Is It ADHD or Autism? Or Both?
Could your child with ADHD also have autism spectrum disorder (ASD)? Or was the original diagnosis possibly incorrect? Here are several case studies that demonstrate how to get a comprehensive evaluation and an accurate diagnosis — and how to best support your child.
What’s the Relationship Between ADHD and Autism?
Roughly two-thirds of children with ADHD have at least one comorbid condition, and autism is among those that commonly occur with ADHD. Some studies suggest that nearly half of autistic children also have ADHD.1
What’s the Difference Between ADHD and Autism?
The most notable symptoms of ADHD include 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 (#CommissionsEarned).
Autism typically includes problems with social interactions, communication, and repetitive or ritualistic behaviors.
“Children with autism do not intuitively understand some aspects of the social world,” Bertin says. They have specific behaviors, such as limited imaginative play or lack of gesture language. They often find it challenging to manage social interactions and emotions.
While the primary components of ADHD and ASD are different, some overlap exists be- tween the two. The trick to differentiating between them is to determine the reason behind the behavior. For example, both can cause social challenges. For children with ADHD, the root causes may include inattention and inability to organize their thoughts, or impulsivity.
For autistic children, the reasons are often different — such as not understanding nonverbal communication or delays in language skills.
“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,” Bertin says. Those traits, when lacking, are critical 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,” Bertin says.
How Are ADHD and Autism Diagnosed?
To obtain an accurate, complete diagnosis, Bertin suggests working with a profession- al who is familiar with both conditions. “A thorough evaluation aims to define a child’s strengths and weaknesses,” he says. “Various test measures try to document ADHD symptoms, executive function, social and communication delays, anxiety, mood disorders, and a host of other symptoms.”
But 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 their life in the real world, a global sense of a child’s social and conversational abilities, as well as their 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 received an
ADHD diagnosis in fourth grade, and Asperger’s syndrome (no longer a discrete diagno- sis) about a year and a half later.
Although parents might find it stressful not knowing the source of their child’s challeng- es, 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 go- ing on with the child,” Bertin says. “It can be helpful to think, ‘What interventions would be most useful right now?’ instead of waiting for complete certainty on the diagnosis. 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. 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,” Bertin says. “He still ran laps around the house, to the left, was insensitive to the feelings of oth- ers, 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 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, some medicines may help with specific facets, such as obsessive behavior, but there is not medication approved for treatment of 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 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.”
James’ delayed speech led Zupke to have him assessed at age three. A neurologist diag- nosed him with autism spectrum disorder. 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. His doctor 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, but it also helped him pay attention in class.”
Beyond Meds: Treating ADD and ASD
Before or after a child gets a definitive diagnosis, behavioral therapies can help. “If a child has ongoing social challenges, for example, many of the interventions are similar — such as behavioral therapy to help develop skills,” Bertin says.
After Clark’s ADHD diagnosis, he received counseling and assistance with organizational skills. Later, when he was identified as autistic, 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 ADHD and Autism
Dr. William Dodson is a psychiatrist who spent his career specializing in both ADHD and autism. When a patient has both, Dodson takes a direct and honest approach: “The concept I try to get across to patients and their parents is that ADHD and autism 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 two life-long conditions that will affect every moment of their lives.”
“For people with co-existing ADHD and ASD, treating the ADHD is a means to an end,” 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 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.”
Is It ADHD Or Autism? Next Steps
- Read: Autism vs. ADHD: A Parent’s Guide to Tricky Diagnoses
- Learn: What Does Autism Spectrum Disorder Look Like In Children?
- Understand: Why Some Children on the Autism Spectrum Are Misdiagnosed with ADHD
Get ADDitude’s free 42-page guide to the autism-ADHD link in children.
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1 Lydia Furman, MD, Children with Both Autism Spectrum Disorder and Attention Deficit Disorder- New Insights (March, 2018) https://www.aappublications.org/news/2018/03/30/children-with-both-autism- spectrum-disorder-and-attention-deficit-disorder-new-insights-pediatrics-3-30-18
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