Your child has been diagnosed with ADHD. But those four letters alone don't seem to explain all of her struggles. You sometimes wonder if she's also on the autism spectrum.
Roughly two-thirds of kids with ADHD have at least one co-existing condition, and Autism Spectrum Disorders — ASD — are among the conditions that commonly occur with ADHD. Some studies suggest that up to half of kids with ASD also have ADHD.
Similarities and Differences
ADHD is marked by inattention, hyperactivity, and impulsivity. "It is primarily a disorder of self-regulation and executive function — skills that act as the 'brain manager' in everyday life," says Mark Bertin, M.D., a developmental behavioral pediatrician and the author of The Family ADHD Solution.
Autism Spectrum Disorders — a continuum of conditions that includes autism, Asperger's syndrome, and pervasive developmental disorder not otherwise specified (PDD-NOS) — are characterized by problems with social interactions, communication, and stereotyped (repetitive or ritualistic) behaviors.
"Children with autism do not intuitively understand some aspects of the social world," says Bertin. "Their social development, reflected in play and communication abilities, is delayed. They have specific symptoms, such as limited imaginative play or lack of gesture language," Bertin says.
While the primary components of ADHD and ASD are different, there is some overlap in symptoms. The trick to differentiating between the two is to determine which executive function or developmental building block is broken or missing, thereby causing the symptom.
"Children with ADHD may struggle socially, but with ADHD alone, markers of early social development, such as turn-taking play, gesture language, responding to names, and imaginative play, are usually intact. Traits like appropriate facial affect (the child's facial expression reflects his or her current emotional experience), humor, and empathy are also unaffected," says Bertin. Those traits, when lacking, are key indicators of autism.
"Kids with ADHD may not be able to stick to turn-taking play, but they understand it. They may not respond when called because of attention problems, but they are socially engaged and recognize their name and what it means," says Bertin.
Diagnosis: A Fluid, Ongoing Process
In order to obtain an accurate, complete diagnosis, Bertin suggests working with a professional who is familiar with both conditions. "A thorough evaluation aims to define a child's strengths and weaknesses," says Bertin. "Various test measures try to document ADHD symptoms, executive function, social and communication delays, anxiety, depression, and a host of other symptoms."
Tests alone are not enough. "Evaluating both ADHD and autism remains a clinical skill based on getting to know a child and seeking a comprehensive picture of his life in the real world, a global sense of a child's social and conversational abilities, as well as his play and daily living skills."
Diagnosis can be a fluid, ongoing process. It was for Clark, now 17, according to his mother, Pamela Fagan Hutchins, the author of the book The Clark Kent Chronicles: A Mother's Tale of Life with Her ADHD and Asperger's Son. Although Hutchins' earliest concerns about Clark were about autism-like symptoms, ADHD, not ASD, was Clark's first diagnosis.
"We first noticed autism-like symptoms when Clark was two, like running to the left in circles while waggling his left hand," Hutchins says. "It was when he started school that we noticed ADHD symptoms. He had a lot of trouble staying on task." Clark was diagnosed with ADHD in fourth grade, and with Asperger's syndrome about a year and a half later.
Although parents find it stressful not knowing the source of their child's challenges, there isn't always a definitive answer. "There are times when we need to put aside the diagnostic debate, in the short run, and focus instead on a plan to address whatever is going on with the child," says Bertin. "It can be helpful to think, 'What interventions would be most useful right now?' instead of waiting for complete certainty. In fact, the interventions themselves may help determine the most accurate diagnosis."
In Clark's case, treatment with ADHD medication helped to clarify his diagnosis. Some time after being diagnosed with ADHD, Clark started taking Concerta to treat his symptoms.
"It was clear, after he started Concerta, that the autism-like symptoms remained," says Bertin. "He still ran laps around the house, to the left, was insensitive to the feelings of others, was prone to making odd statements, and rattled off statistics." Clark, now 17, continues to take Concerta. "He doesn't love it," says Hutchins, "but he recognizes he can hold everything together better when he is on it, and that he is less anxious and less prone to outbursts." For ADHD, there is substantial evidence in favor of using medication. For autism alone, there are medications that may help with specific symptoms, such as obsessive behavior, but not the underlying condition.
Cassie Zupke's son is a case in point. Zupke runs a non-profit group, Open Doors Now, and is the author of We Said, They Said: 50 Things Parents and Teachers of Students with Autism Want Each Other to Know. Her son, James, 17, has mild autism, with a history of severe ADHD symptoms. "As a toddler, James had no fear," says Zupke. "He would take off and wouldn't stop if I called him. I'd have to physically catch him to get him to stop."
It was delayed speech that led Zupke to have James evaluated at age three. A neurologist diagnosed James with mild autism. James was in special education for preschool and kindergarten, then in a regular classroom for first grade. "It was a disaster," Zupke says. "He had severe meltdowns due to his sensory difficulties and poor social communication skills. His impulse control was still terrible. He ran when he got a chance and he got into everything — the teacher's desk, the janitor's closet." Zupke didn't like the idea of starting James on medication, but believed he was in danger. James's teacher reminded Zupke that taking medication wasn't a long-term commitment. They could take him off it if side effects were a problem. James started taking Adderall. "That decision probably saved his life," Zupke says. "Not only did it improve his impulse control dramatically, it also helped him pay attention in class."
Non-medical interventions are also used before children get a definitive diagnosis. "If a child has ongoing social challenges, for example, many of the interventions are similar — such as behavioral therapy to help develop skills," says Bertin.
After Clark was diagnosed with ADHD, he received counseling and assistance with organizational skills. When he was later identified as having Asperger's, the focus of treatment changed. "Treatment now involves helping Clark intellectually grasp the gaps between him and the rest of society — why hygiene matters, what kind of things he does that other people might find odd or insensitive," his mother says.
Several other interventions, including speech therapy, occupational therapy, educational interventions, and parent training, can be explored.
When Your Child Has Both
Dr. William Dodson, of the Dodson ADHD Center, in Greenwood Village, Colorado, is a psychiatrist who specializes in both ADHD and Asperger's. When a patient has both, Dodson takes a direct and honest approach: "The concepts I try to get across to patients and their parents is that ADHD and Asperger's are two separate and distinct conditions that happen to be found together much more frequently than would be expected by chance alone. The patients have won the negative genetic lottery and have two lifelong conditions that will affect every moment of their lives from here on out.
"Next, I try to assess if the person with ASD is motivated to do the work autism requires," Dodson explains. "Is he or she lonely? Does he or she miss human companionship? Without this longing, there is no motivation for the patient to come out of his inner world.
"For people with coexisting ADHD and ASD, treating the ADHD is a means to an end of treating the ASD," says Dodson. "The world is a classroom for people with ASD, and they have to be ready to observe and practice what they've learned."
Toward that end, medication to treat the ADHD is a must, Dodson says. "Few people with both ADHD and ASD succeed without medication to remove the additional obstacle of ADHD from their path."
KAY MARNER is a contributor to ADDitude magazine.