Dear Editor:
We would like to thank the readers for their thoughtful and constructive comments on our study.1 We believe these observations are highly valuable in guiding test developers in the design and implementation of future studies aimed at validating the Cognitive Assessment Tool for Pediatric Clinical Research (CAT-PCR) and similar psychometric instruments.
The validation of a new psychometric instrument requires an iterative, stepwise process to build the evidentiary foundation supporting its intended use in assessing specific constructs within defined populations and contexts. In the present study, we focused on the initial evaluation of the CAT-PCR’s construct validity and reliability. Future investigations should further strengthen the evidence supporting convergent and discriminant validity of CAT-PCR score interpretation. In particular, the relationship between CAT-PCR indices and other cognitive domains—including executive functioning, intelligence, language, mental rotation, social cognition, sustained attention, visual and verbal memory, and visuomotor integration—should be systematically explored.
The readers’ suggestion to assess situational anxiety through standardized behavioral measures, as well as to examine personality traits as potential moderators, is especially pertinent and may substantially contribute to further validation efforts. Psychosocial moderators are indeed highly relevant. Additionally, disentangling the effects of formal education from visuo-spatial constructional abilities represents another important aspect of the validation process.
Validation studies should prioritize the use of instruments originally developed within Sub-Saharan settings, rather than relying exclusively on imported tools adapted through cross-cultural validation. Nevertheless, an important limitation remains the limited availability of validated original psychometric instruments and measures that can serve as reference standards in these contexts.
The potential impact of exposure to environments that do not nurture learning, information exchange, or knowledge-sharing experiences beyond formal schooling was not specifically or systematically addressed in our study design. We collected and analyzed information from a subgroup of participants through structured interviews/questionnaires administered to parents or caregivers. Specifically, we assessed whether both parents/guardians lacked formal education and whether the child experienced psychosocial deprivation related to parental/guardian absence or institutional care (eg, orphanage placement). However, the number of observations was insufficient to support robust conclusions regarding the influence of these factors on CAT-PCR scores.
We have also pursued the development of a digital automated scoring system to evaluate waveform reproduction accuracy in collaboration with the Department of Information Engineering and Mathematics, University of Siena (Prof. Salvietti and Dr. DeBona). The initial approach based on machine learning techniques and relatively simple waveform similarity algorithms based on Hausdorff distance was unsuccessful. For example, test–retest analyses demonstrated an intraclass correlation coefficient equal to 0; no significant correlation was observed between automated measures and clinician-based assessments of reproduction accuracy (unpublished data). At present, conducting a formal inter-rater reliability study can provide additional evidence supporting the reliability of CAT-PCR scores and their applicability in clinical research settings within urban populations. Given the limited time required for reproduction processing, scoring, and interpretation, centralized reading by an expert reviewer— when necessary, under blinded conditions—potentially remains a practical and efficient strategy for test scoring and interpretation in multicenter trial studies.
The design and implementation of future CAT-PCR studies across diverse rural and educational populations, as well as the evaluation of responsiveness to health interventions, remain substantially constrained by limited resources. Sustained access to both human technical expertise and financial support is essential to ensure the progressive advancement of the test validation process through its continued use in practice.
We hope that this letter may further stimulate the interest and engagement of stakeholders involved in the development of psychometric tools for assessing psychological and cognitive health among children and adolescents in under-resourced care settings.
With regards,
All authors are with Leoben Research Aurora in San Vincenzo Valle Roveto (AQ), Italy.
Funding/financial disclosures. The authors have no relevant conflicts of interest. No funding was received for the preparation of this letter.
Correspondence. Franco Di Cesare, MD;
References
- Di Cesare F, Di Carlo C, Di Cesare L. Validation of a pediatric cognitive assessment tool to advance knowledge on children’s cognitive development, health risk factors, and health-promoting interventions in sub-Saharan regions. Innov Clin Neurosci. 2025;22(10–12):33–51.