As with many childhood neuropsychiatric and emotional disorders, symptoms often overlap causing assessment, diagnostic and treatment planning difficulties. With children on the autistic spectrum, it is crucial to have a thorough evaluation process and multiple treatment options to avoid the enduring, lifelong complications these comorbid conditions bring with them. Research studies point to the clinically significant rate of comorbidity of Autism Spectrum Disorders (ASD) and Attention-Deficit/Hyperactivity Disorder (ADHD) symptoms, and also to a less positive prognosis in terms of: academic functioning; substance use/abuse; decreased self-esteem; increased difficulty in social interactions and long-term relationships; criminal and other antisocial behaviors; and difficulty maintaining independence as a result of trouble managing the demands of activities of daily living. This article will provide a greater understanding of how ASD and ADHD overlap, what diagnostic steps are necessary and how to best provide clinical treatment and academic support.
Autism Spectrum Disorders and ADHD fall into distinctly different diagnostic categories. The DSM-IV-TR states that ADHD cannot be diagnosed “if the symptoms of inattention and hyperactivity occur exclusively during the course of Pervasive Developmental Disorder.” However, studies support what is apparent when working with these children; there is a strong overlap and incidence of comorbidity with ASD and symptoms of ADHD. For example, when reading the histories of our students at the Newmark Schools, it is clear that quite often it was the symptoms of ADHD that brought these children to the attention of either the school system or mental health providers. Hyperactivity, impulse control difficulties, trouble maintaining attention (especially to topics that are perceived to be uninteresting), and problems with monitoring and self-regulating behavior are all hallmark symptoms of ADHD and difficult to manage in young children. It is these disruptive behaviors that frequently cause initial concern to parents and school staff.
As the treatment and prognosis for ADHD and ASD are quite different, it is crucial to have a skilled clinician/diagnostician sort out the overlapping symptoms. Early intervention is key for optimal treatment of ASD, so time lost on an ADHD misdiagnosis can be harmful and unsuccessful, leading to negative feedback to the child from his environment, especially in regard to his unique learning and social challenges. Long term exposure to this type of negative experience, whether it is in school, at home or in the social arena, can lead to self-esteem issues, acting out, learned helplessness, depression or anxiety. In my ten years of experience as a clinical Social Worker, a thorough Neuropsychological evaluation completed over time by a seasoned Neuropsychologist with input from the family (including a comprehensive family history), school staff, previous educational and psychological evaluations, and private therapists is often the most helpful way to distinguish the multiple neurological challenges often found in children with ASD and ADHD. The outcomes of medication treatment of ADHD in children who also carry a diagnosis of ASD are inconclusive at this time. However, a concern is that a larger focus and treatment on the ADHD component could create higher or unfair expectations of the child’s ability to function socially. Again, this could set up a pattern of exposure to negative feedback from the child’s environment. In addition, the learning and language challenges that both disorders present are different and require individualized academic interventions that are ideally created by an accurate understanding of the diagnostic picture.
A student with overlapping ASD and ADHD symptoms will require educational support in the following areas: managing the wide gaps between verbal abilities and nonverbal abilities; reading comprehension; memory retrieval; higher level Math and Language Arts skills that require inferencing and critical thinking skills; executive functions such as initiating work, organizing, maintaining sustained attention or managing shifting attention, regulating alertness and processing speed; and impulse control. It is crucial that the classroom setting is structured to meet these specific learning needs. A predictable, structured, consistent environment is so important to helping these students maintain focus and to minimize the anxiety that often accompanies these children to school. For example, at the Newmark Schools, a great deal of thought and planning goes into setting up the classrooms. Student schedules are posted on the wall, and any changes, such as pull-outs, assemblies, and field trips, are discussed and written on the board. Classroom sizes are kept small so students can effectively receive the individualized teaching they require. Specific classroom expectations are taught and reinforced on a daily basis. Not only are our students taught academics, they learn how to be in school successfully.
Social skills training is an important facet of education and clinical treatment for these students. Although the specifics of their social skill deficits may be somewhat different, what students with ASD and ADHD symptoms share is: problematic communication with peers; trouble maintaining focus on topics that are uninteresting to them; difficulty playing games that require turn taking; interpersonal boundary violations, failure to notice or understand the social cues that communicate the intentions and emotional reactions of others, and negative interpersonal interactions with their peers. High degrees of impulsivity in young people can lead to serious social issues such as substance use/abuse, conduct disordered behavior, driving difficulties, trouble maintaining employment and completing activities of daily living. When training these students, it is necessary to help them learn to improve their theory of mind deficits. In other words, they need to be able to take the perspective of others in social situations so that they may choose appropriate behaviors. Refusal skills and impulse control techniques are also essential.
As discussed, students with ASD often present with ADHD symptoms. Whether these symptoms are classified as a separate diagnosis, or they are different branches from the same tree, it is vital that an accurate, thorough diagnostic process takes place to identify the student’s individual needs, strengths and weaknesses so an effective clinical and educational plan is put into place. Students who receive the educational accommodations they need have a greater opportunity to experience academic success, thereby lowering the likelihood of anxiety, depression and feelings of hopelessness.
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