Journal of Autism and Developmental Disorders

https://doi.org/10.1007/s10803-020-04852-2

ORIGINAL PAPER

Executive Function in Autism: Association with ADHD and ASD

Symptoms
Rachel R. Lee1 · Anthony R. Ward1 · David M. Lane2 · Michael G. Aman3 · Katherine A. Loveland1 · Rosleen Mansour1 ·
Deborah A. Pearson1,4

Accepted: 16 December 2020

© The Author(s), under exclusive licence to Springer Science+Business Media, LLC part of Springer Nature 2021

Abstract
There is substantial comorbidity between autism spectrum disorder (ASD) and attention deficit/hyperactivity disorder
(ADHD), and there are well-documented executive functioning (EF) deficits in both populations. An important question
concerns whether EF deficits in children with ASD are related to severity of ASD, ADHD, or both. We examined ADHD
and ASD symptoms in relation to ratings of EF in the home and classroom. The sample comprised 64 children (55 males)
diagnosed with ASD (mean age = 9.26 years; mean FSIQ = 92). Analyses indicated that parent and teacher ratings of EF
(except Shift and Emotional Control) were consistently related to ADHD symptom severity, but not to ASD severity. Thus,
functioning in the domains of Shift and Emotional control appear relatively spared, whereas performance in all other EF
was impaired in relation to ADHD symptoms.

Keywords Autism spectrum disorder · Attention-deficit/hyperactivity disorder · Executive functioning · Parent ratings ·
Teacher ratings · ASD+ADHD

A substantial proportion of children with autism spectrum have also found evidence of EF impairments in ASD (Dem-
disorder (ASD) have symptoms of inattention, hyperactiv- etriou et al. 2018; Granader et al. 2014; Ozonoff and Jensen
ity, and impulsivity that warrant a diagnosis of attention 1999; Sergeant et al. 2002)—although in at least one previ-
deficit/hyperactivity disorder (ADHD). A review by Leitner ous study, approximately one-third of the adult ASD sample
(2014) found prominent ADHD symptoms among 37–85% showed no EF impairment (Johnson et al. 2019).
of individuals with ASD. Indeed, by late elementary school Given that EF deficits are associated with ADHD, and
or early adolescence, the effects of comorbid psychiatric that symptoms of ADHD often co-occur in children with
symptoms—such as ADHD—on individuals with ASD are ASD, children with ASD who also have significant ADHD
often more problematic than core ASD symptoms (Loveland symptoms (i.e., ASD+ADHD) may have a substantially
2005; Mansour et al. 2017a, b; Pearson et al. 2006). Defi- higher risk for EF deficits. A prominent question is whether
cits in executive functioning (EF), including goal-directed deficits in EF in children with ASD+ADHD are more closely
behavior and inhibition, have long been implicated in ADHD related to their ASD or their ADHD symptoms. This is an
(Barkley 1997; Sergeant et al. 2002). A number of studies important question that forms the rationale for this study.
We hypothesize that if EF deficits are more closely asso-
* Deborah A. Pearson ciated with ADHD symptoms, as opposed to ASD symp-
[email protected] toms, that it may be possible to treat these EF deficits with
some of the same interventions that have been shown to be
1
McGovern Medical School, University of Texas Health effective in ADHD such as stimulant medication. Although
Science Center at Houston, Houston, TX, USA
our group has found that cognitive task performance can be
2
Rice University, Houston, TX, USA significantly improved by stimulant treatment in children
3
Ohio State University, Columbus, OH, USA with ASD and ADHD (Pearson et al. 2020), cognitive task
4
Louis A. Faillace M.D. Department of Psychiatry & performance does not always translate to real-work EF con-
Behavioral Sciences, McGovern Medical School, University cerns (Ng et al. 2019; Van Eylen et al. 2015). EF deficits
of Texas Health Science Center at Houston, 1941 East Road, are related to real-world functional problems in ASD such
Room 3.126 BBSB, Houston, TX 77054, USA

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Vol.:(0123456789)
 Journal of Autism and Developmental Disorders

as academic performance (John et al. 2018). Furthermore, Method

they increase from childhood to late adolescence, (Rosenthal
et al. 2013). If EF deficits are associated with ADHD symp- Procedure
toms that could be treated effectively with ADHD interven-
tions, such treatment may result in real-world gains in the This study was conducted as part of a larger investigation
present (school) and in the future (job performance). The of ADHD symptoms in children with ASD. Participants
rationale for this study was to determine if ADHD symp- were recruited from the general community via special
toms were significantly related to EF deficits. If so, would education programs, special-needs schools, community
ADHD treatments be indicated to treat EF deficits in some clinics, ASD events, and parent advocacy groups. Par-
children with ASD (e.g., those who had significant ADHD ents who expressed interest in participation were asked to
symptoms) and perhaps not in other children with ASD (who complete a phone screen interview with a master’s level
do not have significant ADHD symptoms)? psychologist, who administered the Social Communication
It has been difficult to determine the contributions of Questionnaire (SCQ; Rutter et al. 2003a). Only children
ASD symptomatology and ADHD symptomatology to EF who scored ≥ 15 on the SCQ were invited to participate in
concerns because most studies examining EF deficits in the psychological assessment.
ASD and ADHD samples compare EF profiles across differ- This study was approved by the institutional review
ent diagnostic groups (Craig et al. 2016). Semrud-Clikeman board of the University of Texas Health Science Center
et al. (2010) studied EF in children with ASD, ADHD-C, at Houston. Consent from the parents and assent from the
ADHD-PI, and controls. They found that the number of children (when appropriate) were obtained prior to com-
ADHD symptoms and number of ASD symptoms accounted mencing the study procedures. All participants included in
for significant proportions of the variance when all indices the analyses met DSM-IV-TR criteria for Autistic Disor-
of the BRIEF were included in the model. However, ASD der, Asperger’s Disorder, or Pervasive Developmental Dis-
symptoms did not have a significant effect when EF indices order-Not Otherwise Specified (PDD-NOS). In addition,
were analyzed individually. A sizeable literature strongly all participants met cutoff criteria on the Autism Diagnos-
suggests that children with either disorder, or both, exhibit tic Observation Schedule (ADOS; Lord et al. 2001) and
weaknesses in aspects of EF as measured by laboratory- the Autism Diagnostic Interview-Revised (ADI-R; Rutter
based cognitive tests (e.g., Corbett et al. 2009; Craig et al. et al. 2003b). A diagnosis of ADHD was determined if
2016; Geurts et al. 2004; Goldberg et al. 2005; Happe et al. participants met the DSM-IV-TR criteria for ADHD on
2006). However, given that lab-based cognitive tasks may a computerized clinical interview (DICA-IV; Reich et al.
not capture real-world difficulties with planning, organiza- 1997), which was followed by a diagnostic interview con-
tion, and self-regulation (Ng et al. 2019; Van Eylen et al. ducted by a licensed psychologist (DAP). The diagnosis
2015), many clinicians currently rely instead on rating scales disregarded the DSM-IV-TR prohibition of diagnosing
indexing EF, such as the Behavioral Rating Inventory of ADHD in the context of autism. Additionally, we gathered
Executive Function (BRIEF; Gioia et al. 2000a). EF deficits reports of impairment in multiple settings by the parents
in ASD have also been demonstrated in studies using behav- and teachers, and observation by the research team. Sever-
ioral measures such as the BRIEF (e.g., Blijd-Hoogewys ity of ADHD symptoms was assessed using Conners’ Par-
et al. 2014; Lawson et al. 2015; Rosenthal et al. 2013). ent Rating Scale, Revised-Long (CPRS-R) and the Con-
In summary, the literature suggests that EF deficits have ners’ Teacher Rating Scale, Revised-Long ADHD Indexes
consistently been found in children with ADHD and ASD. (CTRS-R; Conners 1997). Final diagnoses were assigned
However, we are not aware of any previous study that has following clinic observation by the study team, and case
simultaneously examined the relative roles of ADHD and review by two licensed psychologists (DAP and KAL).
ASD symptoms in EF in the same children with ASD. Thus, The primary caretaker for each child completed the par-
it is not known if EF can be attributed primarily to sever- ent report measures (e.g., Pearson et al. 2012). Teacher rat-
ity of ADHD, to severity of ASD, or to some combination ings were sent to subjects’ classrooms, and teachers mailed
thereof. Furthermore, previous research has used only parent them back to the clinic. For children taking psychotropic
ratings of EF. Thus, it is also unknown what the relation- medication, both parents and teachers were instructed, to
ship is between teacher ratings of EF and ADHD and ASD the extent possible, to rate the child’s behavior when he or
symptoms. she was not taking medication.
The objectives of this study were twofold: (1) to examine
the contributions of parent-rated ADHD symptoms and ASD
symptoms to ratings of EF deficits in the home, and (2) to
examine the contributions of teacher-rated ADHD symptoms
and ASD symptoms to EF deficits in the classroom.

13
Journal of Autism and Developmental Disorders

Participants psychostimulants (31.25%), SSRIs and SNRIs (15.63%),

atypical antipsychotics (10.94%), antihypertensives (4.69%),
As assessment of EF in children with intellectual dis- tricyclic antidepressants (3.13%), anticonvulsants (3.13%),
ability can be exceptionally complex (Danielsson et al. antipsychotics (1.56%), mood stabilizers (1.56%), atomox-
2012), participants were excluded from this EF study if etine (1.56%), trazodone (1.56%), and central muscarinic
they had an IQ below 70 (determined by the Stanford- antagonists (1.56%).
Binet, 5th Edition [SB5; Roid 2003]). Participants were
also excluded if English was not their primary language. Measures
The sample comprised 64 children (55 male) between the
ages of 6 and 13 years old (mean age = 9.26), with a mean Stanford‑Binet Intelligence Scale, 5th Edition (SB5)
FSIQ of 92 (ranging from 70 to 116) on the SB5. Partici-
pants had an average mental age equivalent of 8.53 years The SB5 (Roid 2003) is normed for ages 2 through 80 years,
(ranging from 4.83 to 15.0). Thirty-two participants (50% and yields a measure of Full, Verbal, and Nonverbal IQ.
of the sample) had a diagnosis of Autism, 14 had a diag-
nosis of Asperger’s Disorder (21.9%), and 18 had a diag- Diagnostic Interview for Children and Adolescents, 4th
nosis of PDD-NOS (28.1%). Fifty-three of the participants Edition‑Parent Interview (DICA‑IV)
(82.8% of the sample) met diagnostic criteria for ADHD in
addition to ASD. Of the 53 participants who had ADHD, The DICA-IV (Reich 2000; Reich et al. 1997) is a struc-
37 had a combined presentation, 15 had Predominantly tured psychiatric interview that was administered to parents
Inattentive type, and 1 had Predominantly Hyperactive/ to assess major diagnostic categories of the DSM-IV. Impor-
Impulsive type. Table 1 provides more details. tantly, the DICA-IV has been sensitive to psychiatric condi-
Twenty-six of the participants (40.63%) were taking tions in children with developmental disabilities (Pearson
psychotropic medications before the study. This included et al. 2013).

Table 1  Participant characteristics

Characteristics n % of
Overall
sample

Gender
Male 55 86
Female 9 14
Race
Caucasian 50 78
African American 7 11
Asian 2 3
Other/unspecified 5 8
Ethnicity
Hispanic 15 23
Non-Hispanic 49 77
ADHD diagnosis
Combined presentation 37 58
Predominantly inattentive presentation 15 23
Predominantly hyperactive-impulsive presentation 1 2
Mean (SD) Range

Age (years) 9.3 (1.8) 6.7–13.5

SB5 FSIQ 92.3 (13.0) 70–116
SB5 FS AE (mental age in years) 8.5 (2.4) 4.8–15.0
Parent education (# years)
Mother 15.7 (2.2) 12–21
Father 16.3 (3.1) 9–25

Total sample: N = 64

13
 Journal of Autism and Developmental Disorders

Social Communication Questionnaire, Lifetime (SCQ) ADHD Index from the CTRS-R is a 12-item scale. Internal
consistency estimates range from .85 to .96 (Conners 1997).
The SCQ (Rutter et al. 2003a) is a 40-item, parent-report
questionnaire used to screen for ASD. Its score ranges from Behavior Rating Inventory of Executive Function (BRIEF),
0 to 40, with scores exceeding 15 indicating that a fuller Parent and Teacher Forms
work-up for ASD is needed.
The BRIEF-Parent (BRIEF-P) and BRIEF-Teacher (BRIEF-
Autism Diagnostic Observation Schedule (ADOS) T) (Gioia et al. 2000b) are widely used rating scales assess-
ing executive functioning. They use age-based norms for
The ADOS (Lord et al. 2001) consists of a standard series individuals ages 5–18 years. They provide eight subscales
of events, behavioral presses, and observations to determine of EF (Gioia et al. 2000b; psychometric properties are
presence of autism. It was used, in conjunction with the presented as parent/teacher): 1. Inhibit—ability to control
ADI-R (below), to diagnose ASD. The master’s level psy- impulses (Parent = 10 items/Teacher = 10 items, Parent
chologist who administered the ADOS and the two supervis- α = .91/Teacher α = .96), 2. Shift—free movement from one
ing Ph.D.-level psychologists were all research-reliable on situation or context to another (8/10 items, α = .81/.91), 3.
the ADOS (and the ADI-R). Most (59/64, or 92.2%) of the Emotional Control—regulation of emotional responses (10/9
children in this project received Module 3, with one child items, α = .89/.93), 4. Initiate—initiation of tasks/activi-
(1.6%) receiving Module 2 and four children (6.3%) receiv- ties (8/7 items, α = .80/.90), 5. Working Memory—ability
ing Module 4. to hold information mentally (10/10 items, α = .89/.93), 6.
Plan/Organize—set goals and create appropriate steps for
Autism Diagnostic Interview, Revised (ADI‑R) future plans (12/10 items, α = .90/.91), 7. Organization of
Materials—orderliness of play/work space and materials
The ADI-R (Rutter et al. 2003b), a 93-item, semi-structured (6/7 items, α = .87/.92), and 8. Monitor—evaluate effects
interview assessing current and historical symptoms of of behavior on others (8/10 items, α = .83/.90). The clini-
ASD, was administered to primary caregivers. It is based cal scales form two broad indexes, Behavioral Regulation
on both DSM-IV and ICD-10 criteria for autism and has (BRI; α = .94/.97) and Metacognition (MI; α = .96/.98), and
demonstrated good reliability and construct validity (Rut- an overall score, the Global Executive Composite (GEC;
ter et al. 2003b). The ADI-R yields scores on each of the α = .97/.98). Parents and teachers rated subjects on the
three major domains [(a) reciprocal social interaction; (b) BRIEF-Parent Form (BRIEF-P) and BRIEF-Teacher Form
communication and language; and (c) restricted, repetitive, (BRIEF-T), respectively. Means, and standard deviations for
and interests]. The ADI-R total score was the measure of the measure of ASD severity (ADI-R total score), parent and
ASD symptom severity. Lefort-Besnard et al. (2020) have teacher measures of ADHD severity (CPRS-R and CTRS-R
shown that the ADI-R is a reliable predictor of ASD symp- ADHD Indices), and parent and teacher BRIEF scores are
tom severity. presented in Table 2. Correlations among these variables are
presented in Table 3.
Conners’ Parent Rating Scale, Revised (CPRS‑R)

The CPRS-R is widely used to assess ADHD and other Results

behavioral/emotional issues (e.g., oppositional behavior,
social problems) in the home setting. The CPRS-R is nor- Multiple linear regressions were used to assess the associa-
med for children ages 3–17 years. The ADHD Index from tion between parent and teacher ratings of EF and parent-
the CPRS-R (Conners 1997) was used to assess ADHD and teacher-rated ADHD and ASD symptomology (deter-
severity. The ADHD Index from the CPRS-R is a 12-item mined by the ADI-R). The ADHD Index from the CPRS-R
scale. Internal consistency estimates range from .89 to .94 was used to estimate severity of ADHD at home, and the
(Conners 1997). ADHD Index from the CTRS-R was used to estimate ADHD
severity at school. ASD severity was estimated using the
Conners’ Teacher Rating Scale, Revised (CTRS‑R) ADI-R Total Score (sum of domain scores). We assessed
possible violations of normality of residuals visually using
The CTRS-R was completed by teachers to assess ADHD, q–q plots and histograms. The residuals for BRIEF showed
behavioral, and emotional symptoms in the classroom set- no meaningful deviation from normality. The variance
ting (Conners 1997). The CTRS-R ADHD Index was the inflation factor (VIF), a measure of the amount of multi-
teacher measure of ADHD severity in the classroom. The collinearity in a set of multiple regression variables, was

13
Journal of Autism and Developmental Disorders

Table 2  Descriptive statistics for study variables other predictor (see Velleman and Welsch 1981). Note that
Variable Parent Teacher
the variable means were added to the residuals for ease of
interpretation. From these plots, a clear positive relationship
M SD M SD
between ADHD symptom severity and EF deficits emerged,
ADI-R total score 46.6 11.0 46.6 11.0 whereas there was no relationship between EF and ASD
Conners’ ADHD Index 69.7 11.1 65.3 10.8 symptoms.
BRIEF inhibit 63.6 12.9 63.5 13.2 Similar results were found for teacher ratings (see
BRIEF shift 69.3 11.8 69.7 15.0 Table 5). Whereas the ADHD index generally predicted
BRIEF Emo. Control 61.5 12.7 67.6 15.8 BRIEF Teacher ratings (p < .001), ASD severity did not.
BRIEF BRI 66.3 11.8 68.7 14.4 Once again, the Shift (p = .05; sr2 = 7%) and the Emotional
BRIEF initiate 63.8 11.4 67.1 10.8 Control subscales (p = .07, sr2 = 6%) were not predicted
BRIEF Working Mem. 67.6 9.8 70.5 12.3 by ADHD severity. Unlike the case with parent ratings,
BRIEF plan/organize 66.4 11.8 64.1 11.8 Organization of Materials was significantly predicted by
BRIEF Org. of Mat. 58.5 10.9 63.0 15.3 ADHD severity. Neither Shift nor Emotional Control was
BRIEF monitor 66.1 11.1 67.0 10.9 significantly predicted by the overall model (i.e., variance
BRIEF MI 67.3 10.3 68.0 11.1 explained by combined ASD and ADHD symptom sever-
BRIEF GEC 68.3 10.2 69.5 11.6 ity). Of variables showing a significant relationship between
ADHD and EF, incremental variance explained by ADHD
Conners’ and BRIEF scores are presented as T-scores
severity ranged from 19 to 36% (see Table 5). Figure 2 dis-
BRIEF Emo. Control BRIEF emotional control, BRIEF BRI BRIEF plays the partial regression plot of teacher ratings of EF and
Behavior Regulation Index, BRIEF Working Mem. BRIEF work-
ing memory, BRIEF Org. of Mat. BRIEF organization of materials, the predictors, ASD and ADHD severity. Similar to parent
BRIEF MI BRIEF Metacognition Index, BRIEF GEC BRIEF general ratings, teacher ratings showed a strong positive relation-
executive composite ship between EF and ADHD severity, and no relationship
between EF and ASD severity.

low (1.0–1.15), indicating that multicollinearity was not a

concern. Discussion
Regression results for parent ratings of EF are presented
in Table 4, where R2 represents the proportion of variation in To our knowledge, this study is the first to examine EF prob-
the EF scales predicted by the overall model (i.e., combined lems and their relationship with ASD and ADHD symp-
ASD and ADHD symptom severity), t is the value used to tom severity using both parent and teacher behavior ratings.
test the significance (i.e., p ≤ .001) of each individual vari- Thus, we were able to examine EF problems within our sam-
able’s (i.e., symptom severities) prediction of EF scales. sr2 ple across environments. In addition, this study was unique
is the proportion of variance explained by each measure of by exploring deficits within our ASD sample rather than
symptom severity, after controlling for the other. Because of between children with ASD and other conditions. The ben-
the large number of comparisons involving EF, we set alpha efit of this approach is that it reflected the high comorbidity
at p = .002 using a Bonferroni Correction. Among parent of ADHD symptoms in children with ASD and included
ratings comparing ADHD and EF indexes on the BRIEF- children with a range of ADHD severity in the analyses.
P, the ADHD index predicted outcomes on all except the Further, it provided insights into what was contributing to
Shift and Emotional Control, and Organization of Materials problematic EF deficits in children with ASD because we
subscales (see Table 4). Interestingly, even the combined could control for one set of symptoms while examining the
effects of ASD and ADHD symptom severity did not sig- relative contribution of the other.
nificantly account for variability in these three subscales. Our analyses found that ASD severity was not signifi-
As seen in Table 4, the proportion of variance explained by cantly related to any parent or teacher ratings of EF. This
ADHD severity, after controlling for ASD severity, ranged is inconsistent with previous research, although at least one
from 23 to 53%. Conversely, incremental variance explained previous study demonstrated no EF impairment in a substan-
by ASD severity was negligible and nonsignificant across all tial proportion (35.8%) of adults with ASD (Johnson et al.
subscales: sr2 < 1% for all BRIEF-P indices and subscales. 2019). Studies examining differences in EF presentations
This is further illustrated in the partial regression plots of across diagnostic groups have consistently documented both
Fig. 1. In this figure, the residuals of parent ratings of gen- broad-based EF deficits compared with typically develop-
eral, broad based executive functioning (as measured by ing children and deficits in shift/flexibility which distinguish
the BRIEF GEC) are plotted against the residuals of ASD children with ASD from other developmental disorders
and ADHD severity after removing the linear effects of the (Gioia et al. 2002; Hovik et al. 2017; Lawson et al. 2015;

13
 Table 3  Correlations between parent and teacher ratings
Variable ADI-R CTRS-R Teacher Teacher Teacher Teacher Teacher Teacher Teacher Teacher Teacher Teacher Teacher
sum of ADHD BRIEF BRIEF shift BRIEF BRIEF BRI BRIEF initi- BRIEF BRIEF plan/ BRIEF BRIEF BRIEF MI BRIEF GEC

13
scales Index inhibit Emo. ate Working org Org. of monitor
Control Mem. Mat.

ADI-R sum ─ − .36** − .22 − .04 − .10 − .14 − .17 − .05 − .19 − .22 − .17 − .19 − .19
of scales
CPRS-R − .02 .46** .27* .18 .08 .22 .22 .19 .24 .28* .11 .26* .28*
ADHD
Index
Parent − .04 .28* .30* .10 .25 .25* − .06 − .15 .10 .11 .01 .01 .13
BRIEF
inhibit
Parent .01 − .11 − .07 .18 .10 .08 − .13 − .25 − .04 − .06 − .26* − .18 − .09
BRIEF
shift
Parent − .15 .15 .18 .09 .38** .25 .00 − .19 .17 .06 − .02 .01 .12
BRIEF
emotional
control
Parent − .09 .19 .22 .13 .31* .26* − .06 − .20 .13 .08 − .06 − .03 .10
BRIEF
Behavior
Regulation
Index
Parent .09 .03 .00 .11 − .11 .00 .18 .20 .22 .12 .07 .19 .12
BRIEF
initiate
Parent − .02 .38** .14 .10 − .03 .08 .23 .10 .25 .11 .08 .18 .16
BRIEF
working
memory
Parent − .08 .25 .20 .15 .09 .19 .14 .17 .35** .17 .11 .23 .24
BRIEF
plan/organ-
ize
Parent − .19 .06 .14 .15 .06 .13 .07 − .09 .19 .17 .01 .08 .12
BRIEF
organiza-
tion of
materials
Parent .03 .31* .18 .08 .07 .14 .23 .14 .26* .11 .07 .19 .19
BRIEF
monitor
Journal of Autism and Developmental Disorders
 Journal of Autism and Developmental Disorders

Semrud-Clikeman et al. 2010). Much of the previous lit-

BRIEF Emo. Control BRIEF emotional control, BRIEF BRI BRIEF Behavior Regulation Index, BRIEF Working Mem. BRIEF working memory, BRIEF Plan/Org. BRIEF plan/organize, BRIEF
BRIEF MI BRIEF GEC
Teacher erature utilized both diagnostic group differences and com-
pared proportions of their samples with clinically significant

.23

.20
scores, rather than relative severity. However, our findings
strongly suggest that the relationship between ADHD symp-
toms and EF is linear and thus the relationship between them
Teacher

is captured better with dimensional, rather than categorical,

.23

.14
measurement. It should also be noted that although all of our
children had ASD, there was a wide range of ASD severity
in our sample. We conducted an analysis of the dispersion of
monitor
Teacher
BRIEF

scores participants received on the ADI-R; and this analysis

.09

.03

revealed a range of 23–65 (SD = 10.98). Thus, there was

sufficient variability in ASD severity to capture meaningful
Teacher

Org. of
BRIEF

relationships if they existed.

Mat.

.18

.15

Because we realize that the ADI-R has not been used

extensively as a dimensional measure, we also conducted
BRIEF plan/

Org. of Mat. BRIEF organization of materials, BRIEF MI BRIEF Metacognition Index, BRIEF GEC BRIEF general executive composite

analyses in which we substituted the SCQ for the ADI-R

Teacher

Total Score as a measurement of ASD symptom severity.

.35**

.29*
org

The results replicated our results using the ADI-R across

parent and teacher ratings of EF. This finding suggests that
our results were not an artifact of the difference in type of
Working
Teacher
BRIEF

Mem.

measurement (i.e., ADI-R total score versus SCQ score).

.16

.01

In terms of ADHD severity, we found that parent rat-

ings were related to EF in the home for all measures except
BRIEF BRI BRIEF initi-

the BRIEF-P Shift, Emotional Control, and Organization of

Teacher

Materials subscales. Similarly, teacher ratings of the sever-

.22

.11
ate

ity of ADHD symptoms were related to impaired EF in the

classroom for all but two BRIEF-T subscales (i.e., Shift and
Emotional Control). Our findings are thus consistent with
Teacher

previous research on EF in school-aged children diagnosed

.16

.22

with ADHD. This has found that children with ADHD

typically present with broad-based EF deficits, particularly
Teacher

Control
BRIEF shift BRIEF

inhibition and EF skills subsumed under Metacognition, but

Emo.

.05

.17

excluding the Shift and Emotional Control subscales (Gioia

et al. 2002). Visual examination of Shift and Emotional Con-
trol scores revealed good dispersion of scores within our
Teacher

sample. This indicates that the lack of any relationship for

.17

.17

Shift and Emotional Control with ADHD symptoms was not

simply due to a lack of variability in scores. Thus, unlike
Conners and BRIEF scores are presented as T-scores

other areas of EF, increased severity of ADHD symptoms

Teacher
BRIEF
inhibit

was not characterized by increased problems with flexibility

.17

.22

and not related to difficulty with emotional control. Our find-

ings demonstrated remarkably consistent results across par-
CTRS-R

ent and teacher ratings. However, the relationship between

ADHD
Index

Organization of Materials and ADHD severity was not rep-

.26*

.26*

licated across parent and teacher ratings. Only teacher rat-

ings showed that increased ADHD severity predicted poorer
ADI-R
sum of

orderliness of workspace and materials. This relationship

scales

− .03

− .07
Table 3  (continued)

*p = .05, **p = .01

between ADHD and organization is consistent with previ-

ous research on parent (Gioia et al. 2002; Hovik et al. 2017;
Metacogni-

composite
tion Index

executive

and Semrud-Clikeman et al. 2010) and teacher (Alloway

BRIEF

BRIEF
Variable

global

et al. 2009) ratings of EF. The fact that it was not found for
Parent

Parent

parent ratings may indicate that the types of organizational

13
 Journal of Autism and Developmental Disorders

Table 4  Regression models EF scales Symptom severity R2 t p sr2

predicting parent ratings of
executive functioning Inhibit .43**
ADHD severity 6.70 < .001 42%
ASD severity − .26 .79 < 0.1%
Shift .01
ADHD severity .80 .43 1%
ASD severity .08 .94 < 0.1%
Emotional control .10
ADHD severity 2.29 .03 8%
ASD severity − 1.16 .25 2%
Behavior Regulation Index .23**
ADHD severity 4.24 < .001 23%
ASD severity − .72 .47 < 0.1%
Initiate .28**
ADHD severity 4.77 < .001 27%
ASD severity .93 .36 < 0.1%
Working memory .53**
ADHD severity 8.33 < .001 53%
ASD severity − .11 .91 < 0.1%
Plan/Organize .41**
ADHD severity 6.52 < .001 41%
ASD severity − .68 .50 < 0.1%
Organization of materials .12
ADHD severity 2.40 .02 9%
ASD severity − 1.51 .14 4%
Monitor .50**
ADHD severity 7.75 < .001 50%
ASD severity .52 .61 < 0.1%
Metacognition Index .53**
ADHD severity 8.31 < .001 53%
ASD severity − .25 .80 < 0.1%
Global executive composite .51**
ADHD severity 7.87 < .001 50%
ASD severity − .69 .50 < 0.1%

EF measured by the BRIEF-P. ADHD Severity measured by the CPRS-R ADHD index. ASD Severity
measured by the ADI-R sum of scale scores. R2 = the proportion of the total variation in the EF measure
that can be explained by the overall model. t and p = a significance test of each individual predictor’s effect
on the EF scale. sr2 = squared semi-partial correlation, a measure of incremental variance. Subscale, index,
and composite scores are T-scores
*p < .002; **p < .001

skills most relevant and sensitive to such a relationship are sources of data in this study were parents and teachers in
more cognitive in nature. Whereas parents may monitor their all instances. However, it is important to bear in mind that
children’s organization in work, play, and storage spaces this the pattern of outcomes was completely different between
may be qualitatively different from teacher perceptions of the ADHD severity comparisons and the ASD severity out-
organizing cognitive tasks. comes, arguing against common-method variance as the
One issue that arises in this study relates to the possibility explanation. There was consistency between parents and
that the associations between EF and ADHD severity were teachers for significance on 10 of 11 EF scales where ADHD
due to “source variance” or common-method variance, a severity was the outcome of interest (missing complete
phenomenon in which relationships are due to the measure- agreement on only Organization of Materials, which was
ment method rather than to true relationships among the significant for teachers but barely missed our .002 Bonfer-
variables under study (Podsakoff et al. 2003). Indeed, the onni correction level). Thus, we suggest that the consistently

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Journal of Autism and Developmental Disorders

et al. 2013; Pearson et al. 2020; Sturman et al. 2017). It is

possible that stimulant treatment can also improve EF in the
domains tapped by the BRIEF-P and BRIEF-T. Thus, the
potential enhancement of EF via stimulant intervention is
an area that deserves investigation—especially given that EF
deficits significantly undermine a child’s ability to function
in day-to-day life—and that these impairments increase from
childhood to late adolescence, when older adolescents/young
adults with ASD are preparing to enter the job market.

Limitations

As our participants only included children with full-scale

IQs greater than or equal to 70, these results may not gen-
eralize to children with ASD and accompanying intellec-
tual impairment. We also realize that most of our sample
of children with ASD had ADHD, and that it would have
been optimal if we could have recruited an equal number
of children with ASD who did not have ADHD. Although
we originally hoped to recruit two equal-sized groups of
children (one with ASD+ADHD, and another with ASD but
without ADHD), as recruitment proceeded, we found that
it was very difficult to locate children in the latter group—a
finding that reflects the growing knowledge regarding the
high comorbidity between ASD and ADHD. This issue
clearly warrants further exploration in future studies with
larger samples.
Further, as is typical with ASD research, our sample was
mostly male and largely Caucasian. Therefore, our results
Fig. 1  Partial regression plots: parent ratings of BRIEF Global vs. may not generalize to samples that are more diverse. Further,
ASD (N.S.) (a) and BRIEF Global vs. ADHD severity (p < 0.001) the females in the study showed little variability in diagnosis
(b). ADHD severity measured by the CPRS-R ADHD index. ASD
severity measured by the ADI-R sum of domain scores. GEC global and presentation; all were diagnosed with ADHD. However,
executive composite our data analytic techniques did not examine ADHD as a
group diagnosis, but analyzed ADHD symptom severity
across the entire sample.
positive outcomes between informants for ADHD severity Future researchers should consider examining whether
on the one hand and the consistently negative outcomes for intervention for ADHD (e.g., medication) not only improves
ASD severity on the other is compelling evidence that EF, but whether enhanced EF in children with ASD leads
source variance does not account for the findings. to improvement in social skills, adaptive behavior, achieve-
It is also interesting to note that EF deficits were related ment, and other psychopathology. This could provide impor-
to ADHD symptoms—and that EF deficits have been suc- tant information for the treatment of school-aged children
cessfully treated using stimulant medication in children with ASD.
with ADHD who do not have ASD (Everett et al. 1991; Gau
and Shang 2010; Hale et al. 2011; Kempton et al. 1999;
Rapoport et al. 1980; Tannock et al. 1995; van Stralen et al. Conclusion
2020; Vance et al. 2003). As EF deficits are closely tied to
ADHD symptoms in children with ASD, stimulant treatment Our results suggest that most BRIEF subscales show a cor-
may prove effective in treating EF deficits in children with respondence between ADHD severity and EF. However,
ASD who also have significant ADHD symptoms. Cogni- Shift and Emotional Control seem to be unrelated to either
tive performance (inattention, inhibition), and behavioral
measures related to inattention, can be effectively treated
in children with ASD+ADHD (Howes et al. 2018; Pearson

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 Journal of Autism and Developmental Disorders

Table 5  Regression models EF scales Symptom severity R2 t p sr2

predicting teacher ratings of
executive functioning Inhibit .37**
ADHD severity − .07 < .001 33%
ASD severity 5.19 .95 < 0.1%
Shift .07
ADHD severity 2.01 .05 7%
ASD severity .38 .71 < 0.1%
Emotional control .07
ADHD severity 1.86 .07 6%
ASD severity − .08 .94 < 0.1%
Behavior Regulation Index .24**
ADHD severity 3.89 < .001 22%
ASD severity .23 .82 < 0.1%
Initiate .25**
ADHD severity 3.89 < .001 21%
ASD severity − .13 .90 < 0.1%
Working memory .28**
ADHD severity 4.60 < .001 28%
ASD severity 1.36 .18 2%
Plan/Organize .25**
ADHD severity 3.87 < .001 21%
ASD severity − .14 .89 < 0.1%
Organization of materials .26**
ADHD severity 3.80 < .001 20%
ASD severity − .63 .53 1%
Monitor .23**
ADHD severity 3.63 .001 19%
ASD severity − .22 .83 < 0.1%
Metacognition Index .36**
ADHD severity 5.16 < .001 32%
ASD severity .11 .91 < 0.1%
Global executive composite .40**
ADHD severity .565 < .001 36%
ASD severity .23 .82 < 0.1%

EF measured by the BRIEF-T. ADHD Severity measured by the CTRS-R ADHD index. ASD Severity
measured by the ADI-R Total Score. R2 = the proportion of the total variation in the EF measure that can
be explained by the overall model. t and p = a significance test of each individual predictor’s effect on the
EF scale. sr2 = squared semi-partial correlation, a measure of incremental variance. Subscale, index, and
composite scores are T-scores
*p < .002; **p < .001

ASD or ADHD symptom severity, both at home and at improving EF skills in children with ASD. Future studies
school. Further research is needed to verify this pattern. If should explore possible intervention techniques that would
the relationships found here hold true, intervention which be helpful for children with ASD who have significant
effectively targets ADHD symptoms may be helpful for ADHD symptoms.

Acknowledgments This study was funded by Grant Number

MH072263 from the National Institute of Mental Health (NIMH).
Preliminary versions of this paper were presented at the American
Academy of Child and Adolescent Psychiatry (AACAP) 56th Annual
Meeting in Chicago, IL, October 30, 2008 and at the 8th Annual Inter-
national Meeting for Autism Research (IMFAR) in Chicago, IL, May

13
Journal of Autism and Developmental Disorders

visory boards, or done investigator training for J & J Pharmaceuticals;

Ovid Therapeutics; Hoffmann-La Roche; Supernus Pharmaceuticals,
and Zynerba Pharmaceuticals. He receives royalties from Slosson Edu-
cational Publications. The other authors report no biomedical financial
interests or potential conflicts of interest.

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tualization and methodology of the project. Dr. Pearson, Dr. Loveland, national Journal of Neuropsychopharmacology, 13(2), 243–256.
and Ms. Mansour were involved in investigation (i.e., conducting the https​://doi.org/10.1017/S1461​14570​99908​36.
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Aman has received research contracts, consulted with, served on ad- Profiles of everyday executive function in acquired and

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