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JADXXX10.1177/1087054718773927Journal of Attention DisordersLeRoy et al.

Article
Journal of Attention Disorders

Neuropsychological Performance
1­–12
© The Author(s) 2018
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DOI: 10.1177/1087054718773927
https://doi.org/10.1177/1087054718773927
journals.sagepub.com/home/jad

Amy LeRoy1, Claudia Jacova1, and Caedy Young1

Abstract
Objective: Neuropsychological performance patterns associated with adult ADHD subtypes are unknown. The aim of
the current systematic review was to identify and synthesize available literature regarding neuropsychological performance
associated with adult ADHD subtypes. Method: Searches were completed using the databases PsycINFO and PubMed
for studies published before March 2017 addressing adult ADHD subtypes and neuropsychological performance. Data
characterizing the neuropsychological tests utilized in each study were obtained and sorted into eight domains. To summarize
the results of all comparisons (ADHD subtype compared with control, or to each other), we counted the proportion of
tests within each domain with significant group differences. Results/Conclusion: We deemed four domains informative
in differentiating ADHD subtypes from controls. Of these, memory was the only domain that held promise in distinguishing
ADHD-Inattentive and ADHD-Combined. Limitations of the available literature are highlighted and recommendations for
future research are provided. (J. of Att. Dis. XXXX; XX[X] XX-XX)

Keywords
adult ADHD, subtype, cognition, neuropsychology, systematic review

Introduction subtypes, with ADHD-I as the most prevalent affecting 45%

ADHD was first described as a lifelong condition with three
specific subtypes in the fifth and current version of the
Diagnostic and Statistical Manual of Mental Disorders (5th
ed.; DSM-5; American Psychiatric Association [APA],
2013). Prior to this description, ADHD was known as a dis-
order of childhood that was due to a motoric disinhibition
(2nd ed.; DSM-II; APA, 1968), due to a deficit in attention
(3rd ed.; DSM-III; APA, 1980), or due to a deficit in atten-
tion and hyperactivity combined (3rd ed., rev.; DSM-III-R;
APA, 1987). The DSM-IV was the first to describe ADHD
as a disorder that was characterized by varying degrees of
inattention and hyperactivity (4th ed.; APA, 1994).
Depending on the degree of inattention and/or hyperactiv-
ity, individuals were categorized into subtypes, including
the Inattentive (ADHD-I), the Hyperactive (ADHD-H), or
the Combined (ADHD-C) subtype. This conceptualization
of ADHD has continued into the present through the DSM-
IV-TR (4th ed., text rev.; APA, 2000) and now into the DSM-
5 (APA, 2013) with the addition of the adult presentation.
Given how recently the fourth and fifth versions of the DSM
were published, research on the differentiation of adult
ADHD from childhood ADHD, and ADHD subtypes from
each other is still in its early stages.
The extant research evidence on adult ADHD subtypes is
sparse but suggests that differences do exist between some,
if not all, subtypes. Prevalence, for instance, varies for
of the ADHD population. ADHD-C follows with 34%, and
ADHD-H is the least prevalent with 21% of the adult ADHD
population (Woo & Rey, 2005). Psychiatric comorbidity also
varies for subtypes. In comparison to ADHD-I, ADHD-C
shows increased comorbidity with anxiety and substance use
disorders (Murphy, Barkley, & Bush, 2002). In addition,
subtypes also appear to experience adverse life events differ-
ently. In comparison to ADHD-I and ADHD-H, ADHD-C
experience significantly more suicide attempts and lifetime
arrests (Murphy et al., 2002).
The diagnosis of adult ADHD is difficult because current
diagnostic criteria rely on childhood symptoms (Barkley &
Biederman, 1997). This overreliance on childhood symp-
toms does not take into account the differences in presenta-
tion that may occur as individuals with ADHD age. A gold
standard for an accurate diagnosis of ADHD comprised of
multiple components has been agreed upon (Davidson,
2008; Gualtieri & Johnson, 2005; Kooij et al., 2010; Taylor
et al., 2004). The first component is a confirmation of child-
hood symptoms to ensure ADHD onset was prior to the age
1
Pacific University, Hillsboro, OR, USA
Corresponding Author:
Claudia Jacova, Associate Professor, School of Graduate Psychology,
Pacific University, 222 SE 8th Ave., Hillsboro, OR 97123, USA.
Email: cjacova@pacificu.edu
2 Journal of Attention Disorders 00(0)
of 12 years (APA, 2013). The second component is the
assessment of current symptoms to determine whether
ADHD symptoms are still present. The third and fourth
components of the diagnostic process are ADHD symptom
rating scales and an evaluation of family history related to
ADHD, considering that genetic factors play a primary etio-
logical role in ADHD (Faraone & Mick, 2010; Gizer, Ficks,
& Waldman, 2009; Larsson et al., 2013; Larsson, Chang,
D’Onofrio, & Lichtenstein, 2014; Lesch et al., 2008; Levy,
Hay, McStephen, Wood, & Waldman, 1997; Sprich,
Biederman, Crawford, Mundy, & Faraone, 2000). Finally,
to obtain the only objective data in the diagnostic process,
the fifth and final component is neuropsychological testing
(Gualtieri & Johnson, 2005). In this phase of diagnosis,
cognitive difficulties are outlined. In children with ADHD,
defining cognitive strengths and difficulties through a neu-
ropsychological evaluation is crucial to elucidate the typical
pattern of impairment that is seen with those with ADHD
and aid in the correct diagnosis. Additional research is nec-
essary for differentiating adult and childhood ADHD, but
there may be similar clinical utility of the neuropsychologi-
cal profile in adults, revealing the individual’s strengths and
weaknesses, providing a positive and accurate diagnosis of
ADHD, and aiding in treatment.
Determining the neuropsychological profile of adult
ADHD could aid in the accurate diagnosis of adult ADHD
subtypes. Neuropsychological findings in children with
ADHD suggest that subtypes differ in their performance,
with children with ADHD-C and ADHD-I showing deficits
in processing speed, and the executive functions of inhibition
and planning, compared with children with ADHD-H. In
addition, in comparison to ADHD-I and ADHD-H, children
with ADHD-C show deficits in perceptual reasoning (Woo &
Rey, 2005). While childhood ADHD has been well character-
ized neuropsychologically, the evidence may not apply to
adult ADHD because of suggested differences in symptom
presentation and manifestation (Asherson et al., 2012;
Gualtieri & Johnson, 2005; Matza, Paramore, & Prasad,
2005; Resnick, 2005; Sawyer et al., 2002). In sum, it is likely
that there are neuropsychological subtype differences, and
these may not be the same in adult as in childhood ADHD.
Various hypotheses exist regarding neuropsychological
performance patterns associated with ADHD subtypes. The
most widely proposed theory regarding subtype neuropsy-
chological performance differences was proposed by
Barkley (1997). This theory was based on animal and
human research literature pertaining to the prefrontal cor-
tex, the primary brain region implicated in the development
of ADHD. Barkley’s theory suggests that the functional
deficits of ADHD-I are different from those of ADHD-H
and ADHD-C. The latter two are most impaired on mea-
sures of executive functioning and sustained attention
whereas for ADHD-I, Barkley hypothesized deficits in
memory, selective attention, and processing speed. Overall,
Barkley’s hypotheses suggest deficits in executive function-
ing for ADHD-H and ADHD-C, and more profound and
specific deficits in attention for ADHD-I.
To date, there are 13 reviews that address the neuropsy-
chological performance of adult ADHD and that were pub-
lished prior to March 2017 when the current review was
conducted. All previous reviews had common limitations.
The first limitation was a lack of a comprehensive assess-
ment, with evaluation of only one cognitive domain or par-
ticipants’ IQ (Bridgett & Walker, 2006; Kofler et al., 2013;
Skodzik, Holling, & Pedersen, 2017). The second limitation
was a generalization of performance across subtypes that
did not allow for distinction of neuropsychological perfor-
mance patterns by subtype (Alderson, Kasper, Hudec, &
Patros, 2013; Boonstra, Oosterlaan, Sergeant, & Buitelaar,
2005; Davidson, 2008; Gallagher & Blader, 2001; Hervey,
Epstein, & Curry, 2004; Kebir & Joober, 2011; Schoechlin
& Engel, 2005; Weyandt & DuPaul, 2006; Woods, Lovejoy,
& Ball, 2002). In general, these reviews found that adults
with ADHD performed worse than controls on tests of
memory and some tests of executive functioning (Schoechlin
& Engel, 2005; Woods et al., 2002). There was some dis-
agreement in the executive functioning domain regarding
the specific tests that differentiated between ADHD and
controls (Schoechlin & Engel, 2005; Woods et al., 2002).
Only one review addressed adult ADHD subtypes in rela-
tion to neuropsychological performance (Willcutt et al.,
2012). This review required comparison of at least two sub-
types in the included articles, was primarily interested in
validating the DSM-IV symptomatology, and assessed pre-
dominantly executive functioning performance. This review
only included literature up to 2010, 3 years prior to the pub-
lication of the DSM-5 (APA, 2013) and a surge of published
studies on adult ADHD. In sum, no review to date addresses
a comprehensive picture of the available literature regard-
ing subtype differences in neuropsychological performance
that is inclusive of the DSM-5 and adult presentation. It is
likely that subtype differences have contributed to the lack
of clarity of the overall profile.
The objective of this review was to evaluate and synthe-
size the literature covering neuropsychological performance
associated with adult ADHD subtypes. In line with Barkley’s
hypotheses, we hypothesized that those with ADHD-I per-
form worse on measures of memory, attention, and process-
ing speed, whereas those with ADHD-C and ADHD-H
perform worse on measures of executive functioning. Given
the lack of literature and hypotheses regarding other neuro-
psychological domains, we examined subtype performance
differences in these domains without a priori hypotheses.
Method
The present systematic review was conducted in accordance
with the Preferred Reporting Items for Systematic Reviews
LeRoy et al. 3
and Meta-analyses (PRISMA) statement (Moher, Liberati,
Tetzlaff, & Altman, 2009).
Inclusion and Exclusion Criteria
We used the following criteria to determine inclusion of full
texts that could be included in our review. First, the full text
of the articles had to be in the English language and include
adult human participants (aged 18 years and above). Second,
articles needed to assess individuals with ADHD, clinically
diagnosed prior to the study assessment or meeting criteria
for ADHD as determined by clinical tools (i.e., standardized
ADHD scales with normative data) used during the assess-
ment. Third, ADHD had to be diagnosed using the DSM-IV
(APA, 1994), DSM-IV-TR (APA, 2000), or DSM-5 (APA,
2013) criteria. Articles that included adults diagnosed with
any version of ADHD using the DSM-II or DSM-III were
not included due to the fact that they conceptualize and
diagnose ADHD subtypes differently than what is currently
done in the field. Fourth, ADHD subtypes had to be clearly
identified and used in the analysis of the neuropsychologi-
cal measures. Studies that only assessed ADHD symptoms
(i.e., hyperactive, impulsive, and inattentive symptoms) in
relation to neuropsychological performance were excluded.
This was done in an effort to ensure that only individuals
who met diagnostic criteria for ADHD were compared in
relation to neuropsychological performance, rather than
individuals who experienced some of the symptomatology
but did not meet diagnostic criteria. Fifth, to ensure we were
able to obtain a comprehensive profile with studies that
adequately addressed neuropsychological performance,
only studies containing at least two objective (i.e., not self-
report) tests of neuropsychological performance were
included. Articles that included multiple tests but reported
them as a composite score (e.g., reporting only the Full
Scale Intelligence Quotient [FSIQ] from the Wechsler Adult
Intelligence Scale–IV [WAIS-IV]) were excluded. Finally,
studies needed to be published articles that presented origi-
nal data. Narrative or nonsystematic reviews, case studies,
letters, editorials, and commentaries were excluded.
Literature Search
The electronic databases PsycINFO and PubMed were
searched for literature published before March 2017 using
adult ADHD, or adult attention-deficit/hyperactivity disor-
der combined with subtype, or cognitive, or cognition, or
neuropsychology, or neuropsychological as keywords.
Additional relevant articles were also included by hand-
searching reference lists of the retrieved articles. Once all
articles were collected, title and author screening was per-
formed first to remove duplicate citations. Following the
removal of duplicates, the first author (A.L.) screened titles,
abstracts, and full-text citations to determine inclusion of
studies. Included studies were reviewed independently by
the third author (C.Y.) with 83.3% of agreement on article
selection. Disagreements in final article selection were
resolved by discussion among the raters. The full list of
included and excluded articles at each step is provided in a
PRISMA flowchart (see Figure 1; Moher et al., 2009).
Data Extraction and Analyses
For each study, sample and study characteristics were
extracted. Data characterizing the neuropsychological tests
utilized in each study were also obtained and sorted into
eight commonly used domains that they are known, or
assumed, to measure (see Table 1, for an overview of the
domains and tests allocated to each domain; Edwards,
Jacova, Sepehry, Pratt, & Benavente, 2013; Jacova et al.,
2012). The domains included executive functioning, work-
ing memory, memory, attention, processing speed, percep-
tual reasoning, language, and motor abilities. These
particular domains were chosen to address a comprehensive
profile of neuropsychological performance. Many measures
reported multiple subscores within tests (i.e., Continuous
Performance Test that measured both omission and commis-
sion errors). All subscores within measures were assessed to
verify that they fit within the domain the overall measure
was sorted into. Three measures were separated and sorted
by their subscores to ensure domains did not capture the per-
formance of a separate domain; these measures included the
Go/No-Go task, the Stop-Signal task, and the Stop-Change
task that were all separated by their Go and No-Go sub-
scores. Subscores within each measure were sorted into
domains based on agreement between the first (A.L.) and
senior author (C.J.). After assigning measures/subscores to
domains, to calculate differences for ADHD subtypes com-
pared with control groups or another ADHD subtype, results
were evaluated by counting the proportion of tests within
each domain with significant group differences.
Obtained studies.  Twenty-four studies met our inclusion cri-
teria. However, six had to excluded because they did not
present their data in enough detail, or used uncommon tests
and/or experimental designs that were not comparable with
other tests. Thus, the final number of studies included in our
review was 16. Due to the stricter inclusion criteria that we
applied, 11 studies utilized in the previous review of ADHD
subtypes and neuropsychological performance (Willcutt
et al., 2012) had to be excluded because they included indi-
viduals younger than 18 years in their analyses, they
assessed only one neuropsychological task, or the data were
composite (i.e., only providing FSIQ data rather than indi-
vidual test performance). In a few studies, along with other
neuropsychological test scores, composite neuropsycho-
logical scores (e.g., FSIQ) were provided. In these cases,
only the single tests were included in the review.
4 Journal of Attention Disorders 00(0)

Idenficaon
Records identified through Additional records identified
database searching through other sources
(n = 5566) (n = 15)

Screening

Records after duplicates removed Records excluded

(n = 1693) (n = 1369)

Articles with unclear

Full-text articles data, uncommon tests or
Eligibility

assessed for eligibility experimental designs

(n = 324) (n = 8)

Full-text articles
excluded, with reasons
(n = 300)
Studies included in
Included

qualitative synthesis
(n = 16)

Figure 1.  PRISMA flow diagram outlining included and excluded articles.
Source. Adapted from “Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement,” by D. Moher, A. Liberati, J.
Tetzlaff, and D. Altman, 2009,. PLoS Medicine, 6, pp. 1006-1012.

Table 1.  Neuropsychological Domains and Associated Tests.

Functional domains Tests

Executive SOA Script Generation; Simon Task; D-KEFS Colour-Word Interference Test; Stroop (different versions); Stop
functioning Task, TMT B; Wisconsin Card Sorting Test; Tower of London; Object Alternation Test; Controlled Word
Fluency Test; Divergent Thinking Task; Raven Advanced Matrices Test; Letter Fluency; Cancel Underline;
D-KEFS TMT; Stop-Signal Task (No-Go); Stop-Change Task (No-Go); Object Usage; Progressive Planning
Test; Go/No-Go Task (No-Go); WAIS-III Similarities
Attention CPT-II; CPT; Stop-Change Task (Go); Stop-Signal Task (Go); Attentional Blink Task; Posner Visual Orienting
Task; Test of Variables of Attention; Go/No-Go Task (Go); Gordon Diagnostic System
Working memory SOA Working Memory Task; WAIS-III Arithmetic; WAIS-III Digit Span Forward and Backward; WAIS-III
Letter-Number Sequence; “Brown-Peterson Paradigm” Auditory Consonant Trigram Test; Simon Game;
WMS-IV Spatial Span; Paced Auditory Serial Addition Test; University of Pennsylvania Smell Identification Test
Memory SOA Prospective Memory Task; SOA Retrospective Memory Task; California Verbal Learning Test-II; Benton
Visual Retention Test; Rey Auditory Verbal Learning Test; modified Diagnosticum fur Cerebralschädigung;
WMS-IV Logical Memory I and II; Shum Visual Learning Test; WMS-IV Visual Reproduction I and II
Processing speed TMT A; WAIS-III Digit Symbol
Perceptual Rey-Osterrieth Complex Figure (Copy); WAIS-III Block Design
reasoning
Language WAIS-III Vocabulary; Category Fluency
Motor Antisaccade Task

Note. Parentheses refer to the measure within the test used in analyses. SOA = Simulation of Occupational Activities; D-KEFS = Delis–Kaplan Execu-
tive Function System; TMT = Trail Making Test; WAIS-III = Wechsler Adult Intelligence Scale–III; CPT = Continuous Performance Test; WMS =
Wechsler Memory Scale.
LeRoy et al. 5

Table 2.  Sample Characteristics.

n Mean age % male Education (years)

Study Year Subtype ADHD Ctrla ADHD Ctrl ADHD Ctrl ADHD Ctrl
Delisle 2001 C 30 30 39.03 40.00 53.0 53.0 14 14
Suarez 2015 C 15 16 22.13 21.70 73.0 87.5 NR NR
Braun 2013 C 28 30 39.39 39.70 46.0 50.0 14 14
Dinn 2001 C; I; H 13; 8; 4 11 35.60 35.40 36.0 45.5 15 16
Dige 2008 C; I; H 52; 27; 26 NR NR — 48.6 — 11 —
Dobson-Patterson 2016 C; I 16; 16 30 37.90 39.60 43.8 30.0 13 14
Miller 2012 C; I 51-83; 31-40b 71-85b 19.60 19.60 0.0 0.0 NR NR
Bekker 2005 C 24 24 34.30 34.90 50.0 50.0 NR NR
Carr 2006 C; I 27; 23 30 23.80 24.20 72.0 73.0 NR NR
Murphy 2001 C+H; I 60; 36 — 21.10 21.20 75.2 68.8 13 14
Epstein 2001 C; I; H 10; 14; 1 — 33.60 33.40 40.0 50.0 NR NR
Kakuszi 2016 C 33 29 31.60 32.90 75.8 72.4 15 15
Konrad 2012 C 37 34 32.50 30.20 56.8 47.1 13 14
Schweitzer 2006 C; I 17; 16 18 34.90 31.90 63.6 72.2 16 17
Gansler 1998 I; H 16; 14 — 28.90 35.00 NR NR 14 14
Riccio 2005 C; I 18;14 — 22.29 — 56 — 15 —

Note. Ctrl = control; C = combined; I = inattentive; H = hyperactive/impulsive; — = not applicable; NR = not reported.
a
Sample sizes for control groups are only included if they were used in the analysis of neuropsychological performance compared with ADHD subtypes.
b
Sample size varies depending on the test.

Results they allowed medication. The executive functioning domain

Study Details and Sample Characteristics
As shown in Table 2, the 16 studies included a total of 718
ADHD participants and 337 controls. Within the ADHD
participants, 461 (64%) were diagnosed with ADHD-C,
210 (29%) were diagnosed with ADHD-I, and 47 (7%)
were diagnosed with ADHD-H. Out of the 16 studies, 15
(94%) assessed ADHD-C, 10 (63%) assessed ADHD-I,
and 5 (31%) assessed ADHD-H. Participants in both the
ADHD and control groups were young, with the average
age ranging from 19.60 to 39.39 years in the ADHD
groups, and ranging from 19.60 to 40.00 years in the con-
trol groups. There was an equal distribution of male and
females within the studies, with the average percent males
in the ADHD groups ranging from 0% to 75.8% and the
average percent males in the control groups ranging from
0% to 87.5%. The average level of education for the
ADHD groups ranged from 11 to 16 years and 14 to 17
years for the control groups; however, four studies did not
report average education levels for ADHD or control
groups.
As shown in Table 3, 12 (75%) of the studies compared
ADHD subtypes to controls, nine (56%) compared ADHD
subtypes to other subtypes, and one (6%) study compared
ADHD subtypes to normative data. A majority of studies
did not allow psychostimulant medications for at least 12
hours prior to testing (i.e., 69% did not allow any stimulant
medications). Three (19%) studies did not report whether
was assessed most often (15 studies equating to 94%), fol-
lowed by attention in 13 (81%) studies, working memory in
seven (44%) studies, memory in six (38%) studies, percep-
tual reasoning in four (25%) studies, processing speed in
three (19%) studies, language in two (13%) studies, and
motor abilities in one (6%) study. The 16 studies reported
154 different subscores using 52 neuropsychological tests.
Studies included a range of two to 15 neuropsychological
tests to address cognitive performance. To evaluate if indi-
viduals met diagnostic criteria for ADHD, participants were
given a range of two to eight diagnostic scales. Diagnostic
scales and participants were judged by one to three separate
raters to determine interrater reliability for meeting diag-
nostic criteria.
ADHD Subtypes Versus Controls (Table 4)
Domains adequately assessed in these comparisons included
executive functioning, attention, working memory, and
memory. The domains of language, perceptual reasoning,
processing speed, and motor abilities were assessed by few,
a single, or no tests.
ADHD-C
Executive functioning. Tests of executive functioning
were the most frequently administered. Significant group
differences indicating poorer performance in ADHD-C
were found for 10 out of the 17 (59%) tests.
6 Journal of Attention Disorders 00(0)

Table 3.  Study Characteristics.

Neuropsychological assessment ADHD assessment

Stimulant
Study Design medications? Domainsa No. of tests No. of scales No. of raters
Delisle ADHD/ctrl No: 24-hr wo 1, 2, 3, 4 5 2 1
Suarez ADHD/ctrl No: 6-month wo 1, 2 3 3 2
Braun ADHD/ctrl No: 24-hr wo 1, 2, 3, 4 7 2 1
Dinn ADHD/ctrl Yes 1, 2 5 2 NR
Dige ADHD/ctrl No: None 1, 3, 4, 5, 6, 7 15 2 1
ADHD/ADHD
ADHD/nrm
Dobson-Patterson ADHD/ctrl No: 12-hr wo 1, 2, 4 10 2 NR
ADHD/ADHD
Miller ADHD/ctrl NR 1, 2, 3, 6 7 3 NR
ADHD/ADHD
Bekker ADHD/ctrl No: None 1, 2, 6, 7 4 5 2
Carr ADHD/ctrl No: 24-hr wo 1, 8 2 8 3
ADHD/ADHD
Murphy ADHD/ADHD No: 24-hr wo 1, 2, 3, 5 8 3 2
Epstein ADHD/ADHD No: 24-hr wo 1, 2 3 2 NR
Kakuszi ADHD/ctrl Yes 1, 2 2 2 1
Konrad ADHD/ctrl NR 1, 2 2 4 2
Schweitzer ADHD/ctrl No: 24-hr wo 3 5 4 NR
ADHD/ADHD
Gansler ADHD/ADHD NR 1, 2, 3, 4, 5, 6 13 2 NR
Riccio ADHD/ADHD No: Day wo 1, 2, 4 9 2 2

Note. Ctrl = normal controls; Nrm = normative data; wo = washout; NR = not reported. a1 = executive functioning; 2 = attention; 3 = working
memory; 4 = memory; 5 = processing speed; 6 = perceptual reasoning; 7 = language; 8 = motor.

Table 4.  Proportion of Tests By Domain With Significant Working Memory.  Tests of working memory ranked sec-
Group Differences (ADHD vs. Controls). ond in terms of tests administered. Of 16 tests, seven (44%)
indicated reliably poorer performance for ADHD-C.
Subtype

Hyperactive/ Memory.  In this domain, seven tests were administered,

Domain Combined Inattentive Impulsive three (43%) of which indicated significantly worse perfor-
mance by the ADHD subtype.
Executive 10/17 (59%) 7/11 (64%) 2/5 (40%)
functioning
Attention 9/11 (82%) 3/4 (75%) 0/1 (0%) Perceptual reasoning.  One of two tests in this domain (50%)
Working memory 7/16 (44%) 6/11 (55%) 1/1 (100%) indicated significantly poorer performance in ADHD-C.
Memory 3/7 (43%) 3/4 (75%) 1/1 (100%)
Processing speed 0/0 0/0 0/0 ADHD-I
Perceptual 1/2 (50%) 1/1 (100%) 0/0 Executive functioning.  Also for this subtype, the executive
reasoning function domain was the most widely addressed. Of 11 tests
Language 0/1 (0%) 0/0 0/0 administered, seven (64%) showed significantly worse per-
Motor 1/1 (100%) 0/1 (0%) 0/0 formance for ADHD-I.

Note. All proportions indicate worse performance by the subtype. p < .05
for all significant group differences.
Attention. Of 11 tests of attention administered, nine
(82%) were found to significantly differentiate the perfor-
mance of ADHD-C from normal controls. ADHD-C per-
formed worse on all nine tests.
Attention.  There were only four tests of attention in the
comparisons of ADHD-I to normal controls. Three of these
(75%) showed performance differences, with poorer scores
for ADHD-I.
Working Memory.  This domain was also widely assessed
in comparing ADHD-I with controls. Eleven tests were given
LeRoy et al. 7

Table 5.  Proportion of Tests By Domain With Significant Group Differences (ADHD vs. ADHD).

Subtype comparison

Combined vs. Inattentive vs. Hyperactive/impulsive

Domain inattentive hyperactive/impulsive vs. combined
Executive functioning 0/16 (0%) 1/8 (13%) I; Ha 0/4 (0%)
Attention 1/7 (14%) C 1/3(33%) I 0/2 (0%)
Working memory 0/14 (0%) 2/6 (33%) I 0/4 (0%)
Memory 4/8 (50%) C 2/7 (29%) H 0/3 (0%)
Processing speed 0/2 (0%) 0/3 (0%) 0/2 (0%)
Perceptual reasoning 0/2 (0%) 1/1 (100%) H 0/1 (0%)
Language 0/2 (0%) 0/2 (0%) 0/2 (0%)
Motor 1/1 (100%) C 0/0 0/0

Note. Letters next to proportions refer to subtype with worse performance in the comparison. p < .05 for all significant group differences. C = ADHD-C;
I = ADHD-I; H = ADHD-H.
a
Each subtype showed worse performance on 13% of tests, separately.

to participants, and six (55%) differentiated the groups, all Processing speed.  No differences were found on two tests of
indicating worse performance for the ADHD subtype. processing speed.

Memory. Of the four tests were administered, three
(75%) revealed group differences, all indicating worse per-
formance for ADHD-I.
ADHD-H
Executive functioning. This subtype was adequately
assessed only in the executive functioning domain. Of five
tests administered, two (40%) revealed significantly worse
performance for ADHD-H.
ADHD-C Versus ADHD-I (Table 5)
Domains assessed by at least two tests in comparisons of
these two subtypes included executive functioning, atten-
tion, working memory, memory, processing speed, per-
ceptual reasoning, and language. The motor domain was
assessed by a single test.
Executive functioning. ADHD-C and ADHD-I were com-
pared on 16 tests but none revealed significant performance
differences.
Attention.  The two subtypes were compared on seven mea-
sures of attention but only one (14%) found significantly
poorer performance for ADHD-C.
Working memory. In this domain, the two subtypes were
compared on 14 tests, with no significant differences on any
measure.
Memory.  Eight tests of memory were used to compare sub-
type performances. Four (50%) tests showed significant dif-
ferences between subtypes. All group differences indicated
poorer performance for ADHD-C.
Perceptual reasoning.  No differences emerged on two tests
of perceptual reasoning.
Language.  Neither of the two language tests differenti-
ated between ADHD-C and ADHD-I.
ADHD-I Versus ADHD-H 
Domains assessed by at least two tests in comparisons of
these two subtypes included executive functioning, attention,
working memory, memory, processing speed, and language.
Perceptual reasoning and motor abilities were not assessed.
Executive functioning.  The two subtypes were compared on
eight tests but only two found significant performance dif-
ferences between the subtypes. One (13%) found signifi-
cantlyly worse performance for ADHD-I, the other(13%)
significantly worse performance for ADHD-H.
Attention.  The two subtypes were compared on three tests. Only
one (33%) of these tests showed significantly worse performance
for ADHD-I. No other significant differences were found.
Working memory.  Of the six tests that compared ADHD-I
with ADHD-H, two (33%) revealed subtype differences,
with significantly worse performance by ADHD-I.
Memory. ADHD-H performed significantly worse on two
out of seven (29%) memory tests administered. There were
no other subtype differences.
Processing speed.  Three tests of processing speed were uti-
lized in the comparison of ADHD-I and ADHD-H. No sig-
nificant differences were found between subtypes.
8 Journal of Attention Disorders 00(0)
Language.  No significant differences were found between
ADHD-I and ADHD-H on the two tests of language admin-
istered to participants.
ADHD-H versus ADHD-C
Domains assessed by at least two tests in comparisons of
these two subtypes included executive functioning, attention,
working memory, memory, processing speed, and language.
Perceptual reasoning and motor abilities were not assessed.
Executive functioning. Four tests of executive functioning
were used in comparisons of ADHD-H and ADHD-C.
There were no significant findings on any of the tests.
Attention.  Two tests evaluated differences between ADHD-
H and ADHD-C. Neither found significant differences
between subtypes.
Working memory.  Four tests were administered to look at
working memory differences. None were found significant
in differentiating performance between ADHD-H and
ADHD-C.
Memory.  Two tests were used in the memory domain, and
neither test significantly distinguished performance between
ADHD-H and ADHD-C.
Processing speed.  Of the two tests that assessed attention dif-
ferences between ADHD-H and ADHD-C, neither found a
significant difference between subtypes.
Language.  Only two tests evaluated language and ADHD-H
and ADHD-C differences. No significant differences were
found.
Discussion
In this systematic review, we summarized the existing evi-
dence regarding neuropsychological performance differ-
ences between ADHD subtypes and attempted to identify
performance patterns associated with each subtype. Below
we discuss our main findings.
ADHD-C and ADHD-I were the two subtypes most ade-
quately studied. Compared with controls, both appear to per-
form worse on measures of executive functioning, attention,
working memory, and memory. Direct comparisons of the
two subtypes showed that those with ADHD-C performed
worse in the memory domain. There were few to no differ-
ences in other domains. We inspected the specific memory
measures that the subtypes were compared on to ascertain
whether memory was comprehensively assessed in the sub-
type comparisons. Measures included immediate and delayed
recall or recognition of visual and verbal materials. Given the
adequate coverage of the memory domain, these results can
be considered suggestive of genuinely worse performance in
ADHD-C compared to ADHD-I. This finding is not consis-
tent with Barkley’s hypotheses regarding ADHD-I, which
proposed worse memory for this subtype. Barkley’s hypoth-
eses also do not appear supported in the domain of attention
where ADHD-I and ADHD-C appear to perform similarly.
Because Barkley’s hypotheses were originally conceptual-
ized with childhood ADHD in mind, our lack of support may
suggest that these hypotheses are accurate for childhood but
not for adult subtypes.
Few studies evaluated ADHD-H in comparison to con-
trols. Lower performance was detected in the domains of
executive functioning, memory, and working memory, but
this evidence rests on too limited a number of studies to
draw any firm conclusion. ADHD-H comparisons with the
other two subtypes revealed a mix of differences (lower as
well as higher performance) compared with ADHD-I, and
no differences compared with ADHD-C despite multiple
comparisons. However, investigations of ADHD-H are lim-
ited and do not allow for any evaluations of Barkley’s
hypotheses regarding this subtype.
We noted several methodological limitations in the stud-
ies included in this review. A primary limitation was unequal
representation of subtypes. ADHD-H only made up 7% of
the ADHD participants in the studies, while ADHD-C made
up 64%. This inequality does not accurately reflect the
prevalence of subtypes that is seen in the ADHD population
as a whole (i.e., ADHD-I is the most prevalent subtype;
Woo & Rey, 2005), plausibly biasing the findings in this
review. A second limitation is inadequate coverage of neu-
ropsychological domains. The tests and measures used to
assess neuropsychological performance varied drastically
across domains and studies. We had to exclude perceptual
reasoning, language, and motor measures from further anal-
ysis of all comparisons because few to no tests were admin-
istered in these domains. Neuropsychological studies of
childhood ADHD have suggested deficits on measures of
perceptual reasoning and language (Woo & Rey, 2005).
Motor abilities have been implicated in both childhood and
adult ADHD research (Rosa Neto, Goulardins, Rigoli, Piek,
& Oliveira, 2015; Stray et al., 2013). Future research should
examine these domains more comprehensively.
A third limitation was missing or inconsistent method-
ological information. Multiple studies did not report
whether or not they allowed stimulant medication. Studies
that did report this information varied on whether or not
they allowed medication prior to testing. Medication is
known to normalize neuropsychological performance,
suggesting performance of individuals with ADHD on
psychostimulants, in particular, does not accurately repre-
sent true cognition of ADHD (Kempton et al., 1999).
Information on participants’ education level, known to
affect performance (Finlayson, Johnson, & Reitan, 1977),
LeRoy et al. 9
was also missing in multiple studies. Finally, the number
of raters performing the diagnostic assessment for ADHD
was often not reported, thus calling into question the accu-
rate diagnosis of ADHD and its subtypes. The gaps and
inconsistencies in the information provided make the find-
ings very difficult to interpret.
Based on these limitations, we present recommendations
for future neuropsychological research on adult ADHD and
its subtypes. Studies should use a common, comprehensive,
and standardized battery that covers the key domains of
executive functioning, attention, working memory, and
memory. Efforts should be made to characterize specific
processes and functions within each domain. Performance
of ADHD and its subtypes should be evaluated beyond
comparisons with control groups, by referencing scores to
normative data. We found only one study that utilized nor-
mative data to characterize performance in those with
ADHD. Finally, most of the studies reviewed here exam-
ined adult samples in the young- to middle-age range.
Future studies should make an effort to incorporate older
adults into their samples to track performance of ADHD
along the life span (Fischer, Gunter-Hunt, Steinhafel, &
Howell, 2012).
Systematic literature reviews are also subject to limita-
tions. One such limitation is that the current review is not a
meta-analysis, with estimation of effect sizes. Given the
considerable variability in assessment methodology, we
chose not to undertake a meta-analysis. Future research
should use meta-analytic techniques to provide more inclu-
sive and quantitative information.
We also recognize that we used very broadly defined
neuropsychological domains to capture the heterogeneous,
comprehensive performance of ADHD. Previous research
has suggested more specific performance characteristics in
ADHD, for example, verbal long-term memory (Schoechlin
& Engel, 2005), memory acquisition processes (Skodzik
et al., 2017), and divided and sustained attention (Salomone,
Fleming, Bramham, O’Connell, & Robertson, 2016).
Therefore, our results may be indicative of the domains we
chose and different results could have been obtained by
evaluating subdomains. Similarly, the allocation of tests
into our chosen domains was somewhat arbitrary and sub-
jective and may have biased our findings. Despite our use of
multiple raters in this process, it was not possible to obtain
complete agreement.
Finally, we need to acknowledge the potential error
introduced by the publication bias, where studies finding no
significant differences between clinical and control groups
may remain unpublished. It is possible that the studies sum-
marized here offer a biased portrayal of the neuropsycho-
logical pattern of ADHD and its subtypes. Future studies
will use a meta-analytic technique, calculating fail-safe N to
compensate for a lack of included studies with nonsignifi-
cant findings.
Conclusion
Adult ADHD is a complex disorder with three distinct sub-
types. Neuropsychological evaluations may aid in the diag-
nosis of overall ADHD and possibly of its subtypes. Our
review has highlighted that there are four domains that are
particularly informative when assessing adult ADHD, inde-
pendent of subtype. These domains include executive func-
tioning, attention, working memory, and memory. We have
found that they reliably differentiate between those with
adult ADHD and controls. However, we have not been able
to identify domains that would aid in the differentiation of
subtypes, with a possible exception of memory measures.
Our hope is for future research to address the current gaps
in the empirical evidence and elucidate subtype differences
on neuropsychological measures. Those differences can
plausibly streamline adult ADHD diagnosis, substantially
reduce misdiagnoses, and allow for treatment approaches to
be created that are catered to not only ADHD but also the
specific subtype and associated deficits.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, author-
ship, and/or publication of this article.
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Author Biographies
Amy LeRoy, MS, is a PhD student at the Pacific University
School of Graduate Psychology. She is interested in neuropsy-
chology and issues related to diagnostic assessment of psychiatric
disorders, including ADHD.
Claudia Jacova, PhD, is an associate professor at the Pacific
University School of Graduate Psychology. She is interested in
aging, cognitive impairment, and dementia.
Caedy Young, MS, is a PhD student at the Pacific University
School of Graduate Psychology. Her research is focused on
neurodegenerative disease, memory function, and cognitive
disorders. She specializes in gerontology and neuropsychologi-
cal assessment.