Journal ofhttp://jad.sagepub.com/ Attention Disorders
Self-Awareness of Executive Functioning Deficits in Adolescents With ADHD Kayla A. Steward, Alexander Tan, Lauren Delgaty, Mitzi M. Gonzales and Melissa Bunner Journal of Attention Disorders published online 5 May 2014 DOI: 10.1177/1087054714530782 The online version of this article can be found at: http://jad.sagepub.com/content/early/2014/05/03/1087054714530782
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JADXXX10.1177/1087054714530782Journal of Attention DisordersSteward et al.
Article
Self-Awareness of Executive Functioning Deficits in Adolescents With ADHD
Journal of Attention Disorders 1–7 © 2014 SAGE Publications Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1087054714530782 jad.sagepub.com
Kayla A. Steward1,2, Alexander Tan1,2, Lauren Delgaty1, Mitzi M. Gonzales2, and Melissa Bunner1,2
Abstract Objective: Children with ADHD lack self-awareness of their social and academic deficits, frequently rating themselves more favorably than external sources. The purpose of the current study was to assess whether adolescents with ADHD also hold a positive bias toward their executive functioning (EF). Method: Participants include 22 control and 35 ADHD subjects, aged 11 to 16. Participants and their parents completed the Behavior Rating Inventory of Executive Functioning (BRIEF) Self and Parent forms, respectively. Discrepancy scores were calculated for each domain by subtracting the adolescents’ T-score from the parents’ T-score. Results: Discrepancy scores were significantly higher in the ADHD group than controls within the Inhibit, Shift, Monitor, Emotional Control, Working Memory, and Plan/Organization domains (all p < .05). Conclusion: As compared with controls, adolescents with ADHD tend to endorse fewer EF difficulties than what parents report. This is the first study to demonstrate that those with ADHD may overestimate their EF ability. ( J. of Att. Dis. XXXX; XX(X) XX-XX) Keywords adolescent ADHD, BRIEF, executive function, self-report
ADHD is one of the most common childhood neuropsychological disorders, causing difficulties in academic, social, emotional, and behavioral domains (Barkley, 1990; LeFever, Villers, & Morrow, 2002; Pelham & Bender, 1982). Due to these problems, it was previously assumed that children with ADHD would have lower self-confidence than those without (Hoza & Pelham, 1995; Slomkowski, Klein, & Mannuzza, 1995; Treuting & Hinshaw, 2001). However, researchers have recently discovered that children and adults with ADHD actually appear to have a positive illusory bias (PIB) toward themselves, meaning that they tend to rate themselves as higher functioning in social and academic situations than teachers, parents, and peers rate them (see Owens, Goldfine, Evangelista, Hoza, & Kaiser, 2007, for review). Similarly, when comparing objective measures of these domains with their self-reports, ADHD children’s self-perception is usually an overestimation of their actual performance (Hoza et al., 2000; Hoza et al., 2001; Manor et al., 2012). This phenomenon has been found in both genders (Hoza et al., 2004) and different ADHD subtypes (Swanson, Owens, & Hinshaw, 2012), and does not seem to improve in children who have received stimulant medication (Ialongo et al., 1994) and extensive behavioral therapy (Hoza et al., 2004). There is much dispute as to whether these positive illusions are adaptive or maladaptive in ADHD. Some studies
hypothesize that this positive illusion may be a protective strategy to help individuals persist during challenges and overcome frequent failures or setbacks (Diener & Milich, 1997; Hoza et al., 2004; Taylor & Brown, 1988). Contrary to this notion though, ADHD children with PIBs still have decreased motivation, persistence, and overall task performance compared with those without the disorder (Owens et al., 2007). Similarly, others argue that the positive illusions may be caused by cognitive immaturity (Milich, 1994), and will lead to poorer social skills and increased risk for negative outcomes later in life (Colvin, Block, & Funder, 1995; Hoza et al., 2004). Overestimation of competence in ADHD children is associated with increased aggression and less prosocial behavior (Hoza et al., 2010; Linnea, Hoza, & Tomb, 2012). Interestingly, McQuade et al. (2011) found that in ADHD-Combined Type and Hyperactive/Impulsive Type children, working memory, attention, and cognitive fluency were more likely to be impaired in children who
1
Austin Neuropsychology, PLLC, TX, USA University of Texas at Austin, USA
2
Corresponding Author: Melissa Bunner, Austin Neuropsychology, PLLC, 711 W. 38th St. F-2, Austin, TX 78705, USA. Email: [email protected]
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had positive illusions about their social competency relative to those without a positive bias. Despite the controversial question of whether PIBs are beneficial or maladaptive, the fact that it exists in ADHD children with regard to social, behavioral, and academic functioning has been well documented. However, it has not been looked at with regard to executive functioning (EF) even though this is a major area of weakness in those with the disorder (Barkley, 1997; Nigg, 2006). EF is a neuropsychological term that refers to a variety of higher-order thinking skills, such as planning, organization, attention, working memory, and inhibition (Martel, Nikolas, & Nigg, 2007). Welsh and Pennington (1989, p. 201) defined the construct as “the ability to maintain an appropriate problem set for attainment of future goals.” EF is an important skill for complex human behavior, and it has been found that ADHD children with impaired EF have poorer academic achievement and peer relationships (Biederman et al., 2004; Diamantopoulou, Rydell, Thorell, & Bohlin, 2007). If children and adolescents with ADHD have an inflated view of their EF skills, it could limit their ability to insightfully selfregulate their behavior and might hinder their receptiveness to behavioral interventions to improve their EF. The current study seeks to fill gaps in the ADHD selfperception and EF literature. This will be the first study to examine how ADHD children view their EF ability in relation to their parents’ estimates. We hypothesize that adolescents with ADHD will overestimate their EF ability more so than controls when comparing their self-reports with parent ratings.
Method Participants Participants between the ages of 11 and 16 years were recruited using archival data from a private neuropsychology clinic. In addition, a portion of the control participants were recruited from the greater community after contacting the clinic and completing a telephone screening to determine initial eligibility. Participants were included if they were free of neurological disease (e.g., epilepsy, clinically significant traumatic brain injury), major psychiatric illness (e.g., depression, anxiety, bipolar disorder), and developmental disorder (e.g., autism, mental retardation). To obtain a sufficient sample size, participants with learning disabilities (LDs) were not excluded from participation. LD inclusion was limited to those with dyslexia (n = 9), dyscalcula (n = 2), dysgraphia (n = 15), and LD−not otherwise specified (n = 4). For all participants, board-certified neuropsychologists used information from patient and parent interviews, developmental and family history questionnaires, and an extensive cognitive assessment battery to make diagnoses of ADHD and any other disorders using the Diagnostic and Statistical Manual of Mental Disorders
(4th ed.; DSM-IV; American Psychiatric Association, 1994) diagnostic criteria. After obtaining written informed consent, the final sample consisted of 35 adolescents with diagnoses of ADHD and 22 without an ADHD diagnosis. Of the ADHD children, 26 were diagnosed with Primary Inattentive subtype, 7 were diagnosed with Combined subtype, and 2 were diagnosed with ADHD−not otherwise specified. According to participants’ self-report, the ethnic distribution of the sample was as follows: 86% Caucasian (n = 49), 4% Hispanic (n = 2), 2% African American (n = 1), and 9% Other/did not specify (n = 5). All participants had a full-scale IQ (FSIQ) greater than 80, as measured by the Weschsler Intelligence Scale for Children-IV (WISC-IV) or the Weschler Abbreviated Intelligence Scale-II (WASI-II; Wechsler, 2003, 2011).
Materials The parent and self-report forms of the Behavior Rating Inventory of Executive Functioning (BRIEF; Gioia, Isquith, Guy, & Kenworthy, 2000) were administered during the clinical interview or delivered through the mail and returned at the time of the neuropsychology testing appointment. The BRIEF parent form (BRIEF-P) is an 86-item questionnaire that parents fill out based on their children’s behavior over the past 6 months. Each question is a short statement such as “Has a short attention span,” “Makes careless errors,” or “Reacts more strongly to situations than other children,” and the parent has to mark “never,” “sometimes,” or “always.” The BRIEF self-report (BRIEF-SR) is similarly designed, with 80 items that the child fills out about their own behavior over the past 6 months. According to the BRIEF manual, a fifth-grade reading level is sufficient to complete the form. To ensure a thorough understanding of the instructions and BRIEF questions, BRIEF-SRs were completed in the presence of examiner or guardian. For both forms, the BRIEF has been standardized and normed for the use of boys and girls within the age range of our sample, and for children with a variety of clinical diagnoses including ADHD. In accordance with standard procedures, normative data were separated by gender and age to derive T-scores for the clinical scales (Inhibit, Shift, Emotional Control, Working Memory, Plan/Organize, Organization of Materials, and Monitor). These scales were combined to form a Behavioral Regulation Index (BRI) and Metacognition Index (MI), as well as a composite summary score called the Global Executive Composite (GEC). With the BRIEF, higher T-scores indicate more subjective impairment. According to Gioia et al. (2000), the BRIEF has an internal consistency ranging from .80 to .98, as assessed using Cronbach’s alpha. Test−retest reliability statistics range from .79 to .88 during a 2-week period. The BRIEF is also reported to have good discriminant and convergent validity with similar measures (McCandless & O’Laughlin, 2007).
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Steward et al. Table 1. Participants’ Demographic Characteristics.
Male/female (n) Age (year) Education level (year) FSIQ On ADHD medication at time of testing (n) LD diagnosis
ADHD (n = 35)
Control (n = 22)
p value
26/9 12.91 ± 1.5 7.49 ± 1.5 107.29 ± 14.0 12 15
9/13 13.64 ± 1.6 8.23 ± 1.8 106.82 ± 14.5 1 7
.01* .09 .10 .90 — .41
Note. Data are M ± SD; FSIQ = full-scale IQ; LD = learning disability. *Significant at p < .05.
A discrepancy score for each clinical scale was calculated by subtracting the BRIEF-SR T-scores from the BRIEF-P T-scores for each participant. Positive scores indicate that the child reported fewer difficulties than parent reports. A negative discrepancy score signifies that the child reported more impairment than parent ratings. This method of obtaining discrepancy scores has been commonly used when studying PIBs in an ADHD population (Hoza et al., 2004; Hoza, Pelham, Dobbs, Owens, & Pillow, 2002; Owens et al., 2007).
Statistical Analyses Group differences in the demographic variables were examined with non-parametric chi-square or independent samples t tests. The normality of standardized residuals for the dependent variables was tested using Shapiro−Wilks tests (all p > .05). Bootstrapping procedures were utilized when parametric assumptions about the underlying distribution were not fulfilled (model residuals with Shapiro−Wilks p < .05). Group differences in the dependent variables were assessed using an analysis of covariance (ANCOVA), with gender used as a covariate. As a follow-up analysis, ADHD medication (yes/no), the presence of a learning disorder (yes/no), and WASI-II/WISC-IV FSIQ were added as additional covariates in the ANCOVA. To control for multiple comparisons, a Sidak-adjusted alpha level of p < .027 was used.
Results The demographic characteristics of the study sample are shown in Table 1. Ethnicity distribution, χ2(4, N = 57) = 2.642, p = .62, and LD distribution, χ2(4, N = 57) = .695, p = .41, in the ADHD and control groups was comparable. There were also no significant differences in age, education, and intelligence between the two groups. The only variable that significantly differed between the two groups was gender, χ2(1, N = 57) = 6.350, p = .01. Discrepancy score group differences are shown in Figure 1 and Table 2. In the overall ANCOVA model (Table 3), discrepancy scores for the BRIEF Inhibit, Shift, Emotional
Control, Monitor, Working Memory, Plan/Organization, BRI, MI, and GEC domains were all significantly more positive in the ADHD group as compared with the control group (p < .027). ADHD had a significant main effect on the Inhibit, Monitor, Working Memory, Plan/Organize, and GEC domains (p < .027). Gender contributed significantly to the Shift and BRI domains (p < .027), with males displaying greater discrepancy scores than females. Group differences in the discrepancy scores for the BRIEF Organization of Materials domain did not reach statistical significance (p > .027). These relationships remained unchanged even after additional adjustment for any potential effects of ADHD medication, the presence of a learning disorder, or FSIQ.
Discussion This study extends the literature on PIB in ADHD by being the first to examine self-perception of EF. The results demonstrate that, in comparison with age-matched controls, adolescents with ADHD tend to over-inflate abilities relative to their parents’ reports within the domains of Working Memory, Emotional Control, Attention and Behavior Shifting, Inhibition of Behavior, Self-Monitoring, and Planning and Organization of Future Events. Adolescents with ADHD also displayed greater discrepancy scores on the metacognition, behavioral regulation, and GEC domains. In contrast to large parent−child discrepancies in the ADHD group, the control group had only negligible or slightly negative discrepancy scores, meaning that these children rated themselves the same as or slightly more impaired than what parents reported. These findings support previous literature that has documented a PIB in ADHD children. Other studies have used similar methodology and found that those with ADHD overestimate academic and social functioning when compared with mother, father, teacher, and peer reports, as well as objective measures of these domains (Evangelista, Owens, Golden, & Pelham, 2008; Hoza et al., 2004; Hoza et al., 2002; Owens & Hoza, 2003). It is important to note that the subjective nature of the parents’ reports elicit the possibility that the large discrepancy scores may be in fact
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20
15
10 ADHD Control
5
0
-5
Figure 1. Mean discrepancy scores for each BRIEF domain.
Note. Discrepancy scores were calculated by subtracting self-reported BRIEF T-scores from the parent T-scores. As larger T-scores indicate more subjective impairment, positive discrepancy scores indicate that the parent reported more difficulties than the child did and vice versa. All domain discrepancy scores, except Organization of Materials, were significantly (p < .027) more positive in the ADHD adolescents compared with controls. BRIEF = Behavior Rating Inventory of Executive Functioning.
Table 2. Discrepancy Scores for the BRIEF Questionnaire.
Inhibit Shift Emotional Control Monitor Working Memory Plan/Organize Organization of Materials Behavior Regulation Index Metacognition Index Global Executive Composite
ADHD (n = 35)
Control (n = 22)
11.23 ± 14.8 6.31 ± 16.8 4.45 ± 15.2 17.06 ± 16.8 14.29 ± 13.4 13.5 ± 14.3 5.54 ± 13.1
−2.54 ± 11.7 0.72 ± 17.0 −3.09 ± 15.2 1.91 ± 15.8 1.41 ± 16.2 −0.64 ± 14.0 3.27 ± 12.7
9.00 ± 15.0
−1.82 ± 14.8
11.54 ± 15.9
−0.46 ± 15.43
12.5 ± 15.6
−0.91 ± 15.7
Note. Data are M ± SD. BRIEF = Behavior Rating Inventory of Executive Functioning.
due to a tendency for parents of ADHD children to rate their children in an excessively negative manner. We attempted to control for this by excluding participants who had an elevated Negativity validity scale on the BRIEF-P forms. To definitively rule out the potential for inaccurate parent reports, future studies should compare child self-reports with objective measures of EF.
One of the strengths of this study is that it incorporated both genders and assessed the contribution of gender to self-awareness of deficits in those with ADHD. The majority of previous studies have failed to include females, and when they did, gender effects were not explored (Owens & Hoza, 2003). The current study used gender as a covariate and found that males are more likely to overestimate their ability to shift their attention and behavior than females. As the current study had significantly different gender ratios between the ADHD and control groups, future studies should incorporate more gender-balanced groups to further assess the impact that gender may have on self-perception of EF in an ADHD population. Of note, discrepancy scores in the Organization of Materials domain were not significantly different between groups. There are several possible reasons that this was the only domain to not reach significance. First, this domain assesses the organization of the child’s environment, such as the level of disorganization of their schoolbags and how frequently they misplace items like homework. As these are more external behaviors as opposed to the Plan/Organize domain, which assesses organization on a more cognitive level, it is probable that these difficulties are brought to the child’s attention more frequently. This would likely create a better sense of self-awareness of this particular area of difficulty. Secondly, this domain had a low number of questions in the parent and self-report forms; therefore, there is
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Steward et al. Table 3. Results From ANCOVA Model Examining the Effects of ADHD and Gender on BRIEF Domain Discrepancy Scores.
Inhibit Shift Emotional Control Monitor Working Memory Plan/Organize Organization of Materials Behavior Regulation Index Metacognition Index Global Executive Composite
Overall model (F value)
Overall model (p value)
ADHD (p value)
Gender (p value)
9.599 4.053 3.584 5.844 5.979 6.657 1.983 6.796 4.922 7.245
.000* .023* .035* .005* .005* .003* .148 .002* .011* .002*
.006* .727 .269 .004* .009* .002* .995 .074 .032 .020*
.034 .014* .060 .547 .262 .785 .066 .019* .177 .052
*Significant at p < .027. BRIEF = Behavior Rating Inventory of Executive Functioning.
a more restricted range of possible total scores. This makes it more difficult for a difference in discrepancy scores to become statistically significant, although there was a trend in the predicted direction (see Figure 1). Despite consistent evidence that children with ADHD lack self-awareness of their deficits, it is still highly debated as to why ADHD children overestimate their ability in so many areas. Owens et al. (2007) discussed four potential explanations for the PIB seen in ADHD children: neuropsychological and frontal lobe deficits leading to mild anosognosia (Owens & Hoza, 2003), an overall cognitive immaturity in ADHD children (Milich, 1994), ignorance of incompetence in the self and others (Hoza et al., 2002), and self-protection from personal failure (Ohan & Johnston, 2002). Very few studies have directly tested any of these hypotheses in relation to ADHD PIBs though, and this area of research remains divided on actual causes for the positive biases seen in children. It is possible that these hypotheses are not mutually exclusive, and one or more of them could contribute to the impaired selfawareness of children and adolescents with ADHD. There are many strengths to this study that allow it to uniquely contribute to the field, such as the inclusion of both genders and ADHD subtypes and the exclusion of comorbid psychiatric and behavioral disorders; however, there are also several limitations. The current study used a relatively small sample size that was largely homogeneous in terms of ethnicity. Future researchers should seek to include a more characteristic and larger sample, as well as expand to other age ranges to test developmental aspects of EF PIB. Another limitation was the source of the control group as some participants were selected from an archival database at a private neuropsychology clinic. These participants had been previously referred to the clinic for suspicions of neuropsychological impairment. Thus, it is possible that the clinic-referred non-ADHD group had more impairment than a control group of children not referred for clinical services. In an attempt to lessen the impact from this limitation, strict exclusion criteria was applied and only
those with no diagnoses of psychiatric, medical, neurologic, and developmental disorders were enrolled. To further address this limitation, control participants were additionally recruited from the general community and required to undergo a telephone screening prior to participation to rule out suspicions of ADHD and other exclusionary criteria. The findings of this study support the ADHD PIB research and expand the number of documented domains that ADHD children hold positive illusions about (Owens et al., 2007). These results hold significance not only for other researchers in the field, but also for caregivers and clinicians who provide EF treatment to adolescents with ADHD. In populations with neurological injuries and psychiatric disorders, impaired self-awareness has been found to lead to low motivation and participation in rehabilitation efforts (Katz, Fleming, Keren, Lightbody, & Hartman-Maeir, 2002; Lam, McMahon, Priddy, & Gehred-Schultz, 1988). Similarly, if ADHD children do not believe they suffer from EF impairment, they may be less receptive to treatment for these deficits. Clinicians should be aware that an EF PIB might exist in ADHD children and incorporate this knowledge when providing therapy. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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Barkley, R. A. (1997). Behavioral inhibition, sustained attention and executive functions: Constructing a unifying theory of ADHD. Psychological Bulletin, 121, 65-94. Biederman, J., Monuteaux, M., Doyle, A., Seidman, L., Wilens, T., & Faraone, S. (2004). Impact of executive function deficits and attention-deficit/hyperactive disorder (ADHD) on academic outcomes in children. Journal of Consulting and Clinical Psychology, 72, 757-766. Colvin, C., Block, J., & Funder, D. (1995). Overly positive selfevaluations and personality: Negative implications for mental health. Journal of Personality and Social Psychology, 68, 1152-1162. Diamantopoulou, S., Rydell, A., Thorell, L., & Bohlin, G. (2007). Impact of executive functioning and symptoms of attention deficit hyperactivity disorder on children’s peer relations and school performance. Developmental Neuropsychology, 32, 521-542. Diener, M. B., & Milich, R. (1997). Effects of positive feedback on the social interactions of boys with attention deficit hyperactivity disorder: A test of the self-protective hypothesis. Journal of Clinical Child Psychology, 26, 256-265. Evangelista, N., Owens, J., Golden, C., & Pelham, W. (2008). Positive illusory bias: Do inflated self-perceptions in children with ADHD generalize to perceptions of others? Journal of Abnormal Child Psychology, 36, 779-791. Gioia, G. A., Isquith, P. K., Guy, S. C., & Kenworthy, L. (2000). Behavior Rating Inventory of Executive Function. Odessa, FL: Psychological Assessment Resources. Hoza, B., Gerdes, A. C., Hinshaw, S. P., Arnold, E. L., Pelham, W. E., Molina, B. S. G., . . .Wigal, T. (2004). Self-perceptions of competence in children with ADHD and comparison children. Journal of Consulting and Clinical Psychology, 72, 382-391. Hoza, B., Murray-Close, D., Arnold, L., Hinshaw, S., & Hechtman, L. (2010). Time-dependent changes in positively biased selfperceptions of children with ADHD: A developmental psychopathology persepective. Developmental Pscyhopathology, 22(2), 375-390. Hoza, B., & Pelham, W. E. (1995). Social-cognitive predictors of treatment response in children with ADHD. Journal of Social & Clinical Psychology, 14, 23-35. Hoza, B., Pelham, W. E., Dobbs, J., Owens, J. S., & Pillow, D. R. (2002). Do boys with attention deficit/hyperactivity disorder have positive illusory self-concepts? Journal of Abnormal Psychology, 111, 268-278. Hoza, B., Pelham, W. E., Waschbusch, D. A., Kipp, H., & Owens, J. S. (2001). Academic task persistence of normally achieving ADHD and control boys: Performance, self-evaluations, and attributions. Journal of Consulting and Clinical Psychology, 69, 271-283. Hoza, B., Waschbusch, D. A., Pelham, W. E., Molina, B. S. G., & Milich, R. (2000). Attention-deficit/hyperactivity disordered and control boys’ responses to social success and failure. Child Development, 71, 432-446. Ialongo, N., Lopez, M., Horn, W., Pascoe, J., & Greenberg, G. (1994). Effects of psychostimulant medication on selfperceptions of competence, control, and mood in children with attention deficit hyperactivity disorder. Journal of Clinical Child Psychology, 23, 161-173. Katz, N., Fleming, J., Keren, N., Lightbody, S., & HartmanMaeir, A. (2002). Unawareness and/or denial of disability:
Implications for occupational therapy intervention. Canadian Journal of Occupational Therapy, 69, 281-292. Lam, C., McMahon, B., Priddy, D., & Gehred-Schultz, A. (1988). Deficit awareness and treatment performance among traumatic head injury adults. Brain Injury, 2, 235-242. LeFever, G. B., Villers, M. S., & Morrow, A. L. (2002). Parental perceptions of adverse educational outcomes among children diagnosed and treated for ADHD: A call for improved school/ provider collaboration. Psychology in the Schools, 39, 63-71. Linnea, K., Hoza, B., & Tomb, M. (2012). Does a positive bias relate to social behavior in children with ADHD? Behavior Therapy, 43, 82-875. Manor, I., Vurembrandt, N., Rozen, S., Gevah, D., Weizman, A., & Zalsman, G. (2012). Low self-awareness of ADHD in adults using a Self-Report Screening Questionnaire. European Psychiatry, 27, 314-320. Martel, M., Nikolas, N., & Nigg, J. T. (2007). Executive functioning in adolescents with ADHD. Journal of the American Academy of Child & Adolescent Psychiatry, 46, 1437-1444. McCandless, S., & O’Laughlin, L. (2007). Utility of the behavior rating inventory of executive function (BRIEF) in the diagnosis of ADHD. Journal of Attention Disorders, 10, 381-389. McQuade, J., Tomb, M., Hoza, B., Waschbusch, D., Hurt, E., & Vaughn, A. (2011). Cognitive deficits and positively biased self-perceptions in children with ADHD. Journal of Abnormal Child Psychology, 39, 307-319. Milich, R. (1994). The response of children with ADHD to failure: If at first you don’t succeed, do you try, try, again? School Psychology Review, 23, 11-28. Nigg, J. T. (2006). What causes ADHD? Understanding what goes wrong and why. New York, NY: Guilford Press. Ohan, J. L., & Johnston, C. (2002). Are the performance overestimates given by boys with ADHD self-protective? Journal of Clinical Child Psychology, 31, 230-241. Owens, J. S., Goldfine, M., Evangelista, N., Hoza, B., & Kaiser, N. (2007). A critical review of self-perceptions and the positive illusory bias in children with ADHD. Clinical Child Family Psychology Review, 10, 335-351. Owens, J. S., & Hoza, B. (2003). The role of inattention and hyperactivity/impulsivity in the positive illusory bias. Journal of Consulting and Clinical Psychology, 71, 680-691. Pelham, W. E., & Bender, M. E. (1982). Peer relationships in hyperactive children: Description, treatment. In K. D. Gadow & I. Bialer (Eds.), Advances in learning and behavioral disabilities (pp. 366-436). Greenwich, CT: JAI Press. Slomkowski, C., Klein, R. G., & Mannuzza, S. (1995). Is selfesteem an important outcome in hyperactive children? Journal of Abnormal Child Psychology, 23, 303-315. Swanson, E., Owens, E., & Hinshaw, S. (2012). Is the positive illusory bias illusory? Examining discrepant self-perceptions of competence in girls with ADHD. Journal of Abnormal Child Psychology, 40, 987-998. Taylor, S. E., & Brown, J. D. (1988). Illusion and well-being: A social psychological perspective on mental health. Psychological Bulletin, 103, 193-210. Treuting, J. J., & Hinshaw, S. P. (2001). Depression and selfesteem in boys with attention-deficit/hyperactivity disorder: Associations with comorbid aggression and explanatory attributional mechanisms. Journal of Abnormal Child Psychology, 29, 23-29.
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Steward et al. Wechsler, D. (2003). Wechsler Intelligence Scale for Children– Fourth edition. San Antonio, TX: Psychological Corporation. Wechsler, D. (2011). Wechsler Abbreviated Scale of Intelligence– Second edition. San Antonio, TX: NCS Pearson. Welsh, M. C., & Pennington, B. F. (1989). Assessing frontal lobe functioning in children: Views from developmental psychology. Developmental Neuropsychology, 4, 199-230.
Alexander Tan, BA, is a psychometrist at Austin Neuropsychology, PLLC, and a research assistant at the University of Texas at Austin. Lauren Delgaty, MA, is a former psychometrist at Austin Neuropsychology, PLLC, and is now employed in North Carolina.
Author Biographies
Mitzi M. Gonzales, MA, is a doctoral candidate in clinical psychology at the University of Texas at Austin.
Kayla A. Steward, BS, is a psychometrist at Austin Neuropsychology, PLLC, and a research assistant at the University of Texas at Austin.
Melissa Bunner, PhD, is a neuropsychologist at Austin Neuropsychology, PLLC.
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Self-Awareness of Executive Functioning Deficits in Adolescents With ADHD Kayla A. Steward, Alexander Tan, Lauren Delgaty, Mitzi M. Gonzales and Melissa Bunner Journal of Attention Disorders published online 5 May 2014 DOI: 10.1177/1087054714530782 The online version of this article can be found at: http://jad.sagepub.com/content/early/2014/05/03/1087054714530782
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Self-Awareness of Executive Functioning Deficits in Adolescents With ADHD
Journal of Attention Disorders 1–7 © 2014 SAGE Publications Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1087054714530782 jad.sagepub.com
Kayla A. Steward1,2, Alexander Tan1,2, Lauren Delgaty1, Mitzi M. Gonzales2, and Melissa Bunner1,2
Abstract Objective: Children with ADHD lack self-awareness of their social and academic deficits, frequently rating themselves more favorably than external sources. The purpose of the current study was to assess whether adolescents with ADHD also hold a positive bias toward their executive functioning (EF). Method: Participants include 22 control and 35 ADHD subjects, aged 11 to 16. Participants and their parents completed the Behavior Rating Inventory of Executive Functioning (BRIEF) Self and Parent forms, respectively. Discrepancy scores were calculated for each domain by subtracting the adolescents’ T-score from the parents’ T-score. Results: Discrepancy scores were significantly higher in the ADHD group than controls within the Inhibit, Shift, Monitor, Emotional Control, Working Memory, and Plan/Organization domains (all p < .05). Conclusion: As compared with controls, adolescents with ADHD tend to endorse fewer EF difficulties than what parents report. This is the first study to demonstrate that those with ADHD may overestimate their EF ability. ( J. of Att. Dis. XXXX; XX(X) XX-XX) Keywords adolescent ADHD, BRIEF, executive function, self-report
ADHD is one of the most common childhood neuropsychological disorders, causing difficulties in academic, social, emotional, and behavioral domains (Barkley, 1990; LeFever, Villers, & Morrow, 2002; Pelham & Bender, 1982). Due to these problems, it was previously assumed that children with ADHD would have lower self-confidence than those without (Hoza & Pelham, 1995; Slomkowski, Klein, & Mannuzza, 1995; Treuting & Hinshaw, 2001). However, researchers have recently discovered that children and adults with ADHD actually appear to have a positive illusory bias (PIB) toward themselves, meaning that they tend to rate themselves as higher functioning in social and academic situations than teachers, parents, and peers rate them (see Owens, Goldfine, Evangelista, Hoza, & Kaiser, 2007, for review). Similarly, when comparing objective measures of these domains with their self-reports, ADHD children’s self-perception is usually an overestimation of their actual performance (Hoza et al., 2000; Hoza et al., 2001; Manor et al., 2012). This phenomenon has been found in both genders (Hoza et al., 2004) and different ADHD subtypes (Swanson, Owens, & Hinshaw, 2012), and does not seem to improve in children who have received stimulant medication (Ialongo et al., 1994) and extensive behavioral therapy (Hoza et al., 2004). There is much dispute as to whether these positive illusions are adaptive or maladaptive in ADHD. Some studies
hypothesize that this positive illusion may be a protective strategy to help individuals persist during challenges and overcome frequent failures or setbacks (Diener & Milich, 1997; Hoza et al., 2004; Taylor & Brown, 1988). Contrary to this notion though, ADHD children with PIBs still have decreased motivation, persistence, and overall task performance compared with those without the disorder (Owens et al., 2007). Similarly, others argue that the positive illusions may be caused by cognitive immaturity (Milich, 1994), and will lead to poorer social skills and increased risk for negative outcomes later in life (Colvin, Block, & Funder, 1995; Hoza et al., 2004). Overestimation of competence in ADHD children is associated with increased aggression and less prosocial behavior (Hoza et al., 2010; Linnea, Hoza, & Tomb, 2012). Interestingly, McQuade et al. (2011) found that in ADHD-Combined Type and Hyperactive/Impulsive Type children, working memory, attention, and cognitive fluency were more likely to be impaired in children who
1
Austin Neuropsychology, PLLC, TX, USA University of Texas at Austin, USA
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Corresponding Author: Melissa Bunner, Austin Neuropsychology, PLLC, 711 W. 38th St. F-2, Austin, TX 78705, USA. Email: [email protected]
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had positive illusions about their social competency relative to those without a positive bias. Despite the controversial question of whether PIBs are beneficial or maladaptive, the fact that it exists in ADHD children with regard to social, behavioral, and academic functioning has been well documented. However, it has not been looked at with regard to executive functioning (EF) even though this is a major area of weakness in those with the disorder (Barkley, 1997; Nigg, 2006). EF is a neuropsychological term that refers to a variety of higher-order thinking skills, such as planning, organization, attention, working memory, and inhibition (Martel, Nikolas, & Nigg, 2007). Welsh and Pennington (1989, p. 201) defined the construct as “the ability to maintain an appropriate problem set for attainment of future goals.” EF is an important skill for complex human behavior, and it has been found that ADHD children with impaired EF have poorer academic achievement and peer relationships (Biederman et al., 2004; Diamantopoulou, Rydell, Thorell, & Bohlin, 2007). If children and adolescents with ADHD have an inflated view of their EF skills, it could limit their ability to insightfully selfregulate their behavior and might hinder their receptiveness to behavioral interventions to improve their EF. The current study seeks to fill gaps in the ADHD selfperception and EF literature. This will be the first study to examine how ADHD children view their EF ability in relation to their parents’ estimates. We hypothesize that adolescents with ADHD will overestimate their EF ability more so than controls when comparing their self-reports with parent ratings.
Method Participants Participants between the ages of 11 and 16 years were recruited using archival data from a private neuropsychology clinic. In addition, a portion of the control participants were recruited from the greater community after contacting the clinic and completing a telephone screening to determine initial eligibility. Participants were included if they were free of neurological disease (e.g., epilepsy, clinically significant traumatic brain injury), major psychiatric illness (e.g., depression, anxiety, bipolar disorder), and developmental disorder (e.g., autism, mental retardation). To obtain a sufficient sample size, participants with learning disabilities (LDs) were not excluded from participation. LD inclusion was limited to those with dyslexia (n = 9), dyscalcula (n = 2), dysgraphia (n = 15), and LD−not otherwise specified (n = 4). For all participants, board-certified neuropsychologists used information from patient and parent interviews, developmental and family history questionnaires, and an extensive cognitive assessment battery to make diagnoses of ADHD and any other disorders using the Diagnostic and Statistical Manual of Mental Disorders
(4th ed.; DSM-IV; American Psychiatric Association, 1994) diagnostic criteria. After obtaining written informed consent, the final sample consisted of 35 adolescents with diagnoses of ADHD and 22 without an ADHD diagnosis. Of the ADHD children, 26 were diagnosed with Primary Inattentive subtype, 7 were diagnosed with Combined subtype, and 2 were diagnosed with ADHD−not otherwise specified. According to participants’ self-report, the ethnic distribution of the sample was as follows: 86% Caucasian (n = 49), 4% Hispanic (n = 2), 2% African American (n = 1), and 9% Other/did not specify (n = 5). All participants had a full-scale IQ (FSIQ) greater than 80, as measured by the Weschsler Intelligence Scale for Children-IV (WISC-IV) or the Weschler Abbreviated Intelligence Scale-II (WASI-II; Wechsler, 2003, 2011).
Materials The parent and self-report forms of the Behavior Rating Inventory of Executive Functioning (BRIEF; Gioia, Isquith, Guy, & Kenworthy, 2000) were administered during the clinical interview or delivered through the mail and returned at the time of the neuropsychology testing appointment. The BRIEF parent form (BRIEF-P) is an 86-item questionnaire that parents fill out based on their children’s behavior over the past 6 months. Each question is a short statement such as “Has a short attention span,” “Makes careless errors,” or “Reacts more strongly to situations than other children,” and the parent has to mark “never,” “sometimes,” or “always.” The BRIEF self-report (BRIEF-SR) is similarly designed, with 80 items that the child fills out about their own behavior over the past 6 months. According to the BRIEF manual, a fifth-grade reading level is sufficient to complete the form. To ensure a thorough understanding of the instructions and BRIEF questions, BRIEF-SRs were completed in the presence of examiner or guardian. For both forms, the BRIEF has been standardized and normed for the use of boys and girls within the age range of our sample, and for children with a variety of clinical diagnoses including ADHD. In accordance with standard procedures, normative data were separated by gender and age to derive T-scores for the clinical scales (Inhibit, Shift, Emotional Control, Working Memory, Plan/Organize, Organization of Materials, and Monitor). These scales were combined to form a Behavioral Regulation Index (BRI) and Metacognition Index (MI), as well as a composite summary score called the Global Executive Composite (GEC). With the BRIEF, higher T-scores indicate more subjective impairment. According to Gioia et al. (2000), the BRIEF has an internal consistency ranging from .80 to .98, as assessed using Cronbach’s alpha. Test−retest reliability statistics range from .79 to .88 during a 2-week period. The BRIEF is also reported to have good discriminant and convergent validity with similar measures (McCandless & O’Laughlin, 2007).
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Steward et al. Table 1. Participants’ Demographic Characteristics.
Male/female (n) Age (year) Education level (year) FSIQ On ADHD medication at time of testing (n) LD diagnosis
ADHD (n = 35)
Control (n = 22)
p value
26/9 12.91 ± 1.5 7.49 ± 1.5 107.29 ± 14.0 12 15
9/13 13.64 ± 1.6 8.23 ± 1.8 106.82 ± 14.5 1 7
.01* .09 .10 .90 — .41
Note. Data are M ± SD; FSIQ = full-scale IQ; LD = learning disability. *Significant at p < .05.
A discrepancy score for each clinical scale was calculated by subtracting the BRIEF-SR T-scores from the BRIEF-P T-scores for each participant. Positive scores indicate that the child reported fewer difficulties than parent reports. A negative discrepancy score signifies that the child reported more impairment than parent ratings. This method of obtaining discrepancy scores has been commonly used when studying PIBs in an ADHD population (Hoza et al., 2004; Hoza, Pelham, Dobbs, Owens, & Pillow, 2002; Owens et al., 2007).
Statistical Analyses Group differences in the demographic variables were examined with non-parametric chi-square or independent samples t tests. The normality of standardized residuals for the dependent variables was tested using Shapiro−Wilks tests (all p > .05). Bootstrapping procedures were utilized when parametric assumptions about the underlying distribution were not fulfilled (model residuals with Shapiro−Wilks p < .05). Group differences in the dependent variables were assessed using an analysis of covariance (ANCOVA), with gender used as a covariate. As a follow-up analysis, ADHD medication (yes/no), the presence of a learning disorder (yes/no), and WASI-II/WISC-IV FSIQ were added as additional covariates in the ANCOVA. To control for multiple comparisons, a Sidak-adjusted alpha level of p < .027 was used.
Results The demographic characteristics of the study sample are shown in Table 1. Ethnicity distribution, χ2(4, N = 57) = 2.642, p = .62, and LD distribution, χ2(4, N = 57) = .695, p = .41, in the ADHD and control groups was comparable. There were also no significant differences in age, education, and intelligence between the two groups. The only variable that significantly differed between the two groups was gender, χ2(1, N = 57) = 6.350, p = .01. Discrepancy score group differences are shown in Figure 1 and Table 2. In the overall ANCOVA model (Table 3), discrepancy scores for the BRIEF Inhibit, Shift, Emotional
Control, Monitor, Working Memory, Plan/Organization, BRI, MI, and GEC domains were all significantly more positive in the ADHD group as compared with the control group (p < .027). ADHD had a significant main effect on the Inhibit, Monitor, Working Memory, Plan/Organize, and GEC domains (p < .027). Gender contributed significantly to the Shift and BRI domains (p < .027), with males displaying greater discrepancy scores than females. Group differences in the discrepancy scores for the BRIEF Organization of Materials domain did not reach statistical significance (p > .027). These relationships remained unchanged even after additional adjustment for any potential effects of ADHD medication, the presence of a learning disorder, or FSIQ.
Discussion This study extends the literature on PIB in ADHD by being the first to examine self-perception of EF. The results demonstrate that, in comparison with age-matched controls, adolescents with ADHD tend to over-inflate abilities relative to their parents’ reports within the domains of Working Memory, Emotional Control, Attention and Behavior Shifting, Inhibition of Behavior, Self-Monitoring, and Planning and Organization of Future Events. Adolescents with ADHD also displayed greater discrepancy scores on the metacognition, behavioral regulation, and GEC domains. In contrast to large parent−child discrepancies in the ADHD group, the control group had only negligible or slightly negative discrepancy scores, meaning that these children rated themselves the same as or slightly more impaired than what parents reported. These findings support previous literature that has documented a PIB in ADHD children. Other studies have used similar methodology and found that those with ADHD overestimate academic and social functioning when compared with mother, father, teacher, and peer reports, as well as objective measures of these domains (Evangelista, Owens, Golden, & Pelham, 2008; Hoza et al., 2004; Hoza et al., 2002; Owens & Hoza, 2003). It is important to note that the subjective nature of the parents’ reports elicit the possibility that the large discrepancy scores may be in fact
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15
10 ADHD Control
5
0
-5
Figure 1. Mean discrepancy scores for each BRIEF domain.
Note. Discrepancy scores were calculated by subtracting self-reported BRIEF T-scores from the parent T-scores. As larger T-scores indicate more subjective impairment, positive discrepancy scores indicate that the parent reported more difficulties than the child did and vice versa. All domain discrepancy scores, except Organization of Materials, were significantly (p < .027) more positive in the ADHD adolescents compared with controls. BRIEF = Behavior Rating Inventory of Executive Functioning.
Table 2. Discrepancy Scores for the BRIEF Questionnaire.
Inhibit Shift Emotional Control Monitor Working Memory Plan/Organize Organization of Materials Behavior Regulation Index Metacognition Index Global Executive Composite
ADHD (n = 35)
Control (n = 22)
11.23 ± 14.8 6.31 ± 16.8 4.45 ± 15.2 17.06 ± 16.8 14.29 ± 13.4 13.5 ± 14.3 5.54 ± 13.1
−2.54 ± 11.7 0.72 ± 17.0 −3.09 ± 15.2 1.91 ± 15.8 1.41 ± 16.2 −0.64 ± 14.0 3.27 ± 12.7
9.00 ± 15.0
−1.82 ± 14.8
11.54 ± 15.9
−0.46 ± 15.43
12.5 ± 15.6
−0.91 ± 15.7
Note. Data are M ± SD. BRIEF = Behavior Rating Inventory of Executive Functioning.
due to a tendency for parents of ADHD children to rate their children in an excessively negative manner. We attempted to control for this by excluding participants who had an elevated Negativity validity scale on the BRIEF-P forms. To definitively rule out the potential for inaccurate parent reports, future studies should compare child self-reports with objective measures of EF.
One of the strengths of this study is that it incorporated both genders and assessed the contribution of gender to self-awareness of deficits in those with ADHD. The majority of previous studies have failed to include females, and when they did, gender effects were not explored (Owens & Hoza, 2003). The current study used gender as a covariate and found that males are more likely to overestimate their ability to shift their attention and behavior than females. As the current study had significantly different gender ratios between the ADHD and control groups, future studies should incorporate more gender-balanced groups to further assess the impact that gender may have on self-perception of EF in an ADHD population. Of note, discrepancy scores in the Organization of Materials domain were not significantly different between groups. There are several possible reasons that this was the only domain to not reach significance. First, this domain assesses the organization of the child’s environment, such as the level of disorganization of their schoolbags and how frequently they misplace items like homework. As these are more external behaviors as opposed to the Plan/Organize domain, which assesses organization on a more cognitive level, it is probable that these difficulties are brought to the child’s attention more frequently. This would likely create a better sense of self-awareness of this particular area of difficulty. Secondly, this domain had a low number of questions in the parent and self-report forms; therefore, there is
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Steward et al. Table 3. Results From ANCOVA Model Examining the Effects of ADHD and Gender on BRIEF Domain Discrepancy Scores.
Inhibit Shift Emotional Control Monitor Working Memory Plan/Organize Organization of Materials Behavior Regulation Index Metacognition Index Global Executive Composite
Overall model (F value)
Overall model (p value)
ADHD (p value)
Gender (p value)
9.599 4.053 3.584 5.844 5.979 6.657 1.983 6.796 4.922 7.245
.000* .023* .035* .005* .005* .003* .148 .002* .011* .002*
.006* .727 .269 .004* .009* .002* .995 .074 .032 .020*
.034 .014* .060 .547 .262 .785 .066 .019* .177 .052
*Significant at p < .027. BRIEF = Behavior Rating Inventory of Executive Functioning.
a more restricted range of possible total scores. This makes it more difficult for a difference in discrepancy scores to become statistically significant, although there was a trend in the predicted direction (see Figure 1). Despite consistent evidence that children with ADHD lack self-awareness of their deficits, it is still highly debated as to why ADHD children overestimate their ability in so many areas. Owens et al. (2007) discussed four potential explanations for the PIB seen in ADHD children: neuropsychological and frontal lobe deficits leading to mild anosognosia (Owens & Hoza, 2003), an overall cognitive immaturity in ADHD children (Milich, 1994), ignorance of incompetence in the self and others (Hoza et al., 2002), and self-protection from personal failure (Ohan & Johnston, 2002). Very few studies have directly tested any of these hypotheses in relation to ADHD PIBs though, and this area of research remains divided on actual causes for the positive biases seen in children. It is possible that these hypotheses are not mutually exclusive, and one or more of them could contribute to the impaired selfawareness of children and adolescents with ADHD. There are many strengths to this study that allow it to uniquely contribute to the field, such as the inclusion of both genders and ADHD subtypes and the exclusion of comorbid psychiatric and behavioral disorders; however, there are also several limitations. The current study used a relatively small sample size that was largely homogeneous in terms of ethnicity. Future researchers should seek to include a more characteristic and larger sample, as well as expand to other age ranges to test developmental aspects of EF PIB. Another limitation was the source of the control group as some participants were selected from an archival database at a private neuropsychology clinic. These participants had been previously referred to the clinic for suspicions of neuropsychological impairment. Thus, it is possible that the clinic-referred non-ADHD group had more impairment than a control group of children not referred for clinical services. In an attempt to lessen the impact from this limitation, strict exclusion criteria was applied and only
those with no diagnoses of psychiatric, medical, neurologic, and developmental disorders were enrolled. To further address this limitation, control participants were additionally recruited from the general community and required to undergo a telephone screening prior to participation to rule out suspicions of ADHD and other exclusionary criteria. The findings of this study support the ADHD PIB research and expand the number of documented domains that ADHD children hold positive illusions about (Owens et al., 2007). These results hold significance not only for other researchers in the field, but also for caregivers and clinicians who provide EF treatment to adolescents with ADHD. In populations with neurological injuries and psychiatric disorders, impaired self-awareness has been found to lead to low motivation and participation in rehabilitation efforts (Katz, Fleming, Keren, Lightbody, & Hartman-Maeir, 2002; Lam, McMahon, Priddy, & Gehred-Schultz, 1988). Similarly, if ADHD children do not believe they suffer from EF impairment, they may be less receptive to treatment for these deficits. Clinicians should be aware that an EF PIB might exist in ADHD children and incorporate this knowledge when providing therapy. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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Alexander Tan, BA, is a psychometrist at Austin Neuropsychology, PLLC, and a research assistant at the University of Texas at Austin. Lauren Delgaty, MA, is a former psychometrist at Austin Neuropsychology, PLLC, and is now employed in North Carolina.
Author Biographies
Mitzi M. Gonzales, MA, is a doctoral candidate in clinical psychology at the University of Texas at Austin.
Kayla A. Steward, BS, is a psychometrist at Austin Neuropsychology, PLLC, and a research assistant at the University of Texas at Austin.
Melissa Bunner, PhD, is a neuropsychologist at Austin Neuropsychology, PLLC.
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