D

D2 Test of Attention of two dashes placed above and/or below), which

are interspersed with nontarget characters (a “d”
Preeti Sinha1, Dawn Bowers1 and with more or less than two dashes, and “p” char-
Adam J. Woods2,3,4 acters with any number of dashes), in 14 succes-
1
Department of Clinical and Health Psychology, sive timed trials.
University of Florida, Gainesville, FL, USA It goes well with the neurobiological model of
2
Department of Clinical and Health Psychology, attention, particularly biased competition model
College of Public Health and Health Professions, (Desimone and Duncan 1995) of attentional con-
University of Florida, Gainesville, FL, USA trol, where target and distracter objects compete
3
Center for Cognitive Aging and Memory, for limited processing capacity during visual
McKnight Brain Institute, University of Florida, search. Primarily, the subject must selectively
Gainesville, FL, USA attend to relevant stimuli while filtering out irrel-
4
Department of Neuroscience, University of evant stimuli in a rapid manner. The presence of
Florida, Gainesville, FL, USA nontarget distracters that are visually quite similar
to targets (i.e., a “d” with varying spatial configu-
rations of two dashes) reduces the competitive
D2 Test of Attention and Comparison to advantage of the targets. There is a need of the
Other Tests of Attention mental-template and neural representation of tar-
get to be complex enough to differentiate d2 tar-
D2 test of attention is a cancellation test involving gets and nontargets and also to detect varying
simultaneous presentation of visually similar stimulus configurations of targets at the same
stimuli. It was originally developed in 1962 in time (i.e., the target letter “d” with varying spatial
Germany and Switzerland as an assessment tool configurations of two dashes). Thus, this simple
for driving efficiency (Brickenkamp 1962) and test requires actually more complex processing
used very commonly in Europe. It came into use and can detect the attentional difficulties in a
in the USA only by 1998 (Brickenkamp and graded manner (Bates and Lemay 2004).
Zillmer 1998). It measures a lot of parameters of
attention within short time, thereby making it
useful to delineate various disorders. It is easy to Procedure of D2 Test of Attention
administer as well. It is available in both paper-
pencil and computerized versions. The task is to Standard Version: It is an interviewer-adminis-
cancel out all target characters (a “d” with a total tered one-page paper-and-pencil cancellation test

# Springer International Publishing AG, part of Springer Nature 2018

J. S. Kreutzer et al. (eds.), Encyclopedia of Clinical Neuropsychology,
https://doi.org/10.1007/978-3-319-57111-9
1040 D2 Test of Attention

(Brickenkamp and Zillmer 1998). One side of it Computerized Version – Construction of the
provides sections for recording identifying data Series: Among the nine items in a screen, there
and test scores, and a practice sample. On the are two to five target items. The order in which the
reverse side is the standardized test, consisting of items (targets and distractors) are presented on
14 rows (trials), each with 47 interspersed “p” and screen is randomized subject to the following
“d” characters, for a total of 658 items. The char- constraints.
acters have one to four dashes that are configured
individually or in pairs above and/or below each (a) First to fourth screens of every series include
letter, forming 10 different symbols/items. The three to five target characters, with a total of
target symbol is a “d” with two dashes (hence 16 target items appearing (out of total
“d2”), regardless of whether the dashes appear 4 ! 9 = 36 items).
both above the “d”, both below the “d”, or one (b) Fifth and sixth screens each include two and
above and one below the “d”. Thus, a “p” with one four target items, the seventh screen contains
or two dashes and a “d” with more or less than two five; the total number of target items is 11 (out
dashes are distracters. The correct hits are called of a total 3 ! 9 = 27 characters).
“relevant items.” All other combinations of letters (c) For 8th to 11th and 12th to 14th screens, it is
and lines are considered “irrelevant,” because same as that of 5th to 7th screens.
they should not be crossed out. The participant’s
task was to cancel out as many target symbols as Computerized Version – Instruction and
possible, moving from left to right, with a time Practice: They are carried out interactively
limit of 20 seconds per trial. No pauses are allo- on-screen. The practice series includes target
wed between trials. items in a random order. Three consecutive
Computerized Version – Test Construction: screens in the practice series must be correctly
This version is different from the standard answered before the test proper begins.
version in terms of number of items and their
distribution. For this reason, internal consisten-
cies, test-retest reliability, acceptability, corre- Scoring of D2 Test of Attention
lation with standard version, and criterion-
related validity have been established. It has There are different types of scores/measures of
keyboard as well as mouse versions; both of this test (Table 1), which have been added gradu-
them are validated. ally over the time. They apply to both standard
Here, there are 12 series of items. Each series and computerized versions. They help in
has 14 screens with 9 items presented per screen. assessing the different measures of attention and
The subject marks the target item by pressing the learning.
appropriate numerical key. The subject should be Given the fast-paced repetition of 14 trials
instructed to always work from left to right. After without resting, similarities between target and
completing the first screen of nine items, the sub- nontarget stimuli, and visual stimulus variations
ject moves to the next screen by pressing the space of correct targets, the d2 test can be used to mea-
bar. The processing time per series is set at 30 s. sure processing accuracy and speed, as well as
The timing begins when the display comes up on learning and test-taking strategies. Its duration
the screen and ends when the first key is pressed and difficulty allow analysis of the participant’s
after the 30 s processing time is over. Depending ability to achieve, shift, and maintain attention
on the computer being used, it takes approxi- (elements of sustained attention); focus on and
mately 3 s for the computer to change screens. select target stimuli (elements of selective atten-
The screen changing time is additional to the tion); improve or worsen with practice; and
processing time. Completion time, including develop strategic approaches to discriminate
instructions and practice, is approximately between targets and nontargets. The study on
10 min. young adult USA population found it to have
D2 Test of Attention 1041

D2 Test of Attention, Table 1 Measures of d2 test of attention

Abbreviation
used in the
manual of first Abbreviation
USA edition used by Bates
(Brickenkamp and Lemay Cognitive measures
Description of measure and Zillmer 1998) (2004) Computation evaluated
Total number of items TN TOT# Sum of number of items Scanning speed
processed processed before the final
cancellation on each trial D
Total errors (raw score) E TOT ERR Sum of all errors Selective scanning/
processing accuracy
Errors of omission O O ERR Sum of number of target Selective scanning/
symbols not cancelled processing accuracy
Errors of commission C C ERR Sum of number of Important in
nontarget symbols evaluating strategy
cancelled
Percent of errors E% % ERR Total number of errors Selective scanning/
(Measures the proportion divided by the total processing accuracy
of errors made (E) within number of items
the area of all items processed
processed (TN) and is a
more exact measure than
the raw score of
errors (E)
Total correctly processed TN-E TOT CORR Total items processed Scanning/processing
items minus total errors made speed and accuracy
to determine overall
performance
Concentration CPa CONC Total number of correctly Scanning/processing
performance cancelled minus total speed
number incorrectly
cancelled
Fluctuation rate FR FLUCT Maximum total items Variation in scanning/
processed in a trial minus processing speed
minimum total items
processed in a trial
Error distribution2 ED ERR DIST Average errors for last Selective scanning/
four trials minus average processing
errors for first four trials deterioration or
acceleration
Acceleration (increase in – ACCEL Intraindividual Selective scanning/
speed) correlation between trial processing
number and speed deterioration or
(Z transformed) acceleration
Deterioration (increases – DETER Intraindividual Selective scanning/
in errors) correlation between trial processing
number and errors deterioration or
(Z transformed) acceleration
Strategy index – STRAT The total number of Strategies to improve
characters processed and attention.
the percent of omission High score= fast with
errors (O ERR/TOT #) many errors (skipping
were standardized strategy); low score=
(z scores) and summed slow with few errors
(cautious strategy)
a
Added during the development of computerized version
1042 D2 Test of Attention

valid construct validity and correlated well with subjective side effects of immediate-release oxycodone
the tests which measures sustained attention in healthy middle-aged and older adults. The Journal of
Pain: Official Journal of the American Pain Society,
(Digit Symbol Test) and selective attention (Trail 10(10), 1038–1050.
Making test) (Bates and Lemay 2004). Desimone, R., & Duncan, J. (1995). Neural mechanisms of
selective visual attention. Annual Review of Neurosci-
ence, 18, 193–222.
Drechsler, R., Straub, M., Doehnert, M., Heinrich, H.,
Use of d2 Test of Attention Steinhausen, H. C., & Brandeis, D. (2007). Controlled
evaluation of a neurofeedback training of slow cortical
potentials in children with Attention Deficit/Hyperac-
There are more than 100 citations of the validation
tivity Disorder (ADHD). Behavioral and Brain Func-
study done by Bates and Lemay (2004) and more tions: BBF, 3, 35.
than 500 citations of first USA edition of this test Guimond, A., Braun, C. M., Rouleau, I., Belanger, F., &
(Brickenkamp and Zillmer 1998). It has been used Godbout, L. (2006). Remembering the past and fore-
seeing the future while dealing with the present:
in various disorders involving attention, which
A comparison of young adult and elderly cohorts on a
includes attention deficit hyperactivity disorder multitask simulation of occupational activities. Exper-
(evaluation of symptoms (Semrud-Clikeman imental Aging Research, 32(3), 363–380.
et al. 2008) and effect of treatment (Bögels et al. Hesslinger, B., Tebartz van Elst, L., Nyberg, E., Dykierek,
P., Richter, H., Berner, M., et al. (2002). Psychotherapy
2008; Drechsler et al. 2007; Hesslinger et al.
of attention deficit hyperactivity disorder in adults–A
2002)), schizophrenia (Ludwig et al. 2016), post- pilot study using a structured skills training program.
traumatic stress disorder (Scott et al. 2015), eating European Archives of Psychiatry and Clinical Neuro-
disorder (Van den Eynde et al. 2012), effect of science, 252(4), 177–184.
Ludwig, S., Spitzer, B., Jacobs, A. M., Sekutowicz, M.,
medications on cognitions (Mulder et al. 2014;
Sterzer, P., & Blankenburg, F. (2016). Spectral EEG
Cherrier et al. 2009), and to explore other related abnormalities during vibrotactile encoding and quanti-
cognition such as novelty processing (Bunzeck tative working memory processing in schizophrenia.
et al. 2014), mental fatigue (Schlosser et al. NeuroImage Clinical, 11, 578–587.
Mulder, S. F., Bertens, D., Desar, I. M., Vissers, K. C.,
2012), and relation with sleep. It is also applied
Mulders, P. F., Punt, C. J., et al. (2014). Impairment of
in all range of populations including children (Van cognitive functioning during Sunitinib or Sorafenib
Dijk et al. 2014), adolescents (Bögels et al. 2008; treatment in cancer patients: A cross sectional study.
Tine 2014), and elderly (Guimond et al. 2006; BMC Cancer, 14, 219.
Peiffer, R., Darby, L. A., Fullenkamp, A., & Morgan, A. L.
Peiffer et al. 2015).
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