Archives of Clinical Neuropsychology

20 (2005) 727–744

Neuropsychological performance in adult

attention-deficit hyperactivity disorder:
Meta-analysis of empirical data
Claudia Schoechlin ∗ , Rolf R. Engel
Ludwig-Maximilians-University, Munich, Germany

Accepted 9 April 2005

Abstract

Attention-deficit hyperactivity disorder (ADHD) is increasingly recognized not only in children but
also in adults. Neuropsychological tests are important tools to quantify the attentional and/or cogni-
tive deficits of patients compared to controls. The present meta-analysis integrates 24 empirical studies
reporting results of at least one of 50 standard neuropsychological tests comparing adult ADHD patients
with controls. The 50 tests were categorized into the following 10 functional domains: verbal ability, fig-
ural problem solving, abstract problem solving, executive function, fluency, simple attention, sustained
attention, focused attention, verbal memory, figural memory. For each domain a pooled effect size d was
calculated. Complex attention variables and verbal memory discriminated best between ADHD patients
and controls. Effect sizes for these domains were homogeneous and of moderate size (d between 0.5
and 0.6). In contrast to results reported in children, executive functions were not generally reduced in
adult ADHD patients.
© 2005 National Academy of Neuropsychology. Published by Elsevier Ltd. All rights reserved.

1. ADHD in adults

The diagnosis of attention-deficit hyperactivity disorder (ADHD) is attracting more and

more attention in adult psychiatry (National Academy for the Advancement of ADHD Care,
∗
Corresponding author. Present address: Department of Clinical Psychology and Psychophysiology, Psychiatric
and Psychotherapeutic Hospital, University of Munich, Nussbaumstr. 7, D-80336 München, Germany.
Tel.: +49 89 5160 5561; fax: +49 89 5160 5562.
E-mail address: claudia.schoechlin@med.uni-muenchen.de (C. Schoechlin).

0887-6177/$ – see front matter © 2005 National Academy of Neuropsychology. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.acn.2005.04.005
728 C. Schoechlin, R.R. Engel / Archives of Clinical Neuropsychology 20 (2005) 727–744

2003). Long-term studies have shown that there is a rather high persistence of ADHD symptoms
into adulthood (Biederman, 1998; Hill & Schoener, 1996; Mannuzza, Klein, Bessler, Malloy, &
LaPadula, 1998; Yan, 1998). Epidemiological studies have suggested ADHD prevalence rates
higher than supposed before (Barkley, Fischer, Smallish, & Fletcher, 2002) and state a high
comorbidity with other psychiatric disorders (Hornig, 1998; Weiss & Hechtman, 1993, p. 408).
ADHD in adults is accompanied by an increased risk of substance abuse, anxiety and mood
disorders (Biederman, Newcorn, & Sprich, 1991; Biederman et al., 1993; Marks, Newcorn,
& Halperin, 2001), as well as a disruptive family environment, which may impair offspring
development (Biederman, Faraone, & Monuteaux, 2002). It accounts for social and economic
problems and impairs academic achievement and work performance. In consequence, health
costs increase (Barkley, 2002; Trollor, 1999). Specific medical treatments have been proposed
and scientifically investigated (Wilens, Spencer, & Biederman, 2002). Adult ADHD is more
difficult to diagnose than childhood ADHD because symptoms are less obvious and more
unspecific. Lack of concentration, unhappiness due to emotional and organizational overload,
and disinhibition-deficit as well as difficulties in affect integration may be the result or the
core symptoms of ADHD, but they also occur as unspecific symptoms in depression, anxiety
disorders, and personality disorders, to mention only a few. Childhood ADHD as a necessary
condition for the diagnosis of adult ADHD is sometimes difficult to assess retrospectively
(Mannuzza, Klein, Klein, Bessler, & Shrout, 2002; Murphy, 2003), although one study by
Murphy and Schachar (2000) reported high validity figures. As a whole, adult ADHD today
is judged as being a valid distinct clinical diagnosis (Spencer, Biederman, Wilens, & Faraone,
1998).
The pivotal instruments most often used in the diagnostic process are observer- and
self-rating scales for both children and adults. These rating instruments focus on patients’
attention, hyperactivity and other behavioral categories. Based on natural observations such
as in classrooms or at home, they are easy to use with children, but less easy to implement
with adults. Moreover the spectrum of behavior and complaints covered by the instruments
has a large overlap with behavior sampled in other diagnostic categories. The core symp-
toms of ADHD are of neurocognitive nature. Neurocognitive symptoms in general can be
assessed not only by observer- or self-ratings, but also by objective neuropsychological tests.
In the literature on ADHD, a few studies have reported neuropsychological test results of
ADHD patients compared to control groups. The studies were usually conducted with small
samples of patients, and each used a different set of neuropsychological standard tests. Indi-
vidual studies could therefore not establish the significance and value of neuropsychological
tests in the diagnostic process; nevertheless, usefulness of neuropsychological evaluation is
supported by the reviews of Woods, Lovejoy, and Ball (2002) and Gallagher and Blader
(2001).
The present paper reviews quantitatively the existing data by categorizing each neuropsy-
chological measure into one of 10 neuropsychological functional domains. Published studies
reporting neuropsychological test results comparing ADHD patients with a control group are
analyzed by means of a meta-analysis. The aim is to review the empirical evidence that patients’
subjective complaints of cognitive deficits are reflected in objective measures of such deficits.
Further, it is intended to describe the quality and extent of specific cognitive deficits of ADHD
patients.
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2. Methods of meta-analysis

2.1. Studies

English-, German-, and French-language literature published before December 2002 was
searched for empirical studies on neuropsychological test results of ADHD patients by using
Medline, Current Contents, and manual cross-referencing in existing reviews. Studies were
included if they compared the neurocognitive performance, measured by neuropsychological
standard tests, of clinically diagnosed ADHD patients aged 16 years or older to a control
group. Thirty-seven studies were identified.
Twenty-four studies were suitable for inclusion in the statistical meta-analysis. Thirteen
studies had to be excluded: Eight used uncommon neuropsychological tests or experimental
designs that were not comparable with other tests, and five did not present their data in enough
detail. In a few studies, some but not all of the variables were uncommon (e.g. smell identi-
fication or time estimation); in these cases, only the common variables were entered into the
meta-analysis.

2.2. Data reduction

The 24 studies reported 104 measures using 50 standard neuropsychological tests. For each
measure of each study an effect size d was calculated as a standardized performance difference
between ADHD and control subjects (see below). In a first step, we assigned each measure
to a functional domain, to reduce the number of measures to a manageable and interpretable
size. Table 1 gives an overview of the domains, a short description and samples of the test
scores allocated to them. In selecting and naming the domains our main goal was to stay
with the neuropsychological nomenclature used in the studies included. Thus, the domains
reflect the common concepts of the authors of the original studies as far as possible. Not all
studies included the same measures, and authors’ integration of different measures mostly
took place only in the discussion, were measures were discussed concerning their different
functional aspects. For statistical reasons, we preferred to assign each measure to only one
category, even if there might be a second category that also could fit. This especially concerns
some of the measures of executive functions, which we preferred to assign to more specific
categories.
As a consequence of the heuristic approach used the list includes domains with a varying
degree of specificity. Not unexpectedly, almost all studies included several tests of attention. We
could therefore break down the attentional domain into several subdomains (simple attention,
focused attention and sustained attention), where each subdomain still included many tests.
On the other hand, we had to use “verbal intelligence” as a broad category to summarize the
few tests measuring different verbal abilities. Thus, the domain names used should be seen
as heuristic concepts reflecting what has been measured in the studies with a narrow focus in
areas widely measured and a broad focus elsewhere.
Secondly, for each study, single effect sizes of all test results belonging to one functional
domain were averaged to obtain the domain effect sizes of the individual study. Thirdly, these
domain-specific effect sizes were pooled across studies.
730 C. Schoechlin, R.R. Engel / Archives of Clinical Neuropsychology 20 (2005) 727–744

Table 1
Functional neuropsychological domains and corresponding test instruments
Functional domain
Verbal intelligence
Executive functions
Fluency
Visual-figural problem
solving
Abstract problem solving;
working memory
Simple attention
Sustained attention
Focused attention
Verbal memory
Figural memory
Description
Verbal abilities;
education-mediated knowledge
Planning and controlling of
actions
Productivity; creativity
Logical structuring, problem
solving, visual
Logical problem solving without
action
Simple attention tasks; mostly
visual-motor processing; mostly
speed measures
Attention tasks that require
attention over a longer period of
time
Complex attention tasks
Learning and reproduction of
verbally presented material
Learning and reproduction of
figural material
Tests
WAIS-R Similarities, information, vocabulary;
reading
Wisconsin Card Sorting Test; Tower of Hanoi
Controlled Oral Word Association Test;
design fluency
WAIS-R Block Design, picture completion,
picture arrangement; Rey-Osterrieth Complex
Figure (accuracy; organization); Embedded
Figures Test
WAIS-R arithmetic; Auditory Consonant
Trigrams
Digit span (forwards);
freedom-from-distractibility (WAIS-R);
Stroop Word, Color; Trail Making Test A;
Visual CPT reaction time; 3RT Simple;
Wechsler Memory Scale-Attention, Target
Orientation Test
CPT, different versions (MHS, X, A,
Auditory); quality measures (false positives;
false negatives; d’)
WAIS-R digit Symbol; Digit span backwards;
Stroop interference; Trail Making Test B; 3RT
complex, conditional; reaction time pattern
comparison, GDS distractibility, TOAD
California Verbal Learning Test; Wechsler
Memory Scale
Rey-Osterrieth Complex Figure Test; Kimura
Recurring Figures Test

2.3. Effect size calculation

The standard meta-analytical techniques for continuous data were used as described by
Hedges and Olkin (1985) and DerSimonian and Laird (1986). Effect size d (Eq. (1)) was
calculated from the statistics given in the papers, mostly means and standard deviations (S.D.s).



3 AMADHD − AMctrl
d = 1−  (1)
4N − 9 (NADHD −1)S.D.2ctrl +(Nctrl −1)S.D.2ADHD
NADHD +Nctrl −2

with AM, mean, S.D., standard deviation and N, number of patients (total).
 C. Schoechlin, R.R. Engel / Archives of Clinical Neuropsychology 20 (2005) 727–744 731

In mathematical terms, d represents the difference between patient and control means cal-
ibrated in pooled S.D. units. If d = 1, the magnitude of study and control group difference
equals one (pooled) S.D.; d = 0.5 reflects half of a S.D. The mean effect size d reflects the
average individual effect size across studies in the synthesis. As we assume a heterogeneous
data set over k studies, the random effects model was applied to yield the pooled effect size d
by weighting each d of study i with its standard error, corrected for possible heterogeneity by
τ 2 (see Eqs. (2)–(8):
k
di w∗i (d)
d = i=1

k
, (2)
∗
i=1 w i (d)
with the weight
w(d)
w∗ (d) = (3)
1 + w(d)τ 2
and
1
w(d) = (4)
S.E.(d)2
with a standard error of d:


N d2
S.E.(d) = + (5)
NADHD × Nctrls 2(N − 3.94)
and
τ 2 = max (T, 0) (6)
with
χ2 − k + 1
T =  k  (7)
i=1 wi (d)
2
k
w
i=1 i (d) −  k
w (d)
i=1 i

and
k

(di − d  ) w(d)i
2
χk−1
2
= (8)
i=1

Homogeneity of study effect sizes was assessed by the usual χ2 -test for homogeneity of

d (Eq. (8); Mantel & Haenszel, 1957). As an indicator for the extent of heterogeneity I was
computed as proposed by Higgins, Thompson, Deeks, and Altman (2003) and Higgins and
Thompson (2002):

2 
χ − (k − 1)
I = max ,0 (9)
χ2
732 C. Schoechlin, R.R. Engel / Archives of Clinical Neuropsychology 20 (2005) 727–744

The usual confidence intervals (CI, Eq. (10)) give information on the statistical weight of
the studies.
CI = d  − (1.96 × S.E.(d  )) (10)

Fail-safe N is the number of unpublished, non-significant studies which would be necessary

to render the results of a meta-analysis non-significant (P < = .05). It was calculated by:
k(kz2 − 2.706)
Nfs = (11)
2.706
with k, number of studies in the meta-analysis and z, combined z-value, as described by Clark-
Carter (1997). The critical number of studies, i.e. the number of unpublished studies one could
expect, is:
Crit No = 5k+10 (12)

Rosenthal (1991, p. 106) argues that is unlikely that file drawers have more than five times
as many studies as the reviewers. The minimum number of studies filed away is set to 15 by
this formula.

3. Results

3.1. Study details and patient characteristics

The 24 studies included a total of 867 ADHD patients and 806 controls. Patient charac-
teristics are described in Table 2, the main study characteristics in Table 3. References are
given in the literature. Patients were young (unweighted mean 31 years); the ADHD group
was predominantly male (70%), whereas the control group comprised fewer males (57%).
Level of education and intelligence of the samples were high. Most studies compared ADHD
patients to healthy controls; in six cases, an outpatient group served as the control group or was
established as an additional control group. Most controls were healthy persons recruited by
advertisement. Some studies included controls who referred themselves to counseling but who
did not receive a psychiatric diagnosis. Nearly all patients fulfilled the criteria for attention-
deficit hyperactivity disorder according to DSM-III-R or DSM-IV. Subtyping of the ADHD
patients into predominantly inattentive versus predominantly hyperactive–impulsive group
was seldom considered. The majority of studies excluded ADHD patients with a comorbid
major psychiatric disorder. Exceptions were Corbett and Stanczak (1999), who also included
patients with comorbid depression, Gansler et al. (1998), who reported a substance abuse
comorbidity of 30% in their ADHD group, and Oie and Rund (1999), 9% of whose patients
were suffering from comorbid obsessive compulsive disorder. Most of the studies did not allow
patients to take any psychotropic drugs, at least not prior to testing. In eight studies, the groups
were explicitly matched, mostly by education, age and sex.
 C. Schoechlin, R.R. Engel / Archives of Clinical Neuropsychology 20 (2005) 727–744 733

Table 2
Patient characteristics
First author Published N Age % Male Education IQ
year (years)
ADHD Ctrl ADHD Ctrl ADHD Ctrl ADHD Ctrl ADHD Ctrl
Arcia 1994 23 25 23 27 65 60 13 14 n.a.
Barkley 1996 25 23 23 22 64 61 14 14 107a 108
Biederman 1993 84 142 39 39 65 47 n.a. 110b 113
Bush 1999 8 8 37 37 60 60 n.a.; ns 107 111
Corbett 1999 27 15 37 40 50 33 15 16 n.a.
Epstein 1998 25 30 35 25 67 62 n.a. n.a.
Epstein 2001 60 72 34 33 40 50 n.a.; ns n.a.
Gansler 1998 30 10 29 35 93 70 14 14 108d 105
Himelstein 2000 9 23 35 23 85 23 n.a.; ns n.a.; ns
Holdnack 1995 25 30 31 27 60 63 15 14 57e 60
Hopkins 1979 70 42 19 19 n.a. n.a.; ns 105 108
Jenkins 1998 22 18 34 32 54 22 k.A. 99 106
Johnson 2001 56 38 33 41 71 63 14 17 57f 58
Katz 1998 58 20 29 35 87 44 14 15 109 111
Klee 1986 12 12 20 29 100 100 n.a. n.a.
Kovner 1998 19 10 31 31 66 66 14 14 110 110
Lovejoy 1999 26 26 41 41 50 50 16 16 115 115
Murphy 2001 18 18 21 21 75 69 13 14 104a 111
Murphy 2002 105 64 40 40 100 100 n.a. 94–125 94–125
Oie 1999 20 30 14 16 100 50 n.a. n.a.
Rapport 2001 35 32 33 33 66 55 15 15 105c 108
Seidman 1998 64 73 36 40 52 45 high 111b 112
Silverstein 1995 16 17 36 31 50 50 n.a.; ns 32g 33
Walker 2000 30 30 26 26 83 63 11 11 n.a.
867 808 31 31 70 57

n.a., not availiable; ns, non significant; Ed, education; Soc, socioeconomic status.
a
Kaufman Brief Intelligence Test.
b
Estimated from WAIS-R Vocabulary and Block Design.
c
Estimated from WAIS-R Similarities, Block Design, Picture Arrangement, Picture Completion.
d
Estimated from WAIS-R Block Design and Vocabulary.
e
Sum of age corrected subscale scores on WAIS-R Information, Digit Span, Vocabulary, Block Design, Digit
Symbol.
f
Shipley Institute of Living Scale—Vocabulary and Abstract Reasoning.
g
Shipley Intelligence Scale.

3.2. Effects

Table 4 shows effect sizes for the 10 functional domains, with negative d values indicating
lower performance in the ADHD group. In all functional domains ADHD patients scored
lower than the combined control groups. The deficits were most pronounced in verbal memory,
focused attention, sustained attention and abstract problem solving requiring working memory.
In these four domains the ADHD patients scored about one half of a S.D. lower than the control
 734
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Table 3
Study characteristics
First author Published year Design Recruitment Diagnosis Medication
ADHD Controls ADHD Comorbidity Subtype Control
Arcia 1994 ADHD/crl/neu Neuropsych. outp DSM-III-R None – Healthy None
Barkley 1996 ADHD/ctrl Clinic Ad DSM-IV No psychosis, no Comb Healthy Stim. (4); AD
neuro (1); 24 h WO
Biederman 1993 ADHD/ctrl Genetic study Genetic study 7 DSM-III-R-Crit. Yes (67% ADHD; – Healthy ?
0% contr.)
Bush 1999 ADHD/ctrl Outp clinic DSM-IV-R No axis I diagnosis Healthy 48 h wo
Corbett 1999 ADHD/ctrl Private practices Ad DSM-IV-R 50% depression 24 full crit.; 3 Healthy None
ina
Epstein 1998 ADHD/ctrl Outp clinic Study DSM-IV; current ? 39 ina; 7 hyp; Healthy ?
sympt. 14 comb
Epstein 2001 ADHD/ctr/anx Professionals; ad Newspaper ad DSM-IV ? 14 ina; 1 hyp; Healthy; Axiety 12 h wo
10 comb
Gansler 1998 ADHD/ctrl SR Ad; rebursed DSM IV No psychosis, no 16 ina; 14 hyp Healthy (40% ?
neuro alcoholism)
Himelstein 2000 ADHD/ctrl Ad, practice, Queens College DSM-IV ? 6 ina; 1 hyper; No ADHD None
groups 2 comb,
Holdnack 1995 ADHD/ctrl Referral Project DSM-III-R No neuro; no ? Healthy None
psychia.
Hopkins 1979 CADHD/ctrl Long-term study Long-term study n. a. No psychia.; no “Hyperactive” Healthy ?
neuro
Jenkins 1998 CADHD/ctrl SR SR DSM-III-R No neuro; no 15 current Multiple ?
(childhood) psychia. ADD; 7 res; diagnoses
comorbidity
Johnson 2001 ADHD/ctrl SR Ad DSM-IV No mood disorder; – Healthy None
no substance use
Katz 1998 ADHD/outp. SR SR DSM-III-R LD (40 ADHS; 6 – Depression None
crtls)
Klee 1986 CADHD/ctrl Formerly treated Staff CADHD – Healthy (?) None for 1 year
Kovner 1998 ADHD/ctrl SR SR DSM-IV 4 LD; 4 – Yes (Depr.; LD; 12 h wo
Depression/Anx Anx)
Lovejoy 1999 ADHD/ctrl SR; stimulant SR; parents; friends DSM-IV Substance – Healthy or 12 h wo
responder abuse/depend. substance abuse
Murphy 2001 ADHD/Ctrl Clinic referral Newspaper ad DSM-IV No axis I diagnosis 55% comb; ? Stim. (17); AD
34% ina; 2% (4); wo 12 h/2
hyp; 9% res weeks
Murphy 2002 ADHD/Ctrl Fathers of Staff DSM-IV-R No axis I diagnosis Com Healthy ?
ADHD-children
Oie 1999 ADHD/Ctrl/Sz Outp Schools; hospitals DSM-III-R OCD 9% ? Healthy Stim. (32); 24 h

C. Schoechlin, R.R. Engel / Archives of Clinical Neuropsychology 20 (2005) 727–744

wo; AP (29 sz)
Rapport 2001 ADHD/Ctrl University center University ad DSM-IV No neurological or ? Healthy Stim. (3); 12 h
subst. abuse wo
Seidman 1998 ADHD/Ctrl SR Studies DSM-III-R (5 66% ADHD; 8% – Normals; 8% None
crit.+CADHD) ctrls. ysychia. dia.
Silverstein 1995 ADHD/Ctrl/ GdT Outp groups Straff; students DSM-III-R No psy. treatment – Controls Stim. (5); AD
(2), both (1)
Walker 2000 ADHD/ctrl/outp SR; outp clinic Community sample DSM-III-R None – Healthy None

Neu, neurological patients; Anx, anxiety; Sz, schizophrenia; GdT, Gilles de la Tourette; Outp, outpatients; CADHD, childhood ADHD; SR, self referral; LD,
learning disabilities; Ina, inattentive; Hyp, hyperactive; Comb, combined; Res, residual type; Psychia., psychiatric; Stim, stimulants; AD, antidepressants; WO,
wash out; AP, antipsychotics; h, hours; crit, criteria.

735
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Table 4
Pooled effect sizes and meta-analytic parameters
N studies N patients d CI low CI upper z (d) P (z) χ2 P (χ2 ) TAU I2
Verbal intelligence 12 863 −.27 −.43 −.11 −3.34 .00 13.5 .26 .014 19
Executive functions 7 464 −.21 −.46 .03 −1.70 .09 9.5 .14 .039 37
Visual/verbal fluency 7 527 −.52 −.83 −.20 −3.23 .00 17.4 .00 .113 65
Visual/figural problem solving 8 762 −.26 −.40 −.11 −3.45 .00 4.0 .78 .000 0
Abstract problem solving; working memory 12 952 −.51 −.64 −.37 −7.40 .00 10.8 .46 .000 0
Simple attention 22 1537 −.38 −.55 −.22 −4.50 .00 47.6 .00 .080 56
Sustained attention 13 963 −.52 −.65 −.39 −7.79 .00 11.1 .52 .000 0
Focused attention 22 1493 −.55 −.68 −.42 −8.31 .00 28.3 .13 .023 26
Verbal memory 8 546 −.56 −.79 −.37 −6.14 .00 6.2 .52 .000 0
Figural memory 8 541 −.18 −.35 .00 −1.93 .05 7.5 .38 .005 7

d, pooled weighted effect size; CI low/upper, confidence interval (d); z, z-value; χ2 , χ2 for heterogeneity; TAU, heterogeneity correction for random effects
model; I2 , percentage of heterogeneity due to study differences. See Formulas 1–10 for all parameters.
 C. Schoechlin, R.R. Engel / Archives of Clinical Neuropsychology 20 (2005) 727–744 737

Table 5
Fail-safe N and critical number of studies
Fail-safe N Critical number
Verbal intelligence 578 70
Executive functions 43 45
Fluency 182 45
Visual/figural problem solving 269 50
Abstract problem solving; working memory 2863 70
Simple attention 3592 120
Sustained attention 875 75
Focused attention 12393 120
Verbal memory 863 50
Figural memory 79 50

persons. Across all domains, pooled effect sizes d ranged from small (−.18) to moderate (−.54)
effects, in eight of the ten domains, difference in performance was significant.
χ2 values of homogeneity indicate that the differences between ADHD patients and controls
in verbal memory, focused attention, sustained attention, and abstract problem solving were
homogeneous across studies. This was not the case with simple attention and fluency, where
the difference between single studies (or test instruments) was obviously large, as indicated
by significant χ2 values. Table 4 also reports the new heterogeneity index I2 (Higgins &
Thompson, 2003), which corresponds to the percentage of total variation across studies due to
heterogeneity, i.e. the variation of effect sizes that is probably due to study differences and not
to chance (Higgins et al., 2003). For visual/verbal fluency, a high degree of heterogeneity was
found (65%), the second highest value was found for simple attention (56%). No heterogeneity
whatsoever was found for visual/figural problem solving, abstract problem solving/working
memory, sustained attention or verbal memory.

3.3. Fail-safe N

Fail-safe N is the number of unpublished, non-significant studies that could render the
significant result of meta-analysis non-significant. It serves as an indicator of the stability of
a meta-analytic result. In the present data, fail-safe N for those functional domains that show
effect sizes of d = 0.5 or above and an acceptable homogeneity across studies (verbal memory,
focused attention, sustained attention and abstract problem solving) reached well above 100.
The theoretical possibility of a falsification of our results by unpublished non-significant studies
is therefore highly unlikely (Table 5).

4. Discussion

The present meta-analysis of published empirical studies of neuropsychological perfor-

mance of ADHD patients summarizes the evidence on performance deficits of ADHD patients
compared to controls by analyzing 1675 patients from 24 studies. In eight of 10 neuropsycho-
738 C. Schoechlin, R.R. Engel / Archives of Clinical Neuropsychology 20 (2005) 727–744

logical functional domains ADHD patients showed significant performance deficits. In most
of the domains, the homogeneity between studies was very acceptable, indicating reliability of
the results. There are, however, numerical differences in the extent of deficits of ADHD patients
across the cognitive functions. Small effect sizes were found for the domains visual memory,
visual problem solving, and, surprisingly, for executive functions. In children, ADHD is sup-
posed to be primarily characterized by impaired function of the frontal lobe, which regulates
executive functions such as planning, inhibition and action (Barkley, Grodzinsky, & DuPaul,
1992; Spencer et al., 2002). Gallagher and Blader (2001), in a qualitative research review on
adults, also emphasizes the role of impaired executive functions. In this meta-analysis, the high-
est effect sizes for adults were found for verbal memory, focused attention, sustained attention
and abstract verbal problem solving with working memory. Simple alertness tasks, which are
highly dependent on basic psychomotor reaction time, were less impaired than more complex
attention tasks. These results fit well with clinical reports of high distractibility in patients,
which has been reported to occur in more complex attention tasks (Weiss & Murray, 2003).
It also supports recommendations in ADHD self-help books emphasizing the importance of
presenting knowledge in multimodal, visual, and auditory form and in a well-structured and
highly interesting way (e.g. Hallowell & Ratey, 2001), in order to arouse interest, avoid a
decrease of attention, and to enhance encoding and consolidating memory processes.
The results of the published studies may be confounded by the existence of diagnostic
subgroups, mainly the hyperactive versus the inattentive type. One hypothesis, advanced by
Barkley (1997), supports the view that (mainly) hyperactive patients perform worse on exec-
utive tasks such as delay of reaction, problem solving, flexibility, and sustained attention,
whereas the inattentive type would be more impaired in tasks of memory, focused attention,
and speed of information processing. Lockwood, Marcotte, and Stern (2001) review neurobi-
ological studies on subtyping children and state that results are inconsistent. They propose the
application of a neuropsychological model of attention (Cohen, 1993), and found in inattentive
type children more problems with selective attention and slow processing, whereas hyperactive
type children had more difficulties in executive and inhibitory functions. Results on adults’
subtyping are limited in number. Gansler et al. (1998) and Dinn, Robbins, Robbins, and Harris
(2002) refer to Petrides (1994) who proposes two separate frontal subsystems of frontal func-
tions, a dorsolateral prefrontal system and a inferior frontal/limbic system. Both systems are
supposed to generate specific functional deficits that are thought to be reflected by the hyper-
active versus the inattentive subtype. Barkley (1990, p. 89) postulates different neuroanatomic
loci and different neurotransmitter systems. According to Barkley, hyperactivity is connected
to dopaminergic dysfunction, whereas hypoactivity is a norepinephrine phenomenon. These
changes are to be accompanied by different neuropsychological profiles. Other authors, how-
ever, do not find any influence of subtyping in their data on cognitive functioning (Murphy,
Barkley, & Bush, 2001), or they emphasize the difficulty of correctly subtyping, especially in
adults (Fisher, 1998, p. 145). Moreover, the diagnostic relevance of hyperactivity has changed
over time (Wender, Wolf, & Wasserstein, 2001); it is probable that studies that were con-
ducted more recently include more patients of the inattentive type (Baumgaertel, Wolraich, &
Dietrich, 1995; Morgan, Hynd, Riccio, & Hall, 1996). In the present study, it was not possible
to evaluate the influence of subtypes, as information given in the publications was insufficient.
If neuropsychological profiles differ between subtypes, smaller effects will result by mix-
 C. Schoechlin, R.R. Engel / Archives of Clinical Neuropsychology 20 (2005) 727–744 739

ing subtypes. Our finding that effects are of moderate size and are highest in verbal memory
tasks, followed by focused attention, refers to the undifferentiated group of ADHD-patients. In
future, selection of patients for neuropsychological studies should be based on more detailed
clinical differentiation.
Another possible confounding factor is comorbidity. High comorbidity of ADHD with var-
ious psychiatric conditions is known in both children (Biederman et al., 1991) and adults
(Tzelepis, Schubiner, & Warbasse, 1995). Neuropsychological deficits are described and
empirically validated in a variety of psychiatric diseases. Most of the data have been pre-
sented for schizophrenia (Aleman, Hijman, de Haan, & Kahn, 1999; Heinrichs & Zakzanis,
1998; Johnson-Selfridge & Zalewski, 2001) and affective disorders (Burt, Zembar, &
Niederehe, 1995; Christensen, Griffiths, Mackinnon, & Jacomb, 1997; Lachner & Engel,
1994; Zakzanis, Leach, & Kaplan, 1998). Neuropsychological profiles of obsessive compul-
sive disorder (Harting & Markowitsch, 1997), post-traumatic stress disorder (Golier & Yehuda,
2002), and personality disorders, mainly borderline (O’Leary, 2000) and antisocial personal-
ities (Morgan & Lilienfeld, 2000), have also been investigated. Various deficits in memory,
attention, speed, fluency, and executive functions and other higher functions are described, with
effect sizes reaching d = 1 and higher, especially in depression and schizophrenia. Frequently,
mood and anxiety disorders as well as substance abuse and personality disorders co-occur with
ADHD, although there are still some questions about prevalence rates in adults (Marks et al.,
2001). These comorbid disorders could be responsible for neuropsychological deficits found
in ADHD patients. Taylor and Miller (2002) report a decline in neuropsychological perfor-
mance with increasing severity in diagnosis in their data of a rather large but heterogeneous
ADHD sample. However, in most of the studies that were included in this meta-analysis, major
psychiatric disorders were excluded. Murphy et al. (2001), as well as Seidman, Biederman,
Weber, Hatch, and Faraone (1998) and Biederman et al. (1993), also found no associations
between psychiatric comorbidity (mostly depression, OCD, anxiety) and neuropsychological
performance.
Our finding that higher executive functions, as measured by planning and flexibility tasks,
are not the strongest predictors of the distinction between ADHD and normal controls is
inconsistent with the current view that ADHD is the result of a deficit in behavioral inhibition
that secondarily leads to deficits in executive function (Barkley, 1997; Ossmann & Mulligan,
2003), or of a diminished capacity to switch between executive and inhibitory engagements
(Rubia et al., 2001). One possible explanation for this finding might be the hypothesis advanced
by Rubia et al. (2000) that ADHD symptomatology in children is partly caused by anomalies
of frontal-lobe maturation, which lose importance in adulthood. Another explanation could
be a population bias. It is probable that the patients included in adult studies represent only a
specific part of the former child samples, as in nearly all studies adult patients are intelligent
outpatients with a relatively good outcome. ADHD children with poor outcome, such as
criminality, chronic drug abuse or severe psychiatric disorders, are usually not included in
the studies analyzed here. These patients, who are excluded from the present studies possibly
show more problems on tasks measuring executive and inhibitory functions. This implies
that children without or with only minimal executive dysfunction have better prognosis than
children with clear executive dysfunction. A further explanation might be that the tests used in
the present studies might be subject to ceiling effects that mask differences in highly educated
740 C. Schoechlin, R.R. Engel / Archives of Clinical Neuropsychology 20 (2005) 727–744

samples. Besides, there is no commonly accepted definition on executive functions (Barkley,

2001). We chose to separate more basic aspects of executive functions such as working memory
and inhibition from higher level functioning. It might also that ADHD impacts some aspects
of executive functions more than others. If we had included all measures that are discussed as
measures of executive functioning, effect size would have reached a much higher value.
The question whether neuropsychological tests may serve as diagnostic tools cannot be
answered by this meta-analysis, as there is no way to compute sensitivity-specifity analyses.
Some authors of primary studies (Epstein, Conners, Sitarenious, & Erhardt, 1998; Katz, Wood,
Goldstein, Auchenbach, & Geckle, 1998; Lovejoy et al., 1999; Rapport, Van Voorhis, Tzelepis,
& Friedman, 2001; Walker, Shores, Trollor, Lee, & Sachdev, 2000) found in their sensitivity
analysis and/or discriminant analysis that about 70% of patients/controls are correctly classi-
fied, with rather high specifity and low sensitivity.
A meta-analysis is subject to methodological restrictions that need to be discussed. The most
obvious source of error is publication bias, which means that a number of (unpublished) studies
exist where no differences between ADHD patients and controls could be found. Fail-safe N
offers the possibility to estimate these chances. For the main results of this meta-analysis,
fail-safe N indicates that these results would remain significant even if a number of negative
results were to be published. Another problematic aspect is the variety of studies integrated
in this meta-analysis. Our effect sizes came from studies with various designs using different
approaches to diagnosis and a variety of neuropsychological test instruments. Nevertheless,
the integration of the effect sizes (between instruments within studies as well as between
studies within domains) showed sufficient homogeneity for nearly all calculations. Therefore,
it is quite clear that a significant deficit in neurocognitive functions is measurable in adult
ADHD patients. This deficit is mainly characterized by impaired verbal memory and low
scores on tasks requiring focused and/or sustained attention. Clinical evaluation of ADHD
patients should include a comprehensive test battery of standard tests, as single test measures
do not have sufficient diagnostic value. In future studies a promising approach might be to
focus on clinical variables of adults, especially hypo- versus hyperactivity, which may correlate
with different profiles of neuropsychological deficits.

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