Cogniie, Creier, Comportament / Cognition, Brain, Behavior

Copyright 2007 Romanian Association for Cognitive Science. All rights reserved.
ISSN: 1224-8398
Volume XI, No. 3 (September), 585 - 608

DIMENSIONS OF ATTENTION AND EXECUTIVE

FUNCTIONING IN 5-TO 12-YEARS-OLD CHILDREN:
NEUROPSYCHOLOGICAL ASSESSMENT WITH THE
NEPSY BATTERY
Laura VISU-PETRA*, Oana BENGA, Mircea MICLEA
Department of Psychology, Babe-Bolyai University, Cluj-Napoca, Romania

ABSTRACT
EF represents an umbrella-type concept for the complex set of cognitive processes
that underlies the coordination of goal-directed responses to novel or complex
situations. Developmental studies using standard neuropsychological tasks have
shown that EF has a protracted developmental course, beginning in early childhood
and continuing into adolescence. Our study aims to investigate the developmental
sequence of attention and executive functions using normative data from a
subsample (N = 485) of 5-to-12-years-old children evaluated during the
standardization process of NEPSY: A developmental neuropsychological
assessment (Korkman, Kirk, & Kemp, 1998) on the Romanian population. Eight
measures (Tower, Auditory Attention, Auditory Response Set, Visual Attention,
Verbal Fluency, Design Fluency, Statue, Knock and Tap) were selected for the
analysis, based on a rigorous task analysis process. The results suggest a
differential maturational timetable, with basic inhibitory responses and visual
search skills maturing early on, followed by response planning, focused attention,
and finally, by fluency measures. The measures clustered into two distinct factors;
based on their commonalities, we named them 1) Task-set selection (Tower, Verbal
and Design Fluency, Auditory Attention and Response Set) and 2) Inhibition (Knock
and Tap, Statue, Auditory Attention and Response Set). Three possible explanatory
frameworks are provided for this factorial structure: a linguistic account, a latent
variable approach and a maturational perspective.

KEYWORDS: executive functions, attention, NEPSY, exploratory factor

analysis.

Corresponding author:
E-mail: laurapetra@psychology.ro

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INTRODUCTION
Welsh, Friedman and Spieker (2005) consider executive functioning (EF)
research a young, active and evolving area of scientific investigation that has not
yet settled on a definition of executive function. As Hughes and Graham (2002)
point out, we are dealing with an umbrella-type concept for the complex set of
cognitive processes that underlie flexible, goal-directed responses to novel or
difficult situations. In our research we will prefer to use the term executive
functioning (rather than executive function/s), not because it is more neutral and
does not require an explicit option between the unitary and the multifaceted
perspective upon EF, but because it reveals its process-oriented nature (Lehto,
Juujrvi, Kooistra, & Pulkkinen, 2003), this representing, in our opinion, the best
way to approach the controversial construct of EF. We consider, along with Welsh
et al. (2005), that ecological problemsolving requires a range of higher-order
cognitive processes that are inextricably linked, this being the very essence of EF:
it is precisely the coordination of multiple skills that makes executive function an
unique cognitive domain.
The context that generated the construct of EF is that of traditional
neuropsychological research. As a consequence of frontal cortical damage, a whole
constellation of cognitive skills appeared to be compromised; however, problems
associated with frontal damage were supramodal, cutting across classical
cognitive, sensory, and motor distinctions (Lezak, 1995). Several case studies of
individuals who had suffered focal frontal damage portray them as easily distracted
by irrelevant stimuli, unable to flexibly switch mental sets, failing to initiate
appropriate activity, lacking purposeful behavior based on anticipation, planning
and monitoring (Shallice, 1982; Luria, 1966; Stuss & Benson, 1984; Eslinger,
1996; Espy & Kaufman, 2002). It was documented that damage to the frontal lobes
did not impair attention, memory or language, per se, but rather the ability to
marshall all of these cognitive skills, as well as others, in the pursuit of a future
goal (Welsh et al., 2005).
General developmental trends in EF
Developmental studies using standard neuropsychological tasks have
shown that EF has a protracted developmental course, beginning in early childhood
and continuing into adolescence. In the literature, two main perspectives have been
proposed for the analysis of developmental trends in EF (Jarman, Vavrik, &
Walton, 1995). Surprisingly, the first one also chronologically - discards a true
developmental trajectory and postulates EF maturation through a series of stages,
beginning in late childhood and early adolescence (Becker, Isaac, & Hynd, 1987).
The frontal lobes were not thought to play a discernible role during the early years
of child development, culminating with the extreme position that true executive
processing in the frontal lobes was not present to any significant degree until the
onset of adolescence (Golden, 1981). Milder versions agree on a transitional period
during the 4th and 5th year, up to the 7th year, during which language exerts a

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prominent influence over controlled behavior (Luria, 1973; Stuss & Benson, 1986;
Kaczmarek, 1987).
The second approach is based on a continuity model of development
(Jarman, Vavrik, & Walton, 1995). According to this view, the functions of the
frontal lobes develop constantly throughout childhood, over a broad age span
(Case, 1992; Thatcher, 1991). There has been some early intuition that, at least in
some rudimentary form, there is evidence for EF in very early age (Welsh &
Pennington, 1988; Bruner, 1973; Haith, Hazan, & Goodman, 1988; Posner &
Rothbart, 1991); this intuition paralleled the proofs of earlier than previously
considered PFC functioning (Rakic, Bourgeois, Zecevic, Eckenhoff, & GoldmanRakic, 1986). Welsh, Pennington and Groisser (1991) make an important point
concerning the very criteria for measuring frontal lobe functional maturation. If
one is to consider EF maturity by reaching adult levels of performance on
traditional adult tasks, than it is most likely that only in adolescence this level
would be approximated. As a consequence of utilizing more adequate
measurement methods, the initial two-stage perspective proposed by Luria was
replaced by a multi-stage view (Welsh et al., 1991). Welsh et al. (1991) suggested
a three-staged skill development trajectory, with peaks at the age of 6, at the age of
10, and during adolescence; the researchers emphasize the 5 to 7 year shift
(White, 1970) as being the most important transition in EF development. However,
current perspectives emphasize essential progress as being made much earlier, this
discovery being a consequence of utilizing more age-appropriate tasks to measure
early EF development (Welsh et al., 2005; Gioia & Isquith, 2004). The progress is
already clear from 3 to 4 years of age, with a further developmental trend in the
ability to suppress information and actions over the ages 4 to 12, both in terms of
reaction time and accuracy (Benga & Petra, 2005).
An integrative perspective from the point of view of the second approach
is put forward by Welsh (2001), trying to integrate several findings on
developmental trends in EF. The author proposes three waves, or cycles: Cycle I,
from 18 months to 5 years of age is characterized by emerging towards proficient
working memory, inhibition, and simple flexibility, revealed by mostly motor
tasks; Cycle II, 5 to 10 years of age, extremely dynamic, characterized by dramatic
improvements in performance at tasks requiring planning, working memory,
inhibition and self-monitoring skills; finally, Cycle III (10 to 14 years and beyond)
is characterized by greater integration of processes and adult levels of performance.
The theoretical framework that we subscribe to is the continuity model of EF
development; in this paper we focus upon the critical changes that unfold during
the 5-12 years interval, approximating the second Cycle of EF development as
proposed by Welsh (2001). However, even within this cycle distinct EF
components develop at differential rates, as will be nuanced in the interpretation of
our results.

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EF differentiation during development

The source of validation for the existence of a distinct cognitive domain,
termed EF, comes consistently from adapting adult neuropsychological models and
is less extensively supported by statistical analyses from standardized
developmental neuropsychological batteries. Regarding the fractionated nature of
the EF domain itself, relatively more developmental data is available. The general
conclusion is that there are differential rates at which distinct executive functions
develop (Diamond, 2002; Welsh, 2002). Although there is a great variation in the
names given to the factors underlying EF in children, there is still convergence on
them including processes such as inhibition, fluency, planning, working memory
(Anderson, 2002). Molar analyses of the executive functions acknowledge the
distinct contribution of two basic components working memory and inhibition
(see Cohen & Servan-Schreiber, 1992; Kimberg & Farah, 1993). In their
normative-developmental study of EF, Welsh, Pennington and Groisser (1991)
reveal a three-factor structure: a Fluid & Speeded Response factor, a Hypothesis
Testing & Impulse Control factor, and a Planning factor.
An adult study of Miyake et al. (2000) reveals a distinct dimension beyond
inhibition and working memory: shifting or flexibility. Hughes (1998) also
obtained a similar three-factor structure, comprising Attentional Flexibility,
Inhibitory Control and Working Memory. This was also supported by findings
from an earlier extensive study (Pennington, 1997), that revealed three factors:
Motor Inhibition, Set Shifting (Cognitive Flexibility) and Verbal Working
Memory.
As they rely on task associations, and not necessarily on process association,
these factors should not be confounded with true EF subcomponents; yet this
approach represents an empirical starting point in generating hypotheses about EF
processes that can be experimentally tested (Zelazo & Mueller, 2002). More
exploratory work is still needed in order to clarify the factorial structure of EF
during the 5-12 years interval: the development of EF is a dynamic process and
specific links between EF subcomponents could be identified at different ages
along this interval.
The Attention / Executive Functions core domain in the NEPSY battery
The NEPSY test battery (Korkman, Kirk, & Kemp, 1998) was developed
based on the flexible model and diagnostic principles of Luria (Luria, 1973;
Korkman, 1999). There are five domains within which the tests have been
construed: Attention/Executive Functions, Language, Visual-Spatial Processing,
Sensoriomotor Functioning and Memory and Learning. According to Lurian
assessment principles, a cognitive function can be impaired in one functional
domain with the deficit affecting performance in other domains as well; the
diagnostic task is to identify the primary deficits in one domain that lead to
secondary deficits in another domain (Korkman, 1999). The tasks that comprise the
Attention / Executive functions domain were selected to tap crucial elements in the
assessment of this domain: selective and sustained attention (Auditory Attention;
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Visual Attention), response set (Auditory Response Set), nonverbal problem

solving (Tower), figural fluency (Design Fluency), inhibition, monitoring and selfregulation (Knock and Tap, Statue) (Korkman et al., 1998). We added to our
analysis the Verbal fluency task from the Language domain; the justification will
be presented in the following task analysis section.
Task analysis
As the NEPSY tasks designed to measure EF mostly rely on classical adult
measures (at least in their general design) that have been adapted for use with
children, we can find evidence for their interrelations and even attempts at
determining their biological underpinnings in the literature. Of course, we prefer to
present developmental data; only if evidence is too scarce will we refer to adult
research, as direct analogies especially in this domain could be misleading. In our
task analysis, we will only refer to neurobiological and cognitive mechanisms and
to developmental trends, the procedure details for each subtest being presented in
the Method section.
The Tower of London (Shallice, 1982), a version of the Tower of Hanoi
test, is a test that is often used to probe the integrity of prefrontal cortex, patients
with frontal lobe damage showing difficulties in solving this task (Anzai & Simon,
1979). Because the success of this task depends on a predetermined set of correctly
executed responses, it has been considered primarily a measure of response
planning. However, this complex task requires multiple cognitive and motor
processes: mainly response inhibition and working memory (Asato, Sweeney, &
Luna, 2006) but also attention, instruction comprehension, imitation of visualspatial models and motor skills (Stinnett, Oehler-Stinnett, Fuqua, & Palmer, 2002).
A study with children aged 7 to 15 (Levin et al., 1991) supported the idea of a
separable planning component and the sensitivity of TOL to developmental
changes; however it has been suggested that TOL might not measure the same
functions in children and in adults (Baker, Segalowitz, & Ferlisi, 2001, as cited in
Baron, 2004); additionally, it seems that there are some particular aspects in the
NEPSY Tower standardized scores that make it less sensitive to the developmental
aspects that it measures (Gioia, Isquith, Hoffhines, & Guy, 1999); thus we decide
to use the raw scores in our analysis. Several studies indicated significant
development of TOL performance through adolescence (De Luca et al., 2003;
Luciana & Nelson, 1998), although the underlying mechanisms of this
development are still unclear.
The two auditory attention subtests have distinct enough demands to
justify a separate analysis. The first part, auditory attention, is a continuous
performance test (CPT) that measures the childs ability to attend selectively to
simple auditory linguistic stimuli during a monotonous task. The second part, the
auditory response set, requires the child to maintain a more complex cognitive set
while sustaining auditory attention; it assesses the ability to shift set and to regulate
a response according to matching and contrasting auditory stimuli (Klenberg.,
Korkman, & Lahti Nuuttila, 2001). Specific rules and task procedure precludes a
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direct comparison with other neuropsychological measures; yet the data from the
Finnish sample reveals a later maturing course, with children reaching the 12-yearold level only at 10 years.
Visual search tests are usually paper-and-pencil cancellation tests used to
determine visual attention, often by calculation of the number of omission and
commission errors in each hemispace (Baron, 2004). In the neuropsychological
literature, it has been proven to be sensitive to frontal lesions (Teuber, Battersby, &
Bender, 1960). The NEPSY subtest is a classic visual search task requiring
selective attention deployment and a degree of inhibition in resisting distractor
information. It requires attentional control in the continual selective processing of
differentially relevant stimuli features (Espy & Bull, 2005), and it has been shown
to mature quite early in development, being indistinguishable from adult
performance as early as the age of 6 (Welsh et al., 1991).
Verbal fluency tests are often mentioned in the neuropsychological
literature as measures of cognitive functions after brain injury; neuroimaging
studies have identified anterior, left prefrontal regions (Elfgren & Risberg, 1998),
supplementary motor cortex, anterior cingulate cortex (ACC), the precuneus and
cerebellum (Fu et al., 2006; Ravnkilde, Videbech, Rosenberg, Gjedde, & Gade,
2002) as being involved during this task, with strong similarities between child and
adult patterns of activation (Gaillard et al., 2000). There are two common forms of
verbal fluency tests: letter (phonemic) fluency, testing the ability to generate words
in response to a letter cue, and category (semantic) fluency, which tests the ability
to generate words in response to a category cue (e.g. animals). The test involves
a generative process based on a linguistic and an ideational component, followed
continuously by orthographic/semantic validation, sustained attention, error
monitoring, response selection, and working memory processes (Friedman et al.,
1998). The ability to form semantic clusters appears to follow a developmental
trajectory from early childhood (children as young as 6 already showed clustering)
to adult maturation (Bjorklund & Douglas, 1997). The second component,
switching/ shifting between the clusters (Troyer, Moscovitch, & Winocur, 1997)
relies more heavily on EFs such as strategic search and set shifting, and shows a
more protracted developmental period, not reaching maturity until adolescence.
Design fluency tests are considered analogous to verbal fluency tests and
potential measures of right frontal cerebral function (Lee et al., 1997). However,
the classical neuropsychological distinction between left frontal mediation of
verbal fluency and right frontal mediation of design fluency proved less clear,
more recent adult studies pointing to contributions from both right and left frontal
regions (Glosser & Goodglass, 1990; Butler, Rorsman, Hill, & Tuma, 1993;
Elfgren & Risberg, 1998). Design fluency involves EF abilities such as shifting,
self-regulating, self-monitoring (Baron, 2004). Design fluency also differs from
verbal fluency tests in the fact that verbal fluency tests rely heavily on strategic
generation of already stored words, therefore relating to long-term memory, while
the designs that are generated are not previously stored in memory. Normative
studies have found that the number of generated figures increased with age, peaked
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between ages 16 and 24, remained constant between 25 and 55, and than declined
(Baron, 2004).
The Statue subtest is a simple measure of response suppression, requiring
a motor response (motor persistence). Conflict is introduced through the distractors
and stimulus type is non-verbal (Espy & Bull, 2005). The Knock and Tap NEPSY
subtest is a classical Lurian GoNoGo test. It is a nonverbal conflict task that
measures self-regulation and inhibition of immediate impulses evoked by visual
stimuli that conflict with verbal directions (Klenberg et al., 2001). The first part
relates to the need to inhibit motor response in a single cognitive set, while the
second part requires the subject to break the well-routinized set, inhibit the desire
to respond to the previous set, and to shift to a new one. Functional neuroimaging
studies link frontal systems function to this task (Kawashima et al., 1996),
especially to the orbitofrontal cortex (Casey et al., 1997). Data suggests that in the
case of response suppression tasks (here we can include the Statue subtest also)
inhibition occurs at a primary, non-mnemonic level, maturing very early in life, as
early as 6 years (Diamond, 1991; Espy & Bull, 2005; Klenberg et al., 2001).
The aims and research questions of the present study
Although EF research represents a hot topic in nowadays developmental
(neuro)psychology, there is little consensus regarding the status of EF among other
cognitive functions, the EF subcomponents and their maturational timetable. The
use of different research paradigms, of various test versions and task demands is
making the establishment of normative data particularly difficult. The current study
aimed to provide further knowledge regarding the standardized assessment of
attention and EF development in a large sample of 5-to-12-year olds. Due to the
abovementioned inconsistencies, even if few similar attempts have been
documented in the literature (Klenberg et al., 2001), the study is essentially
exploratory. The main aims are to reveal the interrelations between different EF
tests and to outline the developmental pathways of the postulated underlying EF
processes (after a rigorous task analysis), and the clustering of these abilities for
the target age range, using exploratory factor analysis. Secondary aims were to test
for gender differences and to reveal the similarities and discrepancies with
previous normative data on the same battery from the Finnish (Klenberg et al.,
2001) and American (Korkman et al., 1998) samples.
METHOD
Participants
The analysis has been performed on a subsample from the data collected in
the ongoing research project of adapting NEPSY: A Developmental
Neuropsychological Assessment for the Romanian population. The project began
in 2004 after a formal agreement between the official copyright-holder: The
Psychological Corporation, and the local publisher, Cognitrom. A total of 485
children (234 girls and 251 boys), aged 5-12 years, with no documented history of
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neurodevelopmental disorders have been selected for the present the study. The
participants were divided into 8 age groups: 5-year-olds (N = 53; 22 girls), 6-yearolds (N = 55; 22 girls), 7-year-olds (N = 63; 35 girls), 8-year-olds (N = 73; 31
girls), 9-year-olds (N = 66; 33 girls), 10-year-olds (N = 72; 30 girls), 11-year-olds
(N = 77; 40 girls), 12-year-olds (N = 26; 16 girls). The sample is highly
representative for the Romanian population, comprising subjects from 23 counties,
both from urban and from rural regions.
EF Measures
Although the original Attention/Executive Functions Domain only
contained six NEPSY subtests (Tower, Auditory Attention and Response Set,
Visual Attention, Design Fluency, Statue, Knock and Tap), based on the literature
describing EF subcomponents and their measurement (see the Introduction) and on
a subsequent study by Klenberg et al. (2001), we decided to add to the analysis the
Verbal Fluency subtest (from the Language domain). The description of the tasks,
of the coding and scoring procedure is briefly provided next:
Tower
This subtest is an adaptation of Shallices (1982) Tower of London test.
The child moves three colored balls to target positions on three pegs in a prescribed
number of moves (1-7). There is a time limit (30-60 sec) and also complex rules to
which the child must adhere. The score is the number of correctly achieved target
positions, within the time limit (maximum 20 points).
Auditory Attention and Response Set (AARS)
The AARS is a continuous performance test that includes two distinct
parts. In both conditions, after the general instruction and some practice trials, the
child hears a recorded sequence of items and has to perform (or refrain from
performing) a certain motor response. Part A (AARS-A), the auditory attention
condition, the child listens to a list of words presented at 1-second intervals; he/she
has to react only to the word red by picking up a red square from the table and by
placing it into a nearby box. In Part B (AARS-B), the response set condition, the
child is asked to shift between target and response categories and to select a yellow
square when the word red was heard and vice-versa, and to select a blue cube
when the word blue was heard. For each correct, immediate selection, 2 points is
scored. For a correct, but delayed response, 1 point is given. Finally, responses to
non-targets receive 1 minus point. For the total 30 target words of AARS-A, a
maximum score of 60 points can be obtained; for AARS-B the maximum score is
72 points.
Visual Attention
In this test, the child is instructed to select only the items that match the
target stimuli on the page containing both targets and distractors. The number of
targets, both on the Cats subtest (max. 20) and on the Faces subtest (max. 20) is
scored, with a maximum of 40 points to be earned.

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Statue
In this test, the child is required to stand still in a position as a statue
holding a flag (eyes closed, no body movements or vocalizations) over a 75-second
interval. At pre-set intervals distractors are introduced (the examiner coughing,
dropping a pen, etc.) For each 5-sec interval, the child is awarded 2 points for lack
of inappropriate responses, 1 point for one inappropriate response (body
movement, vocalization), and 0 points for more than one inappropriate response.
The maximum score is 30.
Knock and Tap
In this test, the child is initially required to knock on the table when the
examiner taps, and to tap when the examiner knocks. On the second part, the child
has to tap with the side of the fist when the examiner knocks with the knuckles,
and vice-versa, and not to respond at all when the examiner taps with the palm.
The score is the total number of correct responses (maximum 30 points).
Verbal Fluency
For a 1-minute interval, children are asked to generate words belonging to
either two semantic categories (animals and food/drinks) or two phonemic
categories (words beginning with an S or an F). The sum of correct distinct
words across the four categories constitutes the test score.
Design Fluency
This visuomotor fluency subtest assesses the childs ability to generate
novel designs on structured and on unstructured arrays of dots as quickly as
possible. The score is the total number of designs produced by the child.
Procedure
The tests were administered by licensed psychologists who had already
undergone a NEPSY training course. When evaluations were conducted in a
childs home, efforts were made to ensure a well-lit, well-ventilated, quiet room
with minimal distractions. However, most of the evaluations were conducted
individually in educational centers (kindergartens and schools) in a quiet, separate
room. The process of administering the whole NEPSY battery lasted about two
hours for the 5-12 year-olds and one hour for the 3-4 year-olds; when it was
deemed necessary, the session was divided in two (in two subsequent days), so as
to ensure an optimum of motivational and attentional implication from the child.

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RESULTS

Table 1
Descriptive Statistics and Age Groups Differences (One-Way ANOVAs) for EF Measures

Descriptive results and developmental trends

The means and standard deviations, as well as age group differences
(compared with one-way ANOVAs) of the EF measures for each age group are
given in Table 1.

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To investigate the effects and interactions of age and sex, a two-way analysis
of variance (ANOVA; 8 x 2) was performed for each subtest. In this analysis, the
effects of age group were proven significant (p < .05) for all the subtests except the
Visual Attention subtest, F(7, 254) = 1.35, p = .22. The gender effect was only
visible in the AARS-A, F(1, 254) = 4.44, p < .04, with girls outperforming boys.
As for the interaction effects, there were no significant results at a p < .05
significance level.
Next, we were interested in developmental trends for each task. We
examined with post-hoc comparisons (Tukeys HSD test) which was the age level
the subtest performance no longer improved significantly. In line with the
Klenberg et al. (2001) similar study on the Finnish sample, we decided that when
the performance of a specific age group in a specific skill did not differ
significantly from that of any older groups, the development in that skill could be
considered to have reached a 12-year-old level (the oldest age-group performance
as measured by the NEPSY battery; so conventionally chosen as the highest level
that can be attained in the NEPSY subtests).
This level was first reached in the Tower subtest at the age of 7 (compared to
the age of 8 in the Finnish sample). Both in the Knock and Tap and in the Statue
subtests, this level was reached at the age of 6 (similar to the Finnish sample). In
the Visual Attention subtest this level was reached already at age 6, much earlier
than the results in the Finnish sample, where 12-year-old performance was only
reached at age 10. In the Verbal Fluency subtest, the level of 12-year-olds was
reached at the age of 10, while Design Fluency reached it at the age of 11 (both
identical to the Finnish sample). Finally, performance at AARS-A / AARS-B
reached the level of 12-year-olds at the age of 9 / 10 years, similar to the Finnish
sample.
Correlations among EF subtests
Taking into account the fact that age correlated significantly with each EF
measure, partial correlations were conducted to determine the interrelatedness of
different EF measures controlling for the influence of the age factor (Table 2).
With few exceptions, all EF measures appear to intercorrelate, although the
magnitude of the correlations varies from low to moderate. Performance at the
Statue subtest is not associated with performance at the Tower subtest, or with any
fluency measure (Design Fluency or Verbal Fluency). Finally, performance at the
Knock and Tap subtest is also not significantly associated with both fluency
measures.
The strongest associations are between the Tower and the AARS-A, and
the Tower and the Verbal Fluency measure; as well as between both AARS-A and
AARS-B and Verbal Fluency. The parts of the same test (AARS-A and AARS-B),
as well as the two measures of fluency (Design and Verbal) have high
intercorrelations, but are clearly distinct enough to suggest separate analysis. The
fact that our EF measures correlated even when controlling for age provided the
basis for our analysis of their groupings with the help of factor analysis techniques.
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Table 2
Partial Correlations between All EF Measures, Controlling for Age
Tower
Tower
AARS-A
AARS-B
Visual
Attention
Statue
Design Fl.

AARS-

AARS-

Visual

Attention
.32**

Statue
-.02

Design

Verbal

Knock

Fluency

Fluency

and Tap

0.27**

0.41**

0.16**

.42**

.29**

0.67**

0.27**

0.20**

0.19**

0.35**

0.20**

0.27**

0.21**

0.26**

0.34**

0.27**

0.20**
-

0.10*
0.05

0.26**
0.05

0.22**
0.23**

0.32**

0.04

0.05

Verbal Fl.

Knock
and Tap
Note. AARS-A = Auditory Attention and Response Set Part A; AARS-B = Auditory Attention and
Response Set Part B; *p < .05, **p < .001.

Exploratory factor analysis

In order to identify the dimensions of EF as measured by the NEPSY tasks,
the total score from each task was entered into the exploratory factor analysis
(EFA). A preliminary analysis with the Kaiser-Meyer-Olkin (KMO) method
regarding the adequacy of performing EFA on the present sample revealed an
adequate value of .76 (KMO varies between 0 and 1, with values between 0.5 and
0.7 considered satisfactory, above 0.7 adequate, and above 0.8 excellent, (Field,
2000, as cited in Sava, 2004). The analysis (Principal Axis Factoring with direct
oblimin rotation) produced a two factor-solution, when applying the criterion of
retaining factors with eigenvalues greater than 1. The solution accounted for 53.84
% of the total variance. The same two-factor solution appeared the best when
examining Cattells scree plot.
When a loading of .30 was used as a criterion, five tests loaded on the first
factor, and four tests (two cross-loading) loaded on the second factor (see Table 3
for factor loadings). Therefore we examined the theoretical sensibility of subtests
that loaded together within the factor solution. The first factor included measures
with a strong verbal component (Verbal Fluency, Tower complex instructions,
AARS-A, AARS-B), but also with a visual component (Design Fluency, Tower).
The main variables grouped in this factor comprise 1) fluency (both verbal and
design), an ability to generate clusters according to a rule (semantic or phonemic
resemblance) and to switch between these clusters; and 2) flexible generation of
plans in order to reach a determined goal (Tower) (we could add an attentional
deployment component, but the AARS A and especially AARS-B loaded weaker
on this factor and much stronger on the second one). Considering the abstract,
high-order, self-generated abilities involved in both planning and fluency tasks, the

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597

first factor was named Task-set selection (after the description of task-set selection
offered by Zelazo, Carlson and Kesek, 2007). The second factor clearly included
measures of inhibition, with a focus on response suppression (AARS-B and
secondly AARS-A, Statue, Knock and Tap). Based on this grouping, the second
factor was named Inhibition. A subtest (Visual Attention) did not load significantly
on any of the two factors; however, looking at the Structure matrix from the EFA it
correlates more (.40) with the second, Inhibition factor.
Table 3
Factor Loadings for EF Measures: Two-Factor Solution
Factor
1

Tower

.604

.012

AARS-A

.441

.466

AARS-B

.371

.537

Visual Attention

.249

.289

-.086

.488

Design Fluency

.560

-.030

Verbal Fluency

.772

-.041

Knock and Tap

.002

.456

Statue

Note: Extraction Method: Principal Axis Factoring with direct oblimin rotation. Bold coefficients
indicate that the subtest loaded on the factor.

DISCUSSION
This study was undertaken in order to reveal the structure and development
of EF in 5- to 12-year-olds typically developing Romanian children. The
performance that we observed on various EF measures was relatively similar to the
one we can approximate from the NEPSY American (Korkman et al., 1998) and
Finnish (Korkman et al., 1997, as cited in Klenberg et al., 2001) standardization
sample, for the same age groups. Table 4 presents informative descriptive data for
comparison with reported performance in these samples; we selected only the

tests and indexes of performance used in all three samples.

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L. Visu-Petra, O. Benga, M. Miclea

Table 4
Mean (Standard Deviation) Performance across Romanian, Finnish, and American
Samples
NEPSY test
Romanian sample
Finnish sample
American sample
Tower

13.2 (3.54)

10.6 (1.72)

9.84 (.60)

AARS-A

43.64 (16.09)

42.37 (6.34)

-*

AARS-B

42.35 (18.94)

40.12 (8.27)

-*

Design Fluency

19.03 (9.57)

19.5 (7.37)

11.20 (3.16)

Statue

26.54 (4.70)

-*

25.32 (6.46)

Knock and Tap

26.51 (5.15)

28.37 (5.12)

27.35 (4.26)

Note. AARS-A = Auditory Attention and Response Set Part A; AARS-B = Auditory Attention and
Response Set Part B.; * = not available in reported data.

The correlations between EF tasks remain significant although moderateeven when controlling for the strong influence of the age factor. Even from a visual
inspection of Table 2, it is clear that the two motor inhibition measures (Statue;
Knock and Tap), although interrelated, are not significantly correlated with the
other EF measures.
Developmental pathways
In our study the development of attentional and EFs appeared to proceed
gradually. The 12-year-old level was first reached on tasks of motor inhibition and
response suppression, subsequently on measures of visual search, response
planning, selective and sustained attention, and finally on verbal and design
fluency measures. These trends are similar to those found in the Klenberg et al.
(2001) study using the same measures. Taking into account disparate findings on
several NEPSY (or similar to NEPSY) subtests, convergent evidence appears (see
also 1.3.1 above). Espy and Bull (2005) found the same early development of
response suppression; Visual Search is already well-developed early in
development (Welsh et al. 1991), while fluency has a more protracted
developmental course (Welsh et al. 1991; Shute & Huertas, 1990).
Two elements should be stressed here. First, although performance at the
Tower subtest reaches a 12-year-old level at an early age (7 years), this does not
mean that it is an adult-level performance, in fact ceiling levels are far from being
attained even in the 12-year-old sample (mean: 13.8 out of 20). Studies by Luciana
& Nelson (1998; 2002) reveal that performance on the TOL is still immature by the
age of 12, and matures during adolescence (De Luca et al., 2003; Asato, Sweeney,
& Luna, 2006). Second, one should also note that in the Lurian tradition, the
NEPSY tests have different degrees of complexity. Some focus on a discrete
ability (e.g. Statue), others integrate skills in order to solve complex tasks. A
careful task analysis (see 1.3.1 above) reveals the multitude of mechanisms
involved in successful task accomplishment; therefore a longer maturational course
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599

in such complex tasks could reflect either lack of maturation in some

subcomponents, or true EF (coordinative) immaturity.
EF structure
As a result of our EFA analysis, we obtained a two-factor solution that
accounts for EF subtest groupings in our sample. The first factor, Task-set
selection, comprises distinct but related abilities, and has been reported by several
previous studies (Mirsky, Anthony, Duncan, Ahearn, & Kellam, 1991; Taylor
Saint-Cyr, & Lang, 1986). Basic task demands are different between a verbal
fluency task (comprising both semantic and phonemic association criteria) and a
design fluency task: while the first one requires search within an existing
vocabulary, the visual fluency task requires a generation of designs according to
rules. However, evidence is provided by our results and by previous findings
(Klenberg et al., 2001) that there is a common underlying variable, revealing
clustering abilities (Troyer, Moscowitch, & Winocur, 1997), abstract reasoning and
a common generative skill. The same association is to be found between the two
auditory attention measures (AARS-A and AARS-B). It is interesting to note that
they cross-load on both factors, but with different weights. AARS-A is better
associated with the first factor, Fluency; while the AARS-B has a stronger link to
the second factor of Inhibition, being obviously a test with multiple inhibitory
demands.
A somehow puzzling finding is the association of the Tower of London
performance with the fluency and attentional measures within the first factor.
Indeed, we could not find evidence for a distinct factor of planning and strategy
employment, as shown by previous studies (Welsh et al., 1991). A first reason
could be the young age of the sample: immature abilities are often considered less
differentiated (Espy & Bull, 2005). Moreover, although performance in the TOL
has been repeatedly associated with inhibitory tasks in adult samples (Asato,
Sweeney, & Luna, 2006) in children this association could not be proven,
suggesting that children could use a different strategy than the adult one to solve
the task (Huiziniga, Dolan, & Van der Molen, 2006). A similar very strong
association between TOL and fluency (poor) performance has been identified in a
mixed neuropsychiatric group (Hanes, Andrewes, Smith, & Pantelis, 1996). A
second reason could be the complex nature of this task, which has been shown to
require planning (Baker et al., 1996; Shallice, 1982), working memory (Carpenter,
Just, & Shell, 1990; Roberts & Pennington, 1996; Welsh et al., 1999), inhibition
(Goel & Grafman, 1995; Miyake et al., 2000), and last, but not least, verbal
comprehension and reasoning abilities, taking into account the complex
instructions the child has to process in order to understand the rules of the task.
The second factor reveals an association between two types of inhibitory
measures: response suppression (Knock and Tap, Statue), and attentional control
(AARS-A and especially -B). In motor response suppression tasks, the conflict is
typically derived through a prohibited action; in attention control tasks, the child
must suppress an internally represented rule or response set that had been
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L. Visu-Petra, O. Benga, M. Miclea

previously active and has to be inhibited in favor of a new response according to

rules (Espy & Bull, 2005). Our findings confirm the lack of differentiation between
these two types of inhibition in children: proficiency in resolving conflict
provided through prohibited action is an earlier, developmentally bound
manifestation of attentional control; both types of conflict might elicit executive
processes that are indistinguishable at this young age, unlike adults (Espy & Bull,
2005, p. 682-683).
AN EXPLANATORY FRAMEWORK
Benson (1998) proposed that validity research should undergo three stages:
an initial substantive stage when psychological constructs are defined in terms of a
theoretical template, followed by a structural stage in which these constructs are
operationalized, measured and re-analyzed to see how well they reflect the
theoretical template on which the measurement is based, and finally, an external
stage during which ecological/clinical validity has to be proven (Stinnett et al.,
2002). From this perspective, the NEPSY has a very solid substantial stage, relying
on a strong (Lurian) tradition enriched with up-to-date developmental
considerations. The external stage is also quite well represented, the test being
proven to be selectively impaired in neurological groups, when compared to
controls or to children with scholastic concerns only (Schmitt & Wodrich, 2004,
although the difference came only from the Language and the Sensoriomotor
domain) and when comparing typical development to populations with prenatal
exposure to organic solvents (Till, Koren, Westall, & Rovet, 2001), in utero
cocaine exposure (Bandstra et al., 2002), juvenile neuronal ceroid lipofuscinosis
(Lamminranta et al., 2001), ADHD, Learning Disabilities, autism, Fetal Alcohol
Syndrome, hearing impairments (Korkman et al., 1998) and different forms of
epilepsy (Bender, Marks, Brown, Zach, & Zaroff, 2007; Petra & Benga, 2003).
However, the essential stage of structural validation is less well
represented, perhaps because the complex nature of the tasks that were devised to
assess interactive functional systems, generating a task impurity problem
(Rabbitt, 1997). Carlson (2003) stated that because there are no process pure
measures of EF, multi-method approaches are valuable for triangulating the
process involved. The difficulty arises in interpreting the results of multiple test
results: composite scores have been used, but when this arbitrary grouping is not
sustained by domain specificity measures, it could be misleading (for instance,
although scores could be homogenous within typical samples, a strong withindomain fractionation is noted in atypical development, arguing against the use of
composite scores Petra & Benga, 2004).
In reference to an earlier version of NEPSY, the author (Korkman, 1988)
stated that factor analysis is not an appropriate mechanism for studying the tests
structure because such data reduction was not considered compatible with Lurias
approach, in which a good test coverage and stepwise, qualitative differences are
essential, and some test overlap is justified (p. 384, as cited in Stinnett et al.,
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601

2002). However, in order to prove that the tasks that measure EF are interrelated
and measure a common latent variable, a factorial approach is indispensable.
Interpretation of factors extracted by EFA or of those postulated in the
confirmatory factor analysis is not straightforward due to the same task impurity
problem.
In children, some studies have found evidence for the same three-factorial
structure as proposed by Miyake, Freidman and Emerson (2000) for the adult
population. Lehto et al. (2003) present a similar three-factor solution, although
there are some things that can be questioned in the apparent similarity with the
Miyake et al. (2000) model. First of all, the tasks are very different from the ones
employed by the adult study. Second, the theoretical interpretation of factors is
post-hoc and sometimes forced to fit the hypothesized factors: the AARS-part B
is considered to be primarily a WM measure rather than an inhibitory one (counterintuitively, as acknowledge by the authors); the Tower of Hanoi (TOH) is entered
in the Inhibition factor (although the correlation between inhibition and
performance at the TOH is frequently found to be low Welsh et al., 1999). The
third factor, named Shifting after the Miyake et al. (2000) study, had a low
eigenvalue (.99) and consisted of a Word Fluency test and the part B of the
classical Trail Making test, with the association between the two being less
obvious.
Our two-factor EFA solution confirms EF task partially confirms
associations identified in previous studies that have included a younger group of
children in the analysis and could suggest at least three conjectures, depending on
distinct frameworks of reference. As mentioned before, the interpretation of EF
factors is a tedious process, and forcing the factorial structure into pre-existent
factors often seems arbitrary and post-hoc (Miyake et al., 2000). We therefore
propose three possible interpretations; future research is needed to clarify which is
the most appropriate, or to suggest an alternative account.
First, when considering previous findings on the one-factor structure of the
whole NEPSY battery (Stinnett et al., 2002; Jarratt, 2005), a general hypothesis
could provide a good account for the associative solution that we have obtained.
The authors state that the primary and robust factor appears to reflect aspects of
linguistic-verbal ability (Stinnett et al., 2002, p. 78), this being confirmed by a
unique, Language factor model identified by Jarratt (2005). The essential role
played by the childs linguistic abilities as a basis for solving all these apparently
unrelated tasks provides a plausible explanation for the strong association found in
our study between the subtests measuring planning, attentional and fluency
measures. As the measures from the second factor have much simpler linguistic
demands (Knock and Tap, Statue) and rely rather on motor (suppression)
responses, we could argue that this is the true reason behind the existence of a
distinct factor in our study. However, this linguistic vs. non-linguistic explanation
cannot completely clarify the cross-loading of the Auditory Attention subtests on
both factors. This test has strong verbal processing demands, and yet it seems to
load strongly on the second, non-linguistic factor.
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An alternative account takes into account possible true underlying latent

variables within these two factors. Accordingly, we have called the first factor
Task-set selection, taking into account the requirements posed by both fluency and
Tower subtests to generate, maintain and flexibly shift between response
categories, an ability that is also required by the two auditory attention subtests.
To adopt a task-set is to select, link, and configure the elements of a chain of
processes that will accomplish a task (Rogers & Monsell, 1995). Zelazo, Carlson,
& Kesek (2007) propose task-set selection as being a reflection on task sets, as
when switching between two abstract rules or when coordinating hierarchically
embedded goals, a higher-order ability relying on the anterior or rostrolateral
prefrontal cortex (RLPFC). We can speculate further on this ability as being
commonly involved by our tasks (Tower and Fluency) considering the unifying
hypothesis for RLPFC functions proposed by Christoff, Ream, Geddes, & Gabrieli
(2003): the RLPFC is supposed to be involved in processing self-generated
information. According to the authors, processing internally generated information
and establishing a task-set occurs when novel information, such as an inference, a
hypothesis, a relation, or a plan, needs to be inferred, or self-generated; and second,
when previous information from an earlier episode or experience needs to be
retrieved from memory, or again, self-generated (p. 1166), the description appears
to fit perfectly the requests of the two types of tasks that load highly on the first
factor: Tower and Fluency. The second factor, Inhibition is less ambiguous in
revealing distinct requirements tapping inhibitory control, both in its motor
response suppression component (Statue, Knock and Tap), and in its attentional
control element (AARS-A and especially AARS-B). Similar to our findings,
inhibitory tasks have presented high intercorrelations in children samples (Espy &
Bull, 2005), although in the adult samples (Friedman & Miyake, 2004) the two
dimensions (response suppression and attentional control) appeared independent.
A third perspective - perhaps complementary to the second account
integrates the maturational aspects captured by this factor structure. However
tempting the second account might be, it has to be validated against developmental
constraints of this age. One should embrace the adult model with great caution,
because as our data points out, there is diverging evidence. Unlike adult findings,
performance in TOL is not associated in our sample with inhibition and it does not
constitute a separate planning factor; additionally, attentional control is not yet
differentiated from response suppression. The task-set selection - RLPFC
hypothesis has been proposed taking into account adult data (Christoff et al., 2003;
Baker et al., 1996), and the authors admit that there is limited research exploring
the neural basis associating self generated task-set selection to RLPFC activity in
children. Therefore, from a third perspective, we can envision the first factor as a
prototype of immature and therefore undifferentiated EFs, while the second reflects
already-matured, distinct, inhibitory abilities. Although mean performance scores
and developmental patterns are extremely similar to the Finnish 5-12 year old
sample (Klenberg et al., 2001), in their exploratory factor analysis performed on
the 7-12 year old subsample they already obtained a four-factor solution, two
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similar to ours (a Fluency factor and an Inhibition factor), two new ones: Visual
Search and Auditory Attention. This provides additional support to the
developmental differentiation of EF as measured by the NEPSY battery. EF has
been repeatedly characterized by functional unity as well as functional diversity
(Miyake et al., 2000); perhaps in the stage of development that we have focused
upon, the functional diversity is still in a latent, potential state; it will only become
reality during later maturational stages. This perspective would be supported by
data revealing the developmental shift from more diffuse to more focal and
efficient frontal networks (Durston et al., 2006; Luna et al., 2001).
At the end of these clarifications, we must acknowledge that a true
assessment of EF, especially in the context of its development, is - adapting an
analogy used by Burgess (1997) - like shooting a moving target. The intrinsic
developmental constraints as well as the dynamic nature of task response make the
process of evaluation elusive and create the need for perpetual task refinement and
subsequent theory revisal.
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