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0034-7450/$ – see front matter © 2013 Asociación Colombiana de Psiquiatría. Publicado por Elsevier España S.L. Todos los derechos reservados.
www.elsevier.es/rcp
REVISTA COLOMBIANA DE
P
SIQUIATRI
A
IS N: 0 34-7450
www.psiquiatria.org.co
Año 49 / Volumen 42
Número
2
/ Junio
2013
REV COLOMB PSIQUIAT. 2013;
42(4)
:324-332
Original article
Cognitive and Executive Functions in Colombian School
Children with Conduct Disorder: Sex Differences
Gina Rocío Urazán-Torres, Mario José Puche-Cabrera,
Mangelli Caballero-Forero y César Armando Rey-Anacona*
San Buenaventura University, Bogotá, Colombia
ARTICLE INFORMATION
Article history:
Received July 5, 2013
Accepted September 3, 2013
Keywords:
Conduct disorder
Neuropsychology
Cognition
Executive function
*Corresponding author.
E-mail:
cesar.rey@uptc.edu.co (C.A. Rey-Anacona).
ABSTRACT
Introduction:
Most of the studies that have examined cognitive and executive functions
in conduct disorders (CD) have been conducted on institutionalized male adolescents. In
this research the cognitive and executive functions of non-institutionalized Colombian
school children with CD were compared with normal school children, all between 6 and
12 years-old.
Materials and methods:
We used a case-control design. The cases were participants who
met the diagnostic criteria for CD (n
=
39) and controls who did not meet these criteria
(n
=
39), according to reports of a professional of the participants’ institution, and a
structured interview for childhood psychiatric syndromes. The two groups were selected
from educational institutions, and there were no differences in age, school grade, or
socioeconomic level. The IQ was reviewed, as well as the presence of other mental disorders,
serious physical illnesses, and more serious neurological signs. The cognitive and executive
functions were evaluated using a child neuropsychological test battery.
Results:
We found that participants with CD had significantly lower scores in construction
abilities, perceptual abilities (tactile, visual and auditory), differed in verbal memory, differed
in visual memory, language (repetition, expression and understanding), meta-linguistic
abilities, spatial abilities, visual and auditory attention, conceptual abilities, verbal and
graphic fluency, and cognitive flexibility. The same differences were found between males,
except in repetition, whereas girls showed fewer differences, thus the cognitive and
executive performance was poorer in males with CD than in females, especially in verbal
and linguistic-related functions.
Conclusions:
Children with CD could show generalized cognitive and executive deficits.
These deficits seem to be more frequent in boys than in girls with CD.
© 2013 Asociación Colombiana de Psiquiatría. Publicado por Elsevier España, S.L.
Todos los derechos reservados.
REV COLOMB PSIQUIAT. 2013;
42(4)
:324-332
325
Introduction
Conduct disorder (CD) is defined as a pattern of behavior that
is characterized by persistent enforcement actions affecting
social norms and the rights of others, including attacks on
humans and animals, destruction of property, dishonesty or
theft and serious violations of rules
1,2
. CD usually appears
towards the end of childhood or early adolescence and is
divided into childhood-onset subtype if at least one of the
antisocial behaviors listed in the diagnosis is made within
ten years of age and adolescent onset subtype if such conduct
occurred only after they were ten years old
1
. According to
Althoff et al
3
, prevalence of this disorder rates as high
as 16% of the samples, though rates tend to be consistent
between different cultures. In Colombia, the National Survey
of Mental Health
4
 found that lifetime prevalence of this
disorder amounted to 8.8% of males and 2.7% of women,
among 4544 sampled between 18 to 65 years of age, while
Pineda et al
5
 reported a prevalence of 8.4%, among 190 male
adolescents, between 12 and 18 from a lower, middle and
high socioeconomic strata, at randomly selected educational
institutions in Medellin, where scores indicate that this
disorder may affect a significant percentage of children and
adolescents in Colombia.
CD is ostensibly more frequent among men than among
women
6-8
 and tends to have a high comorbidity with learning
disorders, substance use disorders and attention-deficit/
hyperactivity disorder [ADHD]
1,9,7
, being a comorbid condition
with the latter that affects 50% of cases
3
. CD is associated,
too, with poor relationships with peers and adults, academic
failure, low emotional reactivity, medical complications
during pregnancy and childbirth, difficult temperament in
early childhood, low empathy, low tolerance for frustration,
impulsivity, irritability, recklessness, sensation seeking,
disinhibition, extraversion and low moral development
1,6,9-12
.
Other features that have been associated with CD include
parental psychopathology, parent’s criminal history, child
abuse, inadequate parenting practices, constant marital
conflict and belonging to a large family
7,9,13
.
One of the aspects that has been examined in individuals
with CD are the cognitive and executive functions evaluated
by neuropsychological tests. According Eme
14
, researchers
have concluded unanimously that there is some type of
Funciones cognitivas y ejecutivas en escolares colombianos
con trastorno disocial: diferencias por sexo
RESUMEN
Introducción:
La mayoría de los estudios que han examinado las funciones cognitivas y
ejecutivas en el trastorno disocial (TD) se han llevado a cabo con adolescentes varones
institucionalizados. En esta investigación, se compararon las funciones cognitivas y
ejecutivas de escolares colombianos no institucionalizados con TD con las de escolares
normales, todos entre 6 y 12 años de edad.
Materiales y métodos:
Se utilizó un diseño de casos y controles, en el que los casos eran los
participantes que cumplían los criterios diagnósticos de TD (
n
 
=
 39) y los controles, aquellos
que no cumplían estos criterios (
n
 
=
 39), de acuerdo con el reporte de un profesional de la
institución de los participantes y una entrevista estructurada de síndromes psiquiátricos
infantiles. Los dos grupos fueron seleccionados de instituciones educativas y no diferían en
edad, grado escolar y nivel socioeconómico. El CI fue controlado, así como la presencia de
otros trastornos mentales, enfermedades físicas graves y signos neurológicos mayores. Las
funciones cognitivas y ejecutivas fueron evaluadas a través de una batería neuropsicológica
infantil.
Resultados:
Los participantes con TD presentaron puntuaciones significativamente más
bajas en habilidades construccionales, habilidades perceptuales (táctiles, visuales y auditi-
vas), memoria verbal diferida, memoria visual diferida, lenguaje (repetición, expresión y
comprensión), habilidades metalingüísticas, habilidades espaciales, atención visual y audi-
tiva, habilidades conceptuales, fluidez verbal y gráfica y flexibilidad cognitiva. Estas mismas
diferencias se encontraron entre los varones entre sí, excepto en repetición, mientras que
las niñas presentaron menos diferencias entre sí, de manera que el desem peño cognitivo
y ejecutivo fue más bajo entre los varones que entre las niñas con TD, especialmente en
funciones verbales y relacionadas con el lenguaje en general.
Conclusiones:
Los niños con TD podrían presentar déficits cognitivos y ejecutivos generali-
zados, que parecen ser mayores entre los niños que entre las niñas con dicho trastorno.
© 2013 Asociación Colombiana de Psiquiatría. Published by Elsevier España, S.L.
All rights reserved.
Palabras clave:
Trastorno disocial,
Neuropsicología,
Cognición,
Funciones Ejecutivas
326
REV COLOMB PSIQUIAT. 2013;
42(4)
:324-332
neuropsychological damage involved in the etiology of CD,
which causes deficits in executive and cognitive functioning,
deficits in the verbal area being the most consistently
reported, but also deficits in spatial and memory functions
have been reported. Olvera et al
15
, for example, found lower
scores on cognitive, inhibitory and behavioral change,
planning, language and verbal memory performance among
26 juvenile offenders with CD, compared with 16 controls with
similar demographic characteristics. Pineda et al
16
, mean-
while, found a verbal IQ, which is general and manipulative,
and a degree of language comprehension, verbal fluency and
schooling significantly lower in a sample of adolescent male
offenders with CD, compared to a control group and exhibited
greater conflictual relationships with peers, attention deficits,
medical complications during pregnancy, use of psychoactive
substances and time required for the resolution of the
Complex Figure Test and Trail Making Test. Pajer et al
17
 also
found lower scores on intelligence and poor performance
on executive functions and visual-spatial area and a lower
academic achievement among 93 adolescent girls with ADHD
compared with 41 normal adolescents, while Trujillo et
al
18
 reported a reduced capacity for immediate recall of verbal
information with a delay in color naming, memory deficits
and slower verbal-visual processing among 117 adolescent
offenders with severe CD, compared with 111 controls.
Since the seminal review by Moffitt
19,20
, it has been
considered that these deficits are more characteristic
neuropsychological symptoms of childhood-onset subtype
of CD, which, compared with adolescent-onset subtype tends
to be more persistent over time and it is related to antisocial
aggression and more severe symptoms of hyperactivity,
comorbidity with ADHD and a higher probability of engaging
in criminal activity in adolescence and adulthood and the
development of antisocial personality disorder
7,9,14,21-23
. It is
considered that this subtype of CD has a strong biological
influence and tends to be more persistent and severe due to
this circumstance
10,14
.
While there is no global agreement regarding the nature
and number of processes that are executive functions, there
is consensus that such processes facilitate self-regulation
necessary to achieve goals successfully, so that a malfunction
increases this probability of inadequate emotional, behavioral
and cognitive regulation, increasing the risk of CD
14,24
.
Deficits in executive functions, therefore, could explain the
charac teristics of individuals with CD, such as impulsivity,
reckless conduct, breaking rules, aggression, disinhibition,
extraversion, poor moral development and sensation
seeking
1,7,25
as well as its high comorbidity with attention
deficit disorder with hyperactivity, due to difficulties with
impulsivity that characterize the latter disorder
23
. Therefore,
the study of cognitive and executive functions among
school-age children could provide more insight into the
etiology of CD. However, most studies that have examined
these functions have been conducted with institutionalized
adolescents diagnosed with CD, so it is not possible to confirm
whether such deficits are present from childhood, and among
non-institutionalized boys and girls with CD.
Based on the above, the purpose of this research was to
evaluate cognitive and executive functions of a sample of
school-age children with CD who are not institutionalized,
compared, at a general level and by sex, to a sample of
children without the disorder with similar demographic
charac teristics. We used the Child Neuropsychological
Assess ment Battery (Evaluación Neuropsicológica Infantil
[ENI]
26
), through which the following cognitive functions
were assessed: constructional skills, perceptual skills
(tactile, visual and auditory) verbal memory (encoding),
visual memory (encoding), delayed verbal memory, delayed
visual memory, language (repetition, expression and
understanding), metalinguistic skills, spatial skills, visual and
auditory attention and conceptual skills, and the following
executive functions: verbal fluency, graphic fluency, cognitive
flexibility and planning and organization.
Materials and methods
Participants
It included a sample of 49 boys (62.8%) and 29 girls (37.2%),
for a total of 78 participants, ranging in age from 6 to 12
(mean, 9.4
±
2.04) years, of which 39 met the diagnostic criteria
for CD, according to Children’s Interview for Psychiatric
Syndromes-Spanish version (ChiPS
27
), while the remaining
39 did not have the disorder under the same criteria.
Participants were selected from three educational institutions
in Bogotá with students that differed in the socioeconomic
status, making way for a sample of 30 participants from
low-low socioeconomic status (38.5%), 30 low socioeconomic
status and low-middle (38.5%) and 18 middle and middle
high (23%). No participants had a score indicating possible
intellectual deficits (e.g., a composite IQ below 70), according
to the Kaufman’s Brief Intelligence Test (K-BIT
28
), or other
mental disorders, serious physical illness or major neuro-
logical symptoms, according to information provided by their
parents in ENI’s clinical history questionnaire
26
.
Participants with CD (30 boys and 9 girls) had a mean
age of 9.54
±
1.99 years and were selected according to their
availability in the three educational institutions, prior
identification of the professional of each institution, while
participants without CD (19 boys and 20 girls) had a mean
age of 9.26
±
2.11 years, with students from 6-12 years of
age selected from these institutions who did not exhibit
behavioral problems. The two subsamples did not differ in
age (F[1, 78]
=
0.369;
P
=
.545), grade (F[1, 78]
=
0.451;
P
=
.504) or
socioeconomic status (U[n
=
78]
=
760.5;
P
=
1).
Instruments
Children’s Interview for Psychiatric Syndromes-Spanish version
(ChiPS
27
).
It is a highly structured interview, based strictly on
the diagnostic criteria of the Fourth Edition of the Diagnostic
and Statistical Manual of Mental Disorders
29
. It is given to
people between 6 and 18 years of age, allowing the diagnosis
of 20 psychiatric disorders. In this study we used only the
CD scale, composed of 15 reagents. The instrument showed
a sensitivity of 87% and a specificity of 76%
27
.
REV COLOMB PSIQUIAT. 2013;
42(4)
:324-332
327
Kaufman’s Brief Intelligence Test-Spanish version (K-BIT
28
).
It is
a test of “screening”, which measures verbal and nonverbal
intelligence in individuals from 4 to 90 years of age, by means
of two subtests: Vocabulary (verbal intelligence) and Matrices
(nonverbal intelligence). The Vocabulary subtest assesses
the development of language and verbal conceptualization
level, while the matrices subtest measures nonverbal skills
and the ability to solve problems. The application of this
test is individual character with dichotomous items (0-1)
and it requires 15 to 30 minutes to complete. To obtain the
composite IQ scores are added in each subtest. The reliability
coefficient reported by authors was .98 for the Vocabulary
subtest, .97 for the Matrices subtest and .98 for IQ Composite
and the test-retest analysis showed correlations ranging from
.86 and. 95, presenting statistically significant correlations
with similar tests
28
.
Child Neuropsychological Assessment (Evaluación Neuro-
psico lógica Infantil [ENI]
26
).
It allows for the evaluation of the
following cognitive functions of schoolchildren aged 5 to
16 years: constructional skills, verbal and visual memory
(encoding and delayed recall), perceptual skills, language,
metalinguistic skills, spatial skills, attention (visual and
auditory) and conceptual skills and the following executive
functions: verbal fluency, graphic fluency, cognitive flexibility
and planning and organization. It also presents a medical
history questionnaire to be filled out by the parents and
two annexes to assess handedness and the presence of soft
neurological signs. The normative values by sex and age were
obtained with a sample of 788 children aged 5 to 16 years of
age, 540 Mexican children and 248 Colombians. The inter-rater
reliability ranged between .86 and .99 and concurrent
validity was assessed with the Wechsler Intelligence Scale
for Children-Revised (WISC-R
30
) which found significant
correlations between scales of ENI and its corresponding
WISC-R.
Constructional skills are measured from the subdomains:
construction with sticks and graphic skills, for which tests are
used with chopsticks construction, a human figure, a copy
of figures and a copy of the complex figure. The memory
consists of two subdomains: encoding and delayed recall.
Word lists are used to evaluate the coding tests, recall of a
story and list of figures, while the delayed recall tests are used
to recover the complex figure evocation of auditory and visual
stimuli: spontaneous recovery of the list words, recovery of
key auditory verbal recognition, a written story recovery,
recovery of the complex figure, spontaneous recovery of the
list of figures, and key recovery for visual recognition
26,31
.
Perceptual abilities are comprised of the subdomains of
tactile perception, visual perception and auditory perception.
The tactile sense is assessed through testing the right
hand and left hand while visual perception is measured
by testing overlapping images, blur, close visual proximity,
speech recognition and integration of objects. Finally,
auditory perception is evaluated by tests of musical notes,
environmental sounds and phonemic awareness
26,31
.
The language domain consists of subdomains: repetition,
expression and understanding. The tests designed to measure
repetition are: repetition of syllables, words, words and
sentences, while for the evaluation of expression: a picture
naming test, narrative coherence and the length of the
expression are used. The subdomain of understanding is
assessed by designating imaging tests, following instructions
and understanding of speech. Metalinguistic skills are
measured through testing synthetic phonics, counting
sounds, spelling and word count. The domain of spatial
skills, in turn, is measured by comprehension tests: right-left,
left-right expression, drawings of different angles, orientation
of
lines and location coordinates, while the domain of
attention, composed by the visual and auditory subdomains,
is evaluated by testing patterns of cancellation, cancellation
of letters, digit retention in progression and regression. The
domain of conceptual skills is assessed through tests of
similarities, matrices and arithmetic problems
26,31
.
The executive functions, in turn, are composed of
domains
26,31
:
Verbal fluency, which consists of two tests of semantic
fluency (fruits and animals) and a phonemic fluency test.
Graphic fluency, consisting of semantic and non-semantic
fluency tests.
Cognitive flexibility, through an abbreviated version of the
Wisconsin Sorting Card Test, where scores were obtained
for the following indicators: correct answers, perseverative
responses, number of categories and inability to maintain
the organization.
Planning and organization, through the “Pyramid of
Mexico” test (similar to the
Tower of Hanoi
), yielding scores
for the following indicators: correct designs and design
with the fewest possible moves, number of and number of
moves.
Procedure
We used a case-control design
32
; the cases were participants
who met the diagnostic criteria for CD and controls who
did not meet these criteria. In the interest of research, we
selected children between 6 and 12 years of age in the three
educational institutions mentioned. To select children with
CD, we previously asked the professional of each institution
to develop a list of students to present the diagnostic criteria
of the APA
1
, confirming the diagnosis through ChiPS
27
.
Participants without CD were selected randomly from the
rest of students without behavior problems and the same age
range, selecting the same number of participants in the CD
group, about half of each sex, confirming the absence of CD
through the same instrument.
The parents of these children were asked their consent
for their children to participate in this research, being
provided with information regarding the objectives and
the general procedure of the study, the confidentiality of
data, independence of the investigation with respect to the
school, the voluntary nature of participation and the respect
for the decision to quit the research participation any time,
possible discomfort for the duration of the tests applied and
the ability to provide the results obtained through these
tests. No monetary rewards were given to these parents.
A semi-structured interview was made with each parent
328
REV COLOMB PSIQUIAT. 2013;
42(4)
:324-332
through the ENI’s clinical history questionnaire
26
, in order
to rule out other mental disorders, serious physical illness or
major neurological disorders. Subsequently, each participant
was individually briefed, the general conditions of the tests
were explained, and administered in two to four sessions in
order to avoid the effect of fatigue, verifying that each child
was in good physical condition and encouraged to answer the
tests. The tests were administered by qualified specialists
in neuropsychological assessment and diagnosis, in the
following order: ChiPS
27
, K-BIT
28
, and ENI
26
.
The two subsamples were compared, at a general level
and by gender, as the average percentile scores in each of
the domains and subdomains of cognitive and executive
functions of the ENI
26
, where the one-way ANOVA was used,
accepting a significance level less than .05 (bilateral). Also the
two groups in the IQ test compound with the same statistics
were compared.
Results
Table 1 presents the comparisons between cases and controls.
Mean scores were statistically lower among cases compared
with controls in almost all domains and subdomains of ENI
26
:
constructional skills (building of toothpicks and graphic
skills), perceptual skills (tactile, visual and auditory), delayed
recall (verbal and visual), language (repetition, expression
and understanding), metalinguistic skills, spatial skills,
attention (visual and hearing), conceptual skills, verbal
fluency, graphic fluency and the following indicators of
cognitive flexibility: correct answers, perseverative responses
and number of categories. The same occurred in relation to
the average of composite IQ of both groups. No statistically
significant differences were observed in the subdomains of
memory-encoding (verbal and visual), an inability to maintain
the organization (an indicator of cognitive flexibility) and
indicators for planning and organization.
CD participants showed an average of below-average
scores (
25), according to the scales provided by Matute et al
26
,
in the following domains and subdomains: verbal memory
delayed, metalinguistic skills, spatial skills, visual attention,
verbal fluency, graphic fluency, correct answers, correct
designs, and design with the fewest possible moves (table 1).
Among men, we found the same differences that were evident
across the board, except in repetition, where the average male
(who met diagnostic criteria) did not differ statistically with
respect to those of men who did not fulfill these diagnostic
criteria (with CD, 38.23
±
29.58; without CD, 52.42
±
26.70):
F
[1,
49]
=
2,880;
P
=
.096.
Thus, males with CD showed significantly lower scores on
the following cognitive and executive functions, than males
who did not fulfil these diagnostic criteria:
a)
 construction
with chopsticks (with CD, 54.40
±
31.28; without CD,
83.05
±
24.90):
F
[1, 49]
=
11,348;
P
=
.002;
b)
 graphic skills (with
CD, 54.43
±
28.50; without CD, 72.10
±
26.86):
F
[1, 49]
=
4672;
P
=
.036;
c)
 tactile perception (with CD, 53.13
±
21.94; without CD,
65.10
±
6.84):
F
[1, 49]
=
5290;
P
=
.026;
d)
 visual perception (with CD,
53.16
±
34.93; without CD, 83.10
±
20.70):
F
[1, 49]
=
11
 
370;
P
=
.002;
e)
 auditory perception (with CD, 36.17
±
32.83; without CD,
68.47
±
39.11):
F
[1, 49]
=
9544;
P
=
.003;
f)
 delayed verbal memory
(with CD, 20.68
±
21.69; without CD, 40.74
±
29.72):
F
[1, 49]
=
7443;
P
=
.009;
g)
 delayed visual memory (with CD, 34.47
±
28.24;
without CD, 50.42
±
24.90):
F
[1, 49]
=
4056;
P
=
.05;
h)
 expression
(with CD, 33.67
±
29.98; without CD, 66.89
±
30.08):
F
[1, 49]
=
14
 
243;
P
<
.001;
i)
 understanding (with CD, 35.17
±
32.13; without CD,
67.94
±
26.97):
F
[1, 49]
=
13
 
133;
P
=
.001;
j)
 metalinguistic abilities
(with CD, 18.26
±
24.07; without CD, 52.84
±
35.44):
F
[1, 49]
=
16
 
575;
P
<
.001;
k)
 spatial skills (with CD, 22.18
±
25.13; without CD,
54.63
±
27.41):
F
[1, 49]
=
18
 
069;
P
<
.001;
l)
 visual attention (with
CD, 20.86
±
24.65; without CD, 41.10
±
33.42):
F
[1, 49]
=
5828;
P
=
.020;
m)
 auditory attention (with CD, 29.93
±
30.51; without
CD, 59.72
±
34.87):
F
[1, 49]
=
9486;
P
=
.004;
n) 
conceptual skills
(with CD, 31.76
±
32.83; without CD, 56.33
±
43.31):
F
[1, 49]
=
4945;
P
=
.031;
o)
 verbal fluency (with CD, 20.16
±
19.36; without CD,
52.68
±
32.63):
F
[1, 49]
=
19
 
243;
P
<
.001;
p)
 graphic fluency (with
CD, 24.80
±
23.41; without CD, 44.47
±
30.13):
F
[1, 49]
=
6562;
P
=
.014;
q)
 correct answers (with CD, 17.61
±
20.91; without CD,
43.41
±
25.60):
F
[1, 49]
=
14
 
859;
P
<
.001;
r)
 perseverative responses
(with CD, 25.34
±
27.68; without CD, 42.68
±
30.12):
F
[1, 49]
=
4265;
P
=
.044, and
s)
 number of categories (with CD, 30.54
±
29.80;
without CD, 50.00
±
32.37):
F
[1, 49]
=
4637;
P
=
.036. Males with
CD also had an average of composite IQ lower than males
without CD (with CD, 79.73
±
19.97; without CD, 93.79
±
25.41):
F
[1, 59]
=
4657;
P
=
.036.
Among women, meanwhile, it was evident that those who
met the diagnostic criteria for CD had an average score lower
in the following areas, compared with girls who did not meet
diagnostic criteria for CD:
a)
 construction with chopsticks
(with CD, 48.67
±
36.07; without CD, 87.75
±
22.26):
F
[1, 29]
=
12
 
902;
P
=
.001;
b)
 graphic skills (with CD, 27.22
±
28.30; without CD,
75.45
±
23.01):
F
[1, 29]
=
23
 
660;
P
<
.001;
c)
 visual perception (with
CD, 47.88
±
29.23; without CD, 77.90
±
11.31):
F
[1, 29]
=
5982;
P
=
.021;
d)
 spatial skills (with CD, 31.77
±
24.04; without CD, 62.85
±
22.78):
F
[1, 29]
=
11
 
168;
P
=
.002;
e)
 visual attention (with CD, 12.66
±
11.20;
without CD, 32.95
±
28.35):
F
[1, 29]
=
4235;
P
=
.049;
f)
 auditory
attention (with CD, 13.00
±
12.27; without CD, 55.10
±
31.73):
F
[1,
29]
=
14
 
602;
P
=
.001;
h)
 verbal fluency (with CD, 10.88
±
15.17;
without CD, 47.30
±
28.67):
F
[1, 29]
=
12
 
717;
P
=
.001;
i)
 graphic
fluency (with CD, 18.88
±
20.22; without CD, 45.30
±
26.44):
F
[1, 29]
=
7061;
P
=
.013;
j)
 correct designs (with CD: 3.45
±
8.61;
without CD, 26.60
±
32.36):
F
[1, 29]
=
4381;
P
=
.046, and
k)
 design
with the fewest possible moves (with CD: 2.01
±
3.96; without
CD, 32.55
±
36.07):
F
[1, 29]
=
6287;
P
=
.018. Girls with CD did not
have an average of composite IQ significantly different than
the average of girls without CD (with CD, 86.33
±
22.71; without
CD, 92.10
±
17.42):
F
[1, 29]
=
.563;
P
=
.459.
Discussion
The objective of this research was to evaluate cognitive and
executive functions of a sample of school-age children with CD
(not institutionalized), compared at a general level and by sex
with a sample of children without the disorder with similar
socio-demographic characteristics. The results showed that
participants with CD had significantly lower scores on most
cognitive and executive functions evaluated, confirming
the relationship found between CD and neuropsychological
REV COLOMB PSIQUIAT. 2013;
42(4)
:324-332
329
Variable
CD
n
M
SD
df
F
P
Cognitive functions
1. Construction abilities
1.1 Construction with chopsticks
Without
39
85.46
23.39
1
25.979
<
.001
a
With
39
53.08
32.04
Total
78
69.27
32.29
1.2 Graphic skills
Without
39
73.82
24.68
1
16.760
<
.001
a
With
39
49.15
30.38
Total
78
60.98
30.38
2. Memory
2.1 Verbal memory-encoding
Without
39
37.38
30.61
1
2.252
.138
With
39
27.07
30.03
Total
78
32.23
30.57
2.2 Visual memory-encoding
Without
39
46.49
27.78
1
2.508
.117
With
39
36.62
27.20
Total
78
41.55
27.76
2.3 Verbal memory-delayed recall
Without
39
40.96
30.72
1
10.300
.002
b
With
39
21.06
23.55
Total
78
31.01
28.98
2.4 Visual memory-delayed recall
Without
39
52.84
25.86
1
4.450
.038
c
With
39
39.69
29.11
Total
78
46.27
28.14
3. Perception
3.1 Tactile perception
Without
39
61.84
12.55
1
5.107
.027
c
With
39
52.61
22.20
Total
78
57.23
18.51
3.2 Visual perception
Without
39
80.43
26.34
1
17.493
<
.001
a
With
39
51.94
33.40
Total
78
66.19
33.14
3.3 Auditory perception
Without
39
72.82
34.82
1
18.051
<
.001
a
With
39
40.00
32.90
Total
78
56.62
37.49
4. Language
4.1 Repetition
Without
39
53.77
26.77
1
6.51
.013
c
With
39
37.28
30.16
Total
78
45.52
29.52
4.2 Expression
Without
39
66.10
33.65
1
14.01
<
.001
a
With
39
38.51
31.40
Total
78
52.31
35.18
4.3 Understanding
Without
38
61.08
29.15
1
12.71
.001
a
With
39
36.33
31.64
Total
77
49.54
32.70
5. Metalinguistic abilities
Without
39
55.49
38.45
1
18.71
<
.001
a
With
39
22.87
27.14
Total
78
39.17
36.91
6. Spatial skills
Without
39
38.84
25.15
1
36.91
<
.001
a
With
39
24.39
24.91
Total
78
41.62
30.31
7. Attention
7.1 Visual
Without
39
36.92
30.79
1
8.58
.004
b
With
38
18.92
22.35
Total
77
28.03
28.27
7.2 Auditory
Without
38
57.28
32.88
1
19.97
<
.001
a
With
38
25.92
28.11
Total
76
41.60
34.24
8. Conceptual skills
Without
38
57.26
41.38
1
5.84
.018
c
With
39
36.58
33.32
Total
77
46.79
38.69
Executive functions
9. Verbal fluency
Without
39
49.92
30.38
1
31.159
<
.001
a
With
39
18.03
18.71
Total
78
33.97
29.76
Table 1 – Group differences in mean percentile scores in executive and cognitive functions (one-way ANOVA)
(Continued)
330
REV COLOMB PSIQUIAT. 2013;
42(4)
:324-332
deficits and the increased incidence of these deficits in
childhood-onset CD
7,14
. Similarly, participants with CD had
lower composite IQ scores than participants without CD,
which confirms that individuals with CD could have below
average IQ scores
1,7
.
The results show in particular that school males with CD
had lower cognitive flexibility, an ability needed to change
the focus and change the response in terms of environmental
requirements and that unaffected children show good
performance during their years in school
24,33
. The fact that
children with CD showed a higher number of perseverative
responses, indicative of low cognitive flexibility, demonstrates
a lower sensitivity to errors and therefore, according to
Rubia
34
, reduced sensitivity to punishment, a feature
consistently found in studies showing a lower emotional
reactivity in children and adolescents with CD
17,35-37
. CD
girls, meanwhile, showed lower scores on two of the three
indicators of planning and organization, indicating deficits
in the functions necessary to the mental representation of a
problem and planned cognitive and behavioral organization
aimed at its resolution functions that are expected to be
sufficiently developed in the school years
24,33
.
The results obtained with tests measuring executive
functions corroborate, in general, the presence of some
type of executive dysfunction which predispose them to the
development of CD
7,9,23,38
, since these functions are necessary
for emotional, cognitive and behavioral regulation
14,23,39
.
The low scores on verbal fluency among both boys and girls
who meet the diagnostic criteria for CD and CD children with
language and metalinguistic skills, on the other hand, are
consistent with results obtained by other studies that found
lower scores in verbal IQ, verbal fluency and verbal memory
and processing
15,16,18
 and corroborate the importance of
verbal information processing for emotional, cognitive and
behavioural regulation, development of self-control and
problem-solving skills, and learning of social and pro-social
skills in which children with CD have difficulties
12,14
.
The lowest scores on visual attention, measured by tests of
cancellation of drawings and letters and auditory attention,
as measured by digit retention in progression and regression
tests, support the existence of deficits in executive functions
of the sample, since the control of attention is considered
an executive function and digit regression is considered a
working memory test, another executive-type function
considered
33,40
. These findings, in turn, are consistent with
the results of Toupin et al
41
, who found a significantly higher
number of symptoms of attention deficit disorder with
hyperactivity (ADHD) among children and adolescents with
Variable
CD
n
M
SD
df
F
P
10. Graphic fluency
Without
39
44.89
27.92
1
13.916
<
.001
a
With
39
23.44
22.60
Total
78
34.17
27.45
11. Cognitive flexibility
11.1 Correct answers
Without
39
45.76
26.95
1
21.668
<
.001
a
With
39
19.78
22.10
Total
78
32.78
27.76
11.2 Perseverative responses
Without
39
49
31.24
1
9.283
.003
b
With
39
28.28
28.74
Total
78
38.64
31.59
11.3 Number of categories
Without
39
49.60
31.39
1
5.151
.026
c
With
39
33.95
29.44
Total
78
41.78
31.24
11.4 Inability to maintain the organization
Without
39
38.25
33.21
1
2.375
.127
With
39
27.15
30.37
Total
78
32.70
32.10
12. Planning and organization
12.1 Number of correct designs
Without
39
27.92
32.01
1
2.773
.100
With
39
17.04
25.32
Total
78
22.49
29.19
12.2 Number of moves
Without
39
45.03
34.72
1
.280
.598
With
39
40.95
33.26
Total
78
42.99
33.85
12.3 Design with the fewest possible moves
Without
39
30.17
34.14
1
3.387
.070
With
39
17.19
27.80
Total
78
23.68
31.61
Composite IQ (K-BIT)
Without
39
92.92
21.41
1
6.036
.016
c
With
39
81.26
20.51
Total
78
87.09
21.64
a
P
.001, two-tailed.
b
P
.01, two-tailed.
c
P
.05, two-tailed.
Percentile ranks (Matute et al., 2007): above average,
84; average, 26-75; low, 5-16, and extremely low,
2.
Table 1 – Group differences in mean percentile scores in executive and cognitive functions (one-way ANOVA) (Continuation)
REV COLOMB PSIQUIAT. 2013;
42(4)
:324-332
331
CD. The results of the meta-analysis by Willcutt et al
40
 show
that in this sense, children and adolescents with ADHD may
experience lower scores on vigilance and working memory,
two functions measured through tests of attention in which
children with CD in this study showed lower scores.
The results obtained in spatial skills in both boys and girls
with CD and delayed verbal and visual memory, in the case of
children with CD are also consistent with previous findings
showing lower scores on spatial and memory functions
among children with CD
14
. Although girls with CD did not
have lower scores on verbal and visual memory like the boys,
they did show lower average scores on the digit retention in
regression, a task which, as already indicated, is related to
working memory.
The results also show deficits in constructional skills,
visual, tactile and auditory perception, conceptual skills
and graphic fluency, indicating the possibility of a lower
generalized cognitive development in many schools with
CD, which is consistent with the lower CI obtained by
children with CD, compared with children without CD,
but not girls with this disorder. These deficits may not
only predispose to the development of CD, because of its
importance in the development of other areas such as social
and moral
42
, but that might be related with lower academic
performance and academic failure, common features in
children with CD
6,7
. The lower scores on visual and auditory
perception, in particular, are consistent with those already
reflected lower scores on visual and auditory attention and
point out that those school children with CD may have
difficulties in primary and secondary processing of these
two types of information.
The results also indicate several common features among
school boys and girls with CD, at the level of constructional
skills, visual perception, spatial skills, visual and auditory
attention and verbal fluency and graphics, but also differences
in the sense that girls affected by CD did not have lower scores
on language and metalinguistic skills, tactile and auditory
perception, verbal and delayed visual memory, conceptual
skills and cognitive flexibility. In addition, these girls
exhibited lower scores in planning and organization, unlike
children with CD, who in this study showed no statistically
significant differences in these functions, compared with
children without CD. The results of this study also indicate
that men with CD often have a composite IQ lower than
women with this disorder.
These sex differences suggest that male and female school
children with CD demonstrate common neuropsychological
characteristics, as outlined in the literature, such as low
verbal fluency deficits in memory and spatial skills, but
differ according to the results obtained, in which males have
more pronounced deficits in cognitive flexibility and on the
verbal level, while women have more deficits in planning
and organizing, but not as pronounced on the linguistic level.
The fact that men with lower CD scores in a larger number
of subdomains compared with girls with CD, on the other
hand, shows that males with CD would be more likely to
exhibit these neuropsychological deficits than schoolgirls
with this disorder. It is possible that these differences are
situated in, according to Eme
14
, a biological predisposition of
males, which explains, in turn, the increased prevalence of
CD among them
6-8
.
Finally, it is important to note that although this research
has its strengths in the use of a comparison group, using
a validated neuropsychological battery with a Colombian
sample and the control of several potential sources of error
such as IQ, socioeconomic status and the presence of other
mental disorders or serious physical illnesses, reveals two
important limitations that should be remedied in future
research. First, this study only examined “cold” executive
functions, such as planning, self-regulation, mental flexibility
and control of attention, but not “hot” function types, i.e.
those related to motivational and affective processes and
incentives
33,34
, and therefore would generate other research
that may yield a more complete profile of executive functions
in school children with CD. Second, this study involved the
participation of a relatively small sample of male and female
students with CD, so it is necessary to confirm the results
obtained with larger samples, particularly of girls with CD.
Conflicts of interests
Authors have no conflict of interest to declare.
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