ASD or ADHD or AUDHD?

[biglipslittlehips]

As many characteristics are shared between ASD and ADHD, how do you (or assessors) determine whether someone has ADHD or ASD or both. I'm talking about when it's not obvious. Things like anxiety, need for routine and difficulty with time demands. These could be either.

I've always held the view that if there are no apparent issues in reading social cues then it can't be ASD even if there are many characteristics of ASD that are shared with ADHD. But how do they really know? Or if someone has been diagnosed as ASD and presents as being overwhelmed with too much stimulation, how do they know it's not that the person has ADHD as well as ASD?

There are very clear differences in the diagnostic criteria - none of it has much to do with anxiety or being overstimulated.

there are indeed criteria that involve sensory stimulation

1 Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).

There are multiple criteria, I'm not sure if you plucked this one out just to prove anoint but there are very large differences in the diagnostic criteria for autism and ADHD. I shall leave it there though as I don't feel this could be a positive discussion.

I'm interested in this too. DS had an autism assessment at age 11. At the end we asked about possible ADHD. (We had thought he was going to be assessed for both, not knowing that they were separate waiting lists.) We were told that all of the things that we were seeing as ADHD symptoms could be covered by his autism diagnosis.

For example the constant fidgeting and movement could be swimming/sensory seeking. The excessive interrupting and talking could be lack of understanding of social norms, and so on.

A few years later it was so absolutely obvious that he has ADHD that he kept bringing it up himself and we ended up paying for a private assessment.

The report from the autism assessment was interesting and he definitely identifies as autistic but the ADHD report so accurately described his difficulties that I suspect had he had that assessment first, his autism would have been missed.

I think it would be useful if people could be assessed for both at the same time where appropriate.

I was assessed for both simultaneously (thanks Bupa). Well, three hours of tests for one and then three hours for the other.

I agree with PP that some behaviours could be either really - is it fidgeting, or stimming, or sensory seeking, or an anxiety response, when a child chews their jumper sleeve for example?

I can’t speak for the diagnostic process for kids but the one I went through seemed designed to look past behaviours to underlying brain differences. One of the ADHD ones involved doing a boring repetitive task for 20 minutes and having my task accuracy as well as focus (eye movements) tracked, one of the ASD ones involved looking at a picture book and explaining the story.

Diagnosed with both, to no one’s surprise.

There's a difference between traits that people with different ND conditions often show, and the diagnostic criteria for being diagnosed with those conditions. There is a lot said online about 'this is an ADHD thing' and 'this is an autism thing' which is just completely made up to be honest (and it's why people often go for 'everyone's a little bit autistic').

I don't think there are actually many overlapping diagnostic criteria between autism and ADHD. Of the ones you've mentioned:

• anxiety - not part of the diagnostic criteria for either autism or ADHD
• need for routine - one fairly small part of the diagnostic criteria for autism (wouldn't be enough on its own and not a requirement for a diagnosis). Not part of the diagnostic criteria for ADHD.
• difficulty with time demands - not sure what you mean by this one but I don't think this is on the diagnostic criteria for either ADHD or autism.

For a clinician who knows what they're doing, it would be hard to get the two conditions confused. It's why I find it frustrating that they're so often lumped together like they're the same thing. You wouldn't lump together deafness and blindness and say people might misdiagnose one as the other!

An autism diagnosis requires (1) persistent deficits in social communication and social interaction across multiple contexts and (2) restricted, repetitive patterns of behavior, interests, or activities.

An ADHD diagnosis requires that the person meets a certain number of symptoms of inattentiveness and/or hyperactivity/impulsiveness.

People can have both but the conditions are completely different.

Also, if there are signs of autism during an ADHD assessment, they should be flagged, and quite often are - it's why it's important to be as honest as possible during assessment (and who wants a diagnosis for a condition they don't have anyway!). Before my children and I had our assessments, we had a general consultation to decide what we/they should be assessed for (although not NHS). DH didn't but we weren't happy with the psychiatrist who assessed him in general.

An autism diagnosis requires (1) persistent deficits in social communication and social interaction across multiple contexts and (2) restricted, repetitive patterns of behavior, interests, or activities.

I still think kids like my (diagnosed with both) ds are hard to unpick!

In his autism assessment, the things that were flagged up as deficits in social communication/interaction included interrupting and monologuing. And the things that came under restricted/repetitive included absolute hyperfocus on one thing and only being able to talk about that, and huge difficulty doing any task set by anyone else.

We were told he showed no signs of ADHD, yet in his ADHD assessment a couple of years later these same things were used as evidence towards his ADHD diagnosis.

@majesticallyopposite I guess the 'clinician who knows what they're doing' is probably the issue here... 😆 It does make me wonder how many clinicians actually know what they're doing.

It's the 'included' though; the diagnosis wasn't solely on the basis of those two things. Interrupting is actually one of the few diagnostic areas of overlap - I am AuDHD and interrupt for two reasons (1) unable to hold back (impulse control - ADHD), and (2) not understanding where the break in the conversation is (social communication issue - autism). Meds reduce (1) significantly, making (2) easier to deal with! It is probably hard to tell which it is to an outsider, but that's why you don't get either diagnosis just because you interrupt! Your son will know why he interrupts though - it's why diagnosis gets easier as you get older because you understand yourself better.

Monologuing is about not appreciating when to shut up because others are bored. It's not the same thing as hyperfocus. Hyperfocus isn't actually part of the diagnostic criteria for ADHD - it's often seen but not an official symptom so not great that was brought up at all in an assessment at all! Talking excessively is but that's not about monologuing. Hyperfocus is controversial - you see it most in social media influencers explaining ADHD, there's no medical consensus it's actually linked to the condition. It might be (and some medical experts think it is) but no one knows.

The reality is there is very high co-morbidity between autism and ADHD - most autistic people also have ADHD (not the case that most people with ADHD have autism though - doesn't work both ways) and until recently you couldn't be diagnosed with both. I reckon a lot of what is recorded as 'hyperfocus' is short term autistic special interests.

(On a side note, I can force myself into hyperfocus, which has proved very useful in life. Medicating actually makes this easier - so more 'evidence' to suggest for me it's an autism thing not an ADHD thing. One of the issues AuDHD people report with medication is that they can spend too long in hyperfocus, which isn't good mentally).

Is it ADHD medication you have?

DS will hopefully be trying it soon, will be interesting to see the impact.

I'm also planning to get assessed, think I'm also AuDHD so v interested in all this!

Yep. There isn't autism medication!

😆

However, it is well document that these criteria are not complete, for example, (emotion) dysregulation which is at the core of ADHD was
purposefully taken out of the criteria in one of the last revisions as an attempt to make diagnosis easier for certain professionals. However it is at the detriment of giving an accurate picture and also is error inducing in so far as a lot people think emotion dyregulation isn’t part of ADHD since it is not in the list of criteria, it is extremely misleading ! The same happened with a number of other traits, sadly.

Could you provide a source for the statement that emotional dysregulation and many other traits were taken out of the criteria in one of the last revisions? I can't find any references to this online and you haven't said which revision which makes it hard to track down.

Emotional dysregulation is a supporting criteria for a diagnosis at the moment, but I can't see anything to suggest it was ever removed as a classifying criteria to make diagnosis either. The best source I can find for commentary on this point is
DSM-5 also highlights the importance of mood lability and emotional dysregulation as “an associated feature that support the diagnosis”. Although emotional dysregulation may dominate the clinical presentation Reference Barkley103–Reference Brown105], it is not a criterion for classifying individuals as it lacks specificity, occurring in many other mental health conditions.

[In my layperson terms I read this as: a pain in your foot when you walk could be because of a blister, a broken bone, a sprain or having stepped on a drawing pin. The fact that you have a pain in your foot when you walk therefore can support a diagnosis of having a blister but isn't relevant in actually diagnosing that you have a blister - it could be caused by some many things it's neither here nor there except it would make you consider whether there might be a blister. To diagnose a blister you have to have a blister.]

and
Emotional dysregulation is listed by DSM-5 as a characteristic feature of ADHD, supporting the diagnosis 113]. The type of emotional dysregulation seen in ADHD has been characterized as deficient self-regulation of emotional symptoms such as irritability, frustration and anger Reference Skirrow and Asherson114], and low frustration tolerance, temper outbursts, emotional impulsivity, and mood lability Reference Surman, Biederman, Spencer, Miller, McDermott and Faraone115]. Emotional dysregulation in ADHD is different from episodic symptoms such as marked sustained irritability occurring within the context of altered mood states, such as an episode of depression or mania. In ADHD, emotional symptoms tend to reflect short lived exaggerated changes, often in response to daily events, with rapid return to baseline within a few hours Reference Skirrow and Asherson114]. Whether the type of emotional instability seen in ADHD is qualitatively different to that seen in other chronic conditions such as borderline personality disorder or post-traumatic stress remains unclear.

(both from the 2018 European Consensus). Although this refers to DSM5 not DSM5-TR I can't find any source to suggest this point came out of the latest revision, and I would expect it to have been a material point of discussion.

I'm not trained in this area, just someone trying to understand themselves, so completely acknowledge I may be wrong but please can I have sources as I'd like to understand.

I'm also unclear about why we're talking about emotional dysregulation in a discussion about the differences between ADHD and autism diagnostic criteria because it's not a requirement for either anyway.

Finally, did I mention I have autism as well as ADHD? I suspect that a clinician could probably have diagnosed that from this post even if I hadn't said!

I work with SEND children. I have yet to meet a child with ASD who I don't also suspect has ADHD (inattentive/combined/hyperactive types). I'm starting to wonder if all ASD diagnoses are accompanied by an element of dopamine dysregulation..

I'm also unclear about why we're talking about emotional dysregulation in a discussion about the differences between ADHD and autism diagnostic criteria because it's not a requirement for either anyway.... [incomplete and meant to say] AND I can't see anyone arguing it should be one of the diagnostic criteria for autism. The main example I gave was hyperfocus (which is what I'm doing now when I need to get some work done!). There is limited evidence for the idea hyperfocus is an ADHD thing, and given how many people with ADHD are also autistic it seems almost impossible to separate out whether higher prevalence of hyperfocus seen compared to controls is because of autism, or because hyperfocus is an ADHD thing. Sources: Testing the relation between ADHD and hyperfocus experiences, Hyperfocus: the forgotten frontier of attention, Hyperfocusing as a dimension of adult attention deficit hyperactivity disorder

What I hate about this trend of describing everything as an ADHD trait is it leads to the impression that 'everyone's a little ADHD' / ADHD = quirky and also makes people think their ADHD diagnosis explains everything so they don't look further. For example, I have a teenager with AuDHD and she doesn't take meds because they make her anxiety worse - it calms her ADHD but the reduction in general noise in her head from the ADHD makes the hyper sensitivity from her autism much more obvious to her. Anecdotally this seems to be common amongst people with AuDHD. Knowing that she has autism as well as ADHD is really key to understanding what's going on.

Equally, I suspect if I hadn't had my meds very recently I'd have been able to drop the thread and do my work because my mind would have already gotten bored of the level of concentration this is taking. Which I am going to force myself to do now.

There is a group of (American) exports who are actually strongly for ADHD to be reclassified as a subtype of ASD

The requirements to meet for the threshold have been waterdown to make diagnosis (ensuing support accessible to those who needed it) that’s why it’s brought up. The criteria are to not thrrr to facilitate the assessments as it is a fact that that not all assessors are equal in the expertise, knowledge or training. But those criteria do not reflect entirely what it is to live with either or and it is misleading for people to try and understand it

Could you provide sources for this? I can't find any support for this online as I mentioned. I'm capable of understanding what you're trying to say (it's not rocket science) but specifically what has been watered down and when?

And just to be clear, the clinical criteria to assess whether someone has a condition shouldn't necessarily take into account what it's like to live with a condition. It's common for cancer patients to experience depression. That doesn't mean whether it not you're depressed should be one of the criteria for a diagnosis of cancer.

Dr Russel Barkley and Dr Dobson have written/spoken about it, there are materials on Additude website

I am out but will try and dig it out later

otherwise I have this handy

https://neurodivergentinsights.com/misdiagnosis-monday/adhd-vs-autism

Thanks. I still can't find anything searching those names so will wait.

Whilst I can believe that Autism might not exist independent of ADHD (and untill recently you couldn't be diagnosed with both), I have met many people with ADHD who are not autistic (I've met many who I suspect are also autistic but not diagnosed). I have a child who has ADHD only, and I have faith in the diagnosis (they intentionally assessed him at the end of a long day when he was tired, expecting him to be high masking and said he never missed a social cue whereas my other child, who is a very talented actor, wasn't able to maintain the mask the whole time). I'm reasonably sure my husband has ADHD only, although he hasn't been assessed for autism.