ANCOVA in SPSS

Journal of Attention Disorders 2017, Vol. 21(4) 316 –322 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1087054714530782 journals.sagepub.com/home/jad

Article

ADHD is one of the most common childhood neuropsy- chological disorders, causing difficulties in academic, social, emotional, and behavioral domains (Barkley, 1990; LeFever, Villers, & Morrow, 2002; Pelham & Bender, 1982). Due to these problems, it was previously assumed that children with ADHD would have lower self-confi- dence than those without (Hoza & Pelham, 1995; Slomkowski, Klein, & Mannuzza, 1995; Treuting & Hinshaw, 2001). However, researchers have recently dis- covered that children and adults with ADHD actually appear to have a positive illusory bias (PIB) toward them- selves, meaning that they tend to rate themselves as higher functioning in social and academic situations than teach- ers, parents, and peers rate them (see Owens, Goldfine, Evangelista, Hoza, & Kaiser, 2007, for review). Similarly, when comparing objective measures of these domains with their self-reports, ADHD children’s self-perception is usu- ally an overestimation of their actual performance (Hoza et al., 2000; Hoza et al., 2001; Manor et al., 2012). This phenomenon has been found in both genders (Hoza et al., 2004) and different ADHD subtypes (Swanson, Owens, & Hinshaw, 2012), and does not seem to improve in children who have received stimulant medication (Ialongo et al., 1994) and extensive behavioral therapy (Hoza et al., 2004).

There is much dispute as to whether these positive illu- sions are adaptive or maladaptive in ADHD. Some studies

hypothesize that this positive illusion may be a protective strategy to help individuals persist during challenges and overcome frequent failures or setbacks (Diener & Milich, 1997; Hoza et al., 2004; Taylor & Brown, 1988). Contrary to this notion though, ADHD children with PIBs still have decreased motivation, persistence, and overall task perfor- mance compared with those without the disorder (Owens et al., 2007). Similarly, others argue that the positive illusions may be caused by cognitive immaturity (Milich, 1994), and will lead to poorer social skills and increased risk for nega- tive outcomes later in life (Colvin, Block, & Funder, 1995; Hoza et al., 2004). Overestimation of competence in ADHD children is associated with increased aggression and less prosocial behavior (Hoza et al., 2010; Linnea, Hoza, & Tomb, 2012). Interestingly, McQuade et al. (2011) found that in ADHD-Combined Type and Hyperactive/Impulsive Type children, working memory, attention, and cognitive fluency were more likely to be impaired in children who

530782 JADXXX10.1177/1087054714530782Journal of Attention DisordersSteward et al. research-article2014

1Austin Neuropsychology, PLLC, TX, USA 2University of Texas at Austin, TX, USA

Corresponding Author: Melissa Bunner, Austin Neuropsychology, PLLC, 711 W. 38th St. F-2, Austin, TX 78705, USA. Email: [email protected]

Self-Awareness of Executive Functioning Deficits in Adolescents With ADHD

Kayla A. Steward1,2, Alexander Tan1,2, Lauren Delgaty1, Mitzi M. Gonzales2, and Melissa Bunner1,2

Abstract Objective: Children with ADHD lack self-awareness of their social and academic deficits, frequently rating themselves more favorably than external sources. The purpose of the current study was to assess whether adolescents with ADHD also hold a positive bias toward their executive functioning (EF). Method: Participants include 22 control and 35 ADHD subjects, aged 11 to 16. Participants and their parents completed the Behavior Rating Inventory of Executive Functioning (BRIEF) Self and Parent forms, respectively. Discrepancy scores were calculated for each domain by subtracting the adolescents’ T-score from the parents’ T-score. Results: Discrepancy scores were significantly higher in the ADHD group than controls within the Inhibit, Shift, Monitor, Emotional Control, Working Memory, and Plan/Organization domains (all p < .05). Conclusion: As compared with controls, adolescents with ADHD tend to endorse fewer EF difficulties than what parents report. This is the first study to demonstrate that those with ADHD may overestimate their EF ability. ( J. of Att. Dis. 2017; 21(4) 316-322)

Keywords adolescent ADHD, BRIEF, executive function, self-report

Steward et al. 317

had positive illusions about their social competency relative to those without a positive bias.

Despite the controversial question of whether PIBs are beneficial or maladaptive, the fact that it exists in ADHD children with regard to social, behavioral, and academic functioning has been well documented. However, it has not been looked at with regard to executive functioning (EF) even though this is a major area of weakness in those with the disorder (Barkley, 1997; Nigg, 2006). EF is a neuropsy- chological term that refers to a variety of higher-order thinking skills, such as planning, organization, attention, working memory, and inhibition (Martel, Nikolas, & Nigg, 2007). Welsh and Pennington (1989, p. 201) defined the construct as “the ability to maintain an appropriate problem set for attainment of future goals.” EF is an important skill for complex human behavior, and it has been found that ADHD children with impaired EF have poorer academic achievement and peer relationships (Biederman et al., 2004; Diamantopoulou, Rydell, Thorell, & Bohlin, 2007). If chil- dren and adolescents with ADHD have an inflated view of their EF skills, it could limit their ability to insightfully self- regulate their behavior and might hinder their receptiveness to behavioral interventions to improve their EF.

The current study seeks to fill gaps in the ADHD self- perception and EF literature. This will be the first study to examine how ADHD children view their EF ability in rela- tion to their parents’ estimates. We hypothesize that adoles- cents with ADHD will overestimate their EF ability more so than controls when comparing their self-reports with parent ratings.

Method

Participants

Participants between the ages of 11 and 16 years were recruited using archival data from a private neuropsychol- ogy clinic. In addition, a portion of the control participants were recruited from the greater community after contacting the clinic and completing a telephone screening to deter- mine initial eligibility. Participants were included if they were free of neurological disease (e.g., epilepsy, clinically significant traumatic brain injury), major psychiatric illness (e.g., depression, anxiety, bipolar disorder), and develop- mental disorder (e.g., autism, mental retardation). To obtain a sufficient sample size, participants with learning disabili- ties (LDs) were not excluded from participation. LD inclu- sion was limited to those with dyslexia (n = 9), dyscalcula (n = 2), dysgraphia (n = 15), and LD−not otherwise speci- fied (n = 4). For all participants, board-certified neuropsy- chologists used information from patient and parent interviews, developmental and family history question- naires, and an extensive cognitive assessment battery to make diagnoses of ADHD and any other disorders using the Diagnostic and Statistical Manual of Mental Disorders

(4th ed.; DSM-IV; American Psychiatric Association, 1994) diagnostic criteria.

After obtaining written informed consent, the final sam- ple consisted of 35 adolescents with diagnoses of ADHD and 22 without an ADHD diagnosis. Of the ADHD children, 26 were diagnosed with Primary Inattentive subtype, 7 were diagnosed with Combined subtype, and 2 were diagnosed with ADHD−not otherwise specified. According to partici- pants’ self-report, the ethnic distribution of the sample was as follows: 86% Caucasian (n = 49), 4% Hispanic (n = 2), 2% African American (n = 1), and 9% Other/did not specify (n = 5). All participants had a full-scale IQ (FSIQ) greater than 80, as measured by the Weschsler Intelligence Scale for Children-IV (WISC-IV) or the Weschler Abbreviated Intelligence Scale-II (WASI-II; Wechsler, 2003, 2011).

Materials

The parent and self-report forms of the Behavior Rating Inventory of Executive Functioning (BRIEF; Gioia, Isquith, Guy, & Kenworthy, 2000) were administered during the clinical interview or delivered through the mail and returned at the time of the neuropsychology testing appointment. The BRIEF parent form (BRIEF-P) is an 86-item question- naire that parents fill out based on their children’s behavior over the past 6 months. Each question is a short statement such as “Has a short attention span,” “Makes careless errors,” or “Reacts more strongly to situations than other children,” and the parent has to mark “never,” “sometimes,” or “always.” The BRIEF self-report (BRIEF-SR) is simi- larly designed, with 80 items that the child fills out about their own behavior over the past 6 months. According to the BRIEF manual, a fifth-grade reading level is sufficient to complete the form. To ensure a thorough understanding of the instructions and BRIEF questions, BRIEF-SRs were completed in the presence of examiner or guardian. For both forms, the BRIEF has been standardized and normed for the use of boys and girls within the age range of our sample, and for children with a variety of clinical diagnoses including ADHD. In accordance with standard procedures, normative data were separated by gender and age to derive T-scores for the clinical scales (Inhibit, Shift, Emotional Control, Working Memory, Plan/Organize, Organization of Materials, and Monitor). These scales were combined to form a Behavioral Regulation Index (BRI) and Metacognition Index (MI), as well as a composite summary score called the Global Executive Composite (GEC). With the BRIEF, higher T-scores indicate more subjective impairment.

According to Gioia et al. (2000), the BRIEF has an inter- nal consistency ranging from .80 to .98, as assessed using Cronbach’s alpha. Test−retest reliability statistics range from .79 to .88 during a 2-week period. The BRIEF is also reported to have good discriminant and convergent validity with similar measures (McCandless & O’Laughlin, 2007).

318 Journal of Attention Disorders 21(4)

A discrepancy score for each clinical scale was calcu- lated by subtracting the BRIEF-SR T-scores from the BRIEF-P T-scores for each participant. Positive scores indi- cate that the child reported fewer difficulties than parent reports. A negative discrepancy score signifies that the child reported more impairment than parent ratings. This method of obtaining discrepancy scores has been com- monly used when studying PIBs in an ADHD population (Hoza et al., 2004; Hoza, Pelham, Dobbs, Owens, & Pillow, 2002; Owens et al., 2007).

Statistical Analyses

Group differences in the demographic variables were exam- ined with non-parametric chi-square or independent sam- ples t tests. The normality of standardized residuals for the dependent variables was tested using Shapiro−Wilks tests (all p > .05). Bootstrapping procedures were utilized when parametric assumptions about the underlying distribution were not fulfilled (model residuals with Shapiro−Wilks p < .05). Group differences in the dependent variables were assessed using an analysis of covariance (ANCOVA), with gender used as a covariate. As a follow-up analysis, ADHD medication (yes/no), the presence of a learning disorder (yes/no), and WASI-II/WISC-IV FSIQ were added as addi- tional covariates in the ANCOVA. To control for multiple comparisons, a Sidak-adjusted alpha level of p < .027 was used.

Results

The demographic characteristics of the study sample are shown in Table 1. Ethnicity distribution, χ2(4, N = 57) = 2.642, p = .62, and LD distribution, χ2(4, N = 57) = .695, p = .41, in the ADHD and control groups was comparable. There were also no significant differences in age, educa- tion, and intelligence between the two groups. The only variable that significantly differed between the two groups was gender, χ2(1, N = 57) = 6.350, p = .01.

Discrepancy score group differences are shown in Figure 1 and Table 2. In the overall ANCOVA model (Table 3), dis- crepancy scores for the BRIEF Inhibit, Shift, Emotional

Control, Monitor, Working Memory, Plan/Organization, BRI, MI, and GEC domains were all significantly more positive in the ADHD group as compared with the control group (p < .027). ADHD had a significant main effect on the Inhibit, Monitor, Working Memory, Plan/Organize, and GEC domains (p < .027). Gender contributed significantly to the Shift and BRI domains (p < .027), with males dis- playing greater discrepancy scores than females. Group dif- ferences in the discrepancy scores for the BRIEF Organization of Materials domain did not reach statistical significance (p > .027).

These relationships remained unchanged even after additional adjustment for any potential effects of ADHD medication, the presence of a learning disorder, or FSIQ.

Discussion

This study extends the literature on PIB in ADHD by being the first to examine self-perception of EF. The results dem- onstrate that, in comparison with age-matched controls, adolescents with ADHD tend to over-inflate abilities rela- tive to their parents’ reports within the domains of Working Memory, Emotional Control, Attention and Behavior Shifting, Inhibition of Behavior, Self-Monitoring, and Planning and Organization of Future Events. Adolescents with ADHD also displayed greater discrepancy scores on the metacognition, behavioral regulation, and GEC domains. In contrast to large parent−child discrepancies in the ADHD group, the control group had only negligible or slightly negative discrepancy scores, meaning that these children rated themselves the same as or slightly more impaired than what parents reported.

These findings support previous literature that has docu- mented a PIB in ADHD children. Other studies have used similar methodology and found that those with ADHD overestimate academic and social functioning when com- pared with mother, father, teacher, and peer reports, as well as objective measures of these domains (Evangelista, Owens, Golden, & Pelham, 2008; Hoza et al., 2004; Hoza et al., 2002; Owens & Hoza, 2003). It is important to note that the subjective nature of the parents’ reports elicit the possibility that the large discrepancy scores may be in fact

Table 1. Participants’ Demographic Characteristics.

ADHD (n = 35) Control (n = 22) p value

Male/female (n) 26/9 9/13 .01* Age (year) 12.91 ± 1.5 13.64 ± 1.6 .09 Education level (year) 7.49 ± 1.5 8.23 ± 1.8 .10 FSIQ 107.29 ± 14.0 106.82 ± 14.5 .90 On ADHD medication at time of testing (n) 12 1 — LD diagnosis 15 7 .41

Note. Data are M ± SD; FSIQ = full-scale IQ; LD = learning disability. *Significant at p < .05.

Steward et al. 319

due to a tendency for parents of ADHD children to rate their children in an excessively negative manner. We attempted to control for this by excluding participants who had an elevated Negativity validity scale on the BRIEF-P forms. To definitively rule out the potential for inaccurate parent reports, future studies should compare child self-reports with objective measures of EF.

One of the strengths of this study is that it incorporated both genders and assessed the contribution of gender to self-awareness of deficits in those with ADHD. The major- ity of previous studies have failed to include females, and when they did, gender effects were not explored (Owens & Hoza, 2003). The current study used gender as a covariate and found that males are more likely to overestimate their ability to shift their attention and behavior than females. As the current study had significantly different gender ratios between the ADHD and control groups, future studies should incorporate more gender-balanced groups to further assess the impact that gender may have on self-perception of EF in an ADHD population.

Of note, discrepancy scores in the Organization of Materials domain were not significantly different between groups. There are several possible reasons that this was the only domain to not reach significance. First, this domain assesses the organization of the child’s environment, such as the level of disorganization of their schoolbags and how frequently they misplace items like homework. As these are more external behaviors as opposed to the Plan/Organize domain, which assesses organization on a more cognitive level, it is probable that these difficulties are brought to the child’s attention more frequently. This would likely create a better sense of self-awareness of this particular area of dif- ficulty. Secondly, this domain had a low number of ques- tions in the parent and self-report forms; therefore, there is

-5

0

5

10

15

20

ADHD

Control

Figure 1. Mean discrepancy scores for each BRIEF domain. Note. Discrepancy scores were calculated by subtracting self-reported BRIEF T-scores from the parent T-scores. As larger T-scores indicate more subjective impairment, positive discrepancy scores indicate that the parent reported more difficulties than the child did and vice versa. All domain discrepancy scores, except Organization of Materials, were significantly (p < .027) more positive in the ADHD adolescents compared with controls. BRIEF = Behavior Rating Inventory of Executive Functioning.

Table 2. Discrepancy Scores for the BRIEF Questionnaire.

ADHD (n = 35) Control (n = 22)

Inhibit 11.23 ± 14.8 −2.54 ± 11.7 Shift 6.31 ± 16.8 0.72 ± 17.0 Emotional Control 4.45 ± 15.2 −3.09 ± 15.2 Monitor 17.06 ± 16.8 1.91 ± 15.8 Working Memory 14.29 ± 13.4 1.41 ± 16.2 Plan/Organize 13.5 ± 14.3 −0.64 ± 14.0 Organization of

Materials 5.54 ± 13.1 3.27 ± 12.7

Behavior Regulation Index

9.00 ± 15.0 −1.82 ± 14.8

Metacognition Index

11.54 ± 15.9 −0.46 ± 15.43

Global Executive Composite

12.5 ± 15.6 −0.91 ± 15.7

Note. Data are M ± SD. BRIEF = Behavior Rating Inventory of Executive Functioning.

320 Journal of Attention Disorders 21(4)

a more restricted range of possible total scores. This makes it more difficult for a difference in discrepancy scores to become statistically significant, although there was a trend in the predicted direction (see Figure 1).

Despite consistent evidence that children with ADHD lack self-awareness of their deficits, it is still highly debated as to why ADHD children overestimate their ability in so many areas. Owens et al. (2007) discussed four potential explana- tions for the PIB seen in ADHD children: neuropsychological and frontal lobe deficits leading to mild anosognosia (Owens & Hoza, 2003), an overall cognitive immaturity in ADHD children (Milich, 1994), ignorance of incompetence in the self and others (Hoza et al., 2002), and self-protection from per- sonal failure (Ohan & Johnston, 2002). Very few studies have directly tested any of these hypotheses in relation to ADHD PIBs though, and this area of research remains divided on actual causes for the positive biases seen in children. It is pos- sible that these hypotheses are not mutually exclusive, and one or more of them could contribute to the impaired self- awareness of children and adolescents with ADHD.

There are many strengths to this study that allow it to uniquely contribute to the field, such as the inclusion of both genders and ADHD subtypes and the exclusion of comorbid psychiatric and behavioral disorders; however, there are also several limitations. The current study used a relatively small sample size that was largely homogeneous in terms of ethnicity. Future researchers should seek to include a more characteristic and larger sample, as well as expand to other age ranges to test developmental aspects of EF PIB. Another limitation was the source of the control group as some participants were selected from an archival database at a private neuropsychology clinic. These partici- pants had been previously referred to the clinic for suspi- cions of neuropsychological impairment. Thus, it is possible that the clinic-referred non-ADHD group had more impair- ment than a control group of children not referred for clini- cal services. In an attempt to lessen the impact from this limitation, strict exclusion criteria was applied and only

those with no diagnoses of psychiatric, medical, neurologic, and developmental disorders were enrolled. To further address this limitation, control participants were addition- ally recruited from the general community and required to undergo a telephone screening prior to participation to rule out suspicions of ADHD and other exclusionary criteria.

The findings of this study support the ADHD PIB research and expand the number of documented domains that ADHD children hold positive illusions about (Owens et al., 2007). These results hold significance not only for other researchers in the field, but also for caregivers and clini- cians who provide EF treatment to adolescents with ADHD. In populations with neurological injuries and psychiatric disorders, impaired self-awareness has been found to lead to low motivation and participation in rehabilitation efforts (Katz, Fleming, Keren, Lightbody, & Hartman-Maeir, 2002; Lam, McMahon, Priddy, & Gehred-Schultz, 1988). Similarly, if ADHD children do not believe they suffer from EF impairment, they may be less receptive to treat- ment for these deficits. Clinicians should be aware that an EF PIB might exist in ADHD children and incorporate this knowledge when providing therapy.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Table 3. Results From ANCOVA Model Examining the Effects of ADHD and Gender on BRIEF Domain Discrepancy Scores.

Overall model (F value) Overall model (p value) ADHD (p value) Gender (p value)

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*Significant at p < .027. BRIEF = Behavior Rating Inventory of Executive Functioning.

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Author Biographies

Kayla A. Steward, BS, is a psychometrist at Austin Neuropsychology, PLLC, and a research assistant at the University of Texas at Austin.

Alexander Tan, BA, is a psychometrist at Austin Neuropsychology, PLLC, and a research assistant at the University of Texas at Austin.

Lauren Delgaty, MA, is a former psychometrist at Austin Neuropsychology, PLLC, and is now employed in North Carolina.

Mitzi M. Gonzales, MA, is a doctoral candidate in clinical psy- chology at the University of Texas at Austin.

Melissa Bunner, PhD, is a neuropsychologist at Austin Neuropsychology, PLLC.