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Winter D, Braw Y. Online search strategies utilized in feigning attention deficit/hyperactivity disorder (ADHD) while performing a continuous performance test (CPT). APPLIED NEUROPSYCHOLOGY. ADULT 2024; 31:1365-1374. [PMID: 36201363 DOI: 10.1080/23279095.2022.2128356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The availability of information regarding neuropsychological tests threatens their confidentiality. This concern may be particularly relevant to Attention-Deficit/Hyperactivity Disorder (ADHD) considering its widespread online coverage. The present study explored simulators' online search strategies. METHOD Simulators (n = 39) searched for information before undergoing an evaluation which included performing a continuous performance test (CPT). Their search strategies were analyzed, and their performance was compared to that of ADHD patients (n = 36) and healthy controls (n = 38). RESULTS Most simulators reached high-risk websites that provided written and video-based information regarding the test. Sixty percent, comprised mostly of 3rd-year students, reached Google Scholar. These students were also easier to detect as simulators. Common strategies included performing the CPT in accordance with typical ADHD symptoms and avoiding the endorsement of both unusual and stereotypical symptoms. CONCLUSION Simulators can access online information that contains key test data. Higher education may increase the ability to reach academic research while decreasing the ability to convincingly feign impairment. While additional research is needed to examine coaching effects on neuropsychological testing, the risk to test security that many websites pose should be acknowledged and steps, including ones taken by test publishers, should be undertaken to minimize it.
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Affiliation(s)
| | - Yoram Braw
- Department of Psychology, Ariel University, Ariel, Israel
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2
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Escobar LE, Liew M, Yirdong F, Mandelos KP, Ferraro-Diglio SR, Abraham BM, Polanco-Roman L, Benau EM. Reduced attentional control in individuals with a history of suicide attempts compared to those with suicidal ideation: Results from a systematic review and meta-analysis. J Affect Disord 2024; 349:8-20. [PMID: 38169241 DOI: 10.1016/j.jad.2023.12.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 12/01/2023] [Accepted: 12/27/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Neurocognitive profiles may be especially useful to identify factors that facilitate transitioning from contemplating suicide to attempting suicide. Generally, those who attempt suicide show greater disruptions in neurocognitive ability compared to those who think about suicide but do not proceed to attempt. The goal of this systematic review and meta-analysis is to test whether this pattern is observed with attentional control. METHODS We systematically searched PubMed, PsychINFO, CINAHL, and Google Scholar to find pertinent studies. All included studies compared attentional functioning using neutral stimuli. Each sample featured adults with a history of suicidal ideation (SI) and no history of suicide attempts (SA) compared to those with a history of SA. RESULTS We identified 15 studies with 32 effect sizes (N = 931; n = 506 with SI only; n = 425 with SA). SA groups, compared to SI groups, exhibited worse accuracy yet similar reaction time, suggesting a comparatively blunted speed-accuracy tradeoff. Relative to SI, SA groups performed worse on Stroop-like and Go/NoGo tasks. SA performed better than SI on Trail Making Test B, but not A. LIMITATIONS There were few available studies. Most samples were small. We did not differentiate current vs. past SI or high vs. low lethality SA. Only English and Spanish language articles were included. CONCLUSIONS Disrupted attentional control may convey risk for transitioning to SA from SI. More work is needed to determine which components of attention are most associated with suicide risk.
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Affiliation(s)
- Lesly E Escobar
- Department of Psychology, SUNY Old Westbury, Old Westbury, NY, USA
| | - Megan Liew
- Department of Psychology, SUNY Stony Brook, Stony Brook, NY, USA; Department of Psychology, University of Missouri, Columbia, MO, USA
| | - Felix Yirdong
- Department of Psychology, CUNY Graduate Center, New York, NY, USA
| | | | | | - Blessy M Abraham
- Department of Psychology, SUNY Old Westbury, Old Westbury, NY, USA
| | | | - Erik M Benau
- Department of Psychology, SUNY Old Westbury, Old Westbury, NY, USA.
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Alves LM, Côco KF, De Souza ML, Ciarelli PM. Identifying ADHD and subtypes through microstates analysis and complex networks. Med Biol Eng Comput 2024; 62:687-700. [PMID: 37985601 DOI: 10.1007/s11517-023-02948-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 10/11/2023] [Indexed: 11/22/2023]
Abstract
The diagnosis of attention-deficit hyperactivity disorder (ADHD) is based on the health history and on the evaluation of questionnaires to identify symptoms. This evaluation can be subjective and lengthy, especially in children. Therefore, a biomarker would be of great value to assist mental health professionals in the process of diagnosing ADHD. Event-related potential (ERP) is one of the most informative and dynamic methods of monitoring cognitive processes. Previous works suggested that specific sets of ERP-microstates are selectively affected by ADHD. This paper proposes a new methodology for the ERP-microstate analysis and identification of ADHD patients based on complex networks to model the microstate topographic maps. The analysis of global and local features of ERP-microstate networks revealed topological differences between ADHD and healthy control. The classification using a neural network with a single hidden layer resulted in an average accuracy of 99.72% in binary classification and 99.31% in the classification of ADHD subtypes. The results were compared to the power band spectral densities and the energy of wavelet coefficients. The temporal features of ERP-microstates, such as frequency of occurrence, duration, coverage, and transition probabilities, were also evaluated for comparison proposes. Overall, the selected topological features of ERP-microstate networks derived from the proposed method performed significantly better classification results. The results suggest that topological features of ERP-microstate networks are promising to identify ADHD and its subtypes with a neural network model compared to power band spectrum density, wavelet transform, and temporal features of ERP-microstates.
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Affiliation(s)
- Lorraine Marques Alves
- Department of Electrical Engineering, Universidade Federal do Espírito Santo, Av. Fernando Ferrari, Vitória, 100190, ES, Brazil.
| | - Klaus Fabian Côco
- Department of Electrical Engineering, Universidade Federal do Espírito Santo, Av. Fernando Ferrari, Vitória, 100190, ES, Brazil
| | - Mariane Lima De Souza
- Department of Psychology, Universidade Federal do Espírito Santo, Av. Fernando Ferrari, Vitória, 100190, ES, Brazil
| | - Patrick Marques Ciarelli
- Department of Electrical Engineering, Universidade Federal do Espírito Santo, Av. Fernando Ferrari, Vitória, 100190, ES, Brazil
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Arrondo G, Mulraney M, Iturmendi-Sabater I, Musullulu H, Gambra L, Niculcea T, Banaschewski T, Simonoff E, Döpfner M, Hinshaw SP, Coghill D, Cortese S. Systematic Review and Meta-Analysis: Clinical Utility of Continuous Performance Tests for the Identification of Attention-Deficit/Hyperactivity Disorder. J Am Acad Child Adolesc Psychiatry 2024; 63:154-171. [PMID: 37004919 DOI: 10.1016/j.jaac.2023.03.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 03/25/2023] [Accepted: 03/29/2023] [Indexed: 04/04/2023]
Abstract
OBJECTIVE We aimed to quantify the clinical utility of continuous performance tests (CPTs) for the diagnosis of attention-deficit/hyperactivity disorder (ADHD) compared to a clinical diagnosis in children and adolescents. METHOD Four databases (MEDLINE, PsycINFO, EMBASE, and PubMed) were screened until January 2023. Risk of bias of included results was judged with the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2). We statistically pooled the area under the curve, the sensitivity, and the specificity of 3 commonly used CPTs subscales: omission/inattention, commission/impulsivity, and total number of errors/ADHD subscales (PROSPERO registration: CRD42020168091). RESULTS A total of 19 studies using commercially available CPTs were identified. Results from up to 835 control individuals and 819 cases were combined in the summary receiver operating characteristic (ROC) curve analyses (sensitivity and specificity pooling), and up to 996 cases and 1,083 control individuals in the area under the curve (AUC) analyses. Clinical utility as measured by AUCs could be considered as barely acceptable (between 0.7 and 0.8) for the most part, with the best results for the total/ADHD score, followed by omissions/inattention, and poorest for commission/impulsivity scores. A similar pattern was found when pooling sensitivity and specificity: 0.75 (95% CI = 0.66-0.82) and 0.71 (0.62-0.78) for the total/ADHD score; 0.63 (0.49-0.75) and 0.74 (0.65-0.81) for omissions; and 0.59 (0.38-0.77) and 0.66 (CI = 0.50-0.78) for commissions. CONCLUSION At the clinical level, CPTs as a stand-alone tool have only a modest to moderate ability to differentiate ADHD from non-ADHD samples. Hence, they should be used only within a more comprehensive diagnostic process. STUDY PREREGISTRATION INFORMATION A systematic review of screening tools for ADHD in children and adolescents; https://www.crd.york.ac.uk/prospero/; CRD42020168091.
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Affiliation(s)
| | - Melissa Mulraney
- University of Melbourne, Australia, and Murdoch Children's Research Institute, Melbourne; Institute for Social Neuroscience, Ivanhoe, Australia
| | | | | | | | | | | | - Emily Simonoff
- Institute of Psychiatry, Psychology and Neuroscience, and Maudsley Biomedical Research Centre, King's College, London, United Kingdom
| | | | - Stephen P Hinshaw
- University of California, Berkeley, and the University of California, San Francisco, USA
| | - David Coghill
- University of Melbourne, Australia, and Murdoch Children's Research Institute, Melbourne
| | - Samuele Cortese
- University of Southampton, Southampton, United Kingdom; Solent NHS Trust, Southampton, United Kingdom; New York University, New York, and the University of Nottingham, United Kingdom
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García Beristain JC, de Celis Alonso B, Barragan Perez E, Dies-Suarez P, Hidalgo-Tobón S. BOLD Activation During the Application of MOXO-CPT in School Patients With and Without Attention Deficit Hyperactivity Disorder. J Atten Disord 2024; 28:321-334. [PMID: 38153047 PMCID: PMC10838480 DOI: 10.1177/10870547231217093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
INTRODUCTION Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder that affects 3% of children in the world. OBJECTIVE In this work, we seek to compare the different brain activations of pediatric patients with and without ADHD. METHODS A functional resonance examination with BOLD contrast was applied using the MOXO-CPT test (Continuous Performance test with single and double visual-auditory distractors). RESULTS Differences in BOLD activation were observed indicating that control children regularly presented negative BOLD activations that were not found in children with ADHD. Inhibitory activity in audiovisual association zones in control patients was greater than in patients with ADHD. The inhibition in the frontal and motor regions in the controls contrasted with the overactivation of the motor areas in patients with ADHD, this, together with the detection of cerebellar activation which attempted to modulate the responses of the different areas that lead to executive failure in patients with ADHD. CONCLUSIONS In view of these results, it can be argued that the lack of inhibition of ADHD patients in their executive functions led to a disorganization of the different brain systems.
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Affiliation(s)
| | | | | | - Pilar Dies-Suarez
- Hospital Infantil de México Federico Gomez, Cuauhtémoc, Mexico City, Mexico
| | - Silvia Hidalgo-Tobón
- Universidad Autonoma Metropolitana-Iztapalapa, Mexico City, Mexico
- Hospital Infantil de México Federico Gómez, Cuauhtémoc, Mexico City, Mexico
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Lindvall MA, Holmqvist KL, Svedell LA, Philipson A, Cao Y, Msghina M. START - physical exercise and person-centred cognitive skills training as treatment for adult ADHD: protocol for a randomized controlled trial. BMC Psychiatry 2023; 23:697. [PMID: 37749523 PMCID: PMC10521407 DOI: 10.1186/s12888-023-05181-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 09/11/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND Core symptoms in attention deficit hyperactivity disorder (ADHD) are inattention, impulsivity and hyperactivity. Many individuals with this disorder also have a sedentary lifestyle, co-morbid mental illness such as depressive and anxiety disorders, and reduced quality of life. People with ADHD often have impaired executive function, which among other things may include difficulty in time management and structuring of everyday life. Pharmacological treatment is often the first-line option, but non-pharmacological treatment is also available and is used in clinical settings. In children and adolescents with ADHD, physical exercise is used as a non-pharmacological treatment. However, the evidence for the effectiveness of exercise in adults is sparse. OBJECTIVE To implement the START intervention (START = Stöd i Aktivitet, Rörelse och Träning [Support in activity, movement and exercise]) consisting of a 12-week, structured mixed exercise programme with or without a cognitive intervention, in adults with ADHD, and study whether it has an effect on core symptoms of ADHD as well as physical, cognitive, mental and everyday functioning compared with usual treatment. A secondary aim is to investigate the participants' experiences of the intervention and its possible benefits, and to evaluate the cost-effectiveness of START compared with usual treatment. METHODS This is a randomized controlled trial planned to be conducted in 120 adults with ADHD, aged 18-65. The intervention will be given as an add-on to standard care. Participants will be randomized to three groups. Group 1 will be given a physiotherapist-led mixed exercise programme for 12 weeks. Group 2 will receive the same intervention as group 1 with the addition of occupational therapist-led cognitive skills training. Group 3 will be the control group who will receive standard care only. The primary outcome will be reduction of ADHD symptoms measured using the World Health Organization (WHO) Adult ADHD Self-Report Scale (ASRS-v1.1), Clinical Global Impression-Severity scale (CGI-S) and CGI-Improvement scale (CGI-I). The effect will be measured within 1 week after the end of the intervention and 6 and 12 months later. DISCUSSION Data collection began in March 2021. The final 12-month follow-up is anticipated to be completed by autumn 2024. TRIAL REGISTRATION ClinicalTrials.gov (Identifier: NCT05049239). Registered on 20 September 2021 (last verified: May 2021).
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Affiliation(s)
- Mialinn Arvidsson Lindvall
- University Health Care Research Centre, Faculty of Medicine and Health, Örebro University, Örebro, 70182, SE, Sweden.
| | - Kajsa Lidström Holmqvist
- University Health Care Research Centre, Faculty of Medicine and Health, Örebro University, Örebro, 70182, SE, Sweden
- Department of Neurology and Rehabilitation Medicine, Faculty of Medicine and Health, Örebro University, Örebro, 70182, SE, Sweden
| | - Lena Axelsson Svedell
- Department of Psychiatry, Faculty of Medicine and Health, Örebro University, Örebro, 70182, SE, Sweden
| | - Anna Philipson
- University Health Care Research Centre, Faculty of Medicine and Health, Örebro University, Örebro, 70182, SE, Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, 70182, SE, Sweden
- Unit of Integrative Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Mussie Msghina
- Department of Psychiatry, Faculty of Medicine and Health, Örebro University, Örebro, 70182, SE, Sweden
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
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7
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Lee DY, Shin Y, Park RW, Cho SM, Han S, Yoon C, Choo J, Shim JM, Kim K, Jeon SW, Kim SJ. Use of eye tracking to improve the identification of attention-deficit/hyperactivity disorder in children. Sci Rep 2023; 13:14469. [PMID: 37660094 PMCID: PMC10475111 DOI: 10.1038/s41598-023-41654-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 08/29/2023] [Indexed: 09/04/2023] Open
Abstract
Attention-deficit/hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder of childhood. Although it requires timely detection and intervention, existing continuous performance tests (CPTs) have limited efficacy. Research suggests that eye movement could offer important diagnostic information for ADHD. This study aimed to compare the performance of eye-tracking with that of CPTs, both alone and in combination, and to evaluate the effect of medication on eye movement and CPT outcomes. We recruited participants into an ADHD group and a healthy control group between July 2021 and March 2022 from among children aged 6-10 years (n = 30 per group). The integration of eye-tracking with CPTs produced higher values for the area under the receiver operating characteristic (AUC, 0.889) compared with using CPTs only (AUC, 0.769) for identifying patients with ADHD. The use of eye-tracking alone showed higher performance compare with the use of CPTs alone (AUC of EYE: 0.856, AUC of CPT: 0.769, p = 0.029). Follow-up analysis revealed that most eye-tracking and CPT indicators improved significantly after taking an ADHD medication. The use of eye movement scales could be used to differentiate children with ADHD, with the possibility that integrating eye movement scales and CPTs could improve diagnostic precision.
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Affiliation(s)
- Dong Yun Lee
- Department of Biomedical Informatics, Ajou University School of Medicine, Suwon, Republic of Korea
- Department of Medical Sciences, Graduate School of Ajou University, Suwon, Republic of Korea
| | - Yunmi Shin
- Department of Psychiatry, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Rae Woong Park
- Department of Biomedical Informatics, Ajou University School of Medicine, Suwon, Republic of Korea
- Department of Biomedical Sciences, Ajou University Graduate School of Medicine, Suwon, Republic of Korea
| | - Sun-Mi Cho
- Department of Psychiatry, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Sora Han
- Department of Psychiatry, Ajou University School of Medicine, Suwon, Republic of Korea
| | | | - Jaheui Choo
- Ajou University Hospital, Suwon, Republic of Korea
| | - Joo Min Shim
- Ajou University Hospital, Suwon, Republic of Korea
| | - Kahee Kim
- Department of Medical Sciences, Graduate School of Ajou University, Suwon, Republic of Korea
- Department of Psychiatry, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Sang-Won Jeon
- Department of Psychiatry, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seong-Ju Kim
- Department of Medical Sciences, Graduate School of Ajou University, Suwon, Republic of Korea.
- Workplace Mental Health Institute, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, 04514, Republic of Korea.
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Jylkkä J, Ritakallio L, Merzon L, Kangas S, Kliegel M, Zuber S, Hering A, Laine M, Salmi J. Assessment of goal-directed behavior and prospective memory in adult ADHD with an online 3D videogame simulating everyday tasks. Sci Rep 2023; 13:9299. [PMID: 37291157 PMCID: PMC10248336 DOI: 10.1038/s41598-023-36351-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 06/01/2023] [Indexed: 06/10/2023] Open
Abstract
The diagnosis of ADHD is based on real-life attentional-executive deficits, but they are harder to detect in adults than in children and objective quantitative measures reflecting these everyday problems are lacking. We developed an online version of EPELI 3D videogame for naturalistic and scalable assessment of goal-directed action and prospective memory in adult ADHD. In EPELI, participants perform instructed everyday chores in a virtual apartment from memory. Our pre-registered hypothesis predicted weaker EPELI performances in adult ADHD compared to controls. The sample comprised 112 adults with ADHD and 255 neurotypical controls comparable in age (mean 31, SD = 8 years), gender distribution (71% females) and educational level. Using web-browser, the participants performed EPELI and other cognitive tasks, including Conner's Continuous Performance Test (CPT). They also filled out questionnaires probing everyday executive performance and kept a 5-day diary of everyday prospective memory errors. Self-reported strategy use in the EPELI game was also examined. The ADHD participants' self-ratings indicated clearly more everyday executive problems than in the controls. Differences in the EPELI game were mostly seen in the ADHD participants' higher rates of task-irrelevant actions. Gender differences and a group × gender interaction was found in the number of correctly performed tasks, indicating poorer performance particularly in ADHD males. Discriminant validity of EPELI was similar to CPT. Strategy use strongly predicted EPELI performance in both groups. The results demonstrate the feasibility of EPELI for online assessment and highlight the role of impulsivity as a distinctive everyday life problem in adult ADHD.
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Affiliation(s)
- Jussi Jylkkä
- Department of Psychology, Åbo Akademi University, Turku, Finland.
| | - Liisa Ritakallio
- Department of Psychology, Åbo Akademi University, Turku, Finland
| | - Liya Merzon
- Department of Neuroscience and Biomedical Engineering, Aalto University, Helsinki, Finland
| | - Suvi Kangas
- Department of Psychology and Logopedics, University of Helsinki, Helsinki, Finland
| | - Matthias Kliegel
- Faculty of Psychology and Educational Sciences, University of Geneva, Geneva, Switzerland
- Centre for the Interdisciplinary Study of Gerontology and Vulnerability, University of Geneva, Geneva, Switzerland
| | - Sascha Zuber
- Centre for the Interdisciplinary Study of Gerontology and Vulnerability, University of Geneva, Geneva, Switzerland
- Swiss National Center of Competences in Research LIVES-Overcoming Vulnerability: Life Course Perspectives, Lausanne, Geneva, Switzerland
| | - Alexandra Hering
- School for Social and Behavioral Sciences, Department of Developmental Psychology, Tilburg University, Tilburg, The Netherlands
- Cognitive Aging Lab, Faculty of Psychology and Educational Sciences, University of Geneva, Geneva, Switzerland
| | - Matti Laine
- Department of Psychology, Åbo Akademi University, Turku, Finland
| | - Juha Salmi
- Department of Neuroscience and Biomedical Engineering, Aalto University, Helsinki, Finland
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Svedell LA, Holmqvist KL, Lindvall MA, Cao Y, Msghina M. Feasibility and tolerability of moderate intensity regular physical exercise as treatment for core symptoms of attention deficit hyperactivity disorder: a randomized pilot study. Front Sports Act Living 2023; 5:1133256. [PMID: 37255729 PMCID: PMC10225649 DOI: 10.3389/fspor.2023.1133256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 04/21/2023] [Indexed: 06/01/2023] Open
Abstract
Background Attention deficit hyperactivity disorder (ADHD) is associated with sedentary lifestyle, low quality of life and low physical fitness. Studies in children with ADHD have shown that regular physical exercise can help reduce core ADHD symptoms, but evidence for this is lacking in adults. Although guidelines recommend multi-modal treatment, central stimulants (CS) remain the mainstay of treatment. CS are effective in the short-term, but their long-term efficacy remains to be established. There is thus huge unmet need for developing non-pharmacological treatment options, and for well-designed randomized controlled trials (RCTs). Objective The study aimed to test the feasibility and tolerability of structured moderate-intensity 12-week physical exercise program for adults with ADHD, as a prelude to an adequately powered RCT which includes long-term follow-up. Materials and methods Fourteen adults with ADHD were recruited, 9 randomized to an intervention group and 5 to a control group. The intervention group received physiotherapist-led 50-minute mixed exercise program, three times a week for 12 weeks, and the control group treatment as usual. Participants were assessed at baseline and after 6 and 12 weeks using clinical and physical evaluations, self-rating questionnaires, and functional magnetic resonance imaging (fMRI) together with paradigms that tested attention, impulsivity and emotion regulation. Results Three participants (21%) dropped out shortly after inclusion before receiving any intervention, while roughly 80% completed the intervention according to protocol. One participant from the intervention group participated in less than 60% of treatment sessions, and one who had done baseline fMRI was unwilling to do post-intervention imaging. Four participants in the intervention group (67%) reported increased stress in prioritizing the intervention due to time-management difficulties. Overall, consistent trends were observed that indicated the feasibility and potential benefits of the intervention on core ADHD symptoms, quality of life, body awareness, sleep and cognitive functioning. Conclusion Physiotherapist-led twelve-week regular physical exercise is a feasible and potentially beneficial intervention for adults with ADHD. There was a 20% drop-out initially and 67% of those who completed the intervention reported stress with time management difficulties due to participation. A third arm was thus added to the planned RCT where cognitive intervention administered by an occupational therapist will be given together with physical exercise.Clinical Trial Registration: https://clinicaltrials.gov, identifier NCT05049239.
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Affiliation(s)
- L. A. Svedell
- Department of Psychiatry, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - K. L. Holmqvist
- Department of Neurology and Rehabilitation Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - M. A. Lindvall
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Y. Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Unit of Integrative Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - M. Msghina
- Department of Psychiatry, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Robinson A, Reed C, Davis K, Divers R, Miller L, Erdodi LA, Calamia M. Settling the Score: Can CPT-3 Embedded Validity Indicators Distinguish Between Credible and Non-Credible Responders Referred for ADHD and/or SLD? J Atten Disord 2023; 27:80-88. [PMID: 36113024 DOI: 10.1177/10870547221121781] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The purpose of the present study was to further investigate the clinical utility of individual and composite indicators within the CPT-3 as embedded validity indicators (EVIs) given the discrepant findings of previous investigations. METHODS A total of 201 adults undergoing psychoeducational evaluation for ADHD and/or Specific Learning Disorder (SLD) were divided into credible (n = 159) and non-credible (n = 42) groups based on five criterion measures. RESULTS Receiver operating characteristic curves (ROC) revealed that 5/9 individual indicators and 2/4 composite indicators met minimally acceptable classification accuracy of ≥0.70 (AUC = 0.43-0.78). Individual (0.16-0.45) and composite indicators (0.23-0.35) demonstrated low sensitivity when using cutoffs that maintained specificity ≥90%. CONCLUSION Given the lack of stability across studies, further research is needed before recommending any specific cutoff be used in clinical practice with individuals seeking psychoeducational assessment.
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Affiliation(s)
| | | | | | - Ross Divers
- Louisiana State University, Baton Rouge, USA
| | - Luke Miller
- Louisiana State University, Baton Rouge, USA
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11
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Winter D, Braw Y. Validating Embedded Validity Indicators of Feigned ADHD-Associated Cognitive Impairment Using the MOXO-d-CPT. J Atten Disord 2022; 26:1907-1913. [PMID: 35861241 DOI: 10.1177/10870547221112947] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND The current study aimed to validate the utility of previously established validity indicators derived from MOXO-d-CPT's continuous performance test. METHOD Healthy simulators feigned impairment after searching online for relevant information, an ecologically valid coaching condition (n = 39). They were compared to ADHD patients (n = 36) and healthy controls (n = 38). RESULTS Simulators performed significantly worse than ADHD patients in all MOXO-d-CPT indices, as well as a scale that integrates their contributions (feigned ADHD scale). Three indices (attention, hyperactivity, and impulsivity) and the latter scale exhibited adequate discriminative capacity. Higher education was associated with an exaggerated impairment among simulators, easing their detection. CONCLUSION Similarity between the current study and a previous study which examned the utlity of the MOXO-d-CPT validity indicators, increases our confidence in the efficacy of the latters embedded validity indicators. Though the findings provide initial validation of these validity indicators, generalizing beyond highly functioning participants necessitates further research.
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Kurokami T, Kobayashi H, Nakajima M, Mikami M, Koeda T. Establishment of an objective index for the diagnosis of attention deficit/hyperactivity disorder by the continuous performance test "MOGRAZ". Brain Dev 2022; 44:664-671. [PMID: 35879141 DOI: 10.1016/j.braindev.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 07/08/2022] [Accepted: 07/08/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The diagnosis of attention deficit/hyperactivity disorder (AD/HD) in Japan is mainly based on information obtained from caregivers. There is therefore a need to establish an objectivity index that can be easily used in clinical practice. The purpose of the study was to create a predictive model for the diagnosis of AD/HD using the MOGRAZ, a visual continuous performance test developed in Japan. METHODS We collected data from an AD/HD group and a non-AD/HD group. The AD/HD group included 75 children with predominantly inattentive type AD/HD and 48 with combined type AD/HD who were aged 6 to 12 years and diagnosed at our department. The non-AD/HD group included 153 Japanese children aged 6 to 11 years enrolled in regular classes at a public elementary school. In both groups, multiple logistic regression analysis was performed using the results of MOGRAZ, age, and sex as parameters, and algorithms for a predictive diagnostic model of AD/HD were created. RESULTS The area under the receiver operating characteristic curve (ROC-AUC) between the predominantly inattentive type AD/HD subgroup and non-AD/HD group was 0.884 (95% confidence interval: 0.837-0.932), and the ROC-AUC between the combined type AD/HD subgroup and non-AD/HD group was 0.914 (95% CI: 0.869-0.959). CONCLUSION The prediction model using the MOGRAZ score allowed us to create an objectivity index to determine the diagnosis of AD/HD that can be easily used in clinical practice. We plan additional verification of this prediction model with additional participants.
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Affiliation(s)
- Tsunehiko Kurokami
- Department of Psychosocial Medicine, National Center for Child Health and Development, Tokyo, Japan; Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan.
| | | | - Moe Nakajima
- Department of Psychosocial Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Masashi Mikami
- Biostatistics Unit, National Center for Child Health and Development, Tokyo, Japan
| | - Tatsuya Koeda
- Department of Psychosocial Medicine, National Center for Child Health and Development, Tokyo, Japan
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Seesjärvi E, Puhakka J, Aronen ET, Lipsanen J, Mannerkoski M, Hering A, Zuber S, Kliegel M, Laine M, Salmi J. Quantifying ADHD Symptoms in Open-Ended Everyday Life Contexts With a New Virtual Reality Task. J Atten Disord 2022; 26:1394-1411. [PMID: 34865551 PMCID: PMC9304743 DOI: 10.1177/10870547211044214] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To quantify goal-directed behavior and ADHD symptoms in naturalistic conditions, we developed a virtual reality task, EPELI (Executive Performance in Everyday LIving), and tested its predictive, discriminant and concurrent validity. METHOD We collected EPELI data, conventional neuropsychological task data, and parent-ratings of executive problems and symptoms in 38 ADHD children and 38 typically developing controls. RESULTS EPELI showed predictive validity as the ADHD group exhibited higher percentage of irrelevant actions reflecting lower attentional-executive efficacy and more controller movements and total game actions, both indicative of hyperactivity-impulsivity. Further, the five combined EPELI measures showed excellent discriminant validity (area under curve 88 %), while the correlations of the EPELI efficacy measure with parent-rated executive problems (r = .57) and ADHD symptoms (r = .55) pointed to its concurrent validity. CONCLUSION We provide a proof-of-concept validation for a new virtual reality tool for ecologically valid assessment of ADHD symptoms.
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Affiliation(s)
- Erik Seesjärvi
- University of Helsinki, Helsinki,
Finland,Child Neurology, University of Helsinki
and Helsinki University Hospital, Finland
| | | | - Eeva T. Aronen
- Child Psychiatry, University of
Helsinki and Helsinki University Hospital, Finland
| | | | - Minna Mannerkoski
- Child Psychiatry, University of
Helsinki and Helsinki University Hospital, Finland
| | | | - Sascha Zuber
- University of Geneva, Switzerland,Swiss National Centre of Competence in
Research LIVES, Switzerland
| | - Matthias Kliegel
- University of Geneva, Switzerland,Swiss National Centre of Competence in
Research LIVES, Switzerland
| | - Matti Laine
- Åbo Akademi University, Turku,
Finland,University of Turku, Turku,
Finland
| | - Juha Salmi
- University of Helsinki, Helsinki,
Finland,University of Turku, Turku,
Finland,Department of Neuroscience and
Biomedical Engineering, Aalto University, Espoo, Finland,Juha Salmi, Department of Neuroscience and
Biomedical Engineering, Aalto University, P.O. Box 00076 (Rakentajanaukio 2,
Espoo), Finland.
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14
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Lev A, Braw Y, Elbaum T, Wagner M, Rassovsky Y. Eye Tracking During a Continuous Performance Test: Utility for Assessing ADHD Patients. J Atten Disord 2022; 26:245-255. [PMID: 33238787 DOI: 10.1177/1087054720972786] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The use of continuous performance tests (CPTs) for assessing ADHD related cognitive impairment is ubiquitous. Novel psychophysiological measures may enhance the data that is derived from CPTs and thereby improve clinical decision-making regarding diagnosis and treatment. As part of the current study, we integrated an eye tracker with the MOXO-dCPT and assessed the utility of eye movement measures to differentiate ADHD patients and healthy controls. METHOD Adult ADHD patients and gender/age-matched healthy controls performed the MOXO-dCPT while their eye movements were monitored (n = 33 per group). RESULTS ADHD patients spent significantly more time gazing at irrelevant regions, both on the screen and outside of it, than healthy controls. The eye movement measures showed adequate ability to classify ADHD patients. Moreover, a scale that combined eye movement measures enhanced group prediction, compared to the sole use of conventional MOXO-dCPT indices. CONCLUSIONS Integrating an eye tracker with CPTs is a feasible way of enhancing diagnostic precision and shows initial promise for clarifying the cognitive profile of ADHD patients. Pending replication, these findings point toward a promising path for the evolution of existing CPTs.
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Affiliation(s)
- Astar Lev
- Bar-Ilan University, Ramat Gan, Israel
| | | | | | | | - Yuri Rassovsky
- Bar-Ilan University, Ramat Gan, Israel.,University of California, Los Angeles (UCLA), Los Angeles, California, USA
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15
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Son HM, Lee DG, Joung YS, Lee JW, Seok EJ, Chung TM, Oh S. A novel approach to diagnose ADHD using virtual reality. INTERNATIONAL JOURNAL OF WEB INFORMATION SYSTEMS 2021. [DOI: 10.1108/ijwis-03-2021-0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
The current golden standard for attention deficit hyperactivity disorder (ADHD) diagnosis is clinical diagnosis based on psychiatric interviews and psychological examinations. This is suboptimal, as clinicians are unable to view potential patients in multiple natural settings – a necessary condition for objective diagnosis. The purpose of this paper is to improve the objective diagnosis of ADHD by analyzing a quantified representation of the actions of potential patients in multiple natural environments.
Design/methodology/approach
The authors use both virtual reality (VR) and artificial intelligence (AI) to create an objective ADHD diagnostic test. Diagnostic and statistical manual of mental disorders, 5th Edition (DSM-5) and ADHD Rating Scale are used to create a rule-based system of quantifiable VR-observable actions. As a potential patient completes tasks within multiple VR scenes, certain actions trigger an increase in the severity measure of the corresponding ADHD symptom. The resulting severity measures are input to an AI model, which classifies the potential patient as having ADHD in the form inattention, hyperactivity-impulsivity, combined or neither.
Findings
The result of this study shows that VR-observed actions can be extracted as quantified data, and classification of this quantified data achieves near-perfect sensitivity and specificity with a 98.3% accuracy rate on a convolutional neural network model.
Originality/value
To the best of the authors’ knowledge, this is the first study to incorporate VR and AI into an objective DSM-5-based ADHD diagnostic test. By including stimulation to the visual, auditory and equilibrium senses and tracking movement and recording voice, we present a method to further the research of objective ADHD diagnosis.
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16
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Berger C, Lev A, Braw Y, Elbaum T, Wagner M, Rassovsky Y. Detection of Feigned ADHD Using the MOXO-d-CPT. J Atten Disord 2021; 25:1032-1047. [PMID: 31364437 DOI: 10.1177/1087054719864656] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Objective: The objective of this study was to assess the MOXO-d-CPT utility in detecting feigned ADHD and establish cutoffs with adequate specificity and sensitivity. Method: The study had two phases. First, using a prospective design, healthy adults who simulated ADHD were compared with healthy controls and ADHD patients who performed the tasks to the best of their ability (n = 47 per group). Participants performed the MOXO-d-CPT and an established performance validity test (PVT). Second, the MOXO-d-CPT classification accuracy, employed in Phase 1, was retrospectively compared with archival data of 47 ADHD patients and age-matched healthy controls. Results: Simulators performed significantly worse on all MOXO-d-CPT indices than healthy controls and ADHD patients. Three MOXO-d-CPT indices (attention, hyperactivity, impulsivity) and a scale combining these indices showed adequate discriminative capacity. Conclusion: The MOXO-d-CPT showed promise for the detection of feigned ADHD and, pending replication, can be employed for this aim in clinical practice and ADHD research.
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Affiliation(s)
| | - Astar Lev
- Bar-Ilan University, Ramat Gan, Israel
| | | | | | | | - Yuri Rassovsky
- Bar-Ilan University, Ramat Gan, Israel.,University of California, Los Angeles, USA
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17
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Rostami M, Khosrowabadi R, Albrecht B, Rothenberger A, Pouretemad H. Classifying ADHD subtypes/presentations considering the joint effect of three levels of investigation. Nord J Psychiatry 2021; 75:31-37. [PMID: 33393425 DOI: 10.1080/08039488.2020.1787512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AIM Discriminant validity of the Attention Deficits/Hyperactive Disorders (ADHD) subtypes/presentations is not yet clear. The purpose of this study was to investigate joint contribution of the strongest factors of the three dimensions, namely psychopathology, neuropsychology and electrophysiology for subtyping of presentations. METHOD A sample of 104 boys aged 7-12 years was subdivided into three groups with ADHD combined (n = 22), inattentive (n = 25) and hyperactive/impulsive subtype (n = 14), and 43 typically developing controls (TDC). Children were investigated regarding the Child Behavior Checklist (CBCL), the Integrated Visual and Auditory Test (IVA), and EEG spectral power during eyes closed resting state. Subsequently, statistical analysis included discriminant functional analysis and principle component analysis. RESULTS Neuropsychological parameters had the highest contribution in classifying of the groups. EEG parameters had no effect on differentiation of the groups, and among the psychopathological parameters, only the oppositional behavioral disorder score contributed to correctly classify 74.3% of the groups. Furthermore, we found four factors with eigenvalues higher than 1 in the ADHD and typical groups, with one factor characterized by four CBCL scales, another one by auditory and visual vigilance, speed and beta band power, the third by auditory and visual prudence, and forth by theta band power. CONCLUSIONS Our results demonstrated that ADHD subtypes/presentations can be differentiated from each other at different levels of investigation despite some clinical symptoms overlap. The results suggested that not only psychopathology but also the impairment of sensory processing should be assessed in children with ADHD in order to use this additional information for a jointly multilevel clinical intervention, which may improve treatment success.
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Affiliation(s)
- Mohammad Rostami
- Institute for Cognitive and Brain Sciences, Shahid Beheshti University, Tehran, Iran
| | - Reza Khosrowabadi
- Institute for Cognitive and Brain Sciences, Shahid Beheshti University, Tehran, Iran
| | - Björn Albrecht
- Clinic for Child and Adolescent Psychiatry and Psychotherapy, University Medical Center of Göttingen, Germany
| | - Aribert Rothenberger
- Clinic for Child and Adolescent Psychiatry and Psychotherapy, University Medical Center of Göttingen, Germany
| | - Hamidreza Pouretemad
- Institute for Cognitive and Brain Sciences, Shahid Beheshti University, Tehran, Iran
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18
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Elbaum T, Braw Y, Lev A, Rassovsky Y. Attention-Deficit/Hyperactivity Disorder (ADHD): Integrating the MOXO-dCPT with an Eye Tracker Enhances Diagnostic Precision. SENSORS (BASEL, SWITZERLAND) 2020; 20:E6386. [PMID: 33182303 PMCID: PMC7664925 DOI: 10.3390/s20216386] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 10/30/2020] [Accepted: 11/02/2020] [Indexed: 11/17/2022]
Abstract
Clinical decision-making may be enhanced when combining psychophysiological sensors with computerized neuropsychological tests. The current study explored the utility of integrating an eye tracker with a commercially available continuous performance test (CPT), the MOXO-dCPT. As part of the study, the performance of adult attention-deficit/hyperactivity disorder (ADHD) patients and healthy controls (n = 43, n = 42, respectively) was compared in the integrated system. More specifically, the MOXO-dCPT has four stages, which differ in their combinations of ecological visual and auditory dynamic distractors. By exploring the participants' performance in each of the stages, we were able to show that: (a) ADHD patients spend significantly more time gazing at irrelevant areas of interest (AOIs) compared to healthy controls; (b) visual distractors are particularly effective in impacting ADHD patients' eye movements, suggesting their enhanced utility in diagnostic procedures; (c) combining gaze direction data and conventional CPT indices enhances group prediction, compared to the sole use of conventional indices. Overall, the findings indicate the utility of eye tracker-integrated CPTs and their enhanced diagnostic precision. They also suggest that the use of attention-grabbing visual distractors may be a promising path for the evolution of existing CPTs by shortening their duration and enhancing diagnostic precision.
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Affiliation(s)
- Tomer Elbaum
- Department of Industrial Engineering and Management, Ariel University, Ariel 40700, Israel;
| | - Yoram Braw
- Department of Psychology, Ariel University, Ariel 40700, Israel
| | - Astar Lev
- Department of Psychology, Bar-Ilan University, Ramat Gan 5290002, Israel; (A.L.); or (Y.R.)
| | - Yuri Rassovsky
- Department of Psychology, Bar-Ilan University, Ramat Gan 5290002, Israel; (A.L.); or (Y.R.)
- Leslie and Susan Gonda (Goldschmied) Multidisciplinary Brain Research Center, Bar-Ilan University, Ramat Gan 5290002, Israel
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles (UCLA), Los Angeles, CA 90095, USA
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Climent G, Rodríguez C, García T, Areces D, Mejías M, Aierbe A, Moreno M, Cueto E, Castellá J, Feli González M. New virtual reality tool (Nesplora Aquarium) for assessing attention and working memory in adults: A normative study. APPLIED NEUROPSYCHOLOGY-ADULT 2019; 28:403-415. [PMID: 31382773 DOI: 10.1080/23279095.2019.1646745] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Attentional and working memory (WM) processes undergo significant changes during different stages of development. However, currently there are not many continuous performance tools based on virtual reality (VR) for measuring attentional capacity in adults. The present study aimed to obtain normative data for the Nesplora Aquarium VR test in a Spanish population, looking at sex and age variables. In addition, this study also aimed to analyze the psychometric properties of the tool such as scale, internal consistency, and item difficulty and discrimination indices. A total of 1,469 participants from different regions of Spain (57.6% female) with ages ranging from 16 to 90 years old took part in this normative study. Nesplora Aquarium was developed in order to support clinicians in the assessment of attentional processes and WM in adults over 16 years old. It is an 18-minute individual test performed through a VR system. The system provides better visual and auditory immersion in the task than computerized CPTs. This study revealed that the new VR tool, designed to measure adult attention and working memory levels, exhibited good psychometric properties related to reliability and internal consistency. In addition, item difficulty and discrimination values were also acceptable.
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Affiliation(s)
- Gema Climent
- Department of I+D+i, Nesplora Technology & Behavior, San Sebastian, Spain
| | | | - Trinidad García
- Department of Psychology, University of Oviedo, Oviedo, Spain
| | - Débora Areces
- Department of Psychology, Faculty Padre Ossó, Oviedo, Spain
| | - Miguel Mejías
- Department of I+D+i, Nesplora Technology & Behavior, San Sebastian, Spain
| | - Amaia Aierbe
- Department of I+D+i, Nesplora Technology & Behavior, San Sebastian, Spain
| | - Marta Moreno
- Department of I+D+i, Nesplora Technology & Behavior, San Sebastian, Spain
| | - Eduardo Cueto
- Department of Psychology, University of Oviedo, Oviedo, Spain
| | - Judit Castellá
- Department of Basic Psychology, Development and Education, Autonomous University of Barcelona, Barcelona, Spain
| | - Mari Feli González
- Department of I+D+i, Nesplora Technology & Behavior, San Sebastian, Spain
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