Can auditory warning signals normalize eye movements in children with ADHD?

The use of eye-tracking technology in supporting children and adolescents with attention deficit/hyperactivity disorder: a comprehensive review

MATERIALS AND METHODS

Through the analysis of 74 studies, we examine how eye-tracking technology has been applied to address ADHD-related challenges, the specific methods used, and the correlations between eye-tracking metrics and ADHD symptoms in youth.Results and conclusions: The findings suggest that eye-tracking offers a non-invasive and reliable approach to objectively assess domains such as visual processing characteristics, early detection or interventions. By discussing both the achievements and limitations of the reviewed studies, this paper not only consolidates existing knowledge but also proposes avenues for future research to enhance support for children and adolescents with ADHD.

Relationship between autonomic arousal and attention orienting in children and adolescents with ADHD, autism and co-occurring ADHD and autism

INTRODUCTION

Attention-Deficit/Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder (ASD) may be characterized by different profiles of visual attention orienting. However, there are also many inconsistent findings emerging from the literature, probably due to the fact that the potential effect of autonomic arousal (which has been proposed to be dysregulated in these conditions) on oculomotor performance has not been investigated before. Moreover, it is not known how visual attention orienting is affected by the co-occurrence of ADHD and autism in people with a double diagnosis.

METHODS

99 children/adolescents with or without ADHD and/or autism (age 10.79 ± 2.05 years, 65% boys) completed an adapted version of the gap-overlap task (with baseline and overlap trials only). The social salience and modality of stimuli were manipulated between trials. Eye movements and pupil size were recorded. We compared saccadic reaction times (SRTs) between diagnostic groups and investigated if a trial-by-trial association existed between pre-saccadic pupil size and SRTs.

RESULTS

Faster orienting (shorter SRT) was found for baseline compared to overlap trials, faces compared to non-face stimuli and-more evidently in children without ADHD and/or autism-for multi-modal compared to uni-modal stimuli. We also found a linear negative association between pre-saccadic pupil size and SRTs, in autistic participants (without ADHD), and a quadratic association in children with ADHD (without autism), for which SRTs were slower when intra-individual pre-saccadic pupil size was smallest or largest.

CONCLUSION

Our findings are in line with previous literature and indicate a possible effect of dysregulated autonomic arousal on oculomotor mechanisms in autism and ADHD, which should be further investigated in future research studies with larger samples, to reliably investigate possible differences between children with single and dual diagnoses.

Eye-movement indices of arousal predict ADHD and comorbid externalizing symptoms over a 2-year period

Attention-deficit/hyperactivity disorder (ADHD) follows a variable course across childhood. Disrupted arousal has been hypothesized to underlie core symptoms as well as comorbid internalizing and externalizing conditions. The current study examined eye-movement and pupil-dilation metrics indexing arousal as longitudinal predictors of ADHD, externalizing, and internalizing symptoms over a 2-year period. Participants aged 8-13 years (N = 54, 30% with a diagnosis of ADHD) completed a modified version of the gap-overlap task including arousal-inducing auditory warning signals. Parents rated symptoms at the time of testing and at 2 years follow-up. Phasic alerting (reaction-time reduction after alerting cues) is an index of arousal. Here, larger phasic alerting effects predicted higher ADHD-symptom levels 2 years later. Blunted pupil-dilation responses predicted externalizing symptoms at T2, controlling for ADHD and externalizing at T1. Our results support the theory that ADHD is associated with altered arousal. Blunted arousal reactivity may be a longitudinal risk factor for externalizing problems in children with ADHD symptoms.

The Eyes Have It: A Meta-analysis of Oculomotor Inhibition in Attention-Deficit/Hyperactivity Disorder

BACKGROUND

Diminished inhibitory control is one of the main characteristics of attention-deficit/hyperactivity disorder (ADHD), and impairments in oculomotor inhibition have been proposed as a potential biomarker of the disorder. The present meta-analysis summarizes the effects reported in studies comparing oculomotor inhibition in ADHD patients and healthy control subjects.

METHODS

Inhibitory outcomes were derived from oculomotor experimental paradigms including the antisaccade (AS), memory-guided saccade, and prolonged fixation tasks. Temporal and spatial measures were also extracted from these tasks and from visually guided saccade tasks as secondary outcomes. Data were available from k = 31 studies (N = 1567 participants). Summary effect sizes were computed using random-effects models and a restricted maximum-likelihood estimator.

RESULTS

Among inhibitory outcomes, direction errors in AS, after correcting for publication bias, showed a moderate effect and large between-study heterogeneity (k = 18, n = 739, g = 0.57, 95% confidence interval [CI] [0.27, 0.88], I²= 74%); anticipatory saccades in memory-guided saccade showed a large effect and low heterogeneity (k = 11, n = 487; g = 0.86, 95% CI [0.64, 1.08], I² = 17.7%); and saccades during prolonged fixation evidenced large effect size and heterogeneity (k = 6, n = 325 g = 1.11, 95% CI [0.56, 1.65], I² = 79.1%) partially related to age. Among secondary outcomes, saccadic reaction time in AS (k = 22, n = 932, g = 0.34, 95% CI [0.06, 0.63], I² = 53.12%) and coefficient of variability in visually guided saccade (k = 5, n = 282, g = 0.53, 95% CI [0.28, 0.78], I² = 0.01%) indicated significant effects with small to moderate effects sizes.

CONCLUSIONS

ADHD groups commit more oculomotor inhibition failures than control groups. The substantial effects support the conclusion that oculomotor disinhibition is a relevant ADHD-related mechanism. Moderate effects observed in saccadic reaction time variability suggest that fluctuant performance in oculomotor tasks is another relevant characteristic of ADHD.

Attentional Engagement and Disengagement Differences for Circumscribed Interest Objects in Young Chinese Children with Autism

The current study aimed to investigate attentional processing differences for circumscribed interest (CI) and non-CI objects in young Chinese children with autism spectrum condition (ASC) and typically developing (TD) controls. In Experiment 1, a visual preference task explored attentional allocation to cartoon CI and non-CI materials between the two groups. We found that ASC children (n = 22, 4.95 ± 0.59 years) exhibited a preference for CI-related objects compared to non-CI objects, and this effect was absent in the TD children (n = 22, 5.14 ± 0.44 years). Experiment 2 utilized the traditional gap-overlap paradigm (GOP) to investigate attentional disengagement from CI or non-CI items in both groups (ASC: n = 20, 5.92 ± 1.13 years; TD: n = 25, 5.77 ± 0.77 years). There were no group or stimulus interactions in this study. Experiment 3 adopted a modified GOP (MGOP) to further explore disengagement in the two groups (ASC: n = 20, 5.54 ± 0.95 years; TD: n = 24, 5.75 ± 0.52 years), and the results suggested that exogenous disengagement performance was preserved in the ASC group, but the children with ASC exhibited increased endogenous attentional disengagement compared to TD peers. Moreover, endogenous disengagement was influenced further in the presence of CI-related objects in the ASC children. The current results have implications for understanding how the nature of engagement and disengagement processes can contribute to differences in the development of core cognitive skills in young children with ASC.

Links between Daytime Napping, Night-Time Sleep Quality and Infant Attention: An Eye-Tracking, Actigraphy and Parent-Report Study

The current study explored the potential influence of infant sleep, measured by parental report and actigraphy, and family functioning on attention development using eye tracking. The use of actigraphy in parallel with parental report, has the advantage of measuring participant’s sleep throughout the night without parental observation and the ability to objectively assess sleep quality. An eye-tracking version of the Gap-Overlap task was used to measure visual attention. Questionnaires and behavioural assessment were used to assess family function, and general cognitive development. Fifty infants (Mean age = 13.44 months, SD = 3.10) participated in the study, 23 of which had full final datasets. Results show that daytime sleep duration, as measured by parental report, and proportion of light sleep at night, as measured by actigraphy, are linked to visual attention. A higher proportion of light sleep, a marker of poorer sleep quality, and less daytime sleep were negatively linked with facilitation and disengagement on the Gap-Overlap task. Family functioning was not associated with attention. The results provide initial evidence that in addition to the amount of daytime sleep; quality of night-time sleep as measured by proportion of light sleep, is a potentially useful sleep variable which requires further focus in the study of attention development.

Assessing sustained attention of children with ADHD in a class flow video task

OBJECTIVE

The aim of the study was to evaluate sustained attention performance of children with ADHD and effect of distractors on sustained attention through an eye-tracking during a class-flow video task.

METHOD

Data were collected using an eye-tracking during a class-flow task conducted with 60 children (ADHD and control groups). Two areas of interest were determined in the task, these are relevant (teacher and whiteboard) and irrelevant (any regions outside the relevant area) areas. The task also included distractors in relevant and irrelevant areas, comprising a brief conversation and dropping of a pencil, respectively. Proportion of total fixation duration on areas of interest (PFDAOI) was used to assess sustained attention.

RESULTS

Children with ADHD had lower PFDAOI in the relevant area during the whole class than children in the control group. After the relevant area distractor, PFDAOI increased in relevant area in ADHD group, indicating these children may have better attention after the distractor. However, children with ADHD also showed increased PFDAOI in the irrelevant area following the irrelevant area distractor, indicating that it negatively affected them. There was no significant change in the control group following the distractors.

CONCLUSION

These findings indicate that children with ADHD have poor sustained attention performance during the whole class. Moreover, distractors in distinct areas could affect children with ADHD differently. Thus, students with ADHD could benefit from increased stimuli in the relevant area and this can be a guide for classroom arrangements to improve the academic functionality of these children.

Visual search in neurodevelopmental disorders: evidence towards a continuum of impairment

Disorders with neurodevelopmental aetiology such as Attention-Deficit/Hyperactivity Disorder (ADHD), Autism Spectrum Disorder (ASD) and Schizophrenia share commonalities at many levels of investigation despite phenotypic differences. Evidence of genetic overlap has led to the concept of a continuum of neurodevelopmental impairment along which these disorders can be positioned in aetiological, pathophysiological and developmental features. This concept requires their simultaneous comparison at different levels, which has not been accomplished so far. Given that cognitive impairments are core to the pathophysiology of these disorders, we provide for the first time differentiated head-to-head comparisons in a complex cognitive function, visual search, decomposing the task with eye movement-based process analyses. N = 103 late-adolescents with schizophrenia, ADHD, ASD and healthy controls took a serial visual search task, while their eye movements were recorded. Patients with schizophrenia presented the greatest level of impairment across different phases of search, followed by patients with ADHD, who shared with patients with schizophrenia elevated intra-subject variability in the pre-search stage. ASD was the least impaired group, but similar to schizophrenia in post-search processes and to schizophrenia and ADHD in pre-search processes and fixation duration while scanning the items. Importantly, the profiles of deviancy from controls were highly correlated between all three clinical groups, in line with the continuum idea. Findings suggest the existence of one common neurodevelopmental continuum of performance for the three disorders, while quantitative differences appear in the level of impairment. Given the relevance of cognitive impairments in these three disorders, we argue in favour of overlapping pathophysiological mechanisms.

Williams syndrome: reduced orienting to other's eyes in a hypersocial phenotype

Williams syndrome (WS) is a rare genetic condition associated with high sociability, intellectual disability, and social cognitive challenges. Attention to others’ eyes is crucial for social understanding. Orienting to, and from other’s eyes was studied in WS (n = 37, mean age = 23, age range 9–53). The WS group was compared to a typically developing comparison participants (n = 167) in stratified age groups from infancy to adulthood. Typically developing children and adults were quicker and more likely to orient to eyes than the mouth. This bias was absent in WS. The WS group had reduced peak saccadic velocities, indicating hypo-arousal. The current study indicates reduced orienting to others’ eyes in WS, which may affect social interaction skills.

Disrupted Attention to Other's Eyes is Linked to Symptoms of ADHD in Childhood

Attention-deficit/hyperactivity disorder (ADHD) is associated with impaired social interaction. Other's eyes are important for understanding the social world. Here, we examined concurrent and longitudinal links between attention to other's eyes and symptoms of ADHD and comorbid externalizing and internalizing symptoms. Eighty-two 8 to 13-year-old children (40% with ADHD) participated. The latency to a first gaze shift to and away from the eye region of human faces, when primed to look at either the eyes or the mouth, was recorded with eye tracking. Parents rated ADHD, externalizing and internalizing symptoms at the time of testing and at 2-year follow-up. The results show that longer looking at the eyes before reorienting was specifically associated with concurrent and future symptoms of inattention, even when accounting for comorbid symptoms. We conclude that the temporal microstructure of attention to other's eyes is altered in children with symptoms of ADHD, which may contribute to social impairments.

Pupil dilation predicts individual self-regulation success across domains

Multiple theories have proposed that increasing central arousal through the brain's locus coeruleus-norepinephrine system may facilitate cognitive control and memory. However, the role of the arousal system in emotion regulation is less well understood. Pupil diameter is a proxy to infer upon the central arousal state. We employed an emotion regulation paradigm with a combination of design features that allowed us to dissociate regulation from emotional arousal in the pupil diameter time course of 34 healthy adults. Pupil diameter increase during regulation predicted individual differences in emotion regulation success beyond task difficulty. Moreover, the extent of this individual regulatory arousal boost predicted performance in another self-control task, dietary health challenges. Participants who harnessed more regulation-associated arousal during emotion regulation were also more successful in choosing healthier foods. These results suggest that a common arousal-based facilitation mechanism may support an individual's self-control across domains.

Can attachment predict core and comorbid symptoms of attention-deficit/hyperactivity disorder beyond executive functions and emotion regulation?

OBJECTIVE

Previous findings propose an association between attachment and symptoms of attention-deficit/hyperactivity disorder (ADHD). However, the predictive ability of attachment beyond deficits in executive functioning (EF) and emotion regulation is understudied.

METHOD

Using a dimensional perspective, we examined the longitudinal role of attachment on ADHD and comorbid symptoms, accounting for EF and emotion regulation. The sample consisted of 84 children (aged 8-13 years), oversampled for ADHD symptoms (42% had a diagnosis of ADHD). We assessed attachment with the Child Attachment Interview, EF with laboratory tests, and emotion regulation with parental ratings. Parents and teachers rated symptoms at baseline (T1) and at follow-up 2 years later (T2).

RESULTS

Attachment insecurity was positively correlated with ADHD symptoms at T2 but with no unique contribution to symptoms beyond EF and emotion regulation. In contrast, poor EF and emotion regulation contributed to more ADHD and ODD/CD symptoms at T2. Poor emotion regulation contributed to more anxiety at T2.

CONCLUSIONS

The results have important implications for understanding the mechanisms underpinning symptom expression in middle childhood/early adolescence and may guide the search for tailored interventions to reduce and prevent symptoms.

PRACTITIONER POINTS

Executive functions and emotion regulation should be explored as targets for intervention in personalized treatment. The current results do not support attachment as a target for intervention at a group level, although this does not rule out that individuals/families with attachment difficulties may benefit from training programmes promoting secure attachment bonds.

Equivalent Behavioral Facilitation to Tactile Cues in Children with Autism Spectrum Disorder

The alerting network, a subcomponent of attention, enables humans to respond to novel information. Children with ASD have shown equivalent alerting in response to visual and/or auditory stimuli compared to typically developing (TD) children. However, it is unclear whether children with ASD and TD show equivalent alerting to tactile stimuli. We examined (1) whether tactile cues affect accuracy and reaction times in children with ASD and TD, (2) whether the duration between touch-cues and auditory targets impacts performance, and (3) whether behavioral responses in the tactile cueing task are associated with ASD symptomatology. Six- to 12-year-olds with ASD and TD participated in a tactile-cueing task and were instructed to respond with a button press to a target sound /a/. Tactile cues were presented at 200, 400, and 800 ms (25% each) prior to the auditory target. The remaining trials (25%) were presented without tactile cues. Findings suggested that both groups showed equivalent alerting responses to tactile cues. Additionally, all children were faster to respond to auditory targets at longer cue–target intervals. Finally, there was an association between rate of facilitation and RRB scores in all children, suggesting that patterns of responding to transient phasic cues may be related to ASD symptomatology.

The Association between Low Blood Pressure and Attention-Deficit Hyperactivity Disorder (ADHD) Observed in Children/Adolescents Does Not Persist into Young Adulthood. A Population-Based Ten-Year Follow-Up Study

Background: Attention-deficit hyperactivity disorder (ADHD) is one of the most common behavioral disorders in childhood and adolescence associated with relevant psychosocial impairments. The basic pathophysiology of ADHD may be related, at least partly, to a deficit in autonomic arousal processes, which not only influence core symptoms of the disorder, but may also lead to blood pressure (BP) deviations due to altered arousal regulation. Objectives: This study examined long-term changes in BP in children and adolescents with ADHD up to young adulthood. Methods: In children and adolescents aged between 7 and 17 years at baseline, we compared BP recordings in subjects with (n = 1219, 11.1%) and without (n = 9741, 88.9%) ADHD over a 10-year follow-up using data from the nationwide German Health Survey for Children and Adolescents (KiGGS). Propensity score matching was used to improve the comparability between children in the ADHD and control groups with now n = 1.190 in each group. Results: The results of these matched samples revealed that study participants with ADHD showed significantly lower systolic BP (107.6 ± 10.7 mmHg vs. 109.5 ± 10.9 mmHg, p < 0.001, Cohen’s d = 0.17) and diastolic BP (64.6 ± 7.5 mmHg vs. 65.8 ± 7.4 mmHg, p < 0.001, Cohen’s d = 0.16) at baseline. In a sensitivity analysis with a smaller (n = 272) and more stringently diagnosed ADHD group, the significant differences remained stable with somewhat higher Cohen’s d; i.e., 0.25 and 0.27, respectively. However, these differences did not persist after 10-year follow-up in a smaller matched longitudinal sub-group (ADHD n = 273; control n = 323), as subjects with and without ADHD had similar levels of systolic (123.4 ± 10.65 vs. 123.78 ± 11.1 mmHg, p = 0.675, Cohen’s d = 0.15) and diastolic BP (71.86 ± 6.84 vs. 71.85 ± 7.06 mmHg, p = 0.992, Cohen’s d = 0.16). Conclusions: At baseline, children and adolescents with ADHD had significantly lower BP (of small effect sizes) compared to the non-ADHD group, whereas this difference was no longer detectable at follow-up ten years later. These developmental alterations in BP from adolescence to early adulthood may reflect changes in the state of autonomic arousal, probably modulating the pathophysiology of ADHD.