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Bringing Real Life into ADHD Testing

MOXO clinical compendium

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 Using environmental distractors in the diagnosis of ADHD
Cassuto H, Ben-Simon A, Berger I. (2013). Frontiers in Human Neuroscience,7,805.

Synopsis
This study showed that children with ADHD demonstrated more omission errors than controls in all MOXO d-CPT conditions (baseline, no
distractors, pure visual or auditory distractors and combined distractors). However, while all types of distracting stimuli increased the rate
of omission errors in ADHD children, only combined visual and auditory distractors increased it in controls.

Study summary
Population: 663 children (7-12 years), of them 345 diagnosed with ADHD, 318 controls.
Measures:
1. Parents and teachers form of Conner’s ADHD/DSM IV scales.

2. Omission errors were observed during MOXO d-CPT performance.

Results
ADHD children demonstrated significantly higher rate of errors than non-ADHD children in all MOXO d-CPT conditions (baseline, visual
distractors, auditory distractor, a combination of visual and auditory distractors, and no distractors).

In the ADHD group, omission errors were significantly higher in all distractors conditions compared to no-distractors. However, in the
control group, only combined distractors resulted in an increase in omission errors (Figure 1).

Figure 1: Group differences in omission errors during MOXO d-CPT performance ADHD CONTROL

4
3.5
3
OMISSION ERRORS (MEAN)

2.5
2
1.5
1
0.5
0

BASE LINE VISUAL* VISUAL** AUDITORY* AUDITORY** COMBINED* COMBINED** NO DISTRACTORS

* Low distractibility- one distracting stimuli at a time ** High distractibility-two distracting stimuli presented simultaneously

Discussion
Study results support the idea that ADHD children are more sensitive to irrelevant environmental distracting stimuli than controls.

In contrast to other studies who showed improvement in cognitive performance of ADHD children in the presence of distractors, this
study consistently found negative effects of distracting stimuli. These findings may be attributed to meaningful/ appealing distractors
used in the MOXO d-CPT, as well as to the method of distractors presentation (various distractors types, various lengths of presentation,
and different locations on the screen), which does not allow adjustment or de-sensitization to the distractors.

In light of the criticism voiced against the low ecological validity of many CPTs, the current study provides evidence for the importance
of environmental distractors in the test’s ability to consistently discriminate ADHD children from controls.
1
 The effect of environmental distractors incorporation into a CPT on
sustained attention and ADHD diagnosis among adolescents
Berger, I., & Cassuto, H. (2014). Journal of Neuroscience Methods, 222, 62-68.

Synopsis
This study showed that adolescents with ADHD were more distracted than controls during all MOXO d-CPT distractors conditions (pure
visual or auditory distractors and combined distractors). Distractibility of ADHD adolescents was marked in the presence of visual
environmental stimuli or the combination of visual and auditory stimuli but not in the presence of auditory stimuli.

Study summary
Population: 176 adolescents (ages 13-18 years), of them 133 with ADHD and 43 controls.
Measures:
1. Parents and teachers form of Conner’s ADHD/DSM IV scales.

2. Omission errors were observed during MOXO d-CPT performance.

Results
ADHD adolescents demonstrated significantly higher rates of omission errors than their unaffected peers in all MOXO d-CPT distractors
conditions (Figure 1).

ADHD adolescents produced significantly more omission errors in the presence of pure visual distractors and the combination of visual
and auditory distractors than in no-distractors conditions. In contrast, distracting stimuli had no effect on CPT performance of
non-ADHD adolescents.

Receiver Operating Characteristic (ROC) analysis further demonstrated that independent of modality, the mere presence of distractors
(AUC = 0.890) significantly improved the areas under the curve (AUC) of the test, as compared to the absence of distractors [χ2(1,N =
176) = 8.51, p < 0.01]. Specifically, the AUC of combined visual and auditory distractors was the highest. Pure visual and pure auditory
distractors did not yield any diagnostic advantage over no-distractors conditions.

Figure 1: Group differences in omission errors during MOXO d-CPT performance ADHD CONTROL

5
OMISSION ERRORS (MEAN)

4
3
2
1
0

no distractor p<0.05 VISUAL p<0.001 AUDITORY p<0.05 COMBINED visual + auditory p<0.001

Discussion
Study results support the idea that ADHD is indeed marked by high distractibility and that teenagers with ADHD have difficulties to
sustain attention in the presence of irrelevant environmental stimuli.

Visual stimuli appeared as more potent distractor for ADHD adolescents than auditory, probably because MOXO d-CPT is based on a
visual task channel, which is more vulnerable to visual distractors that use the same cognitive modality. It is also possible that due to
impaired visual attention in ADHD , additional visual information easily overloads the cognitive/physiological system of an individual,
thus interfering with his performance.

The fact that adolescents with ADHD were distracted by external stimuli suggests that in everyday life these individuals may be more
distracted by irrelevant stimuli in the classroom (e.g., someone talks in the next room) rather than background stimuli (e.g., music) or
distractors that are part of the cognitive task.

Incorporating environmental distractors improves the test’s discriminative validity between ADHD adolescents and their non-affected
peers. Thus, such a CPT test can be useful as an aiding tool in the diagnosis of ADHD in adolescents once employing appropriate task
demands that better simulate distractibility in everyday life.
2
 The dynamics of attentional and inhibitory functions in the presence of
distracting stimuli in children with attention-deficit/hyperactivity disorder,
high-functioning autism and oppositional defiant disorder
Borkowska, A.R. (2016). Psychiatr Psychol Klin ,16 (2), p. 68–80.

Synopsis
The study used the MOXO d-CPT in order to evaluate attention and inhibition functions among three clinical groups of children: ADHD,
high-functioning autism and oppositional defiant disorder. In contrast to controls, the three clinical groups are characterized by specific
dysfunction of attention and inhibition as a function of time and distracting stimuli.

Study summary
Population: A total of 108 children aged 7-12 years. Of them 21 diagnosed with oppositional defiant disorder, 21 with high-functioning
autism, 19 with attention-deficit/hyperactivity disorder; and 47 controls.
Measures:
1. MOXO d-CPT performance was compared on four indices of the test: Attention, Timing, Hyperactivity and Impulsiveness.

Results
Compared to controls, ODD and ADHD children showed significantly worse performance in all MOXO d-CPT indices. No differences in
MOXO d-CPT performance were found between controls and children with high-functioning autism (Figure 1).
A detailed evaluation of test performance dynamics in its eight levels was performed in order to draw distinctive attention profiles of
the four groups. Results showed that children in clinical groups do not differ in their Attention and Timing indices. Impulsive responses
(Impulsiveness index) were noted only in children with ODD. Hyperactive responses decreased over time in the ADHD group, varied over
time and seemed dependent on the presence of distractor in the group of children with autism, and was quite stable in the ODD group,
which means it was comparable to control group performance, and only slightly worse as far as quantitative indices are concerned.

Figure 1: Group differences in MOXO d-CPT performance (z-values) ADHD CONTROL ODD AUTISM

3
2
1
0
-1
-2
-3
-4
-5

ATTENTION TIMING HYPERACTIVITY IMPULSIVITY

Discussion
While the control group did not exhibit difficulties in cognitive task performance over longer periods of time and in the presence of
distractors, various clinical groups show specific dysfunction on attention and inhibition as a function of time and distracting stimuli.

Unlike the analysis of the test’s major indices, a detailed evaluation of test performance dynamics in its eight levels yields more valuable
results and allows the specificity of the studied clinical groups to be discerned.

The MOXO d-CPT allows for simultaneous evaluation of several aspects of attention, including sustained attention, inhibition, and
resistance to distracting stimuli and is proved to be useful in clinical diagnosis of children.
3
 Maturational delay in ADHD: evidence using MOXO d-CPT test
Berger, I., Slobodin, O., Aboud, M., Cassuto, H (2013). Frontiers in Human Neuroscience, 7, 691.

Synopsis
This study demonstrates that children with ADHD show a significant and consistent developmental lag, in CPT performance (MOXO
d-CPT), when compared to normal controls, a lag that is shown to be between 1-3 years.

Study summary
Population: 924 children (6-11 years old). Out of which; 559 ADHD positive, 365 controls.
Groups: 6 age categories (6-11) with similar age and gender distribution.
Measures:
1. Parents and teachers form of Conner’s ADHD/DSM IV scales.

2.MOXO d-CPT - Performance was compared on four indices of the test: Attention, Timing, Hyperactivity and Impulsiveness. The
researchers mention that one of the reasons for choosing MOXO d-CPT is its unique distractor system simulating every-day
environment of children.

Results
In all age groups children with ADHD received significantly lower scores in the Attention and Timing parameters than normal controls.
For these two indices both groups show better results as the years progress but the performance of ADHD children consistently
matched that of younger controls.

In the age groups of 6,7,and 10 ADHD children produced significantly more hyperactive and impulsive responses as compared to normal
controls, and here too their results matched those of 1-3 younger controls.

See Figure 1 (below) for additional information.

Figure 1:Performance in four CPT parameters among ADHD children and control group ADHD CONTROL

ATTENTION TIMING
260 260
250 240
NUMBER OF PRESSINGS

NUMBER OF PRESSINGS

220
240
200
230
180
220
160
210 140
200 120
6 7 8 9 10 11 6 7 8 9 10 11
AGE GROUP AGE GROUP

HYPERACTIVITY IMPULSIVENESS
120 30
100 25
NUMBER OF PRESSINGS

NUMBER OF PRESSINGS

80 20
60 15
40 10
20 5
0 0
6 7 8 9 10 11 6 7 8 9 10 11
AGE GROUP AGE GROUP

Discussion
Both ADHD Children and controls show a similar developmental pattern but on a different time-scale. In most of the MOXO d-CPT
indices performance of ADHD children was delayed and matched that of 1-3 younger controls. These results match findings reported in
earlier clinical studies.

The use of MOXO d-CPT for this study allowed for the objective, non-reporter bias approach of this study , coupled with an increased
complexity of the task through the use of MOXO d-CPT environmental distractors set.
4
 Age-related changes in distractibility:
developmental trajectory of sustained attention in ADHD
Slobodin, O., Cassuto, H., & Berger, I. (2015). Journal of Attention Disorders. DOI: 10.1177/1087054715575066.

Synopsis
The study used the MOXO d-CPT to evaluate age-related changes in distractibility among ADHD children and controls. Results showed that
while distractibility in controls tends to diminish with maturation, in children with ADHD it persists into adolescence.

Study summary
Population: 839 children (7-18 years), of them 478 diagnosed with ADHD, and 361 controls.
Measures:
1. Parents and teachers form of Conner’s ADHD/DSM IV scales.

2. Age appropriate versions of the MOXO d-CPT test were employed for children and adolescents. Omission errors were observed during

test performance.

Results
ADHD children demonstrated higher rate of omission errors in all distractors conditions and all levels of distractibility (low and
high) compared with baseline. In the control group, only combined distractors increased the rate of omission errors. The number
of distracting stimuli, namely the level of distractibility, did not affect the number of omission errors in controls.
ADHD adolescents produced more omission errors in the presence of visual distractors and the combination of visual and
auditory distractors than in baseline level. This finding was consistent for both low and high levels of distractibility. In the control
group, the presence of distractors did not significantly affect the amount of omission errors, as compared with baseline. The
number of distracting stimuli did not affect the number of omission errors in adolescents with or without ADHD.
Children with or without ADHD did not demonstrate higher amount of omission errors in the last level of the test (no
distractors) than at the beginning of it (baseline) (Figure 1).

Figure 1: Developmental trajectory of sustained attention in the presence of MOXO d-CPT distractors
ADHD children 7-12 years non-ADHD children 7-12 years ADHD adolecents 13-18 years non-ADHD adolecents 13-18 years

4
3.5
3
OMISSION ERRORS (MEAN)

2.5
2
1.5
1
0.5
0
no distractors VISUAL VISUAL AUDITORY AUDITORY COMBINED COMBINED NO DISTRACTORS
distractors* distractors** distractors* distractors** distractors* distractors**

* Low distractibility- one distracting stimuli at a time ** High distractibility-two distracting stimuli presented simultaneously

Discussion
ADHD children and adolescents were more distracted than their typically developing peers. Although distractibility diminished
in adolescent controls, those with ADHD continued to be distracted in a way that resembled younger control children.

Findings suggest that although part of the difficulties in ADHD could be explained by developmental delay that improves with
time, other deficits, such as increased distractibility causing more omission errors, do not show a clear developmental trajectory.
5
 Continuous performance test in ADHD and SUD patients (CASP) study
Kaye, S., Peled- Levi, A., Yachin, N., Berger, I., van den Brink, W., Demetrovics, Z., ... van de Glind, G. (2013). Presented at the III
International Congress on Dual Disorders, London.

Synopsis
The multi-center study used the MOXO d-CPT to compare ADHD symptomatology among three clinical groups: adults patients having
Substance Abuse Disorder (SUD) only, patients having ADHD only, patients having SUD and ADHD, and a healthy control group all were
tested in various geographical locations. And in order to evaluated the MOXO d-CPT’s ability to differentiate between SUD patients with
ADHD and SUD patients without ADHD.

Study summary
Population: adults (age 18-65), 447 participants distributed as follows Australia (107), Hungary (148), Ireland (9), U.S.A. (183). Of •
them 143 diagnosed only with SUD, 51 diagnosed with ADHD only, 115 with both SUD and ADHD, and 180 controls.
Measures:
1. MOXO d-CPT - Performance was compared on four indices of the test: Attention, Timing, Impulsiveness and Hyperactivity.

2. DSM-IV based measurements of SUD and ADHD diagnoses.

Results*
Performance on the MOXO d-CPT test was significantly better among the control group compared to the SUD, SUD+ADHD and ADHD
groups, with controls scoring higher in attention and lower in hyperactivity and impulsivity.
No significant differences in attention, hyperactivity and impulsivity between the SUD, SUD+ADHD and ADHD groups. Timing was
poorest for SUD and SUD+ADHD groups.
Lower levels of attention and higher levels of hyperactivity and impulsivity were independently associated with being in the SUD and
SUD+ADHD groups.
Lower levels of attention and higher levels of hyperactivity were independently associated with having ADHD only (Figure 1).
*Preliminary data

Figure 1: Group differences in MOXO d-CPT indices norm sud sud+adhd adhd

***
300 ***
** ***
**
250 *

200

150

100
** ***
50 ** ***
* *
0
attention timing hyperactivity impulsivity

* p<.001 ** p<.01 *** p<.05

Discussion
The MOXO d-CPT is able to discriminate between the performance of controls and adults with SUD and/or ADHD.
SUD and ADHD subjects were associated with poorer attention and higher levels of hyperactivity and impulsivity.
Performance of ADHD subjects could only be distinguished from SUD subjects, but not from SUD with comorbid ADHD.
6
 Beating their chests: University students with ADHD demonstrate
greater attentional abilities on an inattentional blindness paradigm
Grossman, E.S., Hoffman, Y.S.G., Berger , I., & Zivotofsky, A.Z. (2015). Neuropsychology, doi.org/10.1037/neu0000189.

Synopsis
Using a low perceptual load task (the MOXO-d-CPT) and a high perceptual load inattentional blindness task, the study explores whether
ADHD adults have global distractibility impairment, a limited perceptual capacity, or a specific impairment in processing repeated
stimulus. Results support the third model (impairment in repeated tasks).

Study summary
Population: 14 ADHD university students (mean age: 24.07) and 18 matched controls (mean age 23.3).
Measures:
1. MOXO d-CPT - Performance was compared on four indices of the test: Attention, Timing, Hyperactivity and Impulsiveness in order to

assess attentional differences between the controls and ADHD group.

2. High perceptual load inattentional blindness task (detecting unattended stimuli).

Results
Students with ADHD showed increased distractibility in the MOXO-d-CPT task. By contrast, they performed better than controls in the
inattentional blindness task (figure 1).

Figure 1: Attentional blindness and MOXO d-CPT results for ADHD and control groups ADHD CONTROL

Attentional blindness task MOXO d-CPT

attention hyperactivity timing impulsiveness
20.00 * ns ** 1.00
18.00
100% 0.00
16.00
14.00
-1.00
12.00
100%
10.00 -2.00
8.00
-3.00
6.00 100%
4.00
-4.00
2.00
0.00 -5.00 ** **
total aerial bounce

significance at .05 *one tail **two tail

Discussion
ADHD adults can perform a demanding task while simultaneously processing unattended stimuli at no apparent cost. This advantage
did not result from an attentional trade-off. Results support the “hunter versus farmer" hypothesis, which argues that ADHD individuals
have an alternative cognitive style which is less equipped to deal with detection of repeated stimuli while comprising advantages in the
tracking of stimuli moving in a fast dynamic manner.

7
 Usefulness and Validity of CPT in the Diagnosis of ADHD Children
Berger, I., Slobodin, O.,& Cassuto, H. (2016) . Archives of Clinical Neuropsychology

Synopsis
In all MOXO-CPT indices, ADHD children demonstrated worse performance than their unaffected peers.
In addition, all four CPT indices, especially when considered as a whole, showed fair to excellent sensitivity and specificity in ADHD
diagnosis.

Study summary
Population: A total of 798 children aged 7 to 12 years (493 boys and 305 girls), of them 339 with ADHD.
Measures:
1. MOXO-CPT - Performance was compared on four indices of the test: Attention, Timing, Hyperactivity and Impulsiveness.

Results
Compared to their unaffected peers, children with ADHD received significantly lower scores in all four CPT indices: attention, timing,
hyperactivity, and impulsivity (for example see figure 1).

ROC analysis revealed fair to excellent diagnostic ability of the Attention, Timing and Hyperactivity indices.

Impulsivity, showed a lesser ability to distinguish ADHD children from controls and therefore should be considered with at least one
more index showing negative abnormality.

The best diagnostic performance was attributed to failure in all 4 indices.

Figure 1: Example, Group differences in MOXO-CPT indices in children age 7 ADHD CONTROL

attention timing hyperactivity impulsiveness TOTAL SCORE

300 *** ***

***

200

100 ***

*** p<.001 * p<.05

Sensitivity and specificity analyses results show that the test’s validity in diagnosis of ADHD is a function of the number of indices that
were taken into account. That is, considering more indices improves the test’s sensitivity and specificity. Abnormality in all four indices at
the same time is associated with excellent sensitivity and specificity rates of 89.9% and 86.1%, respectively.

Discussion
MOXO-CPT consistently distinguished between children with ADHD and their unaffected peers, so that children with ADHD performed
worse than controls in all study indices. Specifically, ADHD children were less attended to the stimuli and performed fewer reactions on
accurate timing. Furthermore, children with ADHD performed significantly more impulsive and hyperactive responses than controls.

Integration of CPT indices improves the diagnostic capacity of ADHD and may better reflect the complexity and heterogeneity of ADHD.

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