Resting EEG Theta Activity Predicts Cognitive
Performance in Attention-Deficit
Hyperactivity Disorder
Daniel F. Hermens, BSc*†‡, Eleonore X.C. Soei, BSc*§, Simon D. Clarke, MD*储,
Michael R. Kohn, MD*储, Evian Gordon, PhD*‡¶, and Leanne M. Williams, PhD*†
Quantitative electroencephalography has contributed
significantly to elucidating the neurobiologic mecha-
nisms of attention-deficit hyperactivity disorder. The
most consistent and robust electroencephalographic
disturbance in attention-deficit hyperactivity disorder
has been abnormally increased theta band during
resting conditions. Separate research using attention-
demanding tests has elucidated cognitive disturbances
that differentiate attention-deficit hyperactivity disor-
der. This study attempts to integrate electroencepha-
lographic and neuropsychological indices to determine
whether cognitive performance is specifically related to
increased theta. Theta activity was recorded during a
resting condition for 46 children/adolescents with at-
tention-deficit hyperactivity disorder and their sex-
and age-matched control subjects. Accuracy and reac-
tion time during an auditory oddball and a visual
continuous performance test were then recorded. Com-
pared with control subjects, the attention-deficit hy-
peractivity disorder group manifested significantly in-
creased (primarily left) frontal theta. Furthermore, the
attention-deficit hyperactivity disorder group scored
significantly delayed reaction time and decreased ac-
curacy in both tasks. Correlation analysis revealed a
significant relationship between frontal (primarily left)
theta and oddball accuracy for the attention-deficit
hyperactivity disorder group compared with a signifi-
cant relationship between posterior (primarily right)
theta and reaction time in the continuous performance
test for the control group. These results indicate that
spatial neurophysiologic deficits in attention-deficit
hyperactivity disorder may be related to disturbances
in signal detection. This observation has important
From *The Brain Dynamics Centre, ¶Division of Psychological
Medicine, and 储Adolescent Medicine, Westmead Hospital, NSW,
Australia; †School of Psychology, University of Sydney, NSW,
Australia; §Faculty of Psychology, Heinrich-Heine University of
Düsseldorf, Germany; and ‡The Brain Resource International
Database, Sydney, NSW, Australia.
248 PEDIATRIC NEUROLOGY Vol. 32 No. 4
doi:10.1016/j.pediatrneurol.2004.11.009 ● 0887-8994/05/$—see front matter
implications for the role of trait-like biologic deficits in
attention-deficit hyperactivity disorder predicting per-
formance in information processing. © 2005 by
Elsevier Inc. All rights reserved.
Hermens DF, Soei EXC, Clarke SD, Kohn MR, Gordon E,
Williams LM. Resting EEG theta activity predicts cognitive
performance in attention-deficit hyperactivity disorder. Pedi-
atr Neurol 2005;32:248-256.
Introduction
The recent U.S. prevalence of attention-deficit hyperac-
tivity disorder (ADHD) (between 6 and 17 years) is within
the range 1.7% to 16%, consistent with the 11% estimate
for Australia [1]. These figures are beyond the potentially
conservative 3-5% estimate based on the Diagnostic and
Statistical Manual of Mental Disorders–Fourth Edition
(DSM-IV) [2] criteria [3]. The DSM-IV-defined symp-
toms of ADHD include developmentally inappropriate
levels of inattention, hyperactivity, and impulsivity. A
significant number of children diagnosed with ADHD will
ultimately be prescribed treatment with stimulant medica-
tions [4]. This disorder can also have severe consequences
in social, individual, and family settings, resulting from
financial costs of treatment, psychological implications
due to familial stress and breakdown, difficulties in
academic and vocational areas, and increased risk of drug
abuse [5].
Quantitative electroencephalographic recording can
provide a noninvasive measure of baseline or the under-
lying brain states before information processing [6]. Elec-
troencephalographic measures have been observed to have
Communications should be addressed to:
Dr. Hermens; The Brain Dynamics Centre, Acacia House, Westmead
Hospital, Hawkesbury Road, Westmead, NSW, 2145, Australia.
Received May 26, 2004; accepted November 29, 2004.
© 2005 by Elsevier Inc. All rights reserved.
a high degree of sensitivity in distinguishing patients with
ADHD from healthy control subjects in a wide range of
studies [7-12]. Electroencephalographic studies of the
“resting state” (i.e., during eyes open or closed conditions)
have observed a consistent elevation in low-frequency
activity, particularly theta (4-7 Hz), in ADHD subjects
compared with control subjects [7-14]. Elevated theta
activity has been observed primarily in the frontal brain
region and has been linked to a decrease in attention [12].
According to Klimesch [15], a decrease in resting or tonic
theta power is related to improved performance in cogni-
tive and memory performance. In regard to underlying
neurobiologic mechanisms, elevated theta in ADHD has
been central to theories of maturational lag [10,16],
cortical hypoarousal [17,18], and developmental deviation
[8,19] (see [6] for a review of these models). The frontal
focus of raised theta suggests that cortical hypoarousal
may disrupt anterior attentional network function [20].
Given that theta activity decreases with age in normal
subjects (reflecting neurodevelopment), a complementary
interpretation of excessive theta activity in ADHD is that
it reflects a maturational delay, particularly of the frontal
inhibitory networks [7,10-12,18,21-23].
Convergent evidence from neuroimaging and neuropsy-
chology points to the central role of the frontal cortices in
cognitive performance deficits in ADHD [24]. ADHD
patients manifest equivalent performance deficits to fron-
tal lobe lesion patients on neuropsychological tasks such
as sustained attention [25]. Similarly, many studies have
observed slower reaction times and greater false-positive
errors in ADHD compared with healthy subjects, on
frontal lobe executive function tasks [26-29]. In previous
research, results in a continuous performance test were
employed to classify (in addition to behavioral ratings)
ADHD groups who then manifested evidence of electro-
encephalographic slowing compared with control subjects
with high levels of specificity [30]. Lubar et al. [31] found
that ADHD subjects (8-19 years) who manifested de-
creased theta after neurofeedback treatment improved
their performance in the Test of Variables of Attention, a
visual continuous performance test. From the same group,
Swartwood et al. [32] examined a smaller age range (9-11
years) of ADHD-Combined subtype males and demon-
strated that compared with control subjects they were
significantly differentiated by continuous performance test
measures (reaction time and accuracy) and decreased
posterior alpha band activity. Although theta band differ-
ences between the groups were less apparent, they re-
ported a correlation between left frontal theta (during a
baseline task) and continuous performance test reaction
time [32].
Despite the promise of both raised theta and poor
attentional performance as markers of ADHD, the specific
relationship between these measures in the same subjects
requires further examination. The objective of this study
was to determine whether resting theta activity is related to
poor performance in attention-demanding cognitive tasks
in a relatively large sample of young unmedicated ADHD
adolescents. We selected an auditory signal detection
(oddball) and a visual continuous performance test, each
of which elicit substantial and consistent performance
deficits in ADHD. We predicted that ADHD patients
would score increased (primarily frontal) resting theta
activity and poorer performance on both cognitive tasks,
compared with matched healthy control subjects. More-
over, it was expected that excessive theta would be a
significant predictive correlate of performance (both reac-
tion time delays and errors) on these tasks.
Methods
Patients
Forty-six young adolescents diagnosed with ADHD (mean age 13.78;
S.D. 1.7; range 11-17 years; 15 females) and 46 age- and sex-matched
(pair-wise) healthy control subjects (mean age 13.65; S.D. 1.83; range
11-17 yrs) were recruited from the Sydney metropolitan regions as part of
the standardized Brain Resource International Database (http://www.
brainresource.com). Both groups were administered a Spot-the-Word test
as a measure of verbal intelligence. Univariate analysis of variance
controlling for age found that the ADHD group produced decreased
scores in the Spot-the-Word test compared with control subjects (F1,89 ⫽
14.24, P ⬍ 0.001).
All ADHD subjects were referred by two pediatricians (S.C., M.K.),
and diagnosis of ADHD was confirmed using a semi-structured interview
based on DSM-IV criteria for ADHD and Conners Parent Rating Scales
(T-score 1.0 S.D. above the norm in either Inattentive or Hyperactivity/
Impulsivity indices). Twenty-six individuals met the DSM-IV criteria for
the combined subtype of ADHD (8 females), whereas 20 individuals met
the criteria for ADHD of the predominantly inattentive subtype (7
females).
All ADHD subjects were medication-free (at least 48 hours) at the time
of testing. Nineteen ADHD individuals were medication naïve, and 27
were withdrawn from medication for at least 2 days before testing (15
were withdrawn from methylphenidate and 12 were withdrawn from
dexamphetamine).
Exclusion criteria for both groups included a personal history of
physical brain injury, neurologic disorder or other serious medical
condition, or a personal history of drug or alcohol addiction. Control
subjects were also excluded if they had a family history of ADHD, Axis
1 psychiatric disorder, or genetic brain disorder. ADHD subjects were
also excluded if they had an Axis 1 psychiatric disorder or a genetic brain
disorder.
All subjects were asked to refrain from drinking caffeine and smoking
cigarettes 2 hours before the study session. All subjects or their guardians
provided a written informed consent form to participate in the Interna-
tional Brain Resource Database, in accordance with national health and
medical research council guidelines.
Procedure and Tasks
Resting Electroencephalographic Condition. After being fitted with a
Quik-Cap (NeuroScan) for electroencephalographic recording (see “Data
Acquisition” below), subjects were seated comfortably in a sound and
light attenuated room, set at an ambient temperature of 24°C. Subjects
were asked to rest quietly with their eyes open for the duration of the
recording, and were told that the task would last for 3 minutes.
Cognitive Tasks. After a standardized interval of 2 minutes, an
auditory oddball signal detection task was presented. It comprised a
series of high and low tones, at 75 dB of 50 ms, with an inter-stimulus
interval of 1.0 second. Rise and fall times of the tones were 5
Hermens et al: EEG Theta Predicts Performance in ADHD 249
milliseconds. “Background” tones were low (500 Hz), to which the
subject was asked not to respond. “Target” (signal detection) tones were
high (1000 Hz), to which the subject was asked to press buttons with the
index finger of each hand. Speed and accuracy of response were equally
stressed. The 280 background and 60 target tones were presented in a
quasi-random order, with the further constraint that two targets could not
appear consecutively. Subjects were told that the duration of this task is
approximately 6 minutes.
The continuous performance test (sustained attention task was pre-
sented after a further standardized interval of 10 minutes) consisted of a
series of letters (white single capital Arial font letters B, C, D, and G
were presented in pseudo-random order on a black background) pre-
sented to the subject on the computer screen for 200 milliseconds with an
interstimulus interval (ISI) of 2.5 seconds. Subjects were instructed to
simultaneously press two buttons with each index finger, if the same
letter appears twice in a row. Speed and accuracy of response were again
stressed equally. There were 125 stimuli in total; 85 nontarget letters and
20 randomly presented target letters (i.e., repetitions of the previous
letter). Subjects were told that this task would last for 8 minutes.
Data Acquisition
Electroencephalographic Data. A Quik-Cap was used to acquire data
from the F3, Fc3, F7, F4, Fc4, F8, Cp3, T5, P3, Cp4, T5, and P4 electrode
sites (NuAmps; 10-10 International system). Data were recorded relative
to the average of A1 and A2 (mastoids) electrodes sites. Horizontal eye
movements were recorded with electrodes placed 1.5 cm lateral to the
outer canthus of each eye. Vertical eye movements were recorded with
electrodes placed 3 mm above the middle of the left eyebrow and 1.5 cm
below the middle of the left bottom eyelid. Skin resistance was
⬍10 kOhms. A continuous acquisition system was employed, and
electrooculogram correction was carried out using a technique based on
Gratton et al. [33]. The sampling rate was 500 Hz, and a low pass filter
with attenuation of 40 dB per decade above 100 Hz was employed before
digitization.
Cognitive Test Data. Both accuracy and reaction time to targets (tones
or letters) were recorded in each task via a computer linked to the button
press response box.
Data Reduction
Electroencephalographic Data: The electroencephalographic data
were screened visually for artefacts, normal variants, and changes in
alertness (the technician screening these data was unaware of whether
a subject was in the control or ADHD group). There were no
significant differences between ADHD and control groups (indepen-
dent samples t test) in the reported number of hours slept the night
before the testing or the number and frequency of eye blinks recorded
during the task, suggesting they did not differ in alertness (spontane-
ous eye blinks have been demonstrated to be associated with alpha
activity and can be used as an index of alertness [34]). Average power
spectra were computed for 28 epochs during the eyes open paradigm;
2 minutes of electroencephalography were divided into adjacent
intervals of 4 seconds. Power spectral analysis was performed on each
4-second interval by first applying a Welch window to the data, and
then performing a Fast Fourier Transform. Epochs were rejected
if the signal at three or more sites exceeded 100 ␮V for that particular
epoch. The power spectra were averaged for each electrode position,
and power was then calculated for the theta (4-7.5 Hz) frequency
band. Theta power data were square root transformed in order that
they might better approximate the normal distributional assumptions
required by parametric statistical methods.
Cognitive Tasks: The mean number of errors (total of incorrectly
pressed nontargets or false-positive and missed targets or false-negative)
and reaction time were calculated for each subject for both oddball and
continuous performance tests.
250 PEDIATRIC NEUROLOGY Vol. 32 No. 4
Statistical Analysis
A one-way multivariate analysis of variance with “group” as the
between-subjects factor and within-subjects factor of “quadrant” was
undertaken for theta power. The “quadrant” factor had four levels: (left
frontal: [F3, FC3, F7]; right frontal: [F4, FC4, F8]; left posterior: [CP3,
T5, P3]; and right posterior: [CP4, T6, P4]). While the groups were
matched for age, young adolescence is a period of rapid neurodevelop-
mental change; for this reason, additional multivariate analyses of
covariance were conducted with age as the covariate. Mean reaction time
to targets and mean number of errors for both cognitive tasks were
submitted to one-way analyses of variance (ADHD vs control subjects)
and analyses of covariance to control for age effects. A Pearson
correlation matrix was computed to assess whether theta power for each
electrode site (three per quadrant) was related to reaction time and errors
in the two cognitive tasks, with the significance cutoff set at P ⬍ 0.05.
A secondary analysis was performed to assess the effect of ADHD
subtype. Similar statistical tests (see above) were employed; however,
control subjects were omitted from the analysis and a new between-
subjects factor of “subtype” was used. Furthermore, due to case-to-
variable issues in the analyses of electroencephalographic power across
the scalp sites used in the primary analysis (see above), data were
transformed into z scores and collapsed into each quadrant (thereby
reducing the number of dependent variables used).
Before statistical testing, individual variables were assessed for outli-
ers, defined a priori using stringent criterion of beyond 3.5 standard
deviations from the group means for each electrode site. New group
mean replacement was undertaken for each outlier. The range of outliers
across variables for both ADHD and control groups did not exceed 5%.
All statistical analyses were performed using the Statistical Package for
the Social Sciences (SPSS 11.0.1).
Results
Electroencephalographic Analyses
Figure 1 depicts the mean theta power for ADHD and
control subjects across scalp sites during eyes open resting
activity. There was a significant group by quadrant inter-
action for theta power (F ⫽ 4.53, df ⫽ 3,270, P ⬍ 0.01).
Planned contrasts revealed that this finding was due to
increased left frontal theta in ADHD subjects relative to
control subjects (F ⫽ 4.18, df ⫽ 1,90, P ⬍ 0.05; see Fig
1). The subsequent analysis, controlling for age, confirmed
the group by quadrant interaction for theta. In this case
planned contrasts not only revealed the increased left
frontal theta for ADHD subjects (F ⫽ 6.56, df ⫽ 1,89,
P ⬍ 0.02), but also revealed significantly greater right
frontal theta for ADHD compared with control subjects
(F ⫽ 4.10, df ⫽ 1,89, P ⬍ 0.05).
Cognitive Task Analyses
Figure 2 depicts (a) mean reaction time and (b) accuracy
(number of errors) for both the oddball and continuous
performance test for ADHD and control groups.
Oddball. The ADHD group scored significantly de-
layed reaction times to correctly detected oddball targets
(F ⫽ 18.67, df ⫽ 1,90, P ⬍ 0.001) and more errors overall
(F ⫽ 22.57, df ⫽ 1,90, P ⬍ 0.001). Within the errors, the
ADHD group produced more false-positive (F ⫽ 17.72,
df ⫽ 1,90, P ⬍ 0.001) and more false-negative errors (F ⫽
Figure 1. Mean theta (4-7.5 Hz) power (square root transformed) for ADHD and age- and sex- matched control subjects across electrode sites during
eyes open resting activity. Electrodes sites from left to right ordered according to “quadrant”: left frontal (F7, F3, FC3); right frontal (FC4, F8, F4);
left posterior (T5, P3, CP3); right posterior (CP4, P4, T6). ADHD subjects manifested significantly increased theta power in the left frontal quadrant
compared with control subjects.
13.09, df ⫽ 1,90, P ⬍ 0.001) compared with control
subjects. Follow-up analysis controlling for age confirmed
this pattern of results.
Continuous Performance Test. The ADHD group again
produced significantly delayed reaction times to correctly
detected targets (F ⫽ 24.65, df ⫽ 1,90, P ⬍ 0.001) and
more errors overall (F ⫽ 21.132, df ⫽ 1,90, P ⬍ 0.001).
Within the errors, the ADHD group scored more false-
positive (F ⫽ 12.86, df ⫽ 1,90, P ⬍ 0.001) and more
false-negative (F ⫽ 36.33, df ⫽ 1,90, P ⬍ 0.001) errors
compared with control subjects. Similarly, follow-up anal-
ysis controlling for age did not change the pattern of these
results.
Correlation Analyses
Table 1 summarizes the Pearson correlation matrices
conducted for each group. ADHD and control groups were
distinguished by clearly distinct patterns of associations in
these measures. In control subjects, there was a significant
positive association between theta at (primarily) posterior
sites and reaction in the continuous performance test (the
oddball reaction time did not reach significance). The
ADHD group did not manifest any patterns of association
between theta and reaction time. A secondary correlation
analysis controlling for age indicated that the association
between continuous performance test reaction time and
theta for control subjects failed to reach significance.
For the ADHD group, theta power revealed a significant
positive relationship with errors on the oddball (but not
continuous performance test) for left frontal sites. In
contrast, the control group had an association only be-
tween right frontal theta and oddball errors (see Table 1
for the correlation coefficients across sites). Partial corre-
lations (controlling for age) indicated no changes in these
results. The scatter plots depicted in Figure 3 exemplify
the differential pattern of left and right frontal theta
associations with oddball errors for control and ADHD
groups.
The inclusion of the error types (false- positive or
false-negative) revealed that for control subjects the sig-
nificant relationship found between (overall) errors and
(right frontal) theta may be the result of false-positive and
not false-negative errors. For ADHD, however, the asso-
ciation observed between left frontal theta and errors could
be attributed to the combination of false-positives and
false-negatives, because both error types produced rela-
tively high correlation coefficients with left frontal sites
(note: only F7 and FN reached significance). There was a
similar pattern for ADHD in continuous performance test
errors and theta, with false-negative and left frontal theta
(F3) reaching significance. Partial correlations (controlling
for age) yielded no changes in the overall error type results
for both groups.
Subtype Analyses
Secondary analyses indicated that ADHD subtypes
were significantly different in false-negative errors during
the continuous performance test, with ADHD-Combined
producing increased false-negative errors compared with
ADHD-Inattentive (F ⫽ 5.98 df ⫽ 1,44, P ⬍ 0.05), and
Hermens et al: EEG Theta Predicts Performance in ADHD 251
Figure 2. (a) Mean reaction time to correctly detected targets during auditory oddball and visual continuous performance test (CPT) for ADHD and
age- and sex- matched control subjects. (b) Mean total number of errors committed during auditory oddball and visual CPT for ADHD and age- and
sex-matched control subjects. ADHD subjects manifested significantly increased reaction time and made more errors in both tasks compared with
matched control subjects.
continuous performance test reaction time was of border-
line significance with ADHD-Combined revealing de-
layed reaction time compared with ADHD-Inattentive
(F ⫽ 4.03, df ⫽ 1,44, P ⬍ 0.05). These results were
unchanged when controlling for age. There were no other
differences between the ADHD subtype groups for per-
formance and theta measures.
Discussion
This study undertook a direct examination of the rela-
tionship between elevated electroencephalographic theta
(particularly in frontal sites) and poorer cognitive perfor-
mance in ADHD children/adolescents compared with
control subjects. Although previous studies of electroen-
cephalographic and cognitive measures have each impli-
cated the importance of frontal brain dysfunction in
ADHD, a direct association between these measures and
concomitant recording in the same subjects has rarely been
addressed. To our knowledge, one other study [32] has
examined the association between baseline electroen-
cephalographic measures and cognitive tasks in ADHD
Combined subtype males. The current study adds to these
previous findings by examining a larger and older ADHD
group (containing both sexes) with Combined and Inatten-
tive subtypes. This study has focused on theta (because it
is the most robust electroencephalographic finding in
ADHD) and examined relationships with performance
measures in auditory and visual attention-demanding tests.
Consistent with predictions, ADHD subjects manifested
excessive theta power during resting conditions, particu-
252 PEDIATRIC NEUROLOGY Vol. 32 No. 4
larly in (left) frontal regions. They also manifested both
delayed reaction time and increased errors in subsequent
signal detection and continuous performance tests. Nota-
bly, abnormally elevated (primarily left) frontal resting
theta activity correlated with poorer performance in the
signal detection (oddball) task for the ADHD group.
ADHD and control groups were distinguished most clearly
by two patterns of associations between theta and perfor-
mance measures. For ADHD, there was a positive associa-
tion between frontal (primarily left) resting theta and errors in
the oddball task. This association was virtually absent for
control subjects (with one right frontal electrode site yielding
a significant relationship with oddball errors). The different
pattern of association between frontal theta and oddball errors
for ADHD and control groups is exemplified in Figure 3. For
control subjects, reaction time for the continuous perfor-
mance test was predicted positively by (primarily right)
posterior theta; there was no evidence of this pattern in the
ADHD group. This pattern did not reach significance (in
control subjects) when the correlations controlled for the
effects of age.
Swartwood et al. [32] also found a left frontal theta
relationship with poorer performance in ADHD; however,
this was in relation to a reaction time measure during the
test of variables of attention. They did not report correla-
tions between these measures for control subjects. In the
current study, the ADHD group appears to be manifesting
signs of “pervasive ADHD” described by Oades [35],
which is highlighted by impairment in left frontal func-
tion; that is, a deficit relating to detailed stimulus identi-
fication or decision-making, possibly over and above a
Table 1. Correlation coefficients between (a) oddball and (b) continuous performance task measures (reaction time, false-positives, false-
negatives, and errors) for each site*

Reaction Time False-Positives False-Negatives Errors

a. Oddball Control ADHD Control ADHD Control ADHD Control ADHD

F7 0.24 0.25 0.11 0.32‡ ⫺0.14 0.24 0.05 0.34‡

LF F3 0.23 0.23 0.18 0.28 ⫺0.04 0.28 0.15 0.41§
FC3 0.25 0.14 0.15 0.15 ⫺0.09 0.23 0.10 0.24
FC4 0.25 0.18 0.16 0.17 ⫺0.06 0.15 0.12 0.26
RF F4 0.19 0.09 0.23 0.08 0.07 0.19 0.23 0.26
F8 0.08 0.21 0.34‡ 0.27 0.10 0.25 0.35‡ 0.22
T5 0.06 0.15 0.14 0.20 0.07 0.28 0.16 0.16
LP P3 0.18 ⫺0.03 0.12 0.08 ⫺0.17 0.16 0.04 ⫺0.01
CP3 0.18 ⫺0.08 0.10 0.03 ⫺0.15 0.12 0.03 0.00
CP4 0.25 0.01 0.17 0.03 ⫺0.08 0.23 0.12 0.04
RP P4 0.23 0.01 0.13 ⫺0.03 ⫺0.13 0.02 0.07 0.10
T6 0.17 0.06 0.14 0.08 0.00 0.11 0.13 0.06
Reaction Time False-Positives False-Negatives Errors
b. CPT Control ADHD Control ADHD Control ADHD Control ADHD

F7 0.19 0.12 0.14 0.02 ⫺0.09 0.24 0.00 0.22

LF F3 0.28 0.05 0.21 0.17 ⫺0.03 0.35‡ 0.11 0.26
FC3 0.29† 0.03 0.22 0.00 ⫺0.01 0.23 0.10 0.06
FC4 0.27 0.07 0.28 0.03 0.00 0.23 0.16 0.12
RF F4 0.26 0.13 0.24 0.04 0.00 0.24 0.16 0.11
F8 0.18 0.08 0.20 0.00 0.03 0.21 0.10 0.18
T5 0.17 0.19 0.13 0.01 0.06 0.17 0.07 0.05
LP P3 0.30† 0.13 0.16 ⫺0.11 0.01 0.12 0.07 ⫺0.03
CP3 0.29† 0.07 0.12 ⫺0.13 ⫺0.07 0.12 0.02 ⫺0.04
CP4 0.35‡ 0.07 0.21 ⫺0.10 0.01 0.19 0.14 ⫺0.01
RP P4 0.33† 0.03 0.15 ⫺0.15 0.00 ⫺0.07 0.09 ⫺0.12
T6 0.25 0.09 0.21 ⫺0.07 0.04 0.03 0.15 0.01

* Categorized into regions: left frontal (LF), right frontal (RF), left posterior (LP), right posterior (RP) for eyes open theta power for control subjects
(left columns) and ADHD patients (right columns).
Coefficients are highlighted when significant at † P ⬍ 0.05, ‡ P ⬍ 0.025, § P ⬍ 0.005.

Abbreviations:
ADHD ⫽ Attention-deficit hyperactivity disorder
CPT ⫽ Continuous performance test

general deficit in global attention function governed by
right frontal control [35]. The relationship between pri-
marily left frontal theta and oddball errors may reflect a
lateralization unlike normal control subjects (or lack
thereof). However, the association documented in control
subjects of right frontal theta and oddball errors accords
with the broader implication of right frontal networks in
novelty detection, and the role of theta in determining
salient sensory input for incorporation into memory. This
observation is consistent with functional neuroimaging
studies, which reveal preferential right inferior frontal
engagement in oddball and continuous performance tests
[36-38]. The relatively greater association of theta with
errors for the oddball task (in ADHD) compared with
reaction time for the continuous performance test (in
control subjects) may reflect the differential processing
demands of these tasks, namely: accuracy for the oddball
task (in which a nontarget must be ignored), and speed for
the continuous performance test (which requires sustained
vigilance for a changing target, rather than selection of
targets vs nontargets). Furthermore, the modality of these
tasks may also be a factor, which should be tested in future
studies.
For the ADHD group, theta power was a significant
positive predictor (correlate) of oddball task errors across
both left and right frontal sites. In contrast to control
subjects, the most robust positive associations were ob-
served for left frontal theta and oddball errors. In this
regard, we speculate that an excess of frontal theta makes
a central contribution to ADHD decrements in signal
detection. The combination of relatively greater left frontal
theta, and the more consistent association between left
frontal theta and oddball performance in ADHD, may
reflect a related disturbance in the normal right frontal
lateralization of task-relevant signal discrimination.
Our findings provide preliminary evidence to suggest
that abnormal frontal theta activity in ADHD is related
specifically to difficulties with signal detection, given that
the oddball task taps the ability to extract task-relevant
signals from task-irrelevant background “noise”. This
proposal accords with reports that left frontal lesion
patients have similar performance decrements on attention

Hermens et al: EEG Theta Predicts Performance in ADHD 253

Figure 3. Scatter plots depicting the different pattern of associations between theta power at frontal sites and oddball errors. (a) Control subjects (left
frontal); (b) control subjects (right frontal); (c) ADHD (left frontal); (d) ADHD (right frontal) vs number of errors. For ADHD, associations were
significant primarily for left frontal theta, exemplified by F7 electrode (c) and (to a lesser extent) for right frontal theta, exemplified by F8 electrode (d),
whereas control subjects manifested only right frontal theta associations, F8 electrode (b), revealing a different pattern from ADHD.

to task-relevant signals, tapped by choice reaction tasks
[39]. Clinically, the findings suggest that inattention is a
fundamental characteristic of ADHD, in terms of under-
lying brain disturbances and their behavioral manifestation
in “signal vs noise” discrimination deficits. Indeed, resting
theta has previously been interpreted as an index of
inattention in this disorder [12,32], and increased errors in
discriminating targets (predicted by raised theta) also point
to inattention (within both Combined and Inattentive
subtypes). In this regard, normal baseline theta might be
conceptualized as a prelude to good performance in
attention-demanding tasks. In healthy subjects, enhanced
theta has been related to sleepiness [40] and predicts
similarly poor cognitive performance [15], possibly via
enhanced activity in cortico-hippocampal feedback loops
[15]. The role of theta activity in indexing attention should
be further addressed in electroencephalography-based
models of ADHD such as maturational lag [16], develop-
mental deviation [8], and cortical hypoarousal [17] by
incorporating tasks that demand an increasing attentional
load.
A correspondence in the disturbances (increased theta
coupled with poorer performance) across age suggests that
a developmental deviation, rather than a maturational lag,
model may more precisely account for ADHD. Further
light might be shed on this issue in future research by the
analysis of additional electroencephalographic frequency
bands and the inclusion of electrodermal indices, given
that the cortical hypoarousal model has been conceptual-
ized as a specific version of the developmental deviation
model [6]. Clinically, the inclusion of a hyperactive/
impulsive subgroup would be valuable in differentiating
these models, given that these symptoms are thought to be
more susceptible to maturational changes [13,41]. As
Barry et al. [6] have pointed out, these models may prove
to be too simplistic and a profile of information across data

254 PEDIATRIC NEUROLOGY Vol. 32 No. 4

modalities (from performance to physiologic and brain
imaging) may in the longer term provide the most com-
prehensive account of ADHD, particularly at the individ-
ual level.
This study has confirmed findings of robust electroen-
cephalographic theta enhancement in ADHD, and pro-
vided new evidence that this enhancement predicts errors
in signal detection in particular. The observation that
raised theta was most apparent in the left frontal brain is
consistent with ADHD neuroimaging evidence for reduc-
tions in left frontal white matter [42], total volume [43],
and glucose metabolism [44,45]. Future research is war-
ranted to confirm our findings in additional cognitive tasks
and electroencephalographic bands. Given the frontal
focus of theta disturbances in this study and neuroimaging
evidence for frontal deficits in ADHD [46,47], there is
also a need to further explore the neuroanatomic basis of
these disturbances using structural and functional neuro-
imaging techniques.
We acknowledge the support of the Brain Resource International
Database (under the auspices of The Brain Resource Company) for use
of the testing battery and data. A Lucy Firth Postgraduate Scholarship
from the School of Psychology, the University of Sydney, contributed to
support for this work. We would like to acknowledge the valuable
contributions from Ilario Lazzaro (PhD). E.S. would like to thank Ayling
Rubin (MA) and Tom Rubin (MA) for their support. We also thank the
individuals who gave freely their time to take part in the study.
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