Measures Of Executive Function In Adolescents With ADHD

Executive functioning refers to cognitive processes that regulate thought and behavior, including planning, working memory, impulse control, and cognitive flexibility.

Deficits in these domains of executive functioning are common in individuals with attention-deficit/hyperactivity disorder (ADHD) and may significantly contribute to the symptoms of inattention, hyperactivity, and impulsivity as well as functional impairment related to disorganization, emotional dysregulation, and poor self-monitoring.

Andersen, A. C., Sund, A. M., Thomsen, P. H., Lydersen, S., Haugan, A. L. J., & Nøvik, T. S. (2023). Executive function measured by BRIEF in adolescents diagnosed and treated for ADHD: problem profiles and agreement between informants. Child Neuropsychology, 1-15. https://doi.org/10.1080/09297049.2023.2174506

Key Points

• The study examined executive function (EF) deficits in 100 adolescents aged 14-18 with ADHD using the Behavior Rating Inventory of Executive Function (BRIEF) completed by adolescents, parents, and teachers.
• Teachers reported the highest levels of EF deficits across domains, while adolescents self-reported lower levels compared to parents and teachers.
• Agreement was highest between adolescents and parents, especially for females, and lowest between male adolescents and teachers.
• Identifying and addressing EF deficits may improve future outcomes for adolescents with ADHD, but self-awareness of these difficulties poses a challenge.

Rationale

ADHD often persists into adolescence and adulthood with high rates of functional impairment. While medication and psychosocial interventions are recommended, outcomes remain suboptimal for many.

Executive functional deficits (EFDs) are increasingly recognized as an important contributor to impairment in ADHD, but few studies have examined multi-informant perspectives on EFDs in adolescents with persistent ADHD despite treatment.

As adolescents transition to more independent academic and social environments requiring higher-order EFs, gaining a better understanding of EFD profiles and informant discrepancies can help guide more targeted, individualized interventions.

This study aimed to describe EF profiles and informant agreement using teacher, parent, and self-reports in a sample of 100 clinically impaired adolescents aged 14-18 with rigorously diagnosed ADHD despite ongoing standard treatments.

Method

• Design: Cross-sectional, multi-informant questionnaire
• Participants: 100 adolescents age 14-18 (mean 16.1 years) who met DSM-5 criteria for ADHD (65% male), had clinically significant impairment per the Children’s Global Assessment Scale (<60), and were undergoing ADHD medication treatment.
• Materials: Behavior Rating Inventory of Executive Function (BRIEF) parent, teacher, and self-report versions. The BRIEF helps to determine how often the individual has difficulties with behaviors related to inhibition, shifting, emotional control, initiation, working memory, planning/organization, organization of materials, and monitoring across home and school environments. Higher scores indicate more executive functional deficits.
• Procedure: Participants completed questionnaires assessing EFDs in everyday situations.
• Analysis: Agreement between informant ratings was examined using Pearson correlations. Paired t-tests analyzed discrepancies between informants.

Results

Overall, teachers reported significantly higher levels of EFDs across domains compared to adolescents and parents. The metacognition index was rated higher than the behavioral regulation index across informants. Hyperactivity was rated as less impaired relative to other domains.

The strongest agreement occurred between adolescents and parents (r = 0.64-0.79 across indexes), especially for female participants (r = 0.73-0.82). Agreement was lower between male adolescents and teachers (r = 0.23-0.58) compared to female adolescents and teachers (r = 0.61-0.75).

Paired t-tests showed teachers reported significantly more problems than adolescents across all indexes except for organization of materials and monitor.

Adolescents reported significantly fewer problems on most indexes compared to parents, with small effect sizes. Parents reported more problems compared to teachers on shift, emotional control, and monitoring.

Insight

This study provides valuable insights into EF profiles and informant discrepancies in adolescents with rigorously diagnosed ADHD and ongoing impairment despite standard management methods.

It highlights the significant EF deficits persisting across domains for many adolescents, underscoring the need for interventions targeting these processes critical to adaptive functioning.

Notably, teachers reported the highest levels of EFDs compared to parents and adolescents themselves. As teachers observe adolescents interacting with peers across structured and unstructured contexts, they may detect EF challenges less apparent in the home setting.

The study also found adolescents tended to rate their own EFs as less impaired, suggesting potential difficulties with self-awareness that could pose barriers to self-advocacy and treatment engagement.

Gaining multiple informant perspectives allows clinicians to form a more comprehensive picture of adolescents’ EF profiles across settings to better inform intervention planning.

Understanding common patterns of disagreement can aid interpretation. For example, higher parent-adolescent agreement may reflect better awareness of observable challenges at home.

Lower male adolescent-teacher agreement highlights the need to follow up on divergent ratings through interviews, observations, or performance-based measures.

Strengths

The study had several key methodological strengths:

• Used a rigorous diagnostic process ensuring all participants met DSM-5 criteria for ADHD
• Included only adolescents with clinically significant impairment, increasing generalizability to those requiring ongoing treatment
• Utilized multiple informants (teachers, parents, self-reports) allowing examination of agreement and discrepancies
• Used the validated, widely-used BRIEF questionnaire specifically developed to capture behavioral manifestations of executive dysfunction in everyday situations
• Had an adequately large overall sample size with good representation across the adolescent age range studied
• Performed appropriate statistical tests to analyze agreement (correlations) and discrepancies (paired t-tests) between informant ratings
• Reported effect sizes to quantify the magnitude of differences between informant ratings

Limitations

However, some limitations should be considered when interpreting findings:

• The cross-sectional design provides only a snapshot of functioning, not longitudinal trajectories
• May not generalize to broader ADHD population or other cultures, as all participants were undergoing specialty treatment in one geographic region
• Lacked comparison group of adolescents without ADHD
• Informant discrepancies could reflect biases or contextual factors beyond EF deficits
• Self-reported EF ratings may be less accurate in adolescents with ADHD due to limited self-awareness
• Did not include objective EF performance measures to complement informant report
• Cannot determine causal contributions of EFDs to functional impairment

Implications

This study highlights the need to thoroughly assess EFDs in adolescents with rigorously diagnosed ADHD who have persistent impairment despite standard treatments.

Gaining multiple informant perspectives allows more targeted intervention planning informed by understanding areas of agreement versus potential biases underlying discrepancies between raters and settings.

For research, including comparison samples would clarify unique versus generalized EF deficits in ADHD.

Longitudinal and intervention studies are needed to elucidate developmental trajectories and causal relationships between improving EFs and functional gains. Studies combining rating scales with performance-based measures would help determine optimal assessment approaches.

Clinically, findings reinforce the importance of monitoring ADHD symptoms and impairment into the adolescent years rather than assuming prior treatment will sustain gains over time.

They highlight the need to expand interventions to specifically target EFs related to planning, organization, emotional and behavioral regulation – not just core ADHD symptoms. Improving adolescent and parent awareness of EF challenges may facilitate better self-advocacy and treatment engagement.

More individualized, setting-specific recommendations informed by areas of strength and weakness across domains could optimize outcomes.

References

Primary reference

Andersen, A. C., Sund, A. M., Thomsen, P. H., Lydersen, S., Haugan, A. L. J., & Nøvik, T. S. (2023). Executive function measured by BRIEF in adolescents diagnosed and treated for ADHD: problem profiles and agreement between informants. Child Neuropsychology, 1-15. https://doi.org/10.1080/09297049.2023.2174506

Other references

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Barkley, R. A., Fischer, M., Smallish, L., & Fletcher, K. (2002). The persistence of attention-deficit/ hyperactivity disorder into young adulthood as a function of reporting source and definition of disorder. Journal of Abnormal Psychology, 111(2), 279–289. https://doi.org/10.1037/0021-843X. 111.2.279

Chan, E., Fogler, J. M., & Hammerness, P. G. (2016). Treatment of attention-deficit/hyperactivity disorder in adolescents: A systematic review. JAMA, 315(18), 1997–2008. https://doi.org/10. 1001/jama.2016.5453

Keep Learning

• How might discrepancies between teacher, parent, and self-reports of EF deficits reflect differences in demands and expectations for adolescents across home, school, and social settings? What implications does this have for individualized treatment planning?
• How might underlying neurocognitive deficits interact with environmental factors to contribute to persistent EF challenges for adolescents with ADHD despite medication treatment?
• What types of tailored, multimodal interventions addressing both EF skills training and environmental accommodations might help improve outcomes for adolescents with persistent ADHD?