Embracing Adult ADHD, ASD, and AuDHD.

Since the beginning of studying ADHD (attention-deficit/hyperactivity disorder) and ASD (autism spectrum disorder), there have been many beliefs that significantly impacted and impeded the full understanding of these disorders. One belief that perpetuated false ideals and standards was that ADHD and ASD were disorders only children had and that they wore off by adulthood. Because of this for decades millions of adults went undiagnosed. Only within this century it has become widely accepted that neurodiversity affects people of all ages and what changes is how neurodiverse traits present themselves as a person ages.

Additionally, it was long believed that ADHD and ASD could not exist together since they were thought to be too different. With the rise of social media and sharing personal stories about one’s neurodiverse journey, there has been in an increase in adults who realize for the first time that they may be neurodiverse or that they have more than one neurodiverse disorder.¹ Making for a hybrid disorder, combined ADHD and ASD go by the term “AuDHD.” How do the histories and symptoms of ADHD and ASD bring them apart and then together?

A Closer Look at Each Disorder

ADHD

ADHD was first researched by studying a group of children comprised of 15 boys and 5 girls.² These children were observed since they were thought to have had fascinating traits such as being remarkably impulsive, inattentive, and having issues with self-control.³ German physicians Franz Kramer and Hans Pollnow originally studied and named the disorder “hyperkinetic disorder of childhood” since these symptoms were only studied in children.^{4 5} Kramer and Pollnow recorded many of the most recognized symptoms of ADHD and yet, to the detriment of ADHD research for decades to come, they cemented the false idea that ADHD only exists in childhood since the hyperactive, and often most apparent components of the disorder, seemed to dissipate in adulthood.⁶ It wasn’t until the late 1980s when the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) was published that hyperkinetic disorder was renamed ADHD.⁷ ADHD was a more fitting name for the disorder since it encapsulated the main symptoms of the disorder rather than predominantly focusing on the hyperactive aspect. It was also a significant milestone in the ushering in of a new era of ADHD research and treatment, including realizing that the disorder affects adults too.

ADHD Symptoms in Adults

Since ADHD was once thought to be a childhood disorder, resources and awareness for adult ADHD has been greatly impacted. In fact, nearly half of children who have ADHD retain symptoms into adulthood.⁸ And then there are the adults who were never diagnosed with ADHD in childhood. The missed diagnoses can occur perhaps because individuals did not display the most obvious ADHD symptoms but rather experienced more subtle, internal ones. Or perhaps their teachers and parents were unaware that their misbehavior, poor grades, or lack of attention span was linked to ADHD. ADHD is so underdiagnosed in adults it’s thought that only 20% of adults with ADHD know that they have the disorder.⁹ Left undiagnosed or untreated, ADHD can create unnecessary difficulties to one’s life. Many adults who are living with undiagnosed ADHD often feel as though they have never received the correct diagnosis or treatment for their struggles, which can create feelings of isolation and hopelessness. Adult ADHD, diagnosed or undiagnosed, can also cause anxiety, depression, low self-esteem, mood swings, and substance abuse issues.¹⁰ Anxiety is so prevalent in ADHD, research notes that half the population who has ADHD has a comorbidity of anxiety.¹¹ Since these mental health symptoms are other mental conditions on their own, this adds another layer of complexity to diagnosing ADHD in adults.

While ADHD looks different for everyone it affects, there are still broad categories that most ADHD symptoms fit into. These categories are:¹²

1. Inattentiveness – struggling to pay attention.
2. Hyperactivity – having excess energy and need to constantly be moving.
3. Impulsivity – lacking self-control.

These categories for ADHD remain the same for children and adults, although how these symptoms affect one’s life changes with age. Examples of inattentive adult ADHD are struggling to engage in tasks that require continued attention, easily losing everyday items, and being easily distracted.¹³ Examples of adult hyperactivity and impulsivity, which are often grouped together, are extreme restlessness, talking excessively, and interrupting others’ conversations.¹⁴ Adults with ADHD usually “experience at least five persistent symptoms of inattention and/or five persistent symptoms of hyperactivity-impulsivity,” indicating that ADHD is very much an adult disorder too. Yet, many psychology and psychiatry professionals and researchers are unequipped to notice undiagnosed ADHD in adults.¹⁵

ASD

Much like ADHD the beginning research on autism lacked conscientious understanding and logical facts. The 1940s saw a rise of research in autism mainly from an American psychiatrist, Leo Kanner, and a German pediatrician, Hans Asperger.¹⁶ Both men made similar observations of the individuals they studied, including noting difficulties with social interactions, good memory, sensitivity to stimuli, intelligent, and routine oriented.¹⁷ Despite his research being proved eventually incorrect, Asperger’s research on autism was so highly regarded that the former DSM diagnosis “Asperger’s Syndrome” was named after him.¹⁸ As valuable and new as Kanner and Asperger’s research on autism was at the time, neither of these men had personal experience caring for someone with autism, which created a less empathetic approach to conducting autism research. In the 1960s Bernard Rimland, a psychologist and most importantly a father of an autistic child, worked hard to erase the damaging beliefs and found healthier ways to support those with autism.¹⁹ Rimland’s work to improve autism research and establish legitimate research paid off. During the 1970s and 1980s, support for families and individuals with autism rose. Children were given better support in school and different forms of autism therapy emerged.²⁰ In 1980, the DSM III established specific and consistent criteria for diagnosing autism.²¹ However, it still specified autism as a children’s disorder.²² Only in the last twenty years has diagnosing autism become more inclusive. Throughout the 2000s, resources for adults with autism became readily available.²³ In 2013, the American Psychiatric Association changed autism to autism spectrum disorder, finally validating the ranges within the disorder.²⁴

ASD Symptoms in Adults

Unlike ADHD, ASD is diagnosed at the same rate in adults as it is in children. About 1 in 36 or 2.78% of children have ASD while about 2.21% of adults have ASD.^{25 26} But diagnosing ASD in adults has its challenges. Adults who have ASD have become accustomed to masking their symptoms, making it harder to diagnosis.²⁷ Additionally, the diagnostic test of ASD in adults, the ADOS-2, is considered only “fairly reliable” and can only be given if the person with possible ASD or a medical professional know to look and test for ASD.²⁸

Adult ASD can impact the following areas:²⁹

1. Social interactions and communication
1. Struggling to make conversation, not understanding sarcasm, meticulously reading other’s emotions or facial expressions, and having social anxiety.
2. Restrictive or repetitive behavior
1. Making vocalizations, needing to follow a routine, and arranging items in a specific order.
3. Hyper fixations on specific interests or activities
1. Have a limited but deep interest in certain topics, being able to hyperfocus on interests, and pay attention to detail.
4. Sensory processing
1. Hypersensitivity to sounds, smells, and tactile senses.

ASD also has a high comorbidity possibility. With undiagnosed ASD, individuals are more likely to compare themselves to their neurotypical counterparts, which can create feelings of failure to be “normal” which can generate low self-esteem.³⁰ This in turn can cause other psychiatric disorders to arise such as anxiety and depression.³¹ Even with an ASD diagnosis, ASD adults are still highly likely to have other psychiatric disorders. For those who have milder forms of ASD, they can be 70%-80% more likely to have other psychiatric conditions.³² Specifically, 20% have anxiety disorders, 11% have depressive disorders, and 5% have bipolar disorder.³³ Despite sometimes being held opposite of each other, ASD is often misdiagnosed with ADHD since both disorders can cause impulsivity, hyperactivity, and struggles with executive function.³⁴ But in some cases people truly have both ADHD and ASD and only recently is has become normalized to diagnose the two together.

Neurodiversity and Comorbidities:
More Friend Than Foe?

The topic of comorbidity between mental health illnesses and neurodiverse disorders has begun to be closely studied in recent decades since parallels between multiple disorders and conditions have begun to be recorded. The word comorbidity means when a person has more than one diagnosable condition occurring at the same time. This word is used for both physical and mental conditions. But it is not one that has always been associated with two neurodiverse disorders coexisting since disorders like ADHD and ASD were once thought to be undiagnosable together. However, now it's thought that the percentage of individuals with ASD and ADHD is bigger than previously studied. Research states that 50%-70% of people with ASD also have ADHD, while those with ADHD are 20%-50% more likely to have ASD.^{35 36} But how come the correlation between ADHD and ASD is emerging now when these disorders have been extensively studied for the last century? A possible explanation to this question could be because the DSM-IV, which was published in 1994, stated that the two disorders “could never be diagnosed together.”³⁷ Within the next edition of the manual, the DSM-V, it was changed to state each disorder in the description of the other, bringing to light the possibility of an ADHD-ASD comorbidity, although not completely agreeing to it.⁸ “AuDHD” is yet to be found as a term in DSM; however, like the history of ASD and ADHD proves, that does not mean this hybrid disorder is any less real to those it impacts.³⁹

Challenges AuDHD May Create

There are hallmark traits of ADHD and ASD that indicate how the two are starkly different. For instance, people with ADHD can struggle with paying attention and hyperactivity. This can lead to diverging from a task or even a premade schedule. On the other hand, people with ASD thrive with schedules, routine, and hyper fixating on tasks.⁴ Having both disorders can cause incongruities when doing tasks and partaking in schedules that require continuous attention.⁴¹ Similarly, managing time may cause strife with someone who has AuDHD. ADHD symptoms of distraction or time blindness can often lead a person to struggle managing time or can cause them to run late to scheduled events.⁴² Since people with ASD thrive on a schedule, they are usually very aware of managing their time and may even feel distress over being late and deferring from their schedule.⁴³ A third way ADHD and ASD symptoms may contend with each other is repetitive behaviors and specific interests.⁴⁴ People with ADHD are more likely to want to try new experiences and invest in new hobbies, but people with ASD usually adhere to one or two hobbies that they become thoroughly invested in.⁴⁵ Since both disorders differ in each person it affects, these examples only skim the surface in how an ADHD-ASD comorbidity can cause negative impacts.

Symbiotic Symptoms

While the two disorders have distinct differences, the similarities they share run deep. Both ADHD and ASD can cause issues with executive function, an essential part of how human brains work.⁴⁶ Brains run on automatic and executive functions.⁴⁷ Automatic functions take care of 80%-90% of daily tasks whereas executive functions take care of the remaining 10%-20% that “requires purposeful, regulatory effort.”⁴⁸ But for people who are neurodiverse, the purposeful, regulatory effort is much harder to accomplish.⁴⁹ Even though executive function is only in charge of 20%-10% of the brain’s work, it is still an intricate process that includes many components. These components are:⁵⁰

1. Working memory – the ability to retain information and is critical for learning and completing everyday tasks.
2. Cognitive flexibility – the ability to oscillate between different concepts and think about concepts in more than one way.
3. Inhibitory control – being able to ignore distractions and having self-control.

Often referred to as executive dysfunction due to lacking successful function, it’s believed that executive dysfunction is one of the most prevalent ASD symptoms in adults.⁵¹ ASD executive dysfunction can target prioritizing and organizing, which relates to the cognitive flexibility component of executive function.⁵² Even though people with ASD thrive on a schedule, they can still struggle organizing new tasks or plans that do not fit into their preset schedule or routine. For people with ADHD, executive dysfunction plays a role in working memory. Since working memory involves both verbal and non-verbal aspects, this can further overwhelm an already overwhelmed ADHD brain, letting details fall through the cracks.⁵³ This can look like forgetting deadlines, not remembering instructions, and losing items.⁵⁴ Another factor of executive function is emotional regulation or “the ability to exert control over one’s own emotional state.”⁵⁵ Someone with ASD or ADHD or both disorders may experience mood swings, meltdowns, and feeling burned out.⁶ Executive dysfunction for a person with ASD, ADHD, or AuDHD can become problematic, especially if tools are not implemented to help the dysfunctional become more functional.

Moving Forward with AuDHD

Learning how to balance both disorders can be taught by a therapist who specializes in ASD and ADHD. Therapeutic strategies and everyday tools can be used to ease the symptoms of both disorders. And while not as comprehensive as therapy and useful strategies are, the online conversation about adult neurodiversity has opened up a new level of honesty and comradery. This can mostly be attributed to the decades long rise of social media apps and the uptick of people’s honest vulnerability shared in these circles.⁵⁷ When social media users share that they have AuDHD, this can help others realize that they have both disorders as well as supports destigmatizing neurodiversity and highlighting the successes and challenges it may bring.⁵⁸ What was once a quieted “weakness” has now become a unifying, shareable experience. While AuDHD has yet to be widely researched, in the meantime it’s imperative that those with AuDHD continue to share and celebrate their stories.

Citations

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