Impaired sustained attention, focused attention, and vigilance in youths with autistic disorder and Asperger's disorder
Introduction
Autism spectrum disorders (ASDs), characterized by different degree of impaired social interaction, communication deficits, and restricted interests, are a group of complex neurodevelopmental disorders that include autistic disorder (autism), Asperger's disorder (AD), and pervasive developmental disorder not otherwise specified (American Psychiatric Association, 1994). Beyond the core symptoms, attention difficulties and hyperactive behaviors are frequently reported in some individuals with ASD (Wing, 1997). It has been theorized that impairments in attention may underlie some of the primary neuropathological functions in autism (Cornblatt and Malhotra, 2001, Courchesne et al., 1989), based on various experiments (e.g., Garretson et al., 1990, Pascualvaca et al., 1998).
Early investigation by Gillberg (1989) showed that 21% of the ASD youths met the diagnostic criteria of both ADHD and ASD. This early observation was supported by studies based on either structured psychiatric interview (Ghaziuddin, Weidmer-Mikhail, & Ghaziuddin, 1998), or questionnaires (e.g., Fombonne, Simmons, Ford, Meltzer, & Goodman, 2001), showing that a substantial proportion (29–83%) of individuals with ASD have ADHD symptoms. Recent work (sample sizes ranging from 27 to 483) documented that about half (52–78%) of the ASD population also met the diagnostic criteria for ADHD (e.g., Lee and Ousley, 2006, Sinzig et al., 2009, Yoshida and Uchiyama, 2004), despite exclusion of comorbid diagnoses in the DSM-IV-TR. These ADHD symptoms in children with ASD may persist into adolescence (Lee & Ousley, 2006), correlate with autistic symptoms (Sinzig et al., 2009), and may exacerbate executive dysfunction, impaired verbal working memory, and maladaptive behaviors (Murray, 2010), resulting in more severe autistic traits, and externalizing symptoms (Yerys et al., 2009). Despite the high co-occurrence of ADHD and ASD and its impact, few studies have investigated the differential severity of ADHD symptoms between different ASD subtypes (Thede & Coolidge, 2007). In addition, higher prevalence of oppositional defiant disorder, up to 27%, was also noted in children with ASD than typically-developing (TD) children (Gadow et al., 2004, Gadow et al., 2005). Yet, the severity of oppositional symptoms between children with autism and those with AD were controversial (Thede and Coolidge, 2007, Tonge et al., 1999).
Several studies have linked executive function (EF) deficits to ASD with probably different EF patterns between autism and AD. For example, individuals with AD, but not those with autism, had an impaired set-shifting performance (Ozonoff, South, & Miller, 2000), while deficits in response inhibition were found in individuals with high-functioning autism (HFA) but not in individuals with AD (Rinehart, Bradshaw, Brereton, & Tonge, 2002). Other studies, however, did not show such EF deficits either in autism or AD (e.g., Thede & Coolidge, 2007). Whether a more fundamental neurocognitive function, attention performance, differs between autism and AD is largely unknown. Although earlier studies (n = 10–23) have shown impaired attention as assessed by one or two indices of the Continuous Performance Test (CPT) in autism (e.g., Garretson et al., 1990, Pascualvaca et al., 1998), no study has compared the CPT performance between autism and AD.
Previous studies of attention research in ASD have mainly recruited Caucasian but not Asian populations. Moreover, the evidence to differentiate autism from AD is lacking with regards to ADHD-related symptoms and a wide range of attention performance (Thede & Coolidge, 2007). Hence, we conducted this study to compare the severity of inattentive, hyperactive/impulsive, and oppositional symptoms, and the attention profiles (focused attention, cognitive impulsivity, sustained attention, and vigilance) as assessed by the Conners’ CPT (CCPT) among youths with autism, youths with AD, and TD youths and to examine the correlations between the CCPT performance and autistic and ADHD symptoms among ethnic Chinese youths with ASD in Taiwan.
We hypothesized that youths with ASD may have more ADHD-related symptoms and deficits in several attention dimensions than TD youths but the patterns of attention deficits may not be the same between youths with autism and youths with AD, and may not be compatible with the findings documented in ADHD, in terms of attention profiles as well as the correlations with ADHD and ASD symptoms.
Section snippets
Participants and procedures
The sample, in the age range of 6–18 years old, consisted of 354 youths with ASD (male, 90%; mean age ± standard deviation (SD), 11.0 ± 3.2 years), clinically diagnosed with autistic disorder (autism, n = 216) or Asperger's disorder (n = 138) according to the DSM-IV diagnostic criteria, and 255 TD youths (mean age ± standard deviation, 11.8 ± 2.3; male 80%). Participants who had full IQ below 70 or who could not understand the direction of the task were excluded from the study. The autism and AD groups
Sample characteristics and ADHD symptoms
Males were more predominant than females, particularly in the two ASD groups; the TD youths were significantly older than youths with ASD (Table 1). Youths with autism had significantly lower Verbal IQ, Performance IQ, and Full-scale IQ than the other two groups, and youths with AD had a lower Performance IQ than TD youths (Table 1). Youths with autism had greater total scores and more severe social deficits as assessed by the SCQ than youths with AD without significant differences in
Discussion
The present study is the first to compare CCPT performance and ADHD symptoms/diagnosis between youths with autism and those with AD. It is also the first to investigate a wide range of attention performance as assessed systemically by the CCPT and to examine its relationship with autistic and ADHD symptoms using a large sample of youths with ASD. We found that youths with ASD showed more inattentive, hyperactive/impulsive, and oppositional symptoms than TD youths with more oppositional symptoms
Acknowledgements
This work was supported by National Science Council (NSC96-3112-B-002-033, NSC97-3112-B-002-009, NSC98-3112-B-002-004, NSC99-3112-B-002-036, NSC99-2627-B-002-015, NSC100-2627-B-002-014, NSC101-2627-B-002-002) and AIM for Top University Excellent Research Project (10R81918-03, 101R892103, 102R892103). The authors would like to express our thanks to all the participants and their parents and our research assistants for their contribution to this study.
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