luisanz@mindyrlife.com
The purpose of this article is to reflect on the presentation of comorbid ADHD and ASD which is very different to when these two conditions present separately, highlighting the challenges of diagnosing this FASCINATING COMORBIDITY whilst exploring its potential and strength, and learning on the way.
I refer to this comorbidity as fascinating as, how symptoms and traits mix, has the potential of resulting on an amazingly successful combination or, on the other hand, leading to a much greater challenge in getting through life. Individuals with the amazing trait combination of this ADHD + ASD comorbidity are likely to have successful careers and never present in Mental Health (MH services whereas those with the more challenging trait combination are more likely to present in MH services due to the comorbidity itself or secondary presentations such as depression or anxiety.
THE FASCINATING ADHD + ASD COMORBIDITY
50 years ago, comorbid ADHD and ASD was nearly unthinkable. Nowadays, not only we know they do coexist, but they actually express from the same genetic loading.
It’s been a great help that research and science have enabled the transition from ADHD and ASD not coexisting to both conditions having common genetics and often expressing as comorbid conditions… how often is debatable, and this article tries to raise awareness on this comorbid presentation being much more common than it is recognised.
Research and science did its job demonstrating comorbidity of these two conditions, but what it cannot do is enabling professionals to recognise this comorbid ADHD + ASD presentation, which, based on the symptoms/symptom clusters as described in diagnostic classifications (see below), shouldn’t be difficult, but the reality is quite different.
Diagnosing ADHD or ASD on their own, as sole conditions, can be challenging and controversial enough. There is a lot of difference of opinion about what is “normality” and what falls beyond, where is the threshold for diagnosis, how wide is the spectrum on ASD, what “significant impairment” really means, how it makes sense that greater severity in symptoms can get masked by stronger protective factors such as High IQ, special talents or very supportive educational/family environments which means that a less severe presentation would get a diagnosis but a more severe one with protective factors wouldn’t as presenting with overall better functioning…
The consequence of such diagnostic challenge is that many people are not getting a diagnosis of either ADHD or ASD when they may be actually presenting with both.
Here below is a simplified, basic summary of symptoms and symptom-cluster as shown in diagnostic classifications (DSM 5). These are only the symptoms, as there are also other essential diagnosis criteria before a diagnosis can be formulated.
DIAGNOSTIC SYMPTOMS/CLUSTER CRITERIA:
ADHD:
- Inattention
- Impulsivity
- Hyperactivity
ASD:
- Difficulties with Social Communication and social interaction
- Repetitive/restricted Behaviours
And here below are some example areas showing that dichotomy in the comorbid presentation and symptom “contradiction” that leads to the diagnostic challenge:
CHALLENGING AREA | ADHD | ASD |
---|---|---|
Socialisation | Very sociable and interactive; seeks the company of others and “action”; adapt easily to different environments and types of people; friendships are very important | More comfortable in small groups or with either younger or older people, don’t get social subtle cues and relationships tend to be on their terms; prefer being on their own; need their own space and enough calmness |
Peer pressure | They need to fit in, to feel part of and included, to be liked, to get attention; they’ll do things just to please others | They prefer to be un-noticed and don’t like attention; they don’t tend to participate in activities and have minimal social interaction |
Focusing | Difficulty concentrating; scattered focus, short attention span, easily distracted, | Can hyperfocus and obsess on particular things/subjects; fixating |
Organisation | Chaotic, disorganised, no skills to plan or organise things/activities, messy, losing things | Likes order, organisation, control, predictability, things “being right” |
Adaptability/flexibility | Very adaptable, anything goes, will try everything, attracted by new things | Rigid, inflexible; thrives on routine, distress with sudden changes |
Activity level | Hyperactive, restless, fidgety; always fiddling and having to do something | Not an issue, can stay doing something for long if hyper-focused |
Impulsiveness | Impulsive, impatient, doesn’t think before speaking/acting, gets in trouble for "reacting" rather than "acting"; thrives on immediate reward | Not impulsive, thinking carefully, seeks control/predictability, can take too long to make a decision and sometimes, never make it; impatience is more due to fixation and not impulsivity |
Risk taking | Many; thrives on excitement and will not think of consequences; prone to accidents, teenage pregnancy, crime | Rarely as needs to feel in control and have a sense of safety/security/predictability |
Repetitive behaviours | Rarely; gets bored easily, likes novelty as more exciting, change, starts things but doesn’t finish as moves to the next | Typical; repetitive patterns of behaviours as part of their rigid/fixating nature and easily perpetuated as liking routine, predictability, control |
Perfectionism | Rarely; doesn’t have the patience to perfect anything, rushes things to finish them quick | Often; fixates on things to obsession so things have to be perfect; thrives on re-assurance which leads to perfection |
Verbal Communication | “Chatter box”, will take part on most conversations and can talk for the sake of it, dialogue/interested on the other | Tends to be literal, factual, black and white; often one-sided; conversing needs to have a purpose, usually informative so finds “small talk” difficult |
Non-verbal Communication | Able to recognise and communicate through gestures and facial expressions | Difficulty at different level with both understanding and demonstrating non-verbal communication |
Humour | Class clown; naturally funny, humorous, "silly" | May not get humour or humour is dry or they’re not intentionally funny |
Emotion/empathy | Able to recognise and express all emotions; tends to be very empathic, caring and supportive of others | Has difficulty recognising and/or expressing emotions in self and/or others |
Affection | Can be over affectionate and tactile; | Uncomfortable with overt expression of affection, mostly if invading space. |
Anxiety | Can be present | Nearly always present |
Eating | Not a particular pattern | Tend to have a restricted pattern, sometimes resembling an eating dis; sensitive to certain textures/flavours |
Sleep | Tends to be delayed | Can be delayed but it’s more due to the generalised anxiety than the ASD |
Well, if diagnosing these conditions separately, ADHD and ASD, is challenging enough, diagnosing their comorbid presentation is a whole other world! Whilst the symptom/symptom cluster diagnostic criteria can be reasonably clear, the combination, overlapping and interlinking of symptoms and traits can be so unique in each individual that it can make recognising the underlying neurodevelopmental condition an outstanding challenge.
As it can be seen from the table above, someone with this comorbid presentation could have some severe symptoms of one condition that would mask traits supporting the diagnosis of the other condition and so, the comorbid presentation would be missed.
For example, one individual can present with a “deficit of attention”, find it difficult to focus, tend to “scan” and yet, hyper-focus on a certain topic which they get fixated on, that way disguising the diagnosis of ADHD.
Another individual can present with an apparent like for socialisation typical of ADHD but, when explored in depth, relationships are superficial, one sided, controlling or imposing, lacking “intimacy” and yet again, disguising the comorbid diagnosis, the ASD on this occasion.
Therefore, not only there is a unique, individual combination of symptoms/traits within the ADHD + ASD comorbidity, but each of those can separately vary in degree of severity allowing infinite variations on how comorbid ADHD + ASD may present as well as why one of those would get recognised but not the other one when both are present.
Often parents are perplexed with how their child can be so chaotic with most things but so particular with others, so generally disorganised and yet so specific and fixated with others, so forgetful but have such an incredible memory with certain facts or topics.... Often these parents get frustrated with such contradictions and can't understand them.
To add to this diagnostic challenge, if the individual presents with a high IQ, ADHD is going to be masked throughout education, the higher the IQ, the longer the attention deficit is hidden for. And if the social interaction is not the most severe aspect of ASD, again the individual’s ASD is likely to get un-noticed perhaps throughout their whole life.
I believe this fascinating comorbidity is more common than ever before, and I believe one of the reasons may be “Survival of the fittest” and “theory of evolution” as I have mentioned in another previous article. It would seem as if severe presentations of ASD are becoming less common whereas the better adapted ASD is becoming quite more common.
This more adapted version of ASD seems to also express with ADHD symptoms which provide the ASD with a more balanced overall outcome placing the comorbid presentation in quite a stronger position than if isolated.
My observation is that, indeed, many successful businessmen, entrepreneurs, actors, sportsmen, and similar, do present with this fascinating ADHD + ASD comorbidity and they have a wonderful mix of symptoms and traits supporting that successful career.
Furthermore, over 80-90% of patients in my private practice who have parents with particularly successful careers (in the groups mentioned above) present with difficulties on both ADHD and ASD even if they don’t meet criteria for both diagnoses, and when exploring the family history, there is a strong suggestion of ADHD and ASD if no formal diagnoses.
I'd like to finish with some points to reflect on:
- Are these so called “disorders” no longer such and, instead, the best adapting traits are surviving and becoming a stronger genetic version in human evolution?
- Is it time to stop referring to them as disorders?
- If this comorbidity is becoming more and more common, will it go from being the minority to becoming the majority one day?
- If this comorbidity is particularly common amongst very successful people, why are they not diagnosed and what does this mean?
- If so many of the most successful people in the world present with traits and symptoms of this ADHD + ASD comorbidity, is this a sign of Evolution?
Maybe one day we’ll know all these answers but, for now, we continue being curious, open-minded and learning.
THANK YOU.