22/10/2018
Understanding ADHD and ASD: Similarities and Differences
Dr. Lindsay Bates, Registered Clinical Child Psychologist ASD Team Leader, Erica Baker Psychological Services
Ms. Melissa Gendron, Psychologist (Candidate Register) Erica Baker Psychological Services
Most people are familiar with the terms AUTISM or ASPERGER’S, but the term, AUTISM SPECTRUM DISORDER is not as widely recognized or understood What IS
In 2013, a revised version of Autism the Diagnostic and Statistical Manual of Mental Disorders (DSM) was released, the DSM-5. This (controversial) revision Spectrum changed the way autism is classified Disorder and diagnosed. anyway? Although the ‘official’ diagnosis of ASD has changed, the ‘old terms’ do still continue to be used (e.g., Asperger’s syndrome, HFA, Autism).
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Past & Current Terminology
Autism DSM-5 Spectrum (2013) Disorder (ASD)
PERVASIVE DEVELOPMENTAL DISORDERS DSM-IV-TR Asperger’s Disorder (2000) Autistic Disorder PDD-NOS Childhood Disintegrative Disorder
The ‘basics’ re: ASD …
ASD is a lifelong, neurodevelopmental disorder that affects how people communicate and relate to others.
The range and intensity of disability varies, but all people affected by ASD have difficulty with communication, social interaction, and restricted or repetitive interests and behaviours
Autism is referred to as a ‘spectrum disorder’ because the symptoms and characteristics can present themselves in a variety of combinations and degrees of severity, ranging from mild to severe.
ASD is reported to occur in all racial, ethnic, and socioeconomic groups and the overall incidence rate is relatively consistent around the globe.
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The ‘basics’ re: ASD …
Social-Emotional reciprocity: difficulty with back-and-forth conversation, reduced sharing of interests, emotions, difficulty initiating and responding to social interactions
Nonverbal Communication: poorly integrated verbal and nonverbal communication; abnormalities in eye-contact and body language; lack of use and understanding of gestures; lack of facial expressiveness
Relationships: difficulty developing, maintaining, and understanding relationships; difficulty adjusting behaviour to suit various social contexts, challenges in imaginative play, absence of interest in peers
Restricted/Repetitive Behaviour: repetitive motor movements, use of objects, or speech; insistence on sameness, inflexible adherence to routines; Highly restricted/fixated interests; Hyper/Hypo-reactivity to sensory input
Sex differences in ASD
ASDs show a striking male bias in prevalence, with approximately 4 affected males for every 1 affected female. This prevalence difference has been consistent over time and populations, strongly implicating the involvement of sex-specific biological factors in ASD etiology.
A male preponderance is not unique to ASD - studies have reliably documented greater prevalence of ADHD and other developmental conditions in males compared to females.
Current research suggests that prevalence rates may be less striking than once believed (at least 2:1–3:1)
The 4:1 male bias may be partly due to the under-recognition of females (particularly higher-functioning who tend to show increased functional social behaviour and less obvious repetitive behaviours), sampling bias, and issues of diagnostic instruments.
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A definitive cause of Current research ASD is not known. indicates that ASD likely There are no develops from an established biomarkers interaction between for ASD, although there genes and the is evidence to support environment, resulting shared biochemical in a disruption to markers with other typical brain disorders, such as development early in A brief note ADHD. life. re: causes of
ASD… Recurrence risk in siblings is about 2 - 10% Twin studies suggest (although as high as 20% 60 – 90% heritability. when considering broader ASD phenotypes)
You can’t ‘bad poor catch ASD parenting’ nutrition
What cable tv / cell phones / car seats pollution DOESN’T videogames cause ASD
pesticides
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Side note… Celebrity mom and (previously vocal anti- vaxxer), Jenny McCarthy, retracted her claims that vaccines cause autism in 2014 … but the damage was already done
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Other myths re: ASD …
individuals with the ‘rainman’ ASD is a disorder ASD are not myth of childhood social
individuals with ASD can be ASD are individuals with outgrown intellectually ASD are violent and/or cured disabled
Prevalence rates
This year the National Autism Spectrum Disorder Surveillance System (NASS) released a first reporting of national data and information of Autism Spectrum Disorder (ASD) in Canada. The findings of the 2015 NASS report focuses on those aged 5– 17 years, from six provinces and one territory: Newfoundland and Labrador, Nova Scotia, Prince Edward Island, New Brunswick, Quebec, British Columbia and the Yukon.
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Key findings …
Among children and youth 5–17 years old, the combined prevalence of ASD for the year 2015 was 1 in 66 (15.2 per 1,000).
Males were diagnosed with ASD four times more frequently than females. NASS found that 1 in 42 males and 1 in 165 females aged 5–17 years old were diagnosed with ASD.
Among those diagnosed by 17 years of age, 56% had received their diagnosis by 6 years of age; 72% had been diagnosed by 8 years of age; and less than 10% were diagnosed after 12 years of age.
The 2015 overall prevalence of ASD in Nova Scotia was 1 in every 68 (of 5–17 year olds).
ADHD stands for: Attention-Deficit/Hyperactivity Disorder
Most people are familiar with the terms ADHD and ADD, but the official term, ADHD is what is used today.
What IS In 1987, a revised version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) was released, the DSM-III. This revision ADHD dropped the hyperactivity distinction. anyway? Then subsequent DSM’s added subtypes/presentations: ADHD - Inattentive, ADHD - Hyperactive, and ADHD - Combined.
Although the ‘official’ diagnosis of ADHD has changed, ‘old’ language continues to be used (e.g., ADD - Attention-Deficit Disorder).
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The ‘basics’ re: ADHD …
ADHD is a persistent pattern of inattention and/or hyperactivity that interferes with functioning or development.
Inattention: lacking persistence, difficulty staying focused, disorganization, etc. Hyperactivity: excessive motor activity when inappropriate, talkativeness, etc. Impulsivity: hasty actions that occur in the moment without forethought that have the potential for harm to the individual; social intrusiveness (e.g., interrupting, disruptive behaviour)
Symptoms have to be persistent (more than 6 months) to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities. Symptoms cannot be due to defiance, oppositional behaviour, or failure to understand tasks/instructions.
Additional information re: ADHD
ADHD is a neurodevelopmental disorder that begins in childhood. Several symptoms must be present before age 12.
Symptoms vary depending on the context within a given setting. Symptoms may be minimal when the individual is receiving frequent rewards, under close supervision, in a novel setting, engaged in especially interesting activities, has consistent external stimulation (e.g., screens), or interacting one-on-one.
Associated features may include low frustration tolerance, irritability, and/or mood lability.
ADHD is more frequently diagnosed in males than females (approximately 2:1 in children, 1.6:1 in adults). The prevalence is about 5% in children and 2.5% in adults.
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Current research Very low birth weight indicates that ADHD conveys a 2-3x risk for likely develops from an ADHD. Smoking during interaction between pregnancy has been genes and the strongly linked, as well environment resulting as pregnancy and birth in a disruption to complications, brain typical brain damage, toxins, and development early in infections. Risk Factors life. of ADHD The heritability of Twin studies of children ADHD is substantial. with ADHD show that ADHD is elevated in the family first-degree biological environments of the relatives. ~50% risk children contribute parent to offspring. very little to their Twin Studies show 60- individual differences in 80% heritability. ADHD symptoms
Myths re: ADHD …
ADHD is not a Children with ADHD are ADHD is a disorder over-medicated real disorder of childhood (Most evidence from research (Long-term studies of children studies suggest that levels of (Cases date back to 1775 and treating ADHD with medication are since over 10,000 research diagnosed with ADHD show that ADHD is a lifespan disorder) either appropriate or that ADHD is studies have been published) undertreated)
Poor Parenting causes Girls have less severe ADHD is over- ADHD ADHD than boys diagnosed (Twin studies of children with ADHD (Research studies are reporting on show that the family environments (The vast majority (9 out of 10) of the substantial impairments girls of the children contribute very children have been diagnosed by experience, often to the same little to their individual differences practitioners using best practice extent as boys) in ADHD symptoms) guidelines)
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According to DSM-IV-TR, an individual could not be diagnosed with ADHD if they had a diagnosis of a Pervasive Development Disorder (PDD).
One of the reasons for the prohibition of a comorbid diagnosis of autism and ADHD was that the severity of ASD placed it above ADHD in the diagnostic hierarchy.
Epidemiological, clinical, and neuroimaging findings led to a revision of the ADHD exclusion criteria in the DSM-5 (2013). Now, ASD is no longer an exclusion criteria - both ASD and ADHD can be diagnosed together. 30 - 60% youth with ASD also meet criteria for ADHD – ADHD has been described as the most common occurring diagnosis with ASD.
ASD & ADHD: Diagnostics
30 - 80% youth with ASD also meet criteria for ADHD – ADHD has been described as the most common occurring diagnosis with ASD. 20 – 50% of youth with ADHD also show features of ASD
ASD & ADHD: Diagnostics
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It is not uncommon for children to first be diagnosed with ADHD.
Studies have found that an initial diagnosis of ADHD may be associated with delayed ASD diagnosis (older than 6 years of age). This delay persists across age and severity of the ASD.
It has been suggested that symptoms of ADHD may overshadow or mask symptoms of ASD. ASD that goes unrecognized until the child is older may negatively affect their long- term prognosis.
ASD & ADHD: Diagnostics
Although ASD and ADHD are unique neurobiological conditions, they have been shown to share genetic factors and neural pathways as per findings from family and twin studies ASD and ADHD share many similar impairments that can complicate differential diagnosis, including attention deficits, social vulnerabilities, sensory over- responsivity, emotion regulation problems, and behavioural challenges. Both disorders are characterized by reduced performance on tasks of executive function and information processing.
ASD & ADHD: Similarities
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A major distinction between ASD and ADHD is that in ASD there is a marked impairment to initiate and sustain connection with others. Individuals with ASD often have difficulties reading and/or demonstrating nonverbal behaviors that help regulate social interaction - such as eye contact, facial expression, vocal inflection, and gestures. ASD and ADHD share many similar impairments that can complicate differential diagnosis, including attention deficits, social vulnerabilities, and behavioural challenges.
Both disorders are characterized by reduced performance on tasks of executive function and information processing.
ASD & ADHD: Differences
Implications of Comorbidity: ASD/ADHD Frequently associated with greater level of Children with ADHD and ASD impairment, including symptoms, compared with higher rates of tantrums, those with ADHD only, tend irritability, depressed to be prescribed more mood, avoidance, and medications conduct behaviours
Associated with a lower Can have a large negative quality of life and poorer impact on the daily life of adaptive functioning than affected individuals and in any one of these their families conditions
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Comorbidity in Neurodevelopmental Disorders Neurodevelopmental disorders, such as ASD, intellectual Recent studies have found that disability, ADHD, epilepsy, etc. inheritance of one are characterized by strong neurodevelopmental disorder clinical comorbidity, which also confers an increased risk suggests a common genetic for other disorders within the etiology across the diverse same family. group of disorders.
Therefore, it is increasingly For example, twins have been clear that the genetic found to be more likely to underpinnings for these develop ADHD or a learning disorders do not conform to the disability if their co-twin had current singular diagnostic ASD. criteria/classifications
Commonalities between ASD & ADHD
• inattentiveness • Behaviour difficulties • emotional dysregulation • social challenges ASD • intense focuses ADHD • inconsistent eye contact • impulsivity • sensory issues • executive dysfunction
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Symptom : difficulties conversing with others
More ASD-ish… More ADHD-ish
‘monologuing’ Impulsive interrupting – as if can’t wait to share talking at, versus talking to ‘zones out’ and misses parts of Lack of interest or the conversation acknowledgement of others’ comments Loses train of thought and/or forgets what they were going to Oblivious to ‘social rules’ in say conversation – e.g., turn-taking Responds before thinking Correcting conversation partner – irrespective of age or authority
Symptom: social difficulties
More ASD-ish… More ADHD-ish… Infrequently by choice Frequently cannot initiate social interactions (and friendships) Can make friends, but often not keep them Awkward/uncomfortable in social interactions Social dysfunction due to impulsive behaviour Social dysfunction due to social disengagement and indifference to Kids with ADHD can be overly social cues aggressive in trying to be noticed, they may lack basic conversational may show little if any interest in skills and often interrupt, talk too interacting socially, or if they do, much or let emotions get the best they may be completely socially of them. oblivious and even offensive at times
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Symptom : overactivity
More ASD-ish… More ADHD-ish
Repetitive movements – flapping, Restlessness pacing, spinning Fidgetiness
Repetitive movement seems Making excuses to move necessary Overactivity seems necessary often a way to release the tension that comes from the stress of extreme sensory sensitivity or anxiety that comes from a break in their routine.
Symptom: Inattention
More ASD-ish… More ADHD-ish…
Hypervigilent attention and lack of focus and distractibility internal distractibility by external stimuli
Can appear withdrawn (‘in Poor persistence – shifting their own world’) to the quickly from one activity to the exclusion of of more salient next environmental stimuli Poor sustained attention Hyperfocused on details – missing the ‘big picture’
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Symptom: Intense Interests
More ASD-ish… More ADHD-ish…
Can have socially isolating effects due Becoming hyperfocused – to their intensity or unusual nature. Difficulty regulating attention
Unusually intense – knowing every Continuing to engage in a detail about interest and spending most preferred activity for long free time engaging in, learning about it, etc. periods and having difficulty ‘shifting’ away Interest can be outside of developmental norm (e.g., a teenager Interests are often typical for intensely interested in Lego, a child developmental stage very interested in politics, etc.)
Can follow similar themes across people with ASD (e.g., Titanic, etc.)
Can be quite unusual (e.g., eggs, metal objects, etc.)
The de-emphasis on specific clinical categories and a greater focus on dimensions of behavioral and neurobiological measures may have future implications. This approach may…
Inform treatments that extend beyond classic diagnostic boundaries, resulting in use of more integrated approaches.
Implications Increase recognition of co-occurring neurodevelopmental disorders and the genetic and biological factors that underlie them, which may help reframe societal opinions on causality.
Lead to a better understanding of the bio- psycho-social complexity of challenges faced by these individuals and their families.
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Questions?
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