Discussion
motor and sensory impairments
SECONDARY
This study aimed at assessing the efficacy of an 8-week drill-based cognitive training program performed at home by children with non-progressive ABI, BT or CBM.Based on data of existing literature about the positive impact of computer games on visual–spatial abilitiesData of the present clinical trial confirmed the positive training effects on visual–spatial working memory in the whole sample, thus also in children with BT and CBM. Importantly, the gains were maintained in the long-term, 6 months after the training, suggesting the usefulness of a relatively short telerehabilitation period in determining long lasting changes. The reason of such a benefit could be due to the consistent training of visual–spatial processes across all CCT exercises. Indeed, the various training games, albeit focusing on different cognitive domains, addressed visual–spatial competence by requiring to: detect the orientation of a stimulus in space (Disillusion, Lost in Migration); match together (Disillusion) or recognize (Tidal Treasure, Speed Match) visually presented figures that could differ in shape and color; solve arithmetic operations contained in drops that moved vertically on the computer screen and were distributed in space (Raindrops); and maintain in working memory the shapes and colors of visual stimuli (Tidal Treasure, Speed Match). This mechanistic interpretation is sustained by previous research, which reports that computer games heavily address visual–spatial working-memory. The results indicate that the benefits of games requiring mental rotation and visualization and perceptual attention on individuals’ mental health are associated with the occupation of visual–spatial working memoryWith respect to secondary outcome measures (i.e., cognitive flexibility and mathematical operations speed and accuracy), we found no benefits, except for a speed up in arithmetic calculation after the training in the Waiting-first group but not in the Training-first group. However, the Waiting-first group had lower baseline performance than the other group, suggesting that its greater change in this cognitive measure could be more reliably ascribable to its highest margin of improvement, due to specific individual characteristics, rather than to CCT effects. Overall, this study corroborates our preliminary findings on the same clinical trial indicating the absence of benefits on cognitive abilities not intensively addressed by the programThus, our clinical trial suggests that, in patients with different intellectual abilities and without severe motor and sensory impairments, the highest cognitive gains are reached through intensively stimulating the same cognitive function for a certain time period. Indeed, cognitive abilities different than visual–spatial skills were trained by two exercises per day, which however lasted a very limited amount of time (in many cases one minute or less). This could explain why the training failed in improving complex abilities, such as executive functions and mathematical abilities. Up to now, different studies reporting improvement effects following multi-domain CCT enrolled healthy individualsRegarding psychosocial adjustment, we found no significant improvement on internalizing symptoms, self-esteem related to different domains of life nor quality of life. This lack of effects may indicate that drill-based training programs fail to address the adjustment issues that children often encounter in the everyday setting. We may, thus, conclude that a rehabilitation approach focused only on training cognitive abilities through the repetition of exercises cannot be considered the optimal solution to address psychological and behavioral problems, even when an improvement in a specific cognitive domain is found. Indeed, the present evidence does not support the hypothesis that an improvement in visual–spatial working memory could lead to cascade benefits on children’s well-being in everyday lifeIn this respect, previous research suggested that, in order to generate effects on everyday functioning, more complex training types based on metacognitive abilities should be delivered in children with neurological conditionWith respect to the comparison of training efficacy across the three clinical subgroups of patients, we found no differences, with all groups showing comparable improvements in visuo-spatial working memory. This result could reflect the low statistical power associated with the limited numerosity of children with BT and CBM compared with the non-progressive ABI group, possibly limiting the detection of group differences. At the same time, our results may suggest that the feasibility and efficacy of CCT may extend across different types of brain alterations and general cognitive functioning.This data is conflicting with previous studies suggesting that patients with CBM frequently show a complex clinical picture characterized by behavioral and physical issues together with low intellectual abilities, which may lead to limited possibilities to obtain significant gains from a remote trainingLimitations of this study should be acknowledged. First, the stepped-wedge design used for this clinical trial did not involve the inclusion of an active control group performing another type of training, hampering the possibility to evaluate the specific effects of training characteristics on the outcomes. This does not allow providing more defined and evidence-based indication on the optimal training format to boost cognitive abilities, in terms of therapist’s involvement or single- versus multi-domain training. Second, data on attention and processing speed, which were planned to be assessed by means of a computerized task, could not be collected for all patients due to unpredictable technical problems which prevented the use of the task in a large number of patients at some assessment points. This, of course, impeded us to enter into the analyses these core cognitive domains, limiting the detection of other abilities that may, or may not, benefit from the training. Therefore, while the use of computer-based assessment tool ensures to obtain more reliable data, it could constitute a risk in terms of data collection that should be anticipated and prevented (e.g., by allocating a higher number of economic resources to buy a new software in case of technical problems of the target one) when planning a clinical trial. Third, the training had a short duration, which could have limited the effects on the various cognitive domains and the generalizability of benefits to every-day setting adaptation. It is still object of debate how intensive, how long and how focused on a single or multiple cognitive ability a remote cognitive training should be to generate the best gains. Fourth, study randomization was non-stratified based on clinical diagnosis, which caused a non-balanced distribution of patients across clinical subgroups and could have yielded issues related to statistical power. Finally, the findings of this work are related to those games that have been specifically selected for the study and cannot be extended to the more complex format in which the training is provided in its commercial version.