Attention-deficit hyperactivity disorder (ADHD) is frequently associated with language impairment, autism spectrum disorder (ASD) symptoms and higher-order language deficit (HOLD); yet, their complex relationship is poorly understood. HOLD encompasses deficits in using language for reasoning, problem-solving, causal and critical thinking. This study evaluates the roles of HOLD in children with ADHD. We hypothesise that both our subgroups (ADHD-only and ADHD + ‘ASD traits’) will have HOLD difficulties, though to a differing degree, as children with ADHD are compromised by executive function deficits, and those with additional ASD traits are further impaired by pragmatic language deficits. Data were reviewed from 36 children with ADHD (± ‘ASD traits’), who attended the tier 4 statewide specialist clinic for ADHD patients non-responsive to community care. HOLD was assessed by the Test of Problem Solving-3 Elementary (TOPS-3). The age of the sample ranged from 6 to 12 years with a male-to-female ratio of 8:1. The rate of HOLD in our sample was 47.2% (published controls = 16%). Likewise, the rates of Making Inferences (50.0%, p < 0.001), Sequencing (44.4%, p < 0.001), Negative Questions (33.3%, p = 0.278), Problem-Solving (38.9%, p = 0.022), Predicting (27.8%, p = 0.022) and Determining Causes (30.6%, p = 0.022) were all elevated. When stratified, the rates in ADHD-only group and ADHD + ‘ASD traits’ group were 37.5% and 55.0%, respectively. Children with ADHD + ‘ASD traits’ had greater ‘Sequencing’ deficit. Our exploratory study confirms that HOLD is more common in children with ADHD, including deficits in Making Inferences, Sequencing, Problem-Solving, Predicting, Determining Causes and understanding Negative Questions. Our findings provide preliminary support for the potentially important role played by HOLD in neurodevelopmental disorders.
Higher-order language deficit (HOLD) Attention-deficit hyperactivity disorder (ADHD) Autism spectrum disorder (ASD) Language impairment Sequencing deficit
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The authors would like to express their thanks to the children and families who gave consent for their data analysed, and also to Mrs. Kym Shortte and Dr. Daniel Rudaizky for their inputs.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
For this clinical audit study, formal research consent and formal research ethnics committee’s approval are not required, but the permission to conduct this audit was granted by the local governing research ethics committee.
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1.Speech-Language Pathology, Complex Attention and Hyperactivity Disorders Service (CAHDS)Child and Adolescent Mental Health ServicePerthAustralia
2.Child and Adolescent Mental Health ServicePerthAustralia
3.Child Psychiatry, Complex Attention and Hyperactivity Disorders Service (CAHDS)Child and Adolescent Mental Health ServicePerthAustralia
4.Centre & Discipline of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, School of Medicine, Division of Paediatrics and Child Health & Division of Psychiatry and Clinical NeurosciencesThe University of Western AustraliaPerthAustralia
5.Complex Attention and Hyperactivity Disorders Service (CAHDS), 4th Floor West Entrance, iiid Building, Discovery WayMurdoch UniversityMurdochAustralia