Could learning to keep the beat with a metronome be a helpful adjunctive treatment for children with ADHD? This question addressed in a study published in the American Journal of Occupational Therapy (Shaffer, R.J. et al., (2001). Effect of interactive metronome rhythmicity training on children with ADHD. American Journal of Occupational Therapy, 55, 155-162).

A metronome is a simple device that emits a sound at regular and adjustable intervals. It is used to help developing musicians learn to "keep the beat". The Interactive Metronome (IM) is a variant of this device that uses a computer to produces a rhythmic beat that individuals listen to through headphones. As the participant listens, he/she must anticipate the beat and perform various hand and foot exercises for a high number of repetitions. Regular auditory feedback is provided through headphones indicating whether one's response was on time, early, or late. The difference between the participants' response and the actual beat is measured in milliseconds and indicates the size of the discrepancy between the beat of the metronome and the person's response. Over repeated practice sessions, many individuals who initially have trouble coordinating their behavior with the beat of the metronome gradually become more successful at "keeping the beat". This improvement in IM performance is thought to reflect meaningful gains in motor planning and sequencing ability. For additional information about the Interactive Metronome, visit http://www.interactivemetronome.com/.

What does this have to do with helping children with ADHD? The rational for using the interactive metronome as an adjunctive treatment for ADHD is evidence that motor planning and sequencing, rhythm, and timing are all relevant to attention problems. Difficulty regulating the sequence and timing of motor patterns are related to problems with behavioral inhibition (i.e. being able to stop or inhibit oneself from executing a behavioral response) and executive functioning (i.e. higher level cognitive abilities such as goal setting and planning), that some experts believe are critical to the understanding of ADHD. In addition, there is evidence of considerable overlap between attention deficits and motor clumsiness and between the severity of inattentive symptoms and motor clumsiness in boys with ADHD. Finally, substantial overlap in brain areas thought to be involved in ADHD and those involved in the regulation of timing and motor planning have also been reported. Collectively, these findings suggest that technologies aimed at strengthening motor planning, sequencing, timing, and rhythm may have an important role in improving the capacity to learn and attend.

In the study reference above, Fifty-six 6 to 12 year old boys with a confirmed diagnosis of ADHD were recruited to participate in an investigation of the Interactive Metronome. Boys were matched on ADHD severity, age, and medication dosage, and then randomly assigned to one of three different experimental conditions: IM Training, Video game training, and a no training control group.

IM training consisted of 15 one-hour training sessions administered over a 3-week period. The goal was to help participants selectively attend - without interruption by internal thoughts or external distraction - for extended periods of time. This was done as explained above - i.e. by having participants execute various patterns of hand and foot motions in keeping with the beat of the Interactive Metronome for increasingly longer periods. The IM training device provided boys with immediate feedback about how accurately they were "keeping the beat” and all boys showed improvement over the 15 training sessions.

Boys in the video game training group received instruction in 5 commonly available PC-based non-violent video using an identical training schedule - i.e. 15 one-hour sessions over a 3-week period. The games involved hand-eye coordination skills, advanced mental planning, and multiple task sequencing. In each game, the difficulty increased as boys became more skillful. Video game training was included so the researchers could determine whether benefits of IM training exceeded those that may result from concentrated video game play, an activity that also provides practice in focus and concentration skills.

Boys in the IM and video game training groups received the same level of adult supervision, encouragement, and support. The adults supervising both types of training were college students without advanced degrees, who had no formal therapy or teaching experience. Administrators were trained in IM and video game training protocols, and supervised the training for boys in both groups. This assured that there were no systematic differences between adults working with boys in each group.

Boys in the control group received neither IM training nor video game training during the 3-week period.

Before any training began, extensive information was collected on the functioning of all boys. This included assessments of: 1) attention and concentration using a computerized test of sustained attention; 2) intellectual ability using a standardized IQ test; 3) clinical functioning using parent and teacher standardized behavior rating scales; 4) academic and cognitive skills using standardized academic achievement and language processing tests. These measures were administered a second time after training ended - approximately 4-5 weeks after the pretest. When available, a different version of the test was administered at pre- and post-test, and boys were pre-and post-tested at the same time of day to control for medication schedules. Examiners who administered the tests did not know which boys had received IM training, which had received video game training, and which were in the control group.

RESULTS

From these measures noted above, 58 separate scale scores were computed for each boy based on pre and post-test results. Preliminary analysis of pre-test data indicated that boys in each group were essentially equal prior to training.

To examine the impact of IM and video game training, post-test scores were subtracted from pre-test scores on all measures. A positive result was obtained when post-test scores exceeded pre-test scores, thus indicating improved performance.

Boys in the control group had 28 scores improve and 30 scores decline. This is consistent with what would be expected by chance, and indicates that neither prior experience with the test, nor simply the passage of 4-5 weeks time, was sufficient to produce consistent improvement in the different measures.

Boys in the video game training group showed improvement in 40 of the 58 variables assessed. This pattern of improved scores is unlikely to have occurred by chance, and demonstrates that video game training under adult supervision was associated with better outcomes on many variables.

Boys who received IM training showed even greater gains - i.e. they improved on 53 of the 58 different scales. The number of scales on which higher post test scores were found significantly exceeded results for the video game training, suggesting that IM training produced significant additional benefits above and beyond those resulting from video game training.

The authors next compared outcomes for the 3 groups of boys to determine where IM training had yielded significantly better results. Compared to boys in the other 2 groups, boys who received IM training showed greater declines in parent rated aggression, and greater improvements on reading achievement, motor control, and computerized tests of attention. Because the pre and post-treatment means on these variables was not provided in the article, the actual magnitude of these differences is not known.

SUMMARY AND IMPLICATIONS

Results from this study provide initial evidence that IM training directed towards improving rhythm, motor planning, and sequencing may be a beneficial adjunctive treatment for boys with ADHD. As predicted, boys with ADHD who received IM training showed improvement in a wide range of areas, and their gains exceeded those associated with supervised training in a task that also requires sustained concentration and focus in order to improve (i.e. boys who received video game training). These results are consistent with the theory behind IM training - namely that motor planning and sequencing ability influence a broad array of adaptive functions, including attention.

While this was a carefully conducted study in which necessary experimental controls were incorporated and promising results were obtained, it is important to recognize the limitations of this research. First, all boys were already receiving medication treatment for ADHD, so the effectiveness of IM training for ADHD in the absence of medication treatment is not known. One cannot assume that IM training alone would result in effective symptom management and/or functional improvement for children with ADHD who were not taking medication. This would be an important question to pursue in future research. It is worth noting, however, that because children were presumably already benefiting from medication treatment, the fact that IM training resulted in additional gains to those provided by medication is certainly encouraging.

Second, outcomes in this study were assessed immediately following treatment and no additional follow up was conducted. Whether the benefits found for IM training would persist over a sustained period is thus unknown. Because this study was limited to boys with ADHD, the potential benefits of this treatment for girls with ADHD is also unclear. Finally, because actual pre- and post-treatment scores were not included with the results, the actual magnitude of the gains found for IM training could not be examined.

In conclusion, results of this study provide promising indications that IM training may play a useful role in the treatment of ADHD. Additional research in which the limitations noted above are addressed will provide important information about the utility of IM training as an adjunctive or perhaps even a primary treatment for ADHD, and allow better informed decisions about the use of this treatment to be made.