Developmental Neurorehabilitation, February 2013; 16(1): 52–57

Externalizing and tantrum behaviours in children with ASD andADHD compared to children with ADHD

KIM TURECK, JOHNNY L. MATSON, ANNA MAY, & NICOLE TURYGIN

Department of Psychology, Louisiana State University, Baton Rouge, LA 70803, USA

(Received in final form 5 August 2012)

AbstractObjective: Compare rates of externalizing in children with autism spectrum disorder (ASD) and attention deficit/hyperactivity disorder (ADHD) symptoms to children with ADHD.Method: Parents/caregivers of 85 children with ASD and/or ADHD were surveyed about their children’s behaviours usingthe Autism Spectrum Disorders-Comorbidity for Children and the Autism Spectrum Disorders-Behaviour Problem for Children.Results: Specific main effects analyses were then conducted. Children with ASD exhibited a higher number of externalizing(F(1, 83)¼ 83.34, p50.001) and tantrum behaviours (F(1,83)¼ 781.86, p5 0.001) than children without ASD.Conclusions: ASD exacerbates the externalizing symptoms of ADHD during childhood. This study adds to the literatureon the importance of assessing for a wide-range of possible behaviour problems in children presenting with ADHDsymptomatology. The implications of these findings are discussed in the context of other research.

Keywords: Autism spectrum disorders, attention-deficit/hyperactivity disorder, Autism Spectrum Disorders-Behaviour

Problem for Children, Autism Spectrum Disorders-Comorbidity for Children, externalizing behaviour

Introduction

Autism spectrum disorders (ASDs), also calledpervasive developmental disorders, are serious andlifelong [1–3]. Those with ASD suffer from limita-tions and deficits in three main behavioural domains:social skills, verbal and nonverbal communicationand repetitive behaviours or restricted interests[4–10]. These deficits are thought to originateduring neurodevelopment [11] and cause significantimpairment, making ASD one of the most problem-atic disorders affecting children [7, 12, 13]. ASDis also more common than was once thought,occurring in 1 out of every 150 children [14, 15].

Attention deficit/hyperactivity disorder (ADHD)is characterized by two distinct behaviouraldimensions: inattention and hyperactive/impulsivebehaviour (also known as disinhibition) [16–19].Inattention reflects an inability to sustain attentionor follow through on instructions while resistingdistractions, though recent theories indicate thatproblems with the executive functioning of workingmemory might better explain these deficits [20–22].Hyperactive–impulsive behaviour involves difficul-ties with excessive activity level, more so than

would be exhibited by other children of the samedevelopmental level [23–26]. Children with ADHDare at increased risk for a number of functionalimpairments [27], including, poor motor coordina-tion [28–31], impaired academic functioning [32],social problems [33–37] and accident proneness[29, 38].

Currently, the Diagnostic and Statistical Manual

of Mental Disorders-Fourth Edition Text Revision

(DSM-IV-TR) [39] does not allow a comorbiddiagnosis of ASD and ADHD. When comorbidityhas been examined, results have indicated, however,that 31% of children diagnosed with high-functioning ASD met criteria for ADHD, whilean additional 24% showed elevated inattentiveor hyperactive symptoms [40]. Shared behaviouralfeatures are common between ASD and ADHD[40, 41]. Additionally, comorbid psychopathologymay exacerbate challenging behaviours [42, 43].Researchers have demonstrated that those childrenwith high levels of inattention and impulsivityexhibited more aggressive and destructive behav-iours [44]. Another group of researchers foundthat children with ASD and ADHD symptoms

Correspondence: K. Tureck, Department of Psychology, Louisiana State University, 236 Audubon Hall, Baton Rouge, LA 70803, USA. Tel: (225) 578-7792.Fax: (225) 578-4125. E-mail: kturec1@lsu.edu

ISSN 1751–8423 print/ISSN 1751–8431 online/13/010052–6 � 2013 Informa UK Ltd.DOI: 10.3109/17518423.2012.719245

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had higher rates of externalizing behaviour thanchildren with just ASD or typically developingchildren [45].

One hypothesized reason for this increase inexternalizing behaviour is that the communicationdeficits that are central to ASD might exacerbatebehaviour problems due to frustration [5, 6].This may be especially salient as the child becomesolder yet continues to have trouble communicating.In support of this hypothesis, one study foundthat social and communication difficulties weresignificantly higher in those with ADHD comparedto controls [46]. While another study found thatover time, children with persistent hyperactiveand inattentive symptoms also showed persistentsocial-communication deficits [47]. Researchershave suggested that comorbid ADHD may exacer-bate ASD symptoms [48], specifically impairmentsin social interaction [49] and difficulties in dailyfunctioning [50]. In addition, at a biological level,researchers have indicated that ASD and ADHDshare genetic risk loci [51–54]. Adolescents withcomorbid ASD and ADHD are prescribed psycho-tropic medications at higher rates than those withADHD alone. Also, the medications prescribed forthose with comorbid ASD range across numerousmedication classes. This treatment profile differsfrom ADHD alone where stimulant medications areprescribed [55].

Previously, researchers have indicated that there isa subset of children who are experiencing comorbidASD and ADHD [40]. Therefore, it is importantto understand overlapping factors between these twodisorders as well as those that differentiate them.Previously, researchers have suggested that thosewith both conditions tend to have more externalizingproblems [44, 45]. Thus, determining whether theseresults are due to ADHD alone or the result ofa combination of the disorders is significant. Thisstudy compares children with ASD and comorbidADHD to children with ADHD alone to determinewhether ASD is exacerbating the externalizingsymptoms. The communication deficits associatedwith ASD [5, 6] and seen in children with ADHD[46, 47] would likely compound the frustration achild with ASD and ADHD experiences. ADHDmay exacerbate ASD symptoms and/or tantrums andother externalizing behaviours [48–50].

Method

Participants

Participants consisted of an initial pool of childrenseeking services at a psychological clinic inLouisiana. Prior to administration of the measures,informed consent was obtained from all informants,

whom were the children’s biological parents orlegal guardians, according to the Louisiana StateUniversity Institutional Review Board approval.Informed assent was obtained from each childparticipant. Each of the informants was given abattery of parent-report measures to complete inde-pendently. Researchers were available at the time ofadministration to answer any questions the infor-mants may have had. The measures were completedeither in the clinic or at the home, at the informant’sconvenience. Included measures comprised part ofa comprehensive battery to assess ASD symptoms,comorbid psychopathology and behaviour problemsin children. All measures were scored by trainedgraduate students and then recorded in the database.Informants were assigned subject numbers to main-tain confidentiality. Throughout the course of datacollection, supervision was provided by a licensedclinical psychologist.

Participants for this study were selected out of anoriginal sample of 666 children and adolescents.Specific criteria needed to be met for inclusion inthis study. All participants must have completed theAutism Spectrum Disorder Battery – Child Version to beconsidered for inclusion. All participants also neededto meet criteria for ADHD and have received adiagnosis of ADHD or ASD with significant ADHDsymptomatology. Five-hundred eighty-one partici-pants were excluded due to failure to meet allthe inclusion criteria. The final sample included85 children and adolescents between 3 and 17 yearsof age (M¼ 9.49, SD¼ 3.11). Of the total sample,82.4% of the children were Caucasian, 11.8% wereAfrican American and 2.4% were Hispanic, with theremainder of the sample having other or unspecifiedraces. Sixty-two children were male (72.9%) and96.5% of the sample communicated verbally. Also,4.7% of children were diagnosed with an intellectualdisability. In the total sample, 71.8% of the partic-ipants were prescribed one or more psychotropicmedications at the time the measures were com-pleted, 83.3% of those in the ASD group, and65.1% of those in the ADHD group.

Measures

ASD-Comorbid for Children. This, shortly ASD-CC

[56], is a 49-item, informant-based rating scaledesigned to assess symptoms of emotional difficultiesthat commonly occur with ASD. This measure ispart of a larger, comprehensive battery for childrenages 2 through 18, which assesses for a variety ofsymptoms common to children with ASD. Items onthe ASD-CC measure common comorbid disorders:depression, conduct disorder, ADHD, tic disorder,OCD, specific phobia and eating difficulties.Respondents rate each item to the extent that it

Externalizing and tantrum behaviours in children with ASD and ADHD compared to children with ADHD 53

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has been a recent problem: 0¼ ‘not a problemor impairment; not at all’, 1¼ ‘mild problem orimpairment’, 2¼ ‘severe problem or impairment’,or X¼ ‘does not apply or don’t know’. The ASD-CC

has been found to have moderately good inter-rater(k¼ 0.46) and test–retest reliability (k¼ 0.51) andvery good internal consistency (�¼ 0.91) [57].

ASD-Behaviour Problems for Children. This, shortlyASD-BPC [58], is an informant-based assessmentscale designed to assess for behaviour problemsin individuals with ASD, and is another part of thebattery designed to assess for symptoms of ASDin children. Ratings are based on the presence andseverity of the target behaviours compared to othersof the same age: ‘0’¼ ‘not different; no impairment’,‘1’¼ ‘somewhat different; mild impairment’, or‘2’¼ ‘very different; severe impairment’. The itemsin the externalizing scale assess aggression towardsself and others, as well as property destruction.Items in the internalizing scale focus on stereotypy,inappropriate sexual behaviours and odd behaviour.In regards to reliability, internal consistency wasfound to be very good (�¼0.90), with adequatetest–retest reliability (�¼ 0.64) and mean inter-raterreliability is (�¼ 0.49) [59, 60].

Results

Demographic characteristics were gathered onthe participants (i.e. age, gender and race). Referto Table I for the demographic break-down bydiagnostic group. Statistical analyses were con-ducted on the children’s scores on the ASD-CC

and ASD-BPC. Only scores on the tantrum behav-iour subscale of the ASD-CC and the externalizingbehaviour subscale of the ASD-BPC were taken intoconsideration in this study. Two separate one-wayanalyses of variance were conducted to determine

if there were significant differences across groups(ASD/ADHD, only ADHD) on rates of tantrum andexternalizing behaviours.

Simple main effects analysis showed a significantdifference in rates of tantrum behaviour betweenchildren with ASD with significant ADHD symp-tomatology and children with only ADHD. Childrenwith ASD exhibited significantly higher ratesof tantrum behaviour (M¼9.33, SD¼ 4.75) thanchildren with only ADHD (M¼ 5.67, SD¼4.93),F(1, 83)¼ 781.86, p5 0.001. Simple main effectanalysis also showed a significant difference in ratesof externalizing behaviour between children withASD and significant ADHD symptomatology andchildren with only ADHD. Results indicated thatchildren with ASD had significantly higher rates ofexternalizing behaviour (M¼ 4.17, SD¼ 3.63) thanchildren with only ADHD (M¼ 2.16, SD¼2.71),F(1, 83)¼ 83.34, p5 0.001.

Discussion

Externalizing and tantrum behaviours are commonin both children with ASD and those with ADHD[41, 61–64]. Challenging behaviours among thesechildren result in significant difficulties for parentsand/or caregivers who are responsible for their care.These behaviours can often impede the acquisitionof positive adaptive behaviours and hinder thechild’s ability to appropriately interact with otherpeople [12, 35, 36, 65]. The results of this researchsupport both of our hypotheses and lend support tothe concept that ASD exacerbates the symptomsof ADHD [66, 67]. Children with comorbid ASDand ADHD had higher rates of tantrum behavioursthan children with only ADHD. Additionally,children with comorbid ASD and ADHD demon-strated higher rates of externalizing behaviours.These findings are in accordance with previousresearch and support the need to evaluate external-izing behaviours and other ADHD symptoms inchildren presenting with ASD.

One limitation of this study is that the ASD-BPC

and ASD-CC are parent-report measures and didnot involve any direct observation by the researchers.Relying on parent report alone may have affectedrating accuracy. In this instance, parents onlyreported on their child’s behaviour in the homesetting. As a result, they may have been unable toaccurately comment on how their child mightinteract while at school or during other activities.The parents may also have been biased in theirratings in an attempt to secure particular diagnoses.Future research on this topic may benefit fromthe inclusion of teacher reports and/or directobservation.

Table I. Demographic characteristics by diagnostic group(n¼ 85).

Demographiccharacteristics

ASD(n¼ 42)

ADHD only(n¼ 43)

Age (in years)Mean (SD) 9.50 (3.13) 9.49 (3.14)Range 3–15 3–17

Gender (%)Male 85.7 60.5Female 14.3 39.5

Race/ethnicity (%)Caucasian 90.5 74.4African–American 7.1 16.3Hispanic 2.4 2.3‘Other’ 0 7.0

54 K. Tureck et al.

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This study has important implications in termsof the assessment and treatment of externalizingbehaviours in children with ASD. Although currentdiagnostic criteria does not allow for a diagnosisof ADHD in children with ASD, there is a highlikelihood that many children with ASD possesssignificant symptoms of hyperactivity and inatten-tion [40]. Additionally, children with both disordersexperience deficits in verbal and nonverbal commu-nication [5, 6], which might exacerbate behaviourproblems due to frustration. Thus, a comprehensivepsychological evaluation to assess for possible ASDshould include measures aimed at assessing the threecore features of the disorder (i.e. impaired socializa-tion, impaired communication and restricted, repet-itive behaviours or interests) as well as screeningfor the presence of challenging behaviours. Problembehaviours should be similarly screened in typicallydeveloping children with ADHD in addition tothe conventional screening of inattention and hyper-active/impulsive behaviour. If there is evidenceof significant levels of problematic behaviour(e.g. aggression, property destruction, yelling and/or easily becoming upset), then the clinician shouldconduct a functional assessment to help guidetreatment planning [68]. This assessment shouldinclude data collection on antecedents and conse-quences of the behaviours [69, 70].

Once the externalizing behaviours have beenevaluated to determine likely functions and main-taining variables, treatment planning should focuson the implementation of behavioural interventionsthat target the function of the behaviour [71].Researchers have consistently demonstrated thatearly intervention is especially important whenaddressing behaviour problems in children [72, 73].Behavioural interventions should include the useof replacement behaviours that are functionallyequivalent to the challenging behaviour [74] and acontingency management programme to promotethe acquisition of adaptive behaviours that willpromote long-term effects of treatment [75, 76].These types of treatments have been successfullyimplemented with children with ASD and childrenwith ADHD. This study demonstrates the highrates of problem behaviours for both diagnosticgroups, especially those with ASD and comorbidADHD. Thus, assessing for a wide-range of possiblebehaviour problems in children presenting withADHD symptomatology is of critical importance.

Declaration of interest: The authors reportno conflicts of interest. The authors alone aresolely responsible for the content and writing of thearticle.

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Externalizing and tantrum behaviours in children with ASD and ADHD compared to children with ADHD 57

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