Predictive utility of autistic traits in youth with ADHD: a controlled 10-year longitudinal follow-up study

  • Gagan JoshiEmail author
  • Maura DiSalvo
  • Stephen V. Faraone
  • Janet Wozniak
  • Ronna Fried
  • Maribel Galdo
  • Abigail Belser
  • Barbora Hoskova
  • Nina T. Dallenbach
  • Melissa F. De Leon
  • Joseph Biederman
Original Contribution


The objective of this study was to investigate the stability and predictive utility of autistic traits (ATs) in youth with attention-deficit/hyperactivity disorder (ADHD). Participants were referred youth with and without ADHD, without a diagnosis of autism spectrum disorder, and their siblings, derived from identically designed longitudinal case–control family studies of boys and girls with ADHD. Subjects were assessed with structured diagnostic interviews and measures of social, cognitive, and educational functioning. The presence of ATs at baseline was operationalized using a unique profile of the Child Behavior Checklist (CBCL) consisting of an aggregate T score of ≥ 195 on the Withdrawn, Social, and Thought Problems subscales (CBCL-AT profile). At the follow-up, 83% of the ADHD youth with a positive AT profile at baseline continued to have a positive CBCL-AT profile. The presence of a positive CBCL-AT profile at baseline in youth with ADHD heralded a more compromised course characterized by a greater burden of psychopathology that emerged at an earlier age, along with poorer interpersonal, educational, and neurocognitive outcomes. Findings indicate a high level of persisting ATs in ADHD youth over time, as indexed through the CBCL-AT profile, and the presence of this profile prognosticates a compromised course in adult life in multiple domains of functioning.


Attention-deficit/hyperactivity disorder (ADHD) Autistic traits Youth Longitudinal study 



The data acquisition for this analysis was derived was funded by National Institute of Mental Health Grants MH-41314, HD036317, and MH050657 to Dr. Joseph Biederman. The manuscript and analysis of the data were indirectly supported by the Alan and Lorraine Bressler Clinical and Research Program for Autism Spectrum Disorder, the MGH Pediatric Psychopharmacology Council Fund, and by the National Institute of Mental Health Grant awarded to Gagan Joshi (#K23MH100450).

Compliance with ethical standards

Conflict of interest

Dr. Gagan Joshi has received research support from the Demarest Lloyd, Jr. Foundation, F. Hoffman-La Roche, the National Institute of Mental Health (NIMH) of the National Institutes of Health (NIH) under Award Number K23MH100450, Pfizer and the Simons Center for the Social Brain as a principal investigator (PI) for investigator-initiated studies. Additionally, he has received research support from Duke University and Sunovion Pharmaceuticals as a site PI for multi-site trials. He has been a co-investigator for a clinical trial sponsored by the U.S. Department of Defense. He received an honorarium from the Governor's Council for Medical Research and Treatment of Autism in New Jersey for grant review activities and speaker’s honorariums from the American Academy of Child and Adolescent Psychiatry, Massachusetts General Hospital Psychiatry Academy, and the Medical Society of Delaware. In the past year, Dr. Stephen Faraone received income, potential income, travel expenses continuing education support and/or research support from Lundbeck, Rhodes, Arbor, KenPharm, Ironshore, Shire, Akili Interactive Labs, CogCubed, Alcobra, VAYA, Sunovion, Genomind and Neurolifesciences. With his institution, he has US patent US20130217707 A1 for the use of sodium–hydrogen exchange inhibitors in the treatment of ADHD. In previous years, he received support from: Shire, Neurovance, Alcobra, Otsuka, McNeil, Janssen, Novartis, Pfizer and Eli Lilly. Dr. Faraone receives royalties from books published by Guilford Press: Straight Talk about Your Child’s Mental Health, Oxford University Press: Schizophrenia: The Facts and Elsevier: ADHD: Non-Pharmacologic Interventions. He is principal investigator of Dr. Faraone is supported by the K.G. Jebsen Centre for Research on Neuropsychiatric Disorders, University of Bergen, Bergen, Norway, the European Union’s Seventh Framework Programme for research, technological development and demonstration under grant agreement no 602805, the European Union’s Horizon 2020 research and innovation programme under Grant agreement No 667302 and NIMH Grants 5R01MH101519 and U01 MH109536-01. In 2017–2018, Dr. Janet Wozniak received research support from PCORI. She is the author of the book, “Is Your Child Bipolar” published May 2008, Bantam Books. In 2015–2017, her spouse, Dr. John Winkelman, received an honorarium from Otsuka; royalties from Cambridge University Press and UptoDate; consultation fees from Advance Medical, FlexPharma and Merck; and research support from UCB Pharma, NeuroMetrix, and Luitpold. Dr. Ronna Fried has received research support from the Demarest Lloyd, Jr. Foundation, F. Hoffman-La Roche, and the FDA, as well as honoraria from the MGH Psychiatry Academy for tuition-funded CME courses. She has also been on an advisory board for Lundbeck. During previous years, Dr. Fried received research support from the National Institutes of Health and Shire. Dr. Joseph Biederman has received research support from the following sources: the Demarest Lloyd, Jr. Foundation, AACAP, The Department of Defense, Food & Drug Administration, Headspace, Lundbeck, Neurocentria Inc., NIDA, PamLab, Pfizer, Shire Pharmaceuticals Inc., Sunovion, and NIH. Dr. Biederman has a financial interest in Avekshan LLC, a company that develops treatments for attention deficit hyperactivity disorder (ADHD). His interests were reviewed and are managed by Massachusetts General Hospital and Partners HealthCare in accordance with their conflict of interest policies. Dr. Biederman’s program has received departmental royalties from a copyrighted rating scale used for ADHD diagnoses, paid by Ingenix, Prophase, Shire, Bracket Global, Sunovion, and Theravance; these royalties were paid to the Department of Psychiatry at MGH. In 2017, Dr. Biederman is a consultant for Aevi Genomics, Akili, Guidepoint, Ironshore, Medgenics, and Piper Jaffray. He is on the scientific advisory board for Alcobra and Shire. He received honoraria from the MGH Psychiatry Academy for tuition-funded CME courses. Through MGH corporate licensing, he has a US Patent (#14/027,676) for a non-stimulant treatment for ADHD, and a patent pending (#61/233,686) on a method to prevent stimulant abuse. In 2016, Dr. Biederman received honoraria from the MGH Psychiatry Academy for tuition-funded CME courses, and from Alcobra and APSARD. He was on the scientific advisory board for Arbor Pharmaceuticals. He was a consultant for Akili and Medgenics. He received research support from Merck and SPRITES. In 2015, Dr. Biederman received honoraria from the MGH Psychiatry Academy for tuition-funded CME courses, and from Avekshan. He received research support from Ironshore, Magceutics Inc., and Vaya Pharma/Enzymotec. In 2014, Dr. Biederman received honoraria from the MGH Psychiatry Academy for tuition-funded CME courses. He received research support from AACAP, Alcobra, Forest Research Institute, and Shire Pharmaceuticals Inc. In previous years, Dr. Biederman received research support, consultation fees, or speaker’s fees for/from the following additional sources: Abbott, Alza, APSARD, AstraZeneca, Boston University, Bristol Myers Squibb, Cambridge University Press, Celltech, Cephalon, The Children’s Hospital of Southwest Florida/Lee Memorial Health System, Cipher Pharmaceuticals Inc., Eli Lilly and Co., Esai, ElMindA, Fundacion Areces (Spain), Forest, Fundación Dr.Manuel Camelo A.C., Glaxo, Gliatech, Hastings Center, Janssen, Juste Pharmaceutical Spain, McNeil, Medice Pharmaceuticals (Germany), Merck, MGH Psychiatry Academy, MMC Pediatric, NARSAD, NIDA, New River, NICHD, NIMH, Novartis, Noven, Neurosearch, Organon, Otsuka, Pfizer, Pharmacia, Phase V Communications, Physicians Academy, The Prechter Foundation, Quantia Communications, Reed Exhibitions, Shionogi Pharma Inc, Shire, the Spanish Child Psychiatry Association, The Stanley Foundation, UCB Pharma Inc., Veritas, and Wyeth. All other authors declare that they have no conflict of interest.

Ethical standards

The human research committee at Massachusetts General Hospital approved this study, and this study has therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Parents and adult offspring provided written informed consent to participate and parents provided consent for offspring under 18 years of age. Children and adolescents provided written assent to participate.


  1. 1.
    Faraone SV et al (2005) Molecular genetics of attention-deficit/hyperactivity disorder. Biol Psychiatry 57(11):1313–1323CrossRefPubMedGoogle Scholar
  2. 2.
    Freitag CM (2007) The genetics of autistic disorders and its clinical relevance: a review of the literature. Mol Psychiatry 12(1):2–22CrossRefPubMedGoogle Scholar
  3. 3.
    Pickles A et al (2000) Variable expression of the autism broader phenotype: findings from extended pedigrees. J Child Psychol Psychiatry 41(4):491–502CrossRefPubMedGoogle Scholar
  4. 4.
    Lundstrom S et al (2015) Autism spectrum disorders and coexisting disorders in a nationwide Swedish twin study. J Child Psychol Psychiatry 56(6):702–710CrossRefPubMedGoogle Scholar
  5. 5.
    Leitner Y (2014) The co-occurrence of autism and attention deficit hyperactivity disorder in children—what do we know? Front Hum Neurosci 8:268CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Joshi G et al (2014) Examining the clinical correlates of autism spectrum disorder in youth by ascertainment source. J Autism Dev Disord 44(9):2117–2126CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Joshi G et al (2013) Psychiatric comorbidity and functioning in a clinically referred population of adults with autism spectrum disorders: a comparative study. J Autism Dev Disord 43(6):1314–1325CrossRefPubMedGoogle Scholar
  8. 8.
    Joshi G et al (2014) Symptom profile of ADHD in youth with high-functioning autism spectrum disorder: a comparative study in psychiatrically referred populations. J Atten Disord 21:846–855CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Joshi G et al (2010) The heavy burden of psychiatric comorbidity in youth with autism spectrum disorders: a large comparative study of a psychiatrically referred population. J Autism Dev Disord 40(11):1361–1370CrossRefPubMedGoogle Scholar
  10. 10.
    Jang J et al (2013) Rates of comorbid symptoms in children with ASD, ADHD, and comorbid ASD and ADHD. Res Dev Disabil 34(8):2369–2378CrossRefPubMedGoogle Scholar
  11. 11.
    Antshel KM, Zhang-James Y, Faraone SV (2013) The comorbidity of ADHD and autism spectrum disorder. Expert Rev Neurother 13(10):1117–1128CrossRefPubMedGoogle Scholar
  12. 12.
    Uchida M, Faraone SV, Joshi G, Spencer A, Kenworthy T, Woodworth KY, Biederman J (2013) How prevalent are autistic traits among children with attention-deficit/hyperactivity disorder? A qualitative review of the literature. Scand J Child Adolesc Psychiatry Psychol 1(1):33–40Google Scholar
  13. 13.
    Kotte A et al (2013) Autistic traits in children with and without ADHD. Pediatrics 132(3):e612–e622CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Biederman J et al (2016) Are autistic traits in youth meaningful? A replication study in non-referred siblings of youth with and without attention-deficit/hyperactivity disorder. Scand J Child Adolesc Psychiatry Psychol 4(2):77–87Google Scholar
  15. 15.
    Biederman J et al (2010) Child behavior checklist clinical scales discriminate referred youth with autism spectrum disorder: a preliminary study. J Dev Behav Pediatr 31(6):485–490PubMedGoogle Scholar
  16. 16.
    Biederman J et al (2006) Psychopathology in females with attention-deficit/hyperactivity disorder: a controlled, five-year prospective study. Biol Psychiatry 60(10):1098–1105CrossRefPubMedGoogle Scholar
  17. 17.
    Biederman J et al (2006) Young adult outcome of attention deficit hyperactivity disorder: a controlled 10-year follow-up study. Psychol Med 36(2):167–179CrossRefPubMedGoogle Scholar
  18. 18.
    Biederman J et al (2010) How persistent is ADHD? A controlled 10-year follow-up study of boys with ADHD. Psychiatry Res 177(3):299–304CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Biederman J et al (1996) A prospective 4-year follow-up study of attention-deficit hyperactivity and related disorders. Arch Gen Psychiatry 53(5):437–446CrossRefPubMedGoogle Scholar
  20. 20.
    Biederman J et al (1999) Clinical correlates of ADHD in females: findings from a large group of girls ascertained from pediatric and psychiatric referral sources. J Am Acad Child Adolesc Psychiatry 38(8):966–975CrossRefPubMedGoogle Scholar
  21. 21.
    Biederman J et al (2012) Adult outcome of attention-deficit/hyperactivity disorder: a controlled 16-year follow-up study. J Clin Psychiatry 73(7):941–950CrossRefPubMedGoogle Scholar
  22. 22.
    First M et al (1997) Structured clinical interview for DSM-IV axis I disorders. American Psychiatric Press Washington, DC, p 84Google Scholar
  23. 23.
    Orvaschel H (1994) Schedule for affective disorders and schizophrenia for school-age children epidemiologic version, 5th edn. Nova Southeastern University, Center for Psychological Studies, Ft. LauderdaleGoogle Scholar
  24. 24.
    Achenbach TM (1991) Manual for the child behavior checklist/4–18 and the 1991 profile. University of Vermont, Department of Psychiatry, BurlingtonGoogle Scholar
  25. 25.
    Endicott J et al (1976) The global assessment scale. A procedure for measuring overall severity of psychiatric disturbance. Arch Gen Psychiatry 33(6):766–771CrossRefPubMedGoogle Scholar
  26. 26.
    Achenbach TM, Ruffle TM (2000) The child behavior checklist and related forms for assessing behavioral/emotional problems and competencies. Pediatr Rev 21(8):265–271CrossRefPubMedGoogle Scholar
  27. 27.
    Kathoor J et al (1987) The social adjustment inventory for children and adolescents (SAICA); testing of a new semi-structured interview (SAICA). J Am Acad Child Adolesc Psychiatr 26(6):898–911CrossRefGoogle Scholar
  28. 28.
    Wechsler D (1997) Wechsler adult intelligence scale III [manual], 3rd edn. The Psychological Corporation, San AntonioGoogle Scholar
  29. 29.
    Wechsler D (1991) Manual for the Wechsler intelligence scale for children, 3rd edn. The Psychological Corporation, Harcourt Brace Jovanovich, Inc., San AntonioGoogle Scholar
  30. 30.
    Wechsler D (2003) Wechsler intelligence scale for children-fourth edition (WISC-IV). The Psychological Corporation, San AntonioGoogle Scholar
  31. 31.
    Wechsler D (1999) Wechsler abbreviated scale of intelligence (WASI), 4th edn. The Psychological Corporation, San AntonioGoogle Scholar
  32. 32.
    Jastak JF, Jastak S (1985) The wide range achievement test-revised. Jastak Associates, WilmingtonGoogle Scholar
  33. 33.
    Hollingshead AB (1975) Four factor index of social status. Yale Press, New HavenGoogle Scholar
  34. 34.
    Santosh PJ, Mijovic A (2006) Does pervasive developmental disorder protect children and adolescents against drug and alcohol use? Eur Child Adolesc Psychiatry 15(4):183–188CrossRefPubMedGoogle Scholar
  35. 35.
    González Calleja F, García-Señorán MM, González González SG (1996) Consumo de drogas en la adolescencia. Psicothema 8(2):257–267Google Scholar
  36. 36.
    Staiger PK, Kambouropoulos N, Dawe S (2007) Should personality traits be considered when refining substance misuse treatment programs? Drug Alcohol Rev 26(1):17–23CrossRefPubMedGoogle Scholar
  37. 37.
    Ramos M et al (2013) Attitude and risk of substance use in adolescents diagnosed with Asperger syndrome. Drug Alcohol Depend 133(2):535–540CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Gagan Joshi
    • 1
    • 2
    • 3
    Email author
  • Maura DiSalvo
    • 1
    • 2
  • Stephen V. Faraone
    • 4
    • 5
  • Janet Wozniak
    • 1
    • 2
    • 3
  • Ronna Fried
    • 1
    • 2
    • 3
  • Maribel Galdo
    • 1
    • 2
  • Abigail Belser
    • 1
    • 2
  • Barbora Hoskova
    • 1
    • 2
  • Nina T. Dallenbach
    • 1
    • 2
  • Melissa F. De Leon
    • 1
    • 2
  • Joseph Biederman
    • 1
    • 2
    • 3
  1. 1.The Alan and Lorraine Bressler Clinical and Research Program for Autism Spectrum DisorderMassachusetts General HospitalBostonUSA
  2. 2.Clinical and Research Program in Pediatric PsychopharmacologyMassachusetts General HospitalBostonUSA
  3. 3.Department of PsychiatryHarvard Medical SchoolBostonUSA
  4. 4.Departments of Psychiatry and of Neuroscience and PhysiologySUNY Upstate Medical UniversitySyracuseUSA
  5. 5.Department of BiomedicineK.G. Jebsen Centre for Psychiatric Disorders, University of BergenBergenNorway

Personalised recommendations