My friend’s son has been recently been diagnosed with ASD (Autism Spectrum Disorder). We had thought it was ADHD (Attention Deficit Hyperactive Disorder) because some of his traits were remarkably like my daughters with ADHD. Clearly, we are not professionals which is why it should be left to the professionals to diagnose! However, it did get me thinking about what Autism is and the differences between ADHD and Autism.
ADHD is the most common coexisting condition in children with ASD. Some studies suggest a figure of approximately half of all ASD children having ADHD. Equally, about a quarter of children with ADHD may show signs of ASD. ADHD and Autism are both neurodevelopmental disorders. The executive functioning area of the brain (the front bit) has been affected in some way. This part of the brain is responsible for decision making, time management, focus, organisational skills, and impulse control. Social skills can also be affected. Interestingly, ASD, as with ADHD, is more prominent in boys. Whilst there are many similarities there are also many differences. First, let us look at ASD.
What is ASD?
ASD includes what use to be called Autistic Disorder, Asperger syndrome and Pervasive Developmental Disorder. All of these affect an individual’s social and emotional skills, plus non-verbal communication. It can also involve restrictive, repetitive, or ritualistic patterns of behaviour and sensory issues. Children with Autism generally do not fully grasp social situations. This will affect eye contact, social interactions, reading social cues and other people’s emotions. This can cause young children to not want to engage with others. Their ability to speak may be slower or not at all, which will also affect their socialisation with others.
Children with Autism are rigid with their routines. They need the ‘sameness’. This could be from food; needing the same colours, textures etc., to clothing; certain fabrics may irritate; to gestures; hand movements and directions to places. Children with ASD are often over-focused which enables them to remember detailed facts for a long time. No doubt this is where Dustin Hoffman’s ‘Rain Man’ character was derived from (great movie, although probably not entirely accurate).
Asperger’s was once a standalone diagnosis but now comes under the umbrella of ASD. It is generally associated with milder symptoms of autism and was commonly diagnosed later in a child’s life. Pervasive Developmental Disorder was also grouped with ASD due to such similarities in delayed developmental issues, problems with socialising and communicating, repetitive actions etc.
Causes of Autism
Like ADHD there is not one specific cause of Autism. Possible causes are;
- having an immediate family member with autism.
- fragile X syndrome and other genetic disorders.
- being born to older parents.
- low birth weight.
- exposure to heavy metals and environmental toxins.
- a history of viral infections.
What is ADHD?
Attention Deficit Hyperactive Disorder (ADHD), falls into two categories. There is the inattention aspect and the hyperactivity and impulsiveness side. Many people have both hence ADHD. (See What is ADHD?). ADHD does not fall on the spectrum like ASD. Both my children with ADHD definitely have the hyperactive side. They are non-stop!
ADHD and ASD behaviours
Children with ADHD find it exceedingly difficult to focus on one activity or task and are likely to become easily distracted and jump to another activity before completing the first task. They are physically unable to sit still and are extremely restless. However, some children with ADHD may become hyper-focused on a particular toy and/or activity. They do not want to change from what they are doing, especially when they find it super interesting.
Children with ASD are often over-focused and are literally unable to move their attention to something else. They can be inflexible and incapable of making that change. Often they have an intense interest and knowledge in just a few things. They need to stay on one task at a time.
Both children are displaying the same behaviour but for different reasons. This is one of the explanations as to why some children get misdiagnosed with ADHD instead of ASD.
This is the same with certain social interactions between children. Some children with ADHD may struggle with social interactions and therefore struggle to make friends. They may not be able to manage turn-taking in games due to their impulsivity. This is not because they do not understand it but more because they simply cannot wait!
Children may appear bossy and stubborn as they need things done their way. My daughter had to make a thousand rules when playing a simple game with her friends. I could see the faces of her friends thinking this is not fun! They would probably rather be back in school; it was less restrictive than a playdate with my daughter!
Children with ASD however, struggle with social interactions for different reasons. They do not understand turn taking, they cannot always respond to names, and they do not recognise the social cues of their peers playing a game. Sometimes this can also be simply due to a delay in language skills. They can lack humour and take everything virtually. Lack of empathy is considered a critical element. This is where an individual cannot connect with another person by recognising how that person is feeling, understanding them, relating to them and being able to express empathy.
You can see, children with ADHD and Autism struggle, but for different reasons. This is where the differences lie. It is not so much some of the observable behaviour but would appear to be the causes behind them. Social interactions for children with ADHD can be hard also due to their low self-esteem but they generally understand the why’s and how’s etc. Social interactions for children with Autism are difficult because they do not ‘get it’.
Routine helps children with ADHD immensely. It helps them stay on track and know what is coming next. Often in class, a child may have a visual timetable so they can see what is lesson or task next. They may be rewarded for finishing a task by having ‘Golden Time’. This routine keeps them on track and helps try to keep them focused and motivated.
Routine for children with ASD is life. They are inflexible to change, they need it. Same foods, the same routes when going somewhere, and the same clothing. It is essential for them. Everything is thought through and carefully planned. So again, whilst both the child with ADHD and Autism need routine, they are for different reasons.
This is such an oversimplification I know! As with ADHD, ASD is very individual, and the signs are different for every child. But from what I have read, and know of my children, whilst ADHD and Autism can sometimes present the same, the cause is different. And therefore, why so many children can easily be wrongly diagnosed.
For your child to be diagnosed with ASD the following must have been seen from a young age across various situations. They should also be significant enough that they impair the child’s life. I have taken the below criteria from the DSM V but I have tried to put them into normal terms for those of us who don’t hold a Doctorate in Medicine!:
Firstly, each of the below three points must be seen.
- The child will have difficulties with normal back-and-forth conversations and the turn-taking involved. They may find it hard, impossible, to start or respond to a normal chat scenario. Even when a conversation has started they may appear disinterested and lack the proper responses
- The child’s body language can be a big indicator with poor eye contact and a lack of understanding or use of hand gestures and/or facial expressions. Imagine talking to someone and they yawn mid-way through what you are saying, how would that make you feel?! But to a child with ASD, they will be totally unaware that this is not considered appropriate.
- Children with ASD will have difficulties in developing and then maintaining friendships due to the lack of understanding of their behaviour in certain situations, for example, they may be unable to join in imaginative play, or unable to make and keep friends due to their disinterest in what their peers are doing.
Two out of the below four should be seen from this list:
- The child will show repetitive (motor) movements like hand flapping, rocking, twirling
- Children with ASD commonly need specific routines or rituals (and get upset when a routine is changed, even slightly). They will be very rigid in their thinking. This could be to do with food, greetings, travelling the same routes or eating the same food daily.
- They can have fixations on certain activities or objects to the point it becomes a total preoccupation or obsession for them
- Often they are either extremely sensitive to touch, light, and sound or oblivious or indifferent to say pain or temperature.
Now see below for the criteria for ADHD.
For an ADHD diagnosis, you would be looking to see about five to six of the below that must have been present for over six months and not really in line with their developmental level.
- The child will often appear to not be listening, spaced out, daydreaming, and avoiding direct eye contact.
- They will constantly want to change a task or an activity especially if the task is tedious or time-consuming. Conversely, they will be unable to come off a task immediately.
- Their attention span is noticeably short; they are very easily distracted; often unable to finish a task like homework or a chore.
- They may have difficulty organising tasks and can make careless mistakes.
- They may often lose things and be forgetful.
This is largely due to not being able to sustain long periods that involve mental effort.
Hyperactive and Impulsive
Again, you would expect to see five to six of these symptoms, before the age of 12 years. With the hyperactive/impulsive side, you would also be able to witness them in a couple of settings e.g., at school, with friends, at home etc.
- The child is unable to sit still becoming restless in most situations and will constantly fidget, it is like they are being driven by a motor.
- They will talk excessively, interrupt conversations, shouting out.
- They are often unable to concentrate on tasks.
- There is generally little or no sense of danger to what they do, very impulsive and acting out and speaking out without thinking.
- They will find it difficult to wait for their turn, in queues, in conversations etc.
ADHD and Autism together
So, what about when your child has both?
Doctors recommend that you treat ADHD and Autism as two separate diagnoses. Generally, medications such as methylphenidate (e.g., Ritalin, Concerta), amphetamine (e.g., Adderall, Dexedrine, Vyvanse), atomoxetine (Strattera), and guanfacine (Intuniv, Tenex) work well at reducing the major symptoms associated with ADHD such as the hyperactivity, the impulsiveness, and the inattention aspects. I can categorically say that for my son they have been incredible, and school has seen a massive improvement.
There are, however, very few medications for ASD and are often less effective. Behavioural therapy is generally recommended for ASD. Occupational and speech therapy is suggested to aid with social skills and speech. Speak to your GP and/or school for help in finding someone suitable for your child.
As I say, I am no expert, especially with regard to Autism/ASD so I would love any feedback or input on ASD. I am on a learning journey myself. My two children have ADHD, but I was interested to see why ASD and ADHD can sometimes be mistaken. From what I can see, many of the observable behaviours can be similar yet it is more about the reasoning or causation for these behaviours that are behind the diagnosis. Wrongly diagnosing a child can be so detrimental as each diagnosis requires a totally different treatment plan. I hope this has helped. x