Can virtual reality help in the treatment of ADHD?

Virtual-reality (VR) can be defined as an interactive computer-generated experience that can be similar to the real world or fantastical1. For instance, in a VR environment, a person is able to virtually live in the artificial world by looking and moving around it, as well as interacting with virtual characters or items2. Nowadays there are different kinds of VR environments, mainly used for entertainment purposes (e.g. video-games) or professional training (e.g. aviation, military training etc.)3. VR tools usually  range from a headset  (head-mounted displays with a small screens in front of the eyes), to proper full-scale rooms with bigger screens and special equipment  to increase the augmented reality experience.

Virtual reality head-mounted display. Image by Gerd Altmann from Pixabay.

VR has been recently investigated as a potential treatment for different metal health problems or psychiatric disorders such as social anxiety4, specific phobias5, post-traumatic stress disorder (PTSD)6, or persecutory delusions7. The key assumption behind the use of VR tools in mental health practice, relies in the fact that, in VR settings, individuals can repeatedly experience and learn appropriate coping strategies in a controlled environment8,9. For instance, knowing that the exposure is not real, allows people to face difficult situations and learn therapeutic strategies which they can then adopt in the real world.

..but how those VR tools can be used for the treatment of ADHD?

Recent evidence shows that VR can help enhance some of the core therapeutic challenges of ADHD such as attention, problem solving and managing impulsive behaviours10. For example, using VR can create virtual scenarios that can reward and empower skills such as response inhibition and emotional control10. One of the most commonly used scenarios is the class-room environment, which can introduce life-like distractions to asses children’s behaviour in an ecologically-based setting 10-11. In this virtual environment children with ADHD may be more able to use the trial-and-error instructional strategies to train learning skills11. For instance, in these VR settings, children with ADHD can also learn strategies to use in the real world without experiencing failures due to their experiences at school, making them more willing to accept the private feedback of the VR teacher.

Although VR ca be potentially used in ADHD treatment, is still an experimental procedure that needs more research to assess its validity. Also, there are still some concerns regarding potential side effects of long-term VR exposure, such as headaches, seizures, nausea, fatigue, drowsiness, disorientation, apathy, and dizziness10. Overall, despite its therapeutic potential, more studies are needed to assess its long-term treatment efficacy as well as the efficacy of VR environments compared to other non-pharmacological treatments already available for ADHD.

Isabella Vainieri and Jonna Kuntsi

Isabella Vainieri is a PhD student at the Social, Genetic & Developmental Psychiatry Centre at King’s College London.

Jonna Kuntsi is Professor of Developmental Disorders and Neuropsychiatry at King’s College London.

References

  1. Burdea, Grigore C. and Philippe Coiffet. Virtual Reality Technology. John Wiley & Sons, 2017.
  2. Rizzo AA, Buckwalter JG, Neumann U. Virtual reality and cognitive rehabilitation: a brief review of the future. J Head Trauma Rehabil. 1997;12:1–15.
  3. Johnson D. Virtual environments in army aviation training; Proceedings of the 8th Annual Training Technology Technical Group Meeting; Mountain View (CA), USA. 1994.
  4. . Maples-Keller JL, Bunnell BE, Kim SJ, Rothbaum BO. The Use of Virtual Reality Technology in the Treatment of Anxiety and Other Psychiatric Disorders. Harv Rev Psychiatry. 2017;25(3):103–113.
  5. Roy S, Kavitha R. Virtual Reality Treatments for Specific Phobias: A Review. Orient.J. Comp. Sci. and Technol;10(1).
  6. Rizzo A’, Shilling R. Clinical Virtual Reality tools to advance the prevention, assessment, and treatment of PTSD. Eur J Psychotraumatol. 2017;8(sup5):1414560. Published 2017 Jan 16. doi:10.1080/20008198.2017.1414560
  7. Freeman, D., Bradley, J., Antley, A., Bourke, E., DeWeever, N., Evans, N., Černis, E., Sheaves, B., Waite, F., Dunn, G., Slater, M., & Clark, D. (2016). Virtual reality in the treatment of persecutory delusions. British Journal of Psychiatry, 209, 62-67.
  8. Sanchez-Vives M, Slater M. From presence to consciousness through virtual reality. Nat Rev Neurosci 2005; 6: 332–9
  9. Slater M, Rovira A, Southern R, Swapp D, Zhang J, Campbell C, et al. Bystander responses to a violent incident in an immersive virtual environment. PLoS One 2013; 8: e52766.
  10. Bashiri A, Ghazisaeedi M, Shahmoradi L. The opportunities of virtual reality in the rehabilitation of children with attention deficit hyperactivity disorder: a literature review. Korean J Pediatr. 2017;60(11):337–343.
  11. Bioulac S, Lallemand S, Rizzo A, Philip P, Fabrigoule C, Bouvard MP. Impact of time on task on ADHD patient’s performances in a virtual classroom. Eur J Paediatr Neurol. 2012;16:514–521

ADHD and autism – similar or different disorders?

Have you ever thought that ADHD and autism could perhaps be the same disorder? – Or have you thought that they are way too different, two different planets in the psychiatric universe? Researchers do not agree on this. We know that both ADHD and autism are neurodevelopmental conditions with onset in childhood and that they share some common genetic factors, however, they appear with quite different phenotypical characteristics. We also know that people with ADHD or autism have an increased risk of getting other psychiatric disorders, so-called comorbidities, and smaller studies have shown that individuals with ADHD or autism get different psychiatric disorders, and at a different degree.

How can we utilize this knowledge about different psychiatric comorbidities between ADHD and autism? How can we get closer to an answer to this question; are ADHD and autism similar or different conditions? By using large datasets; unique population-based registries in Norway, we wanted to compare the pattern of psychiatric comorbidities in adults diagnosed with ADHD, autism or both disorders. In addition, we wanted to compare the pattern of genetic correlations between ADHD and autism for the same psychiatric traits, and for this, we exploited summary statistics from relevant genome-wide association studies.

In the registries, we identified 39,000 adults with ADHD, 7,500 adults with autism and 1,500 with both ADHD and autism. We compared these three groups with the remaining population of 1.6 million Norwegian adult inhabitants without either ADHD or autism. The psychiatric disorders we studied were anxiety, bipolar, depression, personality disorder, schizophrenia spectrum (schizophrenia) and substance use disorders (SUD).

Interestingly, we found different patterns of psychiatric comorbidities between ADHD and autism, overall and when stratified by sex (Fig.1). These patterns were also reflected in the genetic correlations, however, only two of the six traits showed a significant difference between ADHD and autism (Fig.2).

Figure 1 - Solberg et al. 2019
Figure 1. Prevalence ratios of psychiatric disorders in adults with ADHD, autism or both ADHD and autism, relative to the remaining population, by sex. As can be seen in the figure, schizophrenia is more frequent in autism or ADHD+autism than ADHD alone, while the reverse is true for substance use disorder. There are also significant differences in prevalence between men and women. Figure from Solberg et al. 2019, CC-BY-NC-ND.

Figure 2. Left: The pattern of prevalence ratios of psychiatric comorbidity in adults with ADHD or autism observed in this study (ADHD; n=38,636, autism; n=7,528). Right: genetic correlations (rg) calculated from genome wide association studies. Psychiatric conditions are highly prevalent in both ADHD and ASD, with schizophrenia being most prevalent in ASD and antisocial personality disorders in ADHD. Genetic correlations are also high with both disorders, with especially high correlations between ADHD and alcohol dependence, smoking behavior and anti-social behavoiur. Major depressive disorder has high genetic correlations with both ADHD and autism. Figure from Solberg et al. 2019, CC-BY-NC-ND.

The most marked differences were found for schizophrenia and SUD. Schizophrenia was more common in adults with autism, and SUD more common in adults with ADHD. Associations with anxiety, bipolar and personality disorders were strongest in adults with both ADHD and autism, indicating that this group of adults suffers from more severe impairments than those with ADHD or autism only. The sex differences in risk of psychiatric comorbidities were also different among adults with ADHD and ASD.

In conclusion, our study provides robust and representative estimates of differences in psychiatric comorbidities between adults diagnosed with ADHD, autism or both ADHD and autism. With the results from analyses of genetic correlations, this finding contributes to our understanding of these disorders as being distinct neurodevelopmental disorders with partly shared common genetic factors.

Clinicians should be aware of the overall high level of comorbidity in adults with ADHD, autism or both ADHD and autism, and the distinct patterns of psychiatric comorbidities to detect these conditions and offer early treatment. It is also important to take into account the observed sex differences. The distinct comorbidity patterns may further provide information to etiologic research on biological mechanisms underlying the pathophysiology of these neurodevelopmental disorders.

This study was done at Stiftelsen Kristian Gerhard Jebsen Centre for Neuropsychiatric disorders, University of Bergen, Norway, and published OnlineOpen in Biological Psychiatry, April 2019, with the title:

“Patterns of psychiatric comorbidity and genetic correlations provide new insights into differences between attention-deficit/hyperactivity disorder and autism spectrum disorder”. https://doi.org/10.1016/j.biopsych.2019.04.021

Figure 1 and 2 are re-printed by permission https://creativecommons.org/licenses/by-nc-nd/4.0/

Berit Skretting Solberg is a PhD-candidate at the Department of Biomedicine/Department of Global Health and Primary Care, University of Bergen, Norway. She is also a child- and adolescent psychiatrist/adult psychiatrist. She is affiliated with the CoCa-project, studying psychiatric comorbidities in adults with ADHD or autism, using unique population-based registries in Norway.

 

The cortex and ADHD: the second project of the ENIGMA-ADHD collaboration.

After the first project on subcortical brain volumes in ADHD, published in Lancet Psychiatry in 2017 , ENIGMA-ADHD now analysed cortical data of 2246 people with a diagnosis of ADHD and 1713 people without, aged between four and 63 years old.  The data came from 37 research groups from around the world. FreeSurfer (imaging software) parcellations of thickness and surface area of 34 cortical regions were compared between cases and controls in 3 separate age groups; children, adolescents and adults.

ENIGMAADHD2JPG

Subtle differences only in the group of children were found. The childhood effects were most prominent and widespread for the surface area of the cortex. More focal changes were found for thickness of the cortex. All differences were subtle and detected only at a group level, and thus these brain images cannot be used to diagnose ADHD or guide its treatment.

These subtle differences in the brain’s cortex were not limited to people with the clinical diagnosis of ADHD: they were also present – in a less marked form – in youth with some ADHD symptoms. This second finding results from a collaboration between the ENIGMA-ADHD Working Group and the Generation-R study from Rotterdam, which has brain images on 2700 children aged 9-11 years from the general population. The researchers found more symptoms of inattention to be associated with a decrease in cortical surface area. In a third study, using the NeuroImage data from Nijmegen and Amsterdam, familial effects on those regions that showed case-control differences were investigated.  Siblings of those with ADHD showed changes to their cortical surface area that resembled their affected sibling. This suggests that familial factors such as genetics or shared environment may play a role in brain cortical characteristics.

We identified cortical differences that are consistently associated with ADHD combining data from many different research groups internationally. We find that the differences extend beyond narrowly-defined clinical diagnoses and are seen, in a less marked manner, in those with some ADHD symptoms and in unaffected siblings of people with ADHD. This finding supports the idea that the symptoms underlying ADHD may be a continuous trait in the population, which has already been reported by other behavioural and genetic studies.’ In the future, the ADHD Working Group, which is led by Martine Hoogman and Barbara Franke from the Radboudumc in Nijmegen, hopes to look at additional key features in the brain- such as the structural connections between brain areas – and to increase the representation of adults affected by ADHD, in whom limited research has been performed to date.

Link to the article: Hoogman et al., Brain Imaging of the Cortex in ADHD: A Coordinated Analysis of Large-Scale Clinical and Population-Based Samples

To learn more about other projects that are carried out using ENIGMA-ADHD data, please also read the paper by Yanli Zhang-James and colleagues on bioRxiv. Here, the ENIGMA-ADHD data of the first and the second project were used to do prediction modelling.  

The ADHD Working Group is one of over 50 working groups of the ENIGMA Consortium, in which international researchers pull together to understand the brain alterations associated with different disorders and the role of genetic and environmental factors in those alterations. For more information about ENIGMA-ADHD please visit our website http://enigma.usc.edu/ongoing/enigma-adhd-working-group/ or contact Martine Hoogman martine.hoogman (at) radboudumc.nlenigma_300dpi

Epigenetic signature for attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) is considered a complex disorder caused by underlying genetic and environmental risk factors. To make it even more complex, environmental factors can influence the expression of genes. This is called epigenetics.

Given the large proportion of the heritability of ADHD still to be explained, there is a growing interest in the epigenetic mechanisms that modulate gene expression. microRNAs (miRNA) are small parts in the human genome that do not code for genes, but instead regulate the expression of other genes by promoting the degradation or suppressing the translation of those target genes. miRNA therefore provide a means to integrate effects of genetic and environmental risk factors.

The human genome encodes more than 2500 different miRNAs, the majority of which are expressed in the brain. miRNAs are known to be involved in the development of the central nervous system and in many neurological processes including synaptic plasticity and synaptogenesis. Given the limited accessibility of the human brain for studying epigenetic modifications, miRNA profiling in peripheral blood cells is often used as a non-invasive proxy to study transcriptional and epigenetic biosignatures, and to identify potential clinical biomarkers for psychiatric disorders.

We recently investigated the role of microRNAs in ADHD at a molecular level, by conducting the first genome-wide integrative study of microRNA and gene expression profiles in blood of individuals with ADHD and healthy controls. We identified three miRNAs (miR-26b-5p, miR-185-5p and miR-191-5p) that have different expression levels in people with ADHD, compared to those without ADHD. When we investigated downstream miRNA-mediated mechanisms underlying the disorder this provided evidence that aberrant expression profile of these three miRNA may underlie changes in the expression of genes related with myo-inositol signaling. This mediates the biological response of a large number of hormones and neurotransmitters on target cells. We also found that these miRNAs specifically targeted genes involved in neurological disease and psychological disorders.

These findings show that epigenetic modifications through microRNAs play a role in ADHD, and provide novel insights into how these miRNA-mediated mechanisms contribute to the disorder. In the future, these miRNAs may be used as peripheral biomarkers that can be easily detected from blood, as is shown in the figure.

What´s next?

The mechanism through which miRNAs modify gene expression is complex and dynamic. Therefore, future studies are required to provide deeper insights into the epigenetic mechanisms underlying ADHD, and to identify specific molecular networks that may be crucial in the development of the disorder.

Further reading

Cristina Sánchez-Mora et al. Epigenetic signature for attention-deficit/hyperactivity disorder: identification of miR-26b-5p, miR-185-5p, and miR-191-5p as potential biomarkers in peripheral blood mononuclear cells, Neuropsychopharmacology, volume 44, pages 890–897 (2019).

https://www.nature.com/articles/s41386-018-0297-0

About the author

Cristina Sánchez-Mora is postdoctoral researcher at the Psychiatry, Mental Health and Addictions group at Vall d’Hebron Institut de Recerca (VHIR). Her research is part of the CoCA consortium that investigates comorbid conditions of ADHD

Beneficial effects of high-intensity exercise on the attentive brain

Physical exercise and the brain

Emerging evidence from research studies suggests that physical activity can improve attention, brain function and well-being. In an attempt to understand more about the beneficial effects of high-intensity exercise, we recently conducted a study on the effect of PHysical Activity on Brain function (PHAB study). We examined whether cycling at a high intensity for 20 minutes would improve brain-activity (electroencephalography; EEG) measures of attention and focus during computerised tasks. We also aimed to investigate whether some individuals, for example those who are physically fit, would benefit more or less from exercise.

PHAb setup2

Does high-intensity exercise improve attention?

Participants (young adult men) were invited to our research centre, where they completed computer tasks while we recorded their brain activity. In the first task, they were asked to respond to letter ‘X’ following an ‘O’, but not to respond if another letter was presented after an ‘O’. Participants performed the task both before and after exercise and rest, and so we were able to test if their brain activity changed after exercise.

Task

We found that an attention measure called the “P3” was enhanced after exercise but not after rest. This suggests that the intense exercise session led to improvements in their attention. These improvements in attention from exercise were equal across participants, regardless of how physically fit they were.

The participants also performed two subsequent computer tasks, but we did not find improvements after exercise in these tasks. We believe that the beneficial effects of exercise may have worn off by the time that they performed these tasks.

These results suggest that intense exercise may improve attention. Exercise may therefore be beneficial for individuals with impairing levels of inattentive and restless behaviours, such as ADHD. This is currently being tested in the clinical trial CoCA (https://mind-the-gap.live/2018/10/09/10-weeks-of-physical-exercise-or-light-therapy/) (https://mind-the-gap.live/2017/02/18/coca-proud-trial-ready-to-roll/).

Read more about our study results at:

https://www.sciencedirect.com/science/article/pii/S0166432818308490

If you have any questions

Please feel free to contact Professor Jonna Kuntsi (jonna.kuntsi@kcl.ac.uk). The project was supported by a Medical Research Council studentship to Ebba Du Rietz.

Phelps

 

Ebba Du Rietz and Jonna Kuntsi

ADHD in ancient Greece?

One often hears that the first written description of ADHD stems from the book of the German physician Melchior Adam Weikard “Der Philosophische Arzt” (translated: “The philosophical doctor”) published in 1775. Other well-known old descriptions include for example George F. Still’s description from 1902 published in the Lancet, and Alexander Crichton’s description from 1798. However, this year a Brazilian research group published a report where they claim that the first know description of ADHD, or at least ADHD-like behavior, might be more than 2000 years old!*

The philosopher Theophrastus was a former pupil of Plato and Aristotle who lived in ancient Greece. In approximately 319 years BC he wrote “The Characters”, which essentially is a collection of texts that describes the behavior of 30 stereotypical characters where each character is devoted 10-15 phrases. One of these characters, “the obtuse man”, is an adult man who is described to have both inattention symptoms (forgets important appointments) and hyperactivity symptoms (tires out his children while playing). In addition, “the obtuse man” also has sleep problems and has problems with planning, which both are more common among individuals with ADHD than among those without.

Despite that it can be argued that the behavior of the “the obtuse man” is not a perfect description of typical ADHD, it is still interesting that the oldest known description of ADHD-like behavior describes these symptoms in an adult, in contrast to the later descriptions of ADHD-like behavior that are about children with these symptoms. Moreover, Theophrastus’ more than 2000-year-old text further supports that ADHD (and other psychiatric disorders) has been a part of human life as long as we have been humans.

*Victor MM, Bruna SdS, Kappel DB, Bau CH, Grevet EH. Attention-deficit hyperactivity disorder in ancient Greece: The Obtuse Man of Theophrastus. Aust N Z J Psychiatry. Jun 2018;52(6):509-513.

Tor-Arne Hegvik is medical doctor who is doing research on ADHD and its co-morbidities as a part of the CoCA project: https://coca-project.eu/

Picture from https://pixabay.com

Living day-to-day with ADHD and experience of the CoCA clinical trial

Below is a recent interview from a patient who took part in the PROUD study in London  I would like to thank him for taking the time to answer my questions, his articulate descriptions provide a fascinating insight into what it is like to live with ADHD on a daily basis and his reflections on the PROUD clinical trial, provide us, as researchers, a valuable insight into what it is like to participate from the perspective of a patient.

  1. What is it like to live with ADHD?

Please describe your main symptoms. Have your symptoms changed since childhood vs. adulthood?

I find myself easily distracted. It is very difficult for me to carry out long tasks that require a lot of attention or very tedious tasks. I have racing thoughts going through my head 24/7 and it is very difficult for me to shut them off and focus on what I am doing. I also find myself experiencing mood swings very often. I have multiple highs and lows throughout the day and it is very difficult for me to maintain a stable mood. Also, when I read it is very difficult for me to retain the information and remember what I have just read. I also have trouble trying to organize my thoughts and speak in fluent sentences because my mind is thinking about so many things and I just want to get all of them out.

I would say my symptoms have gotten worse as I transition into adulthood, but it could be because I am more aware of what is going on and the science behind it. I always had anxiety when I was a kid but never really depression. I notice that as I get older I find I get down into slumps and feel really unmotivated. That is the main difference from my childhood and adulthood experiences.

When were you diagnosed with ADHD? By whom? How did you feel about getting the diagnosis?

I was diagnosed when I was roughly 12 years old. I went to see a Doctor to get tested because my reading comprehension was very low and my test taking ability was terrible as well. They discovered that I had ADHD as well as Performance Anxiety.

As a kid, you never want to be told that there is something wrong with you, but it was good to know why I was having the thoughts I had and what exactly was going on. This led me to do extensive research on these mental illnesses and get a better understanding of what was going on and how to better handle my symptoms.

How have you been treated (medication/ psychotherapy)? What are the effects?

I was treated for my anxiety with Anti-depressants as a kid but came off of them due to them making me emotionally numb. I was never treated for my ADHD as a kid because the doctors thought that Anxiety was the main culprit of my problems, but I have actually discovered that ADHD is the main issue.

I did have a psychiatrist for a while as a kid, but I can’t remember much from the sessions and I don’t think they were very helpful. I did do CBT towards the end of 2017 and that did prove to be quite helpful. I just recently decided to get treated for my ADHD with medication just after I finished the Trial at Kings College because I felt that my symptoms were really beginning to affect my life. So I am currently on 40 mg Elvanse and I am on the waiting list for CBT to try and give psychotherapy another shot.

How does ADHD influence your life? (Work, friends/partnership, hobbies etc.)

I am an Actor, so remembering lines and understanding things thoroughly is absolutely crucial! My ADHD comes in the way a bit because sometimes I zone out and don’t completely listen to instructions or other actors. Also, reading scripts can be a bit difficult in trying to retain the information and focus on what I am reading.

I find that it hinders my relationships because I am a bit all over the place sometimes and do not give my friends or family the time or attention they deserve. I have also found that my ADHD causes regular mood swings so sometimes I am feeling depressed and do not feel like doing anything. This affects my work and relationships as well as my hobbies.

Do your friends/ colleagues know about your illness?

Yes, they do. I find it extremely important that everyone understands why I may act strange sometimes and also, they will understand me better. It is not something that I am ashamed of. It is just the way my brain works.

What is the worst thing about having ADHD?

The biggest issues are not being able to focus or getting easily distracted. Another of the big issues I have is the depression side of things. It also drains all of my energy and I end up not feeling like doing anything.

Do you think ADHD has any positive influences in your life?

One of the big benefits of having ADHD is always planning everything! I have to always be very prepared, but it is also a bad thing because it causes me anxiety sometimes. But then again, I don’t believe I would be the same person I am now if I didn’t have these issues.

  1. Study and Intervention

How did you learn about the study?

I believe I learned about the study from the Clinicaltrials.org website.

What motivated you to participate?

I absolutely love psychology and I am always interested in learning about the things that affect me personally. I am always doing research on mental health because it allows me to get a better understanding of what is happening on a more scientific level. It gives me more insight and allows me to better deal with my symptoms.

What were your expectations about the study before you started?

I expected to get a better understanding of ADHD and even finding a new strategy on coping with my symptoms.

Which intervention did you participate in, when?

Exercise intervention.

What did you like about the intervention? What did you dislike?

I liked the fact that it kept me busy and it also forced me to be proactive and accountable because I couldn’t lose the phone or the wrist band tracker. It made me work on that aspect of my ADHD because I do tend to forget to do things and I am always losing things. I also found that my depression is onset when I am not doing anything so having to be accountable for this exercise and doing what I was supposed to do kept my mind busy.

The only thing I didn’t like was the wrist band and having the wear it all the time because it is quite unattractive, and I do travel a lot so having to keep it while traveling it abroad and charging everything was just a bit overwhelming.

Was the intervention helpful? (Any effects on ADHD core symptoms, mood, sleep, weight, fitness etc.?)  

I am already a very active person, so it didn’t really change anything as far as fitness goes. It helped my sleep patterns because I was more aware of how much I was sleeping because I had to write it down. I feel like it helped my mood a bit because I was focused on phone ringing and answering the questions, so my mind was wandering off and causing me depression.

Was it difficult/easy to use the App?

The app was extremely easy to use but it was a bit tedious when it would go off every hour or so and was a bit annoying when I was busy or working. Not to mention that I couldn’t cover up the tracker with a sleeve or a jacket because of the light sensor.

Would you recommend other people with ADHD to participate in the study? Why?

Yes I would because I feel like it gives people a better understanding of their mental health and gives them some helpful things that they can take away from the study to implement into their life. Having a mental illness does not mean you are less of a person or less capable, but it is just important to understand what is going on. If you understand what is causing the symptoms, then it is easier to find ways to overcome these issues.

 Any suggestions/ways that the researchers could improve the experience for people in this study?

I would recommend updating the technology and having a more advanced wrist band sensor that looks more like a watch like apple watches or fitbits. It is an amazing study and I am very happy with how it was conducted. I wish I could offer more ways that you could improve the study, but my experience has been extremely satisfying.

Adam Pawley is a clinical neuroscientist at King’s College London. He is running the CoCA PROUD trial in London.