502079

research-article2013
JADXXX10.1177/1087054713502079Journal of Attention DisordersHorowitz-Kraus

Article
Journal of Attention Disorders

Differential Effect of Cognitive Training on

2015, Vol. 19(6) 515­–526
© 2013 SAGE Publications
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DOI: 10.1177/1087054713502079

Children With ADHD and in Children With jad.sagepub.com

ADHD Comorbid With Reading Difficulties

Tzipi Horowitz-Kraus1,2

Abstract
The comorbidity of ADHD and reading difficulties (ADHD + RD) is believed to be a disability distinct from ADHD
alone, with unique challenges faced by individuals suffering from one disability versus the other. We aimed to examine
the differential effect of 8 weeks of cognitive training on reading abilities and on executive functions, through use of the
Wisconsin task, in children with ADHD and in children with ADHD + RD. Greater impairments in reading and executive
functions, especially in speed of processing, were found in the comorbid group at baseline. The comorbid group showed
greater improvements in most measures after training as well. We propose that the cognitive training used in the present
study affected not only the immediate abilities of executive functioning but also the secondary ability of reading, especially
in the comorbid group, by improving in particular, speed of processing. We suggest that a differential approach should be
taken when treating children with ADHD + RD versus treating ADHD children. (J. of Att. Dis. 2015; 19(6) 515-526)

Keywords
ADHD, executive functions, reading difficulties, training

Introduction processing (Willcutt, Doyle, Nigg, Faraone, & Pennington,

ADHD is a highly prevalent disorder estimated to affect a
range of 2.2% to 17.8% of school-aged children in the
United States and in Europe (Skounti, Philalithis, &
Galanakis, 2007). These individuals suffer from excessive
inattention and impulsivity, starting in childhood and often
persisting into adolescence and adulthood (Faraone,
Sergeant, Gillberg, & Biederman, 2003; Mannuzza, Klein,
Bessler, Malloy, & LaPadula, 1993). These impairments
result in an inability to sit still in class, a tendency to answer
questions before they have been fully asked, and to have
difficulty in organizing oneself and one’s schoolwork, all of
which contribute to academic failures and reading difficul-
ties (Greven, Rijsdijk, Asherson, & Plomin, 2012). Reading
difficulties manifest mainly as inaccurate, slow reading and
they are known to be related to deficits in executive func-
tions (Biederman et al., 2004; Jacobson et al., 2011).
However, children who suffer from ADHD and reading dis-
abilities (i.e., children with an ADHD + RD comorbidity)
exhibit more severe deficits in all domains than do children
with only ADHD (Rucklidge & Tannock, 2002).
Specifically, ADHD + RD children experience more severe
deficits than ADHD children in a number of executive func-
tions: naming (Rucklidge & Tannock, 2002), speed of
2005), working memory, shifting between tasks, inhibition
(Willcutt et al., 2001), verbal auditory working memory
(Vakil, Blachstein, Wertman-Elad, & Greenstein, 2011),
and all timed executive functions (Katz, Brown, Roth, &
Beers, 2011). They exhibit a greater reading impairment, in
decoding and orthographic tasks (Willcutt et al., 2005), and
their reading impairment is accompanied by a phonologi-
cal deficit (Purvis & Tannock, 2000). This group also is
known to have greater psychological, behavioral, and emo-
tional problems than RD and ADHD groups exhibits sepa-
rately, suggesting that ADHD + RD is a distinct disorder (for
review, see Mattison & Mayes, 2012; Sexton, Gelhorn, Bell,
& Classi, 2011). We recently pointed at these distinct cogni-
tive profiles using electroencephalogram (EEG) recordings
(Horowitz-Kraus, 2013): children with ADHD + RD
showed smaller event-related potential (ERP) components
(Error-related Negativity, N100 and N400 components),
1
University of Haifa, Israel
2
Cincinnati Children’s Hospital Medical Center, OH, USA
Corresponding Author:
Tzipi Horowitz-Kraus, Cincinnati Children’s Research Foundation,
Pediatric Neuroimaging Research Consortium, 3333 Burnet Ave.,
Cincinnati, OH 45229-3039, USA.

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516 Journal of Attention Disorders 19(6)
accompanied by lower executive function and reading abili-
ties, as compared with ADHD children. We concluded that
the executive processes in the comorbid group are more
impaired than in the ADHD group, resulting in lessened
error-detection activation in reading and in impaired speed
of processing. The lower error-detection activation in read-
ing, thought to imply a lower awareness of reading errors,
might be one of the causes of the major impairment in read-
ing abilities in general (Horowitz-Kraus, 2013). The speed
of processing deficits represent a longer time that elapses
between the presentation of an external stimulus and a par-
ticipant’s response to it (Kail, 1991), which also could affect
overall reading abilities negatively. In light of these find-
ings, and because pharmaceutical intervention (i.e., stimu-
lant medication) is not always accepted by parents for
treatment of their children (see Hodgson, Hutchinson, &
Denson, 2012), and is not in favor for treating reading dif-
ficulties specifically (Antigas-Pallares, 2009), the present
study aims to find the differential effect of a cognitive train-
ing intervention on executive functions, as well as its effect
on reading measures, in children with ADHD + RD as com-
pared with children with ADHD.
Nonpharmacological interventions are becoming more
widely used for children with various learning disorders
(Hodgson et al., 2012), as parents, children, and clinicians
are less willing to use medications (stimulants) for a child’s
treatment (Donnelly, Haby, Carter, Andrews, & Vos, 2004).
Studies have examined the effect of cognitive training, but
these have mostly been focused on children with ADHD
or with ADHD + RD/learning difficulties separately.
Intervention programs designed specifically to affect the
executive functions are important because of the known
strong negative associations between executive functions
and ADHD symptoms, psychopathology symptoms and
social problems (see Mattison & Mayes, 2012). Green and
colleagues (2012) showed that children with ADHD who
participated in an executive function (specifically, working
memory) training program for 25 days (90 sessions) showed
a significant decrease in ADHD symptoms and an increase
in working-memory measures, as compared with the pla-
cebo-treatment group. The authors suggested that the pro-
gram used in their study activated the prefrontal cortex,
which could lead to these generalized effects. Beck, Hanson,
Puffenberger, Berninger, and Berninger (2010) showed
improvements in executive functions and attention symp-
toms in ADHD + RD participants following a working-
memory training, as compared with a group of children
with ADHD + RD who did not undergo the training (a wait-
ing-list group). In a meta-analysis study, Hodgson et al.
(2012) suggested that neurofeedback training reduced
ADHD symptoms in an experimental group as compared
with nontrained children with ADHD. Highlighting the role
of executive functions in ADHD, a pilot study demonstrated
an increase in executive functions scores and a decrease in
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ADHD symptoms in children (aged 8-12 years) with ADHD
who underwent an executive functions training intervention
for 9 weeks, as compared with their ADHD peers in the
waiting-list group (Green et al., 2012). The researchers
pointed at the effect of computerized games to increase the
motivation and engagement of participants, especially for
children with ADHD (Green et al., 2012). Gray et al. (2012)
showed that a working-memory training program for ado-
lescents (12-17 years old) with ADHD and learning disabil-
ity (LD) improved their working-memory, attention and
academic achievement (reading and math) as compared
with those in an ADHD + LD group that trained in math.
This study’s results conflicted with those of Green et al.
(2012), which found no effect on attention and academic
measures in the ADHD group. Despite these research done
in this field, we have not found a study specifically compar-
ing the differential effect of executive functions training on
executive and reading measures between children with
ADHD + RD and children with only ADHD.
The present study aimed to explore the effects of an
8-week executive functions training program on executive
functioning (immediate effect) and reading (near effect) mea-
sures in children with ADHD + RD and in children with
ADHD alone. We used the “Cognifit” game-based program
(CogniFit Ltd, 2008; see “Method” section). Executive abili-
ties before and after training were measured using a comput-
erized version of the traditional Wisconsin task (see “Method”
section), which has been shown to evaluate measures of
executive functions effectively (Kimberg, D’Esposito, &
Farah, 1997; Lezak, 1995; Milner, 1963). Reading ability
was measured using standardized reading tests.
Method
Participants
This study included 28 age-matched participants (14 chil-
dren diagnosed with ADHD, mean age 12.92 ± .65 years,
14 males), and 14 with ADHD + RD (the comorbid group;
mean age 13.19 ± .75 years, 12 males, 2 females); t(26) =
−1.02, ns, all matched for nonverbal IQ (90 and above) as
measured by the Raven Standard Progressive Matrices
(Raven, 1969). All were native Hebrew speakers from a
middle-class background, right-handed, with normal or
corrected-to-normal vision in both eyes, and all were found
to have normal hearing. We used the Conners’ Rating scale
for teenagers to match the participants for their attention
scores, t(26) = .327, ns, and for their performance relative
to normal (Conners, 1989). All participants met the defini-
tion of ADHD as described in the Diagnostic and Statistical
Manual of Mental Disorders (4th ed.; DSM-IV; American
Psychiatric Association, 1994). No differences were found
on attention measures between the females and the males
in the study.
Horowitz-Kraus 517
Participants signed assents and their parents provided
written informed consent prior to the study. Both groups
were diagnosed as having ADHD or ADHD + RD at least 2
years prior to the study, with ADHD being the primary diag-
nosis in both groups of participants. Diagnoses were veri-
fied by a score of −1.5 or below on a standardized 1-min
word reading test and through a normative reading battery,
involving text read orally, which tests for accuracy and flu-
ency (Shany, Lachman, Shalem, Bahat, & Zeiger, 2006).
ADHD diagnoses were verified by a score of 6 out of 9 or
more, for characteristics of ADHD existing for more than 6
months, using the Conners’ attention/hyperactivity ques-
tionnaire (Conners, 1989). All participants attended a junior
high school for students with learning disabilities. Students
were not medicated during training.
Procedures
Participants were assessed within their school. Tests were
administered individually in a schoolroom, after school
hours, by the research team. The study was reviewed and
approved by the Ethics Committee of the University of
Haifa.
Behavioral and Experimental Measures
Behavioral measures.  Ten tests were administered to mea-
sure reading and executive functions in the two groups.
Reading ability was measured by several subtests: (A)
decoding—1-min word test for children (Shany et al.,
2006), (B) oral reading task (Shany et al., 2006), (C) Read-
ing comprehension task (Shatil, Nevo, & Breznitz, 2008),
and (D) orthographic automaticity (Parsing test; Breznitz,
1997). Executive functions were measured by (A) short-
term memory and capacity—digit span subtest from the
Wechsler Adult Intelligence Scale-Third Edition (WAIS-III;
Wechsler, 1997), (B) grapho-motor speed of processing—
the coding subtest of the WAIS-III (Wechsler, 1997), (C)
visual speed of processing—the symbol search subtest of
the WAIS-III (Wechsler, 1997), (D) naming ability (letters
and Rapid Alternating Stimulus naming; modeled after
Denckla & Rudel, 1976; Wolf, Bally, & Morris, 1986) and
(E) spatial ability (CogniFit Ltd, 2008). Measures for gen-
eral ability, attention, reading, and word recognition were
administered prior to the experiment to verify each partici-
pant’s reading level, IQ, and attention ability. Each behav-
ioral testing session lasted approximately 1.5 hr.
Experimental measure: The Madrid Card-Sorting Test
(MCST). Executive abilities were examined using the
MCST, which is a computerized version of the traditional
task-cuing Wisconsin Card Sorting Test (WCST; adapted
from Barcelo, 2003). Stimuli were presented by Presenta-
tion software (Neurobehavioral Systems Inc., Albany,
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California). The MCST stimulus material consists of 24
choice-cards that are to be matched during each trial with
one of four target-cards, based on one of three stimulus
dimensions, or “rules”: color, shape, or number of items on
the card (see Horowitz-Kraus, 2012, for an illustration).
MCST stimuli were all presented at a visual angle of 4°
horizontally and 3.5° vertically, and remained on the screen
until the participant responded. The colored geometrical
figures were outlined in black against a white background
and were identical in luminance. The trials, totaling 137,
were semirandomly arranged into 18 series, each marked
by a new “rule,” and varying in length from 6 to 8 trials per
series, to avoid rule-switch anticipation. The correct sort-
ing rule was determined by an auditory cue delivered
within 1,500 to 2,000 ms after a participant’s response (200
ms duration, 10 ms rise/fall times; 65 dB SPL; 1000 Hz for
“stay” cues, 500 Hz for “shift” cues). Hence, each correct
trial was followed by a “stay” cue, and each error trial was
followed by a “shift” cue. After a varying number of cor-
rect responses, the rule changed unpredictably, and the par-
ticipant had to adjust to the new rule (e.g., from shape to
color, or from color to number, etc.). There was a fixed
interval of 1,400 ms between the feedback onset and the
onset of the next trial. The full MCST design used in this
study is depicted in Horowitz-Kraus, 2012, modeled after
Barcelo (2003).
Mean reaction times and mean accuracy rates were
obtained from correct and error trials. Error trials were ones
in which the participant failed to select the correct target
response when the rule changed, or when the participant
failed to follow the instruction to switch or repeat the previ-
ous trial. Shift trials were divided into two types of shifts:
(a) first shift, in which the first cue announced the change in
rule, and (b) second shift, in which the second cue announced
the change in rule (Barcelo, 2003).
Executive Functions Training
Auditory, visual, and cross-modality working-memory
skills—naming, speed of processing, inhibition, simple reac-
tion times, flexibility, divided attention, spatial ability, shift-
ing, and attention—were all trained using the CogniFit
Personal Coach (CPC) Computerized Cognitive Program
(CogniFit Ltd, 2008). This program includes a baseline cog-
nitive assessment (T1) that allows the training program to be
individualized for each participant. Normative data from a
large database of previous users define the initial challenge
level of each of the training games/tasks used. Each training
session includes a mixture of games/tasks aimed at training
executive functions. Each of the games/tasks has three levels
of difficulty—easy, moderate, and difficult. The training pro-
gram and the level of the complexity within each domain
were created for each participant according to a personal
“Scheduled Training Option” (CogniFit Ltd, 2008), which
518 Journal of Attention Disorders 19(6)

Table 1.  Means, Standard Deviations, and Results of t-Test for Reading Before (Test 1) and After (Test 2) Training.

T1 T2

  ADHD (A) ADHD + RD (B) ADHD (C) ADHD + RD (D)  

Test M (SD) M (SD) M (SD) M (SD) t-value Contrasts

Decoding— Accuracy 53.1 (27.47) 33.8 (17.47) 59.61 (31.05) 36.93 (19.68) 2.083* A>B
(number of correct
words per minute)
Fluency—Speed (seconds 1.1 (.85) 1.7 (1) 0.95 (.59) 1.19 (.633) −2.596* D<B
per word in oral text
reading)
Fluency—Accuracy 11.15 (7.88) 20.27 (15.45) 9.3 (4.46) 16.63 (16.67) 2.13* D<B
(number of errors in
the passage, out of 292
words)
  −2.05* B>A
Reading comprehension— −1.91 (2.41) −3.89 (3) −1.46 (2.85) −3.33 (3.15) 1.75* A>B
Accuracy (standard
score)
Orthography— Parsing 10.33 (4.59) 10.17 (4.1) 10.77 (6.33) 8.8 (4.11)  
speed (time in sec per
item)

*p < .05. **p < .01. ***p < .001.

was based on the participant’s performance on the baseline
assessment. The level of challenge was further readjusted
after each training session according to the participant’s
progress. Each training session took 15 to 20 min. At the
beginning of each task, the user read a description of the main
cognitive skills that were being trained in that task and at the
end of each day’s training, the user could examine his or her
performance on graphs that described his or her progress.
maze as fast as possible. An important feature of the
overall program is the Personal Coach, which offers
insights and advice based on data from several ses-
sions. For example, if a participant exhibits good
visual memory abilities but poor auditory memory
abilities, the Personal Coach will comment on the
skill difference and advise the participant to pay
special attention to auditory memory tasks.

Examples of the cognitive tasks used in the CPC program

1. Visual memory task: Windows of an on-screen
house open in a certain sequence. The participant is
asked to follow the exact sequence in which the
windows open, and the length of the sequence varies
from task to task.
2. Cross-modality memory task: Pictures and sounds
of objects are presented to the participant sequen-
tially. The participant then has to recognize the
objects from an assortment of images, and recall
whether it was previously presented visually or
auditorally.
3. Attention split task: The participant is presented
with billiard balls, on two separate on-screen boards,
moving from one side of the screen to the other in
different directions. The participant must click on
the balls before they hit the walls of the two boards.
4. Spatial perception task: The participant is presented
with a maze and must find his or her way in the
Research Design and Procedure 
General ability, attention, reading, and word-recognition
tests were administered prior to the experiment to verify
that both groups met the criteria for ADHD and that the
children in the ADHD + RD group also met the criteria for
reading difficulty (−1.5 standard score and below on stan-
dardized word and contextual reading tasks; see Shany et
al., 2006). In general, each behavioral testing session lasted
approximately 1.5 hr (Table 1).
During the experiment, the participant was seated in an
isolated, sound-attenuated room. No interaction took place
between the participant and experimenter during the WCST
administration. Visual stimuli were presented on a com-
puter screen located 1 m in front of the participant. Auditory
stimuli (the feedback “correct” for “stay” or “wrong” for
“shift” in the WCST, and other auditory stimuli in the CTC
program) were presented via headsets from the computer at
a frequency of 2000 Hz. Participants then started their exec-
utive functions training. All participants trained for 8 weeks,

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Horowitz-Kraus 519

Figure 1.  Accuracy rate (in percentage) for each stage of the Wisconsin task in individuals with ADHD before (Test 1) and after
(Test 2) training interventions.
Note. Figure 1 depicts accuracy rates (in percentage) and standard deviations before (Test 1, blue bars) and after (Test 2, red bars) training for individu-
als with ADHD in each stage of the Wisconsin task. The equations for the linear regression lines are listed in the bottom right corner (blue equation =
before training; red equation = after training).

Figure 2.  Accuracy rate (in percentage) for each stage of the Wisconsin task in individuals with ADHD + RD before (Test 1) and
after (Test 2) training interventions.
Note. Figure 2 depicts the accuracy rates (in percentage) and standard deviations before (Test 1, blue bars) and after (Test 2, red bars) training for indi-
viduals with ADHD + RD in each stage of the Wisconsin task. The equations for the linear regression lines are listed in the bottom right corner (blue
equation = before training; red equation = after training).

3 times per week, 15 to 20 min per training session on a
personal computer (for a total of 24 sessions). After com-
pletion of the training, the participants were tested with the
executive functions and reading batteries (see Table 1) and
on the Wisconsin task. This session lasted about 1.5 hr.
Statistical Analysis
Behavioral data (see “Behavioral measures” section
description) were analyzed using independent t-test analy-
ses. We used paired and independent t-test analyses to ana-
lyze the Wisconsin task data before and after training
(Figures 1-4). Family-wise Type I error rates were corrected
by the Bonferroni method for multiple comparisons (α <
.05). Regression analysis was also applied within groups to
determine the differences in learning curves after training.
To verify the differences in variance between the partici-
pants before and following intervention, four paired t-test
analyses were conducted separately using the standard
deviation scores, for accuracy and for reaction times, for
each stage in the Wisconsin task for the two groups sepa-
rately. As the different reading and executive measures
assess different aspects (e.g., in reading: decoding task
measures phonological ability, Parsing—orthographical
ability, Oral reading—fluency and comprehension; in exec-
utive functions: the different subcomponents of the naming

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520 Journal of Attention Disorders 19(6)

Figure 3.  Reaction times (in ms) for error responses for each stage of the Wisconsin task in individuals with ADHD before (Test 1)
and after (Test 2) training interventions.
Note. Figure 3 depicts reaction times (in ms) and standard deviations for error responses on each stage of the Wisconsin task before (Test 1, blue
bars) and after (Test 2, red bars) training, for individuals with ADHD. The equations for linear regression lines are listed in the bottom right corner
(blue equation = before training; red equation = after training).

Figure 4.  Reaction times (in ms) for error responses at each stage of the Wisconsin task in individuals with ADHD + RD before
(Test 1) and after (Test 2) training interventions.
Note. Figure 4 depicts reaction times (in ms) and standard deviations for error responses at each stage of the Wisconsin task before (Test 1, blue
bars) and after (Test 2, red bars) training, for individuals with ADHD + RD. The equations for the linear regression lines are listed in the bottom right
corner (blue equation = before training; red equation = after training).

task examine different aspects, see Norton & Wolf, 2012), functions (see “Behavioral measures” section, executive
Pearson correlation was used to find associations between function measures, Variables A-E). Family-wise Type I
improvements in reading (see “Behavioral measures” sec- error rates were corrected by the Bonferroni method for
tion, reading measures, Variables A-D,) and in executive multiple comparisons (α < .05)

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Horowitz-Kraus 521

Table 2.  Means, Standard Deviations and Results of t-Test for Executive Functions Before (Test 1) and After (Test 2) Training.

T1 T2

  ADHD (A) ADHD + RD (B) ADHD © ADHD + RD (D)  

Measure M (SD) M (SD) M (SD) M (SD) t-value Contrasts

Naming—RAS (time is seconds) 37.68 (9.38) 44.98 (7.12) 35.3 (10.2) 41.81 (7.31) −1.884* A<B
Naming—Letters (time is 34.14 (6.87) 40.46 (5.93) 30.53 (7.17) 35.63 (4.36) 3.09** A>C
seconds)
  2.9* B>D
  −2.048* B>A
Symbol search (standard score) 6.23 (2.2) 4.72 (2.14) 7.53 (2.96) 5.45 (2.58) −2.623* C>A
Symbol search (number of 23.46 (5.63) 20.81 (3.99) 27 (5.61) 24.63 (4.24) −2.822* C>A
correct responses)
  −3.464* D>B
Digit span (standard score) 5.38 (2.56) 4.36 (1.91) 6.38 (2.56) 4.18 (2.71) −2.55* C>A
Digit span forward (highest 5.3 (.63) 5.09 (1.04) 5.3 (.63) 4.72 (.78)  
number of digits reached)
Digit span backwards (highest 3.53 (0.87) 3.36 (0.8) 4 (0.81) 3.81 (1.07) −2.144* C>A
number of digits reached)
Digit symbol (standard score) 5.3 (1.97) 3.27 (1.73) 5.23 (3.94) 3.63 (1.68) 3.002** A>B
Digit symbol (number of 40.46 (8.32) 32.63 (7.44) 42.76 (15.61) 37.27 (5.83) −2.519* D>B
correct responses)
  2.846** A>B
Spatial perception (standard 0.83 (1.09) 0.86 (1.58) 0.81 (0.94) 1.54 (1.14) −2* D>B
score)

*p < .05. **p < .01. ***p < .001.

Results Executive functions. Between-group analyses showed that

Baseline Behavioral Measures (Test 1)
Reading. In general, children with ADHD + RD showed
greater difficulties in several reading measures (signifi-
cantly less words were read accurately, lower comprehen-
sion scores were achieved, and a trend of slower and
less-accurate oral reading was observed) than children with
ADHD (Table 1).
Executive functions. Participants with ADHD + RD were
also significantly slower than the ADHD group in parts of
the speed of processing battery (naming letters and naming
rapid alternating stimulus test [RAS] speed and coding
test). Although in some cases the ADHD + RD group exhib-
ited lower scores than the ADHD group (symbol search,
digit span, and spatial perception), no significant differ-
ences were found in these parameters (i.e., which are listed
in the parentheses) between the groups (Table 2).
The Effect of Intervention (Test 2)
Reading. Children in the ADHD + RD group showed an
increase in speed and accuracy in oral reading following
training, whereas the ADHD group showed no significant
effect in reading measures (Table 1).
children with ADHD + RD showed improved speed of pro-
cessing measures after the intervention (e.g., faster naming
letters, and greater accuracy in symbol search and digit
symbol) and better spatial perception scores. Children in the
ADHD group showed improved memory measures as well
as an improvement in parts of the speed of processing mea-
sures (faster letter naming, and greater accuracy and stan-
dard score in symbol search; Table 2).
After intervention, baseline differences between the
ADHD and ADHD + RD children in words reading and
reading comprehension disappeared, as was observed in the
between-group comparisons analysis. Also, no differences
in speed for naming RAS and letters, or in digit symbol,
were observed after training between the two groups.
The Effect of Executive Functions Training on
Performance in the Wisconsin Task
Accuracy rate. Overall, both groups demonstrated a higher
learning curve along the Wisconsin task, which can be seen in
the positive slope of the linear regression line. No significant
differences in accuracy were found within the groups or
between groups before or after the executive training. No dif-
ferences in standard deviations before and after intervention
were found within the groups (see Figures 1 and 2 and Table 3).

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522 Journal of Attention Disorders 19(6)

Table 3.  Mean Accuracy Rate (in Percentage) on the Wisconsin Task for Children With ADHD as Compared With Children With
ADHD + RD Before (Test 1) and After (Test 2) Executive Training.

Correct responses (%) T1 Correct responses (%) T2

  ADHD (A) ADHD + RD (B) ADHD (C) ADHD + RD (D)

Trial number M (SD) M (SD) M (SD) M (SD)

First shift 11.72 (7.02) 13.58 (6.27) 8.33 (10.22) 6.66 (6.82)
Second shift 36.11 (10.39) 39.31 (11.44) 37.77 (12.5) 40 (17.52)
Stay-1 59.92 (16.03) 60.25 (17.19) 63.88 (57.22) 57.22 (19.6)
Stay-2 68.65 (12.05) 67.09 (17.19) 73.88 (16.77) 65 (18.71)
Stay-3 67.46 (16.71) 70.08 (16.59) 72.77 (12.68) 72.22 (17.37)
Stay-4 66.66 (19.73) 73.93 (13.10) 72.22 (16.71) 82.33 (13.35)
Stay-last 70.96 (17.76) 74.16 (15.37) 84.48 (12.18) 82.04 (11.32)

Note. M = mean (in percentage).

Table 4.  Mean Reaction Times (ms) for Error Responses on the Wisconsin Task for Children With ADHD as Compared With
Children With ADHD + RD, Before (Test 1) and After (Test 2) an Executive Training Intervention.

Reaction times (ms) T1 Reaction times (m) T2

  ADHD (A) ADHD + RD (B) ADHD (C) ADHD + RD (D)  

Trial number M (SD) M (SD) M (SD) M (SD) t-value Contrasts

First shift 2,902.94 (2,838.49) 3,6663.25 (3,679.39) 1,702.86 (357.62) 1,684.82 (367.87) −.01* B>A
  2.127* A>C
Second shift 6,003.07 (5,564.31) 3,371.97 (1,740.2) 2,304.64 (427.03) 2,308.38 (778.24) −.013** B>A
  2.649* B>D
Stay-1 2,548.77 (1,079.72) 3,112.05 (1,768.99) 2,245.56 (605.27) 1,992.57 (663.31)  
  2.558* B>D
Stay-2 2,928.82 (2,714.95) 2,175.54 (979.3) 2,487.5 (1,389.38) 1,976.58 (884.46) .91* A>B
Stay-3 2,857.12 (1,668.56) 4,265.19 (3,779.29) 2,302.15 (1,203.87) 2,026.85 (808.08) −1.269* B>A
  2.009, p = .084 B>D
Stay-4 1,984.32 (1,013. 3,666.39 (3,762.36) 2,182.81 (773.47) 1,960.15 (907.4) −1.613* B>A
Stay-last 3,129.2 (1,680.28) 3,469.31 (2,595.4) 2,026.18 (1,101.82) 2,192.67 (844.7) 2.938** A>C
  1.958, p = .091 B>D

Note. The results from t-test analyses are presented in the right column.
*p < .05. **p < .01. ***p < .001.

Reaction times.  At baseline (Test 1), results indicate shorter
reaction times for errors in children with ADHD + RD in
most stages of the Wisconsin task, except for the last stage,
as compared with the ADHD group. After training (Test 2),
these differences between the groups disappeared. More-
over, after training (Test 2), decreased reaction times in the
ADHD group were found for the first and last stages,
whereas children in the ADHD + RD group showed
decreased reaction times in the second shift, the first time
they were expected to provide a correct response (stay-1),
and a nonsignificant decreased reaction times in the first-
shift and stay-last stages. Differences were found in the
slope of the linear regression line between Tests 1 and 2
within the two groups, though the gap between the groups
remained the same (a gap of definite value 10; Table 4,
Figures 3 and 4). Paired t-test analyses revealed significant
differences in standard deviations (standard deviations
decreased at Test 2 in both groups) before and after inter-
vention, in children with ADHD (p < .05) and in children
with ADHD + RD (p < .01).
Correlations Between Reading and Executive
Measures
The significant correlations between reading measures (see
“Behavioral measures” section, reading measures, Variables
A-D), and executive function measures (see “Behavioral mea-
sures” section, executive function measures, Variables A-E)

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Horowitz-Kraus 523
in the two groups suggested that increased reading speed
was associated with faster speed of processing (RAS naming
time: r = −.499, p < .01; naming-letters time: r = −.443, p <
.05) and with better memory skills (digit span: r = .543, p <
.01) in both groups. Also, having slower naming time was
associated with increased errors on the RAS naming task
(RAS naming time: r = −.567, p < .01; RAS naming errors:
r = .478, p < .01; naming-letters time: r = −.52, p < .01).
Discussion
In light of the differences in reading abilities, executive
functioning and psychological abilities previously found
between ADHD and ADHD + RD children, the present
study aimed to find the differential effect of an executive
functions-based intervention on these measures in these
groups. We also found that these groups differ in their base-
line reading and executive abilities, and that children with
ADHD + RD experience more severe deficits in these
realms than do children with ADHD alone, which supports
findings from previous research. This trend was observed
along all the examined abilities, though some did not reach
statistical significance. The most pronounced significant
difference between the groups’ performances on the
Wisconsin task was in their reaction times, rather than in
what we anticipated, accuracy. We previously demonstrated
that reaction time is actually the result of several subcompo-
nents of the executive system: perception, early attention,
working memory, speed of processing and shifting
(Horowitz-Kraus, 2012). Indeed, in the present study we
observed significantly slower speed of processing and
working-memory abilities in the ADHD + RD group as
compared with the ADHD group. The present findings,
therefore, support the previously proposed explanation, that
these executive function deficits might contribute to the
ADHD + RD group’s significantly slower reaction times.
The executive functions are the foundation of proper
reading abilities (Jerman, Reynolds, & Swanson, 2012).
Therefore, it is not surprising that this executive functions
training program, which resulted in increased speed of pro-
cessing and memory abilities in the ADHD group and faster
speed of processing and better spatial abilities in the ADHD
+ RD group, also diminished the gap in reading ability and
reading comprehension between the two groups. Efficient
speed of processing serves reading ability, as words can be
decoded in a more efficient way without overloading one’s
working memory (Breznitz & Misra, 2003). Then more
attention resources are available to comprehend the verbal
information. Indeed, speed of processing and working-mem-
ory measures were found to be correlated with reading abil-
ity in both groups. These findings are in line with the findings
of Green et al. (2012), who found an improvement in execu-
tive functions, which was accompanied by an increase in
reading achievements in an ADHD + RD population.
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Although we saw improvement in speed of processing in
both groups and improvement in working memory in the
ADHD group, we did not see a resulting improvement in
accuracy on the Wisconsin task following intervention in
either group. We did, however, find decreased reaction
times for both groups after intervention. Even more, in
addition to the general decrease in reaction times, we
observed a trend of decrease in the variability of the reac-
tion time’s standard deviation within each group. While we
observed differential effects of the training program
between groups, each might still contribute to the same gen-
eral effect of decreased variability in reaction times.
Specifically, we postulate that the ADHD + RD group might
benefit from faster speed of processing specifically on the
Wisconsin task, when the participant is asked to screen
cards and to look for the correct match in a fast and efficient
way. However, children in the ADHD group might benefit
from a combination of faster speed of processing and more
efficient working memory, which might help them remem-
ber the unique rule being applied in each trial of the WCST,
and thereby respond faster. Further study using EEG and
ERPs methodology would enable us to segment the differ-
ent cognitive stages used during the Wisconsin task, to ver-
ify this point (see Horowitz-Kraus, 2012, as a model for this
suggested design).
It is important to consider the total score of a given
task, as opposed to overvaluing the absolute number of
correctly answered items. For example, the standard score
from the symbol search battery is calculated as the total
number of correct responses and the subtraction of the
error responses. When looking only at the standard scores,
no significant effect was found in the ADHD + RD group
following training. However, a significant effect of train-
ing was found when counting only the number of correct
responses (the ADHD + RD group showed a greater num-
ber of correct responses). A similar effect was observed in
the digit-symbol subtest, which also represents speed of
processing. This might be due to the low sample size of
this present study. It does, however, point to the value in
examining subcomponents of an overall effect of a certain
intervention program, to provide a more sensitive obser-
vation of the effect.
The present study provided further evidence for differ-
ences in the executive functioning and academic abilities
between ADHD + RD and ADHD children, at baseline and
following the intervention, thereby supporting the assump-
tion that ADHD + RD is a disability with a unique set of
characteristics (de Jong, Oosterlaan, & Sergeant, 2006;
Rucklidge & Tannock, 2002). We also demonstrated that
the foundation of the reading process lies in the executive
functions, and especially in speed of processing. Therefore,
this study supports the use of executive functions training
improve immediate measures (i.e., executive functions) as
well overall reading abilities.
524 Journal of Attention Disorders 19(6)
To conclude, the present study adds validity to the litera-
ture examining the Wisconsin task as an evaluation of execu-
tive functions. The results of the present study show that even
while looking at two closely related disorders, this task makes
it possible to determine differences in specific areas of execu-
tive functioning. The use of the WCST here also helps in sup-
porting the effectiveness of our 8-week executive functions
intervention program (smaller standard deviation scores were
achieved following intervention). An executive functions
training program might be the right approach for children
with ADHD, who suffer primarily from an executive impair-
ment (Biederman et al., 2004), and it has demonstrated effec-
tiveness for children with ADHD + RD.
However, the ADHD and ADHD + RD groups benefit-
ted differently from the same intervention, and the differen-
tial effect should be taken into consideration by clinicians
and educators when determining the appropriate interven-
tions for a child. Each child’s unique cognitive abilities and
challenges should be taken into account, and our results
here can improve a clinician’s ability to factor a child’s indi-
vidual situation into treatment options and decisions.
Overall, this work strongly supports our hypothesis that
ADHD and ADHD + RD are unique diagnoses, and that
researchers and clinicians should be careful not to combine
individuals from these two groups into one. Early identifi-
cation of ADHD and/or ADHD + RD is an important future
direction for research and clinical implication as well, as
intervention programs like the WCST can be started early in
life, to establish a solid foundation for reading abilities that
affect the futures and lives of such children (Diamond &
Lee, 2011).
These conclusions should be taken into account with the
present study’s limitations. First, we worked with a rela-
tively small sample size. This small sample size prevented
us from achieving differential significance when conduct-
ing a Group × Test Repeated Measures Analysis of Variance,
as we originally did, and limited us to a main effect of inter-
vention (data not shown). Also, the inclusion of only two
females in the ADHD + RD group, which was not an equal
number to the males, is a drawback. This study did not use
any technique (e.g., ERPs) that enabled us to conclude
which improved executive abilities affected the change in
reaction times on the WCST. Finally, because the focus of
the present study was to look at the differences between the
ADHD + RD and the ADHD groups, we did not include a
group of children only experiencing reading difficulties or
even a nonclinical group of children.
Therefore, we are unable to conclude whether either
group showed significant impairment relative to a norma-
tive group for any measure. We did, however, use normal-
ized tests in this study, to be able to describe the performance
of each group in relation to generalized normative data.
The present study’s results allow us to conclude that the
effect of the intervention on children with ADHD + RD
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was different from the effect on those with only ADHD. A
future study should enroll an additional group of children
with only RD, as well as a nonclinical group of children, to
better understand if ADHD + RD involves a separate etiol-
ogy than RD and how ADHD + RD and ADHD differ from
a nonclinical group. Studies using imaging data (EEG and
ERPs methodology), which have the ability to map cogni-
tive functioning to a certain stage in a given task, will be
able to better explain which cognitive improvement con-
tributed to a better performance on the WCST. Last but not
the least, while researchers and practitioners would proba-
bly be delighted by the prospect of an effective cognitive
intervention for ADHD, they recognize that the weight of
the existing evidence favors pharmacological interventions
for treatment of the core symptoms of ADHD. Whether
promising cognitive training approaches can serve as a
substitute for pharmacological intervention or are better
conceived as an adjunct approach is an unresolved ques-
tion that demands more intensive research, including ade-
quate group sizes, and spanning years representative of a
range of developmental stages.
Acknowledgments
The author would like to thank Professor Zvia Breznitz, PhD, for
her mentorship and her help in designing the present study.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: The
present study was supported by the Edmond J. Safra Foundation.
References
American Psychiatric Association. (1994). Diagnostic and statisti-
cal manual of mental disorders (4th ed.). Washington, DC:
Author.
Antigas-Pallares, J. (2009). Pharmacological treatment of dys-
lexia. Revista de Neuroligia, 48, 585-591.
Barcelo, F. (2003). The Madrid card sorting test (MCST): A task
switching paradigm to study executive attention with event-
related potentials. Brain Research Protocols, 11, 27-37.
Beck, S. J., Hanson, C. A., Puffenberger, S. S., Berninger, K.
L., & Berninger, W. B. (2010). A controlled trial of work-
ing memory training for children and adolescents with
ADHD. Journal of Child and Adolescents Psychiatry, 39,
825-836.
Biederman, J., Monuteaux, M. C., Doyle, A. E., Seidman, L. J.,
Wilens, T. E., Ferrero, F., . . .Faraone, S. V. (2004). Impact of
executive function deficits and attention-deficit/hyperactivity
disorder (ADHD) on academic outcomes in children. Journal
of Consulting and Clinical Psychology, 72, 757-766.
Horowitz-Kraus 525
Breznitz, Z. (1997). Enhancing the reading of dyslexic children
by reading acceleration and auditory masking. Journal of
Educational Psychology, 89, 103-113.
Breznitz, Z., & Misra, M. (2003). Speed of processing of the
visual–orthographic and auditory-phonological systems in
adult dyslexics: The contribution of “asynchrony” to word
recognition deficits. Brain and Language, 85, 486-502.
CogniFit Ltd. (2008). CogniFit Personal Coach (CPC) training
program and database. Yokneam, Israel: Author.
Conners, C. K. (1989). Conners Rating Scales’ manual. North
Tonawanda, NY: Multi-Health System.
de Jong, C. G. W., Oosterlaan, J., & Sergeant, J. A. (2006). The
role of double dissociation studies in the search for candi-
date endophenotypes for the comorbidity of attention deficit
hyperactivity disorder and reading disability. International
Journal of Disability, Development and Education, 53,
177-193.
Denckla, M. B., & Rudel, R. G. (1976). Rapid automatized nam-
ing (RAN): Dyslexia differentiated from other learning dis-
abilities. Neuropsychologia, 14, 471-479.
Diamond, A., & Lee, K. (2011). Interventions shown to aid execu-
tive function development in children 4 to 12 years old.
Science, 19(vol. 333): 959-964.
Donnelly, M., Haby, M. M., Carter, R., Andrews, G., & Vos, T.
(2004). Cost-effectiveness of dexamphetamine and meth-
ylphenidate for the treatment of childhood attention deficit
hyperactive disorder. Australian and New Zealand Journal of
Psychiatry, 38, 592-601.
Faraone, S. V., Sergeant, J., Gillberg, C., & Biederman, J. (2003).
The worldwide prevalence of ADHD: Is it an American con-
dition? World Psychiatry, 2, 104-113.
Gray, S. A., Chaban, P., Martinussed, R., Goldberg, R., Gotlieb,
H., Kronitz, R., . . .Tannock, R. (2012). Effects of computer-
ized working memory training program on working memory,
attention, and academics in adolescents with severe LD and
comorbid ADHD: A randomized controlled trial. Journal of
Child Psychology and Psychiatry, 53, 1277-1284.
Green, C. T., Long, D. L., Green, D., Iosif, A., Dixon, J. F., Miller,
M. R., . . .Schweitzer, J. B. (2012). Will working memory train-
ing generalize to improve off-task behavior in children with
attention-deficit/hyperactive disorder? Neurotherapeutics, 9,
639-648. doi:10.1007/s13311-012-0124-y
Greven, C. U., Rijsdijk, F. V., Asherson, P., & Plomin, R. (2012).
A longitudinal twin study on the association between ADHD
symptoms and reading. Journal of Child Psychological
Psychiatry, 53, 234-242.
Hodgson, K., Hutchinson, A. D., & Denson, L. (2012).
Nonpharmacological treatments for ADHD: A meta-analytic
review. Journal of Attention Disorders. Advance online pub-
lication. doi:10.1177/1087054712444732
Horowitz-Kraus, T. (2012). Pinpointing the deficit in executive
functions in teenage dyslexic readers: An ERP study using the
Wisconsin Card Sorting Test. Journal of Learning Disabilities.
Advance online publication. doi:10.1177/0022219412453084
Horowitz-Kraus, T. (2013). Can the error monitoring system
differentiate ADHD from ADHD with reading disability?
Reading and executive dysfunction as reflected in error moni-
toring. Journal of Attention Disorders. Advance online publi-
cation. doi:10.1177/1087054713488440
Downloaded from jad.sagepub.com at UNIV NEBRASKA LIBRARIES on October 9, 2015
Jacobson, L. A., Ryan, M., Martin, R. B., Ewen, J., Mostofsky,
S. H., Denckla, M. B., & Mahone, E. M. (2011). Working
memory influences processing speed and reading fluency in
ADHD. Child Neuropsychology, 17, 209-224.
Jerman, O., Reynolds, C., & Swanson, H. L. (2012). Does growth
in working memory span or executive processes predict
growth in reading and math in children with reading disabili-
ties? Learning Disability Quarterly, 35, 144-157.
Kail, R. (1991). Developmental changes in speed of processing
during childhood and adolescence. Psychological Bulletin,
109, 490-501.
Katz, L. J., Brown, F. C., Roth, R. M., & Beers, S. R. (2011).
Processing speed and working memory performance in those
with both ADHD and a reading disorder compared with those
with ADHD alone. Archives of Clinical Neuropsychology, 26,
425-433.
Kimberg, D. Y., D’Esposito, M., & Farah, M. J. (1997). Frontal
lobes: Neuropsychological aspects. In T. E. Feinberg & M.
J. Farah (Eds.), Behavioral neurology and neuropsychology
(pp. 409-418). New York, NY: McGraw-Hill.
Lezak, M. D. (1995). Neuropsychological assessment. New York,
NY: Oxford University Press.
Mannuzza, S., Klein, R. G., Bessler, A., Malloy, P., & LaPadula,
M. (1993). Adult outcome of hyperactive boys. Educational
achievement, occupational rank, and psychiatric status.
Archives in Genetic Psychiatry, 50, 565-576.
Mattison, R. E., & Mayes, S. D. (2012). Relationships between learn-
ing disabilities, executive function, and psychopathology in chil-
dren with ADHD. Journal of Attention Disorders, 16, 138-146.
Milner, B. (1963). Effects of different brain lesions on card sort-
ing. Archives of Neurology, 9, 100-110.
Norton, E. S., & Wolf, M. (2012). Rapid Automatized Naming
(RAN) and reading fluency: Implications for understand-
ing and treatment of reading disabilities. Annual Review of
Psychology, 63, 427-452.
Purvis, K. L., & Tannock, R. (2000). Phonological processing,
not inhibitory control, differentiates ADHD and reading dis-
ability. Journal of American Academy of Child & Adolescent
Psychiatry, 39, 485-494.
Raven, J. C. (1969). Guide to the standard progressive matrices.
London, England: H. K. Lewis.
Rucklidge, J. J., & Tannock, R. (2002). Neuropsychological pro-
files of adolescents with ADHD: Effects of reading difficul-
ties and gender. Journal of Child Psychological Psychiatry,
43, 988-1003.
Sexton, C. C., Gelhorn, H., Bell, J., & Classi, P. (2011). The co-
occurrence of reading disorder and ADHD: Epidemiology,
treatment, psychosocial impact, and economic burden.
Journal of Learning Disabilities, 45, 1-28.
Shany, M., Lachman, D., Shalem, Z., Bahat, A., & Zeiger, T.
(2006). Aleph-Taph: A test for the diagnosis of reading and
writing disabilities, based on national Israeli norms. Tel Aviv,
Israel: Yesod.
Shatil, E., Nevo, B., & Breznitz, Z. (2008). Elull learning dis-
abilities diagnostic test: The reading sub-Test. Haifa, Israel:
University of Haifa.
Skounti, M., Philalithis, A., & Galanakis, E. (2007). Variations in
prevalence of attention deficit hyperactivity disorder world-
wide. European Journal of Pediatrics, 166, 117-123.
526 Journal of Attention Disorders 19(6)

Vakil, E., Blachstein, H., Wertman-Elad, R., & Greenstein, Y.
(2011). Verbal learning and memory as measured by the Rey-
Auditory Verbal Learning Test: ADHD with and without
learning disabilities. Child Neuropsychology, 18, 449-466.
Wechsler, D. (1997). Wechsler Adult Intelligence Scale–Third
Edition (WAIS-III). New York, NY: The Psychological
Corporation.
Willcutt, E. G., Doyle, A. E., Nigg, J. T., Faraone, S. V., &
Pennington, B. F. (2005). Validity of the executive function
theory of attention-deficit/hyperactivity disorder: A meta-
analytic review. Biological Psychiatry, 57, 1336-1346.
Willcutt, E. G., Pennington, B. F., Boada, R., Ogline, J. S.,
Tunick, R. A., Chhabildas, N. A., & Olson, R. K. (2001). A
comparison of the cognitive deficits in reading disability and
attention-deficit/hyperactivity disorder. Journal of Abnormal
Psychology, 110, 157-172.
Wolf, M., Bally, H., & Morris, R. (1986). Automaticity, retrieval
processes, and reading: A longitudinal study in average and
impaired readers. Child Development, 57, 988-1000.
Author Biography
Tzipi Horowitz-Kraus is the program director of the Reading and
Literacy Discovery Center in Cincinnati Children's Hospital,
Ohio, USA. Dr. Horowitz- Kraus is a neuroscientist and clinician
who combines these specialties and implements it into a transla-
tional research in the field.

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