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. Author manuscript; available in PMC: 2025 Dec 20.
Published in final edited form as: J Clin Child Adolesc Psychol. 2024 Jun 20;55(1):66–77. doi: 10.1080/15374416.2024.2361715

Cognitive Disengagement Syndrome in Young Autistic Children, Children with ADHD, and Autistic Children with ADHD

Kimberly LH Carpenter 1, Naomi Davis 1,2, Marina Spanos 1, Maura Sabatos-DeVito 1,2, Rachel Aiello 1, Scott Compton 3, Lauren Franz 1, Julia C Schechter 2, Jessica Summers 1, Geraldine Dawson 1
PMCID: PMC11659507  NIHMSID: NIHMS2002257  PMID: 38900723

Abstract

Objective.

Cognitive Disengagement Syndrome (CDS; previously called Sluggish Cognitive Tempo) refers to a constellation of cognitive and motor behaviors characterized by a predisposition towards mind wandering (cognitive subdomain) and slowed motor behavior in behavior (hypoactive subdomain). While there are a number of studies linking CDS traits to greater global impairment in children with attention-deficit/hyperactivity disorder (ADHD) and autistic children, there are few studies examining the prevalence and impact of CDS traits in autistic children with co-occurring ADHD (Autistic+ADHD). The current study explored CDS traits in autistic children with and without co-occurring ADHD, children with ADHD, and neurotypical children.

Methods.

Participants were 196 children between 3- and 7-years-of-age comprising four groups: Neurotypical (N=44), ADHD (N=51), Autistic (N=55), and Autistic+ADHD (N=46). CDS traits, social and communication skills, repetitive behaviors, and sensory processing were all assessed via parent report.

Results.

Children diagnosed with ADHD, autistic children, and Autistic+ADHD children exhibited similar levels of overall CDS traits. However, when explored separately, Autistic+ADHD children had higher cognitive CDS trait scores compared to children with ADHD alone. Both overall CDS traits and the cognitive subdomain were associated with greater social difficulties, particularly social withdrawal, higher levels of repetitive behaviors, and more sensory sensitivities, regardless of diagnosis.

Conclusions.

Findings suggest that CDS traits may be an additional factor directly impact functional outcomes in both autistic and ADHD children. As such, clinicians should be assessing CDS traits in addition to other clinical domains associated with ADHD and autism when developing intervention plans for young neurodiverse children.

Keywords: Cognitive Disengagement Syndrome, Sluggish Cognitive Tempo, Autism, ADHD

Cognitive disengagement syndrome (CDS), formerly known as sluggish cognitive tempo, is emerging as an important but relatively understudied pattern of behaviors present from early childhood through adulthood. CDS is comprised of two behavioral dimensions: 1) cognitive disengagement, which is characterized by daydreaming and mental fogginess, and 2) motor hypoactivity (e.g. sluggish behavior). While CDS was originally conceptualized as being part of the Attention Deficit/Hyperactivity Disorder (ADHD) phenotype, emerging research suggests that it is a related but distinct set of symptoms (Becker et al., 2023). Nationally representative studies have reported high levels of co-occurrence between CDS traits and a number of psychiatric and neurodevelopmental disorders, including ADHD, autism, internalizing disorders, and developmental delays (Barkley, 2013; Becker et al., 2023; Burns & Becker, 2021). Furthermore, parent-reported CDS traits are significantly associated with parent-reported inattention, autistic traits, depression, and anxiety in a large representative sample of elementary-age children (Mayes, Bangert, et al., 2023). Overall, CDS traits havebeen shown to negatively impact functioning across a number of domains, from school achievement to global functioning and mental health (Reviewed in: Becker et al., 2023). Furthermore, CDS traits impact intervention outcomes in individuals with ADHD (Firat et al., 2021; Froehlich et al., 2018; McBurnett et al., 2017; Owens et al., 2018; Wietecha et al., 2013). As such, conducting research to better understand the presentation and impact of CDS traits in children with ADHD and other co-occurring disorders, such as autism, is critical to developing effective intervention strategies.

To date, the majority of studies on CDS have focused on children and adults with ADHD, where emerging data suggest it is a commonly occurring, yet independent set of traits (Becker et al., 2018; Carlson & Mann, 2002; Dvorsky et al., 2021; Servera et al., 2018). In children with ADHD, higher levels of self-reported, teacher-rated, and parent-rated CDS traits are associated with more internalizing disorders (Becker et al., 2020; Becker et al., 2021; Bernad Mdel et al., 2016; Fredrick et al., 2022), more autistic traits (Ekinci et al., 2021), and has impacts on overall academic success (Becker et al., 2022; Becker, Langberg, et al., 2014; Flannery et al., 2017; Hossain et al., 2022; Langberg et al., 2014; Tamm et al., 2016). In addition, ADHD with co-occurring CDS traits is associated with greater difficulties with social skills, including more social withdrawal, more difficulty detecting social cues, and lower levels of social engagement (Becker, 2014; Becker & Langberg, 2013; Becker, Luebbe, et al., 2014; Ferretti et al., 2019; Fredrick & Becker, 2023; Marshall et al., 2014; Solanto et al., 2009).

Given the overlap between autism and ADHD, as well as the increased rate of autistic traits and social difficulties in children with ADHD with co-occurring CDS traits, recent research has begun to explore CDS traits in autistic children. Early estimates suggest that 30–37% of autistic individuals have clinically significant levels of parent-rated CDS traits as measured with the CBCL (Brewe et al., 2020; Duncan et al., 2019). In autistic children and adolescents, CDS is associated with more social difficulties and higher levels of internalizing symptoms, even when accounting for co-occurring ADHD symptoms (Duncan et al., 2019; Reinvall et al., 2017). In one study, the cognitive disengagement dimension of CDS was shown to be more prevalent than the hypoactivity dimension in 4–17 year olds with autism and those with the combined subtype of ADHD (ADHD-C), as compared to individuals with the inattentive subtype of ADHD (ADHD-I) and neurotypical children and adolescents (Mayes, Becker, et al., 2023). This suggests that CDS traits may manifest differently in autistic and ADHD-C children and adolescents, which has implications for both identification and interventions designed to address CDS in these individuals.

To date, a few studies have assessed whether CDS traits are more common among autistic individuals with co-occurring ADHD as compared to individuals with either autism or ADHD alone. These studies have focused on samples across a large age range, spanning from early childhood to adolescence. Findings from these studies have been mixed, with some groups finding no difference in levels of CDS traits among these three groups (McFayden et al., 2022) and others reporting greater levels of CDS traits in autistic children with co-occurring ADHD as compared to children with either autism or ADHD alone (Mayes et al., 2020). As such, it is still unclear whether CDS traits are more prevalent in young autistic children with co-occurring ADHD than in children with either diagnosis alone.

Furthermore, previous research has shown that CDS traits are associated with greater social and global impairment in autistic individuals with and without ADHD (McFayden et al., 2022). However, it has yet to be established whether there is a differential impact of the cognitive dimension of CDS – which has been shown to be more prevalent in autistic children as highlighted above – on social abilities or whether CDS traits overall are driving these functional differences. Additionally, CDS traits have been shown to increase social withdrawal in children with ADHD (Fredrick & Becker, 2023). While there is evidence that CDS traits lead to greater social difficulties overall in autistic children, regardless of whether or not they have co-occurring ADHD, it remains unclear if this association is driven by increased levels of one aspect of social challenge, namely social withdrawal, in the autistic+ADHD children in particular.

Finally, while previous research has focused on the social implications of co-occurring CDS traits in autistic and ADHD individuals, it is unclear whether co-occurring CDS traits are associated with features of autism beyond the social-communication domain, including restricted and repetitive behaviors and sensory processing differences. This is of interest because some restricted and repetitive behaviors (e.g. circumscribed interests, motor mannerisms, etc.) are not frequently seen in children with ADHD alone, whereas sensory processing differences are common in ADHD (Lane & Reynolds, 2019). Thus, if CDS traits are associated with a broader range of autistic features beyond social and sensory differences, then co-occurring CDS traits could have additive impact on overall functioning in children, regardless of whether they have autism, ADHD, or both conditions. In this scenario, CDS traits may be considered a diagnostic specifier (e.g., Autism with CDS symptoms; ADHD with CDS symptoms) that helps refine diagnostic designations, capturing the individual’s unique clinical presentation more accurately. On the other hand, if CDS traits are only associated with increased difficulties in the domains of social challenges and sensory differences (i.e., features that are shared between autism and ADHD), then it is possible that CDS traits are a transdiagnostic characteristic that impacts the shared features of these disorders, but not the unique features of autism.

The current study explored levels of both overall CDS traits and the cognitive dimension of CDS, in 3- to −7-year old autistic children, children with ADHD, autistic children with co-occurring ADHD (henceforth autistic+ADHD), and neurotypical children. We then explored the relationship between CDS symptoms and autistic traits in the autistic, ADHD, and autistic+ADHD subgroups. We hypothesized that autistic+ADHD children would have higher levels of overall CDS symptoms, particularly in the cognitive domain. We predicted that higher levels of CDS symptoms in the autistic+ADHD group would be associated with 1) greater social difficulties, particularly social withdrawal, 2) more repetitive behaviors, particularly insistence on sameness, compulsive behaviors, and restrictive behaviors, and 3) greater sensory sensitivities. Understanding these relationships will help us to elucidate the potential impact that co-occurring CDS traits have on the functioning of autistic children with and without ADHD and may have implications for intervention planning. Furthermore, exploring the relationship between CDS and autistic traits in young autistic, ADHD, and autistic+ADHD children provides the opportunity to improve our understanding of whether CDS traits are a transdiagnostic factor or a diagnostic specifier for children with ADHD with or without co-occurring autism (Barkley, 2014; Becker & Willcutt, 2019; Becker et al., 2023).

Methods

Study Design and Participants

Participants were 196 children between 3- and 7-years of age from one of four groups: neurotypical children (N=44), children with ADHD (N=51), autistic children (N=55), and autistic children with co-occurring ADHD (autistic+ADHD; N=46). Children were recruited from the community through flyers and brochures, emails, social media posts, and through the research center’s subject registry. Participants attended between 1 and 3 diagnostic assessment visits and two additional study-specific visits. Families were compensated for their time in the study. The study design and methods were approved by Duke University School of Medicine Institutional Review Board (IRB- Pro00085156). Before the initiation of each study phase, the parent or legal guardian signed informed consent forms approved by the Duke IRB. Children over the age of 6 years provided verbal assent if they were capable of giving it.

For all groups, inclusion criteria were 36 to less than 96 months of age at the initial eligibility visit and willing to undergo a 24 hour washout for children on stimulant medication. Exclusion criteria included any known genetic or neurological syndrome or condition with established links to autism (e.g., fragile X). Children with genetic events in which the link to autism is less well known/established (e.g., 16p11.2 CNVs) were not excluded from the study. Children with a history of epilepsy or seizure disorder were also excluded, except for those with a history of simple febrile seizures or if the child had been seizure free for the 12 months prior to their study visits. Children with motor or sensory impairment that would interfere with the valid completion of study measures, including significant hearing or vision impairment not correctable by a hearing aid or glasses/contact lenses, were not eligible for the study. Other exclusionary criteria included history of neonatal brain damage (e.g., with diagnosed hypoxic or ischemic event) and any known environmental circumstance that likely accounted for the picture of autism (e.g., severe nutritional or psychological deprivation).

For the autistic children, additional inclusion criteria included a DSM-5 diagnosis of Autism Spectrum Disorder (ASD). Prior to the Covid-19 pandemic, diagnosis was informed by the Autism Diagnostic Interview – Revised (ADI-R; C. Lord et al., 1994) and the Autism Diagnostic Observation Schedule-2 (ADOS-2; C Lord et al., 2012). Following the renewal of research during the Covid-19 pandemic, the ADOS (N=85) was replaced with the Brief Observation of Symptoms of Autism (BOSA (N=15); Dow et al., 2022) administered by the parent with a clinician coding the interaction. Additionally, to be included in the autistic group, children had to have an ADHD-Rating Scale (ADHD-RS described below; DuPaul et al., 1998a) overall score of <93%ile or clinical rule out of ADHD by study psychologists. Finally, if an autistic child had one but not two or more additional psychiatric diagnoses (e.g. anxiety), they were eligible for the study.

For children with ADHD, additional inclusion criteria included a DSM-5 diagnosis of ADHD established by research study psychologists. Study-conducted ADHD assessments were completed using the Mini-International Neuropsychiatric Interview (MINI; Sheehan et al., 2010), which was administered by a licensed psychologist. The MINI has been used to diagnose preschool ADHD in prior studies (Kollins et al., 2006). Supplemental questions were used to probe for examples of symptoms that were consistent with developmental level and to differentiate autism from ADHD (Davis et al., 2022). ADHD diagnoses were also informed by a review of the ADHD-RS parent forms and teacher forms, when available. In addition, children in the ADHD group had to have an Social Responsiveness Scale 2nd Edition (SRS-2 described below; Constantino, 2012) total score less than 65 or clinical rule out of ASD. Additionally, children with IQ<50 were excluded from the ADHD group. This cutoff was selected to account for situations in which it was determined that the cognitive assessment was likely an underestimate of the participant’s cognitive abilities given difficulties with sustaining attention, impulsivity, and/or activity level during testing. Clinicians decided on a case by case basis whether or not to include children in the ADHD group with an IQ between 50 and 70. Only one ADHD child had an IQ in this range and other measures of their abilities were in the average range (e.g., Vineland Adaptive Behavior Composite Standard Score). All other children in the ADHD group had IQs above 70. Finally, if a child with ADHD had one but not two or more additional diagnoses (e.g., anxiety) then they were eligible for the study.

Participants were included in the autistic+ADHD group if study psychologists confirmed diagnoses of both ASD and ADHD as described above. Importantly, the supplemental questions employed as part of the MINI-Kid allowed study psychologists to examine whether specific symptoms were better accounted for by autism than by ADHD. Finally, as with the other clinical groups, if an autistic+ADHD child had one but not two or more additional diagnosis (e.g., anxiety), they were eligible for the study.

Finally, inclusion criteria in the neurotypical group included having cognitive abilities in the average range (IQ>70), Vineland Adaptive Behavior Scale-3 (VABS-3 described below; Sparrow et al., 2016) scores in the average range, and no clinical elevations on any of the following: the Child Behavior Checklist (except for on the anxiety subscale; Achenbach & Ruffle, 2000), the ADHD-RS, or the SRS-2. Children were excluded from the neurotypical group if they had a sibling or first-degree relative diagnosed with either autism or ADHD.

Measures

Cognitive Abilities

Cognitive abilities were assessed using the Differential Ability Scales, 2nd Edition (DAS-II; Elliott, 1990) if they were seen prior to the COVID-19 pandemic in March 2020. After March 2020, in keeping with social distancing measures, we modified the protocol to allow for the use of validated, tablet-based cognitive measures. Namely, children between 36 and 89 months old completed the Wechsler Preschool and Primary Scale of Intelligence - Fourth Ed. (WPPSI-IV; Wechsler, 2012) and children 90 months and older completed the Wechsler Intelligence Scale for Children-Fifth Edition (WISC-V; Wechsler, 2015). Although the cognitive measures were delivered via tablet, they were still administered in the clinic under the supervision of one of the research clinicians. To ensure that cognitive ability was standardized across these assessments, we calculated a developmental quotient (DQ) for each child by taking the average of all age equivalents (AE) from the associated measures divided by chronological age (CA) of the child and multiplied by 100 (i.e., Mean of AEs / CA) * 100).

Cognitive Disengagement Syndrome Traits

CDS traits were measured with a modified version of the “Sluggish Cognitive Tempo” module from the Child and Adolescent Behavior Inventory (CABI; Burns & Becker, 2021). The modified version included eight items, which parents rated on a 6-point scale ranging from almost never (never or about once per month) to almost always (many times per day). CDS traits were further subdivided into cognitive and hypoactive symptom domains. The cognitive subdomain included six items (e.g., Daydreams or Gets lost in own thoughts). The hypoactive subdomain included two items: Behavior is slow (sluggish) and Low level of activity (underactive). In the current study, we explored both the overall CDS traits and the cognitive subdomain of CDS. Given the small number of questions comprising the hypoactivity subdomain, we were not able to look at that separately.

Social and Communication Abilities

The SRS-2 (Constantino, 2012) was used to assess social ability in all participants. The SRS-2 is composed of 65 items, 53 of which focus on social-communicative abilities. These items examine the ability to interpret social cues, to maintain social conversation, and initiate social interaction. A higher score on the SRS-2 Social Communication and Interaction (SCI) scale indicates increased difficulties with reciprocal social communication.

The VABS-3 (Sparrow et al., 2016), a well-standardized measure for assessing adaptive behavior in the domains of communication, daily living, socialization, motor, and maladaptive behaviors, was used to assess social and communicative adaptive behaviors. Norms are available from birth to 90 years. The VABS-3 has been shown to discriminate clinical samples, such as those with autism, from nonclinical samples.

Social withdrawal was assessed with the Aberrant Behavior Checklist-Community (ABC; Aman & Singh, 1986; Kaat et al., 2014). The ABC is a caregiver-report scale originally developed to assess drug and other treatment effects in studies of individuals with developmental disabilities and is commonly used in descriptive and treatment studies of Autistic individuals. This inventory has five subdomains consisting of (1) Irritability/Agitation; (2) Lethargy and Social Withdrawal; (3) Stereotypic Behavior; (4) Hyperactivity and Non-compliance; and (5) Inappropriate Speech. Each question is rated on a 0–3 severity scale, with 0 indicating the absence of a behavior, and 3 indicating a high severity level. A measure of social withdrawal was derived from the social withdrawal/lethargy scale of the ABC by excluding the three items that target lethargy. This modified social withdrawal subscale is commonly used in autism-related clinical trials (e.g. Spanos et al., 2020). Removing these three items eliminates symptomatic overlap with the hypoactivity aspect of CDS traits, as well as isolates social withdrawal as the construct of interest.

Repetitive Behaviors and Sensory Processing

Repetitive behaviors were assessed with the Repetitive Behavior Scale, Revised (RBS-R; Bodfish et al., 2000). The RBS-R is a 43-item scale that assesses repetitive and stereotyped behaviors and restrictive interests. The RBS-R provides an overall score, as well as subdomain scores for (1) Stereotyped Behaviors, (2) Self-Injurious Behaviors, (3) Compulsive Behaviors, (4) Ritualistic Behaviors, (5) Sameness Behaviors, and (6) Restricted Behaviors. Each item is scored on a three-point scale with a “0” indicating the behavior does not occur and “3” indicating that the behavior occurs and is a severe problem. This scale has established validity in Autistic populations with good to high internal consistency (α’s = 0.78 – 0.91; Lam & Aman, 2007). For the current study, we focused on a five factor model that combined the Ritualistic/Sameness Behavior subdomains to replicate previous work (Hooker et al., 2019; Mirenda et al., 2010).

Sensory processing was measured with version 3.0 of the Sensory Experiences Questionnaire (SEQ-3; Baranek, 2009). The SEQ-3 is a 105-item parent questionnaire designed to measure the frequency of child responses to sensory stimuli in the context of daily activities and routines. The SEQ-3 provides mean scores in the domains of (1) Sensory Hypersensitivity, (2) Sensory Hyposensitivity, (3) Sensory Seeking, and (4) Enhanced Perception (Ausderau et al., 2014). Higher scores indicate greater sensory related behaviors. The SEQ-3 has been shown to discriminate autistic children from neurotypical children and children with other developmental delays (Ausderau et al., 2014; Baranek et al., 2006).

Data Analysis

All analyses were run in SAS version 9.4 (SAS Institute Inc.) using general linear mixed models with standard errors and test statistics of fixed-effect parameters adjusted using the empirical option to account for heteroscedasticity in the data. The level of significance was set at p≤.05. Group differences in both overall CDS traits and the cognitive subdomain were assessed for all four groups (i.e., neurotypical, autistic, ADHD, and autistic+ADHD). Associations between autistic traits and both overall CDS traits and the cognitive subdomain were assessed only within the ADHD, autistic, and autistic+ADHD groups. All models included age, sex, and DQ as covariates. Additionally, in all models the autistic trait and CDS traits were modeled as continuous variables, while group (Neurotypical, autistic, ADHD, and autistic+ADHD) was modeled categorically. Follow-up pair-wise t-tests were corrected for multiple comparisons using the Tukey-Kramer correction. Only the corrected p-values are reported for these follow-up t-tests (denoted pa in the text). For models in which there were both main effects of group and CDS traits on the outcome of interest, we also explored the interaction between group and CDS traits on autistic traits. This two-way interaction was not significant in any of these models, thus we do not present results from those models below.

Results

Participant Characteristics

Participant demographics are described in Table 1. Groups differed significantly in terms of age (F (3,192) = 11.1, p<.0001), with both the ADHD and autistic+ADHD children being older on average than neurotypical and autistic children. Similarly, there was a significant difference in DQs among the four groups (F (3,192) = 38.3, p<.0001), with the neurotypical group, on average, having a higher DQ as compared to both autistic and autistic+ADHD children. Additionally, the ADHD group had a higher DQ than either the autistic or the autistic+ADHD groups, whereas the two autistic groups had similar DQs. The ratios of males to females (χ2=2.5, p=.48) across groups were not statistically different. There also were not significant differences in the ethnicity of the participants (χ2=1.2, p=.76), however there were group differences in race (χ2=11.5, p<.01).

Table 1.

Sample Demographics

NT (N=44) ADHD (N=51) Autistic (N=55) Autistic+ADHD (N=46)
Age in Months [Mean (SD)] 65.9 (16.1) 77.7 (11.7) 67.4 (15.8) 79.5 (14.2)
DQ [Mean (SD)] 115.7 (12.4) 106.8 (21.6) 82.3 (24.3) 86.6 (22.1)
Sex [N, %]
 Female 14 (32%) 10 (20%) 13 (24%) 14 (30%)
 Male 30 (69%) 41 (80%) 42 (76%) 32 (70%)
Ethnicity/Race [N, %]
 Black 1 (2%) 4 (8%) 4 (7%) 5 (11%)
 Hispanic/Latino 3 (7%) 5 (10%) 5 (9%) 4 (9%)
 More than one race 4 (9%) 9 (17%) 9 (16%) 3 (6%)
 Caucasian/White 35 (80%) 32 (63%) 27 (49%) 33 (72%)
 Other 1 (2%) 1 (2%) 10 (18%) 1 (2%)
Autism Severity [N, Mean (SD)]
 ADOS Total CSS N/A N/A N=54, 8.2 (1.2) N=31, 8.0 (1.3)
 BOSA Total N/A N/A N=1, 8 (N/A) N=14, 9.3 (1.9)
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Note. Abbreviations: Attention Deficit/Hyperactivity Disorder (ADHD); Autism Diagnostic Observation Schedule (ADOS); Brief Observation of Symptoms of Autism (BOSA); Calibrated Severity Score (CSS); Developmental Quotient (DQ); Neurotypical (NT); Standard Deviation (SD).

Group Differences in CDS Traits

Neurotypical children had significantly lower CDS traits as compared to autistic, ADHD, and autistic+ADHD children (F(3,189) = 23.1, p<.0001; all follow-up t-tests were pa<.0001). There were no significant differences in overall CDS symptoms among the autistic, ADHD, and autistic+ADHD groups. There were also group differences in CDS cognitive subdomain symptoms (F(3,189) = 26.3, p<.0001), with neurotypical children having significantly lower cognitive symptoms as compared to autistic, ADHD, and autistic+ADHD children (all follow-up t-tests were pa<.0001). Additionally, autistic+ADHD children had higher cognitive symptoms of CDS (t(189)=2.64, pa<.05) as compared to children with ADHD alone, while there were no significant differences in cognitive CDS symptoms between the autistic and autistic+ADHD groups (Figure 1).

Figure 1.

Figure 1

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Group Differences in Overall CDS Symptoms and Cognitive Subdomain Symptoms

Note. This figure demonstrates group differences in both overall CDS symptoms and the cognitive subdomain symptoms. Overall, neurotypical children have lower levels of both the overall symptoms of CDS, as well as cognitive symptoms of CDS. Autistic children with co-occurring ADHD, on average, have more cognitive symptoms of CDS than children with ADHD alone.

Abbreviations: Attention Deficit/Hyperactivity Disorder (ADHD), Cognitive Disengagement Syndrome (CDS).

*p<.05. #significantly different from all other groups.

Relationship between CDS and Autistic Traits

Supplementary Table 1 includes descriptive information of included measures for each group. Table 2 summarizes the relationship between autistic traits and overall CDS symptoms in the three non-neurotypical groups. Across all autistic traits tested, there was a consistent pattern whereby higher CDS symptoms were associated with higher levels of autistic traits. Specifically, in the domain of social and communication abilities, higher CDS symptoms were associated with both greater social difficulties on the SRS-2 and lower social adaptive functioning on the VABS-3 and this was independent of any group differences on these measures. Additionally, overall CDS symptoms were also associated with more social withdrawal and lower communication abilities for all three groups.

Table 2.

Relationship between Overall CDS Symptoms and Autistic Features

Group CDS Symptoms
Social and Communication Abilities
 SRS-2 Social Difficulties 35.81† 42.86†
 ABC Social Withdrawal 1.19 38.36†
 VABS-3 Social Adaptive Behavior 9.53† 6.90**
 VABS-3 Communicative Adaptive Behavior 2.30 7.42**
RBS-R Restricted and Repetitive Behaviors
 Stereotyped Behaviors .88 14.78***
 Restricted Behaviors 6.52** 14.13***
 Ritualistic/Sameness Behaviors 1.30 21.41†
 Compulsive Behaviors .83 11.27***
SEQ-3 Sensory Processing
 Hypersensitivity 3.26* 29.60†
 Hyposensitivity .82 36.88†
 Seeking 3.41* 11.93***
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Notes: Values reported are F-values from general linear mixed models with standard errors and test statistics of fixed-effect parameters adjusted using the empirical option. All models included Group (Autistic, ADHD, and Autistic+ADHD), overall CDS symptoms, age, developmental quotient, and sex. Acronyms: Aberrant Behavior Checklist-Community (ABC); Cognitive Disengagement Syndrome (CDS); Repetitive Behavior Scale-Revised (RBS-R); Sensory Experiences Questionnaire-3 (SEQ-3); Social Responsiveness Scale (SRS-2), Vineland Adaptive Behaviors Scale-3 (VABS-3); Repetitive Behavior Scale-Revised (RBS); Sensory Experiences Questionnaire-3 (SEQ);

*

p≤.05;

**

p≤.01;

***

p≤.001;

†

p≤.0001.

In the domain of restricted and repetitive behaviors, overall CDS symptoms were associated with higher scores on the RBS-R irrespective of group differences in RBS-R across all subdomains of restricted and repetitive behaviors tested. Finally, overall CDS symptoms were also associated with higher levels of sensory hyper-sensitivity, sensory hypo-sensitivity, and sensory seeking across all three groups.

Table 3 summarizes the relationship between autistic traits and the cognitive subdomain of CDS. Similar to above, across all autistic traits tested, there was a consistent pattern whereby higher CDS cognitive symptoms were associated with higher levels of autistic traits across all three groups (autistic, autistic+ADHD, and ADHD).

Table 3.

Relationship between Cognitive Dimension of CDS and Autistic Features

Group Cognitive Subdomain
Social and Communication Abilities
 SRS-2 Social Difficulties 33.80† 47.18†
 ABC Social Withdrawal 1.35 29.71†
 VABS-3 Social Adaptive Behavior 9.29*** 8.10**
 VABS-3 Communicative Adaptive Behavior 2.27 10.21**
RBS-R Restricted and Repetitive Behaviors
 Stereotyped Behaviors .48 23.77†
 Restricted Behaviors 6.00** 13.21***
Ritualistic/Sameness Behaviors .85 17.35†
 Compulsive Behaviors .61 14.06***
SEQ-3 Sensory Processing
 Hypersensitivity 2.94 28.64†
 Hyposensitivity .68 34.63†
 Seeking 2.92 17.17†
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Notes: Values reported are F-values from general linear mixed models with standard errors and test statistics of fixed-effect parameters adjusted using the empirical option. All models included Group (Autistic, ADHD, and Autistic+ADHD), CDS Cognitive Subdomain symptoms, age, developmental quotient, and sex. Acronyms: Aberrant Behavior Checklist- Community (ABC); Cognitive Disengagement Syndrome (CDS); Repetitive Behavior Scale- Revised (RBS); Sensory Experiences Questionnaire-3 (SEQ-3); Social Responsiveness Scale (SRS-2), Vineland Adaptive Behaviors Scale-3 (VABS); Repetitive Behavior Scale-Revised (RBS); Sensory Experiences Questionnaire-3 (SEQ);

*

p≤.05;

**

p≤.01;

***

p≤.001;

†

p≤.0001.

Discussion

Emerging research supports CDS as an important and relatively understudied pattern of behaviors that are associated with greater social and global impairment in both individuals with ADHD and autistic individuals. While several studies have explored CDS traits in autistic individuals, less is known about CDS traits in autistic children with co-occurring ADHD. The current study adds to the growing body of research suggesting that CDS is a common and impairing co-occurring pattern of traits in individuals with autism and/or ADHD. Results of the current study suggest that overall levels of CDS traits are similar in young autistic children with and without co-occurring ADHD, and in young children with ADHD alone. However, when examining the cognitive subdomain of CDS separately, it was found that young autistic+ADHD children have higher levels of the cognitive symptoms as compared to children with ADHD alone. In addition, in all cases, higher levels of CDS symptoms– both overall and solely cognitive symptoms – were associated with higher levels of autistic features across all groups. Together, this suggests that CDS symptoms should be evaluated when assessing functional and clinical outcomes in autistic children with and without ADHD.

There have been only a handful of studies exploring CDS traits in autistic individuals with co-occurring ADHD as compared to individuals diagnosed with either autism or ADHD alone. Across these studies, there have been conflicting results regarding whether parent-reported CDS traits are more prevalent in autistic children with co-occurring ADHD, with one study suggesting that it is more prevalent in this group (Mayes et al., 2020) and another finding similar levels across children diagnosed with autism alone, ADHD alone, and autism with co-occurring ADHD (McFayden et al., 2022). Of note, in each of these two prior studies, the age range of the samples was much wider than ours, including young children through adolescents. Our results are consistent with the McFayden, et al study, which reported similar levels of parent-reported CDS traits among autistic individuals, individuals with ADHD, and autistic individuals with co-occurring ADHD.

Previous research has shown that the cognitive disengagement subdomain of CDS is more prevalent than the hypoactivity subdomain among children diagnosed with autism, leading previous researchers to conclude that CDS may manifest differently in autistic children (Mayes, Becker, et al., 2023). When we constrained our analyses to solely the cognitive subdomain of CDS, we found that autistic children with co-occurring ADHD had higher cognitive symptoms of CDS than children with ADHD alone, while there were no differences in cognitive symptoms between the children with autism alone and those with co-occurring ADHD. This suggests that the cognitive subdomain of CDS is particularly implicated in autistic+ADHD children. Furthermore, this difference might explain the inconsistent findings with respect to group differences in CDS symptoms for studies in which only the overall CDS domain, and not the cognitive subdomain, was examined.

Previous research suggests that, in individuals with ADHD, CDS is associated with increased social difficulties, with increased social withdrawal specifically (Reviewed in Fredrick & Becker, 2023). The current study is consistent with previous research suggesting that CDS traits are associated with greater overall social difficulties regardless of whether a child is diagnosed with autism, ADHD, or both (McFayden et al., 2022). Interestingly, when social withdrawal was examined specifically, we found that CDS was a better predictor of social withdrawal than diagnostic status, suggesting that co-occurring CDS may be a transdiagnostic factor that has particular impacts on social withdrawal behavior. This finding is of particular importance given that previous research using the composite ABC lethargy and social withdrawal scale to explore the relationship between social withdrawal and CDS traits could have been capturing an association between CDS hypoactivity symptoms and lethargy, rather than the social withdrawal component alone. Our findings suggest that this is not necessarily the case and there is in fact a unique association between CDS traits and social withdrawal symptoms in children with autism, ADHD, or both.

To better understand whether CDS symptoms are associated with other features of autism beyond social difficulties and overall global functioning (McFayden et al., 2022), we explored whether CDS symptoms were also associated with repetitive behaviors and sensory sensitivities. Overall, we found that CDS symptoms were a better predictor of repetitive behaviors than diagnostic status across all domains of repetitive behaviors. While we did see differences in sensory traits among children diagnosed with ADHD, autism, and autism with co-occurring ADHD, these differences were attenuated when CDS symptoms were accounted for. This finding suggests that higher levels of CDS symptoms are associated with higher levels of sensory and repetitive behaviors across diagnostic categories, at least across children diagnosed with autism and/or ADHD.

Finally, in light of the finding that autistic children with co-occurring ADHD exhibit higher levels of cognitive symptoms of CDS compared to children with ADHD alone, we sought to understand if there were unique relationships between the cognitive symptoms in particular and autistic features in our groups. We found both overall and cognitive CDS symptoms had similar associations with all autistic features explored in our sample. This suggests that, while the cognitive symptoms are more common in autistic+ADHD children, the presence of overall CDS symptoms in general are associated with more social and communicative difficulties and higher levels of restricted and repetitive behaviors and sensory sensitivities, regardless of diagnosis.

The current study needs to be considered in light of several limitations. First, our sample was comprised of approximately 60% white participants. As such, future studies will need to replicate these findings in more diverse samples and explore whether there are racial, ethnic, or socioeconomic status differences in the presentation of CDS in young autistic children. Additionally, our neurotypical group was younger, less diverse, and had more girls than the other groups. Though we attempted to control for these differences in our statistical models, future studies should explore how these differences may impact the role of CDS traits in overall functioning. Second, previous research has shown that CDS symptoms are associated with higher levels of internalizing symptoms (Brewe et al., 2020; Duncan et al., 2019; Ekinci et al., 2021; Reinvall et al., 2017). As such, while it was outside of the scope of the current manuscript to explore this, it is possible that increased internalizing symptoms may be contributing to the global increase in CDS symptoms among some of the children in our study. Third, our measure of CDS traits was limited to only eight questions, of which only two were associated with the hypoactivity subdomain of CDS. As such, we were underpowered to explore whether there were differences in how the hypoactivity subdomain of CDS traits are associated with children’s functioning as compared to the cognitive subdomain. Similarly, it is possible that the failure to find a relationship between cognitive symptoms and children’s autistic features, as compared to overall CDS symptoms, may be driven by the overweighting of the cognitive symptoms in the overall CDS symptom score (i.e., 6 of the 8 items). Future studies should explore if there are differential impacts of the cognitive and hypoactive subdomains of CDS traits in autistic children with and without ADHD. Additionally, it is well known that parent report measures of different constructs (e.g. CDS symptoms and autistic traits in the current manuscript) often correlate highly due to reporting biases. As such, future research should explore the described relationships in a multimodal/multi-informant manner to better understand how CDS and autistic traits interact. Finally, it is possible that there are differences in the impact of CDS symptoms in children with and without co-occurring intellection disability (ID). Because the proportion of children with IQ < 70 differed between our groups, we made sure to control for IQ in all of our analyses. This should allow us to evaluate the impact of CDS symptoms on our various outcomes over-and-above any impact of IQ differences. That said, future studies are needed to better understand how ID may further contribute to differences in CDS and overall functioning in young children.

In summary, the current manuscript reports two novel findings: (1) This is the first manuscript to explore the cognitive subdomain of CDS traits in autistic children with and without ADHD as a unique predictor of impairment. Overall, while our results support previous research demonstrating that CDS traits are prevalent in young children diagnosed with both autism and ADHD, we found that the cognitive symptoms are particularly elevated in autistic children with co-occurring ADHD. (2) While we had hypothesized that CDS traits would be associated with greater challenges associated with autism given evidence for increased impairment in children with ADHD and co-occurring CDS, this is the first study to empirically demonstrate this increased global impact over and above other autism features and ADHD symptoms. Specifically, the presence of CDS was associated with greater social difficulties, particularly social withdrawal, as well as higher levels of repetitive behaviors and sensory sensitivities, regardless of diagnosis. While there is still debate about whether CDS is a transdiagnostic factor or a diagnostic specifier within children with ADHD with or without co-occurring autism (Barkley, 2014; Becker & Willcutt, 2019; Becker et al., 2023), our results may suggest CDS is more of a transdiagnostic factor and add to the mounting evidence suggesting that the presence of CDS symptoms puts individuals at greater risk for a number of increased difficulties. Given emerging research suggesting that children with ADHD who also have co-occurring CDS symptoms respond differently to ADHD interventions than children with ADHD without CDS symptoms (Firat et al., 2021; Froehlich et al., 2018; McBurnett et al., 2017; Owens et al., 2018; Wietecha et al., 2013), the current study suggests that clinicians should be assessing CDS traits in addition to other clinical domains of both ADHD and autism when developing intervention plans for young, neurodiverse children.

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Acknowledgments

This work was funded by an Autism Center of Excellence (ACE) grant from the Eunice Kennedy Shriver National Institute for Child Health and Human Development (NICHD; P50-HD093074; PI: Dawson, Geraldine) and by NICHD under Award Number R01HD101440 (PI: Carpenter, Kimberly). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Dr. Dawson is on the Scientific Advisory Boards of Akili, Inc, Nonverbal Learning Disability Project, and Tris Pharma, Inc., and received book royalties from Guilford Press, Oxford University Press, Springer Nature Press. Drs. Carpenter and Dawson developed technology, data, and/or products that have been licensed to Apple, Inc. and Carpenter, Dawson, and Duke University have benefited financially. Dr. Sabatos-DeVito consults with and receives personal fees from New Frontiers in Learning.

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