Jack A. Naglieri, Anthony Paolitto
Ohio State University
Attention Deficit Disorder (ADD) is typically described as a delay in the development of response inhibition (DuPaul & Stoner, 1994) (described as Attention Deficit Hyperactivity Disorder in DSM-IV) leading to problems with impulsivity, overactivity, and inattention. To a lesser extent, individuals with inattention (described as Attention Deficit Inattentive in DSM-IV) are also identified. This problem occurs in 3-5% of school ages children from all socioeconomic, cultural, and racial backgrounds, but it is more prevalent in males. Identification of ADD typically involves structured interviews and behavior rating scales (Barkley, 1990) and the Wechsler has been utilized, although evidence for its effectiveness has not been found (Anastopoulos, Spisto, & Maher, 1994). In this workshop, we will discuss the current problems with identification, treatment, and how to effectively identify problems with inattention and/or impulsivity using a variety of methods, including the Cognitive Assessment System (CAS)(Naglieri & Das, 1997).
Attention Deficit Disorder (ADD) is typically described as a delay in the development of response inhibition (DuPaul & Stoner, 1994) (described as Attention Deficit Hyperactivity Disorder in DSM-IV) leading to problems with impulsivity, overactivity, and inattention. Individuals with inattention (described as Attention Deficit Inattentative in DSM-IV) can also identified, but these children are less often found. This problem occurs in 3-5% of school ages children from all socioeconomic, cultural, and racial backgrounds, but it is more prevalent in males and often constitutes as many as 50% of referrals (Lerner, Lowenthal, & Lerner, 1995). ADD is an important problem found in children and it has important implications for academic performance and future success. Identification of ADD typically involves structured interviews and behavior rating scales (Barkley, 1990). Although the Wechsler scales have been used, evidence for its effectiveness has not been found. For example, Anastopoulos, Spisto, and Maher (1994) found that children identified as ADHD had normal scores on the WISC-R Verbal Comprehension (103.9), Perceptual Organization (103.3), and Freedom From Distractibility (96.0) scales. Moreover, Barkley (1990) states "I do not recommend that this factor [Freedom from Distractibility] be used in assessing attention or in establishing evidence for or against a diagnosis of ADHD (p. 331)".
If ADD is seen as primarily a problem of inhibition of action which is associated with frontal lobe activity, then it would be expected that such persons would be poor in planning as well as attention as described by Das, Naglieri & Kirby (1994) in their discussion of the Planning, Attention, Simultaneous, Successive (PASS) theory. Those with inattention problems would likely be poor in the Attention dimension of the PASS theory while children could also have cognitive problems in both areas. These possibilities were examined in the following study.
The four PASS processes were assessed using the CAS (Naglieri & Das, 1997a) which is an individually administered test for children aged 5 through 17 years of age. The test is standardized on 2,200 persons aged 5 years 0 months to 17 years 11 months who closely match the U. S. population on the basis of gender, race (Black, White, Asian, Native American, Other), Hispanic origin, Region, community setting (Urban/Suburban, Rural), classroom placement (full-time regular classroom, part-time Special Education Resource, full-time Self-Contained Special Education), educational classification, and parental educational attainment level. The CAS is comprised of PASS processing subtests that have undergone extensive development and validation in both experimental (see Das, Naglieri, & Kirby, 1994) and final published forms (see Naglieri & Das, 1997b). Each subtest yields a standardized score with a mean of 10 and SD of 3. Subtests are combined into PASS Scales and a Full Scale, each of which are set at a mean of 100 and SD of 15. Evidence for the reliability of the subtests and PASS Scales are provided in the manual. The average reliabilities for the Scales are as follows: Planning= .88; Simultaneous= .93; Attention= .88; Successive= .93; and Full Scale= .96. Support for the content, construct, and criterion-related validity of the scales is also provided (Naglieri & Das, 1997b). Each PASS subtest is described below.
Matching Numbers (MN) consists of four pages each consisting of eight rows of numbers with six numbers per row. Children are instructed to underline the two numbers in each row that are the same. Numbers increase in length across the four pages from one digit to seven digits with four rows for each digit length. Each item has a time limit. Children 5 to 7 years are administered Items 1 and 2, and children 8 through 17 Items 2 through 4. The subtest score is based on the combination of time and number correct (accuracy score) for each page. Accuracy scores are summed and used as a measure of the child's efficiency. This subtest has an average internal reliability of .75.
Planned Codes (PCd) contains two pages, each with a distinct set of codes and arrangement of rows and columns. A legend at the top of each page shows a correspondence of letters with codes (e.g., A, B, C, D to OX, XX, OO, XO, respectively). The page contains seven rows and eight columns of letters without codes. Children fill in the appropriate codes in empty boxes beneath each letter. On the first page, all the As appear in the first column, all the Bs in the second column, all the Cs in the third column, etc. On the second page, letters are configured in a diagonal pattern. The time and number correct (accuracy score) is combined for each page and these two scores are summed to obtain the raw score. This score is a measure of the child's efficiency. The average internal reliability is .82.
Planned Connections contains eight items. The first six items require children to connect numbers appearing in a quasi-random order on a page in sequential order. The last two items require children to connect both numbers and letters in serial order alternating between numbers and letters (for example, 1-A-2-B-3-C). The items are constructed so that children never complete a sequence by crossing one line over the other. The time needed to complete the item sequence correctly is the best measure of efficiency, so the score is the total amount of time in seconds used to complete the items. The average internal reliability is .77.
Expressive Attention (EA) uses two different sets of items, depending on the age of the child, to measures selectivity and the ability to shift attention. The version for children 8 years and older is like the Stroop test. On the first page children read the color words (Blue, Yellow, Green, and Red) presented in quasi-random order. Next, they name the colors of a series of rectangles (printed in blue, yellow, green, and red). Finally, the words Blue, Yellow, Green, and Red are printed in a different color ink than the colors the words name. The child is instructed to name the color ink the word is printed in, rather than to read the word. For all subjects the last page only is used as the measure of attention. The raw score is the ratio of the accuracy (total number correct) and time. The average internal reliability of Expressive Attention is .80.
Number Detection (ND) is comprised of pages of numbers that appear in different formats. On each page children are required to find a particular stimulus (the number 1, 2, and 3 printed in an open font) on a page containing many distracters (the same numbers printed in a different font style). There are 180 stimuli with 45 targets (25% targets) on the pages. The raw score for Number Detection is the ratio of the accuracy (total number correct minus the number of false detections) and the total time for each item, summed across the items, is the raw score. The more accurate the child is at detecting the target stimuli and avoiding the distracting stimuli, the higher the score will be. The average internal reliability is .77.
Receptive Attention (RA) is a two-page paper-and-pencil subtest. For children 8 years and above two pages are given. On the first page letters that are physically the same (for example, T T but not T t) are targets, but on the second, letters that have the same name (for example, Aa not Ba) are targets. Each page contains 200 pairs of letters with 50 targets (25% targets) and the same set of distracters. The raw score is the ratio of the accuracy (total number correct minus the number of false detections) and the total time for each item. These scores are summed across the items to obtain a total raw score. The average internal reliability is .77.
Nonverbal Matrices (NvM) is a 33-item multiple subtest that utilizes shapes and geometric designs that are interrelated through spatial or logical organization. Children are required to decode the relationships among the parts of the item and choose the best of six options. Each progressive matrix item is scored as correct or incorrect. The raw score is the total number of items correctly answered. The average internal reliability is .89.
Verbal-Spatial Relations (VSR) is composed of 27 items that require the comprehension of logical and grammatical descriptions of spatial relationships. Children are shown items containing six drawings and a printed question at the bottom of each page. The items involve both objects and shapes that are arranged in a specific spatial manner. For example, the item "Which picture shows a circle to the left of a cross under a triangle above a square"? would include six drawings with various arrangements of geometric figures, only one of which matches the description. The examiner reads the question aloud and the child is required to select the option that matches the verbal description. Children must indicate their answer within the 30-second time limit to receive credit. The raw score is the total number of items correctly answered. The average internal reliability is .83.
Figure Memory (FM) is a 27-item subtest. Children are shown a two- or three- dimensional geometric figure for five seconds. The figure is then removed and the child is presented with a response page that contains the original design embedded in a larger, more complex geometric pattern. Children are asked to identify the original design embedded within the more complex figure. For a response to be scored correct, all lines of the design have to be indicated without any additions or omissions. The total number of correct items is the raw score. The average internal reliability is .89.
Word Series (WS) requires the child repeat words in the same order as stated by the examiner. The test consists of the following nine single-syllable, high- frequency words: Book, Car, Cow, Dog, Girl, Key, Man, Shoe, Wall. There are 27 items which the examiner reads to the child. Each series ranges in length from two to nine words, presented at the rate of one word per second. Each item is scored as either correct if the child reproduces the entire word series in the order presented. The raw score is the total number of items correctly repeated. Word Series average internal reliability is .85.
Sentence Repetition (SR) requires the child repeat 20 sentences that are read to the child. Each sentence is composed of color words (for example, "The blue is yellowing"). The children are required to repeat each sentence exactly as it was presented. Color words are utilized so that the sentences contain little meaning and help reduce the influence of simultaneous processing and accent the demands of the syntax of the sentence. Each item is scored as correct if the sentence is repeated exactly as presented. The raw score is the total number of sentences correctly repeated. The average internal reliability is .84.
Speech Rate (SpR) is an 8-item subtest that requires children (ages 5-7 only) to repeat a high imagery, single-, and double-syllable word series 10 times in order. The child is timed to determine how long it takes to repeat the series correctly. Examiners begin timing when the child says the first word in the series and stop timing when the child finishes repeating the last word in the tenth repetition. The raw score is the total time in seconds for all items. Speech Rate average internal reliability is .81.
Sentence Questions (SQ) is a 21-item subtest that uses the same type of sentences as those in Sentence Repetition. Children (ages 8- 17 only) are read a sentence and then asked a question about the sentence. For example, the examiner says "The blue is yellowing" and asked the following question: "Who is yellowing?" (The answer is "The blue.") Successful completion of this task demands the comprehension of the sentence based on the serial placement of the words. Each item is scored as correct if the child successfully answers the question regarding the sentence. The raw score is the total number of questions answered correctly. The average internal reliability is .84.
Attention- Deficit/Hyperactivity Disorder (ADHD). A sample of 60 children who met DSM-IV (American Psychiatric Association, 1994) criteria for attention-deficit/ hyperactivity disorder was identified. Exclusionary criteria included the absence of other comorbid diagnoses related to ADHD symptoms (e.g., conduct disorders, anxiety disorders, oppositional defiant disorders). The sample of students with ADHD was composed of mostly white (91.7%) non-Hispanic (95.0%) males (88.3%) who ranged in age from 6.8 to 13.8 years of age (mean= 9.7; SD= 1.4) and came from the Northeast (95.5%) or South (4.5%). These students resided in urban/suburban communities (71.2%). The educational levels of the parents of these students were as follows: high school graduate= 24.2%; some college or technical school= 24.2%; and four or more years of college= 51.6%. The high proportion of males in this sample is consistent with previous ADHD research on prevalence by gender.
The mean scores earned by the ADHD students on the CAS subtests and Scales are presented in Table 1. The children performed lowest in Planning, with depressed Attention scores. This finding is consistent with the view proposed by Barkley (1996) that behavioral disinhibition plays a central role in attention- deficit/hyperactivity disorders. According to Barkley, children with ADHD experience difficulty with the construction of goal-directed actions (plans) which disrupts persistent responding. These findings suggest that the CAS offers an important perspective on the cognitive weaknesses of children with ADHD.