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Training attention control of very preterm infants: protocol for a feasibility study of the Attention Control Training (ACT).
Perra, O., Wass, S., McNulty, A., Sweet, D., Papageorgiou, K., Johnston, M., ... & Alderdice, F. 2020. Pilot and Feasibility Studies
Background: Children born preterm may display cognitive, learning, and behaviour difficulties as they grow up. In
particular, very premature birth (gestation age between 28 and less than 32 weeks) may put infants at increased risk
of intellectual deficits and attention deficit disorder. Evidence suggests that the basis of these problems may lie in
difficulties in the development of executive functions. One of the earliest executive functions to emerge around 1
year of age is the ability to control attention. An eye-tracking-based cognitive training programme to support this
emerging ability, the Attention Control Training (ACT), has been developed and tested with typically developing
infants. The aim of this study is to investigate the feasibility of using the ACT with healthy very preterm (VP) infants
when they are 12 months of age (corrected age). The ACT has the potential to address the need for supporting
emerging cognitive abilities of VP infants with an early intervention, which may capitalise on infants’ neural plasticity.
Methods/design: The feasibility study is designed to investigate whether it is possible to recruit and retain VP infants
and their families in a randomised trial that compares attention and social attention of trained infants against those
that are exposed to a control procedure. Feasibility issues include the referral/recruitment pathway, attendance, and
engagement with testing and training sessions, completion of tasks, retention in the study, acceptability of outcome
measures, quality of data collected (particularly, eye-tracking data). The results of the study will inform the development
of a larger randomised trial.
Discussion: Several lines of evidence emphasise the need to support emerging cognitive and learning abilities of
preterm infants using early interventions. However, early interventions with preterm infants, and particularly very
preterm ones, face difficulties in recruiting and retaining participants. These problems are also augmented by the
health vulnerability of this population. This feasibility study will provide the basis for informing the implementation of
an early cognitive intervention for very preterm infants.
Very preterm infants engage in an intervention to train their control of attention: results from the feasibility study of the Attention Control Training (ACT) randomised trial.
Perra, O., Wass, S., McNulty, A., Sweet, D., Papageorgiou, K. A., Johnston, M., ... & Alderdice, F. 2021. Pilot and Feasibility Studies
Background: Very premature birth (gestational age between 28 and 31 + 6 weeks) is associated with increased risk
of cognitive delay and attention deficit disorder, which have been linked to anomalies in the development of
executive functions (EFs) and their precursors. In particular, very preterm (VP) infants display anomalies in
controlling attention and gathering task-relevant information. Early interventions that support attention control may
be pivotal in providing a secure base for VP children’s later attainments. The Attention Control Training (ACT) is a
cognitive training intervention that targets infants’ abilities to select visual information according to varying task
demands but had not been tested in VP infants. We conducted a feasibility study to test the processes we intend
to use in a trial delivering the ACT to VP infants.
Methods and design: We tested recruitment and retention of VP infants and their families in a randomised trial, as
well as acceptability and completion of baseline and outcome measures. To evaluate these aims, we used
descriptive quantitative statistics and qualitative methods to analyse feedback from infants’ caregivers. We also
investigated the quality of eye-tracking data collected and indicators of infants’ engagement in the training, using
descriptive statistics. Results: Twelve VP infants were recruited, and 10 (83%) completed the study. Participants’ parents had high
education attainment. The rate of completion of baseline and outcome measures was optimal. VP infants
demonstrated engagement in the training, completing on average 84 min of training over three visits, and
displaying improved performance during this training. Eye-tracking data quality was moderate, but this did not
interfere with infants’ engagement in the training.
Changes in behavior and salivary cortisol after targeted cognitive training in typical 12-month-old infants
Wass, S. V., Cook, C., & Clackson, K. 2017. Developmental Psychology
Previous research has suggested that early development may be an optimal period to implement cognitive training interventions, particularly those relating to attention control, a basic ability that is essential for the development of other cognitive skills. In the present study, we administered gaze-contingent training (95 minutes across 2 weeks) targeted at voluntary attention control to a cohort of typical 12-month-old children (N = 24) and sham training to a control group (N = 24). We assessed training effects on (a) tasks involving non-trained aspects of attention control: visual sustained attention, habituation speed, visual recognition memory, sequence learning and reversal learning; (b) general attentiveness (on-task behaviours during testing) and (c) salivary cortisol levels. Assessments were administered immediately following the cessation of training and at a 6-week follow-up. On the immediate post-test infants showed significantly more sustained visual attention, faster habituation and improved sequence learning. Significant effects were also found for increased general attentiveness and decreased salivary cortisol. Some of these effects were still evident at the 6-week follow-up (significantly improved sequence learning and marginally improved […] sustained attention). These findings extend the emerging literature showing that attention training is possible in infancy.
Sustained attention in the face of distractors: A study of children with Rett syndrome
Rose, S. A., Wass, S., Jankowski, J. J., Feldman, J. F., & Djukic, A. 2017. Neuropsychology
Objective. The object of the present study is to advance our understanding of the cognitive
profile of Rett Syndrome (RTT), an x-linked neurodevelopmental disorder caused by mutations
in the MECP2 gene. We focus on sustained attention, which plays a critical role in driving
cognitive growth, and use an innovative, gaze-based task that minimizes demands on the limited
verbal and motor abilities associated with RTT.
Method. The task required the ability to sustain attention on a visual target (a butterfly) whilst
inhibiting a prepotent response to look to moving distractors (trees and clouds) presented in the
peripheral visual field. The sample included children with RTT (N = 32) and their typically
developing (TD) counterparts (N = 32), aged 2-12 years.
Results. Our findings revealed that children with RTT had more difficulty sustaining attention
(with the TD group averaging 60% looking at the butterfly vs only 25% for the RTT group).
Furthermore, they showed that RTT was associated with difficulties in three fundamental factors
influencing sustained attention: engagement, distractibility, and re-engagement. The RTT group
was slower to engage, more distractible, and slower to re-engage.
Conclusion. Our findings suggest there may be a fundamental disruption to sustained attention
in RTT, identifies factors related to this impairment, and points to cognitive areas that could be
assessed in evaluating the usefulness of interventions.
Attention training for infants at familial risk of ADHD (INTERSTAARS): study protocol for a randomised controlled trial
Goodwin, A., Salomone, S., Bolton, P., Charman, T., Jones, E. J., Pickles, A., ... & Johnson, M. H. 2016. Trials
Background: Attention deficit hyperactivity disorder (ADHD) is a prevalent neurodevelopmental disorder that can
negatively impact on an individual’s quality of life. It is pathophysiologically complex and heterogeneous with
different neuropsychological processes being impaired in different individuals. Executive function deficits, including
those affecting attention, working memory and inhibitory control, are common. Cognitive training has been promoted
as a treatment option, based on the notion that by strengthening the neurocognitive networks underlying these
executive processes, ADHD symptoms will also be reduced. However, if implemented in childhood or later, when the
full disorder has become well-established, cognitive training has only limited value. INTERSTAARS is a trial designed to
test a novel approach to intervention, in which cognitive training is implemented early in development, before the
emergence of the disorder. The aim of INTERSTAARS is to train early executive skills, thereby increasing resilience and
reducing later ADHD symptoms and associated impairment.
Methods/design: Fifty 10–14-month-old infants at familial risk of ADHD will participate in INTERSTAARS. Infants
will be randomised to an intervention or a control group. The intervention aims to train early attention skills
by using novel eye-tracking technology and gaze-contingent training paradigms. Infants view animated games
on a screen and different events take place contingent on where on the screen the infant is looking. Infants
allocated to the intervention will receive nine weekly home-based attention training sessions. Control group
infants will also receive nine weekly home visits, but instead of viewing the training games during these visits
they will view non-gaze-contingent age-appropriate videos. At baseline and post treatment, infant attention
control will be assessed using a range of eye-tracking, observational, parent-report and neurophysiological
measures. The primary outcome will be a composite of eye-tracking tasks used to assess infant attention skills.
Follow-up data will be collected on emerging ADHD symptoms when the infants are 2 and 3 years old.
Discussion: This is the first randomised controlled trial to assess the potential efficacy of cognitive training as
a prevention measure for infants at familial risk of ADHD. If successful, INTERSTAARS could offer a promising
new approach for developing early interventions for ADHD.
First evidence of the feasibility of gaze-contingent attention training for school children with autism.
Powell, G., Wass, S. V., Erichsen, J. T., & Leekam, S. R. 2016. Autism
A number of authors have suggested that attention control may be a suitable target for cognitive training in children with autism spectrum disorder. This study provided the first evidence of the feasibility of such training using a battery of tasks intended to target visual attentional control in children with autism spectrum disorder within school-based settings. Twenty-seven children were recruited and randomly assigned to either training or an active control group. Of these, 19 completed the initial assessment, and 17 (9 trained and 8 control) completed all subsequent training sessions. Training of 120 min was administered per participant, spread over six sessions (on average). Compliance with the training tasks was generally high, and evidence of within-task training improvements was found. A number of untrained tasks to assess transfer of training effects were administered pre- and post-training. Changes in the trained group were assessed relative to an active control group. Following training, significant and selective changes in visual sustained attention were observed. Trend training effects were also noted on disengaging visual attention, but no convincing evidence of transfer was found to non-trained assessments of saccadic reaction time and anticipatory looking. Directions for future development and refinement of these new training techniques are discussed.