Often it starts with something fairly ordinary that keeps happening, such as mornings that fall apart over a missing shoe, a school report describing your child as ‘bright, but easily distracted’, or seemingly able to cope at school and then falls apart as soon as she gets home. At some point you start reading about ADHD, then about autism, and find that quite a lot of what you read about both sounds like your child.
That is understandable, sometimes the two conditions overlap, and the same behaviour can have very different causes. For that reason we tend to spend less time on the question of which label its and more on working out what is actually going on for your child, which is usually the more useful thing to know.
How are ADHD and autism different?
Both are neurodevelopmental conditions, which means they relate to how the brain develops and works, but they are defined by quite different things.
ADHD involves persistent difficulties with attention, hyperactivity and impulsivity, or some combination of the three. Most children lose a water bottle now and then, whereas a child with ADHD might get through several in a term, along with their PE kit and the letter about the school trip. They may also find it hard to start a piece of work or to finish it, fidget or wander around the classroom, interrupt, or struggle to wait their turn. Because plenty of children do these things some of the time, a diagnosis requires the difficulties to be persistent, to go beyond what you would expect at their age, and to get in the way of everyday life.
Autism involves differences in social communication and interaction, together with restricted or repetitive patterns of behaviour, interests or activities. An autistic child might find the unwritten rules of the playground hard to follow, rely on familiar routines and find unexpected changes very hard, have an intense interest that they could happily talk about for an hour, or experience sounds and textures differently, so that something as small as the seams in a pair of socks becomes a daily problem. Every autistic child has their own mix of strengths and support needs, so two autistic children can look very different from each other.
Can a child have both?
They can, and the diagnostic manual that clinicians use, the DSM-5-TR, allows both diagnoses to be made together. This has only been the case since 2013, when an earlier rule that effectively prevented a dual diagnosis was dropped, so you may still come across older advice saying that one rules out the other. Current guidance recommends checking for autism, along with other developmental and emotional conditions, as part of any ADHD assessment.
When we assess for both, we consider each condition separately against its own criteria. For ADHD, that means asking whether the attention difficulties, hyperactivity or impulsivity have been present for some time, whether they show up at home and at school rather than in just one setting, whether they are affecting your child’s day-to-day life, and whether something else might explain them better. You do not need to have worked out which condition it might be before asking for help, as that is what the assessment is for.
Why can they be hard to tell apart?
Partly because the same behaviour can have quite different causes. A child who keeps wandering off during group work might be doing so because sitting still for twenty minutes is genuinely difficult for them, because they have lost track of the conversation and cannot find a way back into it, or because the noise in the classroom has become too much to bear, and although these look identical from the other side of the room, each would need quite different support. Children with either condition can struggle with organisation, with moving from one activity to the next, with strong emotions, with sensory experiences and with social situations, and research has found overlap in several of these areas. A list of shared traits will only get you so far, however, and the detail is usually much more helpful to us. ‘She had a meltdown’ tells us something, but ‘she had a meltdown when the class moved to the hall without any warning’ tells us a good deal more, so if you can, it is worth noting what happened before, during and after a difficult moment.
One condition can also draw attention away from the other. A child who is constantly on the move and climbing on the furniture tends to prompt questions about ADHD first, while quieter differences in social communication can go unnoticed for some time. In one US survey of parents of nearly 1,500 autistic children, around one in five had been diagnosed with ADHD first, and those children received their autism diagnosis about three years later than children whose ADHD had been identified at the same time or afterwards. This does not mean that every child with ADHD needs an autism assessment, but it does suggest that an ADHD diagnosis should not be the end of the discussion if other concerns remain.
Are ADHD and autism missed in girls?
Both conditions can be overlooked in girls, often because a girl who is struggling is not causing anyone else a problem. A girl with ADHD whose difficulties are mainly with attention and organisation, who drifts off during instructions and quietly loses track of her work, may go a long time at school before anyone realises that she needs help. Girls can of course be hyperactive
and impulsive as well, but it is the quieter presentation that is more easily missed. Some autistic girls mask, meaning that they hide or compensate for their difficulties, for example by copying their friends, staying quiet, or appearing comfortable in situations that they are in fact finding exhausting. Boys and children of other genders can mask too, so if you are told that your child seems fine at school, it is still worth asking what they find difficult and how much effort it is taking them to manage.
Where should I start?
The best place to start is with what you have noticed, and before a first appointment it helps to jot down:
- some specific examples, including when they happen and how they affect everyday life (‘homework takes three hours most nights’ is more useful to us than ‘struggles with homework’);
- roughly when things started, since difficulties that have been there since nursery can point to quite different explanations from ones that began last term;
- what your child’s teacher has noticed, because children often behave differently at school and at home, and that difference is useful in itself;
- your child’s own view, if they are able to give it, about what feels hard, what they enjoy and what helps; and
- any earlier reports, for example from school, a paediatrician or a speech and language therapist.
Your GP, a paediatrician or a psychologist experienced in childhood neurodevelopmental assessments can then help you decide on next steps. Part of their role is to consider other explanations, since poor sleep, anxiety and learning difficulties can all produce some of the same signs. You also do not need to wait for an assessment before speaking to your child’s school
about practical support.
What happens in an assessment?
An assessment brings together information from several sources, and while the exact content depends on the questions being asked, most follow a broadly similar pattern. We usually begin by talking with you about your child’s development and what a typical day looks like, and then spend time with your child, using conversation, play, observation or structured activities depending on their age. Parents and teachers are asked to fill in questionnaires, and where it would help, we may also speak to teachers directly or observe your child at school. If something else needs a closer look, such as learning, language, emotional wellbeing or daily living skills, we can add further assessments. At the end we go through the findings with you and provide a written report with recommendations. The tools used differ somewhat between ADHD and autism, but in either case a diagnosis should never rest on a single questionnaire score or one observation on its own.
How can an assessment help?
A good assessment should help you understand why certain situations are difficult for your child and what is likely to help, whether that means changes to routines at home, support at school, adjustments to how people communicate with them or to their surroundings, or a referral for further help. It should also identify what your child does well, so that any recommendations can build on those strengths.
The outcome may be ADHD, autism, both, or another explanation altogether, and sometimes a child does not meet the criteria for any diagnosis. That does not mean that nothing is wrong, and their difficulties still deserve attention and appropriate support.
If you come away from an assessment without a clearer picture of your child and some practical next steps, it has not really done its job. And if something about your child has been worrying you for a while, that in itself is a good enough reason to seek advice.
Dr. Janice Freeman
Clinical Psychologist at Us Therapy
PsyD MSc MEd FMBPsS MSPS