Development of a computerised neurocognitive battery for children and adolescents with HIV in Botswana: study design and protocol for the Ntemoga study

Computerized Cognitive Test Batteries for Children and Adolescents-A Scoping Review of Tools For Lab- and Web-Based Settings From 2000 to 2021

OBJECTIVE

Cognitive functioning is essential to well-being. Since cognitive difficulties are common in many disorders, their early identification is critical, notably during childhood and adolescence. This scoping review aims to provide a comprehensive literature overview of computerized cognitive test batteries (CCTB) that have been developed and used in children and adolescents over the past 22 years and to evaluate their psychometric properties.

METHOD

Among 3192 records identified from three databases (PubMed, PsycNET, and Web of Science) between 2000 and 2021, 564 peer-reviewed articles conducted in children and adolescents aged 3 to 18 years met inclusion criteria. Twenty main CCTBs were identified and further reviewed following PRISMA guidelines. Relevant study details (sample information, topic, location, setting, norms, and psychometrics) were extracted, as well as administration and instrument characteristics for the main CCTBs.

RESULTS

Findings suggest that CCTB use varies according to age, location, and topic, with eight tools accounting for 85% of studies, and the Cambridge Neuropsychological Test Automated Battery (CANTAB) being most frequently used. Few instruments were applied in web-based settings or include social cognition tasks. Only 13% of studies reported psychometric properties.

CONCLUSIONS

Over the past two decades, a high number of computerized cognitive batteries have been developed. Among these, more validation studies are needed, particularly across diverse cultural contexts. This review offers a comprehensive synthesis of CCTBs to aid both researchers and clinicians to conduct cognitive assessments in children in either a lab- or web-based setting.

High executive functioning is associated with reduced posttraumatic stress after trauma exposure among male U.S. military personnel

Introduction

Evidence suggests that executive function (EF) may play a key role in development of PTSD, possibly influenced by factors such as trauma type and timing. Since EF can be improved through intervention, it may be an important target for promoting resilience to trauma exposure. However, more research is needed to understand the relation between trauma exposure, EF, and PTSD. The goal of this study was to improve understanding of EF as a potential antecedent or protective factor for the development of PTSD among military personnel.

Method

In a cohort of U.S. Marines and Navy personnel (N = 1,373), the current study tested the association between exposure to traumatic events (pre-deployment and during deployment) and PTSD severity, and whether EF moderated these associations. Three types of pre-deployment trauma exposure were examined: cumulative exposure, which included total number of events participants endorsed as having happened to them, witnessed, or learned about; direct exposure, which included total number of events participants endorsed as having happened to them; and interpersonal exposure, which included total number of interpersonally traumatic events participants' endorsed. EF was measured using the Penn Computerized Neurocognitive Battery.

Results

EF was associated with less PTSD symptom severity at pre-deployment, even when adjusting for trauma exposure, alcohol use, traumatic brain injury, and number of years in the military. EF also moderated the relation between cumulative trauma exposure and interpersonal trauma exposure and PTSD, with higher EF linked to a 20 and 33% reduction in expected point increase in PTSD symptoms with cumulative and interpersonal trauma exposure, respectively. Finally, higher pre-deployment EF was associated with reduced PTSD symptom severity at post-deployment, independent of deployment-related trauma exposure and adjusting for pre-deployment PTSD.

Conclusion

Our results suggest that EF plays a significant, if small role in the development of PTSD symptoms after trauma exposure among military personnel. These findings provide important considerations for future research and intervention and prevention, specifically, incorporating a focus on improving EF in PTSD treatment.

Addressing the Know-Do Gap in Adolescent HIV: Framing and Measuring Implementation Determinants, Outcomes, and Strategies in the AHISA Network

Implementation science (IS) uses systematic methods to close gaps between research and practice by identifying and addressing barriers to implementation of evidence-based interventions (EBIs). To reach UNAIDS HIV targets, IS can support programs to reach vulnerable populations and achieve sustainability. We studied the application of IS methods in 36 study protocols that were part of the Adolescent HIV Prevention and Treatment Implementation Science Alliance (AHISA). Protocols focused on youth, caregivers, or healthcare workers in high HIV-burden African countries and evaluated medication, clinical and behavioral/social EBIs. All studies measured clinical outcomes and implementation science outcomes; most focused on early implementation outcomes of acceptability (81%), reach (47%), and feasibility (44%). Only 53% used an implementation science framework/theory. Most studies (72%) evaluated implementation strategies. Some developed and tested strategies, while others adapted an EBI/strategy. Harmonizing IS approaches allows cross study learning and optimization of delivery of EBIs and could support attainment of HIV goals.

Construction of a computerized adaptive test (CAT-CCNB) for efficient neurocognitive and clinical psychopathology assessment

BACKGROUND

Traditional paper-and-pencil neurocognitive evaluations and semi-structured mental health interviews can take hours to administer and score. Computerized assessment has decreased that burden substantially, and contemporary psychometric tools such as item response theory and computerized adaptive testing (CAT) allow even further abbreviation.

NEW METHOD

The goal of this paper was to describe the application of CAT and related methods to the Penn Computerized Neurocognitive Battery (CNB) and a well-validated clinical assessment in order to increase efficiency in assessment and relevant domain coverage. To calibrate item banks for CAT, N = 5053 participants (63% female; mean age 45 years, range 18-80) were collected from across the United States via crowdsourcing, providing item parameters that were then linked to larger item banks and used in individual test construction. Tests not amenable to CAT were abbreviated using complementary short-form methods.

RESULTS

The final "CAT-CCNB" battery comprised 21 cognitive tests (compared to 14 in the original) and five adaptive clinical scales (compared to 16 in the original).

COMPARISON WITH EXISTING METHODS

This new battery, derived with contemporary psychometric approaches, provides further improvements over existing assessments that use collections of fixed-length tests developed for stand-alone administration. The CAT-CCNB provides an improved version of the CNB that shows promise as a maximally efficient tool for neuropsychiatric assessment.

CONCLUSIONS

We anticipate CAT-CCNB will help satisfy the clear need for broad yet efficient measurement of cognitive and clinical domains, facilitating implementation of large-scale, "big science" approaches to data collection, and potential widespread clinical implementation.

Test-Retest Reliability of a Computerized Neurocognitive Battery in School-Age Children with HIV in Botswana

Human immunodeficiency virus (HIV) infection is prevalent among children and adolescents in Botswana, but standardized neurocognitive testing is limited. The Penn Computerized Neurocognitive Battery (PennCNB) attempts to streamline evaluation of neurocognitive functioning and has been culturally adapted for use among youth in this high-burden, low-resource setting. However, its reliability across measurements (i.e., test-retest reliability) is unknown. This study examined the test-retest reliability of the culturally adapted PennCNB in 65 school-age children (age 7-17) living with HIV in Botswana. Intraclass correlation coefficients (ICCs) for PennCNB summary scores (ICCs > 0.80) and domain scores (ICCs = 0.66-0.88) were higher than those for individual tests, which exhibited more variability (ICCs = 0.50-0.82), with the lowest reliability on memory tests. Practice effects were apparent on some measures, especially within memory and complex cognition domains. Taken together, the adapted PennCNB exhibited adequate test-retest reliability at the domain level but variable reliability for individual tests. Differences in reliability should be considered in implementation of these tests.

Medical stakeholder perspectives on implementing a computerized battery to identify neurocognitive impairments among youth in Botswana

HIV infection and in utero exposure, common in Sub-Saharan Africa, are associated with pediatric neurocognitive impairment. Cognitive screening can identify impairments, but it is rarely used in this setting. The Penn Computerized Neurocognitive Battery (PennCNB), an evidence-based cognitive screening tool, was adapted for use in Botswana. To facilitate future implementation, 20 semi-structured interviews were conducted to elicit key stakeholders' perspectives on factors likely to be related to successful uptake of the PennCNB in clinical settings. An integrated analytic approach combining constructs from the Consolidated Framework for Implementation Research and modified grounded theory was used. Results underscore the need for cognitive screening in Botswana and the acceptability of the PennCNB. Implementation barriers include limited time and resources, whereas facilitators include standard procedures for introducing new tools into medical settings and for training implementers. Recommended implementation strategies include integrating screening into the existing workflow, implementing the tool in the medical and educational sectors, and targeting selection of children for assessment. This research addresses the research-to-practice gap by engaging in pre-implementation inquiry and designing for implementation. Results will inform the development of strategies to maximize the likelihood of successful implementation of the PennCNB to identify neurocognitive impairment in children in this high-need setting.

Predictive Validity of a Computerized Battery for Identifying Neurocognitive Impairments Among Children Living with HIV in Botswana

Children living with HIV (HIV+) experience increased risk of neurocognitive deficits, but standardized cognitive testing is limited in low-resource, high-prevalence settings. The Penn Computerized Neurocognitive Battery (PennCNB) was adapted for use in Botswana. This study evaluated the criterion validity of a locally adapted version of the PennCNB among a cohort of HIV+ individuals aged 10-17 years in Botswana. Participants completed the PennCNB and a comprehensive professional consensus assessment consisting of pencil-and-paper psychological assessments, clinical interview, and review of academic performance. Seventy-two participants were classified as cases (i.e., with cognitive impairment; N = 48) or controls (i.e., without cognitive impairment; N = 24). Sensitivity, specificity, positive predictive value, negative predictive value, and the area under receiver operating characteristic curves were calculated. Discrimination was acceptable, and prediction improved as the threshold for PennCNB impairment was less conservative. This research contributes to the validation of the PennCNB for use among children affected by HIV in Botswana.

Central Nervous System Impact of Perinatally Acquired HIV in Adolescents and Adults: an Update

Purpose of Review

Perinatally acquired HIV infection (PHIV) can confer neurodevelopmental risk. As children with PHIV increasingly survive through adolescence and into adulthood, understanding its long-term central nervous system (CNS) impacts is critical for maximizing adult outcomes and quality of life.

Recent Findings

Recently published neurocognitive and neuroimaging findings show impacts on the CNS associated with early HIV disease progression that endure into adolescence and young adulthood. Although developmental trajectories in adolescence largely appear stable, further research on maturational processes is indicated.

Summary

Although early antiretroviral therapy in infancy appears to be protective, it is not universally available and current youth largely developed without its benefit. The neurocognitive effects of HIV and the multiple other risks to neurodevelopment experienced by youth with PHIV call for further longitudinal research and a multifaceted approach to prevention and intervention.

Imputing cognitive impairment in SPARK, a large autism cohort

Diverse large cohorts are necessary for dissecting subtypes of autism, and intellectual disability is one of the most robust endophenotypes for analysis. However, current cognitive assessment methods are not feasible at scale. We developed five commonly used machine learning models to predict cognitive impairment (FSIQ<80 and FSIQ<70) and FSIQ scores among 521 children with autism using parent-reported online surveys in SPARK, and evaluated them in an independent set (n = 1346) with a missing data rate up to 70%. We assessed accuracy, sensitivity, and specificity by comparing predicted cognitive levels against clinical IQ data. The elastic-net model has good performance (AUC = 0.876, sensitivity = 0.772, specificity = 0.803) using 129 predictive features to impute cognitive impairment (FSIQ<80). Top-ranked predictive features included parent-reported language and cognitive levels, age at autism diagnosis, and history of services. Prediction of FSIQ<70 and FSIQ scores also showed good performance. We show cognitive levels can be imputed with high accuracy for children with autism, using commonly collected parent-reported data and standardized surveys. The current model offers a method for large-scale autism studies seeking estimates of cognitive ability when standardized psychometric testing is not feasible. LAY SUMMARY: Children with autism who have more severe learning challenges or cognitive impairment have different needs that are important to consider in research studies. When children in our study were missing standardized cognitive testing scores, we were able to use machine learning with other information to correctly "guess" when they have cognitive impairment about 80% of the time. We can use this information in research in the future to develop more appropriate treatments for children with autism and cognitive impairment.

Test-retest reliability of the Turkish translation of the Penn Computerized Neurocognitive Battery

Psychiatric disorders are associated with cognitive dysfunction (CD), and reliable screening and follow-up of CD is essential both for research and clinical practice globally; yet, most assessments are in Western languages. We aimed to evaluate the test-retest reliability of the Turkish version of the Penn Computerized Neurocognitive Battery (PennCNB) to guide confident interpretation of results. Fifty-eight healthy individuals completed the PennCNB Turkish version in two sessions. After quality control, reliability analysis was conducted using Intraclass Correlation Coefficients (ICC), corrected for practice effects. Most measures were not significantly different between the sessions and had acceptable ICC values, with several exceptions. Scores were improved considerably for some memory measures, including immediate Facial Memory and Spatial Memory, and for incorrect responses in abstraction and mental flexibility, with correspondingly acceptable ICCs. Test-retest assessment of the Turkish version of the PennCNB shows that it can be used as a reliable real-time measurement of cognitive function in snapshot cross-sectional or longitudinal determinations. Preliminary validity assessment in this normative sample showed expected positive correlations with education level and negative correlations with age. Thus, the Turkish version of the PennCNB can be considered a reliable neuropsychological testing tool in research and clinical practice. Practice effects should be considered, especially when applied in short intervals. Significantly better performances in the retest, beyond practice effect, likely reflect nonlinear improvements in some participants who "learned how to learn" the memory tests or had insight on solving the abstraction and mental flexibility test.