Project Evo: Feasibility and Initial Efficacy of an Interactive Digital Treatment to Improve Attention in Autism Spectrum Disorder

Background: Children with autism spectrum disorder (ASD) and co-morbid attention deficit/hyperactivity disorder (ADHD) symptoms experience significant impairments in attention and executive function skills. These children also demonstrate lower adaptive functioning skills, more severe maladaptive behaviors, poorer responses to social skills treatment, and less successful transitions to independence as adults. Relative to an ADHD population, frontline medications for ADHD, such as stimulants, have a lower success rate and greater rates of side effects in ASD. Thus, there is a need to develop alternative treatments targeting attention and executive function.

Objectives: To examine the feasibility and initial efficacy of an interactive, multi-tasking training “app” for attention and executive function.

Methods: 42 children between the ages of 9 and 15 years enrolled in the study. If children met screening criteria, they were assigned to either an adaptive multi-tasking training condition in a game-like environment or an alternative non-multi-tasking training in a game-like environment. Children accessed the treatment in twenty ~30-minute sessions over four weeks. Pre-treatment testing occurred on Day 0 and post-treatment testing occurred within 3 days of Day 28. Feasibility variables included acceptability (percentage of prescribed sessions played) and consumer satisfaction obtained from post-treatment surveys. The primary outcome was measured with the Attention Performance Index (API) from the Test of Variable Attention (TOVA), and secondary outcomes included validated measures of executive function and parent ratings across several domains of function.

Results: 19 of 42 children met the screening criteria. Nineteen children failed to meet the TOVA API entry criterion, three did not meet the IQ criteria, and one withdrew. Overall, excluded children were significantly older (12.14 years) than included children (10.75 years; Hedges’ g=0.83). Of the 19 children enrolled, 11 completed the multi-tasking treatment and 8 completed the alternative, non-multi-tasking treatment. Acceptability was high and similar across groups (Table 1). Satisfaction surveys revealed that children were impressed with the graphics and rewards in the multi-tasking treatment, but expressed moments of frustration with the training. In both conditions, parents believed the treatment had potential to improve attention and executive function skills.

Given the small samples, only within-group effects were examined. At post-treatment, the multi-tasking treatment group showed a moderate-to-large improvement on the TOVA’s API, and large effects in parent ratings, but weaker effects on other measures. The alternative treatment group showed a worsening effect on the TOVA’s API, and other effects were approximately half the size of those observed in the multi-tasking treatment group (Figure 1).

Conclusions: The high exclusion rate is consistent with prior Project: EVO studies. This ‘personalized’ treatment approach ensures that treated children have impairments in the targeted skills. Acceptability measures indicate high engagement with both treatments, and that the alternative treatment is comparable with respect to child engagement and parent belief of treatment potential. The initial efficacy findings from the TOVA for the multi-tasking treatment are in line with effect sizes from prior Project EVO studies. This finding plus the large parent-reported effects for multi-tasking over the alternative treatment condition, suggest Project: EVO may plausibly improve attention in ASD.