Response inhibition as a critical executive function in differentiating attention-deficit/hyperactivity disorder from autism spectrum disorder: a comprehensive attention test study

Background Autism Spectrum Disorder (ASD) and Attention-Deficit/Hyperactivity Disorder (ADHD) are both associated with impairment in executive function, particularly in complex attention. Although previous studies using clinical assessments have attempted to delineate differences between these disorders, the findings have been inconclusive. Our study aims to elucidate the differences of endophenotype between ASD, ADHD, and their co-occurring condition utilizing a uniform computerized test.Methods The study included children diagnosed with ASD, ASD co-occurring with ADHD (ASD+ADHD), or ADHD who completed the comprehensive attention test (CAT) at Severance Hospital between October 2013 to May 2023. We excluded children with intellectual disability and comorbid major psychiatric or neurologic disorders possibly affecting attention measurement. The participants were categorized into three groups for the comparative analysis of CAT measures: (a) ASD (n=112), (b) ASD+ADHD (n=155), and (c) ADHD (n=104). The study also conducted an exploratory analysis utilizing multivariate linear regression analysis to examine the association between the CAT measures and parent-reported scales.Results Notably, the ASD+ADHD and ADHD groups exhibited higher frequency of commission errors (CE) and perseveration errors (PE) compared to the ASD group. In the exploratory analysis, a significant negative association was observed between reaction time (RT) and both the social communication questionnaire (SCQ) and the child behavior checklist (CBCL) externalization scores in the ASD+ADHD and ADHD groups. The ASD+ADHD group tended to show higher standard deviation of reaction time (RTSD) compared to the ASD group.Conclusions Our findings suggest that impaired response inhibition is more pronounced in ADHD compared to ASD. We propose altered visual attention, reflecting response inhibition, may serve as potential endophenotypic markers differentiating ADHD from ASD in attentional assessment. Elevated RTSD in the ASD+ADHD group demonstrates additive pathology, suggesting that the neurological mechanisms underpinning impaired sustained attention may differ between the two conditions.