Nested Cross-validation Procedure Research Articles

Prognostic subgroups of chronic pain patients using latent variable mixture modeling within a supervised machine learning framework

The present study combined a supervised machine learning framework with an unsupervised method, finite mixture modeling, to identify prognostically meaningful subgroups of diverse chronic pain patients undergoing interdisciplinary treatment. Questionnaire data collected at pre-treatment and 1-year follow up from 11,995 patients from the Swedish Quality Registry for Pain Rehabilitation were used. Indicators measuring pain characteristics, psychological aspects, and social functioning and general health status were used to form subgroups, and pain interference at follow-up was used for the selection and the performance evaluation of models. A nested cross-validation procedure was used for determining the number of classes (inner cross-validation) and the prediction accuracy of the selected model among unseen cases (outer cross-validation). A four-class solution was identified as the optimal model. Identified subgroups were separable on indicators, predictive of long-term outcomes, and related to background characteristics. Results are discussed in relation to previous clustering attempts of patients with diverse chronic pain conditions. Our analytical approach, as the first to combine mixture modeling with supervised, targeted learning, provides a promising framework that can be further extended and optimized for improving accurate prognosis in pain treatment and identifying clinically meaningful subgroups among chronic pain patients.

Comparison of models for stroke-free survival prediction in patients with CADASIL

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy, which is caused by mutations of the NOTCH3 gene, has a large heterogeneous progression, presenting with declines of various clinical scores and occurrences of various clinical event. To help assess disease progression, this work focused on predicting the composite endpoint of stroke-free survival time by comparing the performance of Cox proportional hazards regression to that of machine learning models using one of four feature selection approaches applied to demographic, clinical and magnetic resonance imaging observational data collected from a study cohort of 482 patients. The quality of the modeling process and the predictive performance were evaluated in a nested cross-validation procedure using the time-dependent Brier Score and AUC at 5 years from baseline, the former measuring the overall performance including calibration and the latter highlighting the discrimination ability, with both metrics taking into account the presence of right-censoring. The best model for each metric was the componentwise gradient boosting model with a mean Brier score of 0.165 and the random survival forest model with a mean AUC of 0.773, both combined with the LASSO feature selection method.

Impedance cardiogram based exploration of cardiac mechanisms in post-traumatic stress disorder during trauma recall.

Post-traumatic stress disorder (PTSD) is an independent risk factor for developing heart failure; however, the underlying cardiac mechanisms are still elusive. This study aims to evaluate the real-time effects of experimentally induced PTSD symptom activation on various cardiac contractility and autonomic measures. We recorded synchronized electrocardiogram and impedance cardiogram from 137 male veterans (17 PTSD, 120 non-PTSD; 48 twin pairs, 41 unpaired singles) during a laboratory-based traumatic reminder stressor. To identify the parameters describing the cardiac mechanisms by which trauma reminders can create stress on the heart, we utilized a feature selection mechanism along with a random forest classifier distinguishing PTSD and non-PTSD. We extracted 99 parameters, including 76 biosignal-based and 23 sociodemographic, medical history, and psychiatric diagnosis features. A subject/twin-wise stratified nested cross-validation procedure was used for parameter tuning and model assessment to identify the important parameters. The identified parameters included biomarkers such as pre-ejection period, acceleration index, velocity index, Heather index, and several physiology-agnostic features. These identified parameters during trauma recall suggested a combination of increased sympathetic nervous system (SNS) activity and deteriorated cardiac contractility that may increase the heart failure risk for PTSD. This indicates that the PTSD symptom activation associates with real-time reductions in several cardiac contractility measures despite SNS activation. This finding may be useful in future cardiac prevention efforts.

Combining electromyographic and electrical impedance data sets through machine learning: A study in D2-mdx and wild-type mice.

Needle impedance-electromyography (iEMG) assesses the active and passive electrical properties of muscles concurrently by using a novel needle with six electrodes, two for EMG and four for electrical impedance myography (EIM). Here, we assessed an approach for combining multifrequency EMG and EIM data via machine learning (ML) to discriminate D2-mdx muscular dystrophy and wild-type (WT) mouse skeletal muscle. iEMG data were obtained from quadriceps of D2-mdx mice, a muscular dystrophy model, and WT animals. EIM data were collected with the animals under deep anesthesia and EMG data collected under light anesthesia, allowing for limited spontaneous movement. Fourier transformation was performed on the EMG data to provide power spectra that were sampled across the frequency range using three different approaches. Random forest-based, nested ML was applied to the EIM and EMG data sets separately and then together to assess healthy versus disease category classification using a nested cross-validation procedure. Data from 20 D2-mdx and 20 WT limbs were analyzed. EIM data fared better than EMG data in differentiating healthy from disease mice with 93.1% versus 75.6% accuracy, respectively. Combining EIM and EMG data sets yielded similar performance as EIM data alone with 92.2% accuracy. We have demonstrated an ML-based approach for combining EIM and EMG data obtained with an iEMG needle. While EIM-EMG in combination fared no better than EIM alone with this data set, the approach used here demonstrates a novel method of combining the two techniques to characterize the full electrical properties of skeletal muscle.

Decoding individual differences in self-prioritization from the resting-state functional connectome

Although the self has traditionally been viewed as a higher-order mental function by most theoretical frameworks, recent research advocates a fundamental self hypothesis, viewing the self as a baseline function of the brain embedded within its spontaneous activities, which dynamically regulates cognitive processing and subsequently guides behavior. Understanding this fundamental self hypothesis can reveal where self-biased behaviors emerge and to what extent brain signals at rest can predict such biased behaviors. To test this hypothesis, we investigated the association between spontaneous neural connectivity and robust self-bias in a perceptual matching task using resting-state functional magnetic resonance imaging (fMRI) in 348 young participants. By decoding whole-brain connectivity patterns, the support vector regression model produced the best predictions of the magnitude of self-bias in behavior, which was evaluated via a nested cross-validation procedure. The out-of-sample generalizability was further authenticated using an external dataset of older adults. The functional connectivity results demonstrated that self-biased behavior was associated with distinct connections between the default mode, cognitive control, and salience networks. Consensus network and computational lesion analyses further revealed contributing regions distributed across six networks, extending to additional nodes, such as the thalamus, whose role in self-related processing remained unclear. These results provide evidence that self-biased behavior derives from spontaneous neural connectivity, supporting the fundamental self hypothesis. Thus, we propose an integrated neural network model of this fundamental self that synthesizes previous theoretical models and portrays the brain mechanisms by which the self emerges at rest internally and regulates responses to the external environment.

Digital Mapping of Soil Properties Using Ensemble Machine Learning Approaches in an Agricultural Lowland Area of Lombardy, Italy

Sustainable agricultural landscape management needs reliable and accurate soil maps and updated geospatial soil information. Recently, machine learning (ML) models have commonly been used in digital soil mapping, together with limited data, for various types of landscapes. In this study, we tested linear and nonlinear ML models in predicting and mapping soil properties in an agricultural lowland landscape of Lombardy region, Italy. We further evaluated the ability of an ensemble learning model, based on a stacking approach, to predict the spatial variation of soil properties, such as sand, silt, and clay contents, soil organic carbon content, pH, and topsoil depth. Therefore, we combined the predictions of the base learners (ML models) with two meta-learners. Prediction accuracies were assessed using a nested cross-validation procedure. Nonetheless, the nonlinear single models generally performed well, with RF having the best results; the stacking models did not outperform all the individual base learners. The most important topographic predictors of the soil properties were vertical distance to channel network and channel network base level. The results yield valuable information for sustainable land use in an area with a particular soil water cycle, as well as for future climate and socioeconomic changes influencing water content, soil pollution dynamics, and food security.

Application of A U-Net for Map-like Segmentation and Classification of Discontinuous Fibrosis Distribution in Gd-EOB-DTPA-Enhanced Liver MRI.

Highlights-First application of a U-net for the segmentation and classification of discontinuous liver fibrosis distribution.-Fully automated, scalable pipeline for data pre-processing, segmentation, and classification.-The present research could serve as a cornerstone of further applications for non-invasive determination of liver tissue properties, for instance, in planned parenchymal resection.We aimed to evaluate whether U-shaped convolutional neuronal networks can be used to segment liver parenchyma and indicate the degree of liver fibrosis/cirrhosis at the voxel level using contrast-enhanced magnetic resonance imaging. This retrospective study included 112 examinations with histologically determined liver fibrosis/cirrhosis grade (Ishak score) as the ground truth. The T1-weighted volume-interpolated breath-hold examination sequences of native, arterial, late arterial, portal venous, and hepatobiliary phases were semi-automatically segmented and co-registered. The segmentations were assigned the corresponding Ishak score. In a nested cross-validation procedure, five models of a convolutional neural network with U-Net architecture (nnU-Net) were trained, with the dataset being divided into stratified training/validation (n = 89/90) and holdout test datasets (n = 23/22). The trained models precisely segmented the test data (mean dice similarity coefficient = 0.938) and assigned separate fibrosis scores to each voxel, allowing localization-dependent determination of the degree of fibrosis. The per voxel results were evaluated by the histologically determined fibrosis score. The micro-average area under the receiver operating characteristic curve of this seven-class classification problem (Ishak score 0 to 6) was 0.752 for the test data. The top-three-accuracy-score was 0.750. We conclude that determining fibrosis grade or cirrhosis based on multiphase Gd-EOB-DTPA-enhanced liver MRI seems feasible using a 2D U-Net. Prospective studies with localized biopsies are needed to evaluate the reliability of this model in a clinical setting.

Explanations of Machine Learning Models in Repeated Nested Cross-Validation: An Application in Age Prediction Using Brain Complexity Features

SHAP (Shapley additive explanations) is a framework for explainable AI that makes explanations locally and globally. In this work, we propose a general method to obtain representative SHAP values within a repeated nested cross-validation procedure and separately for the training and test sets of the different cross-validation rounds to assess the real generalization abilities of the explanations. We applied this method to predict individual age using brain complexity features extracted from MRI scans of 159 healthy subjects. In particular, we used four implementations of the fractal dimension (FD) of the cerebral cortex—a measurement of brain complexity. Representative SHAP values highlighted that the most recent implementation of the FD had the highest impact over the others and was among the top-ranking features for predicting age. SHAP rankings were not the same in the training and test sets, but the top-ranking features were consistent. In conclusion, we propose a method—and share all the source code—that allows a rigorous assessment of the SHAP explanations of a trained model in a repeated nested cross-validation setting.

Prediction of Treatment Response in Triple Negative Breast Cancer From Whole Slide Images

The automatic analysis of stained histological sections is becoming increasingly popular. Deep Learning is today the method of choice for the computational analysis of such data, and has shown spectacular results for large datasets for a large variety of cancer types and prediction tasks. On the other hand, many scientific questions relate to small, highly specific cohorts. Such cohorts pose serious challenges for Deep Learning, typically trained on large datasets. In this article, we propose a modification of the standard nested cross-validation procedure for hyperparameter tuning and model selection, dedicated to the analysis of small cohorts. We also propose a new architecture for the particularly challenging question of treatment prediction, and apply this workflow to the prediction of response to neoadjuvant chemotherapy for Triple Negative Breast Cancer.

Data-driven approach for automatic detection of aortic valve opening: B point detection from impedance cardiogram.

Pre-ejection period (PEP), an indicator of sympathetic nervous system activity, is useful in psychophysiology and cardiovascular studies. Accurate PEP measurement is challenging and relies on robust identification of the timing of aortic valve opening, marked as the B point on impedance cardiogram (ICG) signals. The ICG sensitivity to noise and its waveform's morphological variability makes automated B point detection difficult, requiring inefficient and cumbersome expert visual annotation. In this article, we propose a machine learning-based automated algorithm to detect the aortic valve opening for PEP measurement, which is robust against noise and ICG morphological variations. We analyzed over 60 hr of synchronized ECG and ICG records from 189 subjects. A total of 3657 averaged beats were formed using our recently developed ICG noise removal algorithm. Features such as the averaged ICG waveform, its first and second derivatives, as well as high-level morphological and critical hemodynamic parameters were extracted and fed into the regression algorithms to estimate the B point location. The morphological features were extracted from our proposed "variable" physiologically valid search-window related to diverse B point shapes. A subject-wise nested cross-validation procedure was performed for parameter tuning and model assessment. After examining multiple regression models, Adaboost was selected, which demonstrated superior performance and higher robustness to five state-of-the-art algorithms that were evaluated in terms of low mean absolute error of 3.5ms, low median absolute error of 0.0ms, high correlation with experts' estimates (Pearson coefficient=0.9), and low standard deviation of errors of 9.2ms. For reproducibility, an open-source toolbox is provided.

A Novel Machine Learning-Based Approach for Induction Machine Fault Classifier Development—A Broken Rotor Bar Case Study

Rotor bars are one of the most failure-critical components in induction machines. We present an approach for developing a rotor bar fault identification classifier for induction machines. The developed machine learning-based models are based on simulated electrical current and vibration velocity data and measured vibration acceleration data. We introduce an approach that combines sequential model-based optimization and the nested cross-validation procedure to provide a reliable estimation of the classifiers’ generalization performance. These methods have not been combined earlier in this context. Automation of selected parts of the modeling procedure is studied with the measured data. We compare the performance of logistic regression and CatBoost models using the fast Fourier-transformed signals or their extracted statistical features as the input data. We develop a technique to use domain knowledge to extract features from specific frequency ranges of the fast Fourier-transformed signals. While both approaches resulted in similar accuracy with simulated current and measured vibration acceleration data, the feature-based models were faster to develop and run. With measured vibration acceleration data, better accuracy was obtained with the raw fast Fourier-transformed signals. The results demonstrate that an accurate and fast broken rotor bar detection model can be developed with the presented approach.

Improving the diagnostic accuracy for major depressive disorder using machine learning algorithms integrating clinical and near-infrared spectroscopy data

BackgroundGiven that major depressive disorder (MDD) is both biologically and clinically heterogeneous, a diagnostic system integrating neurobiological markers and clinical characteristics would allow for better diagnostic accuracy and, consequently, treatment efficacy. ObjectiveOur study aimed to evaluate the discriminative and predictive ability of unimodal, bimodal, and multimodal approaches in a total of seven machine learning (ML) models—clinical, demographic, functional near-infrared spectroscopy (fNIRS), combinations of two unimodal models, as well as a combination of all three—for MDD. MethodsWe recruited 65 adults with MDD and 68 matched healthy controls, who provided both sociodemographic and clinical information, and completed the HAM-D questionnaire. They were also subject to fNIRS measurement when participating in the verbal fluency task. Using the nested cross validation procedure, the classification performance of each ML model was evaluated based on the area under the receiver operating characteristic curve (ROC), balanced accuracy, sensitivity, and specificity. ResultsThe multimodal ML model was able to distinguish between depressed patients and healthy controls with the highest balanced accuracy of 87.98 ± 8.84% (AUC = 0.92; 95% CI (0.84–0.99) when compared with the uni- and bi-modal models. ConclusionsOur multimodal ML model demonstrated the highest diagnostic accuracy for MDD. This reinforces the biological and clinical heterogeneity of MDD and highlights the potential of this model to improve MDD diagnosis rates. Furthermore, this model is cost-effective and clinically applicable enough to be established as a robust diagnostic system for MDD based on patients’ biosignatures.

Graph-based Recurrence Quantification Analysis of EEG Spectral Dynamics for Motor Imagery-based BCIs.

EEG time series recorded from six healthy participants performing MI-Rest tasks were projected into multidimensional phase space trajectories in order to construct the corresponding recurrence plots (RPs). Eight nonlinear graph-based RQA features were extracted from the RPs then compared to the classical spectral features through a 5-fold nested cross-validation procedure for parameter optimization using a linear support vector machine (SVM) classifier. Nonlinear graph-based RQA features were able to improve the average performance of MI-BCI by 5.8% as compared to the classical features. These findings suggest that RQA and complex network analysis could represent new informative dimensions for nonlinear characteristics of EEG signals in order to enhance the MI-BCI performance.

Data fusion based on Searchlight analysis for the prediction of Alzheimer’s disease

In recent years, several computer-aided diagnosis (CAD) systems have been proposed for an early identification of dementia. Although these approaches have mostly used the transformation of data into a different feature space, more precise information can be gained from a Searchlight strategy. The current study presents a data fusion classification system that employs magnetic resonance imaging (MRI) and neuropsychological tests to distinguish between Mild-Cognitive Impairment (MCI) patients that convert to Alzheimer’s disease (AD) and those that remain stable. Specifically, this method uses a nested cross-validation procedure to compute the optimum contribution of each data modality in the final decision. The model employs Support-Vector Machine (SVM) classifiers for both data modalities and is combined with Searchlight when applied to neuroimaging. We compared the performance of our system with an alternative based on Principal Component Analysis (PCA) for dimensionality reduction. Results show that Searchlight outperformed PCA both for uni/multimodal classification, obtaining a maximum accuracy of 80.9% when combining data from six and twelve months before patients converted to AD. Moreover, Searchlight allowed the identification of the most informative regions at different stages of the longitudinal study, which can be crucial for a better understanding of the development of AD. Additionally, results do not depend on the parcellations provided by a specific brain atlas, which manifests the robustness and the spatial precision of the method proposed.

Nested cross-validation when selecting classifiers is overzealous for most practical applications

When selecting a classification algorithm to be applied to a particular problem, one has to simultaneously select the best algorithm for that dataset and the best set of hyperparameters for the chosen model. The usual approach is to apply a nested cross-validation procedure: hyperparameter selection is performed in the inner cross-validation, while the outer cross-validation computes an unbiased estimate of the expected accuracy of the algorithm with cross-validation based hyperparameter tuning. The alternative approach, which we shall call “flat cross-validation”, uses a single cross-validation step both to select the optimal hyperparameter values and to provide an estimate of the expected accuracy of the algorithm that, while biased, may nevertheless still be used to select the best learning algorithm. We tested both procedures using 12 different algorithms on 115 real-life binary datasets and conclude that using the less computationally costly flat cross-validation procedure will generally result in the selection of an algorithm that is, for all practical purposes, of similar quality to that selected via nested cross-validation, provided the learning algorithms have relatively few hyperparameters to be optimised.

Investigating predictive factors of dialectical behavior therapy skills training efficacy for alcohol and concurrent substance use disorders: A machine learning study

BackgroundDialectical Behavior Therapy Skills Training (DBT-ST) as stand-alone treatment has demonstrated promising outcomes for the treatment of alcohol use disorder (AUD) and concurrent substance use disorders (SUDs). However, no studies have so far empirically investigated factors that might predict efficacy of this therapeutic model. Methods275 treatment-seeking individuals with AUD and other SUDs were consecutively admitted to a 3-month DBT-ST program (in- + outpatient; outpatient settings). The machine learning routine applied (i.e. penalized regression combined with a nested cross-validation procedure) was conducted in order to estimate predictive values of a wide panel of clinical variables in a single statistical framework on drop-out and substance-use behaviors, dealing with related multicollinearity, and eliminating redundant variables. ResultsThe cross-validated elastic net model significantly predicted the drop-out. The bootstrap analysis revealed that subjects who showed substance-use behaviors during the intervention and who were treated with the mixed setting (i.e., in- and outpatient) program, together with higher ASI alcohol scores were associated with an higher probability of drop-out. On the contrary, older subjects, higher levels of education, together with higher scores of DERS awareness subscale were negatively associated to drop-out. Similarly, lifetime co-diagnoses of anxiety, bipolar, and gambling disorders, together with bulimia nervosa negatively predicted the drop-out. The machine learning model did not identify predictive variables of substance-use behaviors during the treatment. ConclusionsThe DBT-ST program could be considered a valid therapeutic approach especially when AUD and other SUDs co-occur with other psychiatric conditions and, it is carried out as a full outpatient intervention.

Predictors of Sickness Absence in a Clinical Population With Chronic Pain

Chronic pain-related sickness absence is an enormous socioeconomic burden globally. Optimized interventions are reliant on a lucid understanding of the distribution of social insurance benefits and their predictors. This register-based observational study analyzed data for a 7-year period from a population-representative sample of 44,241 chronic pain patients eligible for interdisciplinary treatment (IDT) at specialist clinics. Sequence analysis was used to describe the sickness absence over the complete period and to separate the patients into subgroups based on their social insurance benefits over the final 2 years. The predictive performance of features from various domains was then explored with machine learning-based modeling in a nested cross-validation procedure. Our results showed that patients on sickness absence increased from 17% 5 years before to 48% at the time of the IDT assessment, and then decreased to 38% at the end of follow-up. Patients were divided into 3 classes characterized by low sickness absence, sick leave, and disability pension, with eight predictors of class membership being identified. Sickness absence history was the strongest predictor of future sickness absence, while other predictors included a 2008 policy, age, confidence in recovery, and geographical location. Information on these features could guide personalized intervention in the specialized healthcare. PerspectiveThis study describes sickness absence in patients who visited a Swedish pain specialist interdisciplinary treatment clinic during the period 2005 to 2016. Predictors of future sickness absence are also identified that should be considered when adapting IDT programs to the patient's needs.

Machine learning predicts nucleosome binding modes of transcription factors

BackgroundMost transcription factors (TFs) compete with nucleosomes to gain access to their cognate binding sites. Recent studies have identified several TF-nucleosome interaction modes including end binding (EB), oriented binding, periodic binding, dyad binding, groove binding, and gyre spanning. However, there are substantial experimental challenges in measuring nucleosome binding modes for thousands of TFs in different species.ResultsWe present a computational prediction of the binding modes based on TF protein sequences. With a nested cross-validation procedure, our model outperforms several fine-tuned off-the-shelf machine learning (ML) methods in the multi-label classification task. Our binary classifier for the EB mode performs better than these ML methods with the area under precision-recall curve achieving 75%. The end preference of most TFs is consistent with low nucleosome occupancy around their binding site in GM12878 cells. The nucleosome occupancy data is used as an alternative dataset to confirm the superiority of our EB classifier.ConclusionsWe develop the first ML-based approach for efficient and comprehensive analysis of nucleosome binding modes of TFs.

A Machine Learning Framework for Pulse Detection During Out-of-Hospital Cardiac Arrest

The availability of an automatic pulse detection during out-of-hospital cardiac arrest (OHCA) would allow the rapid identification of cardiac arrest and the prompt detection of return of spontaneous circulation. The aim of this study was to develop a reliable pulse detection algorithm using the electrocardiogram (ECG) and thoracic impedance (TI), the signals available in most defibrilators. The dataset used in the study consisted of 1140 ECG and TI segments from 187 OHCA patients, whereof 792 were labelled as pulse-generating rhythm (PR) and 348 as pulseless electrical activity (PEA) by a pool of experts in OHCA. First, an adaptive filtering scheme was used to extract the impedance circulation component and its first derivative from the TI. Then, the wavelet decomposition of the ECG was carried out to obtain the different subband components and the denoised ECG. Pulse/no-pulse (PR/PEA) discrimination features were extracted from those signals and fed into a support vector machine (SVM) classifier that made the pulse/no-pulse decision. A quasi-stratified and patient wise nested cross validation procedure was used to select the best feature subset and to tune the SVM hyperparameters. This procedure was repeated 50 times to estimate the statistical distributions of the performance metrics of the method. The optimal solution consisted in a five feature classifier that yielded a mean (standard deviation) sensitivity, specificity, balanced accuracy and total accuracy of 92.4% (0.7), 93.0% (0.8), 92.7% (0.5) and 92.6% (0.5), respectively. When compared to available methods, our solution presented an improvement in balanced accuracy of at least 2.5 points. A reliable pulse detection algorithm for OHCA using the signals available in defibrillators was acomplished.

Mouse movement measures enhance the stop-signal task in adult ADHD assessment.

The accurate detection of attention-deficit/hyperactivity disorder (ADHD) symptoms, such as inattentiveness and behavioral disinhibition, is crucial for delivering timely assistance and treatment. ADHD is commonly diagnosed and studied with specialized questionnaires and behavioral tests such as the stop-signal task. However, in cases of late-onset or mild forms of ADHD, behavioral measures often fail to gauge the deficiencies well-highlighted by questionnaires. To improve the sensitivity of behavioral tests, we propose a novel version of the stop-signal task (SST), which integrates mouse cursor tracking. In two studies, we investigated whether introducing mouse movement measures to the stop-signal task improves associations with questionnaire-based measures, as compared to the traditional (keypress-based) version of SST. We also scrutinized the influence of different parameters of stop-signal tasks, such as the method of stop-signal delay setting or definition of response inhibition failure, on these associations. Our results show that a) SSRT has weak association with impulsivity, while mouse movement measures have strong and significant association with impulsivity; b) machine learning models trained on the mouse movement data from “known” participants using nested cross-validation procedure can accurately predict impulsivity ratings of “unknown” participants; c) mouse movement features such as maximum acceleration and maximum velocity are among the most important predictors for impulsivity; d) using preset stop-signal delays prompts behavior that is more indicative of impulsivity.