The Overlap Between Autism, ADHD, and Executive Functioning

Ericka Wodka, Ph.D., ABPP-CN

September 26, 2019

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Autism Spectrum Disorder

DSM-5A. Language

and Social Functioning

B. Repetitive and Rigid Patterns of Behavior

Other Childhood Disorders can Look Like Autism (Rule-outs)

• Receptive/Expressive Language Disorder

• Attention Deficit/Hyperactivity Disorder

• Anxiety– Specific Phobia– Social Phobia

• Intellectual Disability• Learning Disability• Tourette Syndrome• Giftedness• Many more…

http://drashokakela.blogspot.com/2015/05/zebra-colour-pattern-in-livestock.html

Other Childhood Disorders thatCome Along with Autism (Comorbidities)

• Receptive/Expressive Language Disorder

• Attention Deficit/Hyperactivity Disorder

• Anxiety– Specific Phobia– Social Phobia

• Intellectual Disability• Learning Disability• Tourette Syndrome• Giftedness• Many more…

http://drashokakela.blogspot.com/2015/05/zebra-colour-pattern-in-livestock.html

Attention Deficit/Hyperactivity Disorder (ADHD)

DSM-5A. 6 or more symptoms of Inattention

(e.g., careless mistakes, poor attention to detail, limited sustained attention, trouble following-through with instructions, distracted, forgetful, loses important items)

B. 6 or more symptoms of Hyperactivity/Impulsivity(e.g., fidgety, overly active- out of seat, always on the move, cannot play quietly, talks excessively, difficulty waiting turn, interrupts others)

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Social Difficulties: Similar but Different…

Autism• Limited nonverbal

communication• Difficulty developing

peer relationships• Limited spontaneous

seeking to share enjoyment

• Limited of social reciprocity

ADHD• Interrupts and intrudes

on others• Talks excessively• Difficulty playing quietly• Difficulty listening when

spoken to directly• Difficulty sustaining

attention to tasks or play

Repetitive Behaviors: Similar but Different…

Autism• Stereotyped motor

movements• Lining up toys• Flipping objects

ADHD• On the go, as if driven

by a motor• Taps hands or feet• Trouble sitting still• Messy or disorganized

work

Related Motor Similarities and Differences

Both ASD and ADHD show abnormalities in basic motor control…

But, deficits in motor skills requiring visuomotor integration and imitation are specific to ASD

8 Izawa et al., 2013

Similar and Shared: Biological Factors

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ASD ADHD

Sex distribution (predominantly male)

Genetics

Brain involvement

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But.. Trajectories are different

ASD:Early rapid and pervasive increase in brain size in infancy and toddlerhood followed by arrested development in later childhood and a potential decline in preadolescence into adulthood

ADHD:Cortical maturation that may be delayed by several years compared to typically developing (TD) children; however, typical cortical volumes may be attained by late adolescence or early adulthood

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Similar & Shared: Behavioral Factors

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ASD ADHD

Executive Dysfunction

Inattention

Hyperactivity

Social Difficulties

Sensory Behavior

What is Executive Functioning (EF)

It requires the ability to plan and sequence complex behaviors, simultaneously attend to multiple sources of information, grasp the gist of a complex situation, resist distraction and interference, inhibit inappropriate responses, and sustain behavior for prolonged periods (Denckla, 1996).

15 https://www.blogography.com/photos24/DavePuppetMaster.gif

EF Subdomains (Powell & Voeller, 2004)

Cognitive Regulation

Behavioral Regulation

EmotionalRegulation

• Attention regulation• Goal

setting/planning• Organization

• Time management• Novel problem

solving• Flexible thinking

• Judgment

• Task initiation• Inhibition of

automatic responses• Sustaining effort

• Impulse control/delayed

gratification• Anticipation of future

consequences of actions

• Modulation of emotional arousal

• Modulation of mood• Self-soothing

strategies

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EF are controlled by the frontal lobes of the brain

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Powell & Voeller 2004

How EF presents in ASD +/- ADHD

• Rigid and routine bound ways of thinking• Hyperfocused interests• Behavioral inflexibility/preferred activities• Rigidity in social dynamics• Efficient and abstract reasoning (vs. getting stuck in the

details)

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Is EF a possible endophenotype, polyphenotype, or additive comorbidity?

19Craig et al., 2016

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Research suggests that individuals with ASD + ADHD demonstrate greater challenges than a single diagnosis.

There is also preliminary evidence that ASD + ADHD may be less responsive to standard treatments for either disorder.

So, what does this mean for our kids with multiple diagnoses and executive functioning challenges?

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ASD ADHDEF

What to do…

Research into behavioral interventions targeting EF in ASD is ongoing.

There is some initial evidence that there are methods for both supporting and improving EF.

Given that a child’s “job” is going to school, it is important that they be provided with support and reinforcement of techniques both at home and in the school setting.

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Potential 504/IEP Accommodations and Goals

• Extended time• Adult support with homework planner- color code

subjects/folders• Formalized study skills class• (Online) graphic organizers/access to computer for

written assignments• Variety of organizational Apps, with timers and

reminders• Advanced warnings prior to changing

activities/subjects• Chunking information, teaching

pneumonic strategies

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School/Classroom-wide Accommodations

• Reminding and providing time for the entire class to proofread an assignment before turning it in.

• Proximity of the homework bin to students

• Posting visual schedules

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Intervention strategies

Unstuck & On Target (Cannon et al., 2018)• Provides strategies and vocabulary for teaching

flexibility, goal-setting, and making/checking plans– Uses Four Primary Teaching Methods:

• Memorize and repeatedly use scripts and key words• Teach by doing: model and coach to teach new

scripts and skills• Make it fun• Provide visual supports

– Can and Should be applied both at home and in school for children with a language level of at least 7-8 years

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Intervention strategies continued…

Smart but Scattered (Dawson & Guare, 2010)

• Targets 11 areas of EF thought to be most related to school success.

• Improving EF is a process, involving setting short-term goals and building ongoing training, practice, and process monitoring.

• Teaches EF strategies through scaffolding.

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Intervention Strategies continued…

• Behavioral Management strategies– Antecedents-Behaviors-Consequences (reinforcements)

• Cognitive Behavioral approaches– Recognizing and challenging unhelpful thoughts and

replacing with positive thinking and coping strategies

• Medication Management

• Hybrid approaches– The Zones of Regulation (Kuypers 2011)

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Intervention Strategies in Social Settings

Social Thinking Curriculum (Winner 2007)– Applying strategies in social settings– Breaks down complex concepts into doable

parts to be applied in multiple settings• Self-regulation• Social-emotional learning• Executive functioning• Perspective taking• Social problem solving

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So what works best!?!

• Evidence for these approaches is growing; however, there is certainly challenge to evaluating behavioral approaches.

• Historically (first published in 1999), the Multimodal Treatment Study of Children with ADHD (not necessarily ASD) found that combination treatment (medication and behavioral therapy) was the most successful approach.

• In the end, the best treatment for an individual child is best selected on evaluation of the child’s needs, considered within the larger environment in which that child needs to function. Often, these techniques are implemented by parents under the guidance of a professional.

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