2014

MOXO Clinical and Research Tools

Eran SandelHead of Professional Training

Attention Deficit Hyperactivity Disorder

(ADHD) ADHD is the most common childhood neuro-

behavioural disorder defined by symptoms ofdevelopmentally inappropriate inattention, impulsivityand hyperactivity (Polanczyk 2007).

Up to 60% of children with ADHD will continue to havesignificant ADHD-related symptoms persistinginto adulthood (Gentile et al. 2006).

Twin, family and adoption studies have suggested thatthere is a strong genetic contribution to ADHD, with amean heritability estimate of 76% (Faraone 2005) .

Control vs. ADHD - fMRI

2-3 years of delay incortical maturationbetween ADHD andhealthy 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.

CPTsContinuous 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=547ADHD (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 7-1215 min

Tests elementsappear always at the center

Target Element Non Target Element

Distractors Visual / Audio / Combination

appear always at the periphery

Practice

Adult Test Age 13-6018.5 min

Target Element Non Target Element

Tests elementsappear 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 GraphMaps performance throughout the test

Continuous Performance.

Distractor effects.

Patient Profile

Comparison Table

Severity Table

Legends

Comparison table

(Z > 0)

(< Z 00.825-)

(0.825-< Z 1.65-)

(1.65-Z

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 evaluationBefore-after Ritalin 10mg

Unmedicated Ritalin IR 10 mg

Medication improves performance

1

Treatment evaluationBefore-after Ritalin 10mg

Unmedicated Ritalin LA 20 mg

Medication impairs performance

2

MOXOClinical Decision Support

Unmedicated

Patient code: 407609 | Male | 22Y | Test Date: February 2014Symptoms: Attention and Anxiety

Medication Selection I

Clinical Interpretation: No significant drug effectProvider moved to address anxiety symptoms

Ritalin LA 30 mg

SSRI only SSRI + Ritalin LA 30 mg

Symptoms not anxiety-or depression-drivenCl

inic

ian

In

terp

reta

tio

n

Alternative MPH formulation with SSRI

shows additional effect

Patient code: 407609 | Male | 22Y | Test Date: April 2014Symptoms: Attention and Anxiety

Medication Selection II

Unmedicated

Male, 11Y Previous Clinician Assessment: ODD

Parental Assessment: ADHD

Clinical Decision SupportObjectively 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

TeacherParents

Hyperactive /

Impulsive

AttentionHyperactive /

Impulsive

Attention

7/98/91/92/9

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 MoxoPoster presentedAnalysis ongoing

Schneider Childrens Hospital

Attention deficits in epilepsyPoster 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 ICASAwww.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 CollaborationCASP 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 startedImportant 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.

ClinicalDecision 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.

ResearchFlexible, Adaptable Collaborative. Standardization across sites. Flexible structure can support multiple control/norm groups.

Thank you!