil-
dren at 7-month follow-up. To determine whether any gain
in performance observed during the follow-up period could
be explained as a natural part of the developmental process,
we included a comparison group consisting of age-matched
VLBW children who did not train, to compare performance
gains across groups. We hypothesized that the VLBW chil-
dren in the intervention group would have persisting higher
scores on neuropsychological tests at follow-up and show
similar performance gains on working memory tasks as well
as generalizing effects 7 months after completing training
than the children in the comparison group.

2015 Mac Keith Press DOI: 10.1111/dmcn.12841 195

METHOD
Inclusion criteria were children born preterm with VLBW
(<1500g) who were admitted to the Neonatal Intensive
Care Unit, St. Olav University Hospital, Norway, during
the years 2005 to 2007. Exclusion criteria were VLBW
children with known epilepsy, with severe cerebral palsy
who were not able to operate a computer, or with blind-
ness or congenital syndromes. Children living outside the
Trondheim region aged less than 5 years at the start of the
study were also excluded. The intervention group included
20 VLBW children born in 2005 to 2006,12 while the non-
training comparison group consisted of 17 age-matched
VLBW children born in 2007. Since all the participants in
the intervention study had trained in a stepped-wedge ran-
domized trial design,12 we had to introduce a different
comparison group using a matched control design for the
long-term evaluation. Neonatal data were retrieved from
the medical journals at St. Olav University Hospital. Medi-
cation status and any additional comorbidity in all children
were recorded at the first examination by the paediatrician.
The VLBW children in the intervention and comparison
groups were assessed with the same neuropsychological
tests and parental questionnaires at baseline and at follow-
up 7 months later. Baseline for the intervention group rep-
resented 4 weeks after completing training.
Intervention program
The Cogmed JM program is designed for preschool aged
children and is based solely on visualspatial stimuli
(www.cogmed.com). The children in the intervention
group trained 10 to 15 minutes a day, 5 days a week over
a 5-week period (25 sessions). Detailed information about
the CWMT program has been reported previously.12
Cognitive assessment
The children in both groups were assessed with the
Wechsler Preschool and Primary Scale of Intelligence, 3rd
edition,13 and Full-scale, Verbal, Performance, and pro-
cessing speed IQ indices were computed. In the interven-
tion group, this assessment was performed before they
started training whereas the control children were assessed
at baseline.
Outcome measures
Standard neuropsychological tests were performed at base-
line and at follow-up 7 months later to assess visual work-
ing memory (spatial span task from Wechsler Memory
Scale, 3rd edition)14 and verbal working memory (digit
span task from Wechsler Intelligence Scale for Children,
3rd edition).15 In addition, subtests from NEPSY (A
Developmental NEuroPSYchological Assessment 2nd edi-
tion)16 were performed to assess any long-term generaliz-
ing effects of training on attention, executive functions,
language, learning, and memory. At both time points,
parents completed standardized questionnaires assessing
attention-deficithyperactivity disorder (ADHD Rating
196 Developmental Medicine & Child Neurology 2016, 58: 195201
What this paper adds
Computerized working memory training (CWMT) in very low birthweight pre-
school children has long-term positive effects.
Improvements were found on working, visual, and verbal memory.
There was no performance gain after training on attention and behaviour.
CWMT might be valuable for children born preterm before starting school.
Scale-IV)17 and the Vineland Adaptive Behavior Scales,
2nd edition, English version (VABS)18 to measure the chil-
drens communication, daily living skills, socialization, and
problem behaviour.
Socio-economic status
Socio-economic status was calculated according to the
Hollingshead two-factor index of social position based on
mean educational levels and current employment of both
or single parents.19
Statistics
IBM SPSS Statistics, version 21 (IBM SPSS Statistics, Ar-
monk, NY, USA) was used for the statistical analyses. Nor-
mality assumption was performed for all variables before
analysis. For normally distributed variables, differences in
group means were analysed by Students t-test, whereas
variables that were not normally distributed were analysed
by MannWhitney U test. A general linear model with age
as covariate was used for between-group comparisons at
pre-intervention/baseline and at follow-up. The Wilcoxon
signed-rank test for two related samples was performed to
compare test results at the two time points within each
group. A general linear mixed model for repeated mea-
sures, with age at testing as covariate and group as fixed
factor, was performed to assess group differences in perfor-
mance gains during the follow-up period.20 Variables that
were not normally distributed were log transformed before
being entered into the general linear model and general
linear mixed model. However, neuropsychological test
scores are presented in the tables as raw scores (mean, SD)
for ease of interpretation. We corrected for multiple com-
parisons in all analyses with the HolmBonferroni step-
down procedure,21 reporting statistically significant results
as a two-tailed p value 0.02.
Ethics
The study was approved by the Regional Committee of
Medical Research Ethics (REK number 2011/532-7) and
registered at www.ClinicalTrials.gov (identifier NCTO151
8452). Written informed parental consent was obtained
and, based on the results of the clinical assessments,
VLBW children in need of specialized health care were
referred for further diagnostics and treatment.
RESULTS
Clinical characteristics and additional comorbidity of the
study population are described in Table I and Table SI
(online supporting information). All children were examined
at both time points and there were no dropouts at follow-up.
Table I: Perinatal risk factors, morbidity, and clinical characteristics of the study population

Intervention group (n=20) Comparison group (n=17) p value

Gestational age, wks; mean (SD) 28.8 (2.8) 29.6 (2.6) 0.388a
Birthweight, g; mean (SD) 1099 (311) 1147 (351) 0.666a
Male sex, n (%) 6 (30) 6 (35) 0.732c
Apgar 1min; mean (median, range) 7 (9, 8) 8 (9, 4) 0.062b
Apgar 5min; mean (median, range) 9 (9, 5) 9 (10, 3) 0.155b
Antenatal steroids, n (%) 17 (85) 15 (88) 0.774c
Surfactant, n (%) 9 (45) 10 (59) 0.402c
Mechanical ventilation, d; mean (median, range) 10 (0, 180) 8 (1, 45) 0.831b
Continuous positive airway pressure, d; mean (SD) 31 (31) 26 (20) 0.563a
Intraventricular haemorrhage 1, n (%) 3 (15) 1 (6) 0.373c
Intraventricular haemorrhage 2, n (%) 2 (10) 0 0.180c
Intraventricular haemorrhage 3, n (%) 0 1 (6) 0.272c
Periventricular leukomalacia, n (%) 0 0
Septicaemia, n (%) 2 (10) 3 (18) 0.498c
Patent ductus arteriosus, n (%) 4 (20) 6 (35) 0.297c
Surgery, n (%) 2 (10) 1 (6) 0.647c
Bronchopulmonary dysplasia/O2 at gestational age 36wks, n (%) 6 (30) 6 (35) 0.732c
Cerebral palsy, n (%) 2 (10) 1 (6) 0.647c
Full-scale IQ; mean (SD) 93 (8) 98 (14) 0.217a
Verbal IQ index; mean (SD) 96 (10) 91 (8) 0.133a
Performance IQ index; mean (SD) 94 (8) 93 (14) 0.919a
Processing speed IQ index; mean (SD) 101 (10) 104 (15) 0.367a
Socio-economic status; mean (SD) 3.8 (0.7) 3.8 (0.7) 0.921a
Age at baseline; mean (SD) 5.8 (0.49) 5.4 (0.29) 0.002a

Students t-test. bMannWhitney U test. cv2 test. Socio-economic status according to the Hollingshead two-factor index.
a

There were no significant group differences in clinical
characteristics, medication status, and additional comorbid-
ity, except that the VLBW children in the comparison
group were 4 months younger at baseline. All analyses
were therefore adjusted for age. The intervention group
had a mean Full-scale IQ of 93 (SD 8, range 80112),
whereas the comparison group had a mean Full-scale IQ
of 98 (SD 14, range 77126). There were no significant
group differences in any of the IQ indices (Table I).
Performance at 7-month follow-up
When analysing performance at 7-month follow-up, the
VLBW children in the intervention group had higher
scores than those in the comparison group on memory for

Table II: Performance at pre-intervention/baseline and at 7-month follow-up in the two study groups

Intervention group Comparison group Intervention group Comparison group

Pre-intervention Baseline GLM Follow-up Follow-up GLM
Mean (SD) Mean (SD) p value Mean (SD) Mean (SD) p value

Visual attention total time 234.0 (41.0) 250.4 (38.6) 0.758 207.3 (33.8) 231.9 (25.5) 0.255
Phonological processing 9.3 (5.5) 10.3 (1.9) 0.309 17.0 (5.4) 15.5 (4.0) 0.451
Auditory attention and response set 49.6 (28.8) 28.2 (30.4) 0.490 68.7 (28.2) 39.8 (23.7) 0.207
Comprehension of instructions 17.3 (2.8) 16.1 (2.9) 0.773 18.6 (2.5) 16.5 (2.6) 0.191
Memory for faces 20.0 (6.2) 18.5 (4.8) 0.338 27.5 (3.8) 21.1 (7.0) 0.023
Narrative memory 12.9 (4.9) 11.3 (5.3) 0.806 21.2 (3.8) 14.1 (6.3) <0.001
Statue 26.1 (5.4) 25.2 (3.0) 0.972 27.8 (3.0) 25.4 (6.7) 0.615
Repetition of nonsense words 28.9 (8.1) 31.9 (7.3) 0.019 37.8 (4.1) 35.5 (4.3) 0.258
Sentence repetition 15.7 (4.3) 17.8 (3.3) 0.002 18.6 (2.7) 18.9 (3.4) 0.357
Spatial span forwards 4.2 (1.6) 3.4 (1.3) 0.929 5.4 (1.0) 4.2 (1.3) 0.039
Spatial span backwards 2.3 (1.6) 1.7 (1.3) 0.649 4.6 (1.8) 2.1 (1.1) 0.001
Spatial span total score 6.4 (3.0) 5.0 (2.3) 0.840 10.0 (2.3) 6.2 (2.1) 0.015
Digit span forwards 5.5 (1.5) 4.7 (1.4) 0.382 6.3 (1.5) 5.1 (1.2) 0.049
Digit span backwards 1.3 (1.4) 1.1 (1.3) 0.410 2.5 (1.2) 1.6 (1.2) 0.442
ADHD inattention 6.5 (4.9) 5.8 (5.3) 0.209 6.0 (5.8) 4.6 (6.7) 0.281
ADHD hyperactivity 6.7 (4.8) 6.2 (5.3) 0.325 4.9 (4.9) 6.2 (7.3) 0.764
ADHD total score 13.2 (9.1) 11.9 (10.0) 0.236 10.8 (9.8) 10.8 (13.7) 0.676
VABS communication 43.3 (3.6) 41.9 (3.9) 0.507 46.7 (6.1) 44.7 (5.3) 0.579
VABS daily living skills 47.4 (6.3) 45.2 (3.8) 0.439 47.5 (7.6) 45.8 (5.2) 0.739
VABS socialization 50.7 (5.9) 48.1 (4.6) 0.418 53.8 (5.9) 49.7 (6.1) 0.125
VABS problem behaviour 32.2 (5.0) 33.4 (4.6) 0.957 30.9 (4.5) 32.1 (4.1) 0.973

GLM (general linear model) with age as covariate for between-group comparisons at pre-intervention/baseline and at follow-up. Not nor-
mally distributed variables were log transformed before being entered into the model. For ease of interpretation, raw scores are presented
in the table as mean (SD). Statistically significant results (in bold) at a two-tailed p value 0.02 (HolmBonferroni corrected for multiple
comparisons). ADHD, attention-deficithyperactivity disorder. VABS, Vineland Adaptive Behavior Scales.

Effect of Cognitive Training in VLBW Preschool Children Kristine Hermansen Grunewaldt et al. 197
Table III: Changes in neuropsychological test scores and parental questionnaires during follow-up from baseline to 7mo follow-up in the two study
groups

Intervention group (n=20) Comparison group (n=17)

Wilcoxon Wilcoxon
Baseline Follow-up signed-rank Baseline Follow-up signed- rank GLMM,
Mean (SD) Mean (SD) p value Mean (SD) Mean (SD) p value p value (PES)

Visual attention total time 212.6 (44.3) 207.3 (33.8) 0.573 250.4 (38.6) 231.9 (25.5) 0.059 0.077 (0.092)
Phonological processing 12.6 (4.7) 17.0 (5.4) 0.001 10.3 (1.9) 15.5 (4.0) 0.007 0.422 (0.019)
Auditory attention and response set 58.2 (30.4) 68.7 (28.2) 0.009 28.2 (30.4) 39.8 (23.7) 0.061 0.167 (0.055)
Comprehension of instructions 18.4 (2.8) 18.6 (2.5) 0.627 16.1 (2.9) 16.5 (2.6) 0.819 0.068 (0.095)
Memory for faces 24.9 (5.7) 27.5 (3.8) 0.006 18.5 (4.8) 21.1 (7.0) 0.088 0.012 (0.171)
Narrative memory 17.5 (5.9) 21.2 (3.8) 0.008 11.3 (5.3) 14.1 (6.3) 0.036 0.002 (0.240)
Statue 27.6 (2.6) 27.8 (3.0) 0.656 25.2 (3.0) 25.4 (6.7) 0.129 0.203 (0.047)
Repetition of nonsense words 34.5 (10.7) 37.8 (4.1) 0.210 31.9 (7.3) 35.5 (4.3) 0.010 0.972 (0.001)
Sentence repetition 17.7 (4.1) 18.6 (2.7) 0.177 17.8 (3.3) 18.9 (3.4) 0.043 0.186 (0.051)
Spatial span forwards 4.7 (2.3) 5.4 (1.0) 0.595 3.4 (1.3) 4.2 (1.3) 0.010 0.226 (0.043)
Spatial span backwards 3.5 (2.2) 4.6 (1.8) 0.073 1.7 (1.3) 2.1 (1.1) 0.191 0.003 (0.232)
Spatial span total score 8.3 (4.2) 10.0 (2.3) 0.151 5.0 (2.3) 6.2 (2.1) 0.015 0.025 (0.140)
Digit span forwards 5.5 (1.5) 6.3 (1.5) 0.009 4.7 (1.4) 5.1 (1.2) 0.266 0.052 (0.106)
Digit span backwards 1.7 (1.1) 2.5 (1.2) 0.007 1.1 (1.3) 1.6 (1.2) 0.145 0.471 (0.015)
ADHD rating scale
Inattention 5.8 (4.5) 6.0 (5.8) 0.972 5.8 (5.3) 4.6 (6.7) 0.107 0.171 (0.054)
Hyperactivity 5.2 (4.2) 4.9 (4.9) 0.659 6.2 (5.3) 6.2 (7.3) 0.411 0.759 (0.003)
Total score 11.0 (7.7) 10.8 (9.8) 0.812 11.9 (10.0) 10.8 (13.7) 0.213 0.292 (0.033)
Vineland Adaptive Behavior Scales
Communication 43.3 (3.6) 46.7 (6.1) 0.002 41.9 (3.9) 44.7 (5.3) 0.027 0.259 (0.036)
Daily living skills 47.4 (6.3) 47.5 (7.6) 0.968 45.2 (3.8) 45.8 (5.2) 0.736 0.293 (0.032)
Socialization 50.7 (5.9) 53.7 (5.9) 0.070 48.1 (4.6) 49.7 (6.1) 0.366 0.037 (0.119)
Problem behaviour 32.2 (5.0) 30.9 (4.5) 0.108 33.3 (4.6) 32.1 (4.1) 0.138 0.417 (0.019)

Within-group changes from baseline to follow-up were analysed with a Wilcoxon signed-rank test. For ease of interpretation, raw scores
are presented as means (SD). GLMM (a general linear mixed model) for repeated measures with age as covariate, p values, and partial eta
squared (PES) was used to compare performance gain in the intervention group with comparison group during follow-up. Differences that
were not normally distributed were log transformed before being entered into the GLMM. Statistically significant results at a two-tailed p
value 0.02 (HolmBonferroni correction for multiple comparisons). In the intervention group, baseline assessments were performed 4wks
after completed working memory training. ADHD, attention-deficithyperactivity disorder.

faces, narrative memory, spatial span backwards, and spatial
span total score corrected for age differences between
groups (Table II). At baseline the comparison group had
significantly higher scores than the intervention group pre-
intervention on the tasks of repetition of nonsense words
and sentence repetition. At 7-month follow-up, no signifi-
cant group differences in these tasks were found. Spatial
span forwards (p=0.039) and digit span forwards (p=0.049)
did not reach statistical significance when correcting for
multiple comparisons. None of these tests showed signifi-
cant group differences before intervention was started.
There were no group differences on attention and behavio-
ural measures at 7-month follow-up (Table II).
Performance in the intervention group before and after
training, and at 7-month follow-up
When analysing performance changes over three time
points in the intervention group separately (Table SII,
online supporting information), we found significant
improvement from before training to 4 weeks after train-
ing, with further significant improvement at 7-month fol-
low-up for phonological processing, auditory attention and
response set, memory for faces, and narrative memory.
Repetition of nonsense words, sentence repetition, and
spatial span backwards were significantly improved by
training, but did not change significantly at further follow-
up. For the VABS, only the socialization score was assessed
at three time points, showing a significant reduction right
after intervention, but no further reduction at follow-up.
VABS communication was significantly reduced at
follow-up.
Performance gain during the follow-up period in the two
study groups
Analysing changes in performance in the two groups sepa-
rately from baseline to 7-month follow-up, we found sig-
nificant performance gain in the intervention group on
phonological processing, auditory attention and response
set, memory for faces, narrative memory, digit span for-
wards and backwards, and VABS communication scale
(Table III). Significant improvement in the comparison
group during follow-up was found on phonological pro-
cessing (common with intervention group), repetition of
nonsense words, spatial span forwards, and total score.
When we compared the performance gain over the follow-
up period in the intervention and comparison groups, there
was a significant performance gain in the intervention
group for memory for faces, narrative memory, and spatial
span backwards (p<0.02). For spatial span total score
(p=0.025) and VABS socialization scale (p=0.037), the

198 Developmental Medicine & Child Neurology 2016, 58: 195201

 Memory for faces Narrative memory
30 25
28
26 20
24
22 15
20
18 10
16
Intervention group
14 5
Controls Intervention group
12
Controls
10 0
0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7

Spatial span backwards Spatial span total score

5,0 12
4,5
4,0 10
3,5 8
3,0
2,5 6
2,0
1,5 4
1,0 2
Intervention group Intervention group
0,5
0,0 Controls Controls
0
0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7

Figure 1: Neuropsychological tests with significantly better performance gains in the intervention group than the comparison group. The figures show
raw scores at two time points in the comparison group, and at three time points in the intervention group. The intervention group had higher scores at
follow-up and increased performance gain during follow-up than the comparison group.

performance gain showed a trend towards significance.
Figure 1 visualizes performance in the intervention group
over three time points and in the comparison group over
two time points for the tasks with the largest group differ-
ences.
DISCUSSION
The major gain in knowledge from the current study is
that computer-based adaptive working memory training
has long-term effects in improving cognitive functions in
children born preterm not restricted to working memory
tasks only. Our study showed beneficial effects on trained
and non-trained working memory tasks, and a generalizing
effect on verbal as well as visual learning and memory
functions.
Few studies have investigated the effect of working
memory training in preschool children, and this is the first
study, to our knowledge, assessing long-term training
effects in VLBW children born preterm. After completing
training, the VLBW intervention group had higher scores
and increased performance gains at follow-up on non-
trained visual working memory tasks, and on tests of visual
and verbal memory and learning, than the comparison
group, indicating a persisting effect of working memory
training on these tests.
A limitation of our initial report of this intervention
study was that it did not include any comparison group
that could participate in long-term follow-up. Our initial
stepped-wedge design, which was chosen for ethical rea-
sons, offered training to all participants. Consequently, for
our 7-month follow-up, we included a non-training com-
parison group of VLBW children aged 5 to 6 years with-
out major cerebral injuries through a matched control
design. By introducing such a comparison group, we
wanted to identify any performance gain due to typical
development over the follow-up period of 7 months. In
this way, greater performance gain in the intervention
group than in the comparison group would then be a per-
sisting effect of training. Strengths of the study were the
prospective cohort design, the extensive assessment battery,
and that all assessments were performed by one examiner,
who was blinded to group adherence. There were no drop-
outs or missing values during the follow-up period. A limi-
tation of the study was the small number of participants,
which reduced generalization of the results.
In our study we found better long-term improvement
on the non-trained visual working memory task spatial
span in the intervention group than the comparison group.
This is not very surprising since this task resembles those
in the training program, which are based solely on visuo-
spatial stimuli. However, the increased score at follow-up
and the performance gain during follow-up seen in the
intervention group seem to confirm a persisting positive
effect of working memory training with time.22 We specu-
late that the preschool intervention program used in this
study might induce a booster effect on visualspatial tasks

Effect of Cognitive Training in VLBW Preschool Children Kristine Hermansen Grunewaldt et al. 199
that persists with time and that could be beneficial when
these children start in school.
Working memory training has been reported to have
positive short-term effects on verbal working memory, with
larger benefits of training being shown in children below
the age of 10 years.23 In our study there was a significant
improvement in verbal working memory performance
(digit span task) during follow-up in the intervention group
(p=0.009), but not among the comparison group
(Table III). Since we did not find any immediate effects of
training on verbal working memory, we speculate that this
might be because the digit span task used may be too diffi-
cult for many of the preschool VLBW children, that the
performance gain at follow-up is caused by older age, and
that the children had possibly learned numbers during the
last months before starting school. Another explanation for
the limited performance gain on this task is that the pre-
school intervention program used in our study does not
contain any verbal working memory tasks, unlike similar
programs developed for school-aged children.
Higher scores at follow-up and even long-term perfor-
mance gain for the children in the intervention group were
also noted on tasks assessing visual (memory for faces) and
verbal (narrative memory) memory and learning. This may
indicate a transfer effect of working memory training to
general memory and learning that persists with time. Simi-
lar results were also found in our previous intervention
study using the school version of the same working mem-
ory program (Cogmed RM) in a group of extremely low
birthweight adolescents.22 In this study, the adolescents
improved significantly on trained and non-trained working
memory tasks, with transfer effects on the same visual and
verbal memory tests, which were maintained at the 6-
month follow-up examination. As visual and verbal mem-
ory tasks are similar to what is presented in childrens
school environments, such improvement after training in
preschool children might be positive for their scholastic
and academic achievement. The close link between work-
ing memory function and academic success gives reason to
expect that this kind of training might improve school out-
come for this group.
In our study, several tasks that had an immediate
improvement after training showed a similar improvement
gain as the comparison group at 7-month follow-up. For
these tests, the children in the intervention group seem to
have had a booster effect of the training program. Even if
the further development until the 7-month follow-up
seemed parallel in both groups, the intervention group had
continuously better skills on these tasks than the non-train-
ing comparison group, which is encouraging (Fig. 1).
In our study parents answered questionnaires about
the childs attention and activity level (ADHD Rating
Scale-IV) and daily living skills (VABS) at baseline and at
follow-up. Although several studies including school-aged
children with ADHD have shown significant reduction in
inattention and hyperactivity scores after CWMT,24,25 we
did not find any significant changes in ADHD in either of
200 Developmental Medicine & Child Neurology 2016, 58: 195201
the groups during follow-up. It is possible that this is due
to the shorter training time required by the current pre-
school intervention program, which may limit transfer
effects like attention gain. However, none of the participat-
ing VLBW children in our study had ADHD scores within
pathological areas before training, which might cause limi-
tations for improvement effects by training.
To measure any positive long-term effects of inter-
vention on personal and social skills needed for daily liv-
ing, we assessed the VABS in the participating children.
Our study revealed that VLBW children in both groups
had improvements on the VABS communication scale
during follow-up (Table III). We interpret this as typical
development due to increasing age and maturity. For the
VABS socialization scale there was a trend (p=0.037)
towards better performance gain in the intervention
group than the comparison group, indicating that the
working memory training might have had a positive
effect on the social skills in these VLBW children.
There is a growing body of literature supporting the
importance of parenting in children born preterm,26 and
we speculate that the interaction between the child and
parents during the intervention might have made the
children more confident and increased their social
emotional competence.
CLINICAL IMPLICATIONS
CWMT in VLBW preschool children seems to have both
short- and long-term positive effects on working memory,
visual and verbal memory, and learning. On several tests
the working memory training seemed to represent a boos-
ter effect, which was apparent in the first month after
training, followed by less but still positive performance
gain with time, resulting in higher scores at follow-up.
Based on this follow-up study, we recommend further and
larger studies to confirm whether such training should be
implemented and performed before starting school in chil-
dren born very preterm. More research is also needed to
define how such cognitive training should be given. It is
possible that repeated training at defined intervals or a
combination of a preschool and a school-aged working
memory program is optimal to provide the best perfor-
mance gains and to improve transfer effects on other cog-
nitive domains and behaviour.
A CK N O W L E D G E M E N T S
We thank the children and their parents for participating in the
study. It was their positive attitude to fulfilling the training and
participating in follow-up assessments that made this study possi-
ble. We also thank Cogmed/Pearson for the licensing contract for
the computer program, which included free use for all the partici-
pants in the research project. The study was funded by the Nor-
wegian University of Science and Technology and the Liaison
Committee between the Central Norway Regional Health
Authority and the University. The authors have stated that they
had no interests that might be perceived as posing a conflict or
bias.
SUPPORTING INFORMATION
The following additional material may be found online:
Table SI: Additional perinatal risk factors, medication status,
and comorbidities in the two study groups.
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