Asian Journal of Psychiatry 81 (2023) 103469

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Asian Journal of Psychiatry

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Short communication

The effect of comprehensive working memory training on executive

functions and behavioral symptoms in children with attention
deficit-hyperactivity disorder (ADHD)
Vahid Nejati *, Zahra Derakhshan, Ahdiyeh Mohtasham
Department of Psychology, Shahid Beheshti University, Po box: 1983969411, Tehran, Islamic Republic of Iran

A R T I C L E I N F O A B S T R A C T

Keywords: This study aimed to evaluate the effect of working memory training on executive functions and behavioral
Attention deficit-hyperactivity disorder symptoms in children with ADHD. Thirty children with ADHD were randomly assigned to active control or Active
(ADHD) Memory Intervention (AMIN) group. Executive functions and rating scales were used for assessment in three
Active Memory Intervention (AMIN)
baseline, post-intervention, and 1-month follow-up sessions. The results show AMIN improves working memory
Working memory training
and inhibitory control as well as ameliorates ADHD symptoms at home and school. Working memory training is
Cognitive rehabilitation
Executive functions beneficial and transferable intervention in children with ADHD.

1. Introduction improve the whole construct effectively. Without a comprehensive

Working memory training (WMT) programs are extensively used for
individuals with Attention deficit-hyperactivity disorder (ADHD).
Numerous studies described improved executive functions (Miranda
et al., 2013; Nejati, 2020) and amelioration of ADHD symptoms
(Ackermann et al., 2018; Miranda et al., 2013; Nejati, 2020) through
WMT. However, some other studies found a null effect of WMT in
children with ADHD on executive functions (Ackermann et al., 2018;
Chacko et al., 2014; Dentz et al., 2020; Menezes et al., 2015; Vanden­
broucke, 1998) and behavioral symptoms (Menezes et al., 2015; van
Dongen-Boomsma et al., 2014). Spencer-Smith and Klingberg (2015)
performed a meta-analysis on 13 WMT studies in children with ADHD
and described an improvement in inattention in daily life after WMT.
However, two other meta-analyses described an immediate improve­
ment with a relatively null long-term effect (Melby-Lervåg and Hulme,
2013; Rapport et al., 2013).
One possible explanation for this discrepancy is related to the variety
or specificity of WMT programs. WMT programs, usually, focus on a
single component of working memory for training, with limited types of
stimuli, which weaken the transferability of training from trained tasks
to untrained domains. Vakil and Heled (2016) compared two models of
constant and varied cognitive training in two separate group and found
constant training group yielded a higher transfer cost. We assumed that
all components of working memory should be trained harmonically to
intervention on all domains, an impaired domain remained untouched
because of compensation of its functions with other components (Nejati
et al., 2022). In the present study, we aimed to target all components of
working memory with various training tasks. Furthermore, the modality
of to-be-processed stimuli is different, auditory and/or visual, written
and/or verbal, and textual and/or pictorial. We hypothesized that a
comprehensive training of all components of working memory with
different stimuli could improve working memory and this training effect
can spread to untrained cognitive domains. In this study, we aimed to
evaluate the impact of a comprehensive WMT program entitled Active
Memory Intervention (AMIN) on the improvement of executive func­
tions and amelioration of ADHD symptoms at home and school.
2. Method
2.1. Participants
Thirty children with ADHD (mean age: 9.07 ± 3.40, age range from 7
to 11, 19 boys) participated in the study. The participants were recruited
from school and were diagnosed with ADHD by a clinical psychologist
through a structural clinical assessment based on DSM-5. The partici­
pants were drug-naïve and did not receive any behavioral intervention
for ADHD. The participants had no current or history of seizure, head
trauma, or other comorbid neurodevelopmental disorders based on

* Corresponding author.
E-mail address: nejati@sbu.ac.ir (V. Nejati).

https://doi.org/10.1016/j.ajp.2023.103469
Received 2 December 2022; Received in revised form 12 January 2023; Accepted 16 January 2023
Available online 17 January 2023
1876-2018/© 2023 Elsevier B.V. All rights reserved.
V. Nejati et al. Asian Journal of Psychiatry 81 (2023) 103469

approved by the ethical committee of Shahid Beheshti University.

One-back, Wisconsin Card Sorting, and Go/No-Go tests and Conner’s
Teacher and Parent Rating scales were used for assessment in three
baseline, post-intervention, and 1-month follow-up sessions.

2.2. AMIN: Active Memory Intervention

AMIN, as a theoretically driven WMT intervention, consists of 21

paper-and-pencil, progressive, variable, and graded tasks for a
comprehensive training of all working memory components based on
Baddeley’s model. We target the main components of the model and
respective functions of each component. Then, some tasks were devel­
oped based on the function with a progressive demand of the respective
function. The component of the model, the respective functions and
designed tasks depicted in the Fig. 2. Each task has 20 stages with
different levels of difficulty based on the logic of targeted function and
with respect to the respective experimental studies about the mechanism
of each component. All tasks were presented in two auditory/visual
modalities and the performance of trainee, accuracy and speed, in each
round registered in a work sheet. The performance in each stage was the
basis of progression or repetition of the same stage.
Fig. 1. Consort chart of the study.
A series of 2 × 3 repeated measures multivariate analyses ANOVA
included a between-subject factor of group (intervention vs. control), a
within-subjects factor of time (pre-test, post-test and follow-up), and the
group × time interaction was used for analysis. The interaction is the
primary effect of interest, as a significant effect would support the
effectiveness of the intervention.

3. Result

Tables 1 and 2 illustrated mean and standard deviation of the tests’

measures in three assessment sessions and respective ANOVA analyses.
Fig. 3 illustrated the LSD pairwise results.

4. Discussion

The results showed improved inhibitory control and working mem­

Fig. 2. AMIN’s conceptual model.
parental report and clinical interview. Fig. 1 depicted participants in two
groups. The procedures were in accordance with the ethical standards of
the Helsinki Declaration of 1975, as revised in 1983. The study was
ory after training with AMIN. The ADHD symptoms was reduced after
intervention. The training effects last at least 1 month, until follow-up
session. In detail, the results show improved working memory accu­
racy, and not speed, after intervention, remained until follow-up. Ac­
curacy is more important than speed in working memory, especially for
children with ADHD who are impulsive (Patros et al., 2016). Notably,
the accuracy of responses is more sensitive than response time in young
children (Carlson, 2005; Diamond and Kirkham, 2005). Earlier accounts
in children with ADHD found improvement in working memory,
measured by digit span test, a time-free measure of working memory, by
Cogmed RoboMemo (Hovik et al., 2013; Klingberg et al., 2005).

Table 1
Mean and standard deviation of measures in assessment sessions.
Assessment sessions Intervention group, M (SD) Control group, M (SD)

Measures I II III I II III

1-back
Accuracy (%) 77.87(11.29) 92.40(7.57) 93.67(4.77) 70.33(21.95) 75(19.65) 65(18.93)
Response Time (s) 247.80(72.70) 236.18(67.79) 238.27(87.75) 223.83(70.18) 197.92(69.36) 148.17(55.99)
Wisconsin Card Sorting
Clusters 3.27(1.33) 4.73(.458) 4.73(.458) 1.73(1.22) 2.73(1.28) 1.53(1.12)
Perseveration Error 13.40(8.35) 9.80(5.15) 9.40(12.45) 24.47(15.50) 22.07(11.83) 24.47(12.45)
Go/No-Go
Go accuracy (%) 73.30(19.25) 89.25(10.79) 89.20(13) 89.44(8.16) 83.88(19.97) 75.27(23.27)
Go RT (ms) 1.01(.43) 1.23(.28) 1.19(.21) 1.21(.24) 1.09(.33) 1.17(.30)
No- go accuracy (%) 63.53(30.79) 84.52(22.60) 83.41(21.46) 60.51(33.95) 74.35(32.88) 64.61(36.46)
Conner’s Rating Scales
Parent Version 2.37(.75) 1.62(.28) 1.65(.39) 2.50(.66) 2.36(.67) 2.55(.81)
Teacher Version 1.72(.45) 1.02(034) 1.14(.31) 1.62(.40) 1.41(.49) 1.56(.44)

Abbreviations. M: mean, SD: standard deviation, I: baseline assessment, II: post-test assessment, III: follow- up assessment.

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V. Nejati et al. Asian Journal of Psychiatry 81 (2023) 103469

Table 2
The result of two factorial ANOVA on the study measures.
Measures Time Effect Group Effect Time * Group

df F Sig ηp2 df F Sig ηp2 df F Sig ηp2

N- Back Test
Accuracy 2,56 4.277 .028 .146 1,28 17.83 .0001 .389 2,56 5.175 .015 .171
Response Time 2,56 3.981 .029 .137 1,28 3.175 .06 .222 2,56 2.645 .087 .096
Wisconsin Card Sorting Test
Clusters 2,56 15.940 .000 .363 1,28 60.669 .000 .684 2,56 7.75 .002 .217
Perseveration Error 2,56 1.370 .262 .047 1,28 16.647 .000 .373 2,56 .618 .508 .022
Go/No-Go Task
Go accuracy 2,56 2.272 .131 .075 1,28 .040 .844 .001 2,56 17.603 .000 .386
Go RT (s) 2,56 .924 .383 .032 1,28 .033 .857 .001 2,56 4.759 .020 .145
No-Go accuracy 2,56 14.882 .000 .347 1,28 1.057 .013 .036 2,56 2.924 .043 .095
Conner’s Rating Scales
Parent 2,56 59.656 .000 .681 1,28 2.599 .118 .085 2,56 23.529 .000 .457
Teacher 2,56 15.534 .000 .357 1,28 7.977 .009 .222 2,56 11.993 .000 .300

Fig. 3. Effects of AMIN on the variables are

shown. Note: Each graph depict one variable.
The first and the second column groups, from
left to right, in each graph are related to AMIN
and active control group in order. Pretest, post
test, and follow-up in each group were shown in
yellow, green, and blue in order. *: significant
at the level of .05 based on the results of the
pairwise comparisons between assessment ses­
sions. The bars depict the means, error bars are
representing standard error of mean.

Similarly, improvement in accuracy of N-back test was found children
with ADHD through WMT (Nejati, 2020), attention training (Jalili et al.,
2019; Nejati, 2021c, 2021a), inhibitory control training (Nejati et al.,
2020), and executive function training (Nejati and Derakhshan, 2021).
The durability of WMT effect in children with ADHD has been described
earlier for 2 months (Mawjee et al., 2015) and even 6 months (Dentz
et al., 2020; Rapport et al., 2013).
The results showed an improvement in inhibitory control, measured
by No-Go accuracy through AMIN. Earlier studies showed both positive
(Klingberg et al., 2005) and null (Ackermann et al., 2018) impact of span
training in children with ADHD. Span training cannot improve working
memory as a whole system. The Klingberg’s study used Stoop test
compared to Go/No-Go as a demanding test of inhibition in the present
and Ackermann’s studies. Another WMT program, namely attentive
rehabilitation of attention and memory (ARAM), with stress on selective
attention/interference inhibition training along WMT found improve­
ment in No-Go accuracy in children with ADHD (Nejati, 2020). The
results show a null effect of WMT on cognitive flexibility. Cognitive
flexibility is not impaired in children with ADHD (Irwin et al., 2019) and
this relatively intact function might leave no room for improvement by
training. However, a WMT study in children with ADHD reported
improved cognitive flexibility, measured by trail making task (Passarotti
et al., 2020), which is less demanding compared to WCST.
It seems inhibitory control, working memory, and cognitive flexi­
bility, in order, play a primary, central, and advanced roles in executive
functions. Inhibitory control is a doorway for selection/inhibition of

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V. Nejati et al. Asian Journal of Psychiatry 81 (2023) 103469

information in the initial stage of information processing. Without this
gating, none of other executive functions can work efficiently. For
instance, irrelevant information overloads working memory (Nejati,
2021b; Nejati et al., 2018) and inability to disengagement form current
information disturbs set shifting (Brocki and Tillman, 2014; Nejati et al.,
2022). Cognitive flexibility serves inhibitory control and working
memory in an advanced manner to alternate the flow of attention be­
tween different sets of information. Cognitive flexibility develops later
(Chevalier et al., 2012) and is crucial for proper allocation of cognitive
resources (Ionescu, 2012). However, there is no evidence to suggest an
isolated cognitive flexibility impairment in children with ADHD (Irwin
et al., 2019). The central role of working memory provides the oppor­
tunity to transfer the training effect to other executive functions.
The behavioral symptoms were reduced at home and school after
intervention in the present study. Correlational studies found an asso­
ciation between ADHD symptoms and impaired working memory
(Patros et al., 2017; Thorell and Wåhlstedt, 2006). A WMT study, with
CogMed RoboMemo, as a span training program, found amelioration of
ADHD symptoms at home, and not school (Klingberg et al., 2005). In this
study, the intervention was performed at home (Klingberg et al., 2005),
and thus the improvement in this study could be attributed to
context-dependent training effect, which limits the transfer of training
effect to new context, like school. Another possible explanation is the
rater bias about the child effort under her/his supervision. This bias and
expectation from training might influence the rating. In the present
study, we found WMT in a clinical setting improves ADHD symptoms in
two other settings, home and school. This transfer could be followed in
qualitative reports of parents, Appendix 1.
About limitation, there was a relatively small sample size with short
time 1-month follow-up. In conclusion, AMIN improved working
memory and inhibitory control in children with ADHD and ameliorate
the ADHD symptoms at home and school.
Funding
This study did not receive any specific grant from funding agencies in
the public, commercial, or not-for-profit sectors.
Conflict of Interest
The authors declare that they have no conflict of interest.
Acknowledgment
This project was conducted by personal grant of the author. We
thank our participants who greatly helped us by patience for performing
the project.

Appendix 1. Parents’ report about the effectiveness of AMIN

Name Some parents’ quote about the intervention effects

(age)

AR (8) “The attention and concentration of Alireza were improved. Furthermore, his conflict with his father was reduced after intervention. He found how to communicate with
his father”
AR (9) “It was okay and I have no more idea”
AA (8) “He was better in doing homework”
AH (8) “We found some improvement in his stuttering after intervention”
AR (8) “His attention was improved. Surprisingly, his urinary incontinence improved after intervention”.
AS (9) “Before intervention, he has some problem in interaction with his classmate, he can interact with peers properly after intervention”
AK (11) “He has not a prominent progress”
IA (8) “His attention was improved. Furthermore, he speaks more fluently after intervention.
KA (11) ”His attention was improved. Beyond improvement in attention, he was improved in aggression control. After intervention, his aggressive behaviors were reduced
significantly”
MD (9) “His attention and concentration were improved. Furthermore, based on his teacher report, his reading fluency was improved significantly”
MH (9) “It was okay, but our expectation was more than this”
NZ (10) “I found some improvement in her attention after intervention”
ZN (9) “She was better in concentration on her homework after training”
TH (10) “Taha’s handwriting improved after the program”
ZH (9) “His impulsivity was reduced after the intervention”

References van Dongen-Boomsma, M., Vollebregt, M.A., Buitelaar, J.K., Slaats-Willemse, D., 2014.
Working memory training in young children with ADHD: a randomized placebo-
controlled trial. J. Child Psychol. Psychiatry 55 (8), 886–896.
Ackermann, S., Halfon, O., Fornari, E., Urben, S., Bader, M., 2018. Cognitive Working
Hovik, K.T., Saunes, B.-K., Aarlien, A.K., Egeland, J., 2013. RCT of working memory
Memory Training (CWMT) in adolescents suffering from Attention-Deficit/
training in ADHD: long-term near-transfer effects. PLoS One 8 (12), e80561.
Hyperactivity Disorder (ADHD): a controlled trial taking into account concomitant
Ionescu, T., 2012. Exploring the nature of cognitive flexibility. New Ideas Psychol. 30 (2),
medication effects. Psychiatry Res. 269, 79–85.
190–200.
Brocki, K.C., Tillman, C., 2014. Mental set shifting in childhood: the role of working
Irwin, L.N., Kofler, M.J., Soto, E.F., Groves, N.B., 2019. Do children with attention-
memory and inhibitory control. Infant Child Dev. 23 (6), 588–604.
deficit/hyperactivity disorder (ADHD) have set shifting deficits? Neuropsychology
Carlson, S.M., 2005. Developmentally sensitive measures of executive function in
33 (4), 470.
preschool children. Dev. Neuropsychol. 28 (2), 595–616.
Jalili, F., Nejati, V., Ahadi, H., Katanforosh, S.A., 2019. Effectiveness of computerized
Chacko, A., Bedard, A.C., Marks, D.J., Feirsen, N., Uderman, J.Z., Chimiklis, A.,
motion-based cognitive rehabilitation on improvement of working memory of
Rajwan, E., Cornwell, M., Anderson, L., Zwilling, A., 2014. A randomized clinical
children with ADHD. Med. Sci. J. Islam. Azad Univ.-Tehran Med. Branch 29 (2),
trial of Cogmed working memory training in school-age children with ADHD: a
171–180.
replication in a diverse sample using a control condition. J. Child Psychol. Psychiatry
Klingberg, T., Fernell, E., Olesen, P.J., Johnson, M., Gustafsson, P., Dahlström, K.,
55 (3), 247–255.
Gillberg, C.G., Forssberg, H., Westerberg, H., 2005. Computerized training of
Chevalier, N., Sheffield, T.D., Nelson, J.M., Clark, C.A.C., Wiebe, S.A., Espy, K.A., 2012.
working memory in children with ADHD–a randomized, controlled trial. J. Am.
Underpinnings of the costs of flexibility in preschool children: the roles of inhibition
Acad. Child Adolesc. Psychiatry 44 (2), 177–186.
and working memory. Dev. Neuropsychol. 37 (2), 99–118.
Mawjee, K., Woltering, S., Tannock, R., 2015. Working memory training in post-
Dentz, A., Guay, M.-C., Parent, V., Romo, L., 2020. Working memory training for adults
secondary students with ADHD: a randomized controlled study. PLoS One 10 (9),
with ADHD. J. Atten. Disord. 24 (6), 918–927.
e0137173.
Diamond, A., Kirkham, N., 2005. Not quite as grown-up as we like to think: parallels
between cognition in childhood and adulthood. Psychol. Sci. 16 (4), 291–297.

4
V. Nejati et al.
Melby-Lervåg, M., Hulme, C., 2013. Is working memory training effective? A meta-
analytic review. Dev. Psychol. 49 (2), 270.
Menezes, A., Dias, N.M., Trevisan, B.T., Carreiro, L.R.R., Seabra, A.G., 2015. Intervention
for executive functions in attention deficit and hyperactivity disorder. Arq. Neuro-
Psiquiatr. 73, 227–236.
Miranda, A., Presentación, M.J., Siegenthaler, R., Jara, P., 2013. Effects of a psychosocial
intervention on the executive functioning in children with ADHD. J. Learn. Disabil.
46 (4), 363–376.
Nejati, V., 2020. Cognitive rehabilitation in children with attention deficit-hyperactivity
disorder: transferability to untrained cognitive domains and behavior. Asian J.
Psychiatry 49, 101949.
Nejati, V., 2021a. Balance-based Attentive Rehabilitation of Attention Networks
(BARAN) improves executive functions and ameliorates behavioral symptoms in
children with ADHD. Complement. Ther. Med., 102759
Nejati, V., 2021b. Effect of stimulus dimension on perception and cognition. Acta
Psychol. 212, 103208.
Nejati, V., 2021c. Program for attention rehabilitation and strengthening (PARS)
improves executive functions in children with attention deficit-hyperactivity
disorder (ADHD). Res. Dev. Disabil. 113, 103937.
Nejati, V., Derakhshan, Z., 2021. The effect of physical activity with and without
cognitive demand on the improvement of executive functions and behavioral
symptoms in children with ADHD. Expert Rev. Neurother. 21 (5), 607–614.
Nejati, V., Fallah, F., Rakin, S., 2020. Inhibitory control training improves ADHD
symptoms and externalizing behavior.
Nejati, V., Heyrani, R., Nitsche, M., 2022. Attention bias modification through
transcranial direct current stimulation (tDCS): a review. Neurophysiol. Clin.
Asian Journal of Psychiatry 81 (2023) 103469
Nejati, V., Salehinejad, M.A., Sabayee, A., 2018. Impaired working memory updating
affects memory for emotional and non-emotional materials the same way: evidence
from post-traumatic stress disorder (PTSD). Cogn. Process. 19 (1), 53–62.
Passarotti, A.M., Balaban, L., Colman, L.D., Katz, L.A., Trivedi, N., Liu, L.,
Langenecker, S.A., 2020. A preliminary study on the functional benefits of
computerized working memory training in children with pediatric bipolar disorder
and attention deficit hyperactivity disorder. Front. Psychol. 10, 3060.
Patros, C.H.G., Alderson, R.M., Hudec, K.L., Tarle, S.J., Lea, S.E., 2017. Hyperactivity in
boys with attention-deficit/hyperactivity disorder: the influence of underlying
visuospatial working memory and self-control processes. J. Exp. Child Psychol. 154,
1–12.
Patros, C.H.G., Alderson, R.M., Kasper, L.J., Tarle, S.J., Lea, S.E., Hudec, K.L., 2016.
Choice-impulsivity in children and adolescents with attention-deficit/hyperactivity
disorder (ADHD): a meta-analytic review. Clin. Psychol. Rev. 43, 162–174.
Rapport, M.D., Orban, S.A., Kofler, M.J., Friedman, L.M., 2013. Do programs designed to
train working memory, other executive functions, and attention benefit children
with ADHD? A meta-analytic review of cognitive, academic, and behavioral
outcomes. Clin. Psychol. Rev. 33 (8), 1237–1252.
Spencer-Smith, M., Klingberg, T., 2015. Benefits of a working memory training program
for inattention in daily life: a systematic review and meta-analysis. PLoS One 10 (3),
e0119522.
Thorell, L.B., Wåhlstedt, C., 2006. Executive functioning deficits in relation to symptoms
of ADHD and/or ODD in preschool children. Infant Child Dev. 15 (5), 503–518.
Vakil, E., Heled, E., 2016. The effect of constant versus varied training on transfer in a
cognitive skill learning task: the case of the Tower of Hanoi Puzzle. Learn. Individ.
Differ. 47, 207–214.
Vandenbroucke, J.P., 1998. Bias in meta-analysis detected by a simple, graphical test.
Experts’ views are still needed. BMJ: Br. Med. J. 316 (7129), 469.