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Italian neuropsychological instruments to assess memory, attention and frontal functions for developmental age

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  • ASST Grande Ospedale Metropolitano Niguarda Milano, Italy

Abstract and Figures

In this study, a series of tests exploring long-term verbal memory (the Short Story Test), attention (a modified version of Attentional Matrices and the Trail Making Test) and frontal functions (a modified version of the Frontal Assessment Battery) have been standardised on an Italian population of 283 children aged 5-14. Raw scores for each test have been adjusted for a series of variables (child's age, years of parents' education, handedness, gender) and transformed in equivalent scores enabling direct comparison across measures. This study was promoted by LICE (the Italian League Against Epilepsy) in order to provide Italian instruments standardised on the developmental age population and to study some of the most frequently impaired cognitive functions in epilepsy.
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some of the most frequently impaired cognitive functions
in epilepsy.
Key words Epilepsy Memory Attention Frontal functions
School-age children
Introduction
The aim of the present study is to provide an Italian stan-
dardisation of cognitive tests assessing long-term episodic
verbal memory (two new parallel versions of the Short
Story Test), attention (a modified version of Attentional
Matrices and the Trail Making Test) and frontal functions
(a modified version of the Frontal Assessment Battery) for
children. Until now, only a quite limited range of instru-
ments to assess these cognitive functions have been avail-
able with an Italian standardisation [1–5].
We have chosen tests available in the adult neuropsy-
chological literature, which are sensitive in assessing both
the cognitive functions under study and their modifications
in time. As they can be easily administered to children,
even those of a young age, demanding a reasonable
amount of time and effort on the part of the child, they
were deemed particularly useful in longitudinal studies
within a wider neuropsychological battery.
The LICE (Italian League Against Epilepsy)
Neuropsychology Study Group promoted this investiga-
tion specifically focused on cognitive functions such as
memory and attention that are frequently impaired in tem-
poral and frontal epilepsy.
Frontal and temporal lobe maturation has often been
analysed in normal children by applying models and tests
derived from the study of adults. Evidence from healthy
children has shown that the structural and physiological
changes occurring during frontal lobe development coin-
cide with increasing efficiency in information processing
and activity modulation [6]. A sequential development of
Neurol Sci (2006) 27:381–396
DOI 10.1007/s10072-006-0717-5
P. Scarpa A. Piazzini G. Pesenti P. Brovedani A. Toraldo K. Turner S. Scotti C. Dal Lago
V. Perelli D. Brizzolara R. Canger M.P. Canevini G. Bottini
Italian neuropsychological instruments to assess memory, attention
and frontal functions for developmental age
ORIGINAL
Received: 27 March 2006 / Accepted in revised form: 16 November 2006
Abstract In this study, a series of tests exploring long-
term verbal memory (the Short Story Test), attention (a
modified version of Attentional Matrices and the Trail
Making Test) and frontal functions (a modified version of
the Frontal Assessment Battery) have been standardised
on an Italian population of 283 children aged 5–14. Raw
scores for each test have been adjusted for a series of vari-
ables (child’s age, years of parents’ education, handed-
ness, gender) and transformed in equivalent scores
enabling direct comparison across measures. This study
was promoted by LICE (the Italian League Against
Epilepsy) in order to provide Italian instruments standard-
ised on the developmental age population and to study
P. Scarpa ()
G. Pesenti S. Scotti G. Bottini
Cognitive Neuropsychology Laboratory
Neuroscience Department
Niguarda Hospital, Milan, Italy
e-mail: pina.scarpa@fastwebnet.it
A. Toraldo
G. Bottini
Psychology Department
University of Pavia, Italy
A. Piazzini
K. Turner C. Dal Lago R. Canger M.P. Canevini
Regional Epilepsy Center
S. Paolo Hospital
University of Milan, Italy
P. Brovedani
D. Brizzolara V. Perelli
IRCCS Stella Maris
Department of Developmental Neuroscience and University of
Pisa, Italy
skills has been hypothesised, with simple planning and
visual search mastered by the age of 6, hypothesis testing
and impulsive responding control achieved not before age
10, while motor sequencing and complex planning contin-
ue to develop beyond 12 [7]. On the other hand, the role of
hippocampal and parahippocampal regions is progressive-
ly clearer: these structures are reciprocally interconnected
with the cerebral neo-cortex, and seem to be involved in
the organisation of long-term declarative memory, as
demonstrated by numerous investigations [8–10]. While
the anatomical and functional development of the frontal
cortex progresses with time, it seems that the architecture
of hippocampal and parahippocampal structures is estab-
lished in the first period of life: an early lesion of these
structures could not be compensated for by the establish-
ment of alternative pathways and the degree of impairment
seems to be age-related [11].
Children with epilepsy, depending on the localisation of
the epileptogenic zone, often show cognitive deficits, or
below-average performance, especially in episodic long-
term memory or in attentional tasks [12–19]. For this reason,
we decided to elaborate and standardise a revisited battery of
tests, in order to offer additional measures for the assessment
of long-term verbal memory, attention and frontal functions.
Materials and methods
Sample
Two hundred and eighty-three children, 148 girls and 135 boys,
aged 5–14 years, were recruited. Their clinical history was nega-
tive for neurological disorders and learning disabilities. Children
were randomly selected from the entire population of three
schools located in three Italian towns (Milan, Pavia and Livorno).
The sample included nine educational levels, from the first year
of primary school to the last year of secondary school. In the
first-year student group, a sub-categorisation was applied, with
17 subjects being tested in the early months of the school year, 13
halfway along the year, and 20 at the end of the year, in order to
be able to take into account the possible effects of teaching. The
sample sizes of the other education levels (from 2 to 8, i.e., from
second year of primary school to third year of secondary school)
were n=32, 35, 38, 35, 35, 34 and 24 respectively (see Table 1).
A handedness index for each subject was established on the
basis of which 257 children were classified as right-handed and 26
as left-handed. Parents’ education ranged from 5 to 17 years of for-
mal schooling (father’s age: range 26–62; mean 42; SD 5.25;
father’s years of education: mean 12.58; SD 3.38; mother’s age:
25–53; mean 39.49; SD 4.57; mother’s years of education: mean
12.56; SD 3).
Parents and school teaching staff gave their informed consent
for the children to participate in the study.
In order to estimate the test–retest reliability indices, a subset
of the sample was re-administered again one week later with all
the tests, including the parallel version of the Short Story Test
(Session 1 vs. Session 2).
382 P. Scarpa et al.: Instruments to assess for developmental age
Table 1 Descriptive statistics – stratification of the sample according to child’s education
Short story Attentional Matrices Trail Making Test FAB
Story I Story II N Time A A/B B
Education N Mean age M SD M SD Med Q Med Q Med Q Med Q Med Q Med Q
(years) (years)
0 17 5.9 19.3 7.1 14.3 5.7 52.5 1.9 246 28.6 * * * * * * 7 0.7
0.5 13 6.1 18.5 2.7 14.3 6.1 51 4 208 48 73 14 * * * * 8 1
1 20 6.5 16.5 7.1 15.4 6.2 52.5 2.4 193 42.1 81 9.4 50.5 7.5 * * 8 1
2 32 7.2 19.8 4.8 15.9 4.4 53 2.6 176 24.9 77 16 51 18.4 * * 7 0.6
3 35 8.2 22.7 4.5 19.6 6 56 2 148 16.8 48 10 34 6.7 104 12 9 0.5
4 38 9.2 21.7 4.8 19.6 4.7 54.5 2.5 134 18.5 39 9.3 30 6 102 16.4 8.5 0.5
5 35 10.2 22.4 3.5 19.3 3.4 56 1.5 132 19.3 41 6 30 5 88 17.5 9 0.5
6 35 11.5 24.7 2.5 21.1 3.5 56 3 100 18.8 36 6.8 24 4.5 72 12 9 0.5
7 34 12.6 22 5.5 19.3 3.9 56 2.5 102 18.3 38 6.3 23.5 4.5 74.5 19.6 9 0.5
8 24 13.5 23.1 4.2 19.2 3.8 57.5 0.8 86 10.5 28 3.3 18.5 1.7 62 13 9 0
Data from Session I are reported. Short story: N of recalled elements (out of 34). Attentional Matrices: the number of crossed targets (N; max. 60) and time (s) to complete the test are
reported. Trail Making Test: time values (s) are reported for the three parts, A, A/B and B. *Most children could not perform the task. FA B: overall score (max. 9). Statistics: M, mean;
SD, standard deviation; Med, median; Q, semi-interquartile range. Non-parametric descriptive statistics (Median and Q) are reported for raw scores that are not normally distributed
Neuropsychological assessment
The overall testing time was about 20 min. The Short Story Test
was administered first; selective attention abilities and frontal
functions were assessed during the 15-min interval between the
immediate and the delayed recalls of the Short Story Test.
Short Story Test
In order to limit verbal material learning effects from the 1st to the
2nd session, two different stories (1 and 2, see Appendix) were
constructed. Eighty-five children recalled Story 1 on the first ses-
sion and Story 2 on the second one; the order was reversed for the
other 72 children. At variance with the standard procedure of
administration of the Story Recall Test [20], we decided to intro-
duce a second immediate recall. Thus, in each session, the exam-
iner read the Short Story aloud, asked for immediate recall, read
the Story aloud again, requesting immediate recall, administered
other tests for 15 min, and finally asked for the delayed recall. We
suggest in clinical practice to administer the attentional and exec-
utive tasks of this battery before the delayed recall to control for
the effects of other forms of interferences.
Scoring. Each Story consisted of 34 morphological units.
The scoring criteria were the following:
nouns were considered correctly recalled when their root was
kept, irrespective of the flexion (e.g., green instead of greenish);
synonyms were accepted as correct recalls (e.g. cat/kitten).
The average of the number of correctly recalled morphologi-
cal units over 3 recall trials was the final score (total maximum
score: 34).
Attentional Matrices
Three matrices of numbers were administered with the instruc-
tion to cross out as fast as possible target numbers of either one,
two or three digits. The purpose of this test was to assess the sub-
jects’ ability to detect visual targets among distractors. The mate-
rial used in this study was the same as that in Spinnler and
Tognoni’s study [21], but instructions were adapted for children
and the task had no time limit. The overall number of targets that
were crossed out divided by the number of seconds across the
three matrices was the final score.
Trail Making Test (TMT)
This test explores different cognitive components, in particular
attentional skills, visuo-motor planning, sustained attention and
working memory. Subjects were presented with an A4 sheet with
circles containing a number and requested to link, as fast as pos-
sible, all the circles, following their ascending numerical order.
There are two TMT forms available [22]: the TMT A with only
numbers (from 1 to 25), and the TMT B with alternating numbers
and letters (from 1, A; 2, B; … to 13). We also introduced a new
form ‘A/B’, to be administered between forms A and B, with only
letters as stimuli (from A to Z). The instructions for this form
were to link the letters in alphabetical order. This test was aimed
at ensuring that children, especially the younger ones, had the
alphabetical knowledge required to solve part B.
Frontal Assessment Battery (FAB)
To investigate mental flexibility, motor planning and executive
control, we selected three out of six subtests from the FAB [23].
Motor planning and executive action control were explored
by means of Luria’s motor tasks. In the ‘contrast’ task, exploring
the ability to prevent interference effects, subjects had to perform
an action opposite to that performed by the examiner, refraining
from the tendency to imitate the examiner’s action. Inhibition of
control was evaluated by a ‘Go-No-Go’ task.
Scores ranged from 0 (no correct responses) to 3 (all correct
responses) for each subtest. The overall score was the sum of the
three subtest scores (range: 0–9).
Statistical methods
Data analysis
Data were analysed by means of a general linear model (GLM)
whenever the assumptions of normality and homoscedasticity
were met. Raw data from the Short Story Test were normally and
homoscedastically distributed, and those from the Attentional
Matrices and Trail Making Subtests after logarithmic transforma-
tions (see Results for further details). Independent variables of
the GLM were Age of Child, Age of Mother, Age of Father, Years
of Education of the Child’s Mother, Years of Education of the
Child’s Father, Gender (male vs. female) and Handedness (left-
vs. right-hander). In the Short Story analysis one further variable
was Story Form (Story 1 vs. Story 2).
The FAB data showed an irreducible ceiling effect so no
transformation could normalise the distribution. Hence non-para-
metrics (Spearman’s r) were applied to this data set.
Reliability indices were computed by means of Pearson’s cor-
relation between the adjusted scores when normality was satis-
fied (Short Story, Attentional Matrices, Trail Making);
Spearman’s r was used otherwise (FAB).
Diagnosis
For all the tests that allowed the application of a GLM (normali-
ty and homoscedasticity satisfied), adjustment tables were com-
puted on grounds of a linear model including only the predictors
yielding a significant effect in the GLM itself.
Adjusted scores were provided together with the rules for
conversion to equivalent scores [24]. Equivalent scores range
from 0 to 4, with children obtaining a score of 0 being diagnosed
with a clear pathology, 1 borderline, 2 and 3 low–normal, and 4
superior (4 corresponds to scores above the mean of the standard-
isation sample). Equivalent scores correspond to specific z points;
thus 0 corresponds to scores below z=–1.86 (3.1% of the stan-
dardisation sample); 1 to scores between z=–1.86 and z=–1.24
(7.6%); 2 to scores between –1.24 and –0.62 (16%); 3 to scores
between –0.62 and 0 (23.2%); and 4 to scores above z=0 (50%).
Another diagnostic system was also provided, whenever
adjustment procedures could be applied, according to the logic of
“non-parametric tolerance limits” [25]. This system takes into
account that the usual cut-offs for pathology, e.g., the 5th per-
centile, are estimates from a sample, and not the true values that
would be obtained from the (infinite) population; thus, there is
some uncertainty as to the real position of the cut-off. The “outer
tolerance limit (OTL)” is a cut-off farther away from the mean
than the usual one; the OTL guarantees (with 95% probability)
that no more than 5% of the reference population score actually
below it. The “inner tolerance limit (ITL)” is another cut-off,
closer to the mean, that guarantees (again with 95% probability)
P. Scarpa et al.: Instruments to assess for developmental age 383
that no less than 5% of the reference population score below it.
Therefore, a diagnosis of pathology is rather safe if the score is
below the OTL, and a diagnosis of normality is also rather safe if
the score is above the ITL. Uncertainty remains for individuals
scoring in between. Quite naturally, three diagnostic categories
follow: pathological (below OTL), “borderline” or “uncertain”
(between OTL and ITL) and normal (above ITL). Clearly, for
tests in which pathological scores are higher (not lower) than the
mean (e.g., Trail Making Test), the OTL is above, not below, the
ITL. Non-parametric tolerance limits were applied because
adjusted scores were used to derive them [25]. Both outer and
inner tolerance limits referred to the estimation of the 5th per-
centile and had a confidence level of 95%.
Results
Table 1 reports subjects’ characteristics and descriptive
statistics of the main raw test scores.
Short Story Test
The score distribution did not show ceiling or floor effects.
Furthermore, the distribution was unimodal and symmetri-
cal, thus allowing for standard parametrical statistical
analyses. This regularity was confirmed after the applica-
tion of the GLM: residuals distributed very closely to a
384 P. Scarpa et al.: Instruments to assess for developmental age
Gaussian (skewness=0.064, SE=0.147; kurtosis=0.126,
SE=0.294).
Variables inducing significant effects (GLM)
Overall scores obtained on the first session were consid-
ered as the reference distribution.
Variables that significantly influenced the subjects’
scores were:
1. Age of child. Older children showed better memory abil-
ities (F(1, 268)=43.576, p<0.001). The average perfor-
mance increased by 0.77 elements per year of age.
2. Years of education of the child’s mother. The child’s
memory performance increased by 0.28 elements/mor-
phological units per year of mother’s education (F(1,
268)=5.918, p=0.016).
3. Years of education of the child’s father. The child’s
memory performance increased by 0.33 units per year
of father’s education (F(1,268)=10.094, p=0.002).
4. Story form. Story 1 was easier to recall than Story 2
(F(1,268)=36.716, p<0.001). The advantage was of
about 3 units, with an average of 21.5 recalled from
Story 1, and 18.5 recalled from Story 2.
Adjustment tables
Table 2 reports the adjustment values and the equivalent
scores. The adjustment values have to be added to the
child’s raw ‘overall’ score as a function of age, father’s
education, mother’s education and form of the Short Story
Test (1 or 2) (Table 2).
Table 2 Adjustment values, equivalent scores and non-parametric tolerance limits for the Short Story Test; to be applied on the raw ‘over-
all’ score
Fye Mye Child’s age (years)
5678 91011121314
5 5 –10.19 –10.95 –11.72 –12.49 –13.26 –14.03 –14.79 –15.56 –16.33 –17.1
5 8 –11.04 –11.81 –12.58 –13.34 –14.11 –14.88 –15.65 –16.42 –17.18 –17.95
5 13 –12.47 –13.23 –14 –14.77 –15.54 –16.31 –17.07 –17.84 –18.61 –19.38
5 17 –13.61 –14.37 –15.14 –15.91 –16.68 –17.45 –18.21 –18.98 –19.75 –20.52
8 5 –11.19 –11.96 –12.73 –13.49 –14.26 –15.03 –15.8 –16.57 –17.33 –18.1
8 8 –12.05 –12.81 –13.58 –14.35 –15.12 –15.89 –16.65 –17.42 –18.19 –18.96
8 13 –13.47 –14.24 –15.01 –15.77 –16.54 –17.31 –18.08 –18.85 –19.61 –20.38
8 17 –14.61 –15.38 –16.15 –16.91 –17.68 –18.45 –19.22 –19.99 –20.75 –21.52
13 5 –12.87 –13.63 –14.4 –15.17 –15.94 –16.71 –17.47 –18.24 –19.01 –19.78
13 8 –13.72 –14.49 –15.26 –16.02 –16.79 –17.56 –18.33 –19.1 –19.86 –20.63
13 13 –15.15 –15.91 –16.68 –17.45 –18.22 –18.99 –19.75 –20.52 –21.29 –22.06
13 17 –16.29 –17.05 –17.82 –18.59 –19.36 –20.13 –20.89 –21.66 –22.43 –23.2
17 5 –14.21 –14.97 –15.74 –16.51 –17.28 –18.05 –18.81 –19.58 –20.35 –21.12
17 8 –15.06 –15.83 –16.6 –17.36 –18.13 –18.9 –19.67 –20.44 –21.2 –21.97
17 13 –16.49 –17.25 –18.02 –18.79 –19.56 –20.33 –21.09 –21.86 –22.63 –23.4
17 17 –17.63 –18.39 –19.16 –19.93 –20.7 –21.47 –22.23 –23 –23.77 –24.54
Fye, father’s years of education; Mye, mother’s years of education
Reliability
A test–retest reliability index was computed by obtaining
Pearson’s linear correlation coefficient between the
(adjusted) scores on the first and second session (n=154).
The obtained estimate was r=0.676.
Attentional Matrices
While adults generally perform the Attentional Matrices
with high accuracy (about 100% targets detected) and vary
only in the time employed to complete the search task,
children can show considerable variability in accuracy.
Therefore, we introduced a measure which takes into
account both time and accuracy.
This measure is the average frequency of detection
(number of targets per second), i.e., the overall number of
detected targets (N) divided by overall time in seconds (t).
One of the advantages of this measure is that it does not
show ceiling or floor effects. It also allows for parametric
statistics and simple linear model analyses after a loga-
rithmic transformation. The final score was thus the natur-
al logarithm of the average frequency: ln(N/t).
The suitability of the GLM model was confirmed by the
analysis of the distribution of the GLM residuals, which was
very close to Gaussian (skewness=0.139, kurtosis=-0.29).
Variables inducing significant effects (GLM)
Variables that significantly influenced the subjects’ M
scores were: age of child (F(1,280)=559.982, p<0.001)
and gender (F(1,280)=9.838, p=0.002).
Adjustment table
Because of the logarithmic transformation, the adjustment
of scores cannot be made directly. Table 3 shows the
equivalent scores as a function of frequency scores (N/t),
age and gender of the child to be assessed. To use the table,
one has to select the row reporting gender and age of the
assessed child (male: first 10 rows; female: last 10 rows).
In each row, the ranges of N/t scores corresponding to
equivalent scores are reported.
For example, a 9-year-old girl who detected 49 targets
in 162 seconds has a N/t=49/162=0.302. By scanning the
row (F, 9), 0.302 is found in the range 0.29–0.33, which
corresponds to an equivalent score of 2 and to a “normali-
ty” diagnosis according to the Tolerance Limits criterion
(Table 3).
Reliability
The test–retest reliability index, computed on 157 subjects
was r=0.825. Performance neither improved nor worsened
at retest.
Trail Making Test (TMT)
It was quite evident that some conditions of this test are
not adequate for children, particularly for those who have
not yet acquired enough numerical and alphabetical
knowledge to perform the task. For instance, children at
the beginning of the 1st school year could not successful-
ly complete TMT part A; some children who were tested in
the middle of their 1st primary school year were not able
to complete TMT part A/B; TMT part B was successfully
performed only by children of the 3rd primary school year
or older.
Therefore, TMT part A is suitable for children who
have already attended the first half of the 1st school year;
TMT part A/B for subjects who have already finished the
1st school year; TMT part B for children who have fin-
ished the 2nd school year. Subjects who did not meet
these criteria were excluded from further statistical
analyses.
TMT part A
We used the measure T=ln(sec/100), i.e., the natural loga-
rithm of the overall time, in seconds, divided by 100. This
measure allowed us to use parametric statistics because it
stabilised the score variance across different levels of per-
formance. The distribution of residuals was very close to
Gaussian (kurtosis=0.458, skewness=-0.026).
Overall time varied from 15 to 215 s in the sample. The
statistical analysis showed a significant learning effect,
i.e., a significant improvement from session 1 (53 s on
average) to session 2 (43 s) (F(1,128)=36.04, p<0.001).
P. Scarpa et al.: Instruments to assess for developmental age 385
Adjusted score Equivalent score
Below –8.42 0
From –8.42 to –5.62 1
From –5.62 to –2.81 2
From –2.81 to 0 3
Above 0 4
Non-parametric tolerance limits for the 5th percentile (level of con-
fidence: 95%)
Adjusted score Diagnosis
Below –8.95 (OTL) Pathological
From –8.95 (OTL) to –6.93 (ITL) Uncertain
Above –6.93 (ITL) Normal
IMPORTANT: If Story 1 was administered, beyond applying the
adjustment parameters of Table 2, subtract another 3.337 points.
For instance, the Adjusted score of a 9-year-old child who was
administered Story 1, whose father has 5 years of education, whose
mother has 8 years of education, and who obtained a raw score of
10, is 10–14.11–3.337=–7.447 (Equivalent score 1)
Variables inducing significant effects (GLM)
Child’s age (F(1,254)=263.573, p<0.001). The older, the
faster. This advantage was 2 s per year for fast subjects
(overall time around 18 s) and 30 s per year for slow sub-
jects (overall time around 220 s).
Father’s education (F(1,254)=5.917, p=0.016). The
higher the fathers’ education, the better the children’s per-
formance. The difference between a child whose father
graduated from university (education=17 years) and a
child whose father completed primary school (education=5
years) ranged between 2 s (very fast children) and 30 s
(very slow children).
Adjustment table
These two variables were used to obtain equivalent scores.
Due to the logarithmic transformation, the computation of
adjusted scores would be quite complex from a mathemat-
ical viewpoint. Table 4 indicates the equivalent scores as a
function of demographic characteristics and overall time to
perform the task.
For example, in the case of an 11-year-old boy whose
father completed primary school education (5 years) and
who took 74 s to complete TMT part A, it is necessary to
find the row matching the child’s age and father’s educa-
tion and then intersect the column showing the range of
values where the child’s overall time falls. In this case, the
386
range 64.6–78.6 corresponds to an equivalent score of 1.
As for the Tolerance Limits criterion, an “uncertain”, or
borderline diagnosis will hold (Table 4).
Reliability
The estimated correlation coefficient was r=0.772,
obtained on 140 subjects.
TMT part A/B
The residuals’ distribution was satisfactorily close to
Gaussian (skewness=-0.593, kurtosis=1.264). We found a
learning effect between test and retest (F(1,122)=29.427,
p<0.001).
Variables inducing significant effects (GLM)
The same variables affecting scores in TMT part A, i.e.,
age and father’s education, significantly influenced the
scores in TMT part A/B too.
Adjustment table
Table 5 shows equivalent scores obtained with the same
procedure as in TMT part A.
Reliability
The estimated correlation coefficient was r=0.685,
obtained on 134 subjects.
P. Scarpa et al.: Instruments to assess for developmental age
Table 3 Attentional Matrices. Ranges of N/t values corresponding to different equivalent scores (0–4) and to different diagnoses accord-
ing to the non-parametric tolerance limits criteria
Equivalent scores Non-parametric tolerance limits
0 1 2 3 4 Pathological Uncertain Normal
Gender Age Below From To From To From To Above Below From–to Above
M 5 0.13 0.13 0.15 0.15 0.18 0.18 0.21 0.21 0.13 0.13–0.14 0.14
6 0.15 0.15 0.18 0.18 0.20 0.20 0.23 0.23 0.15 0.15–0.16 0.16
7 0.17 0.17 0.20 0.20 0.23 0.23 0.27 0.27 0.17 0.17–0.19 0.19
8 0.20 0.20 0.23 0.23 0.26 0.26 0.31 0.31 0.19 0.19–0.21 0.21
9 0.23 0.23 0.26 0.26 0.30 0.30 0.35 0.35 0.22 0.22–0.24 0.24
10 0.26 0.26 0.30 0.30 0.35 0.35 0.40 0.40 0.25 0.25–0.28 0.28
11 0.30 0.30 0.34 0.34 0.39 0.39 0.46 0.46 0.29 0.29–0.32 0.32
12 0.34 0.34 0.39 0.39 0.45 0.45 0.52 0.52 0.33 0.33–0.36 0.36
13 0.39 0.39 0.45 0.45 0.52 0.52 0.59 0.59 0.38 0.38–0.42 0.42
14 0.44 0.44 0.51 0.51 0.59 0.59 0.68 0.68 0.43 0.43–0.48 0.48
F 5 0.15 0.15 0.17 0.17 0.19 0.19 0.22 0.22 0.14 0.14–0.16 0.16
6 0.17 0.17 0.19 0.19 0.22 0.22 0.26 0.26 0.16 0.16–0.18 0.18
7 0.19 0.19 0.22 0.22 0.25 0.25 0.29 0.29 0.19 0.19–0.20 0.20
8 0.22 0.22 0.25 0.25 0.29 0.29 0.33 0.33 0.21 0.21–0.23 0.23
9 0.25 0.25 0.29 0.29 0.33 0.33 0.38 0.38 0.24 0.24–0.27 0.27
10 0.28 0.28 0.33 0.33 0.38 0.38 0.43 0.43 0.28 0.28–0.30 0.30
11 0.32 0.32 0.37 0.37 0.43 0.43 0.50 0.50 0.32 0.32–0.35 0.35
12 0.37 0.37 0.43 0.43 0.49 0.49 0.57 0.57 0.36 0.36–0.40 0.40
13 0.42 0.42 0.49 0.49 0.56 0.56 0.65 0.65 0.41 0.41–0.45 0.45
14 0.48 0.48 0.56 0.56 0.64 0.64 0.74 0.74 0.47 0.47–0.52 0.52
P. Scarpa et al.: Instruments to assess for developmental age 387
Table 4 Trail Making Test (part A). Equivalent scores and non-parametric tolerance limits diagnoses as a function of demographic characteristics and overall time (s) to perform the task
Equivalent scores Non-parametric tolerance limits
4 3 2 1 0 Normal Uncertain Pathological
Age Father’s Shorter From To From To From To Longer Shorter From To Longer than
education than than than
6 5 89.7 89.7 109.1 109.1 132.7 132.7 161.5 161.5 140.2 140.2 157.0 157.0
6 8 85.8 85.8 104.4 104.4 127.0 127.0 154.5 154.5 134.1 134.1 150.1 150.1
6 13 79.7 79.7 96.9 96.9 117.9 117.9 143.4 143.4 124.6 124.6 139.4 139.4
6 17 75.1 75.1 91.3 91.3 111.1 111.1 135.2 135.2 117.4 117.4 131.4 131.4
7 5 77.6 77.6 94.5 94.5 114.9 114.9 139.8 139.8 121.4 121.4 135.9 135.9
7 8 74.3 74.3 90.4 90.4 109.9 109.9 133.7 133.7 116.1 116.1 130.0 130.0
7 13 69.0 69.0 83.9 83.9 102.1 102.1 124.2 124.2 107.9 107.9 120.7 120.7
7 17 65.0 65.0 79.1 79.1 96.2 96.2 117.1 117.1 101.7 101.7 113.8 113.8
8 5 67.2 67.2 81.8 81.8 99.5 99.5 121.1 121.1 105.1 105.1 117.7 117.7
8 8 64.3 64.3 78.2 78.2 95.2 95.2 115.8 115.8 100.6 100.6 112.6 112.6
8 13 59.7 59.7 72.7 72.7 88.4 88.4 107.5 107.5 93.4 93.4 104.5 104.5
8 17 56.3 56.3 68.5 68.5 83.3 83.3 101.4 101.4 88.0 88.0 98.5 98.5
9 5 58.2 58.2 70.8 70.8 86.2 86.2 104.8 104.8 91.0 91.0 101.9 101.9
9 8 55.7 55.7 67.8 67.8 82.4 82.4 100.3 100.3 87.1 87.1 97.5 97.5
9 13 51.7 51.7 62.9 62.9 76.5 76.5 93.1 93.1 80.9 80.9 90.5 90.5
9 17 48.7 48.7 59.3 59.3 72.1 72.1 87.8 87.8 76.2 76.2 85.3 85.3
10 5 50.4 50.4 61.3 61.3 74.6 74.6 90.8 90.8 78.8 78.8 88.2 88.2
10 8 48.2 48.2 58.7 58.7 71.4 71.4 86.8 86.8 75.4 75.4 84.4 84.4
10 13 44.8 44.8 54.5 54.5 66.3 66.3 80.6 80.6 70.0 70.0 78.4 78.4
10 17 42.2 42.2 51.3 51.3 62.5 62.5 76.0 76.0 66.0 66.0 73.9 73.9
11 5 43.6 43.6 53.1 53.1 64.6 64.6 78.6 78.6 68.3 68.3 76.4 76.4
11 8 41.8 41.8 50.8 50.8 61.8 61.8 75.2 75.2 65.3 65.3 73.1 73.1
11 13 38.8 38.8 47.2 47.2 57.4 57.4 69.8 69.8 60.6 60.6 67.9 67.9
11 17 36.5 36.5 44.5 44.5 54.1 54.1 65.8 65.8 57.1 57.1 64.0 64.0
12 5 37.8 37.8 46.0 46.0 55.9 55.9 68.1 68.1 59.1 59.1 66.2 66.2
12 8 36.2 36.2 44.0 44.0 53.5 53.5 65.1 65.1 56.5 56.5 63.3 63.3
12 13 33.6 33.6 40.8 40.8 49.7 49.7 60.5 60.5 52.5 52.5 58.8 58.8
12 17 31.6 31.6 38.5 38.5 46.8 46.8 57.0 57.0 49.5 49.5 55.4 55.4
13 5 32.7 32.7 39.8 39.8 48.4 48.4 58.9 58.9 51.2 51.2 57.3 57.3
13 8 31.3 31.3 38.1 38.1 46.3 46.3 56.4 56.4 49.0 49.0 54.8 54.8
13 13 29.1 29.1 35.4 35.4 43.0 43.0 52.4 52.4 45.5 45.5 50.9 50.9
13 17 27.4 27.4 33.3 33.3 40.6 40.6 49.3 49.3 42.8 42.8 48.0 48.0
14 5 28.3 28.3 34.5 34.5 41.9 41.9 51.0 51.0 44.3 44.3 49.6 49.6
14 8 27.1 27.1 33.0 33.0 40.1 40.1 48.8 48.8 42.4 42.4 47.4 47.4
14 13 25.2 25.2 30.6 30.6 37.3 37.3 45.3 45.3 39.4 39.4 44.1 44.1
14 17 23.7 23.7 28.9 28.9 35.1 35.1 42.7 42.7 37.1 37.1 41.5 41.5
388 P. Scarpa et al.: Instruments to assess for developmental age
Table 5 Trail Making Test (part A/B). Equivalent scores and non-parametric tolerance limits diagnoses as a function of demographic characteristics and overall time (s) to perform the task
Equivalent scores Non-parametric tolerance limits
4 3 2 1 0 Normal Uncertain Pathological
Age Father’s Shorter From To From To From To Longer Shorter From To Longer than
education than than
6 5 59.9 59.9 73.7 73.7 90.6 90.6 111.4 111.4 108.5 108.5 131.9 131.9
6 8 58.2 58.2 71.6 71.6 88.0 88.0 108.2 108.2 105.4 105.4 128.1 128.1
6 13 55.4 55.4 68.1 68.1 83.8 83.8 103.0 103.0 100.4 100.4 122.0 122.0
6 17 53.3 53.3 65.5 65.5 80.5 80.5 99.0 99.0 96.5 96.5 117.3 117.3
7 5 51.6 51.6 63.4 63.4 78.0 78.0 95.9 95.9 93.4 93.4 113.6 113.6
7 8 50.1 50.1 61.6 61.6 75.7 75.7 93.1 93.1 90.7 90.7 110.3 110.3
7 13 47.7 47.7 58.6 58.6 72.1 72.1 88.6 88.6 86.4 86.4 105.0 105.0
7 17 45.9 45.9 56.4 56.4 69.3 69.3 85.2 85.2 83.1 83.1 101.0 101.0
8 5 44.4 44.4 54.6 54.6 67.1 67.1 82.5 82.5 80.4 80.4 97.7 97.7
8 8 43.1 43.1 53.0 53.0 65.2 65.2 80.1 80.1 78.1 78.1 94.9 94.9
8 13 41.1 41.1 50.5 50.5 62.1 62.1 76.3 76.3 74.4 74.4 90.4 90.4
8 17 39.5 39.5 48.5 48.5 59.7 59.7 73.4 73.4 71.5 71.5 86.9 86.9
9 5 38.2 38.2 47.0 47.0 57.8 57.8 71.0 71.0 69.2 69.2 84.1 84.1
9 8 37.1 37.1 45.6 45.6 56.1 56.1 69.0 69.0 67.2 67.2 81.7 81.7
9 13 35.3 35.3 43.4 43.4 53.4 53.4 65.7 65.7 64.0 64.0 77.8 77.8
9 17 34.0 34.0 41.8 41.8 51.4 51.4 63.1 63.1 61.5 61.5 74.8 74.8
10 5 32.9 32.9 40.4 40.4 49.7 49.7 61.1 61.1 59.6 59.6 72.4 72.4
10 8 31.9 31.9 39.3 39.3 48.3 48.3 59.4 59.4 57.8 57.8 70.3 70.3
10 13 30.4 30.4 37.4 37.4 46.0 46.0 56.5 56.5 55.1 55.1 67.0 67.0
10 17 29.2 29.2 36.0 36.0 44.2 44.2 54.3 54.3 53.0 53.0 64.4 64.4
11 5 28.3 28.3 34.8 34.8 42.8 42.8 52.6 52.6 51.3 51.3 62.3 62.3
11 8 27.5 27.5 33.8 33.8 41.6 41.6 51.1 51.1 49.8 49.8 60.5 60.5
11 13 26.2 26.2 32.2 32.2 39.6 39.6 48.6 48.6 47.4 47.4 57.6 57.6
11 17 25.2 25.2 30.9 30.9 38.0 38.0 46.8 46.8 45.6 45.6 55.4 55.4
12 5 24.4 24.4 30.0 30.0 36.8 36.8 45.3 45.3 44.1 44.1 53.6 53.6
12 8 23.7 23.7 29.1 29.1 35.8 35.8 44.0 44.0 42.9 42.9 52.1 52.1
12 13 22.5 22.5 27.7 27.7 34.1 34.1 41.9 41.9 40.8 40.8 49.6 49.6
12 17 21.7 21.7 26.6 26.6 32.7 32.7 40.3 40.3 39.2 39.2 47.7 47.7
13 5 21.0 21.0 25.8 25.8 31.7 31.7 39.0 39.0 38.0 38.0 46.2 46.2
13 8 20.4 20.4 25.0 25.0 30.8 30.8 37.8 37.8 36.9 36.9 44.8 44.8
13 13 19.4 19.4 23.8 23.8 29.3 29.3 36.0 36.0 35.1 35.1 42.7 42.7
13 17 18.6 18.6 22.9 22.9 28.2 28.2 34.7 34.7 33.8 33.8 41.1 41.1
14 5 18.1 18.1 22.2 22.2 27.3 27.3 33.5 33.5 32.7 32.7 39.7 39.7
14 8 17.5 17.5 21.6 21.6 26.5 26.5 32.6 32.6 31.7 31.7 38.6 38.6
14 13 16.7 16.7 20.5 20.5 25.2 25.2 31.0 31.0 30.2 30.2 36.7 36.7
14 17 16.1 16.1 19.7 19.7 24.3 24.3 29.8 29.8 29.1 29.1 35.3 35.3
TMT part B
The residuals’ distribution was very close to Gaussian
(skewness=-0.112; kurtosis=0.128). TMT part B seems to
involve different cognitive processes from those involved
in TMT parts A and A/B. Pearson’s correlation between
TMT part A and part A/B was high (about 0.7); the corre-
lations between A and B on the one hand, and between A/B
and B on the other, were much smaller (about 0.4).
Pearson’s correlation coefficients between TMT parts
A, A/B and B were the following: A/B vs. A=0.699
(n=263), B vs. A=0.421 (n=190) and B vs. A/B=0.419
(n=190).
By analysing TMT part B data, a clear learning effect
was found between test and retest (F(1,95)=25.708,
p<0.001): subjects became about 9 s faster in session 2.
Variables inducing significant effects (GLM)
The GLM analysis on the first session data showed effects
of age (F(1,188)=23.205, p<.001), mother’s education
(F(1,188)=5.84, p=0.017), gender (F(1,188)=3.991,
p=0.047), the interaction gender with handedness
(F(1,188)=8.955, p=0.003) and the interaction gender with
handedness with age (F(3,188)=3.84, p=0.011).
Adjustment tables
For the purpose of score adjustment, all variables produc-
ing significant effects and complex interactions were taken
into account. Table 6a reports data on children aged 8–10
years, who showed also a handedness effect (interacting
with gender). Table 6b reports data on children aged
11–14, who did not show the above interaction.
Reliability
The TMT part B reliability index was lower than that of
parts A and A/B: r=0.613, estimated on 107 subjects.
FAB
The overall scores obtained from the three selected sub-
tests (range: 0–9) were distributed in a strongly asymmet-
rical way (skewness=-1.874; kurtosis=4.619) due to a clear
ceiling effect. Therefore, no adjustment procedure could
be applied and non-parametric statistics were used.
There was a small (0.31 points on average) but significant
learning effect (Wilcoxon: z=3.498, p<0.001).
Variable inducing significant effects
The only significant effect was the child’s age (Spearman’s
r=0.377, p<0.001), calculated on 283 children.
Adjustment table
Although the FAB score distribution is not Gaussian,
equivalent scores having similar meaning as the ‘classical’
ones [21] could be obtained. Thus, for a given FAB score,
the percentage of subjects of the normative sample who
obtained lower scores was taken, and the equivalent score
corresponding to that percentage was assigned to that par-
ticular case. Table 7 reports equivalent scores as a function
of raw FAB scores and child’s age.
Reliability
The non-parametric correlation coefficient was not very
high: Spearman’s r=0.389, obtained from 157 subjects.
Discussion
In this study tests assessing long-term episodic verbal
memory (the Short Story Test), attention (Attentional
Matrices, the Trail Making Test A, A/B and B) and frontal
functions (FAB) have been standardised on an Italian sam-
ple of 283 normally developing subjects aged 5–14.
In the Short Story Test the verbal content seems to be
consolidated in the long-term memory store by the second
recall. The administration of non-verbal tasks between this
recall and the third delayed recall does not seem to affect
the mnemonic trace of the verbal material. The number of
recalled elements increases progressively with age.
Considering the long-term verbal memory perfor-
mance, we observed that the recall pattern changes in the
sample of 6–8-year-olds, suggesting the involvement of
new cognitive strategies at this stage. Different theories on
the mnemonic strategies applied by children during devel-
opment have been elaborated so far: the first systematic
studies began around 1960 [26], with a renewed interest in
Piaget’s [27] and Bruner et al.s investigations [28]. Flavell
et al. developed the learning theory concept applied to ver-
bal rehearsal as a function of age [29]. Further investiga-
tions pointed out the importance of grouping strategies in
memory functioning: some authors speculated that they
are active only starting from the age of 10–11 years [30,
31], while others found that grouping processes can be
applied earlier, even if children are not aware of them [32].
The awareness of adopting memory strategies represents a
relevant factor in the debate on the development of cogni-
tive processes; it can also explain some of the literature’s
different results [33]. We propose that the changes in the
recall pattern observed in our sub-sample of children aged
6–8 years might be ascribed to the development of new
strategies of control, selection and re-arrangement of
information, particularly required for structural contents,
which can be active also at this age [5, 34].
A significant performance variability (i.e., the global
number of correct targets) has been observed at the
Attentional Matrices, in contrast with what is noticed in
adults, who mainly vary in the task execution time.
Children’s performance at the Attentional Matrices proba-
bly depends on a lack of efficiency of the filter process,
which prevents the encoding of irrelevant information,
P. Scarpa et al.: Instruments to assess for developmental age 389
390 P. Scarpa et al.: Instruments to assess for developmental age
Table 6a Trail Making Test (part B). Children aged 8–10 years. Equivalent scores and non-parametric tolerance limits diagnoses as a function of demographic characteristics and overall
time (s) to perform the task
Non-parametric tolerance limits
Equivalent scores
4 3 2 1 0 Normal Uncertain Pathological
Child’s Mother’s Gender/ Shorter From To From To From To Longer Shorter From To Longer
age education Handedness than than than than
8 5 R 123.7 123.7 145.4 145.4 171.0 171.0 201.1 201.1 179.3 179.3 215.3 215.3
8 5 LM 99.5 99.5 117.1 117.1 137.7 137.7 161.9 161.9 144.3 144.3 173.3 173.3
8 5 LF 164.8 164.8 193.8 193.8 227.9 227.9 268.0 268.0 238.9 238.9 286.9 286.9
8 8 R 116.1 116.1 136.5 136.5 160.6 160.6 188.8 188.8 168.3 168.3 202.1 202.1
8 8 LM 93.5 93.5 109.9 109.9 129.3 129.3 152.0 152.0 135.5 135.5 162.7 162.7
8 8 LF 154.7 154.7 181.9 181.9 214.0 214.0 251.6 251.6 224.3 224.3 269.3 269.3
8 13 R 104.5 104.5 122.9 122.9 144.6 144.6 170.0 170.0 151.5 151.5 182.0 182.0
8 13 LM 84.1 84.1 99.0 99.0 116.4 116.4 136.8 136.8 122.0 122.0 146.5 146.5
8 13 LF 139.3 139.3 163.8 163.8 192.6 192.6 226.5 226.5 201.9 201.9 242.5 242.5
8 17 R 96.1 96.1 113.0 113.0 132.9 132.9 156.3 156.3 139.3 139.3 167.3 167.3
8 17 LM 77.4 77.4 91.0 91.0 107.0 107.0 125.8 125.8 112.2 112.2 134.7 134.7
8 17 LF 128.1 128.1 150.6 150.6 177.1 177.1 208.3 208.3 185.7 185.7 223.0 223.0
9 5 R 117.0 117.0 137.6 137.6 161.8 161.8 190.3 190.3 169.6 169.6 203.7 203.7
9 5 LM 94.2 94.2 110.8 110.8 130.3 130.3 153.2 153.2 136.5 136.5 164.0 164.0
9 5 LF 155.9 155.9 183.4 183.4 215.6 215.6 253.6 253.6 226.0 226.0 271.5 271.5
9 8 R 109.9 109.9 129.2 129.2 152.0 152.0 178.7 178.7 159.3 159.3 191.3 191.3
9 8 LM 88.4 88.4 104.0 104.0 122.3 122.3 143.8 143.8 128.2 128.2 154.0 154.0
9 8 LF 146.4 146.4 172.2 172.2 202.5 202.5 238.1 238.1 212.2 212.2 254.9 254.9
9 13 R 98.9 98.9 116.3 116.3 136.8 136.8 160.9 160.9 143.4 143.4 172.2 172.2
9 13 LM 79.6 79.6 93.6 93.6 110.1 110.1 129.5 129.5 115.4 115.4 138.6 138.6
9 13 LF 131.8 131.8 155.0 155.0 182.3 182.3 214.4 214.4 191.1 191.1 229.5 229.5
9 17 R 91.0 91.0 107.0 107.0 125.8 125.8 147.9 147.9 131.9 131.9 158.3 158.3
9 17 LM 73.2 73.2 86.1 86.1 101.2 101.2 119.1 119.1 106.1 106.1 127.5 127.5
9 17 LF 121.2 121.2 142.5 142.5 167.6 167.6 197.1 197.1 175.7 175.7 211.0 211.0
10 5 R 110.7 110.7 130.2 130.2 153.1 153.1 180.1 180.1 160.5 160.5 192.8 192.8
10 5 LM 89.1 89.1 104.8 104.8 123.3 123.3 145.0 145.0 129.2 129.2 155.2 155.2
10 5 LF 147.6 147.6 173.5 173.5 204.1 204.1 240.0 240.0 213.9 213.9 256.9 256.9
10 8 R 104.0 104.0 122.3 122.3 143.8 143.8 169.1 169.1 150.7 150.7 181.0 181.0
10 8 LM 83.7 83.7 98.4 98.4 115.7 115.7 136.1 136.1 121.3 121.3 145.7 145.7
10 8 LF 138.5 138.5 162.9 162.9 191.6 191.6 225.3 225.3 200.8 200.8 241.2 241.2
10 13 R 93.6 93.6 110.1 110.1 129.5 129.5 152.2 152.2 135.7 135.7 163.0 163.0
10 13 LM 75.4 75.4 88.6 88.6 104.2 104.2 122.5 122.5 109.2 109.2 131.2 131.2
10 13 LF 124.7 124.7 146.7 146.7 172.5 172.5 202.9 202.9 180.8 180.8 217.2 217.2
10 17 R 86.1 86.1 101.2 101.2 119.0 119.0 140.0 140.0 124.8 124.8 149.8 149.8
10 17 LM 69.3 69.3 81.5 81.5 95.8 95.8 112.7 112.7 100.4 100.4 120.6 120.6
10 17 LF 114.7 114.7 134.9 134.9 158.6 158.6 186.5 186.5 166.2 166.2 199.7 199.7
R, right-handed; LF, left-handed, female; LM, left-handed, male
P. Scarpa et al.: Instruments to assess for developmental age 391
Table 6b Trail Making Test (part B). Children aged 11–14 years. Equivalent scores and non-parametric tolerance limits diagnoses as a function of demographic characteristics and over-
all time (s) to perform the task
Non-parametric tolerance limits
Equivalent scores
4 3 2 1 0 Normal Uncertain Pathological
Child’s Mother’s Gender Shorter From To From To From To Longer Shorter From To Longer
age education Handedness than than than than
11 5 M 88.2 88.2 104.8 104.8 124.6 124.6 148.1 148.1 127.8 127.8 153.5 153.5
11 5 F 77.4 77.4 92.0 92.0 109.4 109.4 130.1 130.1 112.2 112.2 134.8 134.8
11 8 M 84.4 84.4 100.4 100.4 119.3 119.3 141.9 141.9 122.4 122.4 147.0 147.0
11 8 F 74.1 74.1 88.1 88.1 104.8 104.8 124.6 124.6 107.5 107.5 129.1 129.1
11 13 M 78.6 78.6 93.4 93.4 111.0 111.0 132.0 132.0 113.9 113.9 136.8 136.8
11 13 F 69.0 69.0 82.0 82.0 97.5 97.5 115.9 115.9 100.0 100.0 120.1 120.1
11 17 M 74.2 74.2 88.2 88.2 104.8 104.8 124.6 124.6 107.5 107.5 129.1 129.1
11 17 F 65.1 65.1 77.4 77.4 92.0 92.0 109.4 109.4 94.4 94.4 113.4 113.4
12 5 M 83.5 83.5 99.3 99.3 118.0 118.0 140.3 140.3 121.1 121.1 145.4 145.4
12 5 F 73.3 73.3 87.2 87.2 103.6 103.6 123.2 123.2 106.3 106.3 127.7 127.7
12 8 M 80.0 80.0 95.1 95.1 113.0 113.0 134.4 134.4 115.9 115.9 139.2 139.2
12 8 F 70.2 70.2 83.5 83.5 99.3 99.3 118.0 118.0 101.8 101.8 122.3 122.3
12 13 M 74.4 74.4 88.5 88.5 105.2 105.2 125.0 125.0 107.9 107.9 129.6 129.6
12 13 F 65.4 65.4 77.7 77.7 92.4 92.4 109.8 109.8 94.7 94.7 113.8 113.8
12 17 M 70.3 70.3 83.5 83.5 99.3 99.3 118.0 118.0 101.8 101.8 122.3 122.3
12 17 F 61.7 61.7 73.3 73.3 87.2 87.2 103.7 103.7 89.4 89.4 107.4 107.4
13 5 M 79.1 79.1 94.1 94.1 111.8 111.8 132.9 132.9 114.7 114.7 137.7 137.7
13 5 F 69.5 69.5 82.6 82.6 98.2 98.2 116.7 116.7 100.7 100.7 120.9 120.9
13 8 M 75.8 75.8 90.1 90.1 107.1 107.1 127.3 127.3 109.8 109.8 131.9 131.9
13 8 F 66.5 66.5 79.1 79.1 94.0 94.0 111.8 111.8 96.4 96.4 115.8 115.8
13 13 M 70.5 70.5 83.8 83.8 99.6 99.6 118.5 118.5 102.2 102.2 122.7 122.7
13 13 F 61.9 61.9 73.6 73.6 87.5 87.5 104.0 104.0 89.7 89.7 107.8 107.8
13 17 M 66.6 66.6 79.1 79.1 94.1 94.1 111.8 111.8 96.5 96.5 115.9 115.9
13 17 F 58.4 58.4 69.5 69.5 82.6 82.6 98.2 98.2 84.7 84.7 101.7 101.7
14 5 M 74.9 74.9 89.1 89.1 105.9 105.9 125.9 125.9 108.6 108.6 130.5 130.5
14 5 F 65.8 65.8 78.2 78.2 93.0 93.0 110.6 110.6 95.4 95.4 114.6 114.6
14 8 M 71.8 71.8 85.3 85.3 101.4 101.4 120.6 120.6 104.0 104.0 125.0 125.0
14 8 F 63.0 63.0 74.9 74.9 89.1 89.1 105.9 105.9 91.4 91.4 109.7 109.7
14 13 M 66.8 66.8 79.4 79.4 94.4 94.4 112.2 112.2 96.8 96.8 116.3 116.3
14 13 F 58.6 58.6 69.7 69.7 82.9 82.9 98.5 98.5 85.0 85.0 102.1 102.1
14 17 M 63.1 63.1 75.0 75.0 89.1 89.1 105.9 105.9 91.4 91.4 109.8 109.8
14 17 F 55.4 55.4 65.8 65.8 78.3 78.3 93.0 93.0 80.3 80.3 96.4 96.4
allowing subjects to filter out potential distractors [35].
Attentional tasks also involve a shifting component, which
is a typical executive function monitored by the prefrontal
cortex, although the performance improvement at this task
may also be due to a higher visual searching ability relat-
ed to the progressive development of the Frontal Eye
Fields [36].
Regarding the Trail Making Test, we believe that parts
A, A/B and B involve different cognitive systems. TMT
part A and part A/B, in fact, involve the visual search and
the activation of automatic series knowledge, with a mini-
mal load on working memory (i.e., just the number/letter
to be found next need be kept in the short-term memory
store). TMT part B, on the contrary, requires the genera-
tion of a complex sequence (far from automatic in chil-
dren) from the letter and number series, thus producing a
massively high processing load on working memory and
executive functions. Therefore, TMT part B involves a
working memory component to a greater extent than parts
A and A/B, the latter ones reflecting only the characteris-
tics of visual search and general attentional systems.
A stepwise performance progression has been observed
at the FAB, in particular in 7- and 8-year-old children, as
after this stage children tend to reach 100% correct perfor-
mance. This trend, showing that control processes gradual-
ly consolidate, seems to be related to the anatomical devel-
opment of the frontal cortex, which is known to occur in
this period [37].
We found that parents’ education significantly influ-
ences children’s performance on the Story Test and Trail
Making Test, but does not affect the FAB. We believe that
this result depends on the fact that the first two tests
involve verbal material. Thus, one may speculate that a
richer cultural environment plays an important role in
modulating children’s performance. On the contrary, pro-
cedural and motor components that are involved in the
FAB are not influenced by cultural effects.
It may be objected that our test/retest reliability index
seems lower than that usually reported in the literature.
However, the reliability index is generally calculated on the
raw scores. This procedure overestimates the correlation
index because it does not take into account spurious correla-
392
tion due to concomitant variables. In our analysis, the index
has been calculated on scores that have been adjusted for
those variables (age, father’s education, mother’s education),
thus reflecting the real test–retest correlation. Furthermore,
the correlation index for the Short Story Test has been calcu-
lated between two parallel forms. As a consequence, it is not
surprising that our reliability indices are lower than those
reported in the literature. Memory, attention and frontal func-
tions are frequently impaired in children with epilepsy
[38–43]. These cognitive dysfunctions have to be related to
the various risk factors associated with epilepsy, such as
type, duration, frequency of seizures, type of drug therapy,
transient and chronic electrophysiological activity, and the
possible anatomo-pathological correlates [44–51].
Amongst the several factors inducing learning impair-
ment in patients with epilepsy, the “temporal gate hypoth-
esis” [52] seems to provide a clear neurophysiopathologi-
cal substrate for the typical cognitive dysfunctions found
in children with epilepsy. The normal development of
frontal lobe functions requires intact temporo-limbic con-
nections and temporal lobe epilepsy in childhood may dis-
rupt temporo-limbic input to frontal lobes inducing, as a
consequence, an incomplete cortical maturation. This
anatomo-pathological correlate may also impair previous-
ly acquired skills.
The neuropsychological examination represents a piv-
otal approach in the assessment of children with epilepsy,
as it provides detailed information on the different devel-
opmental stages of specific cognitive domains.
Standardised tests assessing verbal memory, attention
and frontal functions may thus be useful to detect and
monitor cognitive impairments correlated with anatomical
and electrophysiological data, within a more comprehen-
sive assessment framework [53]. The strength of our study
was to provide clinicians both with new diagnostic tools,
as the short story parallel forms, and normative develop-
mental data on tests known to tap specific higher cognitive
functions in adults in a wide age range so far unavailable
for the Italian population. The use of such tests will be crit-
ical for clinicians and researchers who need to monitor the
effects of pharmacological and surgical treatments on
young patients with epilepsy.
P. Scarpa et al.: Instruments to assess for developmental age
Table 7 Equivalent scores as a function of FAB raw score and child’s age
FAB raw score Child’s age
6 7 8 9 10 11 12 13 14
04 000000000
5 1 0000 0 00 0
6 2 1000 0 00 0
7 2 2201 0 00 0
8 4 4222 1 12 1
9 4 4343 3 33 2
Sommario In questo studio è stata standardizzata una bat-
teria di test per la valutazione della memoria verbale a
lungo termine (Breve Racconto), dell’attenzione (versione
modificata delle Matrici Attenzionali e del Trail Making
Test) e delle funzioni frontali (versione modificata della
Frontal Assessment Battery) su una popolazione italiana
di 283 soggetti in età evolutiva, di età compresa tra i 5 e i
14 anni. I punteggi grezzi di ogni test sono stati corretti
per una serie di variabili (età dei soggetti, livello di sco-
larità dei genitori, dominanza manuale, sesso) e trasfor-
mati successivamente in punteggi equivalenti, che con-
sentono un confronto diretto tra i punteggi ottenuti. Questo
studio è stato promosso dalla LICE (Lega Italiana Contro
l’Epilessia), al fine di ottenere la standardizzazione ital-
iana su una popolazione in età evolutiva di una serie di
test che valutano funzioni cognitive spesso deficitarie in
pazienti affetti da epilessia.
Acknowledgements We would like to thank the school staff in
Milan that allowed us to administer the tests, in particular
Dr. Francesca Bellettini, and the other school staff and students
in Pavia and Livorno. We also thank LICE for their financial sup-
port for our project.
Appendix
Short Story Test
Short Story Test 1
Anna/una bambina/di 8 anni/mentre tornava/da scuola/con il
fratellino/vide/sul marciapiede/una scatola/tutta rossa./La aprì/ed
ecco sbucare/il muso/di un gattino./ I due/bambini/corsero/a
casa/contenti/e prepararono/una ciotola/con del latte/tiepido/e
dei biscotti./Il gatto/Piero/mangiò/di gusto /e poi si addormen-
tò/con la pancia /piena/e le zampe all’aria/sul tappeto/della
nonna. /
Anna/a eight-year-old/girl/was coming back/from
school/with her brother/when she saw/a red/box/on the pave-
ment./She opened it/and a kitten/muzzle/appeared sudden-
ly./The two/children/ran/home/happily/and prepared/a
bowl/of warm/milk/and some biscuits./Piero/the cat /ate
them/with gusto/and then fell asleep on his back /on grand-
mother’s/carpet/with a full/belly/and his paws sticking up in
the air /.
Short Story Test 2
Paolo/un ragazzino/di 10 anni/mentre andava/al parco/con un
amico/vide/in piazza/un pagliaccio/tutto giallo./ Si fermò/e il
clown/cominciò a tirare fuori/dal cappello/dei fiori/di carta./I
due/bambini/attraversarono/la strada/incuriositi/e guardarono/ lo
spettacolo/a bocca aperta./Alla fine/il pagliaccio/Alberto /si inch-
inò/con il cappello/in mano/ e poi lanciò/a tutti/una
margherita/colorata. /
Paolo/a ten-year-old/boy/ was going/to the park /with a
friend/when he saw/an all yellow/clown/ in the square./He
stopped/and the clown/started taking/some paper/flowers/out
of his hat./The two/curious/children/crossed /the street/and
stared/open-mouthed/at the show./At the end/the
clown/Alberto/bowed/with the hat/in his hand/and threw/a
coloured/daisy/to everybody.
FAB: Frontal Assessment Battery [23]
1. “SERIE MOTORIE” (programmazione)
Adesso facciamo un gioco insieme: guarda attentamente quello
che faccio io”. L’esaminatore, seduto davanti al bambino, esegue
da solo per tre volte le serie di Luria “pugno – dorso – palmo”.
Adesso, con la tua mano destra (se il bambino è mancino, con la
mano sinistra), fai le stesse serie, prima insieme a me e poi da
solo”. L’esaminatore esegue le serie per tre volte con il bambino,
poi gli dice: “Adesso continua da solo” e gli fa eseguire sei serie
consecutive.
Il bambino esegue correttamente sei serie
consecutive da solo: 3
Il bambino esegue correttamente almeno
tre serie consecutive da solo: 2
Il bambino fallisce da solo, ma esegue correttamente
le tre serie consecutive con l’esaminatore: 1
Il bambino non esegue correttamente le tre serie
consecutive con l’esaminatore 0
123456
si no si no si no si no si no si no
2. “ISTRUZIONI CONFLITTUALI” (sensibilità all’interferenza)
Adesso faremo un altro gioco. Quando io batto il pugno una
volta, tu lo batti due volte”. Per essere sicuri che il bambino abbia
compreso il compito, si esegue una serie di tre prove: 1–1–1.
Adesso invece, quando io batto il pugno due volte, tu batti una
volta”. Anche in questo caso si esegue una serie di tre prove di
verifica: 2-2-2. “Ora faremo insieme queste due cose, tu fai bene
attenzione a quello che faccio io”. L’esaminatore esegue la
seguente serie: 1-1-2-1-2-2-2-1-1-2.
1 121 2 221 12
R corr2 212 1 112 21
R err1 121 2 221 12
non non non non non non non non non non
Nessun errore: 3
Uno o due errori: 2
Più di due errori: 1
Il bambino batte come l’esaminatore almeno quattro volte
consecutive: 0
3. INDICAZIONI “GO–NO GO” (controllo dell’inibizione)
“Questo è l’ultimo gioco. Adesso quando io batto il pugno una
volta, anche tu lo batti una volta sola”. Per essere sicuri che il
bambino abbia compreso il compito, si esegue una serie di tre
prove: 1-1-1.
“Quando io batto due volte invece, tu non devi battere”. Si
esegue nuovamente una serie di tre prove di verifica: 2-2-2. “Ora
ne facciamo una serie insieme”.
L’esaminatore esegue la seguente serie: 1-1-2-1-2-2-2-1-1-2.
1 121 2 221 12
R corr 1 1 non 1 non non non 1 1 non
P. Scarpa et al.: Instruments to assess for developmental age 393
R err2 222 2 222 22
non non 1 non 1 1 non non non 1
Nessun errore: 3
Uno o due errori: 2
Più di due errori: 1
Il bambino batte come l’esaminatore almeno quattro volte
consecutive: 0
Il bambino batte come l’esaminatore almeno quattro volte con-
secutive: 0
Soggetto: _______________________ Punteggio totale: _______
FAB: Frontal Assessment Battery [23]
1. MOTOR SERIES (programming)
“Let’s play together: look carefully at what I’m doing”. The
examiner, seated in front of the patient, performs alone three
times with his left hand the series of Luria “fist-edge-palm”.
“Now, with your right hand (the left hand if the patient is left-
handed) do the same series, first with me, then alone.” The exam-
iner performs the series three times with the patient, then says to
him/her: “Now, do it on your own”.
Score:
Patient performs six correct consecutive series alone: 3
Patient performs at least three correct consecutive
series alone: 2
Patient fails alone, but performs three correct consecutive series
with the examiner 1
Patient cannot perform three correct consecutive series even with
the examiner 0
12 3 456
si no si no si no si no si no si no
2. CONFLICTING INSTRUCTIONS (sensitivity to interference)
“Now we’ll do another game. Tap twice when I tap once” To be
sure that the patient has understood the instruction, a series of
three trials is run: 1-1-1. “Now, tap once when I tap twice”. To be
sure that the patient has understood the instruction, a series of
three trials is run: 2-2-2. The examiner performs the following
series: 1-1-2-1-2-2-2-1-1-2.
112 1 2 2 2 1 12
Right 2 2 1 2 1 1 1 2 2 1
answer
Wrong 1 1 2 1 2 2 2 1 1 2
answer
no no no no no no no no no no
No errors 3
One or two errors 2
More than two errors 1
Patient taps like the examiner at least four consecutive times 0
3. GO-NO-GO (inhibitory control)
“This is the last game. Tap once when I tap once” To be sure that
the patient has understood the instruction, a series of three trials
394
is run: 1-1-1. “Do not tap when I tap twice.”. To be sure that the
patient has understood the instruction, a series of three trials is
run: 2-2-2. The examiner performs the following series: 1-1-2-1-
2-2-2-1-1-2.
112122 211 2
Right 2 2 1 2 1 1 1 2 2 1
answer
Wrong 1 1 2 1 2 2 2 1 1 2
answer
no no no no no no no no no no
No errors 3
One or two errors 2
More than two errors 1
Patient taps like the examiner at least four consecutive times 0
Subject: _______________________Total score: _______________
Trail Making A/B
P. Scarpa et al.: Instruments to assess for developmental age
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P. Scarpa et al.: Instruments to assess for developmental age
... Aims, tools, and main cognitive areas of investigation in clinical neuropsychology are summarized. published paper (e.g., Short Story test for children; Scarpa et al., 2006). Normative scores (or "norms") are collected by administering the test to a normative sample, i.e., a reference group representing the general population, in terms of age, education, and gender. ...
... Parental education is significantly correlated with cognitive performance already in early infancy, as shown by research testing the relationship between parental education with the Mental Development Index, assessed through the Bayley Scales of Infant Cognitive domains and tasks assessed by the MMSPE for preschool (Peviani et al., 2018) and school (Scarpa et al., 2017) aged children. a The Goeno go task has been adapted from Scarpa et al. (2006). ...
... The effect of parental education persists in later years, and affects measures of intelligence and of neuropsychological functioning. In detail, Stanford-Binet and Wechsler IQs are modulated by parental education (Mercy & Steelman, 1982;Zhou, Baghurst, Gibson, & Makrides, 2007), as well as a number of neuropsychological measures, such as sustained and divided attention, visual integration skills, episodic memory, verbal learning, math and reading skills, vocabulary, and verbal production (Gibbs & Forste, 2014;Richels, Johnson, Walden, & Conture, 2013;Scarpa et al., 2006;Schady, 2011). The cutoff scores for the MMSPE (5th percentiles) were computed by fitting a GLM or GzLM, which included child's age and mean parental education as predictors. ...
Chapter
A brief screening of the cognitive functions can be very useful in clinical practice. For instance, cognitive screening is often conducted to facilitate early detection of cognitive decline in adult and elderly patients. The Mini-Mental State Examination is broadly used worldwide; it addresses key cognitive functions and provides a global score, which may prompt the clinician (e.g., general doctor or neurologist) to refer the patient for further neuropsychological assessment. Similarly, in the developmental age, a screening test might be convenient to identify children with cognitive difficulties and delays, to monitor cognitive functions over time, to indicate whether a further neuropsychological assessment is needed. Over the past 20 years, a few attempts have been made to provide clinicians with a cognitive screening test targeting the pediatric age. We will review those attempts and present the Mini-Mental State Pediatric Examination, a cognitive screening test developed for the Italian population.
... A structured neuropsychological evaluation characterizes each assessment carried out by a trained child neuropsychologist (E.C.). The following cognitive domains were assessed: abstract reasoning, using the Raven Colored Matrices (Raven, Raven, & Court, 1998); language, using the naming test and the semantic verbal fluency test (Bisiacchi, Cendron, Gugliotta, Tressoldi, & Vio, 2005); memory, using the digit span test and the Corsi block-tapping test, which evaluate short-term verbal and visual-spatial memory, the words list and list recall, which evaluate learning and long-term verbal memory (Bisiacchi et al., 2005), and the backward digit span test, which evaluates working memory (Bisiacchi et al., 2005); attention, using the Bells test (Stoppa & Biancardi, 1997), which evaluates selective and sustained attention, and the Trial Making Test A (TMT A) (Scarpa et al., 2006), which evaluates scan and search speed; executive functions, using the phonemic verbal fluency test, which evaluates the ability to access the lexicon through a phonemic cue by setting up an adequate verbal search strategy (Bisiacchi et al., 2005); the Frontal Assessment Battery (FAB) (Scarpa et al., 2006), which evaluates frontal lobes functions; the Trial Making Test B (TMT B), which evaluates attention shifting (Scarpa et al., 2006); and visual-motor abilities, using the Rey-Osterrieth Complex Figure Test (Caffarra, Vezzadini, Dieci, Zonato, & Venneri, 2002), which evaluates praxis and planning abilities. ...
... A structured neuropsychological evaluation characterizes each assessment carried out by a trained child neuropsychologist (E.C.). The following cognitive domains were assessed: abstract reasoning, using the Raven Colored Matrices (Raven, Raven, & Court, 1998); language, using the naming test and the semantic verbal fluency test (Bisiacchi, Cendron, Gugliotta, Tressoldi, & Vio, 2005); memory, using the digit span test and the Corsi block-tapping test, which evaluate short-term verbal and visual-spatial memory, the words list and list recall, which evaluate learning and long-term verbal memory (Bisiacchi et al., 2005), and the backward digit span test, which evaluates working memory (Bisiacchi et al., 2005); attention, using the Bells test (Stoppa & Biancardi, 1997), which evaluates selective and sustained attention, and the Trial Making Test A (TMT A) (Scarpa et al., 2006), which evaluates scan and search speed; executive functions, using the phonemic verbal fluency test, which evaluates the ability to access the lexicon through a phonemic cue by setting up an adequate verbal search strategy (Bisiacchi et al., 2005); the Frontal Assessment Battery (FAB) (Scarpa et al., 2006), which evaluates frontal lobes functions; the Trial Making Test B (TMT B), which evaluates attention shifting (Scarpa et al., 2006); and visual-motor abilities, using the Rey-Osterrieth Complex Figure Test (Caffarra, Vezzadini, Dieci, Zonato, & Venneri, 2002), which evaluates praxis and planning abilities. ...
... A structured neuropsychological evaluation characterizes each assessment carried out by a trained child neuropsychologist (E.C.). The following cognitive domains were assessed: abstract reasoning, using the Raven Colored Matrices (Raven, Raven, & Court, 1998); language, using the naming test and the semantic verbal fluency test (Bisiacchi, Cendron, Gugliotta, Tressoldi, & Vio, 2005); memory, using the digit span test and the Corsi block-tapping test, which evaluate short-term verbal and visual-spatial memory, the words list and list recall, which evaluate learning and long-term verbal memory (Bisiacchi et al., 2005), and the backward digit span test, which evaluates working memory (Bisiacchi et al., 2005); attention, using the Bells test (Stoppa & Biancardi, 1997), which evaluates selective and sustained attention, and the Trial Making Test A (TMT A) (Scarpa et al., 2006), which evaluates scan and search speed; executive functions, using the phonemic verbal fluency test, which evaluates the ability to access the lexicon through a phonemic cue by setting up an adequate verbal search strategy (Bisiacchi et al., 2005); the Frontal Assessment Battery (FAB) (Scarpa et al., 2006), which evaluates frontal lobes functions; the Trial Making Test B (TMT B), which evaluates attention shifting (Scarpa et al., 2006); and visual-motor abilities, using the Rey-Osterrieth Complex Figure Test (Caffarra, Vezzadini, Dieci, Zonato, & Venneri, 2002), which evaluates praxis and planning abilities. ...
Article
Objective Patients with epilepsy are at risk for several lifetime problems, in which neuropsychological impairments may represent an impacting factor. We evaluated the neuropsychological functions in children suffering from three main epilepsy categories. Further, we analyzed the longitudinal evolution of the neuropsychological profile over time. Methods Patients undergoing neuropsychological evaluation at our Department from 2012 to 2018 were identified retrospectively. We selected patients aged 6–16 years and with at least two evaluations. Three epilepsy categories were considered: focal/structural, focal self-limited, and idiopathic generalized. Each evaluation included the same structured assessment of main neuropsychological domains. The effect of the epilepsy category, illness duration, seizure status, and medication was computed in multilevel models. Results We identified 103 patients (focal self-limited = 27; focal/structural = 51; and idiopathic generalized = 25), for 233 evaluations. The majority of deficits were reported in attention and executive functions (>30% of patients); the results were dichotomized to obtain global indexes. Multilevel models showed a trend toward statistical significance of category of epilepsy on the global executive index and of illness duration on global attention index. Illness duration predicted the scores of executive and attention tasks, while category and medication predicted executive task performance. Focal/structural epilepsies mostly affected the executive domain, with deficits persisting over time. By contrast, an ameliorative effect of illness duration for attention was documented in all epilepsies. Conclusions This study offers lacking information about the evolution of deficits in time, the role of epilepsy category, and possible psychological implications for high-order cognitive skills, central in several social and academic problems.
... The study by Soldan et al (2017) included only individuals who presented with preclinical AD, as determined by biomarkers, and reported the longitudinal effects of reserve during disease progression. Full text articles excluded (n = 2) Doesn't meet eligibility criteria (n = 2) Studies included in qualitative synthesis (n = 17) (Tombaugh et al, 1999), Attention Matrices (Scarpa et al, 2006), DSF, RAVLT (Spreen and Strauss, 1998), Rey-Osterrieth Complex Figure (Spreen and Strauss, 1998), Raven's Progressive Matrices (Raven and Raven, 2003), Token Test (Spreen and Strauss, 1998) Global cognition: MMSE (Crum et al, 1993) Findings: ...
Article
Cognitive reserve (CR) has been proposed to account for functional outcome differences in brain pathology and its clinical manifestations. The purpose of our paper is to systematically review the effects of CR on cognitive outcomes in individuals with neurodegenerative and structural CNS diseases. We performed a systematic search of PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and PsychInfo using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Seventeen studies met the predetermined inclusion criteria and were selected for review. Education level was the most commonly used measure for CR, and various neuropsychological tests were used to measure cognitive outcomes. Regardless of the CNS disease of the individuals, almost all of the studies reported a positive association between CR and cognitive outcomes when they were evaluated cross-sectionally. However, when evaluated longitudinally, CR had either no effect on, or a negative association with, cognitive outcomes. Based on studies across a broad spectrum of CNS diseases, our findings suggest that CR may serve as a predictor of cognitive outcomes in individuals with CNS diseases. However, studies to date are limited by a lack of imaging analyses and standardized assessment strategies. The ability to use a standardized measure to assess the longitudinal effects of CR may allow for the development of more targeted treatment methods, resulting in improved disease outcomes for individuals.
... The neurocognitive evaluation showed no impairment on visual attention and executive functions (working memory, inhibition and cognitive flexibility). Her performances were within or slightly above the average range at Numerical Stroop (14), Inhibition (15), Trail Making Test (16) and Cancellation (17). Working memory capacity, assessed with backward digit span (18) and an experimental dual-task word span test (19), was above the average range. ...
... We tested patients and HC with a comprehensive neuropsychological battery that included a global assessment with the Montreal Cognitive Assessment (MoCA) [26], language tests with naming nouns and pointing [27], and general intelligence using the Raven colored progressive matrices [28]. Executive functions and attention were tested with the digit span [29], the attentional matrices (AM) [30], trail making test A and B (TMT-A, TMT-B) [31], phonemic fluency (PF), and semantic fluency (SF) [32]. Information processing speed (IPS) was further investigated using the symbol digit modalities test (SDMT) [33]. ...
Article
Objective Timed neuropsychological tests do not take into account physical impairment during scoring procedures. Dysarthria and upper limb impairment can be easily measured with the PATA rate test (PRT) and the nine-hole pegboard test (9HPT). We recently validated a normalization method for timed neuropsychological tests using the PRT and 9HPT (p9NORM). We now validate the p9NORM in Parkinson’s disease (Yarnall et al. Neurology 82(4):308–316; 2014) and multiple system atrophy (MSA).Methods We enrolled twenty-six patients with PD, eighteen patients with MSA, and fifteen healthy controls (HC). p9NORM was applied to patients with abnormal PRT and/or 9HPT. All subjects were tested with a comprehensive neuropsychological battery.ResultsNo differences emerged in demographics across groups: (PD: mean age ± SD 66 ± 8; education 9 ± 4 years; MSA: age 60 ± 8; education 10 ± 4 years; HC: age 61 ± 12; education 9 ± 4 years). In MSA patients, the scores on the trail making test (TMT-A p = 0.003; TMT-B p = 0.018), attentional matrices (AM; p = 0.042), and symbol digit modalities test (SDMT p = 0.027) significantly differed following application of p9NORM. In PD patients, the TMT-A (p < 0.001), TMT-B (p = 0.001), and AM (p = 0.001) differed after correction. PD and MSA showed cognitive impairment relative to HC performance. When comparing MSA with PD, the SDMT, AM, and fluencies were similar. TMT-A and -B raw scores were different between groups (p = 0.006; p = 0.034), but these differences lost significance after p9NORM corrections (p = 0.100; p = 0.186).Conclusions We confirm that the p9NORM can be successfully used in both PD and MSA patients, as it mitigates the impact of disability on timed tests, resulting in a more accurate analysis of cognitive domains.
... It was evaluated with the immediate and delayed Recall of a Short Story Test (Scarpa et al., 2006). Performance was measured as follows: 1 point was assigned for each conceptual cluster if all words were reported exactly as they were heard, and 0.5 points were assigned if the concept retrieved was correct, yet this was done using different words 6 . ...
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Article
It is widely believed that intensive music training can boost cognitive and visuo-motor skills. However, this evidence is primarily based on retrospective studies; this makes it difficult to determine whether a cognitive advantage is caused by the intensive music training, or it is instead a factor influencing the choice of starting a music curriculum. To address these issues in a highly ecological setting, we tested longitudinally 128 students of a Middle School in Milan, at the beginning of the first class and, 1 year later, at the beginning of the second class. 72 students belonged to a Music curriculum (30 with previous music experience and 42 without) and 56 belonged to a Standard curriculum (44 with prior music experience and 12 without). Using a Principal Component Analysis, all the cognitive measures were grouped in four high-order factors, reflecting (a) General Cognitive Abilities, (b) Speed of Linguistic Elaboration, (c) Accuracy in Reading and Memory tests, and (d) Visuospatial and numerical skills. The longitudinal comparison of the four groups of students revealed that students from the Music curriculum had better performance in tests tackling General Cognitive Abilities, Visuospatial skills, and Accuracy in Reading and Memory tests. However, there were no significant curriculum-by-time interactions. Finally, the decision to have a musical experience before entering middle school was more likely to occur when the cultural background of the families was a high one. We conclude that a combination of family-related variables, early music experience, and pre-existent cognitive make-up is a likely explanation for the decision to enter a music curriculum at middle school.
Article
This study examined the executive function (EF) of children with a history of arterial ischemic stroke (AIS) and preserved intellectual abilities, with reference to age at stroke onset, lesion characteristics, language, and motor functioning. In addition, the associations between EF and emotional and behavioral functioning were investigated. A battery of standardized neuropsychological tests was administered to children with previous AIS aged 7-12 in order to assess EF, including inhibition, working memory, cognitive flexibility, and attention. Parents rated questionnaires regarding real-life emotional and behavioral functioning. Finally, clinical and neuroradiological data were also gathered. Thirty patients were enrolled. Eight children fall in the lower end of the normative range or below in more than half of the EF measures, with working memory, inhibition and cognitive flexibility equally impaired, and attention relatively better preserved. Larger lesion size and language deficits were significantly associated with higher EF impairment. Emotional and behavioral functioning was lower in children with weaker EF. Children with a history of AIS, even those with preserved intellectual functioning, have a high risk of showing poor EF, mostly regardless of clinical features or functional impairment. EF difficulties are in turn associated with emotional and behavioral problems. Therefore, a standardized evaluation of EF in this population is mandatory as part of the follow-up, in order to ensure an early intervention and prevent related difficulties.
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Conference Paper
A growing interest about alternative methods for the assessment and training of executive functions in children with neurodevelopmental disorders is emerging. Technology is considerably advancing, and the gamification is giving an important contribution in making the interventions more engaging. However, sometimes a "top-down" design process creates mismatches between technologies and both therapists and children's need. Thus, the analysis of requirements and user's feedback play a crucial role to identify their perspective regarding the technology and gauge its design and development. The present work aims to describe ASTRAS, a software for the assessment and training of executive functions in children, the requirements of therapists and children the software try to fulfil and, finally, the preliminary data reporting the experience of a sample of therapists about the application of software with their patients. In that regard, a survey was used to obtain the opinion of thirty-two therapists about the: a) usability (i.e., comprehensibility, simplicity of the software and the usefulness of its feature); b) the clinical validity of the tasks; c) the attractiveness of the tasks for the children; d) their general opinion about the software. Results demonstrated satisfying responses of the therapists about the software: they considered ASTRAS easy to use and clinically adapt to assesses and train executive functions in their patients. Furthermore, they reported that children well reacted to the software and specifically they were more likely to be engaged in training games than in assessment tasks. Bind together, our results show that ASTRAS is usable for therapists and engaging for their patients, which makes it promising for the assessment and training of executive functions in children.
Article
Objectives: With this explorative study, we aimed to examine time perception in children with childhood absence epilepsy (CAE) and to compare those children with a matched control group. The study also investigated the association between the neuropsychological performance of the group with CAE and time judgment. We hypothesize that children with CAE could fail in time perception and that this may be because of a common underlying substrate with executive impairments. Methods: Thirteen children with CAE, aged 6–13 years, and 17 healthy children were recruited. All children performed the time bisection task; the children with CAE also performed a cognitive and neuropsychological assessment. We performed a univariate analysis using each parameter of the bisection task (bisection point [BP]) and Weber ratio (WR) as dependent variables, the group (patients vs. controls) as fixed factors and age at evaluation and vocabulary scores as covariates. In the subgroup of patients, we correlated bisection task parameters with neuropsychological tests using a nonparametric partial correlation; the analysis has corrected for age at evaluation. Results: The BP and WR measures differed between controls and patients with CAE. In the subgroup of patients also performing a neuropsychological assessment, we found a correlation between theWRmeasure and performance on the inhibition test (r=−0.641, p=.025), coding test (r=−0.815, p=.014), and TrailMaking Test B (TMT B) (r =0.72, p = .042). Conclusions: We found an altered time perception in a pilot study of a small group of children with CAE. A neurophysiological mechanism underlying CAE seems to influence cognitive and behavioral deficits and time sensibility.
Article
Much evidence indicates that drawing is related to different neuropsychological abilities in children. However, a comprehensive cognitive model of drawing in children is still lacking. Here, we conducted a study on the neuropsychological predictors of drawing in a sample of 142 typically developing elementary school children (M age = 8.8 years; SD = 1.1). Based on a path analysis, we examined the contribution of visual perception (matching geometrical figures), complex spatial abilities (e.g., complex figures identification and mental rotation), visual attention, working memory, verbal and visual-motor skills, as well as of gender, age and socio-economic status, to copying the Rey-Osterrieth Complex Figure (ROCF). Results showed that ROCF copying was influenced in a specific and additive way by visual perception, visual-motor coordination, and verbal abilities as well as age, while it was indirectly related to visual attention, working memory, and to complex spatial abilities. These findings provide the grounds for identifying the neuropsychological bases of drawing in elementary school children.
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In this paper some methodological problems related to the use of normative data in neuropsychological assessment are analysed. The difference between the concepts of normality and mastery, and the problems encountered with the adjustment of raw scores for age and education are considered. Other arguments discussed and exemplified with real data are the use of inner and outer nonparametric tolerance limits, confidence limits for individual scores, multivariate norms, and discriminant analysis.
Article
The aim of the present paper is to propose a common neuropsychological battery for the assessment of children with epilepsy (E) to be adopted in different Italian centers. This battery represents the result of several meetings of the LICE Neuropsychology study group among specialists in the fields of child neuropsychology, neurology and psychiatry. The main goal of the study was to prepare a first-level neuropsychological battery for the assessment of the principal cognitive functions that could be administered in a relatively short time. The study group analysed the existing tests, evaluated their pros and cons in order to select those that could be used with a wide enough range of age groups and could offer a valid index of the cognitive functions most frequently impaired in children with E.
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Article
Memory and attention skills were assessed in 84 children with epilepsy who had no documented learning or behavioral disorders. Seizure type, level of control, and antiepileptic drug effects were examined in relation to their influence on memory and attention function. For the entire sample, verbal and visual memory skills were found to be within the average range. However, subtle problems with attentional skills were noted. Two‐way analyses of variance, based on seizure type by level of control, did not indicate significant group differences in memory and attention skills between children with complex partial versus absence seizures. Children with uncontrolled seizures had more difficulty with recall of complex verbal information. A notable finding was that children on polytherapy had significantly lower verbal and visual memory scores than children on monotherapy. Results suggest that children with epilepsy, without learning or behavioral disorders, have intact memory skills but may have subtle difficulties with attention. These children would benefit from repetition of information, whereas children on polytherapy need to be more closely monitored due to increased risk for problems with memory and attention skills.
Article
An overt rehearsal procedure was used to study the relationship between children's rehearsal strategies and recall performance in a free recall task. 2 experiments were conducted, 1 employing unrelated words and the other taxonomically related materials, so that rehearsal could be examined under different conditions of list organization. In both experiments, developmental changes in rehearsal content were observed. Third graders tended to rehearse the item currently being presented either alone or in minimal combination with other words. In contrast, sixth graders (and older subjects) rehearsed several different items together. These changes in rehearsal technique were related to developmental differences in the magnitude of the primacy effect. However, the role of rehearsal seemed to vary as a function of list structure. When categorical items were employed, ninth graders were better able than younger subjects to use taxonomic information to rehearse related words together. This rehearsal of category items was related to improved recall, but blocked presentation of the taxonomic materials facilitated the recall of the third graders, without corresponding changes in rehearsal being observed.
Article
Normative‐developmental performance on a battery of executive function tasks was investigated. Executive function was defined as goal‐directed behavior, including planning, organized search, and impulse control. Measures were drawn from clinical neuropsychology (visual search, verbal fluency, motor sequencing, and Wisconsin Card Sorting Task [WCST]) and from developmental psychology (Tower of Hanoi [TOH] and Matching Familiar Figures Test [MFFT]). A discriminant task, recognition memory, was administered, and IQ scores were available on a subset of the sample. One hundred subjects ranging from 3 to 12 years old participated; an adult group was also studied. Three major results were found: (a) adult‐level performance on different subsets of the executive function tasks was achieved at three different ages—6 years old, 10 years old, and adolescence; (b) the measures clustered into three different factors reflecting speeded responding, set maintenance, and planning; and (c) most of the executive function tasks were uncorrelated with IQ. The implications of these results for our understanding of the development of prefrontal lobe functions are discussed.