hyperactivity disorder

Archives of Clinical Neuropsychology 17 (2002) 531–546

Clock face drawing in children with attention-deficit/ hyperactivity disorder Michelle Y. Kibby a,b,∗ , Morris J. Cohen a , George W. Hynd b a

b

Medical College of Georgia, Augusta, GA, USA School of Professional Studies, University of Georgia, 570 Aderhold Hall, Athens, GA 30602, USA Accepted 20 April 2001

Abstract The clock drawing test has been found to be sensitive to visual–spatial perception, graphomotor skills, verbal reasoning, and executive functioning in adult patient populations, as well as frontal lobe maturation in normal children. Our study is among the first to assess the use of clock drawing as a neuropsychological measure in the pediatric population. Participants included 41 children with attention-deficit/hyperactivity disorder (ADHD) and 41 normal controls, ages 6–12 years, matched for age, gender, and handedness. Conceptualization of time and construction of the clock face were assessed separately using a scoring system normed on school-age children in an earlier study. Children with Predominantly Inattentive Type were found to perform similarly to those with Combined Type of ADHD. However, children with ADHD, regardless of subtype, performed significantly poorer than controls. Qualitative analysis of performance revealed errors that were subsequent to poor planning during task execution, consistent with executive dysfunction commonly present in children with ADHD. Further, multiple regression analysis demonstrated that a neuropsychological measure of executive functioning was predictive of clock construction performance in children with ADHD. Constructional praxis and receptive vocabulary also were predictive of clock construction ability. Implications of these findings are discussed. © 2002 National Academy of Neuropsychology. Published by Elsevier Science Ltd. All rights reserved. Keywords: ADHD; Executive functioning; Children; Neuropsychological assessment

∗

Corresponding author. Tel.: +1-706-542-4494; fax: +1-706-542-5877.

0887-6177/02/$ – see front matter © 2002 National Academy of Neuropsychology. PII: S 0 8 8 7 - 6 1 7 7 ( 0 1 ) 0 0 1 3 3 - 0

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1. Introduction The clock drawing test routinely has been administered as a component of neuropsychological evaluations with adults (Goodglass & Kaplan, 1983; Strub & Black, 1977). Many investigators report clock drawing to be a measure of visuospatial skills and graphomotor abilities (Goodglass & Kaplan, 1983; Mendez, Ala, & Underwood, 1992; Sunderland et al., 1989), while others state that it also measures aspects of executive functioning (Libon, Malamut, Swenson, Sands, & Cloud, 1996; Royall, Cordes, & Polk, 1998). The clock drawing test requires minimal materials and typically takes less than 5 min to administer. While the simplicity of the task may suggest that it has only limited usefulness, the process utilized in constructing a clock, as well as the errors made, provides valuable information as part of a comprehensive evaluation (Freedman et al., 1994). 1.1. Clock face drawing in adults Much has been published on the clock drawing task in the adult literature. For example, the clock drawing test has been found to be an effective means of predicting rate of cognitive decline (Rouleau, Salmon, & Butters, 1996) and of documenting dementia severity (Manos & Wu, 1994; Shulman, Gold, Cohen, & Zucchero, 1993; Sunderland et al., 1989). It also has been used in the identification of unilateral spatial neglect (di Pellegrino, 1995; Heilman, Watson, & Valenstein, 1985; Mesulam, 1985). In earlier studies of this type, it was found that adult patients with unilateral neglect place all numbers on the right half of the clock face (Heilman et al., 1985; Mesulam, 1985). More recently, it has been demonstrated that verbal reasoning ability can be used to mediate completion of the task and to compensate for visuospatial neglect through the use of a planning strategy (e.g., placement of numbers 12, 3, 6, 9 in correct position prior to placement of other numbers; Ishiai, Sugishita, Ichikawa, Gono, & Watabiki, 1993). Much of the adult literature has utilized a “command” version of the clock drawing task (i.e., instructing individuals to “draw a clock” without a model). This version taps language comprehension, along with visual–spatial retrieval and planning/execution; hence, it assesses the integrity of the left temporal lobe, the mesial–temporal regions and the frontal regions (Delis & Kaplan, 1983; Freedman et al., 1994). The clock drawing test also is seen as a measure of constructional praxis regardless of whether a command or copy version is used, assessing parietal functioning (Critchley, 1953; Freedman et al., 1994). In addition, the measure provides information about an individual’s knowledge of time by means of hand placement to the time specified by the examiner. 1.2. Development of clock face drawing in normal children The extent to which clock drawing is a reflection of cognitive functioning in children has received limited attention in the literature. Edmonds, Cohen, Riccio, Bacon, and Hynd (1993) presented the first scoring system normed for use with children ages 6–12 years, which is now in press (Cohen, Riccio, Kibby, & Edmonds, 2000). This scoring system was based upon those published in the adult literature, along with the common error types made by various adult populations. Error types typically included deficits in the spatial arrangement of

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numbers, incorrect sequencing of numbers, omission or repetition of numbers, perseveration, number rotation or reversal, incorrect placement of hands to a specified time, and incorrect proportion of the hour and minute hands. Nevertheless, given potential differences in the development of knowledge of time as compared to the development of constructional ability and planning/organizational skills, hand position and clock face construction were measured on separate scales even though this was not commonly done in the adult scoring systems. Using this adapted scoring system with normal children, Cohen et al. (2000) found a stepwise progression in skill development from ages 6 to 8 years with regard to the ability to record time and from 6 to 10 years with regard to the ability to construct a clock face. Specifically, children 8 years of age performed better than those 7 years of age, and children 7 years of age performed better than those 6 years of age at setting the time. A similar progression was found in clock face construction with the exception of an additional step; children 10 years of age performed better than those 8 years of age. When performance was assessed qualitatively, it was found that most children ages 8 and above could correctly indicate the requested time, whereas clock construction performance continued to gradually improve through age 12, the maximum age assessed. In terms of various error types, it was found that by age 7, the vast majority of children no longer demonstrated number reversals. By age 8, children no longer neglected quadrants of the clock face (neglect referring to not placing numbers in an entire quadrant as opposed to omitting numbers). For those 6- and 7-year-olds who failed to use a quadrant, the pattern generally was of upper left quadrant neglect as opposed to hemineglect, lower left, or lower right quadrant neglect; none of the children neglected the upper right quadrant. The authors suggested that the demonstrated linear progression in quadrant use implied that neglect in young children is developmental in nature as opposed to neuropathological, consistent with the findings of Kirk, McCarthy, and Kaplan (1996). Further, the fact that more children neglected the upper left quadrant as opposed to displaying unilateral left neglect supported the notion that neglect is secondary to planning/organization difficulties coinciding with frontal lobe maturation as individuals with parietal dysfunction typically display unilateral left neglect (Heilman et al., 1985; Mesulam, 1985). In addition to the developmental progression in quadrant usage, a developmental progression was demonstrated in the ability to equally space numbers around the clock face from ages 6 to 11, with this ability not being fully developed by age 12. It is not likely that the maturation of clock construction skill continuing through age 12 and beyond in normal children is reflective primarily of language/temporal development or graphomotor development as the prerequisite skills in these areas are typically in place by age 5 or age 6, respectively (Beery, 1997; Kolb & Fantie, 1989). It also cannot be explained solely by parietal development as hemiattention often is developed by age 3 (Temple, 1997) and parietal development typically continues through ages 5–8 as opposed to age 12 and beyond (Golden, 1981). As noted above, the progression in quadrant usage appears to be related to planning/organizational skills (frontal), as opposed to hemineglect (parietal). The developmental progression of clock construction ability is commensurate with investigations demonstrating a multistage process of frontal lobe development, with stages occurring between the ages of 6–8, 8–10, 10–12, and 12-late adolescence (Becker, Isaac, & Hynd, 1987; Passler, Isaac, & Hynd, 1985; Welsh, Pennington, & Groisser, 1991). To illustrate, by age 6 children tend to have a basic conceptualization of a clock, and by age 8 most demonstrate

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good number formation, quadrant usage, and hand position. Quantitatively, clock construction skills significantly improve again at age 10. Nonetheless, qualitatively, development continues through age 12, and likely beyond, in terms of the ability to equally space numbers around the clock face. Cohen et al. (2000) proposed that their scale may have good sensitivity to frontal lobe maturation given the emphasis placed upon number and hand position, measures found to be especially sensitive to frontal lobe integrity in adults (Freedman et al., 1994). 1.3. Clock face drawing in children with ADHD Attention-deficit/hyperactivity disorder (ADHD) is the most commonly diagnosed behavioral disorder in children, affecting an estimated 3–5% of school-age children (NIH Consensus Statement, 1998). Children with ADHD often present with poor self-regulation and planning during task execution (Barkley, 1997; Carte, Nigg, & Hinshaw, 1996). Further, there is evidence to suggest that ADHD is best characterized as a disorder of executive functioning, with relevant circuitry involving the prefrontal cortex and basal ganglia (Castellanos, 1997). Children with ADHD have been found to have more profound executive impairment than those with Tourette Syndrome (Pennington & Ozonoff, 1996), conduct problems (Nigg, Hinshaw, Carte, & Treuting, 1998; Pennington & Ozonoff, 1996), or learning disabilities (Denckla, 1996; Purvis & Tannock, 1997) alone. Thus, it is expected that they would present with planning and organizational difficulties during the construction of a clock face. Poor clock face construction in children with ADHD was displayed in a presentation by Stern et al. (1998). They assessed children with ADHD who did not have diagnosed learning disabilities or comorbid psychiatric disorders using a scoring system developed by Kirk et al. (1996). Scores were then compared to Kirk et al.’s (1996) normative data. Results revealed that children with ADHD performed significantly below normative data in terms of sequencing and positioning numbers despite adequate visual–spatial and visual–motor integrative abilities. Qualitatively, planning errors in the placement of numbers around the clock face were found frequently. Further, when children were subsequently provided with a predrawn clock that had anchoring stimuli in place (e.g., the numbers 3, 6, 9, and 12 were predrawn), their clock construction improved significantly, validating that errors on their original drawings were due to planning as opposed to visual–spatial deficits. Based upon this preliminary study, children with ADHD demonstrate a reduced ability to plan and organize clock face construction as compared to normal children. These deficits are consistent with research demonstrating that children with ADHD have impaired executive functioning (Barkley, 1997; Castellanos, 1997; Cornoldi, Barbieri, Gajani, & Zoechi, 1999; Denckla, 1996; Pennington & Ozonoff, 1996). These deficits also are consistent with frontal lobe dysfunction based upon the type of clock drawing errors commonly found in adults with frontal lesions (i.e., errors in number positioning; Freedman et al., 1994). At present, there are no published investigations assessing clock face drawing in children with ADHD. Therefore, the purpose of the current study was to assess the extent to which clock face construction in children with ADHD deviates from normal children. A second purpose was to compare children with Predominantly Inattentive Type to those with Combined Type in order to determine if differences in clock drawing performance exist between the two subtypes. Given the dearth of literature related to clock drawing performance in ADHD, specific

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hypotheses related to subtype performance were not formed and analyses were exploratory. Finally, the study sought to determine which cognitive skills are predictive of clock face drawing in children with ADHD. It was hypothesized that measures of executive functioning would predict clock drawing performance in children with ADHD; however, as clock drawing ability also is sensitive to visual–spatial perception, constructional praxis, verbal reasoning, and aspects of language functioning, these cognitive functions were included in the analyses as well.

2. Method 2.1. Participants 2.1.1. Clinical sample Children with ADHD were selected from a large database of patients referred to either the Child Neuropsychology service at the Medical College of Georgia or the Clinical and Developmental Neuropsychology service at the University of Georgia. The database was first screened to identify those children diagnosed with ADHD. Children had been diagnosed with ADHD according to the Diagnostic and Statistical Manual—Fourth Edition (American Psychiatric Association, 1994) based upon a clinical interview with their parents, behavioral questionnaires completed by their parents and teachers (The Conners Rating Scales (Cohen, 1988; Cohen & Hynd, 1986) and Behavioral Assessment System for Children (Reynolds & Kamphaus, 1992)), and the results of a neuropsychological evaluation that assessed various cognitive domains including executive functioning, attention/short-term memory, receptive and expressive language, visual perception, constructional praxis, and academic achievement in reading, mathematics, and written expression. This battery was utilized for diagnostic purposes as part of a clinical service, and, hence, some measures varied across subjects. One hundred thirty children with ADHD were initially identified; those with a comorbid neurological disorder (e.g., traumatic brain injury, epilepsy, stroke), pervasive developmental disorder (e.g., Autism, Asperger’s), or emotional/behavioral disorder as defined by the DSM-IV (e.g., anxiety, mood disorder, conduct disorder, oppositional defiant disorder) were then excluded from the study. Children also were excluded from the study if they had a comorbid developmental disorder such as a specific learning disability or language disorder. This process resulted in the identification of 41 children with pure ADHD; 16 with Predominantly Inattentive Type and with 25 Combined Type. All children were off medication at the time of testing. Participants ranged in age from 5.64 to 12.5 years of age (M = 8.68 years, S.D. = 2.05); 76% were male, 90% were Caucasian, and 96% were right-hand dominant. The mean annual family income was US$30,833 with a standard deviation of US$13,338 as reported by the parents. ANOVA analyses indicated that children with ADHD, Predominantly Inattentive Type, did not differ significantly from children with ADHD, Combined Type, on gender, race, family income, handedness, or VIQ from the WISC-III (Ps > .10). The two groups differed in age [F (1, 39) = 4.97, P < .05] and PIQ [F (1, 38) = 13.74, P < .001]. The reader is referred to Table 1 for descriptive data on clinical participants. Behaviorally, children with ADHD, Predominantly Inattentive Type, differed significantly from children with ADHD, Combined Type, on the Hyperactivity scale of the parent and

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Table 1 Descriptive data on children with ADHD: predominantly inattentive type versus combined type Variable

Inattentivea

Gender (% male) Race (% Caucasian) Dominance (% right-handed)

62.5 93.0 100

Combinedb 84.0 88.0 94.4

Inattentive

Age∗ Family annual income WISC-III VIQ WISC-III PIQ∗∗∗ BASC parent scale—Attention BASC teacher scale—Attention BASC parent scale—Hyperactivity∗∗∗∗ BASC teacher scale—Attention∗∗∗

Combined

M

S.D.

M

S.D.

9.53 US$30.81 97.31 89.63 69.40 65.00 54.07 51.82

2.30 14.01 10.45 8.52 9.18 9.40 8.01 8.27

8.13 US$30.83 103.08 101.29 69.42 64.90 74.05 63.98

1.70 13.34 11.48 10.47 8.69 8.74 11.80 8.34

BASC values are in T scores; IQ values are in standard scores. Family income in units of US$10,000. a n = 16. b n = 25. ∗ P < .05. ∗∗∗ P < .001. ∗∗∗∗ P < .0001.

teacher forms of the BASC [F (1, 34) = 32.24, P < .0001 and F (1, 27) = 14.61, P < .001, respectively]. The two groups also differed on the ADD/Hyperactivity scale from the Conners Rating Scales, parent [F (1, 27) = 11.51, P < .01] and teacher forms [F (1, 26) = 13.08, P < .01]. This scale measures symptoms of both inattention and hyperactivity. In contrast, the two groups did not differ significantly on the Attention scale from the parent and teacher forms [F (1, 34) < 1.00 and F (1, 27) < 1.00, respectively, Ps > .10]. As can be noted from Table 1, many children in the sample had a mild form of ADHD. 2.1.2. Control children Participants were selected from the normative sample gathered by Cohen et al. (2000). First, controls were chosen if they matched children with ADHD on age, gender, and handedness. From this matched sample, children were randomly selected so that there were equal number of controls and children with ADHD. Thus, participants included 41 children who ranged in age from 6 to 12 years of age (M = 8.22 years, S.D. = 1.97); 76% were male, and 86% were right-hand dominant. ANOVA analyses indicated that children with ADHD did not differ significantly from control children on age, gender, or handedness (Ps > .10). Information on race, family income, and IQ were not gathered during normative data collection. Each group was comprised of 11 six-year-olds, 6 seven-year-olds, 10 eight-year-olds, 1 nine-year-old, 5 ten-year-olds, 6 eleven-year-olds, and 2 twelve-year-olds. The original sample of Cohen et al. (2000) included 429 normal public school children ages 6–12 years. The children were randomly selected from two school districts in central

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Georgia, geographically and socioeconomically similar to those of the clinical sample. All children were required to be on grade level in reading and have no history of grade retention, behavior disorder, learning disorder, or stimulant medication usage to be included in the study. Hence, they were performing adequately in school and were believed to be of at least average intellect. The children were subdivided into seven groups based upon chronological age. Each of the seven age groups contained a minimum of 26 children (age 12) and a maximum of 91 children (age 10). 2.2. Procedures Children with ADHD completed the clock drawing task developed by Cohen et al. (2000) as part of an extensive neuropsychological battery. Clocks and watches were removed from view before test administration began. As part of the battery, children with ADHD were told to draw a clock and set the time to either 3:00, 9:30, or 10:20 h based upon their age and exposure to clocks. In the normative study, children set all three times; thus, the time measure used for each control was that which corresponded with the requested time for the child with ADHD to whom he or she was matched. 2.2.1. Development of the original scoring system The scoring system utilized in this study was developed by Cohen et al. (2000) based upon a review of the literature with adults. As the concept of telling time is a developmental task partially independent from constructional abilities, it was deemed necessary to score these functions separately rather than obtaining a single score. As a result, the scoring system was comprised of a 13-point scale for clock construction and a 5-point scale for setting the appropriate time. Interrater reliability using this adapted system was assessed in conjunction with the Cohen et al. (2000) study. Two raters independently scored all clocks for both construction and time. Disputes were settled by the principal investigator (MC). Results from the two raters suggested high interrater reliability for form (r = .96) and time (r = .96 to the hour, r = .94 to the half-hour, and r = .98 to the minute). For the clinical sample, two raters scored all the clocks as well, with one being the same rater across all ADHD clocks. Again, disputes were settled by MC. 2.2.2. Scoring All clocks were scored for clock construction and the ability to set the time accurately. In addition to quantitative scoring, data were coded with regard to neglect of any quadrant(s) and equal spacing of numbers. These measures were of interest as they were found to be sensitive to the development of executive functions (Cohen et al., 2000). 3. Results 3.1. Inattentive versus combined types A mixed factor ANOVA was utilized to assess if children with Predominantly Inattentive Type differed from children with Combined Type on clock construction and hand placement

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Table 2 Clock face drawing performance by group Attention-deficit/hyperactivity disorder Inattentivea

Combinedb

Variable

M

S.D.

M

S.D.

Clock construction Hand placement

94.50 93.75

15.45 18.09

91.88 96.64

18.53 17.72

ADHD vs. controls ADHDc

Clock construction∗ Hand placement∗

Controlsd

M

S.D.

M

S.D.

92.90 95.51

17.24 17.70

102.95 104.20

12.89 10.33

Clock drawing performance is in standard scores (M = 100, S.D. = 15). a n = 16. b n = 25. c n = 41. d n = 41. ∗ P < .01.

covarying for differences in age and PIQ. Analysis of clock construction and the ability to set the requested time yielded insignificant findings [Fs(1, 36) = 1.46 and <1.00, respectively, Ps > .10]. Hence, the two groups were combined for all further analyses. Refer to Table 2 for descriptive data on dependent measures. 3.2. ADHD versus controls A mixed factor ANOVA was utilized to assess if children with ADHD differed from control children on clock construction and hand placement. Age and IQ were not used as covariates, as the two groups were matched on age and the IQ of control subjects was not known. The results of this analysis were significant, with children with ADHD performing more poorly than controls on both clock face construction and setting of the requested time [Fs(1, 80) = 8.93 and 7.36, respectively, Ps < .01]. It should be noted, however, that children with ADHD performed at the low end of the average range on these measures. Hence, it is important to use clock drawing performance as part of a clinical battery of tests when diagnosing ADHD, rather than as a solitary diagnostic tool. Means and standard deviations for clock construction and hand placement are presented in Table 2. 3.2.1. Neglect Neglect for the purposes of this study was defined as the failure to use at least one entire quadrant of space on the clock face, with numbers 1–12 typically being present but crowded together. None of the children older than 8 years of age neglected a quadrant. Some degree of left visual–spatial neglect was evident in children with ADHD through age 8, whereas neglect

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was present through age 7 in matched controls. Further, neglect appeared to be specific to the ability to plan the figure. All children with ADHD who neglected a quadrant failed to use the top left quadrant, and 67% neglected both left quadrants. All controls who neglected a quadrant neglected the top left quadrant, with 33% neglecting both left quadrants. None of the participants neglected quadrants on the right side. This pattern is similar to the performance of the normative sample in the study by Cohen et al. (2000) who demonstrated that quadrant neglect in normal children is secondary to immature planning skills (subjects with neglect typically were less than eight) as opposed to the visual–spatial hemineglect associated with parietal dysfunction (Heilman et al., 1985). 3.2.2. Spacing To further investigate planning ability, spacing of numbers around the clock face was investigated. For both groups, spacing errors were noted at all ages, but for control children the proportion of errors slowly decreased as they matured. For example, none of the 6- and 7-year-olds demonstrated equidistant spacing between numbers, while 27% of 10- and 11-year-olds were able to evenly space numbers around the clock face (both children 12 years of age presented with spacing errors). In contrast, all of the children with ADHD continued to demonstrate poor spacing at ages 10 through 12. Samples of clock face construction for children with ADHD and controls are presented in Fig. 1. 3.3. Predictors of performance Multiple regression using the Backward technique was utilized to assess which aspects of cognitive functioning would be most predictive of performance on clock construction and hand

Fig. 1. Examples of clock construction ability for children with and without ADHD. The child without ADHD was instructed to set the hands to 3:00 h; the child with ADHD was instructed to set hands to 10:20 h.

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placement in children with ADHD. For a more thorough discussion of this statistical technique, the reader is referred to Pedhazur (1982). In brief, this technique allows each variable to be entered into the equation in order to observe which variable adds the least when entered last. Variables that do not significantly contribute to prediction of the dependent variable are successively removed. All children with ADHD were assessed on an outpatient basis through a neuropsychological service. As ADHD participants were seen for clinical diagnosis rather than for strictly research purposes, tests administered varied somewhat from person to person. However, participants received at least two measures from each cognitive domain (e.g., executive, receptive and expressive language, visual perception, constructional praxis). Those measures most commonly administered were identified and included in the regression analysis. Measures included in the regression equations were selected from the following domains: executive functioning Wisconsin Card Sorting Test (WCST) Perseverative Errors (PE) and Failures to Maintain Set (FMS); # of Categories Achieved was not utilized as it is affected by both PE and FMS, as well as being highly correlated with intelligence (Chelune & Baer, 1986; Riccio et al., 1994). Further, PE and FMS, along with Trail Making Test B and Stroop C-W, have been found to successfully classify children as ADHD or control with 79% accuracy according to discriminant analysis (Boucugnani & Jones, 1989), constructional praxis (Developmental Test of Visual Motor Integration, Block Design from the WISC-III), visual–spatial perception (Gestalt Closure from the KABC), verbal reasoning (Similarities from the WISC-III), and language functioning (Peabody Picture Vocabulary Test—Revised (PPVT-R), Formulated Sentences from the CELF-R). These domains, and their respective measures, were selected for inclusion in the regression equations as clock drawing may tap each of these areas as cited in the literature review. In terms of clock construction, the final regression equation explained 43% of the variance in performance and was significant [Multiple R = .65, F (4, 21) = 3.90, P < .05]. Four variables were predictive of clock construction performance in children with ADHD including WCST PE and Failure to Maintain Set, Block Design from the WISC-III, and the PPVT-R. All variables included in the analysis had a positive predictive relationship with clock construction ability except the PPVT-R. In terms of hand placement, the regression equation explained 28% of the variance in performance and was significant [Multiple R = .53, F (1, 24) = 9.23, P < .01]. Only one variable successfully entered the final equation: Gestalt Closure. Gestalt Closure positively predicted hand placement.

4. Discussion Clock drawing has been utilized with adult populations for some time and has been shown to be an effective measure of visual–spatial skills and graphomotor abilities (Mendez et al., 1992), as well as executive functioning (Royall et al., 1998). It also is sensitive to verbal reasoning abilities (Ishiai et al., 1993), language comprehension, and visual–spatial retrieval (Delis & Kaplan, 1983). As such, it may assess the integrity of the parietal lobes, frontal lobes, mesial–temporal regions, and the left temporal lobe (Freedman et al., 1994). Researchers have shown it to be a useful screening tool (Brodaty & Moore, 1997) as well as a valuable addition to a comprehensive neuropsychological evaluation (Freedman et al., 1994).

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Clock drawing performance in children has received limited attention to date. Stern et al. (1998) investigated clock drawing performance in children with ADHD who did not have comorbid learning disabilities or psychiatric disorders. Using the scoring system of Kirk et al. (1996), they found children with ADHD to perform significantly poorer than normative children despite adequate visual–spatial and graphomotor abilities. In addition, they found that performance of children with ADHD improved when planning/organizational demands were reduced. Based upon this preliminary study, clock drawing performance in children with ADHD was investigated using the scoring system of Cohen et al. (2000). It was hypothesized that children with ADHD would perform poorly on the task as compared to age-matched controls given that children with ADHD often present with deficits in self-regulation and planning during task execution (Barkley, 1997; Carte et al., 1996) and that the clock drawing task is sensitive to these functions (Freedman et al., 1994). A secondary purpose of the study was to compare children with Predominantly Inattentive Type to those with Combined Type to determine if differences in clock drawing performance exist between the two subtypes. This analysis was exploratory. Results indicated that children with Predominantly Inattentive Type performed similarly to those with Combined Type. This insignificant result is of interest given the dearth of research on clock performance in ADHD. However, it should be interpreted cautiously as there were only 16 participants with Inattentive Type and 25 with Combined Type in our sample and several participants had a mild form of ADHD. Nevertheless, as a group, children with ADHD performed significantly poorer than controls on both clock face construction and setting the hands to the requested time. Qualitatively, some degree of quadrant neglect was evident in children with ADHD through age 8, and it appeared to be specific to the ability to plan the figure. It should be noted that neglect also was evident in a minority of controls through age 7 in the original normative sample of Cohen et al. (2000), and that it appeared to be secondary to immature planning skills in this population. In the present study, both children with ADHD and matched controls presented with spacing errors at all ages; however, the occurrence of such errors gradually reduced in controls as they matured, whereas all children with ADHD ages 10 through 12 continued to demonstrate poor spacing. These results are consistent with literature suggesting that children with ADHD present with deficits in executive functioning (Barkley, 1997; Castellanos, 1997; Denckla, 1996), particularly in the area of planning and organizational skill during task execution (Carte et al., 1996; Cornoldi et al., 1999; Nigg et al., 1998; Purvis & Tannock, 1997). Errors in number positioning (i.e., spacing) are commonly found in adults with frontal lobe lesions (Freedman et al., 1994), and may be representative of frontal lobe development in children (Cohen et al., 2000). Errors in hand position (i.e., setting the hands to the correct time) also are commonly found in adults with frontal lesions (Freedman et al., 1994). Further, multiple regression analysis revealed that the ability to appropriately inhibit or maintain a response set according to feedback plays a role in the ability to successfully execute clock face construction; those with poor performance on the WCST tended to perform worse during clock face construction. This is consistent with research on adults demonstrating that clock drawing performance positively correlates with measures of executive functioning (Libon, Swenson, Barnoski, & Sands, 1993). It is also commensurate with research on normal children suggesting that clock construction is sensitive to frontal lobe maturation and development of executive functioning (Cohen et al., 2000).

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Deficits in the executive aspects of clock construction are consistent with the work of Hynd, Scmrud-Clikemann, Lorys, Novey, and Eliopulas (1990) who found that children with ADHD have significantly smaller right frontal widths than normal, age-matched controls. Similarly, multiple researchers have demonstrated that children with ADHD present with abnormal functioning in the right prefrontal region or bilateral prefrontal regions (Castellanos, 1997; Epstein, Conners, Erhardt, March, & Swanson, 1997; Giedd et al., 1994). Nonetheless, multiple causes for the difference in performance between children with ADHD and controls need to be considered. As stated previously, clock drawing performance is sensitive to a number of cognitive functions, including visual–spatial perception, graphomotor skills, constructional praxis, verbal reasoning and language functioning, as well as planning/organizational skills. Hence, multiple regression analyses were performed to assess which of these functions are predictive of clock face drawing ability in children with ADHD. The regression analysis indicated that visual–spatial perception and graphomotor skills are not successful predictors of clock construction in children with ADHD. Neither is verbal reasoning as measured by Similarities from WISC-III. Although basic graphomotor skill and visual–spatial perception do not appear to be significant predictors of clock face construction, constructional praxis as measured by block design is a significant predictor of clock construction ability in children with ADHD. Research has found clock drawing ability to be sensitive to parietal lobe dysfunction (Critchley, 1953; Freedman et al., 1994). Although hemineglect during clock construction in children with ADHD appears to be largely secondary to planning difficulties as it is in normal children, perhaps some children with ADHD have difficulty with clock construction secondary to poor constructional praxis. This is consistent with the fact that the mean performance on Block Design was in the low average range for children with ADHD in our sample. Research has found children with ADHD to demonstrate poor spatial relations (Aman, Roberts, & Pennington, 1998) and constructional praxis (Loge, Staton, & Beatty, 1990), as well as to display parietal lobe dysfunction (Aman et al., 1998; Ernst, Cohen, Liebenauer, Jons, & Zametkin, 1997; Filipek et al., 1997; Levy, Barr, & Sunohara, 1998; Overtoom et al., 1998). Deficient spatial relations in some children with ADHD may help to explain the modest ability of Gestalt Closure to predict hand placement. Nonetheless, frontal dysfunction has been suggested to be the prevailing deficit in children with ADHD (Aman et al., 1998; Barkley, 1997; Castellanos, 1997). The negative relationship suggesting that children with ADHD who display better receptive vocabulary perform worse on clock construction, or vice versa, was a surprising finding. Perhaps this is related to the fact that children with Combined Type tended to display higher VIQs than those with Predominantly Inattentive Type, yet their performance on clock construction tended to be worse than those with Inattentive Type. Hence, a proportion of children with ADHD tended to perform poorly on clock construction despite at least average verbal functioning. It should be noted, however, that differences between Inattentive and Combined Types were not significant for VIQ or clock construction. Based upon this research and that of the literature previously reviewed, clock drawing appears sensitive to planning and organizational skills, as well as constructional praxis. This statement is supported by our findings that children with ADHD perform worse than age-matched controls on clock face construction, demonstrating quadrant neglect later into development than controls as well as more frequent spacing errors later in childhood when this ability is

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beginning to solidify in normal children. It is also supported by the results of the regression analyses. Hence, clock drawing appears to be a clinically useful tool in pediatric neuropsychological assessment when incorporated into a battery of tests. It has proven to be a useful tool in the assessment of ADHD as demonstrated by this research and that of Stern et al. (1998). It also may prove useful in the assessment of pediatric disorders where visual–spatial functioning/constructional praxis is affected (e.g., right parietal tumors, fetal alcohol syndrome, Williams syndrome). Our investigation is one of the first studies to address clock drawing performance in a clinical population of children; however, it does present with limitations. First, the sample of children with ADHE) in our study tended to have a mild form of the disorder. It is likely that the differences between groups would have been greater had our sample been comprised of children with a more severe form of the disorder. Second, although children with ADHD performed more poorly than controls, their performance was at the low end of the average range. This may have been due to the fact that our ADHD sample had mild deficits. Nonetheless, it remains important to utilize this measure as part of a battery of tests rather than as a solitary diagnostic tool. Third, our controls and children with ADHD were less than 13 years of age. Given that clock construction skill likely progresses past the age of 12, extending the investigation to include adolescents would be beneficial. Fourth, as our controls were randomly selected from a prior normative study (Cohen et al., 2000), the aspects of neuropsychological functioning that successfully predict clock drawing performance in normal children is unknown (e.g., executive functioning, constructional praxis, graphomotor skills, language comprehension). This will require further evaluation. In addition to the previous suggestions, future research should longitudinally investigate the developmental progression of clock face drawing in children with ADHD as compared to normal controls given that such development could be slower or asymptote earlier than that of normal children. Future investigations comparing children with ADHD and controls utilizing the two scoring systems available for children (Cohen et al., 2000; Kirk et al., 1996) also would be beneficial. Both systems have revealed deficits in planning/organizational skills in children with ADHD; however, it is currently unknown which is more sensitive to such deficits.

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