Back in the days when we used the DSM-IV there was a misguided notion that the diagnosis of autism and attention deficit hyperactivity disorders (ADHD) were mutually exclusionary.  If a person had a primary diagnosis of autism, they could not simultaneously have a diagnosis of ADHD.  Considering that both autism spectrum disorder (ASD) and ADHD are common lifelong conditions, claiming that they do not co-occur is rather disingenuous.  ADHD affects about 11% of children in the 4-17 age group, while autism affects approximately 1.7% of the same population.  Chance alone dictates that they could co-occur.

Symptoms for ASD and ADHD do overlap.  Studies show that 30-50% of ASD individuals share features of ADHD.  Similarly, two thirds of individuals with ADHD exhibit features of ASD (Leitner, 2014).  This is more than a chance occurrence of chronic conditions and, regardless of their respective underlying pathology, implies a commonality in the expression of symptoms.  Recognizing this comorbidity is of importance as it better informs treatment and prognosis.  Indeed, the subgroup of ASD patients with comorbid ADHD usually shows higher symptoms of anxiety and worse working memory (Colombi and Ghaziuddin, 2017). Fortunately, the new diagnostic criteria DSM-5, released in 2013, allows for the dual diagnosis.

Although the readers of our blog may be aware of the symptoms and treatment options available for autism they may be less cognizant of similar interventions for ADHD.  In this blog I would like to describe some of the symptoms of ADHD and to provide some guidance in regards to management. According to the standard reference now used by healthcare providers to diagnoses mental/behavioral diagnoses (i.e., DSM5) the criteria for inattention, hyperactivity, and impulsivity are as follows:

People with ADHD show a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development:

1. Inattention: Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level:
   • Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
   • Often has trouble holding attention on tasks or play activities.
   • Often does not seem to listen when spoken to directly.
   • Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).
   • Often has trouble organizing tasks and activities.
   • Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).
   • Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
   • Is often easily distracted
   • Is often forgetful in daily activities.
2. Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level:
   • Often fidgets with or taps hands or feet, or squirms in seat.
   • Often leaves seat in situations when remaining seated is expected.
   • Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).
   • Often unable to play or take part in leisure activities quietly.
   • Is often “on the go” acting as if “driven by a motor”.
   • Often talks excessively.
   • Often blurts out an answer before a question has been completed.
   • Often has trouble waiting his/her turn.
   • Often interrupts or intrudes on others (e.g., butts into conversations or games)

In addition, the following conditions must be met:

• Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.
• Several symptoms are present in two or more setting, (e.g., at home, school or work; with friends or relatives; in other activities).
• There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning.
• The symptoms do not happen only during the course of schizophrenia or another psychotic disorder. The symptoms are not better explained by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

ADHD is a group of neurobehavioral disorders resulting in a developmentally inappropriate ability to self-regulate attention, impulsivity and hyperactivity.  Individuals with ADHD are interest driven, rather than task driven. They pay attention when they find something interesting. Forced upon and scheduled tasks may prove boring leading to easy distractability which is  compounded by their poor frustration tolerance.  This inattention, or the inability to stay focused on a task, is a result of immature executive functions. Difficulties with a whole range of cognitive functions compromises the capacity to self-regulate; meaning the ability to plan, organize, initiate, maintain and complete tasks along with the ability to monitor and shift priorities, as needed.

ADHD is seldom seen alone. Common comorbidities in children include:

• Oppositional Defiance Disorder (ODD) 40%
• Conduct disorder 10%
• Language disorders LD 30% (just a in ADHD this deficit is usually misattributed to a person being lazy)
• Specific learning disorder 25%
• Anxiety/Obsessive Compulsive Disorder (OCD) 25%,
• Depressive disorders 35%
• smoking 3x more common than in the general population
• Substance Use Disorders 3X more common than in the general population

ADHD teens have 3-4 times the number of car accidents, 4-6 times the speeding tickets, 4 times the number of unplanned pregnancies, and 3 times the number of ER visits than control groups.  Affected individuals usually experience a heavy burden of losses in their lives, e.g., career, marriage, social.  Inattention and distraction is the cause for most of these complications.

Figure: ADHD comorbidity

Hyperactivity and impulsivity tend to diminish over time. However, executive skill dysfunction tends to persist.  Eighty percent of patients maintain some symptoms into adulthood.

ADHD medications are effective, but they only temporarily ameliorate (not eliminate) symptoms.  It stands to reason that treatment of ADHD is much more than just medication. YOU CAN NOT BUY GOOD BEHAVIOR FROM A DRUGSTORE. Set the right expectations.  Behavioral counseling is your best bet to change behaviors.  Emphasize consistent structure and discipline, positive communication, and positive reinforcement.  For those interested in getting additional information regarding medication usage, Dr. Andrew Adesman offers a free ADHD medication guide at www.ADHDmedicationguide.com

References

Colombi C, Ghaziuddin M. Neuropsychological characteristics o children with mixed autism and ADHD. Autism Research and Treatment 2017;2017:5781781.

Keitner Y. The co-occurrence of autism and attention deficit hyperactivity disorder in children- what do we know? Front Hum Neurosci 8:268, 2014.