Brain & Development 34 (2012) 806–811

www.elsevier.com/locate/braindev

Original article

EEG characteristics and visual cognitive function of children

with attention deficit hyperactivity disorder (ADHD)
Tongkun Shi a, Xia Li a,b, Jia Song a, Na Zhao a, Caihong Sun a, Wei Xia a,
Lijie Wu a,⇑, Akemi Tomoda c
a
Department of Child and Adolescent Health, Public Health College, Harbin Medical University, Harbin, PR China
b
Department of Sanitarian of Zaozhuang Maternity and Child Care Hospital, 25# East of Wenhua Road, Shizhong District, Zaozhuang,
Shandong 277100, PR China
c
Child Development Research Center, Graduate School of Medicine, University of Fukui, Fukui, Japan

Received 29 August 2011; received in revised form 16 February 2012; accepted 28 February 2012

Abstract

Using visual and auditory continuous performance tests (CPT) and EEG, cognitive function and EEG power were investigated in
patients with attention deficit hyperactivity disorder (ADHD). CPT and EEG were conducted for 44 ADHD children and 44
healthy controls of comparable age and sex. The EEG power tests include relative power of theta, alpha, and beta, and theta/beta
and theta/alpha ratios. ADHD patients showed significantly higher theta relative power, lower beta relative power, and higher
theta/beta ratio (p < 0.05). ADHD patients showed a significantly lower score of auditory CPT (p < 0.05). The EEG power char-
acteristics were correlated significantly with the visual attention function in ADHD children (p < 0.01). Higher-order level cognitive
dysfunction affects ADHD pathogenesis. Cortical hypoarousal effects on several mechanisms including the fronto-striatal circuitry
may be implicated in the inhibition of prepotent and premature responses.
Ó 2012 The Japanese Society of Child Neurology. Published by Elsevier B.V. All rights reserved.

Keywords: Attention deficit hyperactivity disorder (ADHD); Integrated visual and auditory continuous performance test (IVA-CPT); Children;
EEG; Visual cognitive function

1. Introduction of ADHD. Reportedly, 45–90% of ADHD children

Attention deficit hyperactivity disorder (ADHD) is
the most common psychiatric disorder among children
[1]. As defined in DSM-IV, ADHD symptoms include
developmentally inappropriate levels of attention,
hyperactivity, and impulsive behavior. If untreated,
ADHD, which has been estimated conservatively as
affecting 3–5% of school-aged children [2], can influence
children’s studies, family settings, and social life. The
pathogenesis of this disorder remains unknown, with a
lack of objective, comprehensive indicator for diagnose
⇑ Corresponding author. Tel./fax: +86 451 87502867.
E-mail address: wulijie_123@yahoo.com.cn (L. Wu).
show electroencephalographic abnormalities [3].
Quantitative electroencephalographic recording is a
noninvasive measurement of the baseline or the underly-
ing brain state before information processing [4]. Elec-
troencephalographic measurements have been regarded
as highly sensitive in distinguishing ADHD patients
from healthy subjects in many studies [5,6]. An early
study that identified EEG abnormalities in children with
ADHD was Jasper’s study [7] (1938) of children with
behavior problems: the study examined 71 children aged
2–16 years, most with IQ above 70. Results show that
over half of the subjects had EEG abnormalities, pre-
dominantly increased slow wave (2–6 Hz) activity in
one or more regions, and often in frontal regions. With

0387-7604/$ - see front matter Ó 2012 The Japanese Society of Child Neurology. Published by Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.braindev.2012.02.013
 T. Shi et al. / Brain & Development 34 (2012) 806–811
the application of computer aided tools, many new
methods in EEG analysis were applied, including mea-
surements of amplitude, relative power, absolute power,
and analysis of the dominant frequency and average fre-
quency, each band power percentage, and power ratios.
Clarke et al. [8] reported that 20 ADHD children’s rela-
tive power and absolute power of alpha and beta waves
were lower than those of normal controls. The relative
power and absolute power of theta waves were higher
than in the control group. Monastra et al. [9] found that
the value of theta/beta ratio was useful to distinguish
ADHD patients from normal ones, and found that the
respective degrees of sensitivity and specificity reached
86% and 98%. Clarke’s et al. [8] research also revealed
that the values of theta/alpha ratio and theta/beta ratio
were diverse in normal children and in ADHD children.
In addition, this ratio was useful to distinguish inatten-
tion-type patients and combined-type patients.
We used a biofeedback system to detect the levels of
relative power of EEG and the values of the relative
power ratio, along with neuropsychological testing anal-
yses to assess correlation between the visual cognitive
function and the EEG characteristics. Thereby, we were
able to explore the relations between resting-state EEG
and ADHD behavior symptoms, and to validate the
EEG power in predicting the cognitive activities of
ADHD children.
2. Methods
2.1. Subjects
Subjects included 44 children who were diagnosed
with ADHD (mean age 8.45; SD 2.11; range 6–14 years;
36 boys and 8 girls) and 44 age-and-sex-matched (pair-
wise) healthy children as a control group (mean age
8.32; SD 1.99; range 6–14 years). Forty-four ADHD
children included 34 inattentive type (IT) children, seven
combined type (CT) children and three hyperactive-
impulsive type (HI) children. All ADHD children were
recruited from Child Development and Behavior
Research Center of Harbin Medical University; healthy
children were recruited from primary school as volun-
teers. Both of two groups were residents of Harbin,
the capital city of Heilongjiang province.
All ADHD subjects were selected by two pediatri-
cians. The ADHD diagnosis was further confirmed with
a semi-structured interview based on the Diagnostic and
Statistical Manual of Mental Disorders Fourth Edition,
Text Revision (DSM-IV-TR) diagnostic criteria for
ADHD.
Exclusion criteria for both the ADHD group and the
control group include a personal history of physical
brain injury, neurological disorder, genetic disorder, or
other severe medical condition or a personal history of
substance abuse or dependency. Patients with IQ of 80
807
or less (Wechsler Intelligence Scale for Children, Third
Edition; WISC-III), and those with comorbid epilepsy,
progressive neurological and psychiatric disorders were
excluded. Control group subjects were also excluded if
they reported a family history of ADHD, psychiatric
disorder, or genetic brain disorder.
Both ADHD patients and healthy children were med-
ication free (central nervous system stimulant) for at
least 48 h before testing. Moreover, for at least 2 h prior
to testing, participants were asked to refrain from caf-
feine intake and smoking. All subjects or their guardians
were provided a written informed consent form for par-
ticipation in the research at the Child Development and
Behavior Research Center at Harbin Medical Univer-
sity, in accordance with National Health and Medical
Research Council guidelines.
2.2. Procedures and tasks
2.2.1. Resting electroencephalographic condition
The EEG was recorded in an eyes-closed resting condi-
tion, with subjects sitting in reclining chair. The test used a
biofeedback system (VBFB 3000; Thought Technology
Ltd., Canada). Electrode placement followed the Interna-
tional 10–20 system, using three electrodes. The Fourier
transformation was carried out for 600 s consisting of
one EEG record in each patient. According to the interna-
tional 10–20 Electrode Placement System, Cz [10,11] is
the standard placement sites, which is the most sensitive
EEG area between ADHD and normal children. Active
(record) electrode was placed at site Cz in order to collect
EEG activity signals easily. Reference (A1) and Ground
(A2) electrode were placed on opposite ear lobes. Sub-
jects, who were told that the task would last for 10 min,
were asked to rest quietly with their eyes closed during
the recording. The record index includes the level of the
relative power of theta (4–7 Hz) wave, alpha (8–12 Hz)
wave, the beta (13–32 Hz) wave, and the values of the
theta/beta ratio and theta/alpha ratio.
2.2.2. Cognitive tasks
This test mainly adopted the software of Integrated
Visual and Auditory continuous performance test (IVA-
CPT; Brain Train, USA). Furthermore, information
from the tests was collected by computer. The IVA-CPT
principle is mainly to represent repeated auditory and
visual stimuli, and to record the response of subjects
(including reaction time, omissions, endurance, repetition
frequency, etc.) to assess the attention activity. The IVA-
CPT results include six full-scale quotients and 12 inde-
pendent quotients. The full scale response control quo-
tient (FRCQ) is based on equal weights of the auditory
response control quotient (ARCQ) and the visual
response control quotient (VRCQ), ARCQ and VRCQ
scores are based on equal weights (1/3) of their respective
prudence, consistency and stamina scales.
808 T. Shi et al. / Brain & Development 34 (2012) 806–811

The full scale attention quotient (FSAQ) is based on Table 1

equal weights of the auditory attention quotient (AAQ) Power of EEG between ADHD children and the control group (x  s).
and the visual attention quotient (VAQ). The AAQ and Items AD/HD Control t p
VAQ in turn are based on equal weights (1/3) of their Theta % 21.75 ± 2.94 20.49 ± 1.85 2.402 .021*
respective vigilance, focus and speed scales. Alpha % 14.53 ± 3.84 14.01 ± 4.01 0.481 .634
During the test, subjects were asked to press the Beta % 5.44 ± 1.24 6.41 ± 1.16 4.302 .001**
mouse left key once if they saw or heard the number Theta/beta 4.22 ± 1.23 3.41 ± 0.57 4.194 .001**
“1”, and not to click if they saw or heard the number Theta/alpha 1.62 ± 0.49 1.54 ± 0.34 0.667 .765
“2”. Participants were asked to remember the following
four rules: see “1” press mouse; hear “1” press mouse;
see “2” do not press the mouse left key; hear “2” do
for ADHD subjects and control subjects across scalp
not press the mouse left key. The computer recorded
sites during eyes-closed resting activity. Using paired t-
the statistical analysis feedback of subjects.
tests, significant differences were found between two
groups in theta relative power, beta relative power,
2.3. Statistical analysis
and the theta/beta ratio (t = 2.402, p < 0.05;
t = 4.302, p < 0.05; t = 4.194, p < 0.05). In the ADHD
2.3.1. Statistical method
group, the level of relative power of theta and the value
A paired t-test was used to compare the results of the
of theta/beta ratio were significantly higher than in the
ADHD group to those of the control group. A correla-
control group, and the level of relative power of beta
tion analysis was used to measure the relative power
was significantly lower than in the control group.
between the brain electrical level and cognitive task
grades in two groups. Furthermore, as a secondary anal-
3.2. Cognitive task analyses
ysis, a Pearson correlation matrix was computed to
ascertain whether the power of EEG for each band
Tables 2 and 3 present differences between the
was related to the cognitive function in the IVA-CPT,
ADHD group and the control group in the result of
with the significance cutoff set at p < 0.05. All statistical
IVA-CPT for the response control quotient and atten-
analyses were processed using software (SPSS 13.0;
tion control quotient.
SPSS Inc., USA).
For the response control quotient, the ADHD group
scores were significantly lower in seven quotients of
2.3.2. Quality control
response control: the full scale response control quo-
All testers were strictly trained to be familiar with the
tient, auditory response control quotient, visual
use of test instruments, and to adopt a unified standard.
response control quotient, auditory prudence quotient,
Testers ensured the completion of the whole process for
visual prudence quotient, auditory consistency quotient,
each subject. The test environment was quiet, with no
and visual consistency quotient (p < 0.05).
magnetic interference, thereby ensuring the reliability
Regarding the attention control quotient, the ADHD
of data collection.
group scores were significantly lower in nine quotients of
attention control: the full scale attention quotient, audi-
3. Results
tory attention control quotient, visual attention control
quotient, auditory vigilance quotient, visual vigilance
3.1. Electroencephalographic analyses
quotient, auditory focus quotient, visual focus quotient,
auditory speed quotient, and visual speed quotient
Table 1 presents the relative power in theta, alpha,
(p < 0.05).
and beta, and the theta/beta ratio and theta/alpha ratio
Table 2
Results of IVA-CPT of the response control quotient for ADHD children and the control group (x  s).

Items AD/HD Control t p

FRCQ 80.60 ± 21.55 97.34 ± 18.72 3.274 .002**
ARCQ 83.74 ± 18.95 98.24 ± 17.60 3.436 .001**
VRAQ 81.65 ± 22.28 97.70 ± 17.06 2.996 .005**
Auditory prudence quotient 91.84 ± 20.75 102.92 ± 18.95 2.456 .019*
Visual prudence quotient 87.97 ± 17.92 98.78 ± 15.16 2.932 .006**
Auditory consistency quotient 75.37 ± 15.63 93.92 ± 16.68 5.125 .001**
Visual consistency quotient 80.08 ± 23.22 99.49 ± 18.37 3.849 .001**
Auditory stamina quotient 99.89 ± 22.82 99.50 ± 12.52 .094 .926
Visual stamina quotient 93.51 ± 19.55 98.05 ± 12.24 1.130 .266
Note: FRCQ, full scale response control quotient; ARCQ, auditory response control quotient; VRCQ, visual response control quotient.
 T. Shi et al. / Brain & Development 34 (2012) 806–811 809

Table 3
Result of IVA-CPT of the attention quotient for ADHD children and the control group (x  s).

Items AD/HD Control t p

FAQ 68.86 ± 23.89 98.51 ± 17.75 5.747 .001**
AAQ 69.34 ± 24.45 97.05 ± 18.84 5.028 .001**
VAQ 74.95 ± 23.86 100.62 ± 15.48 5.428 .001**
Auditory vigilance quotient 66.34 ± 32.99 94.21 ± 20.58 4.039 .001**
Visual vigilance quotient 78.11 ± 22.21 99.49 ± 13.57 4.660 .001**
Auditory focus quotient 82.92 ± 16.53 98.68 ± 14.01 4.745 .001**
Visual focus quotient 85.62 ± 18.07 99.73 ± 17.16 3.252 .002**
Auditory speed quotient 94.63 ± 14.79 102.00 ± 12.34 2.174 .036*
Visual speed quotient 94.38 ± 17.49 101.73 ± 13.31 2.125 .041*
Note: FAQ, full scale attention quotient; AAQ, auditory attention quotient; VAQ, visual attention quotient.

Table 4
Correlation between IVA-CPT and the relative power of EEG in ADHD children.

Item Theta % Alpha % Beta % Theta/beta Theta/alpha

FRCQ .050 .303 .094 .043 .261
ARCQ .03 .302 .097 .059 .243
VRAQ .061 .233 .189 .093 .189
Auditory prudence quotient .045 .238 .112 .109 .193
Visual prudence quotient .544** .104 .069 .293 .349
Auditory consistency quotient .040 .127 .090 .093 .007
Visual consistency quotient .078 .150 .238 .156 .030
Auditory stamina quotient .044 .191 .080 .033 .186
Visual stamina quotient .177 .212 .148 .042 .184
FAQ .322 .441* .066 .114 .184
AAQ .227 .302 .016 .097 .159
VAQ .267 .294 .016 .145 .034
Auditory vigilance quotient .102 .406* .027 .035 .246
Visual vigilance quotient .718** .042 .096 .411* .213
Auditory focus quotient .522** .142 .230 .062 .107
Visual focus quotient .074 .104 .281 .235 .010
Auditory speed quotient .647** .079 .039 .358* .291
Visual speed quotient .524** .003 .290 .050 .126
*
p < 0.05.
**
p < 0.01.

3.3. Correlation analyses
The Pearson correlation matrix between indexes of
EEG characteristics and scores of cognitive tasks in
ADHD group is shown in Table 4. For ADHD subjects,
a significant negative linear relation was found between
the level of theta relative power and each of the visual
prudence quotient, visual vigilance quotient, auditory
focus quotient, auditory speed quotient, and visual
speed quotient. Statistically significant positive linear
correlation was found between the level of alpha relative
power and each of the full scale attention quotient and
the auditory vigilance quotient. In addition, a significant
negative linear relation was found between the level of
the theta/beta ratio and the scores of the visual vigilance
and the auditory speed quotient.
4. Discussion
The method of recording the relative power of EEG
in detection analysis, which is used widely in ADHD
studies, can distinguish the normal group from the case
group. Particularly, EEG recording under eyes-closed
conditions is an extremely reliable method [12,13]. In
1996, Chabot and Serfontein [6] reported that the
EEG of the children with ADHD differed from those
of normal children, results showed that the theta abso-
lute power and the relative power of electrical was
increased, mainly concentrated in the frontal lobe, espe-
cially in prefrontal regions. Furthermore, alpha waves
and beta waves changed. In 1998, Clarke et al. [14] first
applied the DSM-IV diagnosis of ADHD and analyzed
the brain electrical power of all subjects, revealing that
test electrode parts of the theta relative power and abso-
lute power are significantly higher than those of the con-
trol group. The brain electrical power of alpha and beta
are decreased significantly. A previous study also sup-
ports the results presented above [15].
This study found that the theta relative electrical
power of ADHD children was statistically significantly
higher than that of the control group. The beta relative
electrical power was lower than that of the control
810 T. Shi et al. / Brain & Development 34 (2012) 806–811
group to a statistically significant degree. These findings
revealed that the EEG characteristics of ADHD chil-
dren are abnormal, which may imply that the average
excitation of the brain is decreased, and that the inhibi-
tion of the cortical nervous system is decreased. Conse-
quently, the ADHD children can not maintain an
appropriate degree of attention. They may not be able
to specifically examine many things, engendering behav-
ior such as inattention in class and hyperactivity. The
dysfunction of specific brain areas associated with these
abnormalities might explain characteristics of clinical
symptoms observed in ADHD patients.
In recent years, with the development of the quantita-
tive electroencephalogram technology for ADHD study,
it has been recognized that the ratio of theta/beta can
forecast the ADHD group and the control group well.
Monastra et al. [9] research showed that theta/beta
ratios can differ between ADHD patients and others,
with specificity and sensitivity reaching 86% and 98%,
respectively. Many scholars have analyzed multiple
quantitative EEGs and have reported an increase in
the value of theta/beta ratio among ADHD children
as a common property, with further conclusions show-
ing that when the value of theta/beta power is 3.08, spec-
ificity and sensitivity both reached 94% [16]. Our results
demonstrate that the mean of theta/beta ratio in ADHD
children (age: 6–14) is 4.22 (SD = 1.26), which was sig-
nificantly higher than that of the control group.
Cognitive testing tasks, which include the prudence
quotient, consistency quotient, and stamina quotient,
reflect the subjects’ auditory and visual response control
ability, especially the prudence quotient. It can measure
the omission of ADHD children in auditory and visual.
The vigilance quotient, focus quotient, and speed quotient
reflect auditory and visual attention abilities of subjects,
especially the vigilance quotient. It can measure the error
of ADHD children in auditory and visual tasks. The sub-
ject is inferred to have cognitive function disorder if the
score is less than 85. These results demonstrate that the
“omission” of the ADHD group was significantly higher
than that of the control group, and that the number of
“errors” in the ADHD group was significantly greater
than that for the control group, thereby revealing that
ADHD children might have cognitive function disorder.
The results of Pearson correlation analysis showed
that the visual prudence quotient and visual vigilance
quotient each shared a significantly negative linear cor-
relation with the level of theta relative power when the
level of theta relative power raised the levels of omission
and numbers of errors. This result is consistent with
results of other studies. Swartwood et al. [17] reported
a significant linear correlation between the left forehead
theta band change and the results of continuous opera-
tion test. Daniel [18] found the power of theta and
response delayed error were significantly higher than
in the control group.
The results of correlation analyses revealed theta
power improvement and the scores of signal detection
tasks significantly correlated to the error rate, which
implied that abnormal theta activities affect ADHD chil-
dren’s performance of cognitive tasks, especially the level
of attention. Some earlier studies identified that a signifi-
cant increase of theta is consistent with decreased white
matter, glucose metabolism, and total brain capacity
[19–22]. Increased theta wave activity of ADHD children
can engender changes in attention, inability to concen-
trate, and other defects of behavior in class. Normal
experiments also revealed a correlation between increased
theta activity and sleep [23]. The theta activity level,
reflecting a person’s cognitive level, also decreased [24].
Additionally, correlation between alpha activity and
attention defects has been shown in go/no go out of task
[25]. The alpha activity level reflects a certain arousal
state. The results of the present study showed that the
level of alpha activities and full scale attention quotient
share a significant positive correlation, implying that the
alpha level affects brain resource allocation.
The results of correlation analyses conducted for brain
electrical power and cognitive function of ADHD chil-
dren show that improvement of the theta/beta ratio is sig-
nificantly and negatively related to performance of visual
memory and the visual vigilance quotient. Many
researchers have reported a significant and positive corre-
lation between the level of EEG power and error rate in
signal stop task [26]. Martine [27] reported that the
theta/alpha ratio and theta/beta ratio are negatively cor-
related to response speed in a signal-to-stop task. The
result of the survey also showed that the level of theta/
beta ratio has a significant negative correlation with audi-
tory speed. This result is inconsistent with that reported
above. The increase of the theta/beta ratio might have
certain relations with hyperactivity and impulsive behav-
iors [28]. A unified account of our findings is provided by
a biophysical model presented by Rowe et al. [29].
This preliminary study includes some limitations: the
samples are small, and we did not carry out stratified
analysis including the age and sub-type of ADHD chil-
dren. Moreover, we did not analyze the electrical activ-
ity characteristics of various brains areas because of the
limited number of brain electrodes. We suggest that
future studies can use an electrode cap, comparing dif-
ferent changes of EEG among various brain areas.
Acknowledgments
The work was supported by the Child Development
Behavioral Research Center, Harbin Medical
University.
Funding support from NSFC (30571576) is gratefully
acknowledged, in addition to the support of Yi Fu Pri-
mary School, Harbin, for data collection.
 T. Shi et al. / Brain & Development 34 (2012) 806–811
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