Journal of Paychaedacational Assessment ‘2008, 21, 3242 PERFORMANCE OF CHILDREN WITH ATTENTION DEFICIT HYPERACTIVITY DISORDER AND ANXIETY/DEPRESSION ON THE WISC-II] AND COGNITIVE ASSESSMENT SYSTEM (CAS) The purpose of this study was to examine dif- ferences in cognitive performance between samples of children diagnosed with ADHD, anxiety and/or depression, and the normative groups on two tests of ability. Matched samples of 25 children diagnosed with Attention Deficit Hyperactivity Disorder were contrasted with 25 children diagnosed with anxiety/depression. Both groups were also compared to the nor mative values for the Wechsler Intelligence Scale for Children, Third Edition (WISC-I) and tests of Planning, Attention, Simultaneous, and Successive cognitive processes from the Cognitive Assessment System (CAS). Children Jack A. Naglieri George Mason University Sam Goldstein University of Utah Jacqueline S. seman George Mason University Adam Schwebach University of Utah with ADHD had lower Planning scores than those with anxiety/depression (6.5 points; effect size of 0.6) and lower Planning scores than the standardization sample (12.7 points, effect size of 0.9). No significant difference was found between children with ADHD, children with anxiety and depression, and the matched, clinical sample on the WISCAIL The findings are commensurate with other studies, suggest- ing that Wechsler scores differentiated the samples minimally but CAS scores appear sen- sitive to the cognitive processing difficulties experienced by children with ADHD. Over the past 25 years clinical as well as epidemiologic studies report the incidence of Attention Deficit Hyperactivity Disorder (ADHD) in children to range between 2% and 15% in the general population (Gaub & Carlson, 1997; Wolraich, Hannah, Baumgaertel, & Feurer, 1998; for review see Goldstein & Goldstein, 1998). Comorbidity of other psychiatric problems with ADHD has been reported to be the rule rather than the exception, presenting over a broad spectrum of conditions (Cuffe et al., 2001; Wilens et al., 2002). In pop- ‘This research project was supported in part by grant #R215K from the U.S. Department of Education, The authors gratefully acknowledge helpful comments from Dr. Johannes Rojahn on an earlier version of this manuscript.ADHD AND ANXIETY/DEPRESSION, 33 ulations referred to clinics for evaluation and treatment, comorbidity of ADHD with other internalizing (Biederman, Faraone, Keenan, & Benjamin, 1992; Rey, 1994), externalizing (Pelham, Gnagy, Greenslade, & Milich, 1992; Szatmari, Boyle, & Offord, 1989), and developmental (Tirosh & Cohen, 1998; Willcutt & Pennington, 2000) disorders is consistently reported, with many affected children presenting with multiple comorbid diagnoses. It has also been suggested that children with ADHD comorbid with specific disorders might actually comprise distinct diagnostic groups (Geller et al., 2002; Jensen, Martin, & Cantwell, 1997). Evaluation of children referred for ADHD typically involves a variety of tests and methods, including clinical interviews, behavior rating scales, classroom observations, and measures of general intelligence (Barkley, 1998). These pro- cedures are often utilized in an effort to address diagnosis beyond simple symp- tom count. Second only to continuous performance measures, intelligence tests have been used in the diagnostic process of ADHD. Nearly 25 years ago, multiple authors suggested that measures of intelligence might measure vigi- lance and concentration (Gardner, 1979), efficient mental tracking (Lezak, 1988), and divided attention (Van Zomeren, 1981). Intellectual measures have been reported to be sensitive to discriminating children with ADHD from those with other disorders as well as controls through the examination of spe- cific subtests (Bowers, Risser, Suchaneck, Tinker, Raemer, & Domoto, 1992; Lufi, Cohen, & Parrish-Plass, 1990). The latter group of authors discussed per- formance on the Wechsler Intelligence Scale for Children-Revised (Wechsler, 1974) Deterioration Index. This method compares the Vocabulary, Information, Object Assembly, and Picture Completion subtests to the Digit Span, Similarities, Coding, and Block Design subtests. According to these authors, the Index correctly classified 59% of children with ADHD and 86% of the non-ADHD group. Findings such as these, however, are not typical of those that have studied the effectiveness of this instrument for ADHD diagnosis. Publication of the Third Edition of the Wechsler Intelligence Scale (Wechsler, 1991) spurred renewed interest in the use of scale and subtest analy- sis to identify ADHD. The WISC-III manual cites a sample of 68 children with ADHD between 7 and 16 years of age similar in ethnic background. The sam- ple had low mean scores on the Freedom from Distractibility factor. Yet the Freedom from Distractibility factor on the Wechsler has not been found to cor- relate well with behavioral observation, parent reports, or teacher reports of ADHD symptoms (Cohen, Becker, & Campbell, 1990). Semrud-Clikeman, Hynd, Lorys, and Lahey (1993) found that subtest performance on intelli- gence measures did not distinguish between children with ADHD and a con- trol group. Anastopoulos, Spisto, and Maher (1994) found that the Freedom. from Distractibility index factor score was significantly lower than either the Verbal Comprehension or Perceptual Organization factor scores for a group of children with ADHD. Nevertheless, when analyzed on an individual basis, the Freedom from Distractibility factor was not significantly lower than the Verbal Comprehension or Perceptual Organization factors for a substantial number of children. Thus, this analysis lacked positive predictive power. Prifitera and34 NAGLIERI ET AL. Dersh (1993) nonetheless reported a different pattern from the standardiza- tion sample for children with ADHD, reflecting lower Freedom from Distractibility and Processing Speed indices in comparison to Verbal Comprehension and Perceptual Organization index scores. Similar results have been reported by Schwean, Saklofske, Yackulic, and Quinn (1993). These authors reported that children with ADHD scored significantly lower than the standardization group on the Freedom from Distractibility and Processing Speed indices. The preponderance of the data, however, supports the opinion of Anastopoulo et al. (1993) that WISC-III factors should not be relied upon for ruling in or out the diagnosis of ADHD. Yet a recent survey of the use of intelligence tests by school psychologists suggests that this continues to be a popular practice (Pfeiffer, Reddy, Kletzel, Schmelzer, & Boyer, 2000) Perhaps the continued popularity and utilization of intelligence tests is responsible for their use in the diagnostic process for ADHD, even though these tests were not designed for this purpose nor have they demonstrated effectiveness in the identification or differentiation of ADHD or, for that mat- ter, any other internalizing or externalizing condition. One reason these tests may have limited utility for detecting the types of cognitive problems that chil- dren with ADHD experience is that they do not measure the cognitive attrib- utes that children with ADHD may share. Barkley (1997, 1998) suggested that ADHD involves problems with behay- ioral inhibition and self-control, which is associated with poor executive con- trol. He, and others (e.g., DuPaul & Stoner, 1994), also concluded that tests of general intelligence are not sensitive to the cognitive problems experienced by children with ADHD. In fact, when referring to the Wechsler scales, Barkley (1998) stated that “no subtest or configuration of subtests is sensitive or specific to the disorder” (p. 297), including the Freedom from Distractibility factor. Given that ADHD, according to Barkley, involves inhibition and control prob- lems and tests that use a general intelligence model were not designed or intended to measure such cognitive activities (Wasserman, 2002), it is logical that tests that use a general intelligence model should provide limited aid in diagnosis of these children. In order to be sensitive to the cognitive problems that some children with ADHD have, a test of ability would have to measure what some have described as executive function or planning. The Planning, Attention, Simultaneous, Successive (PASS) theory described by Das, Naglieri, and Kirby (1994) and Naglieri (1999) uses a cognitive pro- cessing approach that includes, in addition to three other key components, executive or planning processing. This PASS theory, which has been opera- tionalized by the Cognitive Assessment System (Naglieri & Das, 1997a), is an alternative to traditional IQ that takes a multidimensional view of ability based on assessment of cognitive processing rather than general intelligence (Naglieri, 1999). Because of the CAS potential of PASS for assessment of chil- dren with ADHD, researchers have studied this relatively new approach and found that the PASS scales may have utility for identifying the cognitive deficits found in some children who have ADHD. For example, Paolitto (1999) found that the Planning scale helped differentiate children with ADHD from aADHD AND ANXIETY/DEPRESSION 35 demographically matched sample. They reported that the four PASS scales alone yielded sensitivity, specificity, and total classification accuracy rates of 76%, 73%, and 75%, respectively. Similarly, Dehn (2000) found that groups of children diagnosed with ADHD earned significantly lower mean scores on measures of planning. Finally, Naglieri, Salter, and Edwards (2002) compared a sample of regular education children, a group with ADHD, and a sample with reading disabilities. They found that the ADHD group demonstrated a signifi- cant weakness in Planning processing, whereas the children with reading dis- abilities had a significant weakness in Successive processing. The research on PASS conducted so far appears to support the view pro- posed by Barkley (1997, 1998) that ADHD involves problems with inhibition and self-control, which is associated with poor executive control (from PASS, Planning processing). The results of these studies suggest that the CAS may be particularly sensitive to the cognitive problems that some children with ADHD experience and support suggestions by Naglieri (1999) and Sternberg (1999) that the general intelligence model is insufficient for diagnostic purposes. These studies also suggest that the PASS theory may give the user a way to iden- tify a cognitive processing problem that is related to ADHD (planning) and a way to identify when a different cognitive problem related to reading failure (successive) is present. The purpose of this study, therefore, was to examine the performance of children with ADHD using the PASS theory and a traditional test of intelligence to determine if such children might differ from those with anxiety and/or depression. It was anticipated that the children with ADHD would evidence low performance on tests of Planning, but children with anxi- ety and/or depression (an exceptional but not ADHD comparison group) would not necessarily evidence a specific cognitive processing problem because they have emotional rather than cognitive processing problems. METHOD, Participants Subjects were identified through chart review of a large database of children referred to a fee-for-service, tertiary care, university-affiliated neuropsychology clinic. Children were referred for evaluation and treatment primarily by physi- cians, educators, and/or community mental health providers. Children with frank neurologic etiology (e.g., head trauma, stroke, epilepsy) were excluded from this study, as were children with any type of Pervasive Developmental Disorder. Each subject in the database had received a comprehensive neuro- psychological evaluation in the past 3 years, including assessment of intellect, behavior, emotional functioning, and learning. The evaluation consisted of an in-depth history session with parents, the completion of parent and teacher behavioral questionnaires, as well as face-to-face assessment. Either the second author or one of three postdoctoral residents under the supervision of the sec- ond author evaluated all of the children. Diagnoses were provided for all con- ditions on Axis I of the DSM-IV or DSM-IV-TR (American Psychiatric Association, 1994; American Psychiatric Association, 2000). Neither the WISC- III nor the GAS was used in making the diagnosis of ADHD.36 NAGLIERI ET AL, Samples of children with ADHD hyperactive/impulsive type or combined type (n= 25; without other comorbid diagnoses) and anxiety and/or depres- sion (n = 42; without other comorbid diagnoses) were identified from a larger group of children (N= 116). Children with the Inattentive type of ADHD were not included due to theoretical concerns that theirs is a distinetly different con- dition (Barkley, 1997). In order to obtain contrast groups similar on important demographic variables, 25 children from the 42 children with anxiety and or depression were identified to match the ADHD sample on age, race, parental education level, region, community setting, and classroom setting. These sam- ples are similar along these demographic variables (see Table 1). The final sam- ple was comprised of 50 girls and boys who varied in age from 6 through 16 years diagnosed with ADHD (n = 25) or Anxiety and/or Depression (n = 25) The children in the anxiety/depression group included 36% with Dysthymic Disorder (DSM-IV code 300.40), 24% with an Anxiety Disorder Not Otherwise Specified (DSM-IV code 300.00), 20% with an Adjustment Disorder with Anxiety and Depression (DSM-IV code 309.28), 8% with Generalized Anxiety Disorder (DSM-IV code 300.02), 4% with Depression Not Otherwise Specified (DSMLIV code 311.00), 4% with Post Traumatic Stress Disorder (DSM-IV code 309.81), and 4% with Major Depressive Disorder (DSM-IV code 296.20). Table 1 Demographic Characteristics for ADHD and Anxiety/Depression Samples ADHD Anxiety/Depression Age Mean 10.3 10.9 sD 25 23 Sex Male a a Female 4 4 Race White 4 25 Black 0 0 Other 1 0 Region West 4 4 South 1 1 North o 0 Community Urban/suburban 19 a Rural 6 4 Parent education Some college or graduate aa 24 High school graduate 2 1 Some high schoo! 1 0 Not reported 1 0ADHD AND ANXIETY/DEPRESSION, 37 Materials The Wechsler Intelligence Scale for Children—Third Edition (WISC-III; Wechsler, 1991) is a widely used test that measures general intelligence through verbal and nonverbal subtests that are organized into four factorially derived scales (Verbal Comprehension, Perceptual Organization, Freedom From Distractibility, and Processing Speed). The WISC-III is well standardized ‘on a sample of 2,200 children who range in age from 5 to 16 years and are rep- resentative of the United States on a number of key demographic variables. ‘These data were used in this study as a comparison group. The PASS processes were assessed using the Cognitive Assessment System (CAS; Naglieri & Das, 1997a), an individually administered test for children ages 5 through 17 years. The CAS is organized into four scales (Planning, Attention, Simultaneous, and Successive), according to the PASS theory, and a Full Scale standard score. The CAS was standardized on 2,200 persons aged 5 years 0 months to 17 years 11 months who closely matched the United States population on the basis of gender, race, region, community setting, classroom placement, educational classification, and parental education. These data were used in the study as a comparison group. Procedure All participants were administered the entire Wechsler Intelligence Scale for Children (WISC-III) and the standard battery (12-subtest) Das-Naglieri Cognitive Assessment System (CAS) by trained examiners. The tests were given ina specific order (WISC-III in the morning and CAS in the afternoon) as part of a larger neuropsychological battery. Statistical analyses. Results were analyzed utilizing SPSS version 10.0. Standard scores (mean of 100, SD of 15) were obtained from the test manuals and used in all data analyses. Means and SDs were computed for the children with ADHD and the children with anxiety/depression. The significance of the mean differences between the children with ADHD and the children with anx- iety/ depression was examined with a MANOVA, with the child’s diagnosis at the independent variable and the WISC-III standard scores as multiple depend- ent variables. An identical analysis was conducted for the CAS standard scores. Each of the omnibus MANOVAs was examined, and significance was set at p< .05. If the analysis was significant, the univariate analyses of variance (ANOVAs) were then examined. The differences between the mean standard scores earned by children with ADHD, children with anxiety/depression, and the standardized samples were examined by computing d ratios that describe the differences between the chil- dren in standard deviation units (Cohen, 1988) using the formula: (XX) / SQRT [(n, * SD2, + n?* SD2,)/(nj + n2)). These values are described by Cohen as small (.2 to 4), medium (.5 to .7), or large (.8 and above)38 NAGLIERI ET AL. RESULTS WISC.II and PASS standard score means and standard deviations are pro- vided for the two groups in Table 2. Differences between group means are also presented for the four indexes and the Full Seale of the WISC-III and the four PASS scales and the CAS Full Scale score (see Table 8). The WISC-III standard scores for the ADHD sample ranged from 95 on Processing Speed Index to 102 on the Verbal IQ and Verbal Comprehension Index. The Anxiety/Depression group scores ranged from a low of 98 on Processing Speed to a high of 112 on the Verbal Comprehension Index. A one-way MANOVA was conducted to com- pare the WISCIII Index scores for the ADHD and anxiety/depression samples. It was found that the overall effect between groups was not statistically signifi- cant. Table 2 ‘Means, SDs, and Sample Sizes for the Wechsler and CAS Standard Scores ADHD ‘Anxiety/Depression WISC.Il MSD MSD Verbal Comprehension 102.5 15.2 m9 16 Perceptual Organization 99.0 139 1024 154 Freedom from Distractibility 98.5. 16.1 1017153 Processing Speed 95.4 189 981 145 Verbal IQ 102.6 15.2 N02 123 Performance IQ 1011146 024 14.7 Fall Scale 1Q 102.3 13.9 1076 13.3 CAS Planning 873122 938 95 ‘Simultaneous 994 13 10500117 ‘Attention 96.2 14.0 973 9.4 Successive 973° 148 1042 13.0 Full Scale 3.0 135 1002 89 Table 3 Differences between ADHD, Anxiety/Depression, and Normative Value Standard Scores for the WISC-IIl and CAS ADHD vs. ADHD vs. Anxiety/Depression Anxiety/Depression Normative Mean _vs. Normative Mean Wisc. Verbal Comprehension 0.70% 0.17 0.80" Perceptual Organization 023° 0.07 0.16 Freedom from Distractibility 0.20" 0.10 on Processing Speed 0.16 o3i¢ 013 Full Scale 0339" 015 “051 AS Planning, oot 0.85" oat Simultaneous 0.48" 0.04 0.33" ‘Attention 0.09 0.25 0.18 Successive 0.50% 0.18 0.28" Full Scale 0.63"* 0.46" 0.01 Note—d ratio = (Mean 1 - Mean 2)/ SQRT [(m * SD2, + n® * SD®,Vin, + mp). dratios are des. ignated as * = small (.2-.4); ** = medium (.5-.7); and *** = large (.8 and above).ADHD AND ANXIETY/DEPRESSION 39 PASS score means varied from 87 (Planning) to 99 (Simultaneous) for the ADHD sample and from 94 (Planning) to 105 (Simultaneous) for the Anxiety/Depression group. A one-way MANOVA was conducted to compare the PASS standard scores for the ADHD and anxiety/depression samples. It was found that the overall effect between groups was significant, Wilks’s A = .80, F(4, 45) = 2.8, p< .05. The PASS Scale standard scores of the two groups were significantly different for Planning, F (1, 48) = 4.4, p < .05). The effect size was medium (d= .59). There was no significant difference between the two groups on Successive, Attention, and Simultaneous processing. However, the effect sizes were small and medium, respectively, for Simultaneous and Successive processing (d= 48 and d= .50). There was also a large effect size for Planning between the ADHD sample and the standardization sample (d = .85) and a small effect size for Attention (d= .25). DISCUSSION This study, like others before it (e.g., Anastopoulos et al, 1994; Cohen et al., 1990), provides evidence that the general intelligence model used by the WISCIII was not sensitive to the cognitive processing problems experienced by children with ADHD or for that matter anxiety/depression. Although the WISC-III was not developed as a diagnostic tool for these conditions (Wasserman, 2002), it has been widely used by clinicians during ADHD diag- nosis (Pfeiffer et al., 2000). Practitioners evaluating ADHD have relied on the Freedom from Distractibility factor, comparison of WISC-III Index scores (Prifitera and Dersh, 1993), and various subtest profile analysis methods (Kaufman & Lichtenberger, 2000; Lufi et al., 1990) for the Wechsler scales. The results of the current study are consistent with other studies (Anasto- poulos, 1993; Barkley, 1998; Wasserman, 2002), which underscores the limited aid that the general intelligence model provides even when interpretation of subtests, scales, or relationships among scales is used for the identification of children with ADHD or anxiety/depression. The results of this study also support a growing body of literature that sug- gests that the planning component of the PASS theory may offer a way to iden- tify the cognitive processing problems common among many children with ADHD. As expected based on previous research (Dehn, 2000; Naglieri & Das, 1997b; Naglieri et al., 2002; Paolitto, 1999), children diagnosed with ADHD have consistently earned lower mean scores on the CAS Planning scale than children in various comparison groups. These researchers have suggested that children with ADHD appear to perform differently on the PASS scales from normal developing children (Dehn, 2000; Paolitto, 1999) and children with reading disorders (Naglieri et al., 2002). Additionally, the current results sug- gest that children with ADHD also differed from those with anxiety and/or depression. The amount of consistency between the present and previous stud- ies augments the importance of the current findings. The results of this study, especially in combination with those by Dehn40 NAGLIERI ET AL. (2000), Paolitto (1999), and Naglieri et al. (2002) that included samples of children with ADHD, illustrate the difference between the Planning and Attention scales of the CAS. Contrary to suggestions by Kranzler and Keith (1999) that Planning and Attention factors should be combined, this group of research studies illustrates that children who have ADHD often have planning processing problems but not necessarily attentional processing problems. In the present study, the effect size for Planning was very large but not for Attention, which supports the view that Planning and Attention scales should be differentiated. This differentiation has both theoretical and practical impli- cations. The results of this study suggest that the PASS theory may help clinicians identify those children who have cognitive processing deficits that are related to the problems experienced by children who have ADHD. Although the results of this study, along with previous research findings, have suggested that children with ADHD earn low Planning scores, low Planning scores alone are not sufficient for diagnosis but require consistency and integration with a vari- ety of measures to complete the assessment and diagnostic process. This approach demands diagnosis that is based on a variety of sources of informa- tion and is consistent with the recent practice guidelines published by the Committee on Quality Improvement of the American Academy of Pediatrics, Subcommittee on ADHD (2000). The committee urged that the diagnosis of ADHD requires evidence provided by the parent or caregiver regarding the core symptoms of ADHD in various settings, age of onset, duration of symp- toms, and degree of functional impairment. Additionally, a classroom teacher or other school professional must provide evidence regarding the core ADHD symptoms, duration of these symptoms, degree of functional impairment, and associated conditions. Evaluation of a child with ADHD should also include assessment of possible comorbid conditions and careful differential diagnosis, especially the distinction of ADHD from LD. The primary limitation of this study was the number of participants (25 children with ADHD and 25 children with anxiety/depression) and the rela- tively limited demographic population from which they were selected. Although the number of participants included in this study was not large, the children were carefully diagnosed and the groups were carefully matched on demographic characteristics. 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