By Yael Leitner
Symptoms of attention deficit hyperactivity disorder (ADHD) and autistic spectrum disorder (ASD) often co-occur. The DSM-IV had specified that an ASD diagnosis is an exclusion criterion for ADHD, thereby limiting research of this common clinical co-occurrence. As neurodevelopmental disorders, both ASD and ADHD share some phenotypic similarities, but are characterized by distinct diagnostic criteria. The present review will examine the frequency and implications of this clinical co-occurrence in children, with an emphasis on the available data regarding pre-school age. The review will highlight possible etiologies explaining it, and suggest future research directions necessary to enhance our understanding of both etiology and therapeutic interventions, in light of the new DSM-V criteria, allowing for a dual diagnosis.
In the last decade, studies have reported increased prevalence of both attention deficit hyperactivity disorder (ADHD) and autistic spectrum disorders (ASD). While ADHD is defined by impaired functioning in the areas of attention, hyperactivity, and impulsivity, whereas ASD is characterized by core social dysfunction and restrictive-repetitive behaviors, studies show that between 30 and 50% of individuals with ASD manifest ADHD symptoms (particularly at pre-school age), and similarly, estimates suggest two-thirds of individuals with ADHD show features of ASD (Davis and Kollins, 2012). Recent findings from the Autism Treatment Network (ATN) database suggest that co-occurrence of ADHD and ASD is associated with a lower quality of life and poorer adaptive functioning than in any one of these conditions (Vora and Sikora, 2011). Both disorders often include difficulties in attention, communication with peers, impulsivity, and various degrees of restlessness or hyperactivity. Both are more common in boys than in girls, and present, at least partially, at pre-school age. Both disorders have a known genetic pre-disposition, with comorbidity within the same individual and across family members, and both syndromes cause significant behavioral, academic, emotional, and adaptive problems in school, at home, and elsewhere. (Rao and Landa, 2013).
Evidence for common neurobiological substrates has been found through similarities in neuropsychological profiles in individuals with both disorders (Gargaro et al., 2011; Rommelse et al., 2011). It has been shown that children with ADHD have pragmatic language difficulties similar to children in the ASD spectrum (Bishop and Baird, 2001). Further neuropsychological similarities are suggested by a study of emotional recognition and theory of mind, which showed that children with ADHD could not be distinguished from those with ASD (Buitelaar et al., 1999). A study on social perspective taking showed children with ADHD used lower levels of social perspective taking coordination in their definition of problems, identification of feelings, and evaluation of outcomes than children without ADHD, and these differences persisted after the role of language abilities, intelligence, and oppositional and conduct problems were taken into account (Marton et al., 2009).
Despite the growing body of research pointing at the frequent co-occurrence of these two disorders, the previous DSM-IV-TR has not allowed a dual diagnosis. The DSM-V, in its revised ADHD diagnostic criteria, recognizes the frequency of this co-occurrence and allows, for the first time, a co-morbid diagnosis of ADHD with autism spectrum disorder. This new attitude will not only allow for more efficient clinical management of these children, but will also clear the way for a more precise scientific understanding of the overlap of these two disorders. While most research to date has documented developmental trajectories for ADHD and ASD separately, little is known regarding their co-occurrence, particularly at young pre-school age. PUBMED was searched using the definition “co-occurrence of ASD and ADHD in pre-school children.” This led to only 35 studies, and therefore search was broadened to include the more general definition of the “co-occurrence of ASD (or social-communication difficulties) and ADHD in children.” More than 150 articles were eventually reviewed.