2014

MOXO Clinical and Research Tools

Eran Sandel
Head of Professional Training
Attention Deficit Hyperactivity Disorder
(ADHD)
ADHD is the most common childhood neuro-
behavioural disorder defined by symptoms of
developmentally inappropriate inattention, impulsivity
and hyperactivity (Polanczyk 2007).
Up to 60% of children with ADHD will continue to have
significant ADHD-related symptoms persisting
into adulthood (Gentile et al. 2006).
Twin, family and adoption studies have suggested that
there is a strong genetic contribution to ADHD, with a
mean heritability estimate of 76% (Faraone 2005) .
Control vs. ADHD - fMRI
2-3 years of delay in
cortical maturation
between ADHD and
healthy controls.
First developed in the early 60s.
Computerized, objective measurement tool.
Basic go/no-go task.
Serves as an objective decision support tool in
the ADHD diagnosis procedure.
CPTs
Continuous Performance Test
T.O.V.A Test
(Developed in 1966)
Go - No Go Test
Advantages:
Popular & traditional
market.
Allows Test-Retest
evaluation.
Disadvantages:
Visual channel only.
OFFLINE system.
Peripheral vision.
Norms from the 80's
(North American).
T.O.V.A Test Results
d-CPT Test
Next-generation CPT.
Objective tool to evaluate
attentive profile in patients Age
7 and above.
Innovative distractor approach
challenges attentional and
executive systems to improve
sensitivity and specificity over
legacy CPTs.
MOXO Test
moment of clarity(Japanese)
Sensitivity and Specificity by ADHD subtypes
(N=178) (N=369)
N=547
ADHD (178)
Control (369)
Validation Study
Source: Neurotech Solutions data on file
Clinical Value
Decision Support Beyond CPT
Operations
Web-based, low overhead.
No specialized equipment.
Test Design
Stimuli
No language confounds.
Ecologically valid (real-world content).
Distractors
Visual, auditory and combined.
Challenges attentional systems beyond classical CPT.
HIPAA compliant
Results
Obtained immediately once the
test ended.
Statistical differentiation from
norm population.
Patient performance across the
different levels of the test.
Moxo Clinical Adoption
Israel (2012-):
National HMOs offer coverage.
400 clinics certified.
7 Major Hospitals.
28 Regional Psychological Service Centers
(Ministry of Education).
>60,000 tests performed.
Pediatric Test
Age 7-12
15 min
Tests elements
appear always at the center
Target Element
Non Target Element
Distractors
Visual / Audio / Combination
appear always at the periphery
Practice
Adult Test
Age 13-60
18.5 min
Target Element
Non Target Element
Tests elements
appear always at the center
Distractors
Visual / Audio / Combination
appear always at the periphery
Combined distractors
Test Simulation
The Four Attentiveness Indices
Attention (A)
The ability to respond correctly and remain focused.
Timing (T)
The ability to respond quickly and accurately.
Example for a perfect timing
Example for a less perfect timing
The Four Attentiveness Indices
Impulsiveness (I)
The tendency to respond hastily, before evaluating the
situation.
Hyperactivity (H)
A difficulty in regulation of motor responses.
Lets play a short game
Target Void Non -Target Void
time
Every element (Target/Non-Target) is followed by a Void.
The Void period is equal to the Target/Non-Target period.
The Moxo Test Pattern
4s 8s
Target Void Non -Target Void
A
T
I
H
The Four Attentiveness Indices Calculation
Test Results
Patient Profile
Comparison of individual performance to
norm group.
Norm criteria: age and gender.
Z score: Calculated for each index and
categorized by performance level.
Performance Graph
Maps performance throughout the test
Continuous Performance.
Distractor effects.
Patient Profile
Comparison Table
Severity Table
Legends
Comparison table
( Z > 0 )
( < Z 0 0.825 - )
( 0.825 - < Z 1.65 - )
( 1.65 - Z < )
( 2.55 - Z )
( 2.25 - < Z 2.55 - )
( 1.95 - < Z 2.25 - )
( 1.65 - < Z 1.95 - )
Severity table
Performance Graph
Performance Graph
1. Comparison (level 8 to level 1)
3. Fluctuation
2. Distracters
4. Correlation
Principles of MOXO Analysis
Performance Graph
Continuous performance
1
Performance in the Attention index decreases overtime
(less attentive)
Performance Graph
Continuous performance
2
Performance in the Hyperactivity index decreases across time
(more hyperactive)
Performance Graph
Continuous performance
3
Performance in the Impulsiveness index increases across time
(less impulsivity)
Performance Graph
Distractors effect
1
Visual distractors lower attention
Performance Graph
Distractors effect
2
Auditory distractors improve Attention and Timing
Performance Graph
Distractors effect
Major distractors improves Impulsiveness
3
Performance Graph
Correlation Between Indices
Trade off Timing vs. Impulsiveness
1
Performance Graph
Correlation Between Indices
Trade off Timing vs. Impulsiveness
2
Performance Graph
Correlation Between Indices
Trade off Attention vs. Hyperactivity
3
Treatment evaluation
Before-after Ritalin 10mg
Unmedicated
Ritalin IR 10 mg
Medication improves performance
1
Treatment evaluation
Before-after Ritalin 10mg
Unmedicated
Ritalin LA 20 mg
Medication impairs performance
2
MOXO
Clinical Decision Support
Unmedicated
Patient code: 407609 | Male | 22Y | Test Date: February 2014
Symptoms: Attention and Anxiety
Medication Selection I
Clinical Interpretation: No significant drug effect
Provider moved to address anxiety symptoms
Ritalin LA 30 mg
SSRI only SSRI + Ritalin LA 30 mg
Symptoms not anxiety-
or depression-driven
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Alternative MPH
formulation with SSRI
shows additional effect
Patient code: 407609 | Male | 22Y | Test Date: April 2014
Symptoms: Attention and Anxiety
Medication Selection II
Unmedicated
Male, 11Y
Previous Clinician Assessment: ODD
Parental Assessment: ADHD
Clinical Decision Support
Objectively deconflict contradictory assessments
Methylphenidate
Moxo provided clinician with demonstrable evidence to bolster assessment.
After viewing report, parents agreed to ODD-focused treatment approach
Before Therapy
Female | 14Y | Symptoms: Depression with attention problems
Efficacy of Psychotherapy Treatment
After Therapy
Teacher Parents
Hyperactive /
Impulsive
Attention Hyperactive /
Impulsive
Attention
7/9 8/9 1/9 2/9
ADHD questionnaire for parents and teachers
Recent Peer-Reviewed Publications
Haimov-Kochman R et al. Cognitive functions of regularly cycling women may differ
throughout the month, depending on sex hormone status; a possible explanation
to conflicting results of studies of ADHD in females. Frontiers in Human
Neuroscience 8(191): 1-6 (2014).
Berger I. and Cassuto H. The effect of environmental distractors incorporation into
a CPT on sustained attention and ADHD diagnosis among adolescents. Journal of
Neuroscience Methods 222:62-68 (2014).
Cassuto H, et al. Using environmental distractors in the diagnosis of ADHD.
Frontiers in Human Neuroscience 7 (805): 1-10 (2014).
Berger I, et al. Maturational delay in ADHD: Evidence from CPT. Frontiers in Human
Neuroscience 7 (691): 1-11 (2013).
Berger I and Goldzweig G. Objective Measures of Attention Deficit / Hyperactivity
Disorder: A Pilot Study. Israel Medical Association Journal 12:531-535 (2010).
Institution Project March 2014 Status
Hadassah/ Hebrew
University
Attentional loading in autism, measured vs.
siblings and on/off medications
Recruiting
Hadassah/ Hebrew
University
Estrogen effect on attention in
post-menopausal women
Mini-review published,
poster presented,
recruitment ongoing
Nat Inst for Testing
and Eval
Multi-battery assessment of university students
with attention deficits
Analysis
Hadassah/ Hebrew
University
Ritalin effect on ADHD using Moxo
Poster presented
Analysis ongoing
Schneider
Childrens Hospital
Attention deficits in epilepsy
Poster presented,
Analysis ongoing
Wolfson Hospital Attention in ADHD and mental retardation Manuscript in prep
Hadassah/ Hebrew
University
Fatigue effect on attention in medical residents Manuscript in prep
Selected Studies
ICASA
Neurotech Solutions is a founding member
and partner of ICASA
www.adhdandsubstanceabuse.org
ICASA Goals
Prevention of development of SUD in ADHD children,
adolescents and adults.
Increasing the quality of diagnostic and treatment
procedures in adolescents and adults suffering from
both disorders.
USA, Netherland , Australia, Norway, Sweden,
Belgium, France, Spain, Switzerland, Hungary,
Finland, England, Ireland, South Africa, Brazil,
Egypt
Participating countries
45
Number of researchers
ICASA Members
Research Consortium Collaboration
CASP Study
Multi-center study
US, Australia, Hungary, Netherlands, Israel
Initiated 2012
Research Population (n~450):
Adults with Substance Use Disorder (SUD)
Adults with SUD and ADHD
Healthy Controls
Goal: Investigate attention, hyperactivity,
response time and impulsivity in SUD, ADHD &
comorbid disorders
Status: Manuscripts in preparation
CASP Study Consortium
ICASA
Neurotech Solutions is a founding member and partner of ICASA
www.adhdandsubstanceabuse.org
Participating Countries: USA, Netherlands, Australia, Norway,
Sweden, Belgium, France, Spain, Switzerland, Hungary, Finland,
England, Ireland, South Africa, Brazil, Egypt
Developmental
Report
For Pediatric test (7-12)
Developmental Research
Developmental Research
Patients Details
Summary Table
Age Resemblance (z score)
Comparative
Report
For patients with 2-4 tests
Getting started
Important technical issues
Use wired internet connection only (not cellular or WIFI).
Recommended browser Google Chrome.
Use a keyboard thats wired connected to the computer.
Use external speakers (not screen built in speakers).
Turn off any irrelevant software running in the background (Skype, outlook,
etc.).
Make sure all pop-up elements are neutralized.
After test begins- do not touch the mouse.
If using a laptop (not recommended).
Use wire internet connection.
Connect external wired keyboard and mouse.
Summary: MOXO d-CPT Test
General
Objective measures for key attention parameters.
Low overhead, easy deployability.
Flexible business model.
International partnering opportunities.
Clinical
Decision Support Beyond CPT.
Significant unmet need .
Rapid adoption in the field.
Decision support for challenging diagnoses.
DSM-V adult criteria have added additional uncertainty.
Multiple reports, including developmental age and longitudinal tracking.
Research
Flexible, Adaptable Collaborative.
Standardization across sites.
Flexible structure can support multiple control/norm groups.
Thank you!