Toward Operationalizing Executive Function Deficits in Adults With ADHD Using the Behavior Rating Inventory of Executive Function—Adult Version (BRIEF-A)

Joseph Biederman, MD; Maura L. DiSalvo, MPH; Chloe R. Hutt Vater, BA; K. Yvonne Woodworth, BA; Stephen V. Faraone, PhD

J Clin Psychiatry 2023;84(1):22m14530

ABSTRACT

Objective: Although group findings document that executive function deficits (EFDs) contribute to the morbidity associated with adult attention-deficit/hyperactivity disorder (ADHD), it is unclear whether easy-to-use assessment methods can aid in the identification of EFDs at the individual level. The aim of the present study was to assess whether the Behavior Rating Inventory of Executive Function—Adult Version (BRIEF-A), a well-standardized, self-report instrument that assesses behavioral concomitants of EFDs, can serve that purpose.

Methods: 1,090 consecutively referred 18- to 55-year-old adults of both sexes who were clinically referred for the evaluation and treatment of ADHD between June 2016 and December 2021 completed a battery of scales assessing several non-overlapping domains of functioning. Because the BRIEF Global Executive Composite (GEC) offers a single point summary of all other BRIEF-A scales, we used receiver operator characteristic (ROC) curves to identify the optimal cutoff on the BRIEF-A GEC to categorize patients as having executive dysfunction.

Results: We averaged the optimal BRIEF-A GEC cut-points from the ROC curve analyses to categorize patients with (N = 480; 44%) and without (N = 610; 56%) EFDs (BRIEF-A GEC score ≥ 70 or < 70, respectively). Adults with ADHD with EFDs had significantly more severe ADHD symptoms (ADHD Self-Report Scale scores ≥ 24: 94% vs 41%, P < .001); higher levels of psychopathology (Adult Self Report Total Problems T-scores ≥ 64: 75% vs 19%, P < .001), emotional dysregulation (69% vs 23%, P < .001), mind wandering (84% vs 48%, P < .001), and symptoms of autism (Social Responsiveness Scale T-scores ≥ 66: 24% vs 3%, P < .001); and worse quality of life (Quality of Life Enjoyment and Satisfaction Questionnaire mean scores: 44.4 ± 8.2 vs 51.9 ± 8.5, P = .001) compared to those without EFDs. There were no major differences in outcomes by age, sex, or race.

Conclusions: The BRIEF-A helped identify a sizeable minority of adults with ADHD with behavioral concomitants of EFDs that added substantial morbidity and disability beyond that expected by having ADHD alone.

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References (35)

Fischer M, Barkley RA, Edelbrock CS, et al. The adolescent outcome of hyperactive children diagnosed by research criteria, II: academic, attentional, and neuropsychological status. J Consult Clin Psychol. 1990;58(5):580–588. PubMed CrossRef
Barkley RA, Grodzinsky G, DuPaul GJ. Frontal lobe functions in attention deficit disorder with and without hyperactivity: a review and research report. J Abnorm Child Psychol. 1992;20(2):163–188. PubMed CrossRef
Seidman LJ, Biederman J, Monuteaux MC, et al. Impact of gender and age on executive functioning: do girls and boys with and without attention deficit hyperactivity disorder differ neuropsychologically in preteen and teenage years? Dev Neuropsychol. 2005;27(1):79–105. PubMed CrossRef
Seidman LJ, Biederman J, Monuteaux MC, et al. Learning disabilities and executive dysfunction in boys with attention-deficit/hyperactivity disorder. Neuropsychology. 2001;15(4):544–556. PubMed CrossRef
Doyle AE, Faraone SV, Seidman LJ, et al. Are endophenotypes based on measures of executive functions useful for molecular genetic studies of ADHD? J Child Psychol Psychiatry. 2005;46(7):774–803. PubMed CrossRef
Willcutt EG, Doyle AE, Nigg JT, et al. Validity of the executive function theory of attention-deficit/hyperactivity disorder: a meta-analytic review. Biol Psychiatry. 2005;57(11):1336–1346. PubMed CrossRef
Barkley RA. Behavioral inhibition, sustained attention, and executive functions: constructing a unifying theory of ADHD. Psychol Bull. 1997;121(1):65–94. PubMed CrossRef
Seidman LJ, Biederman J, Faraone SV, et al. Toward defining a neuropsychology of attention deficit-hyperactivity disorder: performance of children and adolescents from a large clinically referred sample. J Consult Clin Psychol. 1997;65(1):150–160. PubMed CrossRef
Biederman J, Petty C, Fried R, et al. Impact of psychometrically defined deficits of executive functioning in adults with attention deficit hyperactivity disorder. Am J Psychiatry. 2006;163(10):1730–1738. PubMed CrossRef
Barkley R, Murphy KV, Fischer M. ADHD in Adults. What the Science Says; 2008.
Biederman J, Petty CR, Fried R, et al. Can self-reported behavioral scales assess executive function deficits? a controlled study of adults with ADHD. J Nerv Ment Dis. 2007;195(3):240–246. PubMed CrossRef
Roth R, Isquith P, Gioia G. BRIEF-A Behavior Rating Inventory of Executive Function-Adult Version, Publication Manual. Psychological Assessment Resources, Inc; 2005.
Achenbach TM, Rescorla LA. Manual for ASEBA Adult Forms & Profiles. University of Vermont, Research Center for Children, Youth, & Families; 2003.
Kessler RC, Adler L, Ames M, et al. The World Health Organization Adult ADHD Self-Report Scale (ASRS): a short screening scale for use in the general population. Psychol Med. 2005;35(2):245–256. PubMed CrossRef
Kessler RC, Adler LA, Gruber MJ, et al. Validity of the World Health Organization Adult ADHD Self-Report Scale (ASRS) Screener in a representative sample of health plan members. Int J Methods Psychiatr Res. 2007;16(2):52–65. PubMed CrossRef
Constantino JN, Gruber CP. The Social Responsiveness Scale Manual. 2nd ed. Western Psychological Services; 2012.
Barkley RA. ADHD and the Nature of Self-Control. Guilford; 1997:410.
Mrazek MD, Phillips DT, Franklin MS, et al. Young and restless: validation of the Mind-Wandering Questionnaire (MWQ) reveals disruptive impact of mind-wandering for youth. Front Psychol. 2013;4:560. PubMed CrossRef
Endicott J, Nee J, Harrison W, et al. Quality of Life Enjoyment and Satisfaction Questionnaire: a new measure. Psychopharmacol Bull. 1993;29(2):321–326. PubMed
Kotte A, Joshi G, Fried R, et al. Autistic traits in children with and without ADHD. Pediatrics. 2013;132(3):e612–e622. PubMed CrossRef
Biederman J, DiSalvo M, Woodworth KY, et al. Toward operationalizing deficient emotional self-regulation in newly referred adults with ADHD: a receiver operator characteristic curve analysis. Eur Psychiatry. 2020;63(1):e21. PubMed CrossRef
Biederman J, Lanier J, DiSalvo M, et al. Clinical correlates of mind wandering in adults with ADHD. J Psychiatr Res. 2019;117:15–23. PubMed CrossRef
Liu X. Classification accuracy and cut point selection. Stat Med. 2012;31(23):2676–2686. PubMed CrossRef
Stata Statistical Software: Release 17. StatCorp LLC; 2021.
Barkley RA, Murphy KR. The nature of executive function (EF) deficits in daily life activities in adults with ADHD and their relationship to performance on EF Tests. J Psychopathol Behav Assess. 2011;33(2):137–158. CrossRef
Barkley RA, Fischer M. Predicting impairment in major life activities and occupational functioning in hyperactive children as adults: self-reported executive function (EF) deficits versus EF tests. Dev Neuropsychol. 2011;36(2):137–161. PubMed CrossRef
Barkley RA, Murphy KR. Impairment in occupational functioning and adult ADHD: the predictive utility of executive function (EF) ratings versus EF tests. Arch Clin Neuropsychol. 2010;25(3):157–173. PubMed CrossRef
Barkley RA. The executive functions and self-regulation: an evolutionary neuropsychological perspective. Neuropsychol Rev. 2001;11(1):1–29. PubMed CrossRef
Biederman J, Faraone SV, Keenan K, et al. Further evidence for family-genetic risk factors in attention deficit hyperactivity disorder. Patterns of comorbidity in probands and relatives psychiatrically and pediatrically referred samples. Arch Gen Psychiatry. 1992;49(9):728–738. PubMed CrossRef
Mattfeld AT, Whitfield-Gabrieli S, Biederman J, et al. Dissociation of working memory impairments and attention-deficit/hyperactivity disorder in the brain. Neuroimage Clin. 2015;10:274–282. PubMed CrossRef
Biederman J, Mick E, Fried R, et al. Are stimulants effective in the treatment of executive function deficits? results from a randomized double blind study of OROS-methylphenidate in adults with ADHD. Eur Neuropsychopharmacol. 2011;21(7):508–515. PubMed CrossRef
Safren SA, Sprich S, Mimiaga MJ, et al. Cognitive behavioral therapy vs relaxation with educational support for medication-treated adults with ADHD and persistent symptoms: a randomized controlled trial. JAMA. 2010;304(8):875–880. PubMed CrossRef
Cheung CH, Rijdijk F, McLoughlin G, et al. Childhood predictors of adolescent and young adult outcome in ADHD. J Psychiatr Res. 2015;62:92–100. PubMed CrossRef
Monuteaux MC, Faraone SV, Gross LM, et al. Predictors, course, and outcome of conduct disorder in girls with attention-deficit/hyperactivity disorder: a longitudinal study. Psychol Med. 2007;37(12):1731–1741. PubMed CrossRef
Faraone SV, Rostain AL, Blader J, et al. Practitioner review: emotional dysregulation in attention-deficit/hyperactivity disorder—implications for clinical recognition and intervention. J Child Psychol Psychiatry. 2019;60(2):133–150. PubMed CrossRef