Ci a ion: Rod íguez-P ie o, P.;
Simpson, I.C.; Gomez-Baya, D.; Ga cía
de la Cadena, C.; Ruiz-A anda, D.;
Ibáñez-Al onso, J.A.
Neu opsychological S imula ion
P og am o Child en om Low
Socioeconomic Backg ounds: S udy
P o ocol o a Randomized Con olled
T ial. Heal hca e 2024,12, 596. h ps://
doi.o g/10.3390/heal hca e12050596
Academic Edi o s: Xiang-Yu Hou,
Lijun Fan and Chiung-Jung (Jo) Wu
Recei ed: 2 Feb ua y 2024
Re ised: 2 Ma ch 2024
Accep ed: 4 Ma ch 2024
Published: 6 Ma ch 2024
Copy igh : © 2024 by he au ho s.
Licensee MDPI, Basel, Swi ze land.
This a icle is an open access a icle
dis ibu ed unde he e ms and
condi ions o he C ea i e Commons
A ibu ion (CC BY) license (h ps://
c ea i ecommons.o g/licenses/by/
4.0/).
heal hca e
S udy P o ocol
Neu opsychological S imula ion P og am o Child en om Low
Socioeconomic Backg ounds: S udy P o ocol o a Randomized
Con olled T ial
Pablo Rod íguez-P ie o 1,2 , Ian C aig Simpson 3, Diego Gomez-Baya 4, Claudia Ga cía de la Cadena 5,
Desi ée Ruiz-A anda 1and Joaquín A. Ibáñez-Al onso 1,2,*
1Human Neu oscience Lab, Depa men o Psychology, Uni e sidad Loyola Andalucía, A da. de las
Uni e sidades s/n, 41704 Dos He manas, Spain; [email p o ec ed] (P.R.-P.); [email p o ec ed] (D.R.-A.)
2ETEA Founda ion, De elopmen Ins i u e o Uni e sidad Loyola Andalucía, Calle Esc i o Cas illa Aguayo
n◦4, 14004 Có doba, Spain
3Depa men o Expe imen al Psychology, Campus Uni e si a io de Ca uja, Uni e si y o G anada,
18071 G anada, Spain; isimpson@ug .es
4Depa men o Social, De elopmen al and Educa ional Psychology, Campus de El Ca men, Uni e si y o
Huel a, 21071 Huel a, Spain; [email p o ec ed]
5Depa men o Neu opsychology, Uni e sidad del Valle de Gua emala, Calle 11, Zona 15, Pos n◦82,
Gua emala Ci y 01901, Gua emala; [email p o ec ed]
*Co espondence: [email p o ec ed]; Tel.: +34-955-641-600 (ex . 2483)
Abs ac : Backg ound: Gua emala emains one o he poo es coun ies in Cen al Ame ica and su e s
om high a es o social inequali y and iolence. In addi ion o he nega i e impac ha wo yea s
wi hou a ending school has had on Gua emalan child en due o he consequences o he COVID-19
pandemic, his un a ou able socioeconomic con ex poses a isk o child en’s emo ional and cogni i e
de elopmen . This wo k p esen s a p o ocol o implemen ing a cogni i e and emo ional s imula ion
p og am aimed a inc easing he academic pe o mance o hese child en and consequen ly imp o ing
hei quali y o li e. Me hods: The p o ocol p oposes he implemen a ion o a andomized con olled
ial o assess he e icacy o a 24-session-long s imula ion p og am. I a ge s he cogni i e unc ions
o a en ion, language, execu i e unc ions, and social cogni ion, using he digi al neu o ehabili a ion
pla o m Neu onUP. The pa icipan s (n= 480) will be andomly assigned o an Expe imen al o
Con ol g oup. P e- and pos -in e en ion assessmen s will be ca ied ou , oge he wi h a ollow-up
in he nex academic yea , in which bo h g oups will change oles. Resul s will be compa ed o
he i s and second yea s, looking o di e ences in academic and cogni i e pe o mance be ween
g oups. Discussion: Mid- and long- e m ou comes a e s ill unknown, bu e ec i e in e en ions
based on his p o ocol a e expec ed o acili a e he ollowing bene i s o pa icipan s: (1) imp o ed
cogni i e and emo ional de elopmen ; (2) imp o ed academic pe o mance; (3) imp o ed well-being.
We expec o c ea e a alida ed neu opsychological s imula ion p og am ha could be applied in
simila socioeconomically disad an aged con ex s a ound he wo ld o help hese child en imp o e
hei li e chances.
Keywo ds: neu opsychology; childhood de elopmen ; ulne abili y; cogni i e s imula ion;
emo ional
;
andomized con olled ials
1. In oduc ion
The pandemic (COVID-19) ep esen ed an ex eme h ea o he ad ancemen o
educa ion in Gua emala because o he signi ican impac i has had a a ious le els. A a
local le el, educa ional cen es we e closed o almos wo yea s, and mo e b oadly, he e
has been an economic ecession a he na ional and wo ldwide le els. The closu es wi hin
he school sys em caused a s agna ion o lea ning, along wi h an inc ease in school d opou s
and a educ ion in school a achmen [
1
]. The coun y’s economic c isis impac ed he mos
Heal hca e 2024,12, 596. h ps://doi.o g/10.3390/heal hca e12050596 h ps://www.mdpi.com/jou nal/heal hca e
Heal hca e 2024,12, 596 2 o 13
ulne able indi iduals, di ec ly a ec ing hei quali y o li e and inc easing he inequali ies
ha al eady exis wi hin he coun y [
2
]. Some o he impac s on s uden s and hei
amilies, who ha e been in a o ced dis ance-lea ning model o he pas wo yea s, include
wo sening nu i ional si ua ions (due o he s uden s no being ed a schools), de e io a ing
men al heal h (pa icula ly inc eased anxie y, s ess, and bu nou symp oms [
3
–
6
]), and
a wo sening ulne abli y [
1
]. I is impo an o men ion ha child labou , abuse, and
unwan ed p egnancies a e p oblems ha also mani es when schooling becomes home-
based [
7
,
8
]. Consequen ly, i is necessa y o implemen conc e e s a egies o coun e ac
o lessen he impac o his si ua ion as much as possible, and his is he mo i a ion o
de eloping he ollowing in e en ion p o ocol.
Gua emala emains one o he poo es coun ies in he Ame ican con inen wi h
high a es o social inequali y and iolence, in which s uc u al p oblems such as acial
disc imina ion, gende inequali y, ex eme po e y and exclusion, an uns able poli ical
si ua ion, and an abe an lack o access o jus ice cons i u e obs acles o he ull enjoymen
o human igh s [
2
]. Addi ionally, acism and disc imina ion agains indigenous peoples
a e deeply oo ed. The indigenous popula ion aces mo e un a ou able condi ions han he
non-indigenous popula ion in e ms o access o employmen , heal h, educa ion, as well
as a e age income and a es o ex eme po e y [
2
]. Gua emala is a di e se, mul ilingual,
and mul icul u al coun y wi h 22 language communi ies. Acco ding o da a om he
las Census [
9
], he es ima ed Gua emalan popula ion in 2020 was 16,858,333 inhabi an s.
The coun y’s g oss domes ic p oduc pe capi a is a ound 39,043 que zals, which would
co espond o app oxima ely 5 US dolla s. I is he coun y in La in Ame ica wi h he
mos ch onic child malnu i ion and he ou h wo ldwide, acco ding o da a om he
Wo ld Bank [
2
]. O ele ance, in e ms o he dis ibu ion o he coun y’s inhabi an s,
hal o he popula ion esides in u al a eas, whe e h ee ou o ou inhabi an s li e in
po e y [
2
]. The schools whe e he in e en ion will be ca ied ou a e in so-called high- isk
a eas loca ed wi hin he depa men o Gua emala. These a e a eas whe e ex eme iolence,
assaul s, mu de s, and ex o ion a e si ua ions ha happen daily, and he isk o d opping
ou o school is e y high due o easons including lack o money, child labou , o s uden
demo i a ion [10].
Li ing condi ions du ing childhood and adolescence a ec he cogni i e and emo ional
de elopmen o mino s, esul ing in impo an long- e m e ec s in hei adul li e [11–14].
Exis ing li e a u e on g owing up in disad an aged en i onmen s epo s ha language de-
elopmen , a en ion, and execu i e unc ions can all be a ec ed. Addi ionally, expe iencing
hese ypes o ad e se con ex s can also ha e a conside able nega i e impac on child en’s
social skills and emo ional egula ion [
15
–
18
]. The de elopmen o his s udy p o ocol
a ises om he need o espond o some o he p oblems disco e ed a e he conclusion o
a p e ious p ojec [
19
]. I s goal was o imp o e exis ing neu opsychological assessmen
ask sco es o child en and adolescen s in Gua emala and s udy how di e en ac o s
wi hin hei en i onmen could a ec hei cogni i e de elopmen . The esul s ob ained in
his p e ious s udy e ealed ha Gua emalan child en and adolescen s pa icipa ing in he
p ojec needed e ec i e suppo on mul iple le els due o hei si ua ions o ulne abili y.
In his s udy, ulne abili y was de ined as belonging o an especially disad an aged socioe-
conomic con ex , bo h in e ms o po e y and di ec exposu e o ex eme iolence; his was
he de ini ion used in he p e ious s udy [
20
]. This showed ha he hypo heses ega ding
he nega i e impac o g owing up in disad an aged socioeconomic en i onmen s (e.g.,
low educa ional le el o ca egi e s, li le in ellec ual s imula ion in hei en i onmen , ood
insecu i y) on he cogni i e pe o mance o child en and adolescen s we e con i med in his
popula ion [
20
]. Addi ionally, i was possible o de ec a se ies o men al heal h di icul ies
in some o he pa icipan s ha could no be le una ended. This included high le els
o anxie y and dep ession, especially among child en om u ban a eas wi h high a es o
iolence [
21
]. In summa y, e idence indica es ha li ing condi ions du ing childhood and
adolescence a ec he cogni i e and emo ional de elopmen o child en, ha ing signi ican
e ec s on hei academic pe o mance, which in u n ends o condi ion hei long- e m
Heal hca e 2024,12, 596 3 o 13
adul li e [
12
–
14
]. Likewise, he s ess associa ed wi h po e y causes a se ious impac on
he emo ional and social de elopmen o hese child en, highligh ing he u gen need o
wo k in hese a eas [22,23].
Neu opsychological s imula ion p og ams ocused on bo h cogni i e and emo ional
unc ions ha e a long adi ion in he clinical ield, being he ea men o i s choice in
a ious neu ode elopmen al diso de s [
24
]. These p og ams a e designed o ain speci ic
cogni i e skills (such as a en ion, memo y, language, e c.), wi h a wide ange o ac i i-
ies, games, and o he media, so pa ien s can imp o e cogni i e skills ha a e no ully
acqui ed/de eloped (due o neu ode elopmen al diso de s) o ha e declined (due o ac-
qui ed b ain damage o degene a i e illnesses). In addi ion, esea ch exis s demons a ing
he e icacy o neu opsychological in e en ions ocused on speci ic cogni i e domains in
non-clinical child popula ions belonging o socioeconomically ulne able con ex s [
25
–
27
].
The esul s sugges ha p o ocols employing di e en agen s and ma e ials in cogni i e
in e en ion, wi h ea ly in e en ion and a la ge numbe o sessions, a e he mos e ec i e.
I has also been shown ha child en li ing in socioeconomically ulne able con ex s can
also bene i om lea ning emo ional egula ion ools o cons uc i ely ace he a ious
isk si ua ions hey a e equen ly exposed o in hei daily li es [
28
]. Ne e heless, we
no ed ha scien i ic e idence on he e icacy o neu opsychological s imula ion p og ams
o child en a isk o social exclusion, and hei posi i e e ec s on cogni i e and emo ional
skills, as well as hei expec ed impac on academic pe o mance and quali y o li e, is s ill
somewha limi ed [27,29,30].
The p e ious s udies and ac o s men ioned abo e ha e been s ong mo i a ion o
he de elopmen o he ollowing p o ocol o he neu opsychological s imula ion p og am.
The implemen a ion o a neu opsychological in e en ion p og am ha s imula es bo h cog-
ni i e de elopmen (especially hose men al unc ions in which a g ea e nega i e impac o
he socioeconomic con ex was de ec ed), as well as emo ional skills ha ein o ce he socio-
emo ional de elopmen o hese child en (an impo an p o ec i e ac o agains mood
swings and o he men al heal h diso de s o which hey a e equen ly exposed) would be
g ea ly bene icial o child en li ing in socioeconomically ulne able con ex s [31,32].
2. Ma e ials and Me hods
2.1. Pa icipan s and S udy Se ing
2.1.1. Pa icipan s’ Cha ac e is ics
S uden s om he 5 h g ade o p ima y school, om educa ional cen es loca ed in
pa icula ly ulne able a eas om Gua emala Ci y’s subu bs, will be in i ed o pa icipa e
in he in e en ion p og am. The eason o choosing his g ade is ha he app oxima e
age o he child en in his school s age a e a he minimum ha ensu es hey ha e ac-
qui ed ce ain skills necessa y o adequa e pa icipa ion in he in e en ion p og am (e.g.,
su icien abili y o sus ain hei a en ion, eading comp ehension, e c.), and he e o e,
hey may bene i mo e om he p oposed in e en ion. I has been ound ha his is he
op imal educa ional le el o s imula ion p og ams o succeed [
33
,
34
]. Mos child en will
be be ween 10 and 12 yea s old. Howe e , gi en he challenging social backg ound and
cou se dis up ion caused by he pandemic, i is likely ha he e will be child en 1–2 yea s
olde in his g ade. The ollowing addi ional inclusion c i e ia will be conside ed:
- Being a p o icien speake o he Spanish language.
-
Ha ing acqui ed su icien eading skills o unde s and he ac i i ies included in he
in e en ion (pe cen ile sco e > 5 in he In e -Ame ican Reading Se ies L-3-DEs).
-
Ha ing a su icien le el o non- e bal in elligence o unde s and and in e ac wi h
he ac i i ies included in he in e en ion (pe cen ile sco e > 5 in he Non-Ve bal
In elligence Tes TONI-2).
-
No ha ing a diagnosis o se ious senso y o mo o di icul ies, o ha ing insu icien ly
co ec ed ones, which would p e en adequa e pe o mance in in e en ion ac i i ies.
Heal hca e 2024,12, 596 4 o 13
2.1.2. Rec ui men S a egy
Fe y Aleg ía is an in e na ional Jesui NGO dedica ed o c ea ing schools and o e ing
educa ion in socioeconomically disad an aged a eas h oughou many Spanish-speaking
coun ies. In Gua emala, hey cu en ly ha e a coun y-wide ne wo k o educa ional
cen es, consis ing o 46 schools in o al. Fi e cen es loca ed in he u ban a ea ha e been
chosen as a sample o ep esen he o al popula ion o hei s uden s due o he la ge
logis ical challenge o accessing mo e emo e schools and because hey ha e su icien
echnical in as uc u e (such as adequa e Wi-Fi ne wo k s abili y) o ca y ou he p ojec .
Th ee o he cen es a e in he subu bs o he Depa men o Gua emala, and wo a e in he
Municipali y o Villa Nue a. All o hem a e in colonias (neighbou hoods) cha ac e ized by
low socioeconomic le el, agg a a ed by e y high exposu e o iolence; assaul s, dea hs,
and ex o ions a e daily si ua ions in hese communi ies, which makes hem especially
ulne able a eas. Be ween hese i e cen es, he e a e app oxima ely 1400 5 h g ade
child en en olled. E e y child ha e o p o ide o al consen o pa icipa e in his s udy, and
hei legal gua dians mus sign an in o med consen documen allowing he use o collec ed
da a o esea ch pu poses, a e being ex ensi ely b ie ed abou he goals, me hods, and
po en ial bene i s o pa icipa ion ( his documen was p o ided by he esea ch eam and
can be seen in he Supplemen a y Ma e ials).
2.1.3. Sample Size
To ensu e ha he size o he imp o emen s ealized by he in e en ion a e o p ac ical
signi icance, we p opose a minimum e ec size o Cohen’s d= 0.3, which is a small- o-
medium e ec . A powe calcula ion using his e ec size and he p oposed analysis
plan (see below) was ca ied ou using he p og am G*Powe [
35
] and indica ed ha he
minimum sample size we equi e o he s udy is n = 352. Howe e , due o he di icul
li ing condi ions in he p oposed ec ui men a eas (gang iolence, long dis ances om
esidences o school cen es, e c.), we expec a high d opou a e. The e o e, we p opose o
ec ui a o al o 480 child en as his would allow o sligh ly mo e han 25% o he sample
o s op pa icipa ion in he s udy ye s ill allow us o main ain su icien s a is ical powe
o de ec he a ge e ec size. Fu he mo e, he igu e o 480 ep esen s app oxima ely
one- hi d o 5 h g ade s uden s a ending Fe y Aleg ía Gua emala ac oss hei 46 cen es.
Thus, we would only need consen om one in e e y h ee child en o achie e he necessa y
sample size. This sample size could be educed i esea ch eams we e p epa ed o look o
la ge e ec sizes. Fu he mo e, once his p o ocol is implemen ed, esea ch g oups should
conside c ea ing a con ingency plan based on he speci ic condi ions hey encoun e o
add ess po en ial di icul ies in ec ui men .
2.2. Objec i es and Hypo hesis
The main objec i e o his s udy p o ocol is o imp o e he cogni i e pe o mance
and emo ional compe ence o s uden s a isk o social exclusion in ulne able a eas o
Gua emala (due o hei high exposu e o iolence and low socioeconomic le el) and
consequen ly imp o e hei academic pe o mance, psychological adjus men , and quali y
o li e. The speci ic objec i e is he de elopmen o a comp ehensi e neu opsychological
s imula ion p og am in which he ollowing cogni i e and emo ional unc ions a e a ge ed:
a en ion, language, execu i e unc ions, social cogni ion, and emo ional compe ence. This
comp ehensi e in e en ion esponds o he needs iden i ied in ou p e ious s udies,
and we hypo hesize ha s eng hening cogni i e abili ies and emo ional compe ence will
imp o e o e all heal h and well-being, as p e ious s udies ha e shown [25–27].
2.3. Ins umen s
2.3.1. Comp ehensi e Assessmen Ba e y
To ob ain he baseline da a o he pa icipan s and e alua e hei subsequen cogni i e
and emo ional pe o mance a e he in e en ion, we will use a ba e y o neu opsycho-
logical es s o assess he cogni i e domains o language [
36
–
38
]: a en ion [
39
], execu i e
Heal hca e 2024,12, 596 5 o 13
unc ions [
40
–
44
], and social cogni ion [
45
]. We will also assess hei men al heal h [
46
,
47
],
emo ional managemen [
48
], and quali y o li e [
49
]. Las ly, we will ake measu emen s
o hei amily’s socioeconomic le el, clinical his o y, ood consump ion [
50
], exposu e
o iolence [
51
], and academic pe o mance ( o de ailed explana ions o he assessmen
ins umen s, see Supplemen a y Ma e ials). In o al, he e will be ou assessmen sessions,
each las ing be ween 45 and 60 min. The session plan has been designed in a modula
way ha allows o lexible adminis a ion in o de o accommoda e pa icipan s who
canno a end he educa ional cen e on a daily basis. Each module can be assessed in
any o de , and hey can be applied one a e he o he wi hin he same session (p o iding
b eaks in be ween), al hough assessing each module on di e en days would be ideal.
Gi en he la ge numbe o es s ha will be equi ed o a comp ehensi e assessmen , i
will become di icul o compa e esul s ac oss es s. Fo his eason, con e ing esul s o
pe cen iles o z-sco es will need o be pe o med in o de o make meaning ul compa isons
be ween ins umen s.
2.3.2. Cogni i e and Emo ional In e en ion P og am
The in e en ion p og am will be ca ied ou using able s wi h access o he digi al
neu o ehabili a ion pla o m Neu onUP [
52
], a ool o neu opsychological ehabili a ion,
s imula ion, and session managemen ool [
53
–
55
]. Compu e ized neu opsychological
in e en ions a e an al e na i e o he classic pencil and pape asks ha o e pa ien s a
no el and en e aining way o ain hei cogni i e skills. These in e en ions ha e been
in e na ionally alida ed [
56
–
61
]. The sessions hemsel es will be di ided in o 30 min
o s imula ion ime and 15 min o dis ibu ing he able s a he beginning, logging in
o he s uden s’ accoun s, and collec ing hem a he end. Since he s imula ion p og am
will be ca ied ou h ough he use o his app, he e a e no associa ed heal h isks o he
pa icipan s; i is a non-in asi e me hod o cogni i e s imula ion p epa ed o p omo e
pa icipan engagemen and educe us a ion by p esen ing exe cises as mini-games. The
sessions will be p og ammed by specialis s in neu opsychology om he esea ch eam
using he Neu onUP2GO unc ionali y, an online applica ion ha allows o managing
he s imula ion sessions o use s loca ed anywhe e a ound he wo ld. Remo e moni o ing
p o ides con inuous con ol, hanks o he ac ha all ac i i ies and esul s a e s o ed on he
pla o m i sel . In addi ion, using Neu onUP2GO, p o essionals can adap sessions based
on he p og ess o each use , hus achie ing a con olled and pe sonalized in e en ion.
The s imula ion p og am will aim o ain he pa icipan s in ac i i ies a ge ing a en ion,
language, execu i e unc ions, and social cogni ion in a cyclical manne , dedica ing each
day o a speci ic domain. Ac i i ies will be di e en in e e y session o a oid bo edom.
Howe e , hey will be aining he same cogni i e domains, so pa icipan s a e able o wo k
on imp o ing hem a a simila pace. The p og am will also ha e h ee le els o di icul y
(easy, medium, and ha d) ha will inc ease in di icul e e y wo cycles, so he s uden s
ha e ime o adap o hei cu en di icul y le el wi hou being ushed. The e will be wo
ac i i ies o each cogni i e skill a e e y di icul y le el (see Figu e 1).
This also makes i possible o apply he p og am in a lexible way o en i e class g oups
in which he e a e usually small di e ences in age as well as di e en a es o de elopmen
and special needs. Addi ionally, i allows child en who ake longe o adap he ime hey
need o de elop he in ended capabili ies g adually, while p o iding e e y child he same
le el o s imula ion, so he whole class can keep s eady p og ess. The adminis a ion o
able s o pa icipan s in each session will be ca ied ou by pe sonnel, duly ained and
appoin ed by he managemen eam o he educa ional cen es (no mally academic u o s
o hose esponsible o he compu e a ea), wi h pe iodic supe ision by neu opsychology
and educa ional psychology specialis s om he p ojec in case any p oblems o ques ions
a ise. The i s session will include an ini ial p esen a ion in which p o essionals ins uc
pa icipan s on how o ope a e he able s and he app, making i sligh ly longe han
o he sessions. A pilo ial has al eady been ca ied ou wi h Gua emalan child en om
hese schools o adap he ac i i ies cul u ally and linguis ically. A eam o Gua emalan

Heal hca e 2024,12, 596 6 o 13
and Spanish neu opsychology expe s and na i e eache s e iewed child en’s eedback
om his pilo and, wi h he help o Neu onUP s a , made necessa y adjus men s o
he ac i i ies selec ed o he p og am o ensu e cul u al and linguis ic adap a ion o
Gua emalan child en.
Heal hca e 2024, 12, x FOR PEER REVIEW 6 o 13
Figu e 1. S imula ion p og am, session by session. No e. The names o e e y ac i i y in Neu onUp
can be seen du ing each session. In some sessions, pa icipan s will engage in mo e han one ac i -
i y, depending on he leng h o each ac i i y. The abb e ia ions lis ed alongside he session num-
be e e o: A .: A en ion (o ange), L.: Language (blue), EF.: Execu i e Func ioning (g een), SC.:
Social Cogni ion (pink).
This also makes i possible o apply he p og am in a lexible way o en i e class
g oups in which he e a e usually small diffe ences in age as well as diffe en a es o
de elopmen and special needs. Addi ionally, i allows child en who ake longe o adap
he ime hey need o de elop he in ended capabili ies g adually, while p o iding e e y
child he same le el o s imula ion, so he whole class can keep s eady p og ess. The ad-
minis a ion o able s o pa icipan s in each session will be ca ied ou by pe sonnel, duly
ained and appoin ed by he managemen eam o he educa ional cen es (no mally ac-
ademic u o s o hose esponsible o he compu e a ea), wi h pe iodic supe ision by
neu opsychology and educa ional psychology specialis s om he p ojec in case any
p oblems o ques ions a ise. The i s session will include an ini ial p esen a ion in which
p o essionals ins uc pa icipan s on how o ope a e he able s and he app, making i
sligh ly longe han o he sessions. A pilo ial has al eady been ca ied ou wi h Gua e-
malan child en om hese schools o adap he ac i i ies cul u ally and linguis ically. A
eam o Gua emalan and Spanish neu opsychology expe s and na i e eache s e iewed
child en’s eedback om his pilo and, wi h he help o Neu onUP s aff, made necessa y
adjus men s o he ac i i ies selec ed o he p og am o ensu e cul u al and linguis ic ad-
ap a ion o Gua emalan child en.
The e a e se e al bene i s ha he in e en ion may b ing o pa icipan s. They will
engage in a ound one hou pe week o digi al exe cises c ea ed o s imula e and
s eng hen cogni i e unc ions and emo ional managemen . These unc ions a e essen ial
o p ope child de elopmen and ha e a signi ican impac on hei social and academic
pe o mance. I is impo an o ou line he ac ha his s udy will no ha e a passi e con-
ol g oup, as i is pa o a bigge in e na ional coope a ion p ojec conduc ed by he
ounding o ganiza ion ocused on p o iding heal h and educa ional se ices o ulne a-
ble popula ions, equi ing all child en o ecei e some kind o in e en ion. The con ol
g oup will use he ime dedica ed o in e en ion sessions o ca y ou a eading mo i a-
ion p og am ha is egula ly used in hese schools (a “ he apy as usual” con ol g oup).
This p og am has been p oposed by Fe y Aleg ía o ain eading p o iciency while ex-
plo ing a a ie y o opics, such as gende equali y, sexuali y, and many o he social op-
ics. They will also pe o m egula academic ac i i ies ha he esponsible eaching s aff
conside pe inen .
This s udy will con ibu e o imp o ing he li ing condi ions o Gua emalan child en
h ough inno a i e ac ions designed o espond o he speci ic needs o child en in ul-
ne able con ex s. Ini ially, he p e ious s udy on socioeconomic s a us and cogni i e
Figu e 1. S imula ion p og am, session by session. No e. The names o e e y ac i i y in Neu onUp
can be seen du ing each session. In some sessions, pa icipan s will engage in mo e han one ac i i y,
depending on he leng h o each ac i i y. The abb e ia ions lis ed alongside he session numbe
e e o: A .: A en ion (o ange), L.: Language (blue), EF.: Execu i e Func ioning (g een), SC.: Social
Cogni ion (pink).
The e a e se e al bene i s ha he in e en ion may b ing o pa icipan s. They will
engage in a ound one hou pe week o digi al exe cises c ea ed o s imula e and s eng hen
cogni i e unc ions and emo ional managemen . These unc ions a e essen ial o p ope
child de elopmen and ha e a signi ican impac on hei social and academic pe o mance.
I is impo an o ou line he ac ha his s udy will no ha e a passi e con ol g oup, as i
is pa o a bigge in e na ional coope a ion p ojec conduc ed by he ounding o ganiza ion
ocused on p o iding heal h and educa ional se ices o ulne able popula ions, equi ing
all child en o ecei e some kind o in e en ion. The con ol g oup will use he ime
dedica ed o in e en ion sessions o ca y ou a eading mo i a ion p og am ha is
egula ly used in hese schools (a “ he apy as usual” con ol g oup). This p og am has been
p oposed by Fe y Aleg ía o ain eading p o iciency while explo ing a a ie y o opics,
such as gende equali y, sexuali y, and many o he social opics. They will also pe o m
egula academic ac i i ies ha he esponsible eaching s a conside pe inen .
This s udy will con ibu e o imp o ing he li ing condi ions o Gua emalan chil-
d en h ough inno a i e ac ions designed o espond o he speci ic needs o child en in
ulne able con ex s. Ini ially, he p e ious s udy on socioeconomic s a us and cogni i e
de elopmen has allowed us o iden i y he a eas ha need g ea e ein o cemen [
21
].
The e o e, he exe cises de eloped using able s, which ha e al eady p o en o be suc-
cess ul in o he con ex s, will be adap ed o he needs o he g oup wi h which we will
wo k. In addi ion, he p e ious s udy has ound anxie y and dep ession symp oms ha a e
highe han expec ed and highe han he a e age, especially in u ban–ma ginal sec o s.
Fo his eason, ac ions o s eng hen emo ional in elligence a e included. E idence shows
ha , in addi ion o imp o ing concen a ion and academic pe o mance, his ype o in e -
en ion p omo es he p e en ion o he appea ance o iolen , addic i e beha iou s, and
o he beha iou s associa ed wi h impulsi eness and di icul y in long- e m planning, hus
con ibu ing o pe sonal and collec i e empowe men o hese child en [27,29,30].
2.4. P ocedu e
The design o his s udy p o ocol ollows he guidelines o he CONSORT- e ised
ecommenda ions o imp o ing he quali y o epo s o pa allel g oup andomized
Heal hca e 2024,12, 596 7 o 13
ials [
62
]. The s udy has been p e- egis e ed wi h he Open Science Founda ion. Ideally,
child en should be andomly alloca ed o ei he he con ol o he expe imen al g oup.
Howe e , implemen a ion o his p o ocol equi es he use o a leas wo ooms a he same
ime, along wi h a high le el o logis ical o ganiza ion in e ms o mo ing he child en
o hei co ec ooms o each session. Gi en he na u e o he schools in ol ed, we do
no belie e i is ealis ic o expec ha hese esou ces will always be a ailable. Hence, we
p opose ha he s udy will be ca ied ou h ough a mul icen e andomized con olled
ial in which en i e classes o child en will be assigned o ei he he con ol o expe imen al
condi ions. We no e, howe e , ha he membe s o each class a e alloca ed a andom by
he school as hey en oll, so in his sense, andom alloca ion a he pa icipan le el is s ill
somewha achie ed. To minimize po en ial bias ela ed o school-speci ic ac o s, each
school will p o ide [a leas ] wo classes, hus ensu ing ha each school is ep esen ed
in bo h condi ions. E o s should be made o ensu e as close o a 1:1 a io o s uden s
be ween g oups as possible. The class designa ed as he expe imen al g oup will ecei e
he in e en ion. The second g oup will be made up o he s uden s who will o m he
con ol g oup. A c osso e design will be used in which he ole o each g oup is e e sed
du ing he ollowing academic yea , hus ensu ing ha each child has he oppo uni y
o bene i om he in e en ion p og am. The s udy will he e o e be di ided in o wo
blocks (see Figu e 2). The i s block will occu in yea 1 and will consis o a p io and
pos e io assessmen (T1 and T2) o he child en’s cogni i e and emo ional abili ies and
he implemen a ion o he in e en ion p og am in be ween. The second block will occu
in yea 2 and will consis o a second in e en ion, ollowed by a inal assessmen (T3),
which will occu when he child en a e in he 6 h g ade. In his block, he con ol and
expe imen al g oups will change oles. Apa om ensu ing ha all child en may bene i
om he in e en ion p og am, i will p o ide an oppo uni y o de e mine i he e is
main enance o he bene i s ob ained by he expe imen al g oup du ing he i s block.
All assessmen s will be ca ied ou by p o essional neu opsychologis s and educa ional
psychologis s, duly ained o adminis e he assessmen asks by he expe s om he
esea ch eam.
Heal hca e 2024, 12, x FOR PEER REVIEW 8 o 13
Figu e 2. C osso e design o he s udy. No e. Highligh ed in g ey boxes a e he expe imen al
g oups (Exp.) o each ound on in e en ion. Whi e in e en ion boxes ep esen he con ol g oups
(C l.).
The p og am will ake place du ing he second hal o he academic yea , a a a e o
wo sessions pe week, wi h an es ima ed du a ion o abou 45 min pe session. Pa ici-
pan s will comple e he wo weekly sessions on diffe en days o he week, depending on
he school hey a end, bu always wi h a leas one es day in be ween. I , o some ea-
son, he e a e pa icipan s who miss one o he sessions, hey would ha e o eco e i
du ing he same week o a oid he isk o alling behind hei classma es. I pa icipan s
miss a session and canno eco e i wi hin he same week, hey will skip ha session and
con inue wi h he no mal session planned o he ollowing week, bu he missed session
will be egis e ed as los . The jus i ica ion o his decision is ha some imes access o
schools o a s able in e ne connec ion will no be gua an eed in he con ex o he s udy.
Hence, his p o ocol will p e en pa icipan s om lagging behind hei classma es and
a oids ha ing pa icipan s comple ing diffe en sessions in he same class oom. An addi-
ional eason o making his decision is ha a he end o he p og am, we will be able o
analyze he pe cen age o comple ion o each pa icipan and de e mine he minimum
comple ion pe cen age o ensu e he p og am’s effec i eness.
One ad an age o he g oup sessions is ha many child en can bene i om p o es-
sional in e en ion wi hou he need o ha e one he apis o each child. Ne e heless,
child en wi h a p e iously diagnosed condi ion a e a isk o g ea e disad an age com-
pa ed o hei coun e pa s and may need specialized, one-on-one a en ion. We do no
p opose ha hese child en be excluded om he in e en ion. Howe e , wi h he help Fe
y Aleg ía, an al e na i e in e en ion will be offe ed o amilies ha wish o ecei e addi-
ional suppo by e e ing hem o specialized se ices offe ed o people wi h limi ed
economical possibili ies. Fu he mo e, eache s will be p o ided wi h aining o effec-
i ely aid and suppo hese s uden s wi hin he school.
2.5. Da a Managemen and Analysis Plan
All physical ma e ials, such as answe shee s, hand-w i en esponses o he es s,
and in o med consen o iginals, will be s o ed and sa egua ded a Fe y Aleg ía headqua -
e s in Gua emala. The da a ga he ed om he assessmen s will be ansc ibed in o com-
pu e iles, which will be s o ed in secu e online se e s a Loyola Andalucía Uni e si y
and will only be accessed by au ho ized pe sonnel om he esea ch p ojec . This da a
will be compiled and analyzed by he echnicians and esea ch assis an s collec ing he
in o ma ion, supe ised by he senio membe s o he esea ch eam unc ioning as a
s ee ing g oup. E e y pa icipan will be assigned an iden i ica ion numbe so hei da a
can be compiled and analyzed anonymously, ollowing he O ganic Law on Pe sonal Da a
Figu e 2. C osso e design o he s udy. No e. Highligh ed in g ey boxes a e he expe imen al g oups
(Exp.) o each ound on in e en ion. Whi e in e en ion boxes ep esen he con ol g oups (C l.).
The p og am will ake place du ing he second hal o he academic yea , a a a e o
wo sessions pe week, wi h an es ima ed du a ion o abou 45 min pe session. Pa icipan s
will comple e he wo weekly sessions on di e en days o he week, depending on he
school hey a end, bu always wi h a leas one es day in be ween. I , o some eason,
he e a e pa icipan s who miss one o he sessions, hey would ha e o eco e i du ing
he same week o a oid he isk o alling behind hei classma es. I pa icipan s miss a
session and canno eco e i wi hin he same week, hey will skip ha session and con inue
wi h he no mal session planned o he ollowing week, bu he missed session will be
Heal hca e 2024,12, 596 8 o 13
egis e ed as los . The jus i ica ion o his decision is ha some imes access o schools o a
s able in e ne connec ion will no be gua an eed in he con ex o he s udy. Hence, his
p o ocol will p e en pa icipan s om lagging behind hei classma es and a oids ha ing
pa icipan s comple ing di e en sessions in he same class oom. An addi ional eason
o making his decision is ha a he end o he p og am, we will be able o analyze he
pe cen age o comple ion o each pa icipan and de e mine he minimum comple ion
pe cen age o ensu e he p og am’s e ec i eness.
One ad an age o he g oup sessions is ha many child en can bene i om p o es-
sional in e en ion wi hou he need o ha e one he apis o each child. Ne e heless,
child en wi h a p e iously diagnosed condi ion a e a isk o g ea e disad an age com-
pa ed o hei coun e pa s and may need specialized, one-on-one a en ion. We do no
p opose ha hese child en be excluded om he in e en ion. Howe e , wi h he help
Fe y Aleg ía, an al e na i e in e en ion will be o e ed o amilies ha wish o ecei e
addi ional suppo by e e ing hem o specialized se ices o e ed o people wi h limi ed
economical possibili ies. Fu he mo e, eache s will be p o ided wi h aining o e ec i ely
aid and suppo hese s uden s wi hin he school.
2.5. Da a Managemen and Analysis Plan
All physical ma e ials, such as answe shee s, hand-w i en esponses o he es s, and
in o med consen o iginals, will be s o ed and sa egua ded a Fe y Aleg ía headqua e s
in Gua emala. The da a ga he ed om he assessmen s will be ansc ibed in o compu e
iles, which will be s o ed in secu e online se e s a Loyola Andalucía Uni e si y and
will only be accessed by au ho ized pe sonnel om he esea ch p ojec . This da a will be
compiled and analyzed by he echnicians and esea ch assis an s collec ing he in o ma ion,
supe ised by he senio membe s o he esea ch eam unc ioning as a s ee ing g oup.
E e y pa icipan will be assigned an iden i ica ion numbe so hei da a can be compiled
and analyzed anonymously, ollowing he O ganic Law on Pe sonal Da a P o ec ion and
Gua an ee o Digi al Righ s 3/2018. I , a he ime o da a analysis, any po en ial isks o
he pa icipan s’ men al heal h a e ound by he esea che s, an unblinding p ocedu e will
ake place o iden i y he pa icipan s and no i y hei school cen e so hey can ake any
ac ions deemed necessa y wi h said child en and hei amilies. The unding body will
unde go an audi ing p ocess in he middle and a he end o he s udy o ensu e ha he
planned in e en ions a e p ope ly ca ied ou .
P e/pos -e alua ion da a a e bes analyzed using an ANCOVA design in which
pos -sco es a e he dependen a iable, and p e-sco es se e as he co a ia e [
63
]. This
will be conduc ed sepa a ely o each in e en ion, wi h he da a collec ed a T2 se ing
as pos -da a o in e en ion 1 and p e-in e en ion baseline da a o in e en ion 2. I
desi ed, he e ec s o he wo in e en ions can be di ec ly compa ed by implemen ing a
epea ed measu es ANCOVA. Gi en ha i is likely ha aw sco es will be con e ed o and
analyzed as pe cen ile sco es, no mal dis ibu ions o he dependen a iables may no be
p esen . Acco dingly, Boo s apping o non-no mal dis ibu ions in he Gene alized Linea
F amewo k should be conside ed o accommoda e hese da a. O he co a ia es, such as sex,
age, mean educa ional le el o pa en s, e c., can be included in he analyses. I will also be
possible o pe o m analyses o di e en subg oups o pa icipan s, ei he using mul ile el,
s a i ied models, o by sepa a ing ou he subg oups, depending on he speci ic na u e
o he subg oups. In pa icula , we will explo e he di e ences be ween he “no ma i e”
g oup (pa icipan s be ween he ages o 10 and 12, wi hou any clinical diagnosis and wi h
sco es o e he inclusion limi in he sc eening assessmen asks), and he “non-no ma i e”
g oup (pa icipan s 13 yea s old and abo e, ha ing any clinical diagnosis, o wi h sco es
unde he sc eening asks limi ). This las sepa a ion will be pe o med o explo e he
impac he p og am may ha e on child en wi h addi ional di icul ies. We will pe o m
ano he ANCOVA analysis o explo e he long- e m changes in he pa icipan s a he
end o he p og am (second block), conside ing he changes hey migh ha e expe ienced
on he i s block. Whe e mul iple compa isons a e unde aken due o he p esence o
Heal hca e 2024,12, 596 9 o 13
many schools, age anges, o o he ac o s, app op ia e co ec ions will be applied o he
s a is ical es s.
Since all child en will ecei e he in e en ion, we wan o explo e he e ec s his
p og am may ha e on he child en who do no mee he inclusion c i e ia bu usually
ha e special educa ional needs. Due o he na u e o he in e en ion, i is impossible o
implemen i in a manne ha allows bo h pa icipan s and he pe sonnel adminis e ing
he in e en ion o pa icipa e blindly. Howe e , he pe sonnel om he esea ch eam
assessing he da a will be blinded o g oup assignmen o ensu e as much o an unbiased
ou come as possible. The in e p e a ion o he da a will also ha e o conside he g oup
assignmen o conclude he e icacy o he p og am.
3. Discussion
This s udy p o ocol ocuses on imp o ing he cogni i e and emo ional compe ence
o s uden s om especially ulne able a eas o Gua emala Ci y and consequen ly aims o
imp o e hei academic pe o mance and quali y o li e. In addi ion, as he pa icipan s a e
mino s li ing in e y ad e se socioeconomic condi ions, hey will ha e he oppo uni y
o lea n how o use elec onic de ices ha hey would no no mally ha e access o, such
as able s o i ual eali y headse s. Gi en he ecen si ua ion wi h he COVID-19 pan-
demic, his knowledge can be bene icial o e ec i ely acing he educa ional challenges
ha schools cu en ly ace a e wo yea s o non- egula ized schooling. The p og am
is ambi ious in e ms o he numbe o es s i p oposes o include. Ne e heless, when
eplica ing his s udy, each esea ch g oup can choose o a y he numbe o es s based on
hei pa icula esea ch goals and he speci ic condi ions encoun e ed wi hin hei sample,
and as he in e en ion p og esses.
The e is a g ea educa ional gap among s uden s caused by he wildly a ied si ua ions
in hei homes. The closu e o schools due o he COVID-19 eme gency has widened his
gap, as mos o hese ulne able s uden s do no ha e access o compu e s o he in e ne
in hei amily homes. In addi ion, he low le el o educa ion o hei ela i es and he
ac ha hey end o li e in small and o e c owded houses ha e a signi ican impac
on hei academic pe o mance. The in oduc ion o able s has he seconda y bene i o
making i possible o educe he digi al gap be ween households while s eng hening he
capaci y o eaching eams o design dis ance and ace- o- ace mixed educa ion me hod-
ologies ha inc ease he skill le els o s uden s, hus educing he educa ional gap. An
equi able educa ion is undamen al o exe cising igh s and inc easing oppo uni ies in
he long- e m.
I he esul s o his p oposed p og am success ully achie es he expec ed impac , i
could make a big di e ence in he u u e o hese child en, p o iding hem wi h a chance
o de elop hei cogni i e and social abili ies o p e iously unachie able le els, balancing
he playing ield wi h o he child en o hei age. This p og am has been c ea ed o be
applied in simila low-le el socioeconomic con ex s, which means ha i could become
a eliable ool o help child en in simila condi ions a ound he wo ld, as he li e a u e
sugges s [
27
,
29
,
30
]. I he p og am is e ec i e, he e a e plans o ans e he knowledge
de i ed om he applica ion o he comp ehensi e neu opsychological s imula ion p o-
g am in ulne able a eas o Gua emala o pa icula ly disad an aged con ex s in Andalucía
(Sou he n Spain), whe e 15 o i s neighbou hoods a e among he poo es in Spain, based
on he mos ecen epo o U ban Indica o s (U ban Audi ) published by he Na ional
Ins i u e o S a is ics [64].
4. Conclusions
The long- e m goal o his p ojec is o c ea e a es ed and alida ed cogni i e s imu-
la ion p og am, so ha i can be in eg a ed in o he academic cu iculum o educa ional
cen es ha wo k wi h people belonging o his ype o popula ion. I is in ended o be
implemen ed by he eaching s a o hese cen es and supe ised in pa allel by neu-
opsychology p o essionals h oughou he p ocess. I aims o o e child en who li e in