Psychological Assessment 2016, Vol. 28, No. 2, 245–250
© 2015 American Psychological Association 1040-3590/16/$12.00 http://dx.doi.org/10.1037/pas0000190
BRIEF REPORT
Attention-Deficit/Hyperactivity Disorder (ADHD) Symptoms, Anxiety Symptoms, and Executive Functioning in Emerging Adults Matthew A. Jarrett
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University of Alabama The current study examined attention-deficit/hyperactivity disorder (ADHD) and anxiety symptoms in relation to self-reported executive functioning deficits in emerging adults. College students (N ⫽ 421; ages 17–25; 73.1% female) completed self-reports of ADHD, anxiety, and executive functioning in a laboratory setting. Structural equation modeling analyses revealed that self-reported executive functioning deficits were significantly related to all 3 symptom domains. Executive functioning deficits were most strongly related to inattention followed by hyperactivity/impulsivity and anxiety. Analyses based on clinical groups revealed that groups with ADHD and comorbid anxiety showed greater deficits on self-regulation of emotion and self-organization/problem solving than those with ADHD only or anxiety only. Groups with ADHD showed greater deficits with self-motivation and self-restraint than those with anxiety only. All clinical groups differed from a control group on executive functioning deficits. Overall, anxiety symptoms appear to be associated with college students’ self-reported executive functioning deficits above and beyond relationships with ADHD symptomatology. Further, those with ADHD and anxiety appear to show increased difficulties with self-regulation of emotion and self-organization/ problem solving, a domain which appears to overlap substantially with working memory. Future studies should seek to replicate our findings with a clinical population, utilize both report-based and laboratory task measures of executive functioning, and integrate both state and trait anxiety indices into study designs. Finally, future studies should seek to determine how executive functioning deficits can be best ameliorated in emerging adults with ADHD and anxiety. Keywords: ADHD, anxiety, adults, executive functioning
Ollendick (2012) did not find differences on indices of sustained attention (i.e., continuous performance test omissions and reaction time variability) between those with ADHD and anxiety and ADHD only. In relation to working memory, there is some evidence to indicate that children with ADHD and anxiety show greater working memory impairments and/or working memory variability (Jarrett et al., 2012; Pliszka, 1989; Skirbekk, Hansen, Oerbeck, & Kristensen, 2011; Tannock, Ickowicz, & Schachar, 1995) along with poorer working memory changes following a stimulant medication trial (Bedard & Tannock, 2007; Tannock et al., 1995). Overall, children with ADHD and anxiety may perform worse on more cognitively complex and mentally effortful tasks. For example, anxiety may serve to enhance vigilance and/or mitigate impulsivity on simple tasks but may disrupt more cognitively effortful processes (Tannock, 2009). In relation to adults with ADHD more specifically, few studies have examined the effects of anxiety on EF. In typical adults, research suggests that anxiety interferes with efficient cognitive processing on tasks involving EF (Eysenck, Derakshan, Santos, & Calvo, 2007). In a study of adults with ADHD, Roth et al. (2004) found that state anxiety explained the relationship between ADHD and decreased verbal memory and learning. It should be noted that this relationship was not mediated by semantic organization, depression, or sustained attention, suggesting that anxiety may be uniquely related to disrupted EF.
Children and adults with attention-deficit/hyperactivity disorder (ADHD) frequently exhibit comorbid anxiety disorders (Biederman et al., 1993; Jarrett & Ollendick, 2008; Kessler et al., 2006), but relatively little is known regarding how anxiety relates to executive functioning (EF) deficits. Research on school-age children with ADHD has yielded mixed results for the effects of anxiety on EF. Some studies have found that children with ADHD and anxiety perform better on inhibitory control tasks (Manassis, Tannock, & Barbosa, 2000; Pliszka, 1992; Pliszka, Hatch, Borcherding, & Rogeness, 1993), while other studies have not supported or provided only partial support for this finding (Epstein, Goldberg, Conners, & March, 1997; Newcorn et al., 2001; Sorensen, Plessen, Nicholas, & Lundervold, 2011; Vloet, Konrad, Herpetz-Dahlmann, Polier, & Gunther, 2010). Studies have also examined other EFs such as sustained attention and working memory. For example, one study found that children with ADHD and anxiety showed increased sustained attention and selective attention on laboratory tasks relative to those with ADHD only (Vloet et al., 2010). In contrast, Jarrett, Wolff, Davis, Cowart, and
This article was published Online First June 29, 2015. Correspondence concerning this article should be addressed to Matthew A. Jarrett, Department of Psychology, University of Alabama, Box 870348, Tuscaloosa, AL 35487-0348. E-mail: [email protected] 245
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While these past studies have been valuable, most studies have focused on children and have examined deficits based exclusively on laboratory tasks. Recently, researchers and clinicians have emphasized the examination of EF deficits in everyday life, particularly since laboratory task and rating scale measures of EF do not seem to measure the same construct (Toplak, West, & Stanovich, 2013), and these measures may have different neuroanatomical correlates (Faridi et al., 2015). While studies have started to examine how ADHD and co-occurring symptoms relate to selfreported EF deficits (Jarrett, Rapport, Rondon, & Becker, 2014; Wood, Lewandowski, Lovett, & Antshel, 2014), few studies have utilized approaches such as structural equation modeling to simultaneously consider ADHD, anxiety, and EF. In order to better understand how self-reported EF deficits relate to inattention, hyperactivity/impulsivity, and anxiety in emerging adults, the current study examined these variables using a large sample of college students. Unique strengths of the current study were the use of structural equation modeling via latent constructs of inattention, hyperactivity/impulsivity, and anxiety using multiple indicators. Based on Barkley’s (1997) model of EF and ADHD, it was predicted that EF deficits would be most strongly related to symptoms of ADHD but that EF deficits would also uniquely relate to anxiety symptoms, given that EF is thought to be highly involved with emotion regulation.
Method The initial sample included 500 undergraduate students who participated in an institutional review board (IRB) approved study examining ADHD symptoms and domains of functioning. Students were given credit toward a research participation requirement in their Psychology 101 course. In order to ensure the veracity of self-report, those participants with an elevated inconsistency index (n ⫽ 79) on the Conners Adult ADHD Rating Scale (i.e., scores ⬎ ⫽ 8) were excluded from the study. The final sample of 421 was examined in the current study. Mean age of the participants was 18.83 (SD ⫽ 1.05; range ⫽ 17–25). 73.1% were female. This age mean and sex distribution is consistent with the demographic characteristics of our psychology subject pool. 10% of the sample was currently taking medication relevant to ADHD symptomatology (e.g., stimulants, nonstimulants such as atomoxetine). Participants completed measures during a 2-hr assessment session in a group-based format consisting of three students. Students were divided by carrels which prevented each student from observing the activities of the adjacent student. Participants were also equipped with noise-cancelling headphones. The following measures were utilized in the current study.
Barkley Adult ADHD Rating Scale-IV The Barkley Adult ADHD Rating Scale-IV (BAARS-IV; Barkley, 2011a) contains 18 items from the DSM–IV criteria for ADHD and has been further validated in college students specifically (Becker, Langberg, Luebbe, Dvorsky, & Flannery, 2014; Jarrett et al., 2014). Each item is answered on a 4-point scale (1 ⫽ not at all; 2 ⫽ sometimes; 3 ⫽ often; 4 ⫽ very often). For diagnostic group analyses, items rated as often or very often were counted as having a symptom present. High internal consistency was found for current inattention (␣ ⫽ .89) and hyperactivity/
impulsivity (␣ ⫽ .83) as well as childhood report of inattention (␣ ⫽ .92) and hyperactivity/impulsivity (␣ ⫽ .92).
Conners Adult ADHD Rating Scale–Self Report: Long Version The Conners Adult ADHD Rating Scale–Self Report: Long Version (CAARS-S:L; Conners, Erhardt, & Sparrow, 1999) is a 66-item measure of adult ADHD symptomatology that uses a 4-point Likert scale (0 ⫽ not at all, 1 ⫽ just a little, once in a while, 2 ⫽ pretty much, often, 3 ⫽ very much, very frequently). High internal consistency was found for the CAARS inattention (␣ ⫽ .93) and CAARS hyperactivity/impulsivity (␣ ⫽ .91) factors.
Beck Anxiety Inventory The Beck Anxiety Inventory (BAI; Beck & Steer, 1993) is a 21-item scale that measures the severity of anxiety in adolescents and adults. The measure uses the following 4-point scale: 0 ⫽ not at all, 1 ⫽ mildly, 2 ⫽ moderately, 3 ⫽ severely. Scores of 16 –25 indicate moderate anxiety and scores of 26 – 63 indicate severe anxiety. Internal consistency for the total score was high (␣ ⫽ .92).
State–Trait Anxiety Inventory The State–Trait Anxiety Inventory (STAI; Spielberger, 1983) consists of 40 questions about state and trait anxiety. State and trait anxiety scores range from 20 to 80 with higher scores reflecting greater anxiety. For the current study, only the trait anxiety scale was utilized and high internal consistency was found (␣ ⫽ .93).
Symptom Checklist-90 –R The Symptom Checklist-90 –R (SCL-90 –R; Derogatis, 1994) is a 90-item questionnaire that describes symptoms of general psychological distress experienced by adults. Responses are made on a 5-point scale ranging from not at all to extremely. For the current study, the Anxiety factor was utilized and had high internal consistency (␣ ⫽ .90).
Barkley Deficits in Executive Functioning Scale The Barkley Deficits in Executive Functioning Scale (BDEFS; Barkley, 2011b) is an 89-item self-report measure of EF deficits in everyday life. Each item is answered on a 4-point scale (1 ⫽ not at all; 2 ⫽ sometimes; 3 ⫽ often; 4 ⫽ very often). High internal consistency was found for self-management to time (␣ ⫽ .96), self-organization/problem solving (␣ ⫽ .96), self-restraint (␣ ⫽ .94), self-motivation (␣ ⫽ .93), and self-regulation of emotion (␣ ⫽ .95).
Results and Discussion Data were first analyzed for outliers by examining standardized z scores (e.g., between ⫺3.29 and ⫹3.29). A small number of outliers (n ⫽ 21 values) were identified and were subsequently changed to raw scores reflecting a z score of 3.29 in order to reduce the influence of these outliers on study results (Field, 2009). Analysis of skewness and kurtosis revealed elevated z scores for skewness and kurtosis for study variables, so the nonparametric
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ADHD, ANXIETY, AND EFS
Spearman’s correlation coefficient was utilized for correlational analyses. Using Mplus 7.11 software, a structural equation model was constructed with an EF factor predicting the factors of inattention, hyperactivity/impulsivity, and anxiety. For EF, the factor consisted of the five BDEFS indicators: self-management to time, selforganization/problem solving, self-restraint, self-motivation, and self-regulation of emotions. The latent factor of inattention consisted of BAARS-IV inattention and CAARS inattention. The latent factor of hyperactivity/impulsivity consisted of BAARS-IV hyperactivity/impulsivity and CAARS hyperactivity/impulsivity. Finally, the latent factor of anxiety consisted of SCL-90 –R anxiety, STAI trait anxiety, and the BAI total score. Following recommendations of Hu and Bentler (1998, 1999), additional fit indices were included beyond the chi-square statistic. These additional fit indices included the root-mean-square error of approximation (RMSEA), the comparative fit index (CFI), and the Tucker–Lewis index (TLI). CFI and TLI values greater than .95 are considered a “good” fit. RMSEA values of less than .05 are considered good fit, while values less than .08 are considered as having a reasonable fit (Hu & Bentler, 1999). Finally, the standard root-mean-square residual (SRMR) was also examined as a measure of fit. Values less than .05 reflect a good fit (Geiser, 2013). Table 1 presents correlations among the study variables. Age and gender were generally unrelated to study variables, although females were more likely to report difficulties with self-organization/problem solving, self-regulation of emotion, and anxiety symptoms. These correlations were generally in the small range (i.e., rs ⫽ .17–.19). Self-reported EF deficits were highly correlated with symptoms of inattention, hyperactivity/impulsivity, and anxiety, but not so highly correlated to be indistinguishable (e.g., only five correlations were greater than .8). The first structural equation model involved the latent factor of EF deficits as a predictor of inattention, hyperactivity/impulsivity,
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and anxiety. This model showed borderline reasonable fit to the data, 2(48) ⫽ 380.87, p ⫽ .00, CFI ⫽ .93, TLI ⫽ .90, SRMR ⫽ .05, RMSEA ⫽ .13, 90% confidence interval (CI) [.12, .14]. Mplus model modification indices were explored starting with the highest modification index. Model fit was subsequently explored after each modification. The final model included the following correlated pairs: BDEFS self-management to time with BAARS-IV inattention and CAARS inattention; BDEFS self-regulation of emotion and BAI anxiety, STAI trait anxiety, and SCL-90 –R anxiety; BDEFS self-restraint and BAARS-IV hyperactivity/impulsivity; and finally, BDEFS self-motivation and selfmanagement to time. The final model (see Figure 1) showed reasonable fit to the data, 2(41) ⫽ 221.10, p ⫽ .00, CFI ⫽ .96, TLI ⫽ .94, SRMR ⫽ .04, RMSEA ⫽ .10, 90% CI [.09, .12]. As hypothesized, EF deficits were most strongly related to inattention and hyperactivity/impulsivity symptoms followed by anxiety symptoms. In addition to these dimensional analyses, we further examined the following diagnostic groups: ADHD and anxiety (ADHD ⫹ anxiety; n ⫽ 36), ADHD but not anxiety (ADHD only; n ⫽ 35), anxiety but not ADHD (anxiety only; n ⫽ 53), and a control group (n ⫽ 32) with neither symptom domain elevated. For the ADHD ⫹ anxiety group, participants needed to report childhood and adulthood symptoms above the 93rd percentile (i.e., three or more symptoms of inattention or hyperactivity/impulsivity, or five or more total ADHD symptoms). In addition, impairment in two or more settings was required (i.e., work, school, home, social). For childhood history, those in the ADHD ⫹ anxiety group were required to have four or more childhood symptoms of inattention or hyperactivity/impulsivity, or eight or more total childhood ADHD symptoms (i.e., above the 93rd percentile). Participants in the ADHD ⫹ anxiety group were also required to have an age of onset before age 16 (as recommended by the BAARS-IV manual). Finally, those in the ADHD ⫹ anxiety group were required to have
Table 1 Descriptive Statistics and Zero-Order Correlations (Spearman’s Rho) Among Study Variables
1. Age 2. Gender 3. BAARS-I 4. BAARS-HI 5. CAARS-I 6. CAARS-HI 7. Motivation 8. Time 9. Org 10. Restraint 11. Emotion 12. BAI 13. SCL Anx 14. Trait Anx M SD Range
1
2
.16ⴱ .07 .05 .07 .08 .12 .10 .08 .12 .02 .01 .05 .07 18.83 1.05 17–25
1 ⫺.04 ⫺.09 ⫺.03 ⫺.01 .05 ⫺.07 ⫺.17ⴱ ⫺.02 ⫺.19ⴱ ⫺.17ⴱ ⫺.09 ⫺.10 — — —
3
4
5
6
7
8
9
10
11
12
13
14
.64ⴱ .47 .60 0–2.56
1 39.10 11.01 20–75
1
1
.58ⴱ .81ⴱ .58ⴱ .72ⴱ .81ⴱ .74ⴱ .70ⴱ .58ⴱ .48ⴱ .52ⴱ .57ⴱ 16.67 5.35 9–34
1
.58ⴱ .75ⴱ .57ⴱ .51ⴱ .57ⴱ .66ⴱ .54ⴱ .48ⴱ .51ⴱ .39ⴱ 16.20 4.84 9–32
1
.71ⴱ .80ⴱ .85ⴱ .78ⴱ .79ⴱ .67ⴱ .53ⴱ .57ⴱ .60ⴱ 10.95 8.11 0–33
1
.63ⴱ .57ⴱ .63ⴱ .71ⴱ .56ⴱ .50ⴱ .56ⴱ .41ⴱ 13.66 8.03 1–36
1
.78ⴱ .73ⴱ .80ⴱ .62ⴱ .45ⴱ .51ⴱ .51ⴱ 19.59 7.18 12–43
1
.76ⴱ .73ⴱ .58ⴱ .48ⴱ .49ⴱ .53ⴱ 42.24 14.03 21–82
1
.75ⴱ .68ⴱ .55ⴱ .59ⴱ .59ⴱ 42.50 14.96 24–92
1
.71ⴱ .49ⴱ .53ⴱ .55ⴱ 32.24 10.61 19–67
1
.55ⴱ .55ⴱ .59ⴱ 22.71 8.69 13–51
1
.76ⴱ .64ⴱ 10.37 9.44 0–42
1
Note. BAARS ⫽ Barkley Adult ADHD Rating Scale-IV; ADHD ⫽ attention-deficit/hyperactivity disorder; BAI ⫽ Beck Anxiety Inventory Total Score; CAARS ⫽ Conners Adult ADHD Rating Scale; Emotion ⫽ self-regulation of emotion; HI ⫽ hyperactivity/impulsivity; I ⫽ inattention; Motivation ⫽ self-motivation; Org ⫽ self-organization/problem solving; Restraint ⫽ self-restraint; SCL Anx ⫽ SCL-90-R anxiety; Time ⫽ self-management to time; Trait Anx ⫽ trait anxiety; Gender (0 ⫽ female; 1 ⫽ male). ⴱ p ⬍ .01.
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Figure 1. Final model from structural equation model analyses. Note: 2(41) ⫽ 221.10, p ⫽ .00, CFI ⫽ .96, TLI ⫽ .94, SRMR ⫽ .04, RMSEA ⫽ .10, 90% CI [.09, .12 ]. ⴱ p ⬍ .05.
a score of 16 or higher on the BAI (i.e., the clinical cutoff for the measure). These criteria were also utilized for forming the ADHD only and anxiety only groups. Finally, a control group was formed by selecting those at the 50th percentile for total ADHD symptoms and within the “minimal” range for anxiety (i.e., BAI total score ⬍ 7). Groups did not differ on age (p ⬎ .05), but they did differ on gender, 2(3) ⫽ 10.74, p ⬍ .05, and ADHD medication status, 2(3) ⫽ 17.73, p ⬍ .05. For gender, the anxiety only group had more females than the ADHD only group and the control group. As would be expected, groups with ADHD more frequently endorsed taking medication for ADHD than the anxiety only group and control group. For self-reported EF deficits (see Table 2), the groups with ADHD showed greater deficits on self-motivation and
self-restraint than the anxiety only group. In contrast, the ADHD ⫹ anxiety group showed greater difficulty with self-organization/problem solving and emotional control than both the ADHD only and anxiety only groups, and the ADHD only and anxiety only groups did not differ on these variables. Finally, the ADHD ⫹ anxiety group differed from the anxiety only group on self-management to time but did not differ from the ADHD only group. All clinical groups were more impaired on all EF domains in comparison to the control group. The current study sought to examine how self-reported EF deficits uniquely relate to symptoms of inattention, hyperactivity/ impulsivity, and anxiety symptoms. As noted earlier, self-reported EF deficits were most strongly related to inattention, and to a lesser extent, hyperactivity/impulsivity, but these deficits were also sig-
Table 2 Executive Functioning Differences Across Diagnostic Groups ADHD ⫹ anxiety (n ⫽ 36) Motivation Time manage Organize Restraint Emotion
a
27.46 (7.53) 57.20 (12.39)a 61.58 (15.71)a 45.29 (11.11)a 34.27 (9.50)a
ADHD only (n ⫽ 35) a
27.12 (7.94) 53.08 (13.19)a,b 52.67 (14.96)b 42.61 (9.78)a 26.53 (7.49)b
Anxiety only (n ⫽ 53) b
21.88 (6.95) 49.32 (12.64)b 49.67 (13.07)b 35.38 (9.74)b 27.47 (8.73)b
Control (n ⫽ 32) c
12.94 (1.29) 26.13 (4.67)c 26.91 (2.59)c 21.35 (1.74)c 14.66 (1.91)c
F
p
36.98 48.11 45.65 48.16 39.48
⬍.01ⴱ ⬍.01ⴱ ⬍.01ⴱ ⬍.01ⴱ ⬍.01ⴱ
Note. Emotion ⫽ self-regulation of emotion; Motivation ⫽ self-motivation; Organize ⫽ self-organization/ problem solving; Restraint ⫽ self-restraint; Time manage ⫽ self-management to time. Please note that Levene’s test was significant for all domains, but nonparametric Kruskal-Wallis test results were the same as one-way ANOVA results. Letters in superscript indicate statistically significant differences between groups (p ⬍ .05). ⴱ p ⬍ .05.
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ADHD, ANXIETY, AND EFS
nificantly related to anxiety symptoms. Similar results were found in our diagnostic group analyses, where those with ADHD and anxiety showed particularly pronounced deficits in self-organization/problem solving and self-regulation of emotion. It should be noted that the self-organizational/problem solving domain of the BAARS-IV reflects the ability to organize one’s thoughts, actions, and writing, think quickly when encountering unexpected events, and invent solutions to problems or obstacles encountered while pursuing goals (Barkley, 2011b). This construct has significant overlap with working memory and is consistent with past research suggesting increased working memory deficits in those with ADHD and anxiety (Jarrett et al., 2012; Tannock, 2009). In relation to self-restraint, it appears that problems with selfrestraint are more strongly associated with ADHD than anxiety, a finding consistent with views of inhibitory control deficits as a defining feature of ADHD (Barkley, 1997). At the same time, we found little evidence for the contention that anxiety mitigates self-restraint difficulties in those with ADHD and anxiety. This finding is consistent with past studies that have found that anxiety does not reduce or possibly even enhances difficulties with selfrestraint (Jarrett et al., 2012; Sorensen et al., 2011). Limitations of the current study should be noted. First, our study relied on self-report of symptoms and deficits. A second limitation of the study is that the sample was primarily female given that participants were drawn from a psychology subject pool. We were also unable to examine ADHD subtypes/presentations in the current study given the small number of participants meeting criteria for ADHD and anxiety. Finally, our sample of emerging adults was restricted to a college sample only. Such emerging adults may reflect a higher functioning group than those not in a college population. While the current study offers additional data on the relationships among ADHD, anxiety, and EF, future studies are needed with more carefully diagnosed participants with ADHD in order to draw more definitive conclusions (e.g., obtaining clinician ratings and collateral report). Consistent with other past studies in this area, though, both ADHD and anxiety symptoms appear to be related to difficulties with EF. While the current study focused on report-based measures of executive functioning, future studies should seek to include both report-based measures and laboratory task measures. During laboratory tasks, studies should also seek to evaluate state anxiety (as opposed to trait anxiety) using alternative indices such as physiological reactivity during task completion. Such measures may help to elucidate the clearly complicated pattern among ADHD symptoms, anxiety symptoms, and EF. Finally, our results suggest that those with ADHD and anxiety have particular difficulty with emotion regulation, so treatments for emerging adults should continue to target this area of functioning. Emotional control has been shown to be associated with impairment in major life activities in adulthood (Barkley & Fischer, 2010), so a greater focus on emotion regulation may be needed in treatments for adults with ADHD, particularly when internalizing problems such as anxiety are present.
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Jarrett, M. A., Wolff, J. C., Davis, T. E., III, Cowart, M. J., & Ollendick, T. H. (2012). Characteristics of children with ADHD and comorbid anxiety. Journal of Attention Disorders. Advance online publication. http://dx.doi.org/10.1177/1087054712452914 Kessler, R. C., Adler, L., Barkley, R., Biederman, J., Conners, C. K., Demler, O., . . . ZaslavskyA. M. (2006). The prevalence and correlates of adult ADHD in the United States: Results from the National Comorbidity Survey Replication. American Journal of Psychiatry, 163, 716 – 723. http://dx.doi.org/10.1176/appi.ajp.163.4.716 Manassis, K., Tannock, R., & Barbosa, J. (2000). Dichotic listening and response inhibition in children with comorbid anxiety disorders and ADHD. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 1152–1159. http://dx.doi.org/10.1097/00004583200009000-00015 Newcorn, J. H., Halperin, J. M., Jensen, P. S., Abikoff, H. B., Arnold, L. E., Cantwell, D. P., . . . Vitiello, B. (2001). Symptom profiles in children with ADHD: Effects of comorbidity and gender. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 137–146. http://dx.doi.org/10.1097/00004583-200102000-00008 Pliszka, S. R. (1989). Effect of anxiety on cognition, behavior, and stimulant response in ADHD. Journal of the American Academy of Child and Adolescent Psychiatry, 28, 882– 887. http://dx.doi.org/10.1097/ 00004583-198911000-00012 Pliszka, S. R. (1992). Comorbidity of attention-deficit hyperactivity disorder and overanxious disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 197–203. http://dx.doi.org/10.1097/ 00004583-199203000-00003 Pliszka, S. R., Hatch, J. P., Borcherding, S. H., & Rogeness, G. A. (1993). Classical conditioning in children with attention deficit hyperactivity disorder (ADHD) and anxiety disorders: A test of Quay’s model. Journal of Abnormal Child Psychology, 21, 411– 423. http://dx.doi.org/ 10.1007/BF01261601 Roth, R. M., Wishart, H. A., Flashman, L. A., Riordan, H. J., Huey, L., & Saykin, A. J. (2004). Contribution of organizational strategy to verbal learning and memory in adults with attention-deficit/hyperactivity disorder. Neuropsychology, 18, 78 – 84. http://dx.doi.org/10.1037/08944105.18.1.78
Skirbekk, B., Hansen, B. H., Oerbeck, B., & Kristensen, H. (2011). The relationship between sluggish cognitive tempo, subtypes of attentiondeficit/hyperactivity disorder, and anxiety disorders. Journal of Abnormal Child Psychology, 39, 513–525. http://dx.doi.org/10.1007/s10802011-9488-4 Sorensen, L., Plessen, K. J., Nicholas, J., & Lundervold, A. J. (2011). Is behavioral regulation in children with ADHD aggravated by comorbid anxiety disorder? Journal of Attention Disorders, 15, 56 – 66. http://dx .doi.org/10.1177/1087054709356931 Spielberger, C. D. (1983). State-trait anxiety inventory for adults manual. Palo Alto, CA: Consulting Psychologists Press. Tannock, R. (2009). ADHD with anxiety disorders. In T. E. Brown (Ed.), ADHD comorbidities: Handbook for ADHD complications in children and adults (pp. 131–155). Washington, DC: American Psychiatric Publishing. Tannock, R., Ickowicz, A., & Schachar, R. (1995). Differential effects of methylphenidate on working memory in ADHD children with and without comorbid anxiety. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 886 – 896. http://dx.doi.org/10.1097/ 00004583-199507000-00012 Toplak, M. E., West, R. F., & Stanovich, K. E. (2013). Practitioner review: Do performance-based measures and ratings of executive function assess the same construct? Journal of Child Psychology and Psychiatry, 54, 131–143. http://dx.doi.org/10.1111/jcpp.12001 Vloet, T. D., Konrad, K., Herpertz-Dahlmann, B., Polier, G. G., & Günther, T. (2010). Impact of anxiety disorders on attentional functions in children with ADHD. Journal of Affective Disorders, 124, 283–290. http:// dx.doi.org/10.1016/j.jad.2009.11.017 Wood, W. L., Lewandowski, L. J., Lovett, B. J., & Antshel, K. M. (2014). Executive dysfunction and functional impairment associated with sluggish cognitive tempo in emerging adulthood. Journal of Attention Disorders. Advance online publication. http://dx.doi.org/10.1177/ 1087054714560822
Received July 10, 2014 Revision received May 20, 2015 Accepted May 28, 2015 䡲
© 2015 American Psychological Association 1040-3590/16/$12.00 http://dx.doi.org/10.1037/pas0000190
BRIEF REPORT
Attention-Deficit/Hyperactivity Disorder (ADHD) Symptoms, Anxiety Symptoms, and Executive Functioning in Emerging Adults Matthew A. Jarrett
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University of Alabama The current study examined attention-deficit/hyperactivity disorder (ADHD) and anxiety symptoms in relation to self-reported executive functioning deficits in emerging adults. College students (N ⫽ 421; ages 17–25; 73.1% female) completed self-reports of ADHD, anxiety, and executive functioning in a laboratory setting. Structural equation modeling analyses revealed that self-reported executive functioning deficits were significantly related to all 3 symptom domains. Executive functioning deficits were most strongly related to inattention followed by hyperactivity/impulsivity and anxiety. Analyses based on clinical groups revealed that groups with ADHD and comorbid anxiety showed greater deficits on self-regulation of emotion and self-organization/problem solving than those with ADHD only or anxiety only. Groups with ADHD showed greater deficits with self-motivation and self-restraint than those with anxiety only. All clinical groups differed from a control group on executive functioning deficits. Overall, anxiety symptoms appear to be associated with college students’ self-reported executive functioning deficits above and beyond relationships with ADHD symptomatology. Further, those with ADHD and anxiety appear to show increased difficulties with self-regulation of emotion and self-organization/ problem solving, a domain which appears to overlap substantially with working memory. Future studies should seek to replicate our findings with a clinical population, utilize both report-based and laboratory task measures of executive functioning, and integrate both state and trait anxiety indices into study designs. Finally, future studies should seek to determine how executive functioning deficits can be best ameliorated in emerging adults with ADHD and anxiety. Keywords: ADHD, anxiety, adults, executive functioning
Ollendick (2012) did not find differences on indices of sustained attention (i.e., continuous performance test omissions and reaction time variability) between those with ADHD and anxiety and ADHD only. In relation to working memory, there is some evidence to indicate that children with ADHD and anxiety show greater working memory impairments and/or working memory variability (Jarrett et al., 2012; Pliszka, 1989; Skirbekk, Hansen, Oerbeck, & Kristensen, 2011; Tannock, Ickowicz, & Schachar, 1995) along with poorer working memory changes following a stimulant medication trial (Bedard & Tannock, 2007; Tannock et al., 1995). Overall, children with ADHD and anxiety may perform worse on more cognitively complex and mentally effortful tasks. For example, anxiety may serve to enhance vigilance and/or mitigate impulsivity on simple tasks but may disrupt more cognitively effortful processes (Tannock, 2009). In relation to adults with ADHD more specifically, few studies have examined the effects of anxiety on EF. In typical adults, research suggests that anxiety interferes with efficient cognitive processing on tasks involving EF (Eysenck, Derakshan, Santos, & Calvo, 2007). In a study of adults with ADHD, Roth et al. (2004) found that state anxiety explained the relationship between ADHD and decreased verbal memory and learning. It should be noted that this relationship was not mediated by semantic organization, depression, or sustained attention, suggesting that anxiety may be uniquely related to disrupted EF.
Children and adults with attention-deficit/hyperactivity disorder (ADHD) frequently exhibit comorbid anxiety disorders (Biederman et al., 1993; Jarrett & Ollendick, 2008; Kessler et al., 2006), but relatively little is known regarding how anxiety relates to executive functioning (EF) deficits. Research on school-age children with ADHD has yielded mixed results for the effects of anxiety on EF. Some studies have found that children with ADHD and anxiety perform better on inhibitory control tasks (Manassis, Tannock, & Barbosa, 2000; Pliszka, 1992; Pliszka, Hatch, Borcherding, & Rogeness, 1993), while other studies have not supported or provided only partial support for this finding (Epstein, Goldberg, Conners, & March, 1997; Newcorn et al., 2001; Sorensen, Plessen, Nicholas, & Lundervold, 2011; Vloet, Konrad, Herpetz-Dahlmann, Polier, & Gunther, 2010). Studies have also examined other EFs such as sustained attention and working memory. For example, one study found that children with ADHD and anxiety showed increased sustained attention and selective attention on laboratory tasks relative to those with ADHD only (Vloet et al., 2010). In contrast, Jarrett, Wolff, Davis, Cowart, and
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While these past studies have been valuable, most studies have focused on children and have examined deficits based exclusively on laboratory tasks. Recently, researchers and clinicians have emphasized the examination of EF deficits in everyday life, particularly since laboratory task and rating scale measures of EF do not seem to measure the same construct (Toplak, West, & Stanovich, 2013), and these measures may have different neuroanatomical correlates (Faridi et al., 2015). While studies have started to examine how ADHD and co-occurring symptoms relate to selfreported EF deficits (Jarrett, Rapport, Rondon, & Becker, 2014; Wood, Lewandowski, Lovett, & Antshel, 2014), few studies have utilized approaches such as structural equation modeling to simultaneously consider ADHD, anxiety, and EF. In order to better understand how self-reported EF deficits relate to inattention, hyperactivity/impulsivity, and anxiety in emerging adults, the current study examined these variables using a large sample of college students. Unique strengths of the current study were the use of structural equation modeling via latent constructs of inattention, hyperactivity/impulsivity, and anxiety using multiple indicators. Based on Barkley’s (1997) model of EF and ADHD, it was predicted that EF deficits would be most strongly related to symptoms of ADHD but that EF deficits would also uniquely relate to anxiety symptoms, given that EF is thought to be highly involved with emotion regulation.
Method The initial sample included 500 undergraduate students who participated in an institutional review board (IRB) approved study examining ADHD symptoms and domains of functioning. Students were given credit toward a research participation requirement in their Psychology 101 course. In order to ensure the veracity of self-report, those participants with an elevated inconsistency index (n ⫽ 79) on the Conners Adult ADHD Rating Scale (i.e., scores ⬎ ⫽ 8) were excluded from the study. The final sample of 421 was examined in the current study. Mean age of the participants was 18.83 (SD ⫽ 1.05; range ⫽ 17–25). 73.1% were female. This age mean and sex distribution is consistent with the demographic characteristics of our psychology subject pool. 10% of the sample was currently taking medication relevant to ADHD symptomatology (e.g., stimulants, nonstimulants such as atomoxetine). Participants completed measures during a 2-hr assessment session in a group-based format consisting of three students. Students were divided by carrels which prevented each student from observing the activities of the adjacent student. Participants were also equipped with noise-cancelling headphones. The following measures were utilized in the current study.
Barkley Adult ADHD Rating Scale-IV The Barkley Adult ADHD Rating Scale-IV (BAARS-IV; Barkley, 2011a) contains 18 items from the DSM–IV criteria for ADHD and has been further validated in college students specifically (Becker, Langberg, Luebbe, Dvorsky, & Flannery, 2014; Jarrett et al., 2014). Each item is answered on a 4-point scale (1 ⫽ not at all; 2 ⫽ sometimes; 3 ⫽ often; 4 ⫽ very often). For diagnostic group analyses, items rated as often or very often were counted as having a symptom present. High internal consistency was found for current inattention (␣ ⫽ .89) and hyperactivity/
impulsivity (␣ ⫽ .83) as well as childhood report of inattention (␣ ⫽ .92) and hyperactivity/impulsivity (␣ ⫽ .92).
Conners Adult ADHD Rating Scale–Self Report: Long Version The Conners Adult ADHD Rating Scale–Self Report: Long Version (CAARS-S:L; Conners, Erhardt, & Sparrow, 1999) is a 66-item measure of adult ADHD symptomatology that uses a 4-point Likert scale (0 ⫽ not at all, 1 ⫽ just a little, once in a while, 2 ⫽ pretty much, often, 3 ⫽ very much, very frequently). High internal consistency was found for the CAARS inattention (␣ ⫽ .93) and CAARS hyperactivity/impulsivity (␣ ⫽ .91) factors.
Beck Anxiety Inventory The Beck Anxiety Inventory (BAI; Beck & Steer, 1993) is a 21-item scale that measures the severity of anxiety in adolescents and adults. The measure uses the following 4-point scale: 0 ⫽ not at all, 1 ⫽ mildly, 2 ⫽ moderately, 3 ⫽ severely. Scores of 16 –25 indicate moderate anxiety and scores of 26 – 63 indicate severe anxiety. Internal consistency for the total score was high (␣ ⫽ .92).
State–Trait Anxiety Inventory The State–Trait Anxiety Inventory (STAI; Spielberger, 1983) consists of 40 questions about state and trait anxiety. State and trait anxiety scores range from 20 to 80 with higher scores reflecting greater anxiety. For the current study, only the trait anxiety scale was utilized and high internal consistency was found (␣ ⫽ .93).
Symptom Checklist-90 –R The Symptom Checklist-90 –R (SCL-90 –R; Derogatis, 1994) is a 90-item questionnaire that describes symptoms of general psychological distress experienced by adults. Responses are made on a 5-point scale ranging from not at all to extremely. For the current study, the Anxiety factor was utilized and had high internal consistency (␣ ⫽ .90).
Barkley Deficits in Executive Functioning Scale The Barkley Deficits in Executive Functioning Scale (BDEFS; Barkley, 2011b) is an 89-item self-report measure of EF deficits in everyday life. Each item is answered on a 4-point scale (1 ⫽ not at all; 2 ⫽ sometimes; 3 ⫽ often; 4 ⫽ very often). High internal consistency was found for self-management to time (␣ ⫽ .96), self-organization/problem solving (␣ ⫽ .96), self-restraint (␣ ⫽ .94), self-motivation (␣ ⫽ .93), and self-regulation of emotion (␣ ⫽ .95).
Results and Discussion Data were first analyzed for outliers by examining standardized z scores (e.g., between ⫺3.29 and ⫹3.29). A small number of outliers (n ⫽ 21 values) were identified and were subsequently changed to raw scores reflecting a z score of 3.29 in order to reduce the influence of these outliers on study results (Field, 2009). Analysis of skewness and kurtosis revealed elevated z scores for skewness and kurtosis for study variables, so the nonparametric
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ADHD, ANXIETY, AND EFS
Spearman’s correlation coefficient was utilized for correlational analyses. Using Mplus 7.11 software, a structural equation model was constructed with an EF factor predicting the factors of inattention, hyperactivity/impulsivity, and anxiety. For EF, the factor consisted of the five BDEFS indicators: self-management to time, selforganization/problem solving, self-restraint, self-motivation, and self-regulation of emotions. The latent factor of inattention consisted of BAARS-IV inattention and CAARS inattention. The latent factor of hyperactivity/impulsivity consisted of BAARS-IV hyperactivity/impulsivity and CAARS hyperactivity/impulsivity. Finally, the latent factor of anxiety consisted of SCL-90 –R anxiety, STAI trait anxiety, and the BAI total score. Following recommendations of Hu and Bentler (1998, 1999), additional fit indices were included beyond the chi-square statistic. These additional fit indices included the root-mean-square error of approximation (RMSEA), the comparative fit index (CFI), and the Tucker–Lewis index (TLI). CFI and TLI values greater than .95 are considered a “good” fit. RMSEA values of less than .05 are considered good fit, while values less than .08 are considered as having a reasonable fit (Hu & Bentler, 1999). Finally, the standard root-mean-square residual (SRMR) was also examined as a measure of fit. Values less than .05 reflect a good fit (Geiser, 2013). Table 1 presents correlations among the study variables. Age and gender were generally unrelated to study variables, although females were more likely to report difficulties with self-organization/problem solving, self-regulation of emotion, and anxiety symptoms. These correlations were generally in the small range (i.e., rs ⫽ .17–.19). Self-reported EF deficits were highly correlated with symptoms of inattention, hyperactivity/impulsivity, and anxiety, but not so highly correlated to be indistinguishable (e.g., only five correlations were greater than .8). The first structural equation model involved the latent factor of EF deficits as a predictor of inattention, hyperactivity/impulsivity,
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and anxiety. This model showed borderline reasonable fit to the data, 2(48) ⫽ 380.87, p ⫽ .00, CFI ⫽ .93, TLI ⫽ .90, SRMR ⫽ .05, RMSEA ⫽ .13, 90% confidence interval (CI) [.12, .14]. Mplus model modification indices were explored starting with the highest modification index. Model fit was subsequently explored after each modification. The final model included the following correlated pairs: BDEFS self-management to time with BAARS-IV inattention and CAARS inattention; BDEFS self-regulation of emotion and BAI anxiety, STAI trait anxiety, and SCL-90 –R anxiety; BDEFS self-restraint and BAARS-IV hyperactivity/impulsivity; and finally, BDEFS self-motivation and selfmanagement to time. The final model (see Figure 1) showed reasonable fit to the data, 2(41) ⫽ 221.10, p ⫽ .00, CFI ⫽ .96, TLI ⫽ .94, SRMR ⫽ .04, RMSEA ⫽ .10, 90% CI [.09, .12]. As hypothesized, EF deficits were most strongly related to inattention and hyperactivity/impulsivity symptoms followed by anxiety symptoms. In addition to these dimensional analyses, we further examined the following diagnostic groups: ADHD and anxiety (ADHD ⫹ anxiety; n ⫽ 36), ADHD but not anxiety (ADHD only; n ⫽ 35), anxiety but not ADHD (anxiety only; n ⫽ 53), and a control group (n ⫽ 32) with neither symptom domain elevated. For the ADHD ⫹ anxiety group, participants needed to report childhood and adulthood symptoms above the 93rd percentile (i.e., three or more symptoms of inattention or hyperactivity/impulsivity, or five or more total ADHD symptoms). In addition, impairment in two or more settings was required (i.e., work, school, home, social). For childhood history, those in the ADHD ⫹ anxiety group were required to have four or more childhood symptoms of inattention or hyperactivity/impulsivity, or eight or more total childhood ADHD symptoms (i.e., above the 93rd percentile). Participants in the ADHD ⫹ anxiety group were also required to have an age of onset before age 16 (as recommended by the BAARS-IV manual). Finally, those in the ADHD ⫹ anxiety group were required to have
Table 1 Descriptive Statistics and Zero-Order Correlations (Spearman’s Rho) Among Study Variables
1. Age 2. Gender 3. BAARS-I 4. BAARS-HI 5. CAARS-I 6. CAARS-HI 7. Motivation 8. Time 9. Org 10. Restraint 11. Emotion 12. BAI 13. SCL Anx 14. Trait Anx M SD Range
1
2
.16ⴱ .07 .05 .07 .08 .12 .10 .08 .12 .02 .01 .05 .07 18.83 1.05 17–25
1 ⫺.04 ⫺.09 ⫺.03 ⫺.01 .05 ⫺.07 ⫺.17ⴱ ⫺.02 ⫺.19ⴱ ⫺.17ⴱ ⫺.09 ⫺.10 — — —
3
4
5
6
7
8
9
10
11
12
13
14
.64ⴱ .47 .60 0–2.56
1 39.10 11.01 20–75
1
1
.58ⴱ .81ⴱ .58ⴱ .72ⴱ .81ⴱ .74ⴱ .70ⴱ .58ⴱ .48ⴱ .52ⴱ .57ⴱ 16.67 5.35 9–34
1
.58ⴱ .75ⴱ .57ⴱ .51ⴱ .57ⴱ .66ⴱ .54ⴱ .48ⴱ .51ⴱ .39ⴱ 16.20 4.84 9–32
1
.71ⴱ .80ⴱ .85ⴱ .78ⴱ .79ⴱ .67ⴱ .53ⴱ .57ⴱ .60ⴱ 10.95 8.11 0–33
1
.63ⴱ .57ⴱ .63ⴱ .71ⴱ .56ⴱ .50ⴱ .56ⴱ .41ⴱ 13.66 8.03 1–36
1
.78ⴱ .73ⴱ .80ⴱ .62ⴱ .45ⴱ .51ⴱ .51ⴱ 19.59 7.18 12–43
1
.76ⴱ .73ⴱ .58ⴱ .48ⴱ .49ⴱ .53ⴱ 42.24 14.03 21–82
1
.75ⴱ .68ⴱ .55ⴱ .59ⴱ .59ⴱ 42.50 14.96 24–92
1
.71ⴱ .49ⴱ .53ⴱ .55ⴱ 32.24 10.61 19–67
1
.55ⴱ .55ⴱ .59ⴱ 22.71 8.69 13–51
1
.76ⴱ .64ⴱ 10.37 9.44 0–42
1
Note. BAARS ⫽ Barkley Adult ADHD Rating Scale-IV; ADHD ⫽ attention-deficit/hyperactivity disorder; BAI ⫽ Beck Anxiety Inventory Total Score; CAARS ⫽ Conners Adult ADHD Rating Scale; Emotion ⫽ self-regulation of emotion; HI ⫽ hyperactivity/impulsivity; I ⫽ inattention; Motivation ⫽ self-motivation; Org ⫽ self-organization/problem solving; Restraint ⫽ self-restraint; SCL Anx ⫽ SCL-90-R anxiety; Time ⫽ self-management to time; Trait Anx ⫽ trait anxiety; Gender (0 ⫽ female; 1 ⫽ male). ⴱ p ⬍ .01.
JARRETT
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Figure 1. Final model from structural equation model analyses. Note: 2(41) ⫽ 221.10, p ⫽ .00, CFI ⫽ .96, TLI ⫽ .94, SRMR ⫽ .04, RMSEA ⫽ .10, 90% CI [.09, .12 ]. ⴱ p ⬍ .05.
a score of 16 or higher on the BAI (i.e., the clinical cutoff for the measure). These criteria were also utilized for forming the ADHD only and anxiety only groups. Finally, a control group was formed by selecting those at the 50th percentile for total ADHD symptoms and within the “minimal” range for anxiety (i.e., BAI total score ⬍ 7). Groups did not differ on age (p ⬎ .05), but they did differ on gender, 2(3) ⫽ 10.74, p ⬍ .05, and ADHD medication status, 2(3) ⫽ 17.73, p ⬍ .05. For gender, the anxiety only group had more females than the ADHD only group and the control group. As would be expected, groups with ADHD more frequently endorsed taking medication for ADHD than the anxiety only group and control group. For self-reported EF deficits (see Table 2), the groups with ADHD showed greater deficits on self-motivation and
self-restraint than the anxiety only group. In contrast, the ADHD ⫹ anxiety group showed greater difficulty with self-organization/problem solving and emotional control than both the ADHD only and anxiety only groups, and the ADHD only and anxiety only groups did not differ on these variables. Finally, the ADHD ⫹ anxiety group differed from the anxiety only group on self-management to time but did not differ from the ADHD only group. All clinical groups were more impaired on all EF domains in comparison to the control group. The current study sought to examine how self-reported EF deficits uniquely relate to symptoms of inattention, hyperactivity/ impulsivity, and anxiety symptoms. As noted earlier, self-reported EF deficits were most strongly related to inattention, and to a lesser extent, hyperactivity/impulsivity, but these deficits were also sig-
Table 2 Executive Functioning Differences Across Diagnostic Groups ADHD ⫹ anxiety (n ⫽ 36) Motivation Time manage Organize Restraint Emotion
a
27.46 (7.53) 57.20 (12.39)a 61.58 (15.71)a 45.29 (11.11)a 34.27 (9.50)a
ADHD only (n ⫽ 35) a
27.12 (7.94) 53.08 (13.19)a,b 52.67 (14.96)b 42.61 (9.78)a 26.53 (7.49)b
Anxiety only (n ⫽ 53) b
21.88 (6.95) 49.32 (12.64)b 49.67 (13.07)b 35.38 (9.74)b 27.47 (8.73)b
Control (n ⫽ 32) c
12.94 (1.29) 26.13 (4.67)c 26.91 (2.59)c 21.35 (1.74)c 14.66 (1.91)c
F
p
36.98 48.11 45.65 48.16 39.48
⬍.01ⴱ ⬍.01ⴱ ⬍.01ⴱ ⬍.01ⴱ ⬍.01ⴱ
Note. Emotion ⫽ self-regulation of emotion; Motivation ⫽ self-motivation; Organize ⫽ self-organization/ problem solving; Restraint ⫽ self-restraint; Time manage ⫽ self-management to time. Please note that Levene’s test was significant for all domains, but nonparametric Kruskal-Wallis test results were the same as one-way ANOVA results. Letters in superscript indicate statistically significant differences between groups (p ⬍ .05). ⴱ p ⬍ .05.
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ADHD, ANXIETY, AND EFS
nificantly related to anxiety symptoms. Similar results were found in our diagnostic group analyses, where those with ADHD and anxiety showed particularly pronounced deficits in self-organization/problem solving and self-regulation of emotion. It should be noted that the self-organizational/problem solving domain of the BAARS-IV reflects the ability to organize one’s thoughts, actions, and writing, think quickly when encountering unexpected events, and invent solutions to problems or obstacles encountered while pursuing goals (Barkley, 2011b). This construct has significant overlap with working memory and is consistent with past research suggesting increased working memory deficits in those with ADHD and anxiety (Jarrett et al., 2012; Tannock, 2009). In relation to self-restraint, it appears that problems with selfrestraint are more strongly associated with ADHD than anxiety, a finding consistent with views of inhibitory control deficits as a defining feature of ADHD (Barkley, 1997). At the same time, we found little evidence for the contention that anxiety mitigates self-restraint difficulties in those with ADHD and anxiety. This finding is consistent with past studies that have found that anxiety does not reduce or possibly even enhances difficulties with selfrestraint (Jarrett et al., 2012; Sorensen et al., 2011). Limitations of the current study should be noted. First, our study relied on self-report of symptoms and deficits. A second limitation of the study is that the sample was primarily female given that participants were drawn from a psychology subject pool. We were also unable to examine ADHD subtypes/presentations in the current study given the small number of participants meeting criteria for ADHD and anxiety. Finally, our sample of emerging adults was restricted to a college sample only. Such emerging adults may reflect a higher functioning group than those not in a college population. While the current study offers additional data on the relationships among ADHD, anxiety, and EF, future studies are needed with more carefully diagnosed participants with ADHD in order to draw more definitive conclusions (e.g., obtaining clinician ratings and collateral report). Consistent with other past studies in this area, though, both ADHD and anxiety symptoms appear to be related to difficulties with EF. While the current study focused on report-based measures of executive functioning, future studies should seek to include both report-based measures and laboratory task measures. During laboratory tasks, studies should also seek to evaluate state anxiety (as opposed to trait anxiety) using alternative indices such as physiological reactivity during task completion. Such measures may help to elucidate the clearly complicated pattern among ADHD symptoms, anxiety symptoms, and EF. Finally, our results suggest that those with ADHD and anxiety have particular difficulty with emotion regulation, so treatments for emerging adults should continue to target this area of functioning. Emotional control has been shown to be associated with impairment in major life activities in adulthood (Barkley & Fischer, 2010), so a greater focus on emotion regulation may be needed in treatments for adults with ADHD, particularly when internalizing problems such as anxiety are present.
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Received July 10, 2014 Revision received May 20, 2015 Accepted May 28, 2015 䡲
