The Boston Process Approach to Neuropsychological Assessment_ A Practitioners Guide

Prévia do material em texto

39
 4 
 Process-Focused Assessment 
of Arousal and Attention 
 Elisabeth Moes, Haley Duncanson, and Carmen G. Armengol 
 In this chapter, we seek to heighten awareness of the many factors that contribute to 
disorders of arousal and att ention, review recent conceptualizations of these functions, 
and suggest assessment strategies to identify perturbations in arousal and att ention 
that embody a process approach. Level of arousal and integrity of the various compo-
nents of att ention determine the person’s ability to successfully respond to almost all 
cognitive tasks (as some sensory processing occurs automatically and independently), 
regardless of modality or cognitive demand, so it is critical that their contribution to 
current status be adequately assessed. 
 Att entional disorders are among the most common and most devastating neu-
rological conditions (Gitelman, 2003). Disorders of arousal and att ention not only 
comprise syndromes in and of themselves (e.g., att ention-defi cit/hyperactivity dis-
order [ADHD] and seizure disorders), they are also ubiquitous symptoms of many 
other disorders and conditions, including traumatic brain injuries, dementias, cardio-
vascular disorders, sleep disorders, autism, schizophrenia, and toxic and metabolic 
encephalopathies. Metabolic and structural disturbances resulting from any number 
of conditions can severely disturb arousal (or, more broadly, Mesulam’s “att entional 
matrix”) and may present as confusional states, otherwise referred to as delirium, 
organic psychosis, or acute organic brain syndrome (Gitelman, 2003; Mesulam, 
2000). Even in otherwise healthy individuals, it is well established that not gett ing 
enough sleep over a relatively short period will negatively impact the person’s ability 
to function optimally, due to decreased arousal, reduced encoding, and poor judg-
ment (Lim & Dinges, 2010; Martella, Casagrande, & Lupi áñ ez, 2011). Chronic sleep 
deprivation undermines memory and academic and job performance. It also results in 
hundreds, if not thousands, of car accidents yearly and has been identifi ed as a signifi -
cant human factor implicated in such major catastrophes as the Challenger explosion, 
40 Chapter 4 Moes et al.
the Exxon Valdez oil spill, and the Chernobyl and Th ree Mile Island nuclear plant 
accidents (Coren, 1997). 
 Transient factors impacting arousal (e.g., anxiety or stimulant use) can also infl u-
ence a person’s performance positively or negatively (Fox, Russo, Bowles, & Dutt on, 
2001; Mahoney, Brunye, Giles, Lieberman, & Taylor, 2011). For example, in con-
trast to nicotine’s relatively negligible impact on neuropsychological performance in 
healthy individuals, when att entional demand is exceptionally high or acetylcholine 
(ACh) is low due to pathological conditions such as Alzheimer’s or Parkinson’s dis-
ease, it can have a benefi cial eff ect on test performance, particularly on tests of att en-
tion (Newhouse, Pott er, & Singh, 2004). 
 A diff erent profi le is oft en seen in individuals with localized brain lesions (e.g., focal 
trauma, strokes or tumors). Th ey may show no arousal disturbances but experience dif-
fi culty in the “top–down” aspects of selective att ention, comprising the ability to sus-
tain att ention to a task over time, orient spatially to stimuli, and/or engage the “third 
att entional network” (Petersen & Posner, 2012) that relates to executive functioning. 
Renewed interest in multitasking (divided att ention), sparked in part by the increase in 
accidents caused by texting while driving, has shown that individuals who are particularly 
prone to activating multiple input streams and engaging in multiple activities simultane-
ously actually perform worse on tests of task switching, and are more distractible, than 
those who chose not to multitask to the same extent (Ophir, Nass, & Wagner, 2009). 
Th us, neuropsychologists working in a wide range of sett ings will encounter individuals 
with arousal and att ention-related impairments that are oft en diffi cult to discern but that 
can signifi cantly undermine cognitive performance and negatively aff ect their lives. 
 Both an alert state (intact arousal) and the ability to select and enhance specifi c men-
tal processes while screening out others (att entional functions) are fundamental to nor-
mal cognition. Yet despite their proneness to disruption from either chronic pathological 
conditions and/or temporary aberrant states (e.g., acute sleep deprivation, recovery 
from surgery and illness, medication eff ects, urinary tract infections, and a wide range 
of metabolic disturbances), these two functional areas are rarely adequately assessed by 
neuropsychologists in clinical sett ings (Armengol, 2000). Neuropsychological reports 
oft en address these functions in a cursory fashion, typically limiting assessment to an 
isolated component of att ention (e.g., digit span) or referring to multifactorial tests that 
depend on sustained att ention but that also require complex higher cognitive functions 
for success, thus confounding interpretation when diffi culties arise. Many clinicians, 
unfortunately, treat att ention and executive functions as though they were synonymous. 
Arousal and att ention have long been considered “foundation” functions on which other 
functions depend (Luria, 1973, pp. 43–67); a person either in a confusional state or 
with variable att ention will not be able to select, encode, monitor, remember, name, or 
perform other tasks consistently or effi ciently. Th ese activating and selective functions 
a person either in a confusional state or 
with variable att ention will not be able to select, encode, monitor, remember, name, or tt
perform other tasks consistently or effi ciently. Thffi
Process-Focused Assessment of Arousal and Att ention 41
impact a person’s performance throughout the neuropsychological assessment, and 
failure to identify defi cits in these domains will result in very misleading conclusions; 
opportunities for treatment may also be missed. Only once arousal is back to normal can 
selective diffi culties in other areas be assessed. 
 Identifi cation of att entional problems alone is generally insuffi cient in terms of 
narrowing down the cause. Th e neuropsychologist must be cognizant of clinical con-
ditions likely to be associated with diff erent types of att entional lapses (e.g., momen-
tary loss of awareness resulting from subclinical seizures versus momentarily focusing 
att ention elsewhere versus fl uctuations in overall level of arousal that undermine sus-
tained att ention) to obtain relevant information from the history. Certain commonly 
occurring disorders are briefl y highlighted at the end of the chapter in an eff ort to 
remind the reader that the qualitative aspects of the patient’s presentation, together 
with informed history-taking, can both signal the presence of att entional problems 
and assist in diagnosis. 
 Consistent with theory and evidence that separates the domains of arousal 
and att ention (“since att entional defi cits can occur in perfectly awake individu-
als”; Mesulam, 2000, p. 176), arousal and higher-level att entional functions will be 
addressed individually, even though in practice they are highly interrelated (Dockree, 
Kelly, Foxe, Reilly, & Robertson, 2007; Sturm & Willmes, 2001). In fact, studies docu-
menting the benefi cial eff ect of increased tonic arousal on higher-level att entional pro-
cesses have led to a simple but eff ective intervention approach (self-alert training) for 
use with individuals with unilateral neglect and individuals with ADHD (O’Connell, 
Bellgrove, Dockree, Lau, Fitzgerald, & Robertson, 2008). Nonetheless, research has 
successfully started to tease apart the selective eff ects of certain conditions, substances, 
and treatments on dissociable components of arousal and att ention, and thus it is use-
ful to conceptualize not only the components separatelybut also their assessment. 
 THEORETICAL CONCEPTUALIZATION 
OF AROUSAL AND ATTENTION 
 Arousal refers to the person’s general state of wakefulness, which can vary on a con-
tinuum between hyperexcitability, normal wakefulness, drowsiness, sleep states, 
stuporousness (hard to arouse), and coma (unresponsiveness). Arousal is related to 
activity in the reticular activating system (RA S) of the brainstem, which has both 
ascending (i.e., from RA S to thalamus to cortex) and descending (cortical projections 
to thalamus and brainstem RA S) components consisting of modulatory neurotrans-
mitt er projections (Luria, 1973; Mesulam, 2000). Arousal also fl uctuates in relation 
to circadian rhythms, such that response times (RTs) are usually longer in the morn-
ing and decline over the course of the day, rising again at night and peaking in the 
 momen-
tary loss of awareness resulting from subclinical seizures v
arousal and higher-level attentional functions will bett
addressed individually, even though in practice they are highly interrelated 
(self-alert training) f
 Arousal refers to the person’s general state of wakefulness, 
reticular activating system (RAS) RA
 Arousal also fl uctuates in relation
to circadian rhythms, s
42 Chapter 4 Moes et al.
early morning (Posner & Petersen, 1990). In addition to “bott om-up” arousal (the 
ascending RA S), the “top–down” noradrenergic projections (see also the alerting sys-
tem described later) can activate the ascending RA S in response to events of particular 
importance, to prepare the person and put him or her in a state of readiness for eff ec-
tive response. 
 Petersen and Posner (2012) recently provided an updated account of their theo-
retical conception of att entional functions or networks. Th eir conceptualization, one 
of the most infl uential models to date, addresses top–down processes relating to att en-
tional control and is composed of three functional networks or systems: alerting, ori-
enting, and executive manipulation. 
 Th e alerting system refers to a person’s ability to actively prepare for an expected 
event, allowing for a more rapid and accurate response. Th is selective enhancement is 
referred to as phasic arousal, is superimposed on the resting state (or tonic arousal), 
and is refl ected in faster RTs. Th e alerting system is also invoked in situations where 
the person must maintain a state of increased readiness to respond over longer 
periods of time, referred to as vigilance, with decreases in this ability referred to as 
the vigilance decrement. Unlike tonic arousal, which is infl uenced by a number of 
neurotransmitt ers (particularly ACh), the top–down alerting system is thought to 
depend specifi cally on the noradrenergic system, with increased activity in the locus 
ceruleus following a warning signal. Top–down activation is heavily lateralized to the 
right hemisphere. 
 Th e second att entional system relates to orienting, or the ability to more rapidly 
process events that occur in expected locations (i.e., where something is going to hap-
pen, as opposed to alerting, which focuses on when something is about to occur). In 
contrast to alerting, which relies on the noradrenergic system, Petersen and Posner 
(2012) propose that orienting depends on ACh (but see Corbett a, Patel, & Shulman, 
2008). Th e orienting system is involved in hemispatial neglect and hemi-inatt ention, 
about which more is available here. 
 Th e third att ention network proposed by Petersen and Posner (2012) relates to 
conscious awareness and limited capacity and has been described in terms of a “global 
working space” that sets goals, solves problems, inhibits responses, shift s fl exibly from 
one task to another (also known as shift ing set), and monitors and resolves errors and 
confl ict. Th ere is still controversy regarding the nature of such a network (or networks), 
but in essence this aspect concerns the executive control of att ention. Although most 
of the work to date has looked at dopamine and the modulating role of genetic poly-
morphisms, other neurotransmitt ers (e.g., serotonin) have also been implicated in 
systemwide eff ects, such as the degree of functional connectivity manifested within 
a given network (Green, Munafo, DeYoung, Fossella, Fan, & Gray, 2008). Th ere are a 
host of neuropsychological tests that have been developed for assessment of executive 
 Th eir conceptualization, oneTh
of the most infl uential models to date, addresses top–down processes relating to atten-tt
tional control and is composed of three functional networks or systems: alerting, ori-
enting, and executive manipulation. 
. Top–down activation is heavily lateralized to the 
right hemisphere. 
Process-Focused Assessment of Arousal and Att ention 43
functions in research as well as clinical sett ings, focusing on the diff erent processes 
of inhibition, set-shift ing, working memory, problem-solving, error monitoring, and 
self-regulation. 
 Th ese top–down att entional functions include aspects of att ention referred to in 
the literature as focused or selective att ention (the ability to select a target from among 
distractors) and divided or distributed att ention (the ability to monitor more than one 
aspect of a task and to shift back and forth between foci, as in driving). Focused att en-
tion can vary in terms of breadth, sometimes focusing on specifi c features or details, 
and in other situations distributing att ention over a larger fi eld. Based on the assess-
ment procedures developed to capture this distinction, it is sometimes also referred to 
as local versus global att ention. Normally, people are able to determine the breadth of 
their att entional focus and alternate between a larger or smaller fi eld at will, with a ten-
dency to perceive things at a more global level unless task demands require a change. 
Patients with damage to the left hemisphere show a propensity to focus exclusively on 
the global aspects of a situation or stimulus, while patients with right hemisphere dam-
age show the opposite patt ern and neglect the holistic aspects in favor of a more detail-
specifi c focus of att ention (Delis, Kiefner, & Fridlund, 1988). Span of att ention refers 
to the number of items that can be held simultaneously in awareness and manipulated 
(working memory); typically, this is assessed for verbal and spatial aspects separately. 
 ASSESSMENT OF AROUSAL AND ATTENTION 
 General Considerations 
 In terms of a process approach, it is important to start with a person’s presenting state 
of arousal, because this modulates other higher cognition functions and interacts with 
the other components of att ention. To determine the person’s level of tonic arousal 
(general state of wakefulness) over the course of a neuropsychological assessment, 
indicators arise from behavioral observations and history-taking and can be assessed 
via questionnaires, timed tests (e.g., continuous performance tests [CPTs] and simple 
reaction time tests), and inferred from observed variability in performance within and 
between tests. 
 Even before any testing occurs, the examiner should assess the person’s ability 
to maintain a wakeful state without overt signs of agitation and motor restlessness 
(hyperarousal) or, conversely, without showing signs of sleepiness or fatigue, such as 
yawning, diffi culty keeping eyes open or head up, or reports of feeling tired or sleepy 
(hypoarousal). Individuals suff ering from either condition will have diffi culty main-
taining and focusing att ention. Other behavioral signs of impaired arousal during test-
ing include staring at a computer screen for several seconds, and signifi cant intratest 
44 Chapter 4 Moes et al.
and intertest variability, such as doing well on harder items and missing easier ones 
on tests requiring sustained eff ort (e.g., the Vocabulary, Picture Completion, and 
Block Design subtests of the Wechsler Adult Intelligence Scale [WAIS] or theBoston 
Naming Test). Intertest variability may arise from several causes, including naturally 
occurring fl uctuations in arousal, fatigue, or diff ering levels of intrinsic interest to the 
individual of certain tasks (thus triggering a top–down cortical activating response). 
 Because the ability to update one’s current situation (e.g., with respect to time and 
recent events) rests on ongoing awareness of the environment, individuals with severe 
disorders of arousal oft en are disoriented and will incorrectly respond to a brief assess-
ment of orientation to time, place, and situation (even though they may be able to 
indicate roughly what season it is). Diffi culty in maintaining set on even simple tasks 
(e.g., mental control tests requiring the person to recite forward and backward the days 
of the week, months of the year, the alphabet, and numbers from 1 to 20) will likely 
be observed. 
 In less extreme cases (e.g., postt raumatic stress disorder or sleep deprivation), dis-
ruption of the arousal system may be less obvious, and more subtle diffi culties will 
emerge on testing. Simply asking the person how tired they are on a 10-point scale as 
part of the mental status assessment may provide useful information. Alternatively, 
the Profi le of Mood States (POMS; McNair, Lorr, & Droppleman, 1981) can be 
administered. Th e POMS has six factor-derived scales including Vigor, Fatigue, and 
Depression (the others are Tension, Anger, and Confusion). Two composite scales 
(Arousal and Positive Mood) can also be calculated from the subscales. By way of 
validation, reduction of POMS Fatigue and Depression scaled scores and increase 
in Vigor scaled scores in response to stimulant medication was reported by Bishop, 
Roehrs, Rosenthal, and Roth (1997). Together with changes in the POMS, they 
found an increased latency to fall asleep on the Multiple Sleep Latency Test (MSLT; 
see later) and reversal of the negative eff ects of sleep deprivation on a divided att en-
tion test and on a lengthy auditory vigilance test (producing fewer errors but no dif-
ference in RT). Th e POMS has even been found to be sensitive to changes in arousal 
(induced by methylphenidate) modulated by individual genetic diff erences (Dlugos, 
Hamidovic, Hodgkinson, Goldman, Palmer, & de Wit, 2010; see Lezak, Howieson, 
Bigler, & Tranel, 2012, pp. 820–821, for further neuropsychological fi ndings regarding 
the POMS). 
 Computerized Measures 
 Because arousal relates to effi ciency in cognitive processing, it is not surprising that 
RT is a common way to measure it, even though there are a number of factors that 
aff ect RT (Armengol, 2000; Kosinski, 2012), including the system used to administer 
Process-Focused Assessment of Arousal and Att ention 45
the test (Cernich, Brennana, Barker, & Bleiberg, 2007). Th ere are many diff erent com-
puterized tests commercially available to clinicians that provide RT outcomes and 
normative data. Riccio, Reynolds, and Lowe (2001) describe and review many CPTs 
and their clinical applications at length, although new computerized test batt eries 
are constantly appearing. Some commonly used CPTs include the Conners’ CPT-II 
(Conners & Staff , 2000), the Gordon (Gordon Diagnostic Systems; Gordon & 
Mett elman, 1988), the Test of Variables of Att ention (TOVA; Leark, Greenberg, 
Kindschi, Dupuy, & Hughes, 2008), and VIGIL (Cegalis & Bowlin, 1991). 
 A process approach to CPT tests would include an analysis of responses to each 
trial, wherever available, rather than reliance on summary and mean scores that may 
be misleading, even when provided across short trial blocks. Usually, the scoring 
programs for computerized CPTs use a criterion to decide whether a response has 
occurred too quickly to be considered valid; however, these criteria diff er from one 
program to another and sometimes between versions of the same program. A trial-
by-trial visual analysis of the printout for patt erns of errors and time taken to respond 
takes no more than a few minutes and can provide useful insights into the person’s 
arousal and att ention. Th us, one can quickly identify whether errors of commission 
result aft er omissions in times that exceed or are signifi cantly faster than the person’s 
median RT. Decline in performance over time (the vigilance decrement) is oft en 
not reported but can be assessed by reviewing changes in RT and accuracy across 
the blocks. 
 Using both cued and uncued simple reaction time tests together is useful in sepa-
rating general wakefulness or tonic arousal (uncued) from transient alerting or phasic 
(cued) att ention (Armengol, 2000; Cegalis & Bowlin, 1991; Duncan & Mirsky, 2004). 
For example, Langner, Steinborn, Chatt erjee, Sturm, and Willmes (2009) report a 
study in which simple reaction time increased over a work period of nearly an hour 
as students reported increasing levels of fatigue and discomfort and increasing levels 
of task disengagement; however, there was no selective decrement in relation to vary-
ing periods between a warning signal and target, suggesting that the phasic alerting 
component of att ention was not susceptible to the eff ect of fatigue. Armengol (2000) 
provides examples of clinical situations where, using the VIGIL computerized test, 
the diff erential diagnosis is enhanced by a careful process analysis of RT variables 
and errors, separately and in relation to each other (i.e., speed/accuracy analysis). In 
patients with disorders of the alerting system (e.g., ADHD and Alzheimer’s disease), 
one would expect to see no improvement in RT in response to a warning signal or 
cue, unlike matched healthy controls (Cao et al., 2008; Tales, Muir, Bayer, Jones, & 
Snowden, 2002). Unfortunately, many tests do not specifi cally provide the option of 
assessing both uncued and cued RT (VIGIL and the Att ention Network Test [ANT; 
see later] are the exceptions). Instead, several tests provide normative data for simple 
46 Chapter 4 Moes et al.
(uncued) RT and various choice RT tests (TOVA and ANAM) and others for uncued 
RT only (Conners’ CPT-II) or for cued RT only (Gordon Diagnostic Systems). 
 VIGIL provides a wide variety of presentation options for the user with regard 
to auditory versus visual presentation of stimuli, degraded versus nondegraded 
stimuli, presence or absence of distractors, interstimulus interval, size and identity 
of cues and targets, and sequence of conditions; normative data are provided for a 
standard cued and uncued batt ery for a wide range of ages (although for children 
in 2-year increments only). Th is fl exibility is particularly useful in rehabilitation 
centers in cases where rate of stimulus presentation, etc. may need to be adjusted 
to accommodate sensory defi cits and/or time needed to respond, while still per-
mitt ing quantifi cation of changes in arousal and att ention over time. It is modeled 
on the original CPT described by Rosvold, Mirsky, Sarason, Bransome, and Beck 
(1956), and is part of the Att ention Batt ery for Adults assembled by Duncan and 
Mirsky (2004). [It is of historical interest to note that the target lett er in the VIGIL 
test is K, for Kaplan, based on the test author’s appreciation for Dr. Edith Kaplan’s 
consultation and guidance in using a process-based approach in the development of 
the test ( J.A. Cegalis, personal communication). Unfortunately, as of 2011, VIGIL 
is no longer commercially available.] 
 Simple RT (i.e., RT to uncued targets, refl ecting arousal or intrinsic alertness) has 
been found to be exceptionally sensitive to concussion in studies using the Automated 
Neuropsychological Assessment Metrics (ANAM) batt ery, compared with its other 
subtests (Center for the Study of Human Operator Performance, 2007). Choice RT, 
unlike cued RT, is dependent on the precise nature and complexity of a given task 
(e.g., number and kind of variables to compare, and response demands), so it does not 
provide an index of the alerting functionper se. Choice RT that falls below expecta-
tions provides a more global indication of diffi culty, refl ecting any or all of the mental 
operations specifi c to the task being performed, which therefore cannot be further 
interpreted without additional information. 
 Another factor to consider in test interpretation is the response task. Th e ANAM 
in particular requires the examinee to remember fairly demanding shift s in response 
from one subtest to another, with one subtest requiring that the mouse keys be used to 
signify whether the sum of numbers presented is greater than or less than 5, whereas 
another subtest requires that one key represent the left hand and one the right hand of 
a manikin, and on other subtests still other keys represent yes or no, or the colors red, 
green, or blue. Diff erences in RT across subtests may refl ect not only the particular 
demands of each subtest, therefore, but also the subject’s ability to shift and/or recall 
the response requirements for that particular task. A neuropsychologist taking a pro-
cess approach to assessment would want to be able to partial out the relative contribu-
tions of these processes. 
Process-Focused Assessment of Arousal and Att ention 47
 Some interesting theoretical work on intraindividual variability, originally examined 
in relation to reaction time, has brought to light the importance of variability as a strong 
indicator of abnormalities in the arousal/att ention system of children with ADHD as 
well as in individuals with other disorders, providing bett er discrimination between 
clinical and nonclinical groups than simple mean reaction times (e.g., Castellanos, 
Sonuga-Barke, Scheres, DiMartino, Hyde, & Walters, 2005; Geurts et al., 2008). 
Response variability is also associated with self-reported cognitive fatigue in multiple 
sclerosis (Bruce, Bruce, & Arnett , 2010). Interestingly, when Geurts et al. (2008) exam-
ined RT variability in boys with and without ADHD during the Eriksen Flanker Test (a 
test in which the target is surrounded by arrows pointing in the same or diff erent direc-
tion), they found that boys with ADHD given varying doses of methylphenidate had 
less variable reaction times regardless of the dose (compared with placebo), whereas 
time on task did not aff ect the degree of variability shown, suggesting that the observed 
variability is not related to general arousal but rather to top–down alerting. 
 Clinicians can take advantage of this work by paying careful att ention to variabil-
ity in mean RTs. Normative data for RT variability using the standard deviation are 
available for the TOVA and constitutes one of its more salient predictive variables of 
ADHD; RT variability data are also provided for the Conners’ CPT-II, although the 
emphasis of that test is on inhibition of responses to targets, rather than simple RT to 
targets. 
 CPT tasks are usually presented visually, but auditory versions also exist, such as 
the Continuous Performance Test of Att ention (CPTA; Cicerone, 1997); the Gordon 
Diagnostic System (Aylward, Brager, & Harper, 2002); the NEPSY-II (which stands 
for “A Developmental NEuroPSYchological Assessment”; Korkman, Kirk, & Kemp, 
2007), the Brief Test of Att ention (Schretlen, Bobholz, & Brandt, 1996), and VIGIL. 
Prior research has found that auditory versions are more sensitive than visual CPTs in 
discriminating certain clinical conditions, including epilepsy, schizophrenia, and fetal 
alcohol syndrome (Baker, Taylor, & Leyva, 1995; Duncan & Mirsky, 2004). 
 On these tests, it is useful to ask the respondent, aft er completing a test condition, 
how he or she thinks he or she did, and whether he or she missed any target lett ers or 
numbers. If so, where did those errors occur—in the beginning, the middle, or the end 
of the test? Individuals who were simply distracted can oft en indicate an awareness of 
where they missed targets, while those suff ering from subclinical seizures are quite 
unaware of having missed targets, let alone when. It is important to distinguish indi-
viduals who are consistently slow due to motor impairments or speed of processing 
defi cits from those who normally function at an average speed but whose performance 
is undermined by frequent att entional lapses. 
 Th e computerized ANT (Fan, McCandliss, Sommer, Raz, & Posner, 2002) is 
a widely used reaction time test modeled aft er the tripartite theory of top–down 
48 Chapter 4 Moes et al.
att ention put forward by Posner and Petersen in 1990 (alerting, spatial orienting, 
and control). Th e ANT has been developed in several versions for both adults and 
children, and can be freely downloaded at htt p://www.sacklerinstitute.org/users/
jin.fan/. Administration of the standard test takes about 20 minutes and occurs in 
three blocks with the opportunity to rest in between. Results indicate the relative 
increase in speed of response with a cue versus no cue (alerting eff ect) and with a 
valid spatial cue versus a cue that is uninformative with respect to target location 
(orienting). Speed of correctly identifying the direction of a target arrow surrounded 
(fl anked) by congruent versus incongruent arrows provides a measure of top–down 
control (the executive network). Normative data have not, to date, been compiled 
into a single source to facilitate the clinical use of the ANT, but many publications 
exist (too many to cite here). Diff erent profi les have been identifi ed for a number 
of patient and demographic groups, generally consistent with hypothesized physi-
ological mechanisms underlying each disorder and att ention network (Macleod, 
McConnell, Lawrence, Eskes, Klein, & Shore, 2010; Weaver, Bedard, McAuliff e, & 
Parkkari, 2009). 
 Weaver and colleagues (2009) reported that the overall mean RT on the ANT is 
comparable in predicting scores on the Manitoba Road Test to another test commonly 
used to assess driving, the Useful Field of View (UFOV) test. Th e UFOV test is not 
simply based on peripheral vision or acuity; it also takes into account cognitive speed 
of processing and ability. It represents the area on a screen in which rapidly presented 
visual stimuli (trucks, cars, and other objects) can be identifi ed and responded to. 
Th e test has been successful in predicting crash frequency in automobile drivers, par-
ticularly elderly drivers, who are overrepresented in fatal crashes. Th e two programs 
(UFOV and ANT) diff er substantially in terms of cost, so further research concerning 
the use of the ANT in driving assessment is certainly warranted. 
 Finally, although the ANT is a very useful addition to the assessment of att ention, 
it should also be noted that it does not provide information on other aspects of att en-
tion (e.g., divided att ention, att ention span, and breadth of focus) that would also be 
included in a more comprehensive evaluation. 
 Noncomputerized Measures 
 Computerized administration of tests comes with both pros and cons. Th e benefi ts 
of controlled stimulus presentation and accurate error and RT recording in providing 
useful information regarding arousal and alerting are clear. Baseline tonic arousal and 
the distinction between (tonic) arousal and (phasic) alerting are hard to capture with-
out cued versus uncued RT. Today, the availability of laptops and personal computers 
make such programs easily accessible to the average clinician. However, in addition to 
Process-Focused Assessment of Arousal and Att ention 49
the issues associated with timing precision mentioned earlier (Cernich et al., 2007), 
reliance on electronic equipment carries with it increased risk of malfunction and lost 
data, and durability of the hardware is a consideration. 
 Several noncomputerized tests are available (both timed and untimed) that pro-
vide useful measures of att ention; these include cancellation tests, line bisection 
tests, drawings, and Trail Making tests, as well as the Test of Everyday Att ention 
(TEA; Robertson,Ward, Ridgeway, & Nimmo-Smith, 1994, see later) and the Test of 
Everyday Att ention for Children (TEA-Ch; Manly, Anderson, Nimmo-Smith, Turner, 
Watson, & Robertson, 2001). 
 Alerting is assessed with cued tasks and vigilance tasks as described earlier but can 
also be addressed more informally by observing the person’s general ability to mobi-
lize att ention in response to task demands. It is not unusual to fi nd that individuals 
with ADHD are able to mobilize in response to tasks that are overtly challenging, but 
not to tasks (e.g., the cancellation tests described later) that are perceived as easy or 
nondemanding, resulting in disorganized search patt erns, failure to check for accuracy, 
and rapid completion time at the cost of omission errors. 
 Selective att ention is the ability to select and fi nd specifi c targets (the focus func-
tion identifi ed by Mirsky and colleagues) and can be assessed quite rapidly and simply 
with cancellation tests. Cancellation tasks are oft en administered as paper-and-pencil 
tests that require the examinee to locate a target stimulus distributed randomly within 
an array of stimuli. Th e stimuli used in cancellation tests vary, but the most commonly 
used stimuli consist of bells (the Bells test; Gauthier, Dehaut, & Joanett e, 1989), a 
lett er or sun-like image (Weintraub and Mesulam’s lett er and shape cancellation tests, 
1985), or stars (Star Cancellation Test; Halligan, Wilson, & Cockburn, 1990). Th ese 
stimuli are presented in either structured or unstructured arrays. Th e person’s ability 
to impose an ordered search strategy on the task can be assessed by observing (and 
recording with colored pens, fl ow diagrams, or computerized programs) the order in 
which the person searches the array. Process variables to consider include the start-
ing point (see Unilateral Neglect later), systematicity (how systematically and in what 
direction[s] the person searches a display), and whether the person self-monitors 
(i.e., scans the page at the end to ensure that all targets have been identifi ed), together 
with any pronounced tendency to emphasize speed at the cost of accuracy or vice 
versa (e.g., impulsively saying “Stop!” and then immediately realizing there are more 
targets, versus scrupulously and painstakingly rescanning the page to ensure that all 
targets have been circled). Th e latt er variable can provide important clues to work per-
formance issues. Furthermore, in addition to merely reporting the number of errors, 
a process approach examines the location of errors (number in each hemifi eld and 
upper or lower quadrant) to assess for hemi-inatt ention, as well as their type (omis-
sion or, far less commonly, commission). 
50 Chapter 4 Moes et al.
 By assessing search for a verbal target (the lett er A) in one condition and a nonver-
bal target (a symbol in the shape of a sun with a line through it) in another condition, 
lateralized diff erences can be discerned in response to each, with patients with right 
hemisphere lesions doing more poorly on the symbol cancellation test and those with 
left hemisphere lesions doing worse on the lett er cancellation test (Weintraub, 2000). 
Normative data for completion time and errors on the Weintraub-Mesulam test have 
been reported in several places, including Cegalis and Bowlin (1991, in the VIGIL 
manual) and Lowery, Ragland, Gur, Gur, and Moberg (2004). 
 Th e Map Search subtest of the TEA is another cancellation test that comes with 
three versions for repeated assessment (together with indications of average prac-
tice eff ects over time). It uses a visually complex map of the Philadelphia area and, 
depending on the version, requires the respondent to circle various restaurant, gas 
station, and plumber symbols as rapidly as possible in 2 minutes. Th ere are 80 tar-
gets for each of the three versions, and through the use of colored pens the examiner 
keeps track of how many targets are circled in the fi rst and then the second minute. 
Given the level of detail and visual complexity, reduced visual acuity can impact per-
formance; additionally, it is possible that the specifi c features of the map (the river 
bisecting the map diagonally across from lower left to upper right) and the task itself 
(searching for gas stations or restaurants across a very large area that the traveler 
would be unlikely to actually need information for, given the scale of the map) aff ect 
search strategies. More information on this would be useful in interpreting perfor-
mance qualitatively. Th e subtest is considered useful in identifying problems with 
selective att ention and speed. 
 It should be noted that cancellation tests have been found to provide the most sen-
sitive measure of neglect, compared with other tests such as Line Bisection, sentence 
indentation, etc. (see Unilateral Neglect later). Th e additional information obtainable 
with regard to visual acuity, hemi-inatt ention, organization and approach to the test, 
and impulsivity makes cancellation tests a rapid, low-cost means of assessing these 
functions. 
 Flexibility in breadth of att entional focus has been assessed using Navon stimuli 
(large lett ers composed of smaller lett ers), and while there have been many experi-
mental studies examining att entional bias to holistic (global) aspects versus specifi c 
(local) features, it is also possible to distinguish clinical populations using simple 
paper-and-pencil tasks. Delis et al. (1988) demonstrated that patients with left hemi-
sphere damage show the greatest impairment in reproducing forms at the lower level 
of hierarchical stimuli (i.e., at the local level) presented in the right hemispace, whereas 
patients with right hemisphere compromise displayed the opposite patt ern (i.e., repro-
ducing global aspects in left hemispace). In a separate study, it was shown that mentally 
retarded individuals with Williams syndrome have signifi cant diffi culty with copying 
Process-Focused Assessment of Arousal and Att ention 51
global aspects of stimuli, while individuals with Down syndrome have diffi culty with 
the local features (Bihrle, Bellugi, Delis, & Marks, 1989). 
 Another test typically identifi ed as a measure of selective att ention is the Stroop 
test. Clearly this test requires both the ability to focus on one stimulus dimension 
while inhibiting automatic, prepotent responses to another. It should be noted, how-
ever, that both the color and the word meaning are processed simultaneously, auto-
matically, and in parallel, such that paying att ention to one aspect does not actually 
inhibit processing of the other dimension, only the response to it. Performance on 
measures of response inhibition such as the Stroop can thus be dissociated from per-
formance on search/cancellation tests, despite the fact that both depend on att ention 
to one att ribute (e.g., shape, color, or meaning) and inhibition of response to another. 
Coull (1998) makes a similar distinction between focused att ention (target search, 
as in cancellation tests) and selective att ention (target search and inhibition, as in the 
Stroop) for the same reason. 
 A process approach to assessment seeks to deconstruct a task in terms of its com-
ponent cognitive processes and highlights behavioral markers of such processes. 
Along these lines, Edith Kaplan was instrumental in identifying the fourth condition 
of the Color Word Interference Test (a subtest of the Delis-Kaplan Executive Function 
System [D-KEFS] based on the Stroop paradigm) as a useful test of task switching, 
where previously it was reported as a method to simply raise the ceiling (i.e., increase 
diffi culty) to increase diff erentiation between patients with mild brain injury and con-
trols (see Bohnen, Jolles, & Twijnstra, 1992). Tests that assess executive functions 
(using the Stroop paradigm) but that depend much less on literacy and higher levels 
of education, and that have found great cross-cultural utility,have been developed by 
Sed ó (Sed ó , 2007, 2004a, 2004b; Sed ó & DeCristoforo, 2001). 
 Divided att ention can be assessed using the Paced Auditory Serial Addition Test 
(PASAT; Gronwall & Sampson, 1974; see also Lezak et al., 2012, pp. 411–412, for 
a discussion of factors that contribute to performance on this test, and modifi ca-
tions in scoring to control for these). Th e PASAT requires the respondent to listen 
to a recording that presents numbers at a fi xed pace (which increases across trials). 
Th e examinee has to add the last two numbers in sequence, while at the same time 
keeping the last number in working memory until the next number is presented to 
be added to it. 
 Another test that assesses divided att ention is the Trail Making B subtest (or 
number–lett er condition of the Trail Making subtest of the D-KEFS), which requires 
rapid alternation between numbers and lett ers in sequence, thus requiring not only 
switching but also mentally updating one’s place in each sequence. On the D-KEFS 
version, time to sequence lett ers and time to sequence numbers are assessed separately 
to be able to partial out fl uency on these tasks before assessing the ability to alternate 
52 Chapter 4 Moes et al.
between the two, which may, for example, be slower in individuals with specifi c learn-
ing diffi culties. 
 One noncomputerized test that is explicitly based on Posner and Petersen’s (1990) 
model of att ention, the TEA (Robertson et al., 1994) was developed to provide an eco-
logically valid measure (i.e., subtests are modeled on everyday tasks involving a hypo-
thetical trip to Philadelphia and hence have high face validity) of focused att ention 
and att entional shift ing (but not of orienting). Th e test has proved to be sensitive to 
discriminating individuals with a broad range of disorders, and reliability indices and 
standard intraindividual subtest diff erences have also been made available (Crawford, 
Sommerville, & Robertson, 1997). 
 Th e children’s version (TEA-Ch, Manly, Robertson, Anderson, & Nimmo-Smith, 
1998) comprises very diff erent subtests but aims to assess similar att entional factors 
in 6- to 16-year-olds. It has enjoyed widespread popularity among clinicians, despite 
some complaints about ceiling eff ects in older children and adolescents, and its three-
factor structure (sustained, selective, and controlled att ention) has been replicated in 
several studies. It has been widely used in research studies and has been shown to be 
sensitive to the eff ects of methylphenidate in children with ADHD (e.g., Hood, Baird, 
Rankin, & Isaacs, 2005). One of the process features is that motor speed is partialled 
out of performance on the Sky Search subtest in a way similar to that used on the 
D-KEFS Trail Making subtest. 
 DISORDERS OF AROUSAL AND ATTENTION 
 Common and severe disorders of arousal (which include both hyperarousal and 
hypoarousal) that the clinician is likely to encounter (to diff ering degrees in various 
clinical sett ings) and that are briefl y discussed here include subclinical confusional 
states, sleep disorders, and seizure disorders. However, impaired arousal is character-
istic of many other conditions and disorders (e.g., depression, anxiety, schizophrenia, 
and postt raumatic stress disorder) and can have a more subtle impact on the effi ciency 
with which the brain processes information. Neglect is an att entional disorder that 
oft en results from contralateral damage. 
 Confusional States 
 Delirium is a common and serious disorder of arousal characterized by a waxing 
and waning of symptoms, and although it is usually reversible, it is associated with 
high morbidity and mortality if underlying causes are not detected and treated early 
enough. It occurs in 35% to 80% of critically ill, hospitalized patients, but community 
incidence is estimated to be much lower (1% to 2%; Inouye, Leo-Summers, Zhang, 
Process-Focused Assessment of Arousal and Att ention 53
Bogardus, Leslie, & Agostini, 2005). Th us, it is most likely to be encountered by neu-
ropsychologists working in acute care medical centers, although certainly it needs to 
be ruled out before making a diagnosis of dementia. 
 Confusional states are “the single most common mental state disturbance that 
most physicians will see” (Mesulam, 2000, p. 128), but they are frequently undetected 
(Ali et al., 2011; Inouye, van Dyck, Alessi, Balkin, Siegal, & Horwitz, 1990), with as 
many as 32% missed by physicians in one study (Francis, Strong, Martin, & Kapoor, 
1988, cited in Inouye et al., 1990), and 87% missed by nursing staff in another (Voyer, 
Richard, Doucet, Danjou, & Carmichael, 2008). Delirium is underdiagnosed in large 
part due to the infrequent use of assessment instruments. In a study conducted by 
Patel and colleagues (2009), only 33% of respondents reported using a specifi c vali-
dated screening tool. 
 Many factors can lead to delirium, including infections, malnutrition, medications, 
sleep deprivation, or medication withdrawal. Anticholinergic medications are (not 
surprisingly, given the importance of the cholinergic system in arousal) particularly 
prone to triggering delirium (Ali et al., 2011) and are prescribed for a wide range of 
disorders, including gastrointestinal, genitourinary, and respiratory disorders (they 
are oft en found in inhalers, for example). 
 Infectious diseases continue to present a particular risk for older patients, in part 
because immune dysfunction is associated with aging (Yoshikawa, 2000). Urinary 
tract infections (UTIs) are the most common cause of delirium among the elderly, 
are oft en occult (hidden), and may manifest only by the person unobtrusively slipping 
into a confusional state. Th ey are particularly important to detect to ensure proper 
diagnosis and intervention (antibiotics and the prevention of further complications). 
Elderly people with serious UTIs do not exhibit the hallmark sign of fever because 
their immune system is unable to mount a response to infection, due to the weakening 
eff ects of aging. UTIs in the elderly are oft en mistaken as the early stages of dementia 
or Alzheimer’s disease, according to the National Institutes of Health, because symp-
toms include confusion, or delirium-like state, agitation, hallucinations, other behav-
ioral changes, poor motor skills, or dizziness and falling. Oft en, these are the only 
symptoms of a UTI that show up in the elderly (Berman, Hogan, & Fox, 1987). 
 An individual in a state of hyperaroused confusion will present with a great deal 
of unfocused energy (agitation), motor restlessness, and particular diffi culty staying 
focused on the topic at hand (Ali et al., 2011). Responses may be out of proportion 
in intensity to what is occurring in their environment (Luria, 1973), and at times 
the content of responses will be unrelated to the question asked. “Sundowning” (an 
increase in symptoms later in the day) is also characteristic. 
 Th e most widely used screening tool is the Confusion Assessment Method 
(CAM; Inouye et al., 1990; downloadable with a scoring manual from Inouye’s 
54 Chapter 4 Moes et al.
website at htt p://www.hospitalelderlifeprogram.org/private/cam-disclaimer.php? 
pageid=01.08.00). It is a brief (5-minute), standardized tool that provides a validated 
algorithm for diagnosing delirium, based on observation of the patient while for-
mal cognitive testing is performed, and an interview with a family member or other 
observer. Th e CAM assesses nine features of delirium (acute onset, inatt ention, disor-
ganized thinking, altered level of consciousness, disorientation, memory impairment, 
perceptual disturbances, psychomotor agitation or retardation, and altered sleep–
wake cycle) but focuses on four Diagnostic and Statistical Manual of Mental Disorders 
criteria for the diagnosis: acute onset and fl uctuating course, inatt ention, disorganized 
thinking, and altered level of consciousness. A reviewof 11 bedside instruments used 
to identify the presence of delirium in adults concluded that the CAM was the most 
accurate test for delirium and the Mini-Mental State Examination (MMSE) was the 
least accurate test (Wong, Holroyd-Leduc, Simel, & Strauss, 2010). A meta-analysis 
based on 11 validation studies demonstrated that the CAM has a sensitivity of 94% 
and a specifi city of 89% (Wei, Fearing, Sternberg, & Inouye, 2008). Nonetheless, 
Wei and colleagues concluded that eff ective use of the CAM does require some train-
ing, given disparities in sensitivity and specifi city between researchers, physicians, 
and nursing staff , and that it should be scored on the basis of observed cognitive 
(and preferably verbal) testing, because informal observations or only very brief 
tests of att ention compromised sensitivity. One study (Lowery, Wesnes, Brewster, & 
Ballard, 2008) found that, relative to preoperative status, patients with delirium had 
signifi cantly slower RTs and demonstrated more variability in reaction time than did 
patients who did not become confused. 
 Seizure Disorders 
 Seizure disorders are characterized by brief periods (seconds) of unconsciousness or 
by longer alterations in level of awareness and ability to process information of which 
the person is unaware. Att entional lapses may result from subclinical seizures (i.e., sei-
zures aff ecting consciousness that are not readily apparent to the observer). Absence 
seizures are commonly undetected despite potentially hundreds of momentary lapses 
in att ention occurring throughout the day, each lasting several seconds (Glauser et al., 
2010). During the history-taking, it is therefore important to ask not only the patient 
but also an informant (spouse, partner, family member, or caretaker) for informa-
tion related to the possibility of att entional lapses. One should also inquire whether 
the person fi nds that he or she loses track of events while watching a television pro-
gram or movie, or misses information in conversation with others. During testing, 
performance on a CPT will refl ect frequent errors and variable RTs (e.g., Semrud-
Clikeman & Wical, 1999). 
Process-Focused Assessment of Arousal and Att ention 55
 Th e neuropsychologist needs to integrate information regarding att entional lapses 
into an overall diagnostic picture so as not to miss a relevant diff erential diagnosis (e.g., 
narcolepsy-based att entional lapses are likely to occur in the context of excessive day-
time sleepiness; see MacLeod, Ferrie, & Zuberi, 2005). Other questions that help to 
guide interpretation and diagnosis relate to symptoms associated with specifi c types 
of seizures but that occur with suffi cient infrequency as to make their appearance dur-
ing the assessment unlikely, such as being able to identify several episodes of “jamais 
vu” or “d é j à vu” (a known situation or place that feels unfamiliar or vice versa) in the 
past year. Perceptual distortions such as episodes of micropsia and macropsia (seeing 
objects as unnaturally small or large) have been associated with temporal seizures and 
should also be asked about, as should the experience of any unprovoked sensation, 
motor behaviors (including behaviors tied to emotional expression such as laughing 
or crying in the absence of the associated feeling), and almost any other recurrent “out 
of the blue” feeling or response that cannot be bett er accounted for by circumstances 
(see Schomer, O’Connor, Spiers, Seeck, Mesulam, & Baer, 2000, for a comprehensive 
review of the phenomenology of temporolimbic seizure disorders). 
 Importantly, individuals suff ering from frequent subclinical att entional lapses will 
take longer to complete tests such as lett er and symbol cancellation than is typical, 
due to time “off -line”; similarly, moments of confusion, refl ected in loss of set and per-
severative errors on tests such as the Wisconsin Card Sorting Test and verbal fl uency, 
may also occur (e.g., Conant, Wilfong, Inglese, & Schwarte, 2010). It is worth not-
ing that att entional lapses on timed visuaomotor tasks (e.g., Block Designs, cancel-
lation tests, etc.) may in fact present only as long completion times, as people can 
rapidly reestablish set by looking at, and being cued by, their own responses. Errors are 
more likely to be observed on auditory tests or on a CPT, where stimuli are presented 
briefl y (see also Duncan, Mirsky, Lovelace, & Th eodore, 2009). Omissions without 
rapid responses on the next item, and especially consecutive omissions, would suggest 
att entional lapses; it would again be useful to inquire if the person was aware of having 
made any errors in an eff ort to diff erentiate internal distraction (absent-mindedness 
or even internal stimulation such as hearing voices in the case of schizophrenia) from 
unawareness. 
 Unilateral Neglect and Extinction 
 Unilateral neglect (ULN) is a common neuropsychological disorder observed in 
patients aft er stroke that is characterized by a failure to respond to stimuli shown to 
the side opposite to the brain lesion, accompanied with an ipsilesional spatial att en-
tion bias (Committ eri et al., 2007). Predominant contralateral neglect occurs almost 
exclusively aft er right hemisphere damage and results in neglect of the left visual 
56 Chapter 4 Moes et al.
fi eld (for review, see Mesulam, 2000). Individuals suff ering from neglect may fail to 
complete the left side of drawings or ignore information on the left side of the page. 
Th e phenomenon has been conceptualized as a disorder of directed spatial att ention 
(Mesulam, 2000), as opposed to impairment in the visual system. 
 When healthy, non–brain-injured patients are asked to bisect a line at its midline, 
they tend to indicate a point to the left of the actual midpoint (Luh, 1995). It has been 
shown that the right hemisphere is predominantly activated in healthy controls during 
a line-bisection task that requires individuals to judge whether the line presented was 
bisected correctly (Ci ç ek, Deouell, & Knight, 2009), indicating the dominance of the 
right hemisphere over the left in voluntary spatial att ention. 
 Extinction is thought of as a less severe form of neglect in which the individual 
responds to stimuli when presented unilaterally but fails to respond to one stimulus 
when stimuli are presented bilaterally (Mesulam, 2000). Whether these two clinical 
presentations represent diff erent syndromes aff ecting diff erent brain regions is still 
unclear. A recent report found that full ULN and extinction co-occurred in a subset 
of patients but also were observed independent of each other, indicating a double-
dissociation. Further, the researchers found that severe extinction was associated with 
lesions in the right inferior parietal cortex, whereas ULN was associated with both 
frontoparietal and parietal-occipital brain regions (Vossel et al., 2011), suggesting dif-
ferent neural substrates. 
 Mesulam (2000) proposed that the focal centers of the spatial att entional network 
reside in the posterior parietal cortex, the frontal eye fi eld, and the cingulate gyrus. 
Th ese areas, according to Mesulam, mediate the conversion of extrapersonal events 
into internal representations that can then direct one’s att ention. More specifi cally, 
the parietal component was suggested to convert the external world into an inter-
nal representation, whereas the frontal component orchestrates the motor systems 
to explore and scan one’s environment. Empirical evidence supporting this parietal/
frontal dissociation of function has been documented (L à davas, Zeloni, Zaccara, & 
Gangemi, 1997). 
 Edith Kaplan commented extensively (Kaplan, 1988) on ways in which incorrect 
responses on visuospatial tests can be understood as deriving from an att entional bias 
to the right, as on the Hooper Visual Organization Test (HVOT) or Block Design (see 
Chapter 16). For example, on the HVOT, which requires the respondentto integrate 
fragments of pictures, she noted that a common response to the fi rst item (a fi sh) from 
patients with right hemisphere lesions is “a fl ying duck.” Th is response is based on part 
of the fi sh tail in the right hemifi eld that resembles a duck, while the salient identifying 
fi sh head is in the left hemifi eld. Reversing the direction of the stimulus (such that the 
fi sh head pointed in the opposite direction and fell in the right hemifi eld, while the tail 
fragment that resembles a duck fell in the left side of space) produced a much higher 
Process-Focused Assessment of Arousal and Att ention 57
incidence of correct responses in this group. Th us, a process analysis of the basis for 
an incorrect response, rather than simply tallying right and wrong answers, provides 
useful diagnostic information. Kaplan, Fein, Morris, and Delis (1991) describe the 
tendency of right hemisphere–lesioned patients to start on the right side when draw-
ing, copying fi gures, or putt ing together block designs and puzzles. 
 Common measures to assess ULN include clock drawing, line bisecting, and can-
cellation tasks. On clock drawing (see Chapter 15) in ULN, one generally observes 
that the patient leaves one half of the clock drawing absent of numbers or hands, thus 
demonstrating neglect to one side of space. Clock drawing is, however, best under-
stood as only a screening tool for the presence of ULN. Ishiai, Sugishita, Ichikawa, 
and Gono (1993) found that impairment in the clock drawing task did not parallel 
neglect severity as determined by results of a line-cancellation and line-bisection test. 
Th erefore, the authors cautioned against the use of the clock drawing test alone to 
diagnose neglect. With that said, neglect symptoms can be strikingly apparent from 
clock drawings. 
 Th e Line Bisection Test is another screening measure for unilateral neglect that 
requires the patient to cross through the center of a series of horizontally slanted lines. 
Variations of this test include judging the midline of a series of bisected lines as accu-
rate or inaccurate. In an analysis of 62 standardized and nonstandardized assessment 
tools to evaluate unilateral neglect, Menon and Korner-Bitensky (2004) reported 
that the Line Bisection Test evidenced strong psychometric properties in compari-
son to other paper-and-pencil tests. Cancellation tests are typically regarded as the 
most sensitive paper-and-pencil measure of neglect (Azouvi et al., 2002; Marsh & 
Kersel, 1993). 
 Th e starting point in the cancellation task can be looked at qualitatively as a func-
tion of how an individual with ULN goes about a task. Most healthy individuals typi-
cally begin at the upper left corner (Gauthier et al., 1989; Mark & Heilman, 1997) 
and proceed systematically in a horizontal, left -to-right, and top-to-bott om reading 
patt ern (Warren, Moore, & Vogtle, 2008), although many work in a top-to-bott om, 
left -to-right patt ern. In an evaluation of 70 patients with right hemisphere infarcts, of 
which 15 had visual neglect, and 44 healthy controls, the researchers found that 80% 
of the patients with neglect tended to start cancellation tests mainly from the right, 
while the vast majority of patients without neglect (80%) and healthy controls (95%) 
tended to start from the left (Nurmi, Kett unen, Laihosalo, Ruuskanen, Koivisto, & 
Jehkonen, 2010). Furthermore, based on the performance of the healthy controls and 
optimal cutoff points for correct classifi cation of patients, the researchers found that 
left -sided starting points more than 6 cm to the left of the midline in the line cancella-
tion task, 10 cm in the lett er cancellation task, and 11 cm in the star cancellation task 
can be interpreted as normal. Th e researchers concluded that starting any two of the 
58 Chapter 4 Moes et al.
cancellation tasks outside this guideline is indicative of pathological performance, and 
at least two cancellation tasks should be included in any batt ery designed to assess for 
the presence of neglect. 
 CONCLUSION 
 Identifi cation of arousal and/or att ention disorders in the course of the neuropsy-
chological assessment can be critical in identifying treatable and potentially revers-
ible conditions. It also ensures that cognitive defi cits that occur secondarily to 
disturbances in either arousal and/or att ention are correctly diagnosed and fosters 
the development of new conceptualizations of the mechanisms underlying various 
disorders. Recent advances in theory have led to the development of relatively new 
instruments (e.g., ANT and TEA or TEA-Ch) to assess these functions, while older 
tests (e.g., Weintraub and Mesulam cancellation tests) and procedures (e.g., use of 
fl ow diagrams to record starting point and search process) continue to prove their 
worth in capturing a wealth of observational process–related data. Focusing on care-
ful observation of how a patient goes about completing tests and understanding the 
basis for each behavior not only gives rise to new information (i.e., provides new grist 
for the theoretical mill) it also enhances diagnostic accuracy. In this way, proceeding 
from keen observation of behavior (as exemplifi ed in the work of Edith Kaplan) to 
quantifi cation of observation, and from there to formulation and testing of hypoth-
eses regarding underlying mechanisms (e.g., subtle neglect detected in patients with 
right hemisphere damage without overt neglect on other measures), neuropsychology 
continues to advance with the development of new tests and process-oriented scoring 
procedures and make meaningful contributions to neuroscience and patient care. 
 REFERENCES 
 Ali, S., Patel, M., Jabeen, S., Bailey, R. K., Patel, T., Shahid, M., . . . Arain, A. (2011). Insight into 
delirium. Innovations in Clinical Neuroscience , 8 (10), 25–34 . 
 Armengol, C. G. (2000). Developmental and cross-cultural issues in the assessment of att ention 
and executive functions. Revista Española de Neuropsicologia , 2 (3), 3–20 . 
 Aylward, G. P., Brager, P., & Harper, D. C. (2002). Relations between visual and auditory 
continuous performance tests in a clinical population: A descriptive study. Developmental 
Neuropsychology , 21 (3), 285–303 . 
 Azouvi, P., Samuel, C., Louis-Dreyfus, A., Bernati, T., Bartolomeo, P., Beis, J., . . . Rousseaux, M. 
(2002). Sensitivity of clinical and behavioural tests of spatial neglect aft er right hemisphere stroke. 
 Journal of Neurology, Neurosurgery & Psychiatry , 73 (2), 160–166 . doi:10.1136/jnnp.73.2.160 
 Baker, D. B., Taylor, C. J., & Leyva, C. (1995). Continuous performance tests: A comparison of 
modalities. Journal of Clinical Psychology , 51 (4), 548–551 . 
Process-Focused Assessment of Arousal and Att ention 59
 Berman, P., Hogan, D. B., & Fox, R. A. (1987). Th e atypical presentation of infection in old age. 
 Age and Ageing , 16 (4), 201–207 . 
 Bihrle, A. M., Bellugi, U., Delis, D., & Marks, S. (1989). Seeing either the forest or the trees: 
Dissociation in visuospatial processing. Brain and Cognition , 11 (1), 37–49 . 
 Bishop, C., Roehrs, T., Rosenthal, L., & Roth, T. (1997). Alerting eff ects of methylphenidate 
under basal and sleep-deprived conditions. Experimental and Clinical Psychopharmacology , 
 5 (4), 344–352 . doi:10.1037/1064-1297.5.4.344 
 Bohnen, N., Jolles, J., & Twijnstra, A. (1992). Modifi cation of the Stroop Color Word Test 
improves diff erentiation between patients with mild traumatic brain injury and matched 
controls. Th e Clinical Neuropsychologist , 6 , 178–184 . 
 Bruce, J. M., Bruce, A. S., & Arnett , P. A. (2010). Response variability is associated with self-re-
ported cognitive fatigue in multiple sclerosis. Neuropsychology , 24 (1), 77–83 . doi:10.1037/
a0015046 
 Cao, Q., Zang, Y., Zhu, C., Cao, X., Sun, L., Zhou, X., & Wang, Y. (2008). Alerting defi cits in 
children with att ention defi cit/hyperactivity disorder:event-related fMRI evidence. Brain 
Research , 1219 (2008), 159–168 . 
 Castellanos, F. X., Sonuga-Barke, E., Scheres, A., DiMartino, A., Hyde, C., & Walters, J. R. 
(2005). Varieties of att ention-defi cit/hyperactivity-related intra-individual variability. 
 Biological Psychiatry , 57 , 1416–1423 . 
 Cegalis, J. A., & Bowlin, J. (1991). Vigil: Soft ware for testing concentration and att ention, manual. 
 Nashua, NH : Forethought Ltd . Later sold by Psychological Corporation. 
 Center for the Study of Human Operator Performance. (2007). ANAM4: Soft ware user man-
ual . Norman, OK : Center for the Study of Human Operator Performance, University of 
Oklahoma . 
 Cernich, A. N., Brennana, D. M., Barker, L. M., & Bleiberg, J. (2007). Sources of error in comput-
erized neuropsychological assessment. Archives of Clinical Neuropsychology , 22S , S39–S48 . 
 Ç i ç ek, M., Deouell, L. Y., & Knight, R. T. (2009). Brain Activity During Landmark and Line 
Bisection Tasks. Frontiers in Human Neuroscience, 3 , 7 . doi: 10.3389/neuro.09.007.2009 
 Cicerone, K. D. (1997). Clinical sensitivity of four measures of att ention to mild traumatic brain 
injury. Th e Clinical Neuropsychologist . 11 (3), 266–272 . 
 Committ eri, G., Pitzalis, S., Galati, G., Patria, F., Pelle, G., Sabatini, U., . . . Pizzamiglio, L. (2007). 
 Neural bases of personal and extrapersonal neglect in humans. Brain , 130 (2), 431–441 . 
doi:10.1093/brain/awl265 
 Conant, L. L., Wilfong, A., Inglese, C., & Schwarte, A. (2010). Dysfunction of executive 
and related processes in childhood absence epilepsy. Epilepsy & Behavior , 18 , 414–423 . 
doi:10.1016j.yebeh.2010.05010 
 Conners, C. K.; MHS Staff . (Eds.) (2000). Conners’ continuous performance test II: Computer 
program for Windows technical guide and soft ware manual . North Tonawanda, NY : Multi-
Health Systems . 
 Corbett a, M. Patel, G., & Shulman, G. L. (2008). Th e reorienting system of the human 
brain: From environment to theory of mind. Neuron , 58 (3), 306–324 . doi: 10.1016/ 
j.neuron.2008.04.017 
 Coren, S. (1997). Sleep thieves: An eye-opening exploration into the science and mysteries of 
sleep. New York : Free Press, Simon and Schuster . 
 Coull, J. T. (1998). Neural correlates of att ention and arousal: Insights from electrophysiology, 
functional neuroimaging, and psychopharmacology. Progress in Neurobiology , 55 , 343–361 . 
60 Chapter 4 Moes et al.
 Crawford, J. R., Sommerville, J., & Robertson, I. H. (1997). Assessing the reliability and abnor-
mality of subtest diff erences on the Test of Everyday Att ention. British Journal of Clinical 
Psychology , 36 (4), 609–617 . 
 Delis, D. C., Kiefner, M. G., & Fridlund, A. J. (1988). Visuospatial dysfunction following unilat-
eral brain damage: Dissociations in hierarchical and hemispatial analysis. Journal of Clinical 
and Experimental Neuropsychology , 10 (4), 421–431 . 
 Dlugos, A. M., Hamidovic, A., Hodgkinson, C., Goldman, D., Palmer, A. A., & de Wit, H. (2010). 
 More aroused, less fatigued: Fatt y acid amide hydrolase gene polymorphisms infl uence acute 
response to amphetamine. Neuropsychopharmacology , 35 , 613–622 . doi:10.1038/npp.2009.166 
 Dockree, P. M., Kelly, S. P., Foxe, J. J., Reilly, R. B., & Robertson, I. H. (2007). Optimal sustained 
att ention is linked to the spectral content of background EEG activity: Greater ongoing tonic 
alpha (approximately 10 Hz) power supports successful phasic goal activation. European 
Journal of Neuroscience , 25 , 900–907 . 
 Duncan, C. C., & Mirsky, A. F. (2004). Th e Att ention Batt ery for Adults: A systematic approach 
to assessment. In G. Goldstein & S. Beers (2004). Comprehensive handbook of psychological 
assessment, Volume 1, Intellectual and neuropsychological assessment (pp. 263–276 ). Hoboken, 
NJ : John Wiley & Sons . 
 Duncan, C. C., Mirsky, A. F., Lovelace, C. T., & Th eodore, W. H. (2009). Assessment of the att en-
tion impairment in absence epilepsy: comparison of visual and auditory P300. International 
Journal of Psychophysiology , 73 (2), 118–122 . doi:10.1016/j.ijpsycho.2009.03.005 
 Fan, J., McCandliss, B. D., Sommer, T., Raz, A., & Posner, M. I. (2002). Testing the effi ciency 
and independence of att ention networks. Journal of Cognitive Neuroscience , 14 (3), 340–347 . 
 Fox, E., Russo, R., Bowles, R., & Dutt on, L. (2001). Do threatening stimuli draw or hold 
visual att ention in subclinical anxiety? Journal of Experimental Psychology: General , 130 (4), 
 681–700 . doi:10.1037/0096-3445.130.4.681 
 Gauthier, L., Dehaut, F., & Joanett e, Y. (1989). Th e Bells test, a quantitative and qualitative test 
for visual neglect. International Journal of Clinical Neuropsychology , 11 , 49–54 . 
 Geurts, H. M., Grasman, R. P., Verte, S., Oosterlaan, J., Roeyers, H., van Kammena, S. M., & 
Sergeant, J. A. (2008). Intra-individual variability in ADHD, autism spectrum disorders and 
Tourett e’s syndrome. Neuropsychologia , 46 (13), 3030–3041 . 
 Gitelman, D. R. (2003). Att ention and its disorders. British Medical Bulletin , 65 , 21–34 . 
 Glauser, T., Cnaan, A., Shinnar, S., Hirtz, D., Dlugos, D., Masur, D., . . . Adamson, P. (2010). 
 Ethosuximide, valproic acid, and lamotrigine in childhood absence epilepsy. Th e New 
England Journal of Medicine , 362 (9), 790–799 . 
 Gordon, M., & Mett elman, B. B. (1988). Th e assessment of att ention: I. Standardization and 
reliability of a behavior-based measure. Journal of Clinical Psychology , 44 , 682–690 . 
 Green, A. E., Munafo, M. R., DeYoung, C. G., Fossella, J. A., Fan, J., & Gray, J. R. (2008). Using 
genetic data in cognitive neuroscience: from growing pains to genuine insight. Nature 
Reviews Neuroscience , 9 , 710–720 . 
 Gronwall, D., & Sampson, H. (1974). Th e psychological eff ects of concussion . New Zealand : 
 Auckland University Press/Oxford University Press . 
 Halligan, P., Wilson, B., & Cockburn, J. (1990). A short screening test for visual neglect in stroke 
patients. International Disability Studies , 12 , 95–99 . 
 Hood, J., Baird, G., Rankin, P. M., & Isaacs, E. (2005). Immediate eff ects of methylpheni-
date on cognitive att ention skills of children with att ention-defi cit-hyperactivity disorder. 
 Developmental Medicine & Child Neurology , 47 (6), 408–414 . 
Process-Focused Assessment of Arousal and Att ention 61
 Inouye, S. K., Leo-Summers, L., Zhang, Y., Bogardus, S. T., Jr., Leslie, D. L., & Agostini, J. V. 
(2005). A chart-based method for identifi cation of delirium: Validation compared with 
interviewer ratings using the confusion assessment method. Journal of the American Geriatrics 
Society , 53 (2), 312–318 . 
 Inouye, S. K., van Dyck, C. H., Alessi, C. A., Balkin, S., Siegal, A. P., & Horwitz, R. I. (1990). 
 Clarifying confusion: Th e confusion assessment method. A new method for detection of 
delirium. Annals of Internal Medicine , 43 (12), 941–948 . 
 Ishiai, S., Sugishita, M., Ichikawa, T., & Gono, S. (1993). Clock-drawing test and unilateral spa-
tial neglect. Neurology , 43 (1), 106–110 . 
 Kaplan, E. (1988). A process approach to neuropsychological assessment. In T. Boll & B. K. 
Bryant (Eds.), Clinical neuropsychology and brain function: Research, measurement, and prac-
tice (pp. 129–167 ). Washington, D.C. : American Psychological Association . 
 Kaplan, E., Fein, D., Morris, R., & Delis, D. (1991). Th e WAIS-R as a neuropsychological instru-
ment . San Antonio, TX : Th e Psychological Corporation . 
 Korkman, M., Kirk, U., & Kemp, S. (2007). NEPSY second edition . San Antonio, TX : Pearson . 
 Kosinski, R. J. (2012). A literature review on reaction time. Available at htt p://biae.clemson.
edu/bpc/bp/lab/110/reaction.htm#Mean Times. Last accessed 27 March, 2013. 
 L à davas, E., Zeloni, G., Zaccara, G., & Gangemi, P. (1997). Eye movements and orienting of 
att entionin patients with visual neglect. Journal of Cognitive Neuroscience , 9 (1), 67–74 . 
doi:10.1162/jocn.1997.9.1.67 
 Langner, R., Steinborn, M. B., Chatt erjee, A., Sturm, W., & Wilmes, K. (2010). Mental fatigue 
and temporal preparation in simple reaction-time performance. Acta Psychology (Amst) , 
 133 (1), 64–72 . doi: 10.1016/j.actpsy.2009.10.001 
 Leark, R. A., Greenberg, L. M., Kindschi, C. L., Dupuy, T. R., & Hughes, S. J. (2008). TOVA test 
of variables of att ention professional manual . Los Alamitos, CA : TOVA . 
 Lezak, M. D., Howieson, D. B., Bigler, E. D., & Tranel, D. (2012). Neuropsychological Assessment, 
fi ft h edition . New York, NY : Oxford University Press . 
 Lim, J., & Dinges, D. (2010). A meta-analysis of the impact of short-term sleep deprivation on 
cognitive variables. Psychological Bulletin , 136 (3), 375–389 . doi:10.1037/a0018883 
 Lowery, D. P., Wesnes, K., Brewster, N., & Ballard, C. (2008). Quantifying the association 
between computerised measures of att ention and confusion assessment method defi ned 
delirium: A prospective study of older orthopaedic surgical patients, free of dementia. 
 International Journal of Geriatric Psychiatry , 23 (12), 1253–1260 . 
 Lowery, N., Ragland, J. D., Gur, R. C., Gur, R. E., & Moberg, P. J. (2004). Normative data 
for the symbol cancellation test in young healthy adults. Applied Neuropsychology , 11 (4), 
 216–214 . 
 Luh, K. E. (1995). Line bisection and perceptual asymmetries in normal individuals: 
What you see is not what you get. Neuropsychology , 9 (4), 435–448 . doi:10.1037/0894-
4105.9.4.435 
 Luria, A. R. (1973). Th e working brain: An introduction to neuropsychology . New York, NY : 
 Penguin Books . 
 Macleod, J. W., McConnell, M. M., Lawrence, M. A., Eskes, G., Klein, R. M., & Shore, D. I. 
(2010). Appraising the ANT: Psychometric and theoretical considerations of the Att ention 
Network Test. Neuropsychology , 24 (5), 637–651 . 
 MacLeod, S., Ferrie, C., & Zuberi, S. M. (2005). Symptoms of narcolepsy in children misinter-
preted as epilepsy. Epileptic Disorders , 7 (1), 13–17 . 
62 Chapter 4 Moes et al.
 Mahoney, C. R., Brunye, T. T., Giles, G., Lieberman, H. R., & Taylor, H. (2011). Caff eine-induced 
physiological arousal accentuates global processing biases. Pharmacology, Biochemistry and 
Behavior , 99 , 59–65 . 
 Manly, T., Anderson, V., Nimmo-Smith, I., Turner, A., Watson, P., & Robertson, I.H. (2001). Th e 
diff erential assessment of children’s att ention: the Test of Everyday Att ention for Children 
(TEA-Ch), normative sample and ADHD performance. Journal of Child Psychology and 
Psychiatry , 42 (8), 1065–1081 . 
 Manly, T., Robertson, I. H., Anderson, V., & Nimmo-Smith, I. (1998). Th e Test of Everyday 
Att ention for Children (TEA-Ch). London, UK : Harcourt Assessment . 
 Mark, V.W., & Heilman, K. M. (1997). Diagonal neglect on cancellation. Neuropsychologia , 35 , 
 1425–1436 . 
 Marsh, N. V., & Kersel, D. A. (1993). Screening tests for visual neglect following stroke. 
 Neuropsychological Rehabilitation , 3 (3), 245–257 . doi:10.1080/09602019308401439 
 Martella, D., Casagrande, M., & Lupi áñ ez, J. (2011). Alerting, orienting and executive con-
trol: Th e eff ects of sleep deprivation on att entional networks. Experimental Brain Research , 
 210 (1), 81–89 . 
 McNair, D. M., Lorr, M., & Droppleman, L. F. (1981). EDITS manual for the profi le of mood 
states . San Diego, CA : Educational and Industrial Service . 
 Menon, A., & Korner-Bitensky, N. (2004). Evaluating unilateral spatial neglect post stroke: 
Working your way through the maze of assessment choices. Topics in Stroke Rehabilitation , 
 11 (3), 41–66 . doi:10.1310/KQWL-3HQL-4KNM-5F4U 
 Mesulam, M. M. (2000). Att entional networks, confusional states, and neglect syndromes. In 
M. M. Mesulam (Ed.), Principles of behavioral and cognitive neurology (2nd ed., pp. 174–256 ). 
 New York, NY : Oxford University Press . 
 Newhouse, P. A., Pott er, A., & Singh, A. (2004). Eff ects of nicotinic stimulation on cognitive 
performance. Current Opinion in Pharmacology , 4 , 36–46 . 
 National Sleep Foundation. Children and sleep. Retrieved from htt p://www.sleepfoundation.
org/article/sleep-topics/children-and-sleepd sleep 
 Nurmi, L., Kett unen, J., Laihosalo, M., Ruuskanen, E., Koivisto, A., & Jehkonen, M. (2010). 
 Right hemisphere infarct patients and healthy controls: Evaluation of starting points in 
cancellation tasks. Journal of the International Neuropsychological Society , 16 (5), 902–909 . 
doi:10.1017/S1355617710000792 
 O’Connell, R. G., Bellgrove, M. A., Dockree, P. M., Lau, A., Fitzgerald, M., & Robertson, I. H. 
(2008). Self-alert training: Volitional modulation of autonomic arousal improves sustained 
att ention. Neuropsychologia , 46 (5), 137–190 . 
 Ophir, E., Nass, C., & Wagner, A. (2009). Cognitive control in media multitaskers. 
 Proceedings of the National Academy of Sciences , 106 (37), 15583–15587 . doi:10.1073/
pnas.0903620106 
 Patel, R. P., Gambrell, M., Speroff , T., Scott , T. A., Pun, B. T., Okahashi, J., . . . Ely, E. W. (2009). 
 Delirium and sedation in the intensive care unit: Survey of behaviors and att itudes of 1384 
healthcare professionals. Critical Care Medicine , 37 (3), 825–832 . 
 Petersen, S. E., & Posner, M. I. (2012). The attention system of the human brain: 20 Years 
after. Annual Review of Neuroscience . 35 , 73–39 . doi:10.1146/annurev-neuro-062111-
15-525 
Process-Focused Assessment of Arousal and Att ention 63
 Posner, M. I., & Petersen, S. E. (1990). Th e att ention system of the human brain. Annual Review 
of Neuroscience , 13 , 25–42 . 
 Riccio, C. A., Reynolds, C. R., & Lowe, P. (2001). Clinical applications of continuous performance 
tests; measuring att ention and impulsive responding in children and adults . New York, NY : John 
Wiley & Sons . 
 Robertson, I. H., Ward, T., Ridgeway, V., & Nimmo-Smith, I. (1994). Th e test of everyday att en-
tion . London, UK : Harcourt Assessment . 
 Rosvold, H. E., Mirsky, A. F., Sarason, I., Bransome, E. D., & Beck, L. H. (1956). A continuous 
performance test for brain damage. Journal of Consulting Psychology , 20 (5), 343–350 . 
 Schomer, D. L., O’Connor, M., Spiers, P., Seeck, M., Mesulam, M., & Baer, D. (2000). 
 Temporolimbic epilepsy and behavior. In M. Mesulam (Ed.), Principles of behavioral and cog-
nitive neurology (2nd ed., pp. 373–405 ). New York, NY : Oxford University Press . 
 Schretlen, D., Bobholz, J. H., & Brandt, J. (1996). Development and psychometric prop-
erties of the Brief Test of Att ention. Th e Clinical Neuropsychologist , 10 (1), 80–89 . 
doi:10.1080/13854049608406666 
 Sed ó , M. A., & DeCristoforo, L. (2001). All-language verbal tests free from linguistic barriers. 
 Revista Española de Neuropsicologia , 3 (3), 68–82 . 
 Sed ó , M. A. (2007). FDT – Test de los Cinco Digitos . Madrid, Spain : TEA Ediciones . 
 Sed ó , M. A. (2004a). Test de las cinco cifras: una alternative multilingue y no lectora al test de 
Stroop. Revista Española de Neurologia , 38 ( 9), 824–828 . 
 Sed ó , M. (2004b). Th e “Five Digit Test”: A color-free non-reading alternative to the Stroop. INS 
NET , 13 , 6–7. 
 Semrud-Clikeman, M., & Wical, B. (1999). Components of att ention in children with complex 
partial seizures with and without ADHD. Epilepsia , 40 (2), 211–215 . 
 Sturm, W., & Willmes, K. (2001). On the functional neuroanatomy of intrinsic and phasic alert-
ness. NeuroImage , 14 , S76–S84 . doi:10.1006/nimg.2001.0839 
 Tales, A., Muir, J. L., Bayer, A., Jones, R., & Snowden, R. J. (2002). Phasic visual alertness in 
Alzheimer’s disease and ageing. NeuroReport, Cognitive Neuroscience and Neuropsychology , 
 13 (18), 2557–2560 . 
 Vossel, S., Eschenbeck, P., Weiss, P. H., Weidner, R., Saliger, J., Karbe, H., & Fink, G. R. 
(2011). Visual