Schizophrenia Research 133 (2011) 218–222

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Schizophrenia Research

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Test–retest reliability of Attention Network Test measures in schizophrenia

Eric Hahn a,⁎, Thi Minh Tam Ta a, Constanze Hahn b, Linn K. Kuehl a, Claudia Ruehl a,Andres H. Neuhaus a, Michael Dettling a

a Department of Psychiatry and Psychotherapy, Charité University Medicine, Campus Benjamin Franklin, Berlin, Germanyb Department of Biopsychology, Ruhr University Bochum, Germany

⁎ Corresponding author at: Department of PsychiatrUniversity Medicine Berlin, Campus Benjamin FranklinGermany. Tel.: +49 30 8445 8673; fax: +49 30 8445 8

E-mail address: eric.hahn@charite.de (E. Hahn).

0920-9964/$ – see front matter © 2011 Elsevier B.V. Alldoi:10.1016/j.schres.2011.09.026

a b s t r a c t

a r t i c l e i n f o

Article history:

Received 11 July 2011Received in revised form 10 September 2011Accepted 18 September 2011Available online 14 October 2011

Keywords:Visual attentionTest–retestReliabilityAttention Network TestSchizophrenia

Background: The Attention Network Test (ANT) is a well established behavioral measure in neuropsycholog-ical research to assess three different facets of selective attention, i.e., alerting, orienting, and conflict proces-sing. Although the ANT has been applied in healthy individuals and various clinical populations, data onretest reliability are scarce in healthy samples and lacking for clinical populations. The objective of the pre-sent study was a longitudinal assessment of relevant ANT network measures in healthy controls and schizo-phrenic patients.Methods: Forty-five schizophrenic patients and 55 healthy controls were tested with ANT in a test–retest de-sign with an average interval of 7.4 months between test sessions. Test–retest reliability was analyzed withPearson and Intra-class correlations.Results: Healthy controls revealed moderate to high test–retest correlations for mean reaction time, mean ac-curacy, conflict effect, and conflict error rates. In schizophrenic patients, moderate test–retest correlations for

mean reaction time, orienting effect, and conflict effect were found. The analysis of error rates in schizo-phrenic patients revealed very low test–retest correlations.Conclusions: The current study provides converging statistical evidence that the conflict effect and mean re-action time of ANT yield acceptable test–retest reliabilities in healthy controls and, investigated longitudinallyfor the first time, also in schizophrenia. Obtained differences of alerting and orienting effects in schizophreniacase–control studies should be considered more carefully. The analysis of error rates revealed heterogeneousresults and therefore is not recommended for case control studies in schizophrenia.

© 2011 Elsevier B.V. All rights reserved.

1. Introduction

The Attention Network Test (ANT) has become an extensivelyused behavioral measure to assess selective attention in neuropsy-chological research. Within a single run, ANT provides simultaneousassessment of its three presumably independent attention compo-nents: alerting, orienting, and conflict processing, reflected via specif-ic reaction time (RT) and error rate (ER) patterns (Fan et al., 2002).

In the context of attention networks assessed by the ANT, alertingrefers to the ability ofmaintaining an alert state and phasically respond-ing to a temporal signal. Orienting refers to the beneficial behavioral ef-fect of spatial cueing (Posner, 1980), when a signal pre-indicates thelocation of the target stimulus. Conflict processing or executive control,the third component of the ANT, refers to the ability to resolve flankercompatibility conflicts. In line with the notion that the ANT provides avalid instrument for testing domains of selective attention, earlier stud-ies have investigated two of the three components of the ANT by

y and Psychotherapy, Charité, Eschenallee 3, 14050 Berlin,388.

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individual tasks: a) the flanker task (Eriksen and Eriksen, 1974),which corresponds to the executive control network of the ANT, andb) the cued reaction task (Posner, 1980), corresponding to the orientingnetwork. Findings from neuroimaging studies have further strength-ened the validity of the ANT by linking alerting and orienting to distinctparietal and frontal cortical activation (Coull et al., 2001; Fan et al.,2005), while the conflict network relies on the activation of anteriorcingulate cortex (ACC) and lateral prefrontal cortex (Bush et al., 2000;Fan et al., 2005; Neuhaus et al., 2007).

While earlier neuroimaging studies demonstrated that the threeANT network scores correlate with the activation of largely distinctneuroanatomical circuits, a more recent study using a revised atten-tion network test provided evidence that attentional brain networksinteract and are functionally integrated (Fan et al., 2009). This notionwas further supported by a meta-analysis which found cue x flankerinteractions in all analyzed data sets aswell as a significant inter-networkcorrelation between the alerting and orienting network (MacLeod et al.,2010).

Since 2001 the ANT has been applied in various populations, in-cluding adult control subjects, originating from different ethnicgroups (Fan et al., 2001; Fossella et al., 2003; Breton et al., 2011;Zhou et al., 2011), in children (Rueda et al., 2004) and the ageing

Table 1Summary of demographic, clinical, and IQ data at baseline (mean±standard deviation).

Schizophrenia Controls p

N (female/male) 45 (17/28) 55 (23/32) n.s.a

Age [years] 35.09±10.4 33.60±9.2 n.s.b

Education [years] 13.90±2.4 14.87±2.4 b.05b

Nicotine [pack years] 8.66±10.9 6.62±8.0 n.s.b

DOI [years] 8.12±8.3 – –

N episodes 3.14±2.0 – –

CPZ eq. [mg/d] 580.8±369.5 – –

PANSS P 14.05±5.32 – –

PANSS N 17.21±5.60 – –

Verbal IQ 110.29±15.8 115.42±15.8 n.s.b

Non-verbal IQ 105.13±6.2 110.11±6.1 b.05b

Abbreviations: DOI, duration of illness; PANSS, Positive and Negative Syndrome Scale(P, positive; N, negative); CPZ eq., chlorpromazine equivalents.

a χ2 test.b t-test for independent samples.

219E. Hahn et al. / Schizophrenia Research 133 (2011) 218–222

population (Jennings et al., 2007; Zhou et al., 2011). Studies of atten-tion network measures were also extensively conducted in clinicalpopulations, including attention-deficit hyperactivity disorder (Looet al., 2007; Adolfsdottir et al., 2008), borderline personality disorder(Posner et al., 2002; Rogosch and Cicchetti, 2005), deafness (Dyeet al., 2007), depression (Murphy and Alexopoulos, 2006), dyslexia(Bednarek et al., 2004), and 22q11 deletion syndrome (Sobin et al.,2004; Bish et al., 2005).

In schizophrenia research, the ANT has been widely used for thebehavioral assessment of the alerting (Nestor et al., 2007), orienting(Wang et al., 2005) and conflict effects (Gooding et al., 2006; Urbaneket al., 2009; Neuhaus et al., 2010, 2011; Breton et al., 2011) and in thecontext of nicotine withdrawal effects (AhnAllen et al., 2008). Fur-thermore, intermediate deficits of attention performance for the con-flict effect were reported recently for first-degree relatives ofschizophrenia patients (Breton et al., 2011).

Considering the abundant application of the ANT in clinical andnonclinical studies, it is remarkable that most studies have focusedprimarily on the test quality criterion of validity when assessingbetween-group differences, but they did not control for retest reli-ability within the same individuals. Since any interpretation of specificattention network deficits relies on the ability of the ANT to consistentlyassess this measure across different situations and over time, dataof test–retest reliability is essential. However, studies addressingthe reliability of the ANT are scarce and limited to the healthy popula-tion. Furthermore they do not state clearly the interval between bothtest-sessions (Fan et al., 2001, 2002; Greene et al., 2008; MacLeod etal., 2010). In afirst attempt tofill this gap, the current study investigatedtest–retest reliability scores in healthy control subjects and in schizo-phrenia patients to further elucidate the psychometric properties ofthe ANT.

2. Methods

2.1. Subjects

Forty-five schizophrenia patients (17 f, 28 m), whomet DSM-IV cri-teria, completed the study. All patients received atypical oral antipsy-chotic medication and dosages were calculated using chlorpromazine(CPZ) equivalents (Andreasen et al., 2010). Use of anticholinergicagents, benzodiazepine co-medication, and drug abuse in the pastweeks were exclusion criteria. Positive And Negative Syndrome Scale(PANSS) ratings were conducted at baseline and at retest by a boardcertified psychiatrist. Mean psychopathology scores between the testsessions measured by the positive subscale (14.05±5.32 and 12.11±3.24) and the negative subscale (17.21±5.60 and 15.17±4.50) of thePANSS did not reveal significant differences, but high correlations(r=.853; pb .001; and r=.886; pb .001, respectively), confirming con-sistency of patient characteristics across test sessions. In this respect,CPZ equivalents of oral antipsychotic medication did not differ signifi-cantly between baseline test (580.8 mg±369.5) and retest session(529.2 mg±357.4) either; additionally, CPZ equivalents were highlycorrelated between test sessions (r=0.835; pb .001), again assuringequivalent conditions within the patient group over time. None of theincluded patients had a history of any severe medical or neurologicaldisorder and never underwent electroconvulsive therapy.

Fifty-five healthy subjects (23 females, 32 males) served as con-trols. Control participants had no history of psychiatric axis I disorderaccording to DSM-IV as determined by a semi-structured clinical in-terview (SKID I/ II), had no history of substance abuse other than to-bacco smoking, no severe medical or neurological condition, and hadnever received any psychopharmacological treatment.

All participants were right-handed and reported normal orcorrected-to-normal vision. Mean time between test and retest sessionwas 7.4 months (range 6–9 months) across the sample; test–retest in-terval for schizophrenia patients was 7.49±1.3 months and 7.29±

1.0 months for healthy controls (T98=−.874; p=.385). Table 1 sum-marizes demographic and medical data at baseline.

All participants gavewritten informed consent before participatingin the study. The study protocol was approved by the ethics commit-tee of the University Hospital Benjamin Franklin, Charité UniversityMedicine, Berlin, Germany, and the study was conducted in accor-dance with the Declaration of Helsinki.

2.2. Task design

During the experiment, participants viewed at a 17-inch cathoderay tube monitor from a distance of 60 cm a fixation cross that wasvisible in the center of the screen. Cue stimuli appeared in one ofthe following positions: above or below the fixation cross (spatialcue), above and below the center (double cue), in the center (centercue), or no stimuli were displayed (no cue). Spatial cues alwaysappeared at the upcoming target's location. Target stimuli alwaysconsisted of five horizontally arranged arrows or lines presentedabove or below the fixation cross. By left or right button press, sub-jects had to indicate the direction of the central arrow irrespectiveof flanking conditions. Flankers were either lines (neutral target con-dition) or arrows pointing to the same (compatible) or to the oppo-site (incompatible) direction.

Each trial consisted of a variable fixation period (400–1600 ms),an invariant cue presentation (100 ms) with a subsequent fixation(400 ms), and target presentation (maximum duration 1700 ms). Fol-lowing a training of 24 pseudo-randomized trials with full feedback, atotal of 288 pseudo-randomized trials (4 cues×3 targets×8 repeti-tions per block×3 blocks) without feedback was presented. Subjectswere instructed to maintain focusing on the fixation cross throughoutthe experiment and to respond as fast and as accurately as possible.

The ANT provides response time (RT) and error rate (ER) as de-pendent variables for each of the three attention networks, whichare calculated as reaction time (RT) differences of different task con-ditions. Alerting is computed as RT targets (no previous cue) minusRT targets (previous double cue). Orienting is computed as RT targets(previous center cue) minus RT targets (previous spatial cue). Con-flict is computed as RT incompatible targets minus RT compatible tar-gets. Further illustration of the task is given elsewhere (Neuhauset al., 2011).

2.3. Statistical analysis

All statistical calculations were conducted using PASW for Win-dows 18.0 (Chicago, IL, US). Demographic and clinical data were ana-lyzed with t-tests for independent and for paired samples, asappropriate. Cross-sectional ANT data were analyzed with t-tests for

Table 3Summary of behavioral ANT data of schizophrenia patients (mean±standarddeviation).

Baseline Retest ra ICCb

Mean RT [ms] 653.73±131.9 634.27±114.2 .674⁎⁎ .663⁎⁎

Mean Accuracy [%] 97.49±4.8 97.83±3.6 .091 .089Alerting effect [ms] 37.11±27.7 45.79±34.6 .331⁎ .316⁎

Orienting effect [ms] 57.37±39.5 54.77±30.1 .548⁎⁎ .532⁎⁎

Conflict effect [ms] 97.70±44.3 90.45±38.2 .530⁎⁎ .522⁎⁎

Alerting ER [%] 0.15±2.0 0.16±2.4 .039 .039Orienting ER [%] 1.14±3.0 1.05±2.3 .303⁎ .298⁎

Conflict ER [%] 2.92±4.4 3.34±9.6 .045 .034

Abbreviations: RT, reaction time; ER, error rate.a Pearson's r.b ICC, intra-class correlation.⁎ pb .05.⁎⁎ pb .001.

220 E. Hahn et al. / Schizophrenia Research 133 (2011) 218–222

independent samples. Longitudinal data was analyzed for practiceeffects by means of t-test for paired samples. Retest reliability wasanalyzed by two complementary approaches. In the first approach,test–retest correlations were analyzed calculating Pearson r coeffi-cient following the assumption of normal distribution. In the secondapproach, and controlling for potential systematic errors, intra-classcorrelations (ICC) were calculated separately for single measures.The rationale for including ICC as a more conservative approach inaddition to Pearson correlation analyses was that ICC is more robustto differences of absolute values between two test sessions (Weir,2005). All tests were performed as two-tailed tests with an alphalevel set at pb .05.

3. Results

3.1. Cross-sectional analyses

At baseline, significant behavioral between-group differences oc-curred between controls and patients with faster mean RT(T98=3.658; pb .001) and higher mean accuracy (T98=2.209;pb .05) in the control group. No other significant differences of net-work effect scores were found.

At retest, only faster mean RT for controls remained significantlydifferent between groups (T98=4.237; pb .001), while mean accuracyshowed a trend-level difference between controls and patients(T98=1.856; pb .1). Additionally, and in contrast to the baseline ses-sion, conflict effect scores were significantly higher for patients com-pared to controls (T98=2.290; pb .05).

3.2. Analysis of practice effects

Significant differences between test sessions were found for meanRT and conflict effect in healthy controls. Mean RT decreased from575.04±81.4 ms to 552.20±78.9 ms (T54=3.157; p=.003). Conflicteffect also decreased from 94.78±33.2 ms to 75.21±28.3 ms(T54=5.275; pb .001). In schizophrenia patients, no practice effectswere found.

3.3. Retest reliability analyses

Longitudinal data were analyzed with Pearson and intra-class cor-relations for each group separately. Tables 2 and 3 summarize meanbehavioral data for healthy controls and schizophrenia patients, re-spectively. Mean RT at baseline and retest were highly correlated incontrols (Pearson's r=.776; ICC r=.749; pb .001) and moderatelycorrelated in schizophrenia patients (Pearson's r=.674; ICCr=.663; pb .001), while accuracy measures were correlated in con-trols only (Pearson's r=.558; ICC r=.553; pb .001).

Table 2Summary of behavioral ANT measures data in healthy controls (mean±standarddeviation).

Baseline Retest ra ICCb

Mean RT [ms] 575.04±81.4 552.2±78.9 .776⁎⁎ .749⁎⁎

Mean Accuracy [%] 98.97±1.1 98.78±1.2 .558⁎⁎ .553⁎⁎

Alerting effect [ms] 44.50±25.5 47.63±26.2 .232⁎ .233⁎

Orienting effect [ms] 51.60±22.3 51.81±23.1 .331⁎ .335⁎⁎

Conflict effect [ms] 94.78±33.2 75.21±28.3 .610⁎⁎ .504⁎⁎

Alerting ER [%] 0.02±1.8 0.05±1.8 .162 .166Orienting ER [%] 0.35±1.4 0.10±1.4 .109 .109Conflict ER [%] 2.16±2.8 2.18±3.0 .748⁎⁎ .750⁎⁎

Abbreviations: RT, reaction time; ER, error rate.a Pearson's r.b ICC, intra-class correlation.⁎ pb .05.⁎⁎ pb .001.

Regarding attention network effects in healthy controls, moderatecorrelations were found for the conflict effect (Pearson's r=.610;ICC r=.504; pb .001) and low correlations for the orienting effect(Pearson's r=.331; ICC r=.335; pb .05). In schizophrenic patients,moderate test–retest correlations were revealed for the conflict effect(Pearson's r=.530; ICC r=.522; pb .001) and for the orienting effect(Pearson's r=.548; ICC r=.532; pb .001).

Regarding error rates, high correlations were evident only for theconflict condition in healthy controls (Pearson r=.748; ICC r=.750;pb .001). In schizophrenic patients, low correlations of error rateswere found for the orienting effect only (Pearson r=.303; ICCr=.298; pb .05).

4. Discussion

The objective of the current study was to assess test–retest reli-ability in healthy controls and in schizophrenic patients, thereby pro-viding the first longitudinal ANT data in a psychiatric sample. Inhealthy controls, our findings revealed moderate to high test–retestcorrelations for mean RT and conflict error rate, and moderate corre-lations for mean accuracy and conflict effect. In schizophrenic pa-tients, our results revealed moderate correlations only for mean RT,conflict effect, and orienting effect. Error rates and mean accuracywere not sufficiently reliable in this sample of schizophrenic patients.

Previous research addressing the reliability of the ANT network ef-fect has been scarce and far less conclusive than research on the valid-ity of the ANT, and these few previous reliability studies were limitedto the healthy population. Using a sample of 104 healthy participants,an initial assessment of ANT by Fan et al. (2001) revealed low reliabil-ity scores for alerting (.36) and orienting (.41), but high reliabilityscores for the conflict effect (.81) (Fan et al., 2001). In a smaller sam-ple of 40 subjects, the same research group reported moderate reli-ability scores for alerting (.52), orienting (.61) and consistentlymoderate to high reliability scores for the conflict effect (.77) (Fanet al., 2002). Another study by Greene et al. (2008)reported split-half reliability correlations for a lateralized version of the ANT in asample of 23 young adults and revealed low scores for alerting (.15)and moderate to high scores for orienting (.70) and conflict effect(.74) (Greene et al., 2008).

To date, only one meta-analysis exists that analyzed data from 15independent studies of the ANT resulting in a large sample(N=1,129). In this study, MacLeod et al. (2010) examined split-halfreliabilities of both reaction times (RT) and error rates (ER) andfound similar patterns of reliability measures with respect to RT(alerting: .20, orienting: .32, conflict: .65) and with respect to ER(alerting: .06, orienting: .14, conflict: .71).

Our longitudinal data in healthy adults using Pearson's r correla-tion replicates this pattern with respect to RT (alerting: .23, orienting:.32, conflict: .61) and with respect to ER (alerting: .16, orienting: .11,

221E. Hahn et al. / Schizophrenia Research 133 (2011) 218–222

conflict: .75). Taken together, in research addressing reliability of theANT in the healthy population and in our schizophrenia sample, theconflict effect consistently appears to be the most reliable measureof network effects.

When comparing test–retest reliability measures between healthycontrols and schizophrenic patients, our results revealed that only theconflict effect assessed with Pearson's r and ICC was at least moderatein both groups (0.61 and .50 vs. .53 and .52), respectively. Additional-ly mean reaction time was a high to moderate reliable measure forhealthy controls and in schizophrenic patients (.78 and .75 vs. .67and .66), respectively. In contrast to healthy controls, ER reliabilitydid not reach a moderate level in our sample of schizophrenicpatients.

Practice effects of mean RT and conflict were found for healthycontrols, but not schizophrenia patients. While this finding is not sur-prising, it still fails to explain the similarity of retest reliability corre-lations obtained in this study. When addressing the role of furtherpotentially confounding variables, no differences occurred betweenboth test sessions in our sample of schizophrenic patients with re-spect to antipsychotic medication, as calculated by CPZ equivalents,psychopathology, as measured via subscales of the PANSS, and withrespect to time of test application. Pearson correlation analysis ofmedication level and psychopathology scores showed an overallhigh correlation between baseline and retest suggesting consistencyover time.

Furthermore, nicotine consumption, as measured by pack-years,did not differ between patients and controls. Importantly, we con-trolled for potential differences of absolute values between both testsessions by the complementary assessment of reliability correlationsusing ICC. A very similar pattern of ICC compared to Pearson's r indi-cates the absence of a systematic error in our sample.

In line with the current findings, it is noteworthy that most studiesusing the ANT in schizophrenia research focus on the conflict effect.Converging evidence from electrophysiological studies (Neuhauset al., 2007; 2010; 2011) genetic studies of heritability (Fan et al.,2001), neuroimaging studies (Fan et al., 2005) and studies of candi-date genes (Fossella et al., 2006; Opgen-Rhein et al., 2008; Dubertretet al., 2010) point to a less efficient executive control network inschizophrenia. In a recent study, Breton et al. (2011) found thatonly the conflict effect, in contrast to alerting and orienting, differen-tiates between patients with schizophrenia, their first-degree rela-tives and healthy controls. Considering chronic cannabis abuse inadolescents as a potential risk factor for developing schizophrenia,chronic users differed from controls by showing poorer performancein the conflict condition but not in the networks related to the alert-ing or orienting condition of the ANT (Abdullaev et al., 2010).

Overall, in this first reliability assessment in healthy adults and inschizophrenic patients, our results contribute valuable data of test–retest reliability of the ANT. Furthermore, our results could ultimatelyhelp to explain the heterogeneity regarding the alerting and orientingnetwork in various studies of ANT in schizophrenia and potentially inother clinical samples. Considering that significant differences aremore likely to be revealed for the more reliable conflict conditionthan for the orienting or alerting condition, it is not surprising thatin relation to the conflict effect the alerting and orienting effects ofthe ANT have so far not yielded comparable empirical significancein schizophrenia research.

In conclusion, the current study provides important evidence thatonly the conflict effect and mean reaction time of ANT yield accept-able test–retest reliabilities in both healthy controls and in schizo-phrenia. Differences of orienting and especially alerting effects inschizophrenia samples should be considered more carefully. Giventhe low reliability measures of the current and earlier studies,mean accuracy and specific network error rates may yield controver-sial results in case–control studies and should be handled withcaution.

Role of funding sourceNone.

ContributorsAuthors EH, AHN and MD designed the study. TMT and CR collected the data and

did the analyses together with CH and LKK. EH wrote the first draft of the manuscript.All authors have contributed to and approved the final version of the manuscript.

Conflict of interestAll authors declare that there is no conflict of interests related to this study.

AcknowledgementsThe authors thank all participants of this study. This work is part of the doctoral

thesis of Thi Minh Tam Ta, and Claudia Ruehl.

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