Name: using brain activation (nir-heg/q-eeg) and execution measures (cpts) in a adhd assessment protocol
Uploaded: 2018-04-01T14:00:00.000+00:00
Duration: 13 min 9 s
Description: Watch this Scientific Journal Video about Using Brain Activation nir-HEG/Q-EEG and Execution Measures CPTs in a ADHD Assessment Protocol at JoVE.com

This work has been supported by a project of the Principality of Asturias (FC-15-GRUPIN14-053) and a predoctoral grant from the Severo Ochoa Program (BP14-030). We would like to thank Anna Bujnowska for her contribution and Heather Marsh and Nigel Marsh for their help.

The present study was conducted according to the Declaration of Helsinki, which establishes the ethical principles for research involving human beings. The study&#39;s aims, scope and procedure were also approved by the Ethics Committee of the University of Oviedo and University Hospital of Asturias.
1. Parents Report
<ol>
	<li>Before starting the assessment protocol, obtain signed parental consent for the child to be assessed.</li>
	<li>Conduct a structured interview with families of the participants. 
	NOTE: The structured interview has been provided as an appendix.</li>
	<li>Have families and/or teachers of the participant complete the Scale for the Assessment of ADHD13. This scale comprises 20 items that provide information on the presence of symptoms related to attention deficit and hyperactivity/impulsivity that are referred in the Diagnostic and Statistical Manual of Mental Disorders.
	<ol>
		<li>In this section, have the therapist give the following instructions: &#34;Now, in order to get significant information about your child, you must complete this questionnaire referring to the symptoms that might be representative of your child&#39;s behavior. You must classify the frequency with which you observe these 20 symptoms&#34;.</li>
	</ol>
	</li>
</ol>
2. Cognitive Measures
<ol>
	<li>To measure the attentional variables, administer a cognitive scale.
	<ol>
		<li>Administer a Cognitive Scale14 (following the protocol in the manual) for assessing individual intelligence in children and adolescents between the ages of 6 years and 16 years 11 months.</li>
		<li>Analyze in depth the cognitive profile obtained by the scale. 
		NOTE: Considering the information included in the cognitive scales manual, the results from the Wechsler scale could be influenced by ADHD, leading to lower scores in processing speed and working memory in comparison with perceptual reasoning and verbal comprehension.</li>
	</ol>
	</li>
</ol>
3. Executive Measures Using Continuous Performance Tests
<ol>
	<li>Analyze the performance of the children using two CPTs: one based on a Virtual Reality CPT15 and the other consisting of a Traditional CPT16.</li>
	<li>Administer the virtual-reality based CPT15. This is a CPT based on a virtual reality environment that reproduces the conditions of a regular classroom. It evaluates attention, impulsivity, processing speed, and motor activity in children and adolescents between 6 and 16 years of age. The activities that make up the test are preset, and it is not possible to change any specific characteristic of the tasks.
	<ol>
		<li>Double-click on the Virtual Reality CPT app to start the program.</li>
		<li>Enter the username and password provided by the program license.</li>
		<li>Enter the participant information (name, surname and date of birth) and the click on the &#34;Go into the virtual classroom&#34; window.</li>
		<li>Ask the participant to wear the Head Mounted Display (HMD) glasses and headphones, and inform them of the importance of wearing it during the whole test. Have the therapist say: &#34;Now you need to wear these special glasses during the virtual reality tasks, if you don&#39;t see very well or have any issue about that, please tell me and I help you to resolve it&#34;. 
		NOTE: These glasses are connected to the PC, so the therapist can see the images the participants are looking at in order to ensure that they understand the test (Figure 2).</li>
		<li>Ask the participant to hold the button with their dominant hand before starting the virtual attentional tasks. Have the therapist say: &#34;You need to hold and press the button with the same hand you write with&#34;.</li>
		<li>Have the participant explore the virtual environment (a typical classroom) and take the perspective of a student sitting at one of the desks looking at the blackboard for 15 s (Figure 3). Conduct this part by the virtual teacher though these instructions: &#34;Hello, with the glasses that you are wearing, you can see the entire classroom: to the left, to your right, up, and down. You can see everything. Notice all the things in the room, look at the walls and the other people, look at whatever you want&#34;.</li>
		<li>Have the participant follow the virtual teacher, who guides them through the tasks. The first part the participant performs is training, which consists of visually locating balloons and popping them by pressing the button. Have the virtual teacher in this part instruct this part as follows: &#34;Now that you have inspected everything, you&#39;re going to start doing something fun. We have placed some shiny red balloons around you. You need to find the balloons by moving your head. When you find one, look at it closely, and press the button to make it pop. You have to find 4 balloons. Let&#39;s go! The challenge starts now!&#34;</li>
		<li>Have the participant continue to the next step which is the first exercise. This is based on the &#34;x-no&#34; paradigm (traditionally known as &#34;no-go&#34;), where the participant must press the button when he or she does not see or hear the stimulus &#34;apple&#34;. Have the virtual teacher say: &#34;Now, you will to see some drawings on the chalkboard. I will also say a few words to you. You have to pay attention and click the button, AS FAST AS POSSIBLE, when you see or hear anything THAT IS NOT AN APPLE. But be careful! You need to press the button every time you see or hear any other thing. For example, if you hear &#34;CLOUD&#34; or if a drawing of a cloud appears on the chalkboard, you have to press the button. Remember: Never press the button when you see or hear apple! The challenge starts... Now!&#34;. 
		Note: As the activities are preset by the program, it is not possible to change the target-stimulus (in this case, APPLE).</li>
		<li>Have the participant complete the last exercise by following the instructions to press the button whenever he/she sees or hears the number &#34;seven&#34;. This part consists of a &#34;X&#34; paradigm (or &#34;go&#34; task). Say these instructions: &#34;Now you are going to work with numbers. You will see numbers on the chalkboard and you will also hear numbers. You must press the button every time you hear or see the number &#34;SEVEN&#34;. DO NOT press the button for any other number. For example, if you hear or see the number &#34;THREE&#34; DO NOT press the button. Remember: Always press the button when you see or hear &#34;SEVEN&#34;! The test starts now!&#34; 
		NOTE: As the activities are preset by the program, is not possible to change the target-stimulus (in this case, SEVEN).</li>
		<li>Print the report of the test results via the test website adding the name and surname of the child assessed. This report compiles results for the following variables: omissions, commissions, response time, and variability and complement this information by differentiating these measures of sensory modality (visual vs. auditory), presence/ absence of distractors, and task type (go vs. no-go), thereby leading to different execution profiles.</li>
	</ol>
	</li>
	<li>Administer the Traditional CPT16. This is a CPT that can be used in a visual or auditory version, but in this protocol only the visual version is used. This test contains preset tasks. The visual norms for CPT go from 4 years to more than 80, by age and gender.
	<ol>
		<li>Make sure that the participant is relaxed, paying attention to their breathing and ensuring that it is controlled. If it appears that the participant is not controlling their breathing. Indicate as follows: &#34;You should focus on abdominal contraction and controlled breathing out&#34;.</li>
		<li>Open the CPT application and enter the name and birth date of the child, and press the okay button.</li>
		<li>Click on visual tasks window and click the launch button, the computer will start to load the visual tasks.</li>
		<li>Ensure the participant is holding the button (which is connected to a PC) with his/her dominant hand. Repeat the instruction from step 5 of the Virtual Reality CPT: &#34;You need to hold and press the button with the same hand you write with&#34;.</li>
		<li>Inform the participant of the following instructions for the test: &#34;You have to press the button when you see a black square in the upper part which is the target stimulus. However, do not press the button when the black square is in the bottom part&#34; (Figure 4).</li>
		<li>Have the participant perform the training part (which lasts for approximately 3 min) until it is clear the participant understands the task. In the training part of the CPT, the target (stimulus to which the participant has to respond) and the non-target (stimulus to which the participant has to avoid responding) stimulus appear randomly in the screen; the therapist should observe whether the participant presses the button correctly or not. If the participant does not press the button according to the instructions, have the therapist explain the instructions again and then the participant will need to repeat the training section.</li>
		<li>Tell the participant that the task is very long and that she/he must keep still and concentrate on doing the tasks.</li>
		<li>Have the participant complete the CPT activities. It is divided into two sections. The first section of the test (the &#34;Infrequent&#34; or vigilance mode), is characterized by target: non-target ratio of 1:3.5. This is evidenced by a tendency to not press the button. In the second section (the &#34;Frequent&#34; or high response demand mode) presents a target:non-target ratio of 3.5:1, so the child must inhibit the tendency to respond.</li>
		<li>After completion of the CPT, generate the report which compiles the following variables: omissions, RT (response time between the presentation of target stimulus and subject response), commissions, variability, D prime (quality of concentration during the test based on the number of errors in the test) and ADHD Index, attributable to a presence or absence of attention deficit with hyperactivity. Calculate this ADHD Index from the sum of: TR of first half + D prime second half + total variability and is interpreted as attributable to ADHD when the score is lower than -1.80.</li>
	</ol>
	</li>
</ol>
4. Cortical Activation Measures in Fp1 and Fpz/Cz Regions (Hemoencephalography, and Quantified Electroencephalography) 17
<ol>
	<li>Open the Bioexplorer software and choose the design POCKET_HEG_video_1ch_AI_HEGRatio.bxd.
	<ol>
		<li>Press time on button to see the time during the assessment (35 s).</li>
		<li>Inform the participant that he/she cannot move and must be still. The therapist informs the participant about the importance of remaining still during the assessment of blood oxygenation: &#34;Now it is very important that you are still during the assessment of blood oxygenation because if you move, the system will fail, and it will be necessary to measure again. Are you ready?&#34;</li>
		<li>Click on the red button and enter the name of the subject and the cortical point which is going to be measured (Fp1 region for assessment of inhibition capacity and Fpz for the assessment of attention capacity).</li>
		<li>Put the band on the participant&#39;s forehead in a specific area: Fp1 (for assessment of inhibition capacity) and Fpz (for the assessment of attention capacity) as can be seen in Figure 5.</li>
		<li>Make sure that no external light enters the band. Properly adjust the band to the participant&#39;s head in such a way that it is not loose and does not fall off during the evaluation.</li>
		<li>Put the Hemoencephalography-nirHEG (which is connected to the headband) around the participant&#39;s neck, like a necklace.</li>
		<li>Turn on the hardware to connect the band to the PC.</li>
		<li>Measure the blood oxygenation of a specific area through the nir-HEG program for approximately 35 s. Press the green button to start to measure blood oxygenation and 35 s later press the white button to end the assessment.</li>
		<li>Print the output provided by the program and analyze the nir-HEG Ratio of the participant provided by the program. The mean of this tool is 100 (SD = 20) which is used to calibrate the spectrophotometers. An Attention Index (AI) is also obtained through the nir-HEG , which shows the incapability of the participant to increase the ratio and brain activation. This is useful to identify attentional problems and measure capacity of concentration.</li>
	</ol>
	</li>
	<li>Measure the cortical activity levels of the participant using the quantified electroencephalography (Q-EEG), a computerized EEG system that provides levels of cortical activation through the beta/theta ratio. It is used to measure general levels of attention, not taking the performed task. 
	NOTE: The analysis of beta/theta ratio have been carried out according to previous studies12.
	<ol>
		<li>Inform the participant of the correct abdominal breathing required during the test.</li>
		<li>Open the Bioexplorer software and choose the design combined_Theta_Beta.bxd. The screen will appear divided into two windows (the left side shows the cortical activity of FP1 and the right side shows the cortical activity of the CZ)</li>
		<li>Click on the red button and enter the name of the subject and the cortical point which is going to be measured (Fp1 region for assessment of inhibition capacity and Cz region for the assessment of attention capacity).</li>
		<li>Put the red electrode in the Fp1 region and the blue electrode in the Cz region, applying electrode gel (using the information found at: &#8220;http://neurologiclabs.com/neuromonitoring/eeg/&#8221;, to ensure that the electrodes are correctly placed) (see Figure 6).</li>
		<li>Put two more control electrodes (the black and white electrodes) on the participant&#180;s left and right earlobes, applying electrode gel.</li>
		<li>Ensure the participant has her or his eyes open during the assessment. The therapist must watch the participant throughout the assessment. If the participant closes their eyes at any time, end the assessment process and repeat it once the participant is rested.</li>
		<li>Place an electromyography (EMG) sensor on the right forearm to identify the degree of movement.</li>
		<li>Inform the participant that he/she must remain relaxed, trying not to move during the task an breathing slowly. The participant must be concentrated on the computer screen while the theta and beta waves are being emitted. The therapist says: &#34;You must be still and relaxed for 35 s, the only thing you need to do is to watch the theta/beta waves that will be appearing on the computer screen&#34;.</li>
		<li>Press the green button to start to measure cortical activity, and 35 s later press the white button to end the assessment.</li>
		<li>Print the results generated from program and analyze them. If the beta/theta ratio is lower than 50% at Cz, this evidences a deficit of sustained attention. On the other hand, if the ratio is also lower at Fp1, this result is related to an impairment of executive control, attributable to hyperactivity.</li>
	</ol>
	</li>
</ol>

<ol>
	<li>American Psychiatric Association. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Diagnostic and statistical manual of mental disorders. , (2013).</li><li>Steinau, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Diagnostic+criteria+in+attention+deficit+hyperactivity+disorder-Changes+in+DSM+5.">Diagnostic criteria in attention deficit hyperactivity disorder-Changes in DSM 5.</a> Front Psychol. 4 (49), (2013).</li><li>Polanczyk, G., de Lima, M. S., Horta, B. L., Biederman, J., Rohde, L. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+worldwide+prevalence+of+ADHD:+a+systematic+review+and+metaregression+analysis.">The worldwide prevalence of ADHD: a systematic review and metaregression analysis.</a> Am J Psychiat. 4 (6), 942-948 (2007).</li><li>Willcutt, E. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+prevalence+of+DSM-IV+attention-deficit/hyperactivity+disorder:+a+meta-analytic+review.">The prevalence of DSM-IV attention-deficit/hyperactivity disorder: a meta-analytic review.</a> Neurotherapeutics. 9 (3), 490-499 (2012).</li><li>Catal&#225;-L&#243;pez, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prevalence+of+attention+deficit+hyperactivity+disorder+among+children+and+adolescents+in+Spain:+a+systematic+review+and+meta-analysis+of+epidemiological+studies.">Prevalence of attention deficit hyperactivity disorder among children and adolescents in Spain: a systematic review and meta-analysis of epidemiological studies.</a> BMC psychiatry. 12 (1), 168 (2012).</li><li>Cubillo, A., Halari, R., Smith, A., Taylor, E., Rubia, K. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Review+of+fronto-striatal+and+fronto-cortical+brain+abnormalities+in+children+and+adults+with+Attention+Deficit+Hyperactivity+Disorder+(ADHD)+and+new+evidence+for+dysfunction+in+adults+with+ADHD+during+motivation+and+attention.">Review of fronto-striatal and fronto-cortical brain abnormalities in children and adults with Attention Deficit Hyperactivity Disorder (ADHD) and new evidence for dysfunction in adults with ADHD during motivation and attention.</a> Cortex. 48 (2), 194-215 (2012).</li><li>Lubar, J. F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Discourse+on+the+development+of+EEG+diagnostics+and+biofeedback+for+attention-deficit/hyperactivity+disorders.">Discourse on the development of EEG diagnostics and biofeedback for attention-deficit/hyperactivity disorders.</a> Appl Psychophys Biof. 16 (3), 201-225 (1991).</li><li>Monastra, V. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Assessing+attention+deficit+hyperactivity+disorder+via+Quantified+Electroencephalography:+An+initial+validation+study.">Assessing attention deficit hyperactivity disorder via Quantified Electroencephalography: An initial validation study.</a> Neuropsychol. 13 (3), 424-433 (1999).</li><li>Hall, C. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+clinical+utility+of+the+continuous+performance+test+and+objective+measures+of+activity+for+diagnosing+and+monitoring+ADHD+in+children:+a+systematic+review.">The clinical utility of the continuous performance test and objective measures of activity for diagnosing and monitoring ADHD in children: a systematic review.</a> Eur Child Adolesc Psych. 25 (7), 677-699 (2016).</li><li>Barbaresi, W. J., Katusic, S. K., Colligan, R. C., Weaver, A. L., Jacobsen, S. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Modifiers+of+long-term+school+outcomes+for+children+with+attention-deficit/hyperactivity+disorder:+does+treatment+with+stimulant+medication+make+a+difference?+Results+from+a+population-based+study.">Modifiers of long-term school outcomes for children with attention-deficit/hyperactivity disorder: does treatment with stimulant medication make a difference? Results from a population-based study.</a> J Dev Behav Pediatr. 28 (4), 274-287 (2007).</li><li>Rodr&#237;guez, C., Gonz&#225;lez-Castro, P., Cueli, M., Areces, D., Gonz&#225;lez-Pienda, J. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Attention+deficit/hyperactivity+disorder+(ADHD)+diagnosis:+an+activation-executive+model.">Attention deficit/hyperactivity disorder (ADHD) diagnosis: an activation-executive model.</a> Front Psychol. 7, (2016).</li><li>Gonz&#225;lez-Castro, P., Rodr&#237;guez, C., L&#243;pez, &. #. 1. 9. 3. ;., Cueli, M., &#193;lvarez, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Attention+deficit+hyperactivity+disorder,+differential+diagnosis+with+blood+oxygenation,+beta/theta+ratio,+and+attention+measures.">Attention deficit hyperactivity disorder, differential diagnosis with blood oxygenation, beta/theta ratio, and attention measures.</a> Int J Clinical and Health Psycho. 13 (2), 101-109 (2013).</li><li>Farr&#233;, A., Narbona, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> EDAH: Scale for the assessment of attention deficit hyperactivity disorder. , (2001).</li><li>Wechsler, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> The Wechsler Intelligence Scale for Children- 4th edition. , (2005).</li><li>Climent, G., Banterla, F., Iriarte, Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> AULA: Theoretical manual. , (2011).</li><li>Greenberg, L. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Developmental+normative+data+on+the+Test+of+Variables+of+Attention+(TOVA).">Developmental normative data on the Test of Variables of Attention (TOVA).</a> J Child Psychol Psyc. 34, 1019-1030 (1993).</li><li>Toomim, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intentional+increase+of+cerebral+blood+oxygenation+using+hemoencephalography:+an+efficient+brain+exercise+therapy.">Intentional increase of cerebral blood oxygenation using hemoencephalography: an efficient brain exercise therapy.</a> J Neurother. 8, 5-21 (2005).</li><li>Gonz&#225;lez-Castro, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cortical+activation+and+attentional+control+in+ADHD+subtypes.">Cortical activation and attentional control in ADHD subtypes.</a> Int J Clin Health Psycho. 10 (1), 23-39 (2010).</li><li>Garc&#237;a, T., Gonz&#225;lez-Castro, P., Areces, D., Cueli, M., Rodr&#237;guez, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Executive+functions+in+children+and+adolescents:+The+types+of+assessment+measures+used+and+implications+for+their+validity+in+clinical+and+educational+contexts.">Executive functions in children and adolescents: The types of assessment measures used and implications for their validity in clinical and educational contexts.</a> Papeles del Psic&#243;logo. 35, 215-233 (2014).</li></ol>

The authors who are listed above certify there are no financial interests or other conflicts of interest regarding the present study.

Here we present an effective protocol for assessing ADHD from 6-16 years of ages. Given the symptomatic complexity of ADHD and its high prevalence rates, professionals must have reliable and valid instruments to diagnose this disorder. Generally, questionnaires based on behavioral observations are widely used. However, the use of these instruments as the sole assessment measure has certain limitations, including potential subjectivity on the part of the observer18.
As the results show, this protocol placed emphasis on highlighting the differences between a participant with ADHD against a participant without ADHD. More specifically, it could be seen that a participant with ADHD had lower scores in attentional variables from both CPTs (omissions, commissions, response times and motor activity) as well as lower cortical activation and blood oxygenation in Fp1 and Fpz/Cz brain regions. For this reason, it is very relevant to contrast the information obtained by observation scales with the cognitive profile of the children and the performance in CPTs. Professionals can then perform a more realistic and reliable assessment and, thus provide recommendations for parents and teachers that are more specifically adapted to the individual needs of each child.
However, a critical step of this protocol is the management of exclusion criteria; professionals must ensure the ADHD symptoms are not due to another cause such as perceptive, emotional or social problems19.
A minor limitation of this protocol is the time required to complete each assessment. Generally, this protocol is best divided into several sessions to ensure participant well-being. The applicability of this method has been presented in previous studies11,12 which showed the effectiveness of the assessment model for getting an accurate diagnosis of ADHD according to the Diagnostic and Statistical Manual of Mental Disorders criteria.
Future lines of research would be based on the inclusion of neurological tools for getting an objective assessment of ADHD, considering functional and structural neuroimaging methods. Although, this research used quantitative analysis from Quantified Electroencephalography and Hemoencephalography (nir-HEG), it would be positive the inclusion of other instruments to contrast neuropsychological measures. Moreover, this type of study helps the clinicians to detect specific profiles of cortical activation (Q-EEG) and CPT (executive control) to differentiate the three types of ADHD presentations.

The overall goal of the present protocol is to develop a complete procedure or model of assessment for the diagnosis of Attention Deficit Hyperactivity Disorder, otherwise known as ADHD. ADHD is one of the problems that impacts academic performance. It is understood to be a disorder characterized by problems with attention, inhibitory control and hyperactivity, whose performance is significantly lower than their peers1,2. The latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM)1 includes different updates from the previous version: ADHD has been categorized as a neurodevelopmental disorder; the age of appearance of the symptoms has been increased so now the symptoms can manifest before 12 years of age; the term ADHD presentation should be used instead of subtype (predominantly hyperactive/impulsive; predominantly inattentive; and combined presentation, and); finally, it has been accepted as a comorbidity with autism spectrum disorders.
There are different estimations of prevalence rates depending on the country or region analyzed3,4,5. An international global systematic3 review observed an average prevalence rate of 5.29%. However, applying criteria from the Diagnostic and Statistical Manual of Mental Disorders4, the percentage ranges from 5.9 to 7.1%. Similarly, a meta-analysis of ADHD in a Spanish population provided an average of 6.8%5. The variations in prevalence rates could be due to the different assessment protocols used.
Although there is a considerable body of research suggesting a neurological basis for ADHD, the origins of this disorder remain unclear. Several studies have associated the ADHD symptomatology to brain cortical hypoactivation, which is related to a deficit in the dopaminergic and noradrenergic systems6. The noradrenergic system modules the selective attention and the activation levels needed to carry out a task. On the other hand, the dopaminergic system is responsible for inhibitory control, both at an executive and motivational level. The low cortical activation related to the dopaminergic and noradrenergic systems is presumed to be the basis for the inhibitory and attentional deficits presented in the ADHD. In this sense, children with ADHD show low cortical activation in the dopaminergic and noradrenergic systems, which is manifested by different profiles of electro cortical activity in a state of rest, evidenced by increased theta -and decreased beta- activity7,8 as well as low levels of blood oxygenation in the Fp1 (front left side of the frontal lobe), and FPz/Cz (central zone of the pre-frontal cortex) regions.
Blood oxygenation is measured using nir-HEG, which uses functional near-infrared spectroscopy to measure color changes in the blood in the brain to indicate oxygen saturation areas; oxygenated blood is bright red whereas de-oxygenated blood is a deep, almost purplish crimson. Cortical activation is measured using quantified electroencephalography (Q-EEG). This is a computerized EEG system that records electrical activity in the brain to provide levels of cortical activation through the beta/theta ratio. It measures attention in general, independently of the task being performed. Other studies have focused on the existence of an executive function (EF) impairment in the ADHD population9, which would explain the difficulty children with ADHD have controlling impulsive responses, resisting interference or distraction, organizing activities in a sequential manner, and sustaining cognitive effort while performing an activity.
Generally, these characteristic symptoms of ADHD have serious consequences which result in difficulties in scholastic, social and familial contexts. Children with ADHD have a higher probability of repeating a grade and/or completing fewer grades at school than children without ADHD. Moreover, dropping out of high school is three times more likely among youth with ADHD10,11.
Considering the modifications and the new categorization of ADHD in the current version of the Diagnostic and Statistical Manual of Mental Disorders 1, results relevant to establish the relationship between cortical activation levels in specific brain areas, executive functions, and diagnosis-related variables7,8,11,12 (i.e., differences between the three types of ADHD presentations).
One of the most common problems in the identification of ADHD is the over diagnosis of the disorder due to the absence of global protocols for assessment. The fact that professionals do not have a general protocol based on objective variables is causing a large percentage of false positive and false negative cases of ADHD. This situation highlights the need for professionals and clinicians to have a clear protocol that considers not only the relevant variables but also the relationships between them.
For this reason, the research group of School Learning, Difficulties and Academic Performance (ADIR) from the University of Oviedo has been working on developing a complete protocol to identifyprofiles of cortical activation and executive control to provide a more objective diagnosis of ADHD than what is currently in use. This protocol is particularly important because it takes into account the fact that cortical activation in the frontal and prefrontal cortex impacts the executive function. The current protocol will be useful for clinicians who are interested in performing a complete assessment that considers the interaction between relevant variables in the diagnosis. To that end, the protocol is based on the assessment model from a recent study proposed by Rodriguez et al. which takes into consideration the interaction between cortical activation and executive variables (Figure 1).
In summary, the purpose of this protocol is to provide a more objective diagnostic procedure for this developmental disorder than is currently available, and to analyze in depth the relationship between activation measures and executive function measures. The procedure will also take into consideration some of the hypothetical determinants of ADHD, both in the relationship between activation of selected areas of the brain and differences in performance on various aspects of executive functioning such as omissions, commissions or response times.

<table><tbody><tr><td>EDAH&amp;nbsp;</td><td>TEA Company</td><td></td><td>It is a Scale for the Assessment of ADHD that was administered to families and/or teachers.&lt;br/&gt; &amp;nbsp;It comprises 20 items that provide information on the presence of symptoms relating to attention deficit and hyperactivity/impulsivity, and helps differentiate between the threes subtypes of ADHD. A score above 90% in its subscales indicates attention deficit, hyperactivity/ impulsivity problems, or both.</td></tr><tr><td>Wisc-IV R</td><td>TEA Company</td><td></td><td>The WISC-IV by Wechsler (2005) is a tool that assesses&lt;br/&gt; individual intelligence in children and adolescents between&lt;br/&gt; the ages of 6 years and 16 years 11 months.</td></tr><tr><td>QEEG</td><td>Neurobics pocket</td><td></td><td>Q-EEG (quantified electroencephalogram) is a computerized EEG system,&lt;br/&gt; adapted by Toomin, which provides levels of cortical activation through&lt;br/&gt; the beta/theta ratio. It measures attention in general, independently of the task to be performed.</td></tr><tr><td>NIR-HEG</td><td>Brain trainer company</td><td></td><td>it is a tool used to measure blood oxygenation in expressly selected areas. The nir-HEG employs the translucent property of biological tissue, and low-frequency red and infrared lights with light emitting diodes (LED optodes).&amp;nbsp;</td></tr><tr><td>AULA Nesplora</td><td>Nesplora Company</td><td></td><td>It is a Continuous Performance Test that evaluates attention, impulsivity, processing speed, and motor activity in participants between 6 and 16 years of age.&lt;br/&gt; The task is performed in a virtual reality environment,&lt;br/&gt; which is shown through three-dimensional (3D) glasses&lt;br/&gt; (Head Mounted Display, HMD) equipped with motion&lt;br/&gt; sensors and headphones.&amp;nbsp;</td></tr><tr><td>T.O.V.A (Test of Variables of Attention)</td><td>The T.O.V.A.&amp;nbsp; Company</td><td>T.O.V.A. 8 kit</td><td>T.O.V.A. is an objective, accurate, and FDA cleared continuous performance test&amp;nbsp; (CPT) that measures the key components of attention and inhibitory control.&lt;br/&gt; The T.O.V.A. is used by qualified healthcare professionals as an aid in the assessment&lt;br/&gt; of attention deficits, including attention-deficit/hyperactivity disorder (ADHD), in children and adults.</td></tr></tbody></table>

using brain activation (nir-heg/q-eeg) and execution measures (cpts) in a adhd assessment protocol

Attention Deficit Hyperactivity Disorder (ADHD) is a problem that impacts academic performance and has serious consequences that result in difficulties in scholastic, social and familial contexts. One of the most common problems in the identification of this disorder relates to the apparent over diagnosis of the disorder due to the absence of global protocols for assessment. The research group of School Learning, Difficulties and Academic Performance (ADIR) from the University of Oviedo, has developed a complete protocol that suggests the existence of certain patterns of cortical activation and executive control for identifying ADHD more objectively. This protocol takes into consideration some of the hypothetical determinants of ADHD, including the relationship between activation of selected areas of the brain, and differences in performance on various aspects of executive functioning such as omissions, commissions or response times, using innovative tools of Continuous Performance Testing (based on Virtual Reality CPT and Traditional CPT) and brain activation measures (two different tools, based on Hemoencephalography- nirHEG; and Quantified Electroencephalography --Q-EEG, respectively). This model of assessment aims to provide an effective assessment of ADHD symptomatology in order to design an accurate intervention and make appropriate recommendations for parents and teachers.

Using the assessment procedure presented here, it is possible to carry out an effective assessment about ADHD symptomatology in order to design an accurate intervention and make recommendations for parents and teachers. Below are a series of representative results of a participant with ADHD and a participant without ADHD, which will allow professionals to see the differences between the two profiles.
Once clinicians had the informed consent from the families, a cognitive scale (WISC IV) was administered to the children in order to exclude those participants who present low or high capacities. The following steps then compiled an attentional profile of the children using the Continuous Performance Test and Activation Cortical Techniques (Q-EEG and nir-HEG). Figure 7 shows the results of children with and without ADHD in the Virtual Reality CPT. These results show the children with ADHD have more omissions and commissions errors, as well as higher motor activity and larger response times.
Similarly, Figure 8 shows the results obtained by the Traditional CPT showing how the child with ADHD presented larger percentages in omissions, commissions, response times and in the variability of the response. While the child without ADHD showed the best scores at the end of the tasks, the child with ADHD did not show improvement in any of the four blocks.
Figure 9 shows an example of the Cortical Activation collected by nir-HEG in a child affected by ADHD who obtained 24.5 percentage points below the average in Fp1 region.
Similarly, an example of the measures collected by Q-EEG in a child with ADHD (FP1 region) are shown in Figure 10 that evidences how the symptoms of ADHD cause a decreased in cortical activation (ratio beta/theta under 0.5).
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/56796/56796fig1.jpg" /> 
Figure 1. Model of ADHD assessment 
Based on Hemoencephalograpy (nir-HEG), Quantified Electroencephalography (Q-EEG), and Traditional CPT (CPT). Variables included: HEG-Fp1(nir-HEG ratio from left pre-frontal cortex); HEG-FpZ (nir-HEG ratio from central pre-frontal cortex); Q-EEG-Fp1(beta-theta ratio from left pre-frontal cortex); Q-EEG-CZ (beta-theta ratio from central cortex); CPT-OMIS (omissions committed in CPT ); CPT-COMIS (commissions committed in CPT); CPT-VAR (Response Variability during CPT tasks); CPT-RT (Response Time obtained in CPT); CPT-DPR (D prime Index provided by CPT); ADHD-INDEX (ADHD Index provided by CPT). This model reflects a stronger association between activation (central and left prefrontal) and execution in ADHD children than their peers without the disorder. Low cortical activation (by QEEF) and blood oxygenation (by nir-HEG) in Fp1 region, are related to low performance in CPT. Similarly, normal levels of electrical activation and blood oxygenation are associated to normal results from CPT. Provided by Rodr&#237;guez et al.11. <a href="https://cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/56796/56796fig1large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/56796/56796fig2.jpg" /> 
Figure 2. Head Mounted Display(HMD) glasses of the Virtual Reality CPT. 
The image shows the Head Mounted Display (HMD) glasses, the headphones and the button which must be held with the dominant hand. The image also shows the virtual classroom which is shown to the participant via the glasses and to the therapist via the computer screen. <a href="https://cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/56796/56796fig2large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/56796/56796fig3.jpg" /> 
Figure 3. Virtual classroom provided by the Virtual Reality CPT. 
Virtual classroom environment where the participant does the tasks which are explained by a virtual teacher. <a href="https://cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/56796/56796fig3large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/56796/56796fig4.jpg" /> 
Figure 4. Images present in the Traditional CPT. 
The right-hand picture shows the non-target stimulus and the left-hand picture shows the target stimulus. <a href="https://cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/56796/56796fig4large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/56796/56796fig5.jpg" /> 
Figure 5. Participant wearing the nir-HEG band. 
The image shows the nir-HEG band placed in the Fp1 region and the hardware connected.
<img alt="Figure 6" class="xfigimg" src="/files/ftp_upload/56796/56796fig6.jpg" /> 
Figure 6. Participant with electrodes of Q-EEG. 
The image shows the blue electrode in the Cz region and the red one in the Fp1 region. The control electrodes: black and white, have been placed on the participant&#180;s left and right earlobes, applying electrode gel. Finally, an electromyogram was placed on the right forearm.
<img alt="Figure 7" class="xfigimg" src="/files/ftp_upload/56796/56796fig7.jpg" /> 
Figure 7. Performance and motor activity during the Virtual Reality CPT. 
The Y axis shows the standardized scores from the Virtual Reality CPT (scores above 60 mean low performance in the variable studied and scores below 60 mean good performance of the variables studied. The X axis shows the different variables provided by the Virtual Reality test. The colors: yellow, orange and red, represent the grade of severity: low, medium and high in the performance of different variables. A and C illustrate the performance of a participant without ADHD (A) and a participant with ADHD (C). 
Images B and D represent the subject&#180;s head movement (motor activity) throughout the test. The green square refers to the blackboard and the yellow square represents the area in which the virtual blackboard can be inside the visual range for detecting the stimulus. If child move out of the yellow square, it makes impossible to perform the visual task properly. The dot diagram provides a graphic which represents the child&#39;s attention towards the blackboard and to the general task. Image B represents the motor activity in a participant without ADHD and image D represents the motor activity of a participant with ADHD.
<img alt="Figure 8" class="xfigimg" src="/files/ftp_upload/56796/56796fig8v2.jpg" /> 
Figure 8. Profile provided by the Traditional CPT in the main variables. 
Figure A represents the profile of a student with ADHD while Figure B shows the execution of a child with a performance similar to the normative group. The term &#34;SS&#34; refers to Standardized scores. Standardized scores below 80 represent low performance. &#34;Q1&#34;(25%), &#34;Q2&#34;(50%), &#34;Q3&#34;(75%) and &#34;Q4&#34;(100%) represent the four quartiles of the CPT tasks. This division is useful in order to see whether the subject&#39;s attention decreases during the activities or not.
<img alt="Figure 9" class="xfigimg" src="/files/ftp_upload/56796/56796fig9.jpg" /> 
Figure 9. Activation measure with the nir-HEG. 
This Figure shows the ratio indicator of the oxygenation of the blood at specific point (Fp1/Fpz) and an attention index which is expressed as percentage (a percentage below 50% represents a low attentional index).
<img alt="Figure 10" class="xfigimg" src="/files/ftp_upload/56796/56796fig10.jpg" /> 
Figure 10. Cortical activation measures in FP1. 
The Figures show the output from Q-EEG. The top part shows beta/theta waves measured individually, and the bottom part shows the beta/theta ratio in the Cz region and electromyography results from the right forearm. The CZ beta/theta ratio is shown on the left (in this case is 0.55), cortical activation is good when the ratio is above 0.50. The electromyography from the right forearm is used to ensure that the participant is relaxed at a muscular level, and is on the right (in this case the value of EMG is 4.22). Good values in electromyography are below 5.0. <a href="https://cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/56796/56796fig10large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>

Watch this Scientific Journal Video about Using Brain Activation nir-HEG/Q-EEG and Execution Measures CPTs in a ADHD Assessment Protocol at JoVE.com

Using Brain Activation nir-HEG/Q-EEG and Execution Measures CPTs in a ADHD Assessment Protocol

This work presents a new protocol for the assessment of Attention Deficit Hyperactivity Disorder (ADHD) by providing a more objective diagnostic procedure for this developmental disorder based on the use of innovative tools. It also analyzes the relationship between activation measures and executive function measures.

Using Brain Activation (nir-HEG/Q-EEG) and Execution Measures (CPTs) in a ADHD Assessment Protocol

Attention Deficit Hyperactivity Disorder (ADHD) is a problem that impacts academic performance and has serious consequences that result in difficulties in ...

using-brain-activation-nir-hegq-eeg-execution-measures-cpts-adhd

Nanyang Technological University

Research

JoVE Journal

Neuroscience

10.1K Views.  Oviedo University. This work presents a new protocol for the assessment of Attention Deficit Hyperactivity Disorder (ADHD) by providing a more objective diagnostic procedure for this developmental disorder based on the use of innovative tools. It also analyzes the relationship between activation measures and executive function measures.

Video: Using Brain Activation nir-HEG/Q-EEG and Execution Measures CPTs in a ADHD Assessment Protocol

Functional Near Infrared Spectroscopy of the Sensory and Motor Brain Regions with Simultaneous Kinematic and EMG Monitoring During Motor Tasks

There are several advantages that functional near-infrared spectroscopy (fNIRS) presents in the study of the neural control of human movement. It is relatively flexible with respect to participant positioning and allows for some head movements during tasks. Additionally, it is inexpensive, light weight, and portable, with very few contraindications to its use. This presents a unique opportunity to study functional brain activity during motor tasks in individuals who are typically developing, as well as those with movement disorders, such as cerebral palsy. An additional consideration when studying movement disorders, however, is the quality of actual movements performed and the potential for additional, unintended movements. Therefore, concurrent monitoring of both blood flow changes in the brain and actual movements of the body during testing is required for appropriate interpretation of fNIRS results. Here, we show a protocol for the combination of fNIRS with muscle and kinematic monitoring during motor tasks. We explore gait, a unilateral multi-joint movement (cycling), and two unilateral single-joint movements (isolated ankle dorsiflexion, and isolated hand squeezing). The techniques presented can be useful in studying both typical and atypical motor control, and can be modified to investigate a broad range of tasks and scientific questions.

Monitoring brain activity during upright motor tasks is of great value when investigating the neural source of movement disorders. Here, we demonstrate a protocol that combines functional near infrared spectroscopy with continuous monitoring of muscle and kinematic activity during 4 types of motor tasks.

There are several advantages that functional near-infrared spectroscopy (fNIRS) presents in the study of the neural control of human movement. It is ...

Behavior

Assessing the Multiple Dimensions of Engagement to Characterize Learning: A Neurophysiological Perspective

In a recent theoretical synthesis on the concept of engagement, Fredricks, Blumenfeld and Paris1 defined engagement by its multiple dimensions: behavioral, emotional and cognitive. They observed that individual types of engagement had not been studied in conjunction, and little information was available about interactions or synergy between the dimensions; consequently, more studies would contribute to creating finely tuned teaching interventions. Benefiting from the recent technological advances in neurosciences, this paper presents a recently developed methodology to gather and synchronize data on multidimensional engagement during learning tasks. The technique involves the collection of (a) electroencephalography, (b) electrodermal, (c) eye-tracking, and (d) facial emotion recognition data on four different computers. This led to synchronization issues for data collected from multiple sources. Post synchronization in specialized integration software gives researchers a better understanding of the dynamics between the multiple dimensions of engagement. For curriculum developers, these data could provide informed guidelines for achieving better instruction/learning efficiency. This technique also opens up possibilities in the field of brain-computer interactions, where adaptive learning or assessment environments could be developed.

This paper aims to describe the techniques involved in the collection and synchronization of the multiple dimensions (behavioral, affective and cognitive) of learners&#8217; engagement during a task.

In a recent theoretical synthesis on the concept of engagement, Fredricks, Blumenfeld and Paris1 defined engagement by its multiple dimensions: ...

Measurement of Neurophysiological Signals of Ignoring and Attending Processes in Attention Control

Attention control is the ability to selectively attend to some sensory signals while ignoring others. This ability is thought to involve two processes: enhancement of sensory signals that are to be attended and the attenuation of sensory signals that are to be ignored. The overall strength of attentional modulation is often measured by comparing the amplitude of a sensory neural response to an external input when attended versus when ignored. This method is robust for detecting attentional modulation, but precludes the ability to assess the separate dynamics of attending and ignoring processes. Here, we describe methodology to measure independently the neurophysiological signals of attending and ignoring using the intermodal attention task (IMAT). This task, when combined with electroencephalography, isolates neurophysiological sensory responses in auditory and visual modalities, when either attending or ignoring, with respect to a passive control. As a result, independent dynamics of attending and of a ignoring can be assessed in either modality. Our results using this task indicate that the timing and cortical sources of attending and ignoring effects differ, as do their contributions to the attention modulation effect, pointing to unique neural trajectories and demonstrating sample utility of measuring them separately.

Attention control comprises enhancement of target signals and attenuation of distractor signals. We describe an approach to measure separately but concurrently, the neurophysiology of attending and ignoring in sustained intermodal attention, utilizing a passive control condition during which neither process is continuously engaged.

Attention control is the ability to selectively attend to some sensory signals while ignoring others. This ability is thought to involve two processes: ...

Event-related Potentials During Target-response Tasks to Study Cognitive Processes of Upper Limb Use in Children with Unilateral Cerebral Palsy

Unilateral Cerebral Palsy (CP) is a neurodevelopmental disorder that is a very common cause of disability in childhood. It is characterized by unilateral motor impairments that are frequently dominated in the upper limb. In addition to a reduced movement capacity of the affected upper limb, several children with unilateral CP show a reduced awareness of the remaining movement capacity of that limb. This phenomenon of disregarding the preserved capacity of the affected upper limb is regularly referred to as Developmental Disregard (DD). Different theories have been postulated to explain DD, each suggesting slightly different guidelines for therapy. Still, cognitive processes that might additionally contribute to DD in children with unilateral CP have never been directly studied. The current protocol was developed to study cognitive aspects involved in upper limb control in children with unilateral CP with and without DD. This was done by recording event-related potentials (ERPs) extracted from the ongoing EEG during target-response tasks asking for a hand-movement response. ERPs consist of several components, each of them associated with a well-defined cognitive process (e.g., the N1 with early attention processes, the N2 with cognitive control and the P3 with cognitive load and mental effort). Due to its excellent temporal resolution, the ERP technique enables to study several covert cognitive processes preceding overt motor responses and thus allows insight into the cognitive processes that might contribute to the phenomenon of DD. Using this protocol adds a new level of explanation to existing behavioral studies and opens new avenues to the broader implementation of research on cognitive aspects of developmental movement restrictions in children.

Several children with unilateral Cerebral Palsy seem to disregard the preserved capacity of their affected upper limb. This Developmental Disregard is extensively described in the literature but the involved cognitive processes have not been studied. To study underlying cognitive factors of upper limb control, an event-related potential protocol was developed.

Unilateral Cerebral Palsy (CP) is a neurodevelopmental disorder that is a very common cause of disability in childhood. It is characterized by unilateral ...

An Electrophysiology Protocol to Measure Reward Anticipation and Processing in Children

We present a protocol designed to measure the neural correlates of reward in children. The protocol allows researchers to measure both reward anticipation and processing. Its purpose is to create a reward task that is appropriate for young children with and without autism while controlling reward properties between two conditions: social and nonsocial. The current protocol allows for comparisons of brain activity between social and nonsocial reward conditions while keeping the reward itself identical between conditions. Using this protocol, we found evidence that neurotypical children demonstrate enhanced anticipatory brain activity during the social condition. Furthermore, we found that neurotypical children anticipate social reward more robustly than children with autism diagnoses. As the task uses snacks as a reward, it is most appropriate for young children. However, the protocol may be adapted for use with adolescent or adult populations if snacks are replaced by monetary incentives. The protocol is designed to measure electrophysiological events (event-related potentials), but it may be customized for use with eye-tracking or fMRI.

This protocol is designed to measure reward anticipation and processing in young children with and without autism. Specifically, the protocol is designed to study the neural correlates of reward during social and nonsocial conditions while controlling for reward between conditions.

We present a protocol designed to measure the neural correlates of reward in children. The protocol allows researchers to measure both reward anticipation ...

The Adventures of Fundi Intervention Based on the Cognitive and Emotional Processing in Attention Deficit Hyperactive Disorder Patients

Many children with attention deficit hyperactive disorder (ADHD) are known to have executive dysfunction, which weakens their abilities to learn and behave in daily living. This protocol describes the methodology that is required for the intervention (psychotherapy) based on planning, attention, successive, and simultaneous (PASS theory) cognitive processing and fear emotional processing. It provides guiding principles and practical recommendations. A disproportionately high level of fear (dysregulation) increases the vulnerability for dysfunction in learning and behavior. We explain the interplay between emotion and cognition at the neurological level.
A go/no go task (The Adventures of Fundi), which involves decision making, is administered in a PC- mode to a sample of 66 ADHD subjects. The Adventures of Fundi, a computer program, was constructed to induce successive or simultaneous processing when involving the training of planning and selective attention. It aims to improve the executive function with planning and selective attention. If executive function improves, learning improves, and behavior ameliorates. After intervention over 6 months, remission was achieved in 70% of subjects.
The instructor encourages the use of appropriate strategies and points out the ways in which the strategies can be useful in finding the solution to the problem (go/no go). The emphasis is not on rehearsing and adult instructed verbal sequence. The verbalization may reveal the conscious verbalized strategy to solve a task that is not really the strategy being unconsciously used in that case. A self-verbal report is unreliable. This is an inductive learning rather than deductive rule-learning approach central to cognitive PASS training. This inductive training has proved to produce not only near transfer but also far transfer.
Noncognitive factors (emotional factors) must be considered to maximize the benefit of cognitive training. Indirect and metaphorical communication considers the emotional factor.

This protocol illustrates a remedial therapy based on inductive learning and indirect communication (Ericksonian metaphorical hypnosis) that can be applied to children with Attention Deficit Hyperactive Disorder (ADHD). Particularly, this protocol is intended to test the effectiveness of a go/no-go decision task. Neuroscientific rationale is presented throughout the text.

Many children with attention deficit hyperactive disorder (ADHD) are known to have executive dysfunction, which weakens their abilities to learn and ...

Multimodal Protocol for Assessing Metacognition and Self-Regulation in Adults with Learning Difficulties

Learning disabilities (LDs) encompass disorders of those who have difficulty learning and using academic skills, exhibiting performance below expectations for their chronological age in the areas of reading, writing, and/or mathematics. Each of the disorders making up the LDs involve different deficits; however, some commonalities can be found within that heterogeneity, such in terms of learning self-regulation and metacognition. Unlike in early ages and later educational levels, there are hardly any evidence-based evaluation protocols for adults with LDs. LDs influence academic performance but also have serious consequences in professional, social, and family contexts. In response to this, the current work proposes a multimodal evaluation protocol focused on metacognitive, self-regulation of learning, and emotional processes, which make up the basis of the difficulties in adults with LDs. The assessment is carried out through analysis of the on-line learning process using a variety methods, techniques, and sensors (e.g., eye tracking, facial expressions of emotion, physiological responses, concurrent verbalizations, log files, screen recordings of human-machine interactions) and off-line methods (e.g., questionnaires, interviews, and self-report measures). This theoretically-driven and empirically-based guideline aims to provide an accurate assessment of LDs in adulthood in order to design effective prevention and intervention proposals.

The current work proposes a multimodal evaluation protocol focused on metacognitive, self-regulation of learning, and emotional processes, which make up the basis of the difficulties in adults with LDs.

Learning disabilities (LDs) encompass disorders of those who have difficulty learning and using academic skills, exhibiting performance below expectations ...

Conducting Concurrent Electroencephalography and Functional Near-Infrared Spectroscopy Recordings with a Flanker Task

Concurrent EEG and fNIRS recordings offer an excellent opportunity to gain a full understanding of the neural mechanism of cognitive processing by inspecting the relationship between the neural and hemodynamic signals. EEG is an electrophysiological technology that can measure the rapid neuronal activity of the cortex, whereas fNIRS relies on the hemodynamic responses to infer brain activation. The combination of EEG and fNIRS neuroimaging techniques can identify more features and reveal more information associated with the functioning of the brain. In this protocol, fused EEG-fNIRS measurements were performed for concurrent recordings of evoked-electrical potentials and hemodynamic responses during a Flanker task. In addition, the critical steps for setting up the hardware and software system as well as the procedures for data acquisition and analysis were provided and discussed in detail. It is expected that the present protocol can pave a new avenue for improving the understanding of the neural mechanisms underlying various cognitive processes by using the EEG and fNIRS signals.

The present protocol describes how to perform concurrent EEG and fNIRS recordings and how to inspect the relationship between the EEG and fNIRS data.&#160;

Concurrent EEG and fNIRS recordings offer an excellent opportunity to gain a full understanding of the neural mechanism of cognitive processing by ...

Event Related Potentials (ERPs) and other EEG Based Methods for Extracting Biomarkers of Brain Dysfunction: Examples from Pediatric Attention Deficit/Hyperactivity Disorder (ADHD)

Neuropsychiatric diagnoses like ADHD are based on subjective methods like interviews, rating scales and observations. There is a need for more brain-based supplements. Stimulant medication is the most common treatment for ADHD. Clinically useful predictors of response have so far not been reported. The aim of this paper is to describe the EEG based methods we apply to extract potential biomarkers for brain dysfunction. Examples relate to biomarkers for pediatric ADHD, and prediction of medication response. The main emphasis is on Event Related Potentials (ERPs).
A nineteen channel EEG is recorded during a 3 min eyes-opened task, a 3 min eyes-closed task, and a 20 min cued visual GO/NOGO task (VCPT). ERPs are recorded during this task. The goal of the ERP protocol is to extract biomarkers of assumed brain dysfunctions that significantly differentiate between a patient group and healthy controls. The protocol includes recording during standard conditions and artifact correction. ERP waves can be used or transformed into latent components. The components of the patient group are compared with controls, empathizing components that, when compared, show relatively high effect sizes. Sub-groups of the patients are selected on the basis of the cluster analysis in the space of the components. Treatment procedure (such as medication, tDCS or neurofeedback protocol) can be applied and the changes in components related to treatment in the subgroups are observed, forming the basis for clinical recommendations.
The methods described were applied in a study of 87 pediatric ADHD patients. The index of medication response discriminated significantly between responders and non-responders with a large, and clinically meaningful effect size (d = 1.84). In an ongoing study comparing ADHD children with matched controls, several variables discriminate significantly between patients and controls. The global index will exceed d = .8. The EEG based methods described here could be clinically meaningful.

Event Related Potentials ERPs and other EEG Based Methods for Extracting Biomarkers of Brain Dysfunction: Examples from Pediatric Attention Deficit/Hyperactivity Disorder ADHD

EEG-methods are applied for extracting biomarkers of brain dysfunctions. The focus is on multi-channel event-related potentials (ERPs) recorded in a cued GO/NOGO task. Non-brain artifacts are corrected and ERPs are compared with the normative data. Examples relate to biomarkers for ADHD diagnosis and prediction of medication response.

Neuropsychiatric diagnoses like ADHD are based on subjective methods like interviews, rating scales and observations. There is a need for more brain-based ...

Cerebrovascular Reactivity Measurement with Functional Near Infrared Spectroscopy

Cerebrovascular reactivity (CVR) is the capacity of blood vessels in the brain to alter cerebral blood flow (either with dilation or constriction) in response to chemical or physical stimuli. The amount of reactivity in the cerebral microvasculature depends on the integrity of the capacitance vasculature and is the primary function of endothelial cells. CVR is, therefore, an indicator of the microvasculature&#8217;s physiology and overall health. Imaging methods that can measure CVR are available but can be costly, and require magnetic resonance imaging centers and technical expertise. In this study, we used fNIRS technology to monitor changes of oxyhemoglobin (HbO) and deoxyhemoglobin (HbR) in the cerebral microvasculature to assess the CVR of 15 healthy controls (HC) in response to a vasoactive stimulus (inhaled 5% carbon dioxide or CO2). Our results suggest that this is a promising imaging technology that offers a non-invasive, accurate, portable, and cost-effective method of mapping cortical CVR and associated microvasculature function, resulting from a traumatic brain injury or other conditions associated with cerebral microvasculopathy.

Presented here is a protocol for imaging and measurement of cerebrovascular reactivity in humans with functional Near Infrared Spectroscopy (fNIRS). fNIRS is a novel imaging modality that captures the concentration changes of hemoglobin species in the brain&#8217;s outermost cortex under specific stimuli.

Cerebrovascular reactivity (CVR) is the capacity of blood vessels in the brain to alter cerebral blood flow (either with dilation or constriction) in ...