[Downloaded free from http://www.new.ejpsy.eg.net on Wednesday, August 3, 2022, IP: 179.251.199.

75]

Original article 139

Electrophysiological and psychophysical testing in children with

attention-deficit hyperactivity disorder
Shereen D. Abo Hammera, Reham M. Lasheenb, Mona A. Kotaitb,
Reham A. Amera
a
Department of Neuropsychiatry,
b
Audiovestibular Medicine, Department of
Audiology Otolaryngology, Faculty of Medicine,
Tanta University, Tanta, Egypt
Correspondence to Shereen D. Abo Hammer,
MD, Department of Neuropsychiatry, Faculty of
Medicine, Tanta University, Tanta, 31527,
Egypt. Tel: 0020403337544;
fax: 0020403407734;
e-mail: ashere2009@gmail.com
Received: 23 January 2021
Revised: 20 February 2021
Accepted: 9 April 2021
Published: 28 September 2021
Egyptian Journal of Psychiatry 2021,
42:139–147
Background
Multiple techniques are used for understanding, determining the real
pathophysiological process, and treating attention-deficit hyperactivity disorder
(ADHD). The aim of this study was to assess cortical auditory evoked potentials
(CAEP) as well as P300 in children with ADHD, and its correlation with
neurocognitive tests [Wisconsin card sorting test (WCST), digit span (DS), and
Stroop test (ST)].
Patients and methods
A prospective cross-sectional study was performed on 103 children, who were
divided into two groups: 53 children newly diagnosed with ADHD (according to
Diagnostic and statistical manual of mental disorders, 5th ed.), who were drug
naïve, and 50 normal control matched for age, sex, educational and social level,
and intelligence quotient. All participants had detailed psychiatric history,
intelligence quotient Wechsler intelligence scale for children (WICS), Conners’
parent/teacher rating scale abbreviated form for ADHD, neuropsychological tests
(WCST and Stroop), pure tone audiometry, speech audiometry using GSI 61
audiometer, immittance test using interacoustic, and sustained attention test
using auditory continuous performance test (ACPT) P300.
Results
Children with ADHD had more perseverative responses, more preservative errors,
and more failure to maintain set (FMS) than controls in WCST, with a significant
difference among study groups. ADHD group was impaired in digit span backward
and ST than control group. P300 amplitude and latency were significantly different
between the study groups. In comparison with the control group, statistical delayed
latencies of significance were observed in ADHD between all CAEP components. A
significant difference for P1-N1 amplitude was observed among different
components of CAEP, and no significance was observed regarding P2-N2
amplitude. ACPT showed a significant difference between both groups, with
higher percentage in control group. Positive correlations were observed
between P300 amplitude and WCST (perseverative error), P300 amplitude and
ST results, and N2 latency and DS backward.
Conclusion
Assessment of CAEPs and P300 in children with ADHD, as well as their correlation
with neurocognitive tests (WCST, DS, and ST), is crucial in diagnosis and
management.

Keywords:
ACPT, attention-deficit hyperactivity disorder, P300, Stroop, Wisconsin card sorting test
Egypt J Psychiatr 42:139–147
© 2021 Egyptian Journal of Psychiatry
1110-1105

on many services like education, social, and clinical

Introduction
ones owing to ADHD, and lifetime impairment
Attention-deficit hyperactivity disorder (ADHD) is the
has occurred in some of them (Sergeant et al., 2002).
commonest neurological and developmental childhood
disorder manifested by characteristic symptoms of
The use of new tools for diagnosis, with neurological
degrees of decreased attention, increased activity, and
and psychological evaluation directed toward school-
impulsivity. With an ∼3–7% prevalence and 30–40%
age children, is essential. This is mainly true for
adulthood persistence rate, it became an important
executive function (EF) measure tools. The Auditory
medical challenge because of its effect on children’s
socioeducational life (Polanczyk et al., 2015).
This is an open access journal, and articles are distributed under the terms
of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0
The disease is manifested by characteristic age-unrelated
License, which allows others to remix, tweak, and build upon the work
symptoms of decreased attention, motor restlessness, and non-commercially, as long as appropriate credit is given and the new
impulsive behavior. Major financial costs were placed creations are licensed under the identical terms.

© 2021 Egyptian Journal of Psychiatry | Published by Wolters Kluwer - Medknow DOI: 10.4103/ejpsy.ejpsy_12_21
[Downloaded free from http://www.new.ejpsy.eg.net on Wednesday, August 3, 2022, IP: 179.251.199.75]
140 Egyptian Journal of Psychiatry, Vol. 42 No. 3, September-December 2021
Continuous Performance Test and cortical auditory
evoked potentials (CAEPs) are computerized tests
developed to measure selected EF skills in children
(Marquardt et al., 2018).
Throughout the previous 20 years, the psychotic
diseases’ biological substrates were investigated
using electrophysiology. The advantage of
electrophysiological procedures is the ability to scan
mental processes in real time without invasion.
Moreover, fast neural actions and oscillations with
high frequency are captured by their extremely high
time resolution, and this makes scanning of functional
brain possible through source analysis of maps of high
density (Blakey et al., 2018).
In the few years, the processing of information and
neurological states assessment will be performed
mainly using electrophysiological methods, which are
promising methods for assessment of causes and
predictors of response to clinical treatment
(Kamarajan and Porjesz, 2015).
In ADHD cases, changed event-related potential (ERP)
has been noted, which reflects neurocognitive
dysfunction related to attention domains, inhibitory
control, and processing of reward and data. As a result
of ERP findings, different stages of sensory and cognitive
functions have been shown to be processed in a different
manner in children experiencing ADHD. In addition, a
different form of component of ERP was observed
between subtypes of ADHD. ERP component was
used as a predictor for treatment response (Marquardt
et al., 2018).
Auditory P300 is a positive ERP component
happening nearly 300 ms following target stimuli. It
is a selective attention neurological and physiological
correlate, working memory, and novelty detection. The
P300 is a late ERP component that has been suggested
to assess functions of execution and attention,
including the function of the memory of working,
classifying of event, attentional resource allocation,
and attentional reorientation (Polich, 2007).
The P300 amplitude identifies the attention allocation
effort and correlates with the gray matter volume
contribution to wave, amplitude of P300 could be
utilized to discern ADHD subtypes, and it was
believed to be a neurophysiological indicator of
alerting deficits (Heinrich et al., 2014).
Sangal and Sangal (2006), demonstrated that the
topography of P300 could anticipate stimulant
efficacy, and that P300 amplitude is related to
response to atomoxetine, whereas the P300 latency
reflects the processing speed of stimulus
discrimination.
This work aims to assess CAEPs as well as P300 in
children with ADHD, and its correlation with
neurocognitive tests [Wisconsin card sorting test
(WCST), digit span (DS), Stroop test (ST)].
Patients and methods
This cross-sectional prospective study was conducted on
103 children, who were divided into two groups: first
group was 53 children with ADHD (18 females and 35
males) newly diagnosed with ADHD, who were drug-
naïve children, aged between 8 and 14 years. The
ADHD diagnosis was according to the Diagnostic and
statistical manual of mental disorders, 5th ed.. They were
matched with 50 normal controls (29 female and 21
male) with normal hearing, with no history of attention
deficit or hyperactivity, with normal school performance
and matched with patients for age, sex, educational and
social level, and intelligence quotient (IQ).
All attendants of the outpatient child and adolescent
psychiatry clinic in a Psychiatry and Neurology Center
were recruited. The study was conducted in the
Department of Neuropsychiatry and Department of
Audiovestibular Medicine Units, Tanta University
Hospitals.
The idea of the research was explained in detail to the
participants. Patients who agreed to participate signed an
informed consent. The participation was voluntary, and
the patients could refuse to continue the study at any time
without penalty or loss of advantages. Every patient had a
code number. Results of this research were used only for
scientific purpose. The duration of the study ranged from
6 months, in the period from March 2018 to September
2018. The trial has an approval from the medical ethical
committees of Faculty of Medicine, Tanta University.
An informed consent was taken from the caregivers of all
participants.
Inclusion criteria
The following were the inclusion criteria:
(1) Children aged 8–14 years old.
(2) IQ above 80.
(3) Normal hearing sensitivity with no history of
hearing loss, ear discharge, or ear disease.
(4) Normal middle ear function.
(5) Children ADHD who were drug naive.
[Downloaded free from http://www.new.ejpsy.eg.net on Wednesday, August 3, 2022, IP: 179.251.199.75]
ADHD electrophysiological & psychophysical tests Hammer et al.
Exclusion criteria
The following were the exclusion criteria:
(1) Children with mental retardation.
(2) Children with hearing loss or ear disease that
affects the hearing function.
(3) Children with serious neurological, psychiatric, or
metabolic disorders that affect cognitive and EFs.
All the participants were subjected to the following:
(1) Detailed psychiatric history from parents or
caregiver.
(2) Assessment of IQ: Wechsler intelligence scale for
children (WICS) to measure IQ.
(3) A semi-structured interview in the form of Kiddie
Schedule of affective disorders and schizophrenia-
present and life time version to confirm the
diagnosis of ADHD.
(4) Conners’ parent/teacher rating scale abbreviated
form for ADHD symptoms.
(5) Neuropsychological tests measuring EFs (WCST
and Stroop).
(6) Basic audiological assessment, including
audiometry of pure tone and audiometry of
speech using a GSI 61 audiometer.
(7) Immittance test using interacoustic.
(8) Sustained attention test using auditory continuous
performance test (ACPT).
(9) Electrophysiological test both CAEPs using tone
and speech stimuli and P300 testing using oddball
paradigm.
The participants of the study were recruited from child
and adolescent psychiatric outpatient by the first and
last investigators. Detailed psychiatric history was
taken from the parents or the caregiver of children,
with clinical evaluation of ADHD according to
Diagnostic and statistical manual of mental disorders,
5th ed., and then Kiddie Schedule of affective
disorders and schizophrenia-present and life time
version was applied to ensure diagnosis and exclude
any psychiatric comorbidity. IQ was evaluated by a
trained psychologist, and Conners’ parent rating scale
was completed, and then the children who fulfilled the
inclusion criteria of the research were referred to
Audiovestibular Medicine Unit to be assessed the
second and third investigator, for P300 and CAEPs.
Then the cases and control were referred back to
neuropsychiatry department for further assessment of
their EF in a separate session. The computerized version
of WCST was applied for all participants by the first
instigator, whereas computerized ST was applied by the
141
last investigator, and DS was already a subset of IQ
assessment, which was previously assessed.
P300 and CAEPs were recorded from both control and
study groups by Smart EPs of intelligent hearing system.
Regarding P300, it was recorded in the oddball paradigm
using two kinds of stimuli (speech and tone) that were
presented in two paradigms. In the first paradigm,
1000 Hz and 2000 Hz were utilized as the standard
and deviant stimuli simultaneously, whereas in the
second paradigm, /ga/ stimuli were used as a standard
stimulus and /da/ stimuli were utilized as the deviant
stimulus using Smart EPs of Intelligent hearing system.
The two stimuli types were presented at one second
rate of repetition, 15% deviant probability, and at 50
dBSL (re PTA average at 500, 1000, 2000, and
4000 Hz) monaurally to each ear in the two groups
via an insert-phone. Four electrodes were used to
record P300, which placed at Fz (?ve electrode), Fpz
(ground electrode), and M1 and M2 (mastoids) as
reference electrodes according to side of stimulation.
The child was asked to count the deviant one /da/.
P300 was identified as the most robust positive wave
around 300 ms following N1-P2 complex, and both
absolute latency and amplitude were measured.
CAEPs components were recorded using Speech
stimuli CV syllable /da/ using the same electrode
montage for P300. The settings of filter (recording
bandwidth) were 1–30 Hz (low pass 30 Hz and high
pass 1 Hz). Stimuli have been monaurally presented
to both ears via an ER3A insert phone beginning with
ear of right side. The stimulus was presented at 90
dBnHL. All patients and their parents were informed
of the test procedure.
During acquisition of the test, each patient was informed
to be calm and lie down on a comfortable coach. They
were advised at the same time not to focus on the
presented stimuli. For identification of the response,
the response consisted of a positive wave at about
50 ms (P1), a large negative wave at about 80–100 ms
(N1), and a subsequent positive wave at about
180–200 ms (P2). Classically, the N2 is a negativity
following the P2. Calculation of the latency and
amplitude (peak to peak or baseline to peak) of each
wave was done as follows: the P1-N1-P2 latency, which
was the time from stimulus onset to the first positivity
(P1), first negativity (N1), a subsequent positive wave at
about 180–200 ms (P2), and a second negativity (N2).
The P1-N1-P2 amplitude that was usually measured
from the trace’s zero voltage to the most positive or
negative trough in that trace.
[Downloaded free from http://www.new.ejpsy.eg.net on Wednesday, August 3, 2022, IP: 179.251.199.75]

142 Egyptian Journal of Psychiatry, Vol. 42 No. 3, September-December 2021

Statistical analysis The mean IQ of ADHD group was 97.5, whereas it

Statistical analysis was done by SPSS v25 (IBM,
Chicago, Illinois, USA). Quantitative parametric data
were presented as mean and SD and were analyzed by
unpaired Student t test. Quantitative nonparametric data
were presented as median and interquartile range and
were analyzed by Mann–Whitney test. Qualitative data
were presented as number and percent and were
compared by χ 2. Pearson correlation was done
between two variables. A two-tailed P value less than
0.05 was considered statistically significant.
Results
The mean age of patients with ADHD was 10.9 years
and for control was 11.1 years, with no significant
difference between the two groups regarding age.
Males were more than female in ADHD group 66%
(n=35), whereas females were 42% (n=21) (Table 1).
was 99.2 for controls, with no significant difference.
Regarding Conners’ parent rating scale, a significant
relation was observed among ADHD group and
control (P<0.001).
In WCST, perseverative responses could differentiate
between control and ADHD children, as children with
ADHD had made more perseverative responses than
controls, with a significant relation among the two
groups (P<0.05). Regarding perseverative errors, they
could differentiate control group and ADHD group
and the performance of ADHD group differed
significantly from controls (P<0.05). In failure to
maintain set parameter, children with ADHD also
failed to maintain set in comparison with normal
control, with a statistically significant difference
(P<0.05) (Table 2).

Table 1 Demographic characteristics of the studied group

Groups P value
ADHD (N=53) Control (N=50) Test statistic
Age
Mean 10.9 11.1 t=0.933 0.353
SD 1.6 1.4
Sex [n (%)]
Female 18 (34.0) 29 (58.0) χ 2=5.99 0.014*
Male 35 (66.0) 21 (42.0)
ADHD, attention-deficit hyperactivity disorder. *Significant at P value less than 0.05.

Table 2 Cognitive functions assessment among studied group

Groups P value
ADHD (N=53) Control (N=50) t
IQ
Mean 97.5 99.2 1.03 0.305
SD 9.6 7.3
Conners’ parent rating scale
Mean 21.7 5.1 38.27 <0.001*
SD 2.7 1.6
WCST (PE)
Mean 14.5 8.0 10.14 <0.001*
SD 4.6 0.9
WCST (PR)
Mean 23.7 11.6 16.22 <0.001*
SD 5.2 1.5
WCST (FMS)
Mean 5.8 1.5 20.84 <0.001*
SD 1.5 0.3
DSB
Mean 2.8 5.3 18.15 <0.001*
SD 0.5 0.9
Stroop test
Mean 1.53 0.90 17.34 <0.001*
SD 0.25 0.08
ADHD, attention-deficit hyperactivity disorder; DSB, digit span backward; FMS, failure to maintain set parameter; IQ, intelligence quotient;
PE, perseverative errors; PR, perseverative responses; WCST, Wisconsin card sorting test. *Significant at P value less than 0.05.
[Downloaded free from http://www.new.ejpsy.eg.net on Wednesday, August 3, 2022, IP: 179.251.199.75]

ADHD electrophysiological & psychophysical tests Hammer et al. 143

DS backward, which reflects working memory,
was significantly different among clinical group and
control group. ADHD group could repeat fewer
digits backward than the control group (P<0.05)
(Table 2).
ST, the time needed to name the color of the word, was
significantly different among children with ADHD
compared with the normal control, as children with
ADHD needed more time to read the name of the
color (P<0.05) (Table 2).
P300 in response to speech stimuli using oddball
paradigm was recorded for both groups; both P300
absolute latency and amplitude were measured. P300
absolute latency showed delay in ADHD in
comparison with the control group. This delay was
statistically significant, as shown in Table 3. Regarding
P300 amplitude, statistically significant differences
were found between the two groups (Table 3).
CAEP components were recorded using da stimuli.
Regarding wave detectability, all CAEP waves

Table 3 Results of P300 and cortical auditory evoked potential latency and amplitude using both speech and tone stimuli as well
as ACPT among study and control groups
Groups
ADHD (N=53) Control (N=50) Test statistic P value
Speech
P300 latency
Mean 371.28 328.52 13.94 <0.001*
SD 13.00 17.62
P300 amplitude
Mean 1.82 3.25 17.38 <0.001*
SD 0.47 0.36
Latency
P1
Mean 101.1 60.5 8.56 <0.001*
SD 33.1 9.5
N1
Mean 176.5 108.7 9.75 <0.001*
SD 47.5 17.1
P2
Mean 232.2 184.3 6.15 <0.001*
SD 50.7 24.4
N2
Median 320.0 233.0 7.44 <0.001*
IQR 280.0–340.0 210.0–246.0
Mean rank 73.27 29.45
Amplitude
P1
Median 1.66 3.65 3.67 <0.001*
IQR 1.52–3.00 2.10–6.00
Mean rank 41.51 63.12
N1
Mean 5.19 6.06 1.14 0.254
SD 3.56 4.10
P2
Median 1.99 5.75 6.33 <0.001*
IQR 1.24–2.11 2.30–10.10
Mean rank 33.91 71.18
N2
Median 1.68 5.83 7.11 <0.001*
IQR 1.30–3.85 4.00–9.01
Mean rank 31.68 73.54
ACPT
Mean 74.9 96.9 16.67 <0.001*
SD 9.1 2.9
ACPT, auditory continuous performance test; ADHD, attention-deficit hyperactivity disorder; IQR, interquartile range. *Significant at P value
less than 0.05.
[Downloaded free from http://www.new.ejpsy.eg.net on Wednesday, August 3, 2022, IP: 179.251.199.75]

144 Egyptian Journal of Psychiatry, Vol. 42 No. 3, September-December 2021

(P1N1P2N2) were 100% detectable for both groups.
Regarding wave latency, all CAEP components
presented delayed latencies of significance in ADHD
in comparison with the control group. Different
amplitude components of CAEP were measured in
the two groups, with difference of statistical
significance for P1-N1 amplitude. On the contrary,
a nonsignificant relation was found among both study
groups regarding P2-N2 amplitude (Table 3).
Auditory continuous performance test was recorded for
both groups, and there was a significant difference
between both groups, with higher percentage in the
control group (Table 3).
A correlation test was done between
electrophysiological tests results and the tests of
cognitive functions for ADHD group. A positive
correlation was present between P300 amplitude and
WCST (perseverative errors) (P=0.03). Moreover, a
positive correlation was present among P300 amplitude
and ST results (P=0.01)
There was also a positive correlation between N2 latency
and DS backward (P=0.03). A positive correlation
was present among N1 amplitude results and
Conners’ parent rating scale results (P=0.04) (Table 4).
Conners’ parent rating scale for ADHD symptoms was
used in this study. A score higher than 15 reflects
presence of ADHD, and higher score reflects severity
of ADHD. There was a significant statistical difference
between ADHD group and control group.
WCST was used as an indicator of set shifting,
cognitive flexibility, solving of problem, feedback
using, the ability to alter wrong strategies, and to
prevent arrogant responses.
Perseverative responses (replies in the new group that
were classified per the previous classification principle),
perseverative errors (wrongly classified cards, classified
per the previous classification principle), and failure to
maintain set parameters of WCST were used as
variables in our study. We selected these parameters
especially, as most of the studies on WCST had used
same parameters in the test assessment, especially
preservative responses, which is considered a
sensitive parameter in test assessment.
WCST can differentiate children with ADHD from
normal control. When the child had higher scores than
control, this reflects impairment of set shifting and
cognitive flexibility components of EFs (Heaton and
Staff, 1993).

In this study, a relation of significance was present

Discussion
This study was conducted on 103 children, comprising
53 children with ADHD aged from 8 to 14 years, who
were matched with 50 normal control, matched for age,
sex, educational and social level, and IQ, with no
significant difference.
among ADHD group and control group, as ADHD
group had higher scores in the tested parameters of
WCST (preservative responses, perseverative faults,
and inability to preserve set), as this group tended to
do more perseverative responses and errors than normal
controls, with more times to fail to maintain set.

Table 4 Correlation of P300, cortical auditory evoked potential latency and amplitude as well as ACPT with cognitive functions in
the studied patients (N=53)
IQ ADHD WCST (PR) WCST (PE) WCST (FMS) DSB Stroop
r P r P r P r P R P r P r P
P300 latency −0.18 0.20 0.01 0.50 0.0 0.99 −0.02 0.99 −0.04 0.77 0.11 0.42 0.09 0.58
P300 amplitude −0.23 0.10 0.08 0.57 0.08 0.58 0.30 0.03* −0.04 0.76 0.26 0.06 0.34 0.01*
P1 latency 0.22 0.12 0.24 0.09 0.12 0.41 −0.01 0.50 −0.05 0.74 0.04 0.76 0.12 0.39
N1 latency 0.22 0.12 0.25 0.07 0.14 0.33 0.08 0.96 −0.07 0.62 0.07 0.62 0.18 0.20
P2 latency 0.13 0.36 0.22 0.11 0.05 0.72 −0.09 0.55 −0.05 0.73 0.18 0.19 0.19 0.17
N2 latency 0.05 0.74 0.17 0.22 0.22 0.11 0.08 0.58 0.01 0.97 0.31 0.03* 0.12 0.41
P1 amplitude 0.07 0.60 0.24 0.09 0.03 0.85 0.12 0.39 0.03 0.85 0.13 0.36 0.12 0.39
N1 amplitude −0.06 0.17 0.28 0.04* 0.04 0.79 0.13 0.35 −0.03 0.86 0.22 0.11 0.23 0.09
P2 amplitude 0.10 0.46 0.12 0.39 0.02 0.87 −0.02 0.91 −0.05 0.72 0.11 0.42 0.02 0.87
N2 amplitude 0.02 0.91 −0.04 0.76 0.02 0.08 0.14 0.31 −0.15 0.29 0.07 0.65 0.03 0.85
ACPT −0.12 0.40 0.09 0.51 0.02 0.90 0.10 0.46 0.27 0.05 0.26 0.06 0.19 0.17
ACPT, auditory continuous performance test; ADHD, attention-deficit hyperactivity disorder; DSB, digit span backward; FMS, failure to
maintain set parameter; IQ, intelligence quotient; PE, perseverative error; PR, perseverative response; r, correlation coefficient; WCST,
Wisconsin card sorting test. *Significant at P value less than 0.05.
[Downloaded free from http://www.new.ejpsy.eg.net on Wednesday, August 3, 2022, IP: 179.251.199.75]
ADHD electrophysiological & psychophysical tests Hammer et al.
When we try to connect results in our work with the
pathophysiology of ADHD, there is a relation between
set shifting component of EFs and the impairment
in the left dorsolateral prefrontal cortex, so this test
(WCST) may have a role in evaluation the underlying
impairment in ADHD.
In this study, our results were in concordance with
Sergeant et al. (2002), who stated that many WCST
trials could differentiate ADHD from normal cases,
but these conclusions depend on which parameters
have been used. In most of the studies, perseverative
response (which is considered a sensitive parameter in
WCST), perseverative faults, and inability to preserve
set were used to differentiate between ADHD and
normal controls.
Our study is in concordance with other many studies
that found set shifting impairment in patients with
ADHD in comparison with normal control, for
example, the studies of Barkley et al. (1992), Carter
et al. (1995), Houghton et al. (1999), Seidman et al.
(2000), Weyandt and Willis (1994), and Zakzanis et al.
(2005).
In this study, a positive correlation was present among
P300 amplitude and WCST (perseverative errors),
which is a very important physiological correlate.
Scheres et al. (2003) results were not in concordance
with our results, as they found that perseverative errors
and failure to maintain set did a poor job in
discriminating between ADHD and normal control.
ST was used in our study to detect the executive
inhibition. Our ADHD sample was significantly
impaired relative to control group in the test.
Moreover, a positive correlation was present among
P300 amplitude and ST results. It is a neurological and
physiological correlate of selective attention, working
memory, and novelty detection. The P300 is a late
ERP component and was suggested to identify
executive and attentional functions, including the
function of the working memory, categorizations of
events, attentional resource allocation, and attentional
reorientation (Polich, 2007).
Poor inhibition is manifested in many situations in
children with ADHD who are impulsive as these
children find difficulty in waiting turn, interrupt and
intrude others, and often blurt out responses before
the completion of questions. Inhibitory control of the
deficit can encroach into capacity of working memory.
145
This leads to working memory disruptions and
interferes with planning and organized behavioral
patterns.
Our results were in concordance with the study
carried out by MacLeod (1991), who implied
that an inhibitory control deficit is a key deficit in
ADHD, which is important in situations required
withholding or sudden interruption of an ongoing
action. Our work was also in concordance with Harris
et al. (1995).
This test was used for assessment of working memory.
It was found that children with ADHD could recall
fewer digits than the control, so there was a significant
difference from control, which denotes working
memory impairment in our sample of ADHD.
Working memory impairment in children with
ADHD can be manifested in many occasions, as
these children can find great difficulty in
remembering where they just put something, what
someone just said to them, what they have just read,
or what they are about to say. There was also a positive
correlation between N2 latency and DS backward.
A study of Barnett et al. (2001) agreed with the current
results. They found working memory deficit in patients
with ADHD in comparison with normal controls. Our
trial was also in concordance with many other studies
such as that of Willcutt et al. (2005) and that of
Martinussen et al. (2005) and Finke et al. (2006).
In our study, we measured the P300 absolute latency
and amplitude in response to speech stimuli using
oddball paradigm in both groups. P300 absolute
latency showed statistically significant delay in
ADHD in comparison with the control group.
Regarding the P300 amplitude, a reduction of
statistically significance was present in children with
ADHD.
Our results agreed with Borja and Ponde (2009), Tsai
et al. (2012), and Yamamuro et al. (2016). who reported
P300 latency time increased, and in individuals with
ADHD, the amplitude decreased (Borja and Ponde,
2009; Yamamuro et al., 2016).
In the ADHD, it is noted that the P300 amplitude
decrease represents deficits in the task-relevant
processing or salient data, selective attention, and
context updating, whereas the delayed P300 latency
was explained by slower processing in ADHD cases
(Mercugliano, 1999).
[Downloaded free from http://www.new.ejpsy.eg.net on Wednesday, August 3, 2022, IP: 179.251.199.75]
146 Egyptian Journal of Psychiatry, Vol. 42 No. 3, September-December 2021
On the contrary, some trials did not agree with our
results. Romero et al. (2013) made a comparison
between the performance in children with and
without ADHD. In comparison with the control
group, normal values of P300 latency and amplitude
in the ADHD group were noted (Romero et al., 2013).
They explained these nonsignificant differences in
their study that the sample was small and
recommend a higher number of cases to better
auditory pathway analysis. One other possible reason
for them was that children with ADHD have
modifications in their processes of preattention and
discrimination; nevertheless, through the interaction of
brain plasticity and reconfiguration of nerve cells, these
children may process the data via other structures of the
central nervous system.
CAEP waves include P1, N1, P2, and N2; they provide
information about perception of sound by the auditory
cortex. P1 is a positive wave at 50–100 ms after
stimulus and N1 is a negative peak that occurs at
∼80–120 ms following the stimulus initiation.
Latencies of P1 and N1 are a helpful screening tool
of central auditory development. P2 is a second positive
peak at ∼100–160 ms following stimulus and N2
latency was about 200–280 ms (Durante et al., 2014;
Sharma et al., 2015).
CAEP components obtained from speech stimuli
provide information referring to detection of speech
stimuli and processing in the auditory cortex (Souza
and Tremblay, 2006).
In our study, CAEP was recorded using da stimuli.
Regarding wave detectability, all CAEP waves (P1,
N1, P2, and N2) were 100% detectable for both
groups. Children with ADHD had delay in latencies
by all CAEP components which was significant in
comparison with controls. The amplitudes of different
C components were evaluated in the two groups, with
a statistically significant decrease in the amplitudes of
P1, N1, and P2.
In ADHD, processes of response inhibition are affected
by concurrent data owing to high distractibility, and this
is reflected in the reduction in the amplitude of both P1
and N1. This might be represented in processes of
perceptual gating and bottom-up attentional selection
(P1 and N1) and at the resource allocation level (P2)
(Herrmann and Knight, 2001).
Auditory P1 and N1 is used to assess automatic
attention, and it reflects the sensory stimuli
processing. The N1 decreased in ADHD suggested
decreased automatic attention to salient sound stimuli,
which might be owing to decreased activity of the
pathways of brain-stem arousal (Sable et al., 2013).
Wang et al. (2008) stated that the frontal cortex could
be an integrated component of an inhibitory circuit
that inhibits the response to irrelevant, unattended
stimuli by feeding back on sensory areas (in a
normally functioning brain). This sensory filtering is
reflected in reduced N1 amplitudes, indicating reduced
attention to those sounds. Low-amplitude N1 may
reflect reduced activity in the hindbrain
norepinephrine system, including the locus coeruleus
(Halperin and Schulz, 2006).
The N2 has been associated with cognitive control and
response inhibition. Sable et al. (2013) studied
automatic attention in young adults with ADHD.
Their results showed reduced N1 amplitude and
increased N2 in patients with ADHD, and they
suggested that those patients may have developed
certain compensatory top–down attentional
mechanisms. This may explain the nonsignificance
in the N2 amplitude between the both groups in our
study. However, some studies showed reduced N2
peak in ADHD compared with the control group, and
they suggested that this may indicate an atypical
frontal inhibition process in ADHD (Barry et al.,
2003).
The P2 component was suggested to reflect automatic
stimulus discrimination and the inhibition of further
processing of competing (Oades, 1998).
Romero et al. (2013) stated that N2 latency was delayed
in ADHD, and they explained it by the decrease in the
responses efficiency involving processes of preattention
and discrimination.
Auditory continuous performance test was used in
cases with ADHD to study sustained attention in
those patients. The performance of children and
adults with ADHD was found to be worse
compared with the control group in many studies
(Doehnert et al., 2013). In our study, there was a
statistically significant difference between ADHD
and the control group, with higher percentage in the
controls. Distractibility, hyperactivity, and impulsivity
are the main hallmarks in ADHD (Vahia, 2013). The
efficiency of information processing and the ability to
stay focused on a monotonous task are deficient in
patients with ADHD, and they have poor performance
on sustained attention (Mazor-Karsenty et al., 2019).
[Downloaded free from http://www.new.ejpsy.eg.net on Wednesday, August 3, 2022, IP: 179.251.199.75]
ADHD electrophysiological & psychophysical tests Hammer et al.
Conclusion
Assessment of CAEPs and P300 in children
with ADHD and their correlation with
neurocognitivetests (WCST, DS, and ST) are
crucial in diagnosis and management of children
with ADHD.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
Barkley RA, Grodzinsky G, DuPaul GJ (1992). Frontal lobe functions in
attention deficit disorder with and without hyperactivity: a review and re-
search report. J Abnorm Child Psychol 20: 163–188.
Barnett R, Maruff P, Vance A, Luk ES, Costin J, Wood C, et al. (2001).
Abnormal executive function in attention deficit hyperactivity disorder: the
effect of stimulant medication and age on spatial working memory. Psychol
Med 31:1107–1115.
Barry RJ, Johnstone SJ, Clarke AR (2003). A review of electrophysiology in
attention-deficit/hyperactivity disorder: II. Event-related potentials. Clin Neu-
rophysiol 114:184–198.
Blakey R, Ranlund S, Zartaloudi E, Cahn W, Calafato S, Colizzi M, et al. (2018).
Associations between psychosis endophenotypes across brain functional,
structural, and cognitive domains. Psychol Med 48:1325–1340.
Borja A, Ponde M (2009). Assessment of cognitive evoked potential, p300 in
children with and without ADHD. Rev Ciênc Méd Biol 8:198–205.
Carter CS, Krener P, Chaderjian M, Northcutt C, Wolfe V (1995). Asymmetrical
visual-spatial attentional performance in ADHD: evidence for a right hemi-
spheric deficit. Biol Psychiatry 37:789–797.
Doehnert M, Brandeis D, Schneider G, Drechsler R, Steinhausen HC (2013). A
neurophysiological marker of impaired preparation in an 11-year follow-up
study of attention-deficit/hyperactivity disorder (ADHD). J Child Psychol
Psychiatry 54:260–270.
Durante AS, Wieselberg MB, Carvalho S, Costa N, Pucci B, Gudayol N, et al.
(2014). Cortical auditory evoked potential: evaluation of speech detection in
adult hearing aid users. Codas 26:367–373.
Finke K, Bublak P, Zihl J (2006). Visual spatial and visual pattern working
memory: neuropsychological evidence for a differential role of left and right
dorsal visual brain. Neuropsychologia 44:649–661.
Halperin JM, Schulz KP (2006). Revisiting the role of the prefrontal cortex in the
pathophysiology of attention-deficit/hyperactivity disorder. Psychol Bull
132:560–581.
Harris EL, Schuerholz LJ, Singer HS, Reader MJ, Brown JE, Cox C, et al.
(1995). Executive function in children with Tourette syndrome and/or atten-
tion deficit hyperactivity disorder. J Int Neuropsychol Soc 1:511–516.
Heaton RK, Staff P (1993). Wisconsin card sorting test: computer version 2.
Odessa: Psychological Assessment Resources; 4:1–4.
Heinrich H, Busch K, Studer P, Erbe K, Moll GH, Kratz O (2014). Refining the
picture of reduced alerting responses in ADHD − a single-trial analysis of
event-related potentials. Neurosci Lett 582:49–53.
Herrmann CS, Knight RT (2001). Mechanisms of human attention: event-
related potentials and oscillations. Neurosci Biobehav Rev 25:465–476.
Houghton S, Douglas G, West J, Whiting K, Wall M, Langsford S, et al. (1999).
Differential patterns of executive function in children with attention-deficit
hyperactivity disorder according to gender and subtype. J Child Neurol
14:801–805.
Kamarajan C, Porjesz B (2015). Advances in electrophysiological research.
Alcohol Res 37:53–87.
147
MacLeod CM (1991). Half a century of research on the Stroop effect: an
integrative review. Psychol Bull 109:163.
Marquardt L, Eichele H, Lundervold AJ, Haavik J, Eichele T (2018). Event-
related-potential (ERP) correlates of performance monitoring in adults with
attention-deficit hyperactivity disorder (ADHD). Front Psychol 9:485.
Martinussen R, Hayden J, Hogg-Johnson S, Tannock R (2005). A meta-
analysis of working memory impairments in children with attention-deficit/
hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 44:377–384.
Mazor-Karsenty T, Parush S, Shalev L (2019). Sustained attention in sensory
modulation disorder and attention deficit/hyperactivity disorder. Res Dev
Disabil 88:22–29.
Mercugliano M (1999). What is attention-deficit/hyperactivity disorder?. Pediat
Clin North Am 46:831–843.
Oades RD (1998). Frontal, temporal and lateralized brain function in children
with attention-deficit hyperactivity disorder: a psychophysiological and
neuropsychological viewpoint on development. Behav Brain Res
94:83–95.
Polanczyk GV, Salum GA, Sugaya LS, Caye A, Rohde LA (2015). Annual
research review: a meta-analysis of the worldwide prevalence of mental
disorders in children and adolescents. J Child Psychol Psychiatry 56:345-
–365.
Polich J (2007). Updating P300: an integrative theory of P3a and P3b. Clin
Neurophysiol 118:2128–2148.
Romero AC, Capellini SA, Frizzo AC (2013). Cognitive potential of children with
attention deficit and hyperactivity disorder. Braz J Otorhinolaryngol 79:609-
–615.
Sable JJ, Knopf KL, Kyle MR, Schully LT, Brooks MM, Parry KH, et al. (2013).
Attention-deficit hyperactivity disorder reduces automatic attention in young
adults. Psychophysiology 50:308–313.
Sangal RB, Sangal JM (2006). Attention-deficit/hyperactivity disorder: using
P300 topography to choose optimal treatment. Expert Rev Neurother 6:
1429–1437.
Scheres A, Oosterlaan J, Swanson J, Morein-Zamir S, Meiran N, Schut H, et al.
(2003). The effect of methylphenidate on three forms of response inhibition in
boys with AD/HD. J Abnorm Child Psychol 31:105–120.
Seidman LJ, Biederman J, Monuteaux MC, Weber W, Faraone SV (2000).
Neuropsychological functioning in nonreferred siblings of children with at-
tention deficit/hyperactivity disorder. J Abnorm Psychol 109:252–265.
Sergeant JA, Geurts H, Oosterlaan J (2002). How specific is a deficit of
executive functioning for attention-deficit/hyperactivity disorder? Behav Brain
Res 130:3–28.
Sharma A, Campbell J, Cardon G (2015). Developmental and cross-modal
plasticity in deafness: evidence from the P1 and N1 event related potentials in
cochlear implanted children. Int J Psychophysiol 95:135–144.
Souza PE, Tremblay KL (2006). New perspectives on assessing amplification
effects. Trends Amplif 10:119–143.
Tsai ML, Hung KL, Lu HH (2012). Auditory event-related potentials in children
with attention deficit hyperactivity disorder. Pediatr Neonatol 53:118–124.
Vahia VN (2013). Diagnostic and statistical manual of mental disorders 5: a
quick glance. Indian J Psychol Med 55:220.
Wang AL, Mouraux A, Liang M, Iannetti GD (2008). The enhancement of
the N1 wave elicited by sensory stimuli presented at very short inter-
stimulus intervals is a general feature across sensory systems. PLoS ONE
3:e3929.
Weyandt LL, Willis WG (1994). Executive functions in school-aged children:
potential efficacy of tasks in discriminating clinical groups. Dev Neuropsychol
10:27–38.
Willcutt EG, Pennington BF, Olson RK, Chhabildas N, Hulslander J (2005).
Neuropsychological analyses of comorbidity between reading disability and
attention deficit hyperactivity disorder: in search of the common deficit. Dev
Neuropsychol 27:35–78.
Yamamuro K, Ota T, Iida J, Nakanishi Y, Suehiro Y, Matsuura H, et al. (2016).
Event-related potentials correlate with the severity of child and adolescent
patients with attention deficit/hyperactivity disorder. Neuropsychobiology
73:131–138.
Zakzanis KK, Mraz R, Graham SJ (2005). An fMRI study of the trail making test.
Neuropsychologia 43:1878–1886.