From the start, Tzippora Gold was a smart and loving little girl, with a strong independent streak and tons of energy. During infancy and toddlerhood, her family noticed nothing amiss. But when Tzippora entered preschool, she did not listen to the teacher or sit in a circle. “I had never in my life thought that a three-year-old could get sent to the principal's office,” recalls her mother, Sara Gold of New York City, a graphic designer. “But she was. I pulled her out in the middle of the year because they couldn't handle her. And this was supposed to be a top-of-the-line preschool.”
A few months later Gold began seeing flyers posted by psychologists at nearby Queens College. The researchers were seeking unusually distractible, talkative and active children for a study. Gold signed up Tzippora. She had just turned four.
Plenty of four- and five-year-olds zoom around and have trouble paying attention, but those who qualified for the Queens College study, like Tzippora, were at the extremes. These youngsters showed early signs of attention-deficit hyperactivity disorder (ADHD), a condition associated with a variety of challenges, including trouble with attention, impulsivity and poor school performance.
ADHD affects around 10 percent of children in the U.S., according to the Centers for Disease Control and Prevention. It is typically diagnosed at age seven or eight, when a child's inability to sit still and focus conflicts with the increasingly academic demands of elementary school. Pediatricians and psychiatrists often prescribe drugs such as Adderall and Ritalin, which can dramatically increase productivity and motivation. Yet the drugs have side effects, such as insomnia and loss of appetite, and many parents are uncomfortable medicating their children so they will do better in school.
The Queens College psychologists are exploring a different treatment paradigm. They hope that by addressing signs of ADHD early—before the disorder has even been diagnosed—it may be possible to change kids' brains so that they never get ADHD or, if they do, are less seriously afflicted. The treatment is a five-week series of games designed to strengthen focus, planning ability, memory and impulse control. It draws from growing evidence that the brains of very young children are furiously sprouting new connections, creating a window of opportunity for learning that slows after age five. Two such programs are in development in the U.S.: the one at Queens College and another at Cincinnati Children's Hospital Medical Center. A similar intervention, the New Forest Parenting Program, is already in use in the U.K. and attracting interest from psychologists and educators in Brazil, France, Hong Kong and Japan. “We're trying to capitalize on the fact that the brain is changing rapidly and forming and laying down those connections early on,” says psychologist Leanne Tamm, who is developing the Cincinnati early intervention program.
ADHD brain-training programs are deceptively simple, many of them involving variations on Simon says, I spy, Jenga and freeze dance. Parents and children learn them during weekly laboratory visits, but the real work happens at home, where everyone is expected to repeat the activities on a near-daily basis. (In the U.K. program, trainings also take place in families' homes.) The approach seems to work: recent results from small early trials were impressive enough that the National Institute of Mental Health is underwriting larger ones. “The idea of early intervention is building,” says Jeffrey M. Halperin, the psychologist leading the Queens College study. “The hope is that we can change the long-term trajectory of the disorder.”
ADHD runs in families, and evidence suggests a strong genetic component. “Very few, at this point, think that bad parenting or bad teachers cause ADHD,” Halperin says. “It really is a brain disorder. There is compelling evidence for that.” But about half of children with ADHD eventually outgrow it, although no one knows why. In a 2008 study Halperin and his colleagues tried to understand what differentiates individuals whose ADHD persists from those who get better. They tracked down 98 adolescents and young adults who had ADHD as children and gave them tests of verbal, reasoning and math skills, among other mental abilities.
To the researchers' surprise, they found that those who had recovered from ADHD and those who had not had many similar brain impairments. For example, both groups had trouble consistently focusing during 15 minutes of computer-based exercises. Yet those who overcame the disorder had developed especially strong higher-level thinking skills and mental control, abilities that seemed to compensate for their deficits. These skills reside in the prefrontal cortex, a brain area that because it continues to develop throughout childhood offers the potential for change.
That study inspired Halperin to create a preschool brain-training program. His thinking was that if for some children the natural course of brain development counteracts ADHD, exercises specifically designed to promote that growth might help people shed the symptoms—if not the underlying biology—of the disorder.
Five children watch while a young woman puts six plastic cups upside down on a table. Underneath each she places an M&M. “We are going to take turns lifting a cup,” she tells the children. “If you find a piece of candy, you may eat it.” And so begins a memory game called remember the treasure, in which candy rewards serve as motivation. Children must watch carefully as their peers make their moves, endeavoring to recall which cups have been lifted, so that when their turn comes they will choose a cup that still conceals an M&M.
The children are gathered in a cheerful blue room at Queens College decorated with decals of monkeys and vines, birds and leaves. As they become more adept, the game intensifies. The leader next instructs the children to save the M&Ms they find rather than eating them. Whenever they err by choosing an empty cup, they must forfeit one of their hoarded sweets, placing it under the cup.
Kids with ADHD often have trouble holding in mind several pieces of information, an ability known as working memory that is related to attention and is essential to effective reasoning, planning and problem solving. Games such as remember the treasure enhance working memory because children have to keep track of which cups have been lifted. Another working memory exercise is a list game, in which one person recounts several things, such as activities he did that day or places she has gone on vacation. Players then must name one of the things on the list or, as the game intensifies, repeat all of them in order or, harder still, backward.
Children with ADHD also struggle with impulsivity, so delaying gratification is built into some of the games. The instruction to save the M&Ms is one example. Another activity, used in the Cincinnati program, involves giving children a banana and asking them to notice as much as they can—what it smells like, whether the skin is smooth or rough, what shape it is—before eating it. The programs also use variations on games such as freeze dance and Simon says to help kids learn to abruptly terminate an activity or train of thought.
Picture puzzles such as the ones in Highlights magazine, where unexpected items are hidden in the background, help children hone their ability to concentrate and attend to details. In addition, because kids with ADHD can get wound up and have trouble regulating their emotions, some of the early intervention programs also include meditation and relaxation and sensory awareness exercises.
While the children play in the nature-themed room at Queens College, their parents are learning the same games in a conference room across the hall. Parents are expected to practice the games with their children daily, gradually increasing their complexity. “I describe it to the parents as: you go to the gym to build your muscles; you come here to build your kids' brains,” Halperin says. “If you lift five-pound weights forever, you're not going to get anywhere.”
Parents are encouraged to incorporate the activities into daily life. Memory games can be adapted to morning routines (“please go brush your teeth, then put on your shoes and get your backpack”). The British program employs a timer to teach children to take turns—patience is easier when kids know how long they must wait—and parents find the device also increases self-control at mealtimes. Setting the timer for a few seconds at first, and then for longer intervals, helps kids learn to wait for dessert. “We want to teach them to apply those skills in real-life contexts,” Tamm says.
In addition, the psychologists help parents better understand ADHD so they can tolerate their children's difficult behavior. Kids with ADHD may be intrusive and annoying. Their impulsivity may lead them to blurt out an inappropriate comment or to ask repeatedly for something they want, even if it involves interrupting or bothering someone. Their trouble paying attention and following rules may appear to be willful disobedience.
As a result, rifts often arise because repeated parental criticism creates poor self-esteem and defiance [see “Behave!” by Ingrid Wickelgren, on page 54]. Explaining to parents that their children's behavior is not intentional can help nip conflicts in the bud. “At this age, the negative cycles that so often develop between parents and their ADHD kids haven't really started yet,” says psychologist Edmund Sonuga-Barke of the University of Southampton in England, one of the developers of the New Forest program.
Early results from these interventions are promising. In 2012 Halperin's team published findings from a pilot study conducted with 29 four- and five-year-olds. The researchers asked parents and children to play the assigned games 30 to 45 minutes a day for five to eight weeks, introducing new games each week. Parental assessments of behaviors such as fidgeting, interrupting, not paying attention when spoken to, inappropriate running or climbing, and trouble taking turns improved significantly during the course of the study. Even more encouraging, parents and teachers reported that the gains persisted three months later.
A 2001 study by Sonuga-Barke's team in the U.K. was the first to demonstrate that parent-led, game-based interventions for preschoolers can improve ADHD symptoms. Halperin's recent study and one Tamm published in 2012 confirm that finding. Tamm's team determined that eight weeks of brain-building games with 24 youngsters led to measurable improvements in attention, working memory and the ability to mentally switch gears. Parents and teachers also reported fewer behavioral problems and less inattention in the children.
If early intervention continues to show promise, advocates envision that the programs could be widely implemented at preschools and community centers. The cost would be low because the materials are simple—balls, string, jump ropes, plastic cups—and facilitators need no special expertise. And the exercises would benefit all children.
“Last Year She Was That Kid”
Preschool brain-building programs are not yet available in the U.S. The two main ADHD treatments are behavior therapy and medication. A landmark 1999 study funded by the
But stimulants can cause significant quality-of-life issues. Nessie Sax-Bolder, a 20-year-old premed student at a university in upstate New York, was diagnosed with ADHD in middle school. By college she was taking larger doses to help her manage an increasingly heavy course load. With Adderall, then Vyvanse, schoolwork became pleasant, never dull. She was superefficient, organized, on top of her game. Despite—or perhaps because of—the drugs' ability to help her, Sax-Bolder wants to stop. The substances change her personality, she says, making her sharp-edged and tetchy. She also feels uncomfortable being so reliant on them. “I don't like how dependent I am,” she says.
Personality changes are a common side effect of stimulants, according to pediatrician Sanford Newmark, an ADHD specialist at the University of California, San Francisco. Although many children tolerate the drugs, others can become emotionally flat, angry, anxious or lose the ability to feel joy. One mother who saw a dramatic change in her young daughter when she discontinued her medication told Newmark it was as if the Adderall were a dam holding back her happiness.
Even when stimulants help, the effects are temporary. Medicated children are just as likely to have ADHD as adults, with all the attendant risk factors: lack of job satisfaction and stability, relationship woes, addiction. Meanwhile, in Europe, Asia and South America, where many health professionals disapprove of stimulant treatment, a nonpharmaceutical approach draws great interest. “All these countries are very keen,” says Sonuga-Barke, the Southampton researcher whose program is now being tested in Japan and Denmark.
Here in the U.S., Tzippora Gold is one of a very few children who have experienced the experimental play-based approach. One of the first changes her mother noticed after Tzippora began participating in the Queens College study was at bedtime. Every night at seven o'clock Sara Gold would put her daughter to bed after a calming routine of a warm bath and stories, but Tzippora would spend the next two hours bouncing, singing to herself or knocking on the window to get the attention of passersby. The early intervention program taught Tzippora how to focus on her breathing and relax her muscles. Soon she was falling asleep within 20 minutes.
When walking with her daughter, Sara began playing upbeat songs on her cell phone and practicing the freeze dance game. Eventually Tzippora began stopping when her mother called out, and Sara no longer feared she would dart into the street.
At her new preschool, Tzippora received occupational therapy and was assigned an aide who coached her on proper classroom behavior. Last fall, when Tzippora entered kindergarten, she no longer needed an aide. “She's a different kid in the classroom, like a new person,” her mother said. “There's a kid in her class she comes home telling me stories about, saying that he's a troublemaker and he doesn't listen. Last year she was that kid.”