J Abnorm Child Psychol (2009) 37:551–564

DOI 10.1007/s10802-008-9286-9

Heterogeneity in ADHD: Neuropsychological Pathways,

Comorbidity and Symptom Domains
Cecilia Wåhlstedt & Lisa B. Thorell & Gunilla Bohlin

Published online: 19 November 2008

# Springer Science + Business Media, LLC 2008

Abstract The aim of the present study was to investigate Keywords ADHD . Heterogeneity . Hyperactivity .
different neuropsychological impairments and comorbid behav- Inattention . Neuropsychological factors . Comorbidity
ioral problems in relation to symptoms of Attention-Deficit/
Hyperactivity Disorder (ADHD), studying the independent
effects of different functions as well as specific relations to Introduction
symptoms of hyperactivity/impulsivity and inattention. A
community-based sample of school children (n=182; the higher Recent theoretical formulations have repeatedly emphasized
end of the ADHD symptom range was oversampled) completed that Attention-deficit/Hyperactivity Disorder (ADHD) should
neuropsychological tasks designed to measure executive func- be regarded as a heterogeneous condition (Castellanos et al.
tion (EF), state regulation and delay aversion. Behavioral 2006, Nigg 2006, Willcutt et al. 2005b). Empirically, this
symptoms were measured through parental and teacher ratings heterogeneity is evident in children with ADHD in at least
of the DSM-IV criteria for ADHD and Oppositional Defiant three different respects: expression of the two ADHD
Disorder (ODD). Both categorical and dimensional analyses symptom domains, neuropsychological impairments, and
were used to acquire a deeper understanding of ADHD. The comorbid behavior problems. With regard to symptom
results supported the notion that EF and state regulation expression, ADHD involves the two domains of hyperactiv-
constitute independent pathways to ADHD, primarily to ity/impulsivity and inattention, represented as the primarily
symptoms of inattention. In addition, the present study points inattentive type, the primarily hyperactive/impulsive type
to the importance of viewing ADHD as a heterogeneous and the combined type (APA; American Psychiatric Associ-
condition also with regard to the differential impact of neuropsy- ation 1994). Concerning neuropsychological functioning,
chological functioning and comorbidity on different ADHD ADHD has been shown to include deficits in executive
symptom groups and the two ADHD symptom domains. functioning (EF; Barkley 1997), delay aversion (Sonuga-
Barke 2003, 2005, Sonuga-Barke et al. 1992), and state
This study was supported by a grant from The Bank of Sweden regulation (Sergeant 2000, 2005). However, it has not yet
Tercentenary Foundation been clarified whether these three factors constitute indepen-
The present manuscript contains unpublished work that is not dent pathways to ADHD. In addition to neuropsychological
currently under consideration for publication elsewhere. functioning, differences in comorbid symptom expression,
There is no conflict of interest and this study has been designed in
accordance with the ethics rules of the Swedish Research Council. such as Oppositional Defiant Disorder (ODD), poor aca-
demic achievement and internalizing problems, also contrib-
C. Wåhlstedt (*) : L. B. Thorell : G. Bohlin
Department of Psychology, Uppsala University,
ute to heterogeneity in children with ADHD symptoms.
P.O. Box 1225, SE-751 42, The overall aim of the present study was to investigate
Uppsala, Sweden different neuropsychological impairments and comorbid
e-mail: [email protected] behavior problems in relation to ADHD symptoms,
L. B. Thorell
studying the independent effects of different functions as
Stockholm Brain Institute, well as specific relations to symptoms of hyperactivity/
Stockholm, Sweden impulsivity and inattention. A community-based sample
552 J Abnorm Child Psychol (2009) 37:551–564

was used, in which high levels of ADHD symptoms were symptom domains. Rather, one should control for the
oversampled. Using a community-based sample was justi- overlap using dimensional measures of hyperactivity/im-
fied by the fact that although ADHD is clinically defined as pulsivity and inattention, as children with, for example, the
a categorical disorder (APA 1994), it has repeatedly been inattentive subtype are likely to have higher levels of
argued that ADHD should best be seen as a dimension (e. hyperactivity/impulsivity compared to children in a com-
g., Kraemer et al. 2004, Levy et al. 1997). In addition, parison group, although not high enough to meet the
children who do not meet the full criteria for an ADHD criteria for the combined subtype.
diagnosis have been shown to experience similar negative
consequences as those experienced by children fulfilling the ADHD and State Regulation
diagnosis (Bauermeister et al. 2007), making data from
community-based samples an important complement to The state regulation hypothesis (Sergeant 2000, 2005)
more clinically oriented research. This may be especially agrees with the notion that ADHD symptoms reflect
important when investigating heterogeneity among children dysfunctional EFs. However, instead of a primary deficit
with ADHD symptoms, as it is only by measuring in inhibitory control, it proposes that poor state regulation
symptoms of hyperactivity/impulsivity and inattention as underpins dysfunctional EFs. Poor state regulation is
dimensions, and thereby using the full range of severity of characterized by significant problems in regulation of
symptoms, that one can fully control for the overlap effort, arousal, and activation (Sergeant 2000, 2005). These
between the two ADHD symptom domains. dysfunctions are thought to give rise to slower and more
variable reaction times (i.e., RT variability), and a relation
ADHD and Executive Functioning between ADHD and RT variability has consistently been
demonstrated in many studies using both clinical (e.g.,
Executive functions (EFs) refer to higher-order cognitive Johnson et al. 2007, Klein et al. 2006, Lijffijt et al. 2005)
functions such as inhibitory control, working memory and and non-clinical samples (e.g., Berwid et al. 2005, Kuntsi et
planning, all of which serve the purpose of maintaining al. 2005). With regard to how RT variability is related to the
future goals (Welsh 2002). Barkley’s (1997) influential two symptom domains of ADHD, this issue has mainly
model of EF in relation to ADHD maintains that inhibitory been investigated by studying differences between ADHD
control is a superordinate function within the larger system subtypes, and in these studies, few significant differences
of EF components and that this function in turn contributes have been found (e.g., Martell et al. 2007, Pasini et al.
to working memory, regulation of arousal, emotion and 2007, Tucha et al. 2008).
motivation, as well as planning. Thus, the behavioral In dimensional analyses, Epstein et al. (2003) found that
manifestations of ADHD are proposed to derive from poor RT variability was related to both symptoms of hyperac-
EFs, with poor inhibitory control as a core deficit. In line tivity/impulsivity and symptoms of inattention, but this
with Barkely’s (1997) model, several previous studies have study failed to control for the overlap between symptom
found relations between poor EF and ADHD symptoms in domains. Clarke et al. (2007) did conduct such a control in
both clinical and community-based samples (for reviews analyses investigating independent as well as interaction
see, Martinussen et al. 2005, Willcutt et al. 2005a). effects in the two symptom domains. They found a
Studies of relations to the two ADHD symptom domains significant interaction effect for RT variability, showing
using dimensional analyses have indicated that EFs are that it was the combination of high levels of hyperactivity/
specifically related to symptoms of inattention when impulsivity and inattention that was associated with high
controlling for symptoms of hyperactivity/impulsivity RT variability.
(Chhabildas et al. 2001, Martell et al. 2007). However,
the three ADHD subtypes (i.e., the primarily inattentive, ADHD and Delay Aversion
primarily hyperactive/impulsive and combined subtypes)
have generally not been found to have different EF profiles The delay aversion hypothesis states that children with
(e.g., Geurts et al. 2005, Faraone et al. 1998, Huang- ADHD symptoms more often choose a small, immediate
Pollock et al. 2007). This inconsistency in findings may be reward over a larger, delayed reward than do control
related to the fact that studies using categorical analyses children, especially when this reduces the overall delay
usually exclude the hyperactive/impulsive subtype and period (Sonuga-Barke 2003, 2005, Sonuga-Barke et al.
most often fail to control for the overlap between the two 1992). Research has provided support for a relation
ADHD symptom domains. As argued by, for example, between delay aversion and ADHD symptoms in both
Sonuga-Barke and colleagues (Sonuga-Barke et al. 2008), clinical (e.g., Dalen et al. 2004, Solanto et al. 2001) and
investigating subgroup differences is not enough when non-clinical samples (e.g., Sonuga-Barke et al. 2003,
addressing the issue of specificity of the two ADHD Thorell 2007). However, it should be noted that the relation
J Abnorm Child Psychol (2009) 37:551–564 553

between delay aversion and ADHD has not been at all as more generalized cognitive deficit that underpins other
extensively studied as that between EF and ADHD, and neuropsychological impairments in children with ADHD
some studies have failed to find a relation between delay (e.g., Sergeant 2000, 2005).
aversion and ADHD (e.g., Scheres et al. 2006, Solanto et
al. 2007, Van der Meere et al. 2005). Concerning the Comorbidity
specificity of delay aversion in relation to the two ADHD
symptom domains, there are few studies that have investi- Two common behavior problems in children with ADHD
gated this issue. However, at the theoretical level, it has symptoms are symptoms of ODD and internalizing prob-
been argued that delay aversion should be more strongly lems such as anxiety/mood disorders (e.g., Biederman
related to hyperactivity than to inattention (Castellanos et 2005, Schatz and Rostain 2006). In addition, children with
al. 2006), and support for this claim has been found in two ADHD symptoms often show poor academic performance
studies of community-based samples (Scheres and Sumiya (e.g., Barkley 1998, Massetti et al. 2008). Concerning
2008, Thorell 2007). differences in ADHD symptom domains, ODD symptoms
are assumed to be more strongly related to hyperactivity/
Multiple Neuropsychological Pathways in ADHD impulsivity than to inattention (e.g., Gaub and Carlson
1997), whereas poor academic achievement is assumed to
Several recent theoretical propositions have emphasized the be more strongly related to symptoms of inattention than to
need to regard ADHD as a heterogeneous disorder with symptoms of hyperactivity/impulsivity (e.g., Massetti et al.
multiple neuropsychological pathways due to the fact that 2008, Rabiner and Coie 2000, Gaub and Carlson 1997).
several neuropsychological factors are related to ADHD With regard to internalizing problems, most studies have
symptoms as well as to the moderate effect sizes for each investigated differences between ADHD subtypes, but often
identified impairment (e.g., Castellanos et al. 2006, Nigg without including the hyperactive subtype. However, Gaub
2006, Sonuga-Barke 2003, 2005, Willcutt et al. 2005b). and Carlson (1997) included all three subtypes and found
Nonetheless, few studies have examined EF, delay aversion that only the combined and inattentive subtypes showed
as well as state regulation in the same sample to evaluate internalizing problems. On the other hand, Power et al.
independent effects of these neuropsychological factors in (2004) used dimensional analyses and found that internal-
relation to ADHD symptoms. With regard to EF and delay izing problems were more consistently related to hyperac-
aversion, Sonuga-Barke’s (2003, 2005) dual pathway tivity rather than to inattention. As noted above with regard
model states that these two factors constitute independent to neuropsychological functioning, most previous studies
pathways to ADHD, and support for this has been found in have not used dimensional analyses and have failed to
both clinical (Dalen et al. 2004, Solanto et al. 2001) and control for hyperactivity/impulsivity when investigating
non-clinical samples (Sonuga-Barke et al. 2003, Thorell relations to inattention and vice versa. Thus, further
2007, for reviews, see Castellanos et al. 2006, Sonuga- research investigating specific relations to the two ADHD
Barke et al. 2008). symptom domains using dimensional analyses is needed.
Concerning the role of state regulation within multiple
pathway models, this issue has not been examined Aim of the Present Study
systematically. To our knowledge only two studies have
investigated EF, delay aversion and state regulation in the The first aim of the present study was to investigate
same sample. Kuntsi et al. (2001) did include measures of whether EF (inhibitory control and WM), RT variability
EF, state regulation (i.e., RT variability) and delay aversion. and delay aversion are independently related to ADHD. We
They found that RT variability and delay aversion, but not hypothesized that the ADHD group (the inattentive, the
inhibition, discriminated between hyperactive children and hyperactive and combined symptom groups when merged
controls. In parity with this result, Van der Meere et al. to form a ADHD group), would differ significantly from
(2005) found that only RT variability, but not inhibition or the comparison group with regard to all three neuropsy-
delay aversion, was associated with ADHD symptoms. chological functions and that these differences would
Independent effects of inhibition, when controlling for RT remain significant when studying independent contributions
variability, have however, been found in some previous of EF, delay aversion and RT variability. This hypothesis
studies (Bitsakou et al. 2008, Klein et al. 2006). Although was based on the notion of multiple neuropsychological
the exact nature of the relation between state regulation and pathways, where independence between EF and delay
other neuropsychological constructs in the prediction of aversion is already implied by the dual-pathway model by
ADHD symptoms is far from clear, the little empirical Sonuga-Barke (2003, 2005), and we further suggest that
evidence available suggests that RT variability represents also state regulation constitutes such a separate pathway.
an independent neuropsychological pathway rather than a We base this assumption on the few empirical findings of
554 J Abnorm Child Psychol (2009) 37:551–564

independent contributions of state regulation, measured as This resulted in a total of 182 children (see Table 1 for
RT variability, and inhibition in relation to ADHD (Bitsakou more information) in four different groups: high levels of
et al. 2008, Klein et al. 2006). both symptoms of hyperactivity/impulsivity and inattention
Second, we aimed to examine whether the three neuropsy- (the combined subgroup); high levels of hyperactivity/
chological functions and comorbid behavior problems are impulsivity symptoms and low levels of inattention
specifically related to either one of the two ADHD symptom symptoms (the hyperactive subgroup); low levels of
domains. We hypothesized that EF and academic achievement hyperactivity/impulsivity symptoms and high levels of
would be specifically related to symptoms of inattention or to inattention symptoms (the inattentive subgroup); and low
the two subgroups with high levels of inattention (Chhabildas symptom levels of both hyperactivity/impulsivity (compar-
et al. 2001, Massetti et al. 2008), whereas delay aversion and ison group). The combined symptom group included 65
ODD would be specifically related to hyperactivity/impul- children (boys = 42, M = 8.5 year, SD = 2 months), the
sivity or to the two subgroups with high levels of hyperactive symptom group 29 children (boys = 18, M =
hyperactivity (Castellanos et al. 2006, Gaub and Carlson 8.5 year, SD = 2 months), the inattentive symptom group
1997, Scheres and Sumiya 2008, Thorell 2007). As for state 26 children (boys = 18, M = 8.4 year, SD = 2 months), and
regulation and internalizing problems and their relation to the the comparison group 62 children (boys = 21, M = 8.5 year,
two ADHD symptom domains, no a priori hypotheses could SD = 2 months); the first three groups will be labeled the
be formulated due to scarcity of previous research. ADHD symptom groups.
Information on parental educational status (on a 5-step
scale) was collected as a measure of socioeconomic status
Method (SES). All children were tested individually in a separate
room at their school. Each session took about 60 min and
Participants and Procedures included tests of inhibitory control, WM, delay aversion,
state regulation and intelligence (see below). The tests were
Participants in the present study were part of a larger conducted in random order except for the go/go-no tasks,
longitudinal study (n=650). The children were recruited where the normal condition was always the first and the
from randomly selected childcare centers in Uppsala slow condition always the last.
County, Sweden, in connection with an ordinary health
control when they were 5 years of age. Informed, written Measures
consent was obtained from the parents of all children who
were willing to let their child participate in the study (95%). Inhibition
Approximately 3 years later, the parents of all children in
the sample were contacted by mail and asked to participate Inhibition was studied using two well-validated tasks based
in a follow-up study. About 70% of the parents agreed to on the Stroop and go/no-go paradigms. Both tasks have
answer a questionnaire about their child concerning ADHD been used extensively in previous ADHD research in both
symptoms and comorbid behavior problems. Furthermore, clinical and non-clinical samples, they have been used to
the parents also gave permission for the child’s teacher to discriminate between children with ADHD and normally
answer the same questionnaire. Based on these aggregated developing controls and they have shown adequate (Stroop
behavioral ratings, a sub-sample was selected and the like task; r=0.62 and go/no go task; r=0.84, p<0.0001)
higher end of the ADHD symptom range was oversampled test-retest reliability (Berlin and Bohlin 2002, Berlin et al.
(see criteria below). 2004, Brocki et al. 2007, Thorell 2007).
The sub-sample was selected so as to include children Because the classic Stroop task (Stroop 1935) requires
with either low or high levels of hyperactivity/impulsivity proficient reading skills, a Stroop-like task based on the
symptoms and low or high levels of inattention symptoms. Stroop-like day-night test (Gerstadt et al. 1994) was used in
ADHD symptoms were assessed using both parent and the present study. In the current version (Berlin and Bohlin
teacher ratings (see measures below). High levels of 2002), the children were presented with four pairs of
hyperactivity/impulsivity or inattention symptoms were pictures, where the pictures in each pair were each other’s
defined as scoring in the highest 30% on the respective opposite (day-night, boy-girl, large-small, and up-down).
symptom dimensions and low levels as scoring in the After ensuring that the child understood what each picture
lowest 50%. The parents of the children who met the represented, the child was instructed to say the opposite as
criteria for one of the four groups defined above (n=260) fast as possible every time he or she saw a picture on the
were contacted, and 70% gave permission for their child to computer screen (e.g., to say “boy” every time he or she
participate in the follow-up. The present study only saw a girl). This test measured inhibition as it required the
includes the children who participated in the follow-up. participant to inhibit a prepotent response (i.e., to say what
J Abnorm Child Psychol (2009) 37:551–564 555

Table 1 Descriptive Data for All Variables, n=182 (boys = 94)

Low Inattention High Inattention Range

Low High Low High

hyperactivity 1 hyperactivity 2 hyperactivity 3 hyperactivity 4
(n=62) (n=29) (n=26) (n=65)
M (SD) M (SD) M (SD) M (SD) Obtained Possible1

Neuropsychological masures: Min Max Min Max

Inhibitory 6.4 (3.7) 10.1 (5.3) 9.9 (6.4) 11.6 (6.6) 1.0 – 33.0 0.0 – 68.0
control
Working 45.7 (9.5) 44.5 (6.6) 42.3 (11.2) 40.9 (10.4) 17.0 – 67.0 0.0 –
memory
Delay aversion 47.6 (29.5) 29.7 (19.8) 36.0 (22.1) 40.8 (31.1) 0.0 – 100.0 0.0 – 100.0
(%)
RT 400.0 (170.0) 500.0 (180.0) 630.0 (360.0) 610.0 (340.0) 210.0 – 1630.0 0.0 –
variability
(ms)
Behavioral
ratings:
Hyperactivity/ 0.8 (0.6)2 6.0 (2.6)2 2.1 (1.0)2 8.2 (3.5)2 0.0 – 17.0 0.0 – 27.0
2
Impulsivity
Inattention2 1.5 (1.1)2 3.5 (0.8)2 7.9 (2.5)2 9.9 (3.5)2 0.0 – 20.5 0.0 – 27.0
ODD 1.1 (1.3) 2.9 (1.8) 2.6 (2.5) 4.5 (3.0) 0.0 – 14.5 0.0 – 24.0
Internalizing 7.3 (2.0) 7.6 (2.7) 9.4 (3.3) 8.8 (3.2) 5.0 – 20.0 0.0 – 38.0
problems
Academic 17.1 (2.9) 16.9 (3.3) 15.7 (3.4) 14.4 (3.2) 6.0 – 25.0 0.0 – 25.0
achievement
Control
variables:
SEX; boys/girls 21/41 18/11 14/12 42/23 ————– ————–
SES 4 (1.1) 3.6 (1.1) 3.9 (1.1) 3.8 (1.1) 1.5 – 5.0 1.0 – 5.0
Intelligence 22.4 (5.1) 22.8 (3.4) 21.4 (6.2) 21.9 (4.0) 11.0 – 35.0 0.0 – 38.0
1
For WM and RT variability tasks maximum values for the possible range cannot be determined.
2
The range of ADHD symptom scores for each group: the comparison group; hyperactivity/impulsivity = 0.0–2.0 and inattention = 0.0–3.0; the
hyperactive symptom group; hyperactivity/impulsivity = 4.5–15.5 and inattention = 2.0 – 4.5; the inattentive symptom group; hyperactivity/
impulsivity = 0.0–3.5 and inattention = 6.0–14.5; the combined symptom group; hyperactivity/impulsivity = 4.5–17.0 and inattention = 6.0–20.5

the picture normally represents), and instead say the The go/no-go paradigm has been widely used in ADHD
opposite (c.f. Nassauer and Halperin 2003, Simpson and research (e.g., Trommer et al. 1988). The present task
Riggs 2005). During the first part of the task, the child was (Berlin and Bohlin 2002) included 4 different stimuli: a
presented with each picture three times in random order, but blue square, a blue triangle, a red square and a red triangle.
the pairs were not mixed (i.e., the first six pictures were During the first part of the task, the children were instructed
either a boy or a girl, the next six pictures were either large to press a key (“go”) when a blue figure appeared on the
or small, and so on). During the second part, the screen, as fast as possible, but to make no response (“no-
instructions were the same and each picture was presented go”) when an infrequent stimulus (a red figure) appeared.
three times, but the eight pictures were now presented in a The same stimuli were used for the second part of the task,
fixed random order. Each stimulus was presented for but the children were instructed to press a key every time
1,500 ms, followed by a response time of 1,500 ms and a they saw a square, irrespective of color. Altogether, the task
waiting period of 1,500 ms before the next stimulus was included 60 stimuli with a “go-rate” of 70%. Each stimulus
presented. Errors on this task were registered when the was presented for 800 ms, followed by a response time of
child named, or started to name, the picture instead of 1,200 ms, and a waiting period of 1200 ms, before the next
saying the opposite, or when no answer was given. The stimulus was presented. The results were registered as
total number of errors for the two sessions was used as a commission errors (pressing the key when a “no-go” target
measure of inhibition. was presented). The merged sum for commission errors in
556 J Abnorm Child Psychol (2009) 37:551–564

the first and second part of this task was used as the second Delay Aversion
measure of inhibition. To form a broad measure of
inhibition, the two inhibition measures were standardized The Flower-Delay task is a computer-based task using a
and aggregated (r=0.42, p<0.001). High values indicate design similar to the choice delay task (CDT; Sonuga-Barke
poor inhibitory control. et al. 1992, Solanto et al. 2001). Here, the children had to
choose between a small immediate reward (one flower after
Working Memory 3 s) and a larger delayed reward (two flowers after 30 s).
The experimenter explained to the children that they were
The Children’s Size-Ordering Task (McInerney et al. 2005) going play a game in which they could earn flowers and
was used to measure working memory. In this task, children that the goal of the task was to earn as many flowers as
were presented with a list of common objects (e.g., pencil, possible. To motivate the children they were told that they
mountain, train, church) read out loud at a rate of one item would receive a small prize (pencils) at the end. Before the
per second, and were asked to repeat them back to the game started, the children had five practice trials during
experimenter in order of size from smallest to largest. A which the experimenter made sure that they understood the
minimum of two practice trials were administered first. The difference in the waiting periods and that they would get
test began with two items per trial, and became progres- more flowers if they waited for the larger, delayed reward.
sively more difficult to a maximum of seven items per trial. Before the test trials started, the children were instructed
All children were administered all trials, regardless of their that they would have 20 trials in which to earn flowers.
performance. The test was not time limited. The score for Next to the computer, there was a transparent can
this task consists of the total number of pairs of items containing 20 red balls. The children were told that after
ordered correctly across all trials. High values indicate good each trial, one ball would disappear and that when the can
working memory. was empty, the game would be over. The percentage of
The Pig House Memory Task (Thorell and Wåhlstedt times the delayed reward was chosen is used in the
2006) is a spatial working memory task. The children were analyses as a measure of delay aversion, and low values
presented with a 4-by-4 matrix on the computer screen and indicate a problem with delay aversion. Test-retest
told that this was a house with windows. Further, they were reliability for the delay aversion measure has been shown
informed that pigs would look out of the windows, and that to be adequate (r=0.84, p<0.0001) using 26 children
the goal of the task is to try to remember their locations in tested on average 2 weeks apart (Thorell 2007).
the same order as they appeared. Each pig was displayed for
1,000 ms, and the time between each stimulus was 750 ms. Intelligence
Participants were given two trials at each span length starting
with two and ending when the child failed to repeat at least The WISC-III (Wechsler 1991) is a widely used measure of
one trial correctly at that span length. The child received one general intelligence for children 6-16 years of age. The
point for every correct answer. Thus, high values indicate Information and Block Design subtests of the WISC-III
good working memory, and the total sum was used as a were used. Both subtests are considered reliable and have
measure of spatial working memory. Test-retest reliability for been shown to correlate highly (Information: r=0.95; Block
the spatial WM measure has been shown to be adequate (r= Design: r=0.93) with full-scale IQ (Groth-Marnat 1997).
0.69, p<0.001) using 30 children tested on average two The child’s number of points on the two subtests were
months apart (Thorell and Wåhlstedt 2006). To form a broad converted to standard points available from norms (e.g., the
measure of WM, the two WM measures were standardized raw scores corrected for the child’s chronological age). An
and aggregated (r=0.25, p<0.001). aggregated mean score of standard points for the Informa-
tion and Block Design subtests (r=0.28, p<0.01) was used
State Regulation as a measure of intelligence.

Based on the go/no-go tasks (see description above), within Behavioral Ratings
subject variability in reaction times (RT variability) was
calculated. We used two conditions with different inter- Measures of ADHD, ODD and Internalizing symptoms
stimulus intervals (ISI), normal ISI, 2,000 ms and slow ISI, were based on parent and teacher ratings. However, for all
8,000 ms. Only go trials were included in RT variability, behavioral ratings, we used a composite measure of
and the mean of within RT variability from these two parent and teacher ratings (hyperactivity/impulsivity,
conditions was used as a measure of state regulation. High r=0.41, p<0.0001; inattention, r=0.48, p<0.0001; ODD,
values indicate poor state regulation. r=0.31, p<0.0001; internalizing problems, r=0.33, p<0.0001)
J Abnorm Child Psychol (2009) 37:551–564 557

to obtain a measure that reflected the child’s behavior across Statistical Analyses
contexts.
Prior to analysis, data were screened for outliers, defined as
children with a value of +/− 4 SD. We found one outlier for
ADHD and ODD Symptoms Were assessed using a well-
RT variability, which was handled by replacing the extreme
validated rating scale containing the items for ADHD
value with the second most extreme value, in line with the
and ODD as presented in DSM-IV (APA 1994). This
Winsorizing procedure (Chen et al. 2001). This procedure
measure has been well validated and is frequently used in
eliminated the impact of the outlier and allowed us to retain
ADHD research (e.g., DuPaul et al. 1998). Nine items
all children in the analyses. Both categorical and dimen-
assess symptoms of inattention, nine items assess symp-
sional analyses were conducted. For the categorical
toms of hyperactivity/impulsivity and eight items assess
analyses, analyses of variances (ANOVAs) were used to
ODD symptoms. Each item was rated on a 4-point scale
study group differences.
ranging from 0 (“never or rarely”) to 3 (“very often”). The
In case of significant main effects of group, planned
sum of scores were calculated for parents and teachers,
comparisons were performed to contrast each of the three
and the aggregated mean of parent and teacher ratings was
ADHD symptom groups with the comparison group. To
used as a measure of symptoms of hyperactivity/impul-
study the independent effects of the four neuropsycholog-
sivity, inattention and ODD. Internal consistency
ical measures, we used the other neuropsychological
(Cronbach’s α) scores for the aggregated teacher and
measures as covariates (ANCOVAs, e.g., controlling for
parent measures were 0.93 for hyperactivity/impulsivity,
the effects of inhibition, working memory and RT variabil-
0.93 for inattention and 0.85 for ODD symptoms.
ity when examining group differences in delay aversion).
Internalizing problems were measured using a Swedish
Group effects were complemented with measures of effect
translation of the emotional problem subscale from the
sizes (η2 Cohen 1988). In line with recommendations when
Strengths and Difficulties Questionnaire (SDQ). This
using ANCOVAs (e.g., Tabachnick and Fidell 2007), the
instrument has been used previously on Swedish children
covariates were not shown to be highly intercorrelated (r2
(Malmberg et al. 2003) and has showed good reliability
ranged from 0.07 to 0.28). Moreover, the assumption of
and validity. Five items assessed symptoms of internaliz-
homogeneity of the regression slopes was not violated as
ing problems. The items were: “often complains of
none of the interaction effects of group and each one of the
headaches, stomach-aches or sicknesses”; “many worries
covariates was significant. In addition, data was analyzed
or often seems worried”; “often unhappy, depressed or
using the general linear model (GLM) procedure, which
tearful”; “nervous or clingy in new situations, easily loses
controls for unequal group sizes.
confidence”; and “many fears, easily scared”. Ratings
Dimensional analyses were conducted using correlation
were made on a five-point scale ranging from 1 (“does not
analyses to analyze the relations between the different
apply at all”) to 5 (“applies very well“). Aggregated parent
neuropsychological factors, comorbidity and the two
and teacher ratings yielded α=0.79. High values indicate
ADHD symptom domains. To study specificity, we used
high levels of internalizing problems.
hierarchical regression analyses to control for hyperactivity/
impulsivity when studying relations to inattention and vice
versa. For example, to study specificity of inhibitory
Academic Achievement control in relation to inattention, hyperactivity/impulsivity
was entered as an independent variable in the first step and
Teachers rated children’s academic achievement in Swed- inhibitory control was entered as a second independent
ish, Mathematics, and Social Sciences on five-point variable in the next step in the regression.
scales. Ascending numbers indicate better performance All analyses were made controlling for sex and SES. The
(i.e., 1 = performance much under average, 2 = analyses were repeated with control for symptoms of ODD
performance under average, 3 = average performance, (due to their large overlap with ADHD symptoms) as well
4 = above average performance, 5 = much above average as for intelligence, and all instances in which this led to
performance). Teacher evaluations of performance in changed conclusions are reported.
Swedish and Math have been found to correlate highly
with results on national tests in a Swedish sample of 87
12 year-olds (rs=0.82, p<0.001; Henricsson and Rydell Results
2006), indicating that teachers are reliable reporters of
children’s performance in school. Low values indicate poor Descriptive statistics for the variables and groups included
academic achievement. are presented in Table 1. As can be seen, large individual
558 J Abnorm Child Psychol (2009) 37:551–564

differences were found for all measures and no floor or As part of the group analyses, we also analyzed how
ceiling effects were noted for any of the tasks. many children in the three symptom groups had a clinically
significant impairment on each of the neuropsychological
Neuropsychological Impairments measures (i.e., they had poorer scores than 90% of the
comparison group on a certain task; Nigg et al. 2005). The
Group Analyses results showed (see Table 3) that when the three ADHD
symptom groups were combined, 26% of the children did
The result of the ANOVAs showed significant overall not show impairments on any of the neuropsychological
effects for all four neuropsychological measures (see measures, 40% had a single impairment and 34% had
Table 2). Planned comparisons revealed that when the three multiple impairments. Looking at the three ADHD symp-
ADHD symptom groups were combined, the resulting tom groups separately, the results showed that between 21–
group differed significantly from the comparison group 27% of the children did not show impairments on any of
with regard to all four neuropsychological measures. The the neuropsychological measures, single impairments var-
ANCOVAs showed that the effect for inhibitory control ied between 32–55% and multiple impairments varied
remained, F (1, 174)=6.2, p<0.05, when controlling for between 24–46%.
delay aversion and RT variability, as did the effect for RT
variability, F (1, 173)=7.2, p<0.01, when controlling for Dimensional Analyses
inhibitory control, WM and delay aversion. However, the
effects for WM, F (1, 174)=2.4, p>0.10, and delay Table 4 provides the correlations for the two ADHD
aversion, F (1, 173)=2.0, p>0.10, did not remain signifi- symptom domains and the four neuropsychological meas-
cant when controlling for the other neuropsychological ures. Symptoms of both inattention and hyperactivity/
factors. impulsivity were significantly associated with all neuropsy-
Thereafter, planned comparisons comparing each of the chological functions. Further, regression analyses (see
three ADHD symptom groups with the comparison group Table 5) were used to control for symptoms of hyperactiv-
were conducted (see Table 2). The results showed that the ity/impulsivity when studying relations to inattention and
combined symptom group differed from the comparison vice versa. The results of these analyses showed that
group with regard to inhibitory control, WM and RT inhibitory control, WM and variability in RT were related
variability. The inattentive symptom group differed from to symptoms of inattention, but not to symptoms of
the comparison group only with regard to inhibitory control hyperactivity/impulsivity, whereas delay aversion was not
and RT variability. Finally, the hyperactive symptom group related to either of the two ADHD symptom domains.
differed from the comparison only with regard to inhibitory Among the variables shown to be associated with inatten-
control and delay aversion. When controlling for intelli- tion, both inhibitory control and RT variability, but not
gence, the effect for WM was no longer significant in the WM, showed independent relations. It is important to note
combined symptom group. that when using symptoms of ODD as a control variable, in

Table 2 Results of ANOVA Studying Main Effects of Group Differences Using Sex and SES as Covariates

ANOVAs Planned contrasts

Subgroups 1 vs. 2, 3 & 4 1 vs. 2 1 vs. 3 1 vs. 4

F (η2) T (η2) t (η2) t (η2) t (η2)

Neuropsychological measures:
Inhibitory control 6.9*** (.10) 3.8*** 2.2* (.08) 2.4* (.09) 4.5*** (.13)
Working memory 3.4* (.05) 2.2* 0.6 (.01) 1.7 (.03) 3.0** (.06)
RT variability 7.9*** (.12) 4.1*** 1.6 (.08) 3.7*** (.20) 4.3*** (.11)
Delay aversion (%) 2.9* (.05) 2.6** 2.8** (.08) 1.8 (.04) 1.4 (.01)
Behavioral ratings:
ODD 22.7*** (.27) 6.0*** 3.5*** (0.25) 2.9** (0.14) 8.2*** (0.33)
Internalizing 5.6** (0.09) 3.1** 0.8 (0.01) 3.4*** (0.13) 3.2** (0.10)
Academic achievement 8.5*** (0.12) 2.6** 0.0 (0.00) 2.1* (0.07) 4.5*** (0.13)

Planned contrasts between the three ADHD subgroups both together and separately and the comparison group. Italic entries denote effects that
were not significant (p>0.05) when controlling for intelligence and ODD. Bold entries denote effects that remained significant in the planned
contrasts between the three symptom groups together and the comparison group when controlling for the other neuropsychological factors
*p<0.05, ** p<0.01, *** p<0.001
J Abnorm Child Psychol (2009) 37:551–564 559

Table 3 Percentage of Children with Clinically Significant Impairments (i.e., Poorer Scores than 90% of the Children in the Comparison Group)

Impairments Impairments

Inhibition WM RT variability Delay aversion Single Multiple None

% % % % % % %

Subgroups:
Comparison (n=62) 10 10 10 10 27 9 64
Combined (n=65) 51 31 46 20 32 46 22
Inattentive (n=26) 35 27 50 8 42 31 27
Hyperactive (n=29) 38 3 41 28 55 24 21
ADHD symptom groups total:
ADHD (n=120) 44 23 46 19 40 34 26

both the categorical and dimensional analyses, all signifi- related to both ODD symptoms and academic achievement
cant results remained. (see Table 4). When controlling for the overlap between the
two ADHD symptom domains in the regression analyses
Comorbidity (see Table 5), ODD symptoms were related to hyperactiv-
ity/impulsivity, but not to inattention. Internalizing prob-
Group Analyses lems and academic achievement were related to symptoms
of inattention, but not to hyperactivity/impulsivity.
The results showed that when all three ADHD symptom
groups were combined, the resulting group differed
significantly from the comparison group concerning symp- Discussion
toms of ODD, internalizing problems and poor academic
achievement (see Table 2). The planned comparisons In line with our hypotheses, the results showed that children
revealed that all three symptom groups showed significant- with high levels of ADHD symptoms differed significantly
ly higher levels of ODD symptoms than did the comparison from those in the comparison group with regard to all
group, but only the combined and the inattentive symptom studied neurocognitive variables (inhibition, working mem-
groups differed significantly from the comparison group ory, RT variability, delay aversion). Concerning multiple
with regard to internalizing problems and academic pathways, independent effects were found for inhibition
achievement. When controlling for intelligence, the inat- and RT variability, whereas for delay aversion and WM, the
tentive symptom group no longer differed from the effect did not reach significance when the three ADHD
comparison group with regard to academic achievement. symptom groups were contrasted with the comparison
group. In the dimensional analyses, EF and state regulation
Dimensional Analyses were specifically related to inattention and no variable was
independently related to hyperactivity/impulsivity. Notably,
Inattention was significantly related to all comorbid around 26% of the children in the ADHD symptom groups
behavior problems and hyperactivity was significantly did not show impairment on any of the neuropsychological

Table 4 Inter-Correlations Between All Variables Adjusting for Sex and SES

2. 3. 4. 5. 6. 7. 8. 9.

1. Hyperactivity . 65*** 0.32*** − 0.16* 0.24** − 0.19** 0.58*** 0.13 − 0.29***

2. Inattention 0.35*** −0.25*** 0.35*** − 0.16* 0.45*** 0.23** − 0.47***
3. Inhibitory control − 0.23** 0.34*** − 0.19** 0.16* 0.09 − 0.32***
4. Working memory − 0.18* 0.08 − 0.16* − 0.02 0.36***
5. RT variability − 0.20** 0.08 0.05 − 0.13
6. Delay aversion − 0.03 0.19** 0.21**
7. ODD 0.19** − 0.22**
8. Internalizing problem − 0.15*
9. Academic achievement

Entries in italics denote effects that were not significant (p>0.05) when controlling for intelligence n=182
*p<0.05, ** p<0.01, *** p<0.001
560 J Abnorm Child Psychol (2009) 37:551–564

Table 5 Results of Regression Analyses Studying Specificity of variability in explaining symptoms of ADHD. Thus, in line
Neuropsychological Factors and Comorbidity in Relation to the Two
with our hypotheses and the idea of multiple pathways
ADHD Domains Adjusting for SES and Sex
leading to ADHD, the present finding shows that ADHD
ADHD Symptoms symptoms are related to deficient control of both top-down
(i.e., EF; Barkley 1997) and bottom-up functions (i.e., state
Hyperactivity/ Inattention
Impulsivity regulation; Sergeant et al. 2003). This is an important
β β finding as alternative hypotheses claiming that problems
with state regulation constitute a more generalized cogni-
ADHD domain tive deficit that underpins impairments in EFs such as
Neuropsychological 0.67 0.67 inhibitory control (e.g., Sergeant 2000, 2005), or that
measures:
inhibition is a superordinate process that controls regulation
Inhibitory control 0.10 0.20*** (0.15*)
Working memory −0.01 −0.13* (−0.09) of arousal and motivation (e.g., Barkley 1997), have also
RT variability 0.03 0.19** (0.14*) been presented.
Delay aversion − 0.09 − 0.03 (−0.02) In drawing the conclusion that RT variability and
Behavioral ratings: inhibition are independently related to ADHD symptoms,
ODD 0.35*** 0.11 it should be acknowledged that these measures may not
Internalizing problems 0.02 0.12* fully capture the two phenomena of interest. It has been
Academic achievement 0.02 − 0.31***.
argued, for example, that a latent variable approach to
The alternate symptom domain is entered in a first step with each studying EFs yields more reliable measures and valid
separate neuropsychological factor in a second step. Numbers in results (e.g., Friedman et al. 2007). Similarly, the conclu-
parentheses are values for independent contributions of neuropsycho- sion about state regulation rests on the idea that RT
logical factors when they are all entered together in a second step after
the respective ADHD domain
variability fully represents this phenomenon. Although this
*p<0.05, ** p<0.01, *** p<0.001 operationalization is a common practice, it may only
capture a narrow aspect of state regulation. Further, this
variable has been suggested to be an indicator of other
measures. With regard to comorbidity, higher levels of ODD functions, such as slower cognitive processing, slower
symptoms were obtained for all ADHD symptom groups motor speed, deficient attentional processes (Alderson et
while in the dimensional analyses ODD was primarily related al. 2007) and deficient time perception (Kalff et al. 2005).
to hyperactivity, as hypothesized. However, internalizing The important conclusion is that high RT variability
problems and poor academic achievement were primarily signifies deficiencies in a process that needs to be better
associated with inattention, thus being characteristic of the understood, especially as variability in performance has
inattentive and combined symptom groups. been shown to be one of the most consistent characteristics
of ADHD symptoms across a variety of tasks, cultures and
Neuropsychological Factors and ADHD laboratories (for a review, see Castellanos and Tannock
2002, Castellanos et al. 2006).
The finding of poorer functioning in various neuropsycho- With regard to delay aversion, significant relations were
logical measures for children with high levels of ADHD is found to both symptoms of inattention and hyperactivity/
in line with previous empirical findings as well as with the impulsivity. However, in contrast to our hypotheses, delay
notion that ADHD is a heterogeneous disorder (e.g., aversion was not shown to represent a pathway to ADHD
Castellanos et al. 2006, Nigg 2006, Willcutt et al. 2005b). symptoms that is independent of both EF and state
However, the present study addressed a number of issues regulation. Thus, while independence between delay aver-
that have scarcely been covered in previous studies. A first sion and EF in relation to ADHD is proposed in Sonuga-
issue is whether deficits in different neuropsychological Barke’s (2003, 2005) dual pathway model, delay aversion
factors such as EF, state regulation and delay aversion are had no explanatory power in our model including RT
independently related to ADHD symptoms. A second issue variability. However, as already discussed, measurement
is whether deficiencies with regard to these factors are issues are important in that the operationalization of delay
evident in all three ADHD symptom groups, which in turn aversion in this or any other specific study may not fully
brings up the issue of specificity, that is, whether capture the theoretical construct in question. In future
associations between neurocognitive measures and each of studies, a latent variable approach should be useful in the
the two ADHD symptom domains remain when controlling analyses of independent effects.
for the other symptom domain. Another important finding in the context of independent
The present study adds valuable new information by contributions of various neurocognitive functions and
showing independent contributions of inhibition and RT various pathways is that as many as 26% did not show
J Abnorm Child Psychol (2009) 37:551–564 561

impairment on any of the measures included in the study important when comparing the contribution of various EF
when examining the percentage of children who could be components, because slower maturation of more complex
said to be clinically impaired (i.e., they were above the 90th EF components such as WM may mean that they become
percentile cutoff for the comparison group). The percentage more important in later developmental phases (cf. Bitsakou
of children with no impairment in the present study is et al. 2008, Brocki and Bohlin 2006).
similar to that found for EF and delay aversion in the few Due to the scarcity of previous research, we did not set
previous studies that have undertaken this kind of analysis up a specific prediction regarding the issue of whether RT
(Bitsakou et al. 2008, Nigg et al. 2005, Sonuga-Barke et al. variability is specifically related to either one of the two
2003). Thus, even when adding measures of state regula- ADHD symptom domains when controlling for the overlap
tion, a substantial number of children with high levels of between inattention and hyperactivity/impulsivity. The
ADHD symptoms do not show impairment, which suggests results of the present study, which showed that RT
that other potential factors have to be included in order to variability was primarily related to symptoms of inattention
more fully explain the different pathways to ADHD. We in both the categorical and dimensional analyses, therefore
can only speculate as to what should be taken into account, add new valuable information to this field of research.
although as reviewed by Nigg (2006), associations to Concerning delay aversion and its specific relations to
psychosocial factors such as psychological trauma, early the two ADHD symptom domains, our findings are
deprivation and attachment problems can be expected. inconsistent. In line with our hypotheses and a previous
study (Scheres and Sumiya 2008) stating that delay
Specific Relations to ADHD Symptom Domains aversion is more strongly related to hyperactivity than to
and Symptom Groups inattention, the hyperactive subgroup was shown to differ
significantly from the comparison group. However, the
In our analyses of group differences, each of the three combined subgroup, which is also characterized by high
ADHD symptom groups had significantly poorer inhibitory levels of hyperactivity, did not differ significantly from the
control compared to the comparison group, which is in line comparison group and delay aversion was not specifically
with previous conclusions claiming that EF impairment is related to either hyperactivity or inattention in the regres-
an important pathway to high levels of ADHD symptoms in sion analyses when controlling for the overlap between the
general (Willcutt et al. 2005a). However, when controlling two symptom domains.
for the overlap between the two ADHD symptom domains, The fact that the hyperactive subgroup, but not the
none of the neuropsychological measures was primarily combined subgroup differed significantly from the compar-
related to symptoms of hyperactivity/impulsivity, although ison group with regard to delay aversion cannot easily be
both inhibition and RT variability were specifically related explained. One could speculate that hyperactivity is not a
to symptoms of inattention. unitary phenomenon, implying that some aspects of the
The fact that inhibition was only related to symptoms of broad phenomenon of hyperactivity are indeed character-
inattention when controlling for hyperactivity/impulsivity is ized by delay aversion, whereas others are not. In this
in line with our hypotheses as well as with previous context, the literature on Type A behavior (i.e., restlessness,
findings of for example Chhabildas et al. (2001). However, impatience, difficulty waiting) could be brought to mind. In
all three ADHD symptom groups showed impaired inhibi- child studies, for example, it has been found that ratings of
tion in the categorical analyses, which could be due to the hyperactivity correlate highly with ratings of Type A
fact that children in the hyperactive subgroup had higher behavior, although the two phenomena could be differen-
levels of inattention compared to the comparison group. tiated in their relations to outcomes, with Type A children
This, in turn, highlights the importance of controlling for being superior to children diagnosed with ADHD with
the overlap between the two ADHD symptom domains regard to several measures of executive functioning
when studying specificity. (Nyberg et al. 2003, 2004).
Another interesting finding of the present study is the Regarding comorbidity, the results of our dimensional
prominence of inhibition over WM in terms of contributing analyses are in line with our hypotheses as well as with
independently to the variance in ADHD symptoms and previous research as symptoms of ODD were associated
primarily to symptoms of inattention. This is line with the with hyperactivity/impulsivity (Gaub and Carlson 1997),
results of, for example, Friedman et al. (2007), who used whereas academic achievement was associated with inat-
structural equation modeling with inhibition and updating tention (e.g., Massetti et al. 2008). However, contrary to
of WM as latent constructs, as well as with our own data expectations, also the inattentive symptom group showed
(Brocki et al. 2007), showing that only inhibition indepen- high levels of ODD symptoms, possibly due to higher
dently predicted symptoms of ADHD over a 2 year period. levels of hyperactivity/impulsivity in this group compared
However, it should be noted that child age may be with the comparison group. With regard to internalizing
562 J Abnorm Child Psychol (2009) 37:551–564

problems, the inconsistency in previous studies did not Berlin, L., & Bohlin, G. (2002). Response inhibition, hyperactivity
allow for any a priori hypotheses. In line with findings by and conduct problems among preschool children. Journal of
Clinical Child and Adolescent Psychology, 31, 242–251.
Gaub and Carlson (1997), both our dimensional and Berlin, L., Bohlin, G., Nyberg, L., & Janols, L.-O. (2004). How well
categorical analyses showed that internalizing problems do measures of inhibition and other executive functions discrim-
were specifically related to inattention. This finding is in inate between children with ADHD and controls? Child
contrast to that found by Power et al. (2004), who instead Neuropsychology, 1, 1–13.
Berwid, O. G., Curko Kera, E. A., Marks, D. J., Santra, A., Bender, H.
found internalizing problems to be primarily related to A., & Halperin, J. M. (2005). Sustained attention and response
hyperactivity. Possible explanations to this inconsistency inhibition in young children at risk for attention deficit/
could be sample characteristic such as age (8–14 years of hyperactivity disorder. Journal of Child Psychology and Psychi-
age in the study by Power and colleagues versus 8 years in atry, and Allied Disciplines, 46, 1219–1229. doi:10.1111/j.1469-
7610.2005.00417.x.
the present study) as well as measurement issues (e.g., self- Biederman, J. (2005). Attention-deficit/hyperactivity disorder: a
report measures versus parent and teacher ratings). selective overview. Biological Psychiatry, 57, 1215–1220.
doi:10.1016/j.biopsych.2004.10.020.
Concluding Comments Bitsakou, P., Psychogiou, L., Thompson, M., & Sonuga-Barke, E. J.
S. (2008). Inhibitory deficits in attention-deficit/hyperactivity
disorder are independent of basic processing efficiency and IQ.
Our results suggest that inhibition and RT variability Journal of Neural Transmission, 115, 261–268. doi:10.1007/
constitute independent pathways to high levels of ADHD s00702-007-0828-z.
symptoms, primarily to inattention. The relevance of Brocki, K. C., & Bohlin, G. (2006). Developmental change in the
relation between executive functions and symptoms of ADHD
separating the two symptom domains is also justified by and co-occurring behaviour problems. Infant and Child Devel-
the finding for comorbidity, showing differential relations opment, 15, 19–40. doi:10.1002/icd.413.
for inattention and hyperactivity. These are new and Brocki, K. C., Nyberg, L., Thorell, L. B., & Bohlin, G. (2007). Early
important findings, as very few previous studies have concurrent and longitudinal symptoms of ADHD and ODD: relations
to different types of inhibitory control and working memory. Journal
addressed the issue of independent effects of different of Child Psychology and Psychiatry, and Allied Disciplines, 48,
neuropsychological functions. Additionally, few studies 1033–1041. doi:10.1111/j.1469-7610.2007.01811.x.
have used the full range of symptom severity and controlled Castellanos, F. X., & Tannock, R. (2002). Neuroscience of attention-
for the overlap of inattention and hyperactivity/impulsivity. deficit/hyperactivity disorder: the search for endophenotypes.
Nature Reviews. Neuroscience, 3, 617–628.
By using this approach in the present study, we have gained Castellanos, F. X., Sonuga-Barke, E. J. S., Milham, M. P., & Tannock,
new knowledge of neuropsychological functioning and R. (2006). Characterizing cognition in ADHD: beyond executive
comorbidity in relation to the two ADHD symptom dysfunction. Trends in Cognitive Sciences, 10, 117–123.
domains. Conclusively, the present study lends empirical doi:10.1016/j.tics.2006.01.011.
Chen, L. A., Welsh, A. H., & Chan, W. (2001). Estimators for the
support to the notion that ADHD is a heterogeneous linear regression model based on Winsorized observations.
disorder (e.g., Castellanos et al. 2006, Willcutt et al. Statistica Sinica, 11, 147–172.
2005b) and indicates that the neuropsychological functions Chhabildas, N. A., Pennington, B. F., & Willcutt, E. G. (2001). A
underlying RT variability are worthy of further theoretical comparison of the cognitive deficit in the DSM-IV subtypes of
ADHD. Journal of Abnormal Child Psychology, 9, 28–32.
and empirical attention in analyses of the multiple neuro- Clarke, S. D., Kohn, M. R., Hermens, D. F., Rabbinge, M., Clark, C.
psychological pathways to ADHD. R., Gordon, E., & Williams, L. M. (2007). Distinguishing
symptom profiles in adolescent ADHD using an objective
cognitive test battery. International Journal of Adolescent
Medicine and Health, 19, 355–367.
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