Innov Clin Neurosci. 2026;23(4–6):5–9.

Dear Editor:

We read with great interest the study by Di Cesare et al,1 which introduces the Cognitive Assessment Tool for Pediatric Clinical Research (CAT-PCR), a novel, brief, and culturally situated nonverbal cognitive battery validated in Zambian school-aged children. The authors are to be commended for explicitly modeling visuographomotor constructional processing and selective attention as separable constructs, and for applying structural equation modeling with item response theory to support multidimensional construct validity.

However, the decision to interpret reproduction inaccuracy scores solely as indicators of cognitive deficit, without modeling potential behavioral or affective intermediaries, may constrain the explanatory scope of the tool.2 The Visuographomotor Constructional Processing (VGCP) index may partly reflect anxiety-related task disengagement, especially under delayed memory or closed-eye conditions, where stimulus absence may amplify disengagement effects.3 Incorporating observer-rated behavioral measures during test administration, such as fidgeting or avoidance behaviors, could clarify whether such inaccuracy is mediated by cognitive difficulty or motivational withdrawal. This distinction may be especially relevant in older children where anxiety traits and internalized stigma from chronic illness are more prevalent.

The exclusion of children with formal educational interruptions, while pragmatic for initial feasibility, limits the tool’s generalizability across the broader Zambian pediatric population. Importantly, cognitive performance may differ not only due to school exposure, but also due to variable literacy practices in home environments.4 Incorporating a literacy-neutral visual sequencing task, or a drawing reproduction task without symbolic elements, could help decouple the contribution of formal education from intrinsic visuospatial integration ability, thereby enhancing inclusivity and external validity.

Finally, although test–retest reliability for both the VGCP and Visuomotor Processing indices was strong, the omission of inter-rater reliability estimates leaves open the question of scoring consistency in real-world deployments. Given the reliance on visual inspection of subtle graphic errors, such as morphology and spacing, standardization across raters is critical for deployment in multicenter trials and community-based screening.5 Training protocols, blinded duplicate scoring, or automated digital scoring overlays may strengthen reproducibility and future scalability.

We commend the authors for addressing a critical measurement gap in Sub-Saharan cognitive health research and for advancing a culturally adapted, psychometrically robust tool. Further research validating CAT-PCR in rural, educationally diverse populations and exploring its responsiveness to therapeutic interventions may support its integration into clinical and epidemiological research frameworks across the region.

With regards,

Kishankumar Mahida, MD, and Snehal Rajendra Jagtap, PhD

Dr. Mahida is with the Dr. D. Y. Patil Medical College Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth (Deemed-to-be-University), Pimpri, Pune, 411018, Maharashtra, India. Dr. Jagtap is with the Dr. D. Y. Patil Dental College and Hospital, Dr. D. Y. Patil Vidyapeeth (Deemed-to-be-University), Pimpri, Pune, 411018, Maharashtra, India.

Funding/financial disclosures. The authors have no relevant conflicts of interest. No funding was received for the preparation of this letter.

Correspondence. Kishankumar Mahida, MD;

References

  1. 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.
  2. Martinez KA, Sayers C, Hayes C, et al. Normal cognitive test scores cannot be interpreted as accurate measures of ability in the context of failed performance validity testing: a symptom- and detection-coached simulation study. J Clin Exp Neuropsychol. 2021;43(3):301–309.
  3. Huang X, Levine S, Paradiso MA. Rebounding V1 activity and a new visual aftereffect. J Vis. 2008;8(3):25.1–10.
  4. Arya DJ, McClung NA, Maul A, Cunningham AE. The effects of early home literacy environments on fourth-grade literacy achievement: an international comparison. Int J Quant Res Educ. 2014;2(1):1–16.
  5. Parashari A, Singh V. Reasons for variation in sensitivity and specificity of visual inspection with acetic acid (VIA) for the detection of precancer and cancer lesions of uterine cervix. Asian Pac J Cancer Prev. 2013;14(12):7761–7762.