Journal of Attention Disorders

http://jad.sagepub.com Do Attention Deficits Influence IQ Assessment in Children and Adolescents With ADHD?
Jens Richardt M. Jepsen, Birgitte Fagerlund and Erik Lykke Mortensen J Atten Disord 2009; 12; 551 originally published online Sep 24, 2008; DOI: 10.1177/1087054708322996 The online version of this article can be found at: http://jad.sagepub.com/cgi/content/abstract/12/6/551

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Do Attention Deficits Influence IQ Assessment in Children and Adolescents With ADHD?

Jens Richardt M. Jepsen Birgitte Fagerlund
Copenhagen University Hospital

Journal of Attention Disorders Volume 12 Number 6 May 2009 551-562 2009 SAGE Publications 0.1177/1087054708322996 http://jad.sagepub.com hosted at http://online.sagepub.com

Erik Lykke Mortensen

University of Copenhagen
Objective: To characterize the relationship between IQ and attention deficits in children with ADHD and to estimate the inattention-related mean influence on IQ when children are tested before stimulant drug treatment has been initiated. Method: Studies of various methodologies are reviewed. Results: Correlation studies show mostly weak associations between IQ scores and attention deficits. Meta-analyses report the average short-term stimulant treatment effect on IQ in children with ADHD to be 2 to 7 IQ points. Conclusion: The associations between IQ and attention deficits in ADHD are generally modest, with the mean influence on IQ probably amounting to 2 to 5 IQ points. This may serve as a benchmark when clinicians interpret the validity of IQ in this clinical population. (J. of Att. Dis. 2009; 12(6) 551-562) Keywords: attention deficits; IQ; ADHD; intelligence

linical psychological assessment of children and adolescents, in most cases, includes a measure of general intelligence, usually one of the Wechsler Intelligence Scales for Children (WISC). There are typically several reasons for assessing the global level of intellectual functioning: IQ is important when distinguishing between mental retardation and ADHD as well as in the diagnosis of learning disabilities. During administration of a Wechsler IQ test, the psychologist observes the childs behavior to evaluate the validity of the derived IQ scores and to detect symptoms of psychopathology. While taking the test, children with ADHD or other neuropsychiatric disorders may behave restlessly, fail to pay close attention to details, get up from the seat, answer questions in an impulsive manner, become easily distracted, and quickly lose interest in the test activity. If such inattentive and impulsivehyperactive behaviors are observed, clinical psychologists usually help the child to stay focused on the test materials by redirecting behavior, repeating instructions, and praising the child more frequently without violating the standardized procedures for administration of the WISC version being used. In spite of these procedures, clinicians often fear that the childs true intellectual level will be underestimated and hesitate to consider low

Wechsler Full Scale IQ (FSIQ) scores an accurate estimate of the childs intellectual ability. In extreme cases (e.g., a child sitting under the table during testing), all clinicians would probably agree that the derived IQ scores must be assumed to be significantly influenced by the childs inattention. However, such extreme behavior is rare, and in cases of less clear-cut suboptimal test-taking behavior, it can be difficult to assess the impact of such behaviors on the observed IQ scores. Intrasession validity is a term that has been used to describe the strength of associations between measures of test-taking behaviors and the obtained formal test scores (Glutting, Oakland, & Watkins, 1996). Based on a meta-analysis, a mean correlation of .34 has been observed between problematic test-taking behaviors and the IQ scores obtained during the same test session (Glutting et al., 1996). This means that the negative test behaviors and pathological symptoms of children are only modestly associated with the scores that they earn on tests of general intelligence.
Authors Note: Please address correspondence to Jens Richardt M. Jepsen, Copenhagen University Hospital, Child and Adolescent Psychiatric Center Bispebjerg, Bispebjerg Bakke 23, 2400 Copenhagen NV, Denmark; e-mail: jrj01@bbh.regionh.dk.

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552 Journal of Attention Disorders

ADHD is a mental health problem characterized by a persistent pattern of inattention and/or hyperactivity impulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development and that interferes with appropriate social, academic, or occupational functioning (American Psychiatric Association, 1994). Children with ADHD have been found to display significantly higher mean levels of aberrant test behaviors (e.g., inattention ) during the administration of the WISC-III than normal controls matched on background characteristics and IQ scores (Glutting, Robins, & Lancey, 1997). In line with the idea that test observations may serve as cross-checks on the validity of the childrens IQ scores, Glutting and colleagues (1997) recommended that clinicians pay attention to test behaviors because the very same inattentive dispositions that affect the adjustment and development of children with ADHD are also likely to affect the scores that they obtain on individually administered IQ tests. In addition, Gordon, Barkley, and Lovett (2006) proposed that for a child with symptoms of ADHD, the derived test scores may reflect actual competence more accurately if the test were administered while the child is medicated. In spite of limited research, Kaufman (1994) suggested the WISC-III Freedom from Distractibility Index (FDI) and the Processing Speed Index (PSI) as potential WISC-III validity scales thought to be useful for evaluating the validity of obtained IQ. Kaufman has recommended interpreting these scales in the context of observed behavior during testing and suggested that the observed IQ scores may underestimate the level of verbal intelligence if attention and motivational problems are observed during administration of several of the verbal subtests and if the childs scores are significantly lower on the FDI than on the Verbal Comprehension Index (VCI). In addition, Kaufman (1994) proposed that the nonverbal estimates of intellectual functioning may be considered invalid if attention or motivation problems are observed during administration of performance subtests and the child obtains a significantly lower score on the PSI than on Perceptual Organization Index (POI). Kaufmans method of evaluating validity appears to be based on the assumption that attention problems are reliably reflected in FDI scores. This may, however, not be the case as only 28% of a large sample of children with ADHD obtained FDI scores significantly lower than their VCI scores (Reinecke, Beebe, & Stein, 1999). This percentage is equivalent to the result of a later study that found 25% of children with ADHD to have significantly lower FDI scores than VCI scores (Egeland, Sundberg, Andreassen, & Stensli, 2006). Because large proportions of children with ADHD do not show selective deficits on

FDI, this index does not appear particularly sensitive to the severe attention deficits associated with ADHD. In addition, a meta-analysis did not find the PSI or the FDI significantly more sensitive to ADHD than FSIQ (Frazier, Demaree, & Youngstrom, 2004). These results seriously question the basic assumption of Kaufmans validity assessment method. Although it is an interesting idea, at this point it is cannot be considered sound clinical practice. Instead, we propose that clinicians primarily assess the validity of IQ scores in relation to the severity of the symptoms observed during test administration.

Purpose and Scope

The aim of this article is to characterize the strength of the relationship between observed IQ scores and the attention deficits in children and adolescents with ADHD and to estimate potential influence on observed IQ scores when tests of intelligence are administered before initiation of stimulant drug treatment. The question about the validity of an obtained IQ score as an accurate estimate of a childs true level of intelligence, in case of severe attention problems, may have much broader clinical relevance beyond ADHD children and adolescents because attention deficits are also associated with other neuropsychiatric disorders like childhood and adolescent schizophrenia and other psychoses (Brickman et al., 2004; Fagerlund, Pagsberg, & Hemmingsen, 2006). Nevertheless, the present article focuses on studies of the relationship between IQ and attention and behavioral deficits in ADHD: First, we report from a meta-analysis of the size of IQ deficits observed in children and adolescents with ADHD. Second, we describe a study of the correlation between IQ and behavioral symptoms of ADHD in a sample of children with a high prevalence of ADHD. Third, we report studies on the relationships between IQ and laboratory measures of attention deficits in samples comprised exclusively of children with ADHD or with a substantial prevalence of ADHD. Fourth, meta-analytic studies of the short-term stimulant treatment effects on IQ scores and inattention symptoms are reviewed. This part is based on the assumption that if IQ increases in children with ADHD after short-term medical stimulant treatment, this IQ change may be an indirect indicator of a negative impact from the pretreatment inattention and impulsivehyperactive symptoms on IQ scores. Fifth, we report results from a study on the relation between ADHD and IQ in monozygotic and ADHD-discordant twins. After reviewing these studies, we briefly discuss the attention deficits in ADHD and the question regarding which Wechsler subtests may be most vulnerable to their influence.

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Do Children and Adolescents With ADHD Obtain Lower IQ Scores Than Healthy Children?
If attention deficits and impulsivehyperactive behaviors influence IQ scores in children with ADHD, lower mean IQ scores are expected in groups of children and adolescents with ADHD compared to healthy age- and sex-matched control groups. A meta-analysis by Frazier et al. (2004) identified 123 studies comparing neuropsychological functions in samples with ADHD and in healthy control groups. The vast majority of the studies included children and adolescents with a sample mean age less than 18 years. The IQ scores were primarily assessed with either complete Wechsler Scales or an incomplete, shorter form of these scales. The effect sizes of FSIQ, Verbal IQ (VIQ), and Performance IQ (PIQ) were estimated using Cohens d. The weighted mean d for FSIQ was .61 (for VIQ, d = .67 and for PIQ, d = .58). With respect to the FSIQ, only 63 of the 137 comparisons between an ADHD group and a healthy control group found statistically significant group differences. When IQ differences were observed, all but one study confirmed a lower FSIQ in the ADHD group than in the control group. On average, the ADHD groups performed 9.15 FSIQ points less than the control groups (assuming a theoretical standard deviation of 15). The mean effect sizes for FSIQ were unrelated to differences in the average age of participants, to gender differences in the samples, and to the type of intelligence test used. Nevertheless, the effect sizes for FSIQ differed significantly as a function of the way the FSIQ was derived. The unweighted mean effect size was .73 when FSIQ was based on the complete tests, which was significantly larger than effect size based on selected subtests (d = .38) or a single subtest (d = .45; Frazier et al., 2004). This difference may be because of the use of less sensitive subtests in short-form procedures, or it may be related to the longer testing times associated with administration of the full assessment battery (Frazier et al., 2004). In addition, short forms tend to have lower reliability than do FSIQ based on all subtests, and this may further attenuate observed effect sizes (Frazier et al., 2004). The observed FSIQ deficits may indicate that ADHD is characterized by a mild global intellectual inefficiency or by multiple specific cognitive deficits that affect global intellectual functioning. The deficits, however, may also reflect test-taking differences between groups (Frazier et al., 2004), such as an inattentionrelated influence on intelligence assessments. A few group comparisons included in this large meta-analysis may not have been matched with respect to age or gender

composition, but this possible limitation may have smaller impact on comparisons of age-corrected scores, such as IQs, than on non-age-corrected scores. If it is assumed that deficits of attention in ADHD solely caused this FSIQ deficit through suboptimal testtaking behavior, this influence would typically correspond to 9.15 IQ points. Nevertheless, only about half of the case-control studies included in the meta-analysis detected significant FSIQ deficits in ADHD samples, and the question why attention deficits do not consistently lead to IQ deficits remains equivocal. It is also possible that the observed FSIQ and the ADHD-related suboptimal test-taking behavior may both be influenced by a third factor.

Do IQ Scores Correlate With the Severity of Hyperactivity and Inattention in ADHD?

This and the following section review studies examining the strength of correlations between IQ scores and inattention and impulsivityhyperactivity problems as measured by questionnaires or objective neuropsychological tests in clinical samples of children and adolescents with ADHD. In this context, it is important to keep in mind that the size of observed bivariate correlation coefficients not only depends on the true association between the two variables but also on reliability of measurement. Measurement errors are by definition random and will, therefore, attenuate observed correlations (Jensen, 1998). Nevertheless, it is possible to correct the observed correlations for attenuation by dividing the obtained raw correlation coefficients by the geometric mean of the reliability estimates of the two measures being correlated (Jensen, 1998). Although IQ scores usually have high reliability, this is not necessarily the case for measures of attention deficits and impulsivity hyperactivity problems. Consequently, we have used published testretest reliability estimates of such measures to correct the observed correlations for attenuation (r) to obtain more estimates of the strength of the relationships between IQ and the reliable variance in measures of inattention and impulsivityhyperactivity problems. Naglieri, Goldstein, Delauder, and Schwebach (2005) recently examined the associations between IQ scores and behavioral ratings of inattention and impulsive hyperactive behaviors. The clinical sample included 117 children between the ages of 6 and 16 years with different Diagnostic and Statistical Manual of Mental DisordersFourth Edition (DSM-IV; American Psychiatric Association, 1994) diagnoses, of whom 45% had a primary

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554 Journal of Attention Disorders

Table 1 Correlations Between IQ Scores and Behavioral/Attention Measures

Attention and Behavioral Measures Cognitive problems/inattentionb DSM-IV totalb.11 Cognitive problems/inattentionc DSM-IV totalc.20 GDS efficiency ratiod Correlation With Full Scale IQ (r)a .15 .09 .31** (.46) .15 .16*** (.21) Correlation With Verbal IQ (r)a .14 .07 .31** (46.) .13 .10* (.13) Correlation With Performance IQ (r)a .11 .23 .47 (Conners, 2000) and .96, .95, .91 (Wechsler, 1992) .60 (Gordon & Mettelman, 1988) and .95, .95, .89 (Tuma & Appelbaum, 1980) .72 (Gordon & Mettelman, 1988) .84 (Gordon & Mettelman, 1988) .67 (Gordon & Mettelman, 1988) .85 (Gordon & Mettelman, 1988) .86 (Leark, Wallace, & Fitzgerald, 2004) and .96, .95, .91 (Wechsler, 1992) TestRetest Reliability Estimates (reference)

Reference Naglieri et al. (2005)

Aylward et al. (1997)

.17**** (.23)

Chae (1999)

GDS vigilance correctd GDS vigilance commissionsd GDS distractibility correctd GDS distractibility commissionsd TOVA omissionse

.25**** (.30) .14**** (.16) .21**** (.26) .18**** (.20) .44* (.48)

.21**** (.25) .09** (.10) .17**** (.21) .10** (.11) .20

.22**** (.27) .13**** (.15) .23**** (.30) .20*** (.23) .46* (.52)

Naglieri et al. (2005)

TOVA commissionse TOVA response time5 TOVA variabilitye Attentivenessf Risk takingf Hitsf Omissionsf Commissionsf

.01 .16 .25 .10 .05 .13 .13 .01

.00 .22 .27 .04 .03 .05 .05 .07

.51 .14 .16 .14 .10 .25** .25** .02

a. The p value and the correlation corrected for attenuation (r) are only reported when an observed correlation is statistically significant. b. From Conners Parent Rating ScalesRevised Long Form. c. From Conners Teacher Rating ScalesRevised Long Form. d. From the Gordon Diagnostic System. e. From Test of Variables of Attention. f. From Conners Continuous Performance Test. *p .05. **p .01. ***p .001. ****p .0001.

diagnosis of ADHD and 36% a secondary diagnosis of ADHD. Different measures were administered, including WISC-III, Conners Parent Rating ScalesRevised Long Form (CPRS-R:L), and Conners Teacher Rating ScaleRevised Long Form (CTRS-R:L; Conners, 2000). As shown in Table 1, the parent ratings of the Cognitive Problems/Inattention subscale did not correlate significantly with any of the three WISC-III IQ scores. Parent ratings on the DSM-IV subscale of ADHD symptoms also did not correlate significantly with the IQ scores. The teacher ratings on the Cognitive Problems/Inattention subscale correlated significantly with FSIQ and VIQ but not with PIQ. The testretest reliability of the Cognitive Problems/Inattention subscale from CTRS-R:L is somewhat low, so the differences between observed correlations and the correlations corrected for attenuation increase proportionally. Finally, the teacher ratings on the DSM-IV subscale of symptoms of ADHD did not correlate significantly with IQ scores. Although the childrens behavior was not rated during the IQ assessment, the statistically insignificant and low correlations between IQ scores and the parent and teacher ratings of ADHD behaviors on the

DSM-IV subscale do not point to a substantial association between IQ test performance and the severity of inattention and impulsivityhyperactivity symptoms. The significant and larger correlations between the FSIQ as well as the VIQ and the teacher ratings on the Cognitive Problems/Inattention subscale may point to a significant relationship between performance on IQ tests and attention deficits. However, these two correlations may, to some degree, be explained by the inclusion of items with content of academic functioning (reading and spelling ability) in this subscale.

Do IQ Scores Correlate With Laboratory Measures of Attention in Children and Adolescents With ADHD?
Continuous performance tests (CPT) are used in many studies of ADHD in children and adolescents. The CPT is characterized as the only test paradigm directly assessing sustained attention and impulse control known to be deficient in ADHD (Gordon et al., 2006). Even though

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the clinically diagnostic value of a CPT may be questioned (Nichols & Waschbusch, 2004), the CPT paradigm is considered to provide useful information about ADHD abnormalities in sustained attention (Swanson et al., 1998). Many CPT variants exist, and they may impose different information-processing demands on the child (Corkum & Siegel, 1993; Riccio, Reynolds, & Lowe, 2001). This part of the article summarizes results from studies that examined the strength of the correlations between IQ and the CPT measures of attention functioning in samples of children and adolescents with ADHD or in samples with a high incidence of an attention disorder. Aylward, Gordon, and Verhulst (1997) examined the relationship between a CPT (Gordon Diagnostic System; GDS) and IQ (based on the WISC-III, the WISC-R, and the WPPSI-R) in a very large clinical sample of 1,280 children between 5 and 17 years of age. The children were most frequently referred because of suspected ADHD or learning disabilities. Eighty percent of the sample met the criteria for ADD/ADD-H (DSM-III-R; American Psychiatric Association, 1987), and the comorbidity rate was 50%, typically of ADD/ADD-H and reading disability. The children were most often tested with the WISC-R or the WISC-III; consequently, the testretest estimates of the WISC-R are used in the calculation of the correlations corrected for attenuation (r). The GDS CPT contains a Delay Task, a Vigilance Task, and a Distractibility Task, from which five outcome variables were included in this part of the study. As shown in Table 1, all five GDS CPT outcome scores correlated significantly with the IQ scores. Based on the total sample, the correlations between the GDS CPT outcome scores and IQ scores ranged from a minimum of .09 to a maximum of .25. The correlations suggest that variation in inattention may account for a maximum of about 6% of the variation in FSIQ, and vice versa, in children with ADHD. Chae (1999) assessed the relationship between WISCIII IQ scores and the severity of attention deficits as measured with the Test of Variables of Attention (TOVA; Leark, Dupuy, Greenberg, Corman, & Kindschi, 1996) in a sample of 40 children with ADHD between 6 and 16 years of age. Twelve correlations between the four TOVA outcome measures (omission errors, commission errors, mean response time, and response time variability) and the three WISC-III IQ scores (FSIQ, VIQ, and PIQ) were calculated, and two statistically significant correlations were found. As shown in Table 1, the omission errors correlated significantly with FSIQ and PIQ but not with VIQ. Neither the FSIQ, VIQ, or PIQ scores correlated significantly with commission errors, mean response time, or response time variability. All correlations were negative, such that higher IQ scores were associated with fewer

errors of omission and commission, faster mean response time, and smaller response time variability in the TOVA, which is in the expected direction. Ignoring the level of statistical significance, as the sample size was small, most but not all correlations can be characterized as weak and may point to a large degree of functional independence between IQ and attention functioning in ADHD. Nevertheless, FSIQ and PIQ may be more related to inattention in ADHD than is VIQ. The two significant correlations suggest that variation in inattention may account for 19% of the variation in FSIQ and 21% of the variation in PIQ, and vice versa, in children with ADHD. These associations may be difficult to interpret, because TOVA omission errors did not differentiate between children and adolescents with ADHD and healthy controls (Schatz, Ballantyne, & Trauner, 2001). Nevertheless, in another study, children with ADHD did show significantly more TOVA omissions errors than the normal controls (Wada, Yamashita, Matsuishi, Ohtani, & Kato, 2000). These inconsistent findings raise concern about the TOVA omission errors as a valid measure of the attention deficits in ADHD, as a meta-analytic review has shown that children with ADHD make significantly more errors of omission on continuous performance tests than normal children (Losier, McGrath, & Klein, 1996). In contrast, the diagnostic discriminative ability of the TOVA response time variability was more satisfactory (Schatz et al., 2001), but none of the observed correlations between IQ measurements and the TOVA response time variability exceeded .27 in this study. This means that the TOVA outcome measure thought to be the most sensitive measure of the attention deficits in ADHD may explain less than 8% of the variance in IQ, and vice versa. PIQ may have an important relationship with the impulse control deficit in ADHD (as indexed by the TOVA commission errors), as their correlation was of medium size and would probably attain statistical significance in a larger sample size. Naglieri et al. (2005) also examined the relationship between IQ scores and attention deficits, as reflected by the Conners CPT scores, in the clinical sample of 117 children described above. As can be seen in Table 1, none of the five Conners CPT measures correlated significantly with the WISC-III FSIQ or VIQ scores. Only scores on two of the five Conners CPT variables (hits and omissions) correlated significantly, but modestly, with PIQ scores. These correlations could not be corrected for attenuation because testretest reliability estimates apparently are unavailable for this version of the Conners CPT (Riccio et al., 2001). The range of the 13 insignificant correlations was from .14 to .07. The attention deficits, as reflected by Conners CPT scores, may explain no more than about 6% of the variance in PIQ, and vice

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556 Journal of Attention Disorders

versa. Irrespectively of the level of statistical significance, the overall pattern is characterized by low correlations and points to a very large degree of functional independence between IQ scores and measures of attention functioning in this mixed clinical sample with a high prevalence of ADHD. Executive functions include the ability to organize thoughts in a goal-directed manner, to create and initiate a plan, and to persist with its execution until completion. The ability to inhibit inappropriate behaviors is an important aspect of executive functions (Jurado & Rosselli, 2007), and Barkley (1997) has proposed a model of ADHD in which disinhibition is the core deficit. Schuck and Crinella (2005) analyzed the relationship between IQ scores and measures of executive function in 123 boys with ADHD (DSM-IV) between 7 and 13 years of age. IQ was measured with the WISC-III and the Raven Progressive Matrices (RPM), and the ability to shift and maintain cognitive set was assessed with the computerized Wisconsin Card Sorting Test (WCST). Finally, the capacity to control impulsive errors was measured by Conners CPT. A number of studies have used the WCST to assess deficits in executive function components in ADHD (e.g., Vaurio, Riley, & Mattson, 2008). In a meta-analysis of the sensitivity of WCST variables to ADHD, the perseverative errors variable demonstrated medium-weighted average effect sizes, whereas the failure to maintain a set variable demonstrated small effect sizes and was characterized as only being minimally sensitive to ADHD (Romine et al., 2004). With regard to the capacity to control impulsive errors, another meta-analysis has demonstrated that children with ADHD show significantly more errors of commission on CPT tests than do healthy children (Losier et al., 1996). In the study by Schuck and Crinella (2005), medication was discontinued for at least 24 hours prior to the evaluation. The correlation between the FSIQ scores and the capacity to control impulsive errors scores was low (r = .08). FSIQ correlated significantly with the perseverative error scores (r = .22) (r= .28) and with the failure to maintain set scores (r = .19) (r = .54) from the WCST. The testretest reliability estimate of the failure to maintain set and the perseverative error scores are .13 and .65, respectively (Paolo, Axelrod, & Trster, 1996). The correlation between the perseverative errors scores and FSIQ indicated that higher FSIQ was related to fewer perseverative errors, but it was not anticipated that higher FSIQ was also associated with more errors of failure to maintain set (Schuck & Crinella, 2005). Thus, executive deficits, as measured by the number of perseverative errors, seem to account for less than 5% of the variance in the WISC-III FSIQ

(and vice versa). Two of the three correlations between executive deficits and the RPM IQ were small and statistically insignificant (r = .04 with regard to the capacity to control impulsive errors scores and r = .07 with regard to the failure to maintain set scores). In contrast, the perseverative error score correlated significantly with RPM IQ (r = .25; Schuck & Crinella, 2005). Executive function deficits, as indexed by perseverative errors, thus explain about 6% of the variance in RPM IQ (and vice versa). These results point to a large degree of functional independence between WISC-III IQ scores, or RPM IQ scores, and the deficits in executive function in children and adolescents with ADHD.

Do IQ Scores Change With Stimulant Drug Treatment of Inattention and ImpulsiveHyperactive Symptoms?
A large number of studies have documented short-term (Swanson et al., 1993) and long-term symptomatic improvement with stimulant medication in children with ADHD (MTA Cooperative Group, 1999). Recently, a large naturalistic study evaluated the efficacy of stimulant drug treatment in children with ADHD from the MTA cohort using the Conners CPT test and found that the attention scores in the medically treated ADHD group were comparable to the scores of a comparable normative group (Epstein et al., 2006). With regard to the medical treatment effect on hyperactivity, an early meta-analysis of the efficacy of stimulant medication found that the average ADHD child receiving drug treatment was less hyperactive than 88.5% of control children (Ottenbacher & Cooper, 1983). Given the effects of stimulant medication, it is reasonable to expect the possible inattentionrelated influence on IQ assessment in children with ADHD to disappear or at least to diminish significantly with this treatment. An increase in IQ scores with shortterm stimulant medical treatment may thus reflect the influence on IQ assessment related to the attention deficits and suboptimal test taking behavior in untreated children with ADHD. This hypothesis seems consistent with the interpretation that stimulant treatment related changes in IQ scores probably do not reflect significant changes in basic intellectual processes but rather reflect improvements in attention (Barkley, 1977). In addition, practice effect is an important confounder in designs with repeated use of a psychological test. The testretest effect for the currently used WISC-III has been found to be 7 to 8 FSIQ points during a median of 23 days (Wechsler, 1992). Similarly, the formerly used WISC-R showed substantial practice effect, and even with a 5-month testretest

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Jepsen et al. / Influence on IQ Assessment 557

interval, the FSIQ increased by an average of 4.73 IQ points, the VIQ by 1.09 IQ points, and the PIQ by 7.82 IQ points (Tuma & Appelbaum, 1980). Therefore, practice effects certainly need to be controlled in the treatment studies to assess the magnitude of an inattention-related influence on IQ assessment. A meta-analysis by Kavale (1982) calculated the efficacy of stimulant drug treatment on hyperactivity in children based on 135 studies, which included a comparison group (either no-drug, placebo, or different-drug treatment). It is not made clear if studies comparing two active drugs without inclusion of a placebo- or a healthycontrol group were included in the meta-analysis. The studies are not able to control for practice effects on IQ scores, and if such studies were included, this may have inflated the estimation of medication effects on IQ test performance. The meta-analysis represented 5,300 children who were treated with a stimulant drug for an average period of 18 weeks. Based on different IQ measures and 54 individual effect sizes, the mean effect size for intelligence was .39 (SD = .65). Nine effect sizes were based on the WISC (first version), and the mean effect size of the FSIQ was .45 (SD = .51). This is equivalent to a mean gain of about 6 to 7 IQ points with stimulant drug treatment, given a theoretical standard deviation of 15. The mean effect sizes were .41 (SD = .53) and .40 (SD = .43) for the WISC VIQ and PIQ, respectively. The effect sizes for both VIQ and PIQ suggest a mean gain of about 6 IQ points with stimulant drug treatment. In comparison, the mean effect size for attention was .78 (SD = .57) and for activity level, .85 (SD = .59). A meta-analysis by Thurber and Walker (1983) of the effect of stimulant medication in children with hyperactivity included only double-blinded, placebo-controlled, and randomized studies. In total, 1,219 children with hyperactivity were included in the meta-analysis. The largest treatment effect size was found among the attention functioning variables (average effect size = .75), and the smallest effect size was seen among intelligence test scores (average effect size = .15). This short-term stimulant medical treatment effect on intellectual performance ability is equivalent to a mean increase of 2.25 IQ points (given a theoretical standard deviation of 15). This was interpreted as a consequence of the enhanced attention processes. A third meta-analysis of stimulant drug treatment efficacy by Ottenbacher and Cooper (1983) included 1,972 children diagnosed as hyperactive in randomized, controlled, and double-blinded treatment effect studies with an average duration of 7 weeks. The treatment effect was assessed on tests of academic functioning and IQ, and the outcome scores were combined into one single IQ

achievement category. The treatment effect size was .47 with regard to this composite IQ achievement category, whereas the effect size for the behavioral/social measures (e.g., Conners Parent Rating Scale) was .96. In a review of the three meta-analyses, the average effect size of drug treatment of children with attention deficit was .35 with regard to an IQ academic achievement category (i.e., 5.24 IQ points given a standard deviation of 15), whereas the average effect size was .83 with regard to behavior and attention (Swanson et al., 1993). In total, the three meta-analytic reviews point to smaller stimulant-drug-treatment effects on IQ scores compared to the considerably larger effects on measures of attention and behavior. As the estimated effect size of stimulant drug treatment on IQ ranges from .15 to .47 in the three meta-analyses, the influence on the assessment of IQ in medically untreated children with inattentive and hyperactive behavior amounts to a minimum mean of 2 IQ points and a maximum mean of 7 IQ points. Based on the review of meta-analyses by Swanson and colleagues, the mean influence on the assessment of IQ and achievement as a single category may amount to 5.24 IQ points (Swanson et al., 1993).

What Is the Difference in IQ Between Monozygotic Twins Discordant for ADHD?

To study the nongenetic causes of ADHD, Sharp et al. (2003) recruited monozygotic twin pairs discordant for ADHD. Monozygotic twin pairs discordant for ADHD are a rare occurrence because the heritability of this disorder is high, and only 10 monozygotic twin pairs (i.e., 3% of the initial applicants) met the criteria of true discordance for ADHD (DSM-IV). The mean FSIQ among the twins affected by ADHD was 101.4 (SD = 12.8), whereas the mean FSIQ in the group of unaffected twins was 104.0 (SD = 9.5). By definition, the ADHD-affected twins differed from their unaffected monozygotic twin with respect to the number of symptoms of inattention and impulsivityhyperactivity, but they did not differ significantly in terms of IQ. The small group difference in IQ suggests that performance on intelligence tests was relatively unaffected by the ADHD symptoms of inattention and impulsivityhyperactivity.

Which Components of Attention Are Affected in ADHD?

Before we discuss the findings from the various studies mentioned above, we briefly touch on the nature of the attention deficits of ADHD and which Wechsler subtests may be most sensitive to their influences. Attention

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558 Journal of Attention Disorders

includes different and related functions carried out by a network of anatomical areas that form the attention system of the brain (Posner & Petersen, 1990). The alerting component includes the capacity to maintain an alert state (sustained attention), whereas the orienting function involves selection of specific information among numerous sensory inputs (selective attention). The executive control of attention component (divided attention) involves more complex mental operations needed in situations that involve planning, error detection, decision making, and so on (Fan & Posner, 2004; Fan, Raz, & Posner, 2003; Swanson et al., 1998). The Attention Network Test (ANT) was constructed to evaluate the efficiency of each of the three attention networks (Fan, McCandliss, Sommer, Raz, & Posner, 2002). The test has been adapted for use with children, and it has been suggested that the three functional attention systems are independent (Rueda et al., 2004). Swanson et al. (1998) analyzed whether the clinical concept of inattention in ADHD (DSM-IV) could be aligned with these three functional components of attention. Three inattention symptoms from DSM-IV were thought to refer to selective attention (an orienting deficit), three other inattention symptoms were related to sustained attention (an alerting deficit), and the last three inattention symptoms describing memory and organizational deficits were related to an executive control deficit, as were the three symptoms of impulsivity. Thus, this analysis proposes that ADHD may be related to deficits in all three functional attention systems. The Test of Everyday Attention for Children (TEACh; Manly et al., 2001) is an attention test battery for children with a similar three-factor model of attention namely, selective attention, sustained attention, and attention control or switching. A group of 24 children with ADHD (DSM-IV) and no comorbidity diagnoses were examined with six of the nine TEA-Ch subtests to characterize their attention deficits (Manly et al., 2001). The children with ADHD showed significant deficits in sustained attention and in attention control, whereas selective attention was within the normal range. The authors interpret these results to be consistent with previous findings emphasizing a sustained attention deficit and deficient suppression of prepotent responses (Barkley, 1997; Douglas, 1972). This pattern of attention deficits was confirmed in a study that administered the TEA-Ch to 63 children with ADHD (DSM-IV) and a non-ADHD clinical control group. The children with ADHD performed significantly worse than the clinical control group on subtests assessing sustained attention and attention control or switching but not on subtests in the domain of selective attention (Heaton et al., 2001).

Thus, it is likely that effects of ADHD attention deficits on performance in IQ tests are the consequence of deficits in sustained attention and executive function.

Which WISC-III Subtests May Be Most Sensitive to Influence From ADHD Attention Deficits?
The performance on the different subtests included in an IQ test battery may not be equally sensitive to the symptoms of ADHD. In a large sample of 630 children with ADHD and an IQ of 80 or greater, the lowest scores on the FDI and PSI characterized the WISC-III profile (Mayes & Calhoun, 2004), which is consistent with several earlier findings (e.g., Prifitera & Dersh, 1993; Reinecke et al., 1999). Based on these findings, the WISC-III Arithmetic, Digit Span, Coding, and Symbol Search subtests may appear more sensitive to the effects of attention deficits in ADHD than other subtests. Nevertheless, a meta-analysis including different Wechsler IQ test versions found no statistically significant differences between the weighted effect sizes for FDI (weighted mean effect size [WM] = .75) and PSI (WM = .65) when compared to the weighted effect sizes for FSIQ (WM = .61; Frazier et al., 2004). In addition, the weighted effect sizes for the Arithmetic (WM = .70), Coding (WM = .82), and Digit Span (WM = .64) subtests were not significantly different from the weighted effect sizes for FSIQ. In comparison, the weighted effect sizes for FSIQ were significantly larger than for the Block Design subtest (WM = .44; Frazier et al., 2004). Therefore, neither the Arithmetic or the Digit Span subtest in the FDI or the Coding subtest in the PSI appear significantly more sensitive to the influences from the deficits in the sustained and executive components of attention in children with ADHD compared to the FSIQ, whereas the Block Design subtest does appear less sensitive to these influences than the FSIQ.

Discussion
The purpose of this article was to review the literature to evaluate the relationships between attention deficits and IQ scores in children and adolescents with ADHD and to derive an estimate of the potential influence on IQ scores when this clinical population is tested before drug treatment has been initiated. In this section, the main results will be briefly summarized, and we will discuss some characteristics of the Wechsler IQ tests that may contribute to the low sensitivity to influences from the attention deficits in unmedicated children and adolescents with ADHD.

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Jepsen et al. / Influence on IQ Assessment 559

Naglieri et al. (2005) found statistically insignificant and low correlations between WISC-III IQ scores and the severity of parent- and teacher-rated inattention and impulsivehyperactive behaviors, but the inattentive and impulsivehyperactive behaviors were not registered during the administration of the Wechsler IQ test. In relation to our objective, this is a methodological limitation, but we interpret the results as evidence of relative independence of WISC-III performance and ADHD behaviors. This is corroborated by observed correlations between laboratory measures of attention and FSIQ scores, ranging between .14 and .25 in a large clinical sample described by Aylward et al. (1997) as well as by other studies finding similar low correlations between FSIQ scores and analogues measures of attention (Chae, 1999; Naglieri et al., 2005; Schuck & Crinella, 2005). Nevertheless, two statistically significant correlations of moderate size have been observed between the TOVA omission errors and Wechsler FSIQ and PIQ scores (Chae, 1999). As previously discussed, these correlations are difficult to interpret, because TOVA omission errors may only be of minor relevance to the inattention seen in ADHD. In addition, a statistically nonsignificant correlation of moderate size has been observed between TOVA commission errors and PIQ scores (Chae, 1999). This correlation may turn out to be statistically significant in larger samples and may reflect a potentially important relationship between impulse control deficits and PIQ in ADHD. However, the correlation between PIQ scores and GDS efficiency ratio (another measure of inhibition; Gordon & Mettelman, 1988) was of rather modest strength (r = .17) in the study by Aylward et al. (1997). This does not support a strong relationship between impulse control deficits and PIQ in ADHD. The overall picture emerging from the reviewed studies indicates low correlations and little overlapping variance between performance on Wechsler intelligence tests and measures of attention deficits in children and adolescents with ADHD. The hypothesis of relative independence between FSIQ and attention deficits is supported by the nonsignificant difference in mean FSIQ scores observed in a small sample of monozygotic twins discordant for ADHD (Sharp et al., 2003). More important, this hypothesis is supported by the results from factor analytic studies, as relatively small g loadings have been observed on most measures of attention and executive functions in samples of children with ADHD (Schuck & Crinella, 2005), a high proportion of children with ADHD symptoms (Crinella & Yu, 2000), and a high incidence of ADD/ADD-H (Aylward et al., 1997). The degree to which performance on a given test is unaccounted for by g may reflect specific or non-g abilities and error variance

(Jensen, 1998). Attention in ADHD may primarily constitute deficits of separate and specific abilities. Thus, the influence from g on attention has been observed to be weak, and this also suggests that ADHD attention deficits will not generally result in substantially influenced IQ scores. The IQ improvements with stimulant drug treatment have been thought of as probable secondary effects of enhanced attention processes and not representing significant changes in basic intelligence (Barkley, 1977; Thurber & Walker, 1983). Thus, IQ improvements related to short-term stimulant medication may reflect the size of a pretreatment attention-related influence on IQ assessments. A direct stimulant drug effect on intelligence tests performance cannot be ruled out, but it is unlikely that stimulant medication sufficiently influences the multiple neural networks necessary for improving gloaded problem solving, thus resulting in a true increase in intelligence (Crinella & Yu, 2000). However, an effect of stimulant medication on cognitive functions underlying both attention and intelligence cannot be excluded as a possible confounder, and we interpret the mean IQ improvement with stimulant drug treatment as a conservative maximum estimate of the mean pretreatment and inattention-related influence on IQ assessment in children and adolescents with ADHD. In a review of reviews, Swanson et al. (1993) reported the average stimulant drug treatment effect size on combined IQ and academic achievement measures to be .35, corresponding to a mean of 5.25 IQ points, and we propose this as a conservative estimate of the maximum average inattention-related influence on IQ assessment in unmedicated children and adolescents with ADHD. This may actually be an overestimation of the effect of attention deficits on IQ. In a meta-analysis with rigorous inclusion criteria, Thurber and Walker (1983) found the mean drug effect size on the IQ measures (not confounded by drug effect sizes on academic achievement measures) to be as small as .15. This is equivalent to a mean increase of 2.25 FSIQ points and suggests a clinically insignificant inattentionrelated influence on IQ assessment in untreated children with ADHD. A mean influence of 2.25 IQ points in unmedicated children with ADHD is strikingly similar to the effort-related influence on IQ scores observed in a study of about 400 boys with self-reported degree of delinquent activity (Lynam, Moffitt, & Stouthamer-Loeber, 1993). In a subgroup with the most severe delinquency problems, statistical adjustment of the IQ scores for the effect of suboptimal effort during testing resulted in a 2.09-point increase in mean FSIQ (Lynam et al., 1993). The boredom and impatient/impersistent behaviors observed during administration of a shortened WISC-R

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560 Journal of Attention Disorders

IQ test in this delinquent sample appear to be similar to the suboptimal test-taking behaviors observed in children and adolescents with ADHD. Generalizing the results from this methodologically excellent study to children with ADHD, an attention-related mean influence on IQ assessment of about 2 FSIQ points is suggested. The current article has several limitations. One limitation is that the IQ drug-treatment effect sizes were based on the outdated original WISC version and other measures of intelligence and not based on the currently most often used WISC-III version. This may not be a major problem because the IQ deficits in children with ADHD were not related to the type of IQ test used (Frazier et al., 2004). However, it should be observed that, to our knowledge, the only randomized, placebo-controlled, blinded, and short-term stimulant treatment efficacy study based on WISC-III showed nonsignificant and negligible treatment effects on IQ scores and on Index scores (Schwean, Saklofske, Yackulic, & Quinn, 1993). It is also a limitation to draw conclusions with regard to children and adolescents with ADHD from studies not solely including children and adolescents with an ADHD diagnosis. In addition, we are well aware that it is a limitation to generalize the results from groups of children defined by different and maybe weak diagnostic criteria to the population of children and adolescents with ADHD as defined by the DSM-IV. Kavales (1982) metaanalysis included studies that examined children who manifested hyperactivity as a primary symptom and did not specify this criterion or list any additional diagnostic criteria such as symptoms of inattention. Thus, the different clinical samples of children with hyperactivity included in this meta-analysis may not be equivalent to the population of children with DSM-IV ADHD. The relatively low diagnostic sensitivity of the Wechsler subtest profiles may also reflect the relatively low sensitivity of the Wechsler IQ scores to the effects of suboptimal attention during test administration. Based on the WISC-III version, the diagnostic sensitivity of the subtest pattern characterized by lowest scores on the Arithmetic, Coding, Information, and Digit Span subtests (termed the ACID pattern) was as low as 12.3% in a sample of children and adolescents with ADHD according to DSM-III-R criteria (Prifitera & Dersh, 1993). Only 28% of a sample of children with ADHD had significantly lower FDI scores than VCI scores, and as few as 32% had significantly lower FDI scores than POI scores (Reinecke et al., 1999). Similarly, a significant FDIVCI difference occurred in 25% of children with ADHD, whereas 30% of the sample showed a significant FDIPOI difference (Anastopoulos, Spisto, & Maher, 1994). A subtest pattern characterized by a coding score less than or equal to the

Picture Completion, Picture Arrangement, Object Assembly, and Block Design scores was found in 52% of children with ADHD (with or without a learning disability; Mayes & Calhoun, 2004). Fifty-seven percent of this sample obtained FDI scores less than or equal to the VCI, PQI, and PSI scores. Thus, each of these WISC-III profiles led to a considerable number of false negatives, reflecting the relatively low sensitivity of even the WISC-III subtests that are considered to be the most sensitive to ADHD. The characteristics of the Wechsler intelligence scales that make the derived IQ scores relatively insensitive to the inattentive and impulsivehyperactive behaviors in ADHD may include clear test procedures and instructions that continuously are provided by the examiner. The beginning of a task is prompted by the examiner and the completion of a task is also clearly defined. Therefore, no heavy demands are placed on the childs ability to organize behavior. In addition, many subtests are timed and of relatively short duration, and consequently, sustained attention is not required for longer periods of time. Most of the subtests included in the calculation of the Wechslers IQ scores show fair or good g-loadings (Kaufman, 1994). Hence, there is literally little room left for influence from specific abilities (e.g., attention) and error variance. These and possibly other administration and task characteristics of the Wechsler scales may explain why the inattention-related mean influence on IQ assessment may be in the 2- to 5-point range for the FSIQ. Schuck and Crinella (2005) proposed that the proportional influence of a deficit in one or several executive function components will only have a minimal influence in determining the ability to perform in highly g-loaded tasks, as many diverse nonexecutive function components are required for performance on such tasks. In clinical practice, low scores on a Wechsler IQ test in children and adolescents with ADHD may not only reflect intellectual deficits but also may be the result(s) of attention deficits during IQ test administration. Consequently, we recommend for clinicians to consider the attention deficits observed during test administration when interpreting IQ scores in this clinical population. Nevertheless, given the evidence of no more than modest associations between IQ scores and measures of attention deficits in ADHD, the size of inattention-related influence on IQ scores may easily be overestimated and the intellectual deficits in children with low IQ and ADHD may be underestimated. An inattention-related mean influence on IQ assessment in the 2- to 5-FSIQpoint range may serve as a reasonable benchmark when interpreting IQ scores obtained before stimulant drug treatment has been initiated in children and adolescents with ADHD.

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Jens Richardt M. Jepsen, MSc, is a clinical child neuropsychologist at Copenhagen University Hospital, Child and Adolescent Psychiatric Center Bispebjerg and a PhD student at the Institute of Public Health, University of Copenhagen, Denmark. Birgitte Fagerlund, PhD, is a psychologist currently working as a postdoctoral fellow at Copenhagen University Hospital, Child and Adolescent Psychiatric Center, Bispebjerg, Denmark. Erik Lykke Mortensen, MSc, is associate professor at the Institute of Public Health, University of Copenhagen, Denmark.

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