I recently met with eight-year-old James in my office. Adorable, bright, and energetic, he had been diagnosed with ADHD several years ago. I suspected something else, though, was on the mind of his parents, both of whom came along with him. When I opened the exam room door and saw Mom and Dad sitting there with their child, I knew they were worried.

James’s parents were indeed worried. They had worked hard to help him understand his ADD. They had been passionate advocates for him at school, working with his teachers to develop and implement strategies that enabled him to learn. Then, two weeks earlier, James’s teacher suggested that he showed signs of autism, a complex neurobiological disorder that affects boys four times as often as girls. She noticed that he seemed lonely, without friends. Left to his own devices, he played obsessively with his Game Boy. She called James’s parents. They were alarmed.

This scenario is fairly common in a pediatric primary-care office. Most pediatricians work with children who have ADD, and most follow several children with an autistic spectrum disorder (ASD)—usually called Pervasive Developmental Disorders (PDD) by physicians. PDD is a group of three conditions—autistic disorder, Asperger syndrome, and Pervasive Development Disorder Not Otherwise Specified—characterized by problems with communicating and relating to others and a need to follow rigid routines and to engage in repetitive behaviors or language. Some pediatricians are knowledgeable enough to diagnose PDD, but the majority need the support of a specialist, especially if a child has been diagnosed with ADD. I sent James and his parents to an autism specialist.

To his parents’ relief, James did not meet the criteria for autism. He had a hard time socializing, but this was due to his ADHD. The experience persuaded his parents to start him on ADHD medication. It worked wonders: James did better in school and made friends. Life at home was easier, too!

It’s ADD—Not So Fast!

The overlapping symptoms of ADHD and ASD have confused many families. When a child can’t sit still for homework or a meal, or stay put in class, when he fidgets or talks too much and too insistently, most parents and educators, tutors, and coaches think, “This kid must have ADD!”

The first explanation most doctors arrive at is ADD. The condition is familiar, it’s been around for a long time, and there are effective strategies to manage it. It is important to remember, however, that almost any psychological or developmental disorder of childhood can look like ADD, with or without the “H.” Kids under stress, due to learning disabilities, anxiety, depression, or sensory integration problems, may exhibit the same symptoms. It takes a skillful evaluation to tease out explanations for the behaviors.

ABCs of Diagnosis

Diagnosing ASD requires an evaluation by a developmental pediatrician, child psychiatrist, or pediatric neurologist. Most insurance companies, and virtually all public schools, require a written evaluation by a specialist before they provide, or pay for, the services autistic children need.

Because autism cannot be diagnosed by medical testing, screening and diagnosis involve interviews, observation, and evaluations. Even when a professional ventures an opinion, he will often hedge by saying, “Well, he is quirky and has some typical behaviors, and they are somewhat consistent with a diagnosis of a Pervasive Developmental Disorder.” This kind of talk is frustrating to the parents and the child, but it’s sometimes unavoidable. Another evaluation in a year often clarifies things, and sometimes a child doesn’t need a diagnosis, as long as he is getting the help he needs.

Managing the Symptoms

Usually a child who has been diagnosed with ASD is not given an additional diagnosis of ADHD. This is not to say, however, that children on the autism spectrum don’t benefit from the interventions that help children with ADHD without autism. Most parents and pediatricians prefer to start with non-medical therapies to manage symptoms that hinder social and academic success and lead to a turbulent home life. The mainstay of treatment for ASD is behavioral therapy, which reinforces wanted behaviors and discourages unwanted ones. Posting lists, rules, and schedules to keep ASD kids organized can be helpful.

One mother I work with has placed dry-erase boards all over her house to remind her son about what to bring to school and which days he needs to stay after school. She tells him how much time to spend on each subject when doing homework. He checks off boxes when he finishes each assignment, which gives him a sense of accomplishment.

Physical exercise is a good intervention for children with ADHD and children on the spectrum, all of whom seem to have boundless energy. Channeling that energy into a physical activity, such as swimming or karate—which doesn’t require a lot of interaction with other kids—allows them to burn it off without the pressures of socializing.

Medication Options

If behavioral and educational interventions aren’t sufficient, medication may help. Because children with ASD have unpredictable reactions to stimulants, the most common class of medicines used for children with ADD, they are less likely to be prescribed for autistic children. Most pediatricians, and virtually all child psychiatrists, feel competent in prescribing stimulants for ADD. A pediatrician may refer a child with ASD to a psychiatrist or a psycho-pharmacologist as the dose is increased.

A class of medicines called atypical neuroleptics are often effective treatments for motor restlessness, repetitive behaviors, and sleep disturbance in children with autism. These include aripiprazole (Abilify), quetiapine fumarate (Seroquel), and risperidone (Risperdal, the only one of the three that is FDA-approved for treating behaviors associated with autism). A good response to an atypical neuroleptic may eliminate the need for a stimulant.

Every child with autism will benefit from the support of a developmental and behavioral pediatrician or a child psychiatrist with training in the autism spectrum. Having a specialist who understands what it’s like to live with an active autistic child (is there any other kind?) is a bonus for parents as well.