Is an ADHD Observation-Scale Based on DSM Criteria Able to Predict Performance in a Virtual Reality Continuous Performance Test?

Round 1

Reviewer 1 Report

Manuscript ID: applsci-753370

Title: Is an ADHD observation-scale based on DSM criteria able to predict performance in a Virtual Reality Continuous Performance Test?

Journal: Applied Sciences

Introduction

1) Lines 32-34. Authors wrote that there are four ADHD presentations but, according to DSM-5 criteria, the ADHD presentations should be three, i.e., combined, predominantly inattentive, predominantly hyperactive/impulsive.

2) Lines 79-80. Authors wrote that “the present study aims at analyzing whether the data collected by the EDAH scale might partially explain the results obtained by a VR-CPT called AULA Nesplora”. Are available in the literature any previous-similar studies?

Materials and methods

1) Line 86. Authors wrote “(76% men and 24 % women)”. Because of the age of the participants, authors could replace men and women with boys and girls, respectively.

2) Lines 85-88. Authors should specify the ADHD presentation of participants.

3) Line 133. Maybe in futures studies actigraphy could be used in order to record motor activity.

4) Line 133. Authors could replace .778 with .78.

Results

1) Note of Table 1. Should “medium” be replaced with “mean”?

2) Line 152. Table 4 is missing.

Discussion

1) Authors should comment the significant prediction of the commission errors at the VR-CPT based on the inattention subscale of the EDAH scale which is somewhat counter-intuitive, at least from my point of view.

2) Lines 202-204. Authors wrote that “Moreover, it might also be positive to divide the ADHD group according to the type of ADHD presentation, so as to observe possible differences existing between them”. I believe that it would be very interesting if authors could now divide the participants according to the ADHD presentation aiming to enrich the current study.

Author Response

Responses to Reviewer 1:

Introduction

• Lines 32-34. Authors wrote that there are four ADHD presentations but, according to DSM-5 criteria, the ADHD presentations should be three, i.e., combined, predominantly inattentive, predominantly hyperactive/impulsive.
• We have reviewed this aspect (see lines 33-35).
• Lines 79-80. Authors wrote that “the present study aims at analyzing whether the data collected by the EDAH scale might partially explain the results obtained by a VR-CPT called AULA Nesplora”. Are available in the literature any previous-similar studies?
• Currently, there is not any study which measures the capacity of an observation scale for predicting the performance of variables from a Virtual Reality-CPT. In this sense, we have added a short explanation about this innovation (see lines 90-95).

Materials and methods

• Line 86. Authors wrote “(76% men and 24 % women)”. Because of the age of the participants, authors could replace men and women with boys and girls, respectively.
• Following this recommendation, we have modified the mentioned parts (please, see abstract section and line 87 from participant section).
• Lines 85-88. Authors should specify the ADHD presentation of participants.
• All the participants who compose the sample have been diagnosed with the combined presentation of ADHD (see participant section).
• Line 133. Maybe in futures studies actigraphy could be used in order to record motor activity.
• We have added this suggestion in future research line section (see page 5, lines 208-209).
• Line 133. Authors could replace .778 with .78.
• We have done the mentioned replacement.

Results

• Note of Table 1. Should “medium” be replaced with “mean”?
• We have done the mentioned replacement.
• Line 152. Table 4 is missing.
• The mistake has been corrected.

 Discussion

1) Authors should comment the significant prediction of the commission errors at the VR-CPT based on the inattention subscale of the EDAH scale which is somewhat counter-intuitive, at least from my point of view.

• We have added an explicative paragraph about the unexpected finding (see lines 210-212).
• Lines 202-204. Authors wrote that “Moreover, it might also be positive to divide the ADHD group according to the type of ADHD presentation, so as to observe possible differences existing between them”. I believe that it would be very interesting if authors could now divide the participants according to the ADHD presentation aiming to enrich the current study.
• We encourage this interesting recommendation, but the ADHD sample analyzed is composed of children and adolescents which present both type of symptoms (inattention and impulsive-hyperactive symptoms) so all of them have been diagnosed by the combined presentation of ADHD. Anyway, we have added this important point as a limitation of the study (lines 245-262).

Reviewer 2 Report

This manuscript attempts to determine whether subscales of the EDAH relate to specific measures of a visual reality version of the CPT.  The authors find that the AD subscale of the EDAH, but not others, correlates with CPT measures. The findings are interesting, and generally fit with several other publications by the same authors. However, the authors need to better consider several potential biases. Firstly, the CPT measures that the authors examined were primarily those that would relate to attention deficit. It is unclear whether the VR-CPT used here differed in several important respects from other versions of the CPT (see below), biasing the outcomes towards attentional measures rather than impulsive measures. Secondly, the subjects themselves may have biased this result if they were primarily from the attentional, rather than combined or hyperactive/impulsive diagnoses. Indeed to truly understand this, groups of individuals with each of the diagnoses should be separately examined. Since there was a mix of symptoms, this probably should have come out in the regression analysis, but the overall issue should still be considered in more detail, along with sex, and whether or not diagnosis, EDAH measures, or VT-CPT measures differed with sex.

Major comments:

1. An important aspect of traditional go/no-go and CPT tasks is that the trials are mixed and there is a bias towards “go” responses. This is an important aspect of identifying impulsive behavior. It appears as if this aspect of these tasks was not incorporated into the VR-CPT. Also, premature responses do not seem to have been measured as a part of this task, which are a primary measure of impulsivity in many versions of these tasks. Also, there is usually a choice among responses, based on discrimination of stimuli, that allows an accuracy measure. Overall, the task, and its similarity to a standard CPT needs to be better described, and the similarities and differences discussed and justified.
2. Methods: Before proceeding to other analyses the nature of the subjects should be discussed some. Given the 3 primary sub-diagnoses, what was the nature of the subjects? Did the distribution of diagnosis differ with sex? It should also be considered whether the ultimate results were due to the underlying diagnosis of the subjects, and whether the study lacked the statistical power to examine other types of symptoms.

Minor comments:

1. Line 33: the inattentive/restrictive ADHD presentation was not included in DSM V.
2. Line 58: the phrasing here should be a little different: it should be stated that the different measures of the CPT “are thought to be” associated with specific ADHD symptoms.
3. In the introduction there should be more comparison between standard CPT approaches and the VR-CPT approach.
4. The abstract and the methods differ in the sex ratio.
5. The subject recruitment strategy should be described in more detail.

Minor Corrections:

1. Line 44: insert “assessment” before “depends”; “of” not “from”.
2. Line 58: “The CPT provides” not “CPT provide”.

The manuscript should be revised a bit for English grammar and word usage.

Author Response

Responses for Reviewer 2

Major comments:

1. An important aspect of traditional go/no-go and CPT tasks is that the trials are mixed and there is a bias towards “go” responses. This is an important aspect of identifying impulsive behavior. It appears as if this aspect of these tasks was not incorporated into the VR-CPT. Also, premature responses do not seem to have been measured as a part of this task, which are a primary measure of impulsivity in many versions of these tasks. Also, there is usually a choice among responses, based on discrimination of stimuli, that allows an accuracy measure. Overall, the task, and its similarity to a standard CPT needs to be better described, and the similarities and differences discussed and justified.

• Thanks for making this recommendation, we have added more information about the tool and its efficacy (lines 155-176).

1. Methods: Before proceeding to other analyses the nature of the subjects should be discussed some. Given the 3 primary sub-diagnoses, what was the nature of the subjects? Did the distribution of diagnosis differ with sex? It should also be considered whether the ultimate results were due to the underlying diagnosis of the subjects, and whether the study lacked the statistical power to examine other types of symptoms.

• The sample of the present study is made up of children and adolescents which present the both type of symptoms (inattention and impulsive-hyperactive symptoms). It means, all of them have been diagnosed by the combined presentation of ADHD. We have considered this great suggestion and have added some lines about that in limitation section (lines 245-262).

Minor comments:

1. Line 33: the inattentive/restrictive ADHD presentation was not included in DSM V.

• We have omitted this presentation (see lines 33-35).

1. Line 58: the phrasing here should be a little different: it should be stated that the different measures of the CPT “are thought to be” associated with specific ADHD symptoms.

• We have changed the paragraph following this recommendation (please see lines 63-66).

1. In the introduction there should be more comparison between standard CPT approaches and the VR-CPT approach.

• We have added more information about VR CPT and Traditional CPT in introduction section (lines 80-8·) and we have also added more details in the instruments section (lines 158-179).

1. The abstract and the methods differ in the sex ratio.

• The mistake has been corrected.

1. The subject recruitment strategy should be described in more detail.

• We have described with more detail the procedure section (lines 116-132).

Minor Corrections:

1. Line 44: insert “assessment” before “depends”; “of” not “from”.

• We have added the term “assessment” following the suggestion.

1. Line 58: “The CPT provides” not “CPT provide”.

• We have modified this expression.

The manuscript should be revised a bit for English grammar and word usage.

• Following the reviewer recommendations, the text has been further revised by an external native English-speaking expert.