Development and equivalence of new faces for inclusion in the Childhood Asthma Control Test (C-ACT) response scale.

BACKGROUND: Accurate symptom monitoring is vital when managing pediatric asthma, providing an opportunity to improve control and relieve associated burden. The CHILDHOOD ASTHMA CONTROL TEST (C-ACT) has been validated for asthma control assessment in children; however, there are concerns that response option images used in the C-ACT are not culturally universal and could be misinterpreted. This cross-sectional, qualitative study developed and evaluated alternative response option images using interviews with children with asthma aged 4-11 years (and their parents/caregivers) in the United States, Spain, Poland, and Argentina. Interviews were conducted in two stages (with expert input) to evaluate the appropriateness, understanding and qualitative equivalence of the alternative images (both on paper and electronically). This included comparing the new images with the original C-ACT response scale, to provide context for equivalence results. RESULTS: Alternative response option images included scale A (simple faces), scale B (circles of decreasing size), and scale C (squares of decreasing quantity). In Stage 1, most children logically ranked images using scales A, B and C (66.7%, 79.0% and 70.6%, respectively). However, some children ranked the images in scales B (26.7%) and C (58.3%) in reverse order. Slightly more children could interpret the images within the context of their asthma in scale B (68.4%) than A (55.6%) and C (47.5%). Based on Stage 1 results, experts recommended scales A (with slight modifications) and B be investigated further. In Stage 2, similar proportions of children logically ranked the images used in modified scales A (69.7%) and B (75.7%). However, a majority of children ranked the images in scale B in the reverse order (60.0%). Slightly more children were able to interpret the images in the context of their asthma using scale B (57.6%) than modified scale A (48.5%). Children and parents/caregivers preferred modified scale A over scale B (78.8% and 90.9%, respectively). Compared with the original C-ACT, most children selected the same response option on items using both scales, supporting equivalency. Following review of Stage 2 results, all five experts agreed modified scale A was the optimal response scale. CONCLUSIONS: This study developed alternative response option images for use in the C-ACT and provides qualitative evidence of the equivalency of these response options to the originals.

Accurate monitoring of the symptoms associated with pediatric asthma is important when managing the condition. The CHILDHOOD ASTHMA CONTROL TEST (C-ACT) is a questionnaire widely used to measure asthma severity in young children (aged 4­11 years). Each question answered by the child in the C-ACT has four possible answer choices. To help children answer, each choice is presented alongside an image of a male child's face ranging from sad to happy. However, there are concerns that the images used are not culturally universal and could be misinterpreted­due to difficulties translating to electronic formats and a lack of differentiation between the images used. Through interviewing children with asthma, we aimed to address these concerns by developing and testing new images. Alternative image options developed included simpler faces, circles of decreasing size and squares of decreasing quantity. Children aged 4­11 years old were interviewed to test whether they understood the response scale using the new images and if they answered in the same way as with the original images. Interviews were conducted in two stages, with expert guidance at key stages. Results showed that children can interpret and understand the newly developed images and that they answer the questions the same as they would using the original images. These new images have the advantages of being culturally neutral and easier to implement on an electronic device.

Shared attention for action selection and action monitoring in goal-directed reaching.

Dual-task studies have shown higher sensitivity for stimuli presented at the targets of upcoming actions. We examined whether attention is directed to action targets for the purpose of action selection, or if attention is directed to these locations because they are expected to provide feedback about movement outcomes. In our experiment, endpoint accuracy feedback was spatially separated from the action targets to determine whether attention would be allocated to (a) the action targets, (b) the expected source of feedback, or (c) to both locations. Participants reached towards a location indicated by an arrow while identifying a discrimination target that could appear in any one of eight possible locations. Discrimination target accuracy was used as a measure of attention allocation. Participants were unable to see their hand during reaching and were provided with a small monetary reward for each accurate movement. Discrimination target accuracy was best at action targets but was also enhanced at the spatially separated feedback locations. Separating feedback from the reaching targets did not diminish discrimination accuracy at the movement targets but did result in delayed movement initiation and reduced reaching accuracy, relative to when feedback was presented at the reaching target. The results suggest attention is required for both action planning and monitoring movement outcomes. Dividing attention between these functions negatively impacts action performance.

The role of attention in eye-movement awareness.

People are unable to accurately report on their own eye movements most of the time. Can this be explained as a lack of attention to the objects we fixate? Here, we elicited eye-movement errors using the classic oculomotor capture paradigm, in which people tend to look at sudden onsets even when they are irrelevant. In the first experiment, participants were able to report their own errors on about a quarter of the trials on which they occurred. The aim of the second experiment was to assess what differentiates errors that are detected from those that are not. Specifically, we estimated the relative influence of two possible factors: how long the onset distractor was fixated (dwell time), and a measure of how much attention was allocated to the onset distractor. Longer dwell times were associated with awareness of the error, but the measure of attention was not. The effect of the distractor identity on target discrimination reaction time was similar whether or not the participant was aware they had fixated the distractor. The results suggest that both attentional and oculomotor capture can occur in the absence of awareness, and have important implications for our understanding of the relationship between attention, eye movements, and awareness.

People are unable to recognize or report on their own eye movements.

Eye movements bring new information into our visual system. The selection of each fixation is the result of a complex interplay of image features, task goals, and biases in motor control and perception. To what extent are we aware of the selection of saccades and their consequences? Here we use a converging methods approach to answer this question in three diverse experiments. In Experiment 1, participants were directed to find a target in a scene by a verbal description of it. We then presented the path the eyes took together with those of another participant. Participants could only identify their own path when the comparison scanpath was searching for a different target. In Experiment 2, participants viewed a scene for three seconds and then named objects from the scene. When asked whether they had looked directly at a given object, participants' responses were primarily determined by whether or not the object had been named, and not by whether it had been fixated. In Experiment 3, participants executed saccades towards single targets and then viewed a replay of either the eye movement they had just executed or that of someone else. Participants were at chance to identify their own saccade, even when it contained under- and overshoot corrections. The consistent inability to report on one's own eye movements across experiments suggests that awareness of eye movements is extremely impoverished or altogether absent. This is surprising given that information about prior eye movements is clearly used during visual search, motor error correction, and learning.