814983

research-article2018
EEGXXX10.1177/1550059418814983Clinical EEG and NeuroscienceChow et al

Psychiatry/Psychology
Clinical EEG and Neuroscience

Entropy-Based Quantitative
2019, Vol. 50(3) 172­–179
© EEG and Clinical Neuroscience
Society (ECNS) 2018
Electroencephalogram Analysis for Article reuse guidelines:
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Diagnosing Attention-Deficit DOI: 10.1177/1550059418814983

https://doi.org/10.1177/1550059418814983
journals.sagepub.com/home/eeg

Hyperactivity Disorder in Girls

Julie Chi Chow1, Chen-Sen Ouyang2, Chin-Ling Tsai3, Ching-Tai Chiang4,

Rei-Cheng Yang5, Rong-Ching Wu6, Hui-Chuan Wu5, and Lung-Chang Lin5,7

Abstract
Diagnosis of attention-deficit hyperactivity disorder (ADHD) is currently based on core symptoms or checklists; however,
the inevitability of practitioner subjectivity leads to over- and underdiagnosis. Although the Federal Drug Administration has
approved an elevated theta/beta ratio (TBR) of the electroencephalogram (EEG) band as a tool for assisting ADHD diagnosis,
several studies have reported no significant differences of the TBR between ADHD and control subjects. This study detailed
the development of a method based on approximate entropy (ApEn) analysis of EEG to compare ADHD and control groups.
Differences between ADHD presentation in boys and girls indicate the necessity of separate investigations. This study enrolled
30 girls with ADHD and 30 age-matched controls. The results revealed significantly higher ApEn values in most brain areas in the
control group than in the ADHD group. Compared with TBR-related feature descriptors, ApEn-related feature descriptors can
produce the higher average true positive rate (0.846), average true negative rate (0.814), average accuracy (0.817), and average
area under the receiver operating characteristic curve value (0.862). Therefore, compared with TBR, ApEn possessed the better
potential for differentiating between girls with ADHD and controls.

Keywords
ADHD, entropy, theta/beta ratio, girl, EEG

Received July 31, 2018; revised October 9, 2018; accepted 30 October, 2018

Introduction However, subjectivity involved in determining the criteria or

Attention-deficit hyperactivity disorder (ADHD) is a common
childhood developmental condition characterized by symptoms
of inappropriate behavior, inattention, and/or hyperactivity-
impulsivity.1 The prevalence of ADHD in school children is
estimated to be 3% to 7%, and is more commonly diagnosed in
boys than in girls (range determined by ratios between 3:1 and
9:1).1,2 Although boys are more likely to have ADHD, girls with
ADHD are less hyperactive but more inattentive and are more
likely to develop depression and anxiety disorders than boys
with ADHD.3,4 One study reported that girls with ADHD are
also more likely to exhibit behaviors such as high emotional
reactivity and excessive talking than excess motor activity.4
These differences suggest variance in ADHD mechanisms
between the sexes. Therefore, to better understand the nature of
ADHD in the different sexes, this study included only girls.
The diagnosis of ADHD is primarily dependent on criteria
within the Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-5), and in addition to these crite-
ria, some physicians use checklists to assist ADHD diagnosis.
using checklists can lead to over- and underdiagnosis.5,6 To
overcome these problems, some researchers have used a quanti-
tative electroencephalogram (QEEG) as a marker in diagnosis.
Initially, the most consistent finding was increased absolute
1
Department Pediatrics, Chi-Mei Medical Center, Tainan
2
Department of Information Engineering, I-Shou University, Kaohsiung
3
Department of Neurology, Kaohsiung Municipal Siaogang Hospital, Kaohsiung
4
Department of Computer and Communication, National Pingtung
University, Kaohsiung
5
Departments of Pediatrics, Kaohsiung Medical University Hospital,
Kaohsiung Medical University, Kaohsiung
6
Department of Electrical Engineering, I-Shou University, Kaohsiung
7
Department of Pediatrics, School of Medicine, College of Medicine,
Kaohsiung Medical University, Kaohsiung
Corresponding Author:
Lung-Chang Lin, Department of Pediatrics, Kaohsiung Medical University
Hospital, Kaohsiung Medical University, 807, #100, Tzu-you 1st Road,
Kaohsiung City, 807.
Email: lclin@kmu.edu.tw
Full-color figures are available online at journals.sagepub.com/home/eeg
Chow et al 173
power in the theta EEG band in children with ADHD,7-10 but
some studies have also reported a decreased beta band.11,12 The
theta/beta ratio (TBR) was subsequently approved by the
Federal Drug Administration (FDA) as a tool for assisting
ADHD diagnosis.13 The TBR is the ratio of spectral power in
the theta frequency band (4-7 Hz) relative to the power in the
faster beta frequency band (13-21 Hz) and is sometimes mea-
sured at a single electrode site (Cz) during rest. However, in
recent years, elevated TBR has not been replicated in at least 5
studies with both children and adults.14-19 Buyck and Wiersema17
used a cross-sectional analysis with logistic regression and
reported that TBR demonstrated an accuracy of only 49.2% to
54.8% in predicting ADHD; similarly, Liechti et al18 reported a
diagnostic accuracy of 53%. Furthermore, in the largest TBR
study to date, no significant differences were discovered in a
comparison of 562 children, adolescents, and adults with ADHD
and 309 non-ADHD controls, although both moderate heteroge-
neity and psychiatric comorbidity were attributed to ADHD
subtypes.19
Because EEG signals are closer to nonlinear models than to
linear models, many nonlinear methods have been successfully
employed in EEG time-series analyses, thus enabling the extrac-
tion of meaningful information about neurophysiological pro-
cesses in the brain that are unobtainable through linear analysis.20,21
When used to analyze EEG data, these methods can improve our
understanding of the pathophysiology of ADHD.22,23 In addition
to nonlinear, the EEG signals are considered chaotic. There is an
effective tool for prediction and characterization of EEG.
Applying the concept of entropy to EEG is a way to quantify, in
a statistical sense, the amount of chaos or uncertainty in the
EEG. In other words, entropy measures roughly equate to the
possible configurations or the predictability contained in the
EEG. Higher entropy represents higher uncertainty and more
chaotic signals.24 Furthermore, in the possible nonlinear mea-
sures, approximate entropy (ApEn) is particularly useful for
short, noisy time series because it can provide a potent, model-
independent, and information-theoretic estimation of dynamical
complexity.25,26 Because EEG data are short and noisy time series,
they constitute ideal candidates for entropy-based analysis.27 For
example, Weng et al28 and Lu et al29 analyzed EEG by sample
entropy and multiscale entropy methods in comparing between
children with Tourette syndrome and controls, and predicting
long-term prognosis of neonatal seizure. In another study, multi-
scale entropy was used to analyze EEG in patients with autism
spectrum conditions and controls.30 In addition, ApEn was also
used for the detection of epilepsy by Srinivasan et al.31 The find-
ings regarding the use of the TBR in patients with ADHD are
inconsistent, this study aims to develop a new method using
entropy-based QEEG analysis to assist the diagnosis of ADHD.
Materials and Methods
Subjects
Because distinct mechanisms are believed to underpin ADHD
in males and females, the study cohort comprised only female
subjects: 30 girls with inattention type ADHD and 30
age-matched control subjects. All children were examined by a
pediatric neurologist or psychiatrist and received an EEG eval-
uation. None of the girls were taking medication at the time of
testing, and children with histories of epilepsy, mental retarda-
tion, drug abuse, head injury, and psychotic disorders were
excluded. A diagnosis of ADHD was made according to the
DSM-5 criteria. Depending on the symptoms presented,
patients diagnosed with one of the three ADHD subtypes,
namely the inattentive, hyperactive/impulsive, and combined
subtypes. Patients diagnosed with the inattentive subtype pri-
marily have inattentive symptoms and few or no symptoms of
hyperactivity; those diagnosed with the hyperactive/impulsive
subtype mainly have hyperactive or impulsivity and few or no
symptoms of inattentiveness; and those diagnosed with the
combined subtype have both inattentiveness and hyperactivity.
Written informed consent was obtained from a family member
or legal guardian for each subject. This study was approved by
the Institutional Review Board of the Kaohsiung Medical
University Hospital (KMUIRB-SV(I)-20150052). Figure 1
shows the flowchart of all processing steps, including EEG
acquisition, feature extraction, statistical analysis, and classifi-
cation analysis, which are described as follows.
EEG Acquisition
Identical equipment and procedures were used in EEG acquisi-
tion for the ADHD and control groups. ADHD patients under-
went EEG examinations with their eyes closed for 20 minutes
prior to being receiving any treatment. Subjects were tested in a
quiet, air-conditioned room that contained recording equipment
and the person conducted the experiment. All recordings were
made during the daytime (between 08:00 am and 05:00 pm).
EEG recordings were digitally obtained using 21 electrodes at a
sampling rate of 256 Hz (EBNeuro Mizar 33, Florence, Italy).
Amplifier characteristics were bandpass filtered between 0.5 Hz
and 60 Hz with 10 000 times gain, and electrodes were arranged
based on the international 10-20 system.
Feature Extraction
As previously mentioned, this study enrolled 60 female sub-
jects, who were divided into ADHD and control groups. For
each subject, artifact-free EEG segments were acquired.
Eighteen channels of monopolar montage (“FP1,” “FP2,” “F7,”
“F3,” “FZ,” “F4,” “F8,” “T3,” “T5,” “T4,” “T6,” “C3,” “C4,”
“P3,” “PZ,” “P4,” “O1,” “O2”) were adopted for analysis. To
enable an unbiased comparison, artifacts caused by eye move-
ments and muscle activity were removed manually after visual
examination in the preprocessing step.32 All EEG segments
were acquired from artifact-free sections of EEG recordings
conducted while participants were awake. To characterize the
EEG segments of each subject, 2 types of EEG features, ApEn
and TBR, were first computed from each channel signal in a
window-by-window manner. The window size was set to 5 sec-
onds. The calculations of ApEn25,26 and TBR are presented as
follows. Let x =  x (1) , x ( 2 ) , …, x ( N )  be the sample sequence
of a channel signal with length N. A set of sample vectors,
174 Clinical EEG and Neuroscience 50(3)

Figure 1.  Flowchart of our proposed method.

X = { xi | i = 1, 2, …, N − m + 1} where xi = [x(i), x(i+1),…, where r is a parameter of the filtering level and Φ ( r ) is

m

x(i+m–1)], were further obtained from X. The distance between defined as follows:
vectors xi and x j was defined as
1
∑
N − m +1
Φm ( r ) = ln Cim ( r ) .
( ) ( )
d xi , x j = max k =1, 2,…, m x ( i + k − 1) − x ( j + k − 1) . N − m +1 i =1

ApEn ( m, r , N ) was calculated using the following

For each xi , Ci ( r ) was calculated using the following
m
equation:
equation:

∑ ( )
N − m +1
{1 | d xi , x j ≤ r} ApEn ( m, r , N ) = Φ m ( r ) − Φ m +1 ( r ) .
Cim (r ) = j =1
N − m +1
Chow et al 175
Moreover, TBR was calculated using the following equation:
RelPow ( θ )
TBR =
RelPow ( β )
where RelPow ( θ ) and RelPow ( β ) denote the relative power
of the theta band and beta band, respectively. Then, the average
of all values of each type of EEG feature, ApEn or TBR, cor-
responding to the same channel was calculated. Finally, 2 data-
sets corresponding to ApEn- and TBR-related feature
descriptors, respectively, were obtained. In each dataset, 60
feature-label data extracted from 30 ADHD and 30 control sub-
jects, as mentioned above, were included. Each feature-label
data was described with values of 18 feature descriptors corre-
sponding to adopted 18 channels and the corresponding label
of group, ADHD or control.
Classification Analysis
To compare the discriminant power of ApEn-related and TBR-
related feature descriptors, a classification analysis based on
principal component analysis (PCA) and logistic regression
was made. PCA is a popular feature reduction approach in
which a set of N observations of M possibly correlated feature
descriptors are transformed into a set of values of min ( N − 1, M )
linearly uncorrelated principal components (PCs) by an orthog-
onal transformation. Note that the first PC possesses the largest
possible variance and each succeeding component in turn pos-
sesses the highest possible variance under the constraint that it
is orthogonal to the preceding components. Feature reduction
is performed by preserving values corresponding to the first K,
K < M , PCs and discarding the others. Therefore, the feature
dimension of dataset is reduced from M to K. Logistic regres-
sion is an approach for estimating parameters of a logistic
model in which a logistic function is used to model a binary
output variable (target). In the logistic model, the value of
binary output variable is represented by “0” or “1.” The loga-
rithm of the odds (log-odds) for the output value “1” is a linear
combination of feature variables and is converted to a probabil-
ity by the logistic function. Since the model only produces the
probability of output, a threshold can be chosen to make a
binary result for a binary classification problem.
In this study, resampling strategies were employed to
evaluate the classification performance. The whole dataset
was randomly divided into a training set and a test set in a
size ratio of 9:1. The above splitting of dataset was repeated
20 times and therefore 20 training sets and the corresponding
20 test sets were obtained. A classification model was trained
on each training set by logistic regression and label predic-
tions (ADHD or control) were made on the corresponding
test set. Moreover, 10-fold cross-validation approach was
applied for turning parameters in each model training pro-
cess. The prediction results of each test set were further eval-
uated by four performance indices, including accuracy
(ACC), area under the curve of receiver operating character-
istic curve (AUC), true positive rate (TPR), and true negative
rate (TNR). In this study, TPR is the rate that the label
“ADHD” is predicted correctly for all ADHD subjects; TNR
is the rate that the label “control” is predicted correctly for all
control subjects; ACC is the rate that the label is predicted
correctly for all subjects; AUC is the area under the curve of
receiver operating characteristic curve which is produced by
plotting the TPR against the false positive rate (FPR) at vari-
ous threshold values. Note that FPR is the rate that the label
“ADHD” is predicted incorrectly for all control subjects.
Finally, values of each performance index corresponding to
20 test sets were aggregated by calculating the mean for rep-
resenting the classification performance of the correspond-
ing dataset.
Statistical Analysis
All statistical analyses were conducted using SAS V9.3 (SAS
Institute Inc, Cary, NC). Data are shown as mean ± SD. To
evaluate the statistical significance of each feature descriptor,
the Wilcoxon rank sum test was applied to compare means of
feature values between ADHD and control groups. The reason
of using the nonparametric test, Wilcoxon rank sum test,33
instead of the parametric test, t test, is that through a normality
checking process with the Shapiro-Wilk test,34 only the 18
ApEn-related feature descriptors were statistically significant
with the significance level .05 (ie, P < .05) in both groups. In
other words, the 18 TBR-related feature descriptors violated
the normality assumption of the t test. By the Wilcoxon rank
sum test, a feature descriptor with P < .05 is considered as
statistically significant.
Results
All ADHD patients enrolled in this study were diagnosed with
the inattention subtype. The mean age of the ADHD group was
7 years and 10 months ± 2 years and 2 months, and that of the
non-ADHD group was 8 years and 1 month ± 2 years. No sig-
nificant difference in age distribution was observed between
the 2 groups.
Comparison of ApEn Between ADHD and Control
Groups
In this study, we compared the ApEn between patients with
ADHD and controls. All average ApEn values for different
EEG channels were higher in controls than in patients with
ADHD. Among these 18 EEG channels, significant differences
in average ApEn values were observed across the 12 channels,
including F3 (P = .026), Fz (P = .027), F4 (P = .008), C3 (P
= .036), C4 (P = .023), T5 (P = .003), P3 (P = .001), Pz (P =
.005), P4 (P = .006), T6 (P = .011), O1 (P = .006), and O2 (P
= .007) (Table 1).
176 Clinical EEG and Neuroscience 50(3)

Table 1.  Comparison of ApEn Between ADHD and Control Table 2.  Comparison of TBR Between ADHD and Control
Groups in Different Channels. Groups in Different Channels.

Channel ADHD Control P Channel ADHD Control P

AppEntropy_FP1_avg 1.030 ± 0.069 1.056 ± 0.064 .155 Theta/Beta_FP1_avg 10.962 ± 6.401 10.559 ± 5.240 0.901
AppEntropy_FP2_avg 1.028 ± 0.069 1.054 ± 0.057 .075 Theta/Beta_FP2_avg 10.906 ± 6.364 10.232 ± 4.807 0.994
AppEntropy_F7_avg 1.031 ± 0.080 1.050 ± 0.053 .208 Theta/Beta_F7_avg 11.086 ± 7.559 10.214 ± 4.622 0.866
AppEntropy_F3_avg 1.041 ± 0.071 1.082 ± 0.057 .026* Theta/Beta_F3_avg 10.042 ± 6.737 8.107 ± 4.030 0.542
AppEntropy_FZ_avg 0.995 ± 0.064 1.032 ± 0.054 .027* Theta/Beta_FZ_avg 12.571 ± 7.688 10.725 ± 4.862 0.687
AppEntropy_F4_avg 1.042 ± 0.067 1.086 ± 0.048 .008* Theta/Beta_F4_avg 9.355 ± 5.894 7.785 ± 3.941 0.572
AppEntropy_F8_avg 1.031 ± 0.077 1.050 ± 0.053 .168 Theta/Beta_F8_avg 11.066 ± 7.665 10.192 ± 4.539 0.752
AppEntropy_T3_avg 1.068 ± 0.093 1.065 ± 0.051 .708 Theta/Beta_T3_avg 10.329 ± 6.992 10.162 ± 4.507 0.504
AppEntropy_C3_avg 1.060 ± 0.060 1.093 ± 0.049 .036* Theta/Beta_C3_avg 9.611 ± 5.194 8.694 ± 3.933 0.775
AppEntropy_C4_avg 1.052 ± 0.061 1.089 ± 0.049 .023* Theta/Beta_C4_avg 9.679 ± 5.369 8.562 ± 3.949 0.676
AppEntropy_T4_avg 1.049 ± 0.073 1.073 ± 0.059 .146 Theta/Beta_T4_avg 10.929 ± 6.430 9.883 ± 4.823 0.878
AppEntropy_T5_avg 1.025 ± 0.052 1.069 ± 0.050 .003* Theta/Beta_T5_avg 14.354 ± 7.832 10.919 ± 6.294 0.077
AppEntropy_P3_avg 1.029 ± 0.048 1.072 ± 0.050 .001* Theta/Beta_P3_avg 12.732 ± 6.534 9.715 ± 4.871 0.068
AppEntropy_PZ_avg 1.015 ± 0.049 1.052 ± 0.047 .005* Theta/Beta_PZ_avg 14.702 ± 8.473 11.618 ± 5.564 0.267
AppEntropy_P4_avg 1.024 ± 0.052 1.064 ± 0.050 .006* Theta/Beta_P4_avg 13.419 ± 7.715 10.292 ± 4.969 0.177
AppEntropy_T6_avg 1.022 ± 0.061 1.056 ± 0.052 .011* Theta/Beta_T6_avg 15.043 ± 8.847 12.363 ± 6.994 0.328
AppEntropy_O1_avg 1.013 ± 0.054 1.052 ± 0.051 .006* Theta/Beta_O1_avg 16.277 ± 9.129 11.893 ± 6.546 0.063
AppEntropy_O2_avg 1.014 ± 0.053 1.050 ± 0.048 .007* Theta/Beta_O2_avg 16.383 ± 10.940 12.202 ± 6.764 0.088

Abbreviations: ADHD, attention-deficit hyperactivity disorder; ApEn, Abbreviations: ADHD, attention-deficit hyperactivity disorder; TBR, theta/
approximate entropy. beta ratio.
*P < .05.

EEG time series.35 Thul et al35 reported lower EEG entropy in

Comparison Between ApEn and TBR
Statistical analysis results showed ApEn values were signifi-
cantly higher in the control group than in the ADHD group in
12 of the 18 channels. However, TBR values in all channels in
the present study demonstrated no significant difference
between ADHD and control groups (Table 2). Obviously,
results revealed more significant differences between the
ADHD and control groups when using ApEn (Figure 2A) than
when using the FDA-approved TBR (Figure 2B). Table 3
shows the comparison of classification performance on test
datasets between ApEn-related and TBR-related feature
descriptors. According to the feature reduction step by PCA
mentioned previously, 2 to 4 PCs were preserved in a model
training process. Compared with TBR-related descriptors,
ApEn-related descriptors can produce the higher average true
positive rate (0.846 vs 0.470), average true negative rate (0.814
vs 0.697), average accuracy (0.817 vs 0.583), and average
AUC value (0.862 vs 0.602).
Discussion
In this study, an entropy-based EEG analytic method was used
to distinguish differences between female patients with ADHD
and non-ADHD controls. Compared with the TBR, the ApEn-
related features demonstrated more significant differences
between patients with ADHD and controls and the better dis-
criminant power.
Entropy is an information-theoretic measure that describes
the amount of information contained within a signal, such as an
patients with disorders of consciousness relative to that of
healthy controls.35 Entropy is also an indicator of signal com-
plexity. EEG complexity tends to increase with brain matura-
tion, as indicated by postmenstrual age and birth status.36,37 As
the brain matures, the EEG synchronizes with the alpha rhythm
and brain signals in the higher beta desynchronize with the
lower gamma rhythm,38 leading to increased EEG complexity.
We discovered that ApEn was significantly lower in girls with
ADHD than in controls, suggesting that patients with ADHD
have comparatively immature brains and the immaturation
might be related to inattention. The theory of delay in ADHD
brain maturation has been proved in several imaging studies39-41;
our study is compatible with the notion that brain immaturity
exists in girls with ADHD.
There are few studies that have examined testing EEG exclu-
sively in girls with ADHD. Baving et al42 found that 15 girls
with ADHD had greater frontal alpha activation in the left than
right hemisphere, suggested to represent a left frontal deficit,
compared with aged-matched control girls. Other studies have
found that girls with ADHD had globally elevated absolute
delta, theta and total power, greater relative theta and reduced
relative beta, compared with girl controls.43-45 Although these
findings are similar with boys with ADHD (with an elevation of
slow wave activity and reduction of faster wave activity),11
these studies almost focused on frequency-domain analysis. In
this study, we used a time-domain analytic method, entropy-
based analysis, in comparison between ADHD girls and control
group. We found ApEn values were significantly higher in the
control group than in the ADHD girls in most EEG channels.
Chow et al 177

Figure 2.  Comparison of P values of approximate entropy (ApEn) and theta/beta ratio (TBR) between attention-deficity hyperactivity
disorder (ADHD) and control groups. ApEn values were significantly higher in the control group than in the ADHD group in 12 of 18 EEG
channels (A). However, TBR values in O1 channel only demonstrated significant difference between ADHD and control groups (B).

Table 3.  Comparison of Classification Performance on Test Sets
Between ApEn-Related and TBR-Related Feature Descriptors.
Features Descriptors TPR TNR ACC
TBR-related 0.470 0.697 0.583
ApEn-related 0.846 0.814 0.817
Abbreviations: ACC, accuracy; ApEn, approximate entropy; AUC, area
under the receiver operating characteristic curve; TR, theta/beta ratio; TNR,
true negative rate; TPR, true positive rate.
Because girls with ADHD are less hyperactive, but more inat-
tentive, and have higher rates of depressive and anxiety disor-
ders than boys with ADHD,4 the underlying mechanisms of
ADHD in the different sexes should be discussed separately.
However, the limitation of this study was that we enrolled girls
with inattention type ADHD only. The results may not be gener-
alized to other types of ADHD or ADHD boys. The relationship
between ApEn and other types of ADHD girls and boys with
ADHD should be further explored.
We found that the EEG ApEn over bilateral dorsolateral pre-
frontal cortices (F3, F4) was significantly lower in girls with
ADHD than in controls. We enrolled patients with inattention-
type ADHD only in this study. Attention is a complex function
served by intricate neuronal systems. Sustained attention,
mostly related to vigilance, is dependent on the integrity of the
prefrontal cortex.46 In an animal study, authors found that rats
with frequent prefrontal interictal spikes appeared more inatten-
tive and made more omission errors in the observations,47 indi-
cating that impaired prefrontal function is associated with
inattention. In another study, Miao et al48 demonstrated that
children with ADHD exhibited lower activity in the left prefron-
tal cortex than did controls in a functional near-infrared spec-
troscopy study during go/no-go task. The go/no-go test demands
high-level cognitive functions of decision making, response
selection, and response inhibition.49 Accordingly, patients with
ADHD exhibited lower prefrontal activity than did controls. In
AUC
addition to lower prefrontal cortical activity, the current study
demonstrated significantly lower ApEn in central, temporal,
0.602 parietal, and occipital areas in patients with ADHD, indicating
0.862 that the neural network involved in inattention-type ADHD is
not limited to the prefrontal cortex. Evidence from neurophysi-
ological studies in nonhuman primates indicates that spatial
attention appears to be controlled by structures such as the pre-
frontal cortex,50 the lateral intraparietal area in the parietal
cortex,51 and the superior colliculus.52 Evidence suggests that
one or more of these structures drives the selection of attended
stimuli within the posterior visual cortex.53
Several studies have used the TBR as a measurement for
diagnosing ADHD in children.54-57 One study compared the
TBR between girls with ADHD and controls; and the results
demonstrated that girls with ADHD had globally reduced delta
and beta activity and globally elevated theta activity and TBR in
comparison with controls.58 Furthermore, the TBR has been
approved by the FDA as a tool to assist in the diagnosis of
ADHD.13 However, more recent studies have reported that only
38% and 26% of patients with ADHD significantly deviate from
controls based on the TBR.14,59 Our study demonstrated that the
differences between the ADHD and control groups in terms of
the 12-channel ApEn values were more significant than those in
terms of the TBR. Moreover, compared with TBR-related
descriptors, ApEn-related descriptors possessed the better clas-
sification performance. Therefore, the ApEn is more effective
than the TBR for distinguishing ADHD and controls.
Conclusions
In this study, we found that there were significantly lower
ApEn values in most EEG channels in girls with ADHD than
178 Clinical EEG and Neuroscience 50(3)
controls. The lower ApEn values might be associated with inat-
tention in these girls. In addition, our proposed method is
demonstrably more accurate than the TBR for diagnosing girls
with ADHD. Therefore, ApEn is a promising tool for differen-
tiating between girls with ADHD and controls.
Acknowledgments
We thank the study patients and their families.
Author Contributions
JCC contributed to conception and design; contributed to acquisition
and interpretation; drafted manuscript; critically revised manuscript;
agrees to be accountable for all aspects of work ensuring integrity and
accuracy. CSO, CTC, and RCW contributed to conception and design;
contributed to analysis and interpretation; critically revised manu-
script; agrees to be accountable for all aspects of work ensuring integ-
rity and accuracy. CLT and HCW contributed to design; contributed
to acquisition. RCY contributed to conception and design; contributed
to acquisition and interpretation; critically revised manuscript; agrees
to be accountable for all aspects of work ensuring integrity and accu-
racy. LCL contributed to conception and design; contributed to analy-
sis and interpretation; drafted manuscript; critically revised
manuscript; gave final approval; agrees to be accountable for all
aspects of work ensuring integrity and accuracy.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the
research, authorship, and/or publication of this article: This study was
partly supported by Kaohsiung Medical University Hospital (Grant Nos.
KMUH102-2T09, 105CM-KMU-08, and KMUH106-6R47) and the
Ministry of Science and Technology, Taiwan (Grant Nos. MOST
106-2314-B-037-080-MY2, 106-2221-E-214-048 and MOST 107-2221-
E-214-028).
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