Attention Training in Children with Autism Spectrum Disorder Improves Academic Performance: Application of the Computerized Progressive Attentional Training (CPAT) Program in a Public Health Context in Brazil

Background: Atypical attention processes have been reported in individuals with Autism Spectrum Disorder (ASD) in a variety of settings. Indeed, some studies have pointed to an increase in ADHD-like symptomatology in ASD compared to control groups. Attention processes are generally important for successful interaction with the environment but have also been specifically linked to academic performance. Taken together it raises the possibility that academic difficulties (which are quite common) in ASD are related, at least to some degree, to attention processes, and consequently may benefit from attentional training. In a recent pilot study, Spaniol et al., (2018) have used the Computerised Progressive Attention Training (CPAT) - a program developed to train attention in children with ADHD, in a small group of schoolchildren with ASD in the UK. The results highlighted academic and cognitive improvements in the experimental group (compared to an active control group), pointing to the possible efficacy of attention training in ASD.

Objectives: In the present study, we applied a more rigorous methodology to verify the possible efficacy of CPAT in a cohort of children with ASD in São Paulo, Brazil, a low-income country. Specifically, we ask whether attention training in the context of the Brazilian public health care system will show similar academic benefits as the pilot study conducted in the UK and whether these effects are maintained after the intervention program.

Methods: The study was conducted at the Autism Unit of Santa Casa de Misericórdia Hospital, part of the Center for Integrated Mental Health Care. 26 children and adolescents with ASD ranging from 8 to 14 years old were assigned to either the CPAT (n=14) or active control group (n=12). They were assessed before and immediately after the intervention/active control period (two sessions per week over 8 weeks) as well as 3 months following the completion of the intervention. Cognitive, attentional and academic performance was assessed through a series of standardized tests: Raven's - Educational: Colored Progressive Matrices, Attention Cancellation task (Teste de Atenção por Cancelamento – TAC), and Standardized academic test in maths, reading and writing (TDE: Teste de desempenho escolar). Importantly, the assessment was done blindly with the experimenter unaware of the group affiliation.

Results: We found statistically significant group differences following the CPAT intervention across the three academic assessments. Thus, while no group differences were recorded before the intervention, the CPAT group showed superior performance in the math, reading and writing tests following the intervention compared to the active control group. Interestingly, these differences were maintained at follow-up.

Conclusions: Our results showed that attention training with the CPAT is a viable approach to aid school performance in ASD, providing a replication to the pilot study reported in Spaniol et al., (2018). Furthermore, it points to the generality of the approach, which leads to similar outcomes regardless of the cultural or social context in which it is applied. Importantly, the intervention did not appear to have an overarching effect on autistic behaviour (e.g., in terms of ASD symptomatology) but rather a specific cognitive/academic benefit.