Neurotherapeutics (2012) 9:518–530

DOI 10.1007/s13311-012-0126-9

REVIEW

Treatment for Co-Occurring Attention Deficit/Hyperactivity

Disorder and Autism Spectrum Disorder
Naomi Ornstein Davis & Scott H. Kollins

Published online: 8 June 2012

# The American Society for Experimental NeuroTherapeutics, Inc. 2012

Abstract Interest in the co-occurrence of attention deficit/ Key Words ADHD . autism spectrum disorder .
hyperactivity disorder (ADHD) and autism spectrum disor- psychopharmacology . psychosocial treatment
der (ASD) has grown in the last decade. Research on clinical
populations supports the frequent co-occurrence of ADHD
traits (e.g., hyperactivity) in individuals with ASD and ASD Introduction
traits (e.g., social communication deficits) in individuals
with ADHD. Similar trends in co-occurring traits have been In the last decade, studies have reported increased preva-
observed in population-based samples, as well as family and lence of both attention deficit/hyperactivity disorder
genetic studies of affected individuals. Despite increased (ADHD) and autism spectrum disorder (ASD) [1], as well
interest in co-occurring ADHD and ASD, relatively little as more cases of co-occurring ADHD and ASD symptoms
research has been devoted to treatment considerations. The [2]. Current nosology, however, precludes diagnosis of both
vast majority of intervention research has examined phar- disorders to the same individual and specifies that the pres-
macological treatment using traditional ADHD medica- ence of an ASD is an exclusion criterion for ADHD [3, 4].
tions. Relatively few psychosocial interventions have As neurodevelopmental disorders, ADHD and ASD share
directly addressed co-occurring symptoms. Treatment de- some phenotypic similarities but they are characterized by
velopment will benefit from enhanced understanding of the distinct diagnostic criteria. ADHD is defined by impaired
phenomenon of co-occurring ADHD and ASD. Key topics functioning in the areas of attention, hyperactivity, and
for future research include examining developmental tra- impulsivity, whereas ASD is defined by social dysfunction,
jectories of co-occurring disorders, comorbid psychiatric communicative impairment, and restricted/repetitive behav-
conditions, deficits in social skills, and the nature of iors [3]. Despite these core differences, between 30 and
executive functioning impairment in individuals with co- 50 % of individuals diagnosed with ASD also exhibit ele-
occurring ADHD and ASD. In the current review, research vated levels of ADHD symptoms [5–7]. Similarly, some
in these areas is reviewed along with recommendation for estimates suggest that features of ASD are present in
future study. Given that clinicians are routinely observing approximately two-thirds of individuals with ADHD [8].
and treating individuals with co-occurring symptoms, fur- Epidemiological research has also demonstrated notable
ther research will yield needed information to inform inter- associations between ADHD and ASD traits in nonclinical
vention development and maximize benefits for affected samples [2, 9, 10]. Taken together, these findings have
individuals. significant implications for treatment research and service
provision for individuals affected by co-occurring symp-
N. O. Davis (*) : S. H. Kollins toms of these 2 common disorders.
Department of Psychiatry and Behavioral Sciences, Although clinicians have long recognized behavioral fea-
Duke University Medical Center,
2608 Erwin Rd., Pavilion East, Suite 300,
tures, such as hyperactivity among children with ASD and
Durham, NC 27705, USA impairing social deficits in children with ADHD, research
e-mail: [email protected] on the co-occurrence of ASD and ADHD has burgeoned
Treatment of Co-Occurring ADHD and ASD 519

only in recent years [11]. Multiple family studies have psychosocial interventions are limited. As such, the goals of
shown that family members of individuals with either the current review are: 1) to examine current research on
ADHD or ASD frequently display symptoms of the other pharmacological and nonpharmacological interventions for
disorder [8, 12]. Genetic findings support the possibility of co-occurring ADHD and ASD symptoms, 2) to describe
common genetic origins for both disorders [13–16]. In addi- research on 4 key topics associated with co-occurring ADHD
tion, evidence for common neurobiological substrates has and ASD that have implications for treatment, and 3) to
been found through similarities in neuropsychological profiles outline recommendations for future treatment studies to im-
among individuals with ADHD and ASD [11, 17]. Debate prove care for this high–need population.
continues in the literature regarding the clinical implications
of these findings, such that some researchers argue that co-
occurring symptoms reflect the presence of 2 distinct disor- Treatment for Co-Occurring ADHD and ASD
ders with a common etiology [18], and others suggest these
disorders are better characterized as part of 1 broad spectrum, Pharmacological Interventions
ranging from mild (ADHD) to more severe (ASD) impairment
[11]. Given these findings, many researchers have advocated Pharmacological treatment for ADHD is effective for reduc-
for revising diagnostic criteria to allow for dual diagnosis. By ing impairment associated with core ADHD symptoms (i.e.,
permitting the assignment of both ADHD and ASD, these inattention, hyperactivity, impulsivity) and improving func-
researchers argue that individuals who experience co- tioning in children and adults [25, 26]. For ASD, current
occurring symptoms can be better characterized and studied pharmacological treatments primarily target comorbid symp-
to enhance research on effective treatments [2, 6, 18]. toms (e.g., irritability, aggression, hyperactivity) rather than
Diagnostic constraints have limited the scope of past core social and communication impairments. Only 2 medica-
research on co-occurring ADHD and ASD, because many tions have been formally approved for use with individuals
studies have excluded individuals with any co-occurring with ASD and both of these medicines target irritability:
symptoms to establish homogeneous samples. In addition, risperidone (Risperdal, Janssen Pharmaceutical Inc.; Titus-
studies of ADHD and/or ASD have often excluded individ- ville, NJ) and aripiprazole (Abilify, Otsuka America Pharma-
uals with other psychiatric or developmental difficulties, ceutical Inc.; Rockville, MD) [27–29]. Although some
thereby limiting the ability to generalize findings to the medications have demonstrated the potential to treat stereo-
majority of patients who present with a combination of typed or repetitive behaviors associated with ASD, efficacy
disorders. The co-occurrence of conditions has significant data on these treatments has been less strong [30]. Similarly,
implications for level of functioning and treatment planning. exploratory research is being conducted on new agents, in-
Accumulating research comparing individuals with both cluding intranasal oxytocin to target social impairments [31].
ADHD and ASD to individuals with single a diagnosis Despite limited research on medications, pharmacological
(i.e., ADHD or ASD) suggests that co-occurring symptoms treatment among individuals with ASD has significantly in-
are associated with more impairment than single diagnoses. creased in recent years [32]. This trend is partly accounted for
By both parent and teacher report, children with ADHD and by an increase in use of ADHD medicines with individuals
ASD experience more difficulty in daily situations as com- who are diagnosed with ASD to address ADHD-related
pared to those with only 1 disorder [6]. Higher levels of impairments [33]. In the following section, we present an
additional psychopathology have been reported among indi- overview of current research on the efficacy of medication
viduals with co-occurring ADHD and ASD [19, 20]. Recent for co-occurring ADHD and ASD. More detailed descriptions
findings from the Autism Treatment Network database sug- on past psychopharmacological treatment studies can be
gest that co-occurrence of ADHD and ASD is associated found elsewhere [2, 34, 35].
with a lower quality of life and poorer adaptive functioning
as compared to children with ASD only [21]. Youth char- Psychostimulant Medications
acterized as having both ADHD and ASD are more likely to
be taking psychiatric medication (58 %) than youth with Psychostimulants are the most widely researched medica-
ADHD (49 %) or ASD (34 %) alone [22]. Furthermore, co- tions used to treat ADHD alone [26], but conflicting find-
occurring ADHD and ASD may be less responsive to ings have been reported regarding the efficacy and safety of
standard treatments for either disorder than individuals with stimulants in cases of co-occurring ADHD and ASD. A
“pure” forms of the disorders [23, 24]. series of early studies showed that children with ADHD
In summary, research suggests the existence of a distinct and ASD experienced significant negative side effects
phenotype characterized by both co-occurring symptoms and (e.g., irritability, self–injury, stereotypy) and limited therapeu-
the unique needs for treatment that address multiple domains. tic benefit when treated with methylphenidate, in particular
Unfortunately, guidelines for optimal pharmacological and compared to expected outcomes based on methylphenidate
520 Davis and Kollins

use for treating ADHD [34, 36, 37]. Given methodological trial indicated positive effects in terms of the reduction of
limitations associated with these studies (i.e., open-label rather hyperactivity and impulsivity, but not inattention in youth
than blinded; preschool age subjects only; insufficient mea- with ASD, with fewer adverse events as compared to stim-
surement of ADHD symptoms), recent research has examined ulant trials [43]. Additional research using parents and
stimulant efficacy using more rigorous study designs. teachers as informants showed significant reductions in
The Research Units on Pediatric Psychopharmacology ADHD symptoms among children with ADHD and ASD.
Autism Network conducted a randomized, placebo- Approximately half of the participants were classified as
controlled, crossover trial of methylphenidate with 72 chil- responders (i.e., global improvement rating in the “much-
dren (ages, 5–14 years) who were diagnosed with autism to-moderate” range for 6 of 14 participants), and side effects
who were also characterized with moderate-to-severe hyper- were rated as “minimally present” in 12 of the participants
activity. The study design involved a 1-week test dose [44]. Despite these promising findings, atomoxetine effec-
phase, a 4-week treatment phase, and, for children who tiveness may vary as a function of level of impairment, as
had a positive response to double-blind treatment, an 8- measured by either cognitive ability or ASD symptom se-
week, open-label phase. Results indicated that stimulant verity. Positive results for atomextine are more evident
medication was effective at reducing hyperactivity and im- among children with ASD who are cognitively higher func-
pulsivity in approximately half of the participants, a re- tioning (defined as IQ >70) [45]. In a separate investigation,
sponse rate that is considerably lower than the rates of 70 atomoxetine treatment yielded no observed symptom
to 80 % found in studies of methylphenidate for children reduction in a sample of children with high ASD symptom
with ADHD only [24, 38, 39]. More adverse effects were severity [46].
reported in the children with ASD, and the highest tolerated Guanfacine, an alpha-2 adrenergic agonist approved his-
dose was lower than that tolerated in children without ASD torically for treating hypertension and more recently ap-
[24]. Results also indicated that medication effects were proved for use with ADHD in an extended release
restricted to the target ADHD symptoms (e.g., decreased formulation, Ituniv (Shire; Dublin, Ireland) is used alone
hyperactivity and impulsivity), and no positive effects were and in combination with stimulants to treat children with
found on other behaviors, such as irritability, social with- ADHD [47]. Positive effects have been found in several
drawal, stereotypy, or inappropriate speech [24]. Similar studies using guanfacine for treatment of children with co-
efficacy of methylphenidate was found in a smaller occurring ADHD and ASD symptoms. A retrospective anal-
double-blind, randomized, placebo-controlled study of pre- ysis of 80 patients in the clinic indicated reduction in hy-
school–aged children with a pervasive developmental disor- peractivity and inattention among children with ASD who
der [40]. A 50 % positive response rate was reported, along were higher cognitively functioning (i.e., not in the cogni-
with lower optimal dose and higher side effects, as has been tively impaired range) [48]. Similarly, positive effects on
described in school-aged children. parent- and teacher-rated hyperactivity were also observed
Only 1 study to date has directly compared methylphe- in an open trial examining children who had previously
nidate treatment response between children with ADHD and demonstrated lack of success with methylphenidate [49].
children characterized by ASD plus ADHD [41]. Based on a
retrospective analysis of clinic cases and a small prospective Impact of Medication on Other Aspects of Functioning
clinical trial, Santosh et al. [41] reported overall improve-
ment in ADHD symptoms, with few differences in treat- Reduction in ADHD symptoms has been the primary out-
ment response between the groups. Although these come measure for most medication trials for co-occurring
findings support the use of methylphenidate in children ADHD and ASD. However, 1 secondary analysis of the
with both ADHD and ASD, the results were also consistent Research Units on Pediatric Psychopharmacology Autism
with prior studies that have suggested a greater need for side Network data examined the effects of methylphenidate on
effect monitoring and lower dosing in the context of ASD. social communication skills and self-regulation skills in 33
children with ASD [50]. Weekly observational tasks were
Nonstimulant Medications coded during the 4-week methylphenidate trial, including a
semi-structured caregiver–child interaction and a structured
Given the mixed findings associated with stimulant use, examiner–child interaction. Results indicated that methyl-
other nonstimulant medications have been investigated for phenidate use was associated with several positive social
co-occurring ADHD and ASD symptoms. Atomoxetine, a outcomes, including improved initiation for joint attention,
nonstimulant medication that functions via norepinephrine improved response to bids for joint attention, better self-
and dopamine, has demonstrated better tolerability than regulation, and more regulated affective state [50]. Further
stimulant medications in individuals with co-occurring study is warranted to determine if these gains can be main-
ADHD and ASD [42]. A small placebo-controlled efficacy tained in time and generalized across settings.
Treatment of Co-Occurring ADHD and ASD 521

Summary (and related disruptive behaviors) and ASD originally de-

veloped using operant conditioning procedures, which have
Research generally supports the use of psychopharmacolog- evolved in time to draw on a social learning theory [58].
ical treatments for reducing impairing ADHD symptoms in Whereas both ADHD and ASD include behaviorally orient-
individuals with co-occurring ADHD and ASD, but further ed parenting intervention, the role of the family has been
study is needed to increase understanding of the effective- conceptualized differently [58]. For ADHD, parent interven-
ness and to inform clinical practice. For example, if ADHD tions (“parent training”) typically involve manual, group-
symptoms are effectively treated (i.e., attention is improved, based programs designed to teach parents strategies to man-
disruptive activity levels are reduced), then individuals with age the behaviors of their children (e.g., reduce impulsive
ASD may benefit more from interventions targeting social behavior, increase focus on tasks) [59, 60]. In contrast, ASD
and communication deficits. Several specific limitations of parent interventions (“parent education”) place more em-
the current treatment literature should be addressed in future phasis on individualized treatments that provide parents
studies. First, given that past research samples have been with tools to promote child skills development (e.g., im-
primarily restricted to school-aged children, medication tri- prove social engagement, increase communication attempts)
als are needed to determine treatment guidelines for pre- [61]. While developing a bridge between these 2 interven-
schoolers, adolescents, and adults. Second, several studies tions, traditions may result in an effective intervention for
have pointed to possible differential effects based on level of children who present with co-occurring symptoms and treat-
functioning (e.g., cognitive level, ASD severity), and future ment needs. Programs traditionally designed for ASD may
research should take into consideration both cognitive level benefit from systematically teaching parenting skills to ad-
and ASD severity when evaluating medication response. dress co-occurring disruptive behaviors such as ADHD, and
Finally, an important next step in medication trials will be programs designed to address ADHD may benefit from
to develop and test combined pharmacological and psycho- adding a focus on individual skill development, including
social treatments for co-occurring ADHD and ASD. co-occurring social and communication impairments [58].
Multiple studies have demonstrated that combination
Psychosocial Interventions pharmacological and psychosocial treatments are particular-
ly effective for ADHD symptom management [26, 62]. This
Given that co-occurrence of ADHD and ASD is associated approach may also be indicated for children with co-
with more profound impairments than either ADHD or ASD occurring ADHD and ASD symptoms. To date, 1 published
alone, and considering evidence that medication response is study has used a combined approach for children with ASD,
less adequate in the context of co-occurring symptoms, the but see clinicaltrials.gov for current ongoing research using
need for effective psychosocial treatment is evident. Indeed, combined medication and behavioral approaches [63].
psychosocial interventions (e.g., behavioral therapies, par- Aman et al. [63] primarily targeted aggression in a trial of
ent training, social skills training) are key components of risperdone and parent training, but the combined treatment
treatment for both ADHD and ASD when considered as effects on hyperactivity were also examined [63, 64]. A
independent disorders [51, 52]. For ADHD, empirical sup- manual, individually administered parent training was de-
port exists for behavioral training for parents of children veloped by enhancing standard behavioral training with
with ADHD [53] and cognitive behavioral therapy for af- ASD-specific strategies, such as using visual strategies,
fected adults [54]. In contrast, social skill interventions to allowing more time for discussion of generalization and
reduce social impairments (i.e., social and social communi- maintenance, and allowing 2 individualized sessions [64].
cation problems often associated with ASD) for children Results indicated that children who received parent training
with ADHD are often clinically indicated but have demon- in addition to pharmacological treatment (i.e., risperidone)
strated limited treatment effectiveness [55]. For ASD, early had lower rates of aggression and greater reductions in
intensive behavioral interventions have demonstrated effi- hyperactivity as compared to children who only received
cacy for improving social communication, language, and medication [63].
cognitive outcomes for young children [51, 56]. Other
evidence-based interventions for ASD include behavioral Summary
treatments for anxiety and aggression and group social skills
training [57]. Current behavioral treatments for ASD do not Limited work has examined psychosocial interventions for
specifically target impairing ADHD symptoms. co-occurring ADHD and ASD [42, 65]. Continued research
Although no known psychosocial interventions have is needed to determine which existing psychosocial treatments
been developed to target co-occurring ADHD and ASD, work best for co-occurring symptoms, including both reduc-
there are similarities across approaches that may influence tion of ADHD symptoms for children with ASD and improve-
future treatment development. Treatment for both ADHD ment in social/communication impairments in children with
522 Davis and Kollins

ADHD. Further research characterizing the developmental, treatment. Although both ADHD and ASD are defined by
social, and emotional features of this population may provide childhood onset and persistence into adulthood, the develop-
some of the missing links for the development and testing of mental course observed in the 2 disorders differs. Within
effective psychosocial interventions. ADHD, symptoms may emerge early and diagnostic subtypes
may not be stable for a period of time [73, 74], but impairment
associated with ADHD symptoms typically persists and can
Co-Occurring ADHD and ASD: Key Research Areas be exacerbated by increased demands for independent func-
tioning in adulthood [75, 76]. For ASD, atypical development
Recognition that developmental and psychiatric disorders can be reliability identified by preschool and diagnoses are
rarely manifest as single diagnoses has important implica- very stable for a period of time (i.e., individuals do not
tions not only for understanding etiology and risk factors, outgrow the disorder). Whereas intensive ASD intervention
but also for developing effective interventions [66, 67]. It is services promote communication, social engagement, and
widely believed that cases of “pure” ADHD are relatively adaptive behavior skills, core ASD symptoms typically re-
uncommon, with the majority of individuals also affected by main impairing throughout a lifespan.
a co-occurring psychiatric disorder (e.g., anxiety, opposi- Whereas most research to date has documented trajecto-
tional defiant disorder) or a developmental condition (e.g., ries for ADHD and ASD separately, little is known regard-
learning disability, ASD) [68, 69]. Similarly, ASD is fre- ing developmental trajectories when ADHD and ASD co-
quently accompanied by co-occurring conditions that are occur. Only 1 published study has examined the relation-
targeted for intervention to minimize the impairments that ships between ADHD and ASD symptoms as they develop
are more generally associated with ASD [70–72]. Research for a period of time. St. Pourcain et al. [9] followed over
specifically focusing on co-occurring ADHD and ASD has 5000 participants from ages 4 to 17 years and assessed
only emerged recently, and many studies have focused pri- social communication and hyperactive inattentive traits at
marily on questions of etiology and phenomenology, with multiple time points. Risk profiles were determined using
less direct work on intervention development [11]. In the latent class growth analysis and supported the presence of 2
following section, we identify 4 areas of research that have social communication trajectories (i.e., low risk and
implications for future treatment development. These areas persistently impaired) and 4 hyperactivity inattentive trait
of research include: 1) developmental trajectories, psychiat- trajectories (i.e., low risk, childhood limited symptoms,
ric comorbidities, deficits in social skills, and executive intermediate level symptoms, persistently impaired). Results
functioning. For each research area, we pose the main ques- indicated that children who were persistently impaired in the
tions associated with that topic, review current research domain of social communication were most likely to be
findings, and explore future research directions that may classified in the 2 highest risk groups for hyperactive inat-
inform effective interventions. tentive traits and were least likely to be in the childhood
limited group for hyperactivity inattention. Similarly, chil-
Developmental Trajectories dren with persistently high hyperactive inattentive symp-
toms were almost exclusively classified as persistently
Key Questions impaired in the area of social communication [9]. Despite
several study limitations (e.g., assessment of traits rather
& How do co-occurring ADHD and ASD symptoms de- than disorder, a lack of social communication data prior to
velop in relation to 1 another with time? the age of 8 years old), these findings offer a unique per-
& Do these developmental trajectories differ from expected spective on the interrelationships between ASD and ADHD
trajectories for a single disorder? symptomatology during the course of development. Further
& How will enhanced understanding of co-occurring research using more detailed clinical tools is needed to
symptom trajectories inform both pharmacological and clarify these relationships. For example, findings suggest
psychosocial treatments? that presence of ASD is associated with stability in ADHD
symptoms for a period of time. Given that ASD can typi-
Current Research cally be detected earlier in development than ADHD, it may
be important to examine whether early ASD treatment can
Understanding developmental trajectories for a given disorder influence the stability of ADHD symptoms for a period
is critical to treatment planning. Knowledge regarding the of time.
development and typical course of symptoms can be used to Unlike the longitudinal research by St. Pourcain et al. [9],
identify critical periods for intervention, to describe behavior- most current understanding of co-occurring ADHD and
al profiles that predict risk for a specific outcome, and to ASD for the course of development stems from cross-
inform guidelines for pharmacological versus psychosocial sectional studies. The earliest evidence for ADHD-ASD
Treatment of Co-Occurring ADHD and ASD 523

co-occurrence was reported in a community sample of more considered subthreshold for Diagnostic and Statistical
than 300 pairs of 2-year-old twins. Results indicated modest Manual of Mental Disorders, Fourth Edition diagnosis) may
but statistically significant correlations (r00.23-0.26) be- reduce some of the impairments associated with co-occurring
tween ASD and ADHD symptoms, as measured by the ASD symptoms (e.g., improving social functioning).
Child Behavior Checklist, with associations apparent in Further research is also needed to examine the develop-
both social and nonsocial autistic-like traits [10]. Similar mental changes within each set of symptoms for a period of
associations were reported in a survey of more than 6000 time. For example, the presentation of adult ADHD is char-
families of 8-year-old twins. Results indicated that associa- acterized by a slightly different profile than childhood
tions between ASD and ADHD symptoms ranged from r0 ADHD (i.e., less hyperactivity; more inattention) [54]. It is
0.51 (teacher report) to r0.054 (parent report) [77, 78]. not yet known whether similar changes in ADHD symptoms
Reiersen et al. have also reported phenotypic correlations take place for a period of time in the context of co-
in a series of studies examining ADHD-ASD traits in young occurrence with ASD given that much past research has
adults [15, 65, 79]. focused on hyperactivity in children with less emphasis on
Within clinical samples, co-occurring symptoms of inattentive symptoms and less consideration of older ado-
ADHD and ASD have been documented from preschool lescents and adults. Establishing a better understanding of
through adulthood [2, 5, 80]. Multiple studies have found how ADHD changes for a period of time as a function of co-
ASD traits in individuals diagnosed with ADHD, including occurrence with ASD would have important implications
deficits in social communication, social skills, and repetitive for intervention. Whereas cognitive behavioral strategies are
behaviors [8, 18]. There is some evidence that hyperactivity commonly used to treat adult ADHD, these techniques may
is more commonly associated with younger as compared to need to be altered in the context of ASD in which individ-
older children with ASD [81], which is consistent with the uals may have less insight and self-awareness [54].
observed decline in hyperactivity for individuals with
ADHD and in the general population. Similarly, in a sample Psychiatric Comorbidities
of older school-aged children and adolescents with ASD,
hyperactivity was found to generally diminish in time, but Key Questions
greater levels of hyperactivity were associated with more
severe ASD symptoms [82]. At the same time, co- & What psychiatric comorbidities are commonly associat-
occurrence has also been reported in a clinical sample of ed with co-occurring ADHD and ASD?
adults who experienced ADHD and ASD along with high & How do co-occurring psychiatric problems influence
rates of other psychiatric comorbidity [83, 84]. treatment needs?
& Are standard medications or psychosocial treatments for
Future Research Directions these psychiatric problems effective in the context of
ADHD and ASD?
Current understanding of developmental trajectories in co-
occurring ADHD and ASD is limited by a paucity of longi- Current Research
tudinal studies. Although work by St. Pourcain et al. [9]
suggests associations between impairing symptoms in the Co-morbid psychiatric and developmental disorders are
domains of ADHD and ASD, further research is needed to commonly reported in individuals with ADHD and in indi-
understand how severity of symptoms in 1 domain may viduals with ASD (e.g., mood disorders, anxiety disorders,
influence the emergence of symptoms in the other domain. oppositional defiant disorder, learning disabilities) [68, 70,
Perhaps more importantly, it is not known whether the 71, 86–88]. As research on co-occurring ADHD and ASD
observed associations between ADHD and ASD symptoms has increased, recent studies have revealed a higher risk for
can be altered by specific interventions. For example, de- psychopathology in the context of co-occurring ADHD and
velopmental differences associated with ASD can be ob- ASD [89]. In a series of studies with school-aged children
served prior to 2 years of age [85], whereas distinguishing with ASD, Gadow et al. [19] reported that children with
typical from atypical behaviors in the context of ADHD ASD plus ADHD have more severe anxiety as compared to
may be more challenging at very young ages. Given that children with ADHD only, and as compared to children with
early intensive ASD interventions can have a substantial ASD only [90]. Analyses examining rates of oppositional
impact on ASD symptoms, it will be important to determine defiant disorder (ODD) have been more mixed, with some
whether these early interventions can also mitigate the later evidence suggesting that characteristics of ODD are more
development of impairing ADHD symptoms. Conversely, common among children with ASD who have specific
research has not yet explored whether effective intervention ADHD symptom profiles, but not all cases of co-occurring
for ADHD (perhaps even when symptoms might be ADHD [7]. Other evidence supports higher ODD symptoms
524 Davis and Kollins

in children with ASD plus ADHD when using teacher suggests that comorbid psychiatric conditions may be present
ratings rather than parent ratings [20]. Finally, some evi- from childhood into adulthood, but it is not clear when differ-
dence suggests high rates of substance use disorders, which ent problems emerge in the course of development. In the case
are common in ADHD, but are rarely observed in ASD, in of ADHD, Taurines et al. [68] proposed that different co-
cases of co-occurring ADHD and ASD [91]. occurring conditions arise and influence ADHD differentially
Similar findings have been reported in cases using ADHD, during the course of development. Certain disorders may be
rather than ASD, as the target or primary disorder. Mulligan et present before ADHD symptom onset (e.g., ASD), whereas
al. [8] examined ASD symptoms in 800 children with ADHD for other disorders the onset is likely concurrent with ADHD
and their siblings using the Social Communication Question- symptoms (e.g., learning disabilities) and post-ADHD onset
naire. Among children with ADHD, higher levels of ODD and (e.g., depression, anxiety, substance abuse) [68]. Determining
conduct disorder were associated with more ASD symptoms when symptoms of psychiatric comorbidities manifest in the
(Mulligan et al. [8]). Using a smaller but more rigorously context of co-occurring ADHD and ASD would inform both
ascertained sample of children with ADHD, Grzadzinski et assessment procedures and treatment planning. Future studies
al. [18] used multiple methods to categorize children with should also examine whether adequate treatment of ADHD
ADHD with respect to autism features, including symptoms and ASD symptoms reduces the likelihood of other
from each of these 3 ASD categories: 1) social impairment, 2) psychiatric problems emerging during the course of time
communication impairment, and 3) restricted/repetitive and/or mitigates the impairment caused by these problems.
interests. Of the children classified in the ADHD, plus the Conversely, research is needed to understand whether early
ASD group, significantly more problematic behaviors were treatment of co-occurring psychiatric conditions (e.g.,
also reported including oppositional behavior, withdrawn/ medication management for anxiety) may reduce the
depressed, and total problems as measured by the Child impairment associated with ADHD and ASD symptoms.
Behavior Checklist (CBCL) [18].
Deficits in Social Skills
Future Research Directions
Key Questions
Existing research provides compelling evidence that com-
bined psychiatric problems and co-occurring ADHD and & What is the nature of social impairments in cases of co-
ASD are associated with greater impairment, both during occurring ADHD and ASD?
childhood and adulthood [92]. Clinically, it is clear that & How are deficits in social skills in co-occurring ADHD
treatment considerations are more complex in the context and ASD similar to deficits observed in ADHD or ASD
of greater psychopathology. Because past research samples alone?
have generally excluded participants with complex psycho- & What type of intervention will adequately address the
pathology, there is little data to inform treatment decision- social skill needs of individuals with co-occurring
making for the majority of patients. Many patients present ADHD and ASD?
with multiple comorbid psychiatric symptoms or meet full
diagnostic criteria for another psychiatric condition. How- Current Research
ever, it is not fully understood whether comorbid psychopa-
thology (e.g., mood disorder, anxiety) has the same clinical Although initial interest in co-occurring ADHD and ASD
features when in the context of co-occurring ADHD and focused on hyperactivity in the context of ASD, more recent
ASD. Similarly, some co-occurring psychiatric symptoms work has examined commonalities in observed social defi-
may cause significant impairment, but may not be readily cits. Social problems are not part of the core diagnostic
placed within traditional diagnostic categories. For example, criteria for ADHD; however, social challenges are routinely
affect regulation in the context of ADHD and irritability in recognized in individuals with ADHD. Research suggests
the context of ASD share some common features, but in that children with ADHD are rejected more often by their
both cases it can be difficult to determine if these are true peers [94] and have fewer friends than typically developing
comorbidities rather than features of ADHD or ASD. Al- peers [95]. In many cases, social deficits associated with
though some research has addressed these diagnostic classifi- ADHD are viewed as a direct result of ADHD core symp-
cation issues in each disorder alone [86, 93], further research toms: inattentive behaviors may lead a child to miss social
is needed on categorizing these psychiatric symptoms in the cues during an activity with peers; impulsive behavior may
context of co-occurring ADHD and ASD. result in a child speaking out inappropriately and upsetting
Additional research is also needed to better understand the peers; hyperactive behaviors interfere with organized activ-
role of symptom severity and developmental trajectory on co- ities and lead to avoidance of peers. This profile of deficits
occurring psychiatric disorders. Cross-sectional research in social skills differs from that observed in ASD, in which
Treatment of Co-Occurring ADHD and ASD 525

impairment in the realm of social functioning is central to in impulsive social behavior). In addition, social skills out-
the diagnosis. Social deficits in ASD are characterized by come measures vary in the degree to which they examine
features, such as a lack of interest or enjoyment in social ASD-specific social impairments as compared to the social
engagement, inability to reciprocally participate in interac- deficits commonly observed in ADHD. Developing meas-
tions, and lack of emotional engagement with others [96]. ures that are more specific to the impairments associated
At the same time, heterogeneity is also observed among with ADHD versus ASD may be needed to better under-
individuals with ASD, and some individuals with higher stand outcomes from future interventional studies. Nonethe-
functioning ASD are better described as having interest less, results of this study suggest that the deficits in social
but lacking the skills need to be socially successful. skills associated with ADHD, whether co-occurring with
Recent research suggests that many individuals with ASD or alone, appear to be very difficult to change via
ADHD may experience social impairments that are more structured group social skills intervention, such as those
consistent with those observed in ASD. One study catego- described in the literature [55].
rized the social impairments in children with ADHD as
either associated with relationship difficulty (e.g., conduct Future Research Directions
and affective problems) or associated with social communi-
cation difficulty. Children with the social communication Given the high degree of impairment associated with the
type of impairments were more likely to experience repeti- deficits in social skills in children with both ADHD and
tive behaviors, speech/language impairment, and develop- ASD, and the negative long-term outcomes associated with
mental problems similar to ASD [97]. Furthermore, specific poor social skills [104], gaining a better understanding of
social cognition deficits (e.g., facial affect recognition, em- the social skills profile of children with co-occurring symp-
pathy) that are typically observed in ASD, are often present toms is critical for identifying effective treatment. Future
in individuals with ADHD [98, 99]. These findings not only research is needed to examine the social skill competencies
add to the discussion of shared etiology between the disor- and deficiencies among children with ADHD, ASD, and co-
ders but also highlight the types of deficits in social skills occurring ADHD and ASD. Optimal social skills treatment
that may characterize co-occurring ADHD and ASD. How- for co-occurring ADHD and ASD may require a combina-
ever, little research has examined specific deficits in social tion of techniques that addresses specific areas of impair-
skills (e.g., social problem solving, emotion identification) ment and the unique learning style of these individuals.
in children characterized by co-occurring ADHD and ASD. Treatment features, such as content of the intervention,
Currently, the treatment literature suggests that neither mode of delivery, and methods of reinforcement, need to
pharmacotherapy treatment nor social skills training has a be better understood with respect to the needs of individuals
positive effect on social outcomes for children with ADHD with co-occurring ADHD and ASD. For example, children
alone [55, 100, 101]. In contrast, emerging evidence sug- with co-occurring ADHD and ASD may benefit from ex-
gests that social skills training for children with a diagnosis plicit teaching of foundational social skills (e.g., promoting
of ASD can be effective [51, 102, 103]. It is likely that basic social interest/engagement) in a setting with practice
studies have included children with co-occurring ADHD opportunities among positive peer models (e.g., typical
and ASD, given the high prevalence of co-occurring symp- classroom) and accompanied by a specially designed reward
toms, yet only 1 study has examined the effect of ADHD on system for behavioral reinforcement (e.g., frequent, imme-
treatment outcomes. Results of a 10-week group social skills diate, powerful feedback when skills are used).
training intervention for school-aged children with ASD One promising area for social skills training for these
showed that co-occurring ADHD negatively impacted pro- children includes using parents to support the development
gram efficacy. Outcomes of social skills were rated using the of peer friendships. For children with ADHD and children
Social Skills Rating System (SSRS), a broad measure of with ASD (specifically high functioning ASD), the social
social skills, and were compared among children with ASD, skills training combined with teaching parents to promote
ASD plus anxiety, and ASD plus ADHD. Children with friendship skills (e.g., coaching the child to call a peer) may
ASD and co-occurring ADHD failed to gain social skills, be effective for improving social skills [95, 105–107].
whereas children with ASD without ADHD and children Further research on the role of parents in promoting social
with ASD and anxiety both increased in overall social skills skills in the context of co-occurring ADHD and ASD may
after the intervention [23]. These findings raise a number of be particularly important. The treatment literature for both
questions for future social skills research with this popula- disorders has emphasized parental involvement in contrast-
tion. Specifically, it is not clear from this study how much of ing ways; either the parents provide environmental contin-
the content of the intervention addressed the specific deficits gencies to promote behavioral change (ADHD) or they
of the children with ASD and ADHD (e.g., relative empha- coach child skill development (ASD). Optimal parent
sis on ASD deficits in conversation skills vs ADHD-deficit involvement to promote social skills development for
526 Davis and Kollins

co-occurring ADHD and ASD may involve a marriage research is needed to understand the developmental nature
of these approaches. of executive function in this population.
Some researchers have advocated that executive functions
Executive Functioning can be enhanced through diverse intervention programs, such
as computerized training, exercise, mindfulness, and specially
Key Questions designed school curricula [117]. With respect to ADHD, there
is emerging support for computer-based attention training
& Are there unique deficits in executive functioning asso- programs at improving specific skills, however, findings are
ciated with co-occurring ADHD and ASD in compari- still mixed with respect to generalization and sustained benefit
son with ADHD and ASD alone? [118]. Several recent studies have demonstrated support for
& How can greater knowledge of neuropsychological school-based exercise interventions in promoting executive
strengths and weaknesses in co-occurring ADHD and functioning [119], along with 1 identified study that showed
ASD influence treatment development? positive effects of mindfulness training on executive function
[120, 121]. Even fewer studies have been published on inter-
Current Research vention specifically to address executive function in the con-
text of ASD, and no known studies have examined this
Neuroimaging and neuropsychological studies have shown question in individuals with co-occurring ADHD and ASD
that executive functioning deficits are common in both symptoms [122].
ADHD and ASD, with slightly different areas of impairment
observed [11, 108–111]. The presence of ADHD is consis- Future Research Directions
tently associated with impaired performance on inhibition
tasks (e.g., Stroop tasks) and sustained attention tasks (e.g., Current understanding of the executive functioning profile
continuous performance task) [110]. With respect to ASD, associated with co-occurring symptoms is limited, given that
impaired performance is typically observed on tasks that few studies have included individuals with co-occurring
require planning and flexibility of thought (e.g., shifting ADHD and ASD and limited work has been done to integrate
attention) [112]. Overall, past research has suggested that findings into a developmental perspective. Specifically, it is
ADHD and ASD can be differentiated from 1 another on a not yet known whether co-occurring ADHD and ASD is
neuropsychological level during childhood and adulthood associated with a unique, and potentially more impairing, set
[109, 113]. However, there may be evidence for variability of neuropsychological deficits as compared to ADHD or ASD
even within diagnostic categories. Corbett et al. [114] ex- alone. Another outstanding gap in the literature relates to
amined executive functioning in children with ADHD, examining the association between performance on laboratory
ASD, and typical development and found that a subset of tasks and everyday functioning [123]. Until understanding of
children with ASD had cognitive profiles consistent with executive impairment moves beyond discrete laboratory
those observed in ADHD (e.g., deficits in vigilance and measures to more real-world applications, it will be challeng-
inhibitory control). These findings raise questions about ing to develop highly specialized interventions that can pro-
possible co-occurrence of ADHD and ASD. vide sustained benefit.
Relatively few studies have specifically examined exec-
utive functioning profiles among individuals with co-
occurring ADHD and ASD. Results from 2 recent studies Summary and Future Directions
suggest that children with co-occurring ADHD and ASD
may have a unique cognitive profile. Yerys et al. [115] Interest in the co-occurrence of ADHD and ASD has grown
found greater overall cognitive impairments, including poor tremendously in the last decade, with multiple published
overall global executive control, cognitive flexibility, and studies addressing questions of heritability and shared
verbal working memory, in children with ASD who also had etiology [13, 15, 124], as well as common phenotypic and
hyperactivity. Similarly, Sinzig et al. [116] found disorder- endophenotypic features [17, 42]. The majority of
specific impairments consistent with past research, but not- treatment-focused research has examined pharmacological
ed that children with ASD who had ADHD symptoms also treatment via traditional ADHD medication [35]. With re-
displayed deficits in inhibition. In contrast to these findings spect to psychosocial treatment, very few studies have ex-
among children, results from a recent study of adults with amined behavioral interventions that directly address co-
ADHD, ASD, and co-occurring ADHD/ASD found overall occurring symptoms, and existing treatment studies have
impairment in executive functioning in these groups, but rarely examined outcomes based on co-occurring symptoms
there was no evidence that co-occurring ADHD and ASD profiles [23]. Based on these studies and others, many
was associated with greater deficits [83]. Clearly, further clinicians and researchers have advocated for changes to
Treatment of Co-Occurring ADHD and ASD 527

the diagnostic criteria to allow co-diagnosis of ADHD and occurrence [51, 128]. However, early identification relies on
ASD [2, 18]. These changes are currently being considered improved diagnostic measures to facilitate assessment pro-
for the upcoming revision of the Diagnostic and Statistical cedures and identification of co-occurring symptoms. Re-
Manual and will likely be incorporated into the Diagnostic cent efforts to move toward dimensional approaches to
and Statistical Manual, Fifth Edition [125–127]. Permitting defining impairment may be beneficial for cases of co-
co-diagnosis will facilitate advances in research by elimi- occurring ADHD and ASD, given the multiple outstanding
nating the exclusion of many patients and allowing more questions about co-occurrence. Regardless, further research
heterogeneous samples. Clinically, DSM-5 changes will will yield needed information to inform intervention devel-
provide diagnostic clarification for clinicians who are al- opment and maximize benefits for affected individuals.
ready treating patients with both ADHD and ASD symp-
toms and will facilitate pharmacological and psychosocial Required Author Forms Disclosure forms provided by the authors
treatment studies to guide care. are available with the online version of this article.
Given the paucity of treatment research on this popula-
tion, this review focused on 4 key topics: 1) developmental
trajectories, 2) comorbid psychiatric conditions, 3) deficits References
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