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Child Neuropsychology: A Journal on

Normal and Abnormal Development in
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Computerized Progressive Attentional

Training (CPAT) Program: Effective Direct
Intervention for Children with ADHD
a b c
Lilach Shalev , Yehoshua Tsal & Carmel Mevorach
a
Department of Education and Psychology , Open University of
Israel
b
Department of Psychology , Tel Aviv University
c
School of Psychology , University of Birmingham
Published online: 12 Jun 2007.

To cite this article: Lilach Shalev , Yehoshua Tsal & Carmel Mevorach (2007) Computerized Progressive
Attentional Training (CPAT) Program: Effective Direct Intervention for Children with ADHD, Child
Neuropsychology: A Journal on Normal and Abnormal Development in Childhood and Adolescence,
13:4, 382-388, DOI: 10.1080/09297040600770787

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 Child Neuropsychology, 13: 382–388, 2007
http://www.psypress.com/childneuropsych
ISSN: 0929-7049 print / 1744-4136 online
DOI: 10.1080/09297040600770787

COMPUTERIZED PROGRESSIVE ATTENTIONAL

TRAINING (CPAT) PROGRAM: EFFECTIVE DIRECT
INTERVENTION FOR CHILDREN WITH ADHD

Lilach Shalev,1 Yehoshua Tsal,2 and Carmel Mevorach3

1
Department of Education and Psychology, Open University of Israel, 2Department of
Psychology, Tel Aviv University, and 3School of Psychology, University of Birmingham
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We tested the efficacy of a pioneering intervention program grounded in a contemporary

theoretical framework of attention and designed to directly improve the various attentional
functions of children with ADHD. The computerized progressive attentional training
(CPAT) program is composed of four sets of structured tasks that uniquely activate
sustained attention, selective attention, orienting of attention, and executive attention.
Performance was driven by tight schedules of feedback and participants automatically
advanced in ordered levels of difficulty contingent upon performance. Twenty 6- to 13-year-
old children with ADHD were assigned to the experimental group and received the CPAT
sessions twice a week over an 8-week period. Sixteen age-matched control children with
ADHD were assigned to the control group and participated in sessions of the same fre-
quency, length, and format except that instead of performing the training tasks they played
various computer games during the session. The experimental participants showed a signif-
icant improvement in nontrained measures of reading comprehension, and passage copy-
ing as well as a significant reduction of parents’ reports of inattentiveness. No significant
improvements were observed in the control group. We thus concluded that the above
academic and attentional improvements were primarily due to the CPAT.

INTRODUCTION
Attention deficit/hyperactivity disorder (ADHD) is a chronic mental health disorder of
childhood onset characterized by inattention, impulsiveness, and hyperactivity (Diagnostic and
Statistical Manual of mental disorders, 4th edition [DSM-IV]; APA, 1994). Given the high
prevalence of ADHD and its impact on many aspects of development and every day function-
ing, extensive effort has been focused on various treatments to lessen symptoms. Since this
study reports a novel cognitive nonpharmacological treatment, we will briefly review the
recent developments in the field of nonpharmacological treatments for children with ADHD.

Cognitive Treatment
Many different types of cognitive-behavioral treatments have been applied to
children with ADHD, including verbal self-instructions, problem-solving strategies, cognitive

Address correspondence to Lilach Shalev, Behavioral Brain Sciences Centre, School of Psychology,
University of Birmingham, Edgbaston, B15 2TT, Birmingham, UK. E-mail: 1.shalev.1@bham.ac.uk

© 2007 Psychology Press, an imprint of the Taylor & Francis Group, an Informa business
 ATTENTIONAL TRAINING FOR ADHD 383

modeling, self-monitoring, self-evaluation, and self-reinforcement among others. These

interventions are focused on improvement of self-controlled behavior through the enrich-
ment of problem-solving strategies. Unfortunately, many studies (Abikoff & Gittelman,
1985; Abikoff, 1991; Bloomquist, August, & Ostrander, 1991) showed that cognitive-
behavioral treatments do not provide significant improvements in the behavior and
academic performance of children with ADHD.
More recently, Kerns, Eso, and Thomson (1999) argued that repeated activation and
stimulation of attentional systems can facilitate changes in cognitive capacity that presumably
reflects underlying changes in neuronal activity. They tested the efficacy of a new set of
child-oriented direct intervention materials and found that children with ADHD receiving
this direct intervention did significantly better than a control group on a number of
untrained measures of attention and academic performance. No significant improvement
in parent and teacher rating scales was obtained.
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A recently developed training method (Klingberg et al., 2005; Klingberg, Forssberg, &
Westerberg, 2002) demonstrated that intensive computerized training of working memory
(WM) gradually increased the amount of information that children with ADHD can keep
in WM. Posner and Rothbart (2005) demonstrated that normal 4-year-old children bene-
fited from five days attentional training. Their EEG data suggested that the training altered
activity in the anterior cingulate. They concluded that attentional training could change the
underlying network in ways that might lead to extensive generalization.

Theoretical Framework of the Present Study

The present research is based on Posner and Petersen’s (1990) influential theory of
attention networks and its recent application to ADHD research (Tsal, Shalev, &
Mevorach, 2005). Posner and Petersen (1990) proposed that the attentional system can be
broken down into three networks represented in distinct anatomical areas: (a) The
vigilance network, responsible for maintaining a state of alertness (right frontal and pari-
etal regions); (b) the visual orienting network, which controls the selection of information
from sensory input (superior parietal lobe, temporal parietal junction); and (c) the
executive attention network, responsible for resolving conflicts among responses (midline
frontal areas and lateral prefrontal cortex).
The present study was designed to test the hypothesis that attention deficits of
children with ADHD can be ameliorated by a systematic individualized training program
involving a direct intensive exercising of the attentional networks. Studies examining the
academic achievements of children with ADHD indicate that many of them receive low
grades in academic subjects and low scores on standard measures of reading, math, spelling,
or written language (Anderson, Williams, McGee, & Silva, 1987; Barkley, Fischer,
Edelbrock, & Smallish, 1990; Zentall, 1993). Thus, our aim was to demonstrate that
attentional training in children with ADHD can primarily improve academic performance.
A computerized progressive attentional training (CPAT) program was developed on the
basis of leading theories and commonly used methodologies in the visual attention
literature. The program was specifically designed for use with children (aged 6 years and
above) who cope with attentional difficulties. The program includes four sets of tasks each
designed to extensively train one of the four attentional networks: sustained attention,
selective attention, orienting of attention, and executive attention. The rationale for
improvement in training was based on the gradual progress across difficulty levels driven
by tight schedules of feedback and accumulation of points.
 384 L. SHALEV ET AL.

METHOD
Participants. Participants were diagnosed by a qualified psychiatrist, neurologist
or psychologist according to DSM-IV criteria. The participants were randomly assigned to
either the experimental group or the control group, and group identity was known neither
to participants nor to their parents. Written parental consent was a prerequisite for partici-
pation in the study. The experimental group included 20 children (17 males and 3 females)
and the control group included 16 children (13 males and 3 females) all with ADHD. The
experimental group had a mean age of 9.1 years (range 6–13 years); the mean age of the
control group was 9.2 years (range 6–13 years). There was no significant difference
between ages (p = .88) and intelligence (p = .41) between the two groups. The majority of
the participants met the DSM-IV criteria for ADHD combined subtype (15/20 in
the experimental group and 13/16 in the control group). The other participants met the
DSM-IV criteria for ADHD inattentive subtype (DuPaul et al., 1998).
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The training tasks. The four comprehensive training tasks are based on expan-
sions and modifications of various tasks that have extensively been investigated in the
attention literature and are known to uniquely reflect the various attentional functions. The
four training tasks included the Computerized Continunuous Performance Task (CCPT;
based on Rosvold, Mirsky, Sarason, Bransome, & Beck, 1956), which was designed to
improve the function of Sustained Attention, the Conjunctive Search Task (based on
Treisman & Gelade, 1980), which was designed to improve the function of Selective
Attention, the Combined Orinenting and Flanker Task (based on Eriksen & Eriksen, 1974
and Posner, Snyder, & Davidson, 1980), which was designed to improve the function of
Orienting Attention and the Shift Stroop-like Task (based on Navon, 1977), which was
designed to improve the function of Executive Attention.

Procedure. On the average each session included eight blocks from four different
tasks. Number of blocks varied across participants primarily due to age differences. Every
block contained 40 trials, except for blocks in the CCPT that consisted of either 80 trials or
160 trials depending on the level of difficulty. Participants advanced in levels of difficulty
according to prespecified criteria based on fixed-accuracy and individually adjusted reac-
tion time (RT). Participants received an auditory feedback (beep) when an error was com-
mitted and visual feedbacks on RT performance. These feedbacks were translated into
points that were presented on the screen at the end of each block.

The training program. The training program was carried out over a period of
eight weeks consisting of two one-hour sessions per week. Each participant was supervised
by a research assistant during the entire session. During each session participants performed
a selection of tasks and within each task participants advanced in the levels of difficulty
according to their gradual progress, expressed in speed and accuracy performance.
In order to evaluate the success of our program participants were tested on several
criteria before and after training. Improvement on these tasks (relative to natural progress
of control participants served as an indication for the success of the CPAT. The control
group consisted of children with ADHD who participated in sessions of the same
frequency, length, and format except that instead of performing the training tasks they
played various computer games and were involved in various paper and pencil activities
during the session. These computer games contained inherent scoring and feedback mech-
anisms. These games also included multiple levels of difficulty.
 ATTENTIONAL TRAINING FOR ADHD 385

The training evaluation tests. Pre- and posttreatment measures were adminis-
tered prior to beginning the intervention and within 2 weeks of completing the treatment.
The corresponding pretests and posttests were different but of equal difficulty levels.
Since there are no standard academic tests in Hebrew, the academic tests for each participant
were taken from school-books of the relevant grade. The research assistants who adminis-
tered both the pre- and posttests were randomly assigned to avoid any consistent bias.
Participants were presented with the following tests: passage copying, math exercises,
reading comprehension, and parents’ rating scale (DuPaul et al., 1998).

RESULTS AND DISCUSSION

Figure 1 presents the pre- and posttraining scores of the three academic measures for
experimental and control participants. The figure suggests a clear distinction between the
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experimental and control groups in reading comprehension and passage copying. That is,
on these two measures training produced a substantial improvement and no effect was
obtained for the control participants. Statistical analyses indeed confirmed these observa-
tions.These data were subjected to ANCOVA (Analysis of covariance) in order to remove
the extraneous variability that derives from preexisting individual differences. These analy-
ses revealed that in both reading comprehension, F(1, 31) = 4.89, p < .05; η2 = .12, and
speed of copying, F(1, 31) = 6.11, p < .05; η2 = .17, the significant improvements that
were obtained in the experimental group are attributed to the type of treatment and are not
due to preexisting individual differences. However, the analysis also revealed that the
improvement of experimental participants relative to control participants in mathematical
performance could not be fully attributed to training, F(1, 32) = 1.2, p < .30.
Figure 2 presents the pre- and posttraining scores of parents’ ratings (DuPaul et al.,
1998) of both inattention and hyperactive symptoms. The figure shows a substantial
reduction in inattention symptoms for the experimental participants and no change in the
control participants. The figure also shows a reduction in hyperactive symptoms for
children in both groups. An ANCOVA carried out on these data indicated that while the

a b c
1.00
Math Excercises Passage Copying 1.00
Reading Comprehension
0.18
0.95 0.16 0.95
0.90 0.90
0.14
Evaluation scores

Evaluation scores
Words per second

0.85 0.85
0.12
0.80 0.80
0.10
0.75 0.75
0.08
0.70 0.70
0.65 0.06 0.65
0.60 0.04 0.60
0.55 0.02 0.55
0.50 0.00 0.50
Pre-test Post-test Pre-test Post-test Pre-test Post-test

Experimental Control Experimental Control Experimental Control

Figure 1 Mean pre- and posttraining measures (± s.e.m.) of academic performance for experimental and control
participants. a. Proportion of correct answers in math exercises. b. Number of copied words per second. c. Proportion
of correct answers in reading comprehension.
 386 L. SHALEV ET AL.

a b
Inattention Hyperactivity-Impulsivity
18 18

16 16

14 14

12 12
Scores

Scores
10 10

8 8

6 6

4 4

2 2
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0 0

Pre-test Post-test Pre-test Post-test

Experimental Control Experimental Control

Figure 2 Mean pre- and posttraining scores (± s.e.m.) on the behavioral rating scale for experimental and control
participants. The Y-axis represents the cumulative score of symptoms on each factor: a. Inattentive symptoms.
b. Hyperactive-impulsive symptoms.

reduction in inattention symptoms could be attributed to training, F(1, 24) = 8.37, p < .01;
η2 = .29, the reduction in hyperactive symptoms could possibly be attributed to extraneous
influence, F(1, 24) = 2.34, p = .14.
The results clearly show that a relatively short-term computerized progressive atten-
tional training (CPAT) that operates on attentional networks produced significant
improvements in both academic tests and parents’ behavioral ratings. It should be noted
that in both groups children were treated very positively and were semantically rewarded
for being consistent and cooperating throughout the 16-session intervention. Alternative
explanations such as spontaneous development or a general supportive atmosphere can be
ruled out since no systematic changes on these measures were observed for the control
group. While the program also significantly improved mathematical performance and
reduced behavioral symptoms, the present analyses could not rule out the possibility that
these effects were due to extraneous variability deriving from preexisting individual
differences. The present findings lend support to the proposition (Kerns et al., 1999) that
process specific interventions that directly stimulate and exercise attentional systems improve
cognitive capacity as they presumably reflect underlying changes in neuronal activity.
In considering the manner in which the CPAT could affect academic performance it
is important to keep in mind that every academic task requires the efficient functioning of
attentional systems and that attention deficit is the primary cause for poor academic
performance in children with ADHD (Zentall, 1993). Thus, for example, effective copy-
ing performance requires orienting to the location of the momentarily relevant word
(orienting of attention) while ignoring other adjacent words (selective attention), avoiding
lapses of attention during this prolonged process (sustained attention), and regulating the
entire task in the presence of potential interference (executive attention). Hence, it is
possible that systematic improvement in these four attentional functions may generalize to
academic tasks by virtue of improving the mediating attention processes.
 ATTENTIONAL TRAINING FOR ADHD 387

While it is generally hard to identify the specific cause of changes in treatment-

oriented investigations (Kerns et al., 1999), it is worth noting two unique characteristics of
feedback in CPAT that distinguishes this program from other activities and are likely to
contribute to its success. First, feedbacks provided in other forms of treatment and daily
activities are rather general and vague in the sense that they are not reinforcing the specific
desired response. In the present training the attentional components of the tasks were iso-
lated and, thus, those processes mediating attentional control were immediately and
directly linked to the feedback. The second distinctive characteristic of CPAT was the
advancement in difficulty levels in a systematic fashion under highly structured condi-
tions. Structured training procedures with defined “working rules” have been shown to
facilitate self-regulation and control. For example, Reid and Borkowski (1987) found that
attention of impulsive children could be brought under some degree of voluntary control
by self-instructional procedures. In addition to its positive cognitive aspects, this gradual
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learning process also had a significant motivational influence. Given that within each dif-
ficulty level effective responses were within reach, it is likely that children experience a
gain in self-esteem and sense of control as they improve on treatment tasks. It was clear
that the number of points presented at the end of each block served as a tremendous source
of fulfillment and satisfaction.
There are three major limitations in the present study. The first limitation of the
present study is that we did not include in our evaluation battery any objective attentional
measure assessing attentional difficulties before and after training. Future studies evaluat-
ing the mechanisms that underlie the effects of the CPAT should include attentional mea-
sures in order to investigate the extent to which improvements in academic performance
are associated with improvements in the various attentional measures. The second limita-
tion is that without any long-term follow-up study, it is not possible to determine whether
the improvement observed in the present study is time limited or whether it represents an
enduring change in underlying ability. A longer term investigation is warranted to more
adequately address this question. The third limitation is the absence of teachers’ evalua-
tions regarding the children’s classroom functioning and academic performance. Future
research should enlarge the tools that assess the effectiveness and generalization effects of
the attentional training, including teachers’ evaluations.

Original manuscript received November 9, 2005

Revised manuscript accepted April 21, 2006
First published online October 20, 2006

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