Acauisitions and Acquisitions et ~ibiiographic Servias se&ces bibliographiques
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STWIES OF XrTmTIm D m - DI- IN ADtn;TS
by
Patricia Anne Murphy, Ph.D. (2000)
Institute of Medical Science, Wiiversity of Toronto
Backgmind: Attention dei ic i t hyperactivity disorder (ADHD)
is a c m n and serious condition affecting children and
adults. The symptoms of ADHD include distractibility,
overactivity , irnpulsiveness , and inattentiveness . The
manifestations of ADHD in aduits are not w e l l understocd, and
the current methods of diagnosis are contraversial. The
present research, in two parts, examines the diagnosis of
ADW in adults, and cognitive functioning in adults w i t h the
disorder. abjectivrs: The purposes of the present study were:
1. to determine i f an adult can pravide as accurate a rating
of his own childhood and m e n t ADHD symptcms as can an
informant, and 2. to determine if adults with ADHD have the
same deficits in cognitive functioning as children with the
disorder. Mhtbod: In Study 1, achilt subjects were asked to
ccmplete a questionnaire rating their own childhcod or
curent ADHD symptams. A parent or partner was asked to
caplete a similar questionnaire rating the subject 's
childhood or curent ADHD symptoms. The correlation between
subject and infoxmant ratings of inattentive symptams,
hyperactive-inpulsive symptcms, and total symptcms was
detennined. In Study 2, the perforniance of 18 adults w i t h
ADHû on several cognitive tests was compared to that of 18
normal controls . Results: In Study 1, moderate to high
correlat ions were found between sub j ect and informant ratings
of both childhood and m e n t ADHD symptans. In Stuày 2,
adults with AMID were found to have an impairment in
cognitive functioning. CoIiclusiam: An adult is able to give
as accurate an account of his own childhood and m e n t ADHD
symptoms as is an informant. In addition, adults w i t h ADHD
have an inpairmat similar to that found in children with
ADHD.
iii
1 am indebted to Dr. G. Harvey Anderson for his support
and encouragemnt during my tenure as a doctoral student. 1
wuid like to thank Dr. Catharine Whitesicie for the advice
and assistance which made the coqletion of my degree
possible. 1 am very gratefül to Dr. Marcel Danesi for
agreeing to serve as an examiner. His support was immluable.
1 wouïd like to thank al1 the indiviàuals who participated as
subj ects . Finally 1 want to thank my father, Robert Murphy,
for putting up with RE al1 this tim.
Abatract ..................................m................ ii
- 1 m t s ..................................*......... i v
Thesis Overvi-. ............................................ 1
USE OF SW-REPOLCTS IN D-XS OF
-rn ................................................ 3
..................................... Vsiidity and Aecutacy 3
Ba- ................................................ 4
Retrospective Accounts of m v i o r ....................... 5
............................................. Self-Reports 7
8 .................................................. abj-um ................................................... 9
....*..................*.*.......................... 10
.......................................... Rss.arch mign 10
- j e t s ................................................. 11 P a r t 1 .................................................. 12
................................................ P a r t 2. .12
--ta .............................................. 13 ..................................... Statisticsl Analmis 14
a y p O t h 6 1 ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ o. . m.16
PSUICt 1 ................................................. .16 Part 2. . . ............................................... 16
Subject and Observer Ratings .....................m...... 18
M e a n Scores ............................................. 18 Sex Effects ............................................. 19 Age Effects ............................................. 19 Curreat Rat* m..mm....mmm.....m.....*m*....m....*..mm. 20
Subject and Observer Rathg ............................. 20 Mean Scores ............................................. 21 S a Effects ............................................. 21 Age Effects ............................................. 22
D I S C O S S I W m m m ~ o ~ o m m o m ~ o m m m o o ~ m o m m o o r o e o m m . m o o o ~ m ~ o m m m m m m m 3 1
~ U S I d B J S o o o m m m m o m . m o m m m . o . o m ~ m o o o o o o . * * m o m m . o o o ~ o ~ . m o m m o 4 1
LMtatims of P r e a ~ ~ ~ t Stuby ............................. 41 .................................... Severity of S Y m p t w 41
Vàlidity of A s s e s ~ t .................................. 42
Generalizability of Results ............................. 42
niplicatiam of the mLUirCIh... ...m.mmmm..m.mm.mm...mm.. .42
m- D ~ t i ~ m o m . o m . m m o m o e m m . . m o m . . m o o m m m * o . m . * o m o . o o 4 2
m m ~ k S l e J i C T I ~ I N ~ T S ~ ~
-mm. ..mm*mmmmm*m.mm.m.....mm.mmm.mm.mm.m m . e m m m m m m 4 4
..mmmm*m.mm.mm.*m......m*...mmm.m..mm*.m.m..m 44
Diagnosis of ADD in Adults ............................. 45
................................... Cognitive Functionhg 46
............................................... abjectitree 50
o o o o o o ~ ~ o o o ~ o ~ o o m r o o e o . o ~ e o o e o o o o e e ~ ~ o o o o o ~ o ~ o o o o o ~ o 5 1
~ ~ ~ ~ ~ i ~ ~ ~ ~ ~ . ~ ~ m ~ ~ ~ ~ . ~ ~ ~ ~ ~ * ~ ~ ~ ~ e ~ ~ .....o.......... 5 1
Ekecutive Control Measures .............................. 51 ........................................... Control Tas ks 51
(houps ................................................... 52
................................................. Subj-te 52
Saxrple Size .............................................. 56
.................................. A&ddstrat ion of Study 56
................................................ D i m a i s 57
....................................... Diagnostic Me- 57
........................................... ADW Subjects 57
N o m 1 Controls ......................................... 59 .................................. Diagnostic Reliability 60
Subjecta $#cluàed f n the R e ~ a r i r r ? h . ~ . ~ ~ ~ ~ ~ ~ . ~ . ~ . ~ ~ ~ ~ ~ ~ ~ .. 60
ADHD Group .............................................. 61 .................................... N o m 1 control Group 61
........................................ Research -LI 61
.................................... S top Signal Paradigm 61
Tower of Hanai .......................................... 63 ................................... Trail Makirag Test (A) 64
................................... Trail Making Test (B) 65
........................ Benton Facial Recognition Test ..65
Statietical Analpis m . m m m m m m m m ~ m m m m m m m m m m m m m m . m . m m m m m m m m m 6 6
Stop Signal Paradlm .................................... 67 Tower of m o i .......................................... 68 Trail Making Test (A i5 B) ............................... 68 Benton Facial Recognition Test .......................... 68
. of -i .......................................... .71 Tzail Bhkhg T e s t (8) .................................... 72
Trail Wcixq Test (A) .................................... 72 Ben- Facial Recognitiai T e s t ........................... 73
D I S C U S S I d a J m m m m m m m m m r m m ~ m ~ m m ~ m ~ m m r m ~ m m o m m m m ~ m m ~ m m m m * m m o m m m m m 8 0
- 1 m . m ....................... ..................*.... 93
viii
-ObSE
1.1 A g a m of Partici-ts .................................. 16 1.2 Range of Subject and ûb~emar Rat- of Qiildbood
SynptQYI.............................................. 23
1.3 Range of Subject 8ndCbeemmr Rat* of eUrreat
mm .............................................. 24
........................... 1.4 a l d h a o d m Rat- 2s
............................. 1.S Wean -tApEp) I(at* 26
1.6 Maan asildhood Rat* for Subjectil
> r 34 Yean, of .................................... 27
1.7 &han Childhood Ra- f o ~ Subjects
< 34 Y-s of ~. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28
1.8 Mean Cmmmt Ratixzgs for Subjecta
> 40 Y-8 0 f A g r e . . ~ ~ . ~ . m ~ ~ ~ . ~ . ~ ~ . . ~ ~ ~ ~ * e * . . ~ ~ w . ~ . * 2 9
1.9 Wesn Curreat Rathg8 for Subjactil
< 40 Years of A g 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
-Tm
~ ~ ~ m A D l l L T S ~ A m m
.................................. 2.1 Ages of Patticimm 69
2.2 aAp ~.....,...................... ~ ~ ~ ~ ~ ~ ~ ~ e ~ ~ ~ ~ ~ ~ ~ 7 0
2.3 W S - R Agd-Scald 1L.pi.
(Vocakilm ud Block mi-) o o o ~ e ~ ~ o ~ o ~ ~ o m ~ ~ o ~ ~ o o ~ o ~ .74
2.4 PIRIS-R A Q e - S d d IQ C.Lroup #banr,
( V O C ~ ~ I U ~ S ~ ~ rrd Block mis) . m . e . . . . . . e . . . . e . e . . o e . . . 75
............. 2.5 -8 f00 w 8- si- Parodiw 76
2.6 Orarp for of mi . . . . . o . . . . . . . . . . . . . . 77
2.7 Qmup Means for the Tkail BW&g Test (A i B) ......... 78
.... 2.8 Omup Means for the -tan F a c i a l Recognition T a e t 79
-A: Study 1 Correlations .......................... 109 Agpemdh 8: Results of Analyses of CUvariance ............ -112 Appeardix C: Information and Consent Fo rms ................. 116 Appeaidix O: ûlildhooà and Current Behavior
Questionnaires ................................ 126
Attention def icit hyperactivity disorder (ADHD) is a
camnon condition characterized by such syrrptans as
inattentiveness , overactivity , impulsiveness , and
distractibility . Although estimates v a q widely, ADID affects
approximately 5% of school age children (Anderson, Williams,
McGee, & Silva 1987; Safer & Krager 1988; Offord, & Bayle
1989). At one time ADHD was thought to be strictly a
childhood disorder, outgmwn in adolescence and of little
consecpence for adult mental health (Laufer & Denhoff 1957) . Research now suggests, however, that the disorder persists
into adulthood in 30.70% of affected individuals (Weiss,
Hechtman, Milray, & Perlman 1985; Gittelman, Manuzza,
Shenker, & Bonaguxa 1985; af Klinteberg, Magnusson, &
Schalling 1989; Shekim, Asaniow, Hess, Zaucha, & Wheeler
1990; Mannuzza, Klein, Bonagura, Pkdlay, & Addali 1991),
often with serious conswences. ADHD is an established risk
factor for antisocial behavior (Weiss, Hechtnian, Milray, &
Perlman 1985; Greenfield, Hechtman, & Weiss 1988 ; Mannuzza,
Gittelman Kiein & Prldali 1991; Biedenml, Faraone, Spencer,
Wilens, NoMn, Lapey, Mick, =ifcher Uhlan, & Doyle 1993 ;
Mamuzza, Klein, Bessler, Mallay, & LaPadula 1993;
Satterfield & Schell 1997), substance abuse (Shekim, As-,
Wss, muchar & tShee1er 1990; m u z z a , Gittelman Klein, &
1
Adda1i 1991; Biederman et al. 1993; Mannuzza et al. 1993;
Wilens, Biedernian, Mick, Faraone, h Spencer 1997) , academic underachievemnt and l o w occupational success (Weiss,
Hechtman, Perlman, Hopkins, & Wener 1979; Weiss et ai. 1985;
Mannuzza et al. 1993 ; Biederman et al. 1993 ; Pdannuzza, Klein,
Ekssler, Malloy, & m e s 1997) . The manifestations of the
disorder in achilts are not well understood, howeer, and the
current methods of diagnosing ADHD in adults are
controversial. The present research, i n two stuàies,
hvestigates cognitive functionhg in adults w i t h ADHD, and
examines the ability of aduits to rate their own synptoms of
A m .
viiidity cina Accrirrcy
The present research is concenied w i t h the valiàity of
self-reports. "A ~ o n y m for validity is accuracy. To the
degree that an -ration resuits in observable masures that
are accuate representations of a theoryfs concepts, the
remiting masures are said to be valid" (Bohrnstedt & Knoke
1988, p 14) . This definition of accuracy is accepted in the
literature ( W e n a r 1963; Paganini-Hill & Ross 1982; Bailey &
Gawralda 1985; Tilley et al. 1985; Harlow & L i n e t 1989; Aaron
et al. 1995 ; Liu et al. 1996; Cantwell, Lewinsohn, Rohde, &
Seeley 1997; Olson et ai. 1997; Weiss et al. 1998), and is
used in the present thesis. Concurrent validity occurs when
two masures, taken at the same time, produce canparable
results that lead to the same conclusion (Reading 1977) . nie current research examines the concurrent validity of
self-ratings of childhood and current AûHD synptans by
cornparhg self-atings to infoxmant ratings.
-cm==d
Although D M - I V p e m i t s the diagnosis of ADW in adults,
assessrnent is considered prablemtic. The diagnosis of ADHD
cannot be made sircply on the b a i s of m e n t symptms. It
mst be established that the disorder dates from childhood,
and that some symptahs causing impairment were present in the
individu1 before the age of 7 (Amrican Psychiatrie
Association 1994). Researchers and clinicians workîng with
children generally are able to consuit parents and teachers
when conducting an assessrrient for ADHD. When assessing an
adult for the disorder it is not always practical, or
possible, to consult knowleàgeable infamants. Researchers
and clinicians studying ADHD in adults, therefore, often must
rely on a subjectls recollection of his childhood behavior in
making a diagnosis. As there is same westion regarding the
validity of such information (Wender, Reimherr, & Wood 1981;
Mannuzza & Gittelman 1985; Mannuzza et al. 1993; W d ,
Wender, & R e i n h e r r 1993), assessing achilts for ADW is a
contentious issue. It has been suggested tha t any diagnosis
of AWID in an aduit nnist be vie@ w i t h suspicion due t o the
àifficulty of getting a valid chi ldhcd history (Shaffer
1994; Wender 1997). To further ADHD research, it is necessary
to determine if adults can accurately recall, and report on,
their childhood behavior.
5
In aààition to the problems imrolved in getting a thorough
and accurate account of childhood synptans, it mst be
established that adults can provide an accurate report of
their m e n t symptoms. Researchers stuaying ADHD in adults
usually try to get an informant, such as a spouse, to supply
additional information, but this is not almys possible. It
would facilitate ADED research if it could be established
that aduits can give a valid description of their m e n t
behavior . Infomtion obtained fram an individual about his own
behavior is often viewed as king less valid than that
obtained from an inforniant (Shaffer 1994; Wender 1997).
Research suggests that under sane conditions, a valid account
of childhood behavior can be obtkined retrospectively,
through self -reports, and a valid account of m e n t behavior
can be obtained fran self-reports. The present research
examines the correlation between self-ratings and informant
ratings of symptcms associated with ADHD. The validity of
self-ratings of AWiD symptams will be exwiined using
informant ratings as the criterion for validity. Infamants
have been shown to accurately recall their adult childrenls
childhood ADHD status (Maruiuzza & Gittelman 1993) .
Retrospective accounts of behavior and events,
self-reported or otherwise, are often vie& as
untrustwolthy. (Chess, Thunas, & Birch 1966; Shaffer 1985) . Retrospective self-reports of childhood ADHD symptoms are
viewed as particularly suspect (Wender, Reimherr, & Wood
1981; Mannuzza et al. 1993; W a r d , Wender, & Reimhen 1993;
Schaffer 1994; Wender 1997). Indeed, a person does not always
report his own history accurately (Chess, Thomas, & Bir&
1966; Tilley, Barnes, Bergstralh, Labarthe, Noller, Colton, &
Aàam 1985; Mitchell, Cottler, & Shapiro 1986; Olson, Shu,
Ross, Pendergrass, & Robison 1997) . Reseaxchers have hestigated accuracy of recall for nmrous types of
behavior . Researchers stuâying mmory have reported poor recall for
use of drugs during pregnancy (Tilley et al. 1985) , x-rays
during pregnancy (Tilley et al . 1985) , and pregnancy
conplications (Olson et al. 1997). It has been reported that
achiLts do not pravide valid information on their own
childhwd symptoms of ADHD. In a stuày conducted by Manuzza
et al. (1993) 18% of a sample of adults diagnosed w i t h
hyperactivity as children did not remerriber being hyperactive.
ïnversely, however, 82% of subjects did r-.
Research demonstrates that the type of information an
individual is asked to recall (Paganini-Hill & Ross 1982 ;
Tilley et al. 1985; Olson et bl. 1997) and the m e r in
which the questions are posed can affect the accuracy of
reporthg (Mitchell, O o t t l e r , and Shapiro 1986) . Çcme types
of information are very well recalled even after a
substantial length of time (Coulter, McPherson, Elliot, &
whiting 1985; Oison et al. 1997) . Research demonstrates that highly salient and repeated
incidents can be accurately recalled. Excellent recall for
nonfatal illnesses (Colditz, Martin, Stampfer, Willett , Sanpson, Rossner, Hennekens, & Speizer, 1986) , suyeries
(Coulter et al. 1985), past physical activity (Aaron, Kriska,
Deaxater, Cauley, Metz, & LaPorte 1995) , and alcohol intake (Liu, ~erduia, Byers, williamson, Mokdad, & Flanders 1996)
has been reported.
More specific questions elicit more accurate respomes
than do open-ended questions. The responses to specific
questions have k e n shown to have a very high accuacy.
Mitchell, Cottler, & ~hapiro (1986), for exanpie, found that
wanen were more likely to accurately recall the drugs they
used dwing pregnancy when the drugs were specifically =dw
Researchers have qgestioned the accuracy of self -reports
(Wender 1997; Oltmanns, Turkheimer, & Strauss 1998). Data
about an individual obtkined fran an informant is often
considered to be more accurate than information obtained fran
the individua1 himself (Shaffer 1994; W e n d e r 1997; Ol tmanns ,
TurWieimer, & Strauss 1998) . Maruruzza and Gittelman (1985)
imestigated the persistence of symptuns in adolescents
diagnosed with ADHD in childhood. The study included normal
controls and ADHD probands. In addition, the authors examined
the correlation between diagnoses based on self-reports and
parental reports of current ADHD syrrptuns. A very poor
correlation was founâ. This may be because the adolescents
themselves were interview&, while parental infomtion was
obtained through a questionnaire. On an interesting note, the
authors state that self-reports can be informative. The
researchers were blind as to the childhmd status of the
participants. Four adolescents were intemiewed and diagnosed
with ADHD based solely on their own self-reports of current
symptcms, as a parent was not avkilable. These four
individuals had been diagnosed with ADHû as children.
It appears that self-reports can be accurate even if the
information requested is sensitive. Accurate reports have
been obtained fram indivichikls regardhg their mking habits
(Wills & Cleary 1997) , recreational drug use (Weiss,
Najavits, Greenfield, Soto, Shaw, & Wyner 1998) and social
adjutnent (Weissman & Bothwell 1975) .
Çinmarv
As discussed, accurate self-reports of some types of
behavior, past and present , have been obtained by
researchers. AIso as report&, s a r ~ studies show that
retrospective self-reports of symptoms of ADHD can be
accuate (Maruiuzza & G i t t e h a n 1993). It my wel1 be that an
individual can provide an accuate account of his own
childhood and m e n t symptans of ADHD. It was the present
author's personal belief at the time this research was
forrrailated that there is sufficient evidence to h p t h e s i z e
that adults can p&de a valid account of their own
childhooà and m e n t behavior. However, as sane researchers
in this field have expressed views t o the contrary (Shaf fer
1994; Wender 1997), the hypothesis will reflect their point
of view . objectiar
The objective of the present research was to determine if
the information obtahed frcm an individual about his past
and present behavior is as accurate as that obtained f m a
knowledgeable informant.
mmo0s R e s ~ Design
This research was divicied into two parts. Part 1 examhed
the correlation between subject and informant ratings of
childhood ADW syrrptans. Aàults who had a parent available to
participate in the study were recruited as subjects. The
subjects included adult males and females. Fiifty acailt
subjects, and a parent of each subject , cq le ted
questionnaires rating the subjectls AWID synptuns in
childhood. The subject was given the choice about which
parent, mther or father, conrpleted the *estionnaire.
Childfiood, in this case was defineà as king 12 pars of age
and under. Subjects and parents were instructed to fil1 out
the questionnaires ccnpletely. If a participant was unsure of
a question, he was asked to make his best guess. It was
stressed to each participant that honest answers were
important to the study. Subject and informant were asked not
to confer when caplethg the questionnaires. Two Uicomplete
questionnaires, filled out by parents, were discardeci, and
the &ta were not included in the study.
Part 2 of the study examineci the correlation between
subject and infomant ratings of current ADHD synptans.
ûne-hundred subjects, and the partner of each subject f illed
out questionnaires rathg the subjectls current ADHü
syrrptans. Mul ts who had a partner willirrg to participate in
Il
the stuày weye recdted as subjects. For the purposes of the
stuày, current was defined as the last 6 mnths. Participants
in the stuày were instmcted to fil1 out the questionnaire
honestly, caipletely, and to the best of their ability.
çubjects and partners were asked not to confer in ccnpleting
the questionnaires. Nine questionnaire sets were handed in
incaplete. These were discarded, anci the data were not
incluàeà in the study.
8ubj.cts
The sample of subjects included in the present research
was a comrenience sanple. The participants in this stuây
includeà males and fernales over the age of 20. Subjects were
recruited fran amng the parents of children undergohg
asseswnent at the Hospital for Sick Qiildren, and staff of
the Hospital for Sick Children. Aàditional subjects were
recruited fran among the friends and relatives of inàiviàuals
working at the Hospital for Sick Children. The s-le was
selected in order to study a p u p of subjects having a broad
range of synptans associated with AWID. Questionnaires were
canpleted by the participants &ter the study had been
explained to them, and written cornent obtained. Ethics
a p p d (Hospital for Sick Qiildren) was abtained.
- The subjects
adult males and
and parents in this part of the stuùy were
females . The subjects mged in age fran
20-50 years. The parents ranged in age fran 45-93 years
(see Table 1.1) . Subjects included 28 females and 22 males.
Forty-three m e r s and seven fathers participated. 'Ihere
were 23 daughter and mther pairs, 5 daughter and father
pairs, 20 son and mther pairs, and 2 son and father pairs.
S i x male subjects taking part in the present study were
âiagnosed with ADHD, ccmbined type in Stuüy 2 (Cognitive
Functioning in Adults with Hyperactivity Disorder), and have
a child with the disoràer. It is not known if any other
subjects were parents of ADHD children. No further
information on the background of the subj ects is amilable.
Tbenty-five of the subject and informant pairs ccnpleted the
questionnaires a n o ~ u s l y . Many metmbers of the staff of the
Hospital for Sick Children, and their friends canpleted the
questionnaires d~l~rrymously. It is not known, therefore, how
many of the subjects worked at the hospitaî, and how many
were friends of
BrL2
The subjects
adult maies and
staff rrrenibers .
and partners in Part 2 of this study were
femîes. Partners had to have known each
other for at least 1 year to be inc1uded in the study. The
subjects ranged in age f r a n 25-65 years. The partners ranged
13
in age fran 25-65 years (see Table 1.1) . Subjects included 47
femaies and 53 males. Forty-seven female subjects and their
male partners participated. Fifty-three male subj ects and
their female partners participated. No same sex couples
participated in the stuày. Eleven of the niale Bubjects
participating the present stuày were diagnoseci w i t h ADHD,
combined type in Study 2 (Cognitive F'unctioning in Aduits
with Attention Def icit Hyperactivity Disorder) , and have a child with the disorder. It is not known if any other
subjects have a child with A m . No further information on
the background of the subjects is available. Forty subjects
f illed out the questionnaires anorryniausly. Many of the staff
merribers of the Hospital for Sick Children, and their friends
filled out the questionnaires anonymusly. It is not k;nown,
therefore, how niany subjects were staff or friends of staff.
The instruments used in th is research are based on the
DSM- IV criteria for ADHD (Amrican Psychiatrie Association
1994) (see Appendix B) . A U 18 items included in DSM-IV were
included in the questionnaire. Like the DSM-IV checkiist, the
questionnaire contains 9 items deding w i t h inattentive
syrrptans, and 9 items dealing w i t h synp!tuns of hyperactivity
and inpulsiveness . Inattentive and hypeactive-inpulsive symptaw were inter-mixed. A rating scale rang- fran 0-3
was used to detennine the incidence of each ADW synptaiis
within an indiviàual. In this scale symptans are rateci as
being never (or rarely) ( 0 ) , scmetimes (1) , often (2) , or usually (3) exhibit by the subject . A total score including inattentive and hyperactive-impulsive symptans was obtained.
In addition, separate scores were abtained for inattentive
and hyperactive-inpulsive syrptans. The greatest total score
obtainable was 54. The greatest inattentive or hyperactive-
impulsive scores obtainable were 27. The diagnostic criteria
listed in the manual were adapted slightly for use with
adults . The references to school, schoolwork, hanework, and tays were anitted in the questionnaires used in Stuày 2. The
use of questionnaires based on DSM-IV in the study of AWID is
not unique to this study (Muxphy & Aarkiey 1996), but the
present research is uniwe in that it compares subject and
infoxmant scores.
statistical AMly8i.
In both parts of the stuày, the correlation between
subject and inforniant rat- of inattentive symptans,
hyperactive-ircpulsive symptans, and total -tans vsas
rilieasured ushg the Pearson product-n'ment correlation
coefficient . A test for dif ference in correlation (2 score)
(Lachin 1981) was used to determine if the correlations
obtained for inattentive synptans and hypeactive-inpulsive
gyrcptms differed. Subjects and infamants niay view the sanie
behavior as niore or les8 severe. To determine if this was the
case, the
synpt-,
mean sub ject and informant ratings of inattentive
hyperactive-impulsive symptans, and total symptuns
was canpared uskg two-tailed t-tests for related masures.
The present research capares self-ratings to informant
ratings. Analyses were carried out on data gathered in both
parts of the stuày to determine if the size of the
correlation was affected by subject gender. In each part of
the stuày, the sanple was divideci into two groups according
to subject gender. The correlations for subject and informant
ratings of inattentive symptoms , hyperactive- inpulsive
symptms, and total synptans were calculated for one group in
which the subjects were female, and one gmup in which the
subjects were male. The size of these correlations was
c~mpared ushg a test for difference in correlation (2 score)
(Lachin 1981).
In Part 1 of the study, there was a large age range. To
determine i f subject age at tim of testing affected the size
of the correlation, the s q l e was divided into t w o groups
based on man age. The man subject age v a s 33.76. me gmup
of 25 subjects age 34 and abave, and one gmup of 25 subjects
under the age of 34 were formed. The Pearson prochiet-manent
correlation coefficient was used to d e t h the
correlations for subject and informant ratings of inattentive
16
symptans, hyperactive-inpulsive symptans, and total symptans
in these two groups. A test for difference in correlation
(2 score) (Lachin 1981) was used to determine if the
correlations dif fered due to age of subject . The effect of subject age at time of testing on
correlation was also examined in part 2 of the stuày. The
mean subject age at tim of testing was 39.12. The subjects
were àivided into two p u p s on this basis. Chie group of 48
subjects 40 and aver, and one group of 52 subjects under 40
were fomd. The Pearson product-nrxnent correlation
coefficient was used to determine the correlations for
subject and inforniant ratings of inattentive synptans,
hyperactive-inpuisive symptans, and total symptcms in these
two group. A t e s t for difference in correlation was used to
determine if correlations differed due to age of subject
(2 score) (Lachin 1981).
Al1 resuits were considered significant at the .O5 lewl.
m-808 - 1. A l o w correlation between subject and parent a t i n g s
was q c t e d .
=au 1. A low correlation between subject and partner rat-
was expected.
1 Observer 1 45-93
REsmiTs
CailQlood Rat*
The ranges, means, and standard dedations of subject and
observer scores are shown in Tables 1.2 and 1.4. Correlations
obtained for inattentive symptans, hyperactive- inpuisive
sympt03118, and total syl~lptans were statistically significant . A moderate correlation was found in each case. The values
obtained were: r = -76 , df = 48, p c = .001; r = .69,
df = 48, p c = .001; and r = -79, df = 48, p c = -001
respectively . There is no basis for concluding that the correlations
obtained for inattentive qnptuns, and hyperactive-inpulsive
syqtans dif fered. The Z score obtained was -72, p c = .483.
The t-tests c~mparing the means of the subject and
observer scores were statistically significant. The values
obtained for inattentive symptans , hyperactive-inpulsive symptans, and total syrnptans were as follows : t = 3.21,
df = 49, p c = -002, t = 2.36, df = 49, p c = .022; and
t = 3.40, df = 49, p c = .O01 (see Table 1.4).
asLEmGw
The correlations obtained were al1 moderate or high. The
correlations obtaineà for groups with female subjects for
inattentive synptans, hyperactive-inpulsive syirptoms, and
total csimptans were: r = .86, df = 26, p c = -001; r = .76,
df = 26, p c = -001; and r = .86, df = 26, p < = .O01
respectively. The correlations obtaineà w h e n the subjects
were male were: inattentive symptans, r = .68, df = 20,
p < = .001; hyperactive-inpùlsive symptans, r = .58, df = 20
p c = -004; and total symptans, r = .70, df = 20, p c = .001.
The correlations of the ratings of the femaïe subjects and
their infamants were slightly higher than the correlations
of the ratings of the male subjects and their i n f o m t s , but
the present research does not denw,nstrate that the
correlations dif fered according to subject gender The Z
scores capring correlation s ize for each of these typs of
synptans were not statistically significant. The Z scores
obtained were: inattentive symptans: Z = 1.53, p < = .134;
hypractive-inpulsive symptans, Z = 1.10, p c = -317; and
total symptans, Z = 1.40, p c = .162. - Pearson product-mment correlation coefficients were
calculated to determine if age of subject affected
concordance. Ail correlations were found to be statisticélly
significant. A nioderate or high correlation was faund in each
20
instance. The following correlations for Group 1 (> = 34
years) were found: inattentive symptans, r = .68, df 23,
p c = .001; hyperactive-inpuisive synptams, r = .70, df = 23,
p < = .001; and total symptarts, r = -77 , df = 23, p c = -001
(see Table 1.6) . For G m u p 2 (c 34 years) , the values for each category were: inattentive symptms, r = .85, df = 23,
p c = .001; hyperactive-inpulsive symptans, r = - 7 5 , df = 23,
p c = .001; and total symptoms, r = -83, àf = 23, p c = -001
(see Table 1.7) . There was no evidence ta conclude that the correlations
àif fer& between Graup 1 and Group 2. The 2 scores obtained
were: inattentive symptm, Z = 1.42, p c = -162;
hyperactive-inpulsive symptans, Z = .35, p c = .764 ; and
total synptans Z = -56, p < = -617.
cuzraat Ratiags 6 r-
nie ranges, =ans, and standard Mations of subject and
partmer scores are set out in Tables 3 and S. The
correlations abtained for inattentive symptans, hyperactive-
impulsive synptans, and total 8ymptans were statistically
significant. Moderate correlations were &tain&. The values
obtained were: inattentive sytl[~tans, r = -70, df = 98,
p < = .001; kyperactive-inpilsive sytrptotns, r = -59, df = 98,
p c = .001; and total syrrptans, r = .69, df = 98, p c = .001.
There is no basis for ccncluding that the correlations
obtained for inattentive symptans, and hyperactive-impùlsive
synptom8 àiffered. The Z score was 1.32, p c = -194. - The values obtaineà frm the t-tests cconparing the rtieans
of the subject and informant scores for the three categories
were not statistically significant. The results were as
follows: inattentive syrriptans, t = -13, df = 99, p c = .901;
hyperactive-impulsive symptans, t = 1.56, df = 99,
p < = .122; and total synptcms, t = .92, df = 99, p c = .358
(see Table 1.5). - Al1 correlations abtained were moderate. The correlations
obtained for the group in which the subject was femaie were:
inattentive symptom8, r = .77, df = 45, p c = .001;
hyperactive-impulsive synptans, r = .67, df = 45, p c = .001;
and total synptans, r = .78, df = 45, p c = .001. The
correlations obtained for the group in which the subject was
male were: inattentive synptans, r = -64, df = 51,
p c = .001; hyeeractive-inpulsive synptoms, r = .55, df = 51,
p c = .001; and total synvetom8, r = .63, df = 51, p c = -001.
The correlations of the ratings of the female subjects and
their Morniants were slightly higher than those of the male
subjects and their informants, but it cannot be coslcluded
that the correlations differed according to subject gender.
The Z scores obtained were al1 non-significant. The Z scores
obtained were: inattentive synptans, Z = 1.27, p c = .230;
hyperactive-inpulsive synptm, Z = -93, p c = .368; and
t o t k l sym~t0m8, 2 = 1.47, p < = -162. - Age differences in concordance were tested for using the
Pearson product-manent correlation coefficient. E.rloderate
correlations were obtained. Correlations for al1 categories
were statistically significant. The correlations obtained for
inattentive *tans, hpractive-impulsive synptans, and
total synptonis for Group 1 (s = 40 years) were: r = -74,
df = 46, p c = .001; r = -65, df = 46, p c = .001; and
r = .75, df = 46, p < = .O01 respectively (see Table 1.8) . The correlations found for Group 2 (c 40 years) were:
inattentive symptans, r = -65, df = 50, p c = .001;
hypractive-impulsive synptans, r = .54, df = 50, p c = .001;
and total synptane, r = .63, df = 50, p c = .O01
(see Table 1.9) . There was iio basis to concluàe that correlations differed
according to age. The Z scores abtained were: inattentive
symptans, 2 = .85, p c = -424; hyperactive-irrpulsive
syrptom8, Z = .83, p c = .424; and to ta l symptans, Z = 1.12,
p < = -230.
Note: N = 50
Range of Scores
r
inattentive
hypeactive- inpulsive
II I 0-34 I 0-39 Il
Subject
0-20
0-20
Chserver
0-24
0-18
Range of Scores Subject Observer I
inattentive 0 -22 0-23
hyperact ive-iqulsive 0-17 0-16
total 0 -34 0-36
Note: N = 100
Symptar~~ Score
inattentive I
Observer
Note: N = 50
11 inattentive
Note: N = 100
aban diilQiood Ratbgc for 8ubjects > = 34 Y- of Agm
Il inattentive L
hyperact ive- inpisive
total I
Observer
Note: N = 25
Il inattentive
to ta l I
man
Note: N = 25
Synptans Score sum man SD
inattentive 283 5.90 5 .05
hyperactive-inpulsive 208 4 .33 3.63
total 491 10.23 7.89
Observer
N o t e : N = 48
1.9
#.in -t Rafirig. for Subjictir c 40 Y . u n ot Aga
11 inattentive 1 246 1 4.73
1 total
No te : N = 52
DISCtlSSION
The present research investigated the ability of people to
rate their own childhood and current behavior. The resuits
show a substantial correlation between subject and informant
ratings. This indicates that a subject is as able to give as
valid an accotmt of his own behavior as is a knowledgeable
inforrriant. There are, however , sune issues which naist be
discussed.
For the purposes of diagnosing ADHD in adults, it is
necessary to get an accurate account of childhood behavior.
Accordhg to the literature (Tilley et al. 1985), specific
questions are likely to yield accurate answers. The
questionnaires used in the present research consist of
reasonably specific statements regarding pst and present
behavior . In addition, scme types of information are more
easily recalled than other types of infoxmation
(Paganini-Hiil & Ross 1982; Tilley et al. 1985; Oison et al.
1997) . A good correlation between subject and parent ratings
m y have been obtained in the present research because the
behavior aseociated with ADW) is salient, and continues mer
a significant period of time.
Although it might be expected that a better correlation
between subject and i n f o ~ n t ra thgs d d be obtained for
hyperactive-impulsive s y n p t m than for inattentive symptans
due to saliency, this was not the case. The correlations for
inattentive symptans and hyperactive-inpulsive symptans did
not àiffer.
The possibility that the accuracy of recall of AûHû
synptans decreases w i t h time was tested. Aiso tested was the
possibility that age colours the perception of AMID symptuns.
In the present research, age was not a significant factor
when looking at recall of childhood behavior or judgemnt of
current behavior.
The data were analysed for gender differences in
correlation between subject and Morrriant ratings. The
correlations between the rathgs of female subjects and their
inforniants were slightly higher than the correlations between
the ratings of male subjects and their informants in both
parts of the study. These differences were not significant
and did not appraach significance. It m y be that these
àifferences were very mail, and the test used was not
powerful e ~ u g h to pull them out. W i t h a larger nuber of
subjects it is possible that the differences wouid have
reached signif icance. The present remch, ho-, does not
demnstrate a clifference in correlation accordhg to gender.
Al1 correlations in both groups m mxlerate to high, and
33
statisticklly significant. A larger sanple could be collected
to determine if a gender àifference appears, but a smaîl
difference in correlation might not have any practical
effect . Subjects rated themelves as having mre, or m e intense
ADHD symptcm, than did the observers. This difference,
though, reached signif icance oniy in the study of childhood
ADHD symptoms.
Although infoxmant ratings were used as the criterion for
validity, in those cases where subject and informant ratings
did not agree, it is inpossible to Say which participant gave
the mre accurate account. In fact, both subject and
i n f o ~ n t ratings could have been inaccurate. The present
research dealt w i t h the nunierical ratings of ACHD symptans
and there has ken no research conducted imrestigathg
whether subject or infoniiant ratings are mre accurate.
When describing pst bebavior, it is likely that in many
cases, the subject has better kmwledge of events than the
obsenrer . Mirior transgressions at school, for -le, m y
have gone unreported to the parent, but may be remenibered by
the subject.
Regarding adult behavior, a abject may aot inform a
spause about al1 the difficulties encountered at work. The
subject wuld again be better able to pmvide a catplete and
accurate accoiait of his behavior. In addition many of the
34
qmptoms of ADHD found in adults are subjective. An example
of this would be feelings of restlessness. It seems likely
that a subject wwuld be better able to describe his behavior
in this case than muid an infamant,
Aithough the author of the present study argues that a
subject niay be better able to give an accurate report of his
childhood and m e n t ADHD synptans than can an informant,
the possibility that an inforrriant might be niore objective
naist be acknowledged.
The present study is unique in that it examineci the
correlation between self-ratings and informant ratings of
childhd and m e n t synptans of ADHD using questionnaires.
The concordance between self-reports and informant reports of
current behaviors associated w i t h other types of disorders
has been m e d , Resuits similar to those obtained in the
present research have been found. Dowson (1992) carpared
self-reports and informant reports of m e n t behaviors
associated w i t h various personality disordem. The subjects
of the study were adult psychiatrie patients. A goad
correlation was found between self-ratings and info~mant
ratings of behaviors associated with antisocial personality
disorder, schizoid personality disorder, and borderline
personality disorder. As in the present research, Dowson
35
(1992) found that the subjects rated themselves as having
more symptans than did the informants. Dowson suggested that
the patients may have had a better knowledge of their
symptuns than did the informants.
Researchers have also examined the concordance between
subject and informant reports of current symptans associated
w i t h various mental disorders by means of interviews (Tyrer,
Alexander, Cicchetti, Cohen, & Remington 1979; Cantwell et
al. 1997) . in these studies, the subject and informant were
interviewe& and the ratings were made by the interviewers on
the basis of the participants' answers. In a study of
adolescents, Cantwell and colleagues (1997) found that the
dqree of concordance between subject and parent reports
depended upon the type of behavior king studied. Cantwell et
al. (1997) found good concordance between subject and parent
ratings for symptans associated w i t h conciuct disorder,
attention deficit hyperactivity disorder, and oppositionaI
defiant disorder. The concordance between subject and parent
ratings of behaviors associated with major depression,
dysthpia, aicohol abuse/dependence , substance
abuse/dependence, and anxiety disorders was poor. It has been
suggested that concordance between subject and informant
ratings is better for more observable behaviors (Cantwell et
al. 1997) .
36
The r e d t s of the present research cannot be generaiized
to al1 populations. Severely il1 individuals may not be able
to give an accuate account of their m e n t behavior. A low
conconbnce between subject and informant ratings of symptans
associated with personality disorders has been foiind during
episodes of illness (Tper et al. 1979) . A wide range of scores was obtained in both parts of the
stucty (see Tables 1.3 and 1.4) . Although scme subj ects reported experiencing no ADHD symptans at all, the sample did
include subjects reporthg a ansiderable n u h r of AüHD
synptas . Twenty subjects in Part 1 of the present study reported a total -tan score of 10 or over (man 10.18) . Al1 six of the adùlts diagnosed with ADHD in Study 2 of this
thesis fell into this group. In P a r t 2 of the study, 30
subjects reported a t o t a ï -tan score of 10 or aver (man
9.53) . Ail eleven of the adults diagnosed w i t h ADW in Study
2 fell into this group. The results suggest that individuals
w i t h a wide range of scores can give valid accounts of their
synptans.
Murphy and Barkley (1996) conducteci a stucly in which
adults carpleted a self-report questionnaire similar t o that
used in the present study. Pdults were asked to rate their
own AI3EID symptans on a s a l e of 0-3 (occurrhg rarely or
never, s a n e t h s , often, very often) . A sy[~ptan w a s
considered significant if the subject a t e d it as occurrw
ofteIl or very
4 inattentive
are enough to
37
often. Muphy and Barkley (1996) reported that
syrptans, or 4 hyperactive-inpulsive synptcms
set an adult apart fran the general popùlation.
In Part 1 of the present study, 1 of the subjects reporteci 4
or more inattentive synptoms, and 4 subjects reported 4 or
more inattentive symptans and 4 or niore hyperactive-impulsive
symptans. In Part 2 of the study 8 subjects reported 4 or
more symptans of inattentiveness, and 7 subjects reported 4
or more inattentive symptans and 4 or more hyperactive-
impulsive symptom. These subjects had a level of symptans
possibly consistent with a clinically relevant condition. 'Ihe
present research, and other existing research, has not yet
clarifieci the question of diagnostic thresholds and the use
of questionnaires in diagnosis. For these reasons, it would
not be appropriate to conclude that ai l these subject have
ADHD based on questionnaire remlts. Conversely, it would not
be apprapriate to conclude that the subjects who did not met
criteria do not have ADHD. in Part 1 of the stuày, 4 the of
the subjects diagnosed w i t h ADHD in Study 2 did not mach
criteria on the qestionnaires, and in P a r t 2 of the study 5
of the subjects àiagnosed with ADED in Stuày 2 did not reach
criteria on the qgestionnaires. These findings indicate that
questionnaires may not be the best method of diagnosis. It
s h d d k noted that it is possible to achieve a high score
without meeting the diagnostic criteria of 4 syrtptans.
A few
had been -. -
38
of the subjects participating in the present study
diagnosed with ADHD, and have children with the
disorder. nie background of mst of the subjects and their
families is not known, however. A history of familial ADID
should not have affected subj ect ratings . Adults w i t h A D D
who have children with do not report any mre symptans
of ADHD in themselves than do adults with ADHD who do not
have children with the disorder (Faraone, Biederman, & Mick
1997) . The oniy demographic variables collected on the
participants of the stuày were age and sex. niese two
variables did mt affect correlation s i ze or direction. The
present research cannot determine the effect of other
demgraphic variables on correlation. No research has ken
conclucted to assess the effect of dexmgraphic variables on
concordance between subject and observer ratings of
psychiatrie synptans. Bither has there been any research
into the effect of demogaphic variables on the accuracy of
self-reports anci infonriant reports. The author of the present
study had no a priori hyptheses mgardhg the effect of
deniogaphic variables. There is no infoxmation on which to
base such hypotheses. There is no evidence that correlations
between subject and informant ratings would differ accoràhg
to various Caemogaphic variables. T h e present study was a
f irst step. that it has been detennineà that self-atings
of synptans assaciated w i t h AC%ID and informant atings of
symptans associated with ADHD can be rmderately to highly
correlated, the correlations obtained fran dif ferent grwps
can be examined and carpareci.
It would be of interest to study separate groups of ADHD
subjects and m m 1 controls. The scores of these two groups
should differ, but there should be a sufficient range of
scores in each group to allow correlational analyses. If an
aduit can indeed rate his own childhood and current ADHD
synrptans, the correlations should not differ between groups.
b y of the subjects in the present stuày had knowledge of
ADHD, although it is not possible to know how roany. If a
subject with knowledge of ADW had exaggerated or minimized
his synptans, it muid have decreased the concordance between
his ratings of his behavior, and his informant's ratirags. If
this happeneci often enough, the systematic bias would result
in a 10- m l 1 correlation, leading to the conclusion
that an individual cannot proVidie an accuate of his own
behavior ,
The concepts of reliability and validity are not well
def ined. Research similar to that described in this thesis
has been described as exwllning reliability (wer et ai. 1979; Liu et al. l996), or validity (Aaron et al. 1995;
Hansen 1996; Hill, Zrull, & McIntire 1998) dependinsl upon the
researcher. Reliability refers to the extent to which a
result can be reproduced (Shaughnessy & Zechneister 1990) . While the author of the present thesis chose to view the
research as examining concurrent valiàity, the results of the
research can also be interpreted as demnstrating inter-rater
reliability (Cone 1981; Shaughnessy & Zebister 1990). The
scores of two raters, rating the same subject were mderately
correlated. The two interpretations are not inconpatible. The
issue will not be resolved in this thesis.
The present research demnstrates concurrent validity. The
substantial correlations found between sub j ect and inforniant
ratings suggests that an individual can indeed rate his own
childhood and m e n t ADHD symptams as accurately as can an
informant.
The present research was by no means intended to generate
&ta for the developmnt of an instrinient to be used in the
diagnosis of ADHD. The intent of the research was sinply t o
determine i f the same information can be obtained frm an
observer as can be obtained fram an informant using the same
method. The author of the present research does not mean to
suggest that qestionnaires should be used in the diagnosis
of AWID. An interview ailows the diagnostician t o observe the
subject, probe for information, and clar i fy information.
-1065s
DÇM-IV (1994) &es not mre corroborating evidence fran
an infoxmant before a diagnosis of ADHD can be made.
Similarly, the practice paameters of the Pvnerican Acadeny of
child and Adolescent P s y c h i a t r y do not state that evidence
frun an info~nt is necessary for the diagnosis to be made
in an aduît (AACAP 1997) . The resuits of the present research suggest that an individuai can provide as valid an account of
his childhooà and current behavior as can an infoxmant. An
assessmnt for ADHD could be carried out in the absence of an
informant if one is not available.
Limitatinnn of Re8mt s w
A wide range of scores was obtained in both stuàies.
Although there is no evidence imrestigating this, it has k e n
suggested that high scorers, those with more severe ADED
symptans, m y be less able to assess their own synptuns than
low scorers. The data generated fremthis research c m t be
used to investigate this possibility. The scores obtained
fran the qyestiodres do not allaw the exambation of
concordance baseci on severity of sy~lptans. It is possible t o
divide the subjects into high and low scorers, but because of
the differences in hetemgeneity of data between these two
groups, the correlations obtaineâ oould not be relied upon.
In the present research, there is no way of determining
the validity of any individual subject or infoxmant
assessnient .
As the ADHD status of mst of the subjects in the present
study is not known, it cannot be stated w i t h certainty that
individuals with ADHD can report their symptun level as
accuately as can indivibls without NEID.
The resuits of this research suggest that adults can give
a valid account of their childhood and m e n t behavior. This
finding has irrportant inplications for the study of ADHD. n ie
infonmtion abtained fran a subject king assessed for ADHD
can be as valuable as that obtained fnm a knowledgable
informant. This finding will facilitate researd into the
course of the disorder, and the manifestations of ADHD in
mamrm D i r r c t i a M
The present research daes not directly address the
question of whether or not aàults with AùHü can rate their
own symptans as accurately as can normal controls.
43
Zndividuals diagnosed w i t h ADW), and normal controls could be
recdted, and the present research repeated. The resulting
group correlations couid then be capared.
It is possible that subjects -/or informants
&r-reportecl ADHD qmptms. A cpestionnaire cannot probe
for information, and the participants may not have answered
the questions careNly or with due consideration. To
detexmine if this is the case, the results of participant
ratings couid be ccmpared to diagnostic interviews.
- Researchers have imrestigated cognitive functioning in
children, adolescents, and adults w i t h - . Resuïts of such
studies are sanewhat inconsistent, but in general, these
populations show deficits in a range of processes h l v e d in
executive control (Hopkins, Perlman, Hechtmn, & Weiss 1979;
Chelune, Ferguson, Kocn, & Dickey 1986; Gorenstein, Marmiato,
& Sandy 1989; Dykman & Ackerrrÿui 1991; Shue & Douglas 1992;
Peruiington, Grossier, & Welsh 1993 ; Schachar, Tannock, &
1993; Weyandt & Willis 1994; Trcmoer, Hoeppner, In-,
& Armstrong 1988) . An impairmnt in executive control is
discussed as being a hallmrk of ADHD in the literature
(Boucugnani 6r Jones 1989; Gorenetein, Mwniato, & Sandy 1989;
Shue & Douglas 1992) . The present research examined executive
control in adults w i t h ADHD to detemiine if deficits
specifically in this danain are associated w i t h NEID.
f-
In onler to examine cognitive functioning in an a u t with
ADHD, the achilt nist first be assessed for ADHD. There are
t w o separate issues h l v e d when assessing an adult for
ADHD. It MUS^ be established that the disorder dates f m
childhd, and that clinically significant syrclptms still
exist in adlllthood (DSM-IV 1994) . Assesshg an adult for ADD
is similar to, but different fran, assessing a child for the
disorder.
According to DSM-IV (1994), to diagnose a child with the
inattentive subtyp of ADHD, 6 symptans of inattention rnist
be present. To diagnose a child w i t h the hyperactive-
impulsive subtype, 6 symptans of hyperactivity and/or
impulsiveness must be present. To meet criteria for a
diagnosis of AMID, cocrJ3ined subtype, 6 of each of these types
of synptans must be present. Sane synptans m s t have been
present in the individual before the age of 7 , and scme
inpairment naist be evident in at least two settings (e.g.
hane and school) . When diagrnoshg an adult, it naist be
established that these criteria were met in childhood, and
that significant synptans exist currently.
Although DSM-IV (1994) is @te specif ic in s p e l l h g out
the criteria for diagnosing ADHD, the criteria may not be
appropriate for adults. There is very little research to
indicate how many -tans of ADHü are necessary to Riake an
adult significantly different fran the rest of the
pcipuiation. Barkley and Mwphy (1996) had adults cap le t e
questionnaires rating their own curent symptans of AWID.
Their study suggests that 3 or 4 qmptans of the disorder are
enough to set an individual apart fran N s peers.
Executive control can be viewed as a cognitive
(Pennington, Grossier, Welsh 1993; Peruiington L Ozonoff 1996;
Gansler, FUcetola, Krengel, Stetson, Zimering, & Makary
1998) , or neuropsychological (Perinington & Ozonoff 1996;
Weyandt & W i l l i s 1994) concept. I l I n cognitive psychology,
acecutive processes are a kind of residual, the part of
cognition that logically wt occsur after perception but
before action. In neurcpsychology, an inplicit meanhg is
essentially tasks that patients w i t h frontal lobe lesions do
M y on. (Pemhgton & Ozonof f 1996, p 55) . The author of
the present research considers the cognitive concept to be
the mre valid. Non-executive cantrol tasks have been found
to be mediated, in part, by the frontal lobes (Benton,
EWnsher, V-, & Spreen 1983; Phillips, Builmore, Howard,
WOOdruff, Wright, Williams, Simri~ns, Andrew, B m r I C David
1998). Danrage to the frontal lobes can lead to inpairments in
non-acecutive contml tasks (Blb & Winshaw 1990), and a
swle acecutive contml task niay be meàiated by both the
frontal lobes, and other areas of the b a i n (Frith, Friston,
47
Liddie, & Frackowiak 1991; Rezai, Anàreasen, Alloger, Cohen,
Swayze, & OILeary 1993) . For these reasons , executive control will be discussed as a cognitive concept in the present
thesis.
wcut ive control is a construct. f t has been described as
the ability to plan and irriplemnt a strategy to achieve a
particular goal. Ekecutive control is thought to involve such
processes as set attaining and maintaining, error
detection/correction, regulation of speed and acmacy,
stopping, and switching (Luria 1966; Shallice 1982; Goldman-
Rakic 1987; Shallice 1988; Welsh & Perininyton 1988) . Tasks
are considered to be executive control, or non-executive
control depending upon assurrptions made about the abilities
necessary to perform them. There is no real way of masuring
whether or not a task imrolves executive control. It is
probable that al1 tasks h l v e executive control to same
extent. Researchers and dinicians, however, generally agree
upon whether or not a task mets the criteria for this
category. The executive control tasks used in this study are
conçidered by researchers to k executive control tasks
(Weyandt & Willis 1994; Pennhgton & Ozonoff 1996; Brennan,
Welsh, & Fisher 1997; Gansler et al. 1998) . The non-executive control tasks used in this stuày are considered by
researchers to be non-ewcutive control tasks (Pennington &
Ozonoff 1994; Stewart, Sunderland, & Slunan 1996) .
Researchers have ex- both executive control and
non-executive control functionhg in children, adolescents,
and young adults with ADHD. The subjects of these studies
range in age fran 6-24 (Barkley, Grodinsky, & Waul 1992;
m g t o n & Ozonoff 1994). The mst cmmnly used executive
control tasks include: the Stroop Task; the Matchhg Familiar
Figures Test ; the Wisconsin Card Sorthg Test; the T r a i l
MakU-rg Test (B) ; Porteus Mazes; and the Tower of Hanoi
(Barkley, GrOdUlSky, & nipaul 1992 ; E'ennington & Ozonof f
1994). The non-executive control tasks mst c~nm~nly used are
the mibedded Figures Test and the Trail Making Test (A)
(Panington & Ozonoff 1994).
Studies of acecutive control fiinctionhg in individuals
w i t h AWü are, a t first glance, confusing. Sane studies have
found àifferences in functioning between ADHD inâividuals and
no& controls on particular executive control tasks
(Goremtein et ai . 1989; Shue & Douglas 1992; Perinington et
al. 1993; Weyandt & Willis 1994), w h i l e other studies have *
founà no differences on these same tasks (McGee et al. 1989;
*e, Staton, & Beatty 1990; Fischer et al. 1990; R;irkley,
G r o d i n s k y , & DuPaul 1992) . The executive control tests used
in this research were chosen because they have been founù to
differentiate consistently betwieen individuale w i t h ADHD and
49
nomaï controls (Oorenstein et al. 1989 ; Boucugani & Jones
1989; Schachar & Logan 1990; Schachar et al 1993: DylaMn &
Adceman 1991; Shue and Douglas 1992; Pennington et al. 1993;
Weyandt & Willis 1994) . Resuits of research ccmparing the perfomce of
individuals with ADHD to normal controls on non-executive
control tasks are mre consistent. Children and adolescents
with ADHD geneally perfom as well on non-executive controi
tasks as do noml controls (Chelune et al. 1986; Breen 1989;
Shue & Douglas 1992) . A few studies, however, have found
children with ADHD to perform poorly on sane non-executive
control tests (Cohen, Weiss, & Minde 1972; Hopkins, Perlman,
Hechtman, & Weiss 1978; Robins 1992). In a study by Cohen,
Weiss and Minde (1972) , adolescents with ADHD nere found to
perfom more poorly than n o m 1 controls on the embdded
figures test. Similarly in a study by Hopkins et al. adults
w i t h ADHD u ~ e r e found to perfom more poorly on the enbeàded
figures test than normal controls . Robins (1992) found
children w i t h AWID to perform more p r l y on the V i m a l
Motor-Integration Test than leambg disabled children. In
d l three studies, the authors concludeà that the children
with ADHD had dif ficuity with speed of re-.
The nwber of subjects, diagnostic methoà, synptan
severity, and subtypes of ADHD included in the research vary
fran st* to study. This variation, plus randan chance, niay
account for the inconsistency of the results of studies
ewmining perfommce of individuals w i t h ADW on executive
control tasks and non-acecutive control tasks. Poor
perforniance on executive controls tasks is found mre
consistently in children and adolescents w i t h ADHD than is
poor performance on non-executive control tasks. The purpose
of the present research was to cietennine if adults w i t h AWu)
have a def icit in executive control. The present research
includes control tasks to determine if any deficits
found are confined to the executive control danain, or mre
generalized (occurring in other, but not necessarily al1
other, cognitive danah) .
abj.cuvUB8
The objectives of this study were : 1. to determine if
adults with ADHD have a deficit exclusive to executive
control; and 2. to determine if adults with ADHD have a rriore
generalized cognitive def ic i t .
mTmm Ras- Design
This study examines cognitive functioning in acbilts w i t h
ADW. In particular, it d e s executive control . Three
executive control taske were included in the study. Two
control tasks, not thaught to involve executive control
(Spreen & Strauss 1991; Pennington & Ozonoff 1996; Stewart,
Sunderland, & Sluman 1996) were also incluàed in the
experimntal protocol to detemine if the subjects with ADW
have deficits outside the executive control damain. Tests
were selected which have been found to have no ceiling or
f loor ef fects (Benton & Van Allen 1968; Lwin et al. 1975;
Kennedy 1981; FYam-Auch & Yeudall 1983; Schachar & Ingan
1990 ; Welsh, Perinington, Ozonoff, Rouse, & MCCabe 1990) .
- Stop Signal Paradigm
- Tower of m o i
- Trail Phking T e s t (B) - - Tail Test (A)
- Benton Facial Recognition Test
Thm groups of subject were included in the study.
1. individuals who rrret criteria for ADHD in
childhood, and wfio met criteria for ADHD
2, individuals who did not meet criteria for ADHD in
childhood, and do not m e t criteria for ADHD as
adults,
Subjacts
There is evidence to suggest fran family-genetic studies
( B i e d e m , Munir, Knee, Habelow, Armentano, Autor, Hoge, &
Waternaux 1986; Biedernian, Faraone , Keenan, Knee, & Tsuang
1990; Faraone, B i e d e m , Keenan, & Tsuang 1991; Biederman,
Faaone, &enan, Benjamin, Krifcher, Moore, Sprich-
Buclaninster, Ugaglia, Jellhek, Steingard, Spencer, Norman,
Kolodny, Kaus, Perrin, Keller, & Tsuang 1992; Faraone,
Biederman, & Milberger 1994; Biederrirui, Faraone, Mick,
Spencer, Wilens, Kiely, Guite, Ablon, Reeà, & Warburton
1995) , t w i n studies (Lapez 1965; Goocbnan & Stevenson 1989;
Gilger, -on, & Demies 1992) , and adoption studies
(Morrison & Stewart 1973 ; Cantwell 1975; Dâlby, Fox, & Haslam
1982) , that AùHD is heritable. Parents of children w i t h the
disorder therefore, are mre likely to have ADHD than are
people frcm the general population. Tb hxease the chances
of finding adults w i t h AïHD, potentiai subjects were
recruited fnm amng the parents of children w i t h the
disorder. At the t ime of recruitment for the present stucly, a
numiber of studies examining ADHD in children were being
conclucted at the Hospital for Sick Children. Parents of
children w i t h a confinned diagnosis of ADHD w h o had taken
part in one of these studies were recruited for the study and
screened for the disorder. Those parents meeting criteria for
the disorder were included in the stuày. Contml subject were
recruited fram aniong the staff at the Hospital for Sick
Children, and fran the c d t y . Ail potential control
subjects were screened for ADHD. No potential control subject
was diagnosed w i t h the disorder.
According to nunemus studies, AMID is f a r mre prevalent
amwig males than aniong females (Ancaerson, W i l l i a m s , McGee, &
Silva 1986; Szatmari, Offord, & Boyle 1989) , and the subjects in studies of acecutive contrul in ADHD children and
adolescents are almost exclusively male (Cohen, Weiss, &
Minde 1972; Chelune et al. 1986; Goremtein, Mamriato, & Dandy
1989; Mdjee, Williams, Moffit, & Anderson 1989; Loge, Staton,
& Beatty 1990; Rarkiey, GrOdinsW, & DuPaul 1992; Grodins icy L
Diamond 1992; Shue & Douglas 1992) . For these reasons, only
male adults w i t h ADHD were included as subjects . The control
gmup was comprisecl of normal male adults.
54
In order to control for the effect of age on test results,
efforts were made to ensure ccnparability of experimntal and
control groupa on age. Subjects in the ADHü group ranged in
age fran 27-58 (mean age 41). The control subjects ranged in
age fran 25-59 (mean age 38) . The man age of the t w o p u p s
d idno tà i f f e r (t =1.10, d f = 3 4 , p c 2 7 9 ) (seeTable2.1).
To ensure a ccmparable man Intelligence Quotient in each
group, the block design, and vocabulary subtests of the
Wechsler Aàult Intelligence Scale-Revised (Wechsler 1981)
were administered to each subject . In the experimental group,
the age-scaled IQ scores ranged fran 94 to 125 (man 110). In
the noml control group, the age-scaled IQ scores ranged
f m 94 to 131 (man 116) . The scores obtained fran these two
subtests of the W4ïS-R yield an estimted IQ only. Scores
obtained on these t w o subtests are not mant to pravide a
full scale IQ (Wechsler 1981) . DSM-IV def ines three categories of AtHD (American
Psychiatrie Association 1994) . These are: 1. attention def icit hyperactivity disorder, predaninantly inattentive
type; 2. attention deficit hyperactivity disorder,
Pr= aaninantly hyperactive-inpuisive type and 3 . attention
def kit hyperactivity disorder, mined type. There is
evidence to suggest that individuais w i t h the d n e d
55
subtyp are more severely affected academically and sociaily
(Gaub & Carlson 1997; Faraone, Biedernian, Weber, & Russell
1998). To ensure hamgeneity, oniy individuals w i t h ADHD,
c d i n e à type m e included in the stuày.
The children of the parents included in the study ai l had
evidence of both types of symptans, although they àid not
necessarily al1 met criteria for attention deficit
hyperactivity disorder, carbineci type. Al1 the chilclren met
criteria for one of the subtypes of ADHù . To be included in the study, al1 the fathers had to show
evidence of inattentive and hyperactive-inpulsive symptans , both in childhood and in adulthood. In childhood, subjects
had to met DSM-IV criteria for ADHD, canbined type
(6 inattentive synptans and 6 h-ctive-ici1puîsive
synptans) . To neet research criteria as adults, 4 -tans of
the inattentive subtype, and 4 symptms of the hyperactive-
impuisive subtype nnist have k e n &dent at time of testing.
me criteria of four synptans was adopted based on the
finding that 3 or 4 symptahs of ADHD are enough to set an
adult apart fram the rest of the population ( M u p h y f Barkley
1994) . nie study was explained to the subjects, and Mo-
written consent was obtained. Ekhics a p p d (Hospi ta l for
Sick Children) was obtained.
-le Size
The incidence of ADHD in the adult population has by no
mans been established. It has been estimated that PSHD
affects 3-5 % of school age children (DM-IV) . Various studies have estimated that 30-70 % of affecteci chilàren
continue to -rience signif icant symptuns as adults (Weiss
et al. 1985; Gittelnian et al. 1985; Shekim et al. 1990;
Mannuzza et al. 1991) . At the time this research was planned,
no studies exminhg executive control in aàuits with AWID
had been conducted. By necessity, sanple size was estimted
based on studies of cognitive function in children with ADW.
Such studies have found that sanples of 15-20 subjects are
suff icient to f ind a medium effect size using t-tests (0.05
level of significance and 80% power) . It was decided to
include eighteen individuals with ADHD and 18 normal controls
in the present research. The dif f iculty in getting subjects
for the study made the inclusion of more subjects
impractical . ~ 6 t r a t i ~ of S m d y
The diagnostic interview of potentiai AWiD subjects and
nonml controls was conducted first. It was decided at this
tinie whether or not the subject net research criteria for one
of the test groups. Indiviàual subjects were intervie&
specif ically as either experimntal subjects or nomml
controls. No subjects crossed over. If a subject did not meet
cri ter ia for his p a r t i d a r group, he was drapped fran the
stuày. A f t e r the diagnostic i n t d e w was conüucted, the
vocabuiary subtest and the block design subtest of the PAIS-R
were administered. The order of administration of the
research masures was standard for al1 subjects. The tests
were conducted in the following order: 1. the Stop Signai
Paradigm, 2. the %il Making Test (A k B) , 3. the Benton Facial Recognition Test, and 4. the Tower of Ifanoi. The
exprimental protocol took 2 to 3 hours to addnister. The
diagnostic intendew was conducted by the author of the
present stuày after training in assessnient. The cognitive
tests were admhistered by the author of the present research
af ter training.
D i a g w s i .
ADHD Subjects
A l 1 potential -rimental subjects were assessed for ACHD
to determine if thgr met criteria for the disorder. There is
no standard method of assessing adults for ADHL In this
study diagriosis was based on a semi-stmctured interview
cwering lifetime behavior. This i n t e m i e w probes for ADHD
synptans . Diagnusis was based solely on the subject s account
of his own behavior, and on direct observation of the
subject. This is a ccmirmily accepted practice in the f ie ld of
McCracken 1989; Shekim et al. 1990; Faraone et al. 1991;
Biederrrian et al 1993; Mannuzza et al. 1993; Faraone et al.
1994; Biederman et al. 1995; Milin, Lah, Chow, & Wilson
1997) . Aithough researchers do scmetimes try to get
cormborating evidence (Wender, Reimherr, br W o o d 1981;
Gansler et al 1998), it is accepted that this niay not be
possible. It is especially difficult to get corraborating
evidence when the subjects are older adults, as is the case
in the present study . It is cornrion practice for diagnoses of other disorders to
be made solely on the basis of self-report. ADHD differs fran
0th- disorders oniy in that it naist be established that
clinically significant syrrptans date fran childhood. The ADHD
âiagnosis requires evidence of irrpai~tnent. The impairment
associated with ADHû synptans validates ADHD as a disorder.
Each potential subject ' s level of functioning was rated
using the Global Assessrnent of Functioning Scale (GAF)
(American Psychiatrie Association 1994) . This is a rough
rating sale, but gives an indication of level of impairment.
The lowest 1-1 of functiooiing possible is rated I T 1 , and
the highest level of functioning is rated ltlOO1l. An
individual must have shown at hast a rrpderate degree of
59
impairment to be included in the ADHD group (a score of less
than 60) . This ating scale is very subjective, and too much
emphasis should not be placed on the exact nurribers (see Table
2.2 for a gmup carparison of OAF scores) . In addition to being assessed for ADHD, al1 potential
experimental subjects were screened for canorbidity ushg the
Structured Clinical ïntenriew for DSM-N AI& 1 Disorders
(Clinicians Version) (First , Spitzer. Gibbon, & Williams
1995) , and the Structured Clinicai Interview for Dm-IV Pxis
II Disorders (Version 2.0) (Antisocial Personality Disorder
mocaile) (First, Spitzer, Gibbon, Williams, & Benjamin 1994) . To be included in the study, subjects had to be free of
psychosis, major depression and mania as these
psychopathologies may affect the results of cognitive testing
(kvin & Benton 1977; Kronfol, Hamsher, Digre, & Waziri 1978 ;
Goldberg, Saint-Cyr, & Weinberger 1990; Katz, Wood,
Goldstein, Auchenbach, & Geckle 1998; Nelson, Sax, &
Strakowski 1998) . mnnal Controls
Al1 potential normal controls were assessed in the same
manner as the ADHD subjects. No normâl control was diagnosed
w i t h ADHD. The sam exclusion criteria applied. Bnml
controls aï1 scored 71 or higher on the G W (Atnerican
Psychiatrie Assadaticai 1994) .
Ali diagnoses were discussed w i t h a child psychiatrist
specializing in ADE4D research, and possible alternate
diagnoses consiàered. Agreement on the AtHù diagnoses was
obtained. Twelve (33%) of the diagnostic interviews were
taped. Six taped interviews of normal controls, and six taped
interviews of ADHD subjects were revievd by a psychiatrist
specializing in adult ADHD as a check on the reliability of
the diagnoses. This second diagnosis was based on clinical
opinion, rather than a checklist of DSM-N symptuns. Rater
agreement was 92% Both the researcher and psychiatrist
diagnosed the six ADHD subjects w i t h ADHD, canbined type. The
researcher and psychiatrist agreed on diagnosis for 5 of the
6 n o m l ccntrols. The psychiatrist diagnosed one of the
normal controls as ADHD, canbined type. The researcher
diagnosed this subject as having conduct disorder as a child,
but no psychopthology as an adult. A child psychiatrist was
asked to review the subject file, and based on this, the
subject was included in the study as a normal control.
subjact8 IltYI?lrrrl-ul frai tl!m Ruutch
A n , of subjects were excluded fran the study. These
iiacluded expriment& and control subjects .
- Fourteen potential experimntal subjects in total were
excluded fran the stuày. Eight subjects were excluded because
they did not meet research criteria for ADID. T m subjects
carpleted the interview, but did rmt wish to continue on to
the testing phase of the study. One subject was excluded
because he could not provide mugh information on which to
base a diagnosis. Three subjects were excluded for other
reasons which could have affected the results of cognitive
testing. Of these, 1 subject met criteria for major
depression, 1 subject had suffered three sM1 fractures as a
child, and 1 subj ect was visually handicap@.
c Ttvo potential no- controls were excluded fran the
study. me subject was found to be &ferhg fran major
depression, and one subject stated during the interview that
he suffered fran àyslexia. Although dyslexia was not formklly
Mmed as an exclusion criteria, it was judged that this
disorder could indeed bias test results.
~~
The Stop Signal Paradigm is a laboratory analogue of a
situation which e r e s the inhibition of an origoing
response. In this ta&, the letters *XIv and IWOtt appear
randanly on a ccmputer screen at regular intenmls.
Periodically, and unpredictably, a %eepN sounds after the
presentation of the letter. This %eepIf sounàs on 25% of the
stimulus presentations. The subject is instnicted to push one
button on a button box when an "XI1 is presented, and another
button on a button box when an l1Ol1 is presented, and to do
this as quickly as possible. When a %eepI1 sounds however,
the subject is instrudeà that he mst stop his response, and
not push the button. There are, thus, tno concurrent tasks
involveci in the Stop Signal Paradigm. There is a "go taskV1
and a Ilstop taskI1.
The t i rne between the presentation of the letter and the
%eepH is called the stop signal delay. The stap signal delay
changes &ter every stop signai trial. The ccmputer program
is designed to track the subject's responses. If the subject
successNly staps at the signal, the stop signal delay is
increased by 50 ms. This d e s it more dif ficult for the
subject to stop. If the subject fails to stap, the stap
signal delay is decreased 50 m. This makes it easier for the
subject to stop. The stop signal delay is thus varied until a
balance is reached and the subject is able to stop 50% of the
tim. A stop signal delay is obtained for each subject.
The Stap Signal Paradigm yields two scores. The "go signal
reaction tirne" (GSKT) is the latency to respond to the
stinulus letter on trials where no signal is presented. T b
%top signal reaction tirneIV (SSRT) is the latency of the
response to the stop signal. The scores abtained are in
milliseconds . The GSRT can be meamed directly. The SSKT cannot.
The GSEZT and the stop signal delay are h m . The task is set
up to allow subjects inhibit 50% of the tim, therefore, the
SSKT plus stap signal delay mist equal the man reaction t i m e
to the go task. To calculate the SSRT, the stop signal delay
is subtracted frmn the man GSRT.
Ckildren with ADD generally display longer SSRTvS than do
normkl children (Schachar & -an 1990; Schachar et al. 1993;
Schachar & -an 1995; Schachar, Tannock, Marriot, & l q a n
1995; ûosterlaan, Ingan, & Sergeant 1998) .
aie Tower of Hanoi is a test of problem solving ability.
In this task, the subject is required to nwnre a stack of
discs of graduated size fran the left side of a three peg
stand to the right side. 'Ilro d e s apply. ûnly one disc can
be nioved removed fran the stand at a t irne, and a larger disc
cannot be placed on a wnaller one. Any n-r of discs fnm 2
up can be used in this task and arry n e of trials can be
m. In the present study, one triai using 5 discs was rune
T h e T o n r e r o f H M o i c a n b e s o o r e d i n a r r y n ~ o f w a y s . In
this st*, the tim to f h t mve (in seconds), the riunber
of rncrriies, the mrhr of errors, and the tim to solution (in
seconds) were recorded. The subjects were not given a tire
limit for the solution of the pmblem. A t r i a l was ccnsidered
over when the problem was solved, or the subject announced
that he was giving up.
There is no standriml method of amninistering the Tower of
Hanoi. In other versions of this task, children w i t h ADW
have been found to perform less efficiently than normal
controls (Pennington, Gmisser, & Welsh 1993 ; Weyandt &
The mail Making Test (A) is a test of speed of visual
search. It is not considereà to be an executive control task.
The subject is sinply required to draw lines connecting, in
numerical sequence, 25 encircled nunibers randady placed on a
page (Reitan & Wolfson 1985). The test is timed. If an error
is made the subject is stapped, corrected, and restarted with
the timer niraiirag. In the achninistration of this test, errors
count d y in that they increase the tim ne- to ccmplete
the ta&. Aithough it ie possible to convert the r a w t ime
abtained on this test to a score, to make the data carpaable
to that of other studies, the dependent masure used in this
research was tim to carpletion in seconds. Children w i t h
ADHD ccnplete this task as Wckly as normal controls
(Gorenstein et al. 1989; DyloMn 6c Ackerrrian 1991; Shue &
Douglas 1992) .
This part of the Trail Making Test mixes numbers (1-13)
and letters (A-L) . The subject is inatructed to d r a w lines
joinllig encircled n&rs and encircled letters altenzately,
starting w i t h 1, and endhg with L (Reitan L Wolfson 1985).
The correct numerical and alphabetical sequence mst be
followeà. This test requires the subject to switch between
numbers and letters. This section of the test is timed in the
same m e r as the Trail Making Test (A) . In the present
research, the raw data in seconds was not corrverted to a
score. To be able to carpare the data generated fran this
study to other research, the dependent masure useà was the
n-r of seconds it tookto ccnplete the task. ADID children
have been found to take longer to ccnplete this part of the
Tail Making Test than normal controls (Boucugnani & Jones
1989; Gorenstein et 61. 1989).
The Benton Facial Recognition Test is a test of
visuospatial processing. This three part test requires
subjects to match photographs of unfamiliar faces. In each
part of the test, subjects are shown a photograph of a face
in front-view taken under N 1 lighting conditions, and
instructed to identify it in a display of 6 photographs. The
test has three different styles of display photographs
creathg three different test conditions. fn P a r t A of the
66
test, the àisplay photographs are front-view. The subject is
instructed to find the match to the target face in the
display. In P a r t B of the test the display photographs are
three-quarter view. The subject is instnicted to f inà the
three faces in the àisplay which match the target face. In
Part C of the test, the display photograph are of front-view
faces taken under different lighting conditions. The subj ect
is instnicted to find the three faces in the display which
match the target face (Benton & Van Allen 1968; LRvin,
Hamscher & Benton 1975; Benton, Elamcher, Vaniey, & Spreen
1983). The score on this test is the nUTCJ3er of correct
matches.
statistical AMlySis
Results fran each test were analysed separately. Data were
anaîysed using two-tailed t-tests for independent samples
(0.05 level of significance) . Levene ' s test for equality of variances was enplayed to determine if arry difference in
variances existed between the two groups. In the one instance
where this test was significant (.O5 level), a t-test for
groups w i t h mecpal variances was used.
The present study imrolves multiple Ccnparisons. The
prcbability of makinfl a Type 1 errer for any 1 of these
carparisons is .05. The d a t i v e probability of making a
Type 1 errer for the set of carpari80128 is .45. Tb control
for increased probability of a Type 1 errer, a Bonferroni
correction is scmetimes used in studies with multiple
carparisons, however, this increases the chances of a Type 2
error. Planned ccnparisons are the purpose of a study. If the
adjusted p value is high, important gmup differences may be
missed. For this reason, it has been suggested that a
reasonable number of planned carparisons may be conducted
without enpl-g a correction (Keppel 1982; Keppel & Zedeck
1989; ICeppel 1991). The use of a correction for nailtiple
cornparisons is controversial . O'Brien States "It seems ironic
that when many imrestigators publish their separate findings
in the medical literature, per-caiparison e m r rates are
routinely accepted. Hbwever, when one imrestigator takes on
the entire job himself, the same approach niay no longer be
deemed vaiid. Rather, he is required to achieve a
consiàerably higher level of significance w i t h each
ccmparison, virtuaîly as a punisinient for such an extensive
effort" (1983, p 788) . s-paradiam
The mean group GSRTs and Sms wexe analysed by means of
the two-tailed t-test for h d e p d m t sanples.
'Ihe four masures obtained fran the Tower of Ituioi yield
mean group scores. The time to f irst nwe, nuniber of nioves,
nuIrber of errors, and t i m e to solution were analysed by means
of the two-tailed t-test for independent samples.
t &&BI
The time needed to carplete the test was measured in
seconds. The mean group tires were c-ed using two-tailed
t-tests for independent sanples.
F u Re- T e ~ t O B
A two-tailed t-test for independent samples was employed
to analyse the mean nufiJ3er of correct matches.
aypo+3irnis
1. The subjects w i t h ADHü were expected to perform mre
poorly on the tests of executive control used in this
study when canparedto n o m l controls.
RBCS(AiTS
W S - R
No significant difference was found between the ADHD group
and mmal control group on the conibined age-scaled score
(t = -1.71, df = 34, p < -096) (see Table 2.3). The
performance of the ACHD subjects and the normal controls did
not differ on the block design subtest (t = -78,
df = 34, p < .441) (see Table 2.4). The AIMD subjects did
score signif icantly lower than the normal controls on the
vocabulary subtest (t = -2 .IO, df = 34, p c .043)
(see Table 2.4) . stap Sigxaal Puadi-
The Stop Signal Paradigm yields two scores: the GÇRT and
the SSRT. The man GSRT of the ADHû group did not dif fer
signif icantly frcm that of the n o m l control group
(t = -1.73, df = 24.79, p c .096) (see Table 2.5) The AWID
subjects had a significantly longer m e a n SSRT than did the
normal controls (t = 3.77, df = 34, p c .001) (see Table 2.5)
Tmmr of maoi The Tower of Hami yields 4 scores. The ADHD gmup and the
mrrnal controls did not differ on the time to first m v e
(t = 1.18, df = 34, p c .247) (see Table 2.6). Four A D D
subjects and 2 nornial contrnls failed to solve the Tower of
fEanoi prablern. FaUrteen ADW subjects and surteen no&
controls
the task
72
solved the puzzle. The ADHD subjects who canpleted
were less efficient at solving the problem than were
the normal controls who carpleted the task . The X H D subjects
t w k a significantly greater n-r of mwes to solve the
Tower of Hanoi task (t = 3.01, df = 28, p c .006) (see Table
2.6) . There was no dif ference between the two groups in
nuniber of errors cannitted (t = 1.49, df = 28, p < -146)
(see Table 2 . 6 ) . The two groups did net ciiffer in the t i m e
taken to solve the Tower of Hanoi prablem (t = 1.87, df = 28,
p < .072) (see Table 2.6) , klthough there was a tendency for
the ADHD subjects to take more t h e .
-1 )ukkig Test (B)
The AIMD subjects took significantly longer to ctnplete
this task than did the nomai controls (t = 2.24, df = 34,
p c ,032) (see Table 2.7) Three ADID subjects and one noml
control made 1 errer each on this part of the Tail Makirag
Test.
Trdl Wciilg Tut (A)
The AWID subjects required more time to carplete this test
than did the nomml controls (t = 2.98, df = 34, p < -005)
(see Table 2.7) . Four subjects out of 18 made one error each
on this test. NO normal control made an errer:,
-clriai Facial Reccgxdtiar Tmt
The ADHD subjects performed as well as the normal controls
on this test. There was no difference between the two groups
in the number of comect matches (t = -.80, df = 34,
p c .431) (see Table 2 . 8 ) .
SCORE
ADHD
N
18
CQEJTROLÇ
t
-1.71
m
109.72
N
18
SD
9.23
df
34
m
115.67
SD
11.48
p c =
,096
Y
ADHD (18) 1 Note: scores are in millisecands
Tl = T i m to first mcnre (secs.)
T2 = N&er of Mmes to Solutkm
T3 = Number of Errors
T4 = Tim to Solutim (secs)
ADHD mNIROLS
Trail N m SD N m SD
A 18 29.86 8.33 18 22.70 5.88 1
B 18 60.82 15.88 18 48.80 16.33
Note: scores are in secands
2.8
#.runi, for the Baaatoaa Facial Recqaitiaaa Ta8t
l
SCORE
ADHD
N
18
a N I R O L S
t
9 .80
man
45.78
SD
4.47
SD
3.40
N
18
df
34
mean
46.83
I
p < =
-431
D I S ~ S I O N
aie results of the present research do not support the
hypothesis that adults w i t h ACHD have a def icit exclusively
in executive control. The results of this study denonstrate
that aàults w i t h ADHD do have cognitive deficits. The ADHD
subjects performed less well than did the normal controls on
a nimiber of executive control tasks. The deficits exhibited,
however, were not confined to the executive control danain.
The ADHD subjects were irrpaired on one of the control tasks.
The Wais-R was enplayed in this research to ensure a
carparable IQ between group . As such, the subtests of the
W S - R cannot be vie& as research masures. The t w o groups
were found to differ significantly on the ~ c a b u l a r y subtest
of the W S - R , but not the block design. There was no
significant group difference in man estimated age-scaled IQ.
Studies have been conducted to determine if adults w i t h
ADHD perfom mre poorly on tests of intelligence than do
normal controls. Bi- and colleagues (1993) c~mpared the
estimated IQ of adlllts w i t h ADHD (DÇM-III-R diagmsis) to
that of normal controls. The Mcakilary subtest, and block
design subtest were a-stered. No significant p u p
àifferences were found on the estimated IQ score. The scores
of the ADED aubjects and normal controls did not differ on
either of the two subtests . Gansler and colleagues (1998)
also caipared the perfommce of achiLts w i t h ADHD (DSM-IV
81
diagnosis) to that of normal controls on two subtests of the
WAïS-R. in this case, the researchers used the similarities
subtest, and the block design subtest to detemine the
estirriated age-scaied IQ. The researchers found no signif icant
group differences in age-scaled IQ, or on either of the two
subtests. To sum up, the results of the present research
agree w i t h the resùlts of other studies which have examined
IQ in aàults with ADHD. These studies uncaverd no
differences in oveal1 IQ between adults w i t h ACW) and normal
controls. In the present stu*, the IQ scores of the subjects
w i t h ADHD were still in the average range.
The Stop Signal Paradigm did differentiate between groups.
The subjects with ADHD had significantly longer SSRT's than
did the normal controls. This would indicate that these
Txidividuals had a more difficult t i m e inhibithg their
ongoing behavior. This remit agrees with the results of
studies examining inhibitory control in children (Schachar &
ïayan 1990; Schachar et al. 1993; Schachar & bgan 1995;
Cbsterlaan, -, & Seryeant 1998). The Mer io r inhibitory
control exhibited by the ADHD subjects was not due to a
difference in reaction time to the letter stimulus (-1.
The GSRTs of the subjects in the normal control group tended
to be longer, but the two graups did not differ significantly
on this masure.
The ability to stop an ongoing action is necessary in
everyday situations. It has been speculated that the lack of
inhibitory control demnstrated by AüHD individuals in the
perfoymance of this task reflects a lack of inhibitory
control in daily behavior . A child w i t h AWID, for -le,
may find it difficult to stop the action of chasing a bal1
across the street on the approach of a car (Layan 1994) . Of the four scores obtained frwn the a M s t r a t i o n of the
Tower of Hanoi, the two groups dif fered on only one. The time
to first mwe, and the n u b e r of ors c d t t e d on this
task m y be interpreted as masures of impulsiveness. The
scores obtained fran these two masures did not differ
significantly between groups. The subjects in the ADHD group
did take more moves to solve the problem than did the normal
controls. There was a trend for the ACW3 subjects to take
more tim in solvhg the prablem, but this was not
signif icant . Two researchers studying cognitive functioning in chilàren
with ACW) incluàed the Tower of Itlnoi task in the
ape r imen ta i protocol (Permington, Graisser, & Welsh 1993 ;
Weyandt & Willis 1994) . The mthod of test acMnistration
differed signif icantly fran that used in the present
research. in these two studies, problems of increasing
difficulty were presented
for carpleting a prablem.
solve significantly fewer
controls .
83
to the subject, and points gained
The subjects w i t h ACHû were able to
prablems than were the normal
It is interesting to note that, in the present study, a
n . r of the ADHD subjects comnented that they couîd not
visualize the correct nrnres, but rather continued to move the
discs until they stbled upon the solution. It seems that
the ADHD subjects did poorly on this task due to a prablem in
planning rather than a problem w i t h impuisiveness.
The Trail Making Test (B) requires subjects to switch back
and forth between letters and the alphabet. The ADHD subjects
took longer to caplete the mil Making Test (B) than did
the normal controls. This finding is in keepîng with the
resuîts of stuàies examining cognitive finictioning in
children with ADHD. The performance def icit exhibited by the
ADED subjects in this study m y not be caie to a problem in
switching sets. The perforniance of the subjects w i t h ADHD
tested in this study mist be vie& in the context of their
performance on the Trail Making test (A) . The Trail Making Test (A) was used as a control task in
the present stuày. This ta& tests the subjectWs ability to
scan and zero in on a target qpickly. The aWts w i t h ADHD
perfomeà significantly worse on the Tail Making Test (A)
than did the mrmal aciults . The subjects w i t h ADHD took
longer to caiplete this test than did the normal controls.
This result is not unprecedented. Adults with AMa) have been
fourad to perform more poorly on this task than normal
controls in one other study (Gansler et al . 1998). The mil MakUlg Test (A) has been achllnistered to children w i t h A D D .
Significant differences in t i rne to carpletion have not been
found, but there is a trend for children with AùHD t o take
longer to finish this task than nom1 controls (Goremtein,
Mamnato, & Sandy 1989; DylaMn & Ackernian 1991; Barkley,
Grodinsky, & DuPauï 1992).
The poor performance of the AWID subjects on the Trail
Making Test (A) may have been due to a problem in search
strategy or focus. In the present study it was noted that on
both parts of the Trail M&hg Test, the subjects w i t h ADW
appeared to have difficulty locating the apprapriate n-r
or letter. The subjects in the ADHû group would often pause
on a letter or nurSser, and search for the next in sequence.
There is eddence t o suggest that th is is the case. One of
the f e w non-executive control tasks on which chilàren and
aàoleecents w i t h ADHD have been faund to perfonn poorly in
more than one study, is the Figures Test.
Individuais w i t h the disorder have been faund to take longer
to catplete the Wibedoed Figures T e s t (Cohen, Wei~s, & Minde
1978; Hapkins, PerInian, Hechtrrian, & Weiss 1978) than do
nomal contr01s. This is a t i m d test in which a subject mist
finà a siqle figure w i t h i n a ccrrplex one. It is not
considered to be an executive control task (PennUigton &
Ozonoff 1996) . It niay well be that indiviàuals with ADHD cannot search as quickly as indiviàuals without ADHD. This
would also -lain the relatively paor performance of the
subjects with ACHD on the mail Making Test (B) . There was no significant group difference in performance
found on the Benton Facial Recognition Test. The aclults w i t h
A D D made as m a q correct matches as did the normal controls.
This tasks differs significantly fram the -1 Making Test
(A) in that it is not timed. In the Benton Facial Recognition
Task, the subject has to search for similarities and
ciifferences between the target faces and the faces in the
sanple array, but there is no time limit. Speed of search is
not an issue. This may account for the fact that the aàuits
w i t h AWIO performied as -11 as the normal controls on this
task. This test indicates that the problems the abjects with
ADHD had with the Trail Making Test is m t due to perceptual
ability, but ather to efficiency of s e m .
The present research is the oniy study of cognitive
functionhg in individuals w i t h ADHD to use Benton Facial
Recognition Test as a contml task. It is therefore not
possible to capare the results of the present study to that
of other studies of cognitive fimctionhg in children or
a M t s with m.
86
There is no definitive method of determining if a task is
a test of executive control. The Pearson product-manent
correlation coefficient was used to determine if the scores
on the various tests were correlated. Although not al1 the
tests on which the ADHD subjects performed poorly were
correlated, mst were. Performance on the Trail Makirg Test
(A), which is not considered to be an mcutive control task,
was significantly correlated with p e r f o m c e on the Trail
Making Test (B) (r = .65, df = 36, p c = .001), and the
number of moves needed to solve the Tower of Hanoi (r = - 62 ,
d f = 30, p c = -001). The Trail Making Test was also
significantly correlated w i t h the SSKT of the Stop Signal
Paradlgm (r = 37, df = 36, p c = .026), although this
correlation was low. None of the scores on the executive
control tasks, or the Trail Making Test (A) were
significantly correlated w i t h scores on the Benton F a c i a l
Recognition Test, or the GSRT of the Stop Signal Paradigm
(see Appendix A) . These firadirgs suggest that the executive
control tasks and the Trail Makiiag Test (B) are part of a
single construct . Ail subjects in the present study were screened for major
depression, psychosis, and d a as these psychapatho1ogies
may have affected performance on the cognitive tests. This
ailows for the conclusion that the deficits in performance
found in the ADHD group were associated with ADHD rather than
attributable to these other psychopathologies.
The subjects in the ADW group were of slightly higher
than average intelligence; their relatively p r perforrriance
on the research masures cannot be attributed to low IQ.
The subjects in the ADHD group scoreci signif icantly lower
than did the nomal ccntrols on the wcabulary subtest of the
WUS-R. The Pearson product-rrrxnent correlation coefficient
was use to determine if performance on the wcabulary subtest
was correlated w i t h performance on the research masures. No
signif icant correlations were found (see Pgpendix C) . The subjects with ADHD and the normal controls did not àif fer in
perfommce on the block design subtest of the W S - R . The
Pearson product-manent correlation coefficient was used to
determine if performnce on the block design was correlated
w i t h perforniance on the research masures. A significant
correlation was found oniy between the score on the block
design and the Trâil Making Test (B) (see Appendk A) . The
correlation obtained was low howwer (r = -38, df = 36,
p c = .022), and as the t w o gmups didnlt àiffer on this
subtest, it does not affect the interpretation of the &ta.
88
The Pearson product-mxnent correlation coefficient was
also calculateci to determine if estimated IQ was correlated
with performance on the research masures. No significant
correlations were cbtained (see A) . The data were re-analysed by mans of an analysis of
covariance ( m m ) uskg scores on the ~ c a b u l a r y subtest,
scores on the block design subtest, and estimated IQ as
covariates. Ail the research variables were examineci in this
manner with the exception of the GSRT of the Stop Signal
Paradigrn. The variances of the GSRT differed between groups,
and one of the assumptions of the analysis of covariance is
that the variances of the grogs are equal (Tabachnick &
Fidell 1983). The results obtained fran the analpis of
cavariance were very similar to those obtained using t-tests.
The tests remained significant or non-significant with two
exceptions (see Pgpendix B) . The difference between g m u p on
the 'tirne to solution1 masure of the Tower of Hanoi was not
signif icant when analysed by means of a t-test (t = 1.87,
p c = .072) . This difference did becane significant when the
SIhalysis of covariance was used, and the Mcabulary subtest
of the Wais-R was used as a covariate (F = 4.44, p c = 0.45) . As the t-test m u e was near significance, and the ANCUVA
value was just significant, these two findings are not too
diseimilar. nie correlation between these masures was
non-signif icant ( .0661, p c = -728) .
Analyses of performance on the mil Making Test (B)
produced conflicting results. The difference between groups
on the Tail Making Test (B) was significant when analysed by
means of a t-test (t = 2.24, p < = .032), but non-signifiant
when an analysis of cavariance was conccclucted and estimated
IQ was used as a cuvariate (F = 3.36, df = 1, 33,
p c = . 0 7 6 ) . There was a -11 but non-significant
correlation between IQ and score on the Trail Makhg Test (B)
(r = - .28, p c = .101). Scores on estimated IQ did not differ
according to group. The results of the AN- show, however,
that perforrtiance on this task was related to IQ. l h i s is the
onïy case where performance on the research masures was
found to be relatedto IQ, or to scores on the subtests of
the TWIS-R.
The results of both the t-tests and the AN- show that
a M t s with ADHD have deficits in cognitive functionhg. The
niinor differences obtained fran the t-tests and the AN-
do not change the interpretation of the data.
The subjects in the ADHD group were diagnosed w i t h ADHD,
cdiried type, and had a family history of the disorder. in a
study of cognitive functioning in children w i t h ACHD,
Pennington, Gmisser, & Welsh (1993) found that children with
ADm, and a family history of the disorder, perfonned mre
poorly on tests of executive control than did children w i t h
ADHü who àid not have a family history of t h e disorder. Both
90
gwoups were found to perform more poorly than normal controls
on these tests. The results of the stuày by Pennington,
Graisser, & Welsh (1993) suggest that the adults tested in
the present research may be mre severely affected
cognitively than adults with ADHD without a family history of
ADW. n i i s m y limit the generalizability of the results to
this particular w u p . More research is m r e d to
determine if this is the case. To test this possibility, the
cognitive perforniance of adults with ADHD without a family
history of AûHO could be compareci to that of adults w i t h ADHD
who don't have a family history of the disorder.
It has been theorized that ADHD is associated with frontal
lobe dysfunction (Rosenthal & Allen 1978; Mattes 1980; Shue &
Douglas 1992) . Ekecutive control tasks are also referred to
as lTrontai lobe tasks" (Barkley, Grodinsky, & DuPaul 1992;
Grodinsky & Dianiond 1992; Shue 6r Douglas 1992). The poor
perforniance of Uidividuals with ADHD on executive control
tasks has been taken as evidence that frontal lobe
dysfunction is associated w i t h ADHD (Shue & Douglas 1992) . As prevîously discussed, huwever, performance on executive
control tasks is mediateci by more areas of the b a i n than
just the frontal lobes. In the present research adults with
AMID p e r f o d mre poorly on tests of executive control, and
91
on a non-executive control task than did 110- contnls. The
results suggest that ADHD is not j us t associated with frontal
lobe dysfunction, but with a mre generalized dysfunction.
Nuniemus researchers have reported cognitive deficits in
children, adolescents, and adults with ADHD (Cohen, Weiss, &
Minde 1972; Hopkins et al. 1979 Tramier et al. 1988;
Gorenstein et al. 1989; Iage et al. 1990; Katz et al. 1998;
Gansler et al 1998). The authors of these studies always
discuss associations, and do not d r a w causal conclusions.
In the present research an association was found between ADHD
and cognitive inpairment. Cause and ef fect cannot be
detemiuied.
As ADHD and cognitive deficits are pre-existing
conditions, it is not possible to andcmly assign subjects to
groups . Without randan assigranent, it is not possible to
control for confounding variables (Hanushek & Jackson 1977;
Sheskin 1997; Johnson & Tsui 1998) . It is not possible,
therefore, to definitely assign cause. In the present study
the disorder may hwe caused the cognitive deficits, the
cognitive deficits may have caused the disorder, or an
unknown factor (or factors) couid have caused both. It might,
howwer, be possible to determine if cognitive inpairment
contributes to ADHD symptanatology or vice versa. To & this,
the data would have to be exwcined to see how well poor
perforniance on the tasks predicts -, and how well
status predicts poor performance on the tasks. If the chta
showed that cognitive irrpairment is not necessarily
associated with AtW), but is a good predictor of ADHD, it
would suggest that cognitive impairrrient is a contributing
factor to the disorder though not necessarily the cause.
Cognitive deficit certainly does not cause ACHù in al1
individuals, and is associated w i t h disorders other than ADHD
(Saint-= & Weinberger 1990; Katz et al. 1998; ûosterlaan,
Lagan, & Sergeant 1998). If ADHD were found to be a good
predictor of cognitive def icits, it might be that the
disorder is contributing to the cognitive inpainriient.
ûn average, the ADHD subjects perfomd more poorly than
àid the nom1 controls on the Stap Signal Paradigm, the
Tower of Hanoi, and the T'rail Making T e s t (A & B) . These tests, taken individually, cannot be considered diagnostic.
There was arerlap in performance between the two groups on
every test. In addition, a subject m y have performed poorly
on one test, but well on another. Also, poor performance on
these tests may be indicative of disorders other than ADHù. A
battery of tests such as these, ho-, dces p d d e
information about the cognitive functioning of an indiviàual.
Such information could be useci ancillary to a clinicai
interview in an assessrnent for AûHD.
-1-
The results of the present research suggest that a
in cognitive functionîng is fiindamental to ADHü. This
def icit
def icit
does not affect al1 cognitive dunains, but is not confined to
the mcutive control damain. Chileen w i t h ADHD have
cognitive deficits. The present study found that adults with
A m have very similar cognitive deficits. This finding
pravides evidence for the vaiidity of the diagnosis in
adults . zddtatimm of -..nt s w
The present research examined cognitive fundionhg in a
ml1 gmup of subjects. The stuày included 18 adults with
ADHD and 18 nomai aàuits. Aithough the findings are rabust,
the sanple should be expnàeà to prwide a better
representation of these populations.
ADHD m y be a polyyenic disorder w i t h rniltiple
d i n a t i o n s of alleles leading t o similar symptoms,
including cognitive inpairment. If this is the case, the
likelihood that alleles leading to cognitive inpairment would
be included is higher i f there is expression in closely
related individuale. The present study does not control for
this possibility. Another study should be Conducted ushg the
94
normal parents of ADHD children, and ADHD adults with mm1
children as controls . Such a study, however, would be a very
large undertaking and subjects to fil1 the groups might be
The present study examineci cognitive functioning
in adult d e s with ADHD, canbined type. The reeults cannot
be generalized to the subtypes of ADHD, or to wanen w i t h the
disorder.
Although there are no studies showing that performance on
the tests used in the present research is culture depemîent,
it is possible.
ml- Direct ihain
For practical reasons, the subjects in the present
research were restricted to aduit males w i t h AWai, cunbineà
type. Rie results suggest other avenues of research. As there
is saire indication that the subtypes of ADD are distinct
disorders w i t h dif ferent etiologies (Lahey, Schaughency,
Strauss, & hame 1984; Lahey, Schaughency, Hyde, Carlson, 6r
Nieves 1987) it wuld be of interest to capare cognitive
functioning in the subtypes of ADHD. Also, cognitive
functioning in wanen with AWiD should be imrestigated.
Same children w i t h ADEID appar to out- the syl1ptom8 of
the disorder in adolescence &le others continue to
eqerience significant syr[lpto1118 as achrlts ( G i t t e l m a n et al.
1985; Weiss et aï. 1985; Mamuzza et al. 1991) . It is met
important that cognitive functioning in these two
groups shouid be corrlpawed. It rnay be that an iniderlying
deficit is associated with ADHD unrelated to behavioral
p-typem
Another study s h d d be conàucted with mre and
varied non-executive control tasks included. In this way, a
clearer pattern of the deficits associated with ADHD could be
obtained.
The present thesis is ccmprised of two studies, each
addressing a different issue concerning ADHD. The resuits of
Study 1 demonstrate that adults can p&de as accurate a
rating of their own ~ynptcms of ADW) as can an informant.
Study 2 mkes use of the result that the sanie inforniation
that can be obtained fran an infontiant can be obtained fram a
subject. The diagnoses in Study 2 were bas& self-reports of
behavior obtained fran subject interviews. In addition, the
results of Study 2 suggest the def inition of executive
control may be too narrow.
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Study 2 Correlations AANDB
AP-I][ B
Results of Analpis of Covariance
1 SSRT 1 16.09 1 (1, 33) 1 .O01
M l Making Test (A) 10.50 (1, 33) . 003
Il 'mail Making Test (BI 1 4.37 1 (1. 33)
Tower of Hanoi - 1 2.13 (1, 33) -154
Tower of Hanoi - 2 7 - 8 5 (1,271 ,009
Tower of Hanoi - 3 3.24 (1,27) .O83
I
Tower of Hanoi - 4 4 -44 (1, 27) ,045
I
SSRT = Stop Signal Reaction T i m , Tower of Hanoi 1 = Tim to F i r s t Mwe, Tower of Hanoi 2 = Nmber of Mmes, Tower of 3 = Number of Errors, Tower of Hanoi 4 = Time to Solutim
SRT = Stop Signa1 Reacticn Tirne, Tawer of Hanoi 1 = Time to F i r s t Move, Tower of Hanoi 2 = Nimber of Mmes, Tower of HaMi 3 = Nimber of Errors, Tower of Hanoi 4 = Time to Solution
SSRT 1 13.29 1 (1. 33) 1 .O01 11 Rrail Making Test (A) 1 7.51
Roail Makirtg Test (BI
Tower of Hanoi - 1 1 2.15
Tower of Hanoi - 2 Tuwer of Hanoi 3 1 1.98
ÇSRT = Stop Si@ Reaction Tirne, Tower of HaMi 1 = T i m to F i r s t Mwe, Tower of Hanoi 2 = N w h r of Moves, Tower of Hanoi 3 = Mmiber of Errors, Tawer of Ehmi 4 = Time to Solution
AP-IX C
Information and Coslsent Forms
T i t l e of Research Project : Behavior and Prablern Solving in Adults
Imrestigators: m. Patricia Murphy - Doctoral Candidate Dr. Russell Schachar - ÇupeMsor
The purpose of this research is to leam more about children with behavior erablems by studying the kinds of problems exprienced by their family menbers.
There are two parts to this study. F i r s t of all, your behavior (past and present) vnll be assessed by means of an interview, an oral test, and a puzzle test. After the interview and tests, you will be asked to conplete a series of tasks. Behavior may be linked to the performance of tasks which reqgire planning to achieve a goal. I am interested in lwking at how behavior relates to your performance of fow such tasks. dEE incl&: a cornputer ganie, a paper and pencil task, and twio puzzles.
As a check on the f llidings, same interv3ews will be videotaped, or audiotaped, and revieweà by a s e c d researcher. This will not be dune without y m r separate written casent.
The interview, tests, and tasks are for research purposes &y, and results will not be report& to you.
There is no hann Involved in takin part in this research, but scme peuple may find satie a cts oz the study ta be tediaus, or T frustrating. The st* w i l take abaut 3 hours of p u r tirne.
You will not benefit directly from participation in these studies, but the research will increase our hav1ecige of behavior and problem solving in adults . If any àiff iculties are noted during assessment, these w i l l be discussed with you, and suggestions made about wfiere and how you may get further assistance.
Your participation in this withdraw fran the study participate, or to w i t h d a w continue to have access to
The results of the tests and interviews w i l l be held in ceidence, and used for the ses of t h i s research &y. No information that discloses your i6é"tY will be released or published w i t h o u t your consent.
Yau will not be paid for takllig part in this study.
I acknowledge that the research procedures described abuve have been wla ined to me and that any stiais that 1 have have ken answered to mv satisfactiun. 1 have % en info- of the alternatives to partkipatian in this stuq, including the right not to participte and the right to wi thdraw without campdsing the quàlity of medical care at The Hospital for Sick Children for nie and for other menbers of my family. As well, the potential harms and discomforts have been q l a i n e d to me and 1 also understand the benefits (if any) of participating in the research stuày. 1 kncw that I may ask KIW, or in the future, any questians 1 have about the study or the research procedures. 1 have bew assured that records relating to me and my care will be kept canfidential and that no informatian will be released or printed that waild disclose persmal identity w i t h o u t my permission.
1 hereby consent to
participate.
Name ot Patient and Age Signature (it 16 years ot age or wer)
The persan wfio may be cantacted about the research is:
Who m y be reached at telephane #:
Signature
D a t e
Title of Research Proj ect : Behavior and -lem Solving in Pmilts
Imestigators : Ms. Patricia Murphy - Doctoral Candidate D r . Russell Schachar - Supenrisor
The purpose of this research is to leam more about children w i t h behavior prablems. You are king asked in this study as part of a normal caitrol graup.
the parents of to participate
There are t w o parts to this study. First of all, your behavior (past and prescrit) ml1 be assessed by means of an interview, an oraï test, and a puzzle t e s t . After the interview and tests, you will be asked to canplete a series of tasks. Behavior may be linked to the eerfo~mance of tasks Wch m r e planning to achieve a goal. 1 am interesteci in looking at huw
Tc?= behavior relates to ywur
perfolmance of four such tasks. se include: a canputer game, a paper and pencil task, and t w o puzzles.
As a check cn the findiiags, sane interviewa will be videotaped, or audiotaped, and reviewed by a seccd researcher. This will not be dcaie withuut your separate written consent.
The interview, tests, and tasks are for researchpurposes only, and results will not be reported to yni.
There is no harm involved in t 9- in this research, but sotne people may find scme aspects O the study to be tedious, or frustrating. The study will take about 3 hours of yaur time.
You will not benefit dUectly f m participation in these studies, but the research w i l l increase aur knowledge of behavior and problem solving in adults. If any difficulties are mted during assessmnt, these will k discussed w i t h you, and suggestians made about where and how you may get further assistance.
Y o m participation in this research is voluntary, and you may wi thdraw frm the study at any t irne. If you -se not to participate, or to withdraw fran the s t w , you w i l l and yuur family w i l l continue to have access to quklity care at IIÇC.
The results of the tests and interviews will be held in canfidence, and used for the ses of this research &y. No inforniatien that discloses yaur iEtY will be released or published without y w u r consent.
=Y=-=
Yau will
Ccnisent
not be paid for taking part in this stuciy.
1 acknmvledge that the research procedures described abme have been qlained to me and that any questions that 1 have had have been ansufered to ny satisfaction. 1 have been info- of the altematives to participation in this study, includMg the right not to partlcipate and the right to n t h c ï r a w without compromising the
it of medical care at the Hospital for Sick Qildren for me and %~&er members of my family. As well, the potential hans and discomforts have been explaid t o nie and I aïs0 understand the benefits (if any) of participating in the research stuày. 1 knw that 1 may ask now, or in the future, any questions 1 have about the study or the research procedures. 1 have been assured that records re lathg to me and my care will be kept canfidential and that no information w i l l be released or printed that wwuid disclose personal idwtity w i t h o u t my permission uniess required by Law.
1 hereby consent to
participate.
N a n ~ of Patient and me Signature ( t 16 pars or age or over)
The persan who may be contacted akut the research is:
Name of perscni who obtained coaisent
Signature
Date
Title of Research Project: Assessrnent of Behavior in Aduks
Investigators : Ms. Patncia Muxphy - Doctoral Cadidate D r . Russell Schachar - Supervisor
The -se of this research is to investigate the use of questmnnaires in assessing behavior .
You will be asked to ccmplete a questiamaire assessing your behavior as a child and/or as an aàult. In additian, mu will be asked to have a relative ancilor spouse f il1 out a simile &sti&re rating ynur behavior. The results of these questidres will be used for - research purposes &y.
Tbere is no h m imrolved in taking part in this stuày, but f illing out the q u e s t i h r e s will take 10-15 minutes of your t im.
Y o u will not benefit direct1 fran this research, but your participation will increase our L 1 e d b e of behavior asses-t.
Participaticai in this study is wluntary, and you may w i t h d a w at any time. If ywu choose not to Y icipate, or to withdraw fran the study, you and your family w i 1 cantinue to have access to quality medical care at HSC.
The reeults of the cpestiamaires w i l l be held in confidence, and used for the purposes of this research cmïy. No inforniaticpi that discloses yair identity w i l l be released or published w i t h a i t carsent.
You will not be paid for taking part in this study.
I ackmwledge that the research procedures described above have been ~ l a i n e d to me and that any esticms that 1 have have answered to w satisfactian. 1 have %en iniormed of the dt-tives to participation in this st*, including the right not to participate and the right to withdraw vvlthcut compromising the quality of medical care at The Hospital for Sick Qiildren for m e and for other members of my family. A8 well, the potentiai harme a d àiscanforts have been explained to m and 1 also understand the benefits (if any) of pakticipating in the research study. 1 know that I my ask nÜw, or in the future, any questicns 1 have abaut the study or the research procedures. 1 have been asmed that records relating to me and my care will be kept ccaifidential and that no informatian will be released or printed that wcdd disclose personal identity without my permissian.
participate.
N a m ot Patient and Age Signature (if 16 years ot age or mer)
The person who may be ccntacted abaut the research is:
--
Who may be reached at telephone # :
Name of persan w b abtaineà cansent
Signature
T i t l e of Research Project: Behavior and Problem Sol- in AdllLts
Investigators : Ms. Patricia Murphy - Doctoral Candidate (416) 813 7468 D r . Russell Schachar - Supervisor (416) 813-6564
I hereby ccnsent to be taped/photcgraphed d u r h g participaticn in this research project . 1 have been assureci that my identity will not be discloseci withuut my written ccnsent. 1 understand that I am free not to participate in this part of the study and that if 1 agree to participate 1 am free to withdraw from this part of th.e study at an tirne w i t h m t compromising the it of medical care at The Hospit for Sick chikiren for rrrie and PX, or O members of my family.
Y
The pers- who ma be ccoltacted Name oi Patient about the r e s e d is:
Patricia Eauphy
Who m y be reacheà at telephorne #: (416) 813-7468
Signature (it 16 yrs . )
Signature
Uate
In additiai, 1 give permissiai for this tape/photograph to be used for (check off boxes as appropriate; you may chaose to not check off any of these additionaï baxes) :
1. 0 Other research projects . 2. Teaching and demanstraticn at HSC
3 . Teaching anà demanstation at professional meetings outside M C
in giving permissian for the use of the tape(s)/photograph(s! be rd m e n t research, 1 have been offered the apportunity to n e w / ar the tape(s) /photograph(s) and 1 understand that 1 am free to withdraw mv nermission for other uses of the tame (s) /dmtwra~h(s) at anv
Rie Persan who may be contacted about Patient the research is:
Patricia Mwphy
Signature (if 16 yrs.)
Who may be reached at telephme #: (416) 813-7468
Signature
Date
AP-IX D
ChilQiood and m e n t Behavior Questionnaires
BEHAVIOR QIFSTXOINNAIRE - Subject
Sub j ect ' s Name m e Sex
Circle the nmbes that BEST DESCiUBES your behavior AS A CHILD (12 years and under) .
Failed to give close attention to details or rade careless mstakes in schoolvmrk or other activities
Fi%eted with handa or feet or sqrilrnied in seat
Blurted out anstnfers before questions had been ccmpleted
Had d i f i i d sustainhg attention in taeks or Zay activit~es
bit seat in situations in -ch reniauiing seated was expected
Did not listen when spaken to directly
Did not follow -Yhcm instructians and fai ed to finish schoolwork, or chores
Ran about or climbed excessively i n situations in which it was inappmpriat e
10 . U d aiff ++ty organizing tasks or actlvrt res
il. Avoided, dfsliked, or was reluctant to engage in tasks that required sustauied mental effort (e .g , schoolwork, hnirrwork)
Never or Sonrotinies Often -1~
Inte ted or intrudeà an others k.g7u&itted into conversations or 9-s )
Lnst things necessary for tasks or activities (e.g,, toys, school assignnients, pencils, bmks, or tools)
Was easily distracteci
Was "an the gow or acted as if ''driven by a nritoru
Was often forgetful in daily act ivi ties
If you circled t*oftenw, or Nusuallyw to any of the above statemnts please an- the following questions.
Were any of these traits present before the age of 7? YES NO
f f yes, please specify statement nimibexb)
Were at least scme of these traits resent in mre rhan m e setting (e.9.. hcm, adurne)?
Did these traits euse significant ciiffidties in social, or acadenuc functianing?
Subject 's Narre Age S e x
ûbserverts Nane e= Sex
ODservert s relatieaiship to subject
Circle the number that BEST DESCRIBES the subject ' s behavior AS A CHILD (12 years and under) .
Failed to give close attention t o details or rriade mless mistakes in sciioolwrk or othex activities
FiCbgeted with hands or feet or squilmeb in seat
BlWed out anmers before questions had been completcd
Had difficuït sustainhg attention in tasks or activities
Left . s ~ t in situations in which remammg seated was expected
Did not seem to listen when spoken to directly
Did not follow instructicxm and yhon fai eà to finish school~iiork, or chores
Ran about or ciimbed excessively in situations in which it vas inappropriate
Had dif f iculty awaiting turn
10, Had dff f iciilty organizing tasks or activities
11. Avoided, disliked, or was reluctant to engage in tasks that r e q w k d sustaured mental effort (e .g . , schoolwork, hamework)
Had difficulty engaging in leisure actimties quietly
Ldst things necessary for tasks or activities te.g., tays, school assignments , pencils, books, or tools 1
Was easily distracted
Was "on the gon or acted as i f "üriven by a motorw
Was of ten forgetful in daily activities
Do believe that you have a gmd i i ~ ~ r y the subject ' s chi dhood?
If you circled noftenw, or wusuailyn to any of the above statemnts please answer the following questions.
Were any of these traits present before the age of 7? YES NO
If yes, please specify statement nrmiber (s)
Were at kast same of these traits resent in more than one setting (e.g.. hane. schco?)?
Did these traits cause significant âifficulties in social, or academic functionurg?
Date
Subjectts N a m A@=
Circ1e the number that BEÇT DES- ybur behavior IN THE IliAM' S W t4XMS.
Fails to give close attention to details or makes d e s e mietakee in schuolwork or other activities
Ficigets with hands or feet or squanns in seat
B l u r t s out anmmrs before questions have been canpleted
Has difficulty sustaining attention in tasks or recreational activities
kaves seat in situations in which reniainhg seated rs expected
Does not listen when spoken to directly
Does not follaw through an instntcticms and fails to finish chores, or duties in the wrkplace
1s phYSically very active in situations in which ~t is inappropnate, or feels reatless
Has difficulty awaiting turn
10. Has diff iculty organizing tasks or activities
11. Avoids, dislikes, or is ductant to engage in tasks that require sustaxned mental effort (e .g., p a w r k
Never or Sanetimes Often -Y
EEas dif f iculty engaging in leisure activities quietly
14. Loses things necesBq for tasks or activities (e.g., keys, paperuriork, books, or tools)
15. 1s easily distracted O 1
16. 1s "on the gon or acts as i f n d r i ~ by a motor"
18. 1s of ten forgetful in daily a& ivi t ies
If you circled woften18, or nusuallyn to any of the above statements please answer the followiq questions.
Have these traits been present for at least 6 nionths?
Are at least s a of these traits resent in more than ane setting (e.g., b, workf'?
Do these traits cause si f icant difficulties in social, or occupational 9" unctf oning?
Of ten
2
2
CmRmI' BEHAVIOR QUESTIONNAIRE -
Date
Subjectts Nanie
Observer ' s relarionehip to subject
number that BEST DESCRIBES the subject's behavior IN THE ïAST Circle the 6 m.
1. F a i l s to give close attention to details or makes careless mistakes at work or other activities
2 . F i d t p s w i t h hands or feet or squrrma in seat
3 . Blurts out answers before questions have been canpleted
4. Kas dif f i d t y sustaining attention in ta& or recreatid activities
5. haves seat in situatiam in which reminhg seated is m c t e d
6 . Does not seem ta listen when spaken ro directly
7 . Does not follm thmugh an instructions and f+ls to finish chores, or duties m the workplace
8. 1s phpically very active in in situations in which it is inappmpriate, or seems restless
9 . Has difficulty awaiting turn
II. Avoids, dislikes, or is reluctant to ~ g e in tasks that require sustamed mental effort (e.g., pape-*)
Luses things neœssary for tasks or activities (e.g, , keys, pa-rk, books, or tools)
1s "on the gow or acts as if "driven by a motorw
1s of ten forgetfül in daily activities
N e v e r o r Sonietirms Often U d l y r-1~
If you circled "oftenn, or nusuallyu to any of the above statements please ansulrer the following questions.
Have these traits been pre8ent for at least 6 mths?
Are at least same of these traits resent in more chan m e settuig (e.g., hane, wDickP?
Do these traits cause si ficant difficulties in social, or occupatfonai 8" unctioliing?