Distinct school functioning profiles associated with co-occurring ADHD and learning disability among U.S. children with autism spectrum disorder: a repeated cross-sectional study

Abstract Background: School functioning among autistic children is heterogeneous. Although co-occurring attention-deficit/hyperactivity disorder (ADHD) and learning disability (LD) may identify children with differing educational needs, national evidence that distinguishes academic grades from school–family problem communication is limited. We examined associations of current ADHD and LD, separately and jointly, with two parent-reported school-functioning outcomes among U.S. children with current autism spectrum disorder (ASD). Methods: We pooled 2022–2024 National Survey of Children’s Health data for children aged 6–17 years with current ASD. Current ADHD and LD formed four mutually exclusive groups: neither, ADHD only, LD only, and ADHD + LD. The primary outcome was mostly B/C grades or lower among letter-grade recipients. A secondary, hypothesis-generating outcome was school contact with the household about problems two or more times in the past 12 months among children with a valid response. Survey-weighted logistic models were age-stratified (6–11 and 12–17 years) and adjusted for chronological age, ASD severity, sex, race/ethnicity, survey year, current intellectual disability, caregiver education, and family poverty ratio. Six poverty-ratio implicates were combined using Rubin’s rules. Results: Of 4,713 children with current ASD, 3,294 received letter grades and 3,233 were included in extended grade models; 4,542 were included in extended school-contact models. Relative to neither condition, LD only and ADHD + LD were associated with higher odds of mostly B/C grades or lower in both age strata (adjusted odds ratios [aORs] 2.99–4.77 for ADHD + LD and 3.02–3.71 for LD only). ADHD only was associated with lower grades among adolescents (aOR 2.08, 95% confidence interval [CI] 1.30–3.31), but not younger children. ADHD only and ADHD + LD were associated with two or more school contacts in both age strata (aORs 2.01–2.51); LD only was not. Conclusions: Co-occurring ADHD and LD identified distinct parent-reported school-functioning profiles among U.S. children with current ASD: LD-related groups showed stronger associations with lower grades, whereas ADHD-related groups showed more frequent school–family problem communication. These associations are not causal and should not be interpreted as evidence about educational services or accommodations.