Delis-Kaplan Executive Function System Performance as

Measure of Executive Dysfunction in

Adult ADHD

Thad Q. Lloyd

A dissertation submitted to the faculty of

Brigham Young University
In partial fulfillment of the requirements for the degree of

Doctor of Philosophy

Erin D. Bigler, Ph.D., ABPP, Chair

Bruce N. Carpenter, Ph.D.
M. Gawain Wells Ph.D.
Mark D. Allen, Ph.D.
Patrick Steffen, Ph.D.

Department of Psychology

Brigham Young University

December 2010

Copyright © [2010] [Thad Lloyd]

All Rights Reserved

 
 
  
 

Abstract

Delis-Kaplan Executive Function System Performance as

Measure of Executive Dysfunction in

Adult ADHD

Thad Q. Lloyd

Department of Psychology

Doctor of Philosophy

The evidence suggesting Attention-Deficit/Hyperactivity Disorder (ADHD) has

neurodevelopmental roots with specific impairment in executive functioning continues to grow.
However, no known study to date has explored the relationship between adult males with a
diagnosis of ADHD and performance on a measure of executive functioning, the Delis-Kaplan
Executive Function System (DKEFS). The current investigation attempted to explore (1)
whether adult males with ADHD show an overall pattern of executive dysfunction as measured
by the DKEFS, (2) potential group differences on both level-of-performance and process-
oriented measure scores, and (3) the clinical utility of the DKEFS in diagnosing ADHD in adult
males. A sample of 37 adults with ADHD was compared to a community sample of equal size.
Multivariate statistical analysis yielded significant group differences despite intellectual
advantage by the study group. In addition, analysis of individual measures revealed patterns
which were not initially predicted based upon current theories of ADHD. Overall, however, no
clinically significant impairments emerged, as defined by scores at least one standard deviation
below the mean. These findings and potential clinical implications are discussed with
recommendations for future research.

Keywords: Delis-Kaplan Executive Function System, ADHD, DKEFS, Executive Dysfunction

 
 
  
 

Acknowledgements

The author wishes to acknowledge several individuals that made the current study possible.

First, I wish to express appreciation to Erin Bigler, Ph.D., ABPP who provided the necessary

guidance to me to undertake this project and never lost faith in the final outcome. I am also

deeply indebted to my friend and colleague, Rory Reid, Ph.D., who first provided the idea of the

study and then provided a large portion of the resources (subjects and material) used in the data

collection. Without your generous contributions the project would still likely be ongoing. I wish

to also give thanks to my parents, and father in particular. While at the time I didn’t appreciated

the repeated phone calls and constant nagging to “work on it,” in part the completion of this

work was because of your encouragement and reassurance. Finally, I must give appreciation to

my wife and daughters, who for the most part, had the most difficult role to play as they endured

the thousands of hours in which I was absent and valiantly dealt with the emotional shockwaves

through the whole process. Your vocalized and silent support and strength made the entire

journey possible. Can you believe that after 6 long years it is finally over? Thank you my love

and my dear darling girls, your husband and father is finally coming home!

 
 
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Table of Contents

Table of Contents ........................................................................................................................... iv

List of Tables ................................................................................................................................. vi

List of Figures ............................................................................................................................... vii

Introduction ......................................................................................................................................1

Attention-Deficit Hyperactivity Disorder ........................................................................................1

Overview of ADHD .........................................................................................................................1

Neuroimaging and Anatomy of ADHD ...........................................................................................6

Executive Function ........................................................................................................................11

ADHD and Executive Function .....................................................................................................17

Delis-Kaplan Executive Function System .....................................................................................24

Trail Making Test ..............................................................................................................24

Verbal Fluency Test ...........................................................................................................25

Design Fluency Test ..........................................................................................................25

Color-Word Interference Test ............................................................................................25

Sorting Test ........................................................................................................................26

Twenty Questions Test ......................................................................................................26

Tower Test .........................................................................................................................27

Proverb Test .......................................................................................................................27

Word-Context Test.............................................................................................................27

Purpose of study.............................................................................................................................28

Research hypothesis .......................................................................................................................30

Hypothesis I .......................................................................................................................30

 
 
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Hypothesis II ......................................................................................................................30

Objective ............................................................................................................................31

Method ...........................................................................................................................................31

Participants .....................................................................................................................................31

Procedure .......................................................................................................................................34

Measures ........................................................................................................................................35

DKEFS ...............................................................................................................................35

WASI .................................................................................................................................35

Statistical Approach .......................................................................................................................36

Results ............................................................................................................................................38

Discussion ......................................................................................................................................44

Limitations .....................................................................................................................................55

Recommendations ..........................................................................................................................57

Conclusions ....................................................................................................................................60

References ......................................................................................................................................62

 
 
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List of Tables

Table 1 Child/Adolescent Neuroimaging Studies ............................................................................9

Table 2 Imaging Studies of Adult ADHD .......................................................................................12

Table 3 Common Neuropsychological Tests of Executive Function .............................................15

Table 4 Summary of Studies Reporting Neuropsychological Performance of ADHD Adults .......19

Table 5 Anatomical Correlates of D-KEFS Subtests .....................................................................29

Table 6 Group Differences Among DKEFS Scores .......................................................................40

Table 7 Group Differences Among DKEFS Scores with Outliers Removed .................................43

 
 
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List of Figures

Figure 1 Major Anatomical Regions of the Frontal Lobes ..............................................................8

Figure 2 Interconnections of Prefrontal Cortical Regions ............................................................18

Figure 3 Sample of Common Sequencing Error: TMT 5 ...............................................................46

 
 
 1

Delis-Kaplan Executive Function System Performance as Measure of

Executive Dysfunction in Adult ADHD

Attention-Deficit Hyperactivity Disorder

Attention-Deficit/Hyperactivity Disorder (ADHD) is one of the most frequently studied

and debated diagnostic categories (Rohde et al., 2005). Currently the etiology and

developmental course of the disorder continues to be a pressing issue within the field. While

psychosocial theories of the disorder persist, consensus is that ADHD has a

neurolodevelopmental basis (Sonuga-Barke, 2005). Increasing evidence is linking core

components of ADHD symptomatology to particular structures in the brain, specifically

implicating the frontal cortices (Giedd, Blumenthal, Molloy, & Castellanos, 2001; Schneider et

al., 2010, Stahl, 2009). To date, much of what we know about the disorder has arisen from

observation and experimentation among child and adolescent populations, although what was

generally known as a childhood dysfunction is gaining credibility as an adult disorder

(Castellanos, Kelly, & Milham, 2009; Hervey, Epstein, & Curry, 2004). Despite these recent

advancements there is not a gold standard measure for assessing ADHD in the adult population,

although, as with the case of child/adolescent populations, the use of rating scales and

neuropsychological measures that assess executive function is common (Adler, 2010). Toward

that end the current study evaluated the utility of employing a test of executive functioning, the

Delis-Kaplan Executive Function System (DKEFS) in a specific subpopulation of adults with

ADHD.

Overview of ADHD

ADHD nosological origins are traced back to 1937 when Charles Bradley first began

evaluating hyperkinesis in children and noted that children taking Benzedrine manifested

 
 
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behavioral changes (Bradley, 1937). An associate of Bradley, Marice Laufer, used the term

minimal brain dysfunction to classify a group of children that manifested both a learning disorder

and the hyperkinetic impulse disorder in the presence of average to above average intelligence

(Wenar, 1994). Since that time, several different diagnostic labels have been affixed to ADHD

syndrome including: hyperkinetic reaction, hyperactive child syndrome, minimal brain damage,

and minimal cerebral dysfunction (Cantwell, 1985).

Today ADHD is often described as a developmental neurobehavioral disorder

characterized by developmentally inappropriate degrees of inattention, impulsivity, and

hyperactivity that typically develop early in childhood (before age 7 years), is relatively chronic,

results in significant lifestyle impairments, and cannot be attributed to mental retardation, a

pervasive developmental disorder, or psychosis (APA, 2000; Barkley, 1990). While the specific

etiology of the disorder has yet to be identified, growing support in the literature suggests that

ADHD is derived from a complicated relationship between psychological, neurological,

environmental, and genetic proponents (Wender, 1995). The Diagnostic and Statistical Manual

of Mental Disorders, Fourth Edition, Text Revision (DSM-IV TR) identifies three subtypes of

the disorder which are appended to the diagnostic label according to predominant features

displayed by the individual: inattentive type, hyperactive-impulsive type, and combined type

(APA, 2000).

The DSM-IV TR lists ADHD as a disorder first diagnosed prior to adulthood, and given

the early beginnings of ADHD it is easy to see why many view it as a disorder solely afflicting

children. Even a brief review of the current literature demonstrates that it has received a great

deal of attention in children and adolescents. Various researchers have suggested that it is one of

the most prevalent neurobehavioral conditions of childhood, stretching across cultural and

 
 
 3

national boundaries (Faraone, Sergeant, Gillberg, & Biederman, 2003). Still others report that

ADHD is the most commonly diagnosed childhood disorder (Tucha et al., 2005). Currently,

prevalence rates among the adolescent population are estimated to be in the range of 3-5% (APA,

2000).

Until recently, ADHD has been viewed primarily as a disorder that individuals grew out

of as they matured (Faraone, Biederman, Feighner, & Monuteaux, 2000; Heiligenstein &

Keeling, 1995; Shaffer, 1994); therefore, it was not studied extensively in the adult population

(Tannock, 1998). Some theorized that ADHD was not an impairment due to chronic

neurological deficits but rather developmental delays that would attenuate as the child matured.

This maturational lag hypothesis, as it came to be known, has been supported by research

suggesting that children with ADHD performed on various cognitive tasks at a level two years

behind normal-aged children and that these disparate scores converge as the children mature into

young adults (Rapport, VanVoorhis, Tzelpis, & Friedman, 2001). However, this maturation

effect is not universal, as a large subset of children continue to manifest behaviorally significant

features of the disorder into adulthood. On average, clinical studies show that between 30-50%

of children with ADHD will maintain similar symptoms and impairments as adults (Mannuzza,

Klein, & Addalli, 1991; Schweitzer et al., 2000; Weiss & Hechtman, 1986). Moreover,

prevalence rates of adult ADHD suggest these numbers may under-estimate the number of

children that continue to experience ADHD symptoms into adulthood. In their review, Kessler et

al. (2006) suggest that the prevalence rate in adults is around 4.4% which is in line with the

reported range for the disorder in children and adolescents. In light of these and other clinical

findings, greater attention is being placed on researching ADHD in adult population.

 
 
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Much of what is known about adult ADHD is based upon the framework for

understanding the disorder in younger populations; ergo, the theories and experimental

frameworks of the disorder in the adult population have mimicked that seen in the

child/adolescent domain. While methodologies and techniques (use of rating scales, interviews,

etc), and clinical treatments (medication) reported in the child/adolescent literature have made

the transition into adult studies with little or no difficulty, the same cannot be said for

neuropsychological findings (Hervey et al., 2004). Hervey and his colleagues propose that one

possible explanation for this lack of neuropsychological transition may be due to a “lack of

consensus regarding what neuropsychological deficits actually exist in children with ADHD and

what are the best measures for assessing those deficits” (p. 485). Similarly, another concern is

that what is being measured in children/adolescents may in fact be related to developmental

issues, not neuropsychological deficits associated with ADHD.

Many studies of neuropsychological functioning in children have shown a wide variety of

deficits but fail to suggest consistency across any specific domain. Despite this, there does

appear to be convergence of the data in areas such as attention and working memory (Hervey et

al., 2004; Trani et al., 2010). Thereby providing support that an underlying theory, such as that

proposed by Barkley, is probable and in need of further substantiating evidence.

As suggested, there is currently no theory regarding ADHD and its etiology that is

universally accepted. Despite this fact, there are some who have proposed theories that have

significantly advanced the understanding and guided the current body of research. One of these

theorists, Russell Barkley, has suggested the core deficit in both combined and hyperactive sub-

type ADHD is response inhibition. In his review, Barkley (1999) defends his theory of response

inhibition deficiency as a universal explanation for ADHD. Central to this theory are three

 
 
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interrelated sub-processes: the inhibition of an initial prepotent response to events, interrupting a

current response to allow for a delay before responding, and remaining undistracted during the

delay period.

The first of these, inhibition of an initial prepotent response, is characterized by the

ADHD individual’s response to certain events. Barkley (1999) suggests, “The prepotent

response is that response for which immediate reinforcement (positive or negative) is available

or has historically been associated with that response.” Self-control is limited as the individual is

less able to postpone responding to an event, even if the postponement promises a greater reward

later. The second sub-process is concerned with the individual being able to stop in the middle

of a response, creating a delay period in which critical components of the self and response can

be evaluated or reassessed. Such ability is critical for self-monitoring and the incorporation of

immediate feedback into problem-solving and behavior modification. The third sub-process is

related to freedom from distraction in which the individual is capable of protecting the delay

period that is part of the second sub-process. Once a response has been stopped and the ensuing

delay period begins, the individual must be able to maintain focus on the current task and not

become distracted by either external or internal factors. Failure to maintain this interference

control, as Barkley calls it, results in self-dysregulation with the individual likely to resort to

prepotent responding, which is often an inappropriate or ineffective response.

Barkley (1997) originally proposed that the different subtypes of ADHD might be

conceptually different with different mechanisms fueling behavior. According to his theory, the

impulsive-hyperactive subtype and combined subtype are likely similar, if not the same, disorder

that is most directly mediated by impairments with response inhibition and affects sustained

attention. Deficiencies in the response inhibition, according to Barkley, probably apply only to

 
 
 6

the hyperactive-impulsive and combined subtypes of ADHD and are not a component of the

inattentive type. Barkley (1999) proposes that deficiency in the inattentive sub-type is possibly

related to focus/selective attention and speed of information processing. Earlier reviews failed to

find significant difference across diagnostic subtypes based upon performance on a wide variety

of tests of executive functioning (see Woods, Lovejoy & Ball, 2002). Currently, there is not a

clear consensus about the behavioral or cognitive profile of the different subtypes of ADHD on

various objective measures of attention and executive function with mixed results still being

reported in the research (Biederman et al., 2009; Cordier, Bundy, Hocking & Einfeld, 2010;

Diamond, 2005; Lemiere et al., 2010; Lubke, Judziak, Derks, van Bijsterveldt, & Boomsma,

2009).

Neuroimaging and Anatomy of ADHD

The understanding of ADHD and its associated features have been greatly advanced by

the development of modern scanning instruments that allow images of the brain to be produced,

as well as provide visual representations of neuronal activation. The techniques most commonly

used in this body of literature include: standard structural magnetic resonance imaging (MRI),

single photo emission computed tomography (SPECT), functional magnetic resonance imaging

(fMRI) and positron emission tomography (PET) (Bush, Valera, & Seidman, 2005), although

future studies will likely use more advance techniques such as diffusion tensor imaging (DTI)

and others (Ashtari et al., 2005; Rusch et al., 2007; Russell et al., 2006; Skranes et al., 2007). A

body of literature now available has begun to demonstrate anatomical differences likely

implicated in ADHD disorder, and while an extensive review of the technology is not necessary,

a brief description is helpful. SPECT and PET are very similar. Individuals in both procedures

inhale or ingest a radioactive isotope that emits a particle of radiation that is detected and

 
 
 7

transformed into an image by a computer program. More active structures in the brain receive

greater blood flow and subsequently, greater amounts of radiation are emitted and detected

thereby algorithmically showing increased neuronal activity.

Unlike SPECT or PET, fMRI is a completely non-invasive neuroimaging procedure

which depends upon the principles and procedures of normal MRI. In MRI large magnets create

a powerful magnetic field that causes the hydrogen atoms in an individual to align. A radio

wave, or radio frequency pulse, is directed through the body in the area under examination

disrupting the aligned atoms. Once the pulse is discontinued, the time it takes the atoms to return

to their normal spin is measured. A computer analyzes the data and an image of the structure is

produced (Bremner, 2005). Areas of the brain can be volumetrically quantified and compared

for differences. In fMRI measured blood oxygen levels provide information about neuronal

activity. This is possible because active areas in the brain temporarily undergo anaerobic

metabolism causing capillary blood flow in the active region to be more richly oxygenated than

non-active regions.

Recently, Bush and colleagues (2005) reviewed all major imaging studies since 1984

evaluating ADHD. Based upon the review they suggested decreased global metabolism in the

ADHD brain. This finding was based in large part on the work of Zametkin and colleagues

(1990) who found ADHD subjects had 8.1% lower cerebral glucose metabolism compared to

controls. These findings were challenged by some who criticized Zametkin’s comparison groups

to be gender unbalanced (Baumeister & Hawkins, 2001; Leo & Cohen, 2003), but these same

findings have been duplicated elsewhere (Castellanos et al., 2002). Furthermore, studies using

SPECT technology have also found significant difference in metabolism in the dorsal anterior

cingulate, motor and premotor cortices (Kim et al., 2010; Langlebon et al., 2002); right lateral

 
 
 8

prefrontaal, middle tem

mporal and cerebellum
c (Kim
( et al., 22010; Kim, L
Lee, Shin, C
Cho, & Lee,

2002); do
orsal lateral prefrontal co
ortex, caudatte and thalam
mus (Amen, Hanks, & P
Prunella, 20008;

Kim, Leee, Cho, & Leee, 2001; Szo

obot et al., 2010);
2 and sttriatum and pperiventricular areas (Loou,

Andresen
n, Steinberg,, McLaughliin, & Friberg
g, 1998; Louu, Henriksenn, & Bruhn, 11990; Szoboot et

al., 2010)).

Figure 1.. Major anatomical regiions of the frrontal lobe. DLPFC- Doorso-lateral pprefrontal coortex;
VLPFC-V
Ventro-laterral prefrontall cortex; APF
F-Anterior pprefrontal coortex; MPFC
C-Medial
prefrontaal cortex.

The
T advent off MRI and fM
MRI brough
ht greater spaatial and tem
mporal resoluution, permittting

more preecise measurement and in

nvestigation. Table 1 prrovides brieff summaries of recent

imaging studies evalu

uating ADH
HD in the child and adoleescent populaations. As ccan be seen, there

is converrgent data su
uggesting dysfunction off fronto-striaatal structures particularly the dorsal

anterior cingulate
c corrtex and preffrontal corticces, and stroong implicatiion of the strructures of bbasal

ganglia. This is conssistent with the

t previously reported ffindings of S
SPECT and P
PET studies

 
 
 9

suggesting biological correlates of ADHD. Figure 1 provides an illustration of key anatomical

regions and structures of the frontal lobe implicated in ADHD.

Table 1

Child/Adolescent Neuroimaging Studies

Study Subjects Type Findings

Almeida et Children: 21 ADHD – MRI—volumetric ADHD subjects showed reduced cortical thickness
al. 2010 med. naive, 21 age analysis of cortical in right frontal lobe. Specifically, regions of the
matched controls thickness right superior frontal gyrus were most reduced.
Adolescents: 20
ADHD – med. naive,
20 age matched
controls
Batty et al. Children: 25 ADHD MRI—volumetric ADHD subjects had lower grey matter volumes
2010 combined, 24 age analysis of cortical throughout the brain with the greatest decrease in
matched controls thickness frontal regions. Specifically, the inferior frontal
gyrus.
Depue et al. Adolescents: ADHD Optimized voxel- ADHD subjects had reduced grey matter volume
2010 combined, age based in the right inferior frontal gyrus. No significant
matched controls morphometry difference between groups on whole brain
analysis.
Mazaheri et Children: 14 ADHD, EEG—analysis of Children with ADHD showed slower responses
al. 2010 11 age matched functional and atypical alpha and theta activity associated
controls connectivity during with the attention task. Results suggest functional
a cross-modal disconnection of the frontal cortex.
attention task
Yang et al. Adolescents: 15 Magnetic Adolescents with ADHD showed lower right
2010 ADHD, 22 controls resonance prefrontal levels of creatine plus phosphocreatine
spectroscopy suggesting neurochemical differences from control
subjects.
Epstein et Adolescents: 10 fMRI-functional Adolescents with ADHD showed atypical
al. 2009 ADHD, 14 control analysis of brain activation in the right middle frontal gyrus at
activity while second testing suggesting developmental
performing differences in brain activation in regions of the
attention task. frontal lobe.
Jourdan et Children: 12 ADHD Functional near- ADHD subjects showed greater right dorsolateral
al. 2009 boys, 12 education, infrared prefrontal cortical oxygen consumption.
age and gender spectroscopy Interpreted to be a compensatory reaction
matched controls analysis of suggesting greater impairment of the dorsolateral
performance on a prefrontal cortex.
Stroop task
Rubia et al. Children: 20 boys fMRI – functional Pure ADHD subjects showed ventrolateral
2009 noncomorbid ADHD, analysis of Simon prefrontal cortex dysfunction not seen in healthy
13 boys noncomorbid task assessing control or those with CD.
CD, 20 matched inhibition and
healthy control attention

 
 
 10

Table 1 (continued)
Silk et al. Children/adolescents: DTI- FA Subjects with ADHD showed different
2009 15 ADHD combined evaluations of the developmental trajectories in microstructures of
type, 15 age and structural the caudate nucleus
intellectually matched organization of the
controls basal ganglia
McAlonan Children: 28 male MRI––Volumetric ADHD subjects had significant regional deficits in
et al. 2007 ADHD, 31 matched analysis. Post-hoc R frontal-pallida parietal grey matter and bilateral
controls analysis of white matter tracks. Post-hoc comparison
comorbid CD and suggested ADHD with comorbid CD or ODD
ODD diagnoses disorder had greater cerebellar and striatal volume
deficits.
Ashtari et al. Children: 18 ADHD, DTI––Analysis of ADHD subjects had decreased FA in R
2005 15 age & gender white matter track supplementary motor area, R striatal, R cerebral
matched diffusion peduncle, L middle-cerebellar peduncle and
controls. Lcerebellum.
Tamm et al. Adolescents: 10 fMRI––functional ADHD subjects had significantly less activation in
2004 ADHD, 9 matched assessment using a dACC and L temporal gyrus. Decreased activation
Controls go/no-go task of frontal regions associated with deficits in
response/ task-switching abilities.
Durston et Children: 7 mixed fMRI––functional ADHD subjects had no activation in basal ganglia
al. 2003 gender ADHD, 7 assessment using a and decreased activation in VLPFC and ACC
matched controls go/no-go task compared to controls. ADHD had greater
activation in other regions located in the posterior
parietal and occipital cortices.
Langleben Children: 22 mixed SPECT––MPH Higher rCBF in dACC, motor, and motor cortices
et al. 2002 gender ADHD, 7 age, discontinuation following discontinuation of MPH. Suggest these
gender & IQ matched evaluation with a areas are Implemented in ADHD positive
controls go/no-go task treatment response to medication and therefore are
implemented in overall pathology.
Castellanos Children/adolescents: MRI––Volumetric Unmedicated ADHD subjects had smaller overall
et al. 2002 152 mixed gender study evaluating a brain volumes even when adjusted for covariates.
ADHD, 139 gender & time period Smaller overall white matter volumes were also
age matched controls between 1991 to noted. Severity of symptoms by parent/clinician
2001 report negatively correlated with frontal/ temporal
grey matter, caudate and cerebellar volumes.
Decreased volume remains constant across age for
all areas except caudate, which increased in
volume with age.
Rubia et al. Adolescents: 7 fMRI––functional ADHD subjects had lower activation in R mesial
1999 ADHD, 9 matched assessment using prefrontal cortex during both tasks and lowered
controls stop task and activation of the R VLPFC and L caudate during
motor timing task stop task compared to control subjects.
Note. ADHD = attention-deficit/hyperactivity disorder; dACC = dorsal anterior cingulate gyrus; DTI = diffusion
tensor imaging; EEG = electroencephalographic; fMRI = functional magnetic resonance imaging; FA = fractional
anisotropy; FOC = fronto-occipital cortex; VLPFC = ventro-lateral prefrontal cortex; R = right, L = left; CD =
conduct disorder, ODD = oppositional deficit disorder.

As mentioned, to date the vast majority of imaging studies looking at ADHD disorder

have been on children and adolescents. However, a problem exists in blind translation of these

 
 
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findings to adult populations since some of what has been found may be developmental

phenomena and not chronic neurological deficits related to an underlying ADHD disorder. For

instance, should the frontal and basal ganglia abnormalities seen in children and adolescents be

secondary to ADHD, then similar findings should be found in adults. While the number of

studies utilizing neuroimaging to evaluate ADHD in the adult population has increased, there

still remains ample room for further contributions. Those that have been done to date have

shown promising results and extend the child/adolescent literature linking ADHD to regions of

the frontal lobe. Table 2 presents the current limited body of research on the adult ADHD

population. Similar to findings in children/adolescent populations, there appears to be

converging evidence implicating frontal lobe and basal ganglia deficits both in anatomical

correlates (regional and globally) and functional processes thereby strengthening the hypothesis

that ADHD has a neurological component. While other corroborating studies are needed, it is

likely that future studies will continue to strengthen this proposed relationship.

Executive Function

Many different definitions have been proposed for executive function, although a general

consensus to what executive function is has yet to be reached in the literature (Baddeley, 1986;

Luria, 1980; Shallice & Burgess, 1996). While the debate continues, frequently executive

function is defined as a constellation of cognitive processes that include, but are not limited to

the ability to inhibit, mediate attention, plan, problem-solve, reason, regulate impulsivity, and

allow for flexibility of thinking and concept formation (Eslinger, 1996; Homack, Lee, & Riccio,

2005). Baron (2004) further postulated that these higher level functions also consisted of

hypothesis generation, abstract reasoning, organization, goal setting, fluency, working memory,

self-monitoring, initiative, set-shifting, self-control, mental flexibility, attention, and creativity.

 
 
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Table 2

Imaging Studies of Adult ADHD

Study Subjects Type Findings

Almeida et al. 20 ADHD – never MRI—volumetric Reduced cortical thickness in right frontal lobe.
2010 medicated, 20 age analysis of cortical Specifically, regions of the right superior frontal
matched controls thickness gyrus were most reduced.
Cubillo et al. 11 medication- fMRI—functional ADHD subjects showed reduced activation in
2010 naïve ADHD, 14 evaluation using inferior prefrontal cortex (bilaterally), caudate, and
age matched stop-go task and a thalamus during both tasks. ADHD subjects also
controls task of cognitive showed lower activation in left parietal lobe regions
flexibility during task of cognitive flexibility.
Schneider et al. 19 ADHD males, fMRI—functional ADHD subjects showed impaired activation of
2010 17 matched evaluation using a fronto – Striatal pathways associated with attention.
controls continuous Specifically, reduced activation in the caudate
performance task nuclei and anterior cingulate cortex. Additionally,
reduced activation found in parietal cortical
networks associated with attention.
Dibbets et al. 16 ADHD males, fMRI – functional ADHD subjects showed less activation in the
2009 13 matched healthy analysis during a inferior frontal/orbitofrontal cortices, caudate
controls modified Go/NoGo nucleus, and nucleus accumbens.
task
Hesse et al. 17 treatment naïve SPECT – analysis ADHD subjects showed decreased dopaminergic
2009 ADHD adults, 14 of dopamine and reuptake function but normal serotonergic reuptake
age matched serotonin binding function compared to healthy control
controls
Markris et al. 24 mixed MRI––Volumetric ADHD subjects had decreased cortical thickness in
2007 prefrontal, lateral inferior parietal and cingulate
gender ADHD, 18 analysis of cortical
cortices. More specifically, thinness was found in
matched controls thickness FOC, ACC and DLPFC bilaterally. Strong
conclusions linking ADHD with decreased cortical
integrity in areas of attention modulation and
executive function.
Ernst et al. 2003 10 mixed PET ––Decision ADHD subjects had less extensive activation in
VPC, insula and DLPFC compared to control. No
gender ADHD, 12 making task with
activation in Hippocampus, ACC and left insula
age matched control task compared to control group with activation in these
controls areas.

 
 
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Table 2 (continued)

Schweitzer et al. 6 ADHD males, 6 PET––Working ADHD subjects produced a more diffuse pattern of
2000 matched controls memory task using rCBF compared to control on the PASAT task.
the Paced Auditory General pattern consistent with decreased frontal
Serial Addition lobe activation. Activation of diverse, alternate
Task (PASAT) areas may suggest compensatory strategy
employing visual imagery.

Bush et al. 1999 8 ADHD, 8 fMRI––functional ADHD subjects did not have dACC activation,
matched controls evaluation using control group had robust dACC activation.
Counting Stroop
task.

Note: ADHD- attention-deficit/hyperactivity disorder; (d)ACC- (dorsal) anterior cingulate cortex; DLPFC- dorso-
lateral prefrontal cortex; (f)MRI- (functional) magnetic resonance imaging; FOC- fronto-orbital cortex; PET-
positron emission tomography; rCBF- regional cerebral blood flow; SPECT- single-photon emission computed
tomography; VPC- ventral prefrontal cortex.

Often the term higher cognition is used interchangeably with executive function. This

does not seem completely accurate, as the term executive function implies a higher-order

administrative process that subsumes cognitive sub-processes and acts to integrate, moderate and

regulate for the purpose of achieving an overarching goal or outcome that most often is future

oriented. This is more in line with the definition provided by Welsch and Pennington (1988),

who defined executive function as, “neurocognitive processes that maintain an appropriate

problem solving set to attain a future goal” (p. 201). Although this definition of executive

function appears generally accepted, the relationship of these processes and sub-processes is not

completely understood due to their complexity (Stuss, Alexander, & Benson, 1997). Currently,

therefore, executive functioning can be viewed as a consortium of multiple higher-level

functions that are intimately connected, work in concert, and are difficult, if not impossible, to

isolate (Delis, Kaplan, & Kramer, 2001a, Tucha et al., 2005; Welsch & Pennington, 1988).

Anatomically, a major seat of executive function is believed to involve the frontal lobes

(Max et al., 2005). This association has been made due to early observations and case studies

 
 
 14

involving frontal lobe damage, with subsequent studies evaluating higher cognitive abilities in

individuals with frontal lesions (Barkley, 1997; Delis et al, 2001; Faraone, et al 2000; Josdottir,

Bouma, Sergeant, & Scherder, 2006; Luria, 1980; Max et al., 2005; Woods, Lovejoy, & Ball,

2002; Schweitzer et al., 2000), and more recently by function neuroimaging. In an earlier

publication, Lezak (1978) described five domains of behavioral and personality difficulties

commonly observed in post-head injury patients. These described symptoms are similar to

characterized symptomatology of ADHD (Anderson, Anderson, & Anderson, 2006; Levin et al.,

2007; Max et al., 2004; Max et al., 2005; Slomine, et al., 2005; Wassenberg, Max, Lindren, &

Schatz, 2004). Frontal lobe injuries or disruptions have resulted in both observable and

measurable behavioral and cognitive deficits that are often called executive dysfunction. Lezak

(2004) defined this executive dysfunction as the “defective capacity for self-control, self-

direction such as emotional lability or flattening, a heightening tendency towards irritability and

excitability, impulsivity, erratic carelessness, rigidity, and difficulty in making shifts in attention

and ongoing behavior” (p. 36).

Several measures have been created for the assessment of individual sub-processes of

higher cognition. Traditionally these measures are based upon a level-of-performance analysis

that consists of comparison of the individual’s score to a predetermined cut-off score or provides

a standardized score based upon existing normative descriptions. For example, the Trail Making

Test (TMT; Battery, 1944) is believed to measure set-shifting and tracking by having an

individual sequentially connect numbers and letters scattered across a page, while alternating

between the two different categories. In theory, an individual with a relatively healthy brain

should find the task manageable and be able to accomplish within a relatively brief time,

whereas, an injured brain (frontal lobe) will find tracing and shifting between stimulus items

 
 
 15

more difficult. The TMT can be scored by both a cut-off score (Reitan & Wolfson, 1993) or a

standardized score. Table 3 provides a brief description of common measures currently used to

assess executive function.

Table 3

Common Neuropsychological Tests of Executive Function

Tests Description Higher-Cognitive Ability

Trail Making Test Consists of two conditions. Condition A is a sequential Set shifting; visual tracking
(TMT) task using numbers. Condition B is a double sequential
task that requires subject to alternate between
connecting numbers in sequence with letters in
sequence.
Stroop Color Word Test Consists of three conditions, although alternative Response inhibition, and
versions may have more or less. In condition 1 subject attention
name patches of color. In condition 2 subjects read color
name printed on page. In condition 3 subjects say color
of ink color word is printed in.
Design Fluency Different versions exist. Subject is asked to generate as Nonverbal fluency,
many different designs by connecting dots using straight organization, strategy and
lines. problem solving.
Controlled Oral Word Different versions exist. Subject is asked to generate as Verbal fluency
Association Test ( many different words that begin with specified letter.
COWA) Generally consists of three different letters such as
F,A,S.
Wisconsin Card Sorting Subjects asked to sort cards by three possible groups, Flexibility of thinking,
Test shape, color or number. After specified number of hypothesis generation,
correct sorts the rule for sorting changes. working memory, and
attention.
Tower of London/Hanoi Subjects manipulate blocks prearranged on pegs to Problem-solving, response
construct a specific arrangement. Task must be inhibition.
completed following set guidelines. Rule violations can
be quantified.

The sole use of the level of performance analysis as a measure of overall

neuropsychological function has been challenged. Those in the literature that have been the most

critical of this traditional approach to neuropsychological interpretation argue that an underlying

assumption of the traditional approach is that all tests of higher cognitive function depend only

upon that ability and do not subsume other underlying primary processes (Delis et al., 2001a). In

 
 
 16

other words, poor performance on any given measure may be related to a more basic, primary

process dysfunction and not dysfunction of a higher-order process. For example, poor

performance on the TMT part B is assessed by time of completion and is believed to indicate

dysfunctional set-shifting and multi-task behavior. Delis and colleagues argue that it is possible

a more fundamental skill (i.e., motor-impairment, sequencing or visual perception) may be the

cause of the poorer performance and not difficulties with set-shifting, a higher-order function. In

addition, many of the clinical measures currently used only provide a single score of function

often based upon a single factor (e.g., time to complete) and fail to provide other potentially

meaningful and potentially clinically rich information (e.g., number of errors committed).

Rather, it is recommended that a process approach to assessment in which lower-level functions

and qualitative analysis of test performance are also evaluated, thereby providing information

and analysis of fundamental component skills versus higher-level cognitive functions (Cato,

Delis, Abildskiv, & Bigler, 2004). This process-oriented approach, as it has been called, allows

for a more comprehensive, complex, and rich qualitative evaluation that looks at both normative

and ipsative comparisons, and both inter and intra-test performance.

Support for this newer process-oriented approach is increasing as evidence of its

usefulness is presented in the literature. In a case study presentation, Cato et al. (2004) explored

cognitive deficits in an individual with documented ventromedial prefrontal damage (VM-PFD).

This cortical region was previously shown by neuropsychological and neuroanatomical studies to

be involved in emotional and behavioral regulation and therefore, not believed to be associated

with higher cognitive functions. A traditional level of performance analysis resulted in findings

similar to those reported in the literature supporting a link between VM-PFD and emotional and

behavioral changes; however, when neuropsychological testing was evaluated using a process-

 
 
 17

oriented approach, cognitive deficits were revealed. Likewise, Woods and associates (2002)

found that adults with ADHD had significant group differences compared to controls on a battery

of intelligence and executive function measures. When a process-oriented approach of intra-

individual discrepancy analysis was used, the diagnostic sensitivity greatly increased. Woods

and his colleagues suggest consideration for the use of discrepancy analysis in assessing adult

ADHD.

ADHD and Executive Function

Barkley’s response inhibition theory continues to gain support in the current literature,

although some have been critical of this unitary mechanism approach (Songua-Barke, 2002).

However, neuroanatomical and neuropsychological studies have implemented regions of the

frontal lobe, particularly the anterior cingulate cortex (ACC) (Casey et al., 1997) as mediators of

attention and concentration. As reported above, anatomical and functional deficits of the ACC,

basal ganglia and other frontal lobe regions, including the fronto-striatal tracts, in the ADHD

brain have been substantiated. Figure 2 illustrates the integrated associations of the frontal

region and demonstrates how various anatomical regions are interconnected allowing for the

coordinated execution of higher-order functioning. In actuality, these associations are formed

through a complex integral network of cortical grey and white matter tissue that rapidly receive,

process and send signals via millions of tracks and feedback loops, and form the central hub of

executive functioning. Just as a compromised or insufficient highway greatly reduces the

efficiency of travel, deficits to any area of this network (pathway or structure) will result in a

disruption in the efficiency and efficacy of higher-order function execution.

Where ADHD was previously conceptualized as a disorder of attention and hyperactivity

of a more psychological nature, current views have shifted as evidence of neurological markers

 
 
 18

of frontall lobe deficitts have ariseen. With rep

peated evidennce of anatoomical difference in the

frontal co
ortical region
ns of those with
w ADHD,, observed ddeficits on tessts of cognittive functionn are

no longerr just undersstandable, th

hey are expeccted. Indeedd, the use of executive fuunction meassures

in evaluaating ADHD has been weell substantiated (Peace,, Ryan, & Trripp, 1999) aand is becom
ming

a standarrd practice in
n research on
n ADHD. The hope is thhat employinng measuress of executivve

function will increasee current und

derstanding of the disordder (Walker,, Shores, Troollor, Lee, &

Sachdev,, 2000).

Figure 2.. Interconneection of prefrontal cortical regions aand other coortical regionns. Adapted from
B. Kolb and
a I. Q. Wh hishaw, 2000 0, An Introdu
duction to Bra
rain and Behhavior, p. 4200. Copyrightt
2001 Woorth Publisheers. Reprinteed with permmission.

Initial ressearch has sh

hown adult neuropsycho
n ological funcction to be siimilar to finddings reporteed in

the child and adolesccent literature (Woods, Lovejoy,

L Micchael, Ball, & Fals-Stew
wart, 2002).

Table 4, originally pu
ublished in Woods
W et al. (2002), pressents a compprehensive list of studiess

evaluatin
ng neuropsycchological fu dults. In genneral they fouund converggent data to
unction in ad

suggest adults
a with ADHD
A had greater
g deficiits on tasks rrequiring ressponse inhibbition, compllex
 
 
 19

Table 4

Summary of Studies Reporting Neuropsychological Performance of ADHD Adults.

Authors Participants Neuropsychological measures Results

Woods et al. (in press) 26 ADHD COWA; CVLT; Stroop; TMT; Significant group differences (ADHD < NC) using a discrepancy analysis
26 NC WAIS±R Freedom from between intelligence and executive functions. Moderate diagnostic accuracy
Distractibility. for the individual tests and an impairment index.

Barkley, Murphy, 104 ADHD KBIT; Time estimation; Time ADHD adults displayed significantly larger time estimations, shorter time
& Bush (2001) 64 NC reproduction. reproductions, and more reproduction errors relative to NC.

Dinn et al. (2001) 25 ADHD COWA; DTT; Go/No-Go; OAT; Significant differences reported between ADHD subtypes, and between
11 NC Stroop. ADHD and NC on several dependent measures (ADHD<NC).

Epstein et al. (2001) 25 ADHD CPT; Stop Signal Task; VOT. As compared to NC and patients with anxiety disorders, adults with ADHD
15 Anxiety demonstrated poorer performance on several measures of response inhibition
30 NC (CPT reaction time).

Hollingsworth, 12 ADHD Attentional blink task. ADHD adults exhibited protracted attentional blink relative to NC,
McAuliffe, & 18 NC suggesting poor attentional shifting efficiency.
Knowlton (2001)

Johnson et al. (2001) 56 ADHD 3RT; COWA; GDS; Shipley; Adults with ADHD showed poorer performance on measures of selective
38 NC Stroop; TMT; WCST; WMS±R. visual attention, memory (passage and geometric design recall), response
time, and visuomotor tracking vs. NC.

Murphy et al. (2001) 105 ADHD CPT; COWA; KBIT; Object After controlling for intelligence, significant group differences were reported
64 NC usage; Simon; SIT; Stroop; WAIS- for attention, inhibition, nonverbal working memory, and interference
III subtests. control (ADHD<NC). Gender differences emerged in the ADHD group, but
there were no differences for ADHD subtype.

Rashid et al. (2001) 56 ADHD BNT; COWA; CVLT; WAIS±R; No between-groups differences emerged on any of the dependent measures
29 LD WMS±R. when controlled for IQ.
93 mixed

 
 
 20

Table 4 (continued)

Authors Participants Neuropsychological measures Results

Himelstein & Halperin 9 ADHD CPT; Competing Motor Programs Although the results revealed similar performance between groups on
(2000) 23 NC Task; Target Orientation Task. sustained attention and encoding speed, ADHD adults demonstrated poorer
performance on motor output/response organization.

Fujii et al. (2000) 44 ADHD RCFT; WAIS±R. The authors assert that IQ may be a moderating variable for RCFT copy
performance among ADHD adults.

Walker et al. (2000) 30 ADHD Animal Fluency; COWA; CPT; Significant group differences between the ADHD and control groups on the
30 psychiatric Stroop; TMT; WAIS±R subtests. dependent measures (ADHD<NC); no differences were identified between
30 NC the ADHD and psychiatric samples.

Corbett & Stanczak 27 ADHD Stroop; TOAD. ADHD adults performed significantly poorer than NC on the dependent
(1999) 15 NC measures. The TOAD Noise subtest correctly classified the groups 81% of
the time, with minimal false negative rates.

Lovejoy et al. (1999) 26 ADHD COWA; CVLT; Stroop; TMT; Significant group-differences (ADHD<NC) and adequate diagnostic
26 NC WAIS±R Freedom from classification on a battery of frontal/executive measures considered both
Distractibility individually and as a summary impairment index.

Schreiber et al. (1999) 18 ADHD ROCF Significant between-group differences for the Neatness and Planning
18 NC dependent variables within the ROCF (ADHD<NC). Logistic regression
analysis was significant for Configural Accuracy, Planning, Perseveration,
and Neatness.

Epstein et al. (1998) 60 ADHD CPT Significant between-group differences on three CPT indices, with a strong
72 NC correlation between ADHD symptoms and CPT performance. Diagnostic
classification rates for the CPT were modest.

Gansler et al. (1998) 30 ADHD ACT; CPT; Progressive Planning Group differences found on TMT, CPT, and ACT (ADHD<NC). Differential
10 NC Test; SIT; TMT; WCST; WMS±R. executive impairment was reported for the hyperactive/impulsive and
inattentive subtypes.

 
 
 21

Table 4 (continued)

Authors Participants Neuropsychological measures Results

Jenkins et al. (1998) 22 ADHD COWA; CVLT; Luria ADHD adults demonstrated significantly poorer performance on the
(childhood) Motor/Recurring Figures; PASAT; PASAT, CVLT delayed free recall, and verbal fluency tasks. Classification
18 non- WAIS±R; WCST rates calculated via discriminant function analysis for the battery of tests fell
childhood in an acceptable range.
ADHD controls

Katz et al. (1998) 89 ADHD CPT; CVLT; Stroop; HRB; Significant group differences emerged on 12 dependent variables
20 depression PASAT; WAIS±R; WMS±R. (ADHD<NC), including Stroop, CVLT, PASAT, and WMS±R. Overall
diagnostic accuracy was adequate; however, a large percentage of depressed
participants were misclassified as ADHD.

Kovner et al. (1998) 19 ADHD BFR; CPT; GLNST; LCMP; SST; ADHD adults performed significantly worse than NC on the WAIS±R Digit
10 psychiatric WAIS±R; WRAT±R; WRMT Span Backwards and reaction time from the SST. Group classification rates
derived from these variables were adequate.

Seidman et al. (1998) 64 ADHD CPT; CVLT; Letter Cancellation; ADHD adults were significantly more impaired on the WRAT Arithmetic
73 NC ROCF; Stroop; WAIS; WCST; subtest, CPT omissions and late responses, as well as the CVLT total words,
WRAT. semantic clustering, and long-delay free-recall indices (ADHD<NC).

Weyandt et al. (1998) 21 ADHD Ravens Progressive Matrices; ADHD adults demonstrated higher scores on several self-report measures of
19 LD Tower of Hanoi; TOVA; WCST. ADHD. The LD group committed a greater number of WCST errors
24 NC compared to controls.

Downey et al. (1997) 41 ADHD ACT; Category Test; CVLT; Compared to a normative mean, pure ADHD adults displayed deficits on the
37 ADHD with Finger Tapping; Stroop; TOVA. CVLT and ACT. ADHD participants with comorbid conditions performed
comorbid Axis I more poorly on the ACT and Category Test.

Epstein et al. (1997) 91 ADHD Visual Orienting Task ADHD adults displayed significantly longer VOT delay times, particularly
52 nonADHD at extended cue/target intervals or when an invalid cue to the left hemisphere
prompted an attentional switch to the left.

 
 
 22

Table 4 (continued)

Authors Participants Neuropsychological measures Results

Roy-Byrne et al. (1997) 46 ADHD CPT Possible ADHD participants demonstrated poorer CPT index performance
51 poss. ADHD than either the probable ADHD or non-ADHD groups.
46 nonADHD

Taylor & Miller (1997) 211 ADHD Stroop; TMT; WAIS±R; WCST. An attentional index was related to comorbidity, ADHD subtype, and group
231 psychiatric classification, but diagnostic accuracy for the ADHD and psychiatric groups
28 NC was poor.

Barkley et al. (1996) 25 young COWA; Cookie Theft; CPT; Young ADHD adults performed significantly more poorly on measures of
ADHD creativity tests; Digit Span; Simon. working memory and demonstrated greater impairment on various CPT
23 NC variables compared to NC.

Horton (1996) 11 ADHD CT; FT; Rhythm; Speech Deficits were identified on the WMS±R Logical Memory subtests and the
Perception; TMT; WMS±R. Category Test. When demographically corrected, trends were identified for
borderline scores on TMT B and CT.

Matochik et al. (1996) 21 ADHD CPT; FDQ; GORT; WAIS±R; ADHD adults demonstrated poorer WAIS±R FD performance relative to
WCST; WRAT±R. WAIS±R VC and PO. No other significant impairments were identified.

Holdnack et al. (1995) 25 ADHD CPT; CVLT; TMT; WCST. Significant differences reported on CPT reaction time, TMT Part A, and
30 NC several CVLT variables ADHD<NC).

Silverstein et al. (1995) 17 ADHD Digit Symbol; Perceptual Speed; ADHD subjects demonstrated poorer mental Flexibility, psychomotor speed,
17 Tourette's SOA; Stroop; TMT and test variability compared to controls. ADHD/TS patients showed worse
17 NC neuropsychological impairment than TS only patients.

 
 
 23

Table 4 (continued)

Authors Participants Neuropsychological measures Results

Arcia & Gualtieri 23 ADHD CPT; Finger Tapping; Pattern Compared to NC, ADHD adults demonstrated greater variability on the CPT,
(1994) 26 mCHI Memory and Comparison; Serial poorer pattern recall, and more Serial Digit Learning errors. However, mCHI
25 NC Digit Learning; WAIS±R. patients evidenced slower tapping speed and poorer pattern memory than the
ADHD adults.

Biederman et al. (1993) 84 adult ADHD WAIS±R; WRAT±R. ADHD adults achieved significantly lower WAIS±R FSIQ and FD scores as
140 child compared to adult NC. ADHD adults also demonstrated lower WAIS±R
ADHD Block Design and higher Vocabulary, Digit Span, and FD scores when
43 ADHD rel. compared to children with ADHD.
248 NC

Gualtieri et al. (1985) 12 ADHD Actometer; CPT; MFFT; ADHD adults performed significantly worse on the CPT and actometer (a
12 NC WAIS±R. physiological measure of fidgetiness) as compared to NC.

Mungas (1983) 6 ADHD RAVLT; WAIS±R. ADHD adults performed comparably to the mixed clinical reference groups
24 mixed on each of the dependent variables.

Hopkins et al. (1979) 70 ADHD Embedded Figures Test; MFFT; The ADHD hyperactive group displayed greater MFFT errors, longer EFT
42 NC Stroop. completion time, fewer EFT correct responses, longer Stroop reaction time,
and a greater number of Stroop errors compared to NC.

Note. Table 4 is from “Neuropsychological Characteristics of Adults with ADHD: A Comprehensive Review of Initial Studies,” by S. P. Woods, D. W. Lovejoy,
and J. D. Ball, 2002, The Clinical Neuropsychologist, 16, p.14-17. Copyright 2002 by Taylor and Francis. Adapted with permission.

 
 
 24
 

information processing speed, verbal fluency and visual attention, while discrepant findings were

reported for tasks of set shifting (TMT part A and B), conceptualization, cognitive flexibility and

problem solving. Poor methodology in many of the studies reported on may have accounted for

some of this difference, however, more recent studies have continued to show similar findings of

poor response inhibition, slower processing speed, with mixed findings for cognitive flexibility,

set shifting, verbal fluency, and problem solving (Antshel et al. 2010; Boonstra, Kooij,

Oosterlaan, Sergeant, & Buitelaar, 2010; Brown, 2009; Marchetta, Jurks, Krabbendam, &Jolles,

2008). Further research is needed to increase the current understanding of executive dysfunction

in the ADHD population, especially in adults. The use of employing a process-oriented

approach, which has shown to have added utility both clinically and in research, may provide

greater understanding of and offer greater differentiation for diagnostic assessment.

Delis-Kaplan Executive Function System

The D-KEFS employs nine individual subtests designed to provide a comprehensive

evaluation of higher level cognitive functioning and frontal lobe integrity (Delis, Kaplan, &

Kramer, 2001b). While most of the subtests are based upon already established

neuropsychological tests, many have been slightly modified to reflect recent advancements in the

understanding of executive functioning (Delis et al., 2001a). The following standardized

subtests compose the D-KEFS: Trail Making Test, Verbal Fluency Test, Design Fluency Test,

Color-Word Interference Tests, Sorting Test, Twenty Questions Test, Word Context Test, Tower

Test, and Proverb Test.

Trail Making Test. This subtest is based on the Trail Making Test originally developed

by Partington in 1938, but has been modified to include 5 conditions each purported to assess a

different area of functioning (Delis et al., 2001a). Condition 4 is the only condition that has been

 
 
 25
 

theorized to assess higher level skills; the other four conditions serve to assess and ensure that

lower-level skills, such as motor speed or sequencing, are intact and therefore not confounds in

the interpretation of the results for Condition 4. Condition 4 consists of a switching task that

requires the examinee to connect numbers and letters in sequence while alternating back and

forth between the numbers and letters. Executive functions believed to be important for the

successful completion are: cognitive flexibility and inhibition of perseverative responding.

Verbal Fluency Test. This subtest requires an individual to randomly generate words

based upon given parameters such as words beginning with the letter F, and is based upon the

original FAS verbal fluency test. The D-KEFS builds upon this by including a categorical

fluency test, such as generating boys names and animal names, and a switching task where the

respondent alternates between giving the name of a fruit and a piece of furniture (Delis et al.,

2001a), The believed areas of executive function assessed are cognitive flexibility, response

inhibition, and verbal fluency.

Design Fluency Test. This subtest, similar in nature to the verbal fluency test, evaluates

nonverbal fluency by asking the examinee to generate as many unique designs as possible in a

given time period by drawing four lines that connect an array of dots displayed in boxes (Delis et

al., 2001a). The examinee is presented with rules that must be applied to each design, and credit

is not given for any rule violations. There are three different conditions, each with its own set of

rules. Nonverbal fluency, response inhibition and cognitive flexibility are the features of

executive function believe to be assessed by this subtest.

Color-Word Interference Test. Based upon the original Stroop-Color Word Test, this

subtest is generally believed to be one of the more challenging tasks for those with ADHD

(Rapport et al., 2001). Similarly to the Trail Making Test, this subtest consists of four individual

 
 
 26
 

test conditions. Conditions 1 and 2 serve as lower-level assessments of color naming and word

reading. Condition 3 introduces a distracter by displaying the names of colors across the page

printed in the ink of a different color. For example, the word red would be printed in blue ink.

The subject then has to say the name of the ink color while inhibiting responses of saying the

word. Condition 4 builds upon Condition 3 by introducing a switching response. Here again,

color word names are printed in a different ink color, but random words are outlined with a black

box. The examinee is told to name the color of the ink unless the word is within a box, at which

point they are instructed to read the word, and not name the color of the ink. Executive functions

employed in this subtest are response inhibition and cognitive flexibility.

Sorting Test. This test is based upon an earlier measure shown to be very sensitive to

multiple executive function deficits in patients with frontal lobe lesions (Delis et al., 2001a).

Examinees are presented with six different cards varying in perceptual features and printed

words, and then asked to sort the cards into two groups of three according to as many different

categorical ways as possible, such as by shape, color, etc. (Delis et al., 2001a). Several areas of

executive functioning are assessed with this subtest including initiation of problem-solving

behavior, verbal and nonverbal concept-formation skills, transfer of concepts into action, and

flexibility of thinking.

Twenty Questions Test. In this subtest the examinee is shown a page with 30 common

objects displayed. They are instructed to try and guess which of the objects the examiner is

thinking of by asking as few yes or no questions as they can (Delis et al., 2001a). Each of the 30

objects can be broken down into various categories and subcategories for example, living things:

animals, which can aid the examinee in correctly guessing the item in as few guesses as possible.

While this subtest was based upon a similar test developed by Mosher and Hornsby (1966),

 
 
 27
 

several modifications were made to the version found in the D-KEFS. Key areas of executive

functioning tapped by this subtest include the ability to recognize categories and subcategories,

abstract question formation, and efficiency in problem-solving.

Tower Test. This test has its roots in several earlier tests such as the Towers of Hanoi,

London, and Toronto, but extensions in score ranges were made by including both easier and

more difficult items so as to improve the overall psychometrics of the test (Delis et al., 2001a).

Here examines are presented with n number of discs of varying sizes in a specific array and are

asked to arrange the discs on the board so that they match the stimulus picture presented, and to

do so in as few moves as possible. There are a number of rules the examinee has to follow, such

as moving only one ring at a time and never placing a larger ring on top of a smaller ring. In

each subsequent part the number of rings and the complexity of the moves required to

successfully complete the task increases. This test taps into spatial planning, rule learning,

inhibition of impulsive responding, inhibition of perseverative responding, and establishing and

maintaining instructional set (Delis et al., 2001a).

Proverb Test. This subtest was originally developed in 1988 by the originators of the D-

KEFS and consists of 8 sayings that are presented to the examinee, who is asked to offer an

interpretation into the meaning of the saying (Delis et al., 2001a). Interpretation of this test

includes insights into the examinee’s verbal abstraction skills.

Word-Context Test. The original Word Context Test, developed by Edith Kaplan and

Heinz Werner, is believed to assess the acquisition of word meaning in children (Delis et al.,

2001). Previous research established that performance on this measure required several higher-

level cognitive abilities. The examinee is shown a pseudo-word and tries to discover its meaning

by interpreting a series of clues that begin generally and then narrow down in precision. A

 
 
 28
 

higher score is one that requires as few clues as possible to solve the mystery. Executive

functions tapped by this subtest include: verbal modality and assessing skills such as deductive

reasoning, integration of multiple bits of information, hypothesis testing, and flexibility of

thinking.

The D-KEFS subtests can be administered individually or in concert to provide more

comprehensive evaluation of frontal lobe integrity. Table 5 presents current research

demonstrating regions of frontal lobe dysfunction based upon individual D-KEFS subtests.

Studies evaluating anatomical correlates for all D-KEFS subtests could not be found. In these

instances, tests the D-KEFS subtests were based upon were substituted.

Purpose of Present Study

The purpose of the current study was to further examine the relationship between

executive functioning and adults diagnosed with ADHD. If impaired executive functioning is

observed, the implications for disrupted frontal lobe function will add to the literature

implicating frontal lobe dysfunction in ADHD. While executive functioning has been well

researched in children and adolescents with ADHD, there still remains a paucity of research

looking at these functions in the adult population (Tannock, 1998). Earlier studies have varied in

numerous ways in methodology, diagnostic criteria, and results. None of the studies to date have

employed as comprehensive a battery of frontal lobe functioning as the D-KEFS, and few have

employed a process-oriented analysis. Inasmuch as no study could be found that examined the

relationship between executive functioning in adults with ADHD using the D-KEFS, a

comprehensive tool for assessing the complex multifactorial domains of frontal lobe functioning

(Homack et al., 2005), it seemed only logical that adults with ADHD should be evaluated using

this test.

 
 
 29
 

Table 5

Anatomical Correlates of D-KEFS Subtests and Related Measures

Subtest Study Findings

Trail Making Test Stuss et al. 2001 Error analysis was most revealing. All subjects with 1 or more errors had
frontal lobe lesions. Subjects with greater number of errors had lesions in the
dorsolateral frontal areas.

McDonald et al. Subjects with frontal lobe epilepsy were more impaired on a set-shifting task
2005 compared to subjects with temporal lobe epilepsy. Suggesting frontal lobe
involvement for set-shifting processes.

Yochim et al. 2007 Subjects with LPC lesions performed worse on Conditions 2, 3 and 5 and were
slower on Condition 4. LPC lesion subjects also committed more errors on
Condition 4.

Verbal Fluency Test Levin et al. 2001 Interaction of age with site of lesion detected as adolescents with left frontal
lesions had greater deficits on verbal fluency task.

Phelps et al. 1997 Activation of prefrontal cortex, left inferior frontal and anterior cingulate
cortex on task of verbal fluency.

Cuenod et al. 1995 Activation of left premotor cortex and left dorsolateral prefrontal cortex on
task of verbal fluency.

Design Fluency Test Kramer et al. 2007 Found in a sample of 101 subjects after controlling for working memory, only
left and right frontal lobes correlated with nonverbal set-shifting task.

Color-Word Interference Stuss et al. 2001 Frontal lobe lesions produced significant impairment. Left dorsolateral frontal
Test lobe damage resulted in increased errors and slowness of response for color
naming. Bilateral superior medial frontal lobe damage was associated with
increased errors and slowness in response time for incongruent condition.

Carter et al. 1998 In an fMRI study of a different task that incorporated some of the demands of
the Stroop, both lateral frontal regions appeared recruited for monitoring and
detecting errors and both cingulate regions appeared activated for sustaining
attention during interference.

Sorting Test Parmenter et al. Poorer performance on Sorting Test correlated with brain atrophy in MS
2007 subjects even after controlling for depression. Significant difference in number
of sorts, description score, and repeated sorts.

Twenty Questions Test Marshall et al. Subjects that had sustained close head injuries and had diverse cerebral
2003 damage ask few constraint-seeking questions and had poorer question-asking
efficiency. Total number of questions asked did not differ.

Goldstein et al. Subjects with severe close head injury required more questions and used poor
1991 strategy for solving task compared to control.

Tower Test Levin et al. 1994 Found correlation between head injury and deficits on Tower of London Test.
Larger frontal lesions in the orbital, dorsolateral and white matter of the frontal
lobes predicted greater cognitive impairment.

 
 
 30
 

Research Hypothesis

According to the null hypothesis (H0) there will be no relationship between diagnostic

classification and the domain of executive function. More specifically, poorer individual

performance on measures of higher-cognitive function will not be associated with a diagnosis of

ADHD. This is to say that the two are independent of each other. This relationship is

represented as H0: ρ = 0. Alternatively, should the null hypothesis be rejected and the alternative

hypothesis (HA: ρ ≠ 0) accepted, then empirically one could state with more confidence that there

is a linear relationship suggesting some level of effect between these variables. Based upon the

literature, the following hypotheses were explored.

Hypothesis I. Adults with ADHD will perform more poorly as a group overall on

primary level-of-performance scale scores from the DKEFS. Furthermore, it is anticipated that

most notable differences will be seen in the domains of set-shifting, fluency, and response

inhibition, and that the subtests that theoretically tap into these domains will exhibit the greatest

level of significant difference. Specifically, the following subtests will exhibit the greatest

degree of difference: Trail Making Test: Condition 4 (set-shifting), Verbal Fluency Test:

Conditions 1, 2 and 3 (fluency), Design Fluency: Conditions 2 and 3 (fluency), Color-Word

Interference Test: Conditions 3 and 4 (set-shifting and response inhibition), and Tower Test

(response inhibition).

Hypothesis II. As a group the ADHD subjects will perform significantly different from

control subjects on process-oriented analysis. Specifically it is expected that subjects with

ADHD will make more errors on Condition 4 of the TMT, have greater set-loss errors on both

verbal and design fluency tasks, and make more errors on Condition 3 and 4 of the CWIT.

 
 
 31
 

Objective. The current study evaluated the effectiveness of using the DKEFS as a

diagnostic tool for evaluating ADHD in adult male populations. As is stated in the first

hypothesis, it is expected that ADHD subjects will perform significantly different from matched

control subjects. It is hypothesized that because ADHD subjects have been shown to have

similar deviations in neuroanatomy, specifically with regions associated with mediation of

attention and concentration, they will perform similarly to each other on DKEFS items and that

this similarity may suggest a diagnostic pattern. This pattern is expected to exist for both level-

of-performance and process-oriented analysis.

Method

Participants

The ADHD sample group consisted of thirty-seven right-handed adult males between the

ages of 22 and 53 with an average age of 27.4 (SD = 6.8). Diagnostically, the combined subtype

comprised 54.1% of the sample (n = 20) with 21.6% (n = 8) having the impulsive-hyperactive

subtype, and the remaining 24.3% (n = 9) having the inattentive subtype. Forty-three percent (n

= 16) of those in the experimental group had a comorbid diagnosis. Ethnicity representations

included Caucasian (n = 32, 86.5%), Hispanic (n = 3, 8.1%) and Asian (n = 2, 5.4%).

Participant education ranged from 12 to 18 years (M = 14.3, SD = 1.2), and the average IQ was

118.2 (SD = 8.38). All participants reported being currently enrolled in local universities,

gainfully employed or both.

Participants in the control group were matched as closely as possible to the experimental

group based on age and education status, and consisted of 37 right-handed adult males ranging in

age from 18 to 45 (M = 24.1, SD = 5.9). Thirty-seven percent (n = 14) had a diagnosis other than

ADHD (e.g., mood disturbance, anxiety, etc) while the remaining 23 reported no current or prior

 
 
 32
 

history of mental health concerns. Ethnic representations among the control group included

Caucasian (n = 30, 81.1%), Hispanic (n =3, 8.1%), Asian (n = 2, 5.4%) and other (n = 2, 5.4%).

Education ranged from 12 to 16 years (M = 13.8, SD = 1.2) and the average IQ was 113.7 (SD =

9.43). Participants in the control group all reported current enrollment in local universities,

gainful employment or both.

Participants in both groups were made up of convenience samples from the Utah County

area and recruited primarily from a private outpatient mental health clinic, University

Accessibility Center (UAC) or the university general population. Participants in the

experimental group were previously diagnosed with ADHD by clinicians at either the private

outpatient clinic or UAC. The participating clinics provided individuals with a diagnosis of

ADHD a flyer outlining the current study. Contact information was provided on the flyer and

individuals with questions or interest in participating were directed to contact the principle

investigator. Exclusion criteria were set prior to the start of the study and included: self-reported

history of any type of TBI, including concussion, loss of consciousness (LOC) or trauma

requiring medical attention, history of illicit drug use, or current use of pharmacological agents

for treatment of ADHD.

Currently, there are no definitive guidelines regarding pharmacologically treated ADHD

subjects discontinuing medication for the purpose of obtaining baseline testing. While some

debate continues about the benefits of stimulant-mediated performance on neuropsychological

evaluation, there is increasing evidence that active treatment of stimulant medication, as is

commonly used for the treatment of ADHD, enhances performance on cognitive tests (Pietrzak,

Mollica, Maruff, & Snyder, 2006), whereby artificially masking cognitive and executive

dysfunction associated with the disorder. In addition, there is no clear evidence that

 
 
 33
 

discontinuation of stimulant medication causes any sort of withdrawal state or exacerbation of

symptoms (Greenhill, Findling, & Swanson, 2002) that might compromise performance.

Therefore, if a participant in the current study was willing to discontinue their medication for the

purpse of testing and did not meet any other exclusion criteria, they were permitted to

participate. Swanson and Volkow (2002) report a fairly brief half-life for stimulants used in

ADHD treatment (3-4 hours to return to baseline symptomatology). Therefore, subjects in the

current study were asked to abstain from their medication for a minimum of 24 hours prior to

their scheduled testing session, with the average participant going 2 - 3 days (abstaining over the

weekend and testing on a Monday afternoon). This is line with the recommendations of Ernst et

al. (2003). Of the experimental group only 16 (43%) subjects were currently taking medication

and therefore requested to discontinue short-term for testing, while the other 21 (57%) were

medication naïve because they had recently been diagnosed with ADHD and yet to begin any

medication, or were not currently utilizing medication for symptom management. None of the

participants reported a history of head trauma, LOC, concussion, or substance abuse resulting in

exclusion from the study; one participant preferred not to discontinue his medication and was

therefore excused from the current study.

As indicated previously, participants in the ADHD group were selected for their

preexisting ADHD diagnosis. While the current sample population was used because of its

convenience, both referring mental health agencies were selected to participate based upon their

rigorous screening and assessment procedures that provided increased confidence that those

diagnosed with ADHD actually meet diagnostic criteria. Both agencies utilized a multifaceted

approach that included use of standardized assessment measures of attention (e.g., Conners’

Continuous Performance Test), self-report questionnaires (e.g., Conners’ Adult ADHD Rating

 
 
 34
 

Scale or the Wender Utah Rating Scale), and a thorough clinical interview by a licensed clinical

psychologist or board-certified psychiatrist specializing in working with ADHD. In addition

each site indicated that, where possible, corroborating information was also considered in

making the final ADHD diagnosis.

Participants in the control group were recruited via flyer and/or referral from the

outpatient clinic and university classrooms. Participation in either group was completely

voluntary and no monetary compensation or feedback on test performance was offered. A few of

the control participants were eligible to receive concomitant course credit for participating in

research conducted on campus and in such cases, the appropriate notification was provided to

their instructor.

Procedure

The current study was approved by the Brigham Young University IRB committee.

Before participants were admitted into the study, each received and was required to provide

signed informed consent. Participants then completed a demographics questionnaire, cognitive

testing and the DKEFS. Testing was conducted at either the outpatient clinic or in a private

office on campus by one of two fourth-year doctoral students trained in clinical psychology and

neuropsychological test administration. At the beginning of each testing session, each

participant was reminded of the conditions of their consent. Testing was typically completed in

one session and occurred primarily in the late afternoon, with most sessions lasting between 2-3

hours. Regular breaks were offered. While participants were informed of their right to

discontinue testing at any time during the session, all participants completed the full battery of

measures and no participant gave indication of any excessive discomfort or negative outcome as

a result of participation in the study. Upon completion, tasks were scored by the principle

 
 
 35
 

investigator and later double checked to assure accuracy. Completed scores were then entered

into a spreadsheet, checked for errors and analyzed using SPSS.

Measures

Delis-Kaplan Executive Functioning System (DKEFS). A detailed description of the

DKEFS has been provided above; therefore the following description will only include reported

psychometrics. Reliability and validity for the DKEFS are listed by age group for each subtest

and reported in the technical manual that accompanies the test battery (Delis et al., 2001b).

There is some variance reported in the manual for individual subtests’ reliability and validity

(ranging from the low to high range), with some in the literature being more critical of these

claims suggesting that more work is needed to establish the reliability and validity of the DKEFS

itself. In their critical review, Homack et al. (2005) point out that the psychometric properties,

specifically split-half reliability, as reported in the technical manual vary across subtest,

conditions within subtests, and age groups. Specifically, low to moderate split-half reliability

coefficients were reported for Verbal Fluency Test – Categorical Switching Total Correct (.37-

.68) and Twenty Questions Test – Total Weighted Achievement (.10 – .51). Moderate to high

reliabilities were reported for Verbal Fluency Test – Letter Fluency Condition (.68 – .90, Color-

Word Interference Test (.62 – .86), Sorting Test—Sort Recognition (.62 – .81), Twenty

Questions – Initial Abstraction (.72 – .87), and Proverb Test (.68 – .80). All other subtests fell

within the moderate to good range. Perhaps the greatest strength of the battery is that each of the

nine subtests has been co-normed on a large and relatively representative national sample with

ages ranging from 8 to 89 years.

Wechsler Abbreviated Scale of Intelligence (WASI). The WASI is an abbreviated

adaptation of the well-established Wechsler Adult Intelligence Scale series (WAIS) originally

 
 
 36
 

designed as a screener to briefly assess cognitive functioning in individuals between the ages of

6 and 89 years (Psychological Corporation, 1999). The entire battery consists of four subtests

(two per verbal and nonverbal domains respectively) that are intended to capture both fluid and

crystallized intelligence within the domains of verbal and nonverbal reasoning abilities (Stano,

2004). In addition, the WASI provides an estimate of a Full Scale Intelligence Quotient

comparable to the Full Scale IQ obtained on the WAIS with a mean of 100 and a standard

deviation of 15. The verbal index consists of the Vocabulary and Similarity subtests, while

Block Design and Matrix Reasoning make up the nonverbal domain. The entire four-subtest

form takes an estimated 30 minutes to administer and is favorable for use in research because of

this brevity and adequate psychometric properties. The test boasts excellent reliability

coefficients as reported by the manual ranging from .84 to .98 for adults (Psychological

Corporation, 1999). Furthermore, the battery has been shown to have excellent convergent

reliability (.86) with other brief measures of cognitive assessment, especially when employing

the Full Scale IQ score (Canivez, Konold, Collins, & Wilson, 2009).

Statistical Approach

All data points were entered and re-entered for verification into SPSS and an overall

multivariate analysis of variance (MANOVA) was run on all dependent executive function

variables with group, ADHD vs. Non-ADHD control, as the between-subjects factor. With so

many dependent variables included in the final analysis and because of their theoretical

relationship under the broad domain of executive function, the use of MANOVA seemed not

only appropriate but necessary to reduce the likelihood of committing a Type I error (Spector,

1981). Finally, individual dependent variables were compared for significance. Significance

 
 
 37
 

was set at the p ≤ .05 level with effect size considerations based upon Cohen’s recommendations:

small (.15 – .39), medium (.40 – .74), large (.75 – 1.09) and very large (≥ 1.10) (Cohen, 1988).

Given that subjects in the present study were not matched for IQ, some may question the

reasoning for using MANOVA instead of MANCOVA, with IQ treated as the regressor of no

interest. Indeed, a longstanding debate continues within the field about whether statistical

adjustment for potentially influencing, yet uncontrolled variables is a mathematically and

theoretically sound practice. Certainly research in the behavioral sciences is limited by what

variables investigator can control or ethically should attempt to control. It seems only natural

and perhaps desirable that employing a formulaic way to artificially adjust for preexisting

differences would be warmly welcomed. However, the debate about use of covariate adjustment

in the behavioral sciences continues, and this is particularly true for the present study: should IQ

be covaried in studies of ADHD? The rationale in the current study to forgo covariate analysis is

based upon the recommendations of Lord (1967, 1969) and those of Dennis et al. (2009). In his

early publication on the issue, Lord utilized a simple illustration to demonstrate how disparate

conclusions can be drawn from the same data set depending on which statistical analysis one

employs. Lord concludes that while adjusting for actual preexisting differences may be

desirable, there is not a logical or statistical formula that can validly adjust for these unwanted

differences. Regarding the relationship of IQ and ADHD Dennis et al. (2009) expressed this

view:

Attempting to control for IQ differences when examining specific neuropsychological

deficits like executive function in ADHD (Barkley et al., 2001; Murphy et al., 2001) is

methodologically tenuous (Frazier et al., 2004) because decrements in overall ability are

a feature of ADHD (and of any neurodevelopmental disorder defined in terms of

 
 
 38
 

cognitive-behavioral deficits), making statistical “control” impossible (Campbell &

Kenny, 1999, pp. 338-339).

Results

Box’s M is a statistic that provides information on the homogeneity of the variance-

covariance matrix used in multivariate analysis. Therefore, when this statistic is significant (p ≤

.01) the null hypothesis is rejected and significant difference between covariance is assumed. It

is preferable that when evaluating data points the assumption of homogeneity not be violated,

although, as Tabachnick and Fidell (2001) point out, when utilizing multivariate analysis (i.e.,

MANOVA) and sample sizes are equal across cells, MANOVA is remarkably robust and

resistant to the effects of this violation. For the current study Box’s M was found to be

significant (p < .001). Given equal sample sizes and the recommendations of Tabachnick and

Fidell (2001) proceeding with the multivariate analysis is acceptable. Levene’s test of

homogeneity of variance across dependent variables was non-significant in all cases except: Trail

Making Test: Condition 5 (p < .01); Trail Making Test: Total Errors (p < .01); Color-Word

Interference Test: Condition 2 (p < .01); and Proverb Test: Achievement (p < .01). As indicated,

MANOVA is considered a robust test against violations of the assumptions of homogeneity;

however, individual examination of group differences on these items may not be valid.

Group Comparisons

The overall MANOVA for all dependent executive function measures showed a large

effect for ADHD diagnosis (Wilks’ λ = .244, F(32,41) = 3.98, p < .001, η2 = .76). The two

groups were statistically equal in domains of education, t(72) = -1.88, p = .06, and age, t(72) = -

1.79, p = .08. However, the ADHD group had a higher IQ (M = 118.2) than the Non-ADHD

 
 
 39
 

control group (M = 113.7), t(72) = -2.16, p = .03. Group means, standard deviations and effect

sizes are shown in Table 6.

Trail Making Test. For the Trail Making Test group differences were found for the

level-of-performance measures of Condition 4 (Letter-Number Switching task) and Condition 5

(Motor Speed Task). In both cases, members in the experimental group were slower to complete

the specified task. The former is believed to assess higher-order abilities of cognitive flexibility

and response inhibition, while the latter measures visual-motor speed, believed to be a lower-

order function. In addition, group difference was found when comparing the total number of

errors made for the switching task, a process-oriented measure. The ADHD group, as a whole,

scored lower on this measurement suggesting they were more prone to making errors than their

control counterparts.

Verbal Fluency Test. No group difference immerged on any of the level-of-

performance or process-oriented scores. This measure assesses phonemic and categorical

fluency along with inhibition and cognitive flexibility.

Design Fluency Test. Only Condition 2 (Empty Dots Only) showed a notable group

difference. The ADHD group as a whole created fewer correct designs when the novel task of

inhibition was added to the instruction set.

Color-Word Interference Test. No group differences emerged on measures assessing

lower-order functioning (i.e., color naming or word reading) but when task difficulty was

increased by adding higher-order functions of response inhibition and cognitive flexibility, those

with a diagnosis of ADHD had slower time to completion scores. Surprisingly, performance on

process-oriented approach measures (i.e., total error commission) showed no group differences.

 
 
 40
 

Table 6

Group differences among DKEFS scores

Control ADHD
DKEFS n = 37 n = 37
M SD M SD F Cohen’s d

Trail Making Test: Condition 1 10.16 2.52 10.19 2.63 .002 .01

Trail Making Test: Condition 2 11.19 2.04 11.57 1.64 .773 .21

Trail Making Test: Condition 3 12.14 1.77 12.00 1.61 .118 .08

Trail Making Test: Condition 4 11.41 1.66 10.43 2.5 3.89* .46

T rail Making Test: Condition 5 12.62 0.64 11.92 1.75 5.24* .54

Trail Making Test: Total Errors 11.54 1.15 10.70 1.53 7.14** .63

Verbal Fluency Test: Letter Fluency 12.38 2.60 12.05 3.13 .236 .12

Verbal Fluency Test: Category Fluency 13.22 3.04 13.05 3.28 .049 .03

Verbal Fluency Test: Category Switching

12.03 2.53 12.11 2.50 .019 .05
Total
Verbal Fluency Test: Category Switching
12.38 2.48 12.19 2.27 .117 .08
Accuracy
Verbal Fluency: Setloss Errors 11.46 1.48 11.43 1.71 .005 .02

Verbal Fluency: Repetition Errors 9.76 2.57 9.84 2.48 .019 .03

Design Fluency: Condition 1 11.22 2.57 11.19 2.72 .002 .01

6.051*
Design Fluency: Condition 2 12.62 2.63 11.11 2.66 .58
*

Design Fluency: Condition 3 12.51 2.98 12.32 3.14 .071 .06

Design Fluency: Setloss Errors 11.38 2.47 11.73 1.97 .459 .16

Design Fluency: Repetition Errors 11.76 1.89 11.97 1.24 .339 .13

Color-Word Interference Test: Condition 1 10.70 2.21 10.46 2.43 .203 .10

Color-Word Interference Test: Condition 2 11.70 1.63 10.81 3.40 2.064 .17

Color-Word Interference Test: Condition 3 11.24 2.39 9.78 3.34 4.673* .25

Color-Word Interference Test: Condition 4 11.30 2.69 9.73 2.34 5.138* .53

*p ≤ .05; **p ≤ .01.

 
 
 41
 

Table 6. (continued)

Control ADHD
DKEFS n = 37 n = 37
M SD M SD F Cohen’s d
Color-Word Interference Test: Condition 3
10.49 2.26 9.76 2.77 1.542 .29
Total Errors
Color-Word Interference Test: Condition 4
10.92 1.51 10.76 1.96 .158 .09
Total Errors
Sorting Test: Confirmed Correct 11.08 1.93 12.14 2.18 4.851* .52

Sorting Test: Free Sort Description 10.70 2.23 12.08 2.65 5.852* .57

Sorting Test: Recognition Description 9.76 2.61 11.62 2.61 9.386** .72

Twenty Questions: Abstraction 11.78 3.27 11.86 1.49 .014 .03

Twenty Questions: Total Questions 11.43 1.64 10.76 2.03 2.473 .37

Twenty Questions: Achievement 11.62 2.02 11.22 2.39 .620 .18

Word Context Test: Total Correct 10.95 1.81 12.57 2.01 13.32** .86

Tower Test: Achievement 11.54 3.25 11.73 2.21 .085 .07

Proverb Test: Achievement 11.84 1.83 11.46 1.15 1.134 .25

Note. Mean scores are Scaled Scores that have been converted based upon the individual’s raw data and age as
prescribed by the DKEFS Technical Manual. In all cases, a higher score indicates more favorable performance.
*p ≤ .05; **p ≤ .01

That is to say, those with ADHD required longer times to complete the more difficult task but

were able to do so without committing more errors than the control group.

Sorting Test. Participants in the ADHD group performed better on all level-of-

performance and process-oriented domains assessed suggesting more efficient verbal/non-verbal

concept-formation.

Twenty Questions Test. No group differences emerged on level-of-performance or

process-oriented scores. This measure assesses categorical identification, abstraction, and

working memory.

 
 
 42
 

Word Context Test. For the Word Context Test only the level-of-performance score

was used, which showed a significant group effect. Those with ADHD performed better than

their non-ADHD control counterparts.

Tower Test. On the level-of-performance score, a measure of spatial planning, abstract

problem-solving and inhibition of impulsive responding, no significant group differences

emerged. This task is believed to require spatial planning, inhibition and problem solving

abilities.

Proverb Test. There were no group differences on this measure of verbal abstraction.

This suggests no difference between groups for verbal abstraction and knowledge of social

conventions.

Post hoc review of the data revealed several diametric outliers of IQ scores in both the

experimental and control groups. In the ADHD sample no subjects had a Full Scale IQ lower

than 100 while five subjects in the control group fell in the mid 90 range. Conversely, several

subjects in the experimental group were found to have IQ scores higher than 128 while only one

in the control group was above this level. To assess the impact of these outliers, subjects were

matched for IQ with the outliers removed, and the data were reanalyzed (n = 28 for each group).

As before, no group differences were found for age or education. However, the group means for

IQ were now similar (ADHD M = 114.71; Control M = 114.32, p = .80). The interaction

between group and executive function was still very robust, Wilks’ λ = .016, F(32,22) = 41.58, p

< .001, η2 = .98. Group means, standard deviations and effect sizes for the adjusted sample are

shown in Table 7. In general, removal of outliers resulted in more robust findings suggesting

poorer performance on multiple DKEFS measures in the study group compared to the control.

 
 
 43
 

Table 7
Group differences among DKEFS scores with outliers removed

Control ADHD
DKEFS n = 28 n = 28
M SD M SD F Cohen’s d

Trail Making Test: Condition 1 10.07 2.75 9.71 2.77 3.62 .13

Trail Making Test: Condition 2 11.00 2.31 11.25 1.71 .104 .12

Trail Making Test: Condition 3 12.11 1.99 12.11 1.77 .294 .00

Trail Making Test: Condition 4 11.39 1.71 9.79 2.41 4.77** .76

T rail Making Test: Condition 5 12.57 .690 11.57 1.84 3.58* .72

Trail Making Test: Total Errors 11.61 1.10 10.71 1.68 3.25* .63

Verbal Fluency Test: Letter Fluency 12.43 2.87 11.32 3.08 1.32 .37

Verbal Fluency Test: Category Fluency 12.79 2.5 12.86 3.46 1.49 .02

Verbal Fluency Test: Category Switching

12.21 2.88 11.61 2.31 9.54** .23
Total
Verbal Fluency Test: Category Switching
12.50 2.82 11.71 1.99 8.82** .32
Accuracy
Verbal Fluency: Setloss Errors 11.50 1.62 11.32 1.66 .084 .11

Verbal Fluency: Repetition Errors 9.79 2.67 9.82 2.42 .021 .01

Design Fluency: Condition 1 11.29 2.67 10.29 1.41 1.52 .47

Design Fluency: Condition 2 12.32 2.79 10.64 2.18 3.17* .67

Design Fluency: Condition 3 12.25 2.96 11.21 2.46 1.31 .38

Design Fluency: Setloss Errors 11.21 2.71 11.93 2.12 2.06 .30

Design Fluency: Repetition Errors 11.54 2.06 12.29 1.12 5.62 .45

Color-Word Interference Test: Condition 1 10.36 2.41 10.5 2.03 .425 .06

Color-Word Interference Test: Condition 2 11.71 1.86 10.39 3.66 1.49 .45

Color-Word Interference Test: Condition 3 10.79 2.39 9.00 3.36 3.45* .61

Color-Word Interference Test: Condition 4 10.93 2.78 9.14 3.49 2.37 .57
Color-Word Interference Test: Condition 3
10.14 2.40 9.61 2.9 2.20 .20
Total Errors

 
 
 44
 

Table 7 (continued)
Control ADHD
DKEFS n = 37 n = 37
M SD M SD F Cohen’s d
Color-Word Interference Test: Condition 4
10.93 1.70 10.57 2.22 6.37* .18
Total Errors
Sorting Test: Confirmed Correct 11.57 1.84 11.57 2.13 0.30 .00

Sorting Test: Free Sort Description 11.14 2.26 11.43 2.60 0.31 .12

Sorting Test: Recognition Description 10.11 2.28 10.82 2.37 2.97 .31

Twenty Questions: Abstraction 12.68 3.24 11.79 2.13 1.95 .32

Twenty Questions: Total Questions 11.36 1.70 10.39 2.02 3.34* .52

Twenty Questions: Achievement 11.79 1.99 10.61 2.04 6.79** .59

Word Context Test: Total Correct 11.11 1.73 12.11 1.93 5.11** .55

Tower Test: Achievement 11.68 3.10 11.46 1.93 4.19* .13

Proverb Test: Achievement 11.68 1.98 11.32 1.19 5.02** .22

Note. Mean scores are Scaled Scores that have been converted based upon the individual’s raw data and age as
prescribed by the DKEFS Technical Manual. In all cases, a higher score indicates more favorable performance.
*p ≤ .05; **p ≤ .01.

Discussion

Summary of Findings

The current study evaluated performance on tasks of executive functioning as measured

by the Delis-Kaplan Executive Functioning System in adult males with a diagnosis of ADHD by

comparing their performance to a sample of culturally similar, non-ADHD community

constituents. The study originally proposed to investigate three main questions: (1) do adult

males with ADHD show a difference in performance on overall measures of executive function

as measured by the DKEFS, (2) what differences, if any, emerge between the two groups on both

level of performance and process-oriented approaches; and (3) does a specific clinical profile

observable across DKEFS measures emerge and if so, is there diagnostic utility.

 
 
 45
 

The current findings are consistent with an increasing body of evidence suggesting

ADHD is a neurologically based disorder involving frontal lobe difficulties (Almeida et al.,

2010; Cubillo et al., 2010; Woods et al., 2002). Using multivariate analysis, group comparisons

found overall significant group differences on neuropsychological measures of executive

functioning. As has been previously discussed, the frontal lobes are widely accepted to be the

anatomical seat of executive function we conclude, therefore that, overall impairment in

executive control, as seen in this sample of adult males with ADHD, is likely reflective of

disruption to or under-development of those underlying anatomical correlates responsible for

organization and execution of higher-order functions.

Several group differences were found on specific tasks of higher-order functioning and

between process-oriented scores that are mediated, in part, by self-monitoring and response

inhibition. While many of the observed differences were anticipated, others were found that

were not predicted by the original hypothesis. As expected, the ADHD group took longer to

complete condition 4 from the Trail Making Test, which requires response inhibition, and made

more errors overall, but unexpectedly they also took longer to complete condition 5, a measure

of simple motor speed, motor control, and visual scanning. Interestingly, post hoc review found

that a small sub-group of individuals in the ADHD group (24%) made at least one error on this

task compared to 5% in the control group. Most often the error occurred when the individual

failed to inhibit a response to connect two adjacent circles instead of following the prescribed

line to a more distant target circle. Figure 3 shows the response form of an individual from the

study group with the described error type delineated.

While previous reviews have suggested impaired fluency (Woods et al., 2001), the

current study’s findings are more consistent with the findings of Desjardins, Scherzer, Braun,

 
 
 46
 

Figure 3. Sample of co ommon sequeencing error committed

c onn the TMT Coondition 5 in A ADHD samplle.
The large circle identiffies the site off the error preesent in 24 peercent (n = 9) of the experimental groupp.

 
 
 47
 

Gldbout, and Poissant (2010); that is, no measureable difference on tasks of pure phonologic and

categorical verbal fluency, even with outliers removed. However, with the added difficulty of

having to alternate between generating words from differing categories (cognitive flexibility)

those with ADHD were less capable than their IQ-matched peers.

Surprisingly, only Condition 2 of the Design Fluency Test was found to have a

significant difference between the two groups with the study group generating fewer designs

overall. Although both Condition 2 and 3 theoretically involve inhibition, Condition 3

introduces greater demand with the addition of a switching component and it was predicted that

those with ADHD would be more impeded on this measure as well. This was not found to be the

case. Rather, no difference emerged between the two groups. It is possible that, while inhibition

plays a role in successful management of this task, there are other factors that also must be

considered. Latzman and Markon (2010) conducted a factor analysis of the DKEFS and found

three main factors emerge: Conceptual Flexibility, Monitoring and Inhibition. While the Design

Fluency subtest loaded most directly onto Inhibition, this loading was relatively weak compared

to the other subtests that also loaded on this factor (e.g.,Color-Word Interference Test).

Therefore, there must be some other factor mediating performance.

Achievement across all three conditions of the Design Fluency Test is measured by total

number of novel designs. A fundamental issue relating to good performance, then, is the use of a

strong strategy that allows the individual to rapidly construct multiple designs while limiting

repetition errors. Indeed, an approach in which the individual makes small sequential changes to

their design facilitates both the need for rapid design output while minimizing the amount of

errors committed. Such a process also reduces the need for effortful error monitoring as long as

the individual follows their strategy’s prescribed sequential change pattern. Therefore, adequate

 
 
 48
 

performance, in part, likely becomes a measure of organization, creativity, and fluid reasoning.

It is probable that while those with ADHD struggled with the added inhibition element of

Condition 2, that on the third trial of this overall fluency exercise (Condition 3) they had

developed a useful strategy that reduced the overall difficulty of the task. This explanation is

further supported by a quick comparison of the mean differences between the original

experimental group and the adjusted, IQ-matched sample (see table 6 and 7). When the effects

of fluid intelligence were reduced the difference between the two group means became larger,

although it still did not reach significant levels.

Consistent with the predictions of hypothesis I, those with ADHD showed slower time-

to-completion on both Condition 3 and 4 of the Color-Word Interference Test, which are analogs

of the original Stroop Color and Word Test. Furthermore, as predicted, performance on measures

of lower-level functioning (reading/color naming) did not differ between groups with or without

outliers removed. Poorer performance in individuals with ADHD on the similar Stroop measures

has long been established and the current project continues to add to that base (Antshel et al.,

2010). This study’s second hypothesis predicted that in addition to taking longer to complete,

that those with ADHD would commit more inhibition related errors. The current results are

mixed. Based upon the overall sample, no significant difference in error commission was found.

However, when subjects were matched for IQ and outliers removed those in the ADHD group

were found to commit more errors on Condition 4 (inhibition and flexibility) whereas the time-

to-completion score was now similar. Why this reverse was observed for Condition 4 when

outliers were removed is not fully known. It may be that within the overall ADHD group there

were subgroups that differed on their focused approach to the task. As part of the instruction set,

the examinee is told to work as quickly as possible without making any mistakes. If an

 
 
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individual became fixated on rapidly responding they would be less likely to inhibit the pre-

attentive, incorrect response and make more errors. Whereas, if more emphasis is placed on

accuracy of responding the individual would make fewer errors but at the overall cost of time

(Delis et al., 2001a). It is possible that within the current experimental group that there were

those that focused primarily on accuracy over speed while others focused more on sacrificing

accuracy for speed. This details why a process-oriented approach to clinical interpretation of

scores is so valuable because if one only paid attention to the level-of-performance score

clinically rich data could be lost (Cato et al, 2004).

On all three measures of the Sorting Test that were examined, the ADHD group

outperformed the non-ADHD sample. However, in post hoc analysis when the samples were

adjusted to match for IQ these significances disappeared. One possible explanation for this

observation may be in the IQ difference between the two groups. Davies (2005) generally found

moderate to strong positive correlations between full scale IQ and performance across DKEFS

measures including Sorting Recognition. However, a significant correlation was not found for

the Sorting Confirmed Sorts or Sorting Description measure. In that study correlation between

IQ and DKEFS scores were made both overall and broken down into nine different age groups.

It should be noted that the overall sample size was large (n = 197), but when the data were

broken down by individual age groups correlation between IQ and the Sorting Test could not be

calculated due to an insufficient number of Sorting Test administrations. While the Sorting Test

was included in the IQ-DKEFS correlations for the entire population, no total number of Sorting

Test administrations was reported, and therefore, the study may have lacked sufficient power to

detect the correlation. An alternative explanation is that in this particular sample of individuals

with ADHD those underlying functions contributing to the overall level of performance on the

 
 
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Sorting Test are not only spared, but perhaps well-developed compared to their non-clinical

peers.

Significance between scores on measures of the Twenty Questions Test was not found

with the overall sample; however, post hoc review found that in the IQ-matched group

significance emerged, suggesting that the ADHD sample, overall, may have utilized less efficient

strategies such as random guessing. Intellectual advantage in the non-adjusted sample is a

probable explanation for why no difference was found in the original experimental sample.

In both the original analysis and the post hoc adjusted analysis, performance on the Word

Context Test was found to be in the favor of the experimental group. That is, the control group

performed poorer on this measure. There is no definitive explanation for this finding. However,

it is plausible that as a group, those with ADHD inherently have at their disposal some

underlying skill set that provided them an advantage on this measure. Indeed, much of the

research to date addressing ADHD focuses on a deficits model and fails to explore, or at least

consider that while on whole the symptom cluster of ADHD suggests impaired executive

functioning, there may be a set of adaptive abilities that are well developed and provide these

individuals with a functional advantage. Such a claim is intriguing but well beyond the scope

and power of this study; however, the author of this work recommends that while ADHD will

likely continued to be conceptualized as an executive disorder, future research should explore the

notion that as a developmental cluster, ADHD may have some selective advantage.

Contrary to predictions, no group difference was found on the Tower Test for the overall

sample. A mild significance was found on post hoc exploration when outliers were removed,

however, the effect size was small (.13) and of no clinical utility. Existing research utilizing

similar assessment measures (i.e., Tower of Hanoi, Tower of London) has shown equivocal

 
 
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results (Riccio, Wolfe, Romine, Davis, & Sullivan, 2004) but the current study anticipated that

the increase range of difficulty offered by the Tower Test in the DKEFS battery might offer more

discriminate clarity (Delis et al., 2001a). While in the IQ-matched group the experimental group

showed slightly poorer performance, it cannot be said without equivocation that deficits of

response inhibition greatly impact performance on this measure. Rather, further research is

required to more completely identify the role, if any, that deficits of response inhibition, as

experienced by those with an organic based attention deficit, have on performance on this

particular measure. It is very plausible that while response inhibition can impact an individual’s

tower performance that other performance factors (i.e., problem-solving or spatial planning) are

more salient demands.

Similarly to the results on the Tower Test, no group difference emerged on the Proverb

Test. However, when matched for IQ, individuals with ADHD were found to have the

disadvantage. Again this was not clinically significant and may reflect actual impairments

mediated by the underlying defective substrates implemented in ADHD or may reflect some

other unknown variable unique to the current study’s population. Further studies will need to

explore this further.

While statistical differences were found between those with ADHD and healthy controls,

the findings were not as robust as those reported elsewhere in the literature (Antshel et al., 2010;

Biederman et al, 2009; Schwartz & Verhaeghen, 2008), and this was surprising. A couple of

explanations are possible here. First, the current experimental group may be more an exception

than a rule as it relates to cognitive abilities. There is strong evidence to suggest that a

representative ADHD sample will have below average scores on measures of intelligence

(Bridgett & Walker, 2006; Dennis et al., 2009.) and are often significantly lower than control

 
 
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groups. This was not the current case. Rather, the ADHD subjects were found to have higher

overall scores on intellectual measures. Executive function and cognitive capacity are not

mutually independent but share significant overlap and thereby directly influence one another

(Tillman, Bohlin, Sorensen, & Lundervold, 2008) and current measures fail to purely isolate one

functions of one domain or the other (Davis, 2005). For example, many measures used to assess

cognitive capacity require more executive level functions (e.g., planning, reasoning, etc.)

Therefore, a true executive dysfunction will also impact scores on intellectual tests and may

artificially deflate them. Based upon this notion, the current experimental group’s intellectual

scores may not accurate reflect the group’s true capacity which actually may be higher.

Conversely, higher cognitive capacity would buffer measured impairment on the current tests of

executive function. Wherein one would gain more insight into the degree of individual

impairment by utilizing a intra-individual comparison of abilities rather than a between group

comparison. This is in line with the findings of Brown (2009).

Another potential explanation for the findings in this study relates to the criticism often

levied against objective measures of executive function. An increasing number of researchers

are critical that the current objective measures of executive function lack good ecological

validity. That is to say, these measure do not accurately capture actual deficits as they are

experienced by the individual in the real-world milieu (Chaytor, Schmitter-Edgecombe, & Burr,

2006; Gioia & Isquith, 2004; Manchester, Priestley, & Jackson, 2004). The critics assert that the

relatively structured and low-stimulus environment created during objective assessments of this

nature likely provides the individual an environmentally mediated compensatory advantage.

Furthermore, the game-like format of many of these measures exposes the individual to a task

that is novel and very brief. It is likely that most found the assessment interesting and easier to

 
 
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attend to. This is supported in that a large percentage of participants in both groups expressed

intrigue and enjoyment in completing the assessment measures. The issue, then, becomes a issue

of what the individual is capable of (maximum cognitive capacity) versus what the individual

typically experience in their day-to-day interactions (typicality). Truly, the current way of

assessment administration favors maximum performance and gives an estimate of what the

individual is capable on the “best of days” but poorly reflects what the individual experiences

regularly.

A final explanation for the current studies results are related to the third objective of this

study, which was to explore the diagnostic utility of the DKEFS in identifying ADHD in the

clinical population. This objective relates to the applicability in real-world clinical practice. In

practice the main interest is clinical meaningfulness which is often defined by an individual’s

score in relationship to the overall population. Often, diagnostic significance is set at a point

equivalent to 1.5 standard deviations or greater from the mean, although more liberal allowances

would start at only a single standard deviation. While there is strong evidence that the ADHD

group performed poorer on a constellation of executive functioning tasks, there was not a single

measure that approached clinically meaningful levels. That is to say, was at least a standard

deviation below the mean of the normative sample (scaled score ≤ 7). Therefore, a clear ADHD

profile based upon level-of-performance scores did not emerge with this population. In addition,

analysis of the process-oriented scores yielded similar findings: no clear pattern. This is

consistent with the findings of Wodka et al. (2008) who found no clear evidence of deficits on

DKEFS process measures in a large sample of children with ADHD other than a few mild gender

x ADHD subtype interactions.

 
 
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In developing assessment measures emphasis is placed on issues of sensitivity, the

ability of a measure to detect the variable of interest, and specificity, the ability of the measure to

discriminate unrelated variables from the variable of interest. While the DKEFS has shown

adequate sensitive to deficits in executive function, and arguably even mildly captured that in the

current study, it does not appear to be sensitive enough to be diagnostically useful with the

current study’s population. It must be emphasized here that this conclusion can only be related

to the current study’s population and should not be inappropriately generalized to other

populations (e.g., ADHD in lower cognitive functioning individuals). Future studies will need to

explore the clinical utility of the DKEFS with ADHD and other “minimal brain” deficit

disorders. What may emerge, rather, is that the DKEFS is better suited for detecting more

significant deficits of frontal lobe function as seen in other populations (e.g., TBI, dementia, etc).

Despite the lack of a clear clinical profile of significance, some trends did emerge that are

worth noting. Consistent with the current theories and research of ADHD, the current ADHD

sample had greater problems on tasks placing demands on inhibition. Therefore, it could be

expected that an individual with ADHD will show some difficulty on select subtests placing

greater demand on inhibition such as TMT: Condition 4, Design Fluency: Condition 2 and

CWIT: Conditions 3 and 4. Regarding the process-oriented measures, there is some indication

here that those with ADHD may commit more errors on TMT: Condition 4 and CWIT:

Condition 4, although further research is needed to explore the relationship between ADHD and

error commission rates on the DKEFS.

Finally, while not directly addressed in the DKEFS manual, the errors committed by

examinees while completing Condition 5 of the TMT was interesting and may prove to have

diagnostic importance. As indicated previously, those in the experimental group had a higher

 
 
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frequency of committing an inhibition error on this visual-motor integration task. If future

research with the ADHD population shows similar trends, then such an error may become

diagnostically important.

Limitations

The current investigation is limited in some specific ways. Despite effort to recruit as

diverse and representative sample as possible, the author was limited to a convenience sample

that consisted largely of volunteer college-aged Caucasian males from the Utah County area. In

addition, to the inherent limitations imposed by studies utilizing a self-selecting population, the

current sample population was further limited in that the group came from a unique but

homogenous culture. While this is a limitation, it was also strength as all the participants had no

history of alcohol or controlled substance use thereby minimizing the influence of substance-

abuse confounds. Caution is warranted in inferring about findings beyond those listed.

The current study also failed to directly control for an effects associated with

comorbidity. There is clear evidence that other clinical presentations such as mood disturbances,

anxiety, overt psychotic processes or concerns of developmental delay can disrupt executive

functioning in adolescent and adult populations (Beaudreau, & O’Hara, 2009; Clark, Iversen, &

Goodwin, 2001; Degl’Innocenti, Agren, & Backman, 1998; Greenwood, Morris, Sigmundsson,

Landau, & Wykes, 2008; Merchan-Naranjo et al., 2010; O’Hearn, Asato, Ordaz, & Luna, 2008).

However, this is not seen as a significant limitation given that similar disorders (i.e., mood or

anxiety disorders) were included in the control population as well.

Another limitation is that the current study did not have enough participants to evaluate

the possible interaction profile between ADHD subtype classification and performance on

measures of executive function. There is not a clear standard in the current research as whether

 
 
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or not subtype classification (hyperactive, inattentive, combined) should be considered in

conducting research on ADHD in the adult population. In part, this may be a result of the

observed disproportion of ADHD subtype diagnosis seen in the adult population. Estimates

suggest 56-62% have the combined type, 31-37% have the inattentive type, and 2-7% have the

hyperactive type, with over 90% presenting with the chief complaint of inattentive symptoms

(Millstein, Wilen, Biederman, & Spencer, 1997; Wilen et al., 2009). However, the current study

showed some within group variability for those with ADHD and this may reflect actual

differences in performance between subtypes or may represent some other unknown

characteristic of the sample group. It is possible that treating the study sample as homogenous,

when it appears in fact to be heterogeneous, may have confounded the current results and limited

the effect size of the results.

Another limitation of the current study was the way study participants were diagnosed

and subsequently recruited. The diagnosis of ADHD was given prior to recruitment and

dependent upon clinicians at two independent sites. The current study did not control for the

standardization of diagnostic procedures nor could it completely ensure the rigorous quality of

those diagnostic assessments and therefore is limited by the assumption that each participant

with ADHD was accurately classified. In addition, in most cases those in the study group were

diagnosed as adults, and there is some concerns related to the dependence on retrospective

assessment, as current DSM-IV-TR diagnositic criteria require symptom manifestation occur at a

very early age. However, there is support in the literature supporting retrospective diagnostic

practices as being adequately reliable (Kessler et al., 2005), and as detailed in a previous section,

both referring clinics utilized rigorous assessment methods to insure an accurate diagnosis.

Future research should address this concern by employing either a primary or, at the minimum, a

 
 
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secondary diagnostic verification screen of some type (i.e., objective measure, such as the

Wender Utah Rating Scale, and a clinical interview).

A final limitation of the current study is the characteristics of the study group. The

current ADHD sample may not accurately reflect the overall population of adults with ADHD.

There is evidence of mean differences between IQ scores in those with ADHD and aged matched

controls, with the ADHD group typically scoring lower (Bridgett & Walker, 2006; Dennis et al.,

2009; Kuntsi et al., 2004). However, in the current study, the converse was found with the

ADHD sample showing, on average, higher overall scores on measures of intellectual

functioning. Therefore, the current group likely represents an upper extreme (1.5 - 2 standard

deviations above the general ADHD population). Unfortunately the way the current study was

designed biased for this outcome. It is important to remember that the current group was made

up of primarily university students that were referred for participation in the study following a

recent diagnosis of ADHD. For the majority of these individuals this was the first time they had

been diagnosed and only sought an assessment after finding they no longer could easily manage

the organizational demands and academic rigor that university life requires. While each of these

individuals likely displayed ADHD symptoms at much younger ages, their higher intellectual

abilities provided a buffer preserving them from academic failure or adaptive dysfunction earlier

in life and allowed them to evade diagnostic identification. Therefore, it is possible that the

findings in this study may not be generalizable to more typical presentations of ADHD.

Recommendations for Future Research

The current debate over the clinical presentation of adult ADHD is likely to continue for

some time. However, based upon the current results a few recommendations are made to guide

future research. First, given the overall homogenous nature of the population used in this study,

 
 
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it is recommended that future research try to incorporate a more representative sample of ethnic

and cultural backgrounds. Whereas the current study only considered a male population, future

research will want to incorporate a stratified gender sample as well.

There exist differing views on the clinical manifestations of ADHD subtypes with some

reporting little to no difference between cognitive functioning and ADHD subtype (Murphy,

Barkley, & Bush, 2001) while others report adequate difference (Dinn, Robbins, & Harris, 2001;

Gansler et al., 1998). The current study did not have an adequate sample to explore potential

differences between diagnostic subtypes and as discussed, this was a limitation. The variability

in variance found in the current study may reflect underlying differences in

neuropathophysiological substrates associated with each clinical subtype or may have been a

function of some unique attribute of the study group. It will be important given the equivocal

findings in the current literature and the variability seen in the present study that future research

on this topic, especially studies of adult ADHD using the DKEFS, explore any potential subtype-

performance interactions by including large enough samples of differentiated subtypes. This is

consistent with the recommendations of Wood et al. (2001). Furthermore, future studies should

look at the interaction of ADHD subtypes on both DKEFS level-of-performance and process-

oriented measures. Given the within-group variability seen in the current study, additional

insights of underlying substrate impairment may be found should differences emerge on various

process-oriented tasks of the DKEFS.

While an overall correlation between ADHD and executive dysfunction is being

established in the literature, there still remain variable findings and opinions with some

suggesting a unitary underlying mechanism (Barkley, 1997; Boonstra et al., 2010; Sergent, 2000)

and others calling for a multi-component explanation (Schacher et al., 2004; Sonuga-Barke,

 
 
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2002). The current study attempted to add clarity to this debate, and is believed to have done so.

However, as Wood et al. (2001) detailed in their meta-analysis, a portion of the discrepant results

is likely due to a lack of methodological robustness. Inattention and hyperactivity, while key

symptoms of ADHD, are not diagnositically exclusive and are seen in a variety of disorders

including, mood disturbance, PTSD, autism, substance-abuse, psychosis, and cognitive disorders

associated with acquired brain injury, to name a few. Therefore, future research should utilize

appropriate and rigorous methods to ensure accurate diagnostic labeling. In situations where

there is diagnostic uncertainty, the researcher should be conservative and exclude those subjects.

As more pure ADHD samples are studied, the overall cognitive profile, if one does indeed exist,

may become clearer. Furthermore, if such a clear profile does not immerge, this may provide

insight that the underlying mechanism of ADHD is not necessarily unitary but multidimensional.

As discussed in a previous section Dennis et al. (2009) argue that attempts to control for

IQ in populations of neurodevelopmental disorders (i.e., ADHD) is unfounded, if not poor

practice. These recommendations are based upon understanding that neurodevelopmental

disorders (i.e., ADHD) directly impact IQ functioning resulting in overall lower means on

intellectual measures. The use of IQ-matched subjects in post hoc analysis in the current study is

in line with the recommendations of Dennis and her colleagues, who suggest that when a group

is not representative of the overall population of the group (like the current study population)

then manipulation may be appropriate. When the current group was matched for IQ more robust

findings emerged. Moreover, it is likely that if a more representative ADHD sample (lower

intellectual functioning) were used the findings of the current study may have been significantly

different. Therefore, future work will want to ensure a more representative sample relative to IQ.

The results could then be more generalizable and perhaps more clinically relevant.

 
 
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Conclusions

Recent theories of Attention-Deficit/Hyperactivity Disorder have classified it as more a

neurodevelopmental disorder with disruption of the executive system of cognitive functioning.

Although a growing body of research links ADHD to impaired performance on many measures

of executive function mention, no study to date has examined the relationship between adults

with ADHD and performance on the Delis-Kaplan Executive Function System, a battery of

executive function measures. The current study utilized a small sample of adult males with

ADHD to evaluate overall executive functioning, and individual evaluation of level-of

performance, and process oriented measures from the DKEFS. Results found a significant

correlation between ADHD diagnosis and executive function, despite an overall intellectual

advantage in the ADHD group. Process oriented measures yielded more information when IQ

was matched and suggested those with ADHD were more impulsive and prone to making errors

on tasks of inhibition in addition to requiring more time to complete.

Despite these findings, results were not as robust as initially expected. Reasons for this

may have included underlying functional differences in diagnostic subtypes, disproportionately

high intellectual abilities in the study sample, lower ecological validity of measures of executive

function as a result of a highly structured and novel situation, and/or poor sensitivity of the

measure for this population. These findings should lead researcher in future work to explore

interaction of diagnostic subtypes and utilize a more representative sample to explore profile

analysis of the DKEFS. While the current study did not find clear evidence of an ADHD profile

for diagnostic utility, this is not to say that future research will not demonstrate such a profile of

impairment. The current study does, however, provide some recommendations for clinical

utility, and supports the claims of Delis et al. (2001) that the DKEFS has decent construct

 
 
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validity making it adequately sensitive to executive function. The findings from this dissertation

offer a modest contribution to the field and further support the building evidence that ADHD is a

neurodevelopmental disorder with fundamental deficits in overall executive functioning.

 
 
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