Statement of Potential Conflicts of Interest Continuous performance test in ADHD and SUD patients (CASP) study Relating to this presentation, the following relationships could be perceived as potential conflict of interests: Nir Yacin and Adva (Peled) Levie are executives of Neurotech Solutions Ltd. Neurotech Solutions Ltd have analysed the following data and have provided partial funding of direct research costs.
Continuous performance test in ADHD and SUD patients (CASP) study III International Congress on Dual Disorders, 24 Oct 2013 Sharlene Kaye 1 , Adva (Peled) Levie 2 , Nir Yacin 2 , Itai Berger 3 , Wim van den Brink 4 , Zsolt Demetrovics 5 , Máté Kapitány-Fövény 5 , Csaba Barta 6 , Brian Johnson 7 , Paulette Johnson 7 , Narelle Fordham 1 , Anneke Goudriaan 4 , Geurt van de Glind 4,8 1 National Drug & Alcohol Research Centre, University of NSW, Australia; 2 Neurotech Solutions Ltd, Israel; 3 Hadassah-Hebrew University Medical Center, Israel; 4 Amsterdam Institute for Addiction Research, University 6 Department of of Amsterdam, The Netherlands; 5 Institute of Psychology, Eötvös Loránd University, Hungary; Medical Chemistry, Molecular Biology and Pathobiochemistry, Semmelweis University, Hungary; 7 Dept of Psychiatry, SUNY Upstate Medical University, USA; 8 Trimbos-instituut and ICASA Foundation, The Netherlands.
Background ADHD diagnosis complicated by the heterogeneous nature & severity of ADHD symptoms & clinical presentations both within & between affected individuals. Majority of screening & diagnostic instruments are questionnaires or rating scales answered by parents, partners or teachers, or based on self-report. Lack of instruments that can measure specific deficits and measure change in the severity of symptoms. In an effort to provide objective measures of ADHD and characterise the underlying neurocognitive impairment, neuropsychological tests designed to measure specific areas of cognitive functioning (i.e. executive functioning) known to underlie attention, hyperactivity and impulsivity have been developed. Continuous Performance Tests (CPTs) have been considered by many to be the most reliable means of differentiating those with ADHD from those without ADHD. Widely used to complement structured clinical interviews and rating scales as part of the “gold standard” for ADHD diagnosis.
Background The available CPTs (e.g. TOVA, Conners’ CPT) measure attention, inhibitory/impulse control and reaction time, but have tended to yield high rates of false positives and false negatives. Lack specificity with respect to relationship between results and specific ADHD symptoms and symptom domains (i.e. inattention, hyperactivity, impulsivity). Diagnosis based primarily on visual performance, ignoring other aspects of attention. As such, their validity and utility in the diagnosis of ADHD has been questioned.
Background With these concerns & recommendations from previous research in mind, a new test designed to improve on the validity & utility of previous CPT designs has been developed. MOXO ADHD Test (Neurotech Solutions Ltd) – new generation of CPT designed to objectively assess several domains of attention. Compared to existing CPTs, the MOXO ADHD Test contains additional features that should improve the differential diagnosis process, producing more accurate results: • Use of both visual and auditory distractors in the test. The distractors are complex video clips that have both moving pictures and a sound track. The visual and auditory features are presented separately or together. • Designed to match test items to the expected cognitive development of the individual, by having 2 versions, incorporating different visual & auditory items that are age appropriate - one version designed for children (7-12 yrs), the other for adolescents and adults (13+ yrs). • Distinguishes in a given individual between the three main components of ADHD (Attention, Impulsivity & Hyperactivity), as well as a novel fourth component of "Timing“, which measures reaction time of correct responses. • Using these 4 measures, creates a specific and unique patient profile of difficulties & strengths, providing a more nuanced understanding of the underlying features of ADHD in each individual.
Background MOXO Test monitors the person’s ability to maintain attention throughout the whole test and any variability in performance in response to different distractors, thus indicating the conditions under which they perform best or worst. Individual results are compared to the standardized norms of groups of a similar age and gender. Validity studies have shown the MOXO Test to effectively differentiate between children with and without ADHD more effectively than traditional CPTs (TOVA or Conners’ CPT), with preliminary results of an international study of 547 children demonstrating 90% sensitivity and 86% specificity. May assist in tailoring treatment according to the current symptom presentation and severity.
Aims of CASP study To test in a population of patients referred for Substance Use Disorders (SUD) the ability of the MOXO ADHD Test to - 1. Compare levels of attention, hyperactivity and impulsivity between patients having SUD only, patients having SUD+ADHD, and a “normal” control group from the general population (no ADHD or SUD) in order to develop specific population norms for the psychometric properties of the MOXO; 2. Differentiate between SUD patients having ADHD and SUD patients not having ADHD; 3. Evaluate how attention levels in those with ADHD compare to attention levels in patients with other disorders, such as antisocial personality disorder, bipolar disorder, borderline personality disorder and depression.
Methods Ø Sample • 447 participants; Australia (107), Hungary (148), Ireland (9), U.S.A. (183) Ø Recruitment SUD patients – Recruited as part of IASP study from inpatient & outpatient addiction treatment services – e.g. residential rehabilitation; detox units, methadone clinics. Participants in the IASP study who completed the diagnostic assessment phase were asked to participate in the CASP study. Control group – Convenience sample recruited via advertising and word of mouth.
Methods Ø Measures SUD patients • Structured interview:- As per IASP study + juvenile justice & prison history; past head injury with loss of consciousness; methadone/buprenorphine dosage • ASRS and diagnostic modules from MINI Plus and CAADID as per IASP study + • K-SADS – conduct disorder, oppositional defiant disorder, tobacco use • Fagerstrom Test for Nicotine Dependence • MOXO ADHD test Control group • Structured interview assessing demographics • Screening instruments to exclude ADHD (ASRS) and SUD (CAGE-AID) • MOXO ADHD test
Adult test Target Element Non Target Elements
Adult test Distractors Visual / Audio / Combination
MOXO attentiveness indices ATTENTION- correct responses to stimulus TIMING- correct responses at correct time, i.e. during stimulus presentation HYPERACTIVITY- pressing more than once for a single stimulus IMPULSIVITY- commission errors performed during a non-target stimulus
Criteria Table
Performance graph
Preliminary Results
Age and gender characteristics by group Controls/Norm SUD SUD+ADHD ADHD (n=180) (n=143) (n=115) (n=51) Mean age 32.8 39.7 33.5 28.8 (SD) (12.0) (10.5) (9.7) (9.9) % Male 46 66 57 61
Timing 300 ┌ ----------------------- *** ----------------------- ┐ ┌ ------------------------------------------- ** -----------------------------------------------┐ M ┌------------------------------------------ * --------------------------------------------------┐ 250 e a 200 n Norm SUD 150 SUD+ADHD T ADHD o 100 t a l 50 0 Norm SUD SUD+ADHD ADHD *** p<.001; ** p<.01; * p<.05
Attention 400 ┌ -------------------- *** ------------------ ┐ 350 ┌ --------------------------------- *** -------------------------------------- ┐ M ┌ --------------------------------------------------- ** -------------------------------------------------------- ┐ 300 e a Norm 250 n SUD 200 SUD+ADHD T o 150 ADHD t a 100 l 50 0 *** p<.001; ** p<.01; * p<.05
Hyperactivity 100 90 M 80 e ┌ ------------------**-------------------------- ┐ 70 a ┌ ------------------------------------- ** -------------------------------------- ┐ n Norm 60 SUD 50 ┌ ------------------------------------------------------ * ------------------------------------------------------- ┐ T SUD+ADHD 40 o ADHD t 30 a 20 l 10 0 Norm SUD SUD+ADHD ADHD *** p<.001; ** p<.01; * p<.05
Impulsivity 100 90 M 80 e a 70 ┌ --------------------- *** -------------------- ┐ n Norm 60 SUD ┌ -------------------------------------- *** -------------------------------------- ┐ T 50 SUD+ADHD o 40 ┌ --------------------------------------------------------- * -------------------------------------------------------- ┐ t ADHD a 30 l 20 10 0 *** p<.001; ** p<.01; * p<.05
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