Diagnostic Discrimination of BOKE STARS, a Bimodal Continuous Performance Test, for Attention-Deficit/Hyperactivity...

Attention-deficit/hyperactivity disorder (ADHD) affects 6.3% of Chinese children, but only 10% are diagnosed, as diagnosis is hindered by low awareness and lack of culturally adapted, objective tools. Existing continuous performance tests are unimodal and lack validity.

This study aimed to conduct an initial evaluation of the diagnostic discrimination of BOKE STARS (Sustained Task and Attention Response Screening), a culturally adapted bimodal continuous performance test, for distinguishing children with ADHD from typically developing children in a Chinese clinical setting.

In this prospective, single-center diagnostic accuracy study with a case-control design, 100 children aged 6 to 12 years (n=50 with ADHD and n=50 controls) were recruited at Xinhua Hospital between January and May 2024. Parents completed the Swanson, Nolan, and Pelham Rating Scale-fourth version (SNAP-IV), and children completed the BOKE STARS assessment on a tablet device under standardized conditions. Group comparisons were conducted using independent-sample 2-tailed t tests or Mann-Whitney U tests, as appropriate. Receiver operating characteristic (ROC) curve analysis was performed in the full case-control sample to assess diagnostic discrimination. Sensitivity and specificity were reported descriptively across ROC-derived cutoffs; these cutoffs were not interpreted as clinically validated diagnostic thresholds. Secondary exploratory analyses included comparisons among ADHD subtypes and correlations between BOKE STARS indices and parent-reported SNAP-IV symptom severity scores.

Compared with controls, children with ADHD performed significantly worse on all major BOKE STARS indices, including errors of omission, errors of commission, reaction time, reaction time variability (RTV), discrimination prime, and total score. In the full case-control sample, the total score showed the strongest diagnostic discrimination (area under the ROC curve [AUC] 0.962, 95% CI 0.931-0.992), followed by RTV (AUC 0.919, 95% CI 0.867-0.971), errors of omission (AUC 0.884, 95% CI 0.818-0.950), and discrimination prime (AUC 0.819, 95% CI 0.737-0.900). Errors of commission (AUC 0.689, 95% CI 0.585-0.792) and reaction time (AUC 0.634, 95% CI 0.524-0.743) showed comparatively weaker discrimination. No significant differences were observed among ADHD subtypes. Several BOKE STARS indices were modestly correlated with SNAP-IV inattention and hyperactivity or impulsivity scores.

BOKE STARS showed promising preliminary diagnostic discrimination for identifying Chinese children with ADHD in this case-control sample, with the total score and RTV showing the strongest discriminatory performance. However, because the case-control design artificially fixed the ratio of ADHD cases to controls, diagnostic performance estimates and exploratory cutoffs should be interpreted cautiously and should not be considered representative of real-world clinical diagnostic performance. BOKE STARS may serve as an adjunctive assessment tool to complement clinical interviews and caregiver-reported rating scales, but further external validation in larger and clinically heterogeneous populations is required before broader clinical implementation.