Toward Operationalizing Executive Function Deficits in Adults With ADHD Using the Behavior Rating Inventory of Executive Function—Adult Version (BRIEF-A)

Abstract

Objective: Although group findings document that executive function deficits (EFDs) contribute to the morbidity associated with adult attention-deficit/hyperactivity disorder (ADHD), it is unclear whether easy-to-use assessment methods can aid in the identification of EFDs at the individual level. The aim of the present study was to assess whether the Behavior Rating Inventory of Executive Function—Adult Version (BRIEF-A), a well-standardized, self-report instrument that assesses behavioral concomitants of EFDs, can serve that purpose. Methods: 1,090 consecutively referred 18- to 55-year-old adults of both sexes who were clinically referred for the evaluation and treatment of ADHD between June 2016 and December 2021 completed a battery of scales assessing several non-overlapping domains of functioning. Because the BRIEF Global Executive Composite (GEC) offers a single point summary of all other BRIEF-A scales, we used receiver operator characteristic (ROC) curves to identify the optimal cutoff on the BRIEF-A GEC to categorize patients as having executive dysfunction. Results: We averaged the optimal BRIEF-A GEC cut-points from the ROC curve analyses to categorize patients with (N = 480; 44%) and without (N = 610; 56%) EFDs (BRIEF-A GEC score ≥ 70 or < 70, respectively). Adults with ADHD with EFDs had significantly more severe ADHD symptoms (ADHD Self-Report Scale scores ≥ 24: 94% vs 41%, P < .001); higher levels of psychopathology (Adult Self Report Total Problems T-scores ≥ 64: 75% vs 19%, P < .001), emotional dysregulation (69% vs 23%, P < .001), mind wandering (84% vs 48%, P < .001), and symptoms of autism (Social Responsiveness Scale T-scores ≥ 66: 24% vs 3%, P < .001); and worse quality of life (Quality of Life Enjoyment and Satisfaction Questionnaire mean scores: 44.4 ± 8.2 vs 51.9 ± 8.5, P = .001) compared to those without EFDs. There were no major differences in outcomes by age, sex, or race. Conclusions: The BRIEF-A helped identify a sizeable minority of adults with ADHD with behavioral concomitants of EFDs that added substantial morbidity and disability beyond that expected by having ADHD alone.