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?