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of Child Neurology

Down Syndrome and Attention-Deficit/Hyperactivity Disorder (ADHD)

Sivan Ekstein, Benjamin Glick, Michal Weill, Barrie Kay and Itai Berger
J Child Neurol 2011 26: 1290 originally published online 31 May 2011
DOI: 10.1177/0883073811405201

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Original Article
Journal of Child Neurology
26(10) 1290-1295
Down Syndrome and Attention-Deficit/ ª The Author(s) 2011
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Hyperactivity Disorder (ADHD) DOI: 10.1177/0883073811405201
http://jcn.sagepub.com

Sivan Ekstein, MD1,2, Benjamin Glick, MD2, Michal Weill, MD2,

Barrie Kay, MD1, and Itai Berger, MD1

Abstract
Clinicians might minimize the prevalence of behavioral disorders among mentally retarded people. Decreased attention,
hyperactivity, and impulsivity are frequently reported in children with Down syndrome, yet the exact prevalence of
attention-deficit/hyperactivity disorder (ADHD) has not been clearly estimated in this population. The objective of this
study was to estimate the prevalence of ADHD in children with Down syndrome and to emphasize the possible
relationship between ADHD symptoms and the level of mental retardation and common medical comorbidity. In this
study, the prevalence of ADHD among Down syndrome children was very high, reaching 43.9%. No significant correlation
was found between ADHD symptoms and the level of mental retardation, but significant correlation was found with
ophthalmologic problems. We conclude that children with Down syndrome are at increased risk for ADHD. When
evaluating children with Down syndrome for attention deficits, psychiatric comorbidity as well as medical problems should
be carefully taken into consideration.

Keywords
Down syndrome, attention-deficit/hyperactivity disorder, comorbidity, ADHD

Received January 25, 2011. Received revised March 6, 2011. Accepted for publication March 6, 2011.

Down syndrome is considered the leading major genetic cause
of mental retardation.1 Children with Down syndrome present
different degrees of cognitive disabilities including comorbid
behavioral traits and/or psychiatric disorders.2,3
In the past, the idea that persons with mental retardation could
have coexisting mental illnesses was not accepted.4 It was
widely believed that all behavioral disturbances in mentally
retarded people were linked to the cognitive impairment and did
not require further diagnostic consideration or evaluation.4 In
recent years, there has been wider recognition that the mentally
retarded can also have a coexisting psychiatric disorder.4,5
Moreover, researchers indicate that the prevalence of psy-
chiatric disorders in people with developmental disabilities,
including mental retardation, is much higher than in the general
population.6,7 Some authors even use the term diagnostic
overshadowing referring to clinicians who minimize the
significance of emotional disorders in persons with mental
retardation and may be displaying overshadowing judgmental
bias.8,9 The diagnosis of comorbid disorder is important
because such individuals have higher mortality rates and are
more disabled than those with psychiatric illness alone.10 The
most significant neurologic/psychiatric/behavioral disorders
in mentally retarded persons are disorders of attention, mood,
personality, and thought processes.11 The prevalence of comor-
bid psychiatric disorders in individuals with mental retardation
is estimated with a wide range, from 15.55% to 36%, and even
up to 57% to 64%.12-14 A possible explanation for the high rate
is that individuals with developmental disabilities have lower
coping abilities because of limited cognitive, communication,
and adaptive abilities.15 Environmental as well as genetic fac-
tors may also contribute.3
Decreased attention span, difficulty in concentration, hyper-
activity, and impulsive behavior are frequently reported in
children with Down syndrome, yet the exact prevalence of pro-
fessionally diagnosed attention-deficit/hyperactivity disorder
(ADHD) was not clearly estimated in this population.4,16,17
The objective of this study is to estimate the prevalence
of ADHD in children with Down syndrome and to emphasize
the possible relationship between ADHD symptoms and
the level of mental retardation and/or common medical
comorbidities.
1
Pediatric Neurology Unit, Hadassah-Hebrew University Medical Center,
Jerusalem, Israel
2
Child Development Center, Meuchedet Health Services, Jerusalem, Israel
Corresponding Author:
Itai Berger, MD, Pediatric Neurology Unit, Hadassah-Hebrew University
Medical Center, Mount Scopus, PO Box 24035, Jerusalem, 91240 Israel
Email: itberg@hadassah.org.il

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Ekstein et al
Methods
Participants included all children diagnosed with Down syndrome
who were evaluated by the Down Syndrome Multidisciplinary Clinic
of Meuchedet Health Services in Jerusalem, from January 2008 to
January 2010. This clinic provides timely neurodevelopmental as well
as medical evaluation and support for children with Down syndrome
and their families in Jerusalem.
The diagnosis of ADHD was made by a pediatric neurologist
based on the Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV-TR edition).18
The diagnostic procedure included an interview with the children
and parents, fulfillment of questionnaires based on DSM-IV-TR by
parents and teachers, and neurological examination.
Inclusion criteria included the complete diagnostic procedure as
described above, available details regarding cognitive abilities, and
medical conditions, which might have an effect on clinical symptoms
of ADHD as recorded from medical files.
Exclusion criteria included the following: age < 5 years, lack of
full available information regarding fulfillment of appropriate diag-
nostic procedure and/or inclusion criteria, and another known mental
disorder (schizophrenia, pervasive developmental disorder [PDD],
psychotic, mood, anxiety, personality, or dissociative disorders).
Statistical analysis performed using SPSS 17 program (Statistical
Product and Services Solutions, 17 version, SPSS Inc, Chicago, Illinois).
Continuous data were reported as mean + standard deviation (SD).
Ordinal data were reported as numbers and percentages. Comparisons
between groups were tested for statistical significance using Fisher
exact 2-tailed tests or 2-tailed t tests for independent samples as
appropriate.
Ethical approval was received from the Internal Review Board of
Meuchedet Health Services.
Results
From January 2008 to January 2010, 84 children diagnosed
with Down syndrome were evaluated in the clinic. A total of
43 children were excluded from the study: 23 were younger
than 5 years of age and 20 had incomplete medical records,
missing parts of necessary information as described in exclu-
sion criteria. In all, 41 children were eligible for the study.
Among this group, 18 children (43.9%) fulfilled the criteria
of ADHD diagnosis according to the DSM-IV-TR criteria,
9 of them (22%) were treated by methylphenidate.
It is important to clarify that the data provided describe the
condition of the children at the first clinic visit. The diagnosis
of medical conditions was leading to appropriate treatment and
follow-up as needed.
Age and gender. The study population contained 24 males
(58.5%) and 17 females (41.5%). No significant association
was found between gender and ADHD (P ¼ .524) in this group.
Mean age at evaluation was 8 years (range, 5-16 years). Mean
age between the groups (ADHD and non-ADHD) was not
significantly different.
ADHD and intellectual disability. Children were evaluated for
cognitive dysfunction by the Wechsler Preschool and Primary
Scale of Intelligence-Revised.19
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1291
Table 1. Distribution of Intellectual Disability Among Study
Population
MR Level Frequency % (of total)
Mild MR 7 17.1
Mild to moderate MR 14 34.1
Moderate MR 12 29.3
Moderate to severe MR 3 7.3
Total 36 (out of 41 children) 87.8
Abbreviation: MR, mental retardation.
Full results were available in 36 (87.8%) children. Table 1
describes the distribution of intellectual disability level among
the study population. Table 2 describes the distribution of
ADHD in correlation with intellectual disability level. No
significant correlation was found between ADHD symptoms
and the level of mental retardation (P ¼ .542).
ADHD and sensory deficits. Ophthalmologic disorders (mainly
refractive errors) were documented in 21 (51.2%) children. A
significant correlation was found between visual difficulties
and the presence of ADHD symptoms (P ¼ .028). Table 3
describes the prevalence of ADHD regarding ophthalmologic
disorders, before necessary correction. Some degree of hearing
loss was documented in 21 (51.2%) patients. No significant
correlation was found between hearing loss and ADHD
symptoms (P ¼ .756).
ADHD and sleep disturbances. Problems in sleep such as snor-
ing, sleep apnea, and frequent arousals were described in 10
(24.4%) of the patients. No significant correlation was found
between ADHD and sleep disturbances (P ¼ .724).
Discussion
The diagnosis of ADHD in mentally retarded individuals is
challenging. According to the DSM-IV-TR edition, the symp-
toms of ADHD should be at a degree that is maladaptive and
inconsistent with developmental level, and do not occur
exclusively during the course of other mental disorders such
as mood, anxiety, dissociative, or personality disorders.18
Although intellectual disability was not mentioned as exclu-
sion criteria in the DSM-IV-TR, in the past it was common
to assume that attention and hyperactivity symptoms resulted
simply from the developmental delay, and an additional diag-
nosis was not often proposed.20 Only in recent years, data
concerning comorbidity in individuals with mental retarda-
tion have been published, and several studies estimated the
specific prevalence of ADHD in this population.4,15,17,21,22
In their review,22,(p285) Deutsch et al mention that ‘‘the long-
standing controversy about the definition of attention deficits in
intellectual developmental disabilities stems from a widely
held opinion that such deficits are inherent to intellectual dis-
abilities.’’ At the same time, these and other researchers
declared that attention deficits and the symptomatology
1292 Journal of Child Neurology 26(10)

Table 2. Distribution of ADHD Symptoms According to Intellectual Disability Level

Non-ADHD ADHD Total

Intellectual disability level Mild MR Number 2 5 7

% 28.6 71.4 100.0
Mild to moderate MR Number 8 6 14
% 57.1 42.9 100.0
Moderate MR Number 7 5 12
% 58.3 41.7 100.0
Moderate to severe MR Number 1 2 3
% 33.3 66.7 100.0
Total Number 18 18 36
% 50.0 50.0 100.0
Abbreviations: ADHD, attention-deficit/hyperactivity disorder; MR, mental retardation.

associated with ADHD appear with greater frequency in people Table 3. Prevalence of ADHD Regarding Ophthalmologic
with intellectual disabilities.4,16,17,22,23 However, they also Abnormalities
warn that ‘‘the epidemiology of ADHD in mental retardation
was in a very early stage of investigation and that good esti- Non-ADHD ADHD Total
mates of the base rates of ADHD symptoms in mental retarda- Ophthalmologic No Number 15 5 20
tion were not yet currently available.’’22,(p286),23 abnormality % 75.0 25.0 100.0
The prevalence of ADHD diagnosed according to the Yes Number 8 13 21
DSM-IV-TR was 13.5% in a sample of 184 individuals with % 38.1 61.9 100.0
mental retardation.11 In a sample of 474 individuals 7 to 20 Total Total 23 18 41
years old with intellectual disability, 14.8% met the criteria for % 56.1 43.9 100.0
ADHD according to the DSM-IV.13 Using the ICD-10, 15.7% Abbreviation: ADHD, attention-deficit/hyperactivity disorder.
of children were diagnosed with hyperkinesias from a sample
of 178 children aged 8 to 13 years.24 In a recent study, Fidan ADHD was diagnosed in 30%.32 The high prevalence of
et al explained why it is especially important to address this ADHD found in our study requires discussion regarding pos-
issue in a group with known etiology, because the rate of sible factors.
ADHD among 167 children and adolescents with mental retar-
dation of unknown etiology was 41.7%.21
Down syndrome is of special interest among intellectual Cognitive performance. According to the DSM-IV-TR
disability populations, with birth prevalence of 8.32 to criteria, the diagnosis of ADHD in a person with intellectual
14.47 per 10 000 live births.25,26 This is therefore the most disability is possible if the symptoms of inattention, impulsiv-
common chromosomal disorder in the population.27 This fact ity, and hyperactivity are disproportionate with the mental age
is even more significant in Jerusalem where the prevalence is and result in significant academic or social impairment.18
17.75 per 10 000 live births, higher than in other medical cen- Theoretically, these subjective instructions may lead to bias
ters (personal communication with Prof M. S. Schimmel, and false results, because the assessment can be easily biased
Shaare-Zedek Medical Center, Jerusalem, Israel). This high and depends on cultural and personal views.4 The degree of
prevalence is attributed to the uniqueness of our population, mental impairment in Down syndrome is variable, ranging
mainly ultra-Orthodox Jewish mothers, who have a high rate from mild (IQ: 50-70) to moderate (IQ: 35-50), and occasion-
of delivery over the age of 35 years and high parity and who ally to severe (IQ: 20-35).33
abstain from prenatal screening and abortions because of This fact might have biased previous studies. This possible
strong theological and cultural beliefs.28,29 In our population, bias can be isolated or overcome when the cognitive perfor-
the prevalence of ADHD among children with Down syn- mance of the study group is known and the participants are
drome aged 5 to 16 years was 43.9% according to the DSM- matched with the appropriate (same mental age) control
IV-TR criteria. This number is higher than previously group.22 In such a comparison, attention deficits and the symp-
described. Hyperkinetic disorder among children with devel- tomatology associated with ADHD indeed appear with greater
opmental delay according to ICD-9 was reported in 9% of 193 frequency in intellectual developmental disability samples than
children with Down syndrome aged 6 to 17 years.30 Hyperki- in matched samples drawn from the general population.22 In
nesia was found in 16% of 178 children according to the this study, we used the same available criteria (DSM criteria)
ICD-10 criteria.24 Määttä et al reported a 33% prevalence of used in other studies, but this study includes a relatively iso-
ADHD symptoms in 129 adults with Down syndrome through lated group of children because all of them share a common
the evaluation of health records.31 Green et al evaluated a cultural background and the cognitive performance was deter-
group of 13 Down syndrome children aged 2 to 4 years; mined in most of them (87.8%). Moreover, in this study, no

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Ekstein et al
significant correlation was found between ADHD symptoms
and the level of mental retardation. Current results support the
results of a previous study.21,32
Medical problems. Among Down syndrome children there is
an increased risk of hearing loss (75%), eye disease (60%),
including cataracts (15%), and severe refractive errors (50%),
obstructive sleep apnea (50%-75%), and thyroid disease
(15%).28 All of these disorders can impair attention and beha-
vior and mimic ADHD.
Sensory deficits are especially important, while discussing
ADHD, because within the lateral prefrontal cortex there are
preferential targets of projections from visual, auditory, and
somatosensory cortices associated with directing attention
and monitoring responses for specific tasks.34 Abnormalities
in the sensorimotor region of the brain are associated with
ADHD.34,35 It is suggested that reactivity to sensory input
reflects a link between perception and action, and that
abnormalities in this reactivity might reflect impairment in
perception-to-action mechanisms.34,36,37 ADHD individuals
are impaired in tasks requiring sensorimotor function, attention,
and inhibition. Dock Stader et al proved abnormal sensory mod-
ulation in adult ADHD suggesting a possible underlying deficit
in the perception-to-action system.38
In this study, significant correlation was found only between
ADHD diagnosis and ophthalmologic problems (mainly
refractive errors). Visual deficits, such as abnormal or
immature saccade eye movements, are suggested as part of the
dysfunction in response inhibition among ADHD children.39
Oculomotor findings suggest that deficits in prefrontal func-
tions, in particular response inhibition, contribute to behavioral
abnormalities observed in ADHD.40 It is possible that visual
deficits may be especially debilitating to individuals with
intellectual impairments, resulting in more restricted adaptive
behavior and problem solving repertoires.41 Another
explanation is that visual attention is the main difficulty among
children with Down syndrome, thus ophthalmic impairment
has a more significant effect. This hypothesis is supported by
the finding that individuals with Down syndrome had deficits
in visual spatial working memory in comparison with controls,
while asked to process more than 1 item at a time.42 The
limitations of the study include a relatively small number of
children, and the fact that comorbid psychopathology was not
separately evaluated. The rate of psychiatric comorbidity in
Down syndrome might be relatively high including mood dis-
order, phobia, and pervasive developmental disorder.43
The presence of another psychopathology might complicate
the diagnosis of ADHD in Down syndrome because there
might be some overlap in symptoms. To overcome this prob-
lem, a psychopathology rating scale has been developed for
children with mental retardation, suggested for use in screening
and for help in the analysis of the relationship between certain
behavior problems and psychopathology.44 We did not use this
scale in this study but the medical files of all participants were
carefully evaluated to search for the diagnosis of another
known mental disorder such as schizophrenia, pervasive
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1293
developmental disorder, and psychotic, mood, anxiety,
personality, or dissociative disorders. It is important to men-
tion that even after using the psychopathology rating scale
in 60 children with Down syndrome aged 4 to 21 years, atten-
tion deficit behaviors were still a common diagnosis.10 This
data further supports the results of the current study.
As stated by others,21,22 many aspects of ADHD in mental
retardation such as epidemiology, proper diagnostic methods,
appropriate recommendations for clinicians and parents, and
teachers’ assessment of tolerance and expectations are all in
a very early stage of investigation and good estimates where
conclusions are not yet currently available.
Conclusions
This study demonstrates that children with Down syndrome are
at an increased risk for ADHD with a prevalence as high as
43.9%. It also demonstrates the special difficulties in making
the diagnosis among children with mental disabilities. We con-
clude that when evaluating children with Down syndrome for
attention deficits, psychiatric comorbidity as well as medical
problems should be carefully taken into consideration. More
research is needed to determine the preferred assessment
methods and behavioral and medical treatment approach
among these patients.
Acknowledgments
This study was performed at the Child Development Center,
Meuchedet Health Services, Jerusalem, Israel.
Author Contributions
SE and IB participated in study design, data analysis, and wrote the
first draft of the manuscript. BG and MW participated in study design,
data collection, and analysis. BK participated in data analysis. All
authors participated in manuscript preparation and approved its final
version.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to
the authorship and/or publication of this article.
Financial Disclosure/Funding
The authors received no financial support for the research and/or
authorship of this article.
Ethical Approval
The Internal Review Board of Meuchedet Health Services approved
the study.
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