The Adventures of Fundi Intervention Based on the Cognitive and Emotional Processing in Attention Deficit Hyperactive Disorder Patients

Summary

This protocol illustrates a remedial therapy based on inductive learning and indirect communication (Ericksonian metaphorical hypnosis) that can be applied to children with Attention Deficit Hyperactive Disorder (ADHD). Particularly, this protocol is intended to test the effectiveness of a go/no-go decision task. Neuroscientific rationale is presented throughout the text.

Abstract

Many children with attention deficit hyperactive disorder (ADHD) are known to have executive dysfunction, which weakens their abilities to learn and behave in daily living. This protocol describes the methodology that is required for the intervention (psychotherapy) based on planning, attention, successive, and simultaneous (PASS theory) cognitive processing and fear emotional processing. It provides guiding principles and practical recommendations. A disproportionately high level of fear (dysregulation) increases the vulnerability for dysfunction in learning and behavior. We explain the interplay between emotion and cognition at the neurological level.

A go/no go task (The Adventures of Fundi), which involves decision making, is administered in a PC- mode to a sample of 66 ADHD subjects. The Adventures of Fundi, a computer program, was constructed to induce successive or simultaneous processing when involving the training of planning and selective attention. It aims to improve the executive function with planning and selective attention. If executive function improves, learning improves, and behavior ameliorates. After intervention over 6 months, remission was achieved in 70% of subjects.

The instructor encourages the use of appropriate strategies and points out the ways in which the strategies can be useful in finding the solution to the problem (go/no go). The emphasis is not on rehearsing and adult instructed verbal sequence. The verbalization may reveal the conscious verbalized strategy to solve a task that is not really the strategy being unconsciously used in that case. A self-verbal report is unreliable. This is an inductive learning rather than deductive rule-learning approach central to cognitive PASS training. This inductive training has proved to produce not only near transfer but also far transfer.

Noncognitive factors (emotional factors) must be considered to maximize the benefit of cognitive training. Indirect and metaphorical communication considers the emotional factor.

Introduction

Decision making is linked to the behavior and most behaviors implies decision-making. Decision making, and, also learning, involves both cognitive and emotional processing. The cognitive processing can be conceptualized and assessed according to the planning, attention, successive and simultaneous (PASS) theory of intelligence^{1,2,3,4,5,6,7,8,9}. According to PASS, any behavior is the output of neurological central information processing¹⁰. Therefore, paying attention must be considered a behavior that is independent of the central processing of information^{1,2,3,7,8,9,10,11,12}. One may not pay attention (observable behavior), but the central attention processing may be working on something different. On the other hand, the emotional processing includes the fear processing responsible for self-confidence (self-esteem) or lack of confidence^13,14,15. The fear processing is the underlying undifferentiated autonomic physiological basis of all emotions. Like most emotions (or “affects” or “moods”), fear begins in the amygdala, an almond-shaped structure responsible for detecting threats to our well-being.

Both the cognitive and the emotional processing can happen consciously or more often unconsciously, which is a crucial point to substantiate the diagnosis and intervention of ADHD behavior or any other behavior. Growing and converging neuroscientific evidence indicates that not only unconscious-involuntary processing^{16,17,18,19,20,21} but also anticipatory unconscious processing^{22,23,24,25,26,27,28,29,30,31,32,33,34,35} are true in decision-making. Particularly, a new study on the neuroscience of the interpersonal unconscious (implicit) subliminal communication is evidence of this³⁶.

Decision-making is based on the self-confident feeling associated with what it is cognitively processed, implicitly more frequently than explicitly^{37,38,39,40,41}. The self-confidence is associated with self-concept (beliefs of the knowledge base), but we claim that decision-making is based on what one feels consciously and unconsciously, but not on deliberate rational calculation of consequences³⁸. In fact, the rational arguments that people express (verbal report) to explain behavior and decision-making are a posteriori phenomenon and a cognitive bias^42,43 triggered by the fear processing. First, reaction to feeling occurs, and then an explanation is unconsciously implemented as a posteriori phenomenon. A self-verbal report is questionable. Cognition/emotion research is plagued by problems in which it is not clear what is the emotion response. This is the path to understand the emotional fear response. Therefore, decision making, self-confidence and behavior are closely linked.

From the viewpoint of therapeutic intervention, how exactly should the intervention be carried out? What should be the common and essential properties of the procedure of intervention, mediation, or teaching? Considering the previously expressed procedures, inductive learning² and indirect communications (metaphor and Ericksonian hypnosis)^14,44 are recommended. Growing and converging evidence from neuroscientific investigations^{45,46,47,48,49,50,51,52,53} shows some neurological mechanisms of the indirect communication.

Concerning inductive learning, the emphasis is on the child’s solution to the task, not on rehearsing an adult instructed verbal procedure. It aims at enhancing the processing strategies that underlie the task, while avoiding direct teaching of skills. Successful inductive learning is an experience that provides a growth of the self-concept of personal abilities, and so a growth of self-confidence. In contrast, direct teaching involving more-of-the-same kind of work turns off the interest and motivation. The distinctive feature here is the tacit acquisition and use of appropriate processing strategies in contrast to instruction learning; this is the inductive rather than the deductive rule-learning approach. The child must see the insufficiency in the old approach or strategy and the need for developing a new strategy.

Here, we have shown the foundation (rationale) of the technique Fundi's Adventures as a tool of remedial therapy to apply it in the clinical setting. There are no published previous studies with this program Fundi's Adventure. The main advantage of this procedure is that it is not based on the self-verbal report. In contrast, countless alternative techniques are based on deductive learning, direct communication and literal interpretation of the self-verbal report.

In the example presented in this manuscript, Fundi’s Adventure intervention was performed in Attention Deficit Hyperactive Disorder (ADHD) patients. ADHD is a behavioral dysfunction in terms of inattentive, hyperactive, and impulsive behavior, which involves a dysfunctional decision making¹². Any behavior implies decision making. ADHD is likely caused by a combination of genetics and earlier experience. The overall goal of this protocol is to test the hypothesis about the effectiveness of a go/no-go decision task (Fundi's Adventures) based on both inductive learning and indirect communication in a sample of ADHD children. It has been reported that the basic neuropsychological constructs of the go/no-go task are preserved in the emotional investigation⁵⁴.

Protocol

The protocol follows the guidelines of Fundació Carme Vidal human research ethics committee. Inform consent was obtained.

1. Recruitment of the subjects

NOTE: Recruitment was performed as per the previously published literature¹².  

1. Recruit children with ADHD without comorbidity. In the present study, 66 children, aged 13-15 years, mean 13.89 years with SD ± 0.8, 47 males and 19 females, were recruited. Have trained psychotherapists (qualified in psychology) or psychiatrists perform the procedure of recruitment.
2. Get informed consent from the patient or the caregivers.
3. Practice a discerning clinical history. As needed, perform the following studies: cardiological examination, both auditory and visual event-related potential, thyroid study, sonography, video-EEG, otorrinolaringology exploration, ophthalmological exploration, rule out both previous medication and comorbidity, as well as, any child psychiatric disorders or any other therapy in progress. Use any registered personal medical history available.
4. Ask a pediatric neurologist to confirm the diagnosis using DSM-IV⁵⁵ or DSM-V⁵⁶. Ask a psychiatrist to rule out comorbidity.
5. Complement the diagnosis using another useful criterion like parent and teacher rated Swanson, Nolan, and Pelham scale 18 (SNAP-IV-18) for ADHD symptoms (Swanson, 1995)⁵⁷ as used in this protocol.
   1. Use the narrow band behavioral scale, like SNAP-IV, which is more specific for the diagnosis of ADHD and often correlates with the definition in DSM-V. In this study, all children met the criteria for ADHD combined type at baseline. All 66 children scored ≥ 2.5/1.8 (teacher/parents) in SNAP-IV.
      NOTE: SNAP-IV consists of 18 items and can be filled in by parents and teachers. The items are questions about the occurrence frequency of a series of behavioral characteristics. The answers range from zero (no or not at all), 1 (yes, a little), 2 (yes, quite a lot) to 3 (yes, a lot). A total score can be obtained by adding the values of all the items and dividing by 18. The cutoff point is different according to the response of the parents (1.78) or the teacher (2.56).
6. Perform an unstructured interview of parents and teachers focused on collecting (confirming) data on behavior as mentioned in the SNAP-IV in to have sufficient information to make the diagnosis.
   1. Use the unstructured interview that is more informal and open-ended. There is a high probability that they will give 100% truthful answers. In the present study, each case was assessed by two blinded researchers and inter-observer agreement of 80% was required. The ADHD diagnostic interview was completed face-to-face with the child’s principal caregiver by trained research interviewers.
7. Use inclusion criteria: combined ADHD according to DSM-IV⁵⁵or DSM-V⁵⁶ and SNAP-IV-18 or similar one. Also, use the following exclusion criteria: any child psychiatric disorders or any previous medication or any other therapy.

2. Procedure

1. Cognitive assessment
   NOTE: This was done by administering CAS test⁴ which was performed as per the previously published literature¹².
   1. Measure the cognitive function of participants by applying the Cognitive Assessment System (CAS).
   2. Use a battery like CAS that assesses PASS processing of information: planning, attention, successive and simultaneous.
   3. Record the raw score for each test to be transformed into a standard score according to manual instructions.
      NOTE: For the four PASS processing, a standard score with a normative mean of 100 was used with a standard deviation (SD) of 15. For three subtests in each of the four scales, the mean is 10 and the SD is 3.
   4. Repeat this assessment using again the CAS battery at month 6 after the application of the program “The Adventures of Fundi”.
   5. Compare the results between the score of each cognitive process at baseline and the 6-month follow-up scores.
      NOTE: The 6-month follow-up, without pharmacological intervention, allows ruling out the potential “practice effect” of two closely spaced psychological tests.
2. Behavioral assessment
   NOTE: This was performed by administering the SNAP-IV-18
   1. Administer the SNAP-IV questionnaire (Swanson, 1995)⁵⁷ at baseline, that is, values against which all performances will be compared. After intervention. Record the remission versus the response in each case. Calculate the percentages of remissions and responses in the entire sample.
      NOTE: Remission is defined as a mean total score of 1 on most standardized questionnaires. On the contrary, the response has been usually defined as amelioration in symptoms of at least 25% with disappearance of the malfunctioning DSM-V criteria. Therefore, remission is associated with a loss of diagnostic status and optimal functioning. Remission is optimal, but the response not so much.
   2. Put into practice a regular follow-up communication with the child’s caregiver (parents and teachers) to review the caregiver concerns, evaluate progress, and provide advice and support (e.g., monthly telephone calls).
3. The Adventures of Fundi - Go/No go task
   1. Show to the participant five short videos on how the brain learns before starting the game of “The Adventures of Fundi”. These videos are named “Fundi and the Brain”. In these supplementary videos, the four cognitive processes described by the PASS theory (planning, attention, simultaneous and successive) are explained through a metaphor.
      NOTE: Remember, the indirect metaphorical communication implies inductive learning and indirect communication that makes remediation less painful or more enjoyable. A knowledge is being communicated considering the emotional impact.
   2. Explain the objective of the game of cognitive intervention "The Adventures of Fundi" to the participant: “It seeks to train the brain to facilitate academic learning. Above all, it pursues the self-regulation of the student supported by the PASS cognitive process of planning.”
   3. Have the participant enter the page: http://www.fcarmevidal.com/aventures/ and click on the language to work with.
   4. Provide them with a username and a password so that the participant can start the session (e.g., login: jove / password: jove).
   5. Click on the first country (1-Paris).
   6. Read the screen and click the Continuar button. Perform this step in the same way for each of the nine screens.
   7. Ask the child to solve the proposed task. The first task involves clicking on the boy’s face every time it appears on the screen.
   8. Read the screen results and click Continuar.
   9. Ensure that the game provides a code that the child must remember to input in the next screen. Start the game again from the beginning if he/she does not remember the code.
   10. Repeat step 2.3.4 but with the next country.
   11. End the session after about 40 min.
   12. Inform the child that he will have to figure out a way to remember the code and the country in which the session ended to continue the next day.
   13. Perform one session every week for six months.
   14. Intervene making use of indirect communication. If during the session, the participant makes a mistake, the game itself will indicate that he/she must repeat the task. The most important thing is that in the second attempt, the participant solves the task correctly. One example is presented below.
       1. If the child makes a mistake, and he does not solve a task, say: “Oh! what’s happened? Do you know?” Let the child answer if he does.
       2. Then continue, “I think we were tricked. This happens. Maybe our hand went quicker than our brain.” Observe the child’s body language.
       3. If the child nods, suggest to them to try again but using a stop signal. This signal can be visually presented or can be presented as a clue (e.g., lifting the palm of his hand).
          NOTE: Techniques used in indirect communication include metaphors, introductory phrases, saturation of channels of information, indirect questions, hypothetical phrases, ambiguous terms, silence, dissociation, paradox, false alternative options, melodramatic expression or confusion, prescription of the symptom, and post-trance amnesia.
   15. If the therapist observes the child repeats the error and he/she is blocked, use some metaphor (Ericksonian hypnosis) to change the belief that is blocking the participant. An example is presented below.
       1. If the blocking belief is “I am not able to do this task”, use a pacing prescription like: “Maybe, at this moment, we feel bad because we know we have failed but look, I am going to explain to you a very interesting story, do you agree?”
       2. If the child nods, narrate a story to motivate them. Now, ask them to repeat the task.
   16. Intervene through indirect communication if the child solves the task using a strategy that is inappropriate and they do not modify it without help. If the metaphor can allow the participant to see other alternatives or other strategies, allow them to solve the task successfully.
   17. Use inductive learning and indirect communication throughout the procedure. The effect of the procedure lies in communicating knowledge (messages) without transmitting pain or discomfort, whether consciously or unconsciously. This requires interpreting body language and verbal language as a transmitter of feeling. Self-verbal report is unreliable. This experience increases self-confidence.
       NOTE: Both indirect communication (what it is) and its rationale are explained in the discussion section.

Results

A random, prospective, longitudinal, uncontrolled, analytical study (before – after) was designed. We recruited 66 pharmacologically untreated combined ADHD children according to DSM-V criteria, aged 13-15 years with a mean of 13.89 years with SD ± 0.8 (47 males and 19 females). They also met ADHD criteria according to SNAP-IV-18. Statistical analysis was conducted using a paired Student t-test and effect size statistics (Cohen’s δ) was applied.

All 66 children in the stu...

Discussion

As expected, the training, Adventures of Fundi, was useful to intervene in ADHD behavioral dysfunction based on both the PASS cognitive processing and self-confidence emotional processing. The success is in terms of better cognitive processing and better behavior. The better cognitive processing is mainly in planning and not so much in attention (Table 1). PASS planning and selective attention join the executive function. It is well known that a better executive function is associated with a better behav...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
The Adventures of Fundi	Fundació Carme Vidal Xifre de Neuropsicopedagogia	---	The "Adventures of Fundi" has been designed with the objective of helping to improve the concentration, attention and control of impulsivity for Secondary Education students and it is also possible to apply it to Students in the last cycle of Primary Education. To execute the "Adventures of Fundi" a browser with internet conection is required.
Computer with internet connection and browser	---	---	Mozilla, Firefox, Chrome or Safari