Utility of a CPT in diagnosing ADHD among a representative sample of high-risk children: a cautionary study.

Continuous performance tests (CPTs) are widely used in the assessment and study of attention deficit hyperactivity disorder (ADHD). Although CPTs have reliably found differences between children with ADHD and normal controls, discriminating between children with ADHD and children with subclinical levels of behavioral or cognitive problems is a more clinically relevant and difficult endeavor. Additionally, most studies use convenience samples from clinical care settings that may not represent the ADHD population as a whole. The current study assessed the utility of a clinically used CPT, the Test of Variables of Attention (TOVA), in distinguishing between children with ADHD and children with subclinical levels of attention/behavior problems. Participants constituted a representative sample of elementary school students at high risk for ADHD, including 116 children with ADHD and 51 subclinical controls. Results found no significant differences between the ADHD and subclinical group on CPT variables, and CPT performance did not reliably predict group membership. Implications of the findings are discussed.     

Comparison between two continuous performance tests for identifying ADHD: Traditional vs. virtual realityEjecución continua para la detección del TDAH: pruebas tradicionales frente a la realidad virtual

Background/Objective: Continuous Performance Tests (CPTs) have demonstrated validity when differentiating children with ADHD from healthy controls. However, these CPTs have limitations such as low ecological validity. New CPTs based on the use of Virtual Reality (VR) have appeared as supposedly improved methods for assessing ADHD. This study aims to compare the discriminant value of attentional variables produced by a VR CPT (Aula Nesplora) with that of variables from a traditional CPT (Test of Variables of Attention; TOVA) for identifying ADHD. Method: A total of 338 children aged between 6 and 16 years old (M = 10.84, SD = 3.01) participated in the study: 31.95% correspond to the inattentive presentation, 15.38% to the impulsive-hyperactive presentation, 22.78% to the combined presentation, and the remaining 29.88% correspond to children without ADHD. Results: Results indicated that Aula Nesplora predicts ADHD presentations better than TOVA. It also differentiates better between ADHD and non-ADHD students. Conclusions: These findings show the potential advantages of using virtual reality in ADHD assessment, as it facilitates the diagnosis of ADHD and the differentiation of its presentations in a realistic environment.     

Virtual-reality-based attention assessment of ADHD: ClinicaVR: Classroom-CPT versus a traditional continuous performance test

Virtual-reality-based assessment may be a good alternative to classical or computerized neuropsychological assessment due to increased ecological validity. ClinicaVR: Classroom-CPT (VC) is a neuropsychological test embedded in virtual reality that is designed to assess attention deficits in children with attention deficit hyperactivity disorder (ADHD) or other conditions associated with impaired attention. The present study aimed to (1) investigate the diagnostic validity of VC in comparison to a traditional continuous performance test (CPT), (2) explore the task difficulty of VC, (3) address the effect of distractors on the performance of ADHD participants and typically-developing (TD) controls, and (4) compare the two measures on cognitive absorption. A total of 33 children diagnosed with ADHD and 42 TD children, aged between 7 and 13 years, participated in the study and were tested with a traditional CPT or with VC, along with several cognitive measures and an adapted version of the Cognitive Absorption Scale. A mixed multivariate analysis of covariance (MANCOVA) revealed that the children with ADHD performed worse on correct responses had more commissions and omissions errors than the TD children, as well as slower target reaction times . The results showed significant differences between performance in the virtual environment and the traditional computerized one, with longer reaction times in virtual reality. The data analysis highlighted the negative influence of auditory distractors on attention performance in the case of the children with ADHD, but not for the TD children. Finally, the two measures did not differ on the cognitive absorption perceived by the children.     

Does the Conners' Continuous Performance Test Aid in ADHD Diagnosis?

The performance of clinic-referred children aged 6–11 (N = 100) was examined using the Conners' Continuous Performance Test (CPT) and measures of auditory attention (Auditory Continuous Performance Test; ACPT), phonological awareness, visual processing speed, and visual-motor competence. The Conners' CPT overall index was unrelated to measures of visual processing speed or visual-motor competence. Although the Conners' CPT converged with the ACPT, the latter demonstrated age and order effects. Significant variance in Conners' CPT parameters was predicted by phonological awareness measures, suggesting that Reading Disordered (RD) children could be false positives on the Conners' CPT. The Conners' CPT overall index, phonological awareness, and visual-motor measures were submitted to a 2×2 MANCOVA (ADHD vs. RD, covarying for age and socieoeconomic status): a main effect for RD status was found. Children with ADHD did not have higher Conners' CPT scores than did clinical controls; however, children with Reading Disorders did. Phonological measures distinguished RD children from ADHD children and other clinical controls. ADHD children who failed the Conners' CPT were rated by teachers as more hyperactive. Despite the strengths of the Conners' CPT, its utility for differential diagnosis of ADHD is questioned.     

Parent characteristics and parent-child interactions in families of nonproblem children and ADHD children with higher and lower levels of oppositional-defiant behavior

This study examined parent-child interactions and parent characteristics in families of nonproblem children and attention deficit hyperactivity disorder (ADHD) children with lower (ADHD-LOD) and higher (ADHD-HOD) levels of oppositional-defiant behavior. Families of ADHD children were recruited from a parent training program. Observed and parent-reported child behavior problems were highest in the ADHD-HOD group. Observed parent behavior revealed few differences, but daily reports indicated that parents in both ADHD groups used more negative-reactive and fewer positive parenting strategies than control parents. Maternal psychological functioning differed between the ADHD and nonproblem groups, but not between the two ADHD groups. Fathers of ADHD-HOD children reported more psychological disturbance than controls. Parenting self-esteem was lowest in the ADHD-HOD group and highest in the nonproblem group. The results support the LOD and HOD distinction, but also suggest that, although certain difficulties are more common in the families of ADHD-HOD children, families of ADHD-LOD children also differ from controls on a number of dimensions.This research was supported by grants from the Medical Research Council of Canada and the British Columbia Health Research Foundation. Appreciation is extended to Josie Geller, Kim Behrenz, Susan Greaves, and Sonia Pietzsch who assisted with data collection and coding, and to the families who generously gave their time to participate in the research. Thanks also to two anonymous reviewers for their comments.     

Significance of Childhood Conduct Problems to Later Development of Conduct Disorder Among Children With ADHD: A Prospective Follow-Up Study

This study investigates whether low to moderate levels of childhood oppositional defiant disorder (ODD) and conduct disorder (CD) behaviors contribute to the development of clinically diagnosed CD in adolescence, in children with attention deficit hyperactivity disorder (ADHD). Participants were 207 White boys (ages 6-12) with ADHD free of conduct disorder diagnoses. Parent and teacher ratings were obtained. Participants were assessed at mean age 18 by clinicians blind to childhood status. A non-ADHD group (recruited in adolescence) was also studied. ODD behavior ratings did not predict CD in adolescence, whereas CD behavior ratings did. No single ODD or CD behavior predicted adolescent outcome. ADHD probands with very low ratings (Not at all, Just a little) by parents and teachers on all CD behaviors were still at significantly increased risk for CD in adolescence, compared to non-ADHD controls. The same relationships were found between childhood ODD and CD behaviors, and antisocial personality disorder in adulthood (mean age, 25). We conclude that childhood ADHD is a developmental precursor of later antisocial disorder, even in the absence of comorbid ODD or CD in childhood. However, low levels of CD-type problems are not innocuous, because they predict later CD among children with ADHD without comorbid CD.     

Visuo-spatial working memory span: a sensitive measure of cognitive deficits in children with ADHD.

Working memory (WM) has been hypothesised to be impaired in attention-deficit/hyperactivity disorder (ADHD). However, there are few studies reported on tests measuring visuo-spatial WM (VSWM) in ADHD. Some of these studies used paradigms including episodic memory, others only used low memory loads. In the present study we used a VSWM test that has not been used previously in ADHD research. The sensitivity of the VSWM test and a choice reaction time (CRT) test was evaluated in a pilot study by comparing them to two commonly used tests in ADHD-research; the Continuous Performance Test (CPT) and a Go/no-go test, in children with and without ADHD. The groups differed significantly in performance on the VSWM test (P < .01) and CRT (P < .05) but not on the CPT (P > .1) or on the Go/no-go test (P > .1). The results from the VSWM and CRT tests were replicated in a larger sample of participants (80 boys; 27 boys with ADHD and 53 controls, mean age 11.4 years). The difference between the groups was significant for both the VSWM test (P < .01) and the CRT test (P < .01). The effect size (ES) of the VSWM test was 1.34. There was a significant age-by-group interaction on the VSWM test, with larger group differences for the older children (P < .01). Our results show that the VSWM test is a sensitive measure of cognitive deficits in ADHD and it supports the hypothesis that deficits in VSWM is a major component of ADHD.     

Evidence of difficulties in sustained attention in children with ADDH

It has been suggested that children with ADDH have specific difficulties in sustained attention. Despite some early studies supporting this position, many recent reports using continuous peformance tests (CPTs) have failed to confirm this hypothesis. Possible reasons for this discrepancy are outlined and an attempt to corroborate and extend an earlier study (Sykes, Douglas, & Morgenstern, 1973) was undertaken. CPT results in normal children indicated that changes in performance over time, although not affected by gender, were influenced by age. Data from ADDH subjects indicated that they performed significantly more poorly with time on task than did controls. These results suggest that the ability to sustain attention increases with age and does not vary by gender. Furthermore, difficultues in the ability to sustain attention can be demonstrated in children with ADDH. Finally, it is suggested that within-age-level comparisons between groups of ADDH and controls would be more clinically sensitive than across-age-group comparisons.This research was supported in part by a Sara Spencer Research Fellowship granted to the first author. Portions of this research were presented at the 17th annual meeting of the International Neuropsychological Society, Vancouver.     

Inattentive and noninattentive ADHD children: Do they constitute a unitary group?

Teacher-rated ADHD and normal control children were administered a continuous performance test (CPT), and were then further subdivided based upon the presence or absence of objectively assessed attentional deficits. In addition, children were assessed using several measures of cognitive and behavioral functioning. Attentional deficits were signficantly more prevalent among the ADHD group, but about half of the ADHD children showed no evidence of objectively assessed attentional dysfunction. Further group analyses indicated that ADHD children with objectively assessed attentional dysfunction appeared cognitively impaired, while ADHD children without objective evidence of attentional dysfunction had more conduct problems. CPT inattention was not related to the presence of cognitive impairments or conduct problems in the control group. These data must be considered preliminary because teacher ratings were the only source of diagnosis and a single measure of inattention was used. However, they suggest that two subtypes of ADHD children can be identified, one characterized by inattention and learning problems, and the other by conduct problems.The authors gratefully acknowledge the assistance of Sister Hildegard Kogler and the St. Francis DeSales School, and the parents and children who participated in this study.     

A Playroom Observation Procedure to Assess Children with Mental Retardation and ADHD

Forty-two children (ages 6 to 12 years old) with moderate mental retardation to borderline intellectual functioning were studied in a laboratory playroom setting to determine whether children identified as ADHD (attention deficit hyperactivity disorder) or controls differed on activity and attentional measures. Children with ADHD were further divided into ADHD + conduct problems (ADHD + CD) and ADHD-only subgroups (with an ADHD-combined group comprising children of both subgroups). An interval recording system was used to code observations of independent play and a restricted academic task. Results indicated that the ADHD-combined group was significantly more vocal and engaged in a significantly greater number of toy changes than controls during independent play. Significant group differences were also noted during the restricted academic task, with the ADHD-combined and ADHD + CD groups more off-task and engaging in a greater number of toy touches than controls. Discriminant analyses found independent play measures to predict group membership in 70 percent of cases (ADHD-combined vs. controls), but in only 64 percent of cases using measures from the restricted academic task. No significant findings resulted when the ADHD subjects were further divided into two subgroups. Despite some inconsistent findings, such laboratory-based observations may be of value in the diagnosis of ADHD in children with moderate mental retardation to borderline intellectual functioning.     

A controlled clinical comparison of attention performance in children with ADHD in a virtual reality classroom compared to standard neuropsychological methods.

In this initial pilot study, a controlled clinical comparison was made of attention perforance in children with attention deficit-hyperactivity disorder (ADHD) in a virtual reality (VR) classroom. Ten boys diagnosed with ADHD and ten normal control boys participated in the study. Groups did not significantly differ in mean age, grade level, ethnicity, or handedness. No participants reported simulator sickness following VR exposure. Children with ADHD exhibited more omission errors, commission errors, and overall body movement than normal control children in the VR classroom. Children with ADHD were more impacted by distraction in the VR classroom. VR classroom measures were correlated with traditional ADHD assessment tools and the flatscreen CPT. Of note, the small sample size incorporated in each group and higher WISC-III scores of normal controls might have some bearing on the overall interpretation of results. These data suggested that the Virtual Classroom had good potential for controlled performance assessment within an ecologically valid environment and appeared to parse out significant effects due to the presence of distraction stimuli.     

Executive Functioning, Temporal Discounting, and Sense of Time in Adolescents with Attention Deficit Hyperactivity Disorder (ADHD) and Oppositional Defiant Disorder (ODD)

Clinic-referred teens (ages 12–19) with ADHD and ODD (N = 101) were compared to community control (CC) teens, equated for age and sex, (N = 39) on a variety of psychological tasks assessing executive functioning (EF), temporal reward discounting, and time estimation and reproduction. A factor analysis reduced the EF measures to three dimensions, representing CPT Inattention, Working Memory, and CPT Inhibition. Results indicated that the ADHD group had significantly more CPT Inattention than the CC group. No differences were found for Working Memory or CPT Inhibition. The ADHD group displayed significantly greater temporal discounting of delayed hypothetical monetary rewards relative to immediate ones and manifested more impaired time reproduction, but not time estimation, than did the CC group. Main effects for level of IQ were found only on the Working Memory factor and largely did not interact with the group factor otherwise. The group differences in CPT Inattention, temporal discounting, and time reproduction were not a function of level of comorbid oppositional defiant disorder, delinquency, or anxiety–depression. Results are reasonably consistent with past research on EF and sense of time in children with ADHD and extend these findings to the adolescent age group. Problems with working memory and CPT inhibition found in prior studies of children with ADHD, however, were not evident here, perhaps owing to age-related improvements or insufficient task difficulty.     

AULA virtual reality test as an attention measure: Convergent validity with Conners’ Continuous Performance Test

The majority of neuropsychological tests used to evaluate attention processes in children lack ecological validity. The AULA Nesplora (AULA) is a continuous performance test, developed in a virtual setting, very similar to a school classroom. The aim of the present study is to analyze the convergent validity between the AULA and the Continuous Performance Test (CPT) of Conners. The AULA and CPT were administered correlatively to 57 children, aged 6–16 years (26.3% female) with average cognitive ability (IQ mean = 100.56, SD = 10.38) who had a diagnosis of attention deficit/hyperactivity disorder (ADHD) according to DSM-IV-TR criteria. Spearman correlations analyses were conducted among the different variables. Significant correlations were observed between both tests in all the analyzed variables (omissions, commissions, reaction time, and variability of reaction time), including for those measures of the AULA based on different sensorial modalities, presentation of distractors, and task paradigms. Hence, convergent validity between both tests was confirmed. Moreover, the AULA showed differences by gender and correlation to Perceptual Reasoning and Working Memory indexes of the WISC-IV, supporting the relevance of IQ measures in the understanding of cognitive performance in ADHD. In addition, the AULA (but not Conners’ CPT) was able to differentiate between ADHD children with and without pharmacological treatment for a wide range of measures related to inattention, impulsivity, processing speed, motor activity, and quality of attention focus. Additional measures and advantages of the AULA versus Conners’ CPT are discussed.     

Effects of IQ on Executive Function Measures in Children with ADHD

The present study compared children with Attention-Deficit Hyperactivity Disorder (ADHD) and controls on a selected set of clinical measures of executive function (EF). A total of 92 children (51 ADHD, 41 control), ages 6-16, completed measures chosen from a larger neuropsychological battery to illustrate diverse components of the EF construct (planning, inhibitory control, response preparation, memory search). The selected measures were moderately correlated with one another, and moderately correlated with IQ. After controlling for age, sex, presence of learning disability (LD), ADHD, and IQ test version, Full Scale IQ was significantly related to four of the five selected EF measures. A second analysis showed group differences on the EF measures at different IQ levels. After covarying for age, there was a significant multivariate effect for IQ level (average, high average, superior) and a significant multivariate interaction between group (ADHD vs. control) and IQ level. Three of the five selected EF measures showed significant univariate group effects (controls performing better than ADHD) at the average IQ level; however, there were no significant group differences between children with ADHD and controls at high average or superior IQ levels. These results suggest that clinical measures of EF may differ among children with ADHD and controls at average IQ levels, but there is poorer discriminatory power for these measures among children with above average IQ.     

Effects of IQ on executive function measures in children with ADHD.

The present study compared children with Attention-Deficit Hyperactivity Disorder (ADHD) and controls on a selected set of clinical measures of executive function (EF). A total of 92 children (51 ADHD, 41 control), ages 6-16, completed measures chosen from a larger neuropsychological battery to illustrate diverse components of the EF construct (planning, inhibitory control, response preparation, memory search). The selected measures were moderately correlated with one another, and moderately correlated with IQ. After controlling for age, sex, presence of learning disability (LD), ADHD, and IQ test version, Full Scale IQ was significantly related to four of the five selected EF measures. A second analysis showed group differences on the EF measures at different IQ levels. After covarying for age, there was a significant multivariate effect for IQ level (average, high average, superior) and a significant multivariate interaction between group (ADHD vs. control) and IQ level. Three of the five selected EF measures showed significant univariate group effects (controls performing better than ADHD) at the average IQ level; however, there were no significant group differences between children with ADHD and controls at high average or superior IQ levels. These results suggest that clinical measures of EF may differ among children with ADHD and controls at average IQ levels, but there is poorer discriminatory power for these measures among children with above average IQ.     

Time Perception: Does It Distinguish ADHD and RD Children in a Clinical Sample?

This study used a double-dissociation design to evaluate whether children with ADHD demonstrated specific deficits relative to children with Reading Disorders. Recent theory suggests that ADHD children have deficits in time perception and working memory, whereas RD children have deficits in phonological decoding. The performance of 113 clinic-referred children aged 6-11 was examined using measures of working memory, phonological processing, and time perception. Respondents completed two time production tasks in which they were to judge when 30-s had elapsed, and another in which they were asked to estimate the duration of the Conners' CPT (CCPT). Time Perception and phonological processing variables were submitted to a 2 x 2 ANCOVA (ADHD vs. RD), covarying for age, SES, IQ, and working memory. Children with ADHD were more likely to overestimate the time taken for the CCPT than children without ADHD, but no group differences were found on the 30-s estimation tasks. Children with RD did not display deficits in time estimation, but showed deficits in auditory phonological processing. The lack of interaction effects supported an "etiological subtype" over the "phenocopy" model of ADHD and RD. No group differences were detected using the CCPT. Although our previous studies did not find an order effect for the Conners' CPT in a 1-hr battery, a fatigue effect was evident with a 1.5-hr battery. The implications for Barkley's behavioral inhibition theories (R. Barkley, 1997) are discussed.     

Differences in memory functioning between children with attention-deficit/hyperactivity disorder and/or focal epilepsy

Prior research has shown that attention-deficit/hyperactivity disorder (ADHD) and epilepsy are frequently comorbid and that both disorders are associated with various attention and memory problems. Nonetheless, limited research has been conducted comparing the two disorders in one sample to determine unique versus shared deficits. Hence, we investigated differences in working memory (WM) and short-term and delayed recall between children with ADHD, focal epilepsy of mixed foci, comorbid ADHD/epilepsy and controls. Participants were compared on the Core subtests and the Picture Locations subtest of the Children’s Memory Scale (CMS). Results indicated that children with ADHD displayed intact verbal WM and long-term memory (LTM), as well as intact performance on most aspects of short-term memory (STM). They performed worse than controls on Numbers Forward and Picture Locations, suggesting problems with focused attention and simple span for visual-spatial material. Conversely, children with epilepsy displayed poor focused attention and STM regardless of the modality assessed, which affected encoding into LTM. The only loss over time was found for passages (Stories). WM was intact. Children with comorbid ADHD/epilepsy displayed focused attention and STM/LTM problems consistent with both disorders, having the lowest scores across the four groups. Hence, focused attention and visual-spatial span appear to be affected in both disorders, whereas additional STM/encoding problems are specific to epilepsy. Children with comorbid ADHD/epilepsy have deficits consistent with both disorders, with slight additive effects. This study suggests that attention and memory testing should be a regular part of the evaluation of children with epilepsy and ADHD.     

Heart Rate Variability and Sustained Attention in ADHD Children

The major goal of the current study was to investigate the association between continuous performance tests (CPTs) and the heart rate variability (HRV) of attention deficit hyperactivity disorder (ADHD) children. The HRV, specifically the 0.10-Hz component, may be considered to be a psychophysiological index of effort allocation (motivation): The less effort the subject allocates, the greater the 0.10-Hz component. Results indicated that, compared to controls, ADHD subjects had a greater 0.10-Hz component, which was associated with poor test performance over time. Thus, using a psychophysiological measure, we were able to confirm the clinical concept of ADHD from a motivational perspective.     

A critical appraisal of the role of neuropsychological deficits in preschool ADHD

The present study aimed at improving our understanding of the role of neuropsychological deficits in preschool Attention Deficit Hyperactivity Disorder (ADHD). The study included 52 children in the ADHD group and 72 controls (age 4–6 years). Both laboratory measures and teacher reports of executive deficits (i.e., working memory, inhibition, and shifting), delay-related behaviors (i.e., the preference for minimizing delay), and emotional functions (i.e., emotion recognition and regulation) were included. Variable-oriented analyses were complemented with person-oriented analyses (i.e., identifying the proportion of patients considered impaired). Results showed that the ADHD group differed from controls with regard to all measures of executive functioning and most measures of delay-related behaviors, but few differences were found for emotional functioning. A substantial subgroup (23%) of children with ADHD did not have a neuropsychological deficit in any domain. There were subgroups with executive or delay-related deficits only, but no pure emotional subgroup. The overlap between different neuropsychological deficits was much larger when teacher reports were used as opposed to laboratory measures. Regarding functional impairments, large mean differences were found between the ADHD group and controls. However, neuropsychological deficits were not able to explain individual variations in daily life functioning among children with ADHD. In conclusion, the present study identified some important methodological and theoretical issues regarding the role of neuropsychological functioning in preschool ADHD.     

A Program Intervention for Pediatric Bipolar Disorder: Preliminary Results

The effectiveness of a behaviorally based day treatment program for young children diagnosed with Pediatric Bipolar Disorder (PBD) was evaluated using pretreatment and posttreatment mean scores from the Child Behavior Checklist (CBCL). Data were evaluated in aggregate and using the clinically significant change method for children diagnosed with PBD, Attention Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder (ODD), Adjustment Disorder, and no diagnosis/clinical and subclinical groups. Significant effects were found for all groups except the no diagnosis/subclinical group on the Internalizing scale and for all groups on the Externalizing scale. Clinically significant change was supported for the PBD, ADHD, ODD, and Adjustment Disorder groups. Implications and limitations of the study are discussed.