A 2026 Pennsylvania study found that attention problems, autism symptoms, oppositional defiant disorder (ODD) symptoms and academic impairment frequently appeared together in children referred for behavioral or developmental concerns.
The findings do not show that one condition causes another. They do suggest that a child’s difficulties may involve more than one area, and that attention problems deserve particular consideration when school performance is affected.
Overlap was common in the referred group
The study examined 1,601 children aged 6 to 16 who had a clinical diagnosis of ADHD, autism or both. Mothers rated ODD symptoms and academic impairment using the Pediatric Behavior Scale, while ADHD and autism were based on clinical diagnoses.
Overall, 89.8% of the referred children had elevated symptoms in at least two of the four areas studied. About 34.3% had elevated symptoms in two areas and 37.8% in three. A smaller group, 17.7%, had elevated symptoms in all four areas. By comparison, 10.2% had ADHD or autism without another elevated area.
Within this referred sample, 80% of children with autism also had combined-type ADHD, while another 10% had inattentive-type ADHD. Elevated ODD symptoms were reported for 73% of children with combined-type ADHD and 72% of children with autism.
Children with both combined-type ADHD and autism had the highest ODD scores. Children with combined-type ADHD alone had the next-highest scores. Among children with ODD symptoms, 86% had combined-type ADHD.
Attention problems were most closely tied to academic impairment
Academic difficulties were strongly connected with ADHD in the study. Among referred children with elevated academic impairment ratings, 99% had either type of ADHD. Mothers also rated academic impairment higher for children with ADHD alone than for groups that included autism.
In statistical models covering the referred and community samples, inattention was the only symptom area uniquely linked to academic impairment. In groups that completed standardized achievement tests, inattention was also the only significant correlate of lower reading and math scores.
The relationships were stronger in the community samples than in the referred group. Correlations between attention problems and academic impairment ratings were 0.38 among referred children and 0.67 in both community groups. Correlations between inattention and reading and math scores in the referred group were 0.09 and 0.14; among community children, they were 0.24 and 0.28.
These results describe relationships, not causes. They cannot establish that inattention produces learning problems, or that reducing attention problems would necessarily improve academic performance.
Community ratings showed a different pattern
The study also included 665 community children aged 6 to 12. In this group, 60.2% had no elevated area, 19.5% had one elevated area and 20.3% had two or more. Elevated symptoms in all four areas were reported for 0.6%.
Of 376 children rated again about eight years later, at an average age of 16.4, 71.5% had no elevated area, 15.4% had one and 13.1% had two or more.
About half of the community children with combined-type ADHD symptoms also had elevated ratings for academic impairment and ODD. Forty percent of those with inattentive-type symptoms had elevated academic impairment. Among teens with combined-type ADHD symptoms at follow-up, 56% had elevated ODD ratings and 56% had elevated academic impairment ratings.
Autism symptoms were reported in fewer than 3% of community children. Among those children, 78% also had combined-type ADHD symptoms. Because the community children were not clinically evaluated, these figures represent symptom ratings rather than confirmed diagnoses.
What the findings may mean for families and schools
A child who is struggling academically may also be experiencing attention difficulties, behavioral dysregulation or autism-related challenges. Looking at only one area could miss part of the child’s needs.
The study’s pattern may support a broad review of attention, learning, behavior and developmental characteristics when concerns arise. It does not, however, test any treatment or prove that addressing inattention will improve learning or that addressing hyperactivity and impulsivity will reduce defiant behavior.
Families and educators should also be cautious about interpreting defiance as a stand-alone explanation for a child’s behavior. The study found an association between hyperactive or impulsive ratings and ODD ratings, but it did not establish that hyperactivity causes oppositional behavior.
Important limits of the study
The referred children came from a group seen for behavior problems or possible ADHD or autism. That selection helps explain why rates of overlapping concerns were high and means the results should not be applied directly to all children.
The study relied on mothers’ ratings for behavior and academic impairment. In the referred group, ADHD and autism were clinical diagnoses, but ODD and academic impairment were based on those ratings. In the community samples, all four areas were based on mothers’ reports.
All participants had an IQ of at least 70, so the findings do not cover children with intellectual disability. Both samples came from central Pennsylvania, and 92% of the referred group was White. The researchers noted that the results need replication in more diverse groups.
Anxiety, depression and conduct problems were not analyzed. The study therefore cannot explain how those concerns might affect the overlap among attention, behavior, developmental symptoms and school performance.
AI tools were used to assist with the preparation of this article.
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