Identifying Game-Based Digital Biomarkers of Cognitive Risk for Adolescent Substance Misuse: Protocol for a Proof-of-Concept Study.

BACKGROUND: Adolescents at risk for substance misuse are rarely identified early due to existing barriers to screening that include the lack of time and privacy in clinic settings. Games can be used for screening and thus mitigate these barriers. Performance in a game is influenced by cognitive processes such as working memory and inhibitory control. Deficits in these cognitive processes can increase the risk of substance use. Further, substance misuse affects these cognitive processes and may influence game performance, captured by in-game metrics such as reaction time or time for task completion. Digital biomarkers are measures generated from digital tools that explain underlying health processes and can be used to predict, identify, and monitor health outcomes. As such, in-game performance metrics may represent digital biomarkers of cognitive processes that can offer an objective method for assessing underlying risk for substance misuse. OBJECTIVE: This is a protocol for a proof-of-concept study to investigate the utility of in-game performance metrics as digital biomarkers of cognitive processes implicated in the development of substance misuse. METHODS: This study has 2 aims. In aim 1, using previously collected data from 166 adolescents aged 11-14 years, we extracted in-game performance metrics from a video game and are using machine learning methods to determine whether these metrics predict substance misuse. The extraction of in-game performance metrics was guided by literature review of in-game performance metrics and gameplay guidebooks provided by the game developers. In aim 2, using data from a new sample of 30 adolescents playing the same video game, we will test if metrics identified in aim 1 correlate with cognitive processes. Our hypothesis is that in-game performance metrics that are predictive of substance misuse in aim 1 will correlate with poor cognitive function in our second sample. RESULTS: This study was funded by National Institute on Drug Abuse through the Center for Technology and Behavioral Health Pilot Core in May 2022. To date, we have extracted 285 in-game performance metrics. We obtained institutional review board approval on October 11, 2022. Data collection for aim 2 is ongoing and projected to end in February 2024. Currently, we have enrolled 12 participants. Data analysis for aim 2 will begin once data collection is completed. The results from both aims will be reported in a subsequent publication, expected to be published in late 2024. CONCLUSIONS: Screening adolescents for substance use is not consistently done due to barriers that include the lack of time. Using games that provide an objective measure to identify adolescents at risk for substance misuse can increase screening rates, early identification, and intervention. The results will inform the utility of in-game performance metrics as digital biomarkers for identifying adolescents at high risk for substance misuse. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/46990.

Evaluating the validity of game-based assessments measuring cognitive function among children and adolescents: A systematic review and meta-analysis.

Games offer advantages over traditional methods of assessing cognitive function among children and adolescents. However, the validity of game-based assessments has not been systematically evaluated. We conducted a systematic review and meta-analysis to assess the validity of game-based assessments measuring cognitive function among children and adolescents. We systematically searched several databases using pre-defined inclusion criteria. For papers that met the criteria, we extracted and analyzed the cognitive functions measured by each study, the correlation coefficients between game-based and traditional assessments, and factors that could influence the validity of game-based assessments. Our review identified 19 articles featuring 20 studies, 18 games, and 378 unique correlations between game-based and traditional assessments of cognitive function. Game-based assessments yielded significant correlations (n=282, 75%) with traditional assessments, over half of which were in the low to medium range in strength (r=0.3-0.69, n=227, 80%). Factors related to the child, such as age, gender, and prior gaming experience, may influence the validity of game-based assessments by modifying performance on game-based assessments. In addition, we found that game-based assessments that measured cognitive functions across more than one neurocognitive domain and used a prediction model for scoring were more likely to yield significant correlations. In contrast, including a narrative storyline in a game-based assessment was less likely to yield significant correlations. Most studies were of good quality, although the lack of sample size justification was a limiting factor. Further research is needed to elucidate the influence of identified factors on the validity of game-based assessment to justify the wide adoption of game-based assessments of cognitive function among children and adolescents.

Prognostic Discordance Among Parents and Physicians Caring for Infants with Neurologic Conditions.

OBJECTIVE: To determine the frequency, degree, and nature of prognostic discordance between parents and physicians caring for infants with neurologic conditions. STUDY DESIGN: In this observational cohort study, we enrolled parents and physicians caring for infants with neurologic conditions in advance of a family conference. Parent-physician dyads completed a postconference survey targeting expected neurologic outcomes across 3 domains (motor, speech, and cognition) using a 6-point scale. Prognostic discordance was defined as a difference of ≥2 response options and was considered moderate (difference of 2-3 response options) or high (difference of 4-5 response options). Responses were categorized as differences in belief and/or differences in understanding using an existing paradigm. RESULTS: Forty parent-physician dyads of 28 infants completed surveys. Parent-physician discordance about prognosis occurred in ≥1 domain in the majority of dyads (n = 28/40, 70%). Discordance was generally moderate in degree (n = 23/28, 82%) and occurred with similar frequency across all domains. Of parent-physician dyads with discordance, the majority contained a difference in understanding in at least 1 domain (n = 25/28, 89%), while a minority contained a difference of belief (n = 6/28, 21%). When discordance was present, parents were typically more optimistic in their predictions compared with physicians (n = 25/28, 89%). CONCLUSIONS: Differing perceptions about the prognosis of critically ill infants are common and due to differences in both understanding and belief. These findings can be used to develop targeted interventions to improve prognostic communication.

Adolescent and Young Adult Perspectives on Quality and Value in Health Care.

OBJECTIVE: To describe adolescent and young adult (AYA) perspectives on defining quality and value in health care and to gain understanding of their knowledge of value-based payment. METHODS: A text message-based survey was sent to a convenience sample of AYAs aged 14 to 24 in 2019. Participants were asked 4 open-ended questions: 1) how they would define "good health care," 2) what factors to consider in rating doctors, 3) whose opinions should matter most when rating doctors, and 4) the best ways to collect AYA opinions on doctors, and one yes/no question on their awareness of value-based payment. Analyses included descriptive demographic statistics and an inductive thematic approach with multivariable models comparing adolescent (14-18) and young adult (19-24) responses. RESULTS: Response rate was 61.0% (782/1283). Most participants were White (63.3%), female (53.3%), and adolescents (55.6%). Common themes from the first 2 questions included accessibility (specifically affordability), coverage benefits, and care experience (including compassion, respect, and clinical competence). Young adults more commonly mentioned affordability than adolescents (54.4% vs 43.3%, P = .001) and more commonly felt their opinion should matter more than their parents when rating doctors (80.6% vs 62.0%, P < .001). Only 21.0% of AYAs were familiar with the potential value-based link between physician payment and care quality. CONCLUSIONS: When considering quality and value in health care, AYAs expressed their desired agency in rating the quality of their care and clinicians. AYAs' perspectives on health care quality, including the importance of care accessibility and affordability, should be considered when designing youth-centered care delivery and value-based payment models.

Prognostic Discussion for Infants with Neurologic Conditions: Qualitative Analysis of Family Conferences.

OBJECTIVE: We characterize the content and role of prognostic discussion for infants with neurologic conditions. METHODS: In this descriptive qualitative study, we prospectively enrolled infants (age < 1 year) in the intensive care unit with a neurologic condition anticipated to have ≥1 family conference about prognosis or goals of care. We audiorecorded family conferences as they occurred. We used a rapid-cycle qualitative approach to identify and refine themes. RESULTS: Forty infants and 61 parents were enrolled; 68 family conferences occurred for 24 infants. The majority of infant cases (n = 23/24, 96%) and conferences (n = 64/68, 94%) included discussion of neurologic prognosis. Common infant diagnoses included prematurity (n = 12, 52%), genetic conditions (n = 9, 35%), and brain malformations (n = 7, 30%). We identified 2 themes relating to the characterization of the infant's prognosis: (1) predictions of impairment and (2) rationale for prognostic predictions. We identified 3 themes characterizing the role of prognostic discussion: (1) aligning parent and clinician understanding of infant outcome, (2) influencing decision-making, and (3) preparing for life at home. We identified 2 themes characterizing discussion of prognostic uncertainty: (1) multilayered types of uncertainty and (2) holding space for hope alongside uncertainty. INTERPRETATION: In this cohort of infants with neurologic conditions and their parents, we identified salient themes characterizing the content and role of discussion about neurologic outcome. Our findings highlight that prognostic discussion focuses on anticipated impairments, informs decision-making, and helps families prepare for home life. Future work should characterize whether these findings align with parent preferences for prognostic disclosure. ANN NEUROL 2022;92:699-709.

Assessment of parent understanding in conferences for critically ill neonates.

OBJECTIVES: This study aimed to characterize the use and impact of assessments of understanding in parent-clinician communication for critically ill infants. METHODS: We enrolled parents and clinicians participating in family conferences for infants with neurologic conditions. Family conferences were audio recorded as they occurred. We used a directed content analysis approach to identify clinician assessments of understanding and parent responses to those assessments. Assessments were classified based on an adapted framework; responses were characterized as "absent," "yes/no," or "elaborated." RESULTS: Fifty conferences involving the care of 25 infants were analyzed; these contained 374 distinct assessments of understanding. Most (n = 209/374, 56%) assessments were partial (i.e. okay?); a minority (n = 60/374, 16%) were open-ended. When clinicians asked open-ended questions, parents elaborated in their answers most of the time (n = 55/60, 92%). Approximately three-quarter of partial assessments yielded no verbal response from parents. No conferences included a teach-back. CONCLUSIONS: Although common, most clinician assessments of understanding were partial or close-ended and rarely resulted in elaborated responses from parents. Open-ended assessments are an effective, underutilized strategy to increase parent engagement and clinician awareness of information needs. PRACTICE IMPLICATIONS: Clinicians hoping to facilitate parent engagement and question-asking should rely on open-ended statements to assess understanding.