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Applied Neuropsychology
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Identifying Cognitive Problems in Children and

Adolescents with Depression Using Computerized
Neuropsychological Testing
a b c d a b
Brian L. Brooks , Grant L. Iverson , Elisabeth M. S. Sherman & Marie-Claude
d e
Roberge
a
Neurosciences, Alberta Children's Hospital , Calgary, Canada
b
Departments of Pediatrics and Clinical Neurosciences, University of Calgary , Calgary,
Canada
c
Department of Psychiatry , University of British Columbia , Vancouver, Canada
d
British Columbia Mental Health & Addiction Services , Coquitlam, Canada
e
University of Ottawa , Ottawa, Canada
Published online: 08 Feb 2010.

To cite this article: Brian L. Brooks , Grant L. Iverson , Elisabeth M. S. Sherman & Marie-Claude Roberge (2010) Identifying
Cognitive Problems in Children and Adolescents with Depression Using Computerized Neuropsychological Testing, Applied
Neuropsychology, 17:1, 37-43, DOI: 10.1080/09084280903526083

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 APPLIED NEUROPSYCHOLOGY, 17: 37–43, 2010
Copyright # Taylor & Francis Group, LLC
ISSN: 0908-4282 print=1532-4826 online
DOI: 10.1080/09084280903526083

Identifying Cognitive Problems in Children and

Adolescents with Depression Using Computerized
Neuropsychological Testing
Brian L. Brooks
Neurosciences, Alberta Children’s Hospital, Calgary, Canada and Departments of Pediatrics
and Clinical Neurosciences, University of Calgary, Calgary, Canada
Downloaded by [University of North Texas] at 08:17 04 December 2014

Grant L. Iverson
Department of Psychiatry, University of British Columbia, Vancouver, Canada and British
Columbia Mental Health & Addiction Services, Coquitlam, Canada

Elisabeth M. S. Sherman
Neurosciences, Alberta Children’s Hospital, Calgary, Canada and Departments of Pediatrics
and Clinical Neurosciences, University of Calgary, Calgary, Canada

Marie-Claude Roberge
British Columbia Mental Health & Addiction Services, Coquitlam, Canada and
University of Ottawa, Ottawa, Canada

Depression in children and adolescents can negatively impact cognitive functioning,

social development, and academic performance. The purpose of this study was to
determine whether a computerized battery of neuropsychological tests could detect
neurocognitive difficulties in children and adolescents with depression. Participants
included 30 children and adolescents between the ages of 9 and 17 years (M ¼ 14.6,
SD ¼ 2.1) with a clinical diagnosis of depression. Healthy control participants were
individually matched on age, education, sex, race, primary language, handedness, and
self-reported computer familiarity. All participants completed the Central Nervous
System Vital Signs computerized battery. This battery of seven tests yields 23 test scores
and 5 domain scores (Memory, Psychomotor Speed, Reaction Time, Complex Atten-
tion, and Cognitive Flexibility). Children and adolescents with depression performed
worse on the Memory (Cohen’s d ¼ .43) and Complex Attention domains (d ¼ .58) than
matched controls. On the individual test scores, children and adolescents with
depression performed worse on delayed verbal memory (d ¼ .63), delayed visual
memory (d ¼ .34), measures of reaction time (d ¼ .34–.53), and accuracy=inhibition on
complex attention tasks (d ¼ .49–.65). When considering the five domain scores
simultaneously, children and adolescents with depression were more likely to have
two or more scores at or below the 5th percentile (p ¼ .05). Children and adolescents
with depression have problems with reduced processing speed, memory for verbal

Author Disclosure: Dr. Brooks and Dr. Iverson have received past grant funding from the CNS Vital Signs test publishing company. The
developers or publishers of CNS Vital Signs did not provide funding for, nor influence the conduct of, this study.
Address correspondence to Brian L. Brooks, Ph.D., Neurosciences Program, Alberta Children’s Hospital, 2888 Shaganappi Trail NW, Calgary,
Alberta, Canada, T3B 6A8. E-mail: brian.brooks@calgaryhealthregion.ca
 38 BROOKS, IVERSON, SHERMAN, & ROBERGE
information, and executive functioning on this computerized battery of tests, which
represents a feasible method for neuropsychological screening.
Key words: adolescent, children, cognition, computerized testing, depression, memory
INTRODUCTION
Depression is associated with perceived and=or
measurable problems in cognition. Clinicians are inter-
ested in identifying the presence of cognitive problems
as part of the evaluation, diagnosis, and treatment of
depression. The Diagnostic and Statistical Manual of Men-
tal Disorders, Fourth Edition, Text Revision (American
Psychiatric Association, 2000) indicates that, ‘‘many indi-
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viduals report impaired ability to think, concentrate, or
make decisions (Criterion A8). They may appear easily
distracted or complain of memory difficulties. Those in
intellectually demanding academic or occupational pur-
suits are often unable to function adequately even when
they have mild concentration problems . . .’’ (p. 350).
Cognitive problems associated with depression have
been well studied in adults, with meta-analyses identifying
reductions in sustained attention, psychomotor speed,
memory, verbal fluency, and cognitive flexibility as the
most prominent cognitive features (Burt, Zembar, &
Niederehe, 1995; Christensen, Griffiths, Mackinnon, &
Jacomb, 1997; Henry & Crawford, 2005; Zakzanis,
Leach, & Kaplan, 1998). Less research has been conduc-
ted with children and adolescents with depression. The
neuropsychological effects of depression in children and
adolescents have included measurable problems across
most domains, including Sustained Attention, Processing
Speed, Reaction Time, Learning and Memory, Sequen-
cing, and Problem-Solving (Cataldo, Nobile, Lorusso,
Battaglia, & Molteni, 2005; Emerson, Mollet, & Harrison,
2005; Günther, Holtkamp, Jolles, Herpertz-Dahlmann, &
Konrad, 2004; Kovacs & Goldston, 1991; Lauer et al.,
1994; Wilkinson & Goodyer, 2006). Clearly, identifying
the presence of cognitive problems in children and adoles-
cents with depression is important because impaired
thinking can have a negative impact on academic abilities
(Fröjd et al., 2008; Kovacs & Goldston, 2004) and social
functioning (Kovacs & Goldston, 2004).
The assessment of cognition in children and adoles-
cents with depression using computerized neurocognitive
batteries likely represents a feasible option for screening
cognitive abilities. For example, Kyte, Goodyer, and
Sahakian (2005) reported that adolescents with first-
episode depression had worse performance on several
measures of executive functioning on the Cambridge
Neuropsychological Test Automated Battery.
The Central Nervous System (CNS) Vital Signs com-
puterized neurocognitive battery (Gualtieri & Johnson,
2006d) is normed across the lifespan (i.e., ages 7 to 90)
and represents one computerized method for evaluating
cognition. Recent studies have demonstrated that this
computerized test battery can rapidly identify cognitive
problems in adults with various psychiatric diagnoses,
including depression (Gualtieri & Johnson, 2006a,
2007, 2008; Gualtieri, Johnson, & Benedict, 2006;
Gualtieri & Morgan, 2008; Iverson, Brooks, Young,
Johnson, & Gualtieri, 2007c), anxiety (Gualtieri &
Morgan), bipolar disorder (Gualtieri & Johnson,
2006b; Gualtieri & Morgan; Iverson, Brooks, & Young,
in press), and attention deficit=hyperactivity disorder
(ADHD; Iverson, Brooks, Weiss, Johnson, & Gualtieri,
2007b). The use of this computerized battery in children
and adolescents with various clinical diagnoses is less
well known, although there have been a few studies
examining performance in children and adolescents
with treated (Gualtieri & Johnson, 2006c, 2008) and
untreated (Iverson, Brooks, Weiss, Gualtieri, & Johnson,
2007a) ADHD.
The purpose of this study is to examine whether the
CNS Vital Signs computerized test battery is sensitive
to cognitive problems associated with depression in chil-
dren and adolescents. This is a preliminary examination
of the sensitivity of CNS Vital Signs in this clinical
population because of the relatively small sample size
and the absence of clearly defined depression variables.
It is hypothesized that children and adolescents with
depression will have worse cognitive abilities, parti-
cularly attention, processing speed, memory, and flex-
ible thinking, than matched controls (i.e., these are the
cognitive domains measured by the CNS Vital Signs
battery). In addition, previous work with mood disor-
ders and performance on the computerized battery
(Iverson et al., 2007c; Iverson, Brooks, & Young, in
press) would suggest there is a subset of patients with
depression who have substantial cognitive problems,
and this subset accounts for the group differences and
effect sizes.
METHOD
Participants
The participants for this study included 30 children and
adolescents, selected from an archival database, who
were diagnosed with depression (i.e., major depressive

disorder or depressive disorder not otherwise specified).
Clinicians at the North Carolina Neuropsychiatry Clinics
(Chapel Hill and Charlotte, North Carolina) gave a
primary diagnosis of depression to all patients according
to the Diagnostic and Statistical Manual of Mental Disor-
ders, Fourth Edition (American Psychiatric Association,
1994). The majority of the sample were taking antidepres-
sant medication at the time of their evaluation (e.g.,
63.3%), and 16.7% had a comorbid anxiety disorder.
The average age of the patients was 14.6 years
(SD ¼ 2.1, range ¼ 9–17, median ¼ 15), and their average
years of education was 9.2 (SD ¼ 2.2, range ¼ 4–12,
median ¼ 9). The majority of the patient sample were
right-handed (n ¼ 29, 96.7%), female (n ¼ 22, 73.3%),
and Caucasian (n ¼ 28, 93.3%; African American,
n ¼ 2, 6.7%). The entire sample identified English as their
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primary language and reported they were still going to
school. The sample either had some (n ¼ 4; 13.3%) or
frequent (n ¼ 26; 86.7%) computer use.
Children and adolescents with depression were
compared to 30 healthy control children and adolescents
selected from the CNS Vital Signs normative database.
The CNS Vital Signs database contains 1,069 healthy
people between the ages of 7 and 90 years who com-
prised the standardization sample. They were screened
to be in good health, without past or present psychiatric
or neurological disorders (i.e., head injury, learning
disabilities, etc.), and were free of any centrally acting
medications. The control participants were individually
and closely matched to the participants with depression
on education (M ¼ 9.3, SD ¼ 2.1; t(58) ¼ .12, p ¼ .90),
and individually and precisely matched on age (t(58) ¼
.00, p ¼ 1.00), sex, race, primary language, handedness,
student status, and self-reported computer use. The
precise matching procedure controls for variability in
neurocognitive test performance that might result from
differences in demographic variables (for a discussion
of the impact of computer familiarity on test per-
formance, see Iverson, Brooks, Ashton, Johnson, &
Gualtieri, 2009).
Measures
CNS Vital Signs is a computerized battery composed of
seven common neuropsychological measures, including
verbal and visual memory, finger tapping, Symbol Digit
Coding, the Stroop test, a Shifting Attention Test, and a
Continuous Performance Test (CPT). The battery gen-
erates 15 primary scores (as well as several secondary
scores), which are used to calculate 5 domain scores
(Memory, Psychomotor Speed, Reaction Time, Cogni-
tive Flexibility, and Complex Attention). The domain
(or index) scores are converted into standard scores
and are presented with a mean of 100 and a standard
deviation (SD) of 15.
COMPUTERIZED TESTING IN DEPRESSION 39
The battery is normed across the lifespan for
children, adolescents, and adults, and it is presented at
a grade-four reading level. The measures have adequate
test-retest reliability (Pearson’s r for the domain scores
ranged from r ¼ .65–.87; mean interval of 62 days,
range ¼ 1–282 days), adequate concurrent validity with
traditional paper-and-pencil measures and other compu-
terized tests (i.e., most of the Pearson’s r for the selected
scores were small to medium for both the traditional
paper-and-pencil and other computerized tests), and
the domain scores have been shown to discriminate
between various clinical groups. More detailed
information about the reliability and validity of this test
battery is available from other sources (Gualtieri &
Johnson, 2005, 2006b; Gualtieri et al., 2006). Descrip-
tions of the seven measures on the CNS Vital Signs
battery are presented in Table 1.
Analyses
Analysis of the CNS Vital Signs test results involved: a)
comparing the two groups on the five domain scores
using multivariate analyses of variance (MANOVA)
and following up with independent samples t tests; b)
examining the effect sizes for the individual primary
scores; and c) comparing the base rates of low domain
scores using nonparametric analyses (i.e., chi-square;
v2). Calculations for the base rates of low scores involve
simultaneously examining performance on the five
domain scores, rather than performance on each domain
in isolation. The base rates of low domain scores were
calculated using four cut-off scores that might be
routinely used in clinical practice, including: a) below
the 16th percentile (i.e., more than 1 SD below the mean
or index <85), b) below the 10th percentile (i.e., index
<81), c) at or below the 5th percentile (i.e., index

76), and d) at or below the 2nd percentile (i.e., more
than 2 SDs below the mean or index
70).
RESULTS
The two groups were compared on the five domain
scores using MANOVA followed by t tests. Box’s M test
was significant, indicating that the covariance matrices
differed (p ¼ .006). Moreover, Levene’s test was signifi-
cant for one of the five index scores (i.e., Complex
Attention), indicating heterogeneity of variance between
groups. However, MANOVA is generally robust to
violations of the general linear model assumptions and
will therefore be interpreted. The multivariate effect
was significant (Wilks’ Lambda ¼ .82; F(5, 54) ¼ 2.41,
p < .05, partial eta squared ¼ .18, observed power ¼ .72).
The follow-up t tests revealed significantly worse neu-
ropsychological test scores for those in the depression
 40 BROOKS, IVERSON, SHERMAN, & ROBERGE

TABLE 1
Descriptions of the CNS Vital Signs Measures

CNS Vital Signs Measure Description of Test

Verbal Memory This test measures recognition memory for words. Fifteen words are presented, 1 by 1, on the screen every 2 seconds.
For immediate recognition, the participant has to identify those figures nested among 15 new figures. Then after six
more tests, there is a delayed recognition trial.
Visual Memory This test measures recognition memory for figures. Fifteen geometric figures are presented, 1 by 1, on the screen. For
immediate recognition, the participant has to identify those figures nested among 15 new figures. Then after five
more tests, there is a delayed recognition trial.
Finger Tapping Participants are asked to press the space bar with their right index finger as many times as they can in 10 seconds.
They do this once for practice, and then there are three test trials. The test is repeated with the left hand.
Symbol Digit Coding The test consists of serial presentations of screens, each of which contains a bank of eight symbols above and eight
empty boxes below. The participant types in the number that corresponds to the symbol that is highlighted. Only
the digits from two through nine are used; this is to avoid the confusion between ‘‘1’’ and ‘‘I’’ on the keyboard.
Moreover, the participant is only allowed to use the numbers two through nine at the top of a traditional keyboard
(i.e., the computer program does not allow a person to use a numerical pad). This prevents the potential for a
distinct advantage for those who are skilled at using the numerical pad or for those who are right- versus
left-handed.
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Stroop Test The test has three parts. In the first part, the words RED, YELLOW, BLUE, and GREEN (printed in black) appear
at random on the screen, and the participant presses the space bar as soon as he or she sees the word. In the second
part, the words RED, YELLOW, BLUE, and GREEN appear on the screen, printed in color. The participant is
asked to press the space bar when the color of the word matches what the word says. In the third part, the words
RED, YELLOW, BLUE, and GREEN appear on the screen, printed in color. The participant is asked to press the
space bar when the color of the word does not match what the word says.
Shifting Attention Test A measure of ability to shift from one instruction set to another quickly and accurately. Participants are instructed to
match geometric objects either by shape or by color. Three figures appear on the screen, one on top and two on the
bottom. The top figure is either a square or a circle. The bottom figures are a square and a circle. The figures are
either red or blue (mixed randomly). The participant is asked to match one of the bottom figures to the top figure.
The rules change at random (i.e., match the figures by shape; for another, by color).
Continuous Performance A measure of vigilance or sustained attention or attention over time. The participant is asked to respond to the target
stimulus ‘‘B’’ but not to any other letter. In 5 minutes, the test presents 200 letters. Forty of the stimuli are targets
(the letter ‘‘B’’), 160 are non-targets (other letters). The stimuli are presented at random, although the target
stimulus is ‘‘blocked,’’ so it appears eight times during each minute of the test.

group on the Complex Attention domain score (t(58) ¼
2.14, p ¼ .036, Cohen’s d effect size ¼ .58). However, the
two groups were not significantly different on the
Complex Attention domain using a Mann Whitney U
test (z ¼ 1.36, p ¼ .17), which was performed because of
the heterogeneity of variance. Although the other domain
scores were not significantly different on the between-
group comparisons, there was a medium effect size for
the Memory domain (d ¼ .43, t(58) ¼ 1.65, p ¼ .10). The
Psychomotor Speed (d ¼ .22, t(58) ¼ .83, p ¼ .41), Reac-
tion Time (d ¼ .18, t(58) ¼ 0.70, p ¼ .49), and Cognitive
Flexibility (d ¼ .18, t(58) ¼ .68, p ¼ .50) domain scores
had small effect sizes. The results of the group compari-
sons are presented in Table 2.
Table 2 also presents the mean performance on the
various scores derived from the seven measures for the
children and adolescents with depression and matched
controls. Medium effect sizes were found on the delayed
recognition of words (d ¼ .63) and the number of
commissions on the CPT (d ¼ .65). Similar to the index
scores, there were some small-to-medium effect sizes
on many of the individual test scores. This included
visual memory delayed correct hits (d ¼ .34), number
of errors on the Symbol Digit Coding test (d ¼ .49),
simple reaction time (d ¼ .53), complex reaction time
(d ¼ .44), and errors (d ¼ .56) on the Stroop test, number
of errors on the Shifting Attention Test (d ¼ .59), and
number of correct (d ¼ .57), omissions (d ¼ .57), and reac-
tion time (d ¼ .34) on the Continuous Performance Test.
The base rates of low domain scores are presented in
Table 3. In the children and adolescents with depression,
43.3% obtained two or more scores below 1 SD, compared
with 16.7% of the control group (v2(1) ¼ 5.08, p ¼ .02;
Odds Ratio ¼ 3.8, 95% CI ¼ 1.2–12.2; Sensitivity ¼ .72,
Specificity ¼ .60]. When considering below the 10th per-
centile as a cutoff, 33.3% obtained two or more low scores,
compared with 10% of the control group (v2(1) ¼ 4.81,
p ¼ .03; Odds Ratio ¼ 4.5, 95% CI ¼ 1.2–17.1; Sensitivity ¼
.77, Specificity ¼ .57].
DISCUSSION
This study sought to determine whether the CNS Vital
Signs computerized battery, which is a rapid screen of
a person’s thinking abilities, is sensitive to cognitive
impairment in children and adolescents with depression.
In the present study, children and adolescents with
 COMPUTERIZED TESTING IN DEPRESSION 41

TABLE 2
CNS Vital Signs Test Performance in Depressed and Matched Control Samples

Children & Adolescents Matched Cohen’s Effect

with Depression Controls T test P value Size (d)

CNS Vital Signs Domain Scores

Memory (SD) 95.7 (16.4) 102.0 (12.9) 1.65 0.10 0.43
Psychomotor Speed (SD) 93.9 (12.8) 97.2 (17.3) 0.83 0.41 0.22
Reaction Time (SD) 95.6 (25.4) 99.4 (15.9) 0.70 0.49 0.18
Cognitive Flexibility (SD) 98.0 (20.6) 101.1 (14.3) 0.68 0.50 0.18
Complex Attention (SD) 88.7 (25.4) 100.0 (13.7) 2.14 0.04 0.58
Scores from Individual Tests
VBM Immediate – Hits (SD) 12.7 (2.1) 13.2 (1.9) 1.10 0.28 0.28
VBM Immediate – Passes (SD) 14.4 (0.8) 14.2 (1.1) 0.69 0.49 0.18
VBM Delayed – Hits (SD) 10.2 (4.2) 12.2 (2.3) 2.33 0.02y 0.63
VBM Delayed – Passes (SD) 14.1 (1.6) 14.0 (1.4) 0.34 0.73 0.09
VIM Immediate – Hits (SD) 12.4 (2.1) 12.4 (1.5) 0.14 0.89 0.04
VIM Immediate – Passes (SD) 11.8 (2.0) 11.9 (2.2) 0.25 0.80 0.06
VIM Delayed – Hits (SD) 10.7 (3.5) 11.7 (2.1) 1.29 0.20 0.34
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VIM Delayed – Passes (SD) 12.4 (2.2) 12.5 (1.7) 0.20 0.85 0.05
Finger Tapping – Total Right (SD) 52.5 (13.2) 54.5 (13.5) 0.57 0.57 0.15
Finger Tapping – Total Left (SD) 50.8 (7.9) 50.3 (8.9) 0.26 0.80 0.07
Symbol Digit – Correct (SD) 55.2 (12.5) 58.5 (15.3) 0.44 0.37 0.24
Symbol Digit – Errors (SD) 1.5 (1.4) 0.9 (1.0) 1.19 0.07 0.49
Stroop Simple Reaction Time (SD) 309.4 (99.5) 268.2 (57.2) 1.97 0.05y 0.53
Stroop Complex Reaction Time (SD) 650.7 (163.2) 595.7 (87.8) 1.63 0.11 0.44
Stroop Reaction Time (SD) 759.0 (172.4) 722.6 (118.7) 0.95 0.35 0.25
Stroop Errors (SD) 2.8 (2.3) 1.8 (1.4) 2.10 0.04 0.56
SAT – Correct (SD) 48.9 (8.4) 49.9 (10.3) 0.40 0.69 0.10
SAT – Errors (SD) 13.3 (13.6) 8.0 (4.0) 2.02 0.05 0.59
SAT – Reaction Time (SD) 993.1 (234.7) 1055.6 (180.8) 1.16 0.25 0.30
CPT – Correct (SD) 39.2 (1.7) 39.8 (0.6) 1.98 0.05 0.57
CPT – Omissions (SD) 0.8 (1.7) 0.2 (0.6) 1.98 0.05 0.57
CPT – Commissions (SD) 2.7 (3.4) 1.2 (1.4) 2.34 0.03 0.65
CPT – Reaction Time (SD) 443.5 (52.5) 424.4 (58.2) 1.33 0.19 0.34

Note. Children and adolescents with depression, n ¼ 30; matched controls, n ¼ 30.
SD ¼ Standard deviation; VBM ¼ Verbal Memory; VIM ¼ Visual Memory; SAT ¼ Shifting Attention Test; CPT ¼ Continuous Performance Test.
Degrees of freedom for independent t tests ¼ 68. Cohen’s effect size (d) can be interpreted with the following classifications: small (0.20–0.49),
medium (0.50–0.79), large (0.80). Results marked with a y were also significant at p < .05 using a Mann-Whitney U test.

depression had statistically lower performance com-
pared with matched controls on the Complex Attention
domain (medium effect size, d ¼ .58). The Complex
Attention domain is a composite measure of a person’s
accuracy (i.e., number of errors) during tests of sus-
tained attention, shifting attention, and inhibition. In
other words, this domain represents a person’s perform-
ance on computerized measures of executive functions.
The children and adolescents with depression had worse
performance than controls and medium effect sizes on
all of the measures that contribute to the Complex
Attention domain score: Stroop errors (d ¼ .56), Shifting
Attention Test errors (d ¼ .59), Continuous Performance
Test omissions (d ¼ .57), Continuous Performance Test
commissions (d ¼ .65). They also had worse perform-
ance and a medium effect size on the Stroop Simple
Reaction Time score (d ¼ .53). There were no statisti-
cally significant differences on the other domain scores,
although there was a small-to-medium effect size on the
Memory domain (d ¼ .43), which was likely the result of
lower performance on the delayed Verbal Memory test
(medium effect size, d ¼ .63) and the delayed Visual
Memory test (small effect size, d ¼ .34). The absence of
statistically significant findings, despite having small-to-
medium effect sizes, is likely the result of the relatively
small samples for the two groups and the increased het-
erogeneity of test scores in the children with depression.
Overall, the results of this study suggest that children
and adolescents with depression have problems with
reduced processing speed, memory for verbal infor-
mation, and set shifting, impulsivity, and inhibition
during tests of executive functioning. These results are
consistent with existing studies involving traditional
paper-and-pencil testing of children and adolescents with
depression (e.g., Cataldo et al., 2005; Emerson et al.,
2005; Günther et al., 2004; Kovacs & Goldston, 1991;
Lauer et al., 1994; Wilkinson & Goodyer, 2006) and a
study involving computerized testing of children and
 42 BROOKS, IVERSON, SHERMAN, & ROBERGE
TABLE 3
Base Rates of Low Domain Scores on the CNS Vital Signs in
Children and Adolescents with Depression
Children &
Number of Domain Scores Adolescents
below Cut-offs with Depression
<16th Percentile
0 Domain Scores Below Cutoff 33.3
1 or More Domains Below Cutoff 66.7
2 or More Domains Below Cutoff 43.3
3 or More Domains Below Cutoff 23.3
4 or More Domains Below Cutoff 23.3
5 Domains Below Cutoff 10.0
<10th Percentile
0 Domain Scores Below Cutoff 40.0
1 or More Domains Below Cutoff 60.0
2 or More Domains Below Cutoff 33.3
3 or More Domains Below Cutoff 16.7
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4 or More Domains Below Cutoff 3.3

5th Percentile
0 Domain Scores Below Cutoff 50.0
1 or More Domains Below Cutoff 50.0
2 or More Domains Below Cutoff 30.0
3 or More Domains Below Cutoff 6.7

2nd Percentile
0 Domain Scores Below Cutoff 60.0
1 or More Domains Below Cutoff 40.0
2 or More Domains Below Cutoff 10.0
3 or More Domains Below Cutoff 3.3
Note. Children and adolescents with depression, n ¼ 30; matched
controls, n ¼ 30.
Values represent cumulative percent of each sample.
adolescents with depression (e.g., Kyte et al., 2005) that
identified measurable problems with sustained attention,
processing speed, reaction time, learning and memory,
sequencing, inhibition, and problem-solving.
This study also presented psychometrically derived
information on the base rates of low scores, which can
be used with this computerized testing to supplement
clinical judgment, for identifying those children and
adolescents with depression who have cognitive pro-
blems. When considering the prevalence of low domain
scores, our previous research has often indicated that
having two or more domain scores at or below the 5th
percentile is suggestive of frank cognitive impairment
(e.g., Iverson et al., 2007c; Iverson, Brooks, & Young,
in press). In the present study, 30% of children and ado-
lescents with depression had two or more domain scores
at or below the 5th percentile. This study supports the
hypothesis that there is a subset of patients with
depression who have frank cognitive impairment, and
it is this subset that drives the effect sizes in group com-
parisons. Future studies should focus on the differences
(e.g., number and severity of depressive symptoms, daily
functioning, academic performance, and quality of life)
between those with and those without impairment in
their thinking abilities.
There were some limitations with the present study
that are worth noting. First, the sample sizes of the
groups in this study were relatively small, and this likely
resulted in low power for statistical analyses. This is
Matched most obvious with some of the between-group compar-
Controls
isons that were non-significant but had medium effect
sizes. For example, the difference between the children
56.7 and adolescents with depression and the healthy
43.3 controls on the Symbol Digit Errors score was not
16.7
10.0
significant (p ¼ .07), despite having a medium effect size
— (d ¼ .49). Another limitation of this study is the lack of
— clinical information on the sample of children and ado-
lescents with depression. For example, we are unable to
63.3 determine the severity and=or the duration of depression
36.7
10.0
in these patients. We are unable to determine how long a
10.0 subset of the patients with depression has been on
— medication, the name of the medication, and whether
they have responded to the medication. Moreover, we
73.3 are unable to determine if there is a relation between
26.7
10.0
more symptoms of depression and worse cognition.
— The absence of some of this clinical information, which
is the result of the data being obtained from an archival
80.0 database, does not discount the new knowledge
20.0 obtained from this study. It does, however, limit the
3.3
—
generalizability of the findings, and further evaluations
with larger, better-defined clinical groups are warranted.
A third limitation of this study is that we do not have
information on the subjective report of cognitive
problems, and we do not know how many children
and adolescents also have problems with social and
academic skills. This will be an important contribution
of future research using brief computerized screening
batteries of cognition in children and adolescents
with depression.
The CNS Vital Signs computerized battery represents
a feasible methodology for screening patients’ cognitive
abilities. By quickly getting a sense of a whether a
patient with depression has cognitive impairment, a
clinician can consider the most appropriate treatment
and determine if a more thorough neuropsychological
assessment is warranted.
ACKNOWLEDGEMENTS
The authors thank Drs. Gualtieri and Johnson for pro-
viding the data for this study. This study was presented
at the 28th annual conference of the National Academy
of Neuropsychology (October 2008).
REFERENCES
American Psychiatric Association. (1994). Diagnostic and statistical
manual of mental disorders (4th ed.). Washington, DC: Author.

American Psychiatric Association. (2000). Diagnostic and statistical
manual of mental disorders (4th ed., text rev.). Washington, DC:
Author.
Burt, D. B., Zembar, M. J., & Niederehe, G. (1995). Depression and
memory impairment: A meta-analysis of the association, its pattern,
and specificity. Psychological Bulletin, 117, 285–305.
Cataldo, M. G., Nobile, M., Lorusso, M. L., Battaglia, M., & Molteni,
M. (2005). Impulsivity in depressed children and adolescents: A
comparison between behavioral and neuropsychological data.
Psychiatry Research, 136, 123–133.
Christensen, H., Griffiths, K., Mackinnon, A., & Jacomb, P. (1997).
A quantitative review of cognitive deficits in depression and
Alzheimer-type dementia. Journal of the International Neuropsycho-
logical Society, 3, 631–651.
Emerson, C. S., Mollet, G. A., & Harrison, D. W. (2005). Anxious-
depression in boys: An evaluation of executive functioning. Archives
of Clinical Neuropsychology, 20, 539–546.
Fröjd, S. A., Nissinen, E. S., Pelkonen, M. U., Marttunen, M. J.,
Koivisto, A. M., & Kaltiala-Heino, R. (2008). Depression and
Downloaded by [University of North Texas] at 08:17 04 December 2014
school performance in middle adolescent boys and girls. Journal
of Adolescence, 31, 485–498.
Gualtieri, C. T., & Johnson, L. G. (2005). Neurocognitive testing
supports a broader concept of mild cognitive impairment. American
Journal of Alzheimer’s Disease and Other Dementias, 20, 359–366.
Gualtieri, C. T., & Johnson, L. G. (2006a). Antidepressant side
effects in children and adolescents. Journal of Child and Adolescent
Psychopharmacology, 16, 147–157.
Gualtieri, C. T., & Johnson, L. G. (2006b). Comparative neurocogni-
tive effects of five psychotropic anticonvulsants and lithium.
Medscape General Medicine, 8(3), 46.
Gualtieri, C. T., & Johnson, L. G. (2006c). Efficient allocation of
attentional resources in patients with ADHD: Maturational changes
from age 10 to 29. Journal of Attention Disorders, 9, 534–542.
Gualtieri, C. T., & Johnson, L. G. (2006d). Reliability and validity of a
computerized neurocognitive test battery, CNS Vital Signs. Archives
of Clinical Neuropsychology, 21, 623–643.
Gualtieri, C. T., & Johnson, L. G. (2007). Buproprion normalizes
cognitive performance in patients with depression. Medscape
General Medicine, 9(1), 22.
Gualtieri, C. T., & Johnson, L. G. (2008). Medications do not
necessarily normalize cognition in ADHD patients. Journal of
Attention Disorders, 11, 459–469.
Gualtieri, C. T., Johnson, L. G., & Benedict, K. B. (2006). Neurocog-
nition in depression: Patients on and off medication versus healthy
comparison participants. Journal of Neuropsychiatry and Clinical
Neurosciences, 18, 217–225.
Gualtieri, C. T., & Morgan, D. W. (2008). The frequency of cognitive
impairment in patients with anxiety, depression, and bipolar
COMPUTERIZED TESTING IN DEPRESSION 43
disorder: An unaccounted source of variance in clinical trials.
Journal of Clinical Psychiatry, 69, 1122–1130.
Günther, T., Holtkamp, K., Jolles, J., Herpertz-Dahlmann, B., &
Konrad, K. (2004). Verbal memory and aspects of attentional con-
trol in children and adolescents with anxiety disorders or depressive
disorders. Journal of Affective Disorders, 82, 265–269.
Henry, J., & Crawford, J. R. (2005). A meta-analytic review of verbal
fluency deficits in depression. Journal of Clinical and Experimental
Neuropsychology, 27, 78–101.
Iverson, G. L., Brooks, B. L., Ashton, V. L., Johnson, L. G., &
Gualtieri, C. T. (2009). Does familiarity with computers affect com-
puterized neuropsychological test performance? Journal of Clinical
and Experimental Neuropsychology, 31, 594–604.
Iverson, G. L., Brooks, B. L., Weiss, M. D., Gualtieri, C. T., &
Johnson, L. G. (2007a). Clinical usefulness of CNS-Vital Signs for
assessing neurocognition in ADHD. The Clinical Neuropsychologist,
21(4), 686.
Iverson, G. L., Brooks, B. L., Weiss, M. D., Johnson, L. G., &
Gualtieri, C. T. (2007b, May). Computerized assessment of neurocog-
nitive impairment in adults with ADHD. Paper presented at the 160th
annual meeting of the American Psychiatric Association, San
Diego, CA.
Iverson, G. L., Brooks, B. L., Young, A. H., Johnson, L. G., &
Gualtieri, C. T. (2007c). Identifying frank neurocognitive impairment
with CNS Vital Signs in patients with untreated depression. Paper
presented at the 160th annual meeting of the American Psychiatric
Association, San Diego, CA.
Iverson, G. L., Brooks, B. L., & Young, A. H. (in press). Rapid
assessment of neurocognitive deficits in bipolar disorder. Applied
Neuropsychology.
Kovacs, M., & Goldston, D. (1991). Cognitive and social development
of depressed children and adolescents. Journal of the American
Academy of Child and Adolescent Psychiatry, 30, 388–392.
Kyte, Z. A., Goodyer, I. M., & Sahakian, B. J. (2005). Selected execu-
tive skills in adolescents with recent first-episode major depression.
Journal of Child Psychology and Psychiatry, 46, 995–1005.
Lauer, R. E., Giordani, B., Boivin, M. J., Halle, N., Glasgow, B.,
Alessi, N. E., et al. (1994). Effects of depression on memory per-
formance and metamemory in children. Journal of the American
Academy of Child and Adolescent Psychiatry, 33, 679–685.
Wilkinson, P. O., & Goodyer, I. M. (2006). Attention difficulties
and mood-related ruminative response style in adolescents with
unipolar depression. Journal of Child Psychology and Psychiatry,
47, 1284–1291.
Zakzanis, K. K., Leach, L., & Kaplan, E. (1998). On the nature and
pattern of neurocognitive function in major depressive disorder.
Neuropsychiatry, Neuropsychology, and Behavioral Neurology, 11,
111–119.