522512

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JADXXX10.1177/1087054714522512Journal of Attention DisordersAntshel et al.

Article
Journal of Attention Disorders

The Neuropsychological Profile of

2016, Vol. 20(12) 1047­–1055
© The Author(s) 2014
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DOI: 10.1177/1087054714522512

Disorder in Adult ADHD jad.sagepub.com

Kevin M. Antshel1, Joseph Biederman2, Thomas J. Spencer2,

and Stephen V. Faraone3

Abstract
Objective: ADHD and post-traumatic stress disorder (PTSD) are often comorbid yet despite the increased comorbidity
between the two disorders, to our knowledge, no data have been published regarding the neuropsychological profile of
adults with comorbid ADHD and PTSD. Likewise, previous empirical studies of the neuropsychology of PTSD did not
control for ADHD status. We sought to fill this gap in the literature and to assess the extent to which neuropsychological
test performance predicted psychosocial functioning, and perceived quality of life. Method: Participants were 201 adults
with ADHD attending an outpatient mental health clinic between 1998 and 2003 and 123 controls without ADHD.
Participants completed a large battery of self-report measures and psychological tests. Diagnoses were made using data
obtained from structured psychiatric interviews (i.e., Structured Clinical Interview for DSM-IV, Schedule for Affective
Disorders and Schizophrenia for School-Age Children Epidemiologic Version). Results: Differences emerged between
control participants and participants with ADHD on multiple neuropsychological tests. Across all tests, control participants
outperformed participants with ADHD. Differences between the two ADHD groups emerged on seven psychological
subtests including multiple Wechsler Adult Intelligence Scale—Third edition and Rey-Osterrieth Complex Figure Test
measures. These test differences did not account for self-reported quality of life differences between groups. Conclusion:
The comorbidity with PTSD in adults with ADHD is associated with weaker cognitive performance on several tasks that
appear related to spatial/perceptual abilities and fluency. Neuropsychological test performances may share variance with
the quality of life variables yet are not mediators of the quality of life ratings. (J. of Att. Dis. 2016; 20(12) 1047-1055)

Keywords
attention deficit disorder (ADD), ADHD, post-traumatic stress disorder (PTSD), neuropsychology

Post-traumatic stress disorder (PTSD) is defined by expo-
sure to a traumatic event that provokes the person to feel
danger to life or serious injury. The traumatic event is per-
sistently re-experienced for more than 1 month, leading to
avoidance of stimuli associated with the stressor as well as
increased arousal (American Psychiatric Association
[APA], 2000). Youth with ADHD are more likely than those
without ADHD to develop PTSD and vice versa (Daud &
Rydelius, 2009; Famularo, Fenton, Kinscherff, & Augustyn,
1996; Riggs, Baker, Mikulich, Young, & Crowley, 1995).
Adult data also show that ADHD and PTSD co-occur
together at elevated rates (Adler, Kunz, Chua, Rotrosen, &
Resnick, 2004; Antshel et al., 2013; Biederman et al., 2012;
Gurvits et al., 2000; Kessler et al., 2006).
Despite the increased comorbidity between the two disor-
ders, to our knowledge, no data have been published regard-
ing the neuropsychological profile of adults with comorbid
ADHD and PTSD. While no data have been published
regarding the neuropsychological profile of the comorbid
condition, much data have been published on the neuropsy-
chological profile of both adult ADHD and adult PTSD.
A meta-analysis suggested that adult ADHD is charac-
terized by having an IQ about 9 points lower than their non-
ADHD peers (Hervey, Epstein, & Curry, 2004). Adults with
ADHD perform less well on laboratory tasks that assess
vigilance, motoric inhibition, verbal fluency, organization,
planning, complex problem solving, and verbal learning
and memory (Hervey et al., 2004).
1
Syracuse University, Syracuse, NY, USA
2
Massachusetts General Hospital and Harvard Medical School, Boston,
MA, USA
3
State University of New York Upstate Medical University, Syracuse,
NY, USA
Corresponding Author:
Stephen V. Faraone, Department of Psychiatry and Behavioral Sciences,
State University of New York Upstate Medical University, 750 East
Adams St., Syracuse, NY 13210, USA.
Email: sfaraone@childpsychresearch.org
1048 Journal of Attention Disorders 20(12)
The neuropsychological functioning of adults with
PTSD has also been well researched. Relative to non-PTSD
controls, adults with PTSD have identified impairments in
attention, learning, memory, and executive functioning in
combat veterans (Beckham, Crawford, & Feldman, 1998;
Bremner et al., 1993; Sutker, Winstead, Galina, & Allain,
1991; Vasterling, Brailey, Constans, & Sutker, 1998;
Vasterling et al., 2002) and women with post-rape PTSD
(Jenkins, Langlais, Delis, & Cohen, 2000).
Some studies, however, have failed to find neuropsycho-
logical deficits among adults with PTSD (Crowell, Kieffer,
Siders, & Vanderploeg, 2002; Gurvits et al., 1993; Zalewski,
Thompson, & Gottesman, 1994). The lack of differences
between PTSD and control participants in these studies has
led some to question whether the PTSD neuropsychological
profile is more reflective of comorbid major depressive dis-
order (Barrett, Green, Morris, Giles, & Croft, 1996) or sub-
stance abuse (Stein, Kennedy, & Twamley, 2002). Studies
that controlled for these comorbid conditions found learn-
ing, attention, and attentional shifting deficits in partici-
pants with PTSD (Beckham et al., 1998; Bremner et al.,
1995; Jenkins et al., 2000; Vasterling et al., 2002). These
same cognitive impairments are also typically found in
ADHD (Hervey et al., 2004), yet none of the aforemen-
tioned PTSD studies assessed for the presence of ADHD in
their samples. The present study seeks to fill this void in the
literature and consider the profile of adults with comorbid
ADHD and PTSD.
Previous Work and Current Study
In a previously published study (Antshel et al., 2013) on
the same cohort, we reported that the lifetime (10% vs.
1.6%) and current (4.2%, 0%) prevalence of PTSD was
significantly higher in our ADHD sample compared with
our non-ADHD sample. ADHD adults with and without
PTSD did not differ in age, ADHD treatment status, or in
the clinical features of ADHD (e.g., age of onset of ADHD,
number of current symptoms, number of childhood symp-
toms). Within the ADHD + PTSD group, the age at onset of
PTSD (18.3 years) was significantly older than the age at
onset of ADHD (6.9 years), which suggested that the
ADHD in these individuals was not an epiphenomena of
PTSD.
Compared with the ADHD group, the ADHD + PTSD
group had higher lifetime rates of major depressive disor-
der, oppositional defiant disorder, and several anxiety disor-
ders (social phobia, agoraphobia and generalized anxiety
disorder). The ADHD + PTSD group was more functionally
impaired and reported lower quality of life than participants
with ADHD.
Compared with relatives of controls, both groups of rela-
tives of individuals with ADHD had significantly elevated
rates of both PTSD and ADHD. The two groups of relatives
of individuals with ADHD did not differ significantly from
one another in rates of either ADHD or PTSD (Antshel
et al., 2013).
The current project represents an attempt to further this
line of investigation about the comorbidity of ADHD and
PTSD by considering performance on psychological tests.
Based upon the extant PTSD neuropsychology literature,
we hypothesized that compared with adults with ADHD,
those with ADHD + PTSD would perform less well on
learning, attention, and attentional shifting psychological
tests. The ecological validity of psychological tests has
been questioned in the ADHD literature (Knouse, Barkley,
& Murphy, 2013). Thus, in addition, and in a more explor-
atory fashion, we were interested in assessing the extent to
which neuropsychological test performance mediated the
psychosocial functioning and perceived quality of life dif-
ferences between adults with ADHD with and without
PTSD.
Methods
Participants
Males and females between the ages of 18 and 55 were eli-
gible to participate in the current study. Participants were
excluded if they had major sensorimotor handicaps (deaf-
ness, blindness), psychosis, inadequate command of the
English language, or a Full Scale IQ less than 80. Two ascer-
tainment sources were used to recruit participants with
ADHD: clinical referrals to Psychiatric Clinics at the
Massachusetts General Hospital (MGH; clinical subsample;
n = 185) and advertisements in the greater Boston area (com-
munity subsample; n = 16). We recruited all potential non-
ADHD participants (n = 123) through advertisements in the
greater Boston area. Detailed study methodology has been
previously described (Antshel et al., 2010; Faraone, Kunwar,
Adamson, & Biederman, 2009; Surman et al., 2011).
A three-stage ascertainment procedure was used to select
the participants with ADHD. The first stage was the sub-
ject’s referral (for ADHD participants) or response to media
advertisements (for ADHD and comparison participants).
The second stage screened (for ADHD participants) or ruled
out (for comparison participants) for the diagnosis of ADHD
by using a telephone questionnaire. The questionnaire asked
about the symptoms of ADHD and questions regarding
study inclusion and exclusion criteria. The third stage con-
firmed (for ADHD participants) or ruled out (for comparison
participants) the diagnosis with face-to-face structured inter-
views with the individuals. Only participants who received a
positive (ADHD participants) or a negative (comparison
participants) diagnosis at all three stages were accepted.
After receiving a complete description of the study, the par-
ticipants provided written informed consent. The institu-
tional review board granted approval for this study.
Antshel et al. 1049
Assessment Measures
We interviewed all participants with the Structured Clinical
Interview for DSM-IV (SCID; First, Spitzer, Gibbon, &
Williams, 1997) supplemented with modules from the
Schedule for Affective Disorders and Schizophrenia for
School-Age Children Epidemiologic Version adapted for
DSM-IV (K-SADS-E; Orvaschel, 1994) to cover ADHD and
other disruptive behavior disorders. The structured interview
also included questions regarding academic tutoring, repeat-
ing grades, and placement in special academic classes.
On the K-SADS-E, participants were first queried about
childhood ADHD and disruptive behavioral disorder symp-
toms, and if they were present, were asked about continua-
tion of these symptoms into adulthood and the emergence
of others. Age at onset was defined as the first emergence of
impairing symptoms.
Initial diagnoses were prepared by the study interviewers
and were then reviewed by a Diagnostic Committee of
board-certified child and adolescent psychiatrists or licensed
psychologists. The Diagnostic Committee was blind to the
subject’s ascertainment group and all non-diagnostic data
(e.g., cognitive functioning). Diagnoses were made for two
points in time: lifetime and current (past month).
The interviewers had been instructed to take extensive
notes about the symptoms for each disorder. These notes and
the structured interview data were reviewed by the diagnos-
tic committee so that the Committee could make a Best
Estimate diagnosis as described by Leckman, Sholomskas,
Thompson, Belanger, and Weissman (1982). Definite diag-
noses were assigned to participants who met all diagnostic
criteria. Diagnoses were considered definite only if a con-
sensus was achieved that criteria were met to a degree that
would be considered clinically meaningful. By “clinically
meaningful” we mean that the data collected from the struc-
tured interview indicated that the diagnosis should be a clini-
cal concern due to the nature of the symptoms, the associated
impairment, and the coherence of the clinical picture.
Based on our previous work, we considered a subject to
have ADHD if the subject met full Diagnostic and Statistical
Manual of Mental Disorders (4th ed.; DSM-IV; APA, 1994)
criteria for the disorder (n = 127) as well as participants
with late onset ADHD (participants meeting full DSM-IV
criteria for ADHD except for the age at onset criterion; n =
79). We previously demonstrated that the full and late-onset
ADHD groups had similar clinical correlates, including pat-
terns of Axis I comorbidity, personality traits, and neuro-
psychological deficits (Faraone, Biederman, Doyle, et al.,
2006; Faraone, Biederman, Spencer, et al., 2006).
We computed kappa coefficients of agreement by having
experienced, board certified child and adult psychiatrists
and licensed clinical psychologists diagnose participants
from audio-taped interviews. Based on 500 assessments
from interviews of children and adults, the median kappa
coefficient was .98. Kappa coefficients for individual
diagnoses included ADHD (0.88), conduct disorder (1.0),
major depression (1.0), mania (0.95), separation anxiety
(1.0), agoraphobia (1.0), panic (.95), substance use disorder
(1.0), and tics/Tourette’s (0.89).
Psychological tests. The Wechsler Adult Intelligence Scale
third edition (WAIS-III; Wechsler, 1993) Vocabulary and
Block Design subtests were used to estimate IQ. WAIS-III
Digit Symbol Coding, Symbol Search, Arithmetic, and
Digit Span subtests were also assessed.
The psychological test battery also included the Wisconsin
Card Sorting Test (Heaton, Chelune, Talley, Kay, & Curtiss,
1993), the Stroop Color and Word Test (Golden, 1978), the
California Verbal Learning Test (CVLT; Delis, Kramer,
Kaplan, & Ober, 1987), and the Rey-Osterrieth Complex
Figure Test (ROCF; Rey, 1941). The Seidman auditory
working memory continuous performance task (Seidman
CPT) was also administered (Seidman et al., 1998).
Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-
Q).  Quality of life was assessed with the short-form version
of the Quality of Life Enjoyment and Satisfaction Question-
naire (Q-LES-Q; Endicott, Nee, Harrison, & Blumenthal,
1993). The Q-LES-Q is a self-report instrument that evalu-
ates enjoyment and satisfaction in various areas of daily
functioning, including physical health, work, social rela-
tionships, family, and general activities. Each item is scored
using a 5-point Likert-type scale (1 = very poor; 5 = very
good) where higher scores indicate greater enjoyment and
satisfaction. The Q-LES-Q is a commonly used and a well-
validated tool with good test−retest reliability and high
internal consistency (Bishop, Walling, Dott, Folkes, &
Bucy, 1999; Schechter, Endicott, & Nee, 2007).
Social Adjustment Scale Self-Report (SAS-SR).  Social functioning
was assessed using the Social Adjustment Scale Self-Report
(SAS-SR; Weissman & Bothwell, 1976). This self-report
instrument quantifies social functioning using seven major
areas: work/school, social and leisure, family outside of the
home, primary relationship, parental role, family unit, and
financial status. There are a total of 54 questions and each
item is rated on a 5-point scale where higher numbers repre-
sent greater impairment in social functioning. The SAS-SR
has been shown to be a valid measure of functional status and
is widely used both clinically and in academic research
(Weissman, Olfson, Gameroff, Feder, & Fuentes, 2001).
Occupation/education. Socioeconomic status (SES) was
assessed with the Hollingshead scale (Hollingshead, 1975).
Statistical Analyses
We first compared the three groups of participants (Control,
ADHD, ADHD + PTSD) on potentially confounding
demographic variables. Then, we examined differences in
1050 Journal of Attention Disorders 20(12)

Table 1.  Demographic Features.

Not ADHD (n = 123) ADHD (n = 186) ADHD + PTSD (n = 20)

  M ± SD M ± SD M ± SD Test statistic Omnibus p value

Age of participant 29.8 ± 8.7 35.9 ± 10.9 39.7 ± 8.8 F(2, 326) = 17.46 <.001
Sex (male %) 56 (46) 99 (53) 6 (30) χ2 = 4.80 .09
Marital status χ2 = 13.13 .01
  Never married 93 (77) 104 (57)a 11 (58)a  
 Married 19 (16) 48 (27) 6 (32)  
 Divorced 9 (8) 29 (16) 2 (11)  
Ethnicity χ2 = 10.36 <.001
 White 95 (77) 168 (91) 13 (68)  
  African American 6 (5) 9 (5) 3 (16)  
 Asian 9 (7) 1 (<1) 0 (0)  
 Hispanic 4 (3) 5 (3) 2 (11)a  
 Other 9 (7) 2 (1) 12 (4)  
SES χ2 = 37.21 <.001
a
 1 40 (33) 53 (31) 3 (16)  
 2 75 (63) 82 (47) 7 (37)  
 3 4 (3) 23 (13) 3 (16)  
 4 1 (1) 15 (9) 6 (32)a  

Note. SES = socioeconomic status; PTSD = post-traumatic stress disorder. For pairwise comparisons: avs. Controls.

neuropsychological test performance between the three groups
while controlling for potential demographic confounds.
To assess our a priori hypothesis, we conducted an
omnibus multivariate analysis of covariance (MANCOVA)
using age as a covariate on the dependent variables from the
six neuropsychological tests. If this analysis was signifi-
cant, follow-up univariate ANCOVA tests were planned.
We utilized Holm’s (Holm, 1979) sequential Bonferroni
procedure to adjust p values for multiple comparisons for
asserting statistical significance for the omnibus tests com-
paring the three groups. If the omnibus test was significant,
we used the .05 alpha level to assert significance for pair-
wise comparisons among the three groups.
To assess the relationship between performance on neu-
ropsychological tests and functional/quality of life variables
in our ADHD cohort, we used logistic regression analyses
predicting group membership (ADHD, ADHD + PTSD)
from functional/quality of life variables and neuropsycho-
logical test scores. Only those neuropsychological tests that
differentiated ADHD + PTSD and ADHD participants were
included as predictors. Age was entered as a covariate in all
logistic regression models.
Results
Descriptive Statistics
As shown in Table 1, both ADHD groups were older than
control participants. No age differences emerged between
our two ADHD cohorts; nonetheless, our ADHD + PTSD
group was more likely to be female, to have a lower socio-
economic status, and to have non-Caucasian ethnicity.
Because of these demographic differences, all subsequent
analyses were corrected for sex, age, and ethnicity.
Psychological Test Performance
As shown in Table 2, differences emerged between control
participants and those with ADHD on multiple neuropsy-
chological tests. Across all neuropsychological tests, con-
trol participants outperformed participants with ADHD.
More specific to the hypotheses, significant differences
between the two ADHD groups emerged on seven neuro-
psychological subtests including multiple WAIS-III and
ROCF measures as well as one Stroop Color Word measure.
Across all measures, participants with ADHD + PTSD per-
formed less well than participants with ADHD.
Predicting Self-Reported Quality of Life/
Functioning
Quality of life ratings.  We know from our prior work that,
among individuals with ADHD, PTSD is associated with
a lower quality of life and greater functional impairments.
The following analyses sought to determine if these dif-
ferences are mediated by differences in neuropsychologi-
cal functioning. Using logistic regression models
predicting PTSD status within the ADHD cohort and con-
trolling for demographic group differences, the seven
Antshel et al. 1051

Table 2.  Psychological Test Performance—Group Means (SD).

Variable Not ADHD ADHD ADHD + PTSD F (2, 320) p Main effect
Estimated WAIS-III Full Scale IQ 116.2 (12.6) 112.0 (14.2) 105.0 (14.3) 2.88 .09 N, A > AP
WAIS-III Block Design Scaled Score 10.9 (1.4) 10.6 (1.6) 9.7 (1.5) 3.22 .04 N, A > AP
WAIS-III Vocabulary Scaled Score 11.9 (1.3) 11.4 (1.5) 10.9 (1.5) 2.27 .10 N = A = AP
WAIS-III Digit Span Scaled Score 11.9 (2.9) 11.4 (2.9) 10.5 (2.9) 1.81 .16 N = A = AP
WAIS-III Arithmetic Scaled Score 11.9 (2.4) 10.8 (2.7) 8.6 (2.4) 9.73 .00 N > A > AP
WAIS-III Coding Scaled Score 11.5 (2.9) 9.8 (2.8) 8.0 (2.4) 17.60 .00 N > A > AP
WAIS-III Symbol Search Scaled Score 10.9 (2.4) 9.9 (2.5) 7.8 (2.3) 13.60 .00 N > A > AP
ROCF Copy Organization Score 10.4 (2.8) 9.3 (3.2) 8.5 (3.5) 2.55 .08 N > A, AP
ROCF Copy Style Score 10.4 (2.8) 9.3 (3.2) 8.5 (3.5) 2.55 .08 N > A, AP
ROCF Copy Accuracy Score 63.6 (1.1) 62.9 (2.2) 64.6 (1.0) 3.29 .04 N, A > AP
ROCF Copy Time 146.7 (44.7) 152.2 (49.4) 189.2 (80.0) 5.31 .00 N, A > AP
ROCF Delay Organization Score 9.0 (4.0) 7.7 (3.9) 7.6 (4.1) 2.01 .14 N = A = AP
ROCF Delay Style Score 2.5 (0.7) 2.4 (0.7) 2.3 (0.8) 0.08 .92 N = A = AP
ROCF Delay Accuracy Score 48.3 (9.2) 43.3 (10.8) 41.6 (10.0) 3.41 .03 N > A, AP
ROCF Delay Time 131.1 (54.8) 121.9 (57.6) 119.3 (49.3) 1.21 .30 N = A = AP
Stroop Word T-Score 47.9 (8.1) 46.1 (8.0) 43.6 (10.8) 3.76 .02 N > A, AP
Stroop Color T-Score 46.4 (8.0) 44.1 (8.0) 40.5 (5.5) 6.03 .00 N > A > AP
Stroop Color–Word T-Score 52.1 (10.2) 46.6 (9.8) 43.8 (8.1) 8.74 .00 N > A, AP
Stroop Interference T-Score 53.9 (8.2) 50.4 (7.9) 50.3 (6.9) 3.38 .03 N > A, AP
WCST Number of Categories Completed 5.6 (1.1) 5.3 (1.6) 5.1 (1.9) 0.57 .57 N = A = AP
WCST Perseverative Errors 10.4 (10.9) 13.9 (12.1) 16.2 (21.0) 1.04 .35 N = A = AP
WCST Non-Perseverative Errors 9.0 (8.4) 12.6 (9.5) 11.3 (11.3) 3.10 .04 N > A, AP
WCST Conceptual Level Response % 75.8 (17.3) 69.3 (19.5) 67.7 (22.8) 1.97 .14 N = A = AP
WCST Number of Failures to Maintain Set 0.5 (0.8) 0.8 (1.0) 0.6 (1.0) 1.95 .14 N = A = AP
WCST Learning to Learn –0.1 (3.0) 0.2 (4.7) –0.1 (3.2) 0.03 .97 N = A = AP
CVLT List A Total T-Score 57.5 (10.0) 53.3 (10.0) 52.1 (9.9) 3.24 .04 N > A, AP
CVLT Words Correct List A Trial 1 7.9 (2.4) 7.0 (2.2) 6.9 (1.6) 4.23 .01 N > A, AP
CVLT Words Correct List A Trial 5 13.5 (2.2) 12.6 (2.4) 12.6 (2.5) 1.35 .26 N = A = AP
CVLT Words Correct List B 7.8 (2.1) 6.9 (2.2) 6.2 (2.5) 4.62 .01 N > A, AP
CVLT Words Correct List A Short Delay 12.7 (2.5) 11.4 (2.9) 11.7 (2.6) 2.85 .06 N > A, AP
CVLT Words Correct List A Long Delay 12.7 (2.7) 11.3 (3.0) 11.8 (2.6) 2.48 .09 N > A, AP
CLVT Semantic Cluster Total 23.1 (13.1) 18.6 (11.2) 15.5 (8.1) 4.62 .01 N > A, AP
Auditory CPT–Vigilance Task Correct 29.2 (1.7) 28.8 (2.7) 28.7 (1.3) 1.06 .34 N = A = AP
Auditory CPT–Memory Task Correct 20.4 (4.3) 18.9 (4.1) 17.3 (6.3) 2.61 .07 N = A = AP
Auditory CPT–Interference Task Correct 24.9 (6.6) 22.2 (7.2) 18.7 (7.1) 3.27 .03 N > A, AP

Note. PTSD = post-traumatic stress disorder; N = Not ADHD; A = ADHD; AP = ADHD + PTSD; WAIS-III = Wechsler Adult Intelligence Scale–3rd
edition; ROCF = Rey-Osterrieth Complex Figure; WCST = Wisconsin Card Sorting Test; CVLT = California Verbal Learning Test; CPT = Continuous
Performance Test.

neuropsychological subtests were entered as predictors of
self-reported quality of life and functioning. The following
Q-LES-Q scales were significantly associated with PTSD
among individuals with ADHD after adjusting for neuro-
psychological subtest performance: Social Relationships
(χ2 = 28.63, p = .05), Economic Status (χ2 = 28.89, p = .05),
Living/Housing (χ2 = 35.30, p = .003), Physical Movement
(χ2 = 31.19, p = .013), Vision (χ2 = 26.99, p = .035), and
Q-LES-Q Total (χ2 = 33.21, p = .008). Across all six Q-LES-
Q scales, no neuropsychological subtests emerged as
significant independent predictors of PTSD status. This
suggests that the neuropsychological test performances may
share variance with the quality of life variables yet are not
mediators of the quality of life ratings.
Functional ratings.  In a similar fashion to the Q-LES-Q analy-
ses, SAS-SR ratings were analyzed. SAS-SR scales in which
PTSD status was significantly predicted from neuropsycho-
logical subtest performance included: Extended Family (χ2 =
29.32, p = .033), Primary Family (χ2 = 21.03, p = .030), and
Total SAS-SR Score (χ2 = 30.72, p = .019). Within the Extended
Family domain, WAIS-III Symbol Search (p = .046) emerged
1052 Journal of Attention Disorders 20(12)
as an independent predictor of functional ratings. No other
neuropsychological subtests emerged as significant indepen-
dent predictors of PTSD status.
Discussion
Neuropsychological Test Performance
To our knowledge, this is the first empirical study to assess
neuropsychological test performance between adults with
ADHD and those with ADHD + PTSD. Consistent with the
extant ADHD literature (for a meta-analysis, see Hervey
et al., 2004), compared with control participants, adults
with ADHD (regardless of PTSD status) performed less
well on multiple psychological tests.
Previous studies which have assessed the neuropsycho-
logical functioning of adults with PTSD have demonstrated
that impairments in attention, learning, memory, and execu-
tive functioning are common (Beckham et al., 1998;
Bremner et al., 1993; Jenkins et al., 2000; Sutker et al.,
1991; Vasterling et al., 1998; Vasterling et al., 2002).
Nonetheless, these studies did not control for ADHD status
(or even assess for the presence of ADHD). In this way, the
present data may represent a more clear assessment of the
impact of PTSD while controlling for ADHD status.
Interestingly, our results do not suggest that PTSD in the
context of ADHD is associated with more significant defi-
cits in attention, learning, memory, and executive function-
ing; rather, our results are more suggestive of spatial/
perceptual and fluency vulnerabilities that may be conferred
by PTSD. The WAIS-III Block Design and ROCF Copy
trial performance both rely upon spatial/perceptual skills
(Lezak, Howieson, & Loring, 2004) and performance on
both was less strong in the ADHD + PTSD group. In addi-
tion to the WAIS-III Block Design and ROCF, the WAIS-III
Arithmetic subtest was also significantly different between
the two ADHD cohorts. While the WAIS-III Arithmetic is
thought to be dependent upon working memory abilities
(Lezak et al., 2004), spatial skills are also thought to con-
tribute to math abilities (Rotzer et al., 2009). Thus, there is
some convergence on spatial/perceptual abilities as a pos-
sible associated psychological ability affected by the pres-
ence of PTSD.
WAIS-III Coding and WAIS-III Symbol Search also
both involve spatial/perceptual stimuli yet are more com-
monly associated with measures of fluency (Joy, Kaplan, &
Fein, 2004). Participants with ADHD + PTSD performed
less well on both measures relative to those participants
with ADHD. There are a variety of possible contributors to
less secure performance on these two WAIS-III subtests
including weaker motor skills, memory abilities, and pro-
cessing speed (Lezak et al., 2004). Future research should
attempt to further delineate the relationship between PTSD
and these WAIS-III subtests in adults with ADHD.
Self-Report of Quality of Life/Functioning
Multiple Q-LES-Q scales were associated with PTSD inde-
pendently from neuropsychological test performance. In
contrast, no tests emerged as significant independent pre-
dictors of PTSD status. This suggests that the neuropsycho-
logical test performances may share variance with the
quality of life variables yet are not mediators of the quality
of life ratings. Most of the individuals in our study per-
formed in the average range; if our study sample had been
more cognitively impaired, a stronger relationship may
have emerged between our neuropsychological test perfor-
mance and quality of life ratings. Nevertheless, our data
suggest that test performances may share variance with the
quality of life variables.
PTSD status on self-report of functioning (especially
family functioning) was also significantly predicted by psy-
chological test performances. The WAIS-III Symbol Search
was an independent predictor of functional ratings for the
Extended Family domain. Future research should attempt to
(a) replicate this finding and (b) further assess the relation-
ship between Symbol Search performance and Extended
Family functioning.
Clinical Implications
In addition to the novelty of these data (first study of PTSD
neuropsychology to control for ADHD status), our data
have several implications. Our data suggest that after con-
trolling for ADHD status, spatial/perceptual weaknesses are
more specific to PTSD. This is a novel finding in the PTSD
literature and needs replication before firm clinical implica-
tions can be reached. The development of an integrated
intervention designed to treat comorbid ADHD and PTSD
(presently not in existence) may need to target spatial/per-
ceptual vulnerabilities in addition to attention, inhibition,
and executive function vulnerabilities.
Our data also suggest that when controlling for attention
deficits, PTSD may be associated with spatial/perceptual
weaknesses. If this finding is replicated, this could possibly
alter the manner in which PTSD neuropsychological
research studies are conducted by suggesting that attention
needs to be statistically controlled for in any planned analy-
ses. Clinically, this also implies that spatial/perceptual tests
may be a sensitive measure for screening for possible PTSD
in ADHD samples.
Limitations/Future Directions
These data need to be considered in the context of our meth-
odological weaknesses. While we statistically controlled for
age differences, the ADHD group was significantly older
than the non-ADHD group. Similarly, participants’ ADHD
were predominantly recruited through clinical referrals; we
Antshel et al. 1053
do not know to what degree our findings will generalize to
samples of non-referred adults with ADHD in the commu-
nity. Our ADHD + PTSD sample is relatively small.
Although this will not have caused spurious findings of sta-
tistical significance, it did limit our power to detect some
effects. The cross-sectional design of this study limits our
ability to establish the sequencing of ADHD and PTSD
symptoms. Thus, we relied on retrospective reports. In addi-
tion, the presence of a PTSD-only comparison group would
have been ideal, especially for establishing the independent
effects of PTSD on cognition. Finally, our results may have
been different if we included a different psychological test
battery (e.g., administered a full WAIS-III).
Despite these shortcomings, these data represent an initial
investigation into the relationship between cognition in indi-
viduals with ADHD + PTSD. Given that our previous work
(Antshel et al., 2013) on this topic has identified this comor-
bid cohort as functionally impaired and in need of clinical
intervention, future research should consider how PTSD
might affect cognition and the relationship that this may have
on not only functional outcomes but also the development of
novel interventions. For example, does the presence of PTSD
in ADHD affect the effectiveness of standard interventions
such as stimulant treatments or cognitive behavioral therapy?
Likewise, what is the developmental trajectory of cognition
in individuals with ADHD + PTSD? Do spatial or processing
speed vulnerabilities increase the probability that an individ-
ual with ADHD will develop PTSD? While these data are
preliminary until replicated, our data suggest that these may
be fruitful lines of investigation to consider.
Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of interest
with respect to the research, authorship, and/or publication of this
article: Dr. Biederman is currently receiving research support from
the following sources: The Department of Defense, Ironshore,
Vaya Pharma/Enzymotec, and NIH. In 2013, Dr. Biederman
received research support from APSARD, ElMindA, McNeil, and
Shire. He has a US Patent Application pending (Provisional
Number #61/233,686) through MGH corporate licensing, on a
method to prevent stimulant abuse. Dr. Biederman received depart-
mental royalties from a copyrighted rating scale used for ADHD
diagnoses, paid by Shire and Sunovion; these royalties are paid to
the Department of Psychiatry at MGH. In 2011, Dr. Biederman
received departmental royalties from a copyrighted rating scale
used for ADHD diagnoses, paid by Eli Lilly, Shire and AstraZeneca;
these royalties were paid to the Department of Psychiatry at MGH.
In previous years, Dr. Biederman received research support, con-
sultation fees, or speaker’s fees for/from the following additional
sources: Abbott, Alza, AstraZeneca, Boston University, Bristol
Myers Squibb, Celltech, Cephalon, Cipher Pharmaceuticals Inc.,
Eli Lilly and Co., Esai, Fundacion Areces (Spain), Forest,
Fundación Dr. Manuel Camelo A.C., Glaxo, Gliatech, Hastings
Center, Janssen, McNeil, Medice Pharmaceuticals (Germany),
Merck, MGH Psychiatry Academy, MMC Pediatric, NARSAD,
NIDA, New River, NICHD, NIMH, Novartis, Noven, Neurosearch,
Organon, Otsuka, Pfizer, Pharmacia, Phase V Communications,
Physicians Academy, The Prechter Foundation, Quantia
Communications, Reed Exhibitions, Shionogi Pharma Inc, Shire,
the Spanish Child Psychiatry Association, The Stanley Foundation,
UCB Pharma Inc., Veritas, and Wyeth. Dr. Spencer has received
research support from, has been a speaker for or on a speaker
bureau, or has been an Advisor or on an Advisory Board of the fol-
lowing sources: Alcobra, Shire Laboratories, Inc, Eli Lilly &
Company, Glaxo-Smith Kline, Ironshore, Janssen Pharmaceutical,
McNeil Pharmaceutical, Novartis Pharmaceuticals, Cephalon,
Pfizer, Lundbeck, VayaPharma, the National Institute of Mental
Health and the Department of Defense. Dr. Spencer receives
research support from Royalties and Licensing fees on copyrighted
ADHD scales through MGH Corporate Sponsored Research and
Licensing. Dr. Spencer has a US Patent Application pending
(Provisional Number #61/233,686), through MGH corporate
licensing, on a method to prevent stimulant abuse. In the past year,
Dr. Faraone received consulting income, travel expenses and/or
research support from Ironshore, Shire, Akili Interactive Labs,
Alcobra, VAYA Pharma, and SynapDx, and research support from
the National Institutes of Health (NIH). His institution is seeking a
patent for the use of sodium-hydrogen exchange inhibitors in the
treatment of ADHD. In previous years, he received consulting fees
or was on Advisory Boards or participated in continuing medical
education programs sponsored by: Shire, Alcobra, Otsuka, McNeil,
Janssen, Novartis, Pfizer and Eli Lilly.
Funding
The author(s) declared receipt of the following financial support
for the research, authorship, and/or publication of this article: This
work was supported by a grant to S. V. Faraone from the National
Institute of Health (R01MH57934).
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Author Biographies
Kevin M. Antshel is an Associate Professor of Psychology and the
Director of the Clinical Psychology program at Syracuse University.
Dr. Antshel has published widely on ADHD, autism spectrum dis-
orders and learning disorders. Dr. Antshel is a licensed psycholo-
gist who maintains a practice specific to these populations.
Joseph Biederman is Chief of the Clinical and Research Programs
in Pediatric Psychopharmacology and Adult ADHD at the
Massachusetts General Hospital, Director of the Alan and Lorraine
Bressler Clinical and Research Program for Autism Spectrum
Disorders at the Massachusetts General Hospital, and Professor of
Psychiatry at the Harvard Medical School. He is Board Certified
in General and Child Psychiatry. Dr. Biederman is the author and
co-author over 700 scientific articles, 650 scientific abstracts, and
70 book chapters.
Thomas J. Spencer’s research activities have focused on the
examination of phenotypic characteristics of ADHD, studies of
efficacy and safety of treatments for the disorder and imaging
studies of its pathophysiology. Dr. Spencer edited a book on adult
ADHD, published 300 scientific articles, and 46 book chapters.
Stephen V. Faraone, PhD, is a Distinguished Professor in the
Departments of Psychiatry and Neuroscience & Physiology at SUNY
Upstate Medical University. He is also Senior Scientific Advisor to
the Research Program Pediatric Psychopharmacology at the
Massachusetts General Hospital and a lecturer at Harvard Medical
School. Dr. Faraone studies the nature and causes of mental disorders
in childhood and has made contributions to research in psychiatric
genetics, psychopharmacology, diagnostic issues and methodology.