Autism Spectrum Disorder

Autism and ADHD: The Complete Playbook for Social Challenges

Understanding key differences between the social challenges of ADHD and autism is often the key to effective supports.

A boy with autism and ADHD covers his face with his hands.
Autism and ADHD

All parents want their children to get along, play, and interact well with their peers. Usu- ally, these social abilities develop intuitively. For children who struggle socially, the earlier the interventions start, the quicker kids catch up. Since both autism and ADHD affect relationships, finding the “why” behind social difficulties is a critical first step.

Autism and Social Development

Autism is a neurobiological disability 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 or are nonverbal. On the other end of the spectrum, some extroverted autistic children seek out others and get along with adults, but have a hard time getting along with children their age.

The ability to socialize and communicate begins in infancy and progresses as children move down developmental paths. While autism presents other behaviors, 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 markers.

SOCIAL CHALLENGES: Children with autism lag their peers in social skills. Social and behavioral signs could appear as early as six months old. Still, most medical professionals do not attempt a diagnosis until a child is at least 18 months old. Before the age of two, behaviors can change – some continue to emerge, and others disappear. For example, some children have delayed language skills, but when they do appear, they quickly catch up with their peers. It can also be confusing because some autistic children seem to develop within normal ranges, such as saying their first word at around 12-15 months and then suddenly regress, and at about 18 months to two years, they lose those skills and stop speaking.

At one year, 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, understand humor, and demonstrate empathy happen on their own during typical development, as does a desire to share interests, play with others, and to seek comfort when upset. Early signs of autism include:

  • Poor eye contact
  • Limited facial affect
  • Delays in imaginative play and self-help skills
  • Not engaging in social play
  • Doesn’t respond to parent’s smile or other facial expressions
  • Doesn’t look at objects parent is looking at or pointing to

[Is My Child on the Autism Spectrum? Take This Test To Find Out]

COMMUNICATION CHALLENGES: Most autistic children 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 may be challenged by the non-verbal aspects of communication. Their speaking might seem scripted, repetitive, or awkward. They may struggle to read facial expressions, understand tone and humor, and initiate or follow a conversation. Early signs include:

  • Doesn’t say any words by 16 months
  • Doesn’t point at objects
  • Doesn’t respond to name
  • Doesn’t seem to have a desire to communicate

BEHAVIOR CHALLENGES: Autism can manifest in other behaviors as well, including repetitive physical motions, special interests, or overly rigid thinking. Many autistic people have sensory challenges as well. However, behavioral symptoms alone are not enough for a diagnosis; a child must demonstrate social and communication differences as well. Some early signs include:

  • Rocks, spins, flaps hands
  • Doesn’t adjust well to changes in routine
  • Repeatedly engages in one or two activities
  • Plays with parts of toys instead of the whole toy

ADHD and the Social World

ADHD symptoms affect social interactions, cause communication differences, and can 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.

SOCIAL CHALLENGES: Children with ADHD usually understand what they’re supposed to do socially, but they can’t yet show it in everyday life. Being distracted, impulsive, and off-task affect interactions. Children with ADHD miss social cues they would otherwise understand — if only they noticed them.

[ADHD, Anxiety, and Autism: Your AAA Guidebook]

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. Unlike kids with autism, children with ADHD typically understand the pragmatic part of language, but 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 is disruptive. The chronic challenges with organization and planning related to executive functioning that occur with ADHD are not linked to autism. If a child with autism struggles with attention or executive functions, ADHD could also be present.

The key trait that distinguishes ADHD from autism is the ability to comprehend the social world intuitively. Delays and differences in this skill are the common thread among all diagnoses of autism, regardless of how it presents. Children with ADHD alone may also struggle socially, but their intuitive understanding is present.

Distinguishing & Treating Autism and ADHD

In many situations, the distinction between autism and ADHD 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 appropriate. Most social and communication interventions benefit children, whether they have ADHD or autism.

Ask your child’s school to evaluate their development, including language pragmatics, play, and self-help skills. Or seek a private, comprehensive evaluation outside of your school district. Having a secondary condition frequently occurs with both ADHD and autism, so screening for these disorders is essential.

Some common coexisting conditions with autism include:

For ADHD, common coexisting conditions include:

  • Disruptive behavior disorders, such as oppositional defiant disorder (ODD)
  • Depression
  • Bipolar disorder
  • Anxiety
  • Learning disorders
  • Sleep problems
  • Substance abuse

Interventions that improve symptoms of ADHD usually enhance the social abilities hindered by it. Comprehensive care for ADHD can include individual or parent-based behavioral therapy, social skills groups, medication, and other evidence-based treatment. (As a side note, misbehavior without remorse doesn’t always mean a child lacks empathy. Children with ADHD are often emotionally overwhelmed and immature and might not know how to express remorse when they’ve done something wrong.)

With autism, the foundation of intervention is behavioral therapy. One of the primary tools is applied behavioral analysis (ABA) therapy, which employs the Antecedent-Behavior-Consequence (ABC) theory to improve behaviors. Simplistically this can be explained as, A) you make a request, B) your child complies, and C) you reward the desired action. When you repeat this approach, you increase the positive behaviors and reduce potentially challenging ones.

Depending on need, children with autism may receive intensive behavioral services in a self-contained classroom, or may participate in mainstream, general education classrooms. All children with autism, however, can benefit from consistent behavioral therapy— one of the best predictors of outcome. Think of it this way: If you want your child to be a concert pianist or a professional athlete, they should practice each day. The same goes for social skills. As skills strengthen and grow, therapies need not be so intensive, but the interventions should continue until skills become fluent.

If a child has autism, they have communication challenges. However, it is challenging to measure language pragmatics through testing. Therefore, regardless of test scores, a child with autism benefits from language services. With ADHD, consider the possibility of language delays, and intervene when appropriate.

If progress slows, it might be helpful to look for co-existing conditions, such as the frequent 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 allows a child to focus, act less impulsively, access the skills they developed through intervention, and improve social skills.

Autism at School

Schools work toward placing children in mainstream classrooms whenever possible. Some kids prefer it, but others thrive in a more supportive setting. Keeping up with main- stream demands and typically developing peers can be stressful. Contained classrooms also allow for more intensive social work, which can make mainstream placement easier down the road.

Language and pragmatic delays often affect the necessary skills in school. Reading comprehension, making inferences, and writing are all affected by ADHD or autism. Home- work and in-class assignments frequently require supports or modifications.

While social plans often focus on the classroom, unstructured time (such as recess or gym) is often 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 and less understood, especially for children with autism. Children with autism are 63 percent more likely to be bullied than neurotypically developing children, according to the Autism Society. Children with ADHD are more likely to be bullied and somewhat more likely to bully others, according to Bullied children and children who bully others can have serious, lasting problems and are more likely to develop depression and anxiety.

ADHD and autism stress parents and strain marriages, especially when there are young children with ADHD in the household. Parents of children with ADHD under the age of eight are twice as likely to divorce as parents of children without ADHD. The good news is that this lessens as the child ages, with parents of children with ADHD over the age of eight having no difference in divorce rates than parents of children without ADHD. As far as raising a child with ASD, many parents report less marital satisfaction, according to the American Psychological Association (APA). However, parents who do stay together indicate their marriage is “highly satisfying.”

[Read This Next: Why Some Children on the Autism Spectrum Are Misdiagnosed with ADHD]

Mark Bertin, M.D., is a member of ADDitude’s ADHD Medical Review Panel.

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Autism and ADHD: Next Steps

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