Journal of Autism and Developmental Disorders

https://doi.org/10.1007/s10803-020-04723-w

ORIGINAL PAPER

Pilot Study of an Attention and Executive Function Cognitive

Intervention in Children with Autism Spectrum Disorders
Sarah J. Macoun1 · Isabel Schneider1 · Buse Bedir1 · John Sheehan1 · Andrew Sung2

© Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
This pilot study investigated the efficacy of a game-based cognitive training program (Caribbean Quest; CQ) for improv-
ing attention and executive function (EF) in school-aged children with Autism Spectrum Disorder (ASD). CQ is a ‘serious
game’ that uses a hybrid process-specific/compensatory approach to remediate attention and EF abilities through repetitive,
hierarchically graded exercises delivered in an adaptive format. Game-play is accompanied by instruction in metacognitive
strategies delivered by an adult trainer. Twenty children diagnosed with ASD (ages 6–12 years) completed 12 h of interven-
tion in schools over 8–10 weeks that was facilitated by a trained Research Assistant. Pre-post testing indicated near transfer
gains for visual working memory and selective attention and far transfer effects for math fluency. Exit interviews with par-
ents and school staff indicated anecdotal gains in attention, EF, emotion-regulation, flexibility, communication, and social
skills. Overall, this study provides preliminary support for the feasibility and potential efficacy of the CQ when delivered in
schools to children with ASD.

Keywords Autism · Attention training · Executive function training · Cognitive intervention · Process specific intervention ·
Metacognitive strategy teaching

Introduction

The primary diagnostic features of Autism Spectrum Dis-

orders (ASD) are distinct social-communication tenden-
cies and unusual, restrictive, and/or repetitive behaviours
This research was conducted at the University of Victoria.
and interests, yet up to 85% of this population also have
Electronic supplementary material The online version of this difficulties with attention and executive functioning (EF;
article (https​://doi.org/10.1007/s1080​3-020-04723​-w) contains American Psychiatric Association 2013; Demetriou et al.
supplementary material, which is available to authorized users.
2019; Gargaro et al. 2011). These ‘secondary deficits’ may
* Sarah J. Macoun include problems with concentration/focus (Corbett et al.
sjmacoun@uvic.ca 2009; Noterdaeme et al.2010), orienting attention (Keehn
Isabel Schneider et al. 2010), inhibitory control (Christ et al. 2011), work-
isabel.s.schneider@gmail.com ing memory (Garon et al. 2018), switching/flexibility
Buse Bedir (Demetriou et al. 2019), and/or planning (Robinson et al.
bbedir@uvic.ca 2009), all of which may impact academic, social, and/or
John Sheehan behavioural development and functioning (Demetriou et al.
jsheehan@uvic.ca 2019; O’Brien and Pearson 2004; Pellicano 2012). More
Andrew Sung specifically, attention and EF deficits increase the risk of
ansung@uvic.ca academic underachievement and learning difficulties by
making it more difficult to follow instructions/procedures,
1
Psychology Department, University of Victoria, PO shift between tasks, regulate behaviours/emotions, interact
Box 1700 STN CSC, Victoria, BC V8W 2Y2, Canada
with others, and implement learning strategies (Biederman
2
Educational Psychology Department, University of Victoria, et al. 2004; Fuglestad et al. 2015; St. Clair-Thompson and
Victoria, BC, Canada

13
Vol.:(0123456789)

Gathercole 2006). Untreated attention and EF deficits can
also potentially exacerbate primary symptoms of ASD and
reduce some of the potential benefits gleaned from the clini-
cal interventions that target them (Kenworthy et al. 2009;
Pugliese et al. 2015; Wallace et al. 2016).
The majority of cognitive interventions have traditionally
been separated into two categories: process-specific (i.e.,
restorative; Kleim and Jones 2008; Sohlberg et al. 2003)
and compensatory (Ylvisaker et al. 1998) approaches.
The process-specific approach aims to directly remediate
an underlying cognitive deficit by capitalizing on princi-
ples of experience-dependent neuroplasticity, whereby the
brain continuously remodels its neural circuitry in order to
encode new adaptive experiences and effect behavioural
change (Kleim and Jones 2008; Mishra and Gazzaley 2014).
Therefore, a cognitive function is targeted systematically and
repeatedly through massed practice and intensive exercise,
theoretically resulting in neural change via the strengthen-
ing of functional neural pathways that results in both broad
and specific gains in related behaviours (Kleim and Jones
2008; Sohlberg et al. 2003). Training features thought to be
essential to maximizing outcomes in this approach include
salience, hierarchically-graded tasks, adaptive difficulty lev-
els, sufficient intensity of training exercises, and repetition
(Kleim and Jones 2008).
In contrast, the compensatory approach does not neces-
sarily set out to rebuild neural structures from the bottom-
up but rather focuses on helping an individual to adapt to a
functional deficit by developing “work around” strategies
(i.e., a more ‘top-down’ approach; Horn and Lewis 2014;
Ylvisaker et al. 1998, 2007). This method involves teach-
ing problem-solving approaches and exercises that enable
an individual to change their interactions with the environ-
ment, modify their approach to certain tasks, and adapt their
lifestyle to account for their specific strengths and weak-
nesses (Horn and Lewis 2014). According to its proponents,
the compensatory approach leads to the acquisition of new
skills and strategies that enable the underlying cognitive
abilities to be used more effectively and efficiently (Mateer
et al. 1996; Morrison and Chein 2011).
Recently there has been interest in delivering cognitive
interventions within a computerized format due to the unique
benefits that a computerized medium affords (e.g., engag-
ing, easy to administer, accessible). Despite debate within
the literature (Apter 2012; Klingberg 2010; Melby-Lervåg
and Hulme 2016; Morrison and Chein 2011; Shipstead
et al. 2012) there is mounting evidence that computerized
attention/EF training can be effective for developmentally
and neurologically diverse populations (Blair and Diamond
2008; Forstmann et al. 2008; Karbach and Unger 2014;
Karbach and Verhaeghen 2014; Macoun et al. 2020, Kerns
et al. 1999, 2010, 2017; Klingberg et al. 2002, 2005; Lee
et al. 2016; Morrison and Chein 2011; Prins et al. 2011;
13
Journal of Autism and Developmental Disorders
Robinson et al. 2014; Rueda et al. 2012; Thorell et al. 2009;
Titz and Karbach 2014; Verhaeghen et al. 2004; Westerberg
et al. 2007). Only a handful of interventions have integrated
cognitive rehabilitation into a ‘serious game’ design, which
is one that uses video-game components to create engaging
learning experiences (Whyte et al. 2015). Serious games
draw upon empirical research findings that suggest learn-
ing is maximized when it occurs in relevant contexts that
engages learners (Catalano et al. 2014). Unfortunately, many
existing game-based interventions that show near-transfer
effects have shown little-to-no evidence of generalized gains
(Whyte et al. 2015). Whyte et al. (2015) argue that in order
for serious games to be successful, there would have to be
sufficient learning trials, an appropriate level of difficulty,
and learning contexts provided that are more immersive and
contextualized. Interventions that are delivered in naturalis-
tic settings that bridge computerized and real-life contexts
by involving other persons in the intervention process (e.g.,
parents, peers, practitioners) may facilitate better interven-
tion outcomes and greater likelihood of generalization (Wass
and Porayska-Pomsta 2014). Further, more recent studies
have recommended that cognitive training programs com-
bine process-specific and compensatory approaches, given
that both approaches offer unique potential benefits. These
‘hybrid’ cognitive intervention approaches may be more
likely to result in meaningful change and the far transfer
of gains (i.e., generalization), as they capitalize both on the
mechanisms of improved neural function (capacity) and bet-
ter strategic allocation of existing resources (efficiency; Cic-
erone et al. 2011; Kennedy et al. 2008; Partanen et al. 2015).
Specifically, computer-based attention/EF training has been
proposed as a feasible and potentially preferable option for
children with ASD (Benyakorn et al. 2018), particularly if
combined with compensatory approaches (Partanen et al.
2015).
Despite recommendations to target attention/EF during
formative periods of cognitive development (e.g., see Wass
2015), the limited research on cognitive attention/EF train-
ing in ASD has yielded variable results ranging from null
findings (De Vries et al. 2015) to positive effects (Macoun
et al. 2020; Kerns et al. 2017; Weckstein et al. 2017). De
Vries et al. (2015) delivered a computerized WM and
flexibility intervention to children with ASD and found
marginal near-transfer gains in WM, without gains in flex-
ibility or evidence of far transfer to other related abilities.
Of note is that the intervention selected was fairly narrow
in cognitive targets (flexibility and WM only), it was not
delivered using a hybrid-approach, and the authors had a
fairly high attrition rate of children (particularly those who
may have had greater EF problems). The authors noted
that their findings did not rule out the possibility that
such training may be helpful for specific groups of chil-
dren with ASD. With these points in mind, it is important
Journal of Autism and Developmental Disorders
to consider the heterogeneity amongst individual studies
(e.g., intervention approaches, intensity, duration, focus/
goals) that make systematic or meta-analytic approaches
in this research area, at least thus far, difficult to interpret.
Thus, it remains essential to evaluate individual studies to
look for key factors related to outcomes, including neuro-
logical/clinical diagnosis, targeted domains, intervention
designs, methodology, dose/response, etc. For example,
there is emerging evidence that EF can be improved with
systematic intervention in ASD (Kenworthy et al. 2014)
and that computer-based training can be effective in this
group (Bölte et al. 2015). Bölte et al. (2015) demonstrated
that computer-based social cognition training can lead to
neural change in social information processing systems in
adolescents/adults with ASD. Results from previous stud-
ies of attention/EF training in a mixed pediatric sample
(i.e., children with ASD and FASD), which used trained
Educational Assistants as interventionists, indicated signif-
icant gains in aspects of attention/EF, behaviour/emotional
regulation, reading fluency, academic engagement, self-
monitoring, and strategy use (Kerns et al 2017; Macoun
et al. 2017). The school setting is well-suited for cogni-
tive interventions in that it provides diverse opportunities
to practice the targeted abilities in a naturally complex
environment (Bellini et al. 2007; Wass 2015). As prior
studies illustrate, the limited feasibility, accessibility, and
affordability of existing intervention approaches are bar-
riers for which school-based delivery may offer solutions.
Therefore, the current study sought to investigate the effi-
cacy of the Caribbean Quest (CQ), a game-based cognitive
intervention for improving attention and EF, in children
with ASD as delivered within a school setting.
The CQ is a novel ‘serious game’ that combines process-
specific and compensatory approaches (i.e., a hybrid inter-
vention) to improve attention/EF. Key intervention compo-
nents are built into the CQ, such as engaging graphics and
gameplay, adaptive level progression, and a hierarchical
format that trains a range of attention/EF abilities spanning
from foundational (e.g., focusing attention) to more com-
plex (e.g., visual and auditory WM) skills, with earlier levels
of the game more focused on training selective attention,
inhibitory control, and visual WM and later levels focused
on training auditory WM. The goals of the current study
were to determine whether children with ASD could benefit
from CQ attention/EF training as demonstrated on measures
of near transfer (i.e., objective performance measures) and
far transfer (i.e., measures of behavioural outcome and aca-
demic achievement). We hypothesized that children would
show gains in attention/EF on both near- and far-transfer
measures, including tasks of WM and academic achieve-
ment. We anticipated greater change on measures of visual
WM, given that CQ activities in the current study were pri-
marily focused on visual WM. Finally, we were interested in
evaluating the feasibility of delivering the CQ in schools to
improve accessibility to such intervention options.
Methods
This study was approved by the human subjects review board
at the University of Victoria (British Columbia) and was
conducted in accordance with Tri-council ethical standards.
Participants
The sample consisted of 20 children ages 6–12 years
(M = 8.64, SD = 1.74) with an existing diagnosis of ASD and
difficulties with attention/EF. Children were recruited from
12 suburban/rural schools within a local school district and
all were being instructed in inclusive education programs
amongst same-age peers. Special education staff nominated
children based on criteria provided by the researchers (i.e.,
a formal diagnosis of ASD and a list of behaviours indica-
tive of attention/EF problems) and gave parents informa-
tion pamphlets to contact the researchers if interested. All
children who participated held prior diagnoses of ASD
based upon DSM-IV-TR criteria (American Psychiatric
Association 2000) using B.C. Standards and Guidelines
(Dua 2003), which require that diagnostic assessments be
conducted by a qualified specialist and incorporate meas-
ures of cognitive function, adaptive behaviour, the Autism
Diagnostic Interview Revised (ADI-R; Lord et al. 1994),
and the Autism Diagnostic Observation Schedule (ADOS;
Lord et al. 1999). To confirm ASD diagnoses and symptom
levels, parents were administered an abbreviated ADI-R that
consisted of algorithm items only (Kim and Lord 2012) and
the Gilliam Autism Rating Scale Second Edition (GARS-2;
Gilliam 2006). All children exceeded diagnostic thresholds
for ASD based on the abbreviated ADI-R. Prior to the study,
all parents completed a telephone-screening interview and
childhood history questionnaire to determine study eligi-
bility and gather demographic information. Parent-com-
pleted attention and EF rating scales at pre-test indicated
the overall sample displayed clinically significant problems
with attention (Conner’s Rating Scales—3rd Edition, Short
Form; Conners 2008) and EF (Behavior Rating Inventory of
Executive Function (BRIEF; Gioia et al. 2000; see Table 1).
No children had a history of traumatic brain injury, specific
neurological disorder, inability to communicate verbally,
or a diagnosis of intellectual disability (i.e., FSIQ standard
score below 70 and accompanying adaptive behavior impair-
ments, as outlined by DSM-IV-TR; American Psychiatric
Association 2000).
Twenty-three children with ASD were initially enrolled in
the study, although two parents withdrew their children prior
to the start date due to time and scheduling constraints. One
13
 Journal of Autism and Developmental Disorders

Table 1  Child demographic data services outside of the study and the groups did not differ
Demographic variables CQ Control p
on the number of external services they were receiving (see
N = 11 N=9 Table 1).

Age in years: M (SD) 8.64 (1.74) 8.67 (2.23) .973

Study Design
Gender: M/F 9/2 8/1 .679
1
WRIT SS FSIQ: M (SD) 94 (12.34) 87 (19.64) .384
This study utilized a waitlist-control design with random
Comorbid diagnoses: %
assignment to either an intervention (CQ) or waitlist-control
Total 18% 33% .833
group. A waitlist-control design was chosen for this pilot
ADHD 9% 22%
so that we could offer all participants a potentially helpful
Tics/sensory 9% 0%
intervention while controlling for the effects of maturation
Blank spells 0% 11%
and practice effects. Eleven children started the CQ imme-
Other services: %
diately following pre-test (intervention group) and nine were
Total 45% 78% .158
2
placed on a waitlist (control group) to be given the oppor-
Academic supports 9% 22%
3
tunity to use the CQ after the first group had finished. The
Integrated service 9% 22%
intervention and control groups did not differ significantly
Speech language 9% 11%
with respect to gender, age, diagnostic comorbidities, ASD
Occupational therapy 9% 0%
symptom levels, or attention/EF problems (see Table 1).
Behavior intervention 18% 11%
Children were assessed at two main time points: Time 1
Social group 0% 33%
4
served as pre-test (i.e., prior to starting the intervention or
Other therapies 18% 22%
waitlist control period) and Time 2 served as post-test (i.e.,
Medication 18% 44%
5
conclusion of CQ intervention and end of the waitlist control
Conners-3-P T IN: M (SD) 73.45 (14.56) 78.56 (16.62) .474
6
period) to allow for group comparisons. At pre- and post-
Conners-3-P T HY/IM 80.45 (14.12) 83.44 (17.48) .481
7
test, children were administered a battery of attention, EF,
Conners-3-P T EF 70.82 (9.75) 69.56 (16.96) .837
8
and academic achievement measures (~ 90 min, including
BRIEF-P T GEC.: M (SD) 68.40 (7.17) 71 (10.98) .556
9
breaks) that were counterbalanced and delivered by trained
BRIEF-P T MI.: M (SD) 66.40 (7.34) 67 (10.68) .887
10
RAs who were blind to group status. The pre- and post-
BRIEF-P T BRI.: M (SD) 68.10 (7.22) 74.00 (10.40) .166
11
test batteries were identical with the exception of an intel-
GARS-2 P SS AI 87.00 (13.58) 94.86 (25.68) .442
lectual screening measure (Wide Range Intelligence Test
1
WRIT SS FSIQ (wide range intelligence test standard score full (WRIT); Glutting et al. 2000), which was administered only
scale IQ) at pre-test.
2
Academic supports (tutoring, learning assistance, gifted program- An RA delivered the CQ via laptop during regular school
ming) hours to children in a one-to-one format. Children were
3
Integrated services (ASD focused program with integrated supports pulled from their classroom activities 3×/week to attend
that include behavior intervention, social supports, speech-language,
occupational therapy training sessions lasting approximately 30 min, resulting in
4
Other therapies (music therapy, counselling, therapeutic horseback
24 total sessions over an 8-week period, although the spe-
riding) cific breakdown was amenable to the needs of the child,
5
Conners-3-P T In. (Conners-3, Parent, Short Form, T score, Inatten- family, and school. Sessions took place within private loca-
tion) tions in each child’s respective school. Prior to delivering
6
Conners-3-P T HY/IM (Hyperactivity/Impulsivity) the intervention, the RA completed a 5-h online training
7
Conners-3-P T EF (Executive Functions) course designed for non-expert adult trainers (e.g., parents,
8
BRIEF-P T GEC. (Behaviour Rating Inventory of Executive Func- EAs, teachers, etc.). This training site provides information
tion Parent T Score General Executive Composite) regarding the constructs of attention and EF, basic prin-
9
BRIEF-P MI (Metacognition Index) ciples of process-specific approaches and neuroplasticity,
10
BRIEF-P BRI (Behavioural Regulation Index) CQ-specific applied lessons, progress tracking, performance
11
GARS-2 P SS AI (Gilliam Autism Rating Scale 2 Parent Standard scaffolding, fidelity monitoring, and techniques to promote
Score Autism Index) far-transfer to other settings. It also provides a ‘manualized’
approach to instructing and delivering metacognitive strate-
additional child was withdrawn from the study after missing gies, where RA’s are provided with specific instructions and
several weeks of school due to illness. The final sample of scripts for how and when to teach and facilitate the use of
20 children (3 females, 17 males) was predominantly Cau- specific metacognitive strategies during game play.
casian with incomes in the middle-class range. Children The primary role of the RA was to scaffold the acqui-
were encouraged to continue their regular interventions/ sition and mastery of metacognitive strategies, to engage

13
Journal of Autism and Developmental Disorders
the child in CQ gameplay, and facilitate the generalization
of the intervention. During intervention sessions, the RA
identified difficulties that arose on gameplay/training exer-
cises (e.g., struggling to complete a level due to increased
working memory demands, etc.) and/or during the broader
session (e.g., low frustration tolerance, emotional dysregu-
lation, etc.). The RA then provided ‘scaffolded’ support to
improve the child’s attention, EF, and self-regulation. These
strategies included those that apply to all intervention games
(e.g., “good listening” and “readying your body”) and game-
specific strategies (e.g., “rehearsal,” “chunking,” and “trac-
ing”, etc. See Supplement 1).
Intervention fidelity was demonstrated by the RA via
completion of quizzes that followed each training website
module (requiring mastery via 100% score on quizzes),
weekly check-ins with the research team, and observations
by the senior research team. In addition, the RA completed a
daily record of each intervention session (CQ Tracking form)
that included information on, (1) date, time, and length of
session; (2) games played and levels achieved; and (3) meta-
cognitive strategies used.
The CQ Intervention
The CQ consists of five hierarchically-structured, self-
adjusting mini-games that train WM, inhibitory control,
selective attention, and sustained attention (Kerns et al.
2017). Given the intervention duration within the current
study (12 intervention hours), children primarily engaged in
attention, inhibition, and visual working memory activities,
as opposed to the verbal WM tasks that occur later in the CQ
game hierarchy. The CQ utilizes a process-specific approach
that capitalizes on Kleim and Jones’ (2008) key principles
for optimizing neuroplasticity. Game progression is depend-
ent upon either achieving a specific number of correct trials
(100%) or a certain accuracy level (90%), depending upon
the specific game and cognitive process being targeted.
To enhance motivation, CQ provides a range of fun bonus
games after the completion of each cognitive training task
(i.e., with tokens that can be used to ‘purchase’ trophy/deco-
rative items within the program). The CQ is designed to be
administered in the presence of an adult trainer who teaches
the child metacognitive strategies to help foster generaliza-
tion to real world tasks (Partanen et al. 2015; Sohlberg et al.
2003). Although metacognitive instructional strategies were
provided in a systematic format, by the nature of this type
of intervention the strategies taught to the child depended
on the adult trainer and what appeared to be the most ben-
eficial for the particular child in a given situation (i.e., when
facing various types of challenges in the game). Metacogni-
tive strategies were taught using a 5-step script: (1) Iden-
tify the issue/difficulty, (2) State the reason for the issue/
difficulty, (3) Select and implement a strategy, (4) Evaluate
the outcome of the strategy, and (5) Once a strategy works,
celebrate success (i.e., provide positive reinforcement).
Fidelity and Feasibility
A review of the RA per-session tracking booklet data indi-
cated that the CQ games were played as recommended (2–3
games per session, 3 times a week, for approximately 30 min
per session) and that metacognitive strategies were deliv-
ered as instructed on the training website. Therefore, the
CQ could be delivered in school contexts while maintaining
fidelity with respect to gameplay and metacognitive strat-
egy guidelines. All but one (due to illness) of the children
completed the full 12 h without any reported difficulties.
Exit interviews with participating parents (70%) and teach-
ers (90%) indicated that children enjoyed the intervention.
Teachers/EAs felt that the CQ was not disruptive or diffi-
cult to deliver in the school day and that it did not inter-
fere significantly with regular school activities or learning
opportunities.
Outcome Measures
Attention and Executive Function
Aspects of attention and EF were assessed using three sub-
tests from the Test of Attentional Performance Children’s
Version (KiTAP), a computerized attention/EF battery
for children (Zimmerman et al. 2002; see Supplement B).
KiTAP subtests included measures of sustained attention
(Ghost’s Ball), selective attention (Sad/Happy Ghost), and
divided attention/cognitive flexibility (Owls). Visual and
verbal WM were assessed using the Spatial Span and Digit
Span tasks from the Wechsler Intelligence Scale for Chil-
dren, Fourth Edition (WISC-IV; Kaplan et al. 2004). Vis-
ual working memory/updating was also assessed using the
Colored Boxes Task (Brocki et al. 2008; see Supplement 2).
Academic Achievement
Measures of reading (Oral Reading Fluency Curriculum
Based Measure; ORF; Hosp et al. 2016) and math (Wood-
cock Johnson III- Math Fluency; WJ-III; Woodcock et al.
2007) were administered to assess academic fluency/
efficiency.
Behavioral Ratings
The Behavior Rating Inventory of Executive Function
(BRIEF; Gioia et al. 2000), Conners’ Rating Scale—Short
Version, Third Edition (CRS-3; Conners 2008), BERS-2
(Epstein 2000), SSRS (Gresham and Elliot 1990), and
GARS-2 (Gilliam 2006) were administered at pre- and
13
 Journal of Autism and Developmental Disorders

post-test, but low post-test return rates precluded meaning-

ful pre-/post-test analysis. 20

Adjusted Post-Test Mean Values

18
16
14
Results 12
10
8
Analysis Overview 6
4
2
ANCOVAs (with pre-test scores as the covariate) were run 0
to determine the effects of the attention/EF and control inter- Kitap Selecve Colored Boxes Spaal WJ Math FLuency
A enon Errors WM Errors Error Proporon (%)
ventions on post-test attention/EF and academic achieve-
ment and partial η2 was calculated to determine effect size Control Intervenon

(Howell 2002). Significant findings were followed up with

post-hoc analyses with Bonferroni adjustment. Data reported Fig. 1  Adjusted post-test means (with pre-test scores as covariate) for
the intervention and control groups
are adjusted means unless otherwise stated. Due to technical
challenges, the following data loss occurred: 7 from WJ-III
Math Fluency (2 pre/5 post), 5 from ORF reading fluency There were no significant post-test differences seen for the
(1 pre/4 post), 7 from the Colored Boxes task (2 pre/5 post) WISC-IV Spatial Span or Digit Span tasks.
and 1 from the KiTAP (1 post). Table 2 provides unadjusted
and adjusted means and standard deviations/standard errors
for the analyses reported below. Academic Fluency

Efficacy On the Woodcock Johnson Math Fluency task, after

Attention/EF Performance Measures
On the KiTAP ‘Sad/Happy Ghost’ selective attention task,
after controlling for pre-test scores, there was a statistically
significant difference in errors between the intervention and
control groups, F(1,16) = 4.61, p < .05, partial η2 = .224 (see
Fig. 1). Post-hoc analyses indicated that post-test errors were
significantly lower in the intervention group when compared
with the control group ­(Mdiff = 9.15, 95% CI [.12–18.18],
p < .05). There were no significant post-test differences seen
for the KiTAP ‘Owls’ (divided attention) or ‘Ghost’s Ball’
(sustained attention) tasks.
On the ‘Colored Boxes’ visual-spatial WM task, after
controlling for pre-test scores, there was a significant dif-
ference in errors between the intervention and control
groups, F(1,15) = 12.23, p < .01, partial η 2 = .49 (see
Fig. 1). On post-hoc testing, errors were significantly
lower in the intervention group when compared with the
control group ­(Mdiff = 6.63 [95% CI 2.59–10.68], p < .01).
controlling for pre-test scores, there was a significant
difference in total errors, F(1,16) = 5.98, p < .05, par-
tial η2 = .28, with post-hoc analyses indicating that the
intervention group made fewer errors than the control
group ­(Mdiff = 14.08 [95% CI .544–7.61], p < .05). Inter-
estingly results also trended towards the intervention
group attempting fewer problems than the control group,
F(1,16) = 3.40, p = .08. To account for the possibility that
fewer errors in the intervention group could be a result
of them simply trying fewer problems, we analyzed the
results using proportion of math errors (errors/problems
attempted). There was a significant difference in the pro-
portion of errors between the intervention and control
groups, F(1,12) = 4.60, p = .05, partial η2 = .28 (see Fig. 1),
with the proportion of errors being significantly lower in
the intervention group than the control group ­(Mdiff = .11
[95% CI − .001 to .221], p = .05; see Table 2). No sig-
nificant post-test differences were seen for oral reading
fluency.

Table 2  Adjusted and Test Intervention group Control group

unadjusted post-test means
and variability for post-test Unadjusted Adjusted Unadjusted Adjusted
scores, with pre-test scores as a
covariate M SD M SE M SD M SE

KiTap Selective Attention (Ghosts Total errors) 14.20 10.59 9.40 2.67 13.22 10.81 18.55 2.84
Colored Boxes Visual WM (Total Errors) 5.53 4.14 5.84 1.34 12.80 5.16 12.47 1.34
WJ Math Fluency (Proportion of errors) .07 .08 .07 .04 .18 .15 .18 .04

13
Journal of Autism and Developmental Disorders
Discussion
Children with ASD often present with attention and EF
deficits that impact long-term outcomes, thus making the
need for early remediation crucial (Baijo et al. 2018; De
Vries et al. 2015; Demetriou et al. 2019). Direct cogni-
tive interventions have been used successfully to enhance
attention/EF in children with neurodevelopmental disor-
ders with associated social, emotional, behavioural, and
academic gains (Kerns et al. 2017; Macoun et al. 2017,
2020; Robinson et al. 2014). Research on the use of such
approaches in children with ASD is quite limited, despite
the potential (De Vries et al. 2015; Wass and Porayska-
Pomsta 2014). The current study investigated the efficacy
of a novel ‘serious game’ cognitive training interven-
tion, the CQ, that was designed to improve attention/EF
in children. Twenty school-age children diagnosed with
ASD completed 12 h of cognitive training within their
respective schools, distributed over 8–10 weeks (24 ses-
sions, 3 times/week, 30 min per session). The CQ utilizes
a hybrid cognitive intervention approach that combines
process-specific (Sohlberg et al. 2003) and compensatory
(Ylvisaker et al. 1998) approaches. As such it capitalizes
on the benefits of one-to-one interventionist work within
the context of a ‘serious game’ to improve outcomes and
promote the generalization of new skills.
On near-transfer objective performance measures,
children in the CQ intervention group showed gains in
selective attention and visual WM (as evidenced through
a reduction in errors on post-test after co-varying out pre-
test scores). Gains were not seen on measures of verbal
WM, sustained attention, or divided attention/cognitive
flexibility. This finding was anticipated in that children
completed approximately the first half of the CQ levels,
within the 12 h prescribed, and these levels are focused
heavily on visual WM and selective attention activities.
Thus, the greater emphasis on visual WM and selec-
tive attention activities on the intervention as delivered
in the current study explains why significant gains were
restricted to these domains. It should also be noted that
visual WM gains are consistent with results of other stud-
ies (Macoun et al. 2017; Schwarb et al. 2016) and support
findings that visual WM may be particularly amenable to
training-related change (Alloway et al. 2016; Kundu et al.
2013).
Concerning far transfer, children in the CQ interven-
tion group showed a significant reduction in errors on a
measure of math fluency and a reduction in the numbers
of problems attempted. To investigate the possibility that
a reduction in errors could simply be because the interven-
tion group completed fewer problems, further analysis was
done using the proportion of errors. Results indicated that
the children in the CQ made fewer math errors propor-
tional to the number of problems attempted; however, this
is only a preliminary finding that should be validated in
future studies. Math fluency tasks require a child to focus
their attention on the question at hand, hold key informa-
tion in mind while mentally working with it (or ‘manipu-
lating’ it), and suppress irrelevant information. Consider-
ing these many demands, it is not surprising that WM has
been shown to be an important predictor of math skills
(Gathercole and Pickering 2000; Kroesbergen et al. 2007;
Passolunghi et al. 2007; Swanson and Kim 2007). The
pattern seen in the current study may be due to expanded
attention/EF capacity as a result of the process-specific
aspect of the CQ (Karbach and Schubert 2013), improved
attention/EF efficiency as a result of the metacognitive
training component (Morrison and Chein 2011; Nutley
and Söderqvist 2017; Sohlberg and Mateer 2001), or both.
Regardless, these findings provide preliminary support for
the potential benefits of a broader attention/EF training
program (i.e., one that includes both process-specific and
metacognitive components) on math outcomes. Our data
is consistent with literature suggesting that WM training
programs that include in-person coaching facilitate far
transfer in the area of math (Nelwan et al. 2018). Inter-
estingly, significant gains were not seen on a measure of
oral reading fluency. Given that our intervention did not
focus on verbal WM, and that verbal WM tends to be more
associated with reading outcomes than visual WM (Barnes
et al. 2018; Locascio et al. 2010; Pham and Hasson 2014),
this result is perhaps not surprising.
Low rating scales return rates at post-test precluded
meaningful analysis. However, exit interviews with 70% of
parents and 90% of teachers following the study indicated
anecdotally-reported gains in children’s focus/attention, effi-
ciency/engagement in schoolwork, organization skills, flex-
ibility, and WM. Parents and teachers also reported gains
in self-regulation (e.g., increased patience/tolerance, fewer
behavioural/emotional outbursts, etc.) and completion of
daily tasks (e.g., chores, schoolwork), which they perceived
as being due to improved engagement, regulation, and focus.
Forty percent of teachers reported that task completion in the
classroom was accompanied by an increase in unprompted
metacognitive strategy use by the children, including repeat-
ing things out loud, making self-encouraging statements,
referencing lists, and increased use of visual schedules and
timers. This may be a direct result of the metacognitive
component of the intervention. These results clearly require
future validation using standardized measures of behavioural
change.
With respect to feasibility, it is notable that there was no
attrition following the commencement of the intervention
and that 100% of participating children reported having gen-
erally enjoyed the intervention. Given that process-specific
13

interventions by nature require a significant degree of repeti-
tion, which can make them at least seem intolerable, this is
an important finding. A non-expert within a range of school
settings was able to deliver the CQ with a high degree of
fidelity and without causing disruption to children’s existing
academic demands or adding demands to families’ after-
school routines. Schools provide a setting that is both natu-
ralistic and convenient for the delivery of cognitive inter-
ventions. The usability of the CQ within this setting may
help to increase the accessibility of cognitive interventions
to children with ASD and neurodevelopmental concerns in
general, particularly and crucially within geographically and
socioeconomically limited communities.
Limitations
This study had several limitations that are important to note.
Sample size was limited (n = 20), which likely decreased
our ability to detect the size and scope of meaningful
effects. This study also had low return rates for post-test
rating scales, making it not possible to statistically analyze
the extent of any behavioural changes outside of the formal
controlled test setting. This was in part due to the time of
year (i.e., close to summer) and because parents may have
been over-taxed by the provision of too many rating scales.
Future studies should investigate the effectiveness of such
interventions selecting a more limited core battery of behav-
ioural rating scales to ensure better return rates through
which to evaluate far-transfer effects. Although a wait-list
control design was deemed appropriate for this pilot study,
randomized controlled trials are needed, with their increased
validity via random sampling/assignment, stricter control
groups, and double blinding of participants and those con-
ducting pre- and post-testing. Longitudinal follow-up is also
required to evaluate the maintenance of intervention gains
and to assess for changes in skills that take longer to emerge
(i.e., academic and behavioral gains).
Conclusions
This study presents important preliminary data regarding the
efficacy of a ‘serious game’ intervention for attention/EF in
children with ASD, with evidence suggesting near and far
transfer effects of intervention results. The potential of atten-
tion/EF remediation in ASD is largely unexplored, despite
significant empirical evidence showing the prevalence of
difficulties in this area in those with ASD, as well as their
impact upon core ASD symptoms and other implications
related to lifelong outcomes. Results of this study demon-
strated several key benefits to utilizing a ‘serious game’ for-
mat to initially engage children and to help maintain motiva-
tion throughout the weeks or months that interventions can
13
Journal of Autism and Developmental Disorders
span. The CQ was easily delivered during the school day,
with no discernable negative impact upon the classroom or
school activities. Large-scale randomized controlled stud-
ies with longitudinal follow-up are required to replicate the
positive findings in this preliminary pilot trial and to deter-
mine whether the observed gains are meaningful and lasting.
Author Contributions SJM designed/directed this study, supervised
the analysis, and co-wrote the manuscript. IS and BB supported data
analysis and manuscript preparation. AS delivered the intervention. JS
was involved with manuscript preparation and editing.
Funding This research was supported by a grant from Kids Brain
Health Network (previously NeuroDevNet), which is a member of the
Networks of Centres of Excellence program of Canada.
Compliance with Ethical Standards
Conflict of interest No financial interest or other benefit has arisen
from the direct applications of this research.
Ethical Approval This research was conducted with the approval of the
University of Victoria Human Ethics Board and in accordance with
Tri-Council Human Ethics guidelines.
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