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Validez de las pruebas de atención para el diagnóstico diferencial de TDAH

infantil y Trastornos del Aprendizaje /// Validity of attention tests for
differential diagnosis of child...
Article in Electronic Journal of Research in Educational Psychology · September 2021

DOI: 10.25115/ejrep.v19i54.3868
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Validity of attention tests for differential
diagnosis of childhood ADHD and Learning
Disabilities
Silvia Álava Sordo 1, Helena Garrido-Hernansaiz2, María

Cantero-García3, Iván Sánchez-Iglesias 4, Jesús González-
Moreno5, José Santacreu 6
1
Dept. of Childhood Psychology. Álava Reyes Psychology Center
2
Dept. of Education and Psychology. Centro Universitario Cardenal Cisneros,
University of Alcala.
3
Dept. of Psychology. School of Biomedical and Health Sciences.
Universidad Europea in Madrid.
4
Psychobiology & Behavioral Sciences Methods.
Complutense University of Madrid.
3 and 5
Area of Health. School of Psychology. International University of Valencia
6
School of Psychology. Autónoma University of Madrid.
Spain
Correspondence: María Cantero-García. Área de Salud. Facultad de Psicología. Universidad Internacional de

Valencia. Calle Pintor Sorolla, 21. 46002. Valencia. SPAIN. 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 (2), 437-464. ISSN:1696-2095. 2021. no. 54 437
Silvia Álava Sordo et al.
Abstract
Introduction. There are different tests that assess attention and can help to make a differen-
tial diagnosis between ADHD and Learning Disabilities (LD), but there appears to be little
research on the convergent and predictive validity of these tests. The aim of this study was to
analyze the convergent validity of the EMAV, Caras, d2, AGL, CPT-II and CSAT attention
tests and to assess their usefulness for identifying people diagnosed with ADHD as compared
to people with LD, based on DSM-5 criteria.
Method. Convergent validity of the instruments was studied via non-parametric correlations,
and their predictive validity through binary logistic regression. A clinical sample composed of
437 children was used (234 had an ADHD diagnosis and 203 an LD diagnosis with ADHD
ruled out).
Results. The results indicate that selective attention measures showed weak correlations be-
tween themselves, as was also the case with sustained attention measures. Moreover, correla-
tions between measures of the contrasting types of attention were of similar magnitude, which
casts doubt on whether they measure what they claim to measure. The best predictor of
ADHD vs. LD differential diagnosis was the confidence index of the CPT-II, in all ages. In
addition, for children between the ages of 6 and 16, their percentile in correct answers on the
Caras test was quite informative, and for children from 8 to 17, the d2 concentration index.
Key words: ADHD, attention, Learning Disabilities, convergent validity, predictive validity.
438 Electronic Journal of Research in Educational Psychology, 19(2), 437-464. ISSN:1696-2095. 2021. no. 54
Validity of attention tests for differential diagnosis of childhood ADHD and Learning Disabilities
Resumen
Introducción. Existen diferentes pruebas que evalúan la atención y pueden contribuir a reali-
zar un diagnóstico diferencial entre el TDAH y los Trastornos de Aprendizaje (TA), pero se
han encontrado pocos estudios sobre la validez convergente y predictiva de dichas pruebas. El
objetivo de este estudio es estudiar la validez convergente de las pruebas de atención EMAV,
Caras, d2, AGL, CPT-II y CSAT y valorar su utilidad a la hora de identificar a personas diag-
nosticadas de TDAH frente a personas con TA según los criterios DSM-5.
Método. Se estudió la validez convergente de los instrumentos mediante correlaciones no

paramétricas, y su capacidad predictiva mediante regresión logística binaria. Se utilizó una
muestra clínica de 437 niños, 234 tenían un diagnóstico de TDAH y 203 niños manifestaron
TA en los que se descartó un diagnóstico de TDAH.
Resultados. Los resultados indican que las medidas de atención selectiva mostraron correla-
ciones débiles entre sí, al igual que ocurrió con las de atención sostenida. Además, las corre-
laciones entre pruebas de ambos tipos fueron de la misma magnitud, lo que pone en tela de
juicio si las pruebas miden lo que dicen medir. Por otro lado, lo que mejor predijo el diagnós-
tico diferencial de TDAH respecto a TA fue el índice de confianza del CPT-II en todas las
edades. Además, en niños de entre 6 y 16 años, también resultó bastante informativo el per-
centil de aciertos de la prueba Caras y para niños de entre 8 y 16 años, el índice de concentra-
ción del d2.
Palabras clave: ADHD, attention, Learning Disabilities, convergent validity, predictive va-
lidity
Introduction
The attention deficit with hyperactivity disorder (ADHD), as described in the Diag-
nostic and Statistical Manual of Mental Disorders 5, is characterized by a persistent pattern of
inattention and/or hyperactivity/impulsivity (APA, 2013). Moreover, there is great comorbidi-
ty of other disorders in children and adolescents with ADHD, especially of Learning Disabili-
ties (LD). LD are characterized by difficulties in reading, reasoning, writing or mathematical
skills, where achievement in these areas is below what is expected for the child’s chronologi-
cal age, despite the fact that no sensory deficits are detected, the instruction received has been
adequate, intelligence is within the limits of normality and there are no drastic cultural disrup-
tions or differences (Johnson, 2017; Karande & Kulkarni, 2005).
LD Prevalence in children with ADHD falls between 19% and 35% (CADDRA,
2011; Barkley, 1996; Mayes, Calhoum, & Crowell, 2000). However, Preston, Heaton,
McCann, Watson and Selke (2009) claim that there is no real comorbidity, but rather difficul-
ties in adequately carrying out a differential diagnosis, due to similarities in symptoms. The
key issue is that the academic difficulties experienced by children with ADHD are due to lim-
ited ability to inhibit stimuli and change their focus of attention, while in cases of LD, their
academic difficulties are not due to attention problems. Attention assessment must therefore
be a central aspect in assessment and diagnosis of ADHD and LD.
An ADHD diagnosis is conducted exclusively on the basis of symptoms observed, that

is, the clinical profile. This can become a complication, due to discrepancies between the fre-
quency and intensity of symptoms reported by parents and teachers on assessment tests
(Amador, Forns, Gúardia & Peró, 2005; Rabito-Alcón & Correas-Lauffer, 2014; Sayal &
Taylor, 2005; Servera & Cardó, 2007), and even between one parent and the other. For this
reason, ADHD should not be diagnosed only on the basis of questionnaires completed by par-
ents or teachers; instead, an exhaustive professional assessment is necessary (Barkley, 2000;
Frazier, Demaree & Youngstrom, 2004). Such an assessment should include a clinical inter-
view with the parents and the child, a medical examination (when needed), behavior assess-
ment scales completed by the parents, an interview with the child’s teacher or teachers, simi-
lar behavior assessment scales completed by the teacher(s), and tests of intelligence or aca-
demic knowledge (Gualtieri & Johnson, 2005).
It is worth noting that the use of behavior scales is not recommended for assessing
ADHD (Angello et al., 2003; Demaray & Elting, 2003) without simultaneously considering
other cognitive processes affected, such as attention. Attention is one of the core symptoms of
the diagnosis, predicting both severity of symptoms and behavior (Thaler et al., 2012; Lange
et al., 2014). Attentional processes are closely related to control of performance, that is, inhi-
bition of the tendency to respond automatically and thoughtlessly (Castillo, 2009; Lehman,
Naglieri & Aquilino, 2010.
In this regard, at the attentional level, children with ADHD focus more on the novelty
of stimuli and have difficulty focusing on relevant, subtle or masked stimuli; thus, errors in
problem solving may be due to inattention towards stimuli that really are significant (Gonzá-
lez-Castro, Rodríguez, Cueli, Cabeza & Álvarez, 2014). If we add to this that these children
have poor interference control, the result is poor behavior regulation in most situations and
poor academic achievement (Casas, Andrés, Castellar, Miranda & Diago, 2011; Iglesias-
Sarmiento, Deaño, Alfonso & Conde, 2017; Lipszyc & Schachar, 2010; Menéndez, 2001).
There are different diagnostic tests that assess different types of attention, and these
represent more objective means for making a diagnosis (Areces, Rodríguez, García, Cueli &
González-Castro, 2018; Conners, Epstein, Angold & Klaric, 2003; Gualtieri & Johnson,
2005). In attention assessment tasks, different visual stimuli are presented, with indications of
which stimuli one must respond to (relevant stimuli) and which to disregard (irrelevant stimu-
li) (Ardilla & Ostrosky, 2012). Different measurements are usually recorded: reaction time or
response time, errors of commission, errors of omission, and number of right answers. Many
of the tasks include a global index of attention that results from combining these measure-
ments.
Selective attention is measured through discrimination tasks that present a model fig-
ure (relevant stimulus or target) and a set of stimuli (figures), where some perfectly match the
model and others have differences; the child must identify the matching figures. There are
two types of these tasks, cancelation tasks and visual search tasks. Examples include the “Ca-
ras” perception of differences task (Thurstone & Yela, 2009), the Magallanes Scales of visual
attention (EMAV, García-Pérez & Magaz, 2000), the Toulouse-Piéron test (Toulouse & Piér-
on, 1998), the d2 attention test (Brickenkamp, 2004), and the global-local attention test (AGL,
for its Spanish initials) (Blanca, Zalabardo, Rando, López Montiel & Luna, 2005).
In visual search tasks, however, the stimuli are displayed across a computer screen in
no particular order. The only visual search task developed in Spain is the Discriminación Vis-
ual Simple de Árboles [simple visual discrimination of trees] (Santacreu et al., 2011), a com-
puterized test where the figures to be discriminated are trees.
Table 1. Principal Selective Attention Tasks (Discrimination test)

Test Age Areas assessed Reliability
Cancelation tests
Perception of differences 6 to 18 years Selective attention .91 Total right answers
test (Thurstone & Yela,
2009).
d2 attention test (Brick- 8 years and Selective attention .95 Total right answers
enkamp, 2004) older Variability
Processing speed
Magallanes Scales of visu- 5 to 18 years Selective attention EMAV 1
al attention EMAV (Gar- .48 Quality of Attention
cía-Pérez & Magaz, 2000) .46 Sustained attention
EMAV 2
.56 Quality of attention
.60 Sustained attention
Toulouse-Pièron test (Tou- 17 years and Selective attention .77 Attention and per-
louse & Pièron, 1998) older Perception speed ception
AGL, global-local atten- 12 to 18 Selective attention .80 on all indices

tion (Blanca et al., 2005). years
Visual Search tests
DiViSA test of simple 6 to 12 years Selective attention .95 Global attention
visual discrimination of Inhibition .86 Commissions
trees (Santacreu et al., Organization .77 Omissions
2011). Distraction
Processing speed
For the assessment of sustained attention, the most commonly used tests are continu-
ous performance tests (CPTs) (Areces et al., 2018; Areces, García, Cueli, & Rodríguez, 2019;
Rodríguez, Areces, García, Cueli, & González-Castro, 2018), which are administered using a
computer. There are several different CPTs in Spanish, most notably Conner’s CPT (CCPT-
II, 1995; Conners, 2004), which follows the response inhibition paradigm; the children’s sus-
tained attention test (CSAT; Servera & Llabrés, 2004; CSAT-R, Servera & Llabrés, 2015),
based on the vigilance model; and the Aula Nesplora test (Climent & Banterla, 2010; Areces
et al., 2018), which uses virtual reality (Neguț, Jurma, & David, 2017; Nolin et al., 2016) and
makes use of both the response inhibition paradigm and the vigilance model. Tables 1 and 2
summarize some characteristics of the principal tests available for assessing attention in a
Spanish population.
Table 2. Principal Sustained Attention Tasks (Continuous attention tests).

Test Age Areas assessed Reliability
Conner’s CPT (CCPT, 6 years Sustained attention .83 Commissions
1995; Conners, 2004). and older Processing speed .94 Omissions
.95 Reaction time
Test of sustained atten- 6 to 10 Sustained attention .80 Right answers

tion for children (CSAT, years Processing speed .85 Reaction time
Servera & Llabrés, .80 Commissions
2004).
Aula Nesplora. (Climent 6 to 16 Auditory sustained .96 Auditory right an-

& Banterla, 2010). years attention swers
Visual sustained at- .97 Total right answers
tention .96 Visual right answers
Processing speed .98 X right answers
Variability .97 Not X right answers
In short, there are several attention tests that discrminate between children who may
present attentional impairments compatible with an ADHD diagnosis, and those who only
have attention difficulties, without constituting a disorder. However, one problem with the use
of these tests is that in many of them, measurement of sustained attention and selective atten-
tion are closely related, since sustained attention scores are based on the total number of right
answers on the test, and many also consider the total number of errors (right answers would
serve to measure selective attention). Consequently, there may be a partial overlap of the con-
structs that these instruments measure, representing an important problem to be resolved.
In fact, some research in Spanish populations has studied the relationship between the
scores obtained on different attention tests, for the purpose of clarifying their convergent va-
lidity. A summary of these can be found in Table 3. The Aula Nesplora, for its part, has
shown very high correlations with the concentration indices of the d2 attention test in studies
by Díaz-Orueta, Alonso-Sánchez and Climent (2014; r = .93, N = 60) and by Climent and
Banterla (2010; r = .97, N = 27), as well as with the number of right answers on the Caras test
(r = .96, N = 33; Zulueta Fernández, Iriarte, Díaz-Orueta & Climent, 2013). Moreover, it has
shown moderate correlations with the CPT-II in measures of commission errors (r = .30, N =
57) and omission errors (r = .50, N = 57; Díaz-Ortueta et al., 2014).
Regarding the DiViSA global attention index, moderate to strong significant correla-
tions were found with the d2 concentration index (r = .57, N = 111) and with right answers on
the Caras test (r = .65, N = 111; Lozano, Capote & Fernández, 2015). On the other hand, the
number of right answers on the Caras test was found to correlate significantly with the d2
concentration index (r = .63, N = 111; Lozano et al., 2015), with the total performance index
of the AGL (r = .58, N = 170; Blanca et al., 2005) and with EMAV indices of sustained atten-
tion (r = .52, N = 230) and attention quality (r = -.11, N = 230) (Magaz et al. 2011), where
all correlations were strong except the latter, which was very weak and negative.
Regarding the AGL, the total performance index has shown moderate to high correla-
tions with the sustained attention index (r = .35, n = 53) and with the EMAV attention quality
index (r = .56, N = 53), as well as with the Toulouse-Piéron test (r = .64, N = 119; Blanco et
al., 2005). Finally, concerning the EMAV, the sustained attention index and attention quality
index have shown significant correlations with the Toulouse-Piéron test (r = .81 and r = .12,
respectively, N = 270; Magaz et al., 2011).
Table 3 presents a summary of these correlations. In short, few studies have analyzed
the correlation between measurements from the different tests. The correlations reported for
the Aula Nesplora, the AGL, and the EMAV are published in the test manuals. Moreover, the
correlations found by the authors are not useful for studying convergent validity, given that
they were often relating two measurements that point to different concepts. For example, Dí-
az-Orueta et al. (2014) compared the number of right answers on the Aula Nesplora with the
d2 concentration index, which is a measurement consisting of total right answers minus the
wrong answers; furthermore, to relate the Aula Nesplora to the CPT-II, they used the number
of omission and commission errors, instead of the global indices or number of right answers,
as in the previous test. This generates much diversity of magnitude in the correlations, ranging
from very strong to very weak. Comparisons need to be established between the same forms
of measurement. Additionally, another problematic aspect of the studies mentioned is that
several of them were carried out in rather small samples, such as in the studies by Climent and
Banterla (2010) with 27 participants, Blanco et al. (2005) with 53 and Zulueta et al. (2013)
with 33.
Table 3. Correlations found between the attention tests.
AULA Divisa Caras AGL EMAV

.97 .57 .63
d2 .92 N = 111 N = 111
N = 27
.96
AULA
N = 33
.50
CPT-II .30
N = 57
.65
Divisa
N = 111
.58 .52
Caras N = 170 -.11
N = 230
.35
EMAV .56
N = 53
.64 .81
Toulouse-
N = 119 .12
Piéron
N = 270
On the other hand, another important question is the diagnostic capability of these tests
for detecting positive cases of ADHD. In this regard, the DiViSA has proven useful for dis-
criminiating children with an attention problem from those who do not have one (Santacreu &
Quiroga, 2015) and it may have utility for assessing the child’s attentional profile for both
academic and clinical purposes (Quiroga, Santacreu, Montoro, Martínez-Molina & Shih Ma,
2011). The CSAT, for its part, seems to be sensitive to maturation factors within the expected
parameters in the general population (Servera & Llabrés, 2004), although there are no data on
predictive capacity. The Caras test has shown sensitivity for diagnosing moderate ADHD,
while presenting high specificity (Thurstone & Yela, 2012). According to Magaz et al.
(2011), the EMAV is able to discriminate between children with attention deficit and children
of the general population, although no data are provided on diagnostic accuracy. The predic-
tive capacity of attention tests for detecting boys and girls with ADHD and adequately differ-
entiating them from other children with different difficulties is a very important matter in clin-
ical practice. It is therefore necessary to know, comparatively, which of the different available
tests are most helpful in effective detection of ADHD in children.
In short, studies must examine the convergent validity and diagnostic ability of atten-
tion tests in order to ascertain whether they really measure the same attentional processes,
whether the processes of sustained and selective attention differ from each other, and whether
the tests are able to differentiate between an ADHD and an LD diagnosis. Moreover, in order
to obtain the least biased results possible, larger population samples than those reported in
most studies must be used.
Objectives and hypotheses

The objectives of this study were to calculate (a) the convergent validity between the
most commonly used instruments in Spain for assessing attention in persons with ADHD, and
(b) the ability of these tests to classify persons with ADHD or LD. While the hypotheses
posed below speak of expected relationships between variables, the objective of this study is
exploratory, and results will be discussed from that perspective. The following hypotheses
were posed:
Hypothesis 1. The different tests will show adequate convergent validity with each other, both
in measures of selective attention and of sustained attention, in the global indices and in the
error-related measurements. The correlations between tests that measures the same type of
attention or type of error will be statistically significant, and higher than correlations between
tests that measures different aspects.
Hypothesis 1.1 The correlation between the CSAT and CPT-II d’ sensitivity indices,
both of them measuring sustained attention, will be significant, and higher than the correlation
between these indices and the rest of the indicators compared.
Hypothesis 1.2 Correlations between the EMAV selective attention and quality of at-
tention, correct answers on Caras and the d2, and total performance on the AGL, will also be
higher than their correlations with the other indices, since these five are considered to be
measures of selective attention.
Hypothesis 1.3 Correlations between errors of commission on the CSAT and on the
CPT-II will be significant, and higher than the correlation with commission errors on the vis-
ual search tests, which measure different types of attention.
Hypothesis 2. Scores from selective and sustained attention measures will also be significant-
ly correlated with each other, although to a lesser degree than tests that measure the same type
of attention, given that they measure different processes.
Hypothesis 3. Global scores on the CPT-II will explain a statistically significant proportion of
the variance of the ADHD diagnosis, greater than the other tests used.
Method
Participants
Participants were selected from 679 minor children who were evaluated at a psycholo-
gy center in Madrid between 2003 and 2015; these subjects had come to the center because of
scholastic difficulties, and were administered a psychological evaluation. The study inclusion
criteria were ages from 6 to 16 and presenting an LD with a total intellectual quotient between
80 and 130 (measured by the WISC-IV).
The final sample was composed of 437 children between the ages of 6 and 16 (M =
10.30, SD = 3.09) who came to a psychology center in Madrid because of learning problems
between April 2007 and August 2015. Regarding gender, 278 students were boys (63.62%)
and 159 were girls (36.38%). Of the total sample, 53.54% (n = 234) were diagnosed with
ADHD according to the neurological report, and 46.46% (n = 203) met criteria for an LD di-
agnosis, ruling out ADHD.
Instruments
Selective attention tests
“Caras” perception of differences test (Thurstone & Yela, 2009). Evaluates ability to
quickly and correctly perceive similarities and differences between different stimuli present-
ed. The test consists of 60 graphic elements, each containing three sketches of faces including
mouth, eyes, eyebrows, and hair, drawn with basic strokes. Two of the faces are the same; the
task consists of determining which face is different, and crossing it out. The raw score is the
total number of correct answers; errors of commission or omission are not taken into account.
Scores on this test have shown good reliability ( = .91; Thurstone & Yela, 2009).
d2 attention test (Brickenkamp, 2004). Evaluates several aspects of selective attention

and concentration in ages 8 and above. The test is made up of 14 lines with 47 stimuli in each.
The stimuli consist of the letters “d” or “p”, which may be accompanied by one or two small
dashes located at the top or bottom of each letter. The task consists of marking as many as
possible of the letters “d” that have two dashes (regardless of their placement), in 20 seconds.
Scores on this test have shown acceptable reliability ( = .79-.96; Brickenkamp, 2004). In this
study, we used the measures of total number of right answers, number of omission errors and
number of commission errors.
Escala Magallanes de Atención Visual [Magallanes Scales of visual attention]

(EMAV) (García-Pérez & Magaz, 2000). A visual search task that consists of identifying fig-
ures that are the same as the model. There is a version for children ages 6 to 8 (EMAV-1) and
another for ages 9 to 18 (EMAV-2), which includes more figures and smaller in size. Test-
retest reliability of scores on this test is moderate (p = .48-.56 for quality of attention, p = .46-
.60 for sustained attention). In the present study, the measures used were total number of right
answers (selective attention), total number of right answers minus errors of commission and
omission (quality of attention), as well as the total numbers of errors of commission and er-
rors of omission.
Atención Global-Local [Global-local attention] (AGL) (Blanca et al., 2005). Evaluates

perceptive speed and accuracy using a task that requires distributing attention over two levels
of a visual stimulus. Hierarchical stimuli are used: large figures that represent the global visu-
al pattern, and whose contour is formed by smaller figures, which represent the local level.
The task consists of detecting a model figure at the global or the local level, in order to assess
performance in each level. Test-retest reliability shows a reliability coefficient of .80 in all
indices (Blanca et al., 2005). The present study used the total performance measure from the
test, which consists of the sum of the number of right answers at the local and global levels.
Sustained attention tests

Children Sustained Attention Task (CSAT; Servera & Llabrés, 2004). A version of
continuous performance tasks to measure the capacity of sustained attention in ages 6 to 11,
using a vigilance task. The task consists of detecting the presence of a 3 preceded by a 6, in
which case the space bar should be pressed. A total of 600, 250-millisecond trials are carried
out on the screen. The test lasts for a total of 7 minutes and 30 seconds. Test reliability using
the split-half method is high (r = .80 for right answers, .85 for reaction times and .95 for
commission errors). In this study, the d´ sensitivity index was used (where d´indicates the
distance between the proportion of omissions and of commissions), as well as the total num-
ber of commission errors.
Conner’s CPT (2004). A continuous performance task for measuring sustained atten-
tion, where the person must press the space bar or the right mouse button for all letters that
are projected on the screen, except for “X”. Stimuli intervals are 1, 2, and 4 seconds, and the
letter remains on the screen for 250 milliseconds. The total test duration is 14 minutes, and it
can be applied in ages 6 and older. Test reliability using the split-half method is high (r = .83
for commissions, .94 for omissions and .95 for reaction time). In this study, the measures
used were the d sensitivity index (which measures the ability to discriminate between the tar-
get stimulus and the disallowed stimulus), total number of omission errors and total number
of commission errors.
Procedure
The families were interviewed, and questionnaires were administered to both the par-
ents and the schoolteachers. The interviews and questionnaires included the DSM-IV-TR cri-
teria (in force at the time of the evaluation). Participants’ medical history was also taken, and
complemented with a semi-structured parent interview, as well as the child’s psychological
profile, which included assessment of intellect and attention processes, executive functions,
and reading and writing, using age-appropriate tests. Patients were evaluated individually in
each of the attention tests. There was total agreement on the ADHD diagnosis between the
psychological assessment at the center, and assessments from medical units in juvenile neu-
rology.
Design
The study design was cross-sectional and correlational, with a descriptive aim (to
study convergent validity) and a predictive aim (identifying which instruments can predict an
ADHD diagnosis).
Data analyses
Descriptive statistics for sociodemographic and clinical variables of the sample were
recorded. Correlations between the different attention tests were calculated. Although the dis-
tribution of most variables was similar to the normal distribution, the Kolmogorov-Smirnov
test did not allow the normality assumption to be maintained, prerequisite to the use of Pear-
son's correlation. Spearman’s correlation was therefore used. The sample size in each correla-
tion differs according to the number of participants who had completed both tests, and is indi-
cated in Table 4.
Table 4. Sample sizes of the correlations between attention tests.
CPT-II CSAT CARAS d2 AGL

EMAV 263 137 276 296 59
CPT-II 115 251 196 59
CSAT 124 74 -
CARAS 200 59
d2 52
Correlations between the AGL and the CSAT could not be obtained, given that they
address different age groups. Before analyzing convergent validity, given that the tests gener-
ate a wide variety of indicators, the variables were grouped according to the type of attention
(selective or sustained) that each test theoretically measures, following the multi-trait, multi-
method logic proposed by Campbell and Fiske (1959). The percentile score was used to cor-
rect for the effect of age (except for errors of omission and commission on the EMAV and
Caras, which are raw scores, and the CSAT variables that are T scores).
Subsequently, binary logistic regression models were fitted with the ADHD diagnosis
as criterion variable (where the ADHD diagnosis is the outcome of interest, compared to the
other variable category, LD). In this way, we attempted to establish a model that would re-
duce prognosis errors of the dichotomous, diagnostic variable. We used the hierarchical for-
ward stepwise method of inclusion of predictors. In the first model, the predictive variables
were the subscales from each attention test and the criterion variable was the ADHD diagno-
sis. Finally, another binary logistic regression model was fitted to predict an ADHD diagno-
sis, but in this case, the subscales from all the tests were used as predictive variables. Given
that the d2 test can only be applied starting at age 8, while the rest of the tests start from age
6, the resulting model was adjusted to exclude children younger than 8. In addition, the re-
gression model was repeated with all the participants, but excluding the d2 test. All the statis-
tical analyses were conducted using SPSS 20.
Results
Table 5 shows correlations between scores from the different attention tests. Most of
the test scores from the selective attention tests (EMAV, d2, Caras and AGL) correlated sig-
nificantly with each other, with values from .24 to .47. Higher correlations were found be-
tween different measurements from the same test (e.g., r = -.81 between the EMAV attention
quality index and EMAV omissions). Regarding sustained attention, the CPT-II and the
CSAT showed certain significant correlations, but all of these were correlations between dif-
fering measurements (e.g., CSAT commissions with CPT-II omissions, or the CSAT sensi-
tivity index with CPT-II omissions). Again, the strongest correlations were found between
different measurements within the same test (e.g. the sensitivity indices of each test with
commission errors on the same test). Similarly, sustained attention and selective attention
measures showed certain significant correlations, with absolute values between .18 and .46.
Table 5. Correlations between attention tests according to type of attention measured.
Sustained Attention Selective Attention
Global Omission Commission

Global Index Commission Errors Omission Errors
Index Errors Errors
d´ Pc AQ Pc SA Pc TC Pc TC Pc TP
CPT-II CPT-II CSAT d2 EMAV Caras d2 EMAV Caras
CSAT (EMAV) (EMAV) (d2) (Caras) (AGL)
Pc d ´ CPT-II -.14 .11 .75 ** .06 -.20 ** -.10 -.04 -.09 .03 -.05 -.06 .07 .09 .21 ** .02
Sustained Attention
Global Index **
d´ CSAT - -.43 -.08 -.61 ** .10 .24 **
.46 **
.06 - -.12 -.03 -.22 *
.30 **
.02 .06
Omission
CPT-II - -.07 .39 ** -.07 -.09 -.23 ** -.29 ** -.21 -.18 * .12 .10 -.19 ** -.10 .04
Errors
** **
Commission CPT-II - .02 -.23 -.03 -.05 -.07 -.04 -.14 -.06 .05 .06 .27 -.04
Errors CSAT - .02 -.08 -.27 * -.03 - .01 .04 .18 * -.18 -.09 -.04
Pc AQ (EMAV) - -.02 .24 ** .25 ** .22 .36 ** -.27 ** -.19 ** .34 ** -.81 ** -.13 *
** ** **
Pc SA (EMAV) - .24 .31 .42 -.03 -.07 .04 -.06 .23 ** .08
Global Index ** ** ** **
Pc TC (d2) - .37 .21 .29 -.16 -.02 .40 -.10 -.05
Atención Selectiva
Pc TC (Caras) - .47 ** .16 * -.14 * -.05 .18 * -.11 -.12

Pc TP (AGL) - .02 -.24 -.07 .14 .00 .07
d2 - -.20 ** -.35 ** .27 ** -.31 ** -.16 *
Commission
EMAV - .10 -.19 ** .11 * -.01
Errors
Caras - -.06 .13 * .10
d2 - -.29 ** -.09
Omission
EMAV - .09
Errors
Caras -
Note. Pc = Percentile. d' = sensitivity index. AQ = attention quality. SA = sustained attention. TC = total correct
answers. TP = total performance. * p < .05; ** p < .01. Significant correlations appear in bold face. Shaded cells
represent correlations where different tests measure the same aspect, and are therefore indicative of a level of
convergent validity.
Regarding the ability to detect and predict ADHD, Table 6 shows the scales from each
test that were significant in the binary logistic regression analyses. The test that explained the
highest proportion of the variance was the CPT-II (20% explained variance), especially
through its confidence index, which had the highest Wald statistic.
Table 6. Binary logistic regressions. Indices for each attention test that contributed signifi-
cantly to predicting ADHD.
Test and scale n B Wald df p R2

EMAV 437 .03
Sustained attention (Pc) -.01 4.24 1 .04
Attention quality (Pc) -.01 7.26 1 .01
CARAS-R 269 .06
Correct answers (Pc) -.02 11.84 1 .001
CPT-II 265 .20
Confidence stress index .03 29.34 1 <.001
d´Sensitivity index (Pc) .01 7.25 1 .01
d2 298 .10
Concentration (Pc) -.02 2.77 1 <.001
CSAT 138 -
-
AGL 60 .12
Total performance (Pc)* -.03 4.37 1 .04
Note: forward stepwise introduction method. Pc = Percentile. B = nonstandardized regression coefficient.

Wald = statistic in the logistic regression. df = degrees of freedom. R2 = proportion of explained variance.
** Detracts from classification of individuals with respect to the null model.
Regarding the relative contribution of the attention tests for predicting ADHD, Table 8
shows the instruments that significantly improve the ADHD prediction. Analysis 1 excludes
participants under the age of 8, since test d2 could not be administered to them; Analysis 2
excludes test d2 but includes all the participants. In the first analysis, only the CPT-II confi-
dence index and the d2 concentration index enter the model, explaining 17% of the variance.
In the second analysis, which excludes the d2, the CPT-II confidence and sensitivity indices
and the number of right answers on the Caras test emerge as significant, explaining 22% of
the variance.
Table 7. Logistic regression. Indices that significantly contributed to predicting ADHD.
n B Wald df p R2
Analysis 1. Ages 8 and above, in-
cludes d2 test. 179 .17
CPT-II, Confidence index .02 1.02 1 .002
d2, Concentration (Pc) -.02 8.26 1 .004
Analysis 2. All participants, d2 test
excluded. 248 .22
Caras, Correct answers (Pc) -.01 4.79 1 .03
CPT-II, Confidence index .03 23.62 1 <.001
CPT-II, d´(Pc) .01 4.89 1 .03
Note: forward stepwise method of introducing variables. Pc = Percentile. B = nonstandardized regression coeffi-
cient. Wald = statistic in the logistic regression. df = degrees of freedom. R2 = proportion of explained variance.
Discussion and Conclusions
In this study we have reviewed the convergent and predictive validity of the tests most
often used to measure attention in the juvenile population. The purpose was to identify which
tests are the best predictors of the differential diagnosis of ADHD and which should therefore
be included in an ADHD clinical evaluation protocol.
Hypothesis 1 proposed that the different tests analyzed would show adequate conver-
gent validity in measures of both selective and sustained attention. Although statistically sig-
nificant relationships were found between tests that measure the same type of attention, as
expected, the strength of these correlations was not higher than between tests that measure
different types of attention.
Regarding Sub-hypothesis 1.1 on sustained attention, only one previous study was
found in which convergence with the CPT-II had been analyzed, and in this case, only with
the Aula Nesplora (Zulueta et al., 2013). In our study, CPT-II and CSAT (both of them con-
tinuous attention tests) did not correlate with each other, possibly due to their use of different
types of tasks, even though they both deal with sustained attention. Specifically, the CPT-II is
a cancelation test where the subject must press the bar for all letters except for X, and test
duration is longer (14 minutes); the CSAT is a vigilance task with a shorter duration
(7 minutes 30 seconds), where the subject presses the bar when there is a 6 followed by a 3,
and not for any other combination of numbers. Nonetheless, the lack of a stronger association
between the two tests is troublesome, and future research may need to explore the possibility
that these tests are measuring different aspects of attention.
Regarding sub-hypothesis 1.2 on selective attention indices, despite the existence of

significant correlations (e.g., between the EMAV and Caras, as in the study by Magaz et al.,
2011), these correlations were weaker than correlations with indices that explored sustained
attention. Again, weak or inexistent associations between selection attention tests is cause for
concern, especially given that the four tests in this case are similar, consisting of cancelation
tasks of similar duration. There is room to question, then, whether these tests are measuring
selective attention, and if they are, whether there is some kind of interference in the assess-
ment process that reduces their validity.
Hypothesis 2 stated that the measurements of selective and sustained attention would
also correlate with each other, but would show weaker correlations, since they represent dif-
ferent attentional processes. As mentioned above, the results again show that the measures of
selective and sustained attention do correlate with each other, but these correlations are not
much weaker than the correlations between tests that measure the same trait. Thus, the CPT-II
d´ sensitivity index correlated negatively with the EMAV AQ percentile and with EMAV
omissions. In other words, since the CPT-II percentiles function inversely, the participants
who did not obtain an adequate sensitivity index (who had many omission errors and few cor-
rect answers on this test), also had a high number of omission errors on the EMAV. On the
other hand, the CSAT d' sensitivity index was significantly correlated with percentile in cor-
rect answers on the d2 and with the SA percentile on the EMAV. Thus, the children who cor-
rectly completed the CSAT had a high number of right answers on the d2 and the EMAV.
Moreover, the CSAT d' sensitivity index negatively correlated to the number of commission
errors on Caras and omissions on the CPT-II and the d2. In other words, the children who did
well on the CSAT had a lower number of commission errors on Caras, and overlooked fewer
relevant stimuli on the CPT-II and on the d2. However, CPT-II omissions significantly corre-
lated with percentile in correct answers on the d2, with the CSAT d’, and with the percentile
in correct answers on Caras. The children who did not press the bar for relevant stimuli in the
CPT-II, also crossed out fewer relevant stimuli on the d2 and on Caras, and made more com-
mission errors on the CSAT.
Nonetheless, as has been pointed out, these correlations tended to be weak, just as the
correlations were that should reflect convergent validity. It thus appears that measurement of
selective attention and sustained attention are related inasmuch as the different tests of sus-
tained attention, on the one hand, and selective attention, on the other, are related to each oth-
er. This would negate a claim that some of these tests measure one thing and others measure
another; instead, each test seems to measure something that is slightly related to what the oth-
ers measure. According to Santacreu et al. (2011), the classification into separate groupings of
tasks is somewhat artificial, since all the tasks that are intended to measure attention in isola-
tion involve several attentional and non-attentional processes; they are not purely measures of
sustained or selective attention. This may be one explanation for the inability of these tests to
show convergent validity.
Hypothesis 3 stated that, in line with Epstein et al. (2003), Labruna et al. (1998) and
Reynolds et al. (1998), the global CPT-II scores would explain a greater proportion of the
variance of the ADHD diagnosis than any other test used. In the present study, the test that
most explained the variance of the ADHD diagnosis was indeed the CPT-II, as expected, and
the CPT-II confidence index in particular, which improved the prediction by 19.6% when
discriminating between people with ADHD or with LD.
In addition, in participants of ages 8 and above, the d2 concentration percentile also

contributed significantly to improve prediction of the diagnosis. On the other hand, in the total
participant sample, the percentile of right answers on Caras, the CPT-II clinical confidence
index, and the CPT-II d’ sensitivity index explained 22% of the variance. The test that least
contributed to explaining the variance of the ADHD diagnosis was the AGL; in this study it
actually detracted from correct classification of participants with respect to the null model.
Therefore, in order to predict a possible ADHD diagnosis, the use of both sustained attention
and selective attention tests in the clinical evaluation is recommended, specifically the d2 in
children under 8 years of age, and Caras in older children, as well as CPT-II in both cases.
The AGL test is disadvised, and the EMAV and CSAT are not recommended as a first option.
Regarding study limitations, although a good number of attention tests were included,
not all attention tests have been studied. For example, we did not use the DiViSA, which ac-
cording to Santacreu et al. (2011) and Santacreu and Quiroga (2015), shows good predictive
power for diagnosing ADHD; nor the Tea-CH test, which has not been translated to Spanish
or standardized for a Spanish population. On the other hand, although the clinical sample used
in this study is large, the large sample size is due in part to the wide spread of the children’s
ages. Participants’ age is a factor that affects performance in practically every type of task,
whether in attention or intelligence (Lee et al., 2006; Santacreu et al., 2011; Servera &
Llabrés, 2004; Shaw et al., 2006). In order to avoid the contaminating effect of age, we used
percentiles or T scores in those tests where rankings were available. Nonetheless, this proce-
dure overlooks a possible interaction of age with the study variables, and future studies should
take this factor into account. Such studies should also consider possible gender differences;
these have not been explored here, since they were not the focus of this study, but they may
also interact with the processes studied here. One must also take into consideration the corre-
lational nature of this study and the sample selection method.
While the clinical sample drawn from years of clinical practice is a strength in terms
of ecological validity, external validity is limited, since the participants represent a conven-
ience sample. Regarding the (non-experimental) design and the data analysis method, we
must remember that the relationships found between variables could be contaminated by ex-
traneous variables, or potential interaction from the measurement instruments or idiosyncratic
characteristics of the sample. Since only linear relationship patterns were observed between
variables, correlations were used in this study, but we must remember that the relationship
between variables can be moderated or mediated by third variables. In any case, the methods
of analysis seem to be adequate, keeping in mind the exploratory purpose of this study, and
the number of instruments used.
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Received: 28-09-2020
Accepted: 02-03-2021
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Validez de las pruebas de atención para el diagnóstico diferencial de TDAH

Article in Electronic Journal of Research in Educational Psychology · September 2021

Helena Garrido-Hernansaiz María Cantero-García

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Iván Sánchez-Iglesias Jesús González-Moreno

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Simulation of the filtering role of habituation View project

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Silvia Álava Sordo 1, Helena Garrido-Hernansaiz2, María

Correspondence: María Cantero-García. Área de Salud. Facultad de Psicología. Universidad Internacional de

Método. Se estudió la validez convergente de los instrumentos mediante correlaciones no

An ADHD diagnosis is conducted exclusively on the basis of symptoms observed, that

Table 1. Principal Selective Attention Tasks (Discrimination test)

AGL, global-local atten- 12 to 18 Selective attention .80 on all indices

Table 2. Principal Sustained Attention Tasks (Continuous attention tests).

Test of sustained atten- 6 to 10 Sustained attention .80 Right answers

Aula Nesplora. (Climent 6 to 16 Auditory sustained .96 Auditory right an-

Table 3. Correlations found between the attention tests.

AULA Divisa Caras AGL EMAV

Objectives and hypotheses

d2 attention test (Brickenkamp, 2004). Evaluates several aspects of selective attention

Escala Magallanes de Atención Visual [Magallanes Scales of visual attention]

Atención Global-Local [Global-local attention] (AGL) (Blanca et al., 2005). Evaluates

Sustained attention tests

Table 4. Sample sizes of the correlations between attention tests.

CPT-II CSAT CARAS d2 AGL

Table 5. Correlations between attention tests according to type of attention measured.

Sustained Attention Selective Attention

Global Omission Commission

Pc TC (Caras) - .47 ** .16 * -.14 * -.05 .18 * -.11 -.12

Test and scale n B Wald df p R2

Note: forward stepwise introduction method. Pc = Percentile. B = nonstandardized regression coefficient.

Table 7. Logistic regression. Indices that significantly contributed to predicting ADHD.

Discussion and Conclusions

Regarding sub-hypothesis 1.2 on selective attention indices, despite the existence of

In addition, in participants of ages 8 and above, the d2 concentration percentile also

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Servera, M. & Llabrés, J. (2015). CSAT-R. Tarea de Atención Sostenida en la Infancia-

Thurstone, L. L. & Yela, M. (2012) Caras-R. Test de percepción de diferencias. [“Caras-R”

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