ADHD and autism frequently co-occur, with studies suggesting up to 50-70% of autistic individuals may also meet ADHD criteria.
These conditions share overlapping traits, particularly in emotional regulation. Both can involve difficulties with emotional control, increased irritability, and challenges in social interactions.
This overlap complicates diagnosis and treatment, highlighting the need for comprehensive assessment and individualized approaches when addressing neurodevelopmental differences in children and adolescents.
Kılıç, B., & Ç. Kültür, S. E. Comparison of children and adolescents diagnosed with attention deficit hyperactivity disorder with and without autism traits in terms of emotion regulation, clinical characteristics and functionality. Journal of Neuropsychology. https://doi.org/10.1111/jnp.12411
Key Points
- Children with ADHD and autism traits showed more severe clinical profiles than those without autism traits.
- Autism traits were associated with poorer language skills, separation anxiety, higher irritability, and impaired social functioning.
- Fathers’ lower education levels predicted autism traits in children with ADHD.
- The group with autism traits had higher scores on conduct problems, hyperactivity/inattention, emotional problems, and peer problems.
- No significant differences were found in ADHD presentation or most perinatal characteristics between groups.
Rationale
Attention Deficit Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder (ASD) share various endophenotypes and developmental challenges (Grzadzinski et al., 2011).
Up to 30% of children diagnosed with ADHD show signs of autism without meeting full ASD diagnostic criteria, often experiencing worse clinical outcomes (Uchida et al., 2013).
Previous research has indicated that children with autism traits and ADHD face more severe challenges in areas such as family and peer relationships, school performance, and comorbid psychiatric disorders (Cooper et al., 2014; Joshi et al., 2020; Kotte et al., 2013).
Additionally, difficulties in emotion regulation are common in both ADHD and ASD populations (Shaw et al., 2014).
However, comprehensive studies examining autism traits in medication-naïve ADHD children across various clinical and developmental domains are limited.
This study aims to address this gap by comparing ADHD children with and without autism traits in terms of emotion regulation, clinical features, and functionality, providing valuable insights for diagnostic and treatment approaches.
Method
Procedure
- Participants diagnosed with ADHD were recruited from a child psychiatry outpatient clinic
- Parents and children completed various assessment measures
- Clinical interviews and diagnostic assessments were conducted
- Participants were divided into groups based on the presence of autism traits
Sample
114 children aged 8-16 years (50 with autism traits, 64 without)
- All participants were newly diagnosed with ADHD and had never received medication treatment
- 102 attended public schools, 12 attended private schools
- No participants were enrolled in special education or rehabilitation programs
Measures
- Social Reciprocity Scale (SRS): Evaluated autism-like symptoms
- Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS-PL-DSM-5-T): Identified comorbid psychiatric diagnoses
- Affective Reactivity Index (ARI): Assessed irritability
- Childhood Anxiety Sensitivity Index (CASI): Measured anxiety sensitivity
- Strengths and Difficulties Questionnaire (SDQ): Evaluated behavioral problems and strengths
- Weiss Functional Impairment Rating Scale-Parent Form (WFIRS-P): Assessed functional impairments
Statistical measures
- Independent two-sample t-tests and Mann-Whitney U tests for numerical data
- Chi-square tests for categorical variables
- Logistic regression analysis to identify predictors of autism traits
Results
The study did not explicitly state hypotheses, but the main findings include:
- Children with ADHD and autism traits showed poorer language-speech skills and past fine motor skills.
- Separation anxiety disorder was more prevalent in the autism traits group.
- The autism traits group scored higher on SDQ subscales for conduct problems, hyperactivity/inattention, emotional problems, and peer problems.
- Irritability levels were significantly higher in the autism traits group.
- The autism traits group showed greater impairment in social functioning and overall functionality.
- Predictors of autism traits included father’s lower education, poor language skills, separation anxiety, higher irritability, and impaired social functioning.
Insight
This study provides a comprehensive comparison of children with ADHD, with and without autism traits, across multiple domains.
The findings highlight the complex clinical presentation of children with both ADHD and autism traits, emphasizing the need for a nuanced approach to assessment and treatment.
The association between autism traits and increased irritability, separation anxiety, and social functioning impairment extends previous research by providing a more detailed clinical profile of this subgroup.
These results suggest that clinicians should consider screening for autism traits in ADHD individuals, particularly when observing high levels of irritability or social difficulties.
Implications
The findings have several implications for clinical practice according to the researchers:
- Clinicians should routinely screen for autism traits in children diagnosed with ADHD, especially when observing language difficulties, separation anxiety, or social difficulties.
- Treatment plans for ADHD children with autism traits may need to incorporate strategies addressing emotion regulation and social skills development.
- Special attention should be given to managing separation anxiety in this subgroup.
- Parent education programs could be developed to help families understand and support children with both ADHD and autism traits.
- School-based interventions might focus on improving peer relationships and social functioning for these children.
Implementing these recommendations may face challenges such as limited resources for comprehensive assessments, the need for specialized training for clinicians, and potential resistance to additional diagnoses.
However, the benefits of early identification and targeted interventions could significantly improve outcomes for these children.
Strengths
This study had several methodological strengths, including:
- Large sample size with strict inclusion criteria
- Use of semi-structured interviews for psychiatric comorbidity assessment
- Comprehensive evaluation of multiple domains (developmental, clinical, and functional)
- Inclusion of both parent and child reports
- Focus on medication-naïve patients, eliminating treatment effects
Limitations
This study also had several limitations:
- Lack of a control group without ADHD diagnosis
- Retrospective collection of developmental information from parents
- Cross-sectional design limiting causal inferences
- Potential recall bias in parental reports of early developmental history
- Limited generalizability due to clinic-based sample
Additional Limitations
- The study primarily focuses on deficits and challenges associated with autism traits in ADHD, potentially reinforcing a pathological view of neurodevelopmental differences.
- There is limited exploration of potential strengths or positive attributes associated with the co-occurrence of ADHD and autism traits.
- The study relies on the Social Responsiveness Scale to assess autism traits, which may not capture the full complexity and diversity of autistic experiences. This scale focuses primarily on social deficits and may not adequately represent the strengths or positive attributes associated with autism, potentially reinforcing a deficit-based view of neurodevelopmental differences.
- The research frames autism traits as inherently problematic rather than considering them as part of natural human variation.
- The study does not incorporate the perspectives of neurodiverse individuals or consider how they view their own experiences and needs.
- By categorizing children based on autism traits, the research may contribute to further labeling and stigmatization.
- The emphasis on clinical profiles and functionality may overlook the importance of environmental factors and societal accommodation in shaping outcomes for neurodiverse individuals.
- The research does not address how support systems could be adapted to better serve the needs of children with both ADHD and autism traits without pathologizing their differences.
References
Primary reference
Kılıç, B., & Ç. Kültür, S. E. Comparison of children and adolescents diagnosed with attention deficit hyperactivity disorder with and without autism traits in terms of emotion regulation, clinical characteristics and functionality. Journal of Neuropsychology. https://doi.org/10.1111/jnp.12411
Other references
American Psychiatric Association, & Association, A. P. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). American Psychiatric Association.
Cooper, M., Martin, J., Langley, K., Hamshere, M., & Thapar, A. (2014). Autistic traits in children with ADHD index clinical and cognitive problems. European child & adolescent psychiatry, 23, 23-34. https://doi.org/10.1007/s00787-013-0398-6
Grzadzinski, R., Di Martino, A., Brady, E., Mairena, M. A., O’Neale, M., Petkova, E., Lord, C., & Castellanos, F. X. (2011). Examining autistic traits in children with ADHD: Does the autism spectrum extend to ADHD? Journal of Autism and Developmental Disorders, 41(9), 1178-1191. https://doi.org/10.1007/s10803-010-1135-3
Joshi, G., Faraone, S. V., Wozniak, J., Tarko, L., Fried, R., Galdo, M., Furtak, S. L., & Biederman, J. (2020). Symptom profile of ADHD in youth with high-functioning autism spectrum disorder: A comparative study in psychiatrically referred populations. Journal of Attention Disorders, 21(10), 846-855. https://doi.org/10.1177/1087054714543368
Kotte, A., Joshi, G., Fried, R., Uchida, M., Spencer, A., Woodworth, K. Y., Kenworthy, T., Faraone, S. V., & Biederman, J. (2013). Autistic traits in children with and without ADHD. Pediatrics, 132(3), e612-e622.
Shaw, P., Stringaris, A., Nigg, J., & Leibenluft, E. (2014). Emotion dysregulation in attention deficit hyperactivity disorder. American Journal of Psychiatry, 171(3), 276-293. https://doi.org/10.1176/appi.ajp.2013.13070966
Uchida, M., Faraone, S. V., Martelon, M., Kenworthy, T., Woodworth, K. Y., Spencer, T. J., Wozniak, J., & Biederman, J. (2013). Are autistic traits in youth meaningful? A replication study in non-referred siblings of youth with and without attention-deficit/hyperactivity disorder. Journal of Child and Adolescent Psychopharmacology, 23(6), 418-424.
Socratic Questions
- How might the study’s findings impact our understanding of the relationship between ADHD and autism spectrum disorders?
- What ethical considerations should be taken into account when screening for autism traits in children already diagnosed with ADHD?
- How could the study’s methodology be improved to address some of its limitations?
- In what ways might cultural factors influence the presentation and identification of autism traits in children with ADHD?
- How might the findings of this study inform the development of more personalized treatment approaches for children with ADHD?
- What potential long-term consequences might arise from not identifying autism traits in children with ADHD?
- How could the study’s findings be applied to improve teacher training and classroom management strategies for children with ADHD and autism traits?
- What role might genetic factors play in the co-occurrence of ADHD and autism traits, and how could future research address this question?
- How might the study’s results influence the diagnostic criteria for ADHD and ASD in future revisions of diagnostic manuals?
- In what ways could the findings of this study impact public policy regarding special education services and support for children with neurodevelopmental disorders?
