This protocol illustrates a remedial therapy based on inductive learning and indirect communication (Ericksonian metaphorical hypnosis) that can be applied to children with Attention Deficit Hyperactive Disorder (ADHD). Particularly, this protocol is intended to test the effectiveness of a go/no-go decision task. Neuroscientific rationale is presented throughout the text.
Many children with attention deficit hyperactive disorder (ADHD) are known to have executive dysfunction, which weakens their abilities to learn and behave in daily living. This protocol describes the methodology that is required for the intervention (psychotherapy) based on planning, attention, successive, and simultaneous (PASS theory) cognitive processing and fear emotional processing. It provides guiding principles and practical recommendations. A disproportionately high level of fear (dysregulation) increases the vulnerability for dysfunction in learning and behavior. We explain the interplay between emotion and cognition at the neurological level.
A go/no go task (The Adventures of Fundi), which involves decision making, is administered in a PC- mode to a sample of 66 ADHD subjects. The Adventures of Fundi, a computer program, was constructed to induce successive or simultaneous processing when involving the training of planning and selective attention. It aims to improve the executive function with planning and selective attention. If executive function improves, learning improves, and behavior ameliorates. After intervention over 6 months, remission was achieved in 70% of subjects.
The instructor encourages the use of appropriate strategies and points out the ways in which the strategies can be useful in finding the solution to the problem (go/no go). The emphasis is not on rehearsing and adult instructed verbal sequence. The verbalization may reveal the conscious verbalized strategy to solve a task that is not really the strategy being unconsciously used in that case. A self-verbal report is unreliable. This is an inductive learning rather than deductive rule-learning approach central to cognitive PASS training. This inductive training has proved to produce not only near transfer but also far transfer.
Noncognitive factors (emotional factors) must be considered to maximize the benefit of cognitive training. Indirect and metaphorical communication considers the emotional factor.
Decision making is linked to the behavior and most behaviors implies decision-making. Decision making, and, also learning, involves both cognitive and emotional processing. The cognitive processing can be conceptualized and assessed according to the planning, attention, successive and simultaneous (PASS) theory of intelligence1,2,3,4,5,6,7,8,9. According to PASS, any behavior is the output of neurological central information processing10. Therefore, paying attention must be considered a behavior that is independent of the central processing of information1,2,3,7,8,9,10,11,12. One may not pay attention (observable behavior), but the central attention processing may be working on something different. On the other hand, the emotional processing includes the fear processing responsible for self-confidence (self-esteem) or lack of confidence13,14,15. The fear processing is the underlying undifferentiated autonomic physiological basis of all emotions. Like most emotions (or “affects” or “moods”), fear begins in the amygdala, an almond-shaped structure responsible for detecting threats to our well-being.
Both the cognitive and the emotional processing can happen consciously or more often unconsciously, which is a crucial point to substantiate the diagnosis and intervention of ADHD behavior or any other behavior. Growing and converging neuroscientific evidence indicates that not only unconscious-involuntary processing16,17,18,19,20,21 but also anticipatory unconscious processing22,23,24,25,26,27,28,29,30,31,32,33,34,35 are true in decision-making. Particularly, a new study on the neuroscience of the interpersonal unconscious (implicit) subliminal communication is evidence of this36.
Decision-making is based on the self-confident feeling associated with what it is cognitively processed, implicitly more frequently than explicitly37,38,39,40,41. The self-confidence is associated with self-concept (beliefs of the knowledge base), but we claim that decision-making is based on what one feels consciously and unconsciously, but not on deliberate rational calculation of consequences38. In fact, the rational arguments that people express (verbal report) to explain behavior and decision-making are a posteriori phenomenon and a cognitive bias42,43 triggered by the fear processing. First, reaction to feeling occurs, and then an explanation is unconsciously implemented as a posteriori phenomenon. A self-verbal report is questionable. Cognition/emotion research is plagued by problems in which it is not clear what is the emotion response. This is the path to understand the emotional fear response. Therefore, decision making, self-confidence and behavior are closely linked.
From the viewpoint of therapeutic intervention, how exactly should the intervention be carried out? What should be the common and essential properties of the procedure of intervention, mediation, or teaching? Considering the previously expressed procedures, inductive learning2 and indirect communications (metaphor and Ericksonian hypnosis)14,44 are recommended. Growing and converging evidence from neuroscientific investigations45,46,47,48,49,50,51,52,53 shows some neurological mechanisms of the indirect communication.
Concerning inductive learning, the emphasis is on the child’s solution to the task, not on rehearsing an adult instructed verbal procedure. It aims at enhancing the processing strategies that underlie the task, while avoiding direct teaching of skills. Successful inductive learning is an experience that provides a growth of the self-concept of personal abilities, and so a growth of self-confidence. In contrast, direct teaching involving more-of-the-same kind of work turns off the interest and motivation. The distinctive feature here is the tacit acquisition and use of appropriate processing strategies in contrast to instruction learning; this is the inductive rather than the deductive rule-learning approach. The child must see the insufficiency in the old approach or strategy and the need for developing a new strategy.
Here, we have shown the foundation (rationale) of the technique Fundi's Adventures as a tool of remedial therapy to apply it in the clinical setting. There are no published previous studies with this program Fundi's Adventure. The main advantage of this procedure is that it is not based on the self-verbal report. In contrast, countless alternative techniques are based on deductive learning, direct communication and literal interpretation of the self-verbal report.
In the example presented in this manuscript, Fundi’s Adventure intervention was performed in Attention Deficit Hyperactive Disorder (ADHD) patients. ADHD is a behavioral dysfunction in terms of inattentive, hyperactive, and impulsive behavior, which involves a dysfunctional decision making12. Any behavior implies decision making. ADHD is likely caused by a combination of genetics and earlier experience. The overall goal of this protocol is to test the hypothesis about the effectiveness of a go/no-go decision task (Fundi's Adventures) based on both inductive learning and indirect communication in a sample of ADHD children. It has been reported that the basic neuropsychological constructs of the go/no-go task are preserved in the emotional investigation54.
The protocol follows the guidelines of Fundació Carme Vidal human research ethics committee. Inform consent was obtained.
1. Recruitment of the subjects
NOTE: Recruitment was performed as per the previously published literature12.
2. Procedure
A random, prospective, longitudinal, uncontrolled, analytical study (before – after) was designed. We recruited 66 pharmacologically untreated combined ADHD children according to DSM-V criteria, aged 13-15 years with a mean of 13.89 years with SD ± 0.8 (47 males and 19 females). They also met ADHD criteria according to SNAP-IV-18. Statistical analysis was conducted using a paired Student t-test and effect size statistics (Cohen’s δ) was applied.
All 66 children in the study totally scored ≥ 1.8/2.6 (parents/teachers) in SNAP-IV. To obtain the inattention score, the scores of the first nine questions were added and divided by 9. The cutoff point of the parent inattention scale was 1.44 and the cutoff point of the teacher scale was 1.78. All 66 children in this study scored ≥ 1.6/2.0 (parents/teachers) in the inattention score. To obtain the hyperactivity/impulsivity score, the scores of the last nine questions were added and divided by 9. The cutoff point of the parent’s hyperactivity/impulsivity scale was 1.67 and the cutoff point of the teacher’s hyperactivity/impulsivity scale was 2.0. All 66 children in the study scored ≥ 1.8/2.6 (parents/teachers) in the hyperactivity/impulsivity score .
Concerning CAS assessment, simultaneous tests were conducted by presenting nonverbal matrices, verbal-spatial relations, and figure memory. Successive tests were conducted by presenting word series, sentence repetition, sentence question (from 8 to 17 years) and successive speech rate (from ages 5 to 7 years). Planning tests were conducted by matching numbers, planned codes, and planned connections. Attention tests were conducted by checking expressive attention, number detection, and receptive attention. These four tests were performed in random order for all participants.
Extensive reliability and validity information can be accessed via interpretive handbook. Full Scale reliability is 0.96 with the PASS Scale reliabilities ranging from 0.83 to 0.93. Internal consistency and test-retest reliability studies were conducted. The booklets are intended for paper and pencil responses.
Table 1 shows that in PASS processes, both planning (p= 0.000, Cohen’s δ = 2.32) and attention (p = 0.000, Cohen’s δ = 1.64) were ameliorated at a statistically significant level after intervention over 6 months with a large difference effect with planning rather than attention. On the other hand, after intervention over 6 months, remission was achieved in 70% of subjects (e.g., 70% of subjects achieved a loss of diagnostic ADHD criteria). The other 30% of subjects achieved a criterion of response, a reduction in malfunctioning manifestations of at least 25%.
Processing | Mean | SD | t* | p | Cohen's d** |
Planning before remediation | 77.76 | 6.06 | -18.89 | 0.000 | |
Planning after remediation | 80.3 | 7.43 | 2.32 | ||
Simultaneous before remediation | 101.48 | 7.77 | -1.89 | 0.064 | |
Simultaneous after remediation | 102.39 | 7.9 | 0.23 | ||
Attention before remediation | 80.26 | 6.04 | -13.31 | 0.000 | |
Attention after remediation | 91.14 | 7.01 | 1.64 | ||
Successive before remediation | 86.21 | 13.22 | -0.475 | 0.636 | |
Successive after remediation | 86.35 | 12.78 | 0.06 | ||
*Paired-Samples T Test | |||||
**Cohen's effect size. trivial ( < 0.1), small (0.1– 0.3), moderate (0.3– 0.5), large difference effect ( > 0.5) |
Table 1: Comparison of PASS processing before and after remediation. (A) t-Student paired samples were applied in order to prove significance (p < 0.05). Planning and attention processes ameliorate significantly. (B) Cohen’s Size Effect confirms a large difference effect in both planning and attention processes.
As expected, the training, Adventures of Fundi, was useful to intervene in ADHD behavioral dysfunction based on both the PASS cognitive processing and self-confidence emotional processing. The success is in terms of better cognitive processing and better behavior. The better cognitive processing is mainly in planning and not so much in attention (Table 1). PASS planning and selective attention join the executive function. It is well known that a better executive function is associated with a better behavior, therefore, we can expect improved behavior in an ADHD sample. The remedial procedure involves inductive learning and an emotional communication technique promoting self-confidence that can, at least in part, explain the results. The effectiveness of inductive learning has been previously and sufficiently demonstrated2,6,8.
On the other hand, moods, even positive ones, interfere with the central cognitive tasks (memorizing complex materials, detecting contradictions in texts, etc.). Arguments must be focused on finding how the improvement in self-confidence happens. Self-confidence is the result of subtracting safe-confident experiences from unsafe-unconfident experiences throughout life. The safe experiences throughout life determine the confidence. The improvement in executive function and the inductive learning provide a safe-confident experience, but the more innovative point is that the Ericksonian indirect communication metaphor is a powerful tool to generate self-confidence, communicating well-being unconsciously16,17,18,19,20,21 rather than consciously. Much of the behavior consists precisely in the automatic functioning. Self-confidence is the key point to improve cognition (and learning) and emotion and consequently behavior. Therefore, we can expect better ADHD behavior.
We are developing a rationale for supporting the effectiveness of this technique as a procedure for promoting self-confidence. Supporting evidence is being reported to measure emotion (well-being and discomfort) objectively, in terms of behavioral and physiological changes. Not only emotional response can be objectively studied, like body language, facial expressions, tone of voice, etc., but also psychophysiological responses can also be studied such as, skin conductance, heart rate, and so on58. The role of body language in expressing unconscious processing and implicit (unconscious) decision well described in previously published literatures7,44.
Many body expressions tell us about cognition and emotion. For instance, eyes down and to the left or to the right show body sensations; eyes level and to the left or to the right show successive processing; eyes up and to the left or to the right show simultaneous processing, etc. Other examples of informative body expressions are as follows: shoulders relaxed and drooped and breathing deeply in the abdominal area (as in breathing from the diaphragm) depicts tranquility and relaxation. In contrast, wrinkled forehead and/or contracted jaw and/or shoulders thrown back and/or shallow breathing in the chest and/or a fixed grin show tension and concentration among other expression: unusual posture, rigid body, rocking back and forth or side to side, leaning to one side, head turns, facial expression (mouth and eyebrows), startled look, big grin on the face, eye contact, yawning, specific hand movements, particular words or phrases, voice quality and pitch, tempo (rhythmic, choppy), volume, tone, inflection, speed, and so on.
This technique is based on the cognitive and emotional unconscious processing for diagnosis and treatment. In contrast, almost all cognitive psychology and remediation is based on the self-report of what they perceive, think, remember, and feel. That is, they seem to rely on self-reports of what subjects report. This way, emotion is viewed as a product of cognitive construction such that the factors that differentiate the emotions are the cognitive attributions that people make about their emotions.
In last decade, neuroscience studies have reaffirmed the unconscious mind. This technique is based on the unconscious mind for cognitive and emotional diagnosis and treatment. For instance, people can recognize an image they have seen before even when they have been unaware of having seen it21. About 40 ms is the time it takes to form an opinion of a stranger, which is a shorter time than a blink. However, it is enough time to observe what the subject's face and body language is doing such that the brain-mind can interpret it unconsciously if its facial features and body language inspire confidence or danger36.
A step further is to focus on cognitively unsound uses of reasoning. We base decisions on the availability of justificatory reasons42,43. Conscious reasoning is applied to rationalize more than anything else59. This process is supported by neuroimaging studies. One of them23 concludes that the brain might cheat when learning or behaving, building memorized answers to respond to similar questions. Thoughts and impulses simply arise in consciousness without will or intent. Which is all to say, we are not in any relevant sense the conscious authors of our mental lives, nor the actions that flow from them. Therefore, the self-verbal report is questionable. Another example, the verbally reported strategy to perform a task may not be the one the child used, according to the observable eye movements of the child1,6,7,8,14,15. Likewise, a self-verbal-report of positive view (overconfidence) of oneself is not necessarily a reliable indicator of self-confidence; on the contrary, it could be the opposite7,14,15. Humans reason rather poorly, as reported by Mercier and Sperber (2011)43, irrational biases in decision making37,39,40. It is about intuitive-unconscious inference42,43. This is in sharp contrast to the classical view that pro and con reasoning is the most reliable way to arrive at sound decisions17,18,19,40,58,59.
Following Kahneman37,39,40,60,61, we have a dual-process system of decision-making: automatic linked to emotion (gut reaction) and deliberative linked to rational calculation. However, following Greene62,63, “the response to footbridge has an emotional charge that is missing in the allegedly more rational response to switch.” Brain imaging studies link the emotional ventromedial prefrontal cortex with “footbridge” decision whereas the “switch-type” response is linked with the cognitive-rational dorsolateral prefrontal cortex. On the other hand, injury studies of the ventromedial prefrontal cortex show that this injury predisposes approval of pushing the fat man off the bridge. The LeDoux studies13 showed that the temporal amygdala responses to danger before the cortex (thinking brain). More importantly, the response of the cortex did not modify the earlier response of the amygdala. This fact is entirely consistent with the thinking cortex, putting into action thoughts that justify the response to danger (cognitive bias).
To go one step further, we must elaborate on the anticipatory unconscious processing. This processing (unconscious before conscious decision processing) has been studied, not only, in the field of neuroscience22,23,24,25,26,27,28,29,30,31,32,33,34,35. Brain studies on the pre-decision period22,23,24,25,26,27,28,29,30,31,32,33,34,35 have found neural activity representing the upcoming choice. As Soon et al. reported (2013)31, a decision can be encoded in brain activity of the prefrontal and parietal cortex up to 10 s before it enters awareness.
As previously reported for practical applications7, techniques that are used in this type of communication include the use of metaphors, indirect questions, hypothetical phrases, introductory phrases, ambiguous terms, saturation of channels of information, melodramatic expression or confusion, post-trance amnesia, silence, dissociation, paradox, false alternative options, and prescription of the symptom. These communicative techniques involve extreme attention focalization (trance state) on what is being said and done by the therapist. Attention cannot be focused on other thoughts associated with bad feeling because of the known limited attention span. All this happens unconsciously.
In particular64, the metaphor is an indirect method of verbal and nonverbal communication and it is the basis of Ericksonian hypnosis44,65. This method of communication is an educational and psychotherapeutic proven procedure45,46,47,48,49,50,51,52,53. The metaphor involves a cognitive effect while conveying an idea – thought (message), but also, and more importantly, produces an analgesic-reassuring effect because of a distraction work linked to focused attention, taking into account that the attention span is limited. In other words, a highly focused attention on getting the meaning of the metaphor in action (Ericksonian hypnosis effect) restricts other cognitive processing (thoughts) and the associated memorized painful feeling (discomfort). It causes an analgesic effect. This analgesic effect is the key to avoid resistance to the communication. If so, interpersonal communication requires to fit this principle to be more effective. On the other hand, there is evidence that the metaphor uses a communication based more on tangible-concrete knowledge rather than abstract knowledge, which makes the message (knowledge) more easily processed and far transferred.
In contrast, most procedures to intervene are based on gaining conscious control of thought and action, but we must assume that implicit emotions are less subject to conscious self-regulation. It is intended to help people learn how to cope with otherwise threatening and debilitating emotional situations, assuming one can strengthen the willpower with practice. Not only does this seem too simplistic, but it sidesteps the core problem of self-control: what is controlling what? The consequence of this is to give cognitive psychology a fuller, richer understanding of how the mind operates. This will inevitably have some implications for clinical work on learning and behavioral disorders and ADHD in particular. The only way to do this is to get clinicians to collaborate with experimental psychologists to produce methodologically adequate clinical studies.
In conclusion, the Adventures of Fundi was able to improve PASS cognitive processing planning and attention and also achieved remission66 in manifestations of ADHD. This result should be attributed to the administration of the whole procedure. It took place using inductive learning and indirect communication (metaphorical Ericksonian hypnosis). Taking into account that the main effect of indirect communication is an effective emotional empathic communication (sensitive effect on self-confidence), we must deduce that other factors, non-cognitive, must be taken into account to maximize the benefit of cognitive and behavioral remediation. Likewise, we must summarize that the critical step within the protocol is the indirect communication, the technique has no significant limitations and its future applications are any dysfunction linked to executive dysfunction.
Some limitations deserve to be highlighted. Further research is required—at behavioral, cognitive, and physiological levels—to delineate the components of goal-directed behavior. The presence of the effect does not actually always provide support for the model. It is still needed to check that individual results hold up. The empirical point is now well established. We caution that the evidence for this proposition is consistent and, in some way, convincing, but maybe inadequately supported by the research so far.
The authors have nothing to disclose.
We are indebted to all the personnel of the Fundació Carme Vidal NeuroPsicopedagogia, the children, and their parents for their invaluable collaboration in the research presented here. Also, to all professionals who contributed to this study in any way, such as statistical analysis, computational assistance, suggestions, comments, and encouragement, overall to Joan Timoneda. A special thanks goes to our teammates, Jordi Baus, Jordi Hernández, Oscar Mateu, Anna Orri, and Martí Ribas.
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