Neuropsychology

© 2021 American Psychological Association 2021, Vol. 35, No. 8, 809–821

ISSN: 0894-4105 https://doi.org/10.1037/neu0000768

Development of Executive Functioning From Childhood to Young Adulthood

in Autism Spectrum Disorder and Attention-Deficit/Hyperactivity Disorder:
A 10-Year Longitudinal Study
Ingrid Nesdal Fossum1, 2, Per Normann Andersen3, Merete Glenne Øie2, 4, and Erik Winther Skogli1
1
Division of Mental Health Care, Innlandet Hospital Trust, BUP Lillehammer, Lillehammer, Norway
2
Department of Psychology, University of Oslo
3
Department of Psychology, Inland Norway University of Applied Sciences
4
Research Department, Innlandet Hospital Trust, Lillehammer, Norway
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Objective: This 10-year longitudinal study investigated the developmental trajectories of executive
functioning (EF) in individuals with autism spectrum disorder (ASD) or attention-deficit/hyperactivity
disorder (ADHD), compared to typically developing (TD) individuals from childhood into young
adulthood. Method: There were 173 participants at baseline (T1; ASD = 38 (eight with co-occurring
ADHD), ADHD = 85, TD = 50; Mage = 11.7 years, SD = 2.1), 168 at 2-year follow-up (T2) and 127
at 10-year follow-up (T3). Participants were assessed with three neuropsychological tests aimed at
capturing central components of EF: working memory/Letter–Number Sequencing Test (LNS),
inhibition/Color–Word Interference Test, Condition 3 (CWIT3), and flexibility/Trail Making Test,
Condition 4 (TMT4). Test results were analyzed using linear mixed models (LMM). Results: At
baseline, the TD participants outperformed the ASD and ADHD participants on all three tests. From T1
to T2, the ASD participants had less improvement than the ADHD and TD participants on the LNS test
( p = .007 and .025, respectively), while having more improvement on the CWIT3 relative to the TD
participants ( p = .027). From T2 to T3, the ADHD participants had less improvement on the LNS test
than the ASD and TD participants ( p = .004 and .021, respectively). Conclusions: The ASD and
ADHD groups mainly displayed similar maturation on the neuropsychological measures, and displayed
continuous impairment relative to the TD group. The need for support and facilitation of EF in school,
workplace, and social arenas might continue into young adulthood among certain individuals with ASD
and ADHD.

Key points
Question: How does executive functioning (EF) develop from childhood into young adulthood in
individuals with autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD) and
typically developing (TD) individuals? Findings: The ASD and ADHD groups mainly showed similar
development for results on three neuropsychological tests aimed at capturing central components of EF,
and continuous impairment relative to the TD group. Importance: The clinical groups did not catch up
with the performance of the TD group by young adulthood. Next Steps: Future research could
investigate whether adults with ASD and ADHD will display normalized EF relative to TD individuals
when followed further into adulthood.

This article was published Online First September 27, 2021.
Ingrid Nesdal Fossum https://orcid.org/0000-0002-6217-6154
Per Normann Andersen https://orcid.org/0000-0002-0242-7230
We have no known conflicts of interest to disclose.
We wish to thank all the individuals who participated in the study. We also
wish to thank all those who contributed to the process of data collection at
baseline, 2-year, and 10-year follow-up assessments.
The project has received financial support from the Innlandet Hospital
Trust and from the Regional Resource Center for Autism, attention-deficit/
hyperactivity disorder (ADHD), Tourette syndrome and Narcolepsy, Oslo
University Hospital.
Ingrid Nesdal Fossum played a lead role in formal analysis and writing of
original draft and an equal role in investigation and methodology. Per
Normann Andersen played a supporting role in formal analysis and meth-
odology and an equal role in investigation, supervision, and writing of review
and editing. Merete Glenne Øie played a lead role in conceptualization,
funding acquisition, investigation and project administration, and an equal
role in supervision and writing of review and editing. Erik Winther Skogli
played a lead role in conceptualization, funding acquisition, investigation,
project administration and supervision, and equal role in formal analysis and
writing of review and editing.
Correspondence concerning this article should be addressed to Ingrid
Nesdal Fossum, Division of Mental Health Care, Innlandet Hospital Trust,
BUP Lillehammer, Anders Sandvigs gate 17, Lillehammer 2609, Norway.
Email: Ingrid.Nesdal.Fossum@sykehuset-innlandet.no

809
 810 FOSSUM, ANDERSEN, ØIE, AND SKOGLI
Keywords: ADHD, autism spectrum disorder, neurodevelopmental disorders, executive functioning,
neuropsychology
Supplemental materials: https://doi.org/10.1037/neu0000768.supp
Autism spectrum disorder (ASD) and attention-deficit/hyperac-
tivity disorder (ADHD) represent two separate, yet highly related
neurodevelopmental disorders. Their symptoms frequently co-occur
(Miodovnik et al., 2015; Rommelse & Hartman, 2016), they typi-
cally emerge in childhood and may have lifelong effects for affected
individuals, their families, and society (American Psychological
Association [APA], 2013; Caye et al., 2016; Faraone et al., 2015;
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Gillberg, 2010; Murphy et al., 2018). Converging evidence indi-
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cates a possible pathophysiological link between ASD and ADHD
(Taurines et al., 2012; Vorstman & Ophoff, 2013). Knowing that
behavioral symptoms associated with ASD and ADHD are not
always stable over time, cognitive deficits linked to prefrontal and
temporal brain regions have been proposed as one common hall-
mark of these two disorders (Hartman et al., 2016; Willcutt et al.,
2005). Although not part of the diagnostic criteria, impaired execu-
tive functioning (EF) has been proposed as a factor potentially
contributing to difficulties in functioning in individuals with ASD
and ADHD (Demetriou et al., 2018; Hartman et al., 2016; Willcutt
et al., 2005). However, little is known about the developmental
trajectories of EF across these disorders, relevant studies have
mostly applied cross-sectional designs and the few longitudinal
studies have had short follow-up periods. In the current 10-year
follow-up study, we compared the development of EF between ASD
(IQ > 70), ADHD and typically developing (TD) individuals, as
participants matured from childhood toward young adulthood.
No single agreed-upon definition exists for the multidimensional
EF construct. The majority of definitions seems to propose that EF is
a set of cognitive processes that guides action and behaviors crucial
to learning and everyday human performance tasks, contributes to
the monitoring or regulation of such tasks; and concern the cognitive
domain alongside the socioemotional and behavioral domains of
human performance (Bagetta & Alexander, 2016). The widely
recognized “unity and diversity” model suggested three related
yet partially separated core components to EF (Miyake et al.,
2000). According to a review of more than 100 empirical studies
on EF, these three were the most frequently mentioned components
(Bagetta & Alexander, 2016). Working memory refers to holding
information in mind and mentally manipulating it within a limited
time span (Diamond, 2013). Inhibition refers to the ability to resist
temptations, distractions and habits, and not act impulsively or
prematurely (Diamond, 2013). Flexibility refers to the ability to
change perspectives or approaches to a problem and adjust to change
(Diamond, 2013). In this study, we focused on EF as assessed by
performance-based neuropsychological tests, which are assumed
to capture the efficiency of cognitive abilities, or maximal EF
performance (Toplak et al., 2013).
A growing body of research has investigated EF in individuals
with ASD (Craig et al., 2016). In a large meta-analysis that focused
on EF as assessed by psychometric tests and experimental tasks
from 235 studies the authors found support for a broad executive
dysfunction in ASD, with no indication that individual EF compo-
nents were differentially impaired (Demetriou et al., 2018). The
differences in performance between the ASD and TD individuals
were generally smaller among adults compared with children and
youth, proposedly explained by developmental maturity or adults’
use of compensatory strategies (Demetriou et al., 2018). Despite
reports of some improvement across age (O’Hearn et al., 2008), it
seems that many individuals with ASD continue to display impaired
EF in adolescence and adulthood when compared with TD indivi-
duals (Geurts et al., 2014). Overall, findings remain inconclusive
regarding the trajectories of EF across the lifespan in this clinical
group (Hartman et al., 2016). This uncertainty might be related to
the complexity of the EF construct, with definitional ambiguities and
a large variety of measures being used to capture the phenomenon
(Bagetta & Alexander, 2016), alongside the heterogeneity within the
ASD population.
Regarding EF as measured by neuropsychological tests in in-
dividuals with ADHD, a large systematic review of meta-analyses
reported that TD participants outperformed the ADHD participants
on all neuropsychological domains across age (Pievsky & McGrath,
2018). Greater performance differences between ADHD and TD
individuals were found in children and adults compared to adoles-
cents and emerging adults between the ages of 18 and 24 years
(Pievsky & McGrath, 2018). Another review reported that indivi-
duals diagnosed with ADHD in childhood performed worse on EF
tests than TD individuals in adulthood, regardless of their current
diagnostic status (van Lieshout et al., 2013). The longitudinal
studies to date yield no clear consensus as to how EF develops
in people with ADHD (Hartman et al., 2016). It has been suggested
that certain children with ADHD outgrow their early EF deficits
(Thissen et al., 2014) or approach performance levels of TD in-
dividuals (van Lieshout et al., 2019), while others report that EF
deficits in ADHD continue into adolescence and young adulthood
(Biederman et al., 2009; Biederman, Petty, Doyle, et al., 2007;
Biederman, Petty, Fried, et al., 2007; Miller et al., 2012). One
longitudinal study reported that the initial performance gap between
ADHD and TD groups remained stable after 13 years (Øie et al.,
2010), while the ADHD group overall caught up with the TD group
after 25 years, yet still displaying working memory difficulties (Øie
et al., 2021; Torgalsboen et al., 2021). Overall, the presence of
impaired performance-based EF in adults with ADHD is acknowl-
edged (Hartman et al., 2016), yet a large variation exists between
individuals and some display no impairment in EF (Posner
et al., 2020).
A growing number of empirical studies have directly compared
EF in ASD and ADHD groups (Craig et al., 2016). One review of
such studies in children reported that the ASD group had more
difficulties with the flexibility component, while the ADHD group
had more difficulties with the response inhibition component (Craig
et al., 2016). Performance on tests assumed to capture the working
memory component did not discriminate between the two clinical
groups. A 2-year longitudinal study from our research group has
previously compared test-based EF in children with ASD, ADHD,
and TD children (Andersen et al., 2015, 2016). The clinical groups
displayed deficits in EF compared with TD children, with a larger
extent of difficulties in the ASD group relative to ADHD
 EXECUTIVE FUNCTIONING ASD ADHD
counterparts on both assessments (Andersen et al., 2016). Surpris-
ingly, the ASD group displayed a performance stagnation on a test
that was assigned to the working memory component (Letter–
Number Sequencing Test [LNS]; Wechsler, 2004) from T1 to T2
(Andersen et al., 2015). Another study on adults with ASD and
ADHD reported that no component-specific deficit typical of ASD
or ADHD could be identified, while simultaneously the most severe
neuropsychological impairments were found in the ADHD group
(Nydén et al., 2010).
Taken together, there is an indication of impaired performance-
based EF in ASD and ADHD groups compared to TD groups that
apply across EF components and age (Demetriou et al., 2018;
Pievsky & McGrath, 2018). There are, however, some inconsis-
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tencies in the empirical evidence to date, which among others could
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be influenced by the large variability in EF definitions and tests used
to measure EF (Bagetta & Alexander, 2016). Relatively few empir-
ical studies have directly compared EF in ASD with ADHD groups.
The need for longitudinal studies investigating the stability of EF
impairments in ASD and ADHD beyond childhood, and for com-
parisons between clinical populations, has been emphasized repeat-
edly (Hartman et al., 2016; Hill, 2004; Seidman, 2006; Velikonja
et al., 2019).
Attempting to meet these issues, we compared EF in participants
with ASD to participants with ADHD and to a TD comparison
group, in three assessment waves from childhood to young adult-
hood: baseline (T1), 2- (T2), and 10-year (T3) follow-ups. EF was
assessed by use of three standardized neuropsychological tests
aimed at capturing the core EF components of working memory,
inhibition, and flexibility (LNS, the Color–Word Interference Test,
Condition 3 [CWIT3] and the Trail Making Test, Condition 4
[TMT4], respectively). This 10-year longitudinal study provides
a unique opportunity to enhance the understanding of the maturation
of EF in these neurodevelopmental disorders, which in turn
might benefit intervention and treatment planning for individuals
with ASD or ADHD and their families (Biederman et al., 2009;
Hartman et al., 2016).
Overall, we predicted better performance within each group on all
three tests after 10 years, relative to each group’s baseline perfor-
mance. Based on the previously reported test results in the ASD
group from T1 to T2 (Andersen et al., 2015), we predicted a
stagnation in the ASD group’s results on the LNS test from T1
to T2, but greater improvement in performance in the ASD group
from T2 to T3, relative to the TD group.
Method
Procedure
Data for this longitudinal study were collected through diagnos-
tic, functional, and neuropsychological assessments conducted in
three waves: T1 in 2009–2010, T2 in 2011–2012, and T3 in
2018–2020.
At T1, children and adolescents were recruited from the Child and
Adolescent Mental Health Centers at Innlandet Hospital Trust in
Norway, a secondary level mental health service, upon consecutive
referrals. Individuals who were referred for evaluation and treatment
for a neurodevelopmental disorder, with ages between 8 and
17 years, were invited to take part in the research project. Those
who agreed were assessed at their respective clinic as part of the
811
diagnostic evaluation. After a comprehensive diagnostic assess-
ment, participants who met the criteria for ASD or, ADHD were
further included in the larger research project. For the TD compari-
son group, inclusion criteria were boys and girls aged between 8 and
17 years who attended regular classes at local schools. For a detailed
description of this procedure, see Andersen et al., 2013.
The diagnostic assessment at T1 was based on separate interviews
with children and parents, using the Schedule for Affective Dis-
orders and Schizophrenia for School-Aged Children/Present and
Lifetime version-2009 (K-SADS-PL; Kaufman et al., 1997). This is
a semistructured diagnostic interview based on the Diagnostic and
Statistical Manual of Mental Disorders, fourth edition (DSM-IV;
APA, 2000), consisting of a screening interview and eight diagnos-
tic supplements. Experienced psychologists and educational thera-
pists performed the interviews. We supplemented the interviews
with information from the ADHD Rating Scale-IV (ARS-IV;
DuPaul et al., 1998) and the Autism Spectrum Screening Question-
naire (ASSQ; Ehlers et al., 1999). Following a comprehensive
evaluation of information from K-SADS-PL, self-reports, parent
reports, and teacher reports on academic and social functioning, a
diagnosis of ASD or ADHD was assigned should the DSM-IV
criteria be met. Diagnoses were first set by each clinician before the
supervising senior clinician, who is a specialist in clinical neuro-
psychology (Merete Glenne Øie), independently reviewed all avail-
able information. Disagreements were discussed in meetings with all
the clinicians present, in order to arrive at a “best estimate” DSM-IV
consensus diagnosis. All participants completed a comprehensive
neuropsychological assessment at baseline. Experienced psycholo-
gists and educational therapists performed the testing at T1 and T2,
under the supervision of a specialist in clinical neuropsychology.
The entire assessment at T1 was conducted over 2 days.
Participants were invited for reassessment at 2 and 10 years
following T1. The neuropsychological assessment was repeated
at T2 and T3, using the same tests from T1 in the exact same
versions. One educational therapist, one specialist in clinical neu-
ropsychology, one psychologist and four undergraduate psychology
students carried out the testing at T3, all supervised by a specialist in
clinical neuropsychology. Test administrators underwent thorough
training and reliability checks for test scoring. We estimated inter-
rater reliability for all seven test administrators at T3 on verbal
subtests from the Wechsler Abbreviated Scale of Intelligence during
training, with intraclass correlation coefficients for Vocabulary of
.93 (95% CI [.89–.96]) and for Similarities of .97 (95% CI
[.94–.98]), indicating excellent reliability. We used a fixed test
order at each assessment, with prescheduled breaks and additional
breaks where necessary. The entire procedure at T3, which also
included diagnostic and functional assessment with age-appropriate
measures, lasted between three and four-and-a-half hours. Partici-
pants using stimulant medication discontinued use 24 hr prior to
assessment at T1–T3. Three participants were using stimulant
medication at T1 (all from the ASD group); all discontinued use
prior to baseline assessment. Forty-eight participants were pre-
scribed stimulant medication at T2 (four from the ASD group,
44 from the ADHD group), of whom one in the ADHD group forgot
to discontinue use prior to reassessment. Nine participants reported
using stimulant medication at T3 (two from the ASD group, seven
from the ADHD group), of whom three participants (one from the
ASD group, two from the ADHD group) forgot to discontinue
stimulant medication prior to the assessment. Furthermore,
 812 FOSSUM, ANDERSEN, ØIE, AND SKOGLI
12 participants reported having used cannabinoids during the last 3
months prior to testing at T3 (two from the ASD group, seven from
the ADHD group, three from the TD group).
Participants
Table 1 displays the number of participants at each wave across
the groups, with information on age and retention. The exclusion
criteria at T1 for all participants were prematurity (<36 weeks), IQ
estimate below 70, or any disease affecting the central nervous
system. Prematurity was used as an exclusion criterion in order to
avoid comorbidities such as perceptual difficulties. An additional
exclusion criterion for the ADHD group was no history of stimulant
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treatment. Additional criteria for the TD group were no history of
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psychiatric disorder, dyslexia, or head injury with loss of conscious-
ness. No additional exclusion criteria were applied at the follow-ups.
Eight participants who met the diagnostic criteria for both ASD and
ADHD at T1 were included in the ASD group for the present study.
This decision was based upon ASD having priority over ADHD in
diagnostic algorithms in the DSM-IV (APA, 2000). Participants in
the clinical groups were offered standard psychological and/or
medical treatment in the time between T1 and T3.
Table 2 shows demographic and clinical characteristics for the
sample, with group comparisons. The mothers of participants from
the TD group had significantly more years of education than the
mothers in the ASD and ADHD groups at T1. The participants in the
ADHD group had significantly lower Full-Scale Intelligence Quo-
tient (FSIQ) estimates than the TD group at T2 and T3. The ASD
group had higher ASD symptom levels than the ADHD group at
each assessment. The difference in inattention and hyperactivity/
impulsivity symptom levels between the clinical groups were
nonsignificant at T1 and T2.
Sample Retention
Among the 173 participants at T1 (11.7 years, SD = 2.1), 168
took part at T2, yielding a retention rate of 97.1%. One participant
from the ASD group and four from the ADHD group declined
participation at T2. Unfortunately, we do not have information
relating to their reasons for declining T2 participation.
The total number of participants at T3 was 127, with ages ranging
from 17 to 27 (Mage = 21.4 years, SD = 2.2), yielding an overall
retention rate of 73.4% from the baseline sample. Among the 46
participants from T1 who did not take part in the study at T3, nine
were untraceable (three from the ASD group, four from the ADHD
group, two from the TD group) while 37 declined further participa-
tion (nine from the ASD group, 20 from the ADHD group, eight
Table 1
Number of Participants and Retention Rates at Baseline, 2-, and 10-Year Follow-Up, by ASD, ADHD, and TD Group
ASD ADHD
Assessment wave n (%) Age n (%)
Baseline 38 12.0 (2.3) 85
2-year follow-up 37 (97.4%) 14.2 (2.3) 81 (95.3%)
10-year follow-up 26 (68.4%) 22.2 (2.6) 61 (71.8%)
Note. ASD = autism spectrum disorder; ADHD = attention-deficit/hyperactivity disorder; TD = typically developing. Age in years. Standard deviations for
age are presented in parentheses.
from the TD group). The differences between those who participated
at T3 and those who did not were investigated by use of one-way
analysis of variance (ANOVA) and independent samples T tests,
where Bonferroni corrected p values below .05/4 = .0125 were
considered statistically significant. The results indicated no statisti-
cally significant differences between these two groups in terms of T1
characteristics age ( p = .589), mother’s education ( p = .572), FSIQ
( p = .013) or gender ( p = .929).
Measures
Clinical Measures at T1 and T2
ASSQ. The ASSQ is a questionnaire designed to screen for
ASD, which can be completed by a parent or teacher (Ehlers et al.,
1999). The 27 items concern social interaction problems, commu-
nication problems, and problems with restricted and repetitive
behavior (Ehlers et al., 1999), with each item rated on a 3-point
Likert scale (0 = no problems, 1 = some problems, 2 = severe
problems). A total score is computed by summarizing all responses,
yielding a maximum score of 54. Higher scores indicate more
problems. We used the total score as an indicator of ASD symptom
level.
ARS-IV. The ARS-IV is a rating scale regarding the frequency
of ADHD symptoms in children and adolescents between 5 and
17 years old, based on the diagnostic criteria in the DSM-IV
(DuPaul et al., 1998). Parents or caregivers rate the frequency of
each ADHD symptom describing the child’s behavior at home
during the last 6 months, with response options of Never (0), Rarely
(1), Sometimes (2), Often (3), and Very Often (4). The 18-item
rating scale consists of two subscales, inattention, and hyperactivity.
A total score can be computed for each subscale where higher scores
indicate more problems. These subscale total scores were used as
indicators of inattention and hyperactivity/impulsivity symptom
levels.
Clinical Measures at T3
The Autism Spectrum Quotient for Adults, Short Version. The
Autism Spectrum Quotient for Adults, Short Version (AQ-10) is a
questionnaire screening tool for autism symptoms with 10 items,
developed from an original 50-item version (Allison et al., 2012).
Participants report the degree to which a symptom applies to them
on a four-point scale from Definitely Agree to Definitely Disagree.
Score 1 is given for all responses that indicate autistic traits, while
other responses are scored 0, thus higher scores indicate more autistic
traits. In the present study, we used the sum score as an indication of
TD Total sample
Age n (%) Age N (%) Male/female
11.6 (2.1) 50 11.6 (2.0) 173 110/63
13.6 (2.1) 50 (100.0%) 13.6 (1.9) 168 (97.1%) 106/62
21.4 (2.2) 40 (80.0%) 21.4 (2.3) 127 (73.4%) 81/46
 EXECUTIVE FUNCTIONING ASD ADHD 813

Table 2
Demographic and Clinical Characteristics of Participants at Baseline, 2-, and 10-Year Follow-Up, by ASD, ADHD, and TD Group, With
Group Comparison

ASD (n = 38) ADHD (n = 85) TD (n = 50) Group comparison

Baseline M SD M SD M SD χ2/F p Post hoc

Gender (male/female) 32/6 46/39 32/18 10.28 .006

Age (years) 12.0 2.3 11.6 2.1 11.6 2.0 (2, 172) 0.63 .532
FSIQ 98.3 17.8 94.4 13.7 103.8 12.9 (2, 172) 6.53 .002
Mother’s education (years) 12.8 2.7 12.7 2.1 14.6 2.4 (2, 172) 11.56 <.001 ASD, ADHD < TD
ASSQ 21.5 9.3 9.7 10.1 1.6 1.9 (2, 171) 61.03 <.001 ASD > ADHD > TD
ARS-IV inattention 13.3 6.3 15.6 5.8 1.7 2.0 (2, 170) 119.79 <.001 ADHD, ASD > TD
ARS-IV hyperactivity 8.1 6.1 10.1 6.7 1.0 1.3 (2, 170) 43.38 <.001 ADHD, ASD > TD
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ASD (n = 37) ADHD (n = 81) TD (n = 50)

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2-year follow-up M SD M SD M SD χ2/F p Post hoc

Gender (male/female) 31/6 43/38 32/18 10.30 .006

Age (years) 14.2 2.3 13.6 2.1 13.6 1.9 (2, 167) 1.11 .334
FSIQ 98.0 16.8 95.7 13.9 106.3 12.5 (2, 158) 8.64 <.001 ADHD, ASD < TD
ASSQ 20.6 9.2 7.7 7.3 1.0 2.8 (2, 161) 86.70 <.001 ASD > ADHD > TD
ARS-IV inattention 9.8 5.5 11.7 6.4 1.7 2.1 (2, 165) 57.93 <.001 ADHD, ASD > TD
ARS-IV hyperactivity 4.9 4.3 7.0 6.5 0.6 1.1 (2, 165) 26.15 <.001 ADHD, ASD > TD
T1–T2 interval (months) 25.7 3.5 24.8 2.7 25.1 1.8 (2, 167) 1.26 .287

ASD (n = 26) ADHD (n = 61) TD (n = 40)

10-year follow-up M SD M SD M SD χ2/F p Post hoc

Gender (male/female) 21/5 34/27 26/14 4.98 .083

Age (years) 22.2 2.6 21.4 2.2 20.9 1.9 (2, 126) 2.61 .078
FSIQ 109.3 18.3 102.5 14.4 115.4 12.0 (2, 122) 9.53 <.001 ADHD < TD
AQ-10 5.8 2.0 4.1 1.9 (1, 86) 14.27 <.001 ASD > ADHD
ASRS inattention 2.4 1.9 2.9 2.4 (1, 86) 0.87 .354
ASRS hyperactivity 2.0 1.9 3.0 2.1 (1, 86) 4.39 .039
T1–T3 interval (months) 116.6 6.5 116.6 6.5 114.0 4.7 (2, 125) 2.62 .077
Note. ASD = autism spectrum disorder; ADHD = attention-deficit/hyperactivity disorder; TD = typically developing; FSIQ = Full-Scale IQ, estimated from
Wechsler Abbreviated Scale of Intelligence; ASSQ = Autism Spectrum Screening Questionnaire; ARS-IV = ADHD Rating Scale-IV; AQ-10 = Autism Spectrum
Quotient for Adults, short version; ASRS = Adult ADHD Self-Report Scale. Corrected p level due to multiple comparisons of .001; statistically significant
p values in bold.

the level of autistic symptoms on a scale from 0 to 10 (Allison
et al., 2012).
The Adult ADHD Self-Report Scale Version 1.1. The Adult
ADHD Self-Report Scale Version 1.1 (ASRS) is an 18-item ques-
tionnaire developed by the World Health Organization (WHO). It
assesses current ADHD symptoms in adults, with questions about
symptom frequency (Kessler et al., 2005). Response options are
Never (0), Rarely (1), Sometimes (2), Often (3), and Very Often (4).
We dichotomized the responses to each item in line with the scoring
manual and summarized the number of items indicating ADHD
symptoms for inattention and hyperactivity/impulsivity items sepa-
rately (Kessler et al., 2007). Sum subscale scores were used as an
indication of the level of ADHD symptoms on a scale from 0 to 9.
Measures of Neuropsychological Functioning
Estimated General Cognitive Functioning. The Wechsler
Abbreviated Scale of Intelligence was administered in order to
estimate participants’ intellectual abilities at each assessment
(Wechsler, 1999). We used the FSIQ estimates.
LNS. We used the LNS test from the Wechsler Intelligence
Scales for Children-IV (WISC-IV; Wechsler, 2004) with an aim to
capture the working memory component of EF. This test consisted
of 10 items, each with three trials of the same number but with
different combinations of digits and letters. The test administrator
read each trial aloud and asked the participants to recall the numbers
in ascending order and the letters in alphabetical order (Wechsler,
2004). We examined total correct recalled trials (raw scores). Higher
scores indicated better performance, with a maximum score of 30.
As this test originates from a test battery designed for children and
adolescents, we examined the results for a potential ceiling effect at
T3, finding no indication of such an effect. None of the participants
reached the highest possible score of 30; the highest score in the
sample was 28, with the second highest score being 26.
CWIT3. We used the CWIT3 from the Delis–Kaplan Execu-
tive Function System (D-KEFS; Delis et al., 2001), with an aim to
capture the inhibition component of EF. The task was for partici-
pants to inhibit their automatic response to read the printed word of a
color and instead name the dissonant ink color. We measured
completion time in seconds; lower completion times indicated better
performance. The maximum completion time for this task
was 180 s.
TMT4. We used the TMT4 from D-KEFS (Delis et al., 2001)
as a measure of the flexibility component of EF. The participants
 814 FOSSUM, ANDERSEN, ØIE, AND SKOGLI
were asked to draw a line interchangeably between numbers and letters
in ascending and alphabetical order. We examined the time to
complete the task in seconds, where lower completion times indicated
better performance. The maximum completion time was 240 s.
Background Characteristics
The variable mother’s education level (in years), measured at T1,
was used as an indicator of socioeconomic status. The age of the
participants at each assessment was measured in years. Follow-up
intervals were calculated by subtracting the age in months at T1
from the age in months at each follow-up.
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Ethics
We conducted the study in accordance with the Helsinki Decla-
ration of the World Medical Association Assembly. Participation
was voluntary. Children aged 12 years and older and their parents
gave informed written consent prior to inclusion at T1 and T2, while
children below 12 years of age gave verbal consent prior to inclu-
sion. At T3, all participants gave their informed written consent. The
participants received monetary compensation for their efforts (500
NOK) and their traveling expenses related to testing were covered.
The study was approved by the Regional Committee for Medical
Research Ethics in Eastern Norway (T1 and T2: REK Øst-Norge 6-
2009-24, T3: 2017/2036/REK Sør-Øst) as well as the privacy
ombudsman for research at the Innlandet Hospital Trust (nr. 95495).
Data Analyses
We used the statistical package SPSS for Windows, Version 26 in
the data analyses, while R Studio was used in creating the Figures.
The global alpha level was set to .05
First, we used a one-way ANOVA/independent sample T test to
compare the baseline characteristics (age, gender, mother’s educa-
tional level or FSIQ) of participants who were and were not assessed
at the 10-year follow-up. Due to multiple comparisons, we used
Bonferroni corrections to control for chance findings, thus p values
below .05/4 = .0125 were considered statistically significant.
Second, we investigated demographic and clinical characteristics
in the sample using the chi-squared test for independence (gender)
and one-way ANOVA (age, mother’s educational level, FSIQ,
ASD, and ADHD symptoms, time interval from T1 to T2, and
from T1 to T3). We set a stricter p value of .001, in order to control
for chance findings due to the high number of comparisons.
Significant findings were followed up by Bonferroni post hoc tests.
Third, we used Linear Mixed Models (LMM) for longitudinal
analysis of individual time course, and to relate change in EF
performance over time to group affiliation. EF test raw scores were
used as dependent variables. These data were screened for extreme
outliers, defined as test scores with a value of ±4 SD from the mean for
each group investigated separately (Wåhlstedt et al., 2009). Two
scores were defined as outliers on the TMT4 test, both with poorer
performance than the mean: one from the TD group at T2 and one from
the ADHD group at T3. These outliers were replaced by the second
most extreme value in the respective group, to reduce the effect of
possible spurious outliers (Chen et al., 2001; Wåhlstedt et al., 2009).
The estimation was based on restricted maximum likelihood, with
piecewise linear splines, with one knot at T2. Separate random
intercepts were fitted at the first and second time intervals. The
parameters of main interest were the fixed effect interaction terms
“Time × Group,” at the first and second time intervals, contrasting the
changes in the groups over time. We assessed three group comparisons
separately (ASD–TD, ADHD–TD, ASD–ADHD). The variables
“group” (dichotomous), “time” and “Time × Group” were entered
as fixed effects. “Intercept” was entered as fixed and random effects.
We used unstructured covariance matrix to fit the LMM to the data.
Assessment of model fit was done by Akaike information criteria
investigation. The complete case analysis was compared with the
multiple imputation analysis. We used the global alpha value of .05.
All significant results were reanalyzed without the four participants
taking stimulant medication in the immediate period prior to testing
(one at T2, three at T3). Also, significant results were reanalyzed
without the eight participants who met criteria for both ASD and
ADHD at baseline. Additionally, we ran two separate LMM analyses
where we added baseline FSIQ and mother’s education as covariates.
Results
The LNS, CWIT3, and TMT4 results across group and time are
displayed in Table 3. A visual depiction of each group’s test results
across time is shown for the LNS, CWIT3, and TMT4 tests
separately in Figures 1–3, respectively.
In total from T1 to T3, the ASD group displayed a medium to
large (d = .71) improvement on the LNS test, a large improvement
on the CWIT3 (d = 1.70), and a medium improvement on the
TMT4 (d = .57). The ADHD group displayed a medium to large
improvement on the LNS test (d = .77), and large improvements on
the CWIT3 and TMT4 (d = 1.48 and 1.32, respectively).
The results from the LMM (without covariates) are displayed in
Table 4. Applying to the three tests alike, the two clinical groups
performed significantly worse than the TD group at baseline, with
lower raw scores on the LNS test and longer completion times on the
CWIT3 and TMT4 tests. The baseline differences between the two
clinical groups were nonsignificant.
LNS
Results indicated that 64.6% of the variation in LNS raw scores
was due to variation between individuals. During the first time
interval (T1–T2), the ADHD and TD groups showed increasing
scores, while the ASD group displayed stagnation in LNS scores
(see Figure 1). The stagnation gave the ASD group a significantly
worse change from T1 to T2 than both the TD and ADHD groups
(see Tables 3 and 4). During the second time interval (T2–T3),
however, the ASD group displayed a significantly greater increase in
LNS scores than the ADHD group, while the slope in the ASD group
did not differ significantly from that of the TD group in this time
period. Furthermore, the ADHD group displayed a significantly
smaller increase in LNS scores than the TD group from T2 to T3.
CWIT3
Results indicated that 45.6% of the variation in CWIT3 scores
was due to variation between individuals. Only one of the interac-
tion effects reached statistical significance for the CWIT3 results.
During the first time interval, the ASD group had a significantly
better improvement than the TD group (Table 4).
 EXECUTIVE FUNCTIONING ASD ADHD 815

Table 3
Results of the Neuropsychological Tests LNS, CWIT3, and TMT4: Means and Standard Deviations by ASD, ADHD,
and TD Group, Across Time

ASD ADHD TD
Variable T1 T2 T3 T1 T2 T3 T1 T2 T3
a
Letter–Number Sequencing Test 15.0 (3.4) 15.2 (3.6) 17.5 (3.6) 15.5 (3.3) 17.1 (2.9) 17.9 (2.9) 18.2 (1.9) 19.3 (2.4) 21.2 (2.7)
Color–Word Interference Test, 97.3 (28.3) 72.9 (21.3) 55.1 (12.6) 87.5 (29.8) 72.0 (27.3) 53.7 (15.8) 72.5 (22.3) 58.7 (16.9) 41.9 (9.0)
Condition 3b
Trail Making Test, Condition 4c 115.5 (48.1) 109.0 (49.2) 88.9 (44.9) 124.4 (49.5) 99.9 (41.4) 74.0 (26.9) 99.9 (35.2) 76.5 (23.4) 62.3 (22.3)
Note. ASD = autism spectrum disorder; ADHD = attention-deficit/hyperactivity disorder; TD = typically developing; T1 = baseline; T2 = 2-year follow-up;
T3 = 10-year follow-up; LNS = Letter–Number Sequencing Test; CWIT3 = Color–Word Interference Test, Condition 3; TMT4 = Trail Making Test,
Condition 4.
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a
Raw score, higher scores = better performance. From Wechsler Intelligence Scales for Children-IV. T1: ASD n = 38, ADHD n = 83, TD n = 50. T2: ASD
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n = 35, ADHD n = 75, TD n = 50. T3: ASD n = 23, ADHD n = 60, TD n = 40. b Completion time in seconds, lower scores = better performance. From
Delis–Kaplan Executive Function System (D-KEFS). T1: ASD n = 37, ADHD n = 85, TD n = 50. T2: ASD n = 36, ADHD n = 78, TD n = 50. T3: ASD
n = 23, ADHD n = 60, TD n = 40. c Completion time in seconds, lower scores = better performance. From D-KEFS. T1: ASD n = 34, ADHD n = 82, TD
n = 50. T2: ASD n = 35, ADHD n = 77, TD n = 50. ASD n = 22, ADHD n = 60, TD n = 39.

TMT4
Results indicated that 40.0% of the variation in TMT4 scores was
due to variation between individuals. None of the Time × Group
interactions reached statistical significance.
When adding IQ or mother’s education as covariates, the differ-
ence between the ASD and TD groups on the TMT4 test at baseline
became nonsignificant (data not shown). No other changes on any of
the statistically significant test results were seen when adding these
covariates. All significant findings remained significant when
excluding the four participants who had forgotten to discontinue
stimulant medication immediately prior to testing. Also, no changes
to the significant findings were seen when rerunning the LMM
excluding the eight participants with ASD who at baseline also met
criteria for ADHD. See Supplemental Table 1, for results on the
imputed data.
Discussion
As expected, the ASD group had a significant stagnation in LNS
raw scores in the first interval from T1 to T2 (Mage = 12–14 years),
compared to the ADHD and TD groups. The ASD group grew out of
this stagnation as their raw scores increased from T2 to T3 (Mage =
14–22 years), with a maturation slope similar to the maturation in
the TD group. These findings suggest that the previously reported
LNS stagnation (Andersen et al., 2015) was not permanent, but
could rather be considered as a developmental delay. Yet, it seems

Figure 1
Results of the Letter–Number Sequencing Test, Raw Scores Across Group and Time

22 Group ASD ADHD TD

20
Mean LNS raw score

18

16

14

Baseline Two−year 10−year

follow−up follow−up

Note. N = 171. LNS = the Letter–Number Sequencing Test from the Wechsler Intelligence
Scales for Children-IV; Higher raw score = better performance; ASD = autism spectrum
disorder; ADHD = attention-deficit/hyperactivity disorder; TD = typically developing. Error
bars display 95% Confidence Intervals. See the online article for the color version of this figure.
 816 FOSSUM, ANDERSEN, ØIE, AND SKOGLI

Figure 2
Results of the Color–Word Interference Test, Condition 3, Completion Times in
Seconds, Across Group and Time

Group ASD ADHD TD

Mean CWIT3 completion time

90

70
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This document is copyrighted by the American Psychological Association or one of its allied publishers.

50

Baseline Two−year 10−year

follow−up follow−up

Note. N = 172. CWIT3 = the Color–Word Interference Test, Condition 3, from the Delis–
Kaplan Executive Function System; Lower completion time = better performance; ASD =
autism spectrum disorder; ADHD = attention-deficit/hyperactivity disorder; TD = typically
developing. Error bars display 95% Confidence Intervals. See the online article for the color
version of this figure.

that the performance gap between the ASD and TD groups was not
reduced.
Further, the LNS raw scores in the ADHD group increased
alongside the TD group’s scores from T1 to T2, while the
ADHD group had a significantly lower increase than both the
ASD and TD groups from T2 to T3 (see Figure 1). It thereby seems
that the ASD group showed a normalization in LNS scores relative
to the ADHD individuals from adolescence into young adulthood.
This interaction indicating a slower increase in the ADHD group
relative to the TD group, however, failed to reach statistical

Figure 3
Results of the Trail Making Test, Condition 4, Completion Times in Seconds, Across
Group and Time

Group ASD ADHD TD

Mean TMT4 completion time

120

100

80

60

Baseline Two−year 10−year

follow−up follow−up

Note. N = 166. TMT4 = the Trail Making Test, Condition 4, from the Delis–Kaplan Executive
Function System; Lower completion time = better performance; ASD = autism spectrum disorder;
ADHD = attention-deficit/hyperactivity disorder; TD = typically developing. Error bars display
95% Confidence Intervals. See the online article for the color version of this figure.
 EXECUTIVE FUNCTIONING ASD ADHD 817

Table 4
Fixed Effects in a Linear Mixed Model With Results of the Tests LNS, CWIT3, and TMT4, With Follow-Up Over 10 Years in ASD, ADHD, and
TD Groups

Color–Word Interference Test,

Letter–Number Sequencing Test Condition 3 Trail Making Test, Condition 4
Executive function measure Estimate SE 95% CI Estimate SE 95% CI Estimate SE 95% CI
a
Main effect group
ASD versus TD (ref) −3.25*** 0.61 −4.46, −2.04 24.54*** 4.82 15.01, 34.08 17.95* 8.61 0.91, 34.99
ASD versus ADHD (ref) −0.50 0.63 −1.75, 0.75 9.47 5.43 −1.26, 20.20 −7.50 9.53 −26.31, 11.30
ADHD versus TD (ref) −2.75*** 0.50 −3.73, −1.76 15.06** 4.59 5.99, 24.13 25.63** 7.32 11.20, 40.07
Main effect timeb
T1–T2 1.10*** 0.20 0.69, 1.50 −16.44*** 1.52 −19.44, −13.44 −20.96*** 3.17 −27.22, −14.69
T2–T3 1.41*** 0.21 1.01, 1.18 −16.40*** 1.34 −19.04, −13.75 −21.59*** 3.11 −27.75, −15.44
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Interaction, Group × Time T1–T2c

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ASD versus TD (ref) −1.11* 0.49 −2.08, −0.14 −8.91* 3.95 −16.76, −1.06 14.94 8.47 −1.92, 31.81
ASD versus ADHD (ref) −1.59** 0.58 −2.74, −0.45 −7.42 4.40 −16.13, 1.29 15.83 9.19 −2.39, 34.05
ADHD versus TD (ref) 0.51 0.43 −0.35, 1.37 −1.41 3.24 −7.83, 5.00 −1.01 6.77 −14.42, 12.40
Interaction, Group × Time T2–T3c
ASD versus TD (ref) 0.46 0.62 −0.76, 1.69 −0.14 3.28 −6.69, 6.40 −4.31 8.51 −21.29, 12.67
ASD versus ADHD (ref) 1.52** 0.51 0.50, 2.53 0.59 4.00 −7.37, 8.55 5.30 9.77 −14.11, 24.70
ADHD versus TD (ref) −1.05* 0.45 −1.94, −0.16 −0.68 3.08 −6.79, 5.43 −9.65 6.24 −22.03, 2.72
Note. LNS = Letter–Number Sequencing Test from Wechsler Intelligence Scales for Children-IV; CWIT3 = Color–Word Interference Test, Condition 3,
from Delis–Kaplan Executive Function System (D-KEFS); TMT4 = Trail Making Test, Condition 4, from D-KEFS; ASD = autism spectrum disorder; ADHD
= attention-deficit/hyperactivity disorder; TD = typically developing; T1 = baseline; T2 = 2-year follow-up; T3 = 10-year follow-up. The estimates reported do
not control for any covariates.
a
Negative estimates on LNS and positive estimates on CWIT3 and TMT4 indicate lower performance in the first group relative to the reference group. b Positive
estimates on LNS and negative estimates on CWIT3 and TMT4 indicate improvement over time. c Positive estimates on LNS and negative estimates on CWIT3
and TMT4 indicate more improvement over time relative to the reference group.
* p < .05. ** p < .01. *** p < .001, Uncorrected p values. Statistically significant estimates for effects of group and Group × Time in bold.

significance when running the LMM with imputed data (see
Supplemental Table 1).
Placing the LNS test within the larger EF framework, it has been
considered as a measure of working memory capacity (Wechsler,
2004). Current findings from the LNS test align with those from a
meta-analysis in children, where working memory performance
could not discriminate between ASD and ADHD participants
(Craig et al., 2016). Our findings that the two clinical groups
performed lower than the TD group at baseline fit with reports
from meta-analyses and systematic reviews, where ASD and ADHD
groups displayed relatively stable dysfunction across components of
EF when compared with TD groups (Demetriou et al., 2018;
Pievsky & McGrath, 2018). A selective decline on a working
memory test was also reported in another longitudinal study, where
individuals with ADHD continued to display deficits in adulthood,
which was taken as an indication of a developmental delay in this
group (Øie et al., 2021).
Working memory draws upon the capacity for both manipulation
of information and maintenance of presented stimuli (Diamond,
2013). Previous research has found that the capacity for working
memory manipulation matures later than the capacity for working
memory maintenance (Travers et al., 2011). Some tests mainly
measure the maintenance capacity, while others require more
manipulation; the LNS test is an example of a test that loads on
both skills (Wechsler, 2004). The variation between tests that have
been assigned to the working memory component might account for
some of the variability in findings across studies.
Results from the CWIT3 indicated that the ASD group had a more
positive maturation compared to the TD group from T1 to T2. Apart
from this, the maturation was not significantly different between any
of the groups from T1 to T2 or from T2 to T3, which corresponds
with the visual depiction of the results (Figure 2). The CWIT3 aims
to be a measure of inhibition performance (Delis et al., 2001). At
baseline, both the clinical groups took longer to complete the task
than the TD group, which aligns with findings from prior studies of
lower inhibition performance in these clinical groups (Demetriou
et al., 2018; Pievsky & McGrath, 2018). The baseline difference
between the clinical groups, although not statistically significant,
favored the ADHD group. The latter contrasts with reports from a
meta-analysis showing greater difficulties with inhibition in ADHD
individuals compared with ASD (Craig et al., 2016).
Comparing findings regarding the inhibition component across
studies may be complicated by the fact that inhibition is considered a
multifaceted construct, comprising related processes of prepotent
response inhibition and interference control (Friedman & Miyake,
2004; Geurts et al., 2014). Different measures assumed to assess
inhibition might in fact tap into somewhat different processes, which
might partly explain variations in findings. For instance, Stroop
tasks (Stroop, 1935) like the CWIT3 which we employed for
assessing inhibition are classified by some as prepotent inhibition
tasks (Friedman & Miyake, 2004), while others classify such tasks
as interference control tasks (Nigg, 2000). The Stroop task, in its
different versions, was indeed found to be the most used task in
contemporary studies assessing performance-based EF (Bagetta &
Alexander, 2016).
Overall, our CWIT3 findings indicate an improvement in the
ASD group from T1 to T2 that is better than that of the TD group,
while all three groups display parallel maturation from adolescence
until early adulthood. Assuming that the CWIT3 findings yield
information related to inhibition performance, we consider these
 818 FOSSUM, ANDERSEN, ØIE, AND SKOGLI
findings in support of a hypothesis of similar, rather than diverging,
developmental trajectories of EF in children with ASD and ADHD.
For TMT4 results, the ASD and ADHD groups had longer
completion times at baseline relative to the TD group. The matura-
tion in these clinical groups was not significantly different from one
another or from the TD group’s maturation from T1 to T2, nor from
T2 to T3. This is somewhat surprising given the visual depiction of
the results, where it seems that the ASD and ADHD groups had
diverging trajectories of maturation in the first interval from T1 to T2
(Figure 3). We note that the confidence intervals for the results in the
ASD group, in particular, are very wide, which indicates substantial
uncertainty. In the LMM with imputed data (Supplemental Table 1),
the interaction effect between the ASD group and both the other
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groups from T1 to T2 did indeed reach statistical significance
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( p < .05), with the ASD group having a relatively slower improve-
ment. We interpret this as an indication that the nonsignificant
interaction effects in the main analysis might be related to the rather
small sample size of the ASD group, as with smaller sample sizes,
larger effect sizes are required for the differences to reach statistical
significance (Tabachnick et al., 2007).
The TMT4 is assumed to capture the flexibility component of EF
(Delis et al., 2001). Assuming that the TMT4 results give an estimate
of flexibility performance, current findings of no difference between
the clinical groups at baseline diverge from those of a review
reporting that children with ADHD outperformed children with
ASD on the flexibility component (Craig et al., 2016). Craig and
colleagues did, however, emphasize that the results from the 26
studies included in their review were often contradictory, which they
attributed to differences in methods of assessment and sample
characteristics (Craig et al., 2016). Regarding EF differences
between ADHD and TD groups, a large review of meta-analyses
found that the smallest difference was in the flexibility component
(Pievsky & McGrath, 2018). Current findings from the TMT4 might
support a hypothesis of similar maturation in the clinical and TD
groups, despite differential performance levels. Our findings give no
indication that the clinical groups manage to reduce the gap relative
to the TD group as they mature into adulthood.
When comparing our findings to those of a larger EF research
field, we note the limitations of the present study of using one single
test for each EF component, as previously addressed by Bagetta and
Alexander (2016). Despite this common practice of assigning
neuropsychological tests to separate components of EF, such tests
are typically highly complex and tap into various skills in addition to
those targeted for assessment (Miyake et al., 2000). The term “task
impurity problem” has been used to denote the phenomenon that one
task likely assesses multiple aspects of EF, in addition to skills like
reading efficiency or more general cognitive tempo, which might all
influence the test results (Miyake & Friedman, 2012). For instance,
the review by Bagetta and Alexander reported that the Stroop task
has been used as a measure of inhibition by some, while as a
working memory measure by others. The use of different tasks and
performance measures for single EF components also contribute to
making direct comparison of findings from different studies some-
what uncertain (Ging-Jehli et al., 2021).
At baseline, we decided to include participants meeting criteria
for both an ASD and an ADHD diagnosis in the ASD group. This
comorbidity could potentially have influenced the nonsignificant
differences between the two clinical groups at baseline, which was
found for each of the three EF tests. When omitting the children with
co-occurring ASD and ADHD from the ASD group, the differences
in EF between the ASD and ADHD group did however remain
nonsignificant. A preliminary analysis indicated that the levels of
inattention symptoms and hyperactivity/impulsivity symptoms were
not significantly different between the two clinical groups at T1.
This might also relate to the fact that symptoms of ASD and ADHD
frequently co-occur, also in individuals who do not meet full
diagnostic criteria for both conditions. Thus, we add to the issue
previously addressed, that findings from different studies investi-
gating EF are often not directly comparable because of differential
sample characteristics (Ging-Jehli et al., 2021).
Overall, current findings seem to indicate that the maturation of
EF in the ASD group from T1 to T2 was characterized by a slower
maturation than in the TD group on one out of three tests (LNS),
while by better maturation than the TD group on another test
(CWIT3). The ASD group later develops at the same pace as the
TD group from T2 to T3. There is no indication in the current data
that the ASD group catches up on the performance gap relative to the
TD group.
The ADHD group displays maturation that parallels that of the
TD group on two out of three tests, but their maturation slows down
from T2 to T3 on the LNS test, relative to the TD group. Some prior
studies have suggested that children with ADHD may outgrow their
EF deficits (Thissen et al., 2014) or approach the performance levels
of TD children in relation to certain EF measures (van Lieshout
et al., 2019), yet no indication of such relative improvement was
found in our data. Rather, our findings align with those suggesting
that ADHD individuals develop with a similar pattern to TD
individuals, but with a developmental lag (Coghill et al., 2014).
In addition, the ASD and ADHD groups mainly displayed similar
developmental maturation from childhood into young adulthood as
assessed by the CWIT3 and the TMT4. Yet there was a develop-
mental delay on the LNS test in children with ASD from T1 to T2,
while the ASD group had a better improvement than the ADHD
group in the interval from T2 to T3. Despite considerable improve-
ment within each clinical group as ages increased, individuals with
ASD and ADHD seemed to display continuous impairment in EF
relative to the TD group.
Strengths, Limitations, and Recommendations
for Future Research
The longitudinal design, a long follow-up interval, and a rela-
tively high sample retention constitute major strengths of this study.
Longitudinal studies are especially relevant with ADHD samples
because many individuals who were diagnosed in childhood no
longer meet diagnostic criteria as they grow up, thus the samples in
cross-sectional and longitudinal studies are different. Our study
benefits from having three assessment waves, enabling us to obtain a
clear picture of cognitive maturation with age. An additional
strength is that we included participants with two different neuro-
developmental disorders in the same study, which enabled us to
compare these groups directly, and yield valuable information
beyond that which can be gained when comparing results across
studies. Furthermore, it should be noted that impaired EF is not only
common in neurodevelopmental disorders (Rommelse et al., 2011)
but has also been suggested as a transdiagnostic indicator of atypical
development (Zelazo, 2020).
 EXECUTIVE FUNCTIONING ASD ADHD
As thorough information relating to interventions in the follow-up
period was not available to us, we could not consider the impact of
interventions. Another potential limitation is the relatively small size
of the ASD group, meaning that there is a need to replicate the
findings in larger samples. Ideally, the retention rate for the ASD
group at T3 (68.4%) would have been higher; however, it is still
acceptable compared to other longitudinal studies on ASD, for
example, 76% after 10 years in Helles et al. (2015). It should be
noted that our ASD sample does not capture the heterogeneity for IQ
in ASD, as it only includes individuals with normal range IQ. As the
comparison of dropouts versus T3 participants did not indicate that
there were any systematic differences between these groups, we find
it likely that our findings would generalize to the total T1 sample.
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Furthermore, as our clinical samples were drawn from a clinical
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population, they represent those who were willing to seek help at T1.
The large age span in our sample may represent a possible limita-
tion; however, most participants were around mean age, as indicated
by the small standard deviations.
Another issue relates to the wide confidence intervals in the LMM
estimates, reflecting large variability in the outcome variables within
each group. The current findings reflect trajectories at a group level,
but not at the individual level. Although findings at a group level
may yield valuable information, we emphasize that individuals
within these clinical groups may vary substantially in their cognitive
profiles, just as there is variation among the TD individuals, in this
study and elsewhere.
Current findings concern maturation of EF as measured by
neuropsychological tests, which might provide information of
“best” performance in highly structured environments, as opposed
to self- or informant reports on EF in everyday functioning, which
provide information on typical performance (Toplak et al., 2013).
We emphasize that our findings of impaired EF should by no means
be transferred into everyday EF. We expect that individuals with
ASD and ADHD benefit from the standardized formal assessment
setting and individuals who perform within normal ranges on
standardized tests might nevertheless have trouble in less formal
settings in their everyday lives (Toplak et al., 2013). There is thus a
chance that the lack of group differences in the present study was
influence by the sensitivity of the tests applied (or lack thereof).
Future studies might benefit from using a combination of
performance-based and everyday ratings of EF. Certain everyday
rating instruments of EF have demonstrated better sensitivity in
assessing EF than neuropsychological tests (McCandless & O’
Laughlin, 2007; Skogli et al., 2013; Toplak et al., 2008, 2013),
and might thus be more sensitive to detecting changes in EF as
children with ASD and ADHD mature.
We shed light on the developmental paths of performance on
three neuropsychological tests from childhood to young adulthood
(Mage = 22 years), not knowing whether the participants have
reached their developmental maximum or will continue to improve
their performance when growing older. We suggest that future
longitudinal studies should follow individuals further into adult-
hood, to investigate whether older adults with ASD and ADHD will
display normalized EF relative to TD individuals. Future studies
should strive to meet the challenges of the present study by including
a larger sample of participants with ASD, and ideally a larger
subsample of females with ASD, enabling potential gender com-
parisons. Another suggestion for future research would be to
investigate how EF tracks with quality of life and functional
819
outcome as individuals mature, as it has been suggested that
neuropsychological deficits may affect functional outcome and
quality of life beyond the influence of ADHD symptoms
(Sjöwall & Thorell, 2019).
Clinical Implications
Knowledge of how EF matures within ASD and ADHD popula-
tions might benefit affected individuals, their families, clinicians,
and educators by helping them anticipate development and plan in
line with this trajectory (Conklin et al., 2007). These findings might
provide guidance on what to expect in relation to EF development in
children and adolescents with ASD or ADHD as they grow up. Our
research might also be of benefit in terms of psychoeducational
advice for affected individuals, parents, and teachers, and may
potentially result in increased acceptance of affected individuals.
Overall, our data do not indicate that the clinical groups catch up
with the performance in the TD group by young adulthood, imply-
ing that the need for school or workplace support and facilitation has
not necessarily diminished. The continued presence of impaired EF
at group level for these clinical groups, relative to the TD group
might suggest that individual assessment of EF can also yield useful
information beyond childhood. A previous longitudinal study in
males with ADHD reported that certain individuals displayed no
deficits in childhood, yet displayed the onset of new deficits in
adulthood, indicating that an assessment in adulthood may be useful
regardless of status in childhood (Biederman, Petty, Fried, et al.,
2007). We should also emphasize the substantial heterogeneity of
EF performance within the ASD and ADHD groups. Findings of
impaired EF at the group level should not be transferred to the
individual level.
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Received December 13, 2020
Revision received July 11, 2021
Accepted July 11, 2021 ▪