Beneficial effect of noise on cognition in individuals with and without adhd: a behavioral, neurophysiological and virtual reality research

To appropriately discuss this question, it is necessary to answer others, such as: what is concentrating, paying attention? And, what is noise? Everyone has an idea of what attention is, and can give examples of situations in which it is required: school, work, driving, listening to our parents’ requests and so forth. But who could say that we can fully control attention like if we had a button to press, switching on and off according to the context? When we were little, my father used to say to my brothers and me: “Ok, you did not do this on purpose, but, please, pay attention to your attention”. Well, I can say now that it is not that easy and certainly not for everyone. In the population, around five percent of children and adults meet serious difficulties to pay attention. These people, more than others, often express their deficit with excessive distraction and/or hyperactivity as well as impulsivity. These multiple symptoms, for the individual who lives these behavioral excesses, represent an issue for his/her everyday-life: at school, at work, driving, trying to listen to his/her parents’ requests, etc.

Such symptoms refer to a syndrome called attention-deficit/hyperactivity disorder (ADHD). Although the definition of this syndrome has changed across the course of History, the first descriptions of ADHD go back to 1798. Since, a lot has been written about this disorder, which we do not fully understand yet. Beyond these simple words, “inattention, impulsivity, hyperactivity”, a consequent number of etiologies (environmental, genetic, psychosocial), subtypes, comorbidities, and outcomes reflect the enormous heterogeneity of the phenotypes that are found in this syndrome. The main treatment offered to individuals with ADHD is a psychostimulant drug called methylphenidate. This medication, acting mainly on dopaminergic brain functioning, has proven efficacy regarding ADHD symptoms. However, it has several limitations. For instance, its use remains controversial in the society; it causes side effects and around 30% of individuals with ADHD do not respond to this treatment. These mentioned limitations, among others, highlight the necessity to find alternative ways to reduce ADHD symptoms.

This is the main objective of this thesis. To do so, we will investigate a counterintuitive phenomenon. In certain situations, what can be called noise might improve cognition and, consequently, potentially reduce the symptoms associated with ADHD. As mentioned in the beginning of this preamble, one could think that everything unnecessary in our direct environment is a potential distraction. Intuitively, a sensible person would suggest that individuals prone to distraction, as those with ADHD, would benefit from a stimulation- free environment to improve attention and reduce impulsivity as well as hyperactivity. However, already in the 1970’s, authors such as Zentall (1975) developed a theory supported by empirical data, i.e. the optimal stimulation theory, showing that adding stimulation in the environment (with pictures, posters, music, colors, etc.) might improve symptoms of children with ADHD. Successively, many theories and findings were developed and related to the observation that the environmental context affects attention, hyperactivity and impulsivity. For instance, the delay aversion theory (Sonuga-Barke, Taylor, Sembi, & Smith, 1992) suggests that, as children with ADHD are motivated to discount delay, the inattentive, overactive and impulsive behaviors are the expression of such aversion when they cannot avoid the delay. Related to this theory, adding stimulation in the environment has evidenced hyperactivity and impulsive choice reduction (Antrop, Roeyers, Van Oost, & Buysse, 2000; Antrop et al., 2006). Another theory advocates that the ADHD-related symptoms are explained in terms of energetic dysfunction (Sergeant, 2000). For instance, children with ADHD would meet difficulties to adjust their internal state (e.g. their arousal) required for a task. Accordingly, Sergeant (2000) suggested that performance is influenced not only by cognitive capacity but also by environmentally determined levels of arousal and showed the extent to which variations in these energetic factors can be managed to ensure optimal performance. A recent theory, called the Moderate Brain Arousal model (Sikstrom & Soderlund, 2007), particularly caught our interest. This theory postulates that white noise has beneficial effect on cognition. The first study of these authors (Soderlund, Sikstrom, & Smart, 2007) supported their hypothesis, showing that children with ADHD improved their episodic memory performance when they were exposed to white noise. This is, to our knowledge, the first study that evidenced such improvement with white noise, considered as extra-task stimulation, in children with ADHD.

The objective of this thesis is to investigate the potential beneficial effect of noise in individuals with and without ADHD regarding attentional and executive functioning. We will first review, in the first chapter of this Introduction, the general aspects of ADHD: definition criteria, prevalence, etiologies, treatments and outcomes. In the second chapter, we will present the main theories and findings related to this syndrome and to our main objective.

After the Introduction, we will describe the different experimental studies that we have carried out in the context of this thesis. Hereunder, we propose a short overview of these studies.

The first study of this thesis is a pilot study, aimed to validate the relevance to use event- related potentials (ERPs) in children with and without ADHD to further investigate noise effect. Accordingly, the second study investigated noise effect on behavioral and ERPs aspects in children with and without ADHD. To do so, children performed a visual cued Go/Nogo. They were also submitted to a neuropsychological assessment. Afterwards, in a third study, we used the same paradigm in adults with and without ADHD. Here, we also added a music condition to investigate another stimulation than noise.

In the fourth study, we decided to explore the effect of noise in a more ecological environment. To do so, we used a virtual reality tool that allowed to immerse the children in a virtual classroom environment. Children with and without ADHD were then assessed, being immersed in a classroom, with a continuous performance task (CPT) presented on the blackboard while several auditory and visual realistic distracters emerged during the test. Children performed the task with and without white noise exposure as well as a neuropsychological assessment. In the fifth study, we used the virtual classroom to investigate noise effect on interference control. Children with and without ADHD were submitted to a bimodal virtual reality Stroop (with auditory and visual target stimuli) and to a neuropsychological assessment. Finally, in a last study, we explored the effect of noise in consecutive young adults. Immersed in the virtual classroom, they were submitted to the CPT task with and without white noise. ADHD questionnaires and a neuropsychological assessment were also undertaken.

To end this thesis, we will discuss to what extent our studies allowed going one step further in the investigation of “on what, with whom, when and where” noise can be beneficial. We will discuss all our studies and results in the light of the theories and findings exposed in the Introduction. Finally, we will comment the clinical validation of these results.