Archives oI Clinical Neuropsychology

18 (2003) 317330
Inhibitory capacity in adults with symptoms oI Attention
Decit/Hyperactivity Disorder (ADHD)
Thomas R. Wodushek , Craig S. Neumann
Department of Psvchologv, Universitv of North Texas, P.O. Box 311280, Denton, TX 76203-1280, USA
Accepted 26 March 2002
Abstract
Adult participants Ior the current study were placed into one oI two groups depending on whether
they manifested either high or lowsymptomlevels of Attention Decit/Hyperactivity Disorder (ADHD)
as determined by the Wender Utah Rating Scale. Participants were also assessed on a battery oI cognitive
tasks as well as symptoms oI depression, anxiety and substance abuse. The ADHD symptom groups
were comparable in age and symptoms oI depression, anxiety, and substance abuse. Adults with greater
ADHD symptomatology perIormed more poorly on cognitive measures oI response inhibition (the
Stop-Signal task) and visual attention, compared to those with Iewer ADHD symptoms. Regression
analysis indicated the Stop-Signal task accounted Ior a greater proportion oI the variance oI ADHD
symptomatology than any other cognitive variable. The conclusions from the ndings are discussed in
relation to Barkley`s (1997) selI-regulation model oI ADHD.
2002 National Academy oI Neuropsychology. Published by Elsevier Science Ltd. All rights reserved.
Kevworas. Attention decit disorder; Cognitive processes; Inhibition; Self-report; Neuropsychology; Symptoms
Attention Decit/Hyperactivity Disorder (ADHD), a disorder that involves problems in
attention and inhibition, has been extensively researched in children, and has more recently
become the subject oI studies involving adult participants. Though adult prevalence estimates
remain widely variable and controversial, 5080 oI children diagnosed with ADHD may
continue to exhibit the disorder in adolescence, and 3050 oI these cases persist into adult-
hood (Barkley, DuPaul, &McMurray, 1990). While some adults may not meet all the necessary
DSM-IV (American Psychiatric Association, 1994) criteria oI ADHD, Borland and Heckman
(1996) reported that adults with documented childhood histories oI ADHD continue to
Corresponding author. Tel.: 1-940-565-3788; Iax: 1-940-565-4682.
E-mail aaaresses: trw0004unt.edu (T.R. Wodushek), csn0001jove.acs.unt.edu (C.S. Neumann).
0887-6177/02/$ see Iront matter 2002 National Academy oI Neuropsychology.
PII: S0887- 6177( 02) 00152- X
318 T.R. Woaushek, C.S. Neumann / Archives of Clinical Neuropsvchologv 18 (2003) 317330
exhibit characteristic symptoms of hyperactivity, impulsivity, and concentration difculties
in adulthood.
Despite the controversial nature oI the diagnosis in adulthood(Faraone, 2000), the Iunctional
consequences associated with adult ADHD are signicant. Barkley, Murphy, and Kwasnik
(1996) reported that adults with symptoms oI ADHDobtained lower SES as well as shorter job
tenures compared to healthy controls. Borland and Heckman (1996) reported the same nding
despite equivalent IQ`s and educational attainment between the adults with or without ADHD.
Barkley et al. (1996) also noted that adults with ADHD rated themselves as experiencing
signicantly greater psychological distress compared to controls and reported committing
signicantly more antisocial acts (thefts and disorderly conduct). These same individuals had
also been arrested signicantly more often than the controls. Hansen, Weiss, and Last (1999)
replicated this latter nding and also reported that young men with ADHD were more likely
to drop out oI high school.
In an attempt to explain the elusive etiology oI ADHD, Barkley (1997) proposed that
decient behavioral inhibition is critical in producing the symptoms and associated features
oI ADHD. The theory describes behavioral inhibition as the suppression oI an immediate
response that creates a time lag to allowIor subsequent executive Iunctions. In individuals with
ADHD, a primary decit in behavioral inhibition leads to secondary impairments in executive
functions. As a result, the behavior of individuals with ADHDis more highly inuenced by the
immediate surroundings and context than is the behavior oI healthy controls (Barkley, 1997).
Finally, Barkley proposes that what has been identied as inattention by teachers and parents
may be conceptualized as a lack oI task or goal-oriented persistence, which directly results
Irom poor inhibition and its eIIects on executive Iunctioning (Barkley, 1997).
Several studies have attempted to examine behavioral inhibition, attention and executive
Iunctioning in younger participants who maniIest ADHD symptoms. Oosterlaan, Logan, and
Sergeant (1988) published a meta-analysis oI eight studies investigating perIormance on the
Stop-Signal task (Logan, 1994), a measure oI behavioral inhibition. The authors concluded
that, relative to controls, the ADHD groups showed poor response inhibition, which was
associated with a slow inhibitory process. Losier, McGrath, and Klein (1996) completed a
meta-analysis oI 26studies that hadutilizedthe Continuous PerIormance Test (CPT), a measure
oI sustained attention and behavioral inhibition. Their analysis revealed that children with
ADHD committed signicantly more commission errors (an indicator of disinhibition), but
they also had more omission errors than healthy controls. Finally, Epstein, Conners, Sitarenios,
and Erhardt (1998) found a similar nding for adults; those with ADHDsymptoms committed
signicantly more commission errors (along with omission errors) than did a group of healthy
controls. UnIortunately, commission errors on the CPT do not allow one to determine iI such
errors were due to an overly strong go response versus a decient stop (or inhibitory)
response (Barkley, 1997; Logan, 1994).
While there has been several studies which have documented cognitive decits in adults
with ADHD, none oI these investigations have Iocused on inhibitory capacity. Roy-Byrne et al.
(1997) reported that adults with probable or possible ADHD exhibited poorer perIormance on
the CPT and the reading section oI the Wide-Range Achievement TestRevised (WRAT-R)
than those with low to moderate symptoms oI ADHD, despite comparable rates oI addi-
tional psychopathology in each group. Epstein, Conners, Erhardt, March, and Swanson (1997)
T.R. Woaushek, C.S. Neumann / Archives of Clinical Neuropsvchologv 18 (2003) 317330 319
reported that adults with ADHD showed signicantly worse attentional performances for left
visual eld (right hemisphere) targets on a visual attention task. Gansler et al. (1998) Iound
that adults with ADHD perIormed more poorly on the HalsteadReitan Trail Making Test
and a visual CPT than did controls. Seidman, Biederman, Weber, Hatch, and Faraone (1988)
reported that, compared to controls, adults with ADHDperformed signicantly worse on mea-
sures oI vigilance, semantic encoding and written arithmetic. Finally, Riordan et al. (1999)
found that adults with ADHD showed signicantly worse performance on measures of verbal
memory, motor and processing speed, visual scanning and auditory and visual distractibility
compared to healthy controls.
The present studywas designed to investigate behavioral inhibitionin adults using a measure
oI inhibition which can distinguish between 'go and 'stop responses (Logan, 1994). II,
as Barkley (1997) proposes, behavioral inhibition is a critical variable in the production oI
ADHD symptoms, then adults with greater levels oI ADHD symptoms should demonstrate
signicantly poorer response inhibition. Furthermore, behavioral inhibition should be able to
account for a more signicant amount of the variance in ADHD symptomatology compared
to other cognitive tasks. In addition, since Barkley`s (1997) model suggests that poor response
inhibition interIeres with executive and attentional Iunctioning, we expected that perIormance
onthese measures shouldbe signicantly intercorrelated. Furthermore, we predictedthat adults
who endorsed high levels of ADHDsymptoms would performsignicantly worse on measures
oI attentional Iunctioning than adults with Iewer ADHD symptoms. Finally, it should be noted
that validation oI Barkley`s model in an adult population oI ADHD suIIerers provides Iurther
construct validity to the ADHD diagnosis as a long-course disorder.
1. Method
1.1. Participants
There were 45 participants who took part in the current study (31 Iemales, 14 males). The
sample consisted oI 39 Caucasian individuals, Iour AIrican American individuals, and two
Vietnamese American individuals. The mean age Ior participants was 35 years (S D 11 8),
with an average oI 15 years oI education (S D 2 7). Most of the individuals were identied
as right-handed ( 42), two were leIt-handed, and one showed no hand preIerence. For
the majority oI participants ( 40), the WRAT-R Reading grade equivalent score exceeded
the 12th grade. Levels oI reported substance abuse were rather low as no participant reported
current consumption oI alcohol or other drugs which interIered with social or occupational
Iunctioning. Demographic and descriptive data are presented in Table 1.
Participants were solicited through local urban area newspaper advertisements and postings
on the campus oI a large public southwestern university that encouraged individuals who were
experiencing symptoms oI poor attention to contact the study personnel. As the study partici-
pants demonstrated an uncharacteristically high Iemale-to-male ratio and education level, and
an unexpectedly low substance abuse prevalence Ior such a population it appears likely the
method oI recruitment produced a somewhat uncharacteristic sample. Newspaper recruitment,
as well as University recruitment, appeared to lead to a somewhat higher Iunctioning clinical
population than is typical.
320 T.R. Woaushek, C.S. Neumann / Archives of Clinical Neuropsvchologv 18 (2003) 317330
Table 1
Demographic and symptom variables
Full sample
(n 45)
High ADHD symptom
group (n 23)
Low ADHD symptom
group (n 22)
Variable Mean S.D. Mean S.D. Mean S.D.
Age
a
35.6 11.8 35.0 11.1 36.3 12.8
Years oI education
b
15.2 2.7 14.0 1.7 16.3 2.8
WRAT-R (G.E.) 12.5 1.6 12.3 1.8 12.6 1.3
BIS total score 78.3 11.7 83.1 11.3 73.2 9.9
CES-D total score 17.6 10.0 19.7 10.9 15.5 8.7
STAI-State score (percentile) 62.2 29.7 67.1 29.8 57.0 29.7
STAI-Trait score (percentile) 75.9 24.7 76.0 22.8 75.8 27.1
a
43 36, N.S.
b
43 2 93, 01.
1.2. Apparatus
A Dell 466/MX computer with a 13-in. monitor was used to administer several cognitive
tasks. Participants were asked to use their dominant hand when responding on these tasks.
Handedness was veried via a lateral dominance questionnaire. All other tasks were adminis-
tered using standard apparatus and procedures.
1.3. Measures
The Wender Utah Rating Scale (WURS; Ward, Wender, & Reimherr, 1993), a selI-rating
Iorm, was used to retrospectively quantiIy childhood ADHD symptomatology. Ward et al.
(1993) reported that 25 items were particularly sensitive to a diagnosis oI ADHD. Roy-Byrne
et al. (1997) reported that the WURS was the most discriminating psychometric measure oI
an ADHD diagnosis in a battery which included the CPT and the reading section Irom the
WRAT-R. Stein et al. (1995) reported a high degree oI internal consistency and temporal
consistency (4-week interval) Ior the WURS.
The cognitive measures Iell into three categories: (1) attention/working memory, (2) be-
havioral inhibition, and (3) Irontal lobe/executive Iunctioning. Other assessments involved
selI-reported symptoms oI ADHD, depression, anxiety, substance abuse, and impulsivity.
Attention/workingmemorymeasures included: (a) the Wechsler MemoryScaleThirdEdi-
tion (WMS-III) subtests Ior the Working Memory Index, which included the LetterNumber
Sequencing and the Spatial Span subtests (WAIS-III/WMS-III Technical Manual, 1997)
1
and
(b) the Continuous PerIormance TestIdentical Pairs Version (CPT-IP; Cornblatt & Kelip,
1
In the WAIS-III/WMS-III Technical Manual (1997), the Working Memory Index Ior the WMS-III (consisting
oI Spatial Span and LetterNumber Sequencing) correlates higher with external measures oI attention/concentration
than with verbal and visual memory measures, similarly Ior the WMI Irom the WAIS-III. Thus, a decision was
made to group these two related domains into composite indices. Moreover, internal consistency analysis supports
our decision.
T.R. Woaushek, C.S. Neumann / Archives of Clinical Neuropsvchologv 18 (2003) 317330 321
1994). The CPT-IP is a computer-administered task that is widely used as a measure oI at-
tentional sensitivity (Cornblatt & Kelip, 1994). It is an experimenter-paced task that asks
participants to attend to a sequence oI visually presented stimuli and respond iI two identical
sets oI numbers or shapes are displayed. Based on zero-order correlations and internal con-
sistency estimates, two attention/working memory composites were constructed: (1) a verbal
attention/working memory composite, and (2) a nonverbal attention/working memory com-
posite. The verbal attentional composite score was computed as the sum oI the LetterNumber
Sequencing Scaled Score plus the hit ratio Ior the CPT-IP numbers subtest multiplied by 10
(standardized 60). The nonverbal attentional composite was derived Irom the sum oI
the Spatial Span Scaled Score plus the hit ratio Ior the CPT shapes subtest multiplied by 10
(standardized 60).
The cognitive inhibition measure used in the current study was the Stop-Signal task (Logan,
1994). The Stop-Signal task, which is computer-administered, requires the participant to com-
plete two tasks at the same time. The 'go task requires the subject to discriminate between
an X and an O with an appropriate key stroke. The second task is represented by a tone pre-
sented aIter the letter presentation and occurs on 25 oI the go-task trials. For the stop task,
participants are required to inhibit the prepotent go-task response and make no key strokes
on that trial. The Stop-Signal task allows Ior the measurement oI the latency oI response
to the Stop Signal (the Stop-Signal Reaction Time or SSRT), which represents the speed oI
the inhibitory process. For a comprehensive description oI the Stop-Signal task, see Logan
(1994).
Logan, Schachar, and Tannock (1997) reported that, relative to low impulsive partici-
pants, high impulsive participants showed signicantly longer SSRTs. They concluded that
inability to inhibit responding among the high impulsivity group was determined by poor in-
hibitory control not excessively quick prepotent responses. Oosterlaan et al. (1988) presented
a meta-analysis of eight studies which found children with ADHD had signicantly slower
inhibitory processes when compared to healthy controls.
The executive measures included: (a) the Benton Controlled Oral Word Association Test
(COWAT; Benton, 1968), and (b) the Spaulding Wisconsin Card Sorting Test (WCST;
Spaulding, Barbin, & Dras, 1989).
The WCSTis a measure of cognitive exibility, problem-solving, concept formation(Heaton,
1981) and workingmemory(Spaulding, Garbin, &Dras, 1989). In the current studythe Spauld-
ing version oI the WCST was computer-administered (Spaulding et al., 1989).
Symptom-based measures included: (a) the Center Ior Epidemiological Studies Depression
Scale (CES-D; RadloII, 1977); (b) the Barratt Impulsiveness Scale (BIS-11; Patton, StanIord,
& Barratt, 1995); (c) the StateTrait Anxiety Inventory (STAI; Speilberger, 1993) Form Y; (d)
a modied version of the Dartmouth Assessment of Lifestyle Instrument (DALI; Rosenberg
et al., 1998).
The CES-D (RadloII, 1977) is a 20-item selI-report symptom rating scale that assesses
Ior depressed mood. RadloII (1977) reported high internal consistency across three diIIer-
ent samples with alpha coefcients near .85. Weissman, Sholomskas, Pottenger, PrusoII, and
Locke (1977) reported signicant correlations between the CES-D and the Symptom Check-
list 90, the Raskin Depression Scale, and the Hamilton Rating Scale across ve psychiatric
groups.
322 T.R. Woaushek, C.S. Neumann / Archives of Clinical Neuropsvchologv 18 (2003) 317330
The BIS-11 (Patton et al., 1995) is a 30-item selI-report symptom rating that measures
impulsiveness. Internal consistency coefcients (Cronbachs alpha) for the BIS-11 total score
were within acceptable limits Ior the Iour groups tested (range: .79.83).
The STAI (Speilberger, 1993) is a 40-item symptom rating scale measuring anxiety which
is composed oI two scales; 20 items assess state anxiety and 20 assess trait anxiety. Both the
state and trait anxiety scales have demonstrated adequate validity and internal consistency.
The DALI (Rosenberg et al., 1998) is an 18-item interviewand scale that Iocuses on screen-
ing Ior alcohol, cannabis, and cocaine use disorders. For the current study the DALI was
supplemented with a series oI questions pertaining to the use oI other illegal substances.
Finally, the WRAT-R Reading section and an 8-item measure oI handedness (Peters &
Servos, 1989) were administered. The WRAT-RReading section is a 42-itemword recognition
test that has two Iorms. It has recently been Iound to be an eIIective discriminator between
ADHD and non-ADHD adults (Roy-Byrne et al., 1997).
1.4. Proceaure
Participants whoansweredthe newspaper advertisement andmet the Iollowingrequirements
were included in the study. All individuals were required to be between the ages oI 18 and
55 years. Exclusion criteria included any signicant history of neurological illness or insult,
as well as any vision, hearing, or physical handicaps which would signicantly hinder their
perIormance on the computer-administered tasks.
After providing informed consent, participants were rst interviewed
2
to provide inIor-
mation about the history oI their ADHD symptoms and to engender participant comIort and
motivationIor the remaining tasks. This was Iollowed by administrationoI the DALI, WRAT-R
Reading section, WMS-III LetterNumber Sequencing, WMS-III Spatial Span, COWAT, and
an 8-item handedness questionnaire. In an attempt to obtain the participants` best possible per-
Iormance all participants were oIIered an opportunity to take a short break beIore continuing
with the computerized measures oI the battery. The computerized measures were administered
in the following order: Spaulding WCST, Stop-Signal task, and nally the CPT-IP. Upon com-
pletion oI the computerized measures, the participants were administered the WURS, BIS-11,
CES-D, and the STAI.
1.5. Group classications
Given that the validity oI diagnosing adults via DSM-IV criteria has been extensively
questioned (Faraone, 2000; Roy-Byrne et al., 1997), and that all participants in this study
complained of attentional difculties, group membership for the current study was determined
via selI-report and prior research using the WURS. Murphy and Schachar (2000) Iound that
adult selI-reports oI ADHD symptoms are reliable and valid. As previously noted, Ward
2
A semi-structured, though not Iormally validated, ADHD interview that loosely Iollowed DSM-IV criteria
was administered to gain clinical inIormation and build rapport. Faraone (2000) noted that the DSM-IV criteria Ior
ADHD is developmentally insensitive and may underestimate ADHD symptom in adults, thus this data was not
quantied.
T.R. Woaushek, C.S. Neumann / Archives of Clinical Neuropsvchologv 18 (2003) 317330 323
et al. (1993) reported that 25 WURS items (out oI the total 61) were particularly good in
discriminating between those adults with and without ADHD. Finally, Roy-Byrne et al. (1997)
found the WURS able to signicantly discriminate between adults with and without ADHD.
Based on the ndings of these previous studies, the current study used a 25-item WURS cut
score of 46 to determine group membership. Using this empirical approach to classication,
23 participants endorsed a high level oI ADHD symptoms (High ADHD symptom group) and
22 participants reported low levels oI ADHD symptoms (Low ADHD symptom group).
2. Results
Demographic and symptom data are presented in Table 1. The t-test analysis showed no
signicant differences in participant age between the High ADHDsymptomgroup and the Low
ADHD symptom group, and Chi-square analysis revealed no signicant differences in gender
proportions between the groups. Consistent with previous research, the groups diIIered in years
of education, the Low ADHD symptom group demonstrating signicantly higher educational
obtainment. As such, education was used as a covariate in the subsequent analyses. See Table 1
Ior means and standard deviations.
2.1. Group analvses of svmptom ana cognitive variables
The ADHD symptom groups were compared in terms oI additional symptoms oI psy-
chopathology (STAI-Trait score, STAI-State score, CES-D total score, BIS total score). Group
analysis of all the symptom data was rst completed using a MANCOVA in which years
oI education was used as a covariate. The MANCOVA
3
resulted in a signicant difference,
4 40 2 98, 05. The Iollow-up univariate ANCOVAs revealed that those in the
ADHD symptom group had a signicantly higher BIS total score, 1 43 6 43, 05.
There were no signicant group differences on the STAI scores (State score, 1 43 03,
N.S.; Trait score, 1 43 63, N.S.) or the CES-D total score, 1 43 1 95, N.S.,
suggesting that the groups were similar on these other symptom variables. See Table 1 Ior
means and standard deviations.
To investigate group diIIerences among the cognitive variables, MANCOVAs (education
used as the covariate) and Iollow-up ANCOVAs were utilized. Cognitive-dependent variables
included the COWAT total score, perseverative errors on the WCST, SSRT score, and the
previously dened verbal and nonverbal attention/working memory composites.
The multivariate analysis revealed a signicant main effect for group, 5 38 2 56,
05. Follow up ANCOVAs indicated that the High ADHD symptom group had signicantly
higher SSRTs, 1 42 12 20, 01, and a signicantly lower nonverbal attention
composite score, 1 42 5 58, 05, than the Low ADHD symptom group. There were
no signicant group differences for the remaining cognitive variables. See Table 2 Ior means
and standard deviations.
3
Education was used as a covariate due to its signicant correlations with dependent measures. These analyses
were also run as MANOVAs with no substantial diIIerences in results.
324 T.R. Woaushek, C.S. Neumann / Archives of Clinical Neuropsvchologv 18 (2003) 317330
Table 2
Cognitive variable means and standard deviations Ior ADHD symptom groups
High ADHD symptom
group (n 23)
Low ADHD symptom
group (n 22)
Variable Mean S.D. Mean S.D.
Verbal attention
a
17.17 3.90 18.71 2.75
LetterNumber Scaled Score 9.56 2.67 11.13 2.12
CPT hits (numbers) .76 .16 .76 .14
Nonverbal attention
b
15.99 3.60 18.00 3.21
Spatial Span Scaled Score 9.52 2.15 10.59 2.34
CPT hits (shapes) .64 .22 .74 .14
WCST perseverative errors 14.91 7.33 12.91 9.40
COWAT total score 36.96 11.57 41.95 11.41
SSRT score 289.39 81.64 234.25 42.16
WCST: Wisconsin Card SortingTest; COWAT: ControlledOral Word Association Test; SSRT: Stop-Signal Reaction
Time.
a
Composite oI LetterNumber and 10 CPT hits (numbers).
b
Composite oI Spatial Span and 10 CPT hits (shapes).
2.2. Regression analvses of ADHD svmptomatologv
The next set oI analyses examined how well the variance in ADHD symptomatology could
be predicted by the cognitive and other symptomvariables. Multiple regression equations were
created with the cognitive and other symptom variables as predictors, and the WURS-25 and
BIS total scores as dependent variables. Many of the variables were signicantly correlated,
Table 3
Stepwise regression equations
Predictor variable Standard beta weight Variance accounted R
2
R
2
change
Criterion variable: WURS-25 score
Years oI education .36 10.8 .13 .13
SSRT .36 11.7 .26 .13
Total 22.5
Criterion variable: BIS total score
STAI-State score .43 16.2 .18 .18
SSRT .31 7.6 .27 .09
Years oI education .30 7.8 .36 .09
COWAT .30 6.4 .44 .07
Total 38.0
Predictor variables entered: participant`s age, years oI education, CES-D total score, STAI-State score, STAI-Trait
score, verbal attentional composite score, nonverbal attentional composite score, WCST perseverative errors,
COWAT adjusted total score, SSRT average score.
05.
01.
T.R. Woaushek, C.S. Neumann / Archives of Clinical Neuropsvchologv 18 (2003) 317330 325
Table 4
Cognitive variable intercorrelations: Iull sample ( 45)
Verbal attention Nonverbal attention WCST COWAT SSRT
Verbal attention .50 .23 .50 .50
Nonverbal attention .21 .25 .50
WCST .15 .30
COWAT .28
WCST: Wisconsin Card Sorting Test perseverative errors; COWAT: adjusted Controlled Oral Word Association
Test; SSRT: Stop-Signal Reaction Time.
05.
001.
however, the majority were not so highly correlated that multicollinearity was thought to be a
problem. The greatest correlations were Iound between the CES total score and the STAI-Trait
score ( 71, 001), and the CES total score and the STAI-State score ( 66,
001).
In the rst regression, years of education and the SSRTscore signicantly predicted WURS-
25 symptoms, 2 44 7 38, 01. Years oI education accounted Ior 10.8 oI the
variance, and the SSRT score then accounted Ior an additional 11.7 oI the variance. The two
variable model accounted Ior 22.5oI the variance in WURS scores. In the second regression,
STAI-State score, SSRT, years of education, and COWAT total score signicantly predicted
BIS symptoms, 4 44 7 76, 001. The STAI-State score accounted Ior 16.2 oI
the variance, Iollowing this, the participant`s SSRT accounted Ior an additional 7.6 oI the
variance, level of education then accounted for an additional 7.8% of the variance and nally
the COWAT adjusted score was Iound to account Ior an additional 6.4 oI the variance. The
Table 5
Cognitive variable intercorrelations Ior ADHD symptom groups
Verbal attention Nonverbal attention WCST COWAT SSRT
High ADHD symptom group (n 23)
Verbal attention .51 .40 .60 .57
Nonverbal attention .39 .31 .56
WCST .28 .43
COWAT .18
Low ADHD symptom group (n 22)
Verbal attention .37 .01 .26 .13
Nonverbal attention .02 .08 .20
WCST .01 .11
COWAT .34
WCST: Wisconsin Card Sorting Test perseverative errors; COWAT: adjusted Controlled Oral Word Association
Test; SSRT: Stop-Signal Reaction Time.
05.
01.
001.
326 T.R. Woaushek, C.S. Neumann / Archives of Clinical Neuropsvchologv 18 (2003) 317330
Iour variable model accounted Ior 38.0oI the variance in BIS scores. See Table 3 Ior detailed
regression results.
2.3. Pearson correlation analvses
Finally, in an attempt to Iurther explore how behavioral inhibition was associated with
other cognitive processes, Pearson correlations were computed using the Iollowing cognitive
variables: COWAT total score, perseverative errors on the WCST, SSRT score, and the verbal
and nonverbal attention/working memory composites. As can be seen in Tables 4 and 5, the
SSRT was signicantly correlated with the majority of the other cognitive variables for the
Iull sample and the High ADHD symptom group.
3. Discussion
Overall, the ndings of this study provide some support for Barkley`s (1997) theory. In par-
ticular, we attempted to address Barkley`s notion that response inhibition is a critical variable
Ior understanding the symptoms oI ADHD. Consistent with this idea, we Iound that the High
ADHD symptom group exhibited signicantly longer SSRTs than the Low ADHD symptom
group. This nding indicates the former group experiences a slower inhibitory process and
hence greater difculties inhibiting responses (Logan, 1994). The results are strengthened by
the Iact that the groups were similar in age, gender, and symptom levels oI depression and
anxiety. The Low ADHD symptom group did show a signicantly higher level of education,
but this nding ts well with previous studies (Hansen et al., 1999) and does not argue against
the validity of our group classications.
Our second hypothesis, which predicted that measures oI response inhibition would be the
primary cognitive variable in accounting Ior the variance oI ADHD symptomatology, was
generally supported by the regression analyses. The regression analyses demonstrated that the
SSRT average score was a signicant predictor of both regression equations for which the
criterion variable was felt to reect critical features of ADHD (WURS-25 score and the BIS
total score). The SSRT accounted Ior 11.7 oI the variance oI the WURS-25 score aIter years
oI education had been included in the model. The SSRT accounted Ior 7.6 oI the variance
oI the BIS score aIter the STAI-State score had been included in the model. Furthermore,
with respect to the WURS-25 score and the BIS total score, the SSRT contributed more to the
model thananyother cognitive variable; infact, the onlyother cognitive variable tosignicantly
contribute to either model was the COWAT`s contribution accounting Ior 6.4 oI the variance
in the BIS score. These results suggest that behavioral inhibition is a critical cognitive variable
in explaining ADHD symptomatology.
The current results generally supported our third hypothesis which stated that the perIor-
mance on the Stop-Signal task would be signicantly correlated with the attention/working
memory and executive Iunctioning measures. Barkley`s (1997) model suggests that poor in-
hibition should lead to difculties in subsequent executive functions such as working memory
and reconstitution, operations that are purported to be measured by the CPT-IP, LetterNumber
Sequencing subtest, Spatial Span subtest, WCST, and COWAT. Support Ior Barkley`s (1997)
T.R. Woaushek, C.S. Neumann / Archives of Clinical Neuropsvchologv 18 (2003) 317330 327
model can be seen when examining the correlations in Tables 4 and 5. Table 4 indicates that
the SSRT is signicantly negatively correlated with both of the attention/working memory
composites and the COWAT total score, and is signicantly positively correlated with WCST
perseverative errors Ior the total sample. Moreover, the same pattern oI correlations is evident
Ior the High ADHD symptom group (see Table 5). On the other hand, the intercorrelations
among the cognitive variables Ior the Low ADHD symptom group are in the expected direc-
tion, but are notably attenuated. Interestingly, STAI-Trait scores were signicantly correlated
with the WURS-25 score Ior the Low ADHD symptom group ( 36, 05), but not Ior
the High ADHD symptom group ( 24, 05). Given that attention problems have been
documented in individuals with depression and anxiety (Crowe, 1998), other Iactors, such as
anxiety, may account Ior the Low ADHD symptom groups` experience oI attentional prob-
lems, as opposed to problems with behavioral inhibition. Taken together, the results Iollow the
pattern that Barkley`s (1997) model predicts.
Our nal hypothesis expected poorer attention/working memory performance for the High
ADHD symptom group relative to the Low ADHD symptom group. In partial support, we
Iound that the High symptom group displayed poorer perIormance on the measure oI nonver-
bal attention, but no group diIIerence emerged Ior the verbally-based measure oI attention.
Consistent with our ndings, Epstein et al. (1997) reported that adults with ADHD showed
signicantly worse attentional performances for left visual eld (right hemisphere) targets on
a visual attention task.
While the results provided some support for our nal hypothesis, we believe that attention
problems in ADHD should be seen in the context oI Barkley`s (1997) theory. Specically,
Barkley proposes that attention problems are a secondary aspect oI ADHD, which exists only
as a consequence of the primary decit in inhibition. As supporting evidence, he points out that
research on ADHD has not been able to consistently identify a decit in attention in children
with ADHD (Schachar, Tannock, & Logan, 1993; Schachar, Tannock, Marriott, & Logan,
1995, Van der Meere & Sergeant, 1988a, 1988b). He proposes that what has been identied
as inattention by teachers and parents is really a lack oI task or goal-oriented persistence,
which directly results Irom poor inhibition and its eIIects on executive Iunctioning (Barkley,
1997).
Barkley (1997) suggests that individuals with ADHD should show what appears to be
inattention only on tasks which are 'selI-regulated and goal-directed (p. 84). These are
tasks in which no immediate rewards are available, the motivation Ior completing these tasks
are selI-directed, and the executive Iunctions oI planning and sequencing oI complex be-
havioral patterns is required. Sustained attention, which is contingency-shaped (i.e., deter-
mined by the immediate demands oI the situation), should be unaIIected in ADHD, since
no true decit in attention has been consistently found (Barkley, 1997). On the other hand,
Barkley`s (1997) theory suggests that measures oI attention and response inhibition should
be signicantly correlated. In support, we found that the performance on the Stop-Signal task
was signicantly correlated with both the nonverbal and verbal attention/working memory
composites.
As a whole, the current study provides signicant support for Barkley`s (1997) model,
both in the notion that inhibition may be the primary decit in ADHD and that poor response
inhibition leads to subsequent symptoms and cognitive interIerence.
328 T.R. Woaushek, C.S. Neumann / Archives of Clinical Neuropsvchologv 18 (2003) 317330
3.1. Limitations
The current study was limited by a relatively modest sample size which limited the power
oI the statistical analyses. However, multivariate analyses oI the cognitive variables resulted
in a moderate eIIect size. Nevertheless, Iuture research should include larger sample sizes.
The lack oI a collateral report oI childhood symptoms oI ADHD may have limited the
validity oI the WURS; however, adults have shown the ability to accurately rate childhood
ADHD symptomatology (Murphy & Schachar, 2000).
The current study did not use Iormal diagnostic criteria to determine the ADHD symptom
groups. However, the validityoI diagnosingadults via the DSM-IVcriteria has beenextensively
questioned (Faraone, 2000; Roy-Byrne et al., 1997). Moreover, an empirical approach to
identiIying individuals with symptoms oI ADHD has been quite successIul (Roy-Byrne et al.,
1997; Ward et al., 1993).
Finally, while the groups did exhibit similar symptoms oI anxiety and depression, the exis-
tence oI comorbid conditions may have aIIected the symptom constellations. A sample which
Iurther excluded those individuals who exhibited tendencies towards other psychopathology
may have been more eIIective in identiIying the basic processes associated with ADHD. How-
ever, it is likely that such a sample would have been very difcult to obtain and would not be
representative oI the majority oI individuals with substantial symptoms oI ADHD. The use oI
a problem-identied sample more closely approximates the situation faced by clinicians when
attempting to diagnose ADHD in clinical adult populations.
3.2. Clinical implications
The results oI this study again emphasize the importance on inhibitory capacity rather than
attentional dysfunction as the primary decit in ADHD. As such, the shift in focus may be
benecial for the treatment of ADHD. Treatments which primarily target attention difculties
may not be adequate. Instead, programs designed to lessen the occurrence and Irequency oI
impulsive responding may prove successIul in Iurther alleviating the symptoms oI ADHD.
Increased Iocus on poor response inhibition may also prove helpIul in examining and treating
the comorbid disorders associated withADHD, especially conduct-related and substance abuse
disorders. Finally, medication efcacy may be further established by measuring a drugs effect
on inhibitory capacity in addition to the cognitive consequences of a decit in inhibition.
References
American Psychiatric Association (1994). Diagnostic ana statistical manual of mental aisoraers (4th ed.). Wash-
ington, DC: Author.
Barkley, R. A. (1997). Behavioral inhibition, sustained attention, and executive Iunctions: Constructing a uniIying
theory oI ADHD. Psvchological Bulletin, 121, 6594.
Barkley, R. A., DuPaul, G. J., & McMurray, M. B. (1990). Comprehensive evaluation of attention decit disorder
with and without hyperactivity as dened by research criteria. Journal of Consulting ana Clinical Psvchologv,
58, 775789.
T.R. Woaushek, C.S. Neumann / Archives of Clinical Neuropsvchologv 18 (2003) 317330 329
Barkley, R. A., Murphy, K., & Kwasnik, D. (1996). Psychological adjustment and adaptive impairment in young
adults with ADHD. Journal of Attention Disoraers, 1, 4154.
Benton, A. L. (1968). DiIIerential behavioral eIIects in Irontal lobe disease. Neuropsvchologia, 6, 5360.
Borland, B. L., & Heckman, H. K. (1996). Hyperactive boys and their brothers: A 25-year Iollow-up study.
Archives of General Psvchiatrv, 33, 669675.
Cornblatt, B. A., & Kelip, J. G. (1994). Impaired attention, genetics, and the pathophysiology oI schizophrenia.
Schi:ophrenia Bulletin, 20, 3146.
Crowe, S. F. (1998). Neuropsvchological effects of the psvchiatric aisoraers. Amersham: Harwood Academic
Publishers.
Epstein, J. N., Conners, C. K., Erhardt, D., March, J. S., & Swanson, J. M. (1997). Asymmetrical hemispheric
control of visualspatial attention in adults with Attention Decit/Hyperactivity Disorder. Neuropsvchologv,
11, 467473.
Epstein, J. N., Conners, C. K., Sitarenios, G., &Erhardt, D. (1998). Continuous perIormance test results oI adults
with Attention Decit/Hyperactivity Disorder. The Clinical Neuropsvchologist, 12, 155168.
Faraone, S. V. (2000). Attention Decit/Hyperactivity Disorder in adults: Implications for theories of diagnosis.
Current Directions in Psvchological Science, 9, 3336.
Gansler, D. A., Fucetola, R., Krengel, M., Stetson, S., Zimering, R., &Makery, M. S. (1998). Are there cognitive
subtypes in adult Attention Decit/Hyperactivity Disorder? The Journal of Nervous ana Mental Disease, 186,
776781.
Hansen, C., Weiss, D., & Last, C. G. (1999). ADHD boys in young adulthood: Psychosocial adjustment. Journal
of the American Acaaemv of Chila ana Aaolescent Psvchiatrv, 38, 165171.
Heaton, R. K. (1981). A manual for the Wisconsin Cara Sorting Test. Odessa, FL: Psychological Assessment
Resources.
Logan, G. D. (1994). On the ability to inhibit though and action: A users` guide to the stop signal paradigm. In
D. Dagenback & T. H. Carr (Eds.), Inhibitorv process in attention, memorv, ana language (pp. 189239). San
Diego, CA: Academic Press.
Logan, G. D., Schachar, R. J., & Tannock, R. (1997). Impulsivity and inhibitory control. Psvchological Science,
8, 6064.
Losier, B. J., McGrath, P. J., & Klein, R. M. (1996). Error patterns on the continuous perIormance test in
non-medicated and medicated samples oI children with and without ADHD: A meta-analytic review. Journal
of Chila Psvchologv, Psvchiatrv ana Alliea Disciplines, 8, 971987.
Murphy, P., & Schachar, R. (2000). Use oI selI-ratings in the assessment oI symptoms oI Attention
Decit/Hyperactivity Disorder in adults. American Journal of Psvchiatrv, 7, 11561159.
Oosterlaan, J., Logan, G. D., & Sergeant, J. A. (1988). Response inhibition in AD/HD, CD, Comorbid AD/HD
CD, anxious, and control children: A meta-analysis oI studies with the stop task. Journal of Chila Psvchologv
ana Psvchiatrv, 39, 411425.
Patton, J. H., StanIord, M. S., & Barratt, E. S. (1995). Factor structure oI the Barratt Impulsiveness Scale. Journal
of Clinical Psvchologv, 51, 768774.
Peters, M., & Servos, P. (1989). PerIormance oI subgroups oI leIt-handers and right-handers. Canaaian Journal
of Psvchologv, 43, 341358.
RadloII, L. S. (1977). The CES-D Scale: A selI-report depression scale Ior research in the general population.
Appliea Psvchological Measurement, 1, 385401.
Riordan, H. J., Flashman, L. A., Saykin, A. J., Frutiger, S. A., Carroll, K. E., & Huey, L. (1999). Neuropsy-
chological correlates oI methylphenidate treatment in adult ADHD with and without depression. Archives of
Clinical Neuropsvchologv, 14, 217233.
Rosenberg, S. D., Drake, R. E., WolIord, G. L., Mueser, K. T., Oxman, T. E., Vidaver, R. M., Carrieri, K. L., &
Luckoor, R. (1998). Dartmouth Assessment oI LiIestyle Instrument (DALI): A substance use disorder screen
Ior people with severe mental illness. American Journal of Psvchiatrv, 155, 232238.
Roy-Byrne, P., Scheele, L., Brinkley, J., Ward, N., Wiatrak, C., Russo, J., Towne, B., & Varley, C. (1997).
Adult-Attention Decit/Hyperactivity Disorder: Assessment guidelines based on clinical presentation to a spe-
cialty clinic. Comprehensive Psvchiatrv, 38, 133140.
330 T.R. Woaushek, C.S. Neumann / Archives of Clinical Neuropsvchologv 18 (2003) 317330
Schachar, R. J., Tannock, R., & Logan, G. (1993). Inhibitory control, impulsiveness, and Attention
Decit/Hyperactivity Disorder. Clinical Psvchologv Review, 13, 721739.
Schachar, R. J., Tannock, R., Marriot, M., & Logan, G. (1995). Decient inhibitory control in Attention
Decit/Hyperactivity Disorder. Journal of Abnormal Chila Psvchologv, 23, 411438.
Seidman, L. J., Biederman, J., Weber, W., Hatch, M., & Faraone, S. V. (1988). Neuropsychological Iunction in
adults with Attention Decit/Hyperactivity Disorder. Biological Psvchiatrv, 44, 260268.
Spaulding, W., Garbin, C. P., & Dras, S. R. (1989). Cognitive abnormalities in schizophrenic patients and
schizotypal college students. Journal of Nervous ana Mental Diseases, 177, 717728.
Speilberger, C. D. (1993). Manual for the StateTrait Anxietv Inventorv. (Form Y) ('Self-evaluation
Questionnaire`). Palo Alto, CA: Consulting Psychologists Press, Inc.
Stein, M. A., Sandoval, R., Szumowski, E., Roizen, N., Reinecke, M. A., Blondis, T. A., & Zanvel, K. (1995).
Psychometric characteristics oI the Wender Utah Rating Scale: Reliability and Iactor structure Ior men and
women. Psvchopharmacologv Bulletin, 31, 425433.
Van der Meere, J., & Sergeant, J. (1988a). Focused attention in pervasively hyperactive children. Journal of
Abnormal Chila Psvchologv, 16, 627640.
Van der Meere, J., & Sergeant, J. (1988). Controlled processing and vigilance in hyperactivity: Time will tell.
Journal of Abnormal Chila Psvchologv, 16, 641656.
Ward, M. F., Wender, P. H., & Reimherr, F. W. (1993). The Wender Utah Rating Scale: An aid in the retrospective
diagnosis of childhood AttentionDecit/Hyperactivity Disorder. American Journal of Psvchiatrv, 150, 885890.
WAIS-III/WMS-III Technical Manual (1997). WAIS-III/WMS-III Technical Manual. San Antonio, TX: The Psy-
chological Corporation, Harcourt Brace and Company.
Weissman, M. W., Scholomoskas, D., Pottenger, M., PrusoII, B. A., &Locke, B. Z. (1977). Assessing depressive
symptoms in ve psychiatric populations: Avalidation study. American Journal of Epiaemiologv, 106, 203214.