Journal Pre-proof

Cognitive rehabilitation in children with attention deficit- hyperactivity

disorder: Transferability to untrained cognitive domains and behavior

Vahid Nejati

PII: S1876-2018(20)30057-5
DOI: https://doi.org/10.1016/j.ajp.2020.101949
Reference: AJP 101949

To appear in: Asian Journal of Psychiatry

Received Date: 12 November 2019

Revised Date: 29 December 2019
Accepted Date: 9 February 2020

Please cite this article as: Nejati V, Cognitive rehabilitation in children with attention deficit-
hyperactivity disorder: Transferability to untrained cognitive domains and behavior, Asian
Journal of Psychiatry (2020), doi: https://doi.org/10.1016/j.ajp.2020.101949

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Cognitive rehabilitation in children with attention deficit- hyperactivity disorder:
Transferability to untrained cognitive domains and behavior

Running title: Transferability of cognitive rehabilitation in ADHD

Vahid Nejati
Department of Psychology, Shahid Beheshti University, Tehran, Iran

Corresponding author: Vahid Nejati, Shahid Beheshti University, Velenjak, Tehran, Iran
nejati@sbu.ac.ir, telefax: 982122207601, PO. Box:1983969411

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Highlights
 Cognitive rehabilitation of attention and memory in ADHD can improve some

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untrained cognitive functions such as inhibitory control, risky decision making, and
delay discounting.

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 Cognitive rehabilitation ameliorates the symptoms of ADHD.
 Cognitive rehabilitation can transfer horizontally to other cognitive domains in the
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same level and vertically to behaviors in a top down manner.

Abstract:
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Transferability of cognitive rehabilitation is a crucial point for efficacy. The purpose of the present
study is to determine the transfer effect of cognitive rehabilitation to the untrained cognitive
domains and behavior in children with attention deficit- hyperactivity disorder (ADHD). Thirty
children with ADHD randomly allocated into two intervention and control groups. The intervention
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group received cognitive rehabilitation in 12 to 15 sessions. Analyses indicated that the experimental
group shows an improvement in the trained domain. The result found a lack of near transfer to
selective attention and inhibitory control with a successful far transfer effect to the risky decision
making and delay discounting. Furthermore, the transfer occurred to behavioral symptoms of the
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intervention group. Attention and working memory training decrease delay discounting and delay
discounting. The near transfer is not a prerequisite of far transfer. Cognitive rehabilitation can
transfer horizontally to other cognitive domains at the same level and vertically to behaviors in a
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top-down manner.

Keywords: Cognitive rehabilitation, transferability, ADHD

1- Introduction

Attention deficit- hyperactivity disorder (ADHD), characterized by three core symptoms including
inattentiveness, hyperactivity, and impulsivity (Association, 2013). These main behavioral symptoms
are closely related to cognitive impairments such as inhibitory control (Liotti, Pliszka, Perez,
Kothmann, & Woldorff, 2005), reward processing (Ströhle et al., 2008), time perception (Yang et al.,
2007), cognitive flexibility (Cubillo et al., 2010), working memory (Martinussen, Hayden, Hogg-
Johnson, & Tannock, 2005), selective attention (Landau, Lorch, & Milich, 1992), shifting attention
(Piek, Dyck, Francis, & Conwell, 2007), and divided attention (Carlson, Pelham, Swanson, &
Wagner, 1991). The importance of impaired cognitive domains varies greatly from one function to
the other. Some of these cognitive impairments such as attention and working memory are primary
that leads to secondary impairments. Furthermore, these cognitive impairments underpin the
behavioral symptoms of ADHD. Particularly, the inability to perform a long- time task without

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distraction, as the behavioral symptoms of ADHD, stems in impaired sustained attention. The
sustained attention per se is a cornerstone for other types of attention (Seidel & Joschko, 1990; M.

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M. Sohlberg & Mateer, 2000). Moreover, attention could be considered as the base of all executive
functions. For example, inhibitory control as the ability to inhibit dominant or prepotent responses

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stems in selective attention (Booth et al., 2003).
Similarly, working memory impairment mediates some abnormal behaviors in individuals with
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ADHD. Working memory functioning and components determine how well other higher cognitive
functions are performed (V. Nejati, Salehinejad, & Sabayee, 2018). Particularly, some domains of
cognitive functions such as inhibitory control and updating embedded in working memory (Miyake
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et al., 2000) and some others such as cognitive flexibility (Blackwell, Cepeda, & Munakata, 2009),
impulsivity (Mei, Tian, Xue, & Li, 2017; Panwar et al., 2014; Patros et al., 2015; Wesley & Bickel,
2014), time perception(Wesley & Bickel, 2014), and reward processing (Hammer et al., 2015; Li et
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al., 2016) require working memory to perform. Due to the importance of these functions (e.g.,
inhibitory control and working memory), they have been often targeted in studies aimed for
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improving symptoms/deficits in ADHD (Salehinejad, Wischnewski, Nejati, Vicario, & Nitsche,

2019).
1.1. Cognitive rehabilitation in ADHD
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Cognitive rehabilitation is amplification or strengthening of cognitive processing through

progressive cognitive tasks and/ or environmental modifications (Farah et al., 2004). Respect to the
cognitive impairment in ADHD, cognitive rehabilitation tries to improve impaired cognitive
functions and ameliorates the behavioral symptoms. The well- established connections between
behavioral symptoms and respected cognitive impairments (V. Nejati, Salehinejad, Nitsche, Najian,
& Javadi, 2017) make ADHD a potential candidate for cognitive rehabilitation. Furthermore, the
central role of attention and working memory (Willcutt, Doyle, Nigg, Faraone, & Pennington, 2005)
make them the primary target of numerous cognitive rehabilitation programs. Functionally, the
ultimate goal of cognitive rehabilitation is transferability of improvement into the untrained domains
and daily activity. The assumption is the improvement in attention and working memory through
cognitive rehabilitation would transfer to other cognitive functions (M. Sohlberg & Mateer, 2001).
1.2. Transferability in cognitive rehabilitation and reconceptualization:
Transferability is the contagion of training effect from one trained domain to other non- trained
domain(s). One serious criticism to cognitive rehabilitation is the lack of transfer of gain from lab to

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life. Indeed, some studies state that cognitive rehabilitation programs are not useful for daily
activities. These studies state that performance improvement is limited to trained domains (Lampit,

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Hallock, & Valenzuela, 2014). In contrast, numerous studies found positive transfer effect from
trained to untrained domains (Johnstone et al., 2012; Klingberg et al., 2005; Tamm, Epstein, Peugh,

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Nakonezny, & Hughes, 2013).
Heterogeneous findings about transferability convinced researchers to classify cognitive functions
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and discuss the possibility of transferability according to such classification. The respected
classification is based on contiguity of trained and untrained functions that divide “transfer” into
near and far transfer (Perkins & Salomon, 1992). The near transfer is frequent and the far transfer is
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rare (Sala & Gobet, 2016; Xin, Lai, Li, & Maes, 2014). This classification proposes the proper
cognitive function for training. The more overlap and adjacency, the more transfer would occur. It is
worth noting that the concept of “generalization” is more extensive than near and even far transfer.
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The majority of far transfer occurs in the level of cognitive functions. Hence, the far transfer cannot
solve the problem of generalization from lab to life.
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For the new conceptualization, we assumed three hierarchical and interdependent levels for brain-
behavior interactions consisting neural, cognitive, and behavioral levels in a model (figure 1). The
concept of transfer could be explained based on this model. The transfer of training gain form
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trained cognitive domain into untrained one, either near or far, are intra level (horizontal) transfer. The
main goal of cognitive rehabilitation in behavioral disorders or brain injuries is a transfer for
amelioration of behavioral symptoms or alteration of affected brain areas. We call this kind of
transfer vertical or inter level transfer that could be considered as the ultimate goal of cognitive
rehabilitation and other interventions.
1.3. Transferability in cognitive rehabilitation of ADHD
The efficacy of cognitive rehabilitation in reducing behavioral problems in individuals with ADHD
is a matter of debate in the literature. The improvement of non- trained cognitive domains and
behavioral symptoms after working memory training in ADHD remain elusive. For instance,
working memory training in children with ADHD is shown to improve in visual and verbal working
memory, response inhibition, complex reasoning, and behavioral symptoms based on parent rating
(Klingberg et al., 2005). Similarly, Johnstone and colleagues (2012) found an amelioration in ADHD
symptoms based on rating scales after working memory and inhibitory control training (Johnstone et
al., 2012).
In contrast, some studies report few to no transfer to untrained domains after working memory

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training in individuals with ADHD. For example, Egeland et al (2013) found working memory
training in children with ADHD result in an improvement in psychomotor speed, reading and

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mathematical performance without any significant effect on sustained attention and cognitive
flexibility (Egeland, Aarlien, & Saunes, 2013). Similarly, Capodieci et al (2018) found an

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improvement in working memory performance after training in children with ADHD without any
transfer to inhibitory control (Capodieci, Gola, Cornoldi, & Re, 2018).
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1.4. The present study
In the present study, we use a program for training both attention and working memory using
various tasks. The first goal of the study is to evaluate the effect of training attention and working
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memory in children with ADHD on the very impaired working memory and attention as the target
construct in the rehabilitation program. The second goal is the evaluation of intra level transfer from
attention and working memory to inhibitory control, risky decision making, and delay discounting.
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The third goal is the evaluation of inter level transfer from attention and working memory training
to the ADHD symptoms.
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2. Methods
2.1. Participants
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30 children, diagnosed with ADHD by one psychiatrist based on DSM- V criteria, were

recruited in the study. The children with diagnosis of ADHD were included in the study. The

exclusion criteria were having any other comorbidity, current or past history of seizure disorder,

brain injury, or head trauma, and respited absences from intervention sessions, 3 sessions and more.

Then, they were randomly assigned to experimental (n = 15) and control (n = 16) groups. Both
groups take medication based on the psychiatrist prescription and the cognitive rehabilitation

program was used as add- on program. After the follow-up assessment, the rehabilitation program

proposed to the control group as an option. We used G*power to determine the required sample

size (Buchner, Erdfelder, Faul, & Lang, 2013). Results showed that based on a power of 0.95, an

alpha level of 0.05, and a medium effect size (f= 0.40) suggested for cognitive rehabilitation studies,

the required sample size for our design (repeated-measures ANOVA with 3 measurement) is 14.

The demographic properties of participant illustrated in table 1. There are no significant differences

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between experimental and control group for age (T(1, 31)=0.29, P>0.05), education (T(1, 31)=0.38,

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P>0.05), and IQ measured by WISC IV (T(1, 31)=1.51, P>0.05) The experimental procedures were

approved by the ethics committee for research involving human participants at Shahid Beheshti

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University. The procedures were in accordance with the ethical standards of the Helsinki

Declaration of 1975, as revised in 1983. The concern form was filled by the parents of participants.
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2.2. Materials
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Color- word Stroop task. This task is used for assessment of selective attention (Golden & Freshwater,
1978). In this study, a computerized version of the task was used. In the task, four color words
including red, green, blue and yellow, 7 cm in the size, were presented on the screen and participant
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should press a corresponding color- key on the keyboard as fast and accurate as possible. The task
has three separate stages. In the first stage, the neutral stage, the words are presented in black color
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and the participants should press the corresponding color keys. In the second stage, the congruent
stage, the color words appear with the same ink as their meaning. In the third stage, incongruent
stage, the meaning of the color words and their ink were different and participants had to inhibit the
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meaning and answer based on the ink- color. 50 stimuli were presented in each stage. The output of
this test was the accuracy and reaction time of response in each stage.

Stop signal task. In this task, a dominant response should be inhibited in the presence of stop signal.
This task is used for assessment of prepotent response (Carter et al., 2003). In our study, a plane, 7
× 7 cm in size and black in color, appear on the center of the screen in four directions, up, down,
left, and right, as a go stimulus. The participant had to press corresponding arrow keys as fast and
accurate as possible. In some trials, 25 out of 100 trials, participants had to withhold the answer
when the stop signal, a beep sound in our task. The measures of the test are accuracy and reaction
time of go stages and accuracy of no go stages.

One-Back task. The 1- back test is used for assessment of working memory. In this test, a sequence of
stimuli appear on the screen in order and participant should respond if the current stimulus matches
with the previous one or not (Jaeggi, Buschkuehl, Perrig, & Meier, 2010). In the present study, 100
images of unruly lines were presented serially one after another and participants were instructed to

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press the “same” key on the keyboard for images that are similar to the previous one, in 25 percent,
and press the “different” key in the rest of situations. The accuracy was considered as the working

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memory performance.

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Chocolate delay discounting task. In the chocolate delay discounting tasks (Scheres et al., 2006),
participants faced with two choices, drawn on a sheet of paper. One of them is a small and
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immediate reward (e.g. one chocolate right now) and the other is a bigger and later rewards (e.g. two
chocolate 5 hours later). After any selection of bigger and later choice, the amount of delay increased
gradually with the same reward worth until the sooner and smaller choice is selected. Then another
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situation was presented with a bigger amount in the same delay periods. The immediate reward is
one chocolate now and the delay rewards are 2, 5, 10, 20, 50, and 100 chocolates in a given delay
time including 1, 2, 3, 5, 7, 30, and 180 days after today that matched with any given delay rewards in
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each trail. The total 42 choices in any given trial were presented separately in a page of the booklet.
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Balloon analogue risk tasking task (BART). The BART is a computerized task for evaluation of risky
decision making (C. Lejuez et al., 2007; C. W. Lejuez et al., 2002). In this task, 30 balloons appear on
the screen one by one. In any given balloon, the participant can inflate the balloon with pressing an
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underneath respected bottom with adding an amount of money in a temporary box. The more
pumping number, the more money earns. Any balloon is exploded at an unexpected point and after
the explosion, the money of temporary box was lost out. In each situation, instead of pumping the
balloon for gaining more money, the participant can press the “collect” key and after that, they lose
that balloon but the amount of earned money is transferred from the temporary to the constant box.
The total number of pumping and adjusted number of pumping, as subtracting the number of
exploded balloon pumping from the total number, are considered as the criteria of risky decision
making.
Swanson, Nolan, and Pelham Rating Scale (SNAP-IV). This scale has 18 items, nine items for
inattentiveness, six items for hyperactivity, and three items for impulsiveness, adapted from the
DSM-IV (Swanson, 1992). The items should be rated on a four-point Likert style scale about the
severity of the problem in the last four weeks. The mean of items in subscales, inattentiveness and
hyperactivity/ impulsivity, are considered as cut point. For the parent version, used in the current
study, the cut point is 1.78 for inattentiveness and 1.44 for hyperactivity and impulsivity. A
psychometric study in Iranian population found proper validity and reliability of the scale in the

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respected population (Kiani & Hadianfard, 2016).

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2.3. Intervention: Attentive rehabilitation of attention and memory (ARAM).
The ARAM is a computerized cognitive rehabilitation program with different tasks for training

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attention and working memory. The program consists of 10 graded progressive tasks. All tasks have
10 level and participants could shift to the higher level after gaining the 80 percent of score in each
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level (V. Nejati, 2017). The effectiveness of ARAM in improvement of attention and working
memory found in the elderly (V. Nejati, Shahidi, & Helmi, 2017), children with developmental
stuttering (V. Nejati, Pouretemad, & Bahrami, 2013), and adult with aphasia (Javadipour, Nejati,
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Yadegari, Javadipour, & Fazele, 2018). The ARAM tasks are designed based on the hierarchical
model of attention (M. M. Sohlberg & Mateer, 2000) and Baddeley's model of working memory
(Baddeley & Hitch, 1974) as following.
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1. Colored home task. A schematic simple home, with different color of roof, wall, windows,
and door appear as a target on the top of the page. The participant instructed to find out the
target home in one cell of table with almost similar image in each cell. Participants should
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click on the response as fast and accurate as possible. The contrast of colors, the number of
distractors, and variety of sample home in each trail are used for increasing difficulty of the
task. This task is designed for training of sustained and selective attention.
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2. Faces task. Some faces falling down on the top of screen in different points, moving with
arrow keys. The faces were different in some features consist hair color (black, brown, and
gray), skin color (white, brown, and black), and emotional expression (sad, happy, and
neutral).
The participants should arrange the faces on top of each other respect to given rule. There
were three changing rule consist skin color, hair color, and emotion of faces. Three correct
matching have a score. The speed of falling faces and changing rule increased across
 progression. This task engages sustained, selective, shifting, and divided attention to
perform.
3. Similar windows task. In this task, a table appear on the screen within some similar hidden
images. Clicking on each cell discovers the hidden image until the next click. If two similar
cells are clicked in a row, they would remain open. The instruction is matching similar
images in different cells of table. The number of chain that should be clicked in raw, number
of cells, similarity and meaning of shapes are used for increasing difficulty of the task. This
task trains the visuospatial span in working memory.
4. Marked tables task. In this task, a sequence of cued tables, marked in one cell, appear on the
screen in a row with a predefined show time and inter stimulus interval. Then, after a while,
four tables appear on consist different similar cues in cells as choices. The participants were

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instructed to choose the table respect to the spatial location of cues in the trail. The number
of single cued tables, show time, inter stimulus interval, and delay of choices are used for
difficulty. This task trains the visuospatial span in working memory.

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5. Segmented images task. In this task, different fragments of an image presented serially and
after a delay the whole image should be selected between four choices. The number of
fragment, inter fragment intervals, delay of choices, complexity of image, and similarity of

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choices are used for increasing difficulty of the task. This task trains the visuospatial span
component of working memory.
6. Acronym making task. Different words appear on the screen for a given time serially and
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after a delay four words appears as choices. The trainee is instructed to make a word from
the first letter of stimuli word and find it in the choices. The number, meaning, and length of
stimuli as well as similarity of choices are used for increasing the complexity of the task. This
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task serves phonological processing, inhibitory control, and phonological span to perform.
7. Last colored task. In this task, a sequence of colored squares appeared on the screen serially
and after that 4 choices appear to select. Each choice consists of list two colored cells. The
participant should select the choice based on the last color in order. The variety of colors,
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sequence items and number of choice item are used for increasing difficulty of the task. This
task is used for training updating ability.
8. Animal tracing task. A table consists of an animal in one cell appear on the screen for a
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limited time. Then, a sequence of arrows appears serially with a predefined show time and
inter-stimulus intervals. The participants instructed that each arrow means movement of
animal to the corresponding neighbor cells. After the sequence of arrow, they should say
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about the new location of animal based on the given choices. The number of table’s cell,
number of arrow, and variety of direction are used for progression of complexity of the task.
This task train the visuospatial span and updating component of working memory.
9. Repetitive images task. In this task a series of different images appear on the screen that
some of them were repetitive. The participant had to point the repetitive images. The goal
percent, complexity, and similarity of images are used for progression of the task. This task
based on N- back paradigm improves the updating abilities.
 10. Letter matching task. In this task a series of word or sentence presented serially and
participant should reply whether the initial letter of current text is similar with the last letter
of previous text or not. The length of text is used for increasing complexity of the task. This
task engages the phonological span for the holding of target letter and inhibition and
updating for inhibition of unwanted part of text.

2.4. Procedure.
After assignment to the experimental and control situations, the experimental group was evaluated
before the intervention, and 1 month after intervention as follow up session. The control group was
assessed in a similar time period. The task order of tasks and measures were counter balanced in

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assessment sessions. The intervention sessions took time about 30 to 45 minutes, three sessions per
week for 4-5 weeks, 12 to 15 sessions. The intervention sessions were formulated based on the

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baseline performance, progression, and types of tasks.

2.5. Statistical analysis

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Independent T-tests performed for all baseline variables prior to the intervention for evaluation of
group differences. A series of five 2 × 3 repeated measures multivariate analyses of variance
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(MANOVAs) were performed for evaluation of effectiveness of intervention. Each MANOVA
included a between-subject factor of group (intervention vs control), the within-subjects factor of
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time (baseline, after the intervention and follow up), and the group × time interaction. The
interaction is the primary effect of interest, as a significant effect would support the idea that the 2
groups differ in their degree of change through intervention. We used repeated-measures
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MANOVAs to analyze a different set of conceptually related dependent variables (i.e., Stroop task
RT, 1- back task accuracy, the (K) as an index of delay discounting, the number of total pumping
and adjusted pumping in BART, and the go and no go accuracy as a measure of inhibitory control).
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For each MANOVA, if the overall multivariate group × time effect was significant, we conducted
univariate repeated measures follow-up tests to examine the interaction effect separately for each
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dependent variable. Based on the F ratios for each multivariate test on Wilks’s approximation, we
also calculate the Pearson product–moment correlation coefficients to examine the linear
relationships among the dependent variables included in each MANOVA. Normality and
homogeneity of variance of the variables were confirmed using the Shapiro-Wilk and Levin tests
respectively. Mauchly’s test was used to evaluate the sphericity of the data and in case of violation of
data sphericity, degrees of freedom were corrected using the Greenhouse-Geisser method.
Bonferroni Procedure is used for post- hoc analysis to find differences between assessment sessions.
A significance level of p < 0.05 was used for all statistical comparisons.

3. Result
3.1. overview
Table 1 summarizes the means and standard deviations for all variables in different assessment
sessions. Independent T-tests revealed no significant differences between the experimental and wait-
list control groups for any of the pre-intervention study variables.

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3.2. Effect of cognitive rehabilitation on attention and memory
The first repeated measures MANOVA performed for measures of 1- back test accuracy as the

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main measure, adjusted accuracy with negative grade (.5 score) for false responses and the time of
performing this working memory task as the speed of information processing. For accuracy as a

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main grade of this task, the multivariate tests for the MANOVA yielded a significant main effect for
time (F(2, 54)= 2.458, p= .0001, ηp2=.431), a marginally significant main effect for group (F(1, 27)=
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4.149, p= .05, ηp2=.134 and a non- significant group × time interaction (F(2, 54)= 2.780, p= .107,
ηp2= .093).
For adjusted accuracy as a main grade of this task, the multivariate tests for the MANOVA yielded a
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marginally significant main effect for time (F(2, 54)= 3.987, p=.056, ηp2=.128), a significant main
effect for group (F(1, 27)= 8.784, p =.006, ηp2= .254), and a significant group × time interaction (F(2,
= 7.363, p =.011, ηp2= .214).
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54)

For the speed of performing task, a significant main effect for time (F(1, 27)= 7.210, p= .012, ηp2=
.211), a non- significant main effect for group (F(2, 54)= .011, p =.918, ηp2=.000), and a non-
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significant group × time interaction (F(2, 54)= .712, p =.406, ηp2=.026) are shown. The pairwise
comparisons reveal the main differences of all measures of 1- back test are related to the first and
second assessment sessions.
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The second repeated measures MANOVA was performed for measures of Stroop test including
reaction time for three neutral, congruent and incongruent stages and attention bias index. For the
speed of neutral stage, a significant main effect for the time (F(2, 54)= 3.322, p= .044, ηp2=.110), a
non- significant main effect for the group (F(1, 27)= 3.063, p= .191, ηp2=.102), and a non- significant
group × time interaction (F(2, 54)= 1.971, p = .169, ηp2=.068).
For the speed of congruent stage, a non- marginally significant main effect for the time (F(2, 54)=
1.423, p= .250, ηp2=.050), a non- significant main effect for the group (F(1, 27) = .976, p = .332,
ηp2=.035), and a non- significant group × time interaction (F(2, 54)= 1.098, p= .331, ηp2=.039) has
been revealed.
For the speed of incongruent stage, a significant main effect for time (F(2, 54)= 5.712, p= .006,
ηp2=.175), a non- significant main effect for the group (F(1, 27)= .059, p= .811, ηp2=.002), and a
non- significant group × time interaction (F(2, 54)= .043, p = .927, ηp2=.002) are demonstrated.
For attention bias index, the multivariate tests for the MANOVA yielded a non- significant main
effect for the time (F(2, 54)= 2.034, p =.141, ηp2= .070), a non- significant main effect for the group

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(F(1, 27)= 1.266, p= .270, ηp2= .045), and a non- significant group × time interaction (F(2, 54)= .853, p
= .408, ηp2=.031).

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3.3. Effect of cognitive rehabilitation on inhibitory control

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The third repeated measures MANOVA was performed for measures of stop signal test including
accuracy in go and no go stages. For go stage accuracy, the multivariate tests for the MANOVA
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yielded a non- significant main effect for time (F(2, 54)= 2.496, p= .126, ηp2=.085), a non- significant
main effect for group (F(1, 27)= 1.437, p= .236, ηp2= .025), and a non- significant group × time
interaction (F(2, 54)= 2.775, p= .076, ηp2= .093).
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For no go stage accuracy, as the main measure of the test, the multivariate tests for the MANOVA
revealed a significant main effect for time (F(2, 54)= 14.137, p= .0001, ηp2= .344), a non- significant
main effect for group (F(1, 27)= .988, p= .329, ηp2= .035), and a non- significant group × time
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interaction (F(2, 54)= .866, p= .427, ηp2=.031).

For the speed of go stage, a non- significant main effect for time (F(2, 54)= 2.775, p= .071, ηp2=.093),
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a non- significant main effect for group (F(1, 27)= .449, p= .566, ηp2=.016), and a significant group ×
time interaction (F(1, 54)= .136, p= .013, ηp2=.206)
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3.4. Effect of cognitive rehabilitation on risk-taking.

The forth repeated measures MANOVA was performed for the measures of BART including the
number of pumping and the adjusted number of pumping. For the number of pumping, the
multivariate tests for the MANOVA illustrated a non- significant main effect for time (F(2, 52)= .972,
p = .333, ηp2=.036), a non- significant main effect for group (F(1, 26)= .208, p = .208, ηp2=.029), and
a non- significant group × time interaction (F(2, 52)= .357, p = .702, ηp2=.014).
For the adjusted number of pumping, the multivariate tests for the MANOVA yielded a significant
main effect for time (F(2, 52)= 3.256, p= .047, ηp2= .111), a non- significant main effect for group (F(1,
26) = 1.333, p= .253, ηp2=.024), and a significant group × time interaction (F(2, 52)= 4.284, p = .043,
ηp2=.074).

3.5. Effect of cognitive rehabilitation on delay discounting

The fifth repeated measures MANOVA was performed for the measures of delay discounting task
including the value of K. For this measure, the multivariate tests for the MANOVA demonstrated a
significant main effect for time (F(2, 52)= 3.660, p= .043, ηp2=.112), a marginally significant main

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effect for group (F(1, 26)= 4.137, p = .051, ηp2=.125), and a significant group × time interaction (F(2,
52) = 3.335, p = .043, ηp2=.103).

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3.6. Effect of cognitive rehabilitation on behavioral symptoms

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For measurement of ADHD rating scale including attention deficit (AD) criteria, hyperactivity (HD)
criteria, and total attention deficit and hyperactivity (ADHD) criteria, only treatment group were
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assessed. The univariate tests for the MANOVA showed a significant main effect of time for AD
(F(1, 55)= 5.684, p= .023, ηp2=.321), HD (F(1, 55)=8.943, p = .001, ηp2=.427), and ADHD (F(1, 55)=
9.433, p = .005, ηp2=.440).
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4. Discussion
In the present study, a cognitive training program is used for the improvement of cognitive
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impairment and amelioration of behavioral symptoms in children with ADHD. The result showed
improvement in attention and working memory as the trained domains in the program. The transfer
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to untrained domain could be classified in two level of other cognitive functions and the behavioral
level. The result found transfer in both levels to the delay discounting, and risky decision making in
the cognitive function level and the rating of ADHD behavioral scale.
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4.1. Improvement in the trained functions

The results show a positive impact of ARAM on accuracy of working memory but no effect on
selective attention. In the ARAM, the majority of intervention programs target different
components of working memory. Similarly, improvement in working memory of children with
ADHD have found with RoboMemo training program (Egeland et al., 2013; Gray et al., 2012;
Green et al., 2012; Hovik, Saunes, Aarlien, & Egeland, 2013; Klingberg et al., 2005). The impact of
working memory training remained up to one month follow up in this study. Some researcher found
the working memory training gain in children with ADHD remains up to eight months after
intervention (Hovik et al., 2013). In line with our studies, some investigations found no
improvement on Stroop test scores through working memory training (Egeland et al., 2013; Hovik
et al., 2013; van Dongen‐Boomsma, Vollebregt, Buitelaar, & Slaats‐Willemse, 2014) and even
attention training (Tamm et al., 2013).

4.2. The intra level transferability

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Based on the new classification of transfer, improvement in all untrained cognitive functions are
placed in the category of intra level transfer. We found successful transfer from working memory

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improvement to decreased delay discounting and risky decision-making. In a way, working memory
helps us to remember and to consider the risky outcomes of decisions and the value of delayed

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choices (Nejati, 2013; Wesley & Bickel, 2014). In particular, working memory deficits as mediator
affect risky decision-making in methamphetamine users with ADHD (Duarte et al., 2012). To our
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knowledge, the present study is the first study that demonstrate the effect of working memory
training on the reduction of risky decision making and delay discounting in children with ADHD.
The transfer effect from working memory training to the delay discounting have found previously
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among stimulant addicts (Bickel, Yi, Landes, Hill, & Baxter, 2011).
Additionally, we can interpret this finding with functional relationship between the targeted
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functions. Working memory and attention are important components of executive functions.
Executive control seems to have a supramodal contributions to different components of executive
functions (Ghanavati, Nejati, & Salehinejad, 2018; Ghanavati, Salehinejad, Nejati, & Nitsche, 2019).
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Therefore, improving effects of the central cognitive control can explain its transferability to other
domains. Regarding delay-discounting, it involves both cold and hot components of executive
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functions (V. Nejati, Salehinejad, & Nitsche, 2018) and our results might implicate the cognitive
(cold) components may be more crucial although such conclusion requires examining the hot
component too.
We found no transfer effect from working memory training to inhibitory control. Similar to our
result, three other studies found no transfer effect to the inhibitory control, measured with go- no
go task in children with ADHD (Capodieci et al., 2018; Johnstone, Roodenrys, Phillips, Watt, &
Mantz, 2010; Liu, Lishak, Tannock, & Woltering, 2017). However there are several factors to
consider here. First, the nature of training tasks in the cognitive rehabilitation program are decisive
in the matter of transferability. For example, Hilbert et al used a material- and operation-specific
working memory training and found no transfer to reasoning (Hilbert et al., 2017). The variety of
training task is a crucial matter for successful transferability. Vakil and Heled compared two models
of constant and varied cognitive training with and without identical configuration in two separate
groups. They found the constant training group yielded a higher cost when facing a new task (Vakil
& Heled, 2016).
Moreover, the direction of transfer should be noted in the level of cognitive functions. In other
words, training of higher-order cognitive functions may not be transferred to lower-order one.

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Indeed, the higher order cognitive function underlies several cognitive functions that could be
covered and compensate each other. For example, training of reasoning as a cognitive function that

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is placed higher than working memory does not lead to improvement in working memory
(Stevenson, Heiser, & Resing, 2013). Based on the previous classification of transfer into two near

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and far transfer, the near transfer is more frequent and feasible than far transfer (Sala & Gobet,
2016; Xin et al., 2014). In the present study, we found a far transfer to the delay discounting and
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risky decision making without a near one, to inhibitory control. Thus, near transfer is not a
prerequisite of far transfer. In other words, the far transfer could be occurred without near transfer.
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4.3. The inter level transferability

The result show amelioration of inattentivness, hyperactivity, and attention deficit- hyperactivity
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symptoms after training. There is a significant correlation between working memory performance
and hypearactivity symptoms in children with ADHD (Patros, Alderson, Hudec, Tarle, & Lea, 2017;
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Rapport et al., 2009; Thorell & Wåhlstedt, 2006). Beyond correlational studies, Klingsberg et al
found the improvement of ADHD symptoms after working memory training (Klingberg et al.,
2005) and matrix task training (Klingberg et al., 2005). This is in line with those studies that showed
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such transferability following cognitive improvement. For example, finding from other disorders
(i.e., depression) marked with impaired cognitive functions such as working memory and attention
showed that by improving these functions, an improvement in clinical symptoms are observed too
(Gonda et al., 2015; Salehinejad, Ghanavai, Rostami, & Nejati, 2017).

5. Conclusions
The new classification of transferability in this study provides a framework for evaluation of the
efficacy of cognitive rehabilitation programs. The classic concept of near and far transfer and
plausibility of them throw in the question in the present study. In fact, the far transfer does not
guarantee the near one. Furthermore, both near and far transfer are in the same functional level.
The main goal of cognitive rehabilitation is the amelioration of symptoms and chief complaint.
Hence, the matter of inter- level transfer should be taken into account in the cognitive rehabilitation.
Although the transfer to the other untrained cognitive functions is worth nothing for the impact of
program, but all of these transfer must be considered as intra level transfer that could not approve
the efficacy of program as a treatment modality.

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In this case, numerous cognitive rehabilitation programs found amelioration of different behavioral
symptoms that could be considered as the indicator of their efficacy. For instance, decrease

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rumination with working memory training in the anxiety and depression (Klingberg et al., 2005),
increases self-regulation of food intake through working memory training in overweight individuals

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(Houben, Dassen, & Jansen, 2016), improvement of depression symptoms through attention- and
interpretation- bias training (V. Nejati, Fathi, Shahidi, & Salehinejad, 2019).
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The practical application of this study in clinical set up is the necessity of considering transferability
of cognitive rehabilitation to behavior and untrained domain(s). Cognitive rehabilitation is not the
game of task scores and without transfer to daily activity it is under question as a therapeutic
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modality.

6. Limitation and future direction

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There are some limitations to the present study. The first one is the lack of an active control group.
Furthermore, some cautions should be taken in to account in the interpretation of the proposed
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model. The present study has not any measure in the neural level. Hence, the inter level transfer
effect from cognitive level to brain level, bottom-up transfer, that assumed based on previous
studies should be evaluated across the top- down inter-level transfer in the future studies. The
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correlation between two types of inter-level transfer and the causal effect of them for each other is
outstanding and to- be- answered question.

Research involving Human Participants and/or Animals:

In the present study human participated in the study. The procedures were in accordance with the
ethical standards of the Helsinki declaration of 1975, as revised in 1983.

Funding: This study did not receive any specific grant from funding agencies in the public,
commercial, or not-for-profit sectors

Informed consent:

The informed consent form completed before participation.

Conflict of interest:

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The author declares that there is no conflict of interest regarding the publication of this paper.

Conflict of Interest:

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The author declares that they have no conflict of interest.

Acknowledgment:
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This project was conducted by personal grant of the author. We thank our participants who greatly

helped us by patience for performing the project.

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Figure 1: Schematic model for inter- and intra- transfer. Abbreviations; CF: cognitive flexibility, PS: problem-solving,
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DD: delay discounting, DM: decision making, IC: inhibitory control, WM: working memory
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Table 1: he demographic properties of participants
Variables Intervention Group Control Group
M (SD) M (SD)
Age (years) 9.40 (1.54) 9.56 (1.50)
Gender 7G/8B 7G/8B
Verbal IQ (VC, WISC- IV) 10.50 (2.47) 9.12 (2.47)
Practical IQ (D, WISC- IV) 11.35 (3.15) 9.81 (2.86)
ADHD symptoms
Inattentiveness- hyperactivity/impulsivity 52.40 (15.54) 46.18 (21.75)
Inattentiveness 16.80 (5.59) 15 (7.88)
hyperactivity/impulsivity 24.13 (7.52) 21.06 (9.29)
Abbreviation: M: mean, SD: standard deviation, VC: vocabulary comprehension, BC: block design,

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WISC: Wechsler intelligence scale for children

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 Table1: the mean and standard deviation of measures in three assessment sessions for two groups of
study
Assessment sessions / Intervention group scores, M (SD) Control group assessment, M (SD)
Measurements First Second Third First Second Third
BART

Successful pumping number 4.35 (2.95) 6.14 (6.71) 4.28 (3.07) 4.71 (4.21) 6.78 (4.42) 6.21 (2.35)

Adjusted pumping number 14.59 (5.53) 21.23 (16.15) 20.06 (13.53) 16.77 (6.92) 22.05 (11.21) 21.89 (9.56)

Delay discounting
K 2.28 (5.81) 3.87 (8.05) 9.31 (11.70) 7.75 (11.41) 7.40 (11.57) 7.79 (11.41)

Stroop test
Neutral stage speed (s) 1.42 (.30) 1.33 (.24) 1.40 (.27) 1.93 (.72) 1.57 (.56) 1.56 (.32)

Congruent stage speed (s) 1.40 (.29) 1.44 (.31) 1.35 (.33) 1.61 (.68) 1.44 (.26) 1.40 (.27)

of
Uncongruent stage speed (s) 1.76 (.47) 1.67 (.45) 1.46 (.26) 1.94 (.69) 1.85 (.52) 1.59 (.38)

Attention bias index .34 (.46) .33 (.34) .06 (.24) .0059 (.81) .28 (.75) .02 (.36)

ro
1- back
Accuracy 15.78 (6.89) 20.92 (4.79) 22.00 (3.80) 14.26 (6.31) 16.13 (5.68) 17.13 (5.42)

Stop- signal task

Go- accuracy 92.40 (21.71) 99.06 (1.86) 98.65 (2.84) 94.77 (8.33) 78.40 (37.88) 89.93 (13.60)

-p
Go- reaction time 1.11 (.12) 1.23 (.11) 1.23 (.18) 1.35 (.15) 1.15 (.50) 1.27 (.17)

Nogo accuracy 19.50 (4.81) 24.28 (2.12) 23.42 (3.05) 17.86 (5.80) 20.86 (4.53) 20.06 (4.65)

SNAP-IV
re
Attention deficit (AD) 16.00 (5.59) 13.46 (5.10) 11.84 (5.28) 16.00 (5.59) 13.46 (5.10) 11.84 (5.28)

Hyperactivity (HD) 22.92 (7.31) 18.00 (4.91) 17.61 (5.99) 22.92 (7.31) 18.00 (4.91) 17.61 (5.99)

Attention deficit- hyperactivity 49.84 (14.99) 39.76 (12.49) 37.53 (13.53) 49.84 (14.99) 39.76 (12.49) 37.53 (13.53)
lP

(ADHD)
na
ur
Jo