# A Digital Tool for Assessing the Distinct Effects of Depression, Anxiety, and Attention-Deficit/Hyperactivity Disorder (ADHD) on Children’s Emotional Cognitive Bias: Cross-Sectional Study

## TL;DR

A digital tool was developed to assess how depression, anxiety, and ADHD affect children's emotional and cognitive abilities, showing promising results for early mental health monitoring.

## Contribution

A gamified digital tool was created to dissociate and assess distinct emotional cognitive biases in children related to depression, anxiety, and ADHD.

## Key findings

- General attention improved with age, but emotion-attention interactions did not.
- Children with higher depression symptoms showed slower response times.
- Anxious and depressed children had reduced selective attention to emotional stimuli.

## Abstract

Emotional wellness and healthy neurocognitive development are crucial from early childhood. An imbalance in attentional and emotional regulation system is associated with an increased risk of depression, anxiety, and attention-deficit/hyperactivity disorder (ADHD). Early assessment of these risks is essential, but it is difficult to conduct cognitive tests that are both child-friendly and able to dissociate different behavioral biases.

This study aimed to develop a digital app–based tool designed for young children to objectively assess cognition-affect interactions and examine the association with standardized scales for anxiety, depression, and ADHD.

In this cross-sectional study, 78 healthy children (36 female) aged 4-10 (mean 7.2, SD 1.4) years with no history of mental illness were recruited from the local community center and children’s museum. Emotional regulation and attentional control were assessed using an animated emotional Flanker task, emotional Stroop task, and emotional Go/No-Go task on a touchscreen computer. Children’s current mental health was measured using self-reported depression and anxiety states through the Center for Epidemiological Studies Depression Scale for Children (CES-DC) and State-Trait Anxiety Inventory for Children (STAI-CH), while the ADHD risk was assessed using the Korean ADHD Rating Scale (K-ARS) for parents. Principal component analysis was applied to behavioral measures across the tasks to group them by similarities and extract 3 abstract scores (“E-scores”) representing different aspects of cognitive function (attention, selective inhibition, and emotional sensitivity). Associations between E-scores and mental health or ADHD risk were then tested.

There was a significant improvement in general attention across development (Pearson correlation between E-score 1 and age: r=–0.75; P<.001; 2-sided α=.05) but not emotion-attention interactions. Performance was also correlated with mental health scales. First, children with higher depression symptoms (ie, higher CES-DC) were slower in their responses in general (ie, higher E-score 1; Pearson correlation after controlling for age: r=0.29; P=.04). Second, both anxious and depressed (ie, higher STAI-CH and CES-DC) children demonstrated reduced attention selectively to the emotional stimuli as indicated by elongated RT and lower accuracy (ie, higher E-score 2; anxiety: r=0.34; P=.02; depression: r=0.51; P<.001). Lastly, children with higher ADHD scales (ie, higher Korean ADHD Rating Scale [K-ARS]) showed lower accuracy across the three tasks, particularly for emotional stimuli (ie, lower E-score 3; r=–0.32; P=.03).

By combining well-established emotional cognitive tasks with our dimensionality reduction techniques, we extracted individual affective-cognitive characteristics from diverse but noisy behavioral patterns and identified their association with mental health and ADHD-related symptoms in children. These results demonstrate the scientific validity, versatility, and translational potential of our gamified digital assessment tool for monitoring young children’s affective and cognitive health in daily life. Future longitudinal studies in children with formal clinical diagnoses will further strengthen the generalizability of these findings.