Journal ofhttp://jad.sagepub.com/ Attention Disorders
Cogmed Working Memory Training Product Review Jeffrey D. Roche and Brian D. Johnson Journal of Attention Disorders 2014 18: 379 originally published online 6 March 2014 DOI: 10.1177/1087054714524275 The online version of this article can be found at: http://jad.sagepub.com/content/18/4/379
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JADXXX10.1177/1087054714524275Journal of Attention DisordersRoche and Johnson
Product Review
Cogmed Working Memory Training Product Review
Journal of Attention Disorders 2014, Vol. 18(4) 379–384 © 2014 SAGE Publications Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1087054714524275 jad.sagepub.com
Jeffrey D. Roche1 and Brian D. Johnson1
Abstract Objective: In this review of the Cogmed training program, we discuss its theoretical foundations, materials, the intervention program, use of coaches, customer support, and research support. Method: This review was conducted by means of firsthand exploration of the Cogmed training program in conjunction with a critical synthesis of existing empirical literature. Results: We conclude that Cogmed has the potential to help individuals improve working memory capabilities and focused attention. Conclusion: More research is needed to demonstrate if these changes in working memory and focused attention are enduring and generalizable. (J. of Att. Dis. 2014; 18(4) 379-384) Keywords cognitive performance enhancement, computer attention training, short-term memory, training The Cogmed Working Memory Training system, hereafter referred to as Cogmed, is marketed as “a computer-based solution for attention problems caused by poor working memory (WM),” that combines “cognitive neuroscience with innovative computer game design and close professional support to deliver substantial and lasting benefits” (www.cogmed.com). The program is said to draw from research on the central role of WM deficits for various psychiatric disorders and learning disabilities (e.g., Holmes, Gathercole, & Dunning, 2009; Martinussen, Hayden, HoggJohnson, & Tannock, 2005) as well as research on the application of neuroplasticity principles to WM training and enhancement (Klingberg, Forssberg, & Westerberg, 2002a; Olesen, Westerberg, & Klingberg, 2004). Klingberg and colleagues began marketing Cogmed in 2001 as an evidence-based intervention designed to help those with WM deficits. In 2010, the Pearson Clinical Assessment Group purchased and began marketing Cogmed worldwide with versions currently available in English (British and U.S.), Norwegian, Spanish, French, Swedish, Japanese, Korean, German, and Dutch. Text-based screen instructions make Cogmed accessible for those with hearing impairments, but some auditory memory training tasks may not be appropriate for individuals with severe hearing loss.
Theoretical Foundation
attention, ignoring distractions, planning, short-term memory, and initiating and completing tasks. This theory also recognizes the important role of attentional control (Awh & Jonides, 2001). In addition, Cogmed reports being strongly influenced by the theory of neuroplasticity, which is essential in understanding the brain’s ability to improve and modify task-specific neural pathways in response to repeated and tailored training. Klingberg (2010) demonstrated topdown attention control and WM shared substantial overlap in parietal and prefrontal cortex neural pathways.
Materials Use of Cogmed requires a computer and/or tablet with speakers, stable broadband internet connection of 0.5 Mbit/s or higher, Adobe Flash plugin version 10.0 or later, and minimal hard drive space to store results. It is programmed for Mac, PC, and Android devices. It is most commonly run through the Cogmed website where users are provided a unique ID and password.
Intended Users According to the website, the typical Cogmed user has WM deficits that arise from one of three areas: organic or 1
Cogmed is based upon the multi-compartmental theory of memory (Baddeley & Hitch, 1974), which recognizes both temporary storage and information manipulation functions of WM as being vital for cognitive tasks, such as: focusing
University of Northern Colorado, Greeley, USA
Corresponding Author: Brian D. Johnson, University of Northern Colorado, 202-A McKee Hall, Box 131, Greeley, CO 80639, USA. Email: [email protected]
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lifelong attention or learning difficulties (e.g., ADHD, LD), various forms of brain insult (e.g., stroke, Traumatic Brain Injury), and reasonably expected memory declines (e.g., due to normal aging, environmental demands). Individuals with dementia are not considered to be appropriate for this training. Cogmed is available in three different packages tailored for different age groups: Cogmed JM is designed for preschool children (ages 4-6), Cogmed RM is for school-age children (7-18), and Cogmed QM is for adults. All versions share the same visual-spatial WM tasks and algorithms, with differences occurring in the user interface. The RM and QM also share the same underlying verbal WM tasks and algorithms.
Program Description The rigorous and tailored sequences of activities users complete are thought to be essential to see sustained improvement in WM functioning (Diamond & Lee, 2011). The standard Cogmed administration protocol for the RM and QM versions requires users to complete eight daily tasks (30-45 min), 5 days a week, for 5 consecutive weeks. The JM standard protocol has fewer items and shorter daily training sessions (15-20 min). In 2013, Pearson launched a series of beta features that allow users to modify the length of training sessions, number of training days, and number of weeks. It is likely that published Cogmed research is based on the standard administration protocol. In all three versions, users are permitted to exit a given exercise, return to the home page, and either resume the activity later or begin another one. With the standard protocol, once an exercise has been completed, it cannot be repeated that day. As some of the exercises are timed, poor computer cursor navigation abilities may prove to be a limitation for some users. The program also produces the Cogmed Progress Indicator (CPI) report. The CPI is described as an index of improvement in non-trained tasks, or generalization. It is computed from an individual’s performance on three tasks (i.e., WM, following instructions, and math challenge). These additional tasks are administered six times during the course of training and are said to measure WM-related gains that are not specifically targeted in Cogmed training. However, given the repeated exposure to the CPI tasks, it is quite possible that changes in CPI scores are at least partially the result of practice effects. The preschool version (Cogmed JM) presents users with bright colored theme park designs that have visual-spatial WM tasks embedded into stimuli like a roller-coaster, Ferris wheel, bumper cars, and more. Each theme park item represents specific WM training tasks, with helpful, repeatable, and kid-friendly demonstrations built into the program. Using a mouse or touch pad, preschoolers must first direct their attention and concentrate to a sequence of items, hold the sequence in their WM, and then use the cursor to click
the target objects in the original order. Target objects are predominately silly, giggly fur ball creatures that provide cheers, starbursts, and smiles to reinforce correct responses, while frowning and appropriately redirecting preschoolers for incorrect responses. The duration of each memory training task adjusts according to a child’s performance with more correct responses being associated with longer intervals. The overall length of the preschool training is 15 to 20 min/day. Generally speaking, the JM version appeared fun, interactive, and age appropriate. The school-aged, Cogmed RM offers users a robot, space, and technology themed interface that is more expansive and challenging than the JM version. Users are still provided instructional demonstrations for most tasks and they are to track and replicate a sequence of events from memory. The increased difficulty comes from having more targets, complex tasks, and longer training sequences. While the space theme might not hold broad appeal for all users, its more varied activities and videogame-like qualities (e.g., presenting users’ scores on tasks so they can try to surpass their prior performance) are likely to appeal to many school-aged participants. In addition, the RoboRacing game, a fun racing game that involves moving a character with the directional keys in order to collect coins and race against the clock, is provided at the end of each training day as an incentive and reward for staying on task. The adult version, Cogmed QM, is nearly identical to the RM, as exercises and daily training times are essentially the same. Some exercises have different names and instruction can be skipped in the adult version. There is also less emphasis on competition with trying to improve upon prior performance. We found the user interface to be less colorful and visually pleasing in the adult version and thus it may require participants to focus their attention more when completing tasks. Some general criticisms were noted across all versions of Cogmed. By clicking the space bar, one can skip through most instructional demonstrations and post-item feedback. This brings about concerns regarding the standardized administration, variable positive reinforcement, time to process mistakes, and variable potential for increased perseveration or proactive interference. Throughout most exercises, one is not penalized for waiting to respond, which is not always the case in real-world applications of WM. Another general criticism was that if one’s cursor was hovered over an option following the target sequence, it would light up, which might distract or interfere with the target sequence one had been rehearsing for WM recall. While the beta features were added to offer greater flexibility to accommodate client training needs, this further compromises standardization. Lastly, all tasks required visualspatial skills for executing what was held in WM, neglecting tasks that would allow for verbal recall of information being stored.
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Coaching An important component to the Cogmed training is the role played by treatment coaches who monitor a client’s performance, progress, and the treatment’s fidelity. According to the Cogmed website, there are over 400 certified coaches in the United States and over 1,000 internationally. Collectively they have provided service to over 10,000 users (Cogmed, 2013). Throughout the training, online performance tracking allows the coaches to provide tailored feedback and assistance to users. While Cogmed can be a stand-alone intervention, it is frequently provided in conjunction with other treatments (e.g., medication management, parentmanagement training). In fact, given the intended treatment populations, there is likely to be a strong need for concurrent clinical intervention. The coaches help gauge whether Cogmed is an appropriate treatment, ensure the environment is conducive to training (e.g., free of distractions) and the interface is working properly, and provide encouragement and feedback to help facilitate the generalization of learning. Coaches can also help train parents/teachers/aids how to properly motivate children to stay on task and remain engaged during training exercises; however, their close supervision by a mental health professional is recommended. With the involvement of coaches, program compliance rates above 90% for children and 80% for adults have been reported (Cogmed, 2013). Pearson remains in regular contact with coaches to provide ethical oversight regarding treatment fidelity and collect data for ongoing research. Becoming a certified Cogmed coach requires the completion of an online training program. Coaches in clinical settings are required to have Level B or C credentials, those in educational settings, however, do not need to meet that requirement. After successfully completing the training, certified coaches receive log in/user ID access codes that permit them to train 10 clients. The initial fee for the certification and 10 user codes is currently $1,500. It is possible to purchase user codes in bulk quantities at lower rates, but codes are good for only one year. It should be noted that Pearson does not regulate the fees individual Cogmed coaches charge their clients for the training. As insurance does not cover the cost of Cogmed training, pricing plans from some providers may be a barrier for potential users.
Cogmed Customer Support Cogmed consultants are available to answer questions coaches may have. Those interested in learning more about Cogmed, research evidence, user reviews, or the coaching process can access their website (www.cogmed.com). We found the website to be user friendly, fairly navigable, and informative. It contains numerous testimonials from satisfied users. In addition, Cogmed representatives were found
to be helpful and prompt in their online and over-the-phone assistance.
Cogmed Research A sizable proportion of the research evidence for Cogmed has been evaluating its effectiveness for training children with ADHD. Some studies noted improvements in children’s verbal and visual-spatial WM scores (e.g., Green et al., 2012; Klingberg et al., 2005; Klingberg, Forssberg, & Westerberg, 2002b), while others have found variable, short-term reductions in ADHD behavior ratings (e.g., Beck, Hanson, Puffenberger, Benninger, & Benninger, 2010; Green et al., 2012; Klingberg et al., 2005). Gains in WM have also been demonstrated in children with ADHD and comorbid learning disabilities (Gray et al., 2012). Beck et al. noted that it might be the built in algorithm that allows for Cogmed training to be effective and differentiate itself from other related interventions. However, it should be noted that some prior studies have been confounded by lack of random assignment, control groups, and controls for stimulant medication effects, as well as the use of subjective behavior ratings and small sample sizes (Shipstead, Redick, & Engle, 2012). Research on the effectiveness of Cogmed with adult ADHD is lacking at this time. Brehmer, Westerberg, and Bäckman (2012) found evidence suggesting the appropriateness of Cogmed as an intervention for normal functioning younger (20-30 years) and older (60-70 years) adults, with improvements noted in verbal and visual-spatial WM tasks, sustained attention, and self-reported cognitive functioning. These gains were also reasonably sustained at 3-month follow-up. Evidence for the appropriateness of Cogmed for those with low IQ scores (below 70) is still forthcoming, though Soderqvist, Nutley, Otterson, Grill, and Klingberg (2012) found that training may be feasible provided there is a minimum cognitive capacity or training ability in children with intellectual disabilities. Finally, there is emerging evidence that Cogmed may be effective with individuals who have acquired brain injuries. Some have found variable improvements based on initial severity levels and suggest the need for preserved cognitive functioning and high levels of motivation for training to be successful (Lundqvist, Grunderstrom, Samuelsson, & Ronnberg, 2010). Others have noted variable WM improvements (H. H. Westerberg et al., 2007), and still others found self-reported improvements in occupational performance and decreased cognitive failures (Johansson & Tornmalm, 2012). It is noteworthy that research partialing out the unique role of the coach and coaching interventions is presently lacking, as are dismantling studies which break-down the Cogmed training tasks to see if they are all necessary for treatment gains. Finally, if cognitive neuroplasticity is responsible for treatment gains, then more research
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demonstrating changes in brain functioning is needed. Existent research has largely been conducted by Cogmed program developers, using small samples of healthy adults (e.g., McNab et al., 2009; Olesen et al., 2004; H. Westerberg & Klingberg, 2007). A recent meta-analysis (Melby-Lervåg & Hulme, 2013) questioned the clinical utility of cognitive training programs, including Cogmed training. The authors noted that effect sizes related to WM gains were quite variable across studies, training generally produces short-term and specific gains, and there was no convincing evidence for generalization of learning. This was especially evident when more controlled designs were used. There is also a possibility that near transfer gains might relate to task and modality (e.g., computer). While Melby-Lervåg and Hulme acknowledged methodological shortcomings in their meta-analysis (i.e., collapsing and comparing studies across different age groups when variable effects are possible), they argued that if only near transfer gains are attained and/or sustained, then WM training is not a reasonably effective intervention for the treatment of developmental disorders (e.g., ADHD, learning disabilities). In addition, Shipstead, Redick, and Engle (2010) have reported that Cogmed research results tend to be inconsistent, lack adequate control groups, and insufficiently measure constructs. They cogently argued the lack of controls might lead to effects being due in part to Hawthorne or expectancy effects from users (e.g., parental or self-ratings of behavioral and attention improvements). Furthermore, Gibson et al. (2012) found that Cogmed may only effectively target primary memory components of WM capacity, lacking the necessary complexity to target secondary memory components that are essential for clinical change. Cogmed (2013) has countered some of its critics by citing relevant research supporting improved WM performance on both non-trained simple and complex span tasks that are sustained in the short- and long term (e.g., Bergman Nutley et al., 2011; Holmes et al., 2009). More recent studies have included randomized, placebo controlled designs, and specifically with regards to improved attention, demonstrating the possibility for generalization of gains (Brehmer et al., 2012; Green et al., 2012; Klingberg et al., 2005). Collectively these studies make a case in favor of the near transfer benefits of Cogmed’s WM training; however, one must wonder about the external validity of improvements demonstrated across inter-related WM assessments as opposed to natural environment WM tasks. While the CPI report attempts to estimate generalization, the potential for a practice effect confound is seen as a limitation. Cogmed (2013) has acknowledged that training is specific to WM and its relevant correlates (e.g., attention), and due to variability across studies, claims that it can target other aspects of executive functioning are premature. Furthermore, they explicitly state that Cogmed training
cannot claim to be a cure for ADHD and related behavioral concerns, replace pharmacological interventions, improve long-term memory, improve IQ scores, reverse or cure organic brain diseases (e.g., dementia), result in better school achievement, effect permanent change in functioning, or work effectively for all users. In fact, they note that on average, 20% of users see no improvement from the training (Cogmed, 2013).
Summary Cogmed represents a potentially useful approach to training WM and attentional functioning in children and adults. The interactive, game-like activities provide an appealing approach for training important cognitive functions across a broad age range. With demonstrated short-term and sustained gains in verbal and visual-spatial WM, Cogmed purports to help a majority of users who struggle academically or professionally due to their WM deficits. Research has demonstrated Cogmed may improve inattention and hyperactive symptoms (e.g., Beck et al., 2010; Brehmer et al., 2012; Cogmed, 2013; Green et al., 2012; Klingberg et al., 2005; Klingberg et al., 2002b), reading comprehension (K. Dahlin, 2011), and mathematic ability (K. I. E. Dahlin, 2013; Holmes et al., 2009). Cogmed is not without its skeptics, particularly related to claims made from researchers, theoretical underpinnings, and flawed study designs (e.g., Gibson et al., 2012; Hulme & Melby-Lervåg, 2012; Melby-Lervåg & Hulme, 2013; Shipstead et al., 2010, 2012). These concerns are not limited to Cogmed and apply to other memory training programs as well. To this we would add two additional concerns specifically related to Cogmed. While wellintentioned, the new beta features potentially threaten standardization and treatment fidelity, and currently lack empirical support. In addition, the CPI report needs more validation research before it should be considered a measure of generalization. To their credit, Cogmed (2013) acknowledges its specific effects and encourages professionals not to overstate claims of its effectiveness. Numerous research efforts are currently ongoing and these efforts would be enhanced with improved methodological rigor, use of control groups, random assignment, controls for medication effects, and use of measures more sensitive to generalization of treatment gains. At this time it appears that Cogmed is a product with the potential to help individuals improve WM capabilities and focused attention. While it is unclear if the program facilitates actual changes in neural pathways that can then promote generalization of gains, or if it trains specific memory and attention focusing strategies that are much narrower in their application, it appears to be one of the better WM training programs currently available. How enduring and
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Roche and Johnson generalizable the treatment effects from Cogmed training remains to be demonstrated. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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LD and comorbid ADHD: A randomized controlled trial. Journal of Child Psychology and Psychiatry, 53, 1277-1284. doi:10.1111/j.1469-7610.2012.02592.x Green, C. T., Long, D. L., Green, D., Iosif, A. M., Dixon, J. F., Miller, M. R., . . .Schweitzer, J. B. (2012). Will working memory training generalize to improve off-task behavior in children with attention-deficit/hyperactivity disorder. Neurotherapeutics, 9, 639-648. doi:10.1007/s13311-0120124-y Holmes, J., Gathercole, S. E., & Dunning, D. L. (2009). Adaptive training leads to sustained enhancement of poor working memory in children. Developmental Science, 12, F9-F15. doi:10.1111/j.1467-7687.2009.00848x Hulme, C., & Melby-Lervåg, M. (2012). Current evidence does not support the claims made for CogMed working memory training. Journal of Applied Research in Memory and Cognition, 1, 197-200. doi:10.1016/j.jarmac.2012.06.003 Johansson, B., & Tornmalm, M. (2012). Working memory training for patients with acquired brain injury: Effects on everyday life. Scandinavian Journal of Occupational Therapy, 19, 176-183. doi:10.3109/11038128.2011.603352 Klingberg, T. (2010). Training and plasticity of working memory. Trends in Cognitive Sciences, 14, 317-324. doi:10.1016/j. tics.2010.05.002 Klingberg, T., Fernell, E., Olesen, P. J., Johnson, M., Gustafsson, P., Dahlström, K., & Westerberg, H. (2005). Computerized training of working memory in children with ADHD—A randomized, controlled trial. Journal of the American Academy of Child & Adolescent Psychiatry, 44, 177-186. doi:10.1097/00004583-200502000-00010 Klingberg, T., Forssberg, H., & Westerberg, H. (2002a). Increased brain activity in frontal and parietal cortex underlies the development of visuospatial working memory capacity during childhood. Journal of Cognitive Neuroscience, 14, 1-10. doi:10.1162/089892902317205276 Klingberg, T., Forssberg, H., & Westerberg, H. (2002b). Training of working memory in children with ADHD. Journal of Clinical and Experimental Neuropsychology, 24, 781-791. doi:10.1076/jcen.24.6.781.8395 Lundqvist, A., Grunderstrom, K., Samuelsson, K., & Ronnberg, J. (2010). Computerized training of working memory in a group of patients suffering from acquired brain injury. Brain Injury, 24, 1173-1183. doi:10.3109/02699052.2010.498007 Martinussen, R., Hayden, J., Hogg-Johnson, S., & Tannock, R. (2005). A meta-analysis of working memory impairments in children with attention-deficit/hyperactivity disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 44, 377-384. doi:10.1097/01.chi.0000153228.72591.73 McNab, F., Varrone, A., Farde, L., Jucaite, A., Bystritsky, P., Forssberg, H., & Klingberg, T. (2009). Changes in cortical dopamine D1 receptor binding associated with cognitive training. Science, 323, 800-802. doi:10.1126/science.1166102 Melby-Lervåg, M., & Hulme, C. (2013). Is working memory training effective? A meta-analytic review. Developmental Psychology, 49, 270-291. doi:10.1037/a0028228 Olesen, P., Westerberg, H., & Klingberg, T. (2004). Increased prefrontal and parietal brain activity after training of working memory. Nature Neuroscience, 7, 75-79.
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Shipstead, Z., Redick, T. S., & Engle, R. W. (2010). Does working memory training generalize? Psychologica Belgica, 50, 245-276. Shipstead, Z., Redick, T. S., & Engle, R. W. (2012). CogMed working memory training: Does the evidence support the claims? Journal of Applied Research in Memory and Cognition, 1, 185-193. doi:10.1016/j.jarmac.2012.06.003 Soderqvist, S., Nutley, S. B., Otterson, J., Grill, K. J., & Klingberg, T. (2012). Computerized training of non-verbal reasoning and working memory in children with intellectual disability. Frontiers in Human Neuroscience, 6, 1-8. doi:10.3389/ fnhum.2012.00271 Westerberg, H., & Klingberg, T. (2007). Changes in cortical activity after training of working memory—A single-subject analysis. Physiology & Behavior, 92, 186-192. doi:10.1016/j. physbeh.2007.05.041
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Author Biographies Jeffrey D. Roche is presently a doctoral candidate in the Counseling Psychology program at the University of Northern Colorado. His primary research interests include resiliency, homelessness, neuroplasticity, attachment, and critical research. Brian D. Johnson is a professor of Counseling Psychology at the University of Northern Colorado. He is a licensed psychologist and his primary research interests are in the areas of assessment, childhood behavior disorders, and parenting.
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Cogmed Working Memory Training Product Review Jeffrey D. Roche and Brian D. Johnson Journal of Attention Disorders 2014 18: 379 originally published online 6 March 2014 DOI: 10.1177/1087054714524275 The online version of this article can be found at: http://jad.sagepub.com/content/18/4/379
Published by: http://www.sagepublications.com
Additional services and information for Journal of Attention Disorders can be found at: Email Alerts: http://jad.sagepub.com/cgi/alerts Subscriptions: http://jad.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav Citations: http://jad.sagepub.com/content/18/4/379.refs.html
>> Version of Record - Apr 24, 2014 OnlineFirst Version of Record - Mar 6, 2014 What is This?
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524275
research-article2014
JADXXX10.1177/1087054714524275Journal of Attention DisordersRoche and Johnson
Product Review
Cogmed Working Memory Training Product Review
Journal of Attention Disorders 2014, Vol. 18(4) 379–384 © 2014 SAGE Publications Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1087054714524275 jad.sagepub.com
Jeffrey D. Roche1 and Brian D. Johnson1
Abstract Objective: In this review of the Cogmed training program, we discuss its theoretical foundations, materials, the intervention program, use of coaches, customer support, and research support. Method: This review was conducted by means of firsthand exploration of the Cogmed training program in conjunction with a critical synthesis of existing empirical literature. Results: We conclude that Cogmed has the potential to help individuals improve working memory capabilities and focused attention. Conclusion: More research is needed to demonstrate if these changes in working memory and focused attention are enduring and generalizable. (J. of Att. Dis. 2014; 18(4) 379-384) Keywords cognitive performance enhancement, computer attention training, short-term memory, training The Cogmed Working Memory Training system, hereafter referred to as Cogmed, is marketed as “a computer-based solution for attention problems caused by poor working memory (WM),” that combines “cognitive neuroscience with innovative computer game design and close professional support to deliver substantial and lasting benefits” (www.cogmed.com). The program is said to draw from research on the central role of WM deficits for various psychiatric disorders and learning disabilities (e.g., Holmes, Gathercole, & Dunning, 2009; Martinussen, Hayden, HoggJohnson, & Tannock, 2005) as well as research on the application of neuroplasticity principles to WM training and enhancement (Klingberg, Forssberg, & Westerberg, 2002a; Olesen, Westerberg, & Klingberg, 2004). Klingberg and colleagues began marketing Cogmed in 2001 as an evidence-based intervention designed to help those with WM deficits. In 2010, the Pearson Clinical Assessment Group purchased and began marketing Cogmed worldwide with versions currently available in English (British and U.S.), Norwegian, Spanish, French, Swedish, Japanese, Korean, German, and Dutch. Text-based screen instructions make Cogmed accessible for those with hearing impairments, but some auditory memory training tasks may not be appropriate for individuals with severe hearing loss.
Theoretical Foundation
attention, ignoring distractions, planning, short-term memory, and initiating and completing tasks. This theory also recognizes the important role of attentional control (Awh & Jonides, 2001). In addition, Cogmed reports being strongly influenced by the theory of neuroplasticity, which is essential in understanding the brain’s ability to improve and modify task-specific neural pathways in response to repeated and tailored training. Klingberg (2010) demonstrated topdown attention control and WM shared substantial overlap in parietal and prefrontal cortex neural pathways.
Materials Use of Cogmed requires a computer and/or tablet with speakers, stable broadband internet connection of 0.5 Mbit/s or higher, Adobe Flash plugin version 10.0 or later, and minimal hard drive space to store results. It is programmed for Mac, PC, and Android devices. It is most commonly run through the Cogmed website where users are provided a unique ID and password.
Intended Users According to the website, the typical Cogmed user has WM deficits that arise from one of three areas: organic or 1
Cogmed is based upon the multi-compartmental theory of memory (Baddeley & Hitch, 1974), which recognizes both temporary storage and information manipulation functions of WM as being vital for cognitive tasks, such as: focusing
University of Northern Colorado, Greeley, USA
Corresponding Author: Brian D. Johnson, University of Northern Colorado, 202-A McKee Hall, Box 131, Greeley, CO 80639, USA. Email: [email protected]
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lifelong attention or learning difficulties (e.g., ADHD, LD), various forms of brain insult (e.g., stroke, Traumatic Brain Injury), and reasonably expected memory declines (e.g., due to normal aging, environmental demands). Individuals with dementia are not considered to be appropriate for this training. Cogmed is available in three different packages tailored for different age groups: Cogmed JM is designed for preschool children (ages 4-6), Cogmed RM is for school-age children (7-18), and Cogmed QM is for adults. All versions share the same visual-spatial WM tasks and algorithms, with differences occurring in the user interface. The RM and QM also share the same underlying verbal WM tasks and algorithms.
Program Description The rigorous and tailored sequences of activities users complete are thought to be essential to see sustained improvement in WM functioning (Diamond & Lee, 2011). The standard Cogmed administration protocol for the RM and QM versions requires users to complete eight daily tasks (30-45 min), 5 days a week, for 5 consecutive weeks. The JM standard protocol has fewer items and shorter daily training sessions (15-20 min). In 2013, Pearson launched a series of beta features that allow users to modify the length of training sessions, number of training days, and number of weeks. It is likely that published Cogmed research is based on the standard administration protocol. In all three versions, users are permitted to exit a given exercise, return to the home page, and either resume the activity later or begin another one. With the standard protocol, once an exercise has been completed, it cannot be repeated that day. As some of the exercises are timed, poor computer cursor navigation abilities may prove to be a limitation for some users. The program also produces the Cogmed Progress Indicator (CPI) report. The CPI is described as an index of improvement in non-trained tasks, or generalization. It is computed from an individual’s performance on three tasks (i.e., WM, following instructions, and math challenge). These additional tasks are administered six times during the course of training and are said to measure WM-related gains that are not specifically targeted in Cogmed training. However, given the repeated exposure to the CPI tasks, it is quite possible that changes in CPI scores are at least partially the result of practice effects. The preschool version (Cogmed JM) presents users with bright colored theme park designs that have visual-spatial WM tasks embedded into stimuli like a roller-coaster, Ferris wheel, bumper cars, and more. Each theme park item represents specific WM training tasks, with helpful, repeatable, and kid-friendly demonstrations built into the program. Using a mouse or touch pad, preschoolers must first direct their attention and concentrate to a sequence of items, hold the sequence in their WM, and then use the cursor to click
the target objects in the original order. Target objects are predominately silly, giggly fur ball creatures that provide cheers, starbursts, and smiles to reinforce correct responses, while frowning and appropriately redirecting preschoolers for incorrect responses. The duration of each memory training task adjusts according to a child’s performance with more correct responses being associated with longer intervals. The overall length of the preschool training is 15 to 20 min/day. Generally speaking, the JM version appeared fun, interactive, and age appropriate. The school-aged, Cogmed RM offers users a robot, space, and technology themed interface that is more expansive and challenging than the JM version. Users are still provided instructional demonstrations for most tasks and they are to track and replicate a sequence of events from memory. The increased difficulty comes from having more targets, complex tasks, and longer training sequences. While the space theme might not hold broad appeal for all users, its more varied activities and videogame-like qualities (e.g., presenting users’ scores on tasks so they can try to surpass their prior performance) are likely to appeal to many school-aged participants. In addition, the RoboRacing game, a fun racing game that involves moving a character with the directional keys in order to collect coins and race against the clock, is provided at the end of each training day as an incentive and reward for staying on task. The adult version, Cogmed QM, is nearly identical to the RM, as exercises and daily training times are essentially the same. Some exercises have different names and instruction can be skipped in the adult version. There is also less emphasis on competition with trying to improve upon prior performance. We found the user interface to be less colorful and visually pleasing in the adult version and thus it may require participants to focus their attention more when completing tasks. Some general criticisms were noted across all versions of Cogmed. By clicking the space bar, one can skip through most instructional demonstrations and post-item feedback. This brings about concerns regarding the standardized administration, variable positive reinforcement, time to process mistakes, and variable potential for increased perseveration or proactive interference. Throughout most exercises, one is not penalized for waiting to respond, which is not always the case in real-world applications of WM. Another general criticism was that if one’s cursor was hovered over an option following the target sequence, it would light up, which might distract or interfere with the target sequence one had been rehearsing for WM recall. While the beta features were added to offer greater flexibility to accommodate client training needs, this further compromises standardization. Lastly, all tasks required visualspatial skills for executing what was held in WM, neglecting tasks that would allow for verbal recall of information being stored.
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Coaching An important component to the Cogmed training is the role played by treatment coaches who monitor a client’s performance, progress, and the treatment’s fidelity. According to the Cogmed website, there are over 400 certified coaches in the United States and over 1,000 internationally. Collectively they have provided service to over 10,000 users (Cogmed, 2013). Throughout the training, online performance tracking allows the coaches to provide tailored feedback and assistance to users. While Cogmed can be a stand-alone intervention, it is frequently provided in conjunction with other treatments (e.g., medication management, parentmanagement training). In fact, given the intended treatment populations, there is likely to be a strong need for concurrent clinical intervention. The coaches help gauge whether Cogmed is an appropriate treatment, ensure the environment is conducive to training (e.g., free of distractions) and the interface is working properly, and provide encouragement and feedback to help facilitate the generalization of learning. Coaches can also help train parents/teachers/aids how to properly motivate children to stay on task and remain engaged during training exercises; however, their close supervision by a mental health professional is recommended. With the involvement of coaches, program compliance rates above 90% for children and 80% for adults have been reported (Cogmed, 2013). Pearson remains in regular contact with coaches to provide ethical oversight regarding treatment fidelity and collect data for ongoing research. Becoming a certified Cogmed coach requires the completion of an online training program. Coaches in clinical settings are required to have Level B or C credentials, those in educational settings, however, do not need to meet that requirement. After successfully completing the training, certified coaches receive log in/user ID access codes that permit them to train 10 clients. The initial fee for the certification and 10 user codes is currently $1,500. It is possible to purchase user codes in bulk quantities at lower rates, but codes are good for only one year. It should be noted that Pearson does not regulate the fees individual Cogmed coaches charge their clients for the training. As insurance does not cover the cost of Cogmed training, pricing plans from some providers may be a barrier for potential users.
Cogmed Customer Support Cogmed consultants are available to answer questions coaches may have. Those interested in learning more about Cogmed, research evidence, user reviews, or the coaching process can access their website (www.cogmed.com). We found the website to be user friendly, fairly navigable, and informative. It contains numerous testimonials from satisfied users. In addition, Cogmed representatives were found
to be helpful and prompt in their online and over-the-phone assistance.
Cogmed Research A sizable proportion of the research evidence for Cogmed has been evaluating its effectiveness for training children with ADHD. Some studies noted improvements in children’s verbal and visual-spatial WM scores (e.g., Green et al., 2012; Klingberg et al., 2005; Klingberg, Forssberg, & Westerberg, 2002b), while others have found variable, short-term reductions in ADHD behavior ratings (e.g., Beck, Hanson, Puffenberger, Benninger, & Benninger, 2010; Green et al., 2012; Klingberg et al., 2005). Gains in WM have also been demonstrated in children with ADHD and comorbid learning disabilities (Gray et al., 2012). Beck et al. noted that it might be the built in algorithm that allows for Cogmed training to be effective and differentiate itself from other related interventions. However, it should be noted that some prior studies have been confounded by lack of random assignment, control groups, and controls for stimulant medication effects, as well as the use of subjective behavior ratings and small sample sizes (Shipstead, Redick, & Engle, 2012). Research on the effectiveness of Cogmed with adult ADHD is lacking at this time. Brehmer, Westerberg, and Bäckman (2012) found evidence suggesting the appropriateness of Cogmed as an intervention for normal functioning younger (20-30 years) and older (60-70 years) adults, with improvements noted in verbal and visual-spatial WM tasks, sustained attention, and self-reported cognitive functioning. These gains were also reasonably sustained at 3-month follow-up. Evidence for the appropriateness of Cogmed for those with low IQ scores (below 70) is still forthcoming, though Soderqvist, Nutley, Otterson, Grill, and Klingberg (2012) found that training may be feasible provided there is a minimum cognitive capacity or training ability in children with intellectual disabilities. Finally, there is emerging evidence that Cogmed may be effective with individuals who have acquired brain injuries. Some have found variable improvements based on initial severity levels and suggest the need for preserved cognitive functioning and high levels of motivation for training to be successful (Lundqvist, Grunderstrom, Samuelsson, & Ronnberg, 2010). Others have noted variable WM improvements (H. H. Westerberg et al., 2007), and still others found self-reported improvements in occupational performance and decreased cognitive failures (Johansson & Tornmalm, 2012). It is noteworthy that research partialing out the unique role of the coach and coaching interventions is presently lacking, as are dismantling studies which break-down the Cogmed training tasks to see if they are all necessary for treatment gains. Finally, if cognitive neuroplasticity is responsible for treatment gains, then more research
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demonstrating changes in brain functioning is needed. Existent research has largely been conducted by Cogmed program developers, using small samples of healthy adults (e.g., McNab et al., 2009; Olesen et al., 2004; H. Westerberg & Klingberg, 2007). A recent meta-analysis (Melby-Lervåg & Hulme, 2013) questioned the clinical utility of cognitive training programs, including Cogmed training. The authors noted that effect sizes related to WM gains were quite variable across studies, training generally produces short-term and specific gains, and there was no convincing evidence for generalization of learning. This was especially evident when more controlled designs were used. There is also a possibility that near transfer gains might relate to task and modality (e.g., computer). While Melby-Lervåg and Hulme acknowledged methodological shortcomings in their meta-analysis (i.e., collapsing and comparing studies across different age groups when variable effects are possible), they argued that if only near transfer gains are attained and/or sustained, then WM training is not a reasonably effective intervention for the treatment of developmental disorders (e.g., ADHD, learning disabilities). In addition, Shipstead, Redick, and Engle (2010) have reported that Cogmed research results tend to be inconsistent, lack adequate control groups, and insufficiently measure constructs. They cogently argued the lack of controls might lead to effects being due in part to Hawthorne or expectancy effects from users (e.g., parental or self-ratings of behavioral and attention improvements). Furthermore, Gibson et al. (2012) found that Cogmed may only effectively target primary memory components of WM capacity, lacking the necessary complexity to target secondary memory components that are essential for clinical change. Cogmed (2013) has countered some of its critics by citing relevant research supporting improved WM performance on both non-trained simple and complex span tasks that are sustained in the short- and long term (e.g., Bergman Nutley et al., 2011; Holmes et al., 2009). More recent studies have included randomized, placebo controlled designs, and specifically with regards to improved attention, demonstrating the possibility for generalization of gains (Brehmer et al., 2012; Green et al., 2012; Klingberg et al., 2005). Collectively these studies make a case in favor of the near transfer benefits of Cogmed’s WM training; however, one must wonder about the external validity of improvements demonstrated across inter-related WM assessments as opposed to natural environment WM tasks. While the CPI report attempts to estimate generalization, the potential for a practice effect confound is seen as a limitation. Cogmed (2013) has acknowledged that training is specific to WM and its relevant correlates (e.g., attention), and due to variability across studies, claims that it can target other aspects of executive functioning are premature. Furthermore, they explicitly state that Cogmed training
cannot claim to be a cure for ADHD and related behavioral concerns, replace pharmacological interventions, improve long-term memory, improve IQ scores, reverse or cure organic brain diseases (e.g., dementia), result in better school achievement, effect permanent change in functioning, or work effectively for all users. In fact, they note that on average, 20% of users see no improvement from the training (Cogmed, 2013).
Summary Cogmed represents a potentially useful approach to training WM and attentional functioning in children and adults. The interactive, game-like activities provide an appealing approach for training important cognitive functions across a broad age range. With demonstrated short-term and sustained gains in verbal and visual-spatial WM, Cogmed purports to help a majority of users who struggle academically or professionally due to their WM deficits. Research has demonstrated Cogmed may improve inattention and hyperactive symptoms (e.g., Beck et al., 2010; Brehmer et al., 2012; Cogmed, 2013; Green et al., 2012; Klingberg et al., 2005; Klingberg et al., 2002b), reading comprehension (K. Dahlin, 2011), and mathematic ability (K. I. E. Dahlin, 2013; Holmes et al., 2009). Cogmed is not without its skeptics, particularly related to claims made from researchers, theoretical underpinnings, and flawed study designs (e.g., Gibson et al., 2012; Hulme & Melby-Lervåg, 2012; Melby-Lervåg & Hulme, 2013; Shipstead et al., 2010, 2012). These concerns are not limited to Cogmed and apply to other memory training programs as well. To this we would add two additional concerns specifically related to Cogmed. While wellintentioned, the new beta features potentially threaten standardization and treatment fidelity, and currently lack empirical support. In addition, the CPI report needs more validation research before it should be considered a measure of generalization. To their credit, Cogmed (2013) acknowledges its specific effects and encourages professionals not to overstate claims of its effectiveness. Numerous research efforts are currently ongoing and these efforts would be enhanced with improved methodological rigor, use of control groups, random assignment, controls for medication effects, and use of measures more sensitive to generalization of treatment gains. At this time it appears that Cogmed is a product with the potential to help individuals improve WM capabilities and focused attention. While it is unclear if the program facilitates actual changes in neural pathways that can then promote generalization of gains, or if it trains specific memory and attention focusing strategies that are much narrower in their application, it appears to be one of the better WM training programs currently available. How enduring and
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Roche and Johnson generalizable the treatment effects from Cogmed training remains to be demonstrated. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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Author Biographies Jeffrey D. Roche is presently a doctoral candidate in the Counseling Psychology program at the University of Northern Colorado. His primary research interests include resiliency, homelessness, neuroplasticity, attachment, and critical research. Brian D. Johnson is a professor of Counseling Psychology at the University of Northern Colorado. He is a licensed psychologist and his primary research interests are in the areas of assessment, childhood behavior disorders, and parenting.
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