ANCOVA in SPSS

Analyzing ANCOVA in SPSS

Journal of Attention Disorders
2017, Vol. 21(4) 316 –322
© The Author(s) 2014
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DOI: 10.1177/1087054714530782
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Article

ADHD is one of the most common childhood neuropsy-
chological disorders, causing difficulties in academic,
social, emotional, and behavioral domains (Barkley, 1990;
LeFever, Villers, & Morrow, 2002; Pelham & Bender,
1982). Due to these problems, it was previously assumed
that children with ADHD would have lower self-confi-
dence than those without (Hoza & Pelham, 1995;
Slomkowski, Klein, & Mannuzza, 1995; Treuting &
Hinshaw, 2001). However, researchers have recently dis-
covered that children and adults with ADHD actually
appear to have a positive illusory bias (PIB) toward them-
selves, meaning that they tend to rate themselves as higher
functioning in social and academic situations than teach-
ers, parents, and peers rate them (see Owens, Goldfine,
Evangelista, Hoza, & Kaiser, 2007, for review). Similarly,
when comparing objective measures of these domains with
their self-reports, ADHD children’s self-perception is usu-
ally an overestimation of their actual performance (Hoza
et al., 2000; Hoza et al., 2001; Manor et al., 2012). This
phenomenon has been found in both genders (Hoza et al.,
2004) and different ADHD subtypes (Swanson, Owens, &
Hinshaw, 2012), and does not seem to improve in children
who have received stimulant medication (Ialongo et al.,
1994) and extensive behavioral therapy (Hoza et al., 2004).

There is much dispute as to whether these positive illu-
sions are adaptive or maladaptive in ADHD. Some studies

hypothesize that this positive illusion may be a protective
strategy to help individuals persist during challenges and
overcome frequent failures or setbacks (Diener & Milich,
1997; Hoza et al., 2004; Taylor & Brown, 1988). Contrary
to this notion though, ADHD children with PIBs still have
decreased motivation, persistence, and overall task perfor-
mance compared with those without the disorder (Owens et
al., 2007). Similarly, others argue that the positive illusions
may be caused by cognitive immaturity (Milich, 1994), and
will lead to poorer social skills and increased risk for nega-
tive outcomes later in life (Colvin, Block, & Funder, 1995;
Hoza et al., 2004). Overestimation of competence in ADHD
children is associated with increased aggression and less
prosocial behavior (Hoza et al., 2010; Linnea, Hoza, &
Tomb, 2012). Interestingly, McQuade et al. (2011) found
that in ADHD-Combined Type and Hyperactive/Impulsive
Type children, working memory, attention, and cognitive
fluency were more likely to be impaired in children who

530782 JADXXX10.1177/1087054714530782Journal of Attention DisordersSteward et al.
research-article2014

1Austin Neuropsychology, PLLC, TX, USA
2University of Texas at Austin, TX, USA

Corresponding Author:
Melissa Bunner, Austin Neuropsychology, PLLC, 711 W. 38th St. F-2,
Austin, TX 78705, USA.
Email: mb@neuroaustin.com

Self-Awareness of Executive Functioning
Deficits in Adolescents With

ADHD

Kayla A. Steward1,2, Alexander Tan1,2, Lauren Delgaty1,
Mitzi M. Gonzales2, and Melissa Bunner1,2

Abstract
Objective: Children with ADHD lack self-awareness of their social and academic deficits, frequently rating themselves
more favorably than external sources. The purpose of the current study was to assess whether adolescents with ADHD
also hold a positive bias toward their executive functioning (EF). Method: Participants include 22 control and 35 ADHD
subjects, aged 11 to 16. Participants and their parents completed the Behavior Rating Inventory of Executive Functioning
(BRIEF) Self and Parent forms, respectively. Discrepancy scores were calculated for each domain by subtracting the
adolescents’ T-score from the parents’ T-score. Results: Discrepancy scores were significantly higher in the ADHD group
than controls within the Inhibit, Shift, Monitor, Emotional Control, Working Memory, and Plan/Organization domains (all
p < .05). Conclusion: As compared with controls, adolescents with ADHD tend to endorse fewer EF difficulties than what parents report. This is the first study to demonstrate that those with ADHD may overestimate their EF ability. ( J. of Att. Dis. 2017; 21(4) 316-322)

Keywords
adolescent ADHD, BRIEF, executive function, self-report

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Steward et al. 317

had positive illusions about their social competency relative
to those without a positive bias.

Despite the controversial question of whether PIBs are
beneficial or maladaptive, the fact that it exists in ADHD
children with regard to social, behavioral, and academic
functioning has been well documented. However, it has not
been looked at with regard to executive functioning (EF)
even though this is a major area of weakness in those with
the disorder (Barkley, 1997; Nigg, 2006). EF is a neuropsy-
chological term that refers to a variety of higher-order
thinking skills, such as planning, organization, attention,
working memory, and inhibition (Martel, Nikolas, & Nigg,
2007). Welsh and Pennington (1989, p. 201) defined the
construct as “the ability to maintain an appropriate problem
set for attainment of future goals.” EF is an important skill
for complex human behavior, and it has been found that
ADHD children with impaired EF have poorer academic
achievement and peer relationships (Biederman et al., 2004;
Diamantopoulou, Rydell, Thorell, & Bohlin, 2007). If chil-
dren and adolescents with ADHD have an inflated view of
their EF skills, it could limit their ability to insightfully self-
regulate their behavior and might hinder their receptiveness
to behavioral interventions to improve their EF.

The current study seeks to fill gaps in the ADHD self-
perception and EF literature. This will be the first study to
examine how ADHD children view their EF ability in rela-
tion to their parents’ estimates. We hypothesize that adoles-
cents with ADHD will overestimate their EF ability more so
than controls when comparing their self-reports with parent
ratings.

Method

Participants

Participants between the ages of 11 and 16 years were
recruited using archival data from a private neuropsychol-
ogy clinic. In addition, a portion of the control participants
were recruited from the greater community after contacting
the clinic and completing a telephone screening to deter-
mine initial eligibility. Participants were included if they
were free of neurological disease (e.g., epilepsy, clinically
significant traumatic brain injury), major psychiatric illness
(e.g., depression, anxiety, bipolar disorder), and develop-
mental disorder (e.g., autism, mental retardation). To obtain
a sufficient sample size, participants with learning disabili-
ties (LDs) were not excluded from participation. LD inclu-
sion was limited to those with dyslexia (n = 9), dyscalcula
(n = 2), dysgraphia (n = 15), and LD−not otherwise speci-
fied (n = 4). For all participants, board-certified neuropsy-
chologists used information from patient and parent
interviews, developmental and family history question-
naires, and an extensive cognitive assessment battery to
make diagnoses of ADHD and any other disorders using the
Diagnostic and Statistical Manual of Mental Disorders

(4th ed.; DSM-IV; American Psychiatric Association, 1994)
diagnostic criteria.

After obtaining written informed consent, the final sam-
ple consisted of 35 adolescents with diagnoses of ADHD
and 22 without an ADHD diagnosis. Of the ADHD children,
26 were diagnosed with Primary Inattentive subtype, 7 were
diagnosed with Combined subtype, and 2 were diagnosed
with ADHD−not otherwise specified. According to partici-
pants’ self-report, the ethnic distribution of the sample was
as follows: 86% Caucasian (n = 49), 4% Hispanic (n = 2),
2% African American (n = 1), and 9% Other/did not specify
(n = 5). All participants had a full-scale IQ (FSIQ) greater
than 80, as measured by the Weschsler Intelligence Scale for
Children-IV (WISC-IV) or the Weschler Abbreviated
Intelligence Scale-II (WASI-II; Wechsler, 2003, 2011).

Materials

The parent and self-report forms of the Behavior Rating
Inventory of Executive Functioning (BRIEF; Gioia, Isquith,
Guy, & Kenworthy, 2000) were administered during the
clinical interview or delivered through the mail and returned
at the time of the neuropsychology testing appointment.
The BRIEF parent form (BRIEF-P) is an 86-item question-
naire that parents fill out based on their children’s behavior
over the past 6 months. Each question is a short statement
such as “Has a short attention span,” “Makes careless
errors,” or “Reacts more strongly to situations than other
children,” and the parent has to mark “never,” “sometimes,”
or “always.” The BRIEF self-report (BRIEF-SR) is simi-
larly designed, with 80 items that the child fills out about
their own behavior over the past 6 months. According to the
BRIEF manual, a fifth-grade reading level is sufficient to
complete the form. To ensure a thorough understanding of
the instructions and BRIEF questions, BRIEF-SRs were
completed in the presence of examiner or guardian. For
both forms, the BRIEF has been standardized and normed
for the use of boys and girls within the age range of our
sample, and for children with a variety of clinical diagnoses
including ADHD. In accordance with standard procedures,
normative data were separated by gender and age to derive
T-scores for the clinical scales (Inhibit, Shift, Emotional
Control, Working Memory, Plan/Organize, Organization
of Materials, and Monitor). These scales were combined
to form a Behavioral Regulation Index (BRI) and
Metacognition Index (MI), as well as a composite summary
score called the Global Executive Composite (GEC). With
the BRIEF, higher T-scores indicate more subjective
impairment.

According to Gioia et al. (2000), the BRIEF has an inter-
nal consistency ranging from .80 to .98, as assessed using
Cronbach’s alpha. Test−retest reliability statistics range
from .79 to .88 during a 2-week period. The BRIEF is also
reported to have good discriminant and convergent validity
with similar measures (McCandless & O’Laughlin, 2007).

318 Journal of Attention Disorders 21(4)

A discrepancy score for each clinical scale was calcu-
lated by subtracting the BRIEF-SR T-scores from the
BRIEF-P T-scores for each participant. Positive scores indi-
cate that the child reported fewer difficulties than parent
reports. A negative discrepancy score signifies that the
child reported more impairment than parent ratings. This
method of obtaining discrepancy scores has been com-
monly used when studying PIBs in an ADHD population
(Hoza et al., 2004; Hoza, Pelham, Dobbs, Owens, & Pillow,
2002; Owens et al., 2007).

Statistical Analyses

Group differences in the demographic variables were exam-
ined with non-parametric chi-square or independent sam-
ples t tests. The normality of standardized residuals for the
dependent variables was tested using Shapiro−Wilks tests
(all p > .05). Bootstrapping procedures were utilized when
parametric assumptions about the underlying distribution
were not fulfilled (model residuals with Shapiro−Wilks p < .05). Group differences in the dependent variables were assessed using an analysis of covariance (ANCOVA), with gender used as a covariate. As a follow-up analysis, ADHD medication (yes/no), the presence of a learning disorder (yes/no), and WASI-II/WISC-IV FSIQ were added as addi-
tional covariates in the ANCOVA. To control for multiple
comparisons, a Sidak-adjusted alpha level of p < .027 was used.

Results

The demographic characteristics of the study sample are
shown in Table 1. Ethnicity distribution, χ2(4, N = 57) =
2.642, p = .62, and LD distribution, χ2(4, N = 57) = .695,
p = .41, in the ADHD and control groups was comparable.
There were also no significant differences in age, educa-
tion, and intelligence between the two groups. The only
variable that significantly differed between the two groups
was gender, χ2(1, N = 57) = 6.350, p = .01.

Discrepancy score group differences are shown in Figure 1
and Table 2. In the overall ANCOVA model (Table 3), dis-
crepancy scores for the BRIEF Inhibit, Shift, Emotional

Control, Monitor, Working Memory, Plan/Organization,
BRI, MI, and GEC domains were all significantly more
positive in the ADHD group as compared with the control
group (p < .027). ADHD had a significant main effect on the Inhibit, Monitor, Working Memory, Plan/Organize, and GEC domains (p < .027). Gender contributed significantly to the Shift and BRI domains (p < .027), with males dis- playing greater discrepancy scores than females. Group dif- ferences in the discrepancy scores for the BRIEF Organization of Materials domain did not reach statistical significance (p > .027).

These relationships remained unchanged even after
additional adjustment for any potential effects of ADHD
medication, the presence of a learning disorder, or FSIQ.

Discussion

This study extends the literature on PIB in ADHD by being
the first to examine self-perception of EF. The results dem-
onstrate that, in comparison with age-matched controls,
adolescents with ADHD tend to over-inflate abilities rela-
tive to their parents’ reports within the domains of Working
Memory, Emotional Control, Attention and Behavior
Shifting, Inhibition of Behavior, Self-Monitoring, and
Planning and Organization of Future Events. Adolescents
with ADHD also displayed greater discrepancy scores on
the metacognition, behavioral regulation, and GEC
domains. In contrast to large parent−child discrepancies in
the ADHD group, the control group had only negligible or
slightly negative discrepancy scores, meaning that these
children rated themselves the same as or slightly more
impaired than what parents reported.

These findings support previous literature that has docu-
mented a PIB in ADHD children. Other studies have used
similar methodology and found that those with ADHD
overestimate academic and social functioning when com-
pared with mother, father, teacher, and peer reports, as well
as objective measures of these domains (Evangelista,
Owens, Golden, & Pelham, 2008; Hoza et al., 2004; Hoza
et al., 2002; Owens & Hoza, 2003). It is important to note
that the subjective nature of the parents’ reports elicit the
possibility that the large discrepancy scores may be in fact

Table 1. Participants’ Demographic Characteristics.

ADHD (n = 35) Control (n = 22) p value

Male/female (n) 26/9 9/13 .01*
Age (year) 12.91 ± 1.5 13.64 ± 1.6 .09
Education level (year) 7.49 ± 1.5 8.23 ± 1.8 .1

0

FSIQ 107.29 ± 14.0 106.82 ± 14.5 .90
On ADHD medication at time of testing (n) 12 1 —
LD diagnosis 15 7 .41

Note. Data are M ± SD; FSIQ = full-scale IQ; LD = learning disability.
*Significant at p < .05.

Steward et al. 319

due to a tendency for parents of ADHD children to rate their
children in an excessively negative manner. We attempted
to control for this by excluding participants who had an
elevated Negativity validity scale on the BRIEF-P forms.
To definitively rule out the potential for inaccurate parent
reports, future studies should compare child self-reports
with objective measures of EF.

One of the strengths of this study is that it incorporated
both genders and assessed the contribution of gender to
self-awareness of deficits in those with ADHD. The major-
ity of previous studies have failed to include females, and
when they did, gender effects were not explored (Owens &
Hoza, 2003). The current study used gender as a covariate
and found that males are more likely to overestimate their
ability to shift their attention and behavior than females. As
the current study had significantly different gender ratios
between the ADHD and control groups, future studies
should incorporate more gender-balanced groups to further
assess the impact that gender may have on self-perception
of EF in an ADHD population.

Of note, discrepancy scores in the Organization of
Materials domain were not significantly different between
groups. There are several possible reasons that this was the
only domain to not reach significance. First, this domain
assesses the organization of the child’s environment, such
as the level of disorganization of their schoolbags and how
frequently they misplace items like homework. As these are
more external behaviors as opposed to the Plan/Organize
domain, which assesses organization on a more cognitive
level, it is probable that these difficulties are brought to the
child’s attention more frequently. This would likely create a
better sense of self-awareness of this particular area of dif-
ficulty. Secondly, this domain had a low number of ques-
tions in the parent and self-report forms; therefore, there is

-5

0
5

10

15

20

ADHD

Control

Figure 1. Mean discrepancy scores for each BRIEF domain.
Note. Discrepancy scores were calculated by subtracting self-reported BRIEF T-scores from the parent T-scores. As larger T-scores indicate more
subjective impairment, positive discrepancy scores indicate that the parent reported more difficulties than the child did and vice versa. All domain
discrepancy scores, except Organization of Materials, were significantly (p < .027) more positive in the ADHD adolescents compared with controls. BRIEF = Behavior Rating Inventory of Executive Functioning.

Table 2. Discrepancy Scores for the BRIEF Questionnaire.

ADHD (n = 35) Control (n = 22)

Inhibit 11.23 ± 14.8 −2.54 ± 11.7
Shift 6.31 ± 16.8 0.72 ± 17.0
Emotional Control 4.45 ± 15.2 −3.09 ± 15.2
Monitor 17.06 ± 16.8 1.91 ± 15.8
Working Memory 14.29 ± 13.4 1.41 ± 16.2
Plan/Organize 13.5 ± 14.3 −0.64 ± 14.0
Organization of

Materials
5.54 ± 13.1 3.27 ± 12.7

Behavior
Regulation Index

9.00 ± 15.0 −1.82 ± 14.8

Metacognition
Index

11.54 ± 15.9 −0.46 ± 15.43

Global Executive
Composite

12.5 ± 15.6 −0.91 ± 15.7

Note. Data are M ± SD. BRIEF = Behavior Rating Inventory of Executive
Functioning.

320 Journal of Attention Disorders 21(4)

a more restricted range of possible total scores. This makes
it more difficult for a difference in discrepancy scores to
become statistically significant, although there was a trend
in the predicted direction (see Figure 1).

Despite consistent evidence that children with ADHD lack
self-awareness of their deficits, it is still highly debated as to
why ADHD children overestimate their ability in so many
areas. Owens et al. (2007) discussed four potential explana-
tions for the PIB seen in ADHD children: neuropsychological
and frontal lobe deficits leading to mild anosognosia (Owens
& Hoza, 2003), an overall cognitive immaturity in ADHD
children (Milich, 1994), ignorance of incompetence in the self
and others (Hoza et al., 2002), and self-protection from per-
sonal failure (Ohan & Johnston, 2002). Very few studies have
directly tested any of these hypotheses in relation to ADHD
PIBs though, and this area of research remains divided on
actual causes for the positive biases seen in children. It is pos-
sible that these hypotheses are not mutually exclusive, and
one or more of them could contribute to the impaired self-
awareness of children and adolescents with ADHD.

There are many strengths to this study that allow it to
uniquely contribute to the field, such as the inclusion of
both genders and ADHD subtypes and the exclusion of
comorbid psychiatric and behavioral disorders; however,
there are also several limitations. The current study used a
relatively small sample size that was largely homogeneous
in terms of ethnicity. Future researchers should seek to
include a more characteristic and larger sample, as well as
expand to other age ranges to test developmental aspects of
EF PIB. Another limitation was the source of the control
group as some participants were selected from an archival
database at a private neuropsychology clinic. These partici-
pants had been previously referred to the clinic for suspi-
cions of neuropsychological impairment. Thus, it is possible
that the clinic-referred non-ADHD group had more impair-
ment than a control group of children not referred for clini-
cal services. In an attempt to lessen the impact from this
limitation, strict exclusion criteria was applied and only

those with no diagnoses of psychiatric, medical, neurologic,
and developmental disorders were enrolled. To further
address this limitation, control participants were addition-
ally recruited from the general community and required to
undergo a telephone screening prior to participation to rule
out suspicions of ADHD and other exclusionary criteria.

The findings of this study support the ADHD PIB
research and expand the number of documented domains
that ADHD children hold positive illusions about (Owens et
al., 2007). These results hold significance not only for other
researchers in the field, but also for caregivers and clini-
cians who provide EF treatment to adolescents with ADHD.
In populations with neurological injuries and psychiatric
disorders, impaired self-awareness has been found to lead
to low motivation and participation in rehabilitation efforts
(Katz, Fleming, Keren, Lightbody, & Hartman-Maeir,
2002; Lam, McMahon, Priddy, & Gehred-Schultz, 1988).
Similarly, if ADHD children do not believe they suffer
from EF impairment, they may be less receptive to treat-
ment for these deficits. Clinicians should be aware that an
EF PIB might exist in ADHD children and incorporate this
knowledge when providing therapy.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research,
authorship, and/or publication of this article.

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Table 3. Results From ANCOVA Model Examining the Effects of ADHD and Gender on BRIEF Domain Discrepancy Scores.

Overall model (F value) Overall model (p value) ADHD (p value) Gender (p value)

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*Significant at p < .027. BRIEF = Behavior Rating Inventory of Executive Functioning.

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Author Biographies

Kayla A. Steward, BS, is a psychometrist at Austin Neuropsychology,
PLLC, and a research assistant at the University of Texas at Austin.

Alexander Tan, BA, is a psychometrist at Austin Neuropsychology,
PLLC, and a research assistant at the University of Texas at
Austin.

Lauren Delgaty, MA, is a former psychometrist at Austin
Neuropsychology, PLLC, and is now employed in North
Carolina.

Mitzi M. Gonzales, MA, is a doctoral candidate in clinical psy-
chology at the University of Texas at Austin.

Melissa Bunner, PhD, is a neuropsychologist at Austin
Neuropsychology, PLLC.