Autism and ADHD: The Complete Playbook for Social Challenges
Understanding the difference between the social challenges of ADHD and autism may be the key to proper treatment.
All parents want their children to get along, play, and interact well with their peers. Usually, these social abilities develop intuitively. For children who struggle socially, the earlier the interventions start, the earlier the kids catch up. Since both ADHD and autism affect relationships, finding the “why” behind social difficulties is the first step in figuring out what to do.
Autism and Social Development
Autism is a disorder in which social skills do not develop as expected. More severe impairment affects children who barely interact with others around them, and have limited language. On the other end of the spectrum, there are fairly extroverted children who seek out others and get along with adults, but have a hard time getting along with other children. (The latest version of the DSM groups all autistic spectrum disorders under one diagnosis. Asperger’s syndrome is now called “high-functioning autism.”)
The ability to socialize and communicate progresses from infancy along predictable developmental paths. While autism presents other symptoms, what distinguishes it from ADHD and other developmental disorders are differences in social development. Autism is diagnosed by looking for social delays, along with communication differences and behavioral symptoms.
> SOCIAL CHALLENGES: Children with autism lag behind socially — according to some studies, starting as early as six weeks of age. By one year, without being taught, most children respond to their name, engage in back-and-forth interaction, and understand gesture language, such as pointing and waving. The ability to interpret facial expressions, humor, and empathy happen on their own during typical development, as does a desire to share interests, play with others, and to seek comfort when upset. The other red flags of autism are poor eye contact, limited facial affect, and delays in imaginative play and self-help skills. If your child’s development does not meet these milestones, see a professional for evaluation.
> COMMUNICATION CHALLENGES: Most children with autism have early delays in language, and speak later than their peers. A few never speak at all. Others develop large vocabularies and the ability to form sentences, but they lack the ability to understand the non-verbal aspects of communication. Their speaking may seem scripted, repetitive, or awkward. They can’t read facial expression, understand tone and humor, and initiate and follow a conversation.
> BEHAVIOR CHALLENGES: Autism is also characterized by quirks in behavior, including repetitive physical motions, such as hand flapping or spinning in place, obsessive interests, or overly rigid thinking. Many sufferers have sensory challenges as well. However, a diagnosis of autism is made based on social and communication differences, not on behavioral symptoms alone.
ADHD and the Social World
ADHD symptoms affect social interactions, cause communication differences, and may lead to behavior challenges. The best one-line description of ADHD comes from Russell Barkley, Ph.D., who said, “ADHD is not a disorder of not knowing what to do, it is a disorder of not doing what you know.” This concept also helps distinguish ADHD from autism: Children with ADHD typically know the social rules; they just don’t know how to follow them yet.
> SOCIAL CHALLENGES: Children with ADHD usually understand what they’re supposed to do socially, but they don’t yet have the ability to show it in everyday life. Being distracted, impulsive, and off-task affect interactions directly. ADHD kids miss social cues they would otherwise understand — if only they noticed them.
> COMMUNICATION CHALLENGES: One often-overlooked aspect of ADHD is the relatively high risk of language delays. Yet even in the absence of an actual delay, ADHD undermines communication. Children lose track of details, are overly talkative, interrupt, stray off topic, and have a hard time keeping track of information. They may speak and process information more slowly than peers, which is not a measure of intelligence but of pacing. Unlike kids with autism, children with ADHD typically understand the pragmatic part of language; ADHD itself gets in the way.
> BEHAVIOR CHALLENGES: Behavioral concerns frequently, but not always, occur with ADHD. They involve not following social rules, such as acting impulsively, being overly silly, or disrupting situations in other ways. When peers prefer sticking to one activity, a short attention span may be disruptive on its own. The chronic challenges with organization and planning related to executive function that occur with ADHD have not been as clearly linked to autism alone. If a child with autism struggles a lot with attention or executive function, ADHD may also be present.
The key trait that distinguishes ADHD from autism is the ability to intuitively comprehend the social world. Delays in this skill are the common thread among all diagnoses of autism, regardless of severity. Children with ADHD alone may also struggle socially, but their intuitive understanding is present.
There are many situations where the distinction between ADHD and autism is not black and white. As challenging as it is for a professional to know whether ADHD, autism, or both are present, receiving appropriate intervention matters most for a child. Often, developing a plan helps sort out whether either diagnosis – or neither – is most appropriate. Most social and communication interventions benefit children whether they have ADHD or autism.
Ask your child’s school to evaluate his development, including language pragmatics, play, and self-help skills. Or seek a comprehensive evaluation outside of your school district. Having a secondary condition is common with both ADHD and autism, so screening for these disorders is important.
Any intervention that improves the symptoms of ADHD will also improve the social abilities hindered by it. Comprehensive care for ADHD may mean individual- or parent-based behavioral therapy, social skills groups, medication, or other evidence-based treatment. (As a side note, misbehavior without seeming remorseful doesn’t always mean a child lacks empathy. Children with ADHD are often emotionally overwhelmed and immature, and don’t know how to express remorse or react when they’ve done something wrong.)
With autism, the foundation of intervention is behavioral therapy. Behavioral programs do not only address disruptive behaviors. Interventions such as applied behavioral analysis (ABA) therapy are the primary tools for teaching social skills.
Children with severe autism usually receive intensive behavioral services, frequently in a self-contained classroom. With milder symptoms, children move into mainstream, inclusion-style classrooms, and behavioral interventions become minimal. One of the best predictors of outcome is when children receive ongoing behavioral therapy, regardless of severity of symptoms. Think of it this way: If you want your child to be a concert pianist or a professional athlete, he or she should practice a lot each day. The same goes for social skills. As symptoms become milder, therapies need not be so intensive, but the interventions should continue until skills become fluent.
By definition, if a child has autism, he has communication challenges. However, it is difficult to measure language pragmatics through testing. Therefore, regardless of test scores, a child with autism will benefit from language services until proven unnecessary by his own social success. With ADHD, think about the possibility of language delays, and intervene when appropriate.
If progress slows, a professional should look for coexisting conditions, such as the common comorbidity of autism and ADHD. When children have compromised social and language abilities, adding ADHD to the mix makes it much harder for them to succeed. Addressing ADHD may allow a child to focus, act less impulsively, and access the skills he has developed through intervention, and goes a long way toward getting along with peers.
Autism at School
Mainstream classroom placement is always the goal, but it’s not always best for everyone. Some kids prefer it, but others thrive in a more supportive setting. Keeping up with mainstream demands and typically developing peers can be stressful. Contained classrooms also allow for more intensive social work, which may make mainstream placement easier down the road.
Language and pragmatic delays often affect basic skills in school. Reading comprehension, making inferences, and writing are all affected by ADHD or autism. Homework and in-class assignments will frequently require supports or modifications.
While social plans often focus on the classroom, unstructured time (such as recess or gym) is often most challenging for kids with autism and ADHD. In class, the rules are usually “sit quietly and raise your hand.” On the playground, social mores are more fluid. Children may be subject to bullying, so they may require social interventions during down time.
ADHD and autism stress parents and strain marriages. Find help when needed from family members or friends. Parents may talk over their challenges with a professional or join a support group. Think about practicing mindfulness, a proven intervention for managing stress when life gets to be too much.