MENTAL RETARDATION AND DEVELOPMENTAL DISABILITIES RESEARCH REVIEWS 11: 216225 (2005)

MEASUREMENT OF ATTENTION AND RELATED FUNCTIONS IN THE PRESCHOOL CHILD

E. Mark Mahone*
Department of Neuropsychology, Kennedy Krieger Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland

The goal of this review of the clinical and research literature is to identify, describe, and critique published methods for assessment of attention and related functions in preschool children (ages 6 and younger). The need for valid assessment of preschool children has grown dramatically in the past two decades following the implementation of special education services for infants, toddlers, and preschoolers under Public Law 99 457. At the same time, the number of preschool children presenting to clinicians for assessment of attention problems has grown at a steady rate. In contrast to assessment methods for school-age children, the availability of reliable and valid measures of attention for preschool children is much more limited. The majority of instruments developed to measure attention in preschoolers are described in the experimental literature, with fewer available commercially. Attention tests that can be appropriately used with children aged 3 and younger are scarce. Most preschool tests of attention report validity data involving sensitivity in contrasting clinical groups to controls, while the literature describing the utility of these measures in differentiating between clinical groups is much more limited. The review provides information on performance based tests (e.g., continuous performance, cancellation, auditory/visual span), as well as parent and teacher rating scales. The review concludes that valid assessment of attention and related skills can be effectively achieved in preschool children, with appropriate cautions.

2005 Wiley-Liss, Inc.

MRDD Research Reviews 2005;11:216 225.

Key Words: preschool; ADHD; attention; continuous performance test; cancellation test; rating scales

used for older children and adults rely on some form of motor response. Preschool children, especially those aged 4 and younger, have great difculty inhibiting motor responses on such tasks, leading to high rates of commission errors. For the youngest children (ages 3 and younger), attention tests that use looking behaviors (e.g., eye xation) appear promising as research tools [Goldman et al., 2004]; however, their clinical utility has yet to be established. Assessment of attention is nevertheless an important component, a comprehensive developmental assessment of preschool children. Like their school-age counterparts, healthy preschool children demonstrate rapid, steady development of attention skills between ages 3 and 6, including the ability to shift attention more uently, and inhibit unnecessary motor behaviors to allow for responses [Espy et al., 1999]. Thus, attention skills can serve to provide support for (or interfere with) the completion of a variety of problem solving behaviors in preschoolers. As such, the most important use of preschool attention tests may not be to diagnose attentional disorders, per se, but rather, to more accurately characterize the development of such skills to aid the clinician in planning appropriate behavioral, academic, and possibly pharmacological intervention. Additionally, objective tests of attention and related skills are important in monitoring effects of interventions, and in behavioral research in preschoolers. Development of Attention in Preschoolers The newborn brain continues to develop rapidly over the rst few years of life, and considerable plasticity exists during this period [Yamada et al., 2000]. Environmental experience and stimulation can signicantly affect neuronal development in young children, including the number and density of synapses [Greenough et al., 1987; Wallace et al., 1992]. The brains attentional systems and associated catecholamine neurotransmitters in prefrontal, striatal, and associated subcortical systems have
Contract grant sponsor: National Institute of Neurological Diseases and Stroke; Contract grant number: NS043480; Contract grant sponsor: Thomas Wilson Foundation for the Children of Baltimore City. *Correspondence to: E. Mark Mahone, Ph.D., Department of Neuropsychology, Kennedy Krieger Institute, 1750 East Fairmount Ave., Baltimore, MD 21231, USA. E-mail: mahone@kennedykrieger.org Received 11 July 2005; Accepted 12 July 2005 Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/mrdd.20070

INTRODUCTION he need for valid assessment of preschool children has grown dramatically in the past two decades following the implementation of special education services for infants, toddlers and preschoolers under Public Law 99 457 (IDEA). Since that time, the majority of assessment methods developed for preschool children have focused on either global development [e.g., Bayley Scales, 2nd ed.; Bayley, 1993], general intellectual functioning [e.g., WPPSI-III; Wechsler, 2002], language [e.g., CELF-Preschool; Wiig et al., 1992], motor skills [e.g., BruininksOseretsky Test of Motor Prociency; Bruininks, 1978], or preacademic development [Bracken Basic Concepts Scales-Revised; Bracken, 1998]. In contrast, the development of tools for reliable and valid measurement of attention and related functions in preschool-age children has been more limited. The difculty in measuring attention in children under the age 6 may be due to the variable nature of attention at that age, leading to poor reliability among such tests. A second problem may be a result of the response modality. Most performance based tests of attention

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a rapid maturation period in infancy and preschool years [Solanto et al., 2001] that have the potential to be shaped by environmental inuences [Healy, 2004]. These prefrontal brain systems undergo rapid changes during the preschool years, including pruning of synaptic connections [Huttenlocher and Dabholkar, 1997], and subcortical myelination [Kinney et al., 1988]. A recent report from the environmental protection agency cited concerns about neurotoxic agents in the environment and their association with an increase in attention problems cited among preschoolers [Stein et al., 2002]. Additionally, increased television exposure among infants and toddlers has been linked to the rising rate of attention problems in elementary school [Christakis et al., 2004]. The American Academy of Pediatrics [1999] has recommended no screen time for children under 2 years of age; no more than 12 h a day of quality television and video for older children; and no electronic media in young childrens rooms. Nevertheless, a recent study found that 43% of children aged 2 and younger watch television every day; 26% have televisions in their rooms; and 68% of children younger than 24 months spend over 2 h a day with screen media [Rideout et al., 2003]. Attention Decit/Hyperactivity Disorder (ADHD) in Preschool ADHD has become the most commonly diagnosed form of psychopathology in the preschool years [Armstrong and Nettleton, 2004]. The prevalence of ADHD in preschoolers varies, depending on the samples reported; however, the numbers appear to be increasing [DeBar et al., 2003]. DeBar et al. [2003] reported the occurrence of ADHD to be 2%, in a sample of 38,664 general pediatric patients under the age of 5 years. Connor [2002] reported that the incidence might be as high as 59% in child psychiatry clinics. In another sample of 200 children aged 6 and younger referred to an outpatient psychiatric clinic, 86% met diagnostic criteria for ADHD [Wilens et al., 2002a]. Of particular concern is the observation that preschoolers with ADHD were found to have similar patterns of comorbid psychopathology and functional impairment when compared with those of school-age children with ADHD [Wilens et al., 2002b]. Thus, preschool children presenting with symptoms of ADHD are at signicant risk for social, familial, and academic difculties, relative to children without ADHD [DuPaul et al., 2001].
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Earlier identication and treatment of attentional problems may minimize the harmful impact of ADHD [Wilens et al., 2002a]. In the past decade, there has been an increased interest in the assessment and treatment of preschool children presenting with symptoms of ADHD, and improvements in assessment methods. The core symptoms of ADHD distractibility and hyperactivityare commonly seen in preschool children referred for developmental evaluation [Shelton and Barkley, 1993]. The diagnostic criteria for ADHD, as delineated in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) [American Psychiatric Association (APA), 2000], specify that symptoms must be present before 7 years of age. Research has supported this age-of-onset criterion for ADHD [Applegate et al., 1997], as well as the validity of the diagnosis for younger children [Lahey et al., 1998]. There is also evidence for the predictive validity of ADHD diagnoses made in the preschool years [Lahey et al., 2004; McGee et al., 1991]. Despite the increased interest in assessing ADHD in preschoolers, the NIH [1998] reported that many practitioners do not use structured questionnaires or rating scales, or use teacher/school input in diagnosing. The NIH has since called for additional research on ADHD, particularly in the areas of age- and genderspecic diagnostic criteria, and in the development of reliable and valid assessment procedures. The development of valid assessment methods is particularly important, because relying on parents verbal reports of isolated symptoms of ADHD in preschoolers may lead to overidentication of the disorder [Gimpel and Kuhn, 2000]. Gimpel and Kuhn recommended using full DSM-IV criteria and including standardized measures across multiple informants and settings, when making the diagnosis of ADHD in preschool years. While performancebased tests of attention are not necessary to make a diagnosis of ADHD in the preschool years, they do provide an objective sampling of behavior under standardized conditions, and can be useful in characterizing related behavioral needs. Also, objective assessment of attention and related skills among preschoolers can be particularly useful in measuring the effects of treatments. Even though much less is known about ADHD in 2- to 5-year-old preschool children, the practice of prescribing psychotropic medications for very young children has increased in both the
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US and Europe, [Connor, 2002; Rappley et al., 2002]. Rappley et al.[2002] reported on 223 children aged 3 and younger receiving treatment for ADHD. More than half (n 127) received treatment in an idiosyncratic manner, and had monitoring less than once every 3 months. In an attempt to improve knowledge about assessment and treatment of ADHD in young children, the National Institute of Mental Health (NIMH) began a clinical trial in 2000 to study the effects of methylphenidate in preschoolers (ages 3 6) with ADHD. This ongoing study, known as the Preschool ADHD Treatment Study (PATS), is expected to shed light on the efcacy of diagnostic methods and treatments for ADHD in the preschool years. Medical and Neurodevelopmental Disorders with Associated Attention Problems Attention problems are common among preschool children. By the age of 4 years, as many as 40% of children have sufcient problems with inattention to be of concern to parents and preschool teachers [Palfrey et al., 1985]. Further, a variety of medical conditions are associated with attention problems in preschoolers, including epilepsy, congenital cardiac defects, hypothyroidism, low birth weight, hearing loss, and prenatal exposure to teratogens (e.g., fetal alcohol syndrome). In addition, a variety of neurodevelopmental and genetic conditions are associated with attention problems, and have signicant overlap with the behavioral presentation of ADHD, including cerebral palsy, spina bida, Turner syndrome, fragile X, neurobromatosis, early treated phenylketonuria, sickle cell disease, and Williams syndrome. Children with cognitive delays, neurodevelopmental immaturity, or learning problems are likely to be perceived as inattentive [Blackman, 1999], particularly, if expectations for productivity are inappropriate for the childs developmental level, or if there is a mismatch between a childs skills and demands of certain settings. Further, preschool children with ADHD also tend to have high rates of language problems and developmental coordination disorder [Kadesjo and Gillberg, 1998; Kadesjo et al., 2001]. Given these considerations, there is a growing need for accurate and reliable assessment of attention and related functions in the preschool years to operationalize the construct, to dene normal development, and to assist clinicians in earlier identication and treatment in 217

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Table 1.
Test Simple Reaction Time PVT ZooRunner CPTP C-CPT ACPT-P ECVT K-CPT GDS-Preschool PDTP-R MFFT-PV Number Recall Hand Movements Visual Attention Statue Type CPT CPT CPT CPT CPT CPT CPT CPT CPT

Preschool Tests of Attention and Related Functions

Age Range 25 46 35 35 36 36 23 45 45 35 34 318 418 312 312 Pres A, V A A, V V A, V A V V V V V A V V V, A Min 3.0 14.5 7.2 8.5 5.0 5.0 7.0 7.5 6.0 7.0 5.0 5.0 5.0 6.0 1.5 Com No No No No No No No Yes Yes No No Yes Yes Yes Yes Publisher (Website)

MHS (www.mhs.com) Gordon Systems, Inc. (www.gsi-add.com) AGS (www.agsnet.com) AGS (www.agsnet.com) Psychological Corporation (www.psychcorp.com) Psychological Corporation (www.psychcorp.com)

Cancellation Matching Auditory span Visual span Cancellation Motor persistence

Pres, presentation format; Com, commercially available; Min, approximate administration time (min); CPT, continuous performance test; A, auditory; V, visual; PVT, Preschool Vigilance Test; CPTP, Continuous Performance Test for Preschoolers; C-CPT, Childrens Continuous Performance Test; ACPT-P, Auditory Continuous Performance Test for Preschoolers; ECVT, Early Childhood Vigilance Test, K-CPT, Kiddie Continuous Performance Test; GDS, Gordon Diagnostic System; PDTP-R, Picture Deletion Test for Preschoolers-Revised; MFFT-PV, Matching Familiar Figures Test-Preschool Version.

disorders with associated attention problems. PRESCHOOL ATTENTION TESTS Comprehensive reviews of psychological and neuropsychological tests for preschoolers, including tests of attention, are provided in texts by Baron [2004], Spreen and Strauss [1998], and the Mental Measurements Yearbooks [Plake et al., 2003]. The present review of tests that follows is not exhaustive, but rather intended to represent a collection of measures available both commercially and in the research literature that can be used in assessment of attention and related functions in preschool children, as part of a comprehensive diagnostic workup. When available, reliability and validity data for the instruments are provided. A summary of the performancebased tests is provided in Table 1. Continuous Performance Tests (CPTs) CPTs were originally developed by Mirsky and his colleagues to measure vigilance in individuals with brain injuries [Rosvold et al., 1956]. Today, CPTs are the most commonly used paradigm to assess components of attention in both children and adults [Mirsky et al., 1991; Barkley, 1994, 1998]. CPTs are intended to measure an individuals ability to detect and respond to specic stimulus changes occurring infrequently at either xed or random intervals, over a pro218

longed period of time, while simultaneously inhibiting responses to extraneous stimuli [Corkum and Siegel, 1993; Ballard, 1996]. Although several versions of CPTs are readily available for schoolage children, CPTs are less commonly used with preschoolers [Harper and Ottinger, 1992; Prather et al., 1995]. Only recently have CPTs designed specically for preschoolers become commercially available [Conners, 2001]. Listed below are examples of commercial and experimental CPT measures that have been used to measure attention in preschool children. Simple Reaction Time Several variations on simple reaction tests are available in the literature [e.g., Eliot, 1970; Weissberg et al., 1990]. Because the responses require only pressing of a button in response to a stimulus, with no decisions to be made, children as young as 2 years are often able to complete the measures. Weissberg et al. [1990] described procedures for visual and auditory simple reaction time tasks that were used for preschool children. In their auditory task, children were asked to push a button as quickly as possible after hearing a bell. There were 20 trials. Five delay periods (requiring the child to wait 2, 3, 4, 5, or 6 s before responding) were randomly presented in each of four blocks of ve trials. Omission errors, commission errors (i.e., responses made before the bell), and response latency were recorded. Children as young as 312
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years completed the task successfully, and performance improved rapidly between ages 3 and 5. In a visual version of the simple reaction time task, a picture of a rabbit appeared on the computer screen, and remained until the child pushed a button. Number of trials and delay periods were identical to the auditory task. Children as young as 212 years successfully completed the visual task and performance (omissions, commissions, and response time) all improved steadily from age 2 to 5. Mean response time, but not omission or commission errors, was signicantly correlated with Stanford Binet intelligence quotient (IQ). In contrast, commission errors, but not omissions or reaction time, was signicantly correlated with the Hyperactivity Scale from the CPRS. The authors concluded that the rapid improvements represent a general development of control over excitatory and inhibitory processes [Weissberg et al., 1990]. For this task, commission errors may be the most sensitive indicator of the development of inhibitory control. Preschool Vigilance Task (PVT) The version of the PVT reported by Harper and Ottinger [1992] was a modication of the procedures originally described by Herman et al. [1980] and Streissguth et al. [1984], used for children aged 4 6. The PVT reported by Harper and Ottinger uses a picture of a tree presented continuously on a computer monitor. A bird appears on the branch of the tree at intermittent intervals, ranging
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from 10 to 60 s. The interstimulus intervals (ISI) were random. The bird remained on the screen for 500 ms, and the duration of the task was 14.5 min. Children were asked to press a button as soon as the bird appeared. Errors of omission and reaction time were recorded. In a sample of 20 hyperactive and 20 control preschoolers, ages 4 6, the PVT demonstrated good testretest reliability for omissions (0.80), but not for mean response time (0.16). Hyperactive children demonstrated signicantly greater omission errors than that in controls [Harper and Ottinger, 1992]. Given the low reliability of the reaction time score, caution should be used when interpreting this variable on the PVT. ZooRunner The ZooRunner tasks were developed by Prather et al. [1995] to assess sustained auditory and visual attention in preschoolers aged 3 6. The test uses pictures of animals visually (Visual ZooRunner) or animal sounds auditorally (Auditory ZooRunner) every 2000 ms, with a stimulus presentation time of 1000 ms and an ISI of 1000 ms. Both tasks present a total of 215 trials, and take 7.2 min each. There are 12 stimuli used for both versions (11 nontargets, 1 target). Children are asked to press a button when they see a picture of a cat (Visual ZooRunner), or hear the word tiger (Auditory ZooRunner). Mean reaction time, omissions, and commission errors were recorded. Prather et al. [1995] reported a steady rate of improvement in among typically developing children in omissions, commissions, and reaction time on both the Visual and Auditory ZooRunner. However, the younger children (i.e., 3-year-olds) made an extremely high rate of omissions on both auditory and visual tasks, suggesting that the measure is too difcult for 3-yearolds. Additionally, there is little improvement in performance after 512 years of age, suggesting the presence of ceiling effects in older, or higher functioning preschoolers. Across the age range, children made more errors on the auditory test than the visual test. Byrne et al. [1998] used the Auditory ZooRunner to assess the effects of a 5-month trial of stimulant medication in eight preschoolers (ages 4 and 5) with ADHD, compared with a matched control group of eight typically developing children receiving no treatment. Children with ADHD had signicantly more errors of omission than that in controls on the Auditory ZooRunner at baseline, but not more errors of commission. After
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treatment, children with ADHD improved signicantly from baseline on omission errors, and performance was no longer signicantly different than controls. Commission errors did not improve after treatment, in the ADHD group. Given the observed oor and ceiling effects, the ZooRunner appears best suited for children aged 4 and 5. Continuous Performance Test for Preschoolers (CPTP) Corkum et al. [1995] developed a visual CPT for use with children aged 35. They examined the performance of 60 typically developing preschoolers, using a computer-based paradigm with simple line drawings of familiar objects (e.g., face, ice cream, sun, ower, pig, and lollipop) as stimuli. The CPTP is 812 min in length and uses a ratio of ve nontargets to one target stimulus (total of 240 stimuli of which 40 are targets). Each stimulus remains on the screen for 750 ms, and the ISI is xed at 1350 ms. Children are asked to push a button each time they see the picture of the pig, but not for any of the other stimuli. Response latency, omission, and commission errors were recorded. Although the authors found a clear developmental progression of performance in normal preschool children between the ages of 3 and 5 on response latency, omissions and commissions, more than half of the 3-year-olds in the study had a large number of errors (both omission and commission), calling into question the validity of the test for that age group. Byrne et al., [1998] also used the CPTP to examine effects of stimulant medication in eight preschool children (ages 4 5) with ADHD, compared with controls receiving no treatment. Children with ADHD exhibited signicantly more errors of omission and commission than that in controls at baseline. At 5-month follow up, the children with ADHD had significant reductions in omissions and commissions, and were no longer decient, relative to controls on the CPTP [Byrne et al., 1998]. The CPTP appears to be sensitive to treatment effects, but may be too difcult for 3-year-old children with ADHD or other developmental delays. Childrens Continuous Performance Test (C-CPT) Kerns and Rondeau [1998] developed the computerized C-CPT procedures for preschoolers, using similar parameters as the CPTP [Corkum et al., 1995] and ZooRunner [Prather et al., 1995], but making the entire test shorter to make the test easier for younger chilIN

dren. Three task variations were used each lasting only 5 minwith 200 stimuli, 29 of which were targets randomly presented throughout the procedures. There were 10 total stimuli (9 nontargets, 1 target) presented so that 6 distracters were presented for each target. A xed 1500 ms ISI was used on all three tasks. Task 1 used animal pictures paired with correct animal noises. Children were asked to click the mouse every time they saw and heard the sheep. Task 2 was similar; however, only animal sounds were presented, and children were asked to click the mouse each time they heard the sheep sound. For Task 3, animal pictures were presented with sounds occurring randomly (i.e., not paired correctly). On this task, the child was asked to click the mouse to the picture of the sheep, regardless of the sound. Omission and commission errors were recorded for all three tasks. All but two of the control participants (n 187, ages 36 81 months, recruited from daycare settings) were able to complete all three tasks, and signicant age effects were observed for omissions and commissions for Task1, and for omission errors on Tasks 2 and 3. For all three tasks, however, 3-year-olds had greatest difculty, averaging 69% omission errors for Task 1, 90% omissions errors for Task 2, and 72% omission errors for Task 3, again calling into question the validity of this type of instrument for 3-year-olds. Kerns and Rondeau [1998] also reported results for 18 clinically referred children on the three C-CPT tasks. In contrast to the control group, only 7 of the 18 children in the clinical group could complete all three tasks. The authors concluded that, while the reduced time of the tasks made them more accessible to most typically developing preschoolers, the parameters were too difcult for 3-year-olds, and for many clinically referred children. The ndings of the Kerns and Rondeau [1998] study were also consistent with those of Baker et al. [1995] and Prather et al. [1995] who concluded that auditory continuous performance tasks are potentially more difcult than comparable visual tasks, and that the 1500 ms ISI interval may be too short for 3-year-olds. Auditory Continuous Performance Test for Preschoolers (ACPT-P) The ACPT-P [Mahone et al., 2001] is a computerized, go/no-go test developed to measure sustained attention in children aged 3 6. The test was designed to minimize difculties encountered by the 3-year-olds on other pre219

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school CPTs [Corkum et al., 1995; Kerns and Rondeau, 1998; Prather et al., 1995]. Using a computerized, auditory CPT format with a xed, longer ISI (5000 ms), go/no-go format (i.e., 1 targetdog bark, 1 nontargetbell), and shorter overall time (5 min), the task was successfully completed by typically developing children as young as 36 months [Mahone et al., 2001]. The ACPT-P also revealed strong associations between age and performance, with greatest gains in performance occurring between the ages of 3 and 4. Hagelthorn et al. [2003] compared the format of the APCT-P (5000 ms ISI) to that of a visual CPT with shorter ISI (1350 ms), in 66 preschool children. Although not directly matched on all task parameters, children performed better on the auditory CPT, with error rates on the visual CPT at an unacceptably high level for the 3-year-old group. The 1350 ms ISI proved to be too short for the 3-yearolds to accurately choose a response in this format, and the authors concluded that when considering CPT paradigms for preschoolers, 3-year-olds might need at least a 4000 ms ISI in order to have time to make a choice for the correct stimulus cue. In 3-year-olds, correct hits following an ISI shorter than 1400 ms may reect the childs response to a previous stimulus [Hagelthorn et al., 2003]. Mahone et al. [2005] examined the construct validity of the ACPT-P in preschoolers with ADHD or mild hearing loss because of recurrent otitis media. The authors found no differences between performance of children with mild hearing loss (n 23) and controls (n 40) on the ACPT-P; however, there were signicant differences between children with ADHD (n 40) and matched controls on omission errors, mean response time, and variability. The ACPT-P was also signicantly correlated with the other behavioral measures of motor persistence, i.e., Developmental Neuropsychological Assessment (NEPSY) Statue [Korkman et al., 1998], but not with a working memory measure, i.e., multiple boxes test [Llamas and Diamond, 1991], demonstrating initial convergent and discriminant validity [Mahone et al., 2005]. Early Childhood Vigilance Test (ECVT) The ECVT [Goldman et al., 2004] is one of the only preschool attention tasks that have been validated using not only behavioral measures, but also by orrelating performance with brain electrical activity (i.e., event-related potentials (ERPs)). The ECVT is a computerized vigilance measure that bases performance 220

on the amount of time children attend to a monitor on which cartoon characters appear and disappear. No motor response is required, and children are videotaped during the procedure, and their looking behavior is analyzed later. The task involves a computer screen showing a colorful picture of large rock. Colorful cartoon creatures appear, one at a time, from behind, under, or over the rock. Each creature remained on the screen for 10 s, and disappeared for 5, 10, or 15 s (intervals arranged randomly, so that each interval occurred six times). The creatures continue to appear and disappear across 18 trials. The total task lasted 7 min. The procedure is scored by coding (from the videotape) the total on-tasktime during which the child is focused on the screen. Goldman et al. [2004] reported on the performance of 51 twenty-four- to thirty-month-old children. Boys and girls did not differ in performance, and the inter-rater reliability for videotapes was strong (r 0.98). Performance of the ECVT was moderately correlated with the Mental Development Index of the Bayley Scales (r 0.27). ERPs were collected on a subset of the children (n 14) to identify the patterns of neurophysiological activation that might be associated with sustained attention at this age. There was a signicant correlation between performance on the ECVT and right frontal brain activity; however, more traditional parental reports of behavior were not correlated with ERP ndings. Given the time involved in data analysis of videotape, the ECVT may be better suited for research than for clinical use. Conners Kiddie Continuous Performance Test (K-CPT) The K-CPT [Conners, 2001] is a commercially available, computerized, visual CPT designed to assist with the assessment of attention disorders in 4and 5-year-old children. The K-CPT running time is 712 min. The stimuli consist of a series of familiar pictures (e.g., boat and soccer ball), rather than letters, so that the stimuli are familiar to children at a young age. Children are asked to respond (click the mouse or push the spacebar) for every picture that appears on the screen, except the soccer ball. The ISI is either 1500 ms or 3000 ms, and the display time of the stimuli is 500 ms. There are ve blocks, with two sub blocks each of 20 trials (i.e., 20 pictures presented). Within each block, there is a sub-block of trials with a 1500 ms ISI and one with 3000 ms ISI. InforMRDD RESEARCH REVIEWS

mation obtained includes number of errors (omission and commission), mean response latency, standard error of response latency, variability, signal detection statistics (d and ), and results by block and by ISI. The standardization sample for the K-CPT included 454 four- and ve-year-old children. Of these, 313 were classied as nonclinical; 100 were classied as clinical with ADHD; and 40 were classied as clinical without ADHD. Split-half reliability information provided in the K-CPT manual ranges from 0.72 (Hit Reaction Time) to 0.88 (Omissions). Validity information is reported by comparing normative data from a typically developing general population group to clinical groups with and without ADHD. Significant group differences were reported for all variables, except Response Time by Block and Standard Error of Response Time by Block [Conners, 2001]. The variables showing signicant group differences between clinical groups with and without ADHD, included Hit Response Time, Commissions, Omissions, Perseverations, Standard Error of Response Time (Total and by ISI), Variability, and d. Given the initial reports of both sensitivity and specicity, the KCPT holds promise as an effective, clinically-available diagnostic tool for assessing attention problems in 4- and 5-yearolds, although additional research is required on its testretest reliability and convergent/discriminant validity. Gordon Diagnostic System (GDS) The GDS [Gordon et al., 1986] is among the most researched tests of attention in the past 20 years [Barkley, 1998]. The majority of literature on the validity of the GDS has been with school-age children and adults; however, the instrument can also be used for preschool children aged 4 and 5. The GDS is a portable, self-contained, electronic task that administers a series of game-like tasks. The PVT requires the child to inhibit responding under conditions that require sustained attention. Digits ash onto the electronic display, one at a time. The child is told to press the button every time a 1 appears on the screen. A parallel version can be administered that uses the number 0 as the target. Omission and commission errors were recorded. The delay task requires the child to inhibit responding so as to earn points. The child is asked to push the button, wait a while, and push the button again. If the child refrains from responding for 6 s, a light ashes and a reward counter increments. If the child responds before 6 s, a
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buzzer sounds and the counter is reset. The vigilance task was standardized on 189 four- and ve-year-olds, and the delay task was standardized on 220 fourand ve-year-olds. Musten et al. [1997] reported the performance of 31 children with ADHD (ages 4 6) who were treated with methylphenidate in a placebo-control design. Performance improved on both the delay and vigilance tasks following treatment with methylphenidate, but not with placebo [Musten et al., 1997]. While the GDS has considerable validity literature in school-age children, its use in preschoolers depends on their familiarity with numbers, and as such, may be less useful for children with cognitive or other delays. Additionally, caution should be used when interpreting norms from the GDS, which have not been revised in nearly 20 years. Tests of Related Attention Functions Picture Deletion Test for PreschoolersRevised (PDTP-R) The PDTP-R [Corkum et al., 1995; Byrne et al., 1998 ] is designed to measure selective attention (visual search) in preschoolers aged 35, and is conceptually similar to target cancellation tests used with older children and adults. In contrast to the cancellation tasks used for older children, the PDTP-R uses pictures instead of letters or numbers as stimuli, and allows the child to respond with a self-inking bingo stamper, rather than a pencil, in order to minimize the graphomotor demands. The childs task during the PDTP-R is to visually search an array of pictures, in which targets and nontargets are presented, and identifying (i.e., placing a mark on) each target as quickly as possible. The test is presented in booklet format, so that the child can turn pages and independently proceed. Left- and right-handed versions are available. There are two conditions in the PDTP-R: shapes and cats. Each condition consists of a training phase (3 min) and a test phase (16 min). The training phase uses two pages on which 30 targets and 90 nontargets are presented in a 10 6 array. The test phase consists of 120 targets and 360 nontargets. The shape condition uses a triangle as target and circles, octagons, squares, and diamonds as nontargets. The cats condition uses a prole version of a cat as a target, and with four pictures of cats in different positions as nontargets. Time to completion, omissions, and commission errors are recorded for each of the conditions. Corkum et al. [1995] reported signicant
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age-related improvements in time, as well as accuracy (omissions and commissions) from ages 3 to 5. In a treatment study of eight preschoolers (ages 4 and 5) with ADHD, Byrne et al. [1998] reported that children with ADHD exhibited more commission, but not omission, errors on the PDPT-R, than controls at baseline. After 5 months of treatment with stimulants, the children with ADHD had signicant improvement on the PDTP-R, and had similar performance to controls. This test may have particular utility in assessing attention in children with language difculties, as well those for whom graphomotor skill impairments preclude the use of more traditional pencil/paper methods. Additional research examining reliability and validity with the PDTP-R is recommended. Matching Familiar Figures Tests-preschool Version (MFFT-PV) The MFFT-PV [Kagan, 1966] is a commonly used test of impulsivity in preschool children. The MFFT-PV uses 12 sets of pictures of animals and other familiar objects. The child matches a sample picture to a picture exactly like it from within an array of four similar pictures. Latency to rst choice and number of errors are scored. Schleifer et al. [1975] used the MFFT-PV to assess medication effects in 28 hyperactive preschool children aged 3 4. The hyperactive group was impaired, relative to controls, on the MFFT. Performance of the MFFT-PV improved following a trial of methylphenidate, with the hyperactive group performance equivalent to controls following treatment. The MFFT-PV is well suited for clinical use because of its ease of administration and time-efciency; however, its reliability and discriminant validity have yet to be clearly established. Number Recall The Number Recall subtest of the Kaufman Assessment Battery for Children-II [KABC-II; Kaufman and Kaufman, 2004] was retained from the original KABC [Kaufman and Kaufman, 1983], and is one of a number of standardized digit span measures that have been normed on preschool children (ages 3 6). The Number Recall test is a measure of auditory attention span. In this version, the child repeats a series of numbers in the same sequence as the examiner said them, with series ranging from 2 to 9 numbers. The numbers are single digits, except that 10 is used instead of 7, to ensure that all numbers are one syllable. Standardization of the KABC-II was
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completed from 2001 through 2003, and included 650 children aged 35. The sample was stratied based on the March 2001 Current Population Survey [Current Population Survey, 2001]. Split-half reliability for Number Recall is reported to be 0.89 for 3-year-olds, 0.87 for 4-year-olds, and 0.79 for 5-year-olds, based on the standardization data. Test retest reliability (mean test interval 24 days) for children aged 35 is 0.70. In a study of 34 four- and ve-year old boys with ADHD, Mariani and Barkley [1997] found that the ADHD group performed signicantly worse than a comparison group of 30 controls on the Number Recall. Number Recall is particularly useful as part of an overall assessment battery because of its developmental sensitivity, short administration time, and the lack of need for specialized tools. Hand Movements The KABC-II Hand Movements subtest [Kaufman and Kaufman, 1983, 2004] requires the child to imitate a series of three possible Hand Movements (i.e., st, side, and palm), with the series becoming progressively longer. The subtest is a measure of visual span, although it has a signicant motor control/inhibition demand. This subtest can be administered in 5 min or less. Normative data are available for preschoolers (ages 4 5), and is based on 450 children tested between 2001 and 2003 [Kaufman and Kaufman, 2004]. Split-half reliability is reported to be 0.57 for 4-year-olds and 0.75 for 5-year-olds. Testretest reliability (test interval 24 days) is reported to be 0.58 for children aged 4 5. Mariani and Barkley [1997] also found that hyperactive preschool boys performed signicantly worse than matched controls on the Hand Movements test, and the performance improved following treatment with stimulants. Caution should be used when interpreting scores from this subtest, given the relatively low testretest reliability. Developmental Neuropsychological Assessment The NEPSY [Korkman et al., 1998] was originally developed in Finland as a developmentally appropriate measure of neuropsychological functioning in young children, and was later normed on 1,000 U.S. children, ages 312. The normative sample for the U.S. version includes 50 boys and 50 girls at each of the 10 age levels, stratied for race/ethnicity, and geographic region according to the 1995 U.S. census data. The NEPSY is organized into preschool 221

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(ages 3 and 4) and school age (ages 512) protocols. The NEPSY includes ve broad functional domains: language, attention/executive function, sensorimotor, memory and learning, and visuospatial processing. Administration of the full battery can take 1 h for preschoolers. Many clinicians, however, use only selected subtests of the NEPSY to facilitate more focused assessment of a particular area of diagnostic interest (e.g., Attention/Executive). The preschool Attention/Executive domain of the NEPSY is based on two subtests: Visual Attention and Statue. The NEPSY Visual Attention subtest is a visual cancellation test designed to assess the speed and accuracy with which a child is able to focus selectively on and maintain attention to visual targets within an array [Korkman et al., 1998]. There are two trials presented to preschoolers: bunnies and cats. Each trial is presented on a two-page booklet, with a target at the top of the page. The child is asked to mark (with a red pencil or crayon) each of the targets on the two pages as quickly as possible. The bunny trial is arranged so that the stimuli are in linear arrays, whereas the cat trial presents stimuli randomly across the pages. There are 20 targets on each trial, and the child is given up to 180 s to complete each part. Scores are based on a combination of errors (omissions and commissions) and time to completion. The testretest correlation is reported to be 0.62 for 4and 5-year-olds. The NEPSY Statue subtest is a measure of motor persistence and inhibition. The child is asked to stand still in a set position over a 75-s period, inhibiting a unwanted response (i.e., eyes opening, body movement, and vocalization) in the context of distractors [Korkman et al., 1998]. The examiner observes for presence of these responses in epochs of 5 s, scoring 2 for no responses, 1 for one response, and 0 for two or more responses during each 5-s period. The total possible score is 30, and the test takes less than 2 min to complete. Testretest reliability is reported to be 0.50 for the Statue subtest, and 0.68 for the Preschool Attention/Executive Domain. Mahone et al. [2005] reported that preschoolers (ages 3 6) with ADHD performed signicantly worse than matched controls on the Statue test; however, children with mild hearing loss did not differ from controls n this measure. The Statue subtest was also signicantly correlated with the ACPT-P, but not with an estimate of IQ, or a measure of spatial working memory. The Statue test is also 222

promising because of its developmental sensitivity and short administration time. Preschool Behavior Rating Scales There is a growing awareness of the need for time-efcient, standardized assessment of attention-related behaviors in the preschool years. Performancebased tests are not always possible or practical, and as such, there has been increased interest in methods to improve the ecological validity of comprehensive assessments, using caregiver ratings [Sbordone, 1996]. Published rating scales with normative data for preschool children are available in parent and teacher forms and follow a format of assessing either: (1) a broad range of behavior problems, (2) problems specic to ADHD, or, (3) problems related to some specic behavioral construct (e.g., executive functions). A selection of measures that emphasize attention problems in preschoolers is reviewed later. Conners Rating Scales-Revised The revised Conners Rating Scales [Conners, 1997] are parent and/or teacher reports of child behavior that can be completed in 10 min. Both forms include questions that probe a variety of problematic childhood behaviors, including conduct problems, learning problems, psychosomatic, impulsivity hyperactivity, anxiety, and social competence. The Conners Parent Rating Scale-Revised: Long Form [CPRS-R:L] contains 80 questions and the Conners Teacher Rating Scale-Revised: Long Form [CTRS-R:L] consists of 59 questions. The standardization samples for the parent and teacher scales was drawn from over 2,000 parents and 2,000 teachers for children aged 317. The scales produced by the revised Conners Rating Scales correspond with symptoms used in the DSM-IV-TR as criteria for ADHD. They also contain a new empirically created index for assessing children at risk for a diagnosis of ADHD. Both the CPRS-R and CTRS-R are available in short and long versions. Spanish language translations of all of the revised Conners scales are available. Although separate norms are available for preschool children (ages 35), the same test items and scales are used for assessing preschoolers and older children. In a study of 455 nonreferred and 12 clinically referred preschoolers, Miller et al. [1997] found the CTRS-R Inattention, Hyperactivity, and Conduct Problems scales to be highly (P 0.001) intercorrelated, but
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with good sensitivity in discriminating clinical from nonclinical groups. Some parents and teachers may nd the items on the revised Conners scales not applicable to younger children aged 5 and younger (e.g., Cannot grasp arithmetic; Not reading up to par). Behavior Assessment System for Children-2 (BASC-2) The BASC-2 [Reynolds and Kamphaus, 2004] is a comprehensive set of rating scales and forms that help individuals understand the behaviors, emotions, and adaptive skills of children and adolescents ages 221. The BASC-2 helps in making differential diagnoses of specic categories of disorders, such as those identied in the DSM-IV-TR. For preschool children, the BASC-2 includes rating scales that can be used by parents (Parent Rating ScalePRS), teachers (Teacher Rating ScaleTRS). The PRS and TRS assess internalizing and externalizing behaviors, inattention, hyperactivity, social behavior, and adaptive skills in the home, community, or preschool/ school setting. The preschool form of the BASC-2 is available for children aged 25, and can be completed in 10 20 min. The normative sample for the preschool forms included 1,200 parents and 1,050 teachers of children aged 25, selected using a stratied sample from throughout the U.S., based on 2001 census data. The forms describe specic behaviors that are rated on a 4-point scale of frequency, ranging from Never to Almost Always. The preschool PRS contains 134 items and the TRS contains 100 items. In contrast to the Conners scales, the BASC-2 preschool PRS and TRS include items specically selected to apply to younger children. The manual reports adequate testretest reliability for both the preschool PRS (range 0.73 0.86, median 0.77), and the TRS (range 0.72 0.92, median 0.82). Achenbach Systems of Empirically Based Assessments (ASEBA) The preschool versions of the ASEBA [Achenbach and Rescorla, 2000] include the Child Behavior Checklist [CBCL/1125] and CaregiverTeacher Report Form [CTRF/1125]. Crossinformant syndromes derived from both preschool forms include: Emotionally Reactive, Anxious/Depressed, Somatic Complaints, Withdrawn, Attention Problems, and Aggressive Behavior. A Sleep Problems syndrome scale is also included on the CBCL/1125. Internalizing, Externalizing, and Total Problems composites, as well as DSM-oriented
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scales (Affective Problems, Anxiety Problems, Pervasive Developmental Problems, Attention Decit Hyperactivity Problems, and Oppositional Deant Problems] are obtained on both forms. The CBCL/1125 includes a Language Development Survey (LDS) for ages 18 35 months, to indicate whether vocabulary and word combinations are delayed. Scales for the CBCL/1125 were based on ratings of 1,728 children and are normed on a national sample of 700 children. The C-TRF/1125 scales were based on ratings of 1,113 referred children and were normed on 1,192 nonreferred children. Twelve-month testretest reliability coefcients for the CBCL/ 1125 range from 0.52 to 0.76 (mean r 0.61), and 3-month testretest reliability coefcients for the C-TRF/1125 range from 0.22 to 0.71 (mean r 0.59), which are slightly lower than those reported for the BASC-2. Like the Conners rating scales and the BASC-2, the ASEBA scales show a high degree of sensitivity for discriminating clinically referred preschool children from controls; however, their specicity for demonstrating differential patterns between diagnostic groups in the preschool years is less well established. Behavior Rating Inventory of Executive Function-Preschool Version (BRIEF-P) The BRIEF-P [Gioia et al., 2003] is a questionnaire/rating scale that enables professionals to assess executive function behaviors in the home and preschool environments. Executive function is an umbrella construct that includes several interrelated functions that are important for goal-directed; problem solving behavior. The early development of executive functions includes the ability to maintain problem-solving set for attainment of future goal [Welsh and Pennington, 1988]. These skills often have significant overlap with the developmental constructs measured in assessment of attention in young children [Mahone et al., 2002]. The BRIEF-P is designed for use with children aged 2 years, 0 months to 5 years, 11 months. It is organized into ve clinical scales (Inhibit, Shift, Emotional Control, Working Memory, Plan/Organize), three clinical indexes (Inhibitory Self-Control, Flexibility, and Emergent Metacognition), and a GEC. Parent and teacher forms are identical. The BRIEF-P was standardized using parent ratings from 460 parents (214 girls, 246 boys). For 302 of those children (138 girls, 164 boys), teachers also completed the forms. Internal consistency coefMRDD RESEARCH REVIEWS

cients for the scales and index scores range from 0.85 to 0.95 for the parent ratings and from 0.90 to 0.97 for the teacher ratings. The testretest reliability coefcients for the GEC score (mean retest interval 4 weeks) was 0.90 for parents and 0.88 for teachers. The BRIEF-P manual also reports a high degree of intercorrelation between the BRIEF-P and other PRSs, including the CBCL 1125 and the BASC. The sensitivity of the instrument (comparing clinical groups with controls) is also reported for children with ADHD, autism, prematurity, and language disorders [Gioia et al., 2003]. In a sample of 25 preschoolers with ADHD, ages 35, Mahone and Hoffman [2005] found that parent ratings on all BRIEF-P scales and index scores were signicantly higher than ratings of 25 age-, SES-, and gender-matched controls (mean effect size 2 0.40). Within the ADHD group, the Global Executive Composite (GEC) was signicantly correlated (r 0.81) with the CPRS-R ADHD Index. In contrast, the GEC was uncorrelated (r 0.01) with NEPSY Statue and moderately correlated with NEPSY Visual Attention (r 35). CONCLUSIONS The assessment of attention in preschool children poses unique challenges to clinicians and researchers. It is well established that children develop rapidly during the preschool years, both in terms of brain development and functional skills. However, the increased prevalence of neurodevelopmental and medical conditions associated with attention problems in young children, along with the requirements for assessment outlined in Public Law 99 457 set the stage for a signicant need for valid assessment procedures appropriate for this age group. Indeed, the majority of preschool children presenting to clinicians for assessment have some form of attention problem. Unfortunately, there are a limited number of valid assessment methods available to accurately characterize the multidimensional construct attention in the preschool years. A number of researchers have developed CPT methods to assess sustained attention in preschoolers, using downward extensions of procedures used for older children and adults. These instruments appear to work well for children aged 4 and above; however, there has been less success using these instruments with children aged 3 and younger. The literature suggests that children aged 3 years require an ISI of at least 4,000 ms in order to choose (correctly or not) a reIN

sponse on CPTs, using a choice-reaction time format. In addition, those CPTs longer than 5 min, and for which multiple nontarget stimuli are used, may be too difcult for children younger than 4 years. For children aged 3 and younger, simple reaction time instruments, or measures that do not require a self-directed motor response (i.e., those for which sustained looking behaviors can be video recorded) are likely to be required. The latter, however, may not be useful in routine outpatient clinical settings, in which time-efcient assessment methods are required. In addition to these concerns, there is growing evidence that performance on CPTs in preschoolers may be correlated with overall intellectual functioning. Thus, higher functioning preschool children may perform well on CPTs, despite having attention problems in other settings, while children with lower intellectual functioning may perform poorly on CPTs, for reasons less specic to attention. In addition, careful consideration should be given to the ceiling effects when using preschool CPTs with older preschool children (ages 5 and 6), as some measures have more limited developmental sensitivity in that age range. Additional research is certainly needed in this area to better establish the utility of CPT measures for routine clinical use in preschoolers. Assessment of related attention functions in preschoolers may be more practical in clinical settings. A variety of methods for assessing auditory (e.g., digit span) and visual span are readily available for preschoolers, and have the benet of brief administration time, no requirement for special tools, and developmental sensitivity. Variations on cancellation tests are also available for preschoolers, and are considered to represent assessment of focused or visual selective attention. In contrast to the use of cancellation test procedures in older children and adults, their use in preschool children is signicantly dependent on the development of graphomotor skill. Some researchers have attempted to reduce this confound by using bingo stampers or having children point, rather than write responses. These adaptations appear appropriate for preschoolers; however, additional research is needed. Given the variability in behavior and performance among typically developing preschoolers, performance-based tests may have lower testretest reliability than that observed for older children. Clinicians using performance-based tests of attention in preschoolers are encouraged to carefully examine the available 223

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literature regarding testretest regarding stability of these tests before interpreting low scores obtained after a single administration. Especially in preschoolers, multiple baseline assessments may be required. Parent and teacher rating scales are widely available for preschool children. The commercially available rating scales are based on current, representative standardization samples, with adequate numbers of children at each age level in the preschool years. Many of the preschool rating scales (particularly PRSs) correlate highly with one another, suggesting that they may be tapping into some common rating of behavioral maladjustment in preschool age childrenrather than having specicity for attention problems in isolation. In addition, like the tests available for older children, parent and teacher ratings of attention problems in preschoolers show only modest correlation with actual test performance, suggesting that the rating scales and performance-based tests likely measure different aspects of the attention construct [Mahone et al., 2002; Mahone and Hoffman, 2005]. In conclusion, there continues to be considerable need for development and validation of procedures to measure attention in preschool children. Continued advances in medical care, including surgical procedures, infection control, and neonatal care are likely to continue to result in greater survival of infants that would not have been born, or survived following birth, twenty years ago. In addition, with improved medical diagnostic procedures, clinicians are being called on more frequently to describe behavioral phenotypes of neurodevelopmental and genetic disorders. The incidence of suspected ADHD has continued to grow, with greater demand for assessment and treatment in the preschool years. Our available assessment methods show good diagnostic sensitivity in the preschool years; however (again, similar to that of tests for older children), evidence of their specicity continues to be limited. Thus, use of these tests in isolation to diagnose disorders of attention (including ADHD) is not recommended. Rather, with appropriate caution, clinicians can use many of the procedures reviewed in this article to assess the development of attention, as part of a comprehensive assessment of preschool children. f REFERENCES
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