Research in Developmental Disabilities 70 (2017) 175–184

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Research in Developmental Disabilities

journal homepage: www.elsevier.com/locate/redevdis

Inattention and hyperactivity/impulsivity among children with MARK

attention-deficit/hyperactivity-disorder, autism spectrum disorder,
and intellectual disability
⁎
Maryellen Brunson McClaina, , Amber M. Hasty Millsb, Laura E. Murphyc
a
Utah State University, Emma Eccles Jones College of Education and Human Services, Department of Psychology, 2800 Old Main Hill, Logan, UT
84322, USA
b
Glenwood Autism and Behavioral Health Center, 150 Glenwood Lane, Birmingham, AL, 35242, USA
c
University of Tennessee Health Science Center (UTHSC), Boling Center for Developmental Disabilities (BCDD) and UTHSC Department of Psychiatry,
711 Jefferson Avenue, Memphis, TN 38105, USA

AR TI CLE I NF O AB S T R A CT

Number of completed reviews is 2. Background: Attention-Deficit/Hyperactivity Disorder (ADHD), Autism Spectrum Disorder
Keywords: (ASD), and Intellectual Disability (ID) are common co-occurring neurodevelopmental disorders;
Co-occurring neurodevelopmental disorders however, limited research exists regarding the presentation and severity of overlapping symp-
Inattention tomology, particularly inattention and hyperactivity/impulsivity, when a child is diagnosed with
Hyperactivity/impulsivity one of more of these neurodevelopmental disorders.
Autism spectrum disorder Aims: As difficulties with inattention and hyperactivity/impulsivity are symptoms frequently
Intellectual disability associated with these disorders, the current study aims to determine the differences in the se-
Attention-deficit/hyperactivity disorder
verity of inattention and hyperactivity/impulsivity in children diagnosed with ADHD, ASD, ID,
and co-occurring diagnosis of ADHD/ID, ASD/ADHD, and ASD/ID.
Methods and procedures: Participants in the current study included 113 children between the ages
of 6 and 11 who were diagnosed with ADHD, ASD, ID, ADHD/ID, ASD/ADHD, or ASD/ID. Two
MANOVA analyses were used to compare these groups witih respsect to symptom (i.e., in-
attention, hyperactivity/impulsivity) severity.
Outcomes and results: Results indicated that the majority of diagnostic groups experienced ele-
vated levels of both inattention and hyperactivity/impulsivity. However, results yielded differ-
ences in inattention and hyperactivity/impulsivity severity. In addition, differences in measure
sensitivity across behavioral instruments was found.
Conclusions and implications: Children with neurodevelopmental disorders often exhibit in-
attention and hyperactivity/impulsivity, particularly those with ADHD, ASD, ASD/ADHD, and
ADHD/ID; therefore, differential diagnosis may be complicated due to similarities in ADHD
symptom severity. However, intellectual abilities may be an important consideration for prac-
titioners in the differential diagnosis process as children with ID and ASD/ID exhibited sig-
nificantly less inattention and hyperactive/impulsive behaviors. Additionally, the use of multiple
behavior rating measures in conjunction with other assessment procedures may help practi-
tioners determine the most appropriate diagnosis.

What this Paper Adds

⁎
Corresponding author.
E-mail addresses: maryellen.mcclainverdoes@usu.edu (M.B. McClain), amills@glenwood.org (A.M. Hasty Mills), lmurphy@uthsc.edu (L.E. Murphy).

http://dx.doi.org/10.1016/j.ridd.2017.09.009
Received 18 February 2017; Received in revised form 18 August 2017; Accepted 15 September 2017
0891-4222/ © 2017 Elsevier Ltd. All rights reserved.
M.B. McClain et al. Research in Developmental Disabilities 70 (2017) 175–184

Attention-Deficit/Hyperactivity Disorder, Autism Spectrum Disorder, and Intellectual Disability are neurodevelopmental dis-
orders that exhibit some overlap in symptoms, including inattention and hyperactivity/impulsivity. The current paper adds to the
extant literature by providing additional information about how symptoms of inattention and hyperactivity/impulsivity are pre-
sented in ADHD, ASD, and ID as well as co-occurring ADHD/ID, ASD/ADHD, and ASD/ID. Comparing the severity of inattention and
hyperactivity/impulsivity ratings across these disorders has direct implications for practitioners, particularly during the diagnostic
process. The current paper presents results that will help practitioners better understand the presentation of inattention and hy-
peractivity/impulsivity across these diagnostic categories as well as how this knowledge may impact diagnostic considerations.

1. Introduction

1.1. DSM-IV-TR, DSM-5, and Co-occurring neurodevelopmental disorders

The recent shift from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition − Text Revision (DSM-IV-TR;
American Psychiatric Association, 2000) to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; APA,
2013) has changed how several disorders are defined. With regard to neurodevelopmental disorders, these changes have impacted
how clinicians conceptualize and diagnose Autism Spectrum Disorder (ASD), Attention-Deficit/Hyperactivity Disorder (ADHD), and
Intellectual Disability (ID). Modifications range from simple (e.g., change in name or age of onset) to more complex (e.g., criteria for
diagnosis). One of the most profound changes is the acknowledgement of the co-occurrence of these neurodevelopmental disorders.
ADHD, ASD, and ID are common co-occurring disorders (APA, 2013). Notably, ID is one of the more common co-occurring
diagnoses in individuals with ASD as approximately between 30% and 80% of children with ASD also meet criteria for ID (Baio, 2014;
Itzchak, Lahat, Burgin, & Zachor, 2008; Leyfer et al., 2006). Children with dual diagnoses of ASD and ID do not respond as positively
to treatment as they tend to exhibit slower gains in skills acquisition than children with either diagnosis in isolation (APA, 2013;
Matson & Shoemaker, 2009). Given the high rates of co-occurring ID and ASD plus the negative impact that a dual diagnosis has on
outcomes, the DSM-5 requires that clinicians determine if intellectual impairments are co-occurring with ASD. In addition to being
commonly diagnosed in conjunction with ASD, ID can also co-occur with individuals who have ADHD. In fact, individuals who have
ID are at greater risk for an ADHD diagnosis (APA, 2013; Neece, Baker, Blacher, & Crnic, 2011; Neece, Baker, Crnic, & Blacher, 2013;
Strømme & Diseth, 2000) with prevalence rates of co-occurring ADHD and ID as high as 14% (Dekker & Koot, 2003) in comparison to
the 1% in the general population (APA, 2013). Estimated prevalence rates of co-occurring ASD and ADHD in children range from 20%
to 50% (Azizian, 2005; Levy et al., 2010).
DSM-5 criteria do not preclude clinicians from making a co-occurring diagnosis of ASD/ADHD or ADHD/ID (APA, 2013).
However, in order for an ADHD diagnosis to be made in conjunction with ASD or ID, deficits in inattention and hyperactivity/
impulsivity should be more severe than expected given the child’s mental age. Thus, in theory, not all children with ID who ex-
perience elevated levels of ADHD symptoms will meet criteria for an ADHD diagnosis due to delays in intellectual development in
comparison to same-age peers without ID.
Although the DSM-5 deems a dual diagnosis of ADHD and ID appropriate when developmental functioning is taken into con-
sideration, the research regarding the possibility of co-occurring ADHD and ID is mixed. Some research has suggested that ADHD is
not prevalent in children who have intellectual disabilities when controlling for their developmental age (Burack, Evans,
Klaiman, & Iarocci, 2001). However, other research has demonstrated that ADHD may be an appropriate diagnosis for those with ID
and shown that, even when controlling for mental age, children with ID still exhibit clinically significant levels of inattention and
hyperactivity/impulsivity (Antshel, Phillips, Gordon, Barley, & Faraon, 2006; Hastings, Beck, Daley, & Hill, 2005; Voigt, Barbaresi,
Colligan, Weaver, & Katusic, 2006). Given the symptom overlap and conflicting research regarding co-occurring ADHD and ID,
clinicians may struggle with differential diagnosis and determining if a diagnosis of ADHD/ID or solely ID best explains elevated
ADHD symptoms in children with ID.
Differential diagnosis difficulties also exist with ASD and ADHD. In fact, the DSM-IV-TR indicated that, due to symptom overlap,
co-occurring diagnoses of ADHD and Pervasive Developmental Disorder (now referred to as ASD) were mutually exclusive (APA,
2000). The DSM-5, however, indicates that ASD may co-occur with ADHD when the individual shows elevated inattention, hyper-
activity, and/or impulsivity that exceed peers of similar mental age (APA, 2013). Nevertheless, given the limited research, it may be
difficult for clinicians to tease apart if inattention and hyperactivity/impulsivity are best explained by a single diagnosis of ADHD or
ASD or a co-occurring diagnosis of ASD/ADHD.

1.2. Common overlapping symptoms across neurodevelopmental disorders

There are several examples of overlapping symptoms across ADHD, ASD, and ID. Inattention and hyperactivity/impulsivity are
both commonly seen in ADHD and ID. For example, Neece et al., (2013) found that approximately 40% of adolescents with ID
exhibited elevated levels of inattention and/or hyperactivity/impulsivity in comparison to their typically developing, same-age
counterparts. Simonoff, Pickles, and Gringras (2007) also reported that hyperactivity was more associated with children with ID in
comparison to inattention. When comparing the ADHD symptom severity levels of children with ADHD and ADHD/ID, Ahuja, Martin,
Langley, and Thapar (2013) did not find any significant differences, indicating that both children with ADHD and ADHD/ID exhibited
the similar levels of inattention and hyperactivity/impulsivity. Previous research has also shown that in children with ID and ADHD,
parent-reported ADHD symptom severity decreased as children age (Hastings et al., 2005). Furthermore, intelligence level impacts
ADHD symptom severity in children; Voigt et al. (2006) found that children with ID met criteria for an ADHD diagnosis more

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frequently than children without ID.

Many studies also suggest symptom overlap between ASD and ADHD (e.g., Mayes, Calhoun, Mayes, & Molitoris, 2012; Ronald,
Larsson, Anckarsater, & Lichtenstein, 2014; Taurines et al., 2012). Children with ASD often exhibit some features of ADHD and vice
versa. In some instances symptom overlap can be extensive enough to cause young children with ASD to be misdiagnosed with a sole
diagnosis ADHD (Levy et al., 2010; Matson, Rieske, & Williams, 2013). Moreover, ADHD symptoms are among the most common
mental health concerns for children and young adults with ASD according to teacher and parent reports. In a study examining ADHD
symptoms in children with ASD, teachers and parents indicated that 60% of participants were easily distracted, 50% of participants
experienced difficulty concentrating, and between 42% and 44% showed increased activity levels and restlessness (Lecavalier, 2006).
Although inattention and hyperactivity/impulsivity are the primary symptoms and diagnostic criteria for an ADHD diagnosis
(APA, 2013), many children with ADHD also experience social deficits, which is a diagnostic criterion for ASD. For example, parents
rated children with ADHD as having social skill deficits commonly seen in children ASD (Clark, Feehan, Tinline, & Vostanis, 1999).
Notably, parents reported that their children did not understand the feelings of others, had trouble making friends, experienced
difficulty initiating and sustaining conversations, exhibited unusual speech, and displayed poor nonverbal communication. They also
reported that their children exhibited stereotyped body movements (Clark et al.), which is also an ASD diagnostic criterion under the
category of restricted and repetitive patterns of behavior, interests, or activities (APA, 2013). More recent research has also high-
lighted symptom overlap in females with ADHD. In these studies, females with ADHD were more socially inappropriate than same-
aged female peers without ADHD and rated themselves as having stronger social skills than exhibited in actuality, which is similar to
females with ASD (Ohan & Johnston, 2007; Ohan & Johnston, 2011). The additional symptom overlap related to deficits in social
communication and restricted patterns of behavior further complicates the diagnostic process for clinicians.
While the DSM-IV-TR used an exclusionary clause for a dual diagnosis of ASD/ADHD due to the overlapping symptoms (APA,
2000), the publication of the DSM-5 has suggested that clinicians should consider the appropriateness of assessing for ASD symptoms
in children diagnosed with ADHD (APA, 2013; Clark et al., 1999; Gargaro, Rinehart, Bradshaw, Tonge, & Sheppard, 2011;
Grzadzinski et al., 2011). However, research varies regarding the percentage of children with ASD who also meet criteria for an
ADHD diagnosis. Some estimates have suggested that 4.5% of toddlers with ASD also meet criteria for ADHD, which is not sig-
nificantly different from the prevalence rates of ADHD in typically developing toddlers (Turygin et al., 2013). Conversely, other
findings propose ADHD is the most common co-occurring psychological disorder in children with ASD and that as high as 26% to 28%
of children with ASD also meet criteria for ADHD (Goldstein & Schwebach, 2004; Simonoff et al., 2008). Of note, these differences
may be accounted for by participant age; the mean age of participants was 8.5 years in the Goldstein and Schwebach study whereas
participants did not exceed 3 years of age in the Turygin and colleagues study. As a reliable ADHD diagnosis may be difficult to
achieve prior to 4 years of age (APA, 2013), estimating the prevalence of ADHD symptoms in toddlers, with or without ASD, may
inherently be an inaccurate.
Given the recent changes in the DSM-5, research focusing explicitly on exploring ADHD symptoms in children diagnosed with
neurodevelopmental disorders, particularly ASD, is limited. However, findings from the research that does exist is mixed. For ex-
ample, current findings have suggested that children diagnosed with ASD/ADHD evidenced significantly more symptoms of ASD,
ADHD, or both ADHD and ASD than children diagnosed solely with ADHD or ASD (Sprenger et al., 2013; Jang et al., 2013). Other
results have found that children with ASD/ADHD show an increase in the severity of symptoms associated with ASD and ADHD for
some traits, and not others (Yerys et al., 2009). Specifically, children with ASD/ADHD had more problems with executive functioning
and working memory as compared to children with ASD; however, no differences regarding impulsivity and inhibition were noted. In
addition, children with ASD/ADHD showed more ASD symptomatology as measured by a parent report, but no differences in
symptomology were found as a result of autism-specific testing or structured interviews (Yerys et al., 2009). Other research has
indicated that children with ASD/ADHD exhibit significantly lower adaptive skills (Sikora, Vora, Coury, & Rosenberg, 2012). In order
to provide clinicians with useful information to guide them in the diagnostic process, additional research solidifying symptoms is
needed.
In addition to focusing on ADHD symptoms among children with ASD and ASD/ADHD, prior research has also focused on
individuals who have a dual diagnosis of ASD/ID. Children with co-occurring diagnoses of ASD/ID may exhibit more severe levels of
inattention and hyperactivity/impulsivity as compared to children with a sole ID diagnosis. Specifically, it has been shown that as
much as 52% of participants with ASD/ID show clinically significant signs of hyperactivity/impulsivity and inattention, whereas only
19% of participants with a diagnosis of only ID showed clinically significant symptoms of ADHD (Bradley & Isaacs, 2006). These
results indicate that ADHD is warranted as a co-occurring diagnosis with ASD.

1.3. Study purpose

In light of the recent changes regarding the co-occurrence and issues surrounding differential diagnosis of ASD, ADHD, and ID due
to symptom overlap, additional research investigating ADHD-related symptoms across these neurodevelopmental disorders is needed.
This is a particularly important topic now that the DSM-5 endorses the practice of diagnosing ASD and ADHD together (APA, 2013).
In addition, little research has examined the impact that cognitive functioning has on the level of inattention, hyperactivity, and
impulsivity an individual with ASD or ADHD may exhibit. Furthermore, many children diagnosed with ASD and ADHD also have a
co-occurring diagnosis of ID, making this a particularly important area of research. Clinicians are faced with determining the most
appropriate diagnosis or co-occurring diagnoses and understanding the symptoms present in children with ADHD, ASD, and/or ID has
become increasingly more important.
Given the relevance and importance of the topic, the current study aims to determine the differences in inattention and

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Table 1
Demographic Information across Diagnostic Groups (N = 113).

ADHD ASD ID ADHD/ID ASD/ADHD ASD/ID

n = 20 n = 16 n = 20 n = 16 n = 16 n = 25

△
Age
Mean 89.65 95.25 93.40 90.31 89.99 91.24
SD 11.175 21.057 15.859 14.836 19.923 14.486
Range 72–113 72–138 76–132 77–126 72–132 73–130

Sex
Male 18 14 13 14 13 22
Female 2 2 7 2 3 3

Race/Ethnicity
Black 7 6 12 8 7 15
White 12 9 5 7 9 5
Hispanic 1 1 2 1 0 4
Other 0 0 1 0 0 1

△
Months.

hyperactivity/impulsivity severity in children diagnosed with ADHD, ASD, ID, co-occurring ADHD and ID (i.e., ADHD/ID), co-
occurring ASD and ADHD (i.e., ADHD/ID), and co-occurring ASD and ID (i.e., ASD/ID). The current paper is exploratory in nature as
the extant research regarding inattention and hyperactivity/impulsivity in these populations is limited, and the existing results are
inconsistent.

2. Material and methods

2.1. Participants

Data from the current study were part of a larger research project at a university development center in a southern state and
included information for children ranging from 2 to 18 years of age. All children seen at the clinic were referred for a psychological
evaluation by licensed professionals (e.g., pediatricians) due to concerns of possible developmental disabilities. All participants’
caregivers consented to the use of assessment data in research. Participants in the current study were 113 children between the ages
of 6 and 11. Although a wide age range of children were seen in the clinic, this particular study focused on children ages 6–11 as this
age range provided sufficient sample size for all study groups. Further, this age range necessitated the use of only one version of the
Behavior Aassessment System for Children − Second Edition, Parent Rating Form − Child Version (BASC-2; Reynolds & Kamphaus,
2008) and one version of the Attention Deficit Disorders Evaluation Scale − Third Edition, School Age Version (ADDES-3;
McCarney & Arthaud, 2004).
Participants were diagnosed with ADHD (n = 20), ASD (n = 16), ID (n = 20), a dual diagnosis of ADHD/ID (n = 16), a dual
diagnosis of ASD/ADHD (n = 16), or a dual diagnosis of ASD/ID (n = 25). Diagnostic determinations were made by a psychology
team composed of a licensed psychologist and an advanced clinical psychology student from an APA accredited Ph.D. program using
direct observation of the child, parent diagnostic interview reports, and adherence to DSM diagnostic criteria. Differences were
resolved by consensus. The team of psychologists was not blinded to the rating scales; however, a subsample of 31 children were seen
by two participating psychologists instructed to avoid reviewing behavior rating scales and only had access to the child’s IQ and
adaptive scores. Each psychologist independently recorded their diagnosis on a form prior to a discussion. The diagnoses in this inter-
rater reliability study were consistent for 28 of the 31 participants (r = 0.90). The psychologist differed on: 1. ASD vs ASD/ID, 2.
ADHD/ASD vs. ASD, and 3. ADHD/ID vs ADHD. The final diagnosis was resolved by discussion.
Ninety-four participants were male and 19 were female. Participants’ caregiver(s) identified their children as Black (n = 55),
Caucasian (n = 47), Hispanic (n = 9), or as another race/ethnicity (n = 2). There was not a significant difference in gender χ2 (5,
N = 53) = 6.28, p = 0.280 or race/ethnicity across groups, χ2 (15, N = 113) = 16.71, p = 0.337. See Table 1 for detailed parti-
cipant information.
Three separate one-way ANOVAs were conducted to examine any differences in age, full scale intellectual quotients (FSIQs), and
adaptive skills across group. FSIQs were measured by either the Stanford-Binet Intelligences Scales, Fifth Edition (SB5; Roid, 2003) or
the Wechsler Preschool and Primary Scale of Intelligence, Fourth Edition (WPPSI-IV, Wechsler, 2014); 110 participants were ad-
ministered the SB5 and 3 were administered the WPPSI-IV. The intelligence test used during the evaluation was chosen based on
relevant factors (e.g., child age, presenting concerns) by the lead psychologist. Adaptive skills were measured by the Vineland
Adaptive Behavior Scale, Second Edition (VABS-II; Sparrow, Cicchetti, & Balla, 2005). The VABS-II total score was used in analyses
(Tables 2 and 3).
Participant age did not significantly differ across groups F (5, 107) = 0.329, p = 0.895. Results yielded a significant difference in
FSIQ [F (5, 107) = 22.278, p < 0.001] and adaptive skills [F (5, 75) = 3.487, p = < 0.01]. Regarding FSIQ, post hoc analyses
using Tukey HSD indicated that participants with ADHD (M = 82.65, SD = 13.65) had significantly higher FSIQ than participants

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Table 2
Cognitive, Adaptive, and ADHD Specific Measures across Diagnostic Groups (N = 113).

ADHD ASD ID ADHD/ID ASD/ADHD ASD/ID

n = 20 n = 16 n = 20 n = 16 n = 16 n = 25

Full Scale IQ
Mean+ 82.65 82.31 52.80 64.19 82.25 54.88
SD 13.65 16.50 10.32 10.35 13.67 14.60

Adaptive Skills
Mean+ 71.55 77.31 59.42 71.30 80.54 71.30
SD 26.99 10.80 12.89 4.60 10.96 4.60

Inattention
ADDES-3○ 4.35^ 5.63^ 6.40^ 4.69^ 5.44^ 7.00
SD 3.18 3.03 2.91 2.82 1.97 2.16
BASC-2▼ 72.10* 67.63^ 69.45^ 71.50* 68.31^ 66.88^
SD 6.27 7.05 6.70 6.69 4.81 7.81

Hyperactivity/Impulsivity
ADDES-3○ 5.30^ 6.69^ 7.10 4.25^ 6.25^ 6.76^
SD 3.88 2.09 3.21 2.79 2.62 3.13
BASC-2▼ 70.45* 65.00^ 57.70 64.63^ 67.56^ 58.96
SD 14.59 9.96 12.07 13.29 13.05 13.02

▼
+
Standard Score; T-Score; ○Scaled Score; ^Elevated Score.

Table 3
One-Way MANOVA Effects and Significant Post Hoc Comparisons*.

Group Comparison Mean Difference df F p Effect Size

ADDES-3 Inattention – 5 2.601 0.029 .108+

ADHD vs. ASD/ID 2.650 – – < 0.05 0.86○
ADDES-3 Hyperactivity/Impulsivity – 5 2.227 < 0.057 .057+
BASC-2 Inattention – 5 1.955 .084+
BASC-2 Hyperactivity/Impulsivity – 5 3.010 < 0.05 .123+
ADHD vs. ID 12.75 – – < 0.05 0.95○
ADHD vs. ASD/ID 11.49 – – < 0.05 0.83○

*
Due to the high number of comparison, the current table on reflects significant effects and subsequent post hoc results.
+η2 ○
; Cohen’s d.

with ID (M = 52.80, SD = 10.32, p < 0.001), ASD/ID (M = 54.88, SD = 14.60, p < 0.001), and ADHD/ID (M = 64.19,
SD = 10.34, p < 0.01). Furthermore, participants with ID (M = 52.80, SD = 10.32, p < 0.000) had significantly lower FSIQ than
participants with ADHD/ID (M = 64.19 SD = 10.35, p < 0.05), ASD/ADHD (82.25, SD = 13.67, p < 0.000), and ASD
(M = 82.31, SD = 16.50, p < 0.000). Moreover, participants with ASD/ID (M = 54.88, SD = 14.60) had significantly lower FSIQ
than participants with ASD (M = 82.31, SD = 16.50, p < 0.000) and ASD/ADHD (M = 82.25, SD = 13.67, p < 0.000). Finally,
participants with ADHD/ID (M = 64.19, SD = 10.34) exhibited significantly lower FSIQs than participants with ASD (M = 82.31,
SD = 16.50, p < 0.01) and ASD/ADHD (M = 82.25, SD = 13.67, p < 0.01). Pertaining to adaptive skills, participants with ID
(M = 59.42, SD = 12.89) had significantly lower adaptive skills than participants with ASD (M = 77.31, SD = 10.80, p < 0.05)
and ASD/ADHD (M = 80.54, SD = 10.96, p < 0.01). As measures of intellectual and adaptive functioning deficits are requirements
for a diagnosis of ID, these results were expected.

2.1.1. Diagnoses
Diagnoses were obtained during the aforementioned comprehensive psychological evaluation. Assessment teams consisted of one
licensed psychologist as well as a doctoral-level graduate student and/or postdoctoral psychology trainee. Evaluations consisted of a
semi-structured diagnostic interview conducted by the licensed psychologist with caregiver(s), behavioral observations, completion
of parent rating forms (e.g., the BASC-2) and the administration of standardized measures of intelligence (e.g., Stanford Binet
Intelligence Scales, Fifth Edition or the Wechsler Preschool and Primary Scale of Intelligence, Fourth Edition), academics (e.g.,
Bracken Basic Concept Scale, Revised or the Kauffman Achievement Test for Children, Third Edition), adaptive behavior (e.g.,
Vineland Adaptive Behavior Scale, Second Edition), and symptom-specific measures (e.g., Autism Diagnostic Observation Schedule,
Second Edition or the Conners, Third Edition). The previously mentioned measures are not an exhaustive list. Specific measures used
were tailored to the unique presenting concerns of the child. Although various measures were used to determine diagnoses, in the
present study, measures used in data analyses included: (1) the BASC-2 (Reynolds & Kamphaus, 2008) and (2) the ADDES-3
(McCarney & Arthaud, 2004). At the time of the initial data collection, the most recent editions of the BASC and the ADDES were
used.

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2.2. Measures

2.2.1. Attention deficit disorders evaluation scale, third edition (ADDES-3)

The ADDES-3 is a 46-item parent/caregiver report that measures ADHD symptoms (i.e., inattention and hyperactivity/im-
pulsivity) in children. The ADDES-3 was normed on 2848 children ages 4–18. This measure yields scaled scores for Inattentive and
Hyperactive/Impulsive domains and provides a percentile rank to represent total ADHD symptom concerns. On the ADDES-3, lower
scaled scores represent more severe symptoms. Specifically, a scaled score less than or equal to 4.0 indicates that a child engages in
clinically significant levels of hyperactivity and/or inattention in comparison to same-aged peers. In addition, a scaled score greater
than 4.0 and less than 7.0 indicates a child is at-risk for inattention and/or hyperactivity/impulsivity. Psychometrically, the ADDES-3
shows good test-retest (coefficients ranging from 0.82–.86) and inter-rater (coefficients ranging from 0.85–0.87) reliability across all
domains. Internal consistency reliability was also strong (r = 0.98; McCarney & Arthaud, 2004). For consistency in describing like-
symptoms across measures in the current paper, the Inattentive domain will be referred to as inattention and the Hyperactive/
Impulsive domain will be referred to as hyperactivity/impulsivity.

2.2.2. Behavior assessment system for children, second edition (BASC-2)

The BASC-2 is a broadband measure of children’s current behavioral, social-emotional, and adaptive functioning. For the purposes
of the present study, two subscales (i.e., Hyperactivity and Attention Problems) were examined. On the BASC-2, higher T-scores
represent more severe symptoms. Specifically, a T-score greater than or equal to 70 indicates that a child engages in clinically
significant levels of hyperactivity and/or inattention in comparison to same-aged peers. In addition, a T-score between 60 and 69
indicates that a child is at-risk of attention problems and/or hyperactivity/impulsivity. Both subscales used in the current study have
an internal consistency coefficient of 0.85. Hyperactivity (r = 0.86) and Attention Problems (r = 0.85) have similar test-retest
coefficients (Reynolds & Kamphaus, 2008). For consistency in describing similar symptoms across subtests, the Hyperactivity subscale
will be referred to as hyperactivity/impulsivity and the Attention Problems subscale will be referred to as inattention.

2.3. Procedures

As part of the psychological evaluation, participants’ caregiver(s) underwent a diagnostic interview, completed relevant rating
scales, and signed the IRB-approved research consent prior to the assessment with the child. On a subsequent date, the caregiver(s)
and the child participated in a comprehensive psychological evaluation, which included a brief follow-up to the previously conducted
diagnostic clinical interview as well as the administration of adaptive measures with the caregiver(s) and behavioral observations by
members of the psychology team.

2.3.1. Data analyses

Data analyses were performed using two one-way multivariate analysis of variances (MANOVAs). Group sizes were initially
unequal with the ADHD group substantially larger than the others. Therefore, the researchers randomly selected 20 participants using
IBM SPSS Statistics 24 (SPSS, 2016) to include in the analyses. Assumptions for normality, linearity, and homogeneity of variance
were met. The multicollinearity assumption was met for all dependent variables. The first MANOVA examined the mean differences
in inattention and hyperactivity/impulsivity, as measured by the ADDES-3 across diagnoses. The second MANOVA examined the
mean differences in inattention and hyperactivity/impulsivity across diagnoses, as measured by the BASC-2, across diagnoses. Post-
hoc analyses (Tukey HSD) were conducted to examine individual mean comparisons when appropriate.

2.3.2. Independent and dependent variables

Diagnosis (i.e., ASD, ADHD, ID, ADHD/ID, ASD/ADHD, and ASD/ID) was the independent variable in the current study. ADHD
symptoms (i.e., inattention, hyperactivity/impulsivity) as measured by the ADDES-3 and the BASC-2 were the dependent variables
used in the first and second MANOVAs, respectively.

3. Results

3.1. Evaluation of inattention and hyperactivity/impulsivity across diagnoses and measures

Prior to statistical analyses, mean standardized inattention and hyperactivity/impulsivity scores were examined. On the ADDES-3,
all groups, with the exception of ASD/ID, exhibited elevated scores (i.e., in the at-risk or clinically significant range) for inattention.
All groups, with the exception of ID, exhibited elevated scores for hyperactivity/impulsivity on the ADDES-3. Participants diagnosed
with ADHD and ADHD/ID showed the most severe levels of inattention and hyperactivity/impulsivity on the ADDES-3, respectively.
The ASD/ID and ID groups demonstrated the least severe levels of inattention and hyperactivity/impulsivity on the ADDES-3, re-
spectively.
On the BASC-2, and similar to the ADDES-3, all groups evidenced elevated scores on inattention. All groups, with the exception of
ID and ASD/ID, exhibited elevated scores on hyperactivity/impulsivity on the BASC-2. Participants with ADHD exhibited the most
severe symptoms of both inattention and hyperactivity/impulsivity on the BASC-2. The ASD/ID and ID groups had the least severe
scores of inattention and hyperactivity/impulsivity on the BASC-2, respectively.

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3.2. Attention problems and hyperactivity/impulsivity across diagnoses and measures

A one-way MANOVA tested for differences in ADHD symptoms (both inattention and hyperactivity/impulsivity) as measured by
the ADDES-3 across diagnoses. Results indicated significant differences in inattention [F (5, 107) = 2.601, p < 0.05, partial
η2 = 0.108], but not hyperactivity/impulsivity [F (5, 107) = 2.227, p = 0.094, η2 = 0.057]. Tukey HSD post hoc analyses were
conducted; comparisons across all groups were made. Results showed that participants diagnosed with ADHD (M = 4.35, SD = 3.18)
exhibited significantly more inattention than children diagnosed with ASD/ID (M = 7.00, SD = 2.92, p < 0.05).
A second one-way MANOVA tested for differences in ADHD symptoms as measured by the BASC-2 across diagnoses. Results from
the one-way MANOVA did not show significant differences in inattention [F (5, 107) = 1.955, p < 0.091, partial η2 = 0.084];
however, results yielded significant differences in hyperactivity/impulsivity [F (5, 107) = 3.010, p < 0.05, partial η2 = 0.123].
Tukey HSD post hoc analyses were conducted; comparisons across all groups were made. Participants with ADHD (M = 70.45,
SD = 14.59) exhibited significantly higher levels of hyperactivity/impulsivity than participants with ID (M = 57.70, SD = 12.07,
p < 0.05) and ASD/ID (M = 58.96, SD = 12.07, p < 0.05).

4. Discussion and implications

The current study examined the differences in ADHD symptoms (i.e., inattention and hyperactivity/impulsivity) across several
independently- and co-occurring neurodevelopmental disorders. For children with ADHD, ASD, ADHD/ID, ASD/ID, and ASD/ADHD
elevations (i.e., in the at-risk or clinically significant ranges) in inattention were observed on the broad-band (BASC-2) and/or
disorder-specific (ADDES-3) instruments. These results align with previous reports that children with ID exhibit less severe ADHD
symptoms in comparison to children with ASD/ID (Bradley & Isaacs, 2006). Overall findings also align with previous research that
suggests that children with neurodevelopmental disorders exhibit elevated levels of inattention and hyperactivity/impulsivity in
comparison to their neurotypical peers (e.g., Mayes et al., 2012; Neece et al., 2012; Ronald et al., 2014).
Results yielded differences in sensitivity when measuring ADHD symptoms in children with neurodevelopmental disorders.
Specifically, only the ADDES-3 detected any significant differences in inattention whereas only the BASC-2 detected significant
differences in hyperactivity/impulsivity. ADDES-3 analyses showed that children with ADHD exhibited significantly higher levels of
inattention than children with ASD/ID. BASC-2 results concluded that participants with ADHD exhibited significantly more hyper-
activity/impulsivity than participants with ASD/ID or ID. According to these findings, children with ASD, ADHD, and co-occurring
ASD/ADHD and ADHD/ID exhibit similar levels of inattention and hyperactivity/impulsivity. The similarities in ADHD symptom
severity across children with ADHD, ASD, and ASD/ADHD contradicts previous findings that suggest a dual diagnosis of ASD/ADHD
is associated with more severe ADHD symptoms (Jang et al., 2013). However, results corroborate results that have indicated no
differences in ADHD symptoms severity in children with ADHD and ADHD/ID (Ahuja et al., 2013).

4.1. Implications for practitioners

Findings from the current study are pertinent for practitioners in several ways. First, noteworthy differences in the use of the
ADDES-3 and BASC-2 to identify ADHD symptoms in children with neurodevelopmental disorders were found. Specifically, the only
significant difference in inattention across diagnoses (ADHD vs. ASD/ID) was found when using the ADDES-3. Conversely, significant
differences in hyperactivity/impulsivity across diagnoses (ADHD vs. ID; ADHD vs. ASD/ID) were found only when using the BASC-2.
The ADDES-3 appears to differentiate inattention severity across neurodevelopmental disorders better than the BASC-2 and the BASC-
2 seems to differentiate hyperactivity/impulsivity across neurodevelopmental disorders better than the ADDES-3. However, it is
important to note that, although not significant, results regarding BASC-2 attention problems and ADDES-3 hyperactivity/impulsivity
were approaching significance. As such, given the overlapping ADHD symptoms across neurodevelopmental disabilities and the
finding that different measures do not differentiate ADHD symptoms across neurodevelopmental disorders equally, practitioners will
likely benefit from utilizing multiple rating forms when assessing ADHD symptomology in children with neurodevelopmental dis-
abilities (Matson & Cervantes, 2014). Moreover, these results should be interpreted in conjunction with other information collected
during the evaluation, such as behavioral observations and informant reports.
Second, results highlight the importance of interpreting elevated results from ADHD-specific measures during differential diag-
nosis. For example, a child with ASD may exhibit elevated levels of inattention or hyperactivity/impulsivity, but an additional ADHD
diagnosis may, or may not, be appropriate as a co-occurring diagnosis. Differential diagnosis of neurodevelopment disorders requires
careful attention to the etiology and topography behavioral presentations. Elevated scores alone are not necessarily indicative of the
presence of ADHD; rather, it is the role of the diagnostician to interpret findings within the context of the child's history. In order to
navigate differential diagnosis scenarios such as this, practitioners are encouraged to thoroughly review results from rating forms
(e.g., examining individual items), follow-up with parents to gain a better understanding of the specific behaviors that have influ-
enced their rankings on the behavior rating forms, and take detailed behavioral observations of the child during the evaluation.
Given the importance of understanding ADHD symptom severity in children with neurodevelopmental disorders, it is suggested
that practitioners consider evaluating for the presence and, if applicable, severity of inattention and hyperactivity/impulsivity during
evaluations. However, as various measures may differ in ability to differentiate ADHD symptoms across neurodevelopmental dis-
orders, it is recommended that practitioners use more than one standardized rating form in conjunction with behavioral observations
and interviews to determine ADHD symptom severity. Both a broad-band and ADHD-specific rating scale contribute to differential
diagnosis.

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4.2. Limitations and future research

The current study has noteworthy limitations and suggestions for future research. First, data were from a developmental dis-
abilities clinic. As a result, researchers were not blind to participant diagnoses and used the BASC-2 and ADDES-3 to inform the
diagnostic process. Thus, some of the differences in diagnostic groups may be inherent to the evaluation process. However, if the
diagnosing psychologist was solely influenced by the rating scales, one might expect greater differences in the group means than seen
in the study. In fact, although the ADDES-3 and BASC-2 were used to inform the clinicians, these measures were not solely used to
make a diagnosis; instead, information from all facets of the psychological evaluation were used holistically. Furthermore, while the
current results provide initial understanding of ADHD symptoms across various neurodevelopmental disabilities in children, future
research should further examine the relation between ADHD symptoms, cognitive abilities, and neurodevelopmental disorders with
researchers who are blind to the participant’s diagnoses. If the research is being conducted in a clinical setting similar to the current
study, it is suggested that additional measures of ADHD symptoms, not associated with diagnostic decision-making, be administered
to parents/caregivers.
Secondly, more recent editions of both the ADDES and the BASC were published after the start of the present study. As such, the
current findings are most applicable for the third edition of the ADDES and the second edition of the BASC; thus, findings may not be
generalizable to newer editions. More research studies exploring the link between ADHD symptoms, cognitive abilities, and neu-
rodevelopmental disorders using the updated editions of the ADDES and BASC, as well as other behavioral measures not used in the
present study (e.g., Conners Third Edition) is needed. In addition, changes in the ADHD diagnostic criteria are reflected in the fourth
edition of the ADDES as it aligns with the DSM-5 criteria (McCarney & Arthaud, 2013), which may provide additional differences in
parent-reported ADHD symptoms in children with neurodevelopmental disorders. Furthermore, ADHD symptom severity was
measured by parent reports in the current study. Future studies should examine ADHD symptom severity from others’ perspectives
(e.g., teacher and self-reports). Teachers’ reports as well as more objective cognitive data may provide clinicians with additional
information to help with differential diagnosis. Teacher reports may be of particular importance given that, for an ADHD diagnosis,
symptoms must be occurring in more than one setting (APA, 2013). Teacher reports provide important perspectives on a setting other
than the home (i.e., the classroom).
Thirdly, participants in the current study were within a specific age bracket that was assessed at one time point. As such, results
are only generalizable to school-aged children (ages 6 through 11). Additionally, results are not longitudinal in nature and only
represent the functioning of the participants on one date. ADHD symptoms in children with neurodevelopmental disabilities may
present differently depending on age (Turygin et al., 2013; Hastings et al., 2005), which impacts differential diagnosis and treatment
recommendations. More research that examines ADHD symptoms severity for children with various neurodevelopmental disorders
and across several age ranges both at one time point and longitudinally would contribute to an understanding of differences in ADHD
symptoms severity at specific ages, but also how these differences change overtime.
Another limitation is the lack of refined differential measurement of attention. With rare exception, all neurodevelopmental
disability study groups demonstrated inattention regardless of the rating scale. The Matson et al. (2013) review presents evidence of
different attention problem presentations. More refined measurement of sustained attention vs. the inability to shift attention may be
helpful in differential diagnosis.
Finally, intellectual abilities and adaptive skills were broadly taken into consideration and were conceptualized by a diagnosis of
ID or no ID. However, specific FSIQ scores on these measures were not used in analyses. Subsequently, a relation between specific
ranges of intellectual abilities and adaptive behavior was not examined. Thus, additional research that examines differences in ADHD
symptoms for children with ADHD/ID based on intellectual abilities (e.g., FSIQ, specific neurocognitive profiles) and adaptive skills is
warranted. Moreover, given the importance of evaluating ADHD symptoms in comparison to developmental levels for children with
ID and the mixed results of the extant research, comparison of ADHD symptom severity across neurodevelopmental disorders when
taking into account developmental functioning is essential.

4.3. Conclusions

The current study found that both the BASC-2 and the ADDES-3 are useful measures in determining the presence of elevated
ADHD symptoms, namely inattention and hyperactivity/impulsivity, in children with neurodevelopmental disorders. Results further
indicated that the ADDES-3 and the BASC-2 have unique strengths in their capacity to differentiate between inattention and hy-
peractivity/impulsivity in children with various neurodevelopmental disorders. Regarding ADHD symptom severity, the majority of
participants across diagnoses experienced elevated levels of inattention and hyperactivity/impulsivity. Overall, ADHD symptoms
appear to be frequently reported in children with neurodevelopmental disorders, particularly ADHD, ASD, ASD/ADHD, and ADHD/
ID.

Funding source

This work was supported in part by the Maternal Child Health Bureau of Health Resources and Administration, U.S. Department of
Health and Human Services (DHS HRSA Grant MC00038-24), and the Administration for Developmental Disabilities, U.S.
Department of Health and Human Services (DHHS Grant 90DD0003-04).

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Conflict of interests

The authors of this article certify that they have no affiliations with or involvement in any organization or entity with any
financial or non-financial interest or non-financial interest in the subject matter or materials discussed in this manuscript.

Acknowledgements

We would like to thank Tera Bradley, Lauren Gardner, and Sarah M. Irby for their assistance with this research.

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