atention function in preschool

MEASUREMENT OF ATTENTION AND RELATEDFUNCTIONS IN THE PRESCHOOL CHILD

E. Mark Mahone*Department of Neuropsychology, Kennedy Krieger Institute, Johns Hopkins

University School of Medicine, Baltimore, Maryland

The goal of this review of the clinical and research literature is toidentify, describe, and critique published methods for assessment of atten-tion and related functions in preschool children (ages 6 and younger). Theneed for valid assessment of preschool children has grown dramatically inthe past two decades following the implementation of special educationservices for infants, toddlers, and preschoolers under Public Law 99–457.At the same time, the number of preschool children presenting to cliniciansfor assessment of attention problems has grown at a steady rate. In contrastto assessment methods for school-age children, the availability of reliableand valid measures of attention for preschool children is much more limited.The majority of instruments developed to measure attention in preschoolersare described in the experimental literature, with fewer available commer-cially. Attention tests that can be appropriately used with children aged 3and younger are scarce. Most preschool tests of attention report validitydata involving sensitivity in contrasting clinical groups to controls, while theliterature describing the utility of these measures in differentiating betweenclinical groups is much more limited. The review provides information onperformance based tests (e.g., continuous performance, cancellation, au-ditory/visual span), as well as parent and teacher rating scales. The reviewconcludes that valid assessment of attention and related skills can be effec-tively achieved in preschool children, with appropriate cautions.

© 2005 Wiley-Liss, Inc.MRDD Research Reviews 2005;11:216–225.

Key Words: preschool; ADHD; attention; continuous performance test;cancellation test; rating scales

INTRODUCTION

The need for valid assessment of preschool children hasgrown dramatically in the past two decades following theimplementation of special education services for infants,

toddlers and preschoolers under Public Law 99–457 (IDEA).Since that time, the majority of assessment methods developedfor preschool children have focused on either global develop-ment [e.g., Bayley Scales, 2nd ed.; Bayley, 1993], general intel-lectual functioning [e.g., WPPSI-III; Wechsler, 2002], language[e.g., CELF-Preschool; Wiig et al., 1992], motor skills [e.g.,Bruininks–Oseretsky Test of Motor Proficiency; Bruininks, 1978], orpreacademic development [Bracken Basic Concepts Scales-Revised;Bracken, 1998]. In contrast, the development of tools for reli-able and valid measurement of attention and related functions inpreschool-age children has been more limited. The difficulty inmeasuring attention in children under the age 6 may be due tothe variable nature of attention at that age, leading to poorreliability among such tests. A second problem may be a result ofthe response modality. Most performance based tests of attention

used for older children and adults rely on some form of motorresponse. Preschool children, especially those aged 4 andyounger, have great difficulty inhibiting motor responses onsuch tasks, leading to high rates of commission errors. For theyoungest children (ages 3 and younger), attention tests that uselooking behaviors (e.g., eye fixation) appear promising as re-search tools [Goldman et al., 2004]; however, their clinicalutility has yet to be established.

Assessment of attention is nevertheless an important com-ponent, a comprehensive developmental assessment of preschoolchildren. Like their school-age counterparts, healthy preschoolchildren demonstrate rapid, steady development of attentionskills between ages 3 and 6, including the ability to shift atten-tion more fluently, and inhibit unnecessary motor behaviors toallow for responses [Espy et al., 1999]. Thus, attention skills canserve to provide support for (or interfere with) the completionof a variety of problem solving behaviors in preschoolers. Assuch, the most important use of preschool attention tests maynot be to “diagnose” attentional disorders, per se, but rather, tomore accurately characterize the development of such skills toaid the clinician in planning appropriate behavioral, academic,and possibly pharmacological intervention. Additionally, objec-tive tests of attention and related skills are important in moni-toring effects of interventions, and in behavioral research inpreschoolers.

Development of Attention in PreschoolersThe newborn brain continues to develop rapidly over the

first few years of life, and considerable plasticity exists during thisperiod [Yamada et al., 2000]. Environmental experience andstimulation can significantly affect neuronal development inyoung children, including the number and density of synapses[Greenough et al., 1987; Wallace et al., 1992]. The brain’sattentional systems and associated catecholamine neurotransmit-ters in prefrontal, striatal, and associated subcortical systems have

Contract grant sponsor: National Institute of Neurological Diseases and Stroke; Con-tract grant number: NS043480; Contract grant sponsor: Thomas Wilson Foundationfor the Children of Baltimore City.*Correspondence to: E. Mark Mahone, Ph.D., Department of Neuropsychology,Kennedy Krieger Institute, 1750 East Fairmount Ave., Baltimore, MD 21231, USA.E-mail: [email protected] 11 July 2005; Accepted 12 July 2005Published online in Wiley InterScience (www.interscience.wiley.com).DOI: 10.1002/mrdd.20070

MENTAL RETARDATION AND DEVELOPMENTAL DISABILITIESRESEARCH REVIEWS 11: 216–225 (2005)

© 2005 Wiley-Liss, Inc.

a rapid maturation period in infancy andpreschool years [Solanto et al., 2001] thathave the potential to be shaped by envi-ronmental influences [Healy, 2004].These prefrontal brain systems undergorapid changes during the preschool years,including pruning of synaptic connec-tions [Huttenlocher and Dabholkar,1997], and subcortical myelination [Kin-ney et al., 1988]. A recent report fromthe environmental protection agencycited concerns about neurotoxic agentsin the environment and their associationwith an increase in attention problemscited among preschoolers [Stein et al.,2002]. Additionally, increased televisionexposure among infants and toddlers hasbeen linked to the rising rate of attentionproblems in elementary school [Chris-takis et al., 2004]. The American Acad-emy of Pediatrics [1999] has recom-mended “no screen time” for childrenunder 2 years of age; no more than 1–2 ha day of quality television and video forolder children; and no electronic mediain young children’s rooms. Nevertheless,a recent study found that 43% of childrenaged 2 and younger watch television ev-ery day; 26% have televisions in theirrooms; and 68% of children younger than24 months spend over 2 h a day withscreen media [Rideout et al., 2003].

Attention Deficit/HyperactivityDisorder (ADHD) in Preschool

ADHD has become the most com-monly diagnosed form of psychopathol-ogy in the preschool years [Armstrongand Nettleton, 2004]. The prevalence ofADHD in preschoolers varies, dependingon the samples reported; however, thenumbers appear to be increasing [DeBaret al., 2003]. DeBar et al. [2003] reportedthe occurrence of ADHD to be 2%, in asample of 38,664 general pediatric pa-tients under the age of 5 years. Connor[2002] reported that the incidence mightbe as high as 59% in child psychiatryclinics. In another sample of 200 childrenaged 6 and younger referred to an out-patient psychiatric clinic, 86% met diag-nostic criteria for ADHD [Wilens et al.,2002a]. Of particular concern is the ob-servation that preschoolers with ADHDwere found to have similar patterns ofcomorbid psychopathology and func-tional impairment when compared withthose of school-age children withADHD [Wilens et al., 2002b]. Thus,preschool children presenting withsymptoms of ADHD are at significantrisk for social, familial, and academic dif-ficulties, relative to children withoutADHD [DuPaul et al., 2001].

Earlier identification and treatmentof attentional problems may minimizethe harmful impact of ADHD [Wilens etal., 2002a]. In the past decade, there hasbeen an increased interest in the assess-ment and treatment of preschool childrenpresenting with symptoms of ADHD,and improvements in assessment meth-ods. The core symptoms of ADHD—distractibility and hyperactivity—arecommonly seen in preschool children re-ferred for developmental evaluation[Shelton and Barkley, 1993]. The diag-nostic criteria for ADHD, as delineatedin the Diagnostic and Statistical Manual ofMental Disorders, Fourth Edition, TextRevision (DSM-IV-TR) [American Psy-chiatric Association (APA), 2000], spec-ify that symptoms must be present before7 years of age. Research has supportedthis age-of-onset criterion for ADHD[Applegate et al., 1997], as well as thevalidity of the diagnosis for younger chil-dren [Lahey et al., 1998]. There is alsoevidence for the predictive validity ofADHD diagnoses made in the preschoolyears [Lahey et al., 2004; McGee et al.,1991].

Despite the increased interest in as-sessing ADHD in preschoolers, the NIH[1998] reported that many practitionersdo not use structured questionnaires orrating scales, or use teacher/school inputin diagnosing. The NIH has since calledfor additional research on ADHD, par-ticularly in the areas of age- and gender-specific diagnostic criteria, and in the de-velopment of reliable and validassessment procedures. The developmentof valid assessment methods is particularlyimportant, because relying on parents’verbal reports of isolated symptoms ofADHD in preschoolers may lead tooveridentification of the disorder [Gim-pel and Kuhn, 2000]. Gimpel and Kuhnrecommended using full DSM-IV crite-ria and including standardized measuresacross multiple informants and settings,when making the diagnosis of ADHD inpreschool years. While performance-based tests of attention are not necessaryto make a diagnosis of ADHD in thepreschool years, they do provide an ob-jective sampling of behavior under stan-dardized conditions, and can be useful incharacterizing related behavioral needs.Also, objective assessment of attentionand related skills among preschoolers canbe particularly useful in measuring theeffects of treatments.

Even though much less is knownabout ADHD in 2- to 5-year-old pre-school children, the practice of prescrib-ing psychotropic medications for veryyoung children has increased in both the

US and Europe, [Connor, 2002; Rapp-ley et al., 2002]. Rappley et al.[2002]reported on 223 children aged 3 andyounger receiving treatment for ADHD.More than half (n � 127) received treat-ment in an idiosyncratic manner, and hadmonitoring less than once every 3months. In an attempt to improveknowledge about assessment and treat-ment of ADHD in young children, theNational Institute of Mental Health(NIMH) began a clinical trial in 2000 tostudy the effects of methylphenidate inpreschoolers (ages 3–6) with ADHD.This ongoing study, known as the Pre-school ADHD Treatment Study (PATS),is expected to shed light on the efficacyof diagnostic methods and treatments forADHD in the preschool years.

Medical and NeurodevelopmentalDisorders with AssociatedAttention Problems

Attention problems are commonamong preschool children. By the age of4 years, as many as 40% of children havesufficient problems with inattention to beof concern to parents and preschoolteachers [Palfrey et al., 1985]. Further, avariety of medical conditions are associ-ated with attention problems in pre-schoolers, including epilepsy, congenitalcardiac defects, hypothyroidism, lowbirth weight, hearing loss, and prenatalexposure to teratogens (e.g., fetal alcoholsyndrome). In addition, a variety of neu-rodevelopmental and genetic conditionsare associated with attention problems,and have significant overlap with the be-havioral presentation of ADHD, includ-ing cerebral palsy, spina bifida, Turnersyndrome, fragile X, neurofibromatosis,early treated phenylketonuria, sickle celldisease, and Williams syndrome. Chil-dren with cognitive delays, neurodevel-opmental immaturity, or learning prob-lems are likely to be perceived asinattentive [Blackman, 1999], particu-larly, if expectations for productivity areinappropriate for the child’s develop-mental level, or if there is a mismatchbetween a child’s skills and demands ofcertain settings. Further, preschool chil-dren with ADHD also tend to have highrates of language problems and develop-mental coordination disorder [Kadesjoand Gillberg, 1998; Kadesjo et al., 2001].Given these considerations, there is agrowing need for accurate and reliableassessment of attention and related func-tions in the preschool years to operation-alize the construct, to define “normal”development, and to assist clinicians inearlier identification and treatment in

217MRDD RESEARCH REVIEWS ● ATTENTION IN PRESCHOOLERS ● MAHONE

disorders with associated attention prob-lems.

PRESCHOOL ATTENTIONTESTS

Comprehensive reviews of psy-chological and neuropsychological testsfor preschoolers, including tests of atten-tion, are provided in texts by Baron[2004], Spreen and Strauss [1998], andthe Mental Measurements Yearbooks [Plakeet al., 2003]. The present review of teststhat follows is not exhaustive, but ratherintended to represent a collection ofmeasures available both commerciallyand in the research literature that can beused in assessment of attention and re-lated functions in preschool children, aspart of a comprehensive diagnosticworkup. When available, reliability andvalidity data for the instruments are pro-vided. A summary of the performance-based tests is provided in Table 1.

Continuous Performance Tests(CPTs)

CPTs were originally developedby Mirsky and his colleagues to measurevigilance in individuals with brain inju-ries [Rosvold et al., 1956]. Today, CPTsare the most commonly used paradigm toassess components of attention in bothchildren and adults [Mirsky et al., 1991;Barkley, 1994, 1998]. CPTs are intendedto measure an individual’s ability to de-tect and respond to specific stimuluschanges occurring infrequently at eitherfixed or random intervals, over a pro-

longed period of time, while simulta-neously inhibiting responses to extrane-ous stimuli [Corkum and Siegel, 1993;Ballard, 1996]. Although several versionsof CPTs are readily available for school-age children, CPTs are less commonlyused with preschoolers [Harper and Ot-tinger, 1992; Prather et al., 1995]. Onlyrecently have CPTs designed specificallyfor preschoolers become commerciallyavailable [Conners, 2001]. Listed beloware examples of commercial and experi-mental CPT measures that have beenused to measure attention in preschoolchildren.

Simple Reaction TimeSeveral variations on simple reac-

tion tests are available in the literature[e.g., Eliot, 1970; Weissberg et al., 1990].Because the responses require only press-ing of a button in response to a stimulus,with no decisions to be made, children asyoung as 2 years are often able to com-plete the measures. Weissberg et al.[1990] described procedures for visualand auditory simple reaction time tasksthat were used for preschool children. Intheir auditory task, children were askedto push a button as quickly as possibleafter hearing a bell. There were 20 trials.Five delay periods (requiring the child towait 2, 3, 4, 5, or 6 s before responding)were randomly presented in each of fourblocks of five trials. Omission errors,commission errors (i.e., responses madebefore the bell), and response latencywere recorded. Children as young as 31⁄2

years completed the task successfully, andperformance improved rapidly betweenages 3 and 5. In a visual version of thesimple reaction time task, a picture of arabbit appeared on the computer screen,and remained until the child pushed abutton. Number of trials and delay peri-ods were identical to the auditory task.Children as young as 21⁄2 years success-fully completed the visual task and per-formance (omissions, commissions, andresponse time) all improved steadily fromage 2 to 5. Mean response time, but notomission or commission errors, was sig-nificantly correlated with Stanford Binetintelligence quotient (IQ). In contrast,commission errors, but not omissions orreaction time, was significantly correlatedwith the Hyperactivity Scale from theCPRS. The authors concluded that therapid improvements represent a generaldevelopment of control over excitatoryand inhibitory processes [Weissberg etal., 1990]. For this task, commission er-rors may be the most sensitive indicatorof the development of inhibitory control.

Preschool Vigilance Task (PVT)The version of the PVT reported

by Harper and Ottinger [1992] was amodification of the procedures originallydescribed by Herman et al. [1980] andStreissguth et al. [1984], used for childrenaged 4–6. The PVT reported by Harperand Ottinger uses a picture of a treepresented continuously on a computermonitor. A bird appears on the branch ofthe tree at intermittent intervals, ranging

Table 1. Preschool Tests of Attention and Related Functions

Test TypeAgeRange Pres Min Com Publisher (Website)

Simple ReactionTime

CPT 2–5 A, V 3.0 No

PVT CPT 4–6 A 14.5 NoZooRunner CPT 3–5 A, V 7.2 NoCPTP CPT 3–5 V 8.5 NoC-CPT CPT 3–6 A, V 5.0 NoACPT-P CPT 3–6 A 5.0 NoECVT CPT 2–3 V 7.0 NoK-CPT CPT 4–5 V 7.5 Yes MHS (www.mhs.com)GDS-Preschool CPT 4–5 V 6.0 Yes Gordon Systems, Inc.

(www.gsi-add.com)PDTP-R Cancellation 3–5 V 7.0 NoMFFT-PV Matching 3–4 V 5.0 NoNumber Recall Auditory span 3–18 A 5.0 Yes AGS (www.agsnet.com)Hand Movements Visual span 4–18 V 5.0 Yes AGS (www.agsnet.com)Visual Attention Cancellation 3–12 V 6.0 Yes Psychological Corporation

(www.psychcorp.com)Statue Motor persistence 3–12 V, A 1.5 Yes Psychological Corporation

(www.psychcorp.com)

Pres, presentation format; Com, commercially available; Min, approximate administration time (min); CPT, continuous performance test; A, auditory; V, visual; PVT, Preschool Vigilance Test; CPTP, ContinuousPerformance Test for Preschoolers; C-CPT, Children’s Continuous Performance Test; ACPT-P, Auditory Continuous Performance Test for Preschoolers; ECVT, Early Childhood Vigilance Test, K-CPT, KiddieContinuous Performance Test; GDS, Gordon Diagnostic System; PDTP-R, Picture Deletion Test for Preschoolers-Revised; MFFT-PV, Matching Familiar Figures Test-Preschool Version.

218 MRDD RESEARCH REVIEWS ● ATTENTION IN PRESCHOOLERS ● MAHONE

from 10 to 60 s. The interstimulus inter-vals (ISI) were random. The bird re-mained on the screen for 500 ms, and theduration of the task was 14.5 min. Chil-dren were asked to press a button as soonas the bird appeared. Errors of omissionand reaction time were recorded. In asample of 20 hyperactive and 20 controlpreschoolers, ages 4–6, the PVT dem-onstrated good test–retest reliability foromissions (0.80), but not for mean re-sponse time (0.16). Hyperactive childrendemonstrated significantly greater omis-sion errors than that in controls [Harperand Ottinger, 1992]. Given the low re-liability of the reaction time score, cau-tion should be used when interpretingthis variable on the PVT.

ZooRunnerThe ZooRunner tasks were devel-

oped by Prather et al. [1995] to assesssustained auditory and visual attention inpreschoolers aged 3–6. The test uses pic-tures of animals visually (Visual Zoo-Runner) or animal sounds auditorally(Auditory ZooRunner) every 2000 ms,with a stimulus presentation time of 1000ms and an ISI of 1000 ms. Both taskspresent a total of 215 trials, and take 7.2min each. There are 12 stimuli used forboth versions (11 nontargets, 1 target).Children are asked to press a buttonwhen they see a picture of a cat (VisualZooRunner), or hear the word “tiger”(Auditory ZooRunner). Mean reactiontime, omissions, and commission errorswere recorded. Prather et al. [1995] re-ported a steady rate of improvement inamong typically developing children inomissions, commissions, and reactiontime on both the Visual and AuditoryZooRunner. However, the youngerchildren (i.e., 3-year-olds) made an ex-tremely high rate of omissions on bothauditory and visual tasks, suggesting thatthe measure is too difficult for 3-year-olds. Additionally, there is little improve-ment in performance after 51⁄2 years ofage, suggesting the presence of ceilingeffects in older, or higher functioningpreschoolers. Across the age range, chil-dren made more errors on the auditorytest than the visual test.

Byrne et al. [1998] used the Audi-tory ZooRunner to assess the effects of a5-month trial of stimulant medication ineight preschoolers (ages 4 and 5) withADHD, compared with a matched con-trol group of eight typically developingchildren receiving no treatment. Chil-dren with ADHD had significantly moreerrors of omission than that in controlson the Auditory ZooRunner at baseline,but not more errors of commission. After

treatment, children with ADHD im-proved significantly from baseline onomission errors, and performance was nolonger significantly different than con-trols. Commission errors did not im-prove after treatment, in the ADHDgroup. Given the observed floor and ceil-ing effects, the ZooRunner appears bestsuited for children aged 4 and 5.

Continuous Performance Test forPreschoolers (CPTP)

Corkum et al. [1995] developed avisual CPT for use with children aged3–5. They examined the performance of60 typically developing preschoolers, us-ing a computer-based paradigm withsimple line drawings of familiar objects(e.g., face, ice cream, sun, flower, pig,and lollipop) as stimuli. The CPTP is�81⁄2 min in length and uses a ratio offive nontargets to one target stimulus (to-tal of 240 stimuli of which 40 are targets).Each stimulus remains on the screen for750 ms, and the ISI is fixed at 1350 ms.Children are asked to push a button eachtime they see the picture of the pig, butnot for any of the other stimuli. Re-sponse latency, omission, and commis-sion errors were recorded. Although theauthors found a clear developmental pro-gression of performance in normal pre-school children between the ages of 3and 5 on response latency, omissions andcommissions, more than half of the3-year-olds in the study had a large num-ber of errors (both omission and commis-sion), calling into question the validity ofthe test for that age group. Byrne et al.,[1998] also used the CPTP to examineeffects of stimulant medication in eightpreschool children (ages 4–5) withADHD, compared with controls receiv-ing no treatment. Children with ADHDexhibited significantly more errors ofomission and commission than that incontrols at baseline. At 5-month followup, the children with ADHD had signif-icant reductions in omissions and com-missions, and were no longer deficient,relative to controls on the CPTP [Byrneet al., 1998]. The CPTP appears to besensitive to treatment effects, but may betoo difficult for 3-year-old children withADHD or other developmental delays.

Children’s Continuous Performance Test(C-CPT)

Kerns and Rondeau [1998] devel-oped the computerized C-CPT proce-dures for preschoolers, using similar pa-rameters as the CPTP [Corkum et al.,1995] and ZooRunner [Prather et al.,1995], but making the entire test shorterto make the test easier for younger chil-

dren. Three task variations were used—each lasting only 5 min—with 200 stim-uli, 29 of which were targets randomlypresented throughout the procedures.There were 10 total stimuli (9 nontargets,1 target) presented so that 6 distracterswere presented for each target. A fixed1500 ms ISI was used on all three tasks.Task 1 used animal pictures paired withcorrect animal noises. Children wereasked to click the mouse every time theysaw and heard the sheep. Task 2 wassimilar; however, only animal soundswere presented, and children were askedto click the mouse each time they heardthe sheep sound. For Task 3, animal pic-tures were presented with sounds occur-ring randomly (i.e., not paired correctly).On this task, the child was asked to clickthe mouse to the picture of the sheep,regardless of the sound. Omission andcommission errors were recorded for allthree tasks. All but two of the controlparticipants (n � 187, ages 36–81months, recruited from daycare settings)were able to complete all three tasks, andsignificant age effects were observed foromissions and commissions for Task1,and for omission errors on Tasks 2 and 3.For all three tasks, however, 3-year-oldshad greatest difficulty, averaging 69%omission errors for Task 1, 90% omis-sions errors for Task 2, and 72% omissionerrors for Task 3, again calling into ques-tion the validity of this type of instrumentfor 3-year-olds.

Kerns and Rondeau [1998] also re-ported results for 18 clinically referredchildren on the three C-CPT tasks. Incontrast to the control group, only 7 ofthe 18 children in the clinical groupcould complete all three tasks. The au-thors concluded that, while the reducedtime of the tasks made them more acces-sible to most typically developing pre-schoolers, the parameters were too diffi-cult for 3-year-olds, and for manyclinically referred children. The findingsof the Kerns and Rondeau [1998] studywere also consistent with those of Bakeret al. [1995] and Prather et al. [1995] whoconcluded that auditory continuous per-formance tasks are potentially more dif-ficult than comparable visual tasks, andthat the 1500 ms ISI interval may be tooshort for 3-year-olds.

Auditory Continuous Performance Test forPreschoolers (ACPT-P)

The ACPT-P [Mahone et al.,2001] is a computerized, go/no-go testdeveloped to measure sustained attentionin children aged 3–6. The test was de-signed to minimize difficulties encoun-tered by the 3-year-olds on other pre-


school CPTs [Corkum et al., 1995;Kerns and Rondeau, 1998; Prather et al.,1995]. Using a computerized, auditoryCPT format with a fixed, longer ISI(5000 ms), go/no-go format (i.e., 1 tar-get—“dog bark,” 1 nontarget—“bell”),and shorter overall time (5 min), the taskwas successfully completed by typicallydeveloping children as young as 36months [Mahone et al., 2001]. TheACPT-P also revealed strong associationsbetween age and performance, withgreatest gains in performance occurringbetween the ages of 3 and 4. Hagelthornet al. [2003] compared the format of theAPCT-P (5000 ms ISI) to that of a visualCPT with shorter ISI (1350 ms), in 66preschool children. Although not di-rectly matched on all task parameters,children performed better on the audi-tory CPT, with error rates on the visualCPT at an unacceptably high level forthe 3-year-old group. The 1350 ms ISIproved to be too short for the 3-year-olds to accurately choose a response inthis format, and the authors concludedthat when considering CPT paradigmsfor preschoolers, 3-year-olds might needat least a 4000 ms ISI in order to havetime to make a choice for the correctstimulus cue. In 3-year-olds, correct hitsfollowing an ISI shorter than 1400 msmay reflect the child’s response to a pre-vious stimulus [Hagelthorn et al., 2003].

Mahone et al. [2005] examined theconstruct validity of the ACPT-P in pre-schoolers with ADHD or mild hearingloss because of recurrent otitis media.The authors found no differences be-tween performance of children with mildhearing loss (n � 23) and controls (n �40) on the ACPT-P; however, therewere significant differences betweenchildren with ADHD (n � 40) andmatched controls on omission errors,mean response time, and variability. TheACPT-P was also significantly correlatedwith the other behavioral measures of mo-tor persistence, i.e., Developmental Neu-ropsychological Assessment (NEPSY)Statue [Korkman et al., 1998], but not witha working memory measure, i.e., multipleboxes test [Llamas and Diamond, 1991],demonstrating initial convergent and dis-criminant validity [Mahone et al., 2005].

Early Childhood Vigilance Test (ECVT)The ECVT [Goldman et al., 2004]

is one of the only preschool attentiontasks that have been validated using notonly behavioral measures, but also by or-relating performance with brain electricalactivity (i.e., event-related potentials(ERPs)). The ECVT is a computerizedvigilance measure that bases performance

on the amount of time children attend toa monitor on which cartoon charactersappear and disappear. No motor responseis required, and children are videotapedduring the procedure, and their lookingbehavior is analyzed later. The task in-volves a computer screen showing a col-orful picture of large rock. Colorful car-toon creatures appear, one at a time,from behind, under, or over the rock.Each creature remained on the screen for10 s, and disappeared for 5, 10, or 15 s(intervals arranged randomly, so that eachinterval occurred six times). The crea-tures continue to appear and disappearacross 18 trials. The total task lasted 7min. The procedure is scored by coding(from the videotape) the total “on-task-time” during which the child is focusedon the screen.

Goldman et al. [2004] reported onthe performance of 51 twenty-four- tothirty-month-old children. Boys and girlsdid not differ in performance, and theinter-rater reliability for videotapes wasstrong (r � 0.98). Performance of theECVT was moderately correlated withthe Mental Development Index of theBayley Scales (r � 0.27). ERPs werecollected on a subset of the children (n �14) to identify the patterns of neurophys-iological activation that might be associ-ated with sustained attention at this age.There was a significant correlation be-tween performance on the ECVT andright frontal brain activity; however,more traditional parental reports of be-havior were not correlated with ERPfindings. Given the time involved in dataanalysis of videotape, the ECVT may bebetter suited for research than for clinicaluse.

Conners’ Kiddie Continuous PerformanceTest (K-CPT)

The K-CPT [Conners, 2001] is acommercially available, computerized,visual CPT designed to assist with theassessment of attention disorders in 4-and 5-year-old children. The K-CPTrunning time is 71⁄2 min. The stimuliconsist of a series of familiar pictures(e.g., boat and soccer ball), rather thanletters, so that the stimuli are familiar tochildren at a young age. Children areasked to respond (click the mouse orpush the spacebar) for every picture thatappears on the screen, except the soccerball. The ISI is either 1500 ms or 3000ms, and the display time of the stimuli is500 ms. There are five blocks, with twosub blocks each of 20 trials (i.e., 20 pic-tures presented). Within each block,there is a sub-block of trials with a 1500ms ISI and one with 3000 ms ISI. Infor-

mation obtained includes number of er-rors (omission and commission), meanresponse latency, standard error of re-sponse latency, variability, signal detec-tion statistics (d� and �), and results byblock and by ISI. The standardizationsample for the K-CPT included 454four- and five-year-old children. Ofthese, 313 were classified as nonclinical;100 were classified as clinical withADHD; and 40 were classified as clinicalwithout ADHD. Split-half reliability in-formation provided in the K-CPT man-ual ranges from 0.72 (Hit ReactionTime) to 0.88 (Omissions). Validity in-formation is reported by comparing nor-mative data from a typically developinggeneral population group to clinicalgroups with and without ADHD. Signif-icant group differences were reported forall variables, except Response Time byBlock and Standard Error of ResponseTime by Block [Conners, 2001]. Thevariables showing significant group dif-ferences between clinical groups withand without ADHD, included Hit Re-sponse Time, Commissions, Omissions,Perseverations, Standard Error of Re-sponse Time (Total and by ISI), Variabil-ity, and d�. Given the initial reports ofboth sensitivity and specificity, the K-CPT holds promise as an effective, clin-ically-available diagnostic tool for assess-ing attention problems in 4- and 5-year-olds, although additional research isrequired on its test–retest reliability andconvergent/discriminant validity.

Gordon Diagnostic System (GDS)The GDS [Gordon et al., 1986] is

among the most researched tests of atten-tion in the past 20 years [Barkley, 1998].The majority of literature on the validityof the GDS has been with school-agechildren and adults; however, the instru-ment can also be used for preschool chil-dren aged 4 and 5. The GDS is a porta-ble, self-contained, electronic task thatadministers a series of “game-like” tasks.The PVT requires the child to inhibitresponding under conditions that requiresustained attention. Digits flash onto theelectronic display, one at a time. Thechild is told to press the button everytime a “1” appears on the screen. A par-allel version can be administered that usesthe number “0” as the target. Omissionand commission errors were recorded.The delay task requires the child to in-hibit responding so as to earn points. Thechild is asked to push the button, wait awhile, and push the button again. If thechild refrains from responding for 6 s, alight flashes and a reward counter incre-ments. If the child responds before 6 s, a


buzzer sounds and the counter is reset.The vigilance task was standardized on189 four- and five-year-olds, and the de-lay task was standardized on 220 four-and five-year-olds. Musten et al. [1997]reported the performance of 31 childrenwith ADHD (ages 4–6) who weretreated with methylphenidate in a place-bo-control design. Performance im-proved on both the delay and vigilancetasks following treatment with methyl-phenidate, but not with placebo [Mustenet al., 1997]. While the GDS has consid-erable validity literature in school-agechildren, its use in preschoolers dependson their familiarity with numbers, and assuch, may be less useful for children withcognitive or other delays. Additionally,caution should be used when interpret-ing norms from the GDS, which havenot been revised in nearly 20 years.

Tests of Related AttentionFunctions

Picture Deletion Test for Preschoolers-Revised (PDTP-R)

The PDTP-R [Corkum et al.,1995; Byrne et al., 1998 ] is designed tomeasure selective attention (visual search)in preschoolers aged 3–5, and is concep-tually similar to target cancellation testsused with older children and adults. Incontrast to the cancellation tasks used forolder children, the PDTP-R uses pic-tures instead of letters or numbers asstimuli, and allows the child to respondwith a self-inking bingo stamper, ratherthan a pencil, in order to minimize thegraphomotor demands. The child’s taskduring the PDTP-R is to visually searchan array of pictures, in which targets andnontargets are presented, and identifying(i.e., placing a mark on) each target asquickly as possible. The test is presentedin booklet format, so that the child canturn pages and independently proceed.Left- and right-handed versions are avail-able. There are two conditions in thePDTP-R: shapes and cats. Each condi-tion consists of a training phase (�3 min)and a test phase (�16 min). The trainingphase uses two pages on which 30 targetsand 90 nontargets are presented in a 10 �6 array. The test phase consists of 120targets and 360 nontargets. The “shape”condition uses a triangle as target andcircles, octagons, squares, and diamondsas nontargets. The “cats” condition uses aprofile version of a cat as a target, andwith four pictures of cats in differentpositions as nontargets. Time to comple-tion, omissions, and commission errorsare recorded for each of the conditions.Corkum et al. [1995] reported significant

age-related improvements in time, aswell as accuracy (omissions and commis-sions) from ages 3 to 5. In a treatmentstudy of eight preschoolers (ages 4 and 5)with ADHD, Byrne et al. [1998] re-ported that children with ADHD exhib-ited more commission, but not omission,errors on the PDPT-R, than controls atbaseline. After 5 months of treatmentwith stimulants, the children withADHD had significant improvement onthe PDTP-R, and had similar perfor-mance to controls. This test may haveparticular utility in assessing attention inchildren with language difficulties, aswell those for whom graphomotor skillimpairments preclude the use of moretraditional pencil/paper methods. Addi-tional research examining reliability andvalidity with the PDTP-R is recom-mended.

Matching Familiar Figures Tests-preschoolVersion (MFFT-PV)

The MFFT-PV [Kagan, 1966] is acommonly used test of impulsivity inpreschool children. The MFFT-PV uses12 sets of pictures of animals and otherfamiliar objects. The child matches asample picture to a picture exactly like itfrom within an array of four similar pic-tures. Latency to first choice and numberof errors are scored. Schleifer et al. [1975]used the MFFT-PV to assess medicationeffects in 28 hyperactive preschool chil-dren aged 3–4. The hyperactive groupwas impaired, relative to controls, on theMFFT. Performance of the MFFT-PVimproved following a trial of methyl-phenidate, with the hyperactive groupperformance equivalent to controls fol-lowing treatment. The MFFT-PV is wellsuited for clinical use because of its easeof administration and time-efficiency;however, its reliability and discriminantvalidity have yet to be clearly established.

Number RecallThe Number Recall subtest of the

Kaufman Assessment Battery for Children-II[KABC-II; Kaufman and Kaufman,2004] was retained from the originalKABC [Kaufman and Kaufman, 1983],and is one of a number of standardizeddigit span measures that have beennormed on preschool children (ages3–6). The Number Recall test is a mea-sure of auditory attention span. In thisversion, the child repeats a series of num-bers in the same sequence as the exam-iner said them, with series ranging from 2to 9 numbers. The numbers are singledigits, except that 10 is used instead of 7,to ensure that all numbers are one sylla-ble. Standardization of the KABC-II was

completed from 2001 through 2003, andincluded 650 children aged 3–5. Thesample was stratified based on the March2001 Current Population Survey [Cur-rent Population Survey, 2001]. Split-halfreliability for Number Recall is reportedto be 0.89 for 3-year-olds, 0.87 for4-year-olds, and 0.79 for 5-year-olds,based on the standardization data. Test–retest reliability (mean test interval � 24days) for children aged 3–5 is 0.70. In astudy of 34 four- and five-year old boyswith ADHD, Mariani and Barkley[1997] found that the ADHD group per-formed significantly worse than a com-parison group of 30 controls on theNumber Recall. Number Recall is par-ticularly useful as part of an overall assess-ment battery because of its developmen-tal sensitivity, short administration time,and the lack of need for specialized tools.

Hand MovementsThe KABC-II Hand Movements

subtest [Kaufman and Kaufman, 1983,2004] requires the child to imitate a seriesof three possible Hand Movements (i.e.,fist, side, and palm), with the series be-coming progressively longer. The subtestis a measure of visual span, although it hasa significant motor control/inhibitiondemand. This subtest can be adminis-tered in 5 min or less. Normative data areavailable for preschoolers (ages 4–5), andis based on 450 children tested between2001 and 2003 [Kaufman and Kaufman,2004]. Split-half reliability is reported tobe 0.57 for 4-year-olds and 0.75 for5-year-olds. Test–retest reliability (testinterval 24 days) is reported to be 0.58 forchildren aged 4–5. Mariani and Barkley[1997] also found that hyperactive pre-school boys performed significantlyworse than matched controls on theHand Movements test, and the perfor-mance improved following treatmentwith stimulants. Caution should be usedwhen interpreting scores from thissubtest, given the relatively low test–re-test reliability.

Developmental NeuropsychologicalAssessment

The NEPSY [Korkman et al.,1998] was originally developed in Fin-land as a developmentally appropriatemeasure of neuropsychological function-ing in young children, and was laternormed on 1,000 U.S. children, ages3–12. The normative sample for the U.S.version includes 50 boys and 50 girls ateach of the 10 age levels, stratified forrace/ethnicity, and geographic region ac-cording to the 1995 U.S. census data.The NEPSY is organized into preschool


(ages 3 and 4) and school age (ages 5–12)protocols. The NEPSY includes fivebroad functional domains: language, at-tention/executive function, sensorimo-tor, memory and learning, and visuospa-tial processing. Administration of the fullbattery can take 1 h for preschoolers.Many clinicians, however, use only se-lected subtests of the NEPSY to facilitatemore focused assessment of a particulararea of diagnostic interest (e.g., Atten-tion/Executive). The preschool Atten-tion/Executive domain of the NEPSY isbased on two subtests: Visual Attentionand Statue.

The NEPSY Visual Attentionsubtest is a visual cancellation test de-signed to assess the speed and accuracywith which a child is able to focus selec-tively on and maintain attention to visualtargets within an array [Korkman et al.,1998]. There are two trials presented topreschoolers: bunnies and cats. Each trialis presented on a two-page booklet, witha target at the top of the page. The childis asked to mark (with a red pencil orcrayon) each of the targets on the twopages as quickly as possible. The bunnytrial is arranged so that the stimuli are inlinear arrays, whereas the cat trial presentsstimuli randomly across the pages. Thereare 20 targets on each trial, and the childis given up to 180 s to complete eachpart. Scores are based on a combinationof errors (omissions and commissions)and time to completion. The test–retestcorrelation is reported to be 0.62 for 4-and 5-year-olds.

The NEPSY Statue subtest is ameasure of motor persistence and inhibi-tion. The child is asked to stand still in aset position over a 75-s period, inhibitinga unwanted response (i.e., eyes opening,body movement, and vocalization) in thecontext of distractors [Korkman et al.,1998]. The examiner observes for pres-ence of these responses in epochs of 5 s,scoring “2” for no responses, “1” for oneresponse, and “0” for two or more re-sponses during each 5-s period. The totalpossible score is 30, and the test takes lessthan 2 min to complete. Test–retest re-liability is reported to be 0.50 for theStatue subtest, and 0.68 for the PreschoolAttention/Executive Domain. Mahoneet al. [2005] reported that preschoolers(ages 3–6) with ADHD performed sig-nificantly worse than matched controlson the Statue test; however, childrenwith mild hearing loss did not differ fromcontrols n this measure. The Statuesubtest was also significantly correlatedwith the ACPT-P, but not with an esti-mate of IQ, or a measure of spatial work-ing memory. The Statue test is also

promising because of its developmentalsensitivity and short administration time.

Preschool Behavior Rating ScalesThere is a growing awareness of

the need for time-efficient, standardizedassessment of attention-related behaviorsin the preschool years. Performance-based tests are not always possible orpractical, and as such, there has been in-creased interest in methods to improvethe ecological validity of comprehensiveassessments, using caregiver ratings[Sbordone, 1996]. Published rating scaleswith normative data for preschool chil-dren are available in parent and teacherforms and follow a format of assessingeither: (1) a broad range of behaviorproblems, (2) problems specific toADHD, or, (3) problems related to somespecific behavioral construct (e.g., exec-utive functions). A selection of measuresthat emphasize attention problems inpreschoolers is reviewed later.

Conners’ Rating Scales-RevisedThe revised Conners’ Rating

Scales [Conners, 1997] are parentand/or teacher reports of child behav-ior that can be completed in �10 min.Both forms include questions thatprobe a variety of problematic child-hood behaviors, including conductproblems, learning problems, psycho-somatic, impulsivity– hyperactivity,anxiety, and social competence. TheConners’ Parent Rating Scale-Revised:Long Form [CPRS-R:L] contains 80questions and the Conners’ TeacherRating Scale-Revised: Long Form[CTRS-R:L] consists of 59 questions.The standardization samples for theparent and teacher scales was drawnfrom over 2,000 parents and 2,000teachers for children aged 3–17. Thescales produced by the revised Con-ners’ Rating Scales correspond withsymptoms used in the DSM-IV-TR ascriteria for ADHD. They also contain anew empirically created index for as-sessing children at risk for a diagnosis ofADHD. Both the CPRS-R andCTRS-R are available in short andlong versions. Spanish language trans-lations of all of the revised Conners’scales are available. Although separatenorms are available for preschool chil-dren (ages 3–5), the same test items andscales are used for assessing preschoolersand older children. In a study of 455nonreferred and 12 clinically referredpreschoolers, Miller et al. [1997] foundthe CTRS-R Inattention, Hyperactiv-ity, and Conduct Problems scales to behighly (P � 0.001) intercorrelated, but

with good sensitivity in discriminatingclinical from nonclinical groups. Someparents and teachers may find the itemson the revised Conners’ scales not ap-plicable to younger children aged 5 andyounger (e.g., “Cannot grasp arith-metic”; “Not reading up to par”).

Behavior Assessment System for Children-2(BASC-2)

The BASC-2 [Reynolds and Kam-phaus, 2004] is a comprehensive set ofrating scales and forms that help individ-uals understand the behaviors, emotions,and adaptive skills of children and ado-lescents ages 2–21. The BASC-2 helps inmaking differential diagnoses of specificcategories of disorders, such as thoseidentified in the DSM-IV-TR. For pre-school children, the BASC-2 includesrating scales that can be used by parents(Parent Rating Scale—PRS), teachers(Teacher Rating Scale—TRS). The PRSand TRS assess internalizing and exter-nalizing behaviors, inattention, hyperac-tivity, social behavior, and adaptive skillsin the home, community, or preschool/school setting. The preschool form of theBASC-2 is available for children aged2–5, and can be completed in �10–20min. The normative sample for the pre-school forms included 1,200 parents and1,050 teachers of children aged 2–5, se-lected using a stratified sample fromthroughout the U.S., based on 2001 cen-sus data. The forms describe specific be-haviors that are rated on a 4-point scale offrequency, ranging from “Never” to“Almost Always.” The preschool PRScontains 134 items and the TRS contains100 items. In contrast to the Conners’scales, the BASC-2 preschool PRS andTRS include items specifically selected toapply to younger children. The manualreports adequate test–retest reliability forboth the preschool PRS (range � 0.73–0.86, median � 0.77), and the TRS(range � 0.72–0.92, median � 0.82).

Achenbach Systems of Empirically BasedAssessments (ASEBA)

The preschool versions of theASEBA [Achenbach and Rescorla, 2000]include the Child Behavior Checklist[CBCL/11⁄2–5] and Caregiver–TeacherReport Form [C–TRF/11⁄2–5]. Cross-informant syndromes derived from bothpreschool forms include: EmotionallyReactive, Anxious/Depressed, SomaticComplaints, Withdrawn, AttentionProblems, and Aggressive Behavior. ASleep Problems syndrome scale is alsoincluded on the CBCL/11⁄2–5. Internal-izing, Externalizing, and Total Problemscomposites, as well as DSM-oriented


scales (Affective Problems, AnxietyProblems, Pervasive DevelopmentalProblems, Attention Deficit Hyperactiv-ity Problems, and Oppositional DefiantProblems] are obtained on both forms.The CBCL/11⁄2–5 includes a LanguageDevelopment Survey (LDS) for ages18–35 months, to indicate whether vo-cabulary and word combinations are de-layed. Scales for the CBCL/11⁄2–5 werebased on ratings of 1,728 children and arenormed on a national sample of 700 chil-dren. The C-TRF/11⁄2–5 scales werebased on ratings of 1,113 referred chil-dren and were normed on 1,192 nonre-ferred children. Twelve-month test–re-test reliability coefficients for the CBCL/11⁄2–5 range from 0.52 to 0.76 (mean r �0.61), and 3-month test–retest reliabilitycoefficients for the C-TRF/11⁄2–5 rangefrom 0.22 to 0.71 (mean r � 0.59),which are slightly lower than those re-ported for the BASC-2. Like the Con-ners’ rating scales and the BASC-2, theASEBA scales show a high degree ofsensitivity for discriminating clinically re-ferred preschool children from controls;however, their specificity for demon-strating differential patterns between di-agnostic groups in the preschool years isless well established.

Behavior Rating Inventory of ExecutiveFunction-Preschool Version (BRIEF-P)

The BRIEF-P [Gioia et al., 2003]is a questionnaire/rating scale that en-ables professionals to assess executivefunction behaviors in the home and pre-school environments. Executive functionis an umbrella construct that includesseveral interrelated functions that are im-portant for goal-directed; problem solv-ing behavior. The early development ofexecutive functions includes the ability tomaintain problem-solving set for attain-ment of future goal [Welsh and Penning-ton, 1988]. These skills often have signif-icant overlap with the developmentalconstructs measured in assessment of at-tention in young children [Mahone et al.,2002].

The BRIEF-P is designed for usewith children aged 2 years, 0 months to 5years, 11 months. It is organized into fiveclinical scales (Inhibit, Shift, EmotionalControl, Working Memory, Plan/Orga-nize), three clinical indexes (InhibitorySelf-Control, Flexibility, and EmergentMetacognition), and a GEC. Parent andteacher forms are identical. TheBRIEF-P was standardized using parentratings from 460 parents (214 girls, 246boys). For 302 of those children (138girls, 164 boys), teachers also completedthe forms. Internal consistency coeffi-

cients for the scales and index scoresrange from 0.85 to 0.95 for the parentratings and from 0.90 to 0.97 for theteacher ratings. The test–retest reliabilitycoefficients for the GEC score (mean re-test interval � 4 weeks) was 0.90 forparents and 0.88 for teachers. TheBRIEF-P manual also reports a high de-gree of intercorrelation between theBRIEF-P and other PRSs, including theCBCL 11⁄2–5 and the BASC. The sensi-tivity of the instrument (comparing clin-ical groups with controls) is also reportedfor children with ADHD, autism, prema-turity, and language disorders [Gioia etal., 2003]. In a sample of 25 preschoolerswith ADHD, ages 3–5, Mahone andHoffman [2005] found that parent ratingson all BRIEF-P scales and index scoreswere significantly higher than ratings of25 age-, SES-, and gender-matched con-trols (mean effect size �2 � 0.40). Withinthe ADHD group, the Global ExecutiveComposite (GEC) was significantly cor-related (r � 0.81) with the CPRS-RADHD Index. In contrast, the GEC wasuncorrelated (r � 0.01) with NEPSYStatue and moderately correlated withNEPSY Visual Attention (r � �35).

CONCLUSIONSThe assessment of attention in pre-

school children poses unique challengesto clinicians and researchers. It is wellestablished that children develop rapidlyduring the preschool years, both in termsof brain development and functionalskills. However, the increased prevalenceof neurodevelopmental and medical con-ditions associated with attention prob-lems in young children, along with therequirements for assessment outlined inPublic Law 99–457 set the stage for asignificant need for valid assessment pro-cedures appropriate for this age group.Indeed, the majority of preschool chil-dren presenting to clinicians for assess-ment have some form of attention prob-lem. Unfortunately, there are a limitednumber of valid assessment methodsavailable to accurately characterize themultidimensional construct attention inthe preschool years.

A number of researchers have de-veloped CPT methods to assess sustainedattention in preschoolers, using down-ward extensions of procedures used forolder children and adults. These instru-ments appear to work well for childrenaged 4 and above; however, there hasbeen less success using these instrumentswith children aged 3 and younger. Theliterature suggests that children aged 3years require an ISI of at least 4,000 ms inorder to choose (correctly or not) a re-

sponse on CPTs, using a choice-reactiontime format. In addition, those CPTslonger than 5 min, and for which multi-ple nontarget stimuli are used, may betoo difficult for children younger than 4years. For children aged 3 and younger,simple reaction time instruments, ormeasures that do not require a self-di-rected motor response (i.e., those forwhich sustained looking behaviors can bevideo recorded) are likely to be required.The latter, however, may not be useful inroutine outpatient clinical settings, inwhich time-efficient assessment methodsare required. In addition to these con-cerns, there is growing evidence that per-formance on CPTs in preschoolers maybe correlated with overall intellectualfunctioning. Thus, higher functioningpreschool children may perform well onCPTs, despite having attention problemsin other settings, while children withlower intellectual functioning may per-form poorly on CPTs, for reasons lessspecific to attention. In addition, carefulconsideration should be given to the ceil-ing effects when using preschool CPTswith older preschool children (ages 5 and6), as some measures have more limiteddevelopmental sensitivity in that agerange. Additional research is certainlyneeded in this area to better establish theutility of CPT measures for routine clin-ical use in preschoolers.

Assessment of related attentionfunctions in preschoolers may be morepractical in clinical settings. A variety ofmethods for assessing auditory (e.g., digitspan) and visual span are readily availablefor preschoolers, and have the benefit ofbrief administration time, no require-ment for special tools, and developmentalsensitivity. Variations on cancellationtests are also available for preschoolers,and are considered to represent assess-ment of focused or visual selective atten-tion. In contrast to the use of cancellationtest procedures in older children andadults, their use in preschool children issignificantly dependent on the develop-ment of graphomotor skill. Some re-searchers have attempted to reduce thisconfound by using bingo stampers orhaving children point, rather than writeresponses. These adaptations appear ap-propriate for preschoolers; however, ad-ditional research is needed.

Given the variability in behaviorand performance among typically devel-oping preschoolers, performance-basedtests may have lower test–retest reliabilitythan that observed for older children.Clinicians using performance-based testsof attention in preschoolers are encour-aged to carefully examine the available


literature regarding test–retest regardingstability of these tests before interpretinglow scores obtained after a single admin-istration. Especially in preschoolers, mul-tiple baseline assessments may be re-quired.

Parent and teacher rating scales arewidely available for preschool children.The commercially available rating scalesare based on current, representative stan-dardization samples, with adequate num-bers of children at each age level in thepreschool years. Many of the preschoolrating scales (particularly PRSs) correlatehighly with one another, suggesting thatthey may be tapping into some commonrating of behavioral maladjustment inpreschool age children—rather than hav-ing specificity for attention problems inisolation. In addition, like the tests avail-able for older children, parent andteacher ratings of attention problems inpreschoolers show only modest correla-tion with actual test performance, sug-gesting that the rating scales and perfor-mance-based tests likely measuredifferent aspects of the attention con-struct [Mahone et al., 2002; Mahone andHoffman, 2005].

In conclusion, there continues tobe considerable need for developmentand validation of procedures to measureattention in preschool children. Contin-ued advances in medical care, includingsurgical procedures, infection control,and neonatal care are likely to continueto result in greater survival of infants thatwould not have been born, or survivedfollowing birth, twenty years ago. In ad-dition, with improved medical diagnosticprocedures, clinicians are being called onmore frequently to describe behavioralphenotypes of neurodevelopmental andgenetic disorders. The incidence of sus-pected ADHD has continued to grow,with greater demand for assessment andtreatment in the preschool years. Ouravailable assessment methods show gooddiagnostic sensitivity in the preschoolyears; however (again, similar to that oftests for older children), evidence of theirspecificity continues to be limited. Thus,use of these tests in isolation to “diag-nose” disorders of attention (includingADHD) is not recommended. Rather,with appropriate caution, clinicians canuse many of the procedures reviewed inthis article to assess the development ofattention, as part of a comprehensive as-sessment of preschool children. f

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