Journal of Attention Disorders OnlineFirst, published on May 10, 2007 as doi:10.

1177/1087054707299412

A Comparative Study of Performance in the Conners Continuous Performance Test Between Brazilian and North American Children
Mnica Carolina Miranda Elaine Giro Sinnes Sabine Pompia Orlando Francisco Amodeo Bueno
Department of Psychobiology, Federal University of So Paulo, Brazil

Journal of Attention Disorders Volume X Number X Month XXXX xx-xx Sage Publications 10.1177/1087054707299412 http://jad.sagepub.com hosted at http://online.sagepub.com

Objective: The present study investigated the performance of Brazilian children in the Continuous Performance Test, CPT-II, and compared results to those of the norms obtained in the United States. Method: The U.S. norms were compared to those of a Brazilian sample composed of 6- to 11-year-olds separated into 4 age-groups (half boys) that represented the socioeconomic class distribution of So Paulo City. The children were prescreened for attention deficit disorders (ADHD). Results: Age and gender effects in the Brazilian sample were similar to those previously described. However, the Brazilian sample showed better performance in almost all measures in all age-groups compared to that of the United States. Conclusion: It is discussed that differences between samples probably reflect lack of ADHD screening of the U.S. children. More studies are necessary to determine if the CPT-II is a cross-cultural test with participants from different samples matched for age, gender, and socioeconomic status screened for ADHD. (J. of Att. Dis. XXXX; X(X) xx-xx) Keywords: Continuous Perfomance Test; child development; attention; comparative study; cultural differences; ADHD; cross-cultural

Introduction
Tasks such as Continuous Performance Tests (CPTs) that require the detection of transitory signals in relatively prolonged periods of time are known as vigilance or sustained attention tasks (Parasuraman, 1999). The original CPT was initially developed by Rosvold in 1956 for measuring deficits in sustained attention in individuals with cerebral lesions. Since then CPTs have become popular research and diagnosis tools in studies of children with attention deficit hyperactivity disorder (ADHD; Corkum & Siegel, 1993; Epstein et al., 2003; Losier, McGrath, & Klein, 1996; McGee, Clark & Symons 2000; Riccio & Reynolds, 2001). Despite controversies on the adequacy of CPTs in diagnosing ADHD, most consider this instrument useful if allied to other measures (Corkum & Siegel, 1993). CPTs are also

used in research on learning disabilities (Lindsay, Tomazic, Levine, & Accardo, 2001; McGee et al., 2000), development of sustained attention (Greenberg & Waldman, 1993; Levy, 1980; Lin, Hsiao, & Chen, 1999; Riccio, Reynolds, Lowe, & Moore, 2002), and risk for developing schizophrenia (Lin et al., 1999).
Authors Note: The authors would like to thank Camila Cruz Rodrigues for her assistance in collecting data; the Board of Schools EE Pandi Calgeras, Externato N. Sra Menina, EE Heitor Carusi, EE Padre Manoel de Paiva, EE Homero dos Santos Fortes, for permission and collaboration in data collection; and the volunteer children and their parents. Financial Support: FAPESP (grant 02/09395-3); AFIP (Associao Fundo de Incentivo a Psicofarmacologia). Address correspondence to Mnica Carolina Miranda, PhD, Department of Psychobiology, Federal University of So Paulo (UNIFESP), Brasil; R. Emba, 54 CEP: 04039060. So Paulo, SP, Brasil. phone: (5511) 5549-6899 / 55495496; FAX: (5511) 5572-5092; mcarol@psicobio.epm.br.

Copyright 2007 by SAGE Publications.

2 Journal of Attention Disorders

Several CPT versions were developed after the original task (CPT-X; CPT-AX; CPT-XX; CPT-IP), which vary with regards to modality (auditory or visual), type of stimulus (letters, numbers, colours, or geometric forms), and nature of the task (response to a single stimulus, a sequence of stimuli, or all stimuli except one). In general, CPTs require participants to respond to the presence or absence of a specific stimulus within a range of distracting stimuli continuously presented. The target may consist of a single stimulus (e.g., a letter X) to which participants must respond, or a sequence of stimuli, such as the letters AX, participants being required to respond only when the letter X is immediately preceded by the letter A. The number of targets missed (omissions) is considered a measure of inattention. In contrast, responses to nontarget stimuli, or false alarms (commissions), reflect impulsivity (Corkum & Siegel, 1993; Cornblatt, Risch, Faris, Friedman, & ErlenmeyerKimling, 1988; Klee & Garfinkel, 1983; Levy, 1980). At present the most popular commercial version of the CPT is probably the Conners CPT II (Conners, 2002). This version consists of a computerised visual task that requires the discrimination between nontarget (letter X) and target (non-X) stimuli: Individuals are instructed to press a computer key for any letter that is displayed on the screen, except for the letter X. Consequently, the test requires a response inhibition, because it demands interruptions of a continuous motor response. The index scores of Conners CPT II differ from other versions. Besides the reaction time, omission and commission errors that constitute the traditional measures, it also includes changes in reaction time in different interstimulus intervals (ISIs), as well as measures based on signal detection theory, better predictors of attention deficits than omission and commission errors (Corkum & Siegel, 1993; Epstein et al., 2003; Lin et al., 1999; McGee et al., 2000). Signal detection theory is applied as a measure of distinction between several determinants of the participants performance in a vigilance task. In any sustained attention task, the fundamental question is to determine whether there is attention impairment because of loss of perceptual sensitivity to detect the signal (d) or to changes in response decision criteria (; Parasuraman, 1999). An overall index is also calculated, a weighted sum of CPT II measures (Conners, 2002). A few clinical and control case studies have been undertaken to verify the developmental aspects of the CPT measures. McGee et al. (2000) failed to find correlations between age, gender, and socioeconomic status with the overall index, and also did not succeed in using the overall index in distinguishing ADHD and learning disabilities from clinical controls, indicating that this

measure alone is not sensitive to developmental changes and does not differentiate distinct disabilities. As regards age and gender effects, studies have shown that these factors are highly relevant in determining performance on several CPT measures (Greenberg & Waldaman, 1993; Lin et al., 1999). It must be kept in mind, however, that there are in fact very few studies of this nature, and the CPT versions applied in each one of them differs significantly, rendering comparisons between them difficult. Lin et al. (1999), who used the degraded CPT version (that presents numbers instead of letters), found that reaction time and d increased from age 6 to 15, whereas false alarms and commission errors decreased. In Lin et al.s study, gender effects were also significant for reaction time and d indicating that adjustment for age and gender are necessary to classify a child as having attention deficit using such indexes. Greenberg and Waldman (1993) also demonstrated age and gender effects using the Test of Variables of Attention version of the CPT, in percentage of omission and commission errors, as well as in reaction times. Age and gender norms are important for performance evaluation in sustained attention tasks, but it is also essential to identify the characteristics of index norms in the populations under investigation. However, very few studies have made comparisons that included differences in CPT measures among different cultures, and those that have done so unfortunately used different CPT versions. In an epidemiological, multicentric study with 9- to 18-year-olds conducted by Conners et al. (2003), using the Conners CPT version, no meaningful patterns of difference were found between ethnic groups in the United States in terms of age and gender effects for almost all measures. Levav, Mirsky, French, and Bartko (1998) compared performance in the CPT version AX (auditory and visual) of children and adults in five countries and found differences in commission errors in the visual tasks in the 8- to 12-year-old agegroup and in the auditory task in those older than 54, as well as differences in auditory reaction time in the 13to 53-year-old age-groups. Consequently, sufficient evidence is lacking that CPT measures are not affected by cultural factors. Thus, the aim of the present study was to analyze the performance of a sample of Brazilian children, applying the measures of the latest version of the Conners CPT (CPT II). This study analyzes age and gender factors in a sample of children aged 6 to 11 separated into four age-groups and compares the data of this sample to that of the standardized U.S. norms.

Miranda et al. / Conners CPTComparative Study 3

Methods
Sample
The children selected as participants for the present study were students of state and private schools in So Paulo City and reflected the socioeconomic class distribution for this city provided by the Brazilian Association of Market Research Institutes. The children initially selected, totalling 951 children aged 6 to 11, were enrolled in the first to fifth grades and were assigned even numbers on the schools attendance list. The second step was to apply the abbreviated Conners scale, adapted to the Brazilian population (Brito, 1987), widely used as a screening tool in the selection process for research on patients with ADHD. The scale was rated by the childrens teacher and it evaluates behavioural problems, such as hyperactivity, inattention, and others. The 63 children that presented scores above the cutoff point for age and gender, and/or who were indicated by teachers as having learning difficulties, were excluded. Parents were then called to sign informed consent forms authorizing the childrens participation in the study and also to answer a short questionnaire about the childrens development (including questions related to medical history, use of medication, learning disabilities, and developmental disorders). Of the remaining 888 children, the parents of 481 did not reply, 4 did not authorize the childs participation, and 4 children were excluded for presenting a history that could be related to development disorders (meningitis, head trauma, convulsion, and learning disabilities). A total of 67 children were excluded for having indications of having ADHD. After the aforementioned exclusions, a total of 399 children were submitted to the Conners CPT attention test. Of these, 13 administrations were invalidated (failure to execute task or data not recorded by program) and 2 children were excluded for presenting scores that were too discrepant from the statistic measures of the test. The final sample was therefore composed of 384 children aged 6 to 11. All procedures of the present study were approved by the Research Ethics Committee of the institution to which the researchers belonged (Universidade Federal de So Paulo).

presented in a laptop computer. The total time for the application was around 25 minutes, including training followed by the application of the test itself. The children were instructed to press the space bar on the keyboard for any letter displayed on the screen, except the letter X. Each letter was presented for approximately 250 milliseconds (ms). There are 324 target stimuli (non-X letters) and 36 nontarget stimuli (letter X). Six blocks of stimuli are presented, each one with three subblocks of 20 trials (letter presentations), one for each interstimulus interval: 1, 2, and 4 seconds. The order in which the different ISIs are presented varies between blocks (Conners, 2002)

CPT Measures
The program generates the following measures 1. Errors: measures of lack of response accuracy, divided into two categories: a) Omission: number of targets the participant fails to respond to, i.e., when the response is not given (omitted) after non-X appears on screen. High rates normally indicate nonorientated and slow responses. b) Commission: number of times the participant responds to a nontarget stimulus, i.e., when response is when an X is displayed on the screen. High reaction time combined with a high number of omissions and commissions errors indicate inattention, whereas fast reaction time combined with a lot of commission errors, but with few omissions errors, reflect impulsivity. Hit Reaction Time: speed and consistency of reaction measured in milliseconds. The program classifies any reaction time lower than 100 ms as perserveration (please see below). The following subtypes of measures are provided: a) Hit Reaction Time (Hit RT): average response time for all target responses in all six time blocks. b) Hit Reaction Time Standard Error (Hit RT Std Error): consistency of response time expressed in standard error for responses to target. High scores indicate highly variable reactions, frequently linked to inattention. c) Variability of Standard Error: variability of the respondent (variability presented by participants to their own general standard error). Signal Detections TheoryDerived measures a) Detectability (d): A measure of the participants discrimination level between the target (non-X) and nontarget (X). Higher d values

2.

Procedures
The version utilized was the Conners Continuous Performance Test Computer Program for Windows CPT II (Conners, 2002). The test was carried out exactly as described in the instruction manual. The children were assessed individually at the school they attend, in rooms with appropriate lighting and sound levels. The test was

3.

4 Journal of Attention Disorders

4.

5.

indicate better discrimination between target and foil stimuli (Conners et al., 2003). b) Response Style (): indicates the participants response criterion. Cautious participants who do not respond often present higher values for this index. Participants who respond more freely and are less concerned about failing present lower rates. c) Perserverations: Because of physiological limitations, responses are impossible in less than 100 ms after the stimuli are presented (Conners, 2002). Thus, reaction times faster than 100 ms are classified as perseverations. A high rate of perseverations is a result of anticipatory responses (it may indicate impulsivity), random responding (indicating severe impairment), or very slow responses to the previous stimulus (indicating inattention). By Blocks Results: The CPT is presented in six blocks, which allows the assessment of changes over time and vigilance, and also the consistency of responses as the test progresses. Two measures are provided: a) Hit Reaction Time Block Change (Hit RT Block Change): changes in mean reaction time over the six time blocks. Positive values indicate a slowing reaction time as the blocks are presented, whereas negative values indicate that the reaction time increases as the test progressed. b) Hit Standard Error Block Change (Hit SE Block Change): changes in reaction time standard errors as blocks are presented. Positive values indicate less consistency in reaction times, suggesting a possible loss of vigilance, whereas negative values indicate higher response consistency as the test progresses. By ISIs Results: enable the assessment of the participants ability to adjust to changing interstimulus intervals. There are two measures: a) Hit Reaction Time ISI Change (Hit RT ISI Change): changes in mean reaction time over the three ISI subblocks. Positive values indicate a slowing in reaction time as the ISI increases, whereas negative values indicate a faster reaction time. b) Hit Standard Error ISI Change (Hit SE ISI Change): changes in mean standard error over the three ISI subblocks. Positive values indicate less consistency in the reaction time during longer ISIs, and negative values indicate more consistency during longer ISIs.

6.

T-score and percentage: All CPT measures are converted to t-scores and percentiles, allowing the comparison of scores of each respondent to those in the normative group who are of the same age-group and gender age-group.

The t-score represents the participants scores in relation to the populations standardization average score. A t-score is a standard score with a mean of 50 and a standard deviation of 10. A t-score of 60 represents a score that is 1 standard deviation above the mean. In relation to the percentiles, scores of 90 or above indicate attention problems.

Statistical Analysis
The statistical programs used were SPSS version 11.0 and SASs proc. GLM version 8.01. The significance level adopted was 0.05. The performance of the sample of children from the present study, according to age (in years) and gender, was determined using the scores of each variable made available by the program package, except for the t-score and percentiles because these are transformed values in relation to the normative data obtained in the United States. The hypothesis of normal distribution was evaluated by descriptive statistics, asymmetric measures and kurtosis, diagrams type Box-plot, histograms and normal graphics of probabilities. For the following variables for which the hypothesis of normality was rejected, a logarithmic transformation was applied: omissions; Hit RT Std Error; Variability; Response Style; Perseverations; Hit RT Block Change; Hit SE Block Change; and Hit RT ISI Change. To evaluate the age and gender effects, analysis of variance with age-groups (from the ages of 6 to 7, 8 to 9, and 10 to 11) and gender as factors were applied for each of the individual variables. Where the scores were considered different, the orthogonal contrast method to locate differences was used. For the analysis of differences between age-groups in relation to the variable gender, the Chi-Square Test was used. For the analysis of the variable age in each gender, the Students T Test was applied. The comparison between the data obtained from the 384 Brazilian children and that from the sample of North American children from the standardization study (Conners, 2002) was carried out by age-group and gender. The statistical test used was the Z test for a mean with known variance (Bussab & Morettin, 1987). In this study we compared the sample rates (means observed in Brazilian children) with the mean of the reference population (mean

Miranda et al. / Conners CPTComparative Study 5

observed in American children), taking into consideration the size of the sample and the standard deviation of the reference population. The comparison of measures included only the data provided by the authors of the American standardization: Hit RT (log), percentage of omissions, percentage of commissions, perseverations, Hit RT Block Change, Hit RT ISI Change, Hit RT Std error (log), Hit SE Block Change, and Hit SE ISI Change. Comparison between the Brazilian and North American samples in relation to the mean age in each age-group, number of male and female children, and socioeconomic status was not undertaken because there is no access to this data for the U.S. population.

Table 1 Number of Children from Brazilian Sample by Age and Gender

Age-Group (Years) 6-7 8-9 10-11 Total Gender Female Male Female Male Female Male Age in Years Mean (SD) 7.02 (0.54) 7.08 (0.56) 8.87 (0.62) 8.85 (0.59) 10.77 (0.55) 10.90 (0.66) N 71 71 69 59 55 59 384

Results
Overall Effects
Table I shows the distribution of the sample in the present study in relation to the age-group and gender. The number of male and female participants was similar in all the age-groups (p = 0.801). Mean ages of boys and girls in each age-group also did not differ (ps < 0.26). Table 2 shows the CPT performance of the Brazilian sample by age-group and gender. Tables 3 and 4 show the means and standard deviations of t-score and percentiles. There was no interaction between sex and age effects (Table5).

Comparison Between the Brazilian and North American Samples

In the 6- to 7-year-old age-group, male and female participants of the Brazilian sample performed better than the North American children in almost all measures (Tables 6 and 7). The samples only did not differ in the percentage of omissions. In the 8- to 9-year-old age-group no differences were verified only between girls from both samples and this only occurred in the measure of percentage of omissions. In all measures where the differences were significant the sample of Brazilian children showed enhanced performance in relation to the North Americans. In the 10to11-year-old age-group all measures differed for male and female participants, and the scores again indicated better performance for the Brazilian sample.

Gender Effects
Female participants had higher percentage of omissions, higher scores in the measures of Hit RT, Hit RT Std error, and elevated d and compared to males; however, the percentage of commissions was lower for the girls (please refer to Table 5 for significance levels).

Discussion
Performance of Brazilian Sample
Overall, the age and gender effects found in the present study in a sample of Brazilian children using the Conners CPT II were similar to the ones found in other CPT studies (Conners et al., 2003; Greenberg & Waldman, 1993; Lin et al. 1999), confirming that this population responds to the task in a similar manner as children from other cultures. Furthermore, there were no interactions of age and gender as previously shown, confirming that differences between genders do not depend on the childrens age in the age range here investigated (Conners et al., 2003; Lin et al., 1999). Specifically, when analysing difference between genders, in the present study irrespective of age-group females presented lower commissions errors, higher signal detection abilities, and were more cautious when responding to the test (). In contrast, they made more omission errors, and had higher and less consistent reaction times. Gender effects for the age range studied here

Age Effects
There was an age effect in almost all measures, except for , Hit RT Block Change, Hit RT ISI Change, and Hit SE ISI Change, and in most cases performance significantly increased progressively as children aged (6-7 8-9 10-11). In the measures of percentage of omissions, percentage of commissions, Hit RT, Hit RT Std error, variability, and perseverations, younger children presented higher values which decreased in older children (ps < 0.01). In the measure of detectability (d) the values were lower for younger children, and there was a progressive increase as children aged (ps < 0.04). In the measure of Hit SE Block Change, children aged 6 to 7 had higher scores than children aged 8 to 9 (p = 0.02) and tended to differ from children aged 10 to11 years (p = 0.06), but there was no difference between the older age-groups.

Table 2 Mean and Standard Deviations for Each CPT Measures of Brazilian Sample
Hit RT Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Hit RT Std Error Variability Persev. Detectability (d) Response Style () Hit RT BC HIT SE BC HIT RT ISI Change HIT SE ISI Change Mean SD

% % Omissions Commissions

AgeGroup Gender Mean SD Mean SD

6-7

8-9

10-11

Male Female Male Female Male Female

5.41 7.08 2.91 4.77 1.44 1.49

3.88 5.67 2.90 4.05 2.11 2.03

60.48 48.01 49.48 42.47 45.24 33.03

19.74 21.17 20.79 22.32 21.76 20.08

538.0 97.1 12.7 590.7 106.9 13.5 492.4 94.1 9.5 556.3 107.1 11.1 442.9 68.5 7.5 480.1 81.8 7.9

5.1 6.4 4.4 3.5 2.8 2.3

21.4 22.1 14.2 17.1 12.4 11.2

13.1 14.7 8.5 7.9 11.5 6.6

0.4 0.6 0.5 0.7 0.5 0.9

0.4 0.4 0.4 0.4 0.4 0.5

0.9 1.3 0.9 1.5 0.9 1.1

0.9 1.7 1.5 1.6 1.7 1.3

5.3 4.8 2.6 3.1 1.0 0.9

4.7 3.9 3.3 2.6 1.6 1.1

0.00 0.01 0.00 0.01 0.01 0.00

0.04 0.04 0.03 0.03 0.06 0.0

0.05 0.05 0.01 0.04 0.02 0.04

0.1 0.1 0.1 0.1 0.1 0.1

0.04 0.05 0.1 0.4 0.05 0.05

0.1 0.1 0.1 0.1 0.1 0.1

0.04 0.02 0.02 0.02 0.02 0.01

0.1 0.1 0.1 0.1 0.2 0.1

Note: Hit RT = Hit Reaction Time; Hit RT Std Error = Hit Reaction Time Standard Error; Persev. = Perseverations; Hit RT BC = Hit Reaction Time Block Change; HIT SE BC = Hit Standard Error Block Change; HIT RT ISI Change = Hit Reaction Time ISI Change; Hit SE ISI Change = Hit Standard Error ISI Change

Table 3 Mean and Standard Deviation of T-Score For Each CPT Measure of Brazilian Sample
Hit RT Mean SD Mean SD Mean SD Mean Hit RT Std Error Variability SD Detectability (d) Response Style () Mean SD Persev. Mean SD Hit RT BC Mean HIT SE BC SD Mean SD HIT RT ISI Change Mean SD HIT SE ISI Change Mean SD

Omissions Commissions

AgeGroup Gender Mean SD Mean SD

6-7

8-9

10-11

Male Female Male Female Male Female

49.7 51.4 46.7 51.8 43.3 44.7

9.0 8.6 6.5 9.7 4.5 4.4

45.4 41.2 36.8 38.6 36.7 36.9

9.8 10.5 11.9 11.3 12.5 10.4

57.5 58.9 58.7 61.6 54.1 55.3

11.6 10.1 11.7 11.2 9.6 10.1

49.4 50.5 47.0 51.2 43.7 44.9

8.5 9.1 7.5 6.5 5.7 5.5

48.2 49.7 45.4 48.9 43.0 42.8

8.1 8.1 8.7 6.2 6.1 6.2

47.8 43.0 39.1 40.0 41.4 36.8

9.5 11.6 14.0 12.5 14.8 15.0

49.5 51.0 53.3 62.5 49.7 54.6

10.4 7.40 16.0 20.0 14.9 17.0

45.4 47.1 44.4 47.0 43.4 45.6

5.4 4.6 2.6 3.6 1.5 1.1

48.1 47.8 46.5 48.9 46.6 44.1

6.1 7.0 6.3 9.4 8.2 7.3

47.9 46.2 45.5 46.1 44.9 45.0

6.4 6.7 6.2 8.7 7.3 6.6

44.0 44.9 45.0 45.6 44.8 44.8

9.1 7.5 7.7 10.0 5.9 7.4

46.5 45.7 44.5 43.0 43.9 45.6

8.7 8.2 6.9 8.5 6.3 6.2

Note: Hit RT = Hit Reaction Time; Hit RT Std Error = Hit Reaction Time Standard Error; Persev. = Perseverations; Hit RT BC = Hit Reaction Time Block Change; HIT SE BC = Hit Standard Error Block Change; HIT RT ISI Change = Hit Reaction Time ISI Change; Hit SE ISI Change = Hit Standard Error ISI Change

Table 4 Mean and Standard Deviation of Percentile for Each CPT Measure of Brazilian Sample
Hit RT Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Hit RT Std Error Variability Persev. Mean Detectability (d) Response Style. () Hit RT BC HIT SE BC SD Mean SD HIT RT ISI Change Mean SD HIT SE ISI Change Mean SD

Omissions Commissions

AgeGroup Gender Mean SD Mean SD

6-7

8-9

10-11

Male Female Male Female Male Female

46.7 52.9 38.9 54.0 27.7 32.2

24.8 22.8 20.8 24.3 15.3 14.8

40.6 31.2 20.8 24.8 21.5 19.1

28.0 28.3 24.4 26.9 24.8 24.4

69.1 34.2 71.2 79.8 62.2 64.7

27.6 22.1 25.8 22.4 26.1 27.5

49.1 51.2 41.0 55.6 30.4 34.2

26.7 26.3 22.4 21.3 17.9 19.0

46.2 50.2 35.5 48.2 28.4 29.5

26.0 24.8 23.0 21.0 19.7 20.6

44.8 35.0 28.3 28.5 32.4 24.6

27.5 27.5 24.3 25.0 29.8 27.3

46.2 53.1 51.2 67.5 43.8 55.2

23.5 16.3 29.2 29.4 28.9 32.1

34.9 41.3 30.9 41.7 26.8 36.4

17.6 16.4 9.7 13.5 6.2 4.2

44.6 44.0 38.4 48.9 40.7 33.1

19.3 22.0 20.1 25.0 25.6 22.9

44.7 38.8 36.3 38.4 34.7 36.3

21.2 22.1 19.6 25.7 22.4 20.2

32.6 35.4 35.7 37.9 30.1 35.3

23.4 26.3 24.1 28.2 18.6 22.1

40.2 37.0 33.7 39.6 30.7 35.3

26.4 25.1 21.7 24.9 19.8 20.9

Note: HT RT = Hit Reaction Time; Hit RT Std Error = Hit Reaction Time Standard Error; Persev. = Perseverations; Hit RT BC = Hit Reaction Time Block Change; HIT SE BC = Hit Standard Error Block Change; HIT RT ISI Change = Hit Reaction Time ISI Change; Hit SE ISI Change = Hit Standard Error ISI Change.

8 Journal of Attention Disorders

Table 5 Age, Gender, and Interaction Effects in Brazilian Sample

Gender F Omissions (%) Commissions (%) HIT RT Hit RT std Error Variability Detectability (d) Response Style () Perseverations HIT RT Block Change HIT SE Block Change Hit RT ISI Change Hit SE ISI Change 9.52 24.03 28.19 3.90 0.53 28.42 9.34 0.01 0.84 3.32 0.09 1.79 p 0.0022 < 0.0001 < 0.0001 0.0490 0.4682 < 0.0001 0.0024 0.9227 0.3587 0.0693 0.7692 0.1822 F 50.71 16.56 37.13 47.04 26.87 10.96 0.54 51.25 0.12 3.03 0.17 1.38 Age p < 0.0001 < 0.0001 < 0.0001 < 0.0001 < 0.0001 < 0.0001 0.5811 < 0.0001 0.8895 0.0496 0.8420 0.2540 F 2.06 0.69 0.56 0.58 1.03 1.21 0.35 0.87 1.20 1.11 0.51 0.34 Gender x Age p 0.1287 0.5020 0.5713 0.5620 0.3584 0.3008 0.7025 0.4210 0.3013 0.3292 0.5999 0.7105

Note: Please refer to Tables 2 to 4 for the measures acronyms

Table 6 Comparison Between Brazilian and American Children Sample for HIT RT, Commissions and Omission Errors, and Perseverations
HIT RT (log) AgeGroup 6-7 Gender Male Female 8-9 Male Female 10-11 Male Female Popul. Amer. Brazil Amer. Brazil Amer. Brazil Amer. Brazil Amer. Brazil Amer. Brazil M 6.1 2.7 6.2 2.8 6.0 2.7 6.1 2.7 6.0 2.6 6.1 2.7 SD 0.15 0.08 0.16 0.07 0.15 0.08 0.16 0.08 0.17 0.06 0.17 0.07 192.44 p < 0.001 181.95 p < 0.001 171.80 p < 0.001 175.06 p < 0.001 148.33 p < 0.001 148.49 p < 0.001 Estat. (z) (%) Commis. M 70.4 60.5 64.8 48.0 73.0 49.5 65.2 42.5 70.4 45.6 57.7 33.0 SD 19.5 19.5 19.4 21.2 17.5 20.8 19.8 22.3 17.6 21.7 19.4 20.1 4.27 p < 0.001 7.28 p < 0.0001 10.34 p < 0.0001 9.50 p < 0.0001 10.55 p < 0.0001 9.45 p < 0.0001 Estat. (z) (%) Omis. M 5.8 5.4 6.4 7.1 4.3 2.9 3.9 4.7 4.7 1.4 4.0 1.5 SD 4.5 3.9 6.6 5.7 4.4 2.9 4.2 4.0 4.8 2.1 4.8 2.0 0.74 p = 0.2286 0.91 p = 0.8201 2.44 p = 0.0072 1.65 p = 0.9510 5.25 p < 0.0001 3.94 p < 0.0001 Estat. (z) Persev. M 9.4 5.3 7.3 4.8 10.0 2.6 5.1 3.13 8.6 1.0 5.9 0.9 SD 8.4 4.7 8.4 3.9 13.5 3.3 7.1 2.6 10.9 1.6 11.9 1.1 418 p < 0.0001 2.52 p = 0.0058 4.21 p < 0.0001 2.35 p = 0.0094 5.22 p < 0.0001 3.16 p = 0.0008 Estat. (z)

Note: popul. = population; Amer. = American; Brazil = Brazilian; HIT RT = HIT Reaction Time; % Commis. = percentage commission; % Omis. = percentage omissions ; Persev. = perseverations

in d (Conners et al., 2003; Lin et al., 1999), reaction time and commission errors (Conners, 2002; Conners et al., 2003; Greenberg & Waldman, 1993; Lin et al. 1999) are consistent with previous findings even when the studies used different CPT versions, which are distinguishable in their demands on attentional focus (Denney et al., 2005). Different gender effects from those showed here were found for (Conners et al., 2003), a fact that may be ascribed to the use of older participants (9- to 18-year-olds). Omission errors also differed (Greenberg & Waldman, 1993), possibly because of the use of different CPT version and older children (6- to 15-year-olds).

As regards age effects, the results of this study demonstrated that CTP II performance improved with age in most measures in accordance with previous CPT studies (Conners et al., 2003; Greenberg & Waldman, 1993; Lin et al. 1999). In particular, as the children aged lower rates of omission and commission errors, higher d, lower reaction time, less variability and consistency in reaction time, and less perseverations were verified. Lin et al. (1999) failed to find significant differences in index related to the childrens age, confirming our results, but this contrasts with Conners et al. (2003). However, different CPT versions were used in our study and Lin et al.s (1999) and

Table 7 Comparison Between Brazilian and American Childrens Sample for Other Measures
Hit RT ISI Change Hit SE BC Estat. (z) M SD Estat. (z) Estat. (z) M SD Estat. (z) M SD Hit RT Std Error (log) Hit SE ISI Change M SD Estat (z)

Hit RT Block Change SD

AgeGroup

Gender

Popul.

6-7

Male

Female

8-9

Male

Female

10-11

Male

Female

Amer. Brazil Amer. Brazil Amer. Brazil Amer. Brazil Amer. Brazil Amer. Brazil

0.02 0.00 0.02 0.01 0.02 0.00 0.02 0.01 0.13 0.01 0.02 0.00

0.04 0.04 0.04 0.04 0.04 0.03 0.03 0.03 0.03 0.06 0.03 0.00

4.81 p < 0.0001 3.03 p = 0.0012 3.84 p = 0.0001 3.53 p = 0.0002 31.09 p < 0.0001 4.94 p < 0.0001 0.08 0.04 0.08 0.05 0.08 0.06 0.07 0.04 0.08 0.05 0.08 0.05 0.06 0.08 0.05 0.06 0.05 0.12 0.05 0.06 0.05 0.10 0.06 0.07 2.5 1.1 2.5 1.1 2.3 0.94 2.3 1.0 2.34 0.86 2.3 0.88 0.44 0.16 0.43 0.17 0.50 0.16 0.45 0.13 0.55 0.13 0.52 0.12 0.08 0.05 0.10 0.05 0.07 0.01 0.09 0.04 0.09 0.03 0.09 0.04

5.70 p < 0.0001 5.41 p < 0.0001 3.70 p = 0.0001 4.41 p < 0.0001 4.22 p < 0.001 4.27 p < 0.0001

26.30 p < 0.0001 27.40 p < 0.0001 21.13 p < 0.0001 23.53 p < 0.0001 20.19 p < 0.0001 20.23 p < 0.0001

0.11 0.13 0.12 0.08 0.12 0.08 0.09 0.09 0.12 0.10 0.10 0.11

192 p = 0.0274 3.16 p = 0.008 3.94 p < 0.0001 4.16 p < 0.0001 4.05 p < 0.0001 3.57 p = 0.0002

0.10 0.04 0.09 0.02 0.12 0.02 0.10 0.02 0.13 0.02 0.11 0.01

0.18 0.15 0.16 0.13 0.18 0.12 0.16 0.13 0.19 0.19 0.10 0.14

0.29 p = 0.0019 3.63 p = 0.0001 4.32 p < 0.0001 6.09 p < 0.0001 4.20 p < 0.0001 7.35 p < 0.0001

Note: popul. = Population; Amer. = American; Brazil = Brazilian; Hit RT Block Change = Hit Reaction Time Block Change; Hit RT ISI Change = Hit Reaction Time ISI Change; Hit RT std error = Hit Reaction Time Standard Error; Hit SE BC = Hit Standard Error Block Change; Hit SE ISI Change = Hit Standard Error ISI Change.

10 Journal of Attention Disorders

Conners et al.s (2003) studies. Unfortunately, age effects in this measure are not analyzed in the normative publication (Conners, 2002), which prevents the comparison with the results of the present study. Another important finding, revealed by the analysis of age differences in reaction time over the six time blocks, was that there was less response consistency as the test progressed in younger children (6- to 7-year-old agegroup). It is important to analyze these measures in future studies on sustained attention development using Conners CPT II as studies have demonstrated that measures such as omissions, commissions and signal detectability are affected by the changes in speed in the reaction time after a certain length of time (Conners et al., 2003; Parasuraman, 1999).

Comparison Between the Brazilian and North American Samples

When comparing the Brazilian and North American samples, the results were unexpected. Except for the measure of percentage of omission errors, which did not differ only in the 6- to 7-year-olds (male and female participants) and in the female 8- to 9-year-olds, when compared to the North American sample, all other measures presented significant differences, Brazilian children having better scores. It is interesting to note that in the 8- to 9-year-old age-group the differences between populations became more evident. This is an age when it has been demonstrated that sustained attention becomes more stable after presenting rapid changes in the course of child development (Corkum & Siegel, 1993; Lin et al. 1999). The finding that the Brazilian children had better scores in the CPT-II can be interpreted in two ways considering that social-cultural experiences (Ratner, 2000) are thought to influence cognitive functioning, although it has not been determined how or why, as well as gender, age, and schooling (Levav et al., 1998). Either this test is sensitive to this as yet unspecific cultural factor or differences arose from lack of demographic comparability between samples. Against the first hypothesis, it could be argued that the age and gender effects obtained in the present study were somewhat equivalent to those reported in other countries as discussed above, corroborating the widespread idea that performance on CPT-II measures may be relatively constant in different cultures. This cannot be ascertained, however, because to our knowledge only Levav et al. (1998) compared performance between children of different countries using the degraded CPT version. This author found some specific differences between samples, concluded that they were not clinically significant using the rule of thumb of more than

.50 SD, but admitted her studys limitations which included a very small number of children, lack of screening, and inclusion of clinical samples. Hence, there is still no compelling evidence for or against the cross-cultural nature of CPTs. As concerns demographic characteristics, because the present and North American samples were matched for age and schooling was also equivalent, results could be accounted for by differences in socioeconomic class, different proportion of girls and boys in each age-group, or ADHD screening. The author of the CPT-II manual (Conners, 2002) does not provide participants socioeconomic status, so it could be that their sample was not random and included only children who were underprivileged in comparison to the Brazilian sample, and thus had worse scores. This would be surprising because in the present study participants were selected so as to reflect the socioeconomic status distribution of the city of So Paulo, located in an underdeveloped country in which only 1% of the population is classified as class A and 26% as class B (ABEP, n.d.) Likewise, despite overall equivalent proportion of boys and girls in the U.S. sample the author of the CPT-II does not mention if this proportion is equivalent in each agegroup. We do not find that this difference in this distribution is a plausible explanation for our results because a preponderance of boys in all age-groups in the U.S. sample could explain the higher number of errors when compared to the present study, but not the smaller reaction times obtained here as girls react more slowly to visual stimuli in the CPT (Conners et al., 2003). We believe our findings are better explained by differences in ADHD screening. In contrast to the present investigation, the normative study (Conners, 2002) only excluded youths who had obvious attention deficits or who had been diagnosed as such, but . . . in general, the sample was otherwise not prescreened, as described in the test manual (p. 49). Hence, it is possible that the North American sample included children with ADHD, a fact that could lead to a decrease in the main CPT measures (Corkum & Siegel, 1993). The CPT-II authors themselves claim that . . . the presence of some clinical cases in the general population sample means that the classification accuracy ratings for the CPT are conservative and will tend to underestimate the true classification accuracy of the test (Conners, 2002, p. 49). It is noteworthy, however, that the following work conducted by the CPT-II authors did alter this screening procedure by including externalizing broad band scale items from the Child Behavior Checklist (Conners, 2003). The main implication of this is that normative CPT studies must include ADHD screening if they are to be used to assess childrens likelihood of having attention deficits.

Miranda et al. / Conners CPTComparative Study 11

Otherwise, a high number of false negatives will be obtained. In addition, so that it can be determined whether CPT measures differ according to cultural origin, studies must be conducted using the same CPT version in prescreened samples matched for age, gender, and socioeconomic background.

Conclusions
In summary, the present study shows the importance of sample selection when determining CPT normative scores. The sample employed in this study was based in So Paulo and showed better performance in almost all CPT II measures than the original population of standardization of this CPT version in the United States, despite samples having been matched for age and overall gender distribution. Age and gender effects were similar to those previously described, confirming that this population responded to the task in a similar manner as children from other cultures. It is discussed that differences between studies more probably reflected lack of ADHD screening of the normative U.S. sample. Future studies are needed that employ children matched for age, gender, and socioeconomic status using the same CPT version so that conclusions can be drawn about the social-cultural effects on CPT performance.

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Mnica Carolina Miranda is a researcher and doctor of sciences at the Federal University of So Paulo, Brazil. Elaine Giro Sinnes is a psychologist at the Federal University of So Paulo, Brazil. Sabine Pompia is a doctor of sciences and affiliate professor at the Federal University of So Paulo, Brazil. Orlando Francisco Amodeo Bueno is a professor at the Federal University of So Paulo, Brazil.