Background and Aims Substance use disorders (SUD) are associated with cognitive deficits that are not always addressed in current treatments, and this hampers recovery. Cognitive training and remediation interventions are well suited to fill the gap for managing cognitive deficits in SUD. We aimed to reach consensus on recommendations for developing and applying these interventions. Design Delphi approach with two sequential phases: survey development and iterative surveying of experts. Setting Online study. Participants During survey development, we engaged a group of 15 experts from a working group of the International Society of Addiction Medicine (Steering Committee). During the surveying process, we engaged a larger pool of experts (n=53) identified via recommendations from the Steering Committee and a systematic review. Measurements Survey with 67 items covering four key areas of intervention development, i.e., targets, intervention approaches, active ingredients, and modes of delivery. Findings Across two iterative rounds (98% retention rate), the experts reached a consensus on 50 items including: (i) implicit biases, positive affect, arousal, executive functions, and social processing as key targets of interventions; (ii) cognitive bias modification, contingency management, emotion regulation training, and cognitive remediation as preferred approaches; (iii) practice, feedback, difficulty-titration, bias-modification, goal setting, strategy learning, and meta-awareness as active ingredients; and (iv) both addiction treatment workforce and specialized neuropsychologists facilitating delivery, together with novel digital-based delivery modalities. Conclusions Expert recommendations on cognitive training and remediation for SUD highlight the relevance of targeting implicit biases, reward, emotion regulation, and higher-order cognitive skills via well-validated intervention approaches qualified with mechanistic techniques and flexible delivery options.

Introduction: Current treatments for cocaine use disorder (CUD) are not very effective and better treatments are needed. This study investigates the effectiveness of a combined intervention that targets the assumed underlying glutamate pathology in cocaine users. To this end, the combined effects of N-acetylcysteine (NAC) and working memory (WM) training on glutamate concentrations in the dorsal and rostral ACC were investigated in a randomized, double-blind placebo-controlled design. Methods: In this study, 38 regular cocaine-using men were randomized to either 25-days with 2400 mg/day NAC and WM-training or 25 days with placebo with WM-training. Cocaine use, impulsivity, and glutamate concentrations in the dACC and rACC using proton Magnetic Resonance Spectroscopy were assessed at baseline and after treatment. Results: Twenty-four participants completed the study, of which 9 received NAC and 15 received placebo. There were no baseline correlations of glutamate concentrations in the dACC or rACC with cocaine use measures or impulsivity. Additionally, there were no effects of NAC, WM-training, or the combination thereof on (changes in) glutamate concentrations in the dACC or rACC. Discussion: This randomized proof of concept study could not confirm our hypotheses. Possible explanations are insufficient power and the possible absence of deviant baseline glutamate concentrations in the included participants. Future studies should consider larger samples and a non-using control group to confirm baseline deviations in glutamate in cocaine users.

Background Attachment theory predicts that patients who are not securely attached may benefit less from psychological treatment. However, evidence on the predictive role of attachment in the effectiveness of treatment for depression is limited. Methods Explicit attachment styles, levels of attachment anxiety and attachment avoidance, as well as implicit relational self-esteem and implicit relational anxiety were assessed in 67 patients with major depressive disorder (MDD) receiving Acceptance and Commitment Therapy (ACT) or Cognitive Behavioral Therapy (CBT). ANOVA and hierarchical regression analyses were performed to investigate the predictive power of explicit and implicit attachment measures on treatment outcome. Results Explicit attachment avoidance at pre-treatment significantly predicted reduction of depressive symptoms following treatment. Reductions in attachment anxiety and avoidance from pre- to post-treatment predicted better treatment outcomes. Neither one of the implicit measures, nor change in these measures from pre- tot post-treatment significantly predicted treatment outcome. Conclusions Our findings show that attachment avoidance as well as reductions in avoidant and anxious attachment predict symptom reduction after psychological treatment for depression. Future research should use larger sample sizes to further examine the role of attachment orientation as moderator and mediator of treatment outcome. Trial registration clinicaltrials.gov ; NCT01517503.

The current study investigated the combined effects of N-acetylcysteine and working memory (WM) training on behavioral and neural mechanisms of cue reactivity and WM in cocaine users in a randomized, double-blind design. Twenty-four of 38 cocaine-using men completed a 25-day treatment with either 2400 mg/day NAC or placebo. Both groups performed WM-training. During pre- and post-test lab-visits, neural mechanisms of cue reactivity and WM, and cue-induced craving and WM performance were assessed. Additionally, exploratory whole brain analyses were performed. Overall, the hypotheses were not confirmed, possibly due to small sample size, low WM-training adherence and/or ongoing substance use.

Obesity is a widespread problem that starts from an early age. Previous studies suggest that obese youngsters have an attentional bias and an automatic approach tendency towards high-calorie food and display difficulties inhibiting impulses, which may result in a higher intake of (high-calorie) food. An interesting idea for improvement of the current obesity treatment is adding a program that enables to train their difficulties. Subjects were 36 youngsters aged 9–15 years old from an inpatient treatment program for obesity, randomized over a training group and an active control group. The training consisted of six training sessions with cognitive tasks aimed at enhancing inhibition towards unhealthy food items (with a go/no-go task), as well as decreasing a food approach bias (using an approach/avoidance task) and a food attentional bias (using a dot-probe task). The current study evaluated the feasibility, acceptability and initial effectiveness of the training and explores if these characteristics helps obese youngsters to maintain weight-loss once they return home at the end of their inpatient treatment program. Results on the cognitive performances were investigated during two measurement sessions, spread over 5 weeks while weight evolution was followed over 13 weeks. Results showed that the training program was feasible and acceptable to the majority of participants and clinicians. Furthermore, the preliminary findings suggest that the training tasks used were ineffective in this group of obese children. Lessons learned and suggestions for future research are discussed.

Childhood obesity treatment programs only result in moderate outcomes in the short term and do not reduce risk for future weight gain. Therefore, in the current study, Approach Avoidance Training (AAT) with motivational game elements will be added to an inpatient childhood obesity program with the aim of improving outcomes. Forty-one children (10–15 years) in the final months of an inpatient treatment program were randomised to either the AAT plus care-as-usual condition group or to a care-as-usual-only control group. During the 10 sessions, the children were trained to approach healthy food stimuli and to avoid unhealthy food stimuli. Treatment outcomes were child performances on tasks of AAT, implicit attitudes and attentional bias, self-report ratings on craving symptoms, and weight loss maintenance after leaving the clinic (12-week follow-up). Changes over time were not significantly different between conditions for the measures of automatic processes, craving, and weight loss maintenance. Possible accounts for the null findings, including sample size, influence of game elements, point of time in therapeutic process, limitations of the setting, and the control group are discussed. More research is needed before firm conclusions can be drawn about the clinical usefulness of CBM for weight control in childhood obesity.

INTRODUCTION:Effective treatment for cocaine use disorder should dampen hypersensitive cue-induced motivational processes and/or strengthen executive control. Using a randomized, double-blind, placebo-controlled intervention, the primary aim of this study was to investigate the effect of N-Acetylcysteine (NAC) and working memory (WM)-training to reduce cocaine use and craving and to improve inhibition assessed in the laboratory and during Ecological Momentary Assessment (EMA). The second aim was to examine correspondence between laboratory and EMA data.METHODS:Twenty-four of 38 cocaine-using men completed a 25-day intervention with 2400mg/day NAC or placebo and WM-training as well as two lab-visits assessing cocaine use, craving and inhibition (Stop Signal task). Additionally, cocaine use, craving and cognition (Stroop task) were assessed using EMA during treatment, with 26 participants completing 819 assessments.RESULTS:Cocaine problems according to the Drug Use Disorder Identification Test (DUDIT) decreased more after NAC than after placebo, and the proportion of cocaine-positive urines at lab-visit 2 was lower in the NAC group. No NAC effects were found on craving. For cocaine use and craving, results from the lab data were generally similar to EMA results. NAC also showed some effects on cognitive control: improved inhibition assessed with the Stop Signal task in the lab, and decreased classic Stroop performance during EMA. There were no significant effects of number of completed WM-training sessions.CONCLUSIONS:Overall this study revealed mixed findings regarding the treatment of cocaine use disorders with NAC and WM-training. The effect of NAC on inhibition should be further investigated.

Alcohol and cannabis use are subject to change during the adolescent period. Social, contextual and developmental factors influence the patterns of use of these substances. Longitudinal trajectory studies can shed light on the normative development of the use of these substances as well as on problematic patterns of use. It is important that underlying determinants of problematic and relatively normal use are identified so treatment efforts can be aligned towards these determinants. Results are therefore discussed with a focus on informing the development of effective intervention strategies. In this study, data of large longitudinal national representative study are presented including +/-2,230 adolescents who were followed from 11-22 years (study is ongoing). Trajectories of alcohol and cannabis use covering the whole adolescent period (14-22 years) are evaluated in relation to important cognitive determinants such as behavioral control and reward sensitivity. Latent transition analyses revealed that pubertal development as well as reward sensitivity are important predictors of the increase in both substances. Relatively stronger increase in behavioral control skills predicted decrease in the use of alcohol use, not in cannabis use, and only in a small group of adolescents (

Alcohol and cannabis use are subject to change during the adolescent period. Social, contextual and developmental factors influence the patterns of use of these substances. Longitudinal trajectory studies can shed light on the normative development of the use of these substances as well as on problematic patterns of use. It is important that underlying determinants of problematic and relatively normal use are identified so treatment efforts can be aligned towards these determinants. Results are therefore discussed with a focus on informing the development of effective intervention strategies. In this study, data of large longitudinal national representative study are presented including +/-2,230 adolescents who were followed from 11-22 years (study is ongoing). Trajectories of alcohol and cannabis use covering the whole adolescent period (14-22 years) are evaluated in relation to important cognitive determinants such as behavioral control and reward sensitivity. Latent transition analyses revealed that pubertal development as well as reward sensitivity are important predictors of the increase in both substances. Relatively stronger increase in behavioral control skills predicted decrease in the use of alcohol use, not in cannabis use, and only in a small group of adolescents (

BACKGROUND:Working memory capacity has been found to be impaired in adolescents with various psychological problems, such as addictive behaviors. Training of working memory capacity can lead to significant behavioral improvements, but it is usually long and tedious, taxing participants' motivation to train. OBJECTIVE:This study aimed to evaluate whether adding game elements to the training could help improve adolescents' motivation to train while improving cognition. METHODS:A total of 84 high school students were allocated to a working memory capacity training, a gamified working memory capacity training, or a placebo condition. Working memory capacity, motivation to train, and drinking habits were assessed before and after training. RESULTS:Self-reported evaluations did not show a self-reported preference for the game, but participants in the gamified working memory capacity training condition did train significantly longer. The game successfully increased motivation to train, but this effect faded over time. Working memory capacity increased equally in all conditions but did not lead to significantly lower drinking, which may be due to low drinking levels at baseline. CONCLUSIONS:We recommend that future studies attempt to prolong this motivational effect, as it appeared to fade over time.

De adolescentie kenmerkt zich veelal door een toename van risicogedrag, zoals het experimenteren met grote hoeveelheden alcohol. Hoewel dit soort gedrag niet per se tot problemen hoeft te leiden, kan overmatig drankgebruik op deze leeftijd wel gezondheidsproblemen of schooluitval veroorzaken en vergroot het de kans op verslaving op latere leeftijd. Daarom is het belangrijk dat er vroeg wordt ingegrepen, zodat escalatie kan worden voorkomen. Uit onderzoek is gebleken dat het trainen van bepaalde controlerende cognitieve processen (zoals het werkgeheugen en inhibitievermogen) effectief kan zijn om jongeren meer grip te laten krijgen op hun alcoholgebruik. Bovendien kan een aantal meer automatische processen (zoals selectieve aandacht voor alcohol) opnieuw worden hertraind. Hoewel deze beide vormen van training, uitgevoerd op de computer, bewezen effectief zijn bevonden, worden ze ook vaak ervaren als lang en saai. Om jongeren extra te motiveren de cognitieve trainingen te voltooien, kunnen serious games wellicht uitkomst bieden. In dit artikel wordt een promotieonderzoek beschreven waarin dit is bestudeerd. Allereerst wordt een raamwerk beschreven waarbinnen deze serious games kunnen worden ontwikkeld, waarna er diverse gametrainingen aan bod komen. Het blijkt dat serious games inderdaad een motiverende rol kunnen spelen bij het trainen van jongeren. De omstandigheden waaronder dat precies gebeurt, zullen nog nader onderzocht moeten worden.

Samenvatting De adolescentie kenmerkt zich veelal door een toename van risicogedrag, zoals het experimenteren met grote hoeveelheden alcohol. Hoewel dit soort gedrag niet per se tot problemen hoeft te leiden, kan overmatig drankgebruik op deze leeftijd wel gezondheidsproblemen of schooluitval veroorzaken en vergroot het de kans op verslaving op latere leeftijd. Daarom is het belangrijk dat er vroeg wordt ingegrepen, zodat escalatie kan worden voorkomen. Uit onderzoek is gebleken dat het trainen van bepaalde controlerende cognitieve processen (zoals het werkgeheugen en inhibitievermogen) effectief kan zijn om jongeren meer grip te laten krijgen op hun alcoholgebruik. Bovendien kan een aantal meer automatische processen (zoals selectieve aandacht voor alcohol) opnieuw worden hertraind. Hoewel deze beide vormen van training, uitgevoerd op de computer, bewezen effectief zijn bevonden, worden ze ook vaak ervaren als lang en saai. Om jongeren extra te motiveren de cognitieve trainingen te voltooien, kunnen serious games wellicht uitkomst bieden. In dit artikel wordt een promotieonderzoek beschreven waarin dit is bestudeerd. Allereerst wordt een raamwerk beschreven waarbinnen deze serious games kunnen worden ontwikkeld, waarna er diverse gametrainingen aan bod komen. Het blijkt dat serious games inderdaad een motiverende rol kunnen spelen bij het trainen van jongeren. De omstandigheden waaronder dat precies gebeurt, zullen nog nader onderzocht moeten worden.

Background: Young adults often experiment with heavy use of alcohol, which poses severe health risks and increases the chance of developing addiction problems. In clinical patients, cognitive retraining of automatic appetitive processes, such as selective attention toward alcohol (known as “cognitive bias modification of attention,” or CBM-A), has been shown to be a promising add-on to treatment, helping to prevent relapse. Objective: To prevent escalation of regular use into problematic use in youth, motivation appears to play a pivotal role. As CBM-A is often viewed as long and boring, this paper presents this training with the addition of serious game elements as a novel approach aimed at enhancing motivation to train. Methods: A total of 96 heavy drinking undergraduate students carried out a regular CBM-A training, a gamified version (called “Shots”), or a placebo training version over 4 training sessions. Measures of motivation to change their behavior, motivation to train, drinking behavior, and attentional bias for alcohol were included before and after training. Results: Alcohol attentional bias was reduced after training only in the regular training condition. Self-reported drinking behavior was not affected, but motivation to train decreased in all conditions, suggesting that the motivational features of the Shots game were not enough to fully counteract the tiresome nature of the training. Moreover, some of the motivational aspects decreased slightly more in the game condition, which may indicate potential detrimental effects of disappointing gamification. Conclusions: Gamification is not without its risks. When the motivational value of a training task with serious game elements is less than expected by the adolescent, effects detrimental to their motivation may occur. We therefore advise caution when using gamification, as well as underscore the importance of careful scientific evaluation. (JMIR Serious Games 2016;4(2):e20) doi:10.2196/games.6464

OBJECTIVE Risk taking, such as heavy alcohol use, is commonplace among adolescents. Nevertheless, prolonged alcohol use at this age can lead to severe health problems. The goal of this study was to develop and evaluate a serious game training ("The Fling"), aimed at increasing behavioral control in adolescents and thereby helping them to improve control over their alcohol use. The game training was compared to a game placebo and a nongame training version in a randomized controlled trial. MATERIALS AND METHODS A sample of 185 adolescents (mean age 14.9 years) in secondary education participated in the study. They performed four sessions of training, as well as a set of questionnaires and cognitive assessment tasks before and after the training. The basis for the training was the stop-signal paradigm, aimed at increasing behavioral control. RESULTS The game variants were shown to motivate adolescents beyond the level of the nongame version. Behavioral control improved significantly over time, but this effect was also present in the game placebo, suggesting that the game activities alone may have had a beneficial effect on our measures of behavioral control. As baseline drinking levels were low, no significant training effects on drinking behavior were found. CONCLUSIONS Although the current results are not yet conclusive as to whether "The Fling" is effective as a cognitive training, they do warrant further research in this direction. This study also shows that serious games may be uniquely suitable to bridge the gap between an evidence-based training paradigm and an attractive, motivating training environment.

Objective Young adults often experiment with heavy use of alcohol, which poses severe health risks and increases the chance of developing addiction problems. In clinical patients, cognitive re-training of automatic appetitive processes, such as selective attention towards alcohol (known as “Cognitive Bias Modification of Attention”, or CBM-A), has been shown to be a promising add-on to treatment, helping to prevent relapse. To prevent escalation of regular use into problematic use in youth, motivations appear to play a pivotal role. As CBM-A is often viewed as long and boring, we present this training in the form of a serious game, as a novel approach aimed at enhancing motivation to train. Methods: 96 Heavy drinking undergraduate students carried out either a regular CBM-A training, a gamified version (called “Shots”), or a placebo training version over four training sessions. Measures of motivation to change their behavior, motivation to train, attentional bias for alcohol and drinking behavior were included before and after training. Results: Alcohol attentional bias was reduced after training only in the regular training condition. Self-reported drinking behavior went down slightly in all conditions, but motivation to train also decreased in all conditions, suggesting that the motivational features of the Shots game were not enough to fully counteract the tiresome nature of the training. Moreover, some of the motivational aspects decreased slightly more in the Game condition, which may indicate potential detrimental effects of disappointing gamification. Conclusions: We therefore stress that caution is advised when using gamification, as well as underscore the importance of careful scientific evaluation.

Based on information processing models of anxiety and depression, we investigated the efficacy of multiple sessions of online attentional bias modification training to reduce attentional bias and symptoms of anxiety and depression, and to increase emotional resilience in youth. Unselected adolescents (N 1⁄4 340, age: 11e18 years) were randomly allocated to eight sessions of a dot-probe, or a visual searchbased attentional training, or one of two corresponding placebo control conditions. Cognitive and emotional measures were assessed preand post-training; emotional outcome measures also at three, six and twelve months follow-up. Only visual search training enhanced attention for positive information, and this effect was stronger for participants who completed more training sessions. Symptoms of anxiety and depression reduced, whereas emotional resilience improved. However, these effects were not especially pronounced in the active conditions. Thus, this large-scale randomized controlled study provided no support for the efficacy of the current online attentional bias modification training as a preventive intervention to reduce symptoms of anxiety or depression or to increase emotional resilience in unselected adolescents. However, the absence of biased attention related to symptomatology at baseline, and the large drop-out rates at follow-up preclude strong conclusions. © 2016 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Anxiety and depression are among the most prevalent psychiatric disorders and show a considerable increase during adolescence (Costello, Mustillo, Erkanli, Keeler, & Angold, 2003). Given the detrimental influence on later functioning, prevention and early intervention are of paramount importance. For this purpose, online cognitive training might be a potentially fruitful approach, especially for adolescents, given its low barriers, low costs, and anonymity. Also, adolescence is not only a period of increased vulnerability for emotional disorders, but also of heightened plasticity and potentially greater opportunities to profit from cognitive training (Crone, 2009). There is ample evidence indicating that anxiety and depression are associatedwith the tendency to selectively attend to negative or threatening information: an ‘attentional bias’ (for meta-analyses

BACKGROUND:Young adults often experiment with heavy use of alcohol, which poses severe health risks and increases the chance of developing addiction problems. In clinical patients, cognitive retraining of automatic appetitive processes, such as selective attention toward alcohol (known as "cognitive bias modification of attention," or CBM-A), has been shown to be a promising add-on to treatment, helping to prevent relapse.OBJECTIVE:To prevent escalation of regular use into problematic use in youth, motivation appears to play a pivotal role. As CBM-A is often viewed as long and boring, this paper presents this training with the addition of serious game elements as a novel approach aimed at enhancing motivation to train.METHODS:A total of 96 heavy drinking undergraduate students carried out a regular CBM-A training, a gamified version (called "Shots"), or a placebo training version over 4 training sessions. Measures of motivation to change their behavior, motivation to train, drinking behavior, and attentional bias for alcohol were included before and after training.RESULTS:Alcohol attentional bias was reduced after training only in the regular training condition. Self-reported drinking behavior was not affected, but motivation to train decreased in all conditions, suggesting that the motivational features of the Shots game were not enough to fully counteract the tiresome nature of the training. Moreover, some of the motivational aspects decreased slightly more in the game condition, which may indicate potential detrimental effects of disappointing gamification.CONCLUSIONS:Gamification is not without its risks. When the motivational value of a training task with serious game elements is less than expected by the adolescent, effects detrimental to their motivation may occur. We therefore advise caution when using gamification, as well as underscore the importance of careful scientific evaluation.

Behavioral control weaknesses are a strong predictor of problematic behaviors in adolescents, such as heavy alcohol use. Heavy alcohol use at this young age can lead to health and school-related problems and is a severe societal problem. Strengthening of cognitive control mechanisms through computerized training has been shown to have positive effects on behavior, but is often perceived as a tedious exercise. Applying novel serious gaming techniques to evidence-based training paradigms may offer a solution to this motivational problem. This paper describes the design and analysis plan that will be used to evaluate an innovative Serious Game called The Fling, aimed specifically at increasing cognitive control over impulses in adolescents. The game will be evaluated in a randomized controlled trial (RCT) among adolescents between 15–18 years in mainstream and special education.

Background: Executive functioning (EF) has repeatedly been associated with the use and misuse of alcohol and other substances in adolescence. Impairments in executive functions, such as response inhibition and working memory, important for organizing, controlling and planning of behavior have been found to be predictive of problematic and heavy alcohol use in adolescents. How these functions are related to the initiation of alcohol use (and other substances) has less often been studied in early adolescence. Method: Results of two different studies are presented. The first sample included 534 adolescents (69% boys) between 12 and 15 years at baseline. Two measures of EF, response inhibitions and working memory, were assessed at four different waves including a period of two years, and outcomes were linked to the onset of drinking and the onset of binge drinking. In a second study (TRAILS study), 715 adolescents (49% boys) were followed over a period of 5 years (11-16) years. Participants completedmeasures of EF (response inhibition and working memory), effortful control and reward sensitivity. Only substance naive (alcohol and/or cannabis) adolescents were included at baseline to look at the predictive effects of behavioral control (EF + effortful control). Results: The results of the survival analysis in the first study demonstrated that the onset of alcohol use and the onset of binge drinking was predicted by weak EF functioning. That is, adolescents with relatively poor EF, initiated alcohol use and binge drinking at a younger age compared to adolescents with relatively good EF. In the second study, only effortful at age 11 predicted alcohol and cannabis use at age 16, and only for those who weremore reward sensitive. We did not find an effect of EF on cannabis or alcohol use. Discussion: The findings of both studies highlight the important role of EF and behavioral control, in relation to the onset of drinking and cannabis use in young adolescents. These results are important in relation to previous results linking cognitive deficits to alcohol use. It appears that some deficits are present before alcohol or cannabis use is initiated.