Elizabeth A. Schaughency University of Oregon and The Oregon Health Sciences University

Neuropsychological Test Performance and the Attention Deficit Disorders: Clinical Utility of the Luria-Nebraska

Neuropsychological Battery-Children's Revision

Elizabeth A. Schaughency

University of Oregon and The Oregon Health Sciences University

Benjamin B. Lahey and George W. Hynd

University of Georgia

John C. Piacentini

Columbia University College of Physicians and Surgeons

Penny A. Stone

St. Jude's Children's Research Hospital Memphis, Tennessee

Paul J. Frick

University of Georgia

The Luria-Nebraska Neuropsychological Battery-Children's Revision (LNNB-CR) was administered to 54 clinic-referred children aged 8-12 yean. Children reliably diagnosed as attention deficit disor- der with hyperactivity were compared with children diagnosed as attention deficit disorder without hyperactivity and with a clinic control group diagnosed with internalizing disorders. Both attention deficit disorder groups were lower than the control group in verbal and Full Scale IQ scores but did not differ from one another. The groups did not differ significantly on any of the LNNB-CR clinical scales, on the right or left hemisphere scores, or on the pathognomonic score using analyses of vari- ance or analyses of covariance with both Full Scale IQ and age as covariates. These findings failed to support the hypothesis that attention deficit disorder, either with or without hyperactivity, is associ- ated with neuropsychological dysfunction as measured by the LNNB-CR.

Historically, the broad childhood disorder referred to in the Diagnostic and Statistical Manual of Mental Disorders (DSM- III; American Psychiatric Association, 1980) as attention defi- cit disorder (ADD) was first labeled minimal brain damage or minimal brain dysfunction (Cruicfcshanck, 1967; Strauss &

Lehtinen, 1947). Terminology such as hyperkinetic reaction of childhood and attention deficit disorder, which avoids the im- plication of neurological etiology, has been used in most subse- quent nomenclatures, but the notion that ADD is a syndrome rooted in brain dysfunction remains the dominant theoretical stance today (Barkley, 1986). Indeed, there is some provocative support for this position.

Lou, Henriksen, and Bruhn (1984) measured brain meta- bolic activity using a regional cerebral bloodflow computed to- pography technique in 11 children with ADD. Subjects in this group appeared to exhibit ADD with hyperactivity (ADDH), although their subject description included "temper that se- verely hampered scholastic achievement," which suggests that the children may have also exhibited conduct disorder or learn- ing disabilities. Compared with control subjects, ADD subjects showed consistently lowered metabolic activity in the frontal

This article is based on a doctoral dissertation conducted by Elizabeth A. Schaughency. We gratefully acknowledge the assistance of the staff of the Georgia Children's Center for their assistance in data collection.

Correspondence concerning this article should be addressed to Elizabeth A. Schaughency, Department of Psychology, University of Or- egon, Eugene, Oregon 97403.

cortex and related subcortical structures. Similarly, Zametkin (1986) reported that a group of parents of children with ADDH who had current ADDH themselves showed on position emis- sion tomography reduced metabolism in the right anterior fron- tal region.

Some of the metabolic studies of brain functioning in ADDH seem to implicate a deficient frontal-subcortical arousal/inhibi- tory system. This idea, of course, has long been the focus of psychophysiological studies of ADDH children (e.g., Dykman, Ackerman, Clements, & Peters, 1971; Dykman, Ackerman, &

McCray, 1980). More recent behavioral clinical studies seem to support this perspective as well. For example, McKay et al.

(1985) reported a relevant case study: They provided descrip- tions of a child's behavior and performance on the Luria- Nebraska Neuropsychological Battery-Children's Revision (LNNB-CR; Golden, 1981) before and after neurosurgery. The surgery required removal of a tumor beneath the hypothala- mus, which involved retraction of the frontal cortex for over 7 hr. Evaluations using electroencephalography, magnetic reso- nance imaging, and computed tomography (CT) techniques re- vealed postoperative damage to the frontal cortex that was ac- companied by declines on 9 of the 11 clinical scales of the LNNB-CR; by increases in inattentiveness, distractibility, impul- sivity, and aggression; and by declines in school grades.

Chelune, Ferguson, Koon, and Dickey (1986) also provided evidence of frontal lobe dysfunction in children with ADDH.

Using a number of behavioral measures, they found that ADDH children, when compared with a control population, performed particularly poorly on the Wisconsin Card Sorting

112

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Task, a task that requires conceptual set shifting or inhibition.

Inhibition is a behavior long associated with frontal lobe func- tioning (Milner, 1963). These and earlier studies, reviewed by Werry (1979), suggest that neurological dysfunction may play an etiological role in ADD and, particularly, in ADDH. Indeed, the entire literature on the treatment of ADD using stimulants can be interpreted as supporting the notion that dysfunctional monoaminergic systems underlie ADD (Zametkin & Rapa- port, 1986).

The present study tested the hypothesis that children with a clinical diagnosis of ADD exhibit neurological dysfunction as measured by the LNNB-CR. Because of recent evidence that the DSM-III subtypes of ADD (with and without hyperactivity) differ on behavioral measures (Carlson, 1986; Lahey, Schaugh- ency, Frame, & Strauss, 1985; Lahey, Schaughency, Strauss, &

Frame, 1984), separate groups were formed of children given diagnoses with (ADDH) and without (ADD) hyperactivity.

Based on the previous research, it was predicted that (a) chil- dren with ADDH would exhibit deficits and (b) ADD and ADDH would differ in their neuropsychological functioning as measured by the LNNB-CR.

Method Subjects

The sample was composed of 54 clients of the Georgia Children's Center (GCC). The GCC provides outpatient psychological and neuro- psychological assessment services to elementary- and middle-school children from the slate of Georgia. Referral sources of the GCC include parents and physicians as well as agencies such as the school system and a state center for children with severe emotional and behavior disorders.

Clients are from the range of socioeconomic strata, although the major- ity are of middle and lower socioeconomic status as measured by the Myers and Bean (1968) index. Our client population was predominantly male, White, and ranged from 8 to 12 years of age. Children who achieved a Full Scale 1Q of less than 70 on the Wechsler Intelligence Scale for Children-Revised (wisc-R; Wechsler, 1974), exhibited psy- chotic behavior, or had a history of neurological disorder were excluded.

Subject goups included (a) ADD children, (b) ADDH children, and (c) a control group of clinic-referred children who did not meet the DSM-III diagnostic criteria for ADD or ADDH. Four of the children in the control group received no DSM-III diagnosis. The remaining 20 children in the control group received a variety of diagnoses, including overanxious disorder, separation anxiety disorder, major depression, conduct disorder, dysthymic disorder, and obsessive-compulsive disor- der.

The formation of diagnostic groups was based on information ob- tained from a structured diagnostic interview with parent, teacher, and child, using the children's version of the Schedule for Affective Disor- ders and Schizophrenia (K-SADS; Puig-Antich & Chambers, 1978), and from parent and teacher rating scales. First, one diagnostician con- ducted the K-SADS interview, which was observed from behind a one- way mirror by a second diagnostician. Next, both diagnosticians re- viewed the results of parent and teacher rating scales and the results of the teacher interview conducted at the school; diagnosticians then made independent DSM-III diagnostic decisions based on all available infor- mation, compared results, and resolved any discrepancies to create the final experimental diagnoses. Interdiagnostician agreement was com- puted using Cohen's kappa (Spitzer, Cohen, Fleiss, & Endicott, 1967) to determine the reliability of subject diagnoses. From a total of 89 con- secutive cases, 54 subjects met the selection criteria.

Measures

Standardized interview. The children's version of the Schedule for Affective Disorders and Schizophrenia (K-SADS; Puig-Antich & Cham- bers, 1978) is a structured diagnostic interview administered separately to the child and his or her parent The version used was a modification designed to cover all symptoms of the following DSM-III diagnoses:

conduct disorder (all subtypes), attention deficit disorder with and with- out hyperactivity, overanxious disorder, separation anxiety disorder, de- pression, dysthymic disorder, obsessive-compulsive disorder, and schizophrenia.

Rating scales. Parent- and teacher-completed questionnaires derived from previous factor analytic work were used to provide additional taxc- metric information about a variety of behavior and school adjustment problems, including behaviors characteristic of attention deficit disor- der with and without hyperactivity, conduct problems, and anxiety. Par- ent questionnaires were the Conners Parent Rating Scale (CPRS; Con- ners, 1970) and the Revised Behavior Problem Checklist (RBPC; Quay

& Peterson, 1983); teachers completed the parallel Conners Teacher Rating Scale (CTRS; Conners, 1969), the Children's Behavior Rating Scale (CBRS; Neeper & Lahey, 1986), and the SNAP Checklist (Pelham, Atkins, Murphy, & White, 1981). Diagnosticians reviewed these rating scales both quantitatively for significant elevations on factor scores con- taining items of relevance to particular diagnostic categories and quali- tatively for the endorsement of specific symptom items.

Cognitive and neuropsychological measures. All subjects were ad- ministered the WISC-R (Wechsler, 1974) and the complete LNNB-CR (Golden, 1981). The LNNB-CR is a newly developed instrument de- signed to provide a comprehensive assessment of neuropsychological functioning in children 8-12-years old. It is essentially a downward ex- tension of the Luna-Nebraska battery for adults. The items in the Luria batteries are based on Luna's developmental neuropsychological theo- ries (Luria, 1980), as presented by Christensen (1973). The LNNB-CR has been found to discriminate brain damaged from non-brain-dam- aged groups and has generally been found to discriminate learning dis- abled children from normal children (Hynd, Snow, & Becker, 1986). In addition, it has been found to be specifically sensitive to frontal lobe dysfunction in a case bchaviorally manifesting itself as inattention, im- pulsivity, and distractibility (McKay et al., 1985). The LNNB-CR con- sists of 11 subtests: Motor Skills, Rhythm, Tactile, Visual, Receptive Speech, Expressive Language, Writing, Reading, Arithmetic, Memory, and Intelligence (Golden, 1981). Total raw subtest scores are converted to age-adjusted rscores that have a mean of 50 and a standard deviation of 10.

Procedure

Subjects were individually evaluated at GCC as part of a comprehen- sive clinical evaluation. The K-SADS interviews, parent-rating scales, and WISC-R were administered during a full-day assessment session.

The LNNB-CR was administered during a second assessment session, held within 4 days of the first session, by neuropsychological examiners blind to the diagnostic classifications or referral reasons of subjects.

Teacher report measures were obtained during a school visit held prior to the child's evaluation at GCC.

Results

Cohen's kappa (Spitzer et al., 1967) for the diagnosis of

ADDH was .80 and for ADD was .77. Kappa for the diagnosis

of any anxiety disorder (overanxious disorder, separation anxi-

ety disorder, obsesssive-compulsive disorder) was .80 and for

any depressive disorder (major depressive episode or dysthymic

disorder) was .67. All coefficients were above the criterion for

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Table 1

Demographic Characteristics of Subjects

ADDH group ( n = 1 4 )

Variable

Age (years)

WISC-R

Full Scale IQ Verbal IQ Performance IQ Socioeconomic

status index Sex (% male) Race (% White)

M 9.20.

96.08

h

97.52

b

94.84

3.48 83.33 87.50

SD 1.07

14.25 15.72 12.93

1.50

ADD group (« = 14)

M 10.94s

96.64

b

96.64t 97.43

3.29 92.86 71.43

SD 1.08

14.46 15.47 16.00

1.14

Control group ( n = 1 6 )

M 9.68."

109.00.**

110.31.*

105.50

2.87 75.00 100.00

SD 1.69

16.71 13.19 18.74

0.99

Note. ADD = attention deficit disorder, ADDH = attention deficit dis- order with hyperactivity. WISC-R = Wechsler Intelligence Scale for Chil- dren-Revised. Means with different subscripts differed significantly at thep < .05 level.

•p<.05. "/x.OOl.

adequate reliability of .60 recommended by Hartmann (1977) and were near or above the criterion of .70 recommended by Spitzer, Forman, and Nee (1979).

Demographic characteristics of the three groups are pre- sented in Table 1. Comparisons of the three groups showed that they did not differ at the .05 level in sex, race, or socioeconomic status but that they did differ significantly in age, F(2, 53) = 8.31, p < .001; in Full Scale IQ, f\2, 53) = 4.06, p < .05; and in verbal IQ, F(2,53) = 4.37, p < .05. Duncan's multiple range

tests revealed that the ADD group was significantly older than both the ADDH and the control groups, which did not differ from one another. In addition, the control group was higher than both the ADD and the ADDH groups on Full Scale and verbal IQ, but the latter two groups did not differ from one an- other on these measures.

The mean LNNB-CR scores for the three groups are presented in Table 2. No significant differences at the .05 level were found using analyses of variance (ANOVAS) for any of the clinical or special scales, even when the alpha level was not adjusted to control the experimentwise error rate.

Because of the statistically significant differences in age and Full Scale IQ, these variables were tested as potential covariates.

Full Scale IQ was found to be moderately correlated with all LNNB-CR variables, and age was weakly but significantly corre- lated with four of these scales (see Table 2). An analysis of covar- iance (ANCOVA) was conducted for each dependent variable us- ing Full Scale IQ as the covariate due to this strong pattern of correlations. All but one of these ANCOVAS failed to reach statis- tical significance, even when the alpha level was unadjusted to control the experimentwise error rate. The ANCOVA for the Memory scale was significant at the unadjusted .05 level, F[3, 53) = 3.38, p < .05, but subsequent Duncan's multiple range tests revealed that this finding was based on a significant differ- ence between the ADD and the ADDH groups (with the ADDH group poorer) rather than on a significant difference between ADD or ADDH groups and the control group. Because the Tac- tile, Reading, Arithmetic, and Memory scales were found to be correlated with age as well as IQ, ANCOVAS using both Full Scale IQ and age as covariates were also conducted for these scales, with none of these tests reaching significance at the unconnected .05 level.

Table 2

Unadjusted LNNB-CR Scores ami Correlations With Age and Full Scale Intelligence

ADDH group (n = 25)

Variable

Subtest Motor Skills Rhythm Tactile Visual

Receptive Speech Expressive Speech

Writing Reading Arithmetic Memory Intelligence Mean raw score

Left hemisphere Right hemisphere Pathogonomic

M

51.71 60.38 59.21 52.75 58.91

57.46 61.42 60.58 63.38 59.21 58.46

2.92 2.46 9.12

SD

11.63 13.02 11.52 8.69 14.33

16.63 18.82 18.81 17.85 13.17 11.34

2.34 2.32 5.35

ADD group

M

50.71 53.21 56.21 54.78 61.<4

51.86 60.93 58.57 56.36 51.36 53.36

4.64 1.79 8.86

SD

9.65 13.91 12.69 8.89 15.77

16.92 13.84 15.05 14.76 11.02

9.88

8.00 1.67 6.00

Control group

M

46.69 51.81 50.50 48.81 52.31

50.38 50.88 51.88 54.69 51.13 52.12

2.19 1.69 6.25

SD

7.07 11.62 9.90 8.15 13.29

12.27 8.49 11.90 14.52 11.59 10.78

2.01 1.30 4.58

P(2, 54)

1.27 2.56 2.81 1.93 1.72

1.16 2.64 1.45 1.64 2.85 1.94

1.19 0.97 1.55

Correlation withFSIQ

-.34"

-.47"

-.42"

-.61"

-.52"

-.54"

-.51"

-.44"

-.56"

-.63"

-.63"

-.31*

-.46"

-.70"

Correlation with age

-.27*

-.30*

-.26*

-.27*

Note. ADD = attention deficit disorder, ADDH = attention deficit disorder with hyperactivity. LNNB-CR = Luria-Nebraska Neuropsychological Battery-Children's Revision; FSIQ = Full Scale IQ.

*p<.05. **;><.001.

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Discussion

These results failed to support the hypothesis that the atten- tion deficit disorders, particularly ADD with hyperactivity, would be associated with significantly deviant scores on a stan- dardized neuropsychological test battery, the LNNB-CR. As such, they do not lend support to the notion that neurological dysfunction plays an etiological role in either ADD or ADDH.

In addition, despite the somewhat elevated scores on most scales of the LNNB-CR for the ADDH children, no support was generated for the notion that ADD or ADDH are distinguish- able syndromes when compared on neuropsychological func- tioning to a clinical control population composed primarily of internalizing disorders.

For two reasons, however, the present findings do not consti- tute a strong argument against neurological theories regarding ADD. First, the experimental power to detect possible true differences in performance on the LNNB-CR is reduced by small sample size. Second, the failure to reject the null hypothesis (i.e., that children with ADD and ADDH do not show relative deficits on the LNNB-CR) also cannot, of course, be interpreted as evidence that the diagnostic groups do not diifer in their per- formance on all neuropsychological measures. That is, the fail- ure to detect differences may reflect deficiencies in the method- ology used to assess neuropsychological functioning rather than a true absence of differences.

The present findings suggest that significant elevations in scores on the present version of the LNNB-CR are not typically found to be associated with the attention deficit disorders.

Therefore, from a clinical perspective, it should not be expected that the LNNB-CR will be useful in the diagnosis of these disor- ders.

There may be several reasons for these findings. Perhaps most important, the construct validity of the LNNB-CR remains an issue (Hynd et al., 1986). For example, Snow and Hynd (1985) examined the across-scales factor structure of the LNNB-CR with learning disabled children. They found three factors, a Ver- bal Intelligence factor, a General Academic factor, and the weakest factor, a Sensory-Motor factor.

The present results of significant correlations between intelli- gence and performance on the LNNB-CR are consistent with these findings, and ANCOVAS were conducted to control for the contribution of intelligence to LNNB-CR performance in the present analyses. Although significant differences were found between groups on Full Scale and verbal IQ, it should be noted that the Full Scale and verbal IQ scores of the ADD groups fell within the average range, whereas the mean Full Scale and ver- bal IQ scores of the control gorup approached the high average range, which suggests that this finding might be an artifact of a high-functioning control group.

In addition, the kinds of deficits suggested by children with ADD are consistent with dysfunctional frontal lobe develop- ment. The LNNB-CR was constructed to assess the neuropsy- chological abilities of children aged 8-12 years. In designing the LNNB-CR, items were eliminated from Luna's examination (Christensen, 1973) that were believed to assess frontal lobe functioning based on the hypothesis that those behaviors associ- ated with frontal lobe functioning did not develop in children until adolescence or later (Golden, 1981).

Recent research has proved this assumption to be invalid be- cause behaviors associated with frontal lobes show a variable but stepwise development in normal children between the ages of 6 and 12 years (Becker, Isaac, & Hynd, 1987; Passler, Isaac,

& Hynd, 1985), a finding more consistent with Luria's (1980) formulation of the maturation of the frontal cortex. Conse- quently, many of the items that may have assessed abilities perti- nent to the hypotheses examined in this study may have been eliminated in the test construction phase. In conclusion, al- though it appears that ADD is not associated with neurological dysfunction as assessed by the LNNB-CR, several factors suggest that more focused assessment of frontal lobe development may have yielded different results.

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Received April 6,1987 Revision received February 17,1988

Accepted April 15, 1988 •

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