This study was conducted at a medical center in Taiwan. Participants were recruited and study data were collected between August 2024 and April 2025. Participants were recruited from 2 sources. Participants in the HC group were recruited through institutional review board–approved printed study flyers posted on hospital bulletin boards and through word-of-mouth referral by friends and colleagues. Community-dwelling individuals who reported no prior clinical diagnosis of dementia were invited to undergo Mini-Mental State Examination (MMSE) screening to determine eligibility for the HC group. Participants in the MCI and dementia groups were recruited from neurology outpatient clinics after routine clinical evaluation conducted by board-certified neurologists. For these clinically referred participants, classification and referral were determined independently of the AI-based behavioral analysis and prior to study enrollment. Clinical classification was based on neurological assessment, Clinical Dementia Rating (CDR) staging, and review of computed tomography and/or magnetic resonance imaging findings performed as part of standard clinical care. For the purpose of behavioral comparison in this exploratory feasibility study, participants were stratified into cognitive performance levels operationally defined as HC, MCI, and dementia. A total of 60 participants were enrolled in the study and categorized into 3 cognitive performance strata, with 20 participants in each group. Because this was an exploratory feasibility study, the sample size was determined pragmatically based on recruitment feasibility, with a target of 20 participants per cognitive performance group.

Cognitive grouping in this study was operationally defined using screening instruments and clinical staging measures, including the MMSE and CDR, for the purpose of behavioral group-level comparison in exploratory analysis, rather than to establish new clinical diagnoses.

Participants were eligible for inclusion if they were aged between 50 and 75 years, were alert and able to follow instructions during testing procedures, and were able to complete the audiovisual stimulus procedures. For the HC group, participants were required to have an MMSE score of 26 or higher, consistent with commonly used screening thresholds for normal cognitive performance in older adults [16]. For the MCI group, participants were required to have a CDR score of 0.5, representing MCI for the purpose of this study [17]. For the dementia group, participants were required to have a CDR score of 1.0 or higher and to have been evaluated by neurologists [17].

Participants were excluded if they had a diagnosis of Parkinson disease, a history of stroke with associated facial paralysis, an inability to complete the assessments due to severe cognitive impairment, altered consciousness, or language deficits, or use of psychiatric medications that could substantially affect facial expression.

The study protocol consisted of cognitive assessment, demographic data collection, and facial expression testing under emotionally evocative and cognitively demanding conditions.

Global cognitive performance was assessed using the MMSE administered by a licensed clinical psychologist. Screening-based cognitive performance strata were subsequently used for group-level behavioral comparison in the analysis of spontaneous affective facial responses. Participants also completed a demographic and health questionnaire including gender, age, education level, marital status, BMI, exercise habits, social engagement, and history of chronic medical conditions.

Participants were then seated in front of a computer screen in a controlled testing environment. Prior to emotional stimulus presentation, a 5-second neutral baseline recording was obtained while participants were instructed to maintain a relaxed facial expression. This baseline segment was used to establish an individualized reference for subsequent AI-based detection of nonneutral affective facial responses during task conditions. Before stimulus presentation, participants’ ability to perceive the audiovisual stimuli was checked in the testing setting. When participants or family members reported presbyopia, reduced visual acuity, or hearing difficulty, participants were asked to wear their usual corrective glasses if available, verbal instructions were provided at an increased volume, and the video playback volume was adjusted as needed to support adequate perception of the stimuli during testing.

Emotional video stimuli were selected through a pilot screening procedure conducted prior to study implementation. Candidate clips were evaluated by adult volunteers across a wide age range for perceived emotional category (positive or negative) and engagement. Based on pilot feedback and consultation with a clinical psychologist, 2 positive emotional video stimuli of differing durations, approximately 14 seconds and 52 seconds, were selected to examine whether stimulus length influenced the emergence of observable affective facial responses, particularly in cognitively impaired individuals who may demonstrate delayed emotional engagement.

Following baseline recording, participants were presented with the 2 positive emotional video clips in sequence. A cognitively demanding task condition was subsequently introduced between positive and negative emotional stimuli. Specifically, participants completed MMSE subtests involving short-term memory recall and calculation ability, which served as a structured transitional condition intended to reduce potential affective carryover between emotionally evocative tasks. Finally, a 48-second negative emotional video stimulus depicting an affectively salient real-life narrative was presented to elicit sadness-related responses. After the negative stimulus, a brief positive video clip was presented as a mood-recovery procedure to help participants return to a more positive emotional state. Data from this recovery clip were not included in the primary analysis.

During both the emotional stimulation and cognitive task conditions, synchronized video recording was performed to capture facial expressions for subsequent AI-based analysis of affective expression onset latency and expression congruency. Facial expressions recorded during MMSE subtests were not used to evaluate cognitive task performance but rather to quantify spontaneous affective expressivity under cognitive load conditions.

This study was approved by the Institutional Review Board of National Taiwan University Hospital, Hsinchu Branch (approval number 202405102RINA). Written informed consent was obtained from all participants or their legally authorized representatives in accordance with the Declaration of Helsinki. When consent was provided by a legally authorized representative, participant assent was sought whenever possible before study procedures. Participants who declined participation or showed unwillingness, discomfort, or distress during the study procedures were not enrolled or were withdrawn from testing. All study data were deidentified before analysis. Video recordings and AI-derived data were stored on a secure hospital server with access restricted to authorized research personnel. No participant compensation was provided.

All statistical analyses were performed using IBM SPSS Statistics version 25. Demographic and clinical characteristics of the 3 cognitive performance groups (HC, MCI, and dementia) were summarized as mean (SD) for continuous variables and as frequencies and percentages (n, %) for categorical variables. Between-group differences in demographic and clinical characteristics were examined using 1-way ANOVA for continuous variables and Pearson chi-square tests or Fisher-Freeman-Halton exact tests, as appropriate, for categorical variables.

AI-derived affective expression onset latency was analyzed as a continuous outcome. Group differences in onset latency across cognitive performance groups were examined using 1-way ANOVA, followed by Bonferroni-adjusted post hoc pairwise comparisons. The significance threshold for pairwise comparisons was set at P<.0167. Because age and education level differed across cognitive performance groups, additional analysis of covariance (ANCOVA) models were performed for each latency outcome, with cognitive performance group entered as the fixed factor and age and education level entered as covariates. Education level was coded as college education or higher vs below college education. Partial η² was reported as an estimate of effect size for ANCOVA models.

Using the 3 affective response classes defined above, positive affective responses were considered congruent for positive video conditions. For the negative video condition and the MMSE-based cognitive-task condition, negative affective responses were considered congruent. In the MMSE-based cognitive-task condition, negative affective facial expressions were operationally classified as task-congruent responses because such expressions may reflect task-related cognitive effort, frustration, uncertainty, or mental strain during recall and calculation demands. This operational definition was informed by prior studies suggesting that facial behavioral signals and facial action units may be associated with cognitive load, task difficulty, listening effort, confusion, and frustration during cognitively demanding or difficult task conditions [21,22]. This definition was not intended to imply that negative expressions exclusively or directly represent cognitive effort.

AI-derived affective expression congruency was analyzed as a categorical outcome by comparing response distributions across cognitive performance groups using Pearson chi-square tests or Fisher-Freeman-Halton exact tests, as appropriate. The MMSE-based cognitive-task condition included short-term memory recall and serial subtraction. Frames classified as nonneutral expressions were further used for latency estimation to quantify spontaneous affective expressivity under cognitive load.

In trials where no nonneutral affective facial expression was detected during a given video stimulus condition, affective onset latency was assigned as n+1 seconds, where n represents the duration of the corresponding video stimulus. This coding approach was used to indicate that no affective response was detected within the observation window and that the true onset latency, if present, exceeded the stimulus duration. Because n+1 represents the smallest possible extension beyond the observation window, this approach was intended to preserve the ordinal relationship between responders and nonresponders while minimizing artificial variance inflation compared with assigning larger arbitrary latency values. For the MMSE-based cognitive-task condition, participants with no AI-detected affective response throughout the task were assigned a maximum latency value of 90 seconds, corresponding to the predefined maximum observation window for the cognitive-task condition. These observations were conceptually treated as right-censored responses for descriptive and group-level latency analyses.

Because this was an exploratory feasibility study with a modest sample size, receiver operating characteristic (ROC) curve analyses were conducted as hypothesis-generating analyses to examine the preliminary discriminative ability of AI-derived affective expression onset latency for distinguishing between cognitive performance groups across emotional video and MMSE-based cognitive-task conditions. No internal cross-validation procedure, such as leave-one-out cross-validation or k-fold cross-validation, was performed. Therefore, the area under the curve (AUC) values and Youden index–derived cutoff values should be interpreted as preliminary estimates derived from the present sample rather than validated classification thresholds.

All statistical tests were 2-tailed. A P value of <.05 was considered statistically significant, except for Bonferroni-corrected pairwise post hoc comparisons, as described above.

A total of 60 participants were enrolled in this exploratory feasibility study, with 20 individuals in each of 3 cognitive performance strata: HC, MCI, and dementia. There were no significant differences in gender distribution among the 3 groups (χ²₂=0.94; n=60; P=.63; Cramér V=0.13). Age differed significantly across cognitive performance groups (F_2,57=13.62; P<.001; η²=0.32). Post hoc comparisons indicated that participants in the HC group were significantly younger than those in the MCI and dementia groups, whereas no significant difference in age was observed between the MCI and dementia groups.

BMI also differed significantly across groups (F_2,57=4.77; P=.01; η²=0.14), as did the proportion of participants with a college education or higher (χ²₂=13.65; n=60; P=.001; Cramér V=0.48). Social participation differed significantly across cognitive performance groups (χ²₂=10.10; n=60; P=.006; Cramér V=0.41).

Significant between-group differences were also observed for several exercise-related characteristics, including regular exercise, exercise frequency greater than 150 minutes per week, exercise intensity, and walking as an exercise type (Table 1). No significant between-group differences were observed for current smoking, alcohol consumption, insomnia, or retired status.

AI-derived affective expression distributions differed significantly across cognitive performance strata under both emotional video and cognitive-task conditions. Across groups, affectively congruent facial expressions were generally less frequent and neutral responses more frequent among participants with lower cognitive performance.

During the first positive video stimulus (14 seconds), affectively congruent positive expressions were observed in 65% (13/20) of participants in the HC group, compared with 20% (4/20) in the MCI group and 0% (0/20) in the dementia group (χ²₄=28.48; exact P<.001; Cramér V=0.49). During the second positive video stimulus (52 seconds), affectively congruent positive expressions were observed in 75% (15/20) of HC participants, 45% (9/20) of MCI participants, and 20% (4/20) of participants with dementia (χ²₄=15.53; exact P=.001; Cramér V=0.36).

In response to the negative emotional stimulus (48 seconds), 60% (12/20) of participants in the HC group displayed affectively congruent negative facial expressions, whereas only 5% (1/20) of both the MCI and dementia groups did so (χ²₄=26.29; exact P<.001; Cramér V=0.47). A similar pattern was observed during the MMSE-based cognitive-task condition, in which affectively congruent negative facial expressions, operationally defined as task-congruent responses, were observed in 50% (10/20) of HC participants, compared with 15% (3/20) of MCI participants and 10% (2/20) of participants with dementia (χ²₄=15.35; P=.004; Cramér V=0.36).

These findings indicate that AI-derived patterns of affective facial responses varied across cognitive performance levels, with neutral responses generally more prevalent among participants with lower cognitive performance (Table 2).

Bonferroni-corrected post hoc comparisons using a significance threshold P<.0167 showed significant between-group differences in selected testing conditions.

Compared with the MCI group, participants in the HC group showed significantly different affective expression distributions during the 14-second positive video stimulus and the 48-second negative video stimulus, whereas no significant differences were observed during the 52-second positive video stimulus, or MMSE-based cognitive-task condition. Similarly, the HC group showed significantly different affective expression distributions compared with the dementia group across all 4 conditions. In contrast, no statistically significant differences were observed between the MCI and dementia groups across any testing condition (Table 3).

AI-derived affective expression onset latency differed significantly across cognitive performance groups in all testing conditions, including the 14-second positive video stimulus (F_2,57=19.63; P<.001; η²=0.41), 52-second positive video stimulus (F_2,57=4.25; P=.02; η²=0.13), 48-second negative video stimulus (F_2,57=15.61; P<.001; η²=0.35), and MMSE-based cognitive-task condition (F_2,57=11.28; P<.001; η²=0.28). Overall, onset latency showed a consistent pattern of longer latency in the MCI and dementia groups than in the HC group across the emotional video conditions and the MMSE-based cognitive-task condition. Bonferroni-adjusted post hoc comparisons primarily indicated shorter onset latency in the HC group than in the MCI and dementia groups, whereas differences between the MCI and dementia groups were generally not statistically significant. The distributions of individual onset latency values are illustrated in Figures 1-4.

Because age and education level differed across cognitive performance groups, additional ANCOVA models were performed to examine whether group differences in AI-derived affective expression onset latency remained significant after adjustment for these variables. Cognitive performance group remained significantly associated with onset latency across all 4 testing conditions after adjustment for age and education level (F_2,55=3.89-10.68; all P≤.03; partial η²=0.12-0.28; Table 4). In contrast, neither age nor education level showed significant covariate effects in any ANCOVA model. These findings suggest that the observed group differences in affective expression onset latency were not fully explained by baseline differences in age or education level.

In exploratory ROC analyses comparing HC and MCI performance levels, AI-derived affective facial expression onset latency showed variable separation across testing conditions. The 14-second positive video stimulus demonstrated an AUC of 0.803 (cutoff=11.48 seconds; sensitivity=90%; specificity=70%), while the 48-second negative video stimulus yielded a comparable AUC of 0.783 (cutoff=42.38 seconds; sensitivity=85%; specificity=70%). The MMSE-based cognitive-task condition showed an AUC of 0.741 (cutoff=29.99 seconds; sensitivity=75%; specificity=80%), whereas the 52-second positive video stimulus demonstrated limited separability (AUC=0.560).

In comparisons between HC and dementia performance levels, higher AUC values were observed across several task conditions. The 14-second positive stimulus yielded an AUC of 0.875 (cutoff=14.36 seconds; sensitivity=100%; specificity=75%), while the 52-second positive video stimulus and the 48-second negative video stimulus demonstrated AUC values of 0.800 and 0.815, respectively. The MMSE-based cognitive-task condition yielded an AUC of 0.823 (cutoff=29.14 seconds; sensitivity=85%; specificity=80%).

In comparisons between MCI and dementia performance levels, latency-based separation was comparatively limited, with AUC values ranging from 0.546 to 0.678 across testing conditions. Although sensitivity estimates were relatively high for several thresholds, specificity values remained low, suggesting substantial overlap in affective response latency between these groups.

Overall, AI-derived onset latency demonstrated variable exploratory classification performance across cognitive performance levels, with greater separation observed between cognitively healthy participants and those with lower cognitive performance. These latency-based behavioral signals may reflect group-level variability associated with cognitive performance; however, they should not be interpreted as diagnostic indicators and may require integration with additional behavioral or clinical measures in future studies (Table 5).

This exploratory feasibility study examined whether AI-derived measures of spontaneous affective facial responses, including affective expression congruency and onset latency, varied across cognitive performance levels in older adults. The main findings were that participants with lower cognitive performance demonstrated lower affective expression congruency and longer onset latency during both emotionally evocative video viewing and MMSE-based cognitive-task conditions. These group differences remained significant for onset latency after adjustment for age and education level. Exploratory ROC analyses further suggested that latency-based features showed greater separation between cognitively healthy participants and those with lower cognitive performance than between the MCI and dementia groups. Together, these findings suggest that AI-derived facial behavioral metrics may capture observable variation in spontaneous affective engagement across cognitive performance levels, although they should be interpreted as preliminary and nondiagnostic markers.

Alterations in emotional processing and affective responsiveness have been increasingly recognized in individuals with cognitive impairment. Prior studies have reported impairments in the perceptual recognition of emotional facial expressions in individuals with MCI and Alzheimer dementia, particularly for negative emotions such as sadness or fear [9,23]. More recent evidence also supports impairments in facial emotion recognition among older adults with MCI and broader alterations in social cognition across the MCI-dementia continuum [7,8]. However, these paradigms primarily assess explicit perceptual recognition of emotional stimuli rather than spontaneous affective expression during emotionally evocative or cognitively demanding conditions. These findings suggest that reduced congruency of observable facial expressions in cognitively impaired individuals may reflect alterations in spontaneous affective engagement rather than perceptual emotion recognition ability alone. Such observable variation in affective expression may be associated with reduced behavioral responsiveness or attenuated affective expressivity, phenomena that have previously been described in individuals with MCI and dementia and linked to neuropsychiatric features such as apathy [6].

The relevance of automated facial expressivity analysis in neurocognitive disorders is also supported by a previous exploratory study that used computer vision–based facial analysis to quantify facial expressivity in older adults with neurocognitive disorders and examined its association with apathy symptoms [11]. That study suggested that reduced facial expressivity may provide objective behavioral information related to emotional blunting and apathy in neurocognitive populations. In line with this work, this study further extends automated facial behavior analysis by focusing on spontaneous affective response congruency and onset latency during emotionally evocative and cognitively demanding conditions.

Prolonged onset latency of spontaneous affective facial responses may be interpreted as a behavioral manifestation of altered emotional expressivity rather than as evidence of impaired perceptual recognition of emotional stimuli. Previous studies have reported reduced emotional facial responding and variation in affective motor expression in individuals with neurodegenerative disorders, which may contribute to delayed or attenuated observable emotional responses under emotionally evocative conditions [15,24]. Similarly, the increased prevalence of neutral facial expressions observed during cognitively demanding tasks may reflect reduced behavioral expression of affective engagement under cognitive load conditions. The limited separation observed between MCI and dementia performance levels across task conditions may further suggest that observable variation in spontaneous affective expression is present across multiple levels of reduced cognitive performance but does not clearly distinguish adjacent impairment levels.

In the cognitive-task condition, negative facial expressions were interpreted as task-congruent only in an operational sense. Recall and calculation tasks may elicit observable negative affective responses related to cognitive effort, frustration, uncertainty, or perceived task difficulty. This interpretation is consistent with recent evidence suggesting that facial behavioral signals and facial action units may be informative for cognitive load estimation and that automatically detected facial expressions may reflect difficulty-related emotional responses under challenging task conditions [21,22]. Therefore, reduced negative expressivity during this condition may indicate attenuated observable affective engagement under cognitive load rather than a direct absence of cognitive effort.

These findings may also be interpreted within the emerging framework of digital phenotyping and digital biomarkers. Recent work has emphasized that digital biomarkers in Alzheimer disease and related cognitive disorders may include objective and quantifiable physiological or behavioral data collected through digital technologies, including wearable sensors, eye tracking, speech analysis, and other behavioral signal streams [25]. In addition, recent scoping evidence has highlighted the growing use of AI-based technologies for the early detection of behavioral and psychological symptoms of dementia, supporting the clinical relevance of AI-assisted behavioral monitoring in dementia care settings [10]. Such approaches may complement conventional episodic clinical assessments by enabling more objective and potentially longitudinal monitoring of subtle cognitive, behavioral, and functional changes. In parallel, recent studies on contactless facial expression assessment have highlighted automated facial expression analysis as a promising approach for monitoring cognitive and emotional changes in older adults [26]. Within this context, this study extends prior work by examining not only the presence or category of facial affective expressions but also their temporal characteristics, particularly onset latency, during emotionally evocative and cognitively demanding conditions. These findings support the potential relevance of AI-derived facial behavioral metrics as adjunctive, noninvasive features within future multimodal digital phenotyping frameworks.

Exploratory ROC analyses indicated that AI-derived onset latency of spontaneous affective facial responses demonstrated variable classification performance across cognitive performance levels. Greater separation was observed between cognitively healthy participants and those with lower cognitive performance, whereas separation between the MCI and dementia groups was limited. Although sensitivity estimates were relatively high in several emotionally evocative and cognitively demanding task conditions, specificity remained limited, suggesting substantial overlap in affective response timing between adjacent cognitive performance levels.

These findings suggest that temporal characteristics of spontaneous affective facial responses may reflect group-level behavioral variability but may have limited separability when used in isolation. Behavioral timing metrics alone may therefore provide only partial information regarding affective response variability, underscoring the potential need to integrate these features with additional behavioral or clinical measures in future multimodal observational frameworks [25].

This study has several limitations. First, the modest sample size may limit generalizability, and the cross-sectional design does not permit examination of longitudinal changes in behavioral response timing.

Second, although the ANCOVA models adjusted for age and education level, other baseline differences, including lifestyle-related factors such as physical activity and social participation, were not included as covariates. Previous epidemiological studies and recent dementia prevention evidence have reported associations between lifestyle-related factors, including physical activity and social participation, and cognitive health in older adults [27,28]. Therefore, variation in AI-derived affective facial expression onset latency may partly reflect residual confounding related to baseline lifestyle differences rather than cognitive performance alone.

Third, baseline affective state, apathy, depressive symptoms, and other preexisting mood states were not assessed using standardized instruments such as the Positive and Negative Affect Schedule [29]. Given prior evidence linking reduced facial expressivity with apathy-related features in neurocognitive disorders [11], spontaneous facial expressivity and AI-derived onset latency may have been influenced by participants’ preexisting emotional states rather than task-evoked affective responses alone. The interpretation of negative facial expressions during the MMSE-based cognitive-task condition should also be considered exploratory. Although these expressions were operationally treated as task-congruent behavioral responses, they may reflect a mixture of cognitive effort, frustration, uncertainty, or affective discomfort rather than cognitive effort alone [21,22].

Fourth, cognitive grouping in this study was based on screening-level cognitive assessment for the HC group and clinical evaluation, CDR staging, and neuroimaging review for clinically referred participants in the MCI and dementia groups as part of standard clinical care. However, comprehensive neuropsychological profiling, biomarker-supported classification, or dementia subtype–specific analyses were not systematically performed. Therefore, the dementia group was analyzed as a single clinically defined category, and subtype heterogeneity, including Alzheimer disease, dementia with Lewy bodies, or vascular cognitive impairment, may have influenced facial expressivity and AI-derived onset latency.

Fifth, emotional stimuli were restricted to 2 emotional categories, positive and negative, which may not fully represent the broader spectrum of affective responsiveness across cognitive performance levels. The relatively short video durations may also have constrained emotional elicitation, particularly among participants with slower spontaneous affective engagement. In addition, all participants received the same fixed sequence of stimuli, including positive video stimuli, MMSE-based cognitive-task condition, and a negative video stimulus; therefore, potential order effects, habituation, fatigue, or affective carryover between testing conditions cannot be excluded. Although practical steps were taken during testing to support audiovisual stimulus perception, formal standardized visual and hearing assessments were not performed. Therefore, unmeasured sensory impairment may have influenced stimulus perception and AI-derived onset latency independently of cognitive performance. Cultural and linguistic mismatches between certain stimuli and participants may have further influenced emotional engagement and observable facial responses. These methodological considerations are consistent with recent reviews emphasizing the need for standardized data collection, improved interpretability, and multimodal integration in AI-based facial emotion analysis for dementia-related applications [30].

Finally, the ROC analyses were exploratory and were not internally validated using leave-one-out or k-fold cross-validation. Therefore, the AUC values and Youden index–derived cutoff values may be sample-dependent and should be interpreted as preliminary estimates rather than validated classification thresholds.

Future research should consider methodological refinements to improve the interpretability, ecological validity, and generalizability of AI-assisted facial expression analysis across varying levels of cognitive performance. Expanding the range of emotional stimuli beyond positive and negative affective categories may provide a more comprehensive characterization of emotion-cognition interactions across cognitive performance levels. The delayed affective onset observed in participants with lower cognitive performance suggests that brief stimuli may be insufficient to elicit measurable spontaneous facial responses in some individuals; therefore, future protocols may benefit from longer, culturally and linguistically appropriate, or more emotionally salient stimuli. In addition, longitudinal investigations in larger and more diverse cohorts will be necessary to examine intraindividual changes in affective facial responsiveness over time and to determine whether AI-derived facial behavioral metrics can contribute to multimodal monitoring frameworks for cognitive health.

In this exploratory feasibility study, AI-assisted facial expression analysis revealed observable variation in the timing and congruency of spontaneous affective facial responses across cognitive performance levels. Participants with lower cognitive performance demonstrated delayed onset of observable affective facial expressions and a higher prevalence of neutral or incongruent responses during both emotionally evocative video viewing and cognitively demanding task conditions.

These findings suggest that temporal and categorical features of facial expressions, particularly onset latency and expression congruency, may reflect group-level variation in spontaneous affective engagement across cognitive performance levels. Latency-based measures showed preliminary potential for distinguishing cognitively healthy participants from those with lower cognitive performance, although separation between adjacent impairment levels remained limited.

AI-derived quantification of affective facial responsiveness may complement existing behavioral and clinical observations by providing an additional noninvasive observational measure in both clinical and community-based aging contexts. Further studies involving larger cohorts, longitudinal designs, and internal and external validation procedures are required to examine the stability, generalizability, and clinical relevance of these behavioral features over time.