Sustained and Selected Attention in ADHD subtypes and LD: A Clinical Comparison
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Sustained and Selected Attention in ADHD subtypes and LD: A Clinical Comparison Silvia Álava Sordo1, María Cantero-García2, Helena Garrido-Hernansaiz 3, Iván Sánchez-Iglesias4, José Santacreu Mas5 1 Departamento de Psicología Infantil. Centro de Psicología Álava Reyes. 2 Departamento de Psicología. Facultad de Ciencias Biomédicas y de la Salud. Universidad Europea de Madrid & Área de Salud. Facultad de Psicología. Uni- versidad Internacional de Valencia. 3 Departamento de Educación y Psicología. Centro Universitario Cardenal Cis- neros. 4 Psychobiology and Behavioral Sciences Methods. Universidad Complutense de Madrid. 5 Facultad de Psicología. Universidad Autónoma de Madrid Spain Correspondence: María Cantero-García. Departamento de Psicología. Facultad de Ciencias Biomédicas y de la Salud. Universidad Europea de Madrid & Área de Salud. Facultad de Psicología. Universidad Internacional de Valencia. Calle Pintor Sorolla, 21. 46002. Valencia. E-mail: maria.canterogar@gmail.com © Universidad de Almería and Ilustre Colegio Oficial de la Psicología de Andalucía Oriental (Spain) Electronic Journal of Research in Educational Psychology, 19(1), 117-144. ISSN:1696-2095. 2021. no. 53 117
Álava Sordo et al. Abstract Introduction: The goal of this study is to examine whether there are differences in selective and sustained attention between children diagnosed with ADHD and children with LD, thus allowing to establish differences among these groups in several objective measures regarding attention and contributing to differential diagnosis between ADHD and LD. Method: The sample consisted of 437 children who attended a psychology center, of which 234 had ADHD and 203 had LD (in which a diagnosis of ADHD was ruled out). Sustained and selective attention tests (Caras, d2, EMAV, AGL, CSAT and CPT-II) were applied to the participants during their evaluation and descriptive analyses, one-way ANOVAs and planned F tests were performed. Results: The differences between the indicators of the tests used to measure attention sug- gested that children with ADHD have difficulties in performance in selective and sustained attention, and they process information significantly slower. Discussion and Conclusions: The indicators of some of the tests used could be useful to make a differential diagnosis between children with ADHD and LD, and to design a personal- ized treatment intervention for each child. Keywords: ADHD, sustained attention, selective attention, learning disorder. 118 Electronic Journal of Research in Educational Psychology, 19(1), 117-144. ISSN:1696-2095. 2021. no. 53
Sustained and Selected Attention in ADHD subtypes and LD: A Clinical Comparison Resumen Introducción. El objetivo de este estudio es conocer si existen diferencias en atención selec- tiva y sostenida entre niños con diferentes subtipos de TDAH y niños con trastornos del aprendizaje (TA), para mejorar el diagnóstico diferencial entre TDAH y TA y entre los diferentes subtipos de TDAH. Método. La muestra estuvo formada por 437 niños que acudieron a un centro de psicología, de los cuales 234 tenían TDAH y 203 TA (en los que se descartó un diagnóstico de TDAH). Se aplicaron pruebas de atención sostenida y selectiva (Caras, d2, EMAV, AGL, CSAT y CPT-II) a los participantes durante su evaluación y se realizaron análisis descriptivos, ANO- VAs de un factor y pruebas F planeadas. Resultados. Las diferencias entre los distintos indicadores de las pruebas utilizadas para medir la atención sugieren que los niños con TDAH tienen dificultades en el rendimiento en atención selectiva y sostenida y procesan la información de forma significativamente más lenta que los niños con TA. Discusión y conclusiones. Los indicadores de algunas de las pruebas utilizadas podrían ser de utilidad para hacer un diagnóstico diferencial entre los niños con TDAH y con TA y para poder establecer un plan de intervención de tratamiento individualizado. Palabras Clave: TDAH, atención sostenida, atención selectiva, trastorno de aprendizaje. Electronic Journal of Research in Educational Psychology, 19(1), 117-144. ISSN:1696-2095. 2021. no. 53 119
Álava Sordo et al. Introduction In addition to the symptoms of inattention, impulsivity and hyperactivity previously described in the Diagnostic and Statistical Manual of Mental Disorders 5 (APA, 2013), chil- dren with ADHD show cognitive deficits, such as difficulty for planning, working memory, inhibition and attention (Cortese et al., 2015) and they are likely to have more problems with focalized attention or the information processing speed (inputs analysis and memory storage recall, Barkley, 1990). Furthermore, even though an alteration of the sustained attention ca- pacity in children with ADHD has been registered (Borger and Cassutto, 2014; Conners, 1994; de la Torre y de la Torre, 2003; González Castro, et al., 2014; Oades, 2000; Miranda et al. 2008), there is controversy as far as selective attention is concerned (Barkley, 1990; Cre- spo Eguillaz et al, 2006; de la Torre y de la Torre, 2003; Magaz et al., 2011; Rodríguez et al., 2009), which can be better understood focusing on the existing ADHD subtypes. In this sense, although ADHD can be considered as a unique entity, its manifestations can be very diverse, thus various patrons can be distinguished in the same alteration. In the DSM-IV (APA, 1994), there are three ADHD subtypes listed, which are still present in the en el DSM-IV-TR (APA, 2000) and in the DSM-5 (APA, 2013): Predominantly inattentive, pre- dominantly hyperactive/impulsive, and combined. The main difference between these sub- types has to do with the existing patterns of attention deficit, which can suggest neurocogni- tive substrates different for each subtype (Barkley, 1997). Generally speaking, children with an inattentive subtype have more difficulties in se- lective and sustained attention, they seem to be slower when focusing attention and respond- ing to stimuli of their environment, and they have also difficulties in the immediate and de- layed verbal memory and in cognitive flexibility; however, they have no difficulties in impul- sivity control (Arán and Mías, 2009; Solanto et al., 2007). On the other hand, children with a hyperactive/impulsive subtype, show difficulties in impulse control, in sustained attention, and in immediate and delayed verbal memory (Arán and Mías, 2009; Barkley, 1990). Finally, children with a combined subtype show a high level of impulsivity, both cognitive (linked to tasks and learning general style) and motor (linked to a lack of motor control Balbuena, 2016; Belanger, Andrews, Gray and Korczak, 2018). As far the attention cognitive process is concerned, most of the investigations agree on the existence of the sustained attention deficit in all subtypes, especially in the inattentive one; 120 Electronic Journal of Research in Educational Psychology, 19(1), 117-144. ISSN:1696-2095. 2021. no. 53
Sustained and Selected Attention in ADHD subtypes and LD: A Clinical Comparison however, as far as selective attention is concerned, there is greater controversy (Belanger et al., 2018), as previously mentioned. Available literature on this topic suggests that selective attention deficits are a characteristic of the inattentive subtype while alterations in sustained attention are typical of the combined subtype (Balbuena, 2016; Jiménez, Rodríguez, Camacho, Alfonso and Artiles, 2015; Schmitz et al., 2002). To sum up, every subtype of ADHD seems to have different cognitive manifestations and characteristics where attention has an fundamental role, therefore it would be crucial to have instruments allowing to established a neuropsychological profile for each of the subtypes (García-Savaté et al., 2012; Luo, Weibman, Halperin and Li, 2019). In this sense, accuracy, number of mistakes, and, to a lesser extent, the processing speed are the three key variables in the use of assessment tests to distinguish different profiles (Santacreu, Shih y Quiroga, 2011). Thus, errors of omission seem to be related to inattention symptoms while errors of commis- sion, to impulsivity symptoms (Epstein et al., 2003). On this matter, there are just a few studies showing different profiles in children with ADHD inattentive and combined subtype, and very few studies taking into account the hyper- active/impulsive subtype (because of its low prevalence). As a result, the existing studies have problems of internal and external validity due to the reduced size of the samples (Reale, et al., 2017). For example, using the Continuous Performance Test (CPT) by Conners, Bara- Jimenez, Vicuña, Pineda y Henao (2003), it was found that there was a significantly greater impulsivity and an alteration in the sustained attention capacity in comparison with the inat- tentive group, in which only difficulties in sustained attention were observed. This result is similar to the one obtained in the study of Chiang and Gau (2008), which showed that chil- dren with ADHD combined subtype were more impulsive (they committed more errors of commission) and also had greater difficulties in sustained attention than children with ADHD inattentive subtype. In a similar way, Fernández-Jaén et al. (2012) using the CPT also found greater problems of sustained attention (higher number of errors of omission and shorter reac- tion time) in the combined subtype than in the inattentive subtype. In addition, in the inatten- tive subtype, there were a greater number of errors of commission, which may be related to a deficit selective attention. Electronic Journal of Research in Educational Psychology, 19(1), 117-144. ISSN:1696-2095. 2021. no. 53 121
Álava Sordo et al. In the same line, it is appropriate to mention the study of Arán and Mías (2009), who used several tests to analyze the attention performance in the three ADHD subtypes. The re- sults indicated that in the inattentive subtype there were deficits both in selective and in sus- tained attention, with no alteration in the impulsivity control. In the hyperactive/impulsive subtype, on the other hand, there was a normal selective attention performance and considera- ble deficits both in sustained attention and in impulsivity control. Finally, in the combined subtype there were more errors of commission (which suggests greater impulsivity) than in the inattentive subtype, with the same result in China (Chiang and Gau, 2008 and in the Unit- ed States (Hinshaw, Carte, Sami, Treuting and Zupan, 2002). Nevertheless, other studies did not find such differences. Also using the CPT by Con- ners, Solanto et al., (2007) they concluded that both inattentive and combined subtypes had a longer reaction time and a fewer number of correct answers in comparison with the control group, not showing any differences between subtypes. In the same way, Chiang and Gau (2008) realized that the d’ discrimination index was lower in both ADHD subtypes compared to a control group. This suggests the possibility of a worse level of attention, not only sus- tained but also selective in both subtypes. Besides the existing differences between the ADHD subtypes, other important matter for the ADHD in children and adolescents is the high level of comorbidity with other disor- ders, especially with learning disorders (LD). LD are characterized by difficulties in reading, reasoning, writing, or math skills, with a lower performance than expected by age, despite no sensorial physical deficits are detected (Johnson, 2017; Karande and Kulkarni, 2005). LD prevalence in children with ADHD is, in accordance with several studies, between 16% and 56% (CADDRA, 2011; Efron et al., 2016; Lonergan et al., 2019; Oerbeck et al., 2017; Reale et al., 2017; Tistarelli, Fagnani, Troianiello, Stazi and Adriani, 2020). However, these data do not express a real comorbidity prevalence, but difficulties to correctly identify the differential diagnosis due to the symptoms similarity (Peterson et al., 2017; Preston, Heaton, McCann, Watson and Selke, 2009). In this sense, it must be taken into account the very low quantity of existing studies where ADHD and LD groups are compared, as well as the samples size of such studies (e.g., de la Torre and de la Torre, 2003; Gónzalez-Castro et al., 2014; Miranda et al., 2008; Rodríguez et al., 2009). 122 Electronic Journal of Research in Educational Psychology, 19(1), 117-144. ISSN:1696-2095. 2021. no. 53
Sustained and Selected Attention in ADHD subtypes and LD: A Clinical Comparison Because of that, it is necessary to carry out studies to clarify both the existing differ- ences in ADHD sustained and selective attention between the inattentive and combined sub- types, and the differences between these subtypes and LD. Applying tests of attention could help to find the specific characteristics for each ADHD subtype and to develop a differential diagnosis between them, as well as to develop a differential diagnosis between ADHD and LD. Objectives and hypothesis There are two objectives in this study: Firstly, comparing performance in the sustained attention tests CPT-II and CSAT, and in the selective attention cancellation tests EMAV [Escala Magallanes de Atención Visual - Magallanes Scale of Visual Attention], d2, CARAS- R [Differences Perception Test “Faces”] and GLA (Global-Local Attention) in a clinical sam- ple formed by children with ADHD and children with LD to whom a diagnosis of ADHD had been dismissed. Secondly, checking if there are any differences in the attention tests, both sustained and selective attention, in children with ADHD inattentive and combined subtype. Thus, the following hypotheses have been established (see description of the mentioned in- struments further on). Regarding the comparison of ADHD with LD: • Hypothesis 1: The scores of the ADHD group will be lower than the ones of the LD group in the sustained attention indexes (d’ discrimination of the CSAT; d’ and the CPT-II confidence index) and they will commit more errors (both errors of omission and commission) in tests. • Hypothesis 2: The scores of the ADHD group will be lower than the ones of the LD group in the selective attention indexes (QA [Quality of Attention] and SA [Selective Attention] of the EMAV; correct answers of the CARAS; correct an- swers of the d2 and TP [Total Performance] of the GLA) and a higher number of errors of omission in EMAV, CARAS and d2 tests. • Hypothesis 3: The ADHD group will complete the task more slowly than the LD group, so that group will get lower scores in SA of the EMAV; correct answers of the CARAS; TOT [Total] of the d2; TP of the GLA; and time of the CSAT. Electronic Journal of Research in Educational Psychology, 19(1), 117-144. ISSN:1696-2095. 2021. no. 53 123
Álava Sordo et al. Regarding the comparison between ADHD subtypes: • Hypothesis 4: The ADHD combined subtype group will show more impulsivity than the inattentive and the LD group, so the number of errors of commission (of the EMAV, CARAS, d2, CSAT, and CPT-II) and perseverations (of the CPT-II) will be higher. • Hypothesis 5: The ADHD inattentive subtype group will complete the task more slowly than the ADHD combined subtype group and the LD group, so that group will get lower scores in SA of the EMAV; correct answers of the CARAS; TOT of the d2; TP of the GLA; and a higher reaction time of the CSAT. • Hypothesis 6: The ADHD inattentive subtype group will get worse results than the combined group and LD group in the selective attention indexes (QA and SA of the EMAV; correct answers of the CARAS; correct answers of the d2 and TP of the GLA) and will commit a higher number of errors of omission and commis- sion in the mentioned tests (EMAV, CARAS and d2). • Hypothesis 7: The ADHD combined subtype group will get worse results than the inattentive group and the LD group in the sustained attention indexes (d’ discrim- ination of the CSAT; d’ and confidence index of the CPT.II) and will commit a higher number of errors in both tests. Method Participants A total of 437 people took part in the study: 278 men and 159 women, who attended the Psychology Centre Álava Reyes because of learning disorders from April 2003 to August 2015. Out of 437 participants, 237 were diagnosed with ADHD and 203 with LD in which a diagnosis of ADHD was ruled out. In the ADHD group, 97 subjects showed an inattentive profile (22.19%) and 137 a combined profile (31.35%). Ages from 6 to 16 (A = 10.30, SD = 3.09). It is also important to say that the sample in this study will be used in other articles. On the other hand, most of participants were treated in the mentioned centre after the assessments reported in this paper. 124 Electronic Journal of Research in Educational Psychology, 19(1), 117-144. ISSN:1696-2095. 2021. no. 53
Sustained and Selected Attention in ADHD subtypes and LD: A Clinical Comparison Instruments Selective attention / visual search tests - CARAS test [differences perception test “Faces”] (Thurstone and Yela, 2009). It as- sesses the ability to quickly and correctly perceive similarities and differences between the stimuli presented. It consists of 60 graphic elements; each of them is formed by 3 simplified faces drawings, with mouth, eyes, eyebrows, and hair drawn with basic lines. Two of the faces are the same and the objective of the task is to identify the dif- ferent one and cross it out. The test reliability has a Cronbach’s of .91. - Attention test d2 (Brickenkamp, 2004) assesses several aspects of selective attention and focusing in children from 8 years old, teenagers and adults. The test consists of 14 lines with 47 characters, 658 elements in total. The study of Brickenkamp (2004) has a good inner consistency, with a a Cronbach’s in the USA sample of .79 to .96. - Escala Magallanes de Atención Visual – EMAV [Magallanes Scale of Visual Atten- tion] (García-Pérez y Magaz, 2000). In this test, the subject must identify the figure identical to the model among a group of different figures. For ages from 6 to 8, it con- sists of a total of 720 figures, 140 of them identical to the model. In the EMAV-2, for ages from 9 to 18, the figures are smaller. It consists of 1820 figures, 340 of them identical to the model. The Pearson correlation coefficients of the test-retest reliability were (p < .001) of .48 for quality of attention of the EMAV-1, .56 for the EMAV.2, .46 for the selective attention of the EMAV-1, and .60 for the EMAV-2. - GLA, Global-Local Attention (Blanca et al., 2005). It assesses the perceptive speed and accuracy in a task which demands the attention distribution in two levels of a vis- ual stimulus. Graphic elements, called hierarchical stimuli, are used in this test. They consist of big figures, which represent the global level of the visual pattern, and small figures, which are in the outline and represent the local level. The test-retest reliability index has a reliability coefficient of .80 in every index. Electronic Journal of Research in Educational Psychology, 19(1), 117-144. ISSN:1696-2095. 2021. no. 53 125
Álava Sordo et al. Sustained attention tests - CSAT (Children Sustained Attention Task, (Servera and Llabrés, 2004). It is a version of the continuous performance tasks or CPTs to measure the capacity of sustained at- tention in childhood. There is a double target: Reacting to presence of a 3 before a 6, that is, 6-3. The response is pressing the computer space bar every time this target is shown. 600 stimuli are shown on screen and each one is there for 250 milliseconds. Coefficient correlations between blocks fluctuate from .80 for correct answers, .85 for reaction times, and .80 for commissions. - Conner CPT-II (2004). This test consists of 6 blocks containing 3 sub-blocks each, and these, in turn, contain 20 letters presentations. The total length of the test is 14 minutes, and it can be applied from 6 years old. Reliability data of two halves have correlation coefficients between blocks of .83 for commissions, .94 for omissions, and .95 for reaction time. Data analysis The scores in all the attention tests were described by its average and standard davia- tion. In the different attention tests given to the groups (ADHD inattentive, ADHD combined and LD) average comparisons were made by one-way ANOVAs with post hoc comparisons (applying Bonferroni correction to avoid increasing the family-wise type I error rate). In order to compare LD group and both ADHD groups as a whole (inattentive and combined), an F- test planned beforehand was used. Despite the scores distribution in the different attention tests did not fit the normal distribution according to the statistician Kolmogorov-Smirnov, the F-statistic is solid against the non-fulfillment of the normality assumption (Pardo, Ruiz, and San Martín, 2010). The data analysis was made with SPSS 20. Results Comparisons of attention scores averages between the different groups of clinical samples are displayed below. From Table 1 to Table 7 descriptive statistics of these scores are presented, and the averages comparisons together with the effect size of the differences. The results were grouped according to the assessed attention type, the performance speed, and the impulsivity control. 126 Electronic Journal of Research in Educational Psychology, 19(1), 117-144. ISSN:1696-2095. 2021. no. 53
Sustained and Selected Attention in ADHD subtypes and LD: A Clinical Comparison Table 1. Descriptive statistics of Scales of Sustained Attention ADHD ADHD LD (1) inattentive (2) combined (3) Scale n A SD n A SD n A SD d´ CPT-II percentile 121 54.44 27.24 70 64.89 22.73 77 61.70 26.31 CPT-II confidence index 121 52.58 20.20 69 65.68 22.71 76 72.20 23.75 d´ CSAT percentile 42 0.88 1.10 38 0.41 1.05 58 0.45 1.59 CPT-II omissions 120 52.75 13.20 68 63.65 18.52 72 68.46 24.13 CPT-II commissions 120 50.07 10.60 68 53.88 9.02 73 50.06 8.99 CSAT commissions 42 54.69 69.64 39 166.21 402.21 58 84.50 109.11 Table 2. Averages Comparison in the Scales of Sustained Attention ANOVA Averages comparison between groups (p) Scale F df p η2 1-2 1-3 2-3 1 - (2 y 3) d´ CPT-II percentile 4.11 2, 265 .018 .030 .014 .151 .711 .006 CPT-II confidence index 20.33 2, 263 < .001 .134 < .001 < .001 .214 < .001 d´ CSAT percentile 1.69 2, 135 .188 .024 .246 .247 .985 .068 CPT-II omissions 18.69 2, 257 < .001 .127 < .001 < .001 .382 < .001 CPT-II commissions 3.83 2, 258 .023 .029 .029 1.000 .055 .118 CSAT commissions 2.62 2, 136 .076 .037 .215 .224 .438 .047 Note: 1: LD; 2: ADHD inattentive; 3: ADHD combined; (2 and 3): ADHD inattentive and combined subtype groups are taken as a whole. Important p values in bold. In Table 1, averages and standard deviations of the participants’ percentile scores in the scales of sustained attention are seen. In d’ of the CPT-II, important differences between participants with LD and the ADHD inattentive subtype group were found (Table 2). They were found between LD group and both ADHD groups taken as a whole as well (it is ob- served here a higher average, that is, a higher number of difficulties in ADHD groups) with an effect size of η2 = .030. Also, there were important differences in the confidence index and the CPT-II omissions between the LD group and the ADHD inattentive subtype group, the LD group and ADHD combined subtype groups, and between LD group and both ADHD groups taken as a whole with an effect size of η2 = .134 y η2 = .127 respectively. Subjects with ADHD taken as a whole committed significantly more commissions in the CSAT than the ones in the LD group with an effect size of η2 = .037. Electronic Journal of Research in Educational Psychology, 19(1), 117-144. ISSN:1696-2095. 2021. no. 53 127
Álava Sordo et al. Table 3. Descriptive Statistics of Scales of Selective Attention ADHD ADHD LD (1) inattentive (2) combined (3) Scale n A SD n A SD n A SD QA EMAV percentile 203 33.96 24.83 97 24.07 22.46 137 30.40 25.29 SA EMAV percentile 203 49.63 27.60 97 40.98 26.87 137 46.79 30.24 CARAS correct answer percentile 129 52.69 27.67 70 35.61 24.88 79 46.95 28.05 LD d2 percentile 146 48.07 28.78 70 30.76 29.81 83 36.53 28.11 TP (total performance) GLA 41 38.20 24.40 11 16.55 13.31 8 33.13 28.53 percentile EMAV commissions 201 2.78 13.92 96 2.29 8.49 134 2.09 6.52 CARAS commissions 127 1.70 2.16 69 2.43 5.01 74 2.24 2.88 d2 commissions 146 7.04 7.82 66 11.03 10.12 77 11.42 11.06 EMAV omissions 201 17.93 24.51 96 22.67 26.77 134 19.04 23.28 CARAS omissions 127 0.79 4.39 69 1.45 8.52 74 0.65 2.69 d2 omissions 146 13.86 24.02 66 16.73 18.41 77 17.48 21.53 Table 4. Averages Comparison in the Scales of Selective Attention Averages comparison between groups ANOVA (p) Scale F df p η2 1-2 1-3 2-3 1 - (2 y 3) QA EMAV percentile 3.07 2, 434 .048 .014 .036 .635 .270 .036 SA EMAV percentile 5.37 2, 434 .005 .024 .003 .387 .126 .005 CARAS correct answer percen- 9.01 2, 275 < .001 .061 < .001 .301 .031 .001 tile LD d2 percentile 9.79 2, 296 < .001 .062 < .001 .011 .434 < .001 TP (total performance) GLA 3.71 2, 57 .031 .115 .023 .842 .288 .046 percentile EMAV commissions 0.17 2, 428 .840 .001 .931 .838 .990 .579 CARAS commissions 1.31 2, 267 .272 .010 .298 .499 .936 .113 d2 commissions 7.36 2, 286 .001 .049 .015 .007 .974 < .001 EMAV omissions 1.21 2, 428 .299 .006 .270 .915 .514 .224 CARAS omissions 0.46 2, 267 .634 .003 .695 .983 .653 .694 d2 omissions 0.81 2, 286 .447 .006 .658 .479 .978 .215 Note: 1: LD; 2: ADHD inattentive; 3: ADHD combined; (2 and 3): ADHD inattentive and combined subtype groups are taken as a whole. Important p values in bold. 128 Electronic Journal of Research in Educational Psychology, 19(1), 117-144. ISSN:1696-2095. 2021. no. 53
Sustained and Selected Attention in ADHD subtypes and LD: A Clinical Comparison Table 3 shows averages and standard deviations of the participants’ percentile scores in the scales of selective attention. In Table 4, averages comparisons in these scales are dis- played. In EMAV Selective Attention (SA) and Quality of Attention (QA) percentiles, the ADHD inattentive subtype group get significantly lower scores than the LD group; and both ADHD groups taken as a whole get also significantly lower scores than the LD group with an effect size of = .036 y η2 = .003 respectively. In the CARAS correct answers percentile im- portant differences can be seen: Between the ADHD inattentive subtype group and the LD groups; between both ADHD groups taken as a whole with the LD in favour of LD; and be- tween the ADHD inattentive and combined subtype groups, having the inattentive group the lowest average with a, effect size of η2 = .061. In the d2 total correct answers percentile, the LD group got a significantly higher score than the inattentive, the combined, and both ADHD groups taken as a whole with an effect size of η2 = .062. In the total performance (TP) of the GLA percentile, the LD group got a significantly higher score than the ADHD inattentive subtype and both groups taken as a whole with an effect size of η2 = .115. Regarding the EM- AV, CARAS and d2 errors of commission and omission, important differences are found only in the d2 commissions between the LD and the ADHD inattentive subtype groups, the LD group and the ADHD combined subtype groups, and the LD group and both ADHD groups taken as a whole (having the LD group a lower average) with an effect size of η2 = .049. In Table 5, averages and standard deviations of the participants’ percentile scores in the scales of impulsivity control are seen. Table 5. Descriptive Statistics of Scales of Impulsivity Control ADHD ADHD LD (1) inattentive (2) combined (3) Scale n A SD n A SD n A SD EMAV commissions 201 2.78 13.92 96 2.29 8.49 134 2.09 6.52 CARAS commissions 127 1.70 2.16 69 2.43 5.01 74 2.24 2.88 d2 commissions 146 7.04 7.82 66 11.03 10.12 77 11.42 11.06 CPT-II commissions 120 50.07 10.60 68 53.88 9.02 73 50.06 8.99 CSAT commissions 42 54.69 69.64 39 166.21 402.21 58 84.50 109.11 CPT-II Perseverations 120 54.13 14.59 68 74.35 37.74 72 63.25 20.95 In the d2 commissions, important differences were found: Between LD group and ADHD inattentive subtype, LD group and ADHD combined subtype, and between LD and Electronic Journal of Research in Educational Psychology, 19(1), 117-144. ISSN:1696-2095. 2021. no. 53 129
Álava Sordo et al. both ADHD groups taken as a whole (having the ADHD groups a higher average) with an effect size of η2 = .049. ADHD inattentive subtype group commit significantly more omis- sions in the CPT-II than the LD group with an effect size of η2 = .029. In the CPT-II perseve- rations important differences were found: Between participants with LD and the ADHD inat- tentive subtype group, between LD groups and ADHD combined subtype groups, and be- tween LD groups and both ADHD groups taken as a whole (having the ADHD groups a high- er average) with an effect size of η2 = .105. Table 6 shows averages and standard deviations of the participants’ percentile scores in the scales of performance speed. In Table 7, averages comparisons of the mentioned scales are displayed. Subjects with ADHD inattentive subtype completed the CARAS, d2, EMAV, and GLA tests significantly more slowly than LD groups; subjects with ADHD combined subtype completed the d2 test significantly more slowly than LD groups. Subjects with ADHD inattentive subtype completed the CARAS test significantly more slowly than ADHD combined subtype groups; and subjects in both ADHD groups taken as a whole completed the CARAS, d2, EMAV, and GLA test significantly more slowly than LD groups, with effect sizes from η2 = .014 to .115. Table 6. Descriptive Statistics of Sacales of Performance Speed ADHD ADHD LD (1) inattentive (2) combined (3) Scale n A SD n A SD n A SD CSAT Time percentile 42 62.86 24.35 39 57.67 23.67 58 56.90 23.11 CARAS correct answers percentile 129 52.69 27.67 70 35.61 24.88 79 46.95 28.05 d2 TOT percentile 148 48.86 27.94 68 31.66 30.00 83 37.61 28.26 EMAV SA percentile 203 49.63 27.60 97 40.98 26.87 137 46.79 30.24 TP GLA percentile 41 38.20 24.40 11 16.55 13.31 8 33.13 28.53 130 Electronic Journal of Research in Educational Psychology, 19(1), 117-144. ISSN:1696-2095. 2021. no. 53
Sustained and Selected Attention in ADHD subtypes and LD: A Clinical Comparison Table 7. Averages Comparison in the Scales of Performance Speed Averages comparison between ANOVA groups (p) Scale F df p η2 1-2 1-3 2 - 3 1 - (2 y 3) CSAT Time percentile 0.85 2, 136 .430 .012 .586 .429 .986 .207 CARAS correct answers 9.01 2, 275 < .001 .061 < .001 .301 .031 .001 percentile d2 TOT percentile 9.74 2, 296 < .001 .062 < .001 .012 .409 < .001 EMAV SA percentile 3.07 2, 434 .048 .014 .036 .635 .270 .036 TP GLA percentile 3.71 2, 57 .031 .115 .023 .842 .288 .046 Note: 1: LD; 2: ADHD inattentive; 3: ADHD combined; (2 and 3): ADHD inattentive and combined subtype groups are taken as a whole. Important p values in bold. Discussion and Conclusions In the Hypothesis 1, the factor being checked was if the ADHD group would get re- sults lower than subjects with LD in tasks measuring sustained attention, given the evidence found about sustained attention difficulties in subjects with ADHD (Berger and Cassuto, 2014, Conners, 1994, Epstein et al., 2003; González-Castro et al., 2014, Oades, 2000; O´Dougherty et al., 1984; Losier et al., 1996 and Miranda et al., 2008). The obtained results supported this hypothesis. This may mean that, learning difficulties being equal, those ones of people with ADHD are due to sustained attention and those of people with LD are not. Thus, the ADHD group got significantly lower scores in the CPT-II test indexes (d’ sensitivity in- dex, confidence index, omissions). Results were not important as far as the CSAT d’ detecta- bility index is concerned but they were important regarding the number of commissions in that test. These results concur with the ones found by Soroa et al. (2009) with the CSAT test. They are meaningful in the CPT-II. We think this could be because the CPT-II is easier: It is a cancellation task test, where the instruction is pressing the button in all the letters except in “X”. In contrast, the CSAT test is a vigilance task where the order is more difficult: the sub- ject must press the button having a double stimulus instruction “every time they see a 6 fol- lowed by a 3 on screen”, so children with LD may complete this task worse, not meaning this they have attention deficit disorder. In the Hypothesis 2, it was anticipated that subjects with ADHD would get lower scores than LD group in tests measuring selective attention, as indicated in previous research Electronic Journal of Research in Educational Psychology, 19(1), 117-144. ISSN:1696-2095. 2021. no. 53 131
Álava Sordo et al. by Barkley (1990); Crespo Eguilaz et al. (2006); De la Torre and de la Torre (2003); Magaz et al. (2011); Santacreu et al. (2011), and Rodríguez et al. (2009) about selective attention diffi- culties in subjects with ADHD. The obtained results, again, supported the hypothesis. Thus, the ADHD group got significantly lower scores than LD group in every global index of the cancelation tests used: SA and QA of the EMAV, correct answers of the CARAS, correct an- swers of the d2, and TP of the GLA. Lower scores results in the concentration and in the cor- rect answers percentile of the d2 concur with ones found by Rodríguez et al. (2009) and a lower percentile in QA and SA of the EMAV in the ADHD group Magaz et al. (2011) study. This could mean that learning difficulties of children with ADHD are due to their low level of selective attention, which did not occur in subjects with LD. Regarding the errors, the results were significant as far as the number of errors of omission in CARAS, d2, and EMAV tests is concerned, nor the errors of commission in EM- AV and CARAS. But it was in d2 commissions. ADHD group committed significantly more errors of commission than LD group in the d2. This might occur because of the task difficulty level: d2 test is a more difficult task than the CARAS and the EMAV (in the d2, the subject must distinguish between “d” and “p”, while in the CARAS they must choose between a se- ries of drawings of different faces, and in the EMAV, between drawings of figures in the same position), in fact, the errors average in the CARAS was very low. Authors like Moreno- Méndez y Martínez-León (2010) suggest that the CARAS has not a sufficient discriminative power for ADHD. However, in our study, the number of errors in this test was not important, that is, ADHD group did not commit more errors than LD group. In the Hypothesis 3, we suggested that subjects with ADHD would complete the atten- tion tests more slowly than LD group, given that the fact that children with ADHD process information more slowly was evinced in previous studies (Barkley, 1990; Conners, 1994; González-Castro et al., 2014; Santacreu et al., 2011, and Soroa et al., 2009). In our research we found that the ADHD group completed the EMAV significantly more slowly (they got lower score in SA index, and a lower number of correct answers, which refers here to the amount of processed stimuli in this test) and got lower scores in the correct answers percentile of the CARAS, in the TP percentile of the GLA, and in the total number of processed items of the d2; this would imply that subjects with ADHD completed the EMAV, CARAS, GLA, and d2 tasks more slowly than LD group because they process a lower amount of stimuli. Howev- er, data were not meaningful for the CSAT time. This could have occurred because, both 132 Electronic Journal of Research in Educational Psychology, 19(1), 117-144. ISSN:1696-2095. 2021. no. 53
Sustained and Selected Attention in ADHD subtypes and LD: A Clinical Comparison CARAS and EMAV, GLA, and d2 is the subject the one in charge of their own time admin- istration. Nevertheless, in the research by Soroa et al. (2009), results showed that subjects with ADHD got a higher reaction time in the CSAT. In view of the obtained results, the hypothesis about children with ADHD process in- formation in a slower way than children with LD in paper-and-pencil cancellation tests is supported. In order to measure the subjects’ information processing speed, some authors used the WISC-IV Processing Speed index. Thus, in the studies made by Bustillo and Servera (2015); Fenollar-Cortés et al. (2015); Mayes and Calhoun (2006), San Miguel-Montes et al. (2010); Wechsler (2005); Yang et al. (2013) y Zhu and Chen (2013), significantly lower scores for the ADHD group in the WISC-IV Processing Speed index (PSI) were evinced. This would imply a slower information processing. Fernández Marcos (2017) concludes that the best predictor of ADHD is the speed at which the subject completes the task, so time predicts better than errors. In the Hypothesis 4, the premise was that subjects with ADHD predominantly com- bined subtype would complete the tests in a more impulsive way than subjects with ADHD predominantly inattentive subtype, and subjects with LD, as stated by Arán and Mías (2009); Balbuena (2016); Bará-Jiménez et al. (2003); Barkley (1990); Chiang and Gau (2008); Eptstein et al. (2013), and Hinshaw et al. (2002); so the number of errors of commission in the given tests would be higher. In this case, this hypothesis could not be proven, since there were no meaningful differences between ADHD inattentive subtype group and combined subtype group in any of the variables related to impulsivity. However, the difference was statistically significant between ADHD combined sub- type group and LD group in the number of commissions of the d2 and in the number of per- severations of the CPT-II. That is, children with ADHD combined subtype completed the d2 and the CPT-II tests in a significantly more impulsive way than LD group, but not more than ADHD inattentive subtype group. Children with ADHD inattentive subtype committed signif- icantly more commissions in the d2 and in the CPT-II tests than LD group, which may be related to selective attention difficulties in this group, that is, they had more difficulties when they had to select the target stimuli, what led them to commit a higher number of errors (Arán and Mías, 2009; Balbuena, 2006; Chiang and Gau, 2008; Fernández-Jaén et al., 2012; Jimé- nez et al., 2015; and Schmitz et al., 2002). Electronic Journal of Research in Educational Psychology, 19(1), 117-144. ISSN:1696-2095. 2021. no. 53 133
Álava Sordo et al. Results were not statistically significant as far as the number of errors of the CARAS, CSAT, and EMAV tests is concerned in neither of the groups; but, as stated before, this might be due to the CARAS test task is easy and the errors have not a sufficient discriminative pow- er for ADHD, since both LD group and ADHD group commit a very low number of errors of commission in these tests. Moreno-Méndez and Martínez-León (2010), and Fernández-Jaén et al. (2012) did not found significant differences in the commissions of the d2 either. We did find differences statistically meaningful in the number of commissions of the d2 between LD group and ADHD inattentive subtype group, and between LD group and ADHD combined subtype group, but no between both groups. Results did not concur with the ones obtained by Arán and Mías (2009), Chiang and Gau (2008), Hinshaw et al., (2002), and Epstein et al. (2003), who found that ADHD combined subtype group commit a higher number of commis- sions in the CPT-II test. However, in the study by Fernández-Jaén et al. (2012) the group committing a higher number of commissions in the CPT-II test was the ADHD inattentive subtype group. In our research, ADHD inattentive subtype group committed more commis- sions in the CPT-II than LD group, but not more than ADHD combined subtype group, which could mean that subjects with ADHD inattentive subtype have more difficulties than subjects with LD when discriminating the target stimuli. This leads them to commit a higher number of errors, both of commission and omission. In the Hypothesis 5, we guessed that ADHD inattentive subtype group would com- plete the tasks more slowly (Barkley, 1990 and Solanto et al., 2007) than ADHD combined subtype group and LD group, so they would get lower scores in the QA and AS of the EM- AV; correct answers of the CARAS; total answers of the d2 (since they would process a lower amount of stimuli); TP of the GLA; and time of the CSAT. In this case, we found only one meaningful difference between ADHD inattentive subtype groups vs. ADHD combined sub- type groups in the number of correct answers of the CARAS. Subjects with ADHD inattentive subtype completed the CARAS more slowly than subjects with ADHD combined subtype and subjects with LD. In addition, the difference was also significant between children with ADHD inattentive subtype and children with LD. As far as EMAV test is concerned, ADHD inattentive subtype group completed the task significantly more slowly than LD group, and processed a lower number of stimuli. However, the difference was not statistically significant between ADHD inattentive subtype 134 Electronic Journal of Research in Educational Psychology, 19(1), 117-144. ISSN:1696-2095. 2021. no. 53
Sustained and Selected Attention in ADHD subtypes and LD: A Clinical Comparison groups vs. ADHD combined subtype groups. If we focus on the number of correct answers of the EMAV and the total number of processed items in the d2 test, both the ADHD inattentive subtype group and the ADHD combined subtype group obtained a significant lower number than LD group, which may be because both a higher speed and a problem of selective atten- tion in both groups (Arán and Mías, 2009; Balbuena, 2006; Chiang and Gau, 2008; García et al. 2012; Jiménez et al. 2015, and Schmitz et al. 2002). Differences were not significant in the time of the CSAT, as they were not between subjects with ADHD and with LD, which could be due to both the difficulties in selective attention of the ADHD inattentive subtype group with respect to LD group (they select less target stimuli than LD group) and a lower tasks performance speed with respect to LD group (they complete the paper-and-pencil cancellation tests more slowly). In the Hypothesis 6, we suggested that ADHD inattentive subtype would get worse re- sults than ADHD combined subtype group and LD group in the selective attention indexes (Arán and Mías, 2009; Balbuena, 2006; Chiang and Gau, 2008; García et al. 2012; Jiménez et al. 2015, and Schmitz et al. 2002). In this case, it was proved that ADHD inattentive subtype group obtained a lower selective attention level than LD group, but not lower than ADHD combined subtype group (since the only significant difference between them is found in the correct answers percentile of the CARAS). In global indexes of the EMAV (QA and SA) it is found that ADHD inattentive subtype group got significantly lower scores than LD group, but not lower than ADHD combined subtype group. The same event occurs in the total number of correct answers of the d2; ADHD inattentive subtype group got lower scores than LD group, but not lower than ADHD combined subtype group; and in the correct answers percentile of the CARAS, children with ADHD inattentive subtype got significantly lower scores than LD group and ADHD combined subtype group. Regarding the number of errors, we found signif- icant differences neither in the CARAS nor in the EMAV; but we did find them between ADHD inattentive subtype group and LD group in the number of commissions of the d2 test. A higher number of commissions in ADHD inattentive subtype group would concur with the results found by Fernández-Jaén et al. (2012), which may imply that children with ADHD inattentive subtype have more difficulties in selective attention than children with LD, but not than children with ADHD combined subtype because these children have difficulties in selec- tive attention too. Electronic Journal of Research in Educational Psychology, 19(1), 117-144. ISSN:1696-2095. 2021. no. 53 135
Álava Sordo et al. In the Hypothesis 7, the suggestion was that ADHD combined subtype group would get lower results in sustained attention indexes (Arán and Mías, 2009, Balbuena, 2016; Bara- Jiménez et al., 2003; Barkley, 1990; Chiang and Gau, 2008; Eptstein et al., 2013; Fernández- Jaén et al., 2012; Jiménez et al., 2015; and Schmitz et al., 2002) than ADHD combined sub- type group, and LD group. In this case, we cannot prove this hypothesis. Results were not meaningful for any of the variables between ADHD inattentive subtype group and ADHD combined subtype group. However, results were significant as far as confidence index and the number of omissions of the CPT-II are concerned, where both ADHD inattentive subtype group and ADHD combined subtype group got significantly lower scores than LD group; nevertheless, there is no significant difference between both ADHD groups (inattentive sub- type vs. combined subtype). These results would concur with data found by authors who state that certain deficit in sustained attention in both subtypes exists (Arán and Mías, 2009; Bal- buena, 2016; Bara-Jiménez et al., 2003; Barkley, 1990; Chiang and Gau, 2008; Epstein et al., 2003; Fernández-Jaén et al., 2012; and Jiménez et al., 2015). As a limitation, it is important to consider that not all existing attention tests have been used and, as in previous studies, the sample is not representative of the children population with ADHD. It is a clinical conven- ience sample. The effect sizes found are small, this may be because of the compared groups are quite similar, since all of them have learning difficulties. Based on found data, we can conclude that: 1) According to revised studies, subjects with ADHD had difficulties with sustained attention. This may suggest that, learning difficulties being equal, the ones in ADHD are caused by sustained attention, while the ones in LD are not. 2) Subjects with ADHD had difficulties with selective attention. In our research, sub- jects with ADHD got significantly lower scores in global indexes of selective attention tests than subjects with LD. This would imply that academic difficulties in subjects with ADHD may be derived from selective attention, while those in LD are not. 3) Subjects with ADHD processed information significantly more slowly in cancella- tion tests (EMAV, d2, CARAS, and GLA) but not in sustained attention tests (CSAT). This 136 Electronic Journal of Research in Educational Psychology, 19(1), 117-144. ISSN:1696-2095. 2021. no. 53
Sustained and Selected Attention in ADHD subtypes and LD: A Clinical Comparison would imply that subjects with ADHD are slower when they must manage their own perfor- mance themselves, but they are not when facing a timed task, as in CPTs. 4) Subjects with ADHD combined subtype did not complete the tests in a significant more impulsive way than subjects with ADHD inattentive subtype. Thus, there was no signif- icant difference in the number of errors and perseverations between both groups (inattentive vs. combined) in any of the given tests. However, ADHD combined subtype group committed a higher number of perseverations and commissions in the CPT-II than LD group; but this also occurred with ADHD inattentive subtype group (they committed more perseverations and commissions than children with LD in that test and in the d2). This fact may also be caused by the mentioned difficulties in ADHD selective and sustained attention. 5) Subjects with ADHD inattentive subtype processed information significantly more slowly than subjects with ADHD combined subtype and subjects with LD in CARAS test, but the results were not meaningful for all the other given tests. Nevertheless, children with ADHD inattentive subtype completed all cancellation tests (EMAV, d2, CARAS, and GLA) significantly more slowly than children with LD; while children with ADHD combined sub- type completed significantly more slowly than children with LD only the d2 test. That is, children with ADHD inattentive subtype are slower when processing information than chil- dren with LD, but they are not slower than children with ADHD combined subtype. 6) ADHD inattentive subtype group had a lower selective attention level than LD group but not lower than ADHD combined subtype group. Scores were statistically meaning- ful between subjects with ADHD inattentive subtype and subjects with LD in all tests but between ADHD inattentive subtype group and ADHD combined subtype group they were meaningful as far as the number of correct answers of the CARAS is concerned. This may be due to the difficulties in selective attention of both groups. 7) ADHD combined subtype group did not have a lower sustained attention level than ADHD inattentive subtype group, but they did have significant differences in the confidence index of the CPT-II in relation to LD group. In the case of children with ADHD inattentive subtype, these differences were significant in relation to LD group in all scores of the CPT-II. Electronic Journal of Research in Educational Psychology, 19(1), 117-144. ISSN:1696-2095. 2021. no. 53 137
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