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JADXXX10.1177/1087054716685838Journal of Attention DisordersÅsberg Johnels et al.

Article
Journal of Attention Disorders

A Hyperlexic-Like Reading Style Is

1­–10
© The Author(s) 2017
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DOI: 10.1177/1087054716685838
https://doi.org/10.1177/1087054716685838

Features in Girls With ADHD journals.sagepub.com/home/jad

Jakob Åsberg Johnels1, Christopher Gillberg1, and Svenny Kopp1

Abstract
Objective: Hyperlexic-like reading (defined as word decoding much better than comprehension) has been associated with
autism spectrum disorder (ASD). Here we study correlates of a hyperlexic-like reading style (HPL) in ADHD, a condition
known to co-occur both with reading difficulties and ASD. Method: We compared 10 girls with an ADHD diagnosis plus
HPL with 26 with ADHD minus HPL. Results: Girls with HPL scored marginally lower in reading comprehension but did
not differ from non-HPL girls in IQ, vocabulary, or in the severity of ADHD ratings. However, in addition to scoring much
better on word decoding, HPL readers also displayed higher levels of social-communication deficits on the ADOS-G and
the ADI-R. Moreover, correlation analysis in the full sample revealed an association between increasing autistic features
and word reading. Conclusion: The study underscores the heterogeneity of reading skills in ADHD, and shows the
relevance of subclinic autistic features for understanding this variability. (J. of Att. Dis. XXXX; XX(X) XX-XX)

Keywords
autism, ADHD, reading, comprehension, hyperlexia, autistic traits

Introduction The relative strength in word decoding in ASD contrasts

Research into the reading skills of school-age children with
autism spectrum disorder (ASD) has noted great within-
group variation (e.g., Åsberg, Kopp, Berg-Kelly, & Gillberg,
2010; Nation, Clarke, Wright, & Williams, 2006; White
et al., 2006), which is similar to the variability in cognitive
and oral language skills seen in the population. Still, several
research studies of ASD have also noted a distinct pattern of
reading ability. Specifically, word reading/decoding skills
have often been reported to be better developed than read-
ing comprehension (for recent reviews and empirical exam-
ples, see Huemer & Mann, 2010; Nation, 1999; Nation
et al., 2006; Newman et al., 2007; Saldana, Carreiras, &
Frith, 2009). Interestingly, some researchers have argued
that the word reading process draws on cognitive strengths
in ASD; for example, a preoccupation with and close atten-
tion to details (Nation, 1999), relatively well developed
phonological skills (Newman et al., 2007; Saldana et al.,
2009) and strong visuo-spatial skills (Åsberg Johnels &
Miniscalco, 2014) that could support written word process-
ing skills and development. Furthermore, Grigorenko, Klin,
and Volkmar (2003) highlighted that some children with
ASD display a restricted and repetitive interest for decoding
print that may fuel a (circumscribed) word reading exper-
tise. In fact, the hypothesis of an attentional orientation
toward print and letters in ASD has received empirical sup-
port in an eye-tracking study (Nakano et al., 2010).
with reading comprehension, that is, the extraction of mean-
ing from written text, which is often difficult for many chil-
dren with ASD. The source of poor reading comprehension in
ASD is largely unknown (Saldana & Frith, 2007), but has pre-
viously been suggested to reflect the coherence-making diffi-
culties, the oral language impairments, or the executive
difficulties that tend to be associated with ASD (Nation, 1999;
Newman et al., 2007; Henderson, Clarke, & Snowling, 2011).
Core difficulties in social-communication might also affect
reading comprehension negatively, possibly independently of
basic language and cognitive skills. For instance, Jones et al.
(2009) described and explored “dips” in reading comprehen-
sion attainment relative to IQ in a relatively large sample of
adolescent males (n = 80) and females (n = 20) with ASD.
These researchers found that a discrepancy score between
reading comprehension performance and IQ was significantly
related to the severity of social and communicative difficulties
according to results from the Autistic Diagnostic Observation
Schedule–Generic (ADOS-G; Lord et al., 2000), thus “sug-
gesting that reading comprehension falls increasingly below
1
University of Gothenburg, Sweden
Corresponding Author:
Jakob Åsberg Johnels, Gillbergcentrum, Göteborgs universitet,
Kungsgatan 12, 411 19 Göteborg, Sweden.
Email: jakob.asberg@gnc.gu.se
2 Journal of Attention Disorders 
Figure 1. A graphic topology of different types of reading/
comprehension difficulties based on the framework of Aaron
(1989/2012).
Source. Figure from Åsberg Johnels (2014).
general intellectual ability in line with increasing social and
communication impairments” (p. 724). In a more recent study,
using the same sample, Ricketts, Jones, Happé, and Charman
(2013) showed that measures of social behavior and social
cognition predicted reading comprehension performance
even when statistically controlling for the variance explained
by word reading-decoding and oral language comprehension.
The authors argue that this result suggests that text reading
comprehension and social-communicative functioning may
be functionally coupled in ASD. Specifically, failing to under-
stand social and communicative norms may hamper a reader’s
ability to make inferences and, consequently, constrain the
processing of the overall gist in connected text (cf. Wahlberg
& Magliano, 2004, for a similar argument).
Although consensus is lacking in the best usage of the
term,1 in previous research, the discrepant pattern of stron-
ger word reading vis-à-vis comprehension has been referred
to as hyperlexia (for reviews, see Grigorenko et al., 2003;
Nation, 1999). This pattern of reading is clearly distinct
from dyslexia, which often is defined as poor decoding
skills despite normal language comprehension (e.g., Catts,
Hogan, & Fey, 2003, and many others). Hyperlexia also dif-
fers from mixed word reading/comprehension difficulty,
where both comprehension and decoding are poorly devel-
oped. A graphic topology of these types of reading/compre-
hension difficulties is presented in Figure 1.
Another, much more common, neurodevelopmental dis-
order is ADHD. ADHD is characterized by a constellation
of difficulties in attention and/or activity level and impul-
sivity, and is typically associated with impaired social and
academic functioning (American Psychiatric Association
[APA], 1994). While ADHD is commonly considered a dis-
tinct condition relative to ASD, an overlap between ADHD
and ASD features has also been established in the literature
(e.g., Gillberg, 1983; Hattori et al., 2006; Kopp, Berg-Kelly,
& Gillberg, 2010). Moreover, a literature review by Uchida
et al. (2013) and a recent study by Biederman et al. (2016)
found that when compared with children with ADHD with-
out these traits, the presence of autistic traits in children
with ADHD was associated with more severe dysfunction
in a wide range of non-overlapping domains.
Much research has been done on word reading-decoding
in ADHD. The existing research has established that word
decoding/dyslexic difficulties are common among children
with ADHD. Estimates from different studies indicate that
somewhere between 25% and 40% has comorbid reading
disability (e.g., Gillberg & Gillberg 1989; cf. Germano,
Gagliano, & Curatolo, 2010, for a review). According to
Willcutt et al. (2007), correlations between continuous mea-
sures of word reading and ADHD-symptomatology usually
fall between .2 and .4 among school-aged children, and
there is much evidence to suggest that the correlations with
word reading tend to be stronger for inattention than for
hyperactivity-impulsivity. Less research is available for
reading comprehension in ADHD, but available evidence
suggests that reading comprehension appears to be a chal-
lenge (e.g., Mayes & Calhoun, 2006). Such difficulties have
been linked with executive dysfunctions within the reading
context (Barkley, 1997; Miller et al., 2013), but could in
many cases also be secondary to inaccurate and/or dysflu-
ent word decoding. To our knowledge, no research has
examined the hyperlexic-like patterns of reading in school-
age children with ADHD.
In a previous study, we have reported data on reading
skills in school-aged girls with ASD, ADHD, and typical
development (Åsberg et al., 2010). In that study, the ADHD-
group as a whole conformed to a “mixed word reading/
comprehension difficulty”–pattern of reading, in keeping
with previous research on male or predominantly male sam-
ples (Mayes & Calhoun, 2006). In the current study, we
return to these data specifically to look for hyperlexic-like
discrepancies between (better) word decoding and (poorer)
reading comprehension among individual participants in
the group with ADHD. Initially, we therefore asked whether
there were cases of hyperlexic-like reading (HPL) within
the ADHD–group. Once identified, we asked whether HPL
reading in ADHD was coupled with a certain cognitive,
psycholinguistic, or behavioral phenotype when compared
with non-HPL cases of ADHD. Specifically, considering
that an overlap in expression has been suggested, we
hypothesized that HPL would be associated with elevated
levels of autistic symptomatology (i.e., social, communica-
tive, and/or restricted and repetitive behaviors). We took a
dimensional approach in analyzing this question as the ASD
symptoms of all ADHD participants in the study were at
“subthreshold” levels for an ASD-diagnosis. In addition, a
number of other potentially explanatory factors that have
Åsberg Johnels et al.
been linked with word decoding and/or reading comprehen-
sion skills in children were assessed. Specifically, perfor-
mance and verbal IQ, oral vocabulary, as well as the severity
of core difficulties in hyperactivity-impulsivity and/or inat-
tention could be assumed to be important for both word
decoding and reading comprehension skill development.
Therefore, these factors were also explored in relation to
HPL reading in ADHD, although we had no a priori hypoth-
eses regarding these latter associations.
Method
Participants
Three groups participated in the previously mentioned
study (“The Girl Project”) by Åsberg et al. (2010), namely,
clinic girls with ADHD (n = 36), ASD (n = 20), and com-
parison girls without known disabilities (n = 54), aged
between 8 to 17 years of age. The three groups were not
significantly different in terms of chronological age or
WISC-III performance IQ (Wechsler, 1992) (see below) .
Girls with ASD and ADHD had been referred to the child
neuropsychiatric clinic (CNC) in Gothenburg, Sweden, for
social, mental health, and/or attentional difficulties (no
advertisement). None of the girls was or had previously
been on medication for difficulties relating to ADHD at the
time of assessment. Girls in the comparison group were
recruited from a local pediatric outpatient clinic register in
the Gothenburg region (Mölnlycke), and these girls did not
have any neurodevelopmental disabilities according to out-
patient registers and interviews with parents.
All girls had a full scale IQ above 70, and diagnoses
were based on Diagnostic and Statistical Manual of Mental
Disorders (4th ed.; DSM-IV; American Psychiatric
Association, 1994) criteria. All girls received a full neuro-
psychiatric/neurodevelopmental examination by a multi-
professional team at the CNC, consisting of psychiatrists,
psychologist, and educational specialist. All members of the
team had relevant formal training and experience for their
respective part of the assessments as described below. The
assessment included interview and examination of each girl
and interview with the parent(s) regarding the child’s early
development and current behaviors and symptoms. The
examination lasted on an average 20 hr for clinic girls and
10 hr for comparison girls. Moreover, all girls were observed
at school by the study educationalists, and the same educa-
tionalist also interviewed all the teachers about the girls’
behavioral problems. The “Five to Fifteen” (FTF) question-
naire (Kadesjö et al., 2004) and the Conners’ Teacher Rating
Scale–Revised: Long Form (CTRS-R; Conners, Sitarenios,
Parker, & Epstein, 1998; see details below) were used to
gather ratings of ADHD symptoms from parents and teach-
ers, respectively. Diagnoses according to DSM-IV were
assigned when both symptom and impairment criteria for a
3
disorder were met. On the basis of all available information,
the senior author S.K., an experienced child, and adolescent
psychiatrist assigned diagnoses after a thorough discussion
with the professionals who had performed the individual
assessments. All records and diagnoses were rechecked on
two further occasions: at a follow-up meeting after 3 months
and after all evaluations were finished. The diagnoses of
ambiguous cases were discussed in detail with another
author (C.G.), a professor in child and adolescent psychia-
try with very long-term experience of clinical and research
work in neuropsychiatry. Of the 36 cases with ADHD, 20
met criteria for the combined subtype, 14 for the predomi-
nantly inattentive subtype, and two for the predominantly
hyperactive-impulsive subtype. A separate paper published
in the current journal provides detailed description of the
procedure and clinical presentation of the participants
(Kopp et al., 2010).
The mothers of all girls provided informed consent to
participate. All the girls ≥16 years also provided informed
consent personally. The Ethics Committee at the University
of Gothenburg approved the study.
There is no consensus as to how to define or identify
hyperlexia (e.g., with regard to the severity of the compre-
hension deficit, the type and size of discrepancy, the neces-
sity for a spontaneously acquired reading skill, and so on;
for example, Grigorenko et al., 2003; Nation, 1999), and it
is not a formal diagnosis in the DSM-IV or in any other offi-
cial diagnostic manual. Because of this situation and these
inconsistencies, we here prefer to use the term “hyperlexic-
like reading style” (HPL) rather than “hyperlexia” in our
study to signal that this is a descriptive label rather than a
formal medical diagnosis with clearly agreed criteria. To
operationalize HPL, a >15 standard score discrepancy (i.e.,
1 SD) cutoff was applied between (stronger) word decoding
and (weaker) reading comprehension according to test
results collected at the clinic (see test descriptions below).
This means, in turn, that levels of word decoding and read-
ing comprehension were allowed to be quite variable in
absolute levels. However, the procedure ensured that all
HPL readers were much stronger in word decoding than in
reading comprehension, which is consistent with the opera-
tionalization in most current research (e.g., Castles,
Crichton, & Prior, 2010).
According to the criterion adopted, there were individu-
als with HPL in all three groups in the sample described in
Åsberg et al. (2010). Specifically, in the ASD group, eight
out of 192 girls (42%) showed HPL. This was significantly
different (p = .017; Fisher’s exact two-tailed test) from the
comparison group where seven out of 54 girls (13%)
showed HPL.3 Interestingly, also in the ADHD-group, a siz-
able minority were classified as displaying HPL.
Specifically, 10 out of 36 (28%) met our criteria for HPL,
and this rate approached significance (p = .10) in relation to
the comparison group. The current study report describes
4 Journal of Attention Disorders 
and compares the characteristics of these 10 girls with
ADHD (but not ASD) with HPL (ADHD + HPL) with those
26 girls with ADHD (but not ASD) without HPL (ADHD
− HPL).
Measures
Selection measures. Performance in reading comprehension
and word decoding was assessed individually at the clinic
by the same special educator. The following instruments
were used:
1. The tests “Diagnostiska läs- och skrivprov”
(“Diagnostic reading and writing tests”) were used
to assess reading comprehension for girls in Grades
2 to 6 (Grade 2 and 3: Björkquist & Järpsten,
1975/1976; Grade 4-6: Järpsten & Taube, 1997).
The LS test (Johansson, 1992) was used for older
girls. These tests all consist of passage and text com-
prehension with comprehension questions or state-
ments in a multiple-choice format.
2. Timed tests of single, out of context, word reading
were chosen as a measure of word decoding effi-
ciency. The H4 test (Franzén, 1997) was used for
girls in Grades 2 to 6 (approximately 8-12 years),
and the LS test (Johansson, 1992) was used for the
older girls. The number of correctly read words/time
unit was registered. Such efficiency measures are
typically used in Sweden and other semi-consistent
orthographies.
As reported in Åsberg et al. (2010), the raw scores on
these tests were first converted to z scores, based on the
population means and SDs reported in the test manuals for
different ages. Specific norms for girls were used when
available. After this, z scores were converted into standard
scores based on the normative mean of 100 and a SD of 15,
with a standard score floor of 50. This procedure could not
be upheld throughout, as SDs were not reported in the read-
ing comprehension test manual for 8- and 9-year olds; only
norm-referenced stanine values were reported (=the stan-
dard procedure for reporting test results in Swedish schools).
We therefore calculated the standard scores based on the
obtained stanine score for these participants to allow for
comparisons across participants, while also maximizing
data information.
Other measures
1. Verbal IQ and Performance IQ from WISC-III were
collected for the girls. These two measures are
expressed around a mean of 100 and a SD of 15.
2. Considering the large literature placing oral vocabu-
lary skills at the center of the reading comprehen-
sion ability (e.g., Hulme & Snowling, 2009; Nation
et al., 2006), the oral vocabulary subtest from the
verbal scale on WISC-III was also analyzed sepa-
rately. This subtest is expressed in scaled scores
around a mean of 10 (SD = 3).
3. Inattention and hyperactivity/impulsivity (ADHD-
symptomatology): Ratings of DSM-IV (APA, 1994)
symptoms of inattention (nine criteria) and hyperac-
tivity/impulsivity (nine criteria) were collected from
teachers and parents using the CTRS-R (Conners
et al., 1998) and the “Five to Fifteen” (FTF) ques-
tionnaire (Kadesjö et al., 2004), respectively. The
CTRS-R items are scored as 0, 1, 2, or 3 for “not
true at all,” “just a little true,” “pretty much true,” or
“very much true,” respectively. The FTF items are
scored as 0, 1, or 2 for “does not apply,” “applies
sometimes,” or “definitely applies,” respectively.
Five girls with ADHD did not have teacher ratings
(three ADHD + HPL and two ADHD − HPL).
Results are expressed in T-scores (M = 50, SD = 10)
and raw scores on the Conners’ teacher ratings and
FTF, respectively. According to Conners et al.
(1998), a T-score > 65 indicates a clinically relevant
level of difficulty.
4. Autistic symptomatology was assessed in two
ways: (a) The Autism Diagnostic Observation
Schedule–Generic (ADOS-G; Lord et al., 2000)
was used. The ADOS-G is a semi-structured assess-
ment of social interaction, communication, play,
and imaginative use of materials. Due to the range
in age and functioning of the individuals in our
study, either Module 3 or 4 was administered. The
difference between Modules 3 and 4 lies primarily
in whether information about social-communica-
tion is more appropriately acquired during play or
an interview, but both modules involve conversa-
tion and overlap in activities. In the ADHD + HPL
group, n = 5 had Module 3 and n = 4 had Module 4.
ADOS data is lacking for one girl with ADHD +
HPL. In the ADHD − HPL group, n = 17 had
Module 3 and n = 9 had Module 4. Although
Modules 3 and 4 are not completely parallel in
terms of scaling, they were considered sufficiently
similar to be analyzed together in the current study.
Furthermore, we ensured that the distribution of
modules for the two groups was not significantly
different (Fisher’s exact test: p = .69). (b) The
Autism Diagnostic Interview–Revised (ADI-R;
Lord, Rutter, & Le Couteur, 1994) is a standard-
ized, semi-structured clinical interview with the
caregivers of the children. Higher scores indicate
higher current and prior behaviors related to autism.
Besides a total score, specific scores are provided
for the social, communication, and repetitive/ste-
reotyped behaviors domains.
Åsberg Johnels et al. 5

Table 1. Descriptives (Means and SDs) in Study Groups For the Selection, Background, and Clinical Measures.

Group

Measure ADHD + HPL ADHD − HPL

Selection and background measures
Word decodinga* 109.2 (23.6) 76.5 (16.0)
Reading comprehensiona 75.8 (21.4) 89.5 (18.6)
Chronological ageb 13.1 (3.1) 12.9 (2.1)
Clinical measures
Performance IQa 93.6 (15.3) 99.8. (15.5)
Verbal IQa 93.1 (16.4) 93.4 (11.9)
Vocabularyc 9.7 (2.7) 9.0 (2.5)
Inattention, teacher ratingd 72.4 (16.1) 73.9 (13.3)
Hyperactivity-impulsivity, teacher ratingd 62.1 (17.3) 69.0 (18.6)
Inattention, parent ratingb 14.5 (3.0) 13.1 (4.6)
Hyperactivity-impulsivity, parent ratingb 9.1 (4.2) 8.0 (5.4)
ADOS-G, totalb* 5.2 (4.4) 2.3 (2.3)
ADI-R, communicationb* 4.9 (3.4) 2.8 (3.0)
ADI-R, socialb 4.5 (4.6) 3.7 (3.4)
ADI-R, repetitive behaviorsb 1.9 (1.6) .96 (1.2)
ADI-R, totalb 12.2 (9.4) 8.5 (6.5)

Note. ADOS-G = Autistic Diagnostic Observation Schedule–Generic; ADI-R = The Autism Diagnostic Interview–Revised.
a
Standard scores (based on the normative M = 100, SD = 15).
b
Raw score.
c
Scaled scores (based on the normative M = 10, SD = 3).
d
T-scores (based on the normative M = 50, SD = 10).
*Significant group difference according to Mann–Whitney U test.

Statistical Analyses As expected, the ADHD + HPL group scored statistically

Mann–Whitney U tests were used to compare the ADHD +
HPL and ADHD − HPL groups on the measures of interest.
Nonparametric statistics was preferred (a) due to small and
unequally sized samples, (b) due to several cases of non-
normality according to histogram inspection, and (c) to
reduce the impact of any outliers in the data set. In addition,
non-parametric correlation analyses (Spearman’s rho) were
conducted to explore bivariate associations. The signifi-
cance level was set to p < .05 (two-tailed).
Results
Selection and Background Measures
Descriptives (means and SDs) are presented in Table 1 for
selection, background, and clinical measures. Girls with
ADHD + HPL had a mean score on the word decoding mea-
sure in the high average range, but scored strikingly poorly
in reading comprehension. As can be seen in Table 1, the
average discrepancy between word reading and reading
comprehension in the HPL group was more than 30 stan-
dard points (i.e., 2 SDs). The ADHD − HPL group scored
poorly in word decoding (approximately 1.5 SDs below the
normative mean) and also low (albeit somewhat higher) in
reading comprehension.
better than the ADHD − HPL group in word decoding, U =
34.0, p = .001. This contrasted with the results in reading
comprehension where there was a non-significant advan-
tage for the ADHD − HPL group, U = 79.0, p = .07.
The two groups did not differ in chronological age, U =
115.5, p = .61.
IQ and Vocabulary Scores
The groups did not differ on performance IQ (U = 94.0, p =
.20) or on verbal IQ (U = 124.5, p = .85). Furthermore, they did
not differ on oral vocabulary (U = 121.5, p = 76), with both
groups approaching the normative value of 10 on this subtest.
Inattentive and Hyperactive-Impulsive Symptoms
The groups were equally challenged in terms of ADHD-
symptomatology according teacher and parent ratings of
inattention and hyperactivity-impulsivity, ps range between
.24 to .78. Note that both groups scored high on the stan-
dardized teacher ratings, with the Inattentiveness scale
averaging more than 2 SDs above the normative mean of 50
on the T scale.
We also checked the prevalence of ADHD subtypes in
the two groups. In the ADHD + HPL group, five had the
6 Journal of Attention Disorders 
combined subtype of ADHD and five the primarily inatten-
tive subtype. In the ADHD − HPL group, 15 had the com-
bined subtype of ADHD, nine the primarily inattentive
subtype, and two the primarily hyperactive-impulsive
subtype.
Autistic Symptomatology
On the ADOS, readers with ADHD + HPL had a signifi-
cantly higher total social-communication score, thus indi-
cating greater autistic symptomatology in this group, U =
54.0, p = .016. Also on the ADI-R communication deficit
score did the ADHD + HPL group score significantly higher
than the ADHD − HPL group, U = 71.5, p = .037. No sig-
nificant difference (p > .05) was found between groups on
the ADI total, “repetitive,” or “social” scores, though
numerically the trend pointed in the same direction on these
measures. Mean scores on the ADOS-G and the ADI-R all
fell below clinical cutoffs for ASD in both reading sub-
groups, providing further support that we explore the asso-
ciations between HPL and autistic features in cases with
ADHD and subthreshold levels for ASD.
Complementary Correlation Analyses in the Full
Sample
Given the pattern of performance displayed by the ADHD +
HPL group, we wanted to explore the associations between
autistic features (measured with the ADOS-G and ADI-R) and
word reading-decoding and reading comprehension in greater
detail. For this purpose, correlation analyses was performed
between these variables in the full sample with ADHD (N =
36). Results showed that ADOS scores were positively associ-
ated with word decoding (rho = .357, p = .035) suggesting
that, in this sample, increasing autistic features were associ-
ated with better word reading capacity. However, the correla-
tions between word decoding and the different ADI-scores
were not significant (all p > .09), nor were the correlations
with reading comprehension (all p > .16).
Discussion
A hyperlexic-like style of reading (HPL), defined as word
decoding substantially better than reading comprehension,
was found in an important minority of female school-age
children with a diagnosis of ADHD. The subgroup that pre-
sented with HPL was furthermore found to have elevated
levels of autistic features according to the social and com-
munication score of the ADOS-G and the communication
difficulties score of the ADI-R. These findings are, we
think, of interest for several reasons.
First, it proved to be worthwhile to look for individual
differences and reading patterns within the ADHD-group.
In our first literacy study on this sample (Åsberg et al.,
2010), the ADHD-group appeared to resemble a mixed
word reading/comprehension difficulty group as a whole,
but in the current study, it was clear that a substantial minor-
ity among children with ADHD sharply diverge from this
pattern. This finding, once again, highlights that the “aver-
aging artefact” is a constant threat in research on childhood
neurodevelopmental disabilities, suggesting that the mean
score does not necessarily well represent the performance
of any single participant (Brock, 2011). Yet, we also want to
remind the reader that the current study exclusively included
Swedish-speaking girls. Whether the results can be general-
ized to boys and to children from other countries and lan-
guage background could be topics for future research.
Second, strong word decoding in the context of poorer
comprehension was associated with an increased presence
of certain autistic symptoms. The ADHD + HPL group
scored in the high average range according to the norm-
referenced word decoding measure. This result is particu-
larly striking in view of the fact that the two groups did not
differ in ratings of ADHD-characteristics, which were very
high in both groups. The fact that a complementary analysis
also revealed a positive correlation between increasing
autistic features ADOS-G and word decoding skills is all
the more remarkable. However, this association was not
equally clear on the ADI-scores, suggesting that the result
should be interpreted with caution. Still, these finding high-
lights that researchers with an interest in the connection
between word reading difficulties/dyslexia and ADHD may
want to take account of the moderating role of autistic
symptomatology in their studies.
Although striking, the finding that co-occurring autism
features in a clinical sample are coupled with good word
decoding is not unique to this study. A longitudinal study by
St. Clair, Durkin, Conti-Ramsden, and Pickles (2010) fol-
lowed children with specific language impairment (SLI)
with or without elevated levels of autistic features, and in
fact found stronger word decoding skills in the comorbid
group. While the study by St. Clair et al. differed in a num-
ber of ways from the current one,4 it is still of interest in the
current context, as it pointed in the same direction.
Moreover, when researchers and clinicians in the field of
neurodevelopmental disorders examine comorbidity, it is
typically framed in terms of “extra burdens” (Biederman
et al., 2016). The current research and that by St. Clair et al.
both demonstrate that when it comes to the isolated skill of
word decoding, then the comorbidity of autism features is
not necessarily an “extra burden.”
Third, the other aspect of the HPL phenotype is severe
comprehension difficulties, and this was evident in the
ADHD + HPL group in the current study as well. Given a
strong word reading score (ss109), the question arises why
the HPL-group experienced poor reading comprehension
(ss76) in the first place. While acknowledging the associa-
tional nature of the current study, we suspect that certain
Åsberg Johnels et al.
features directly associated with the autism might be caus-
ally linked with text-level comprehension difficulties.
Cognitively oriented research has focused on different
psycholinguistic levels as potential sources to text compre-
hension difficulties experienced by children with fluent
word reading-decoding: from word semantics (vocabulary)
to meta-cognition and self-regulation within the reading
context (for reviews, see Cain & Oakhill, 2007; Hulme &
Snowling, 2009). In their research on children with ASD-
diagnosis, Nation et al. (2006) and Norbury and Nation
(2011) have stressed the importance of impaired vocabulary
and other core oral language skills when explaining reading
comprehension difficulties in this group of children. In the
current study, the groups did not differ in oral vocabulary.
Furthermore, both groups had age-adequate oral vocabulary
skills relative to norm data (mean scaled scores of 10 and 9
for ADHD + HPL and ADHD − HPL, respectively). Thus, it
seems difficult to explain the reading comprehension diffi-
culties displayed by the ADHD + HPL group with reference
to their vocabulary knowledge. Of course, this does not
mean that oral language comprehension skills in the HPL-
group were “normal.” Rather, research on reading in chil-
dren with clinical diagnoses of ASD suggest that poor
text-level comprehension might reflect underlying social-
communicative difficulties that by definition are integral to
ASD, possibly in the form of impaired pragmatic inferenc-
ing skills (e.g., Ricketts et al., 2013) and/or difficulties in
identifying author intentions and tracking mental states of
characters in the texts (Hulme & Snowling, 2009). The text
comprehension impairment could also be related to linguis-
tically based cognitive control difficulties. A novel perspec-
tive in this context was offered by Henderson et al. (2011).
These researchers used a semantic priming paradigm origi-
nally developed in cognitive psychology to show that indi-
viduals with ASD appear to have intact access to semantic
information early in the time course of text processing, but
that impairments are present in the later—top-down con-
trolled—aspects of the meaning-making process. Future
research could examine if such difficulties underlie text
comprehension difficulties in children with ADHD with or
without autistic traits, and whether these measures also dif-
ferentiate within a population of children with ADHD
depending on HPL status.
A completely different possible explanation for the link
between autistic features and weak reading comprehension
was preliminarily suggested by St. Clair et al. (2010) in
their SLI study, namely, that the direction of the relation
could be reversed. Indeed, these authors speculated that
“being able to adequately decode words without the corre-
sponding level of understanding may . . . create a sense of
isolation in these individuals, which may lead to social dif-
ficulties and other features of autistic symptomatology” (St.
Clair et al., 2010, p. 127). This is an intriguing proposal and
may account for the findings also in the present study.
7
Speaking against this hypothesis is, however, the fact that
several other populations have been shown to sometimes
comprehend text poorly without obvious signs of either
autism or word decoding difficulties, for example, typically
developing children who read in a second language (e.g.,
Burgoyne, Kelly née Hutchinson, Whiteley, & Spooner,
2009). Taken together, our study show that HPL reading
appears to be associated with subclinical social-communi-
cative difficulties among students with ADHD as the pri-
mary disorder, and we have tentatively ruled out some
possible explanatory variables or confounders (e.g., oral
vocabulary skills or general IQ) in this association. Rather,
our study strengthens the notion of a connection between
autistic features (especially communicative or social-com-
municative difficulties) and HPL reading, which in this
study was expanded to a novel population (ADHD) and at a
subclinical level of autistic traits.
A final question pertains to the label used to describe
the study groups in our study. Given the definitional
inconsistencies surrounding the hyperlexia term, we pre-
ferred to use the term “a hyperlexic-like reading style” to
describe the patterns of reading displayed by the ADHD +
HPL group. Still, it could be questioned whether “hyper-
lexic” is the best word to use at all. Grigorenko and col-
leagues (2003) suggested that the hyperlexia-concept
should be reserved for a type of reading behavior seen in
some children with ASD-diagnosis, and they also sug-
gested other aspects than a word decoding vis-à-vis read-
ing comprehension discrepancy in the definition (e.g., a
precocious and spontaneously acquired reading ability). In
contrast, Snowling and Frith (1986) argued that “hyper-
lexia is not a syndrome-specific phenomenon” (p. 410).
This discussion relates broadly to the unsettled issue of
whether hyperlexia best should be conceptualized a super-
ability (in word decoding relative to a low overall func-
tioning of the child) or as a disability (in reading
comprehension relative to age-expectations and word
decoding; Grigorenko et al., 2003). Notwithstanding
which “label” to use to best describe the current group’s
pattern of ability, we believe that there is a quite complex
causal-developmental story behind the set of findings
reported in the current study, and the mismatch between
strong word decoding and weak comprehension is of both
theoretical and clinical/practical importance. We also
believe that a lot could be learned about reading and com-
prehension as well as the cognitive phenotypes of ADHD
and autism, more generally, by shedding further light on
the nature of these associations. In terms of practical clini-
cal consequences, the study underscores the heterogeneity
of reading skills in ADHD. The results also speak against
models of neurodevelopmental examinations that build on
sharp demarcations between categorically defined condi-
tions; instead, they show the value of also using a dimen-
sional approach to parse this heterogeneity, where
8 Journal of Attention Disorders 
symptoms at subthreshold levels for diagnosis (e.g., autis-
tic features) provide important information in terms of
outcome in another domain (e.g., profiles of reading dif-
ficulties). In terms of implications for educational support,
the results show that individuals with ADHD often need
support for reading-related difficulties, but that such sup-
port must be tailored according to the individual’s profile
of difficulties: Whereas readers with ADHD − HPL likely
need (compensation and/or training) to ameliorate poor
word reading alongside reading comprehension difficul-
ties, readers with ADHD + HPL need to be supported in
“reading for meaning,” rather than just decoding the
words, which otherwise might be their spontaneous
response in a reading situation. Research describing effec-
tive reading comprehension interventions for students
with an ASD-diagnosis might be informative in this regard
(e.g., Randi, Newman, & Grigorenko, 2010).
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
Notes
1. See the “Method” section for a further discussion of the defi-
nition used in the current study.
2. Word decoding results was missing for one girl with autism
spectrum disorder (ASD), due to selective mutism.
3. To refer to children (without other known disabilities) who
present with poor reading comprehension in the face of stron-
ger word reading capacity, the term “poor comprehenders”
is commonly used. To our knowledge, there is no published
research on Swedish poor comprehenders, but Hulme and
Snowling (2009) reported that the incidence of poor compre-
henders is about 10% in English schools.
4. For example, it focused on another clinical group, and the
discrepancy between word decoding and reading comprehen-
sion was lower in their “comorbid” group: standard scores of
88 versus 79, respectively.
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Author Biographies
Jakob Åsberg Johnels, PhD, is an associate professor at the
University of Gothenburg, including at the Gillberg
Neuropsychiatry Centre and the Section for Speech and language
pathology. He also works clinically with academic skills assess-
ments at the Child Neuropsychiatric Clinic (CNC) at Queen
Silvia Children’s Hospital, Sahlgrenska University Hospital.
Journal of Attention Disorders 
Christopher Gillberg is a professor of Child and Adolescent
Psychiatry at the University of Gothenburg, Sweden, since the
mid-1980s. He heads the Gillberg Neuropsychiatry Centre. He is
also a Chief Physician at the Sahlgrenska University Hospital and
one of the world’s most experienced, clinically active, child- and
adolescent psychiatrists, with over 40 years of extensive clinical
work in treatment of patients and families with complex psychiat-
ric/neurodevelopmental problems.
Svenny Kopp, MD, PhD, is a specialist in child and adolescent
psychiatry, a senior physician and a researcher at the Gillberg
Neuropsychiatry Centre. Svenny Kopp’s research is focused on
females with neuropsychiatric difficulties. From 1999 to 2001,
Kopp led the “Girl Project”, and her current research involves a
follow-up study of these girls (now young women).