The Clinicians’ Guide to Differential Diagnosis of ADHD is a clinical compendium from Medscape, MDEdge, and ADDitude designed to guide health care providers through the difficult, important decisions they face when evaluating pediatric and adult patients for ADHD and its comorbid conditions. This guided email course will cover the following topics:

• DECISION 1: How can I better understand ADHD, its causes, and its manifestations?
• DECISION 2: What do I need to understand about ADHD that is not represented in the DSM?
• DECISION 3: How can I avoid the barriers and biases that impair ADHD diagnosis for underserved populations?
• DECISION 4: How can I best consider psychiatric comorbidities when evaluating for ADHD?
• DECISION 5: How can I differentiate ADHD from the comorbidities most likely to present at school and/or work?
• DECISION 6: How can I best consider trauma and personality disorders through the lens of ADHD?
• DECISION 7: What diagnostic criteria and tests should I perform as part of a differential diagnosis for ADHD?

NOTE: This resource is for personal use only.

INATTENTIVE ADHD: What other conditions may cause symptoms of inattention typically associated with ADHD?

A: Several disorders can present with cognitive, attentional, and executive functioning deficits that resemble the presentation of ADHD. These include absence seizures and other types of seizures, Lyme disease, HIV infection, and encephalopathy…. | Keep reading on MDedge »

AUTISM AND ADHD DIAGNOSTIC CRITERIA: How are the diagnostic criteria for autism and ADHD in adults differentiated?

A: While research on adult autism and ADHD is scarce, clinicians largely agree on best practices in the evaluation and treatment of patients with both disorders… | Keep reading on ADDitude »

AUTISM VS ADHD:  What criteria must be present to merit an autism diagnosis vs. an ADHD diagnosis?

A: It’s critical for professionals to understand what constitutes a thorough ASD evaluation, and that a patient must demonstrate at least five of the seven criteria outlined in the DSM-5 in order to merit an autism diagnosis… | Keep reading on ADDitude »

TIC DISORDERS: What are the diagnostic criteria for the tic disorders that typically co-occur with ADHD, anxiety, and autism?

A: Tic disorders frequently co-occur with other conditions, like ADHD and anxiety, and can lead to problems in school and in social settings… | Keep reading on ADDitude »

ADHD VS LEARNING DISABILITIES: How is ADHD mistaken for comorbid learning disabilities like dyslexia, dyscalculia, and nonverbal learning disorder?

A: Learn how certain red flags, like an inability to communicate or difficulty remembering facts, might mean your child is struggling with a learning disability… | Keep reading on ADDitude »

HIGH IQ MASKING: How might a high IQ mask symptoms of ADHD and/or autism spectrum disorder?

A: Individuals with an above-average IQ and high-functioning autism, especially those with co-morbid ADHD, are less likely to be diagnosed and more likely to struggle in social spheres… | Keep reading on ADDitude »

Free Webinar: Diagnosing and Treating Comorbid Conditions in Children

Expert Webinar with Mark Bertin, M.D. | Listen now on ADDitude »

Free Webinar: How to Recognize and Address Dyscalculia

Expert Webinar with Daniel Ansari, Ph.D. | Listen now on ADDitude »

Free Webinar: Understanding Body-Focused Repetitive Behaviors with ADHD

Expert Webinar with Roberto Olivardia, Ph.D. | Listen now on ADDitude »

7-Week Guide to Differential Diagnosis of ADHD, from Medscape x ADDitude:

DECISION 1: How can I better understand ADHD, its causes, and its manifestations?
DECISION 2: What do I need to understand about ADHD that is not represented in the DSM?
DECISION 3: How can I avoid the barriers and biases that impair ADHD diagnosis for underserved populations?
DECISION 4: How can I best consider psychiatric comorbidities when evaluating for ADHD?
> DECISION 5: How can I differentiate ADHD from the comorbidities most likely to present at school and/or work?
DECISION 6: How can I best consider trauma and personality disorders through the lens of ADHD?
DECISION 7: What diagnostic criteria and tests should I perform as part of a differential diagnosis for ADHD?

ADHD is a stronger predictor of depression and anxiety in adults than is autism spectrum disorder, according to a new study that suggests patients with attention deficit hyperactive disorder are more likely that autistic patients to experience “internalizing problems” like mood disorder. The study, led by researchers at the University of Bath and published in Scientific Reports, underscores the importance of screening for comorbid conditions in adults with ADHD. ¹

As many as 80% of adults with ADHD have at least one co-existing psychiatric disorder.² According to a recent ADDitude survey of 1,500 readers, anxiety and depression are the two most common comorbid conditions diagnosed alongside ADHD in adults, with co-diagnosis rates of 72% and 70%, respectively.

Despite this high rate of comorbidity, researchers said, “ASD has often been prioritized over ADHD in both research on internalizing problems and clinical practice, particularly for anxiety.”³

Notably, approximately 28% of autistic individuals have ADHD, making it difficult to determine which disorder — ASD or ADHD — more significantly impacts mental health outcomes.² (The ADDitude reader survey found that 9% of adults with ADHD have ASD.)

Researchers aimed to clarify the associations between self-reported ASD traits and ADHD traits with mental health conditions like anxiety and depression using a general population sample, which included 504 adults from the U.K. (49% male, 51% female) aged 18–79 years.

While the results linked both ASD and ADHD with anxiety and depression, ADHD was a stronger statistical predictor of both mental-health conditions than was ASD. Further analysis confirmed that ADHD traits were associated with more severe anxiety and depression symptoms in adults than were ASD traits.

Researchers “speculate that response inhibition difficulties, which appear to be a cognitive feature of ADHD, may also potentially underpin the stronger association between ADHD traits and internalizing problems.”

To the researchers’ knowledge, this is the first study showing ADHD more strongly predicts mental health outcomes in adults than do other neurodevelopmental conditions, like ASD.

“Our finding that ADHD traits dominated ASD traits in predicting internalizing disorder symptoms could inform strategies to identify individuals who are at an increased risk of internalizing problems,” researchers said. “This might allow preventative measures and interventions to be implemented at an earlier age, which, for example, could focus on managing ADHD symptoms for a greater impact on ameliorating internalizing problems and improving mental wellbeing in adults.”

Recognizing complex ADHD (attention deficit plus one or more co-occurring conditions) is of “high clinical importance,” said Theresa Cerulli, M.D., of Beth Israel Deaconess Medical Center and the Neuroscience Education Institute, in the ADDitude webinar titled, “Complex ADHD: The New Approach to Understanding, Diagnosing, and Treating Comorbidities in Concert.”

“The presence of co-occurring conditions almost always muddles the diagnosis, treatment, and prognosis of ADHD,” she said. “ADHD and comorbidities may also influence the presentation and severity of one another, which can complicate the detection and treatment of symptoms, and impair overall quality of life.”

Researchers hope the study’s findings will encourage more research probing whether genetics help explain why ADHD traits are more strongly associated with internalizing problems than are autistic traits.

Sources

¹Hargitai, L.D., Livingston, L.A., Waldren, L.H. et al. (2023). Attention-Deficit Hyperactivity Disorder Traits Are a More Important Predictor of Internalising Problems Than Autistic Traits. Sci Rep. 13, 31. https://doi.org/10.1038/s41598-022-26350-4

²Katzman, M. A., Bilkey, T. S., Chokka, P. R., Fallu, A., & Klassen, L. J. (2017). Adult ADHD and Comorbid Disorders: Clinical Implications of a Dimensional Approach. BMC psychiatry. 17(1), 302. https://doi.org/10.1186/s12888-017-1463-3

³Bishop, D. V. M. (2010). Which Neurodevelopmental Disorders Get Researched and Why? PLoS ONE 5, e15112/

⁴Young, S. et al. (2021). Failure of Healthcare Provision for Attention-Deficit/Hyperactivity Disorder in the United Kingdom: A Consensus Statement. Front. Psychiatry 12, 324.

The brains of autistic individuals experience widespread molecular changes across the cerebral cortex. The most differential changes occur in the primary visual cortex, according to a recent study published in Nature that analyzed 11 cortical areas of the brain.¹ Most molecular profiling studies highlight changes limited to the frontal and temporal cortex.

To further understand the brain pathology of autism spectrum disorder (ASD), researchers performed RNA-sequencing analysis on 112 post-mortem samples. Consistent transcriptomic signatures of ASD were found across all cortical regions analyzed in the study. The greatest signal of expression came from the primary visual cortex (BA17).

When compared to control samples, ASD brains demonstrated significantly reduced gene expression between regions of the cerebral cortex. The primary visual cortex and parietal cortex (BA39/40), which function as primary sensory regions, exhibited significant patterns of attenuation. These results suggest cortical regions are more molecularly homogeneous in autistic individuals and pronounced in the posterior region of the brain.

“It is interesting to speculate that the substantial changes observed in primary sensory regions may relate to the widespread sensory processing differences in ASD, which are so pervasive that they have been included in the DSM-5 diagnostic criteria,” the researchers wrote.

An attenuation of transcriptomic regional identity (ARI) translates to a “reduction in the magnitude of gene expression” and was often used as a marker in the current study. By grouping ARI up- and down-regulated genes into co-expression modules, researchers identified consistent dysregulation that spanned cortical association regions in ASD samples. Neuronal changes (GeneM9), astrocyte reactivity (GeneM32), and blood-brain barrier disruption (GeneM24) were found to extend beyond the frontotemporal regions. ASD genetic risk variants (GeneM5 and IsoformM37) were also identified.

“The findings presented here substantially refine our understanding of ASD molecular pathology beyond the previously established ‘downregulated neuron’ and ‘upregulated glia/immune’ functional categories observed in frontal and temporal lobes.”

Of the 112 post-mortem samples, 49 were individuals with idiopathic ASD and 54 were matched neurotypical controls. A total of 725 brain samples were used. An ASD diagnosis was confirmed using the Autism Diagnostic Interview–Revised or based on clinical history. Samples were collected through the Harvard Brain Bank as part of the Autism Network Project, in addition to the University of Maryland Brain Banks.

Sources

¹Gandal, M.J., Haney, J.R., Wamsley, B. et al. Broad transcriptomic dysregulation occurs across the cerebral cortex in ASD. Nature (2022). https://doi.org/10.1038/s41586-022-05377-7

What Is PMDD?

Premenstrual Dysphoric Disorder (PMDD) is a hormonal health condition that causes clinically significant and impairing depression, anxiety, mood swings, and uncomfortable physical symptoms in the week leading up to menses, the onset of a period. PMDD symptoms improve following menses and are minimal, if not absent, in the weeks following. PMDD disproportionately affects people with autism and ADHD. Various medications can help control PMDD symptoms¹.

PMDD Symptoms

A patient meets the diagnostic criteria for PMDD if at least five of the following symptoms are met, including at least one from each category. The symptoms must cause distress or interfere with activities of daily living during most menstrual cycles over the preceding year:

• Category A:
  • Unstable and easily influenced mood
  • Irritability
  • Depressive or hopeless mood
  • Anxiety or tension
•  Category B:
  • Decreased interest in usual activities
  • Difficulty concentrating
  • Fatigue
  • Appetite changes
  • Sleep difficulties, either insomnia or hypersomnia
  • Feeling of overwhelm
  • Physical symptoms: breast tenderness, joint or muscle pain, a sensation of bloating, or weight gain²

PMDD vs PMS

While PMDD shares symptoms with premenstrual syndrome (PMS), PMDD is less common and more severe. PMS may occur in up to 48% of people who menstruate, while PMDD only occurs in 3 to 9%³⁴. In addition, PMDD symptoms interfere with daily functioning, and often require medication to resolve. People with PMDD are at risk for suicidality and suicide attempts, so diagnosis and treatment are vital⁵. Some people who do not meet the criteria for PMDD may have severe PMS and benefit from similar treatment.

[Read: PMS and ADHD: How the Menstrual Cycle Intensifies Symptoms]

Autism, ADHD, and PMDD

PMDD disproportionately affects people with ADHD and autism, with up to 92% of autistic women and 46% of women with ADHD experiencing PMDD, though estimates vary^{6 7}. There is no agreed-upon cause of PMDD, nor is it known why it affects certain populations more than others, though there are various theories. Possible explanations include:

• Genetics. PMDD is highly heritable, indicating that there is a genetic link.
• Hormone sensitivity. As people with ADHD have reduced dopamine levels across the brain, hormone fluctuations may be more likely to reduce dopamine to critically low levels, leading to more severe feelings of exhaustion, moodiness, and lack of motivation. In addition, estrogen may affect cellular pathways that have been implicated in ADHD⁸.
• Sensory sensitivity. Autistic people generally have greater sensory sensitivity, and therefore may be more likely to be negatively affected by menses-related symptoms.

Treating PMDD

PMDD has various treatments ranging from lifestyle changes to medication.

• Antidepressants. Some selective serotonin reuptake inhibitors (SSRIs) have been proven effective at reducing psychiatric PMDD symptoms.
• Contraceptives. Hormonal contraceptives regulate hormones and can alleviate both physical and psychiatric PMDD symptoms⁹.
• Lifestyle changes. Though most people with severe PMDD benefit from medication, lifestyle changes such as improved diet and exercise may improve some symptoms.

PMDD, Autism, and ADHD: Next Steps

• Read: ADHD and Menopause: How Changing Hormones Exacerbate ADHD Symptoms
• Download: Treating ADHD During Perimenopause and Menopause
• Listen: Why ADHD is Different for Women — Gender-Specific Symptoms & Treatments

Sources:

¹American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.), 171. https://doi.org/10.1176/appi.books.9780890425596
²American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.), 171, 172. https://doi.org/10.1176/appi.books.9780890425596
³ A, D. M., K, S., A, D., & Sattar, K. (2014). Epidemiology of Premenstrual Syndrome (PMS)-A Systematic Review and Meta-Analysis Study. Journal of clinical and diagnostic research : JCDR, 8(2), 106–109. https://doi.org/10.7860/JCDR/2014/8024.4021
⁴Thakrar, P.D., Bhukar, K., & Oswal, R.M. (2021). Premenstrual dysphoric disorder: Prevalence, quality of life and disability due to illness among medical and paramedical students.
⁵Osborn, E., Brooks, J., O’Brien, P.M.S. et al. Suicidality in women with Premenstrual Dysphoric Disorder: a systematic literature review. Arch Womens Ment Health 24, 173–184 (2021). https://doi.org/10.1007/s00737-020-01054-8
⁶Obaydi, H., & Puri, B. K. (2008). Prevalence of premenstrual syndrome in autism: a prospective observer-rated study. The Journal of international medical research, 36(2), 268–272. https://doi.org/10.1177/147323000803600208
⁷Dorani F, Bijlenga D, Beekman ATF, van Someren EJW, Kooij JJS. Prevalence of hormone-related mood disorder symptoms in women with ADHD. J Psychiatr Res. 2021 Jan;133:10-15. doi: 10.1016/j.jpsychires.2020.12.005. Epub 2020 Dec 3. PMID: 33302160.
⁸Dorani F, Bijlenga D, Beekman ATF, van Someren EJW, Kooij JJS. Prevalence of hormone-related mood disorder symptoms in women with ADHD. J Psychiatr Res. 2021 Jan;133:10-15. doi: 10.1016/j.jpsychires.2020.12.005. Epub 2020 Dec 3. PMID: 33302160.
⁹Hofmeister, S., & Bodden, S. (2016). Premenstrual Syndrome and Premenstrual Dysphoric Disorder. American family physician, 94(3), 236–240.

Autism evaluations can be nerve-racking. Preparing in advance by completing this checklist will calm your nerves and improve your chances of an accurate diagnosis.

Autism symptoms can mirror other disorders, like attention deficit hyperactivity disorder (ADHD) or learning differences, so it’s important to provide your clinician with detailed, specific information.

Use this ADDitude Patient Resource to check off symptoms, take notes, and jot down questions. Though not exhaustive, this checklist also provides guiding questions to consider before an evaluation.

Be sure to bring this ADDitude Patient Resource to your evaluation and save it for reference.

NOTE: This resource is for personal use only.

I also recognized early on that my boy was off-the-charts sensitive — physically, emotionally, intellectually, and sensorially. The world around him was always too much. Because of that, Owen had exacting standards, which required exacting parenting. Everything had to be exact to avoid a meltdown. I heated his towels in the dryer for exactly 5 minutes, or else he’d refuse to get out of the bath. I adjusted his shoes endlessly until they were exactly right. I read him the same books, rocked him in my arms in a pitch-black room, and quietly walked out of his room at 7 p.m. on the dot.

As Owen grew, his vast energy and wild behavior became his defining features. My mother, who has ADHD, accurately identified his brain type before he was officially diagnosed. “He’s one of us,” she declared.

I was confused. I saw so much of myself – the ultra-sensitivity, unbridled fits of rage, and a desire to control – in Owen. And I couldn’t have ADHD myself. Surely there was something else that explained our shared lens on the world.

The Truth Comes Out

Over time, as I tried to make sense of my son’s familiar quirks, I realized that I couldn’t hide from myself any longer. The truth was that I had always felt different. I was either too much, too little, or just wrong. At a young age, I had crafted an elaborate mask to hide my differences from the world, but the older I got, the more ill-fitting that mask became. I was also in denial over my differences. Like a child with a blanket over their head, I believed that my differences would disappear if I didn’t acknowledge them. And yet, I saw myself in Owen.

[Get This Free Download: The Guide to Autism in Adults]

Three days before my 38th birthday, I was diagnosed with autism. Sitting before the gentle, understanding gaze of the diagnosing psychologist, herself an autistic person with ADHD, I finally released all my truths. And as I talked, I kept going back to Owen. How watching him grow up brought up memories of my own childhood. How his rightness eased a lifelong pain that I was somehow wrong. I was being reborn through my loving, unconditional acceptance of my children.

New Ways of Seeing

An autistic mom to an ADHD son, I left my evaluation with a new perception of myself and my child. Like a true autist, I dove into the research to understand just how fundamentally overlapping ADHD and autism can be. Now I look at my son and can say: I see you. I see you because I know what you are experiencing from the inside out.

I see your sensory sensitivity that erupts into meltdowns over itchy hairs no one can see, pants that “jiggle,” and socks that shift imperceptibly in your shoes.

I see your shoddy memory that can lose key details, yet helps you recall specific, random facts.

[Read: Is It ADHD or Autism? Or Both?]

I see your discomfort with eye contact and your urge to wiggle, bounce, and tap your fingers. I see you stimming to calm down or find focus.

I see your giant passions that overshadow everything else in your life, and how you’ll lose yourself in thought, blind to the passage of time.

Make no mistake that ADHD and autism are distinct conditions. And yet, though we are not the same, we are deeply aligned. Until I learned to see my neurodivergent, autistic self, I lacked the key to unlock our sameness. Blind to my own truth, I could not see you fully. But now, I see you, my marvelously-wired child. I see you, and I love what I see.

Autistic Mom, ADHD Child: Next Steps

• Self-Test: Autism Spectrum Disorder in Adults
• Read: Autism vs. ADHD – A Parent’s Guide to Tricky Diagnoses
• Blog: “Building a Life That’s Right for Me – On Living with Autism and ADHD”

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Internalizing symptoms of autism spectrum disorder (ASD), including withdrawn and anxious behavior, were correlated with gastrointestinal (GI) problems like stomach pain and constipation, according to a new study of 621 children and adolescents under the age of 18 recently published in the Journal of Autism and Developmental Disorders. ¹

The exploratory, cross-sectional study analyzed parent reports of internalizing symptoms and GI problems — such as constipation, diarrhea, nausea, and stomach pain — in study participants with an ASD diagnosis who were enrolled in the Autism Care Network registry at the University of Mis­souri Thompson Center for Autism & Neurodevelopmental Disorders. Most participants were male and Caucasian (81%).

Less than half of the study participants (43%) had GI problems. Of those who did, 55% experienced one GI problem. Only 18 youth took medication specifically for GI problems, and this was almost exclusively an over-the-counter polyethylene glycol (MiraLAX®) option.

“GI medications may pro­vide temporary relief for some GI problems, but GI symptoms may persist if an underlying anxiety disorder is left untreated,” the authors wrote. “Similarly, GI problems may lead to anxiety or depression, and clini­cians and caregivers should be mindful to treat GI problems directly and not expect that all GI problems will resolve in response to clinical therapy.”

This is the first study to examine the relationship between internalizing symptoms and GI prob­lems in youth with ASD, to the authors’ knowledge. They recommended that longi­tudinal research is needed to better identify individuals with ASD at risk for anxiety-related GI problems or GI-related anxiety problems.

“A better understanding of the development and pro­gression of GI problems would offer improved recommen­dations for both prevention and treatment in ASD,” they wrote.

Sources

¹Dovgan, K., Gynegrowski, K. & Ferguson, B.J. (2022). Bidirectional relationship between internalizing symptoms and gastrointestinal problems in youth with Autism Spectrum Disorder.Journal of Autism Developmental Disorders.//doi.org/10.1007/s10803-022-05539-6

Like most cats, my cat will not follow orders to sit and stay — even when so directed by experts who have successfully trained thousands of dogs to do these things on command.

While people understand and accept that cats don’t do dog things, many continue to insist that my cat is a dog, and that my cat can do dog things. They refuse my explanations to the contrary.

People who think I have a dog may “helpfully suggest” compliance training methods, but I know from experience that most dog methods don’t work on my cat. I see and acknowledge that I have a cat (despite his often looking like a dog to others!). Treating him like a dog who can be compliant only results in significant frustration for all involved. Those who treat my cat like a cat early on end up with far more rewarding relationships.

I’ve learned to limit contact with people who insist I have a dog, and especially those who try to force dog methods on my cat while criticizing my cat methods. What has helped is finding people who have cats themselves and asking them what is effective with their cats. Even though cats have similar traits, it’s important to understand that each cat is unique, and to accept that many things that work well for other cats might not work for yours.

[Get This Free Download: 13-Step Guide to Raising a Child with ADHD]

Understanding Pathological Demand Avoidance

I’ve used the cat-dog metaphor to describe what it’s like to raise my son, who is gifted with ADHD and autistic PDA (Pathological Demand Avoidance). The latter is a term increasingly used to describe autistic children who exhibit extreme resistance to demands and requests, no matter how big or small, even if the demands are of obvious benefit and interest to them.

PDA means that, for my son, compliance is impossible. Cooperation, however, is very possible, and far more likely when you relinquish the idea of compliance.

I have accepted that I will never be able to force my child to do anything. Instead, I focus on guiding him toward cooperation. It took years for him to trust that we really weren’t going to try to force him to do things. Now that the trust is established, we treat each other mostly respectfully as equal adults (he’s 12).

We creatively problem-solve for undesirable things that must be done, explaining the logic and science behind solutions. (For example, he hates getting shots, but he cooperates because we explain that they protect him from disease. We have even negotiated a complex shot protocol with several steps, each of which we carefully carry out to his specifications.)

[Related Reading: Why Is My Child So Angry and Defiant? An Overview of Oppositional Defiant Disorder]

Required tasks must be backed by science and logic, and we must give him time to understand and decide to cooperate, even with all the evidence laid out. Sudden demands will nearly always be met with refusal, so we try never to make them. But this is hard, and requires a total change in all thinking about parenting. We try to see ourselves as coaches now rather than parents.

Working with his school to develop and implement a detailed IEP that works for him is difficult, ongoing work. Many school staff remain in denial that children like mine exist, despite the clear evidence in front of them. Sometimes, staff insist on ridiculously inappropriate methods that always fail, leaving them baffled, but still unwilling to try other methods.

A rare handful of the best educators have recognized that we, as parents, know our child best and have actually implemented proven “cat” methods with positive, rewarding results. Still others identify my son as a unicorn — a mythical animal never before seen — and recognize that he does, indeed, exist and need different things for his survival.

I’m deeply grateful for the online groups of parents and adult “cats” that have helped us figure out what kind of a cat we have and how to treat him properly.

Cats simply can’t be trained as if they were dogs. Kids and adults with PDA are cats in a dog world. Still, the vast majority are instead treated “normally” — which can lead to serious consequences. Many parents of children with PDA endure years of parenting classes and professionals’ disbelief about what they’re actually facing. The handful who get an early diagnosis, proper treatment, and accurate guidance (which involves changing the environment and interactions with all people) have the chance at a successful life.

What metaphors help you explain your life to others?

Pathological Demand Avoidance: Next Steps

• Free Download: 10 Rules for Parents of Defiant Kids with ADHD
• Self-Test: Could My Child Have Oppositional Defiant Disorder (ODD)?
• Self-Test: Is My Child Autistic? Signs of Autism Spectrum Disorder
• Read: Is My Child with ADHD on the Autism Spectrum?

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

It’s equally challenging for an autistic woman to be officially diagnosed with autism spectrum disorder (ASD).

Why? The reasons are similar: Women are socialized to mask their autistic traits, and even when they don’t succeed in hiding the signs, autism is perceived by many as an exclusively male condition. The older an autistic woman gets without a formal diagnosis, the more likely clinicians are to be skeptical when she seeks an autism evaluation. These women often hear, as I once did, that they seem “too normal” or have had too much success to be autistic.

These sentiments are borne out of misinformation, which can affect the most qualified psychologists and scientists when it comes to women on the spectrum. The presentation of autism in adult women varies greatly from that of the young boys clinicians typically see. And since the current DSM-5 diagnostic criteria are based on studies of mostly boys and men, it is common for women with the same neurological variations to slip through the cracks.

Autism and ADHD in Women: Overview

ADHD vs. Autism: Similarities and Differences

Autistic women and women with ADHD can share the following traits:

• executive functioning challenges
• sensory processing differences
• social difficulty
• higher rates of learning disorders and comorbid conditions
• “stimming,” which refers to movements, or occasionally noises, that a person makes in order to soothe their nervous system. These often-repetitive actions self-stimulate the senses in a predictable way, and many people who stim do so instinctively or subconsciously to manage stress.

[Take This Self-Test: Autism in Adults]

ADHD is diagnosed when a patient has symptoms of inattentiveness, hyperactivity, and/or impulsivity. For an ASD diagnosis, however, the patient must have clinically significant difficulty with social interaction or communication, and unusually restricted or repetitive patterns of behavior or interests. In fact, many autistic people have a “special interest” — a topic or subject that they are heavily invested in and are more knowledgeable about than most.

Autistic individuals are also more likely to have sensory processing disorder, discomfort making/maintaining eye contact, and hyper-logical methods of thinking, with a tendency to be extremely literal.

How Do I Know if I’m Autistic?

If you are an adult female and suspect you may be on the autism spectrum, you are not alone. it’s important to evaluate your behaviors in light of your other diagnoses. For example, if you already have an ADHD diagnosis, your executive functioning difficulties can be attributed to that diagnosis. Thus, determining whether you could be autistic as well requires a closer look at behaviors related to social communication, need for routine, sensory differences, and logical/literal thinking.

Autism traits may also be masked to some degree by your gender socialization, as many women typically learn to hide autistic traits that would otherwise prompt a diagnostic evaluation.

[Read: What Does Autism Spectrum Disorder Look Like in Adults?]

Take social camouflaging – or when someone on the spectrum intentionally or unintentionally mimics other people’s social behaviors to cover up their autism traits. Autistic people often use this coping strategy after experiencing negative social interactions (making the camouflage a reaction, not an instinct). Social camouflage is distinct from the traditional development of social skills because the individual has no intuitive understanding of why the social norm exists.

Autism in Women: Diagnostic Considerations

If you are seeking a diagnosis, prepare yourself to face skepticism — possibly even from your clinician. Unfortunately, anyone without a nuanced understanding of the spectrum may be doubtful of a seemingly “normal” adult female requesting an evaluation.

That’s why it is essential to work with clinicians who have experience diagnosing autism in adults. It is especially helpful if they have knowledge of any existing diagnoses, like ADHD, and have previously evaluated or counseled other women. While the research on autism in women is sparse, first-hand experience can equip these clinicians to accurately assess the possibility of autism.

The good news is that experienced, knowledgeable psychologists and psychiatrists do exist, and one of those individuals will take your concerns and questions seriously. The clinician will likely evaluate you using a combination of diagnostic surveys and interviews with you and someone who knew you as a child. Generally, this is a parent, but it could be any person who observed you consistently before age four or five. After your doctor gathers this information, it will inform your diagnosis.

You can decide to be evaluated at any point in your life. Receiving my diagnosis, at age 19, improved my relationships with family and friends. I didn’t become a different person, but afterward I could articulate my ways of thinking and perception.

Autism in Women: Accommodations and Treatment

There is no universally prescribed medication for people on the autism spectrum. Prescription treatments more often address a comorbid condition, such as anxiety, mood disorders, ADHD, or seizures.

However, almost all autistic people are encouraged to try cognitive behavioral therapy (CBT). This talk-based counseling can help autistic adults identify and process the ways they experience the world differently. A therapist can help an autistic patient develop an understanding of social rules or learn how to advocate for themselves in a work setting.

It is important to note that an adult with autism can determine which new skills they want to learn and which personal differences they want to keep or change. By contrast, many young children placed in Applied Behavior Analysis (ABA) therapy are trained to behave “less autistic” while still too young to parse out how being on the spectrum affects their sense of self.

Accommodations for people with autism include creating sensory-friendly spaces, establishing clearly defined social rules, and holding neurodiversity-based autism education in the community. In a work-place, there might be the provision of a job mentor or the flexibility to work from home.

Autism in Women: Dispelling Myths

The medical establishment has been slow to develop an accurate profile of autism in women with low support needs. (Instead of calling an autistic person “high-functioning” or “low-functioning,” it is more accurate and respectful to describe them as having high, medium, or low support needs. Someone with high support needs likely requires very frequent assistance completing everyday tasks and is unlikely to be able to live independently. Someone with low support needs — what was once called Asperger’s syndrome — likely requires fewer accommodations.)

Though our knowledge of autism, especially in women, is increasing, it has been slow to make its way into the mainstream. It’s why common myths like the following persist, and why we must work to raise awareness:

1. Is ADHD on the autism spectrum? No. there is a clear distinction between the two. ADHD and autism are separate neurological differences that can both exist in the same person. Scientists have suggested that the two conditions have a biological connection, which causes a high rate of comorbidity.

2. Autistic people feel little or no empathy. This is categorically untrue. Some autistic people report feeling their emotions more intensely than most. This stereotype seems more connected to the social nuance used to convey emotion/empathy than to the actual experience of it.

3. You can immediately tell if someone is autistic. There is no way to know whether someone is autistic just by looking at — or talking to — them. Still, many people can’t accept the fact that someone who isn’t obviously disabled could be on the spectrum. In fact, I often hear people say to me, “You don’t look autistic!”

4. People who are extroverted can’t be on the autism spectrum. It’s easy to see why this myth has arisen, but it isn’t true! Someone can have difficulty with social communication and still enjoy interacting with other people. Being naturally extroverted does not preclude autism.

Even though we have a long way to go toward neurodiversity empowerment, I encourage potentially autistic women to explore the possibility. As our ranks grow, perhaps the world’s understanding of us will grow as well.

Autism in Women with ADHD: Next Steps

• Free eBook: The Guide to Autism in Adults
• Read: ADHD and Adult Autism – Symptoms, Diagnosis & Interventions for Both
• Q&A: How Can I Get Evaluated for Autism as an Adult?
• Find: Specialists or Clinics Near You

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To successfully address picky eating and related food issues, parents must first recognize possible underlying factors so they can seek the appropriate professional help and treatments.

Picky Eating and Feeding Difficulties: Common Causes and Related Conditions

SPD and Eating Problems

While not an official medical diagnosis, sensory processing disorder is tied to immature neurological development and characterized by faulty processing of sensory information in the brain. With SPD, the brain can misread, under-read, or be overly sensitive to sensory input. Typical symptoms include heightened or deadened sensitivity to sound and light; extreme sensitivity to clothing and fabrics; misreading social cues; and inflexibility. The stress caused by sensory dysregulation can affect attention, behavior, and mood.

Eating is a key SPD problem area, as all aspects of food – from preparation to ingestion – involve reading and organizing data from all of the senses. SPD-related eating issues include:

• Appetite: Sensory overload stimulates the release of stress hormones. Mild to moderate stress increases desire for starches and sweets but chronic or high levels of stress reduces the appetite and interferes with digestion.
• Hunger signals. Young children often miss hunger cues when they are playing. They want to stay at the park for just 10 more minutes when it is obvious that without an immediate influx of food, the afternoon will be shot. When elevated to SPD, children rarely notice they are hungry as the hunger signal is lost amidst a mass of misread and disorganized sensory data. When they do ask for food, they may refuse items that are not to their exact specifications. A small percentage misread satiety, chronically feel hunger and ask continuously for food.
• Food sensory characteristics. How the brain makes sense of smell, taste, temperature, color, texture, and more impacts the eating experience. Because food has so many sensory characteristics, there are many areas where children can get thrown off.

[Read: What’s Causing My Child’s Sensory Integration Problems?]

The most common symptom of SPD is psychological inflexibility. Individuals with SPD attempt to limit sensory discomfort by controlling their external environment in the areas where they are overloaded. With eating, this rigidity can mean only one brand of acceptable chicken nuggets (not the homemade ones),  the same foods repetitively, strict rules about foods not touching,  and random demands about and rejection of core favorites. (e.h. “The apple is bad because of a tiny brown spot,” or suddenly, noodles are on the “don’t like” list.)

Autism

Many people on the autism spectrum identify as having strong or diminished responses to sensory information. If delays in motor planning and oral motor issues are also present, in addition to the sensory aspects of food and eating, children on the spectrum may have trouble chewing and swallowing some foods.

ADHD

ADHD symptoms and behaviors may also contribute to problems with food.

• Impulse control and self-regulation problems can cause overeating and make it difficult to notice and respond to satiety.
• Poor executive functioning can derail meal planning and preparation in adolescents and young adults who prepare their own foods.
• Distractibility and inattention can lead to missed hunger signals or even forgetting to eat.
• Stimulant medications can dull the appetite.
• Mood stabilizers can increase appetite.

[Read: 9 Nutrition Tricks for Picky Eaters]

ARFID

Also known as “extreme picky eating,” ARFID is described in the DSM-5, the guide clinicians use to diagnose health conditions, as an eating or feeding disturbance that can include:

• Lack of interest in eating or food
• Avoiding foods based on sensory characteristics
• Avoiding foods out of concern over aversive experiences like choking or vomiting

These disturbances result in failure to meet appropriate nutritional and/or energy needs, as manifested by one of more of the following:

• Significant weight loss or faltering growth and development
• Significant nutritional deficiency
• Dependence on enteral feeding or oral nutritional supplements
• Marked interference with psychosocial functioning

To merit a diagnosis, the disturbance must not be better explained by a lack of available food or a culturally sanctioned practice, and it must not be associated with body image concerns or a concurrent medical condition/treatment (like chemotherapy).

Children with ARFID may experience certain foods, such as vegetables and fruit, as intensely unpalatable and take great care to avoid them.¹ They may be fearful of trying new foods and rely on highly processed, energy-dense foods for sustenance.¹ Common feeding advice like hiding and disguising vegetables in food, relying on your child to “give in” to avoid starving, or repeating requests to eat does not work with children who have ARFID. This disorder is associated with extreme nutritional and health deficiencies.

Research on the prevalence of ARFID is limited, but findings from studies on patients with eating disorders estimate ARFID rates between 5%² and 23%.³ Notably, ARFID appears to be most common in young males and more strongly associated with co-occurring conditions than are other eating disorders. One study on young patients with ARFID, for example, found that 33% had a mood disorder; 72% had anxiety; and 13% were diagnosed with autism spectrum disorder.³

In my view, the extreme eating behaviors in ARFID are sensory processing disorder symptoms. (Maybe one manifestation of SPD is quietly in the DSM-5 after all.) If you see your child in this description, get professional help. Parents of those with ARFID are usually as frustrated and discouraged as the children they are trying to help.

Picky Eating and Feeding Difficulties: Solutions

Parents can take small daily steps to better fulfill a child’s nutritional needs and reduce stress around meals. Serious feeding difficulties and eating problems warrant professional help.  Occupational therapists, speech therapists, nutritionists, GI specialists, and psychologists are several of the professionals who can help evaluate and treat youngsters that resist your best efforts.

1. Assess the Severity of Sensory and/or Behavioral Challenges

These symptoms may point to challenges that require therapeutic intervention:

• Only eating one type of texture (e.g. crunchy, mushy or foods that require limited chewing, like crackers)
• Avoiding food at certain temperatures (e.g. will only eat cold food)
• Exaggerated reactions to new food experiences. (e.g. vomiting and/or lengthy, explosive temper tantrums)
• Extreme sensitivity to smells
• Brand loyalty, only eating products made by a certain company. (Processed foods may have more sugar and salt to boost flavor, which can exacerbate feeding problems)
• Refusing to eat foods if small changes are made, including in the packaging or presentation
• Refusing to eat or excessive fussing over unpreferred foods on the same plate or table when eating
• Takes 45 minutes or more to finish a meal
• Is losing weight over several months (and is not overweight)

Physical and biological problems can also contribute to feeding difficulties, including:

• Reflux; esophagitis
• Allergies and aversive food reactions
• Poor digestion and gut issues including excessive gas, bloat, constipation, diarrhea, and abdominal pain
• Underdeveloped oral motor skills. Symptoms include frequent gagging, pocketing food, takes forever to get through a meal, difficulty transitioning from baby food to solid food, drooling.
• Chronic nasal congestion.

2. Keep Nutritious Foods at Home

Try not to keep any foods at home that you do not want your child to eat. That includes certain snack foods, which are designed to be extremely appealing to the senses, but often offer paltry nutritional value. (It’s easier to remove these foods than to introduce new ones.) Consider saving leftover lunch or dinner for snacks instead.

It is also better for your child to eat the same healthy meals over and over again than to try to vary meals by filling in with snack foods or different versions of white bread (such as muffins, pancakes, bagels, noodles, rolls and crackers). Find a few good foods that your child enjoys and lean into them.

Rather than make drastic changes at once, focus on one meal or time of day, like breakfast, and start on a weekend so the initial change doesn’t interfere with school and other activities. Breakfast is a good meal to tackle, as most kids are home and this meal sets the tone for the day. These tips can help make the most of the day’s first meal:

• Limit sugary, processed items like cereal, frozen waffles, breakfast pastries, and the like. These foods fuel sudden spikes and drops in your child’s energy levels through the school day. If your child also has ADHD and takes medication for it, it’s important to serve breakfast before the medicine kicks in, as stimulants can dampen appetite.
• Focus on protein. Protein provides long-lasting energy and fullness. A protein-rich breakfast can include eggs, smoothies, paleo waffles, salmon, hummus, beans and nut butters.
• Think outside of the box. Breakfast doesn’t have to look a certain way. Leftover dinner can be an excellent meal to start the day.

3. Consider Supplements

Nutritional deficiency is a common outcome of restricted, picky eating. These deficiencies can impact appetite and mood and, in the severe cases, exact long-term consequences on development and functioning. Vitamins, minerals, and other supplements can close the gap on these deficiencies while you work with your child on eating a more varied diet.

Among the body’s many required nutrients, zinc appears to have the greatest impact on feeding difficulties, as poor appetite is a direct symptom of zinc deficiency. Insufficient zinc intake is also associated with altered taste and smell, which can impact hunger signals and how your child perceives food. Zinc is found in meat, nuts, oysters, crab, lobster, and legumes. “White” foods like milk and rice are not rich in zinc.

4. Stay Calm and Carry On

Family collaboration can play an important role in addressing picky eating and reducing stress around new foods. Even if only one person in the family has feeding difficulties, ensure that everyone is following the same plan for creating and maintaining a positive, cooperative environment at home.

How to Introduce New Foods

• Concentrate on one food at a time to reduce overwhelm. Give your child a limited set of new food options from which to choose. Consider keeping a kid-friendly food chart in the kitchen. If your child won’t choose, pick one for them.
• Introduce one bit of the same food for at least two weeks. Repetition is a sure way to turn a “new” food into a familiar one. Sensory processing issues means new things are bad things, because new means more potentially overwhelming data to read and sort.
• Do not surprise your child – make sure they know what’s coming.
• Offer choices that are similar to foods they already eat. If your child likes French fries, consider introducing sweet potato fries. If they like crunchy foods, consider freeze-dried fruits and vegetables. If they like salty and savory flavors, try preparing foods with this taste in mind.
• Set up natural consequences using when:then to increase buy-in and avoid the perception of punishment. Say, “When you finish this carrot, then you can go back to your video game.” As opposed to, “if you don’t eat your carrot, you can’t play your game.”

No matter the plan or your child’s challenges, stay calm in the process. Losing your temper can cause your child to do the same (especially if they are sensory sensitive) and create undue stress around an already tough situation:

• Start with the assumption that you and your child will be successful
• Explain expectations in simple terms
• It’s OK if your child fusses, gags, and complains about a new food in the beginning
• Give yourself time-outs when needed
• Always keep feedback positive

Picky Eating Problems: Next Steps

• Download: Best Vitamins and Supplements for People with ADHD
• Symptom Test: Sensory Processing Disorder in Children
• Read: The Parent’s Guide to Mealtime with Picky Eaters

The content for this article was derived from the ADDitude Expert Webinar Got a Picky Eater? How to Solve Unhealthy Food Challenges in Children with SPD and ADHD [podcast episode #355] with Kelly Dorfman, M.S., LND, which was broadcast live on May 18, 2021.

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Sources

¹ Brigham, K. S., Manzo, L. D., Eddy, K. T., & Thomas, J. J. (2018). Evaluation and Treatment of Avoidant/Restrictive Food Intake Disorder (ARFID) in Adolescents. Current pediatrics reports, 6(2), 107–113. https://doi.org/10.1007/s40124-018-0162-y

² Norris, M. L., Robinson, A., Obeid, N., Harrison, M., Spettigue, W., & Henderson, K. (2014). Exploring avoidant/restrictive food intake disorder in eating disordered patients: a descriptive study. The International journal of eating disorders, 47(5), 495–499. https://doi.org/10.1002/eat.22217

³ Nicely, T. A., Lane-Loney, S., Masciulli, E., Hollenbeak, C. S., & Ornstein, R. M. (2014). Prevalence and characteristics of avoidant/restrictive food intake disorder in a cohort of young patients in day treatment for eating disorders. Journal of eating disorders, 2(1), 21. https://doi.org/10.1186/s40337-014-0021-3

While autism and ADHD are life-long conditions for most people, research has focused almost exclusively on children because that is when symptoms first emerge. This emphasis on childhood leaves clinicians to extrapolate interventions and supports for adults. What we do know is that co-occurring autism and ADHD in adults carries unique implications and considerations that don’t exist for either condition on its own. In short, autistic who exhibit more ADHD symptoms also experience greater functional impairments.

Despite anemic research beyond childhood, there is a growing clinical consensus regarding approaches to evaluation, treatment, and support for autistic adults with a co-occurring ADHD diagnosis.

Adult Autism: Evaluation and Diagnosis

Autism Symptoms and Criteria

Autism is broadly characterized by persistent challenges in social communication and social interaction, as well as the presence of repetitive behaviors. Full diagnostic criteria for autism spectrum disorder are outlined in the Diagnostic and Statistical Manual of Mental Disorder (DSM-5). During an evaluation, clinicians look for significant challenges in the following domains to determine whether an adult is on the autism spectrum. These behaviors must be present during development, and they must cause significant impairment in functioning to warrant a diagnosis:

[Read: What Does Autism Spectrum Disorder Look Like in Adults?]

1. Deficits in Social Communication and Social Interaction

Social emotional reciprocity refers to the back-and-forth interaction that takes place with another person during social interactions and conversations. Naturally, clinicians evaluate different behaviors in adults and children.

Non-verbal communication is another way of saying body language. Clinicians evaluate the use and integration of gestures, facial expression, and other body parts in communication. Lack of eye contact while communicating is one common behavior observed in individuals on the autism spectrum. Clinicians also evaluate a person’s ability to understand non-verbal communication in others.

Developing, maintaining, and understanding relationships. Clinicians often evaluate understanding of how relationships work, differences among types of relationships (friendships, acquaintances, romantic, and family, including how the patient adjusts behavior to suit context and their level of interest in close relationships.

2. Repetitive Behaviors

Clinicians look for restrictive, repetitive patterns of behavior, interests, or activities that are maintained across the following four categories; only two categories need to be present for a diagnosis:

• Stereotypes or repetitive motor movements, use or objects, or speech. Some examples include hand flapping, odd or unusual finger movements, and pacing; lining up toys rather than playing with them (when younger); a narrow repertoire for starting or maintaining conversations or using idiosyncratic phrasing.
• Insistence on sameness. Autistic adults may want things to be exactly the same day after day (from taking the same route to eating the same food, for example), and will experience difficulty if routines are changed. They often experience difficulties with unexpected or rapid transitions, suffer extreme distress at small changes, and exhibit rigid thinking patterns.
• Interests. Autistic adults can be highly fixated on interests that can span any subject or theme. Their interest and intensity level are far greater than they would be for other people, to the point that they may interfere with other activities and functioning. These interests must last for at least 3 months.
• Sensory reactivity. Many individuals on the autism spectrum identify as having unusually strong or diminished responses to sensory information. Certain sensory inputs that would be “everyday sounds” for many people may be particularly bothersome or fascinating to people on the spectrum. Autistic adults may want to avoid certain sensory experiences because they find them aversive, or they may seek experiences they find particularly appealing. Some individuals may also have an apparent “absence” of reaction (e.g. indifference to pain and temperature).

[Read: Commonly Missed Signs of Autism in Adults]

Clinicians should also specify co-occurring conditions in the following three domains:

• intellectual disability (present in about 30 percent of autistic people)
• language impairment (can be receptive, expressive, or mixed expressive/receptive)
• association with a known medical, genetic, or environmental factor (e.g., roughly 25% to 50% of people with Fragile X syndrome, particularly males, will also meet criteria for autism)

At the time of diagnosis, clinicians should also acknowledge an appropriate and helpful level of support for each patient. Many individuals who receive an ASD diagnosis in adulthood tend to fall under Level One, i.e. “requires support,” as they have developed and utilized coping mechanisms over time that allowed them to move through childhood and adulthood with enough success to not seek or be referred for an evaluation. Without supports, however, impairments may be noticeable.

Adult Autism Assessment

An autism diagnosis at any age typically follows a referral. Some factors that usually prompt a referral in adulthood include difficulty with work and relationships; “failure to launch”; and, especially in the age of social media, learning about autism and seeing personal similarities.

There is no single test that identifies autism in adulthood or at any age. There are, however, gold standard screening and diagnostic tools that clinicians use to evaluate patients for autism:

• Detailed developmental histories help clinicians understand how a patient’s symptoms unfolded over time, and whether signs were present early in life or driven by major life changes.
• Autism screening tools, like the Social Communication Questionnaire and the Autism Spectrum Quotient, carry some pros and cons. Some autistic individuals report that the questions do not accurately capture their experience.
• The Autism Diagnostic Observation Schedule-2 (ADOS) includes a clinical interview and observation of the patient’s non-verbal communication and other social skills, as well as observation of repetitive behaviors.
• An Adaptive Behavior Assessment focuses on skills needed in everyday life to achieve independence. It covers three major domains: conceptual skills (e.g. communication, cognitive tasks), daily living skills (e.g. hygiene, household management), and socialization (e.g. relationships, coping skills, hobbies). For many autistic adults, these skills can lag compared to their general intelligence, and may be a bigger barrier to living independently than any autism symptom.
• Psychiatric assessments help ascertain an autism diagnosis by ruling out other conditions that could explain symptoms. Common diagnostic differentials for autism include social anxiety, generalized anxiety disorder, ADHD, and obsessive compulsive disorder (OCD).

Adult Autism and ADHD

Though little research exists on autism and ADHD in adults, some studies estimate that the disorders coexist at rates between 20% and 37%.^{1 2}

ADHD is characterized by symptoms of inattention, hyperactivity, and/or impulsivity – different from the social communication symptoms and restricted behaviors associated with autism.

Still, some ADHD symptoms relate to the diagnostic criteria for autism. Not listening when spoken to directly, for example, is indicative of inattention, a common ADHD symptom. But given the strong social demands embedded in rating a person on this symptom, it could also indicate autism. If an adult is not making eye contact during a conversation, then it may give the appearance of ‘not listening when spoken to directly’. Differential psychiatric assessments as well as other diagnostic tools can help clinicians determine whether this symptom stems from distractibility (which indicates ADHD) or from deficits in social-emotional reciprocity and nonverbal communication (which indicate autism).

It’s critical for clinicians to consider whether an ADHD symptom appears in non-social situations. If a patient reports feeling distracted when working alone and without social demands, that may indicate ADHD more than autism. Distractions should be further analyzed – is the patient daydreaming, or are they being pulled into a sound they hear that may be bothering them? The latter may indicate sensory sensitivity related to autism.

ADHD in Autistic Adults: Outcomes

Greater functional impairments exist in autistic adults as more ADHD symptoms are present. That’s according to a recent study involving 724 autistic adults who were asked about the frequency and severity of behaviors associated with autism and ADHD, their quality of life, and other aspects of living. In all cases, comorbid ADHD explained measurable variances in adaptive behaviors compared to controls.³

Adult Autism and ADHD: Treatment and Interventions

There are currently no studies available on the use of ADHD treatments with adults with both ADHD and autism diagnoses. Most treatment recommendations for adults have been adapted from research on autistic children.

Clinicians, however, generally agree on the supports and therapeutic interventions that matter most to autistic adults with ADHD — and which ones increase independence and improve quality of life, as highlighted in a recent paper authored by ASD and ADHD researchers. The recommendations cover pharmacological and non-pharmacological interventions, as well as behavioral and environmental approaches in work and higher education. They include but are not limited to:

Non-pharmacological Interventions

• Cognitive behavioral therapy (CBT), cognitive remediation therapy, and similar approaches; specific adaptations may be necessary for individuals with social communication and intellectual limitations. Adults may respond better to group-delivered treatments than do children.
• Therapies focusing on executive function; Flexible Futures is an upcoming program that targets these skills in autistic adults with ADHD (a children’s version, Unstuck and On Target, is available and has research supporting its efficacy).
• Psychoeducation helps to support many patients and families.

Educational/Vocational Supports

• Identifying realistic career goals
• Seeking volunteer opportunities to learn about the work environment
• Using supports for completing applications and job interviews
  Identifying and seeking adjustments and accommodations at work or school (Standardized accommodations like extended time on tests, for example, may not be suitable for autistic adults with an ADHD diagnosis, who may benefit more from a mid-point break)
• Coaching to support long-term goals
• Using strategies to aid concentration and reduce anxiety
• Adopting assistive technology devices
• Making use of organizational supports (peer systems, skills training)

Pharmacological Interventions

Pharmacological treatments for co-occurring ASD and ADHD in adults do not differ significantly from the treatments used with each disorder individually. Stimulant and non-stimulant medications are commonly prescribed to treat ADHD. Though there are no FDA-approved pharmacological medications to address core symptoms of ASD, antipsychotics like risperidone and aripiprazole are often used to address anger and irritability. Behavioral and environmental interventions, however, are more common and appropriate first-line approaches for targeting core autism behaviors.

Still, expert consensus is that prescribers should start on low doses and move slowly through treatment, as adults with both conditions may be more treatment resistant and sensitive to medication. The goals and targets for medications (as with any intervention) should also be clarified at the outset along with measures of effectiveness.

Other best practices:

• Adults with ASD and ADHD diagnoses may be unable to swallow medications in pill/tablet form due to sensory issues and/or physical difficulties. Clinicians should consider liquid formulations and alternative preparations.
• Some adults may have difficulty describing their thoughts, feelings, and sensations, which could impact patient feedback on treatments. Clinicians should use visual tools, including mood scales and drawings, to aid with reporting.

The content for this article was derived from the ADDitude Expert Webinar “Do I Have Autism? ADHD? Both? An Adult’s Guide to Diagnosis and Treatment”  [ADDitude ADHD Experts Podcast Episode #354] with Benjamin E. Yerys, Ph.D., which was broadcast live on May 11, 2021.

Adult Autism and ADHD: Next Steps

• Self-Test: Autism Spectrum Disorder in Adults
• Download: The Guide to Autism in Adults
• Read: Is It Just ADHD? Comorbidities That Unlock an Accurate Mental Health Diagnosis

The Clinicians’ Guide to Differential Diagnosis of ADHD from Medscape and ADDitude

• How can I better understand ADHD, its causes, and its manifestations?
• What do I need to understand about ADHD that is not fully represented in the DSM?
• How can I avoid the barriers and biases that impair ADHD diagnosis for underserved populations?
• How can I best consider psychiatric comorbidities when evaluating a patient for ADHD?
• How can I differentiate ADHD from the comorbidities most likely to present at school and/or work?
  • What other conditions may cause symptoms of inattention typically associated with ADHD?
  • What criteria must be present to merit an autism diagnosis vs. an ADHD diagnosis?
  • What are the diagnostic criteria for the tic disorders that typically co-occur with ADHD, anxiety, and autism?
  • How is ADHD mistaken for comorbid learning disabilities like dyslexia, dyscalculia, and nonverbal learning disorder?
  • How might a high IQ mask symptoms of ADHD and/or autism spectrum disorder?
  • Free Webinar: Diagnosing and Treating Comorbid Conditions in Children
  • Free Webinar: How to Recognize and Address Dyscalculia
  • Free Webinar: Understanding Body-Focused Repetitive Behaviors with ADHD
• How can I best consider trauma and personality disorders through the lens of ADHD?
• What diagnostic criteria and tests are recommended for performing a differential diagnosis of ADHD?

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Sources

¹ Hollingdale J., Woodhouse E., Young S, Fridman A, Mandy W. (2019) Autistic spectrum disorder symptoms in children and adolescents with attention deficit/hyperactivity disorder: a meta-analytical review. Psychol Med, BMC Psychiatry. 19:404. https://doi.org/10.1186/s12888-019-2284-3

² Lai, M. C., Lombardo, M. V., & Baron-Cohen, S. (2014). Autism. Lancet (London, England), 383(9920), 896–910. https://doi.org/10.1016/S0140-6736(13)61539-1

³ Young, S., Hollingdale, J., Absoud, M. et al. (May 2020). Guidance for identification and treatment of individuals with attention deficit/hyperactivity disorder and autism spectrum disorder based upon expert consensus. BMC Medicine 18, 146. https://doi.org/10.1186/s12916-020-01585-y

When very smart kids or adults chronically underperform in school, work, or social interactions, it is often assumed that they are bored, lazy, or uncaring. Parents, teachers, and employers of those who are obviously bright but floundering may not recognize two challenges that often co-occur: ADHD and autism, including signs formerly associated with Asperger syndrome.

Asperger syndrome was removed from the DSM in 2013 in favor of the umbrella diagnosis of autism spectrum disorder, which many researchers and clinicians see as a mistake. In this webinar, Thomas E. Brown, Ph.D. will describe his work with high-IQ students and adults who did very well in their earlier school years, but who had increasing difficulty academically and socially as they navigated middle school, high school, college, and/or employment.

Despite their strong intelligence, some of these individuals struggled not only in managing their schoolwork, but also in understanding and managing emotions and their interactions with other people. They had both unrecognized ADHD and unrecognized signs of autism formerly classified as Asperger syndrome.

In this webinar you will learn to:

• Recognize ADHD impairments in those who are very bright, but not hyperactive
• Understand autism as a chronic problem in reading others’ emotions and figuring out social interactions
• Recognize the differences between Asperger syndrome and classic autism
• Learn about didactic psychotherapy in treating those with Asperger syndrome

Watch the Video Replay

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Download or Stream the Podcast Audio

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Read More on ADHD in Smart Kids and Adults with ASD

Why High-IQ Patients with Autism or ADHD Face Elevated Risk

Is My Child with ADHD on the Autism Spectrum?

Obtain a Certificate of Attendance

If you attended the live webinar on May 26, 2021, watched the video replay, or listened to the podcast, you may purchase a certificate of attendance option (cost: $10). Note: ADDitude does not offer CEU credits. Click here to purchase the certificate of attendance option »

Meet the Expert Speaker:

Thomas E. Brown, Ph.D., is a Yale-trained clinical psychologist who specializes in assessment and treatment of ADHD and related problems in children, adolescents, and adults. After serving on the clinical faculty of Yale Medical School for 25 years he has relocated to Manhattan Beach, California, to open his new Brown Clinic for Attention and Related Disorders. He is also an adjunct clinical associate professor of psychiatry and behavioral sciences at the Keck School of Medicine of the University of Southern California.

Dr. Brown has published 30 peer-reviewed scientific journal articles and five books on ADHD. His Smart but Stuck: Emotions in Teens and Adults with ADHD was published in 2014. His newest book is Outside the Box: Rethinking ADD/ADHD in Children and Adults: A Practical Guide. You can reach him at: BrownADHDclinic.com. |See expert’s full bio »

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Listener Testimonials

“This webinar was extremely insightful and it helped me gain a better perspective on neurodiversity.”

“I enjoyed Dr. Brown’s combination of fact and empathy. His use of the real-life experiences of children was a big help in understanding the effect of Asperger’s on their education and social experiences.”

“This was exactly what I needed. I have a better understanding of the help my high-achieving 11 year old daughter needs now!”

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ADHD is one of the most common co-occurring conditions for individuals on the autism spectrum. Adults with ADHD and ASD diagnoses experience a poorer quality of life and less developed communication and social skills than do those with ASD alone. Surprisingly, almost all that we know about the intersection of ADHD and ASD comes from studies with children.

What about adults? Does ADHD persist into adulthood for adults on the autism spectrum? How do clinicians tease apart these diagnoses? Are adults diagnosed with ASD affected by ADHD in the same ways as children? What can we do to support adults who have both diagnoses?

Stakeholders on the autism spectrum, their families, and clinicians are in search of information on diagnosis, treatment, and outcomes for individuals affected by both ADHD and ASD. Here, Benjamin Yerys, Ph.D., will discuss the latest research about co-occurring ADHD and autism, the best strategies for diagnosis, the most effective treatments, and future directions to support adults diagnosed with autism and ADHD.

In this webinar, you will learn:

• Best practices for making an autism spectrum disorder diagnosis in adulthood taking into consideration common co-occurring conditions (i.e. ADHD, anxiety)
• How ADHD affects individuals on the autism spectrum
• Currently available treatments for individuals with ADHD and ASD diagnoses
• Long-term outcomes for adults with ADHD and ASD diagnoses

Watch the Video Replay

Enter your email address in the box above labeled “Video Replay + Slide Access” to watch the video replay (closed captions available) and download the slide presentation.

Download or Stream the Podcast Audio

Click the play button below to listen to this episode directly in your browser, click the symbol to download to listen later, or open in your podcasts app: Apple Podcasts; Google Podcasts; Stitcher; Spotify; iHeartRADIO.

Read More on Autism in Adults

ADHD and Adult Autism: Symptoms, Diagnosis & Interventions for Both

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Obtain a Certificate of Attendance

If you attended the live webinar on May 11, 2021, watched the video replay, or listened to the podcast, you may purchase a certificate of attendance option (cost: $10). Note: ADDitude does not offer CEU credits. Click here to purchase the certificate of attendance option »

Meet the Expert Speaker:

Benjamin E. Yerys, Ph.D., is a licensed psychologist in the Center for Autism Research (CAR) at the Children’s Hospital of Philadelphia and an Assistant Professor in the Department of Psychiatry at the Perelman School of Medicine, University of Pennsylvania. Dr. Yerys leads CAR’s research on the brain basis and treatment of attention and executive function. Dr. Yerys research has been funded by the National Institute of Mental Health and private foundations (Philadelphia Foundation, McMorris Foundation). Dr. Yerys conducts evaluations for children and adolescents suspected of an ASD at the Outpatient Clinic of the Department of Child and Adolescent Psychiatry and Behavioral Sciences. |See expert’s full bio »

Webinar Sponsor

The sponsor of this week’s ADDitude webinar is….

Accentrate® is a dietary supplement specifically formulated to address the nutritional deficiencies known to be associated with ADHD. Accentrate® contains the omega-3 fatty acids EPA and DHA in the phospholipid form, which has been shown to be the preferred carrier to the brain over fish oils. The Brain Ready Nutrition provided in Accentrate® works 24/7 to help the body even while sleeping. www.accentrate.com

ADDitude thanks our sponsors for supporting our webinars. Sponsorship has no influence on speaker selection or webinar content.

Listener Testimonials

“Excellent instructor: pleasant, interesting, packed with information. I would love to have a longer training from him.”

“This webinar was so eye-opening and helpful! Thank you very much for your clear, informative presentation.”

“Excellent topic. I work with ASD teens and most are diagnosed with ADHD as well. More of this please!”

Follow ADDitude’s full ADHD Experts Podcast in your podcasts app:
Apple Podcasts | Google Podcasts | Spotify | Google Play | Pocket Casts | iHeartRADIO | Stitcher

Use this free 42-page download as a guide to understanding the distinctions and similarities between ASD and ADHD in children. Access case studies illustrating the ADHD-autism link and learn:

• How to receive an accurate diagnosis for your child
• Strategies to overcoming your child’s social challenges
• How to determine if your child with ADHD is on the autism spectrum
• Effective supports for children with autism and ADHD
• The relationship between autism, ADHD, and anxiety in children

NOTE: This resource is for personal use only.