Intelligence tests have recently become popular assessment tools used by pediatric rehabilitation service agencies. According to a survey conducted in 2012, the number of agencies that have adopted the Wechsler Intelligence Scale for Children (WISC) and other intelligence tests is increasing [1]. Despite the popularity of individually administered intelligence tests, they have a serious drawback, i.e., their administration cost is not negligible. For example, the WISC - Fourth Edition (WISC-IV) [2] takes approximately 1–1.5 h to complete and should be administered by a psychologist or speech-language pathologist, who are not always available in many agencies. Taking account of this situation, it is worthwhile to develop a simple intelligence test utilizing information and communication technology.

This study examined the usability of a new cognitive assessment tool, the “Kids’ Brain Balancer” (hereinafter, the “Balancer”) [3]. The Balancer is a digital application developed by the LEDEX Corp. to assess cognitive function using a tablet. To test the validity of the Balancer, we calculated the correlations between the scores derived from the tool and those obtained by the WISC-IV. In addition, we investigated the sensitivity and specificity of the Balancer as a tool to identify children with low cognitive function.

The participants were 32 children (25 boys) aged 7–11 years (mean, 8.16 years; standard deviation [SD], 0.92) who were receiving special education services at different locations: one special education school (four children), two special education classes (12 children), and three after-school special education services (16 children). Before participation in the study, written informed consent was obtained. The study was approved by the Ethics Review Committee of the National Center for Child Health and Development (approval number 1355).

The Balancer is a digital application that can be implemented on iPads and other tablets. In the Balancer, the examinees are asked to complete the following 13 tasks: (1) Count the Blocks, (2) Cubic Fit, (3) Initial Letter, (4) Same Shape, (5) Flashing Lights, (6) Which Picture? (7) Catch the Mole, (8) Drag Race, (9) Same-Game, (10) Speed Touch, (11) Follow the Order, (12) Who am I? and (13) Matching Words. Among the 13 tasks, four (Count the Blocks, Cubic Fit, Same Shape, and Drag Race) measure visuospatial cognition, four (Initial Letter, Which Picture? Who am I? and Matching Words) evaluate language abilities, four (Catch the Mole, Same-Game, Speed Touch, and Follow the Order) assess executive function including attention and inhibition, and one (Flashing Lights) examines working memory. Additionally, performances on the Catch the Mole and Drag Race tasks are also influenced by motor ability. The raw scores for each of the subtests are obtained based on the task completion time and accuracy. The raw scores are then converted into index scores, taking account of the age of the examinees. Screenshots of six representative tasks are displayed in Figure 1.

Figure 1: The six main tasks of the Kids’ Brain Balancer.

1. Count the Blocks: state the number of blocks in the stack.
2. Cubic Fit: identify the same shape as the sample block in the center among the surrounding options.
3. Initial Letter: state the word that begins with the specified letter from the picture choices.
4. Flashing Lights: four lights of different colors will shine in succession. Remember their order and touch the lights in the correct order.
5. Which Picture?: listen to the task, understand its meaning, and choose an option.
6. Follow the Order: touch the buttons in the incremental order of the numbers on the playing cards.

The WISC-IV is an individually administered intelligence test for children aged 5–16 years that consists of 10 core subtests and five supplementary subtests. The scores obtained through this test are the Full-Scale Intelligence Quotient (FSIQ) and the four composite scores Verbal Comprehension Index (VCI), Perceptual Reasoning Index (PRI), Working Memory Index (WMI), and Processing Speed Index (PSI), all of which are standardized so that the means and SD are 100 and 15, respectively. The participants were administered the Balancer and WISC-IV in the same setting. For statistical analysis, we first calculated Pearson’s correlation coefficients between the index score for each task in the Balancer and the FSIQ and four composite scores of the WISC-IV. The correlation coefficients were interpreted following the guidelines provided by Mukaka [4]. We also examined the sensitivity and specificity of each index score of the Balancer for detecting intellectual disability using the WISC-IV FSIQ. The cut-off scores were set as 70 for the Balancer and WISC-IV. All statistical analyses were conducted using IBM® SPSS Statistics 27 software.

The means and SDs of the WISC-IV FSIQ and four composite scores were as follows: FSIQ: 82.55 ± 20.20; VCI: 87.44 ± 17.65; PRI: 84.25 ± 18.29; WMI: 83.91 ± 20.70; and PSI: 84.56 ± 19.05. Table 1 shows the correlations between the index scores of the Balancer and the WISC-IV FSIQ and four composite scores. Among the 13 tasks in the Balancer, the index scores on the Count the Blocks and Flashing Lights tasks showed high correlations (0.7 ≤ r < 0.9) with the WISC-IV FSIQ and PRI. Moderate correlations (0.5 ≤ r < 0.7) were also found between the index scores of eight other tasks and the WISC-IV FSIQ. As for the sensitivity of each Balancer task for detecting intellectual disability, high sensitivity (≥0.7) was found for the Count the Blocks, Which Picture? Who am I? And Matching Words tasks. while moderate sensitivity (≥0.5) was found for seven other tasks. Regarding specificity, 11 tasks showed high specificity (≥0.7).

Table 1: Correlations between Brain Balancer Kids Index and WISC-IV composite scores, sensitivity, and specificity for intellectual disability.

**Correlation coefficient significant at 1% level (two-tailed)

*Correlation coefficient is significant at 5% level (two-tailed)

FSIQ, Full Scale Intelligence Quotient; PSI, Processing Speed Index; PRI, Perceptual Reasoning Index; SD, standard deviation; VCI, Verbal Comprehension Index; WISC-IV, Wechsler Intelligence Scale for Children – Fourth Edition.

The aim of this study was to examine the usability of the Balancer. Our analyses showed that the index scores of 10 of the 13 tasks showed moderate or high correlations with the WISC-IV FSIQ, indicating that the Balancer can measure children’s intellectual abilities with some accuracy. Specifically, the Count the Blocks and Flashing Lights tasks, measuring visuospatial cognitive ability and visual working memory, respectively, showed high correlations with the FSIQ and PRI, and were found to be useful to understand general intelligence, visuospatial skills, and non-verbal reasoning. In addition, among the 13 tasks in the Balancer, Count the Blocks and the two language tasks Matching Words and Which Picture? Demonstrated high sensitivity and specificity for detecting low cognitive function, suggesting their applicability in the clinical setting as screening tools. In contrast, low correlations were found between the WISC-IV FSIQ/composite scores and the index scores of several tasks (e.g., catch the Mole and Drag Race). These tasks measure neuromotor and executive functioning, which are not measured directly by the WISC-IV.

As shown above, this study demonstrated that the Balancer can be useful as an assessment tool for cognitive function by comparing its index scores with the WISC-IV composite scores. While this study has several limitations, including limited sample size and diversity and incomplete standardization of the Balancer, it is considered important to attempt to validate a digital tool for the assessment of cognitive function [3], taking account of the merits of developing such a tool under the current worldwide situation, including the coronavirus disease 2019 pandemic. In future, it will be necessary to conduct a validation study with a larger number of samples, including children without developmental problems, and establish cut-off values.

This study found that the digital application “Kids Brain Balancer” can be useful as an assessment tool for cognitive function by comparing its index scores with the WISC-IV composite scores and demonstrated enough sensitivity and specificity to detect intellectual disability.

Conflicts of Interest: Hashimoto K owns shares of the LEDEX Corporation and receives royalties for the use of digital software copyrights. None of the other authors have any conflicts of interest to declare.

IRB Approval Code and Name of the Institution: Ethics Review Committee of the National Center for Child Health and Development (approval number 1355).

Informed Consent: Patients’ informed consent for the publication of this study was obtained.

Data Availability: The datasets analyzed during the current study are not publicly available due to study protocol and strict privacy protection.

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