ADHD vs Autism
Autism and ADHD Overlap
Taking on ADHD and Autism has felt like the most daunting diagram to create out of the #misdiagnosismonday series. I think this feels harder to tease out because I struggle to tease it out in my own mind! Writing it out into neat categories for an article is one thing—but experiencing it in my own brain is quite different.
Is my desk always a mess because of my executive functioning struggles associated with Autism or ADHD? Is the reason my email inbox says 1967 unread emails (most of them spam, but probably some important ones hidden in there) because of ADHD or Autism? Is my impulsivity, failure to close drawers, constant restlessness, tendency to interrupt people or the fact that I’m always looking for my keys, phone, and credit cards my Autism or ADHD?
Even with psychological training, when it comes to my lived experience, I struggle to tease out what is what. I believe this speaks to the complexity and messiness that is Autism-ADHD. It turns out that in my state of confusion, I am in good company. The research points to the fact this is incredibly convoluted and difficult to clinically distinguish between the two.
Overview of Autism and ADHD
Autism is characterized by difficulties with neurotypical social interaction and communication; and a tendency to self-regulate through repetition and routine (i.e., special interests and restricted, stereotyped, and repetitive behavior).
Autism is the fastest-growing developmental condition, and prevalence rates are around 2.8 % (among children 3-17) (National Survey of Children’s Health).
ADHD is characterized by difficulty regulating attention and difficulty with hyperactivity/impulsivity (American Psychiatric Association 2013). ADHD is estimated to have a prevalence rate of 5-11% (Allely, 2014; Visser et al., 2014)
Contents:
Co-Occurring ADHD and Autism: Understanding the Genetics
Understanding of the genetic and phenotypic (characteristic expression) overlap of ADHD/Autism is relatively new. Until recently, if a patient presented with symptoms of both conditions, the clinician had to choose which diagnosis fits best. Until the DSM-5, a diagnosis of Autism or Asperger’s precluded a diagnosis of ADHD Taurines et al., 2012. Thankfully this was updated in DSM-5-- both conditions can now be diagnosed. So, in the history of things, considering the ADHD/Autism overlap is relatively new.
Recent studies have demonstrated significant phenotypical, genetic, and neurobiological overlap between ADHD and Autism Sokolova et al., 2017.
It is estimated that between 22-83% of Autistic children meet the criteria for ADHD (Sokolova et al., 2017).
Approximately 30-65% of ADHD children have significant Autistic traits Sokolova et al., 2017.
Twin studies and family studies consistently show substantial genetic overlap between the two conditions. There is approximately a 50-72 % overlap of contributing genetic factors Sokolova et al., 2017.
While co-occurrence is common, it is also common to see elevated ADHD traits within Autistics or elevated Autistic traits for the ADHDer. A person may not meet the criteria of both and yet still have significant trait overlap. I suspect that “pure ADHD” or “pure Autism” is the exception, not the norm.
Genetic Overlap
There are various hypotheses regarding this common co-occurrence. Leitner et al., 2014 hypothesize that they share a common genetic etiology.
This hypothesis is supported by twin studies that suggest a substantial genetic overlap (approximately a 50-72% overlap). This theory suggests genetics explain why ADHD/Autism commonly co-occurs within individuals and families at such high rates (Leitner et al., 2014; Rommelse et al., 2010).
Furthermore, evidence points to a strong neurobiological overlap. Sokolova et al., 2017 suggest biological pathways involved in attentional control (inattention and task-switching difficulty) may be a key factor in understanding the genetic overlap between these conditions.
Trait Overlap
ADHD and Autism, classified as Neurodevelopmental conditions, impact how the brain processes sensory input and cognitive processes. Both impact executive functioning, attention processes, and sensory processing. Following are some of the trait overlaps.
Executive Functioning Difficulties
Executive functioning challenges are core features of both ADHD and Autism. Challenges may include difficulty organizing tasks, object permeance, memory, focus, decision-making, and regulating attention.
Social Difficulties
Both groups often struggle with picking up social cues but often for different reasons. For the ADHDer, this may be related to inattention and impulsivity. For the Autistic, it is more often related to difficulties with intuitively picking up on social cues/body language/understanding pretense and difficulty with task switching (social communication involves considering multiple tasks at one time).
Interoception Issues
Interoception, the “8th sensory system,” refers to the ability to sense internal signals. For example, signals associated with elimination, hunger, thirst, and emotions are all examples of interoception. Interoception is integral to the ability to regulate emotions.
A person with poor interoception will have more difficulty registering and responding flexibly to their internal states and emotions. While results among ADHDers are more mixed*, there is research to suggest that both ADHDers and Autistics struggle with interoception at higher rates than the general public.
To read more about interoception issues and neurodivergence, you can see my full article on it here.
Time perception
Partly associated with interoception, ADHD and Autistics often have an altered perception of time, sometimes referred to as “time-blindness” (Carmelo et al., 2020).
Sensory Sensitivities
Sensory sensitivities are common with both ADHD and Autism and are related to how the brain processes sensory input.
Hyperactivity/Repetitive Movement (Stimming)
Stimming (repetitive movement) to regulate is common among both Autistic people and ADHDers. Further, ADHD fidgeting can look a lot like stimming seen in the context of Autism.
Hyper-Fixation/Special Interests
Hyper-fixation and hyper0focus (particularly as they center around our passions and special interests, i.e., interest-based nervous system) are common among both ADHDers and Autistic people. Hyperfocus, as seen in the context of ADHD, can look a lot like hyper-fixation. ADHD passions can look a lot like Autistic special interests.
Emotional Regulation
Due to various factors such as brain circuitry (more sensitive amygdalas), interoception issues, more rigid nervous systems, and sensory processing, both ADHDers and Autistics can struggle with regulating and soothing intense emotions.
Rejection Sensitivity Dysphoria
Rejection Sensitivity Dysphoria is common among both ADHDers and Autists.
Shared Psycho-Social Risks
In addition to having shared brain circuitry, traits, and symptoms, we also have shared psycho-social risks and similar experiences.
Addiction
Addiction is common among both ADHDers and Autistics and may be related to a tendency to self-medicate, self-soothe overactive nervous systems, regulate sensory experiences, or may occur in the context of co-occurring depression/anxiety.
Several studies have shown a correlation between ADHD, drug abuse, and alcoholism. ADHD is estimated to be 5 to 10 times more common among adult alcoholics. Among adults being treated for alcohol and substance abuse, the rate of ADHD is about 25% (WebMD)
Smith et al., 2002 found that approximately 25% of adults and 30% of adolescents receiving treatment for alcohol disorder have ADHD (for reference, approximately 2-5 % of adults and 3-7 % of children have ADHD).
A recent study in Sweden found that Autistic folks with average to high intelligent quotients (IQ) were twice as likely to struggle with addiction to alcohol or other drugs. Among autistics, drugs are sometimes used to cope with social stress and sensory problems (Szalavitz). There is also a high prevalence of behavioral impulsivity/addiction to shopping, gambling, and internet gaming among Autistics (Szalavitz).
OCD
Both have significantly higher rates of OCD, and similar neural circuitry is involved in all three conditions.
The prevalence rate for OCD among ADHDers is estimated to be around 30% Geller et al., 2002 And 25% of people with OCD are estimated to have ADHD (Walitza et al., 2008).
It is speculated that a larger proportion of people with OCD may also be Autistic. A population-based study in Denmark found familial links between OCD and Autism. They found that people diagnosed with Autism were 2x as likely to be diagnosed with OCD later in life. And people diagnosed with OCD were 4x more likely to be diagnosed with Autism later in life (Meier et al., 2015).
Self-Harm and Suicidality
Self-harm behavior and suicidality are high among both groups. The risk is likely amplified among ADHDers and Autistics with other marginalized identities. Self-harm may occur as an attempt to regulate sensory load or may be used as an attempt to regulate difficult emotions.
Self-harm is alarmingly high among girls with ADHD. Girls are more prone to internalize many of their ADHD symptoms. The risk of self-harm behavior is highest among those with ADHD combined type Allely, 2014; Hinshaw et al., 2012 found that self-harm behavior happened at a rate of 69% among adolescents with ADHD (compared to 32% non-ADHDers). Self-harm has also been noted to be more common among Autistic girls and Autistic-Trans/gender-diverse (Dudas et al., 2017)
Previous research has consistently shown a connection between ADHD and suicide. The correlation was strong for both men and women (Allely, 2014). Hurtig et al., 2012 evaluated the relationship between ADHD and suicidal and self-harm behavior among adolescents. They found that when compared to non-ADHD adolescents, ADHD adolescents experience more suicidal ideation (57% compared to 28%).
Rates are similarly high among Autistics—a recent longitudinal study involving 6.5 million people found that autistics were three times more likely to both attempt suicide and to die by suicide. Suicidality was more elevated among women and those with a co-occurring mood disorder such as anxiety or depression (South et al.)
Eating Disorders
Both ADHDers and Autistics are more likely to struggle with eating disorders; anorexia appears to be more common than Bulimia among Autistics, while rates of anorexia and Bulimia are approximately equal among ADHDers Bleck et al., 2015.
Biederman et al., 2007 found that ADHD girls were 3.6 more likely to have an eating disorder.
ADHD girls may be more prone to bulimia than Autistic girls. ADHD girls were 5.6 times more likely to have bulimia than the general population Biederman et al., 2007. Similarly, Bleck et al., 2015 found ADHD had a significantly higher rate of eating disorders (4.2%) than the non-ADHD population (2.0%) and had 2.8 times more likely to have an eating disorder.
While the rates vary, most researchers agree that about 23% of people diagnosed with anorexia nervosa are Autistic. However, many agree this is likely an underrepresentation due to the fact ASD often goes undiagnosed within this population (Westwood and Tchanturia).
Victimization
Both groups have elevated rates of peer victimization. This happens at even higher rates among ADHD/Autistics with additional marginalized identities.
ADHD: ADHD traits, particularly hyperactivity-impulsivity, are correlated with an increased risk of peer victimization (Papadopoulos et al., 2021). Humphrey et al., 2007 also found a correlation between peer victimization and ADHD.
Rates of victimization were found to be exceptionally high among girls with ADHD (Wiener and Mak, 2009).
Recent research has demonstrated that Autistic Trans/Gender-Diverse individuals and women are more likely to be survivors of violent victimization. Some risk factors include the challenge in social reasoning, missing contextual cues, and a tendency to take things literally. In one study, Autistic adults were 7.3 times more likely to endorse having experienced sexual assault from a peer during adolescence (Weiss and Fardella).
Shared Social Identities
Gender and Sexual Diversity
Autistic people and ADHDers are more likely than neurotypicals to be genderqueer, and genderqueer people are more likely to have ADHD or be Autistic than cisgender people. People who don’t identify with the sex they were assigned at birth are 3-6 times more likely to be autistic than cisgender people (ADHDers (Warrier et al., 2020). In a study done by Strang et al. 2014. gender variance was found to be 7.59 times more common among Autistics and 6.64 times more often among ADHDers (Strang et al. 2014.
Similarly, Autistics are more likely to be non-heterosexual than the general population (Sarris). While the general population has a 4.5% (Gallup poll), a rate of 15-35% identifies as LGB. And the prevalence of LGB is 2 to 3 times higher (than the general population) among Autistics. Several studies suggest Autistic men are more likely to be heterosexual than Autistic women (Dewinter et al., 2017; George and Stokes, 2018). Similarly, Barkley, R. A., Murphy, K., & Fischer, M. (2008) found that ADHDers were more likely to identify as non-heterosexual and more likely to identify as bisexual than non-ADHDers.
Co-occurring Mental Health Conditions
Both groups have an elevated risk of having mood disorders such as depression and anxiety. According to one study, 79% of Autistics met the criteria for a co-occurring psychiatric condition at least once in their life (Lever and Geurts). Co-occurring mood disorders are also common among ADHDers. While ADHD children only represent 3-7% of the population, they comprise 50% of the children receiving psychiatric treatment (Smith et al., 2002).
Depression co-occurs with adult ADHD in 9%–50% of cases and complicates the assessment and management of ADHD (McIntosh et al., 2009). Furthermore, Almeida et al., 2007 found higher rates of ADHD among adults participating in outpatient psychiatric care. While it is estimated that ADHD impacts 4.4% of the adult population, the prevalence among adults receiving outpatient psychiatric care was 8.5% for men and 21.6% for women.
How to Spot the Difference
Given the high level of overlap and tendency for a person to have both ADHD and Autistic traits, it can be difficult to distinguish between the two. Here are some considerations the clinician should consider when working with a suspected ADHD/Autism client.
Social Differences
In order to tease out Criteria A of Autism (Social difficulties), you’ll need to spend time here teasing out the nature of the social difficulties, as Criteria A items for Autism can look like ADHD social difficulties and vice-versa. While both groups experience social difficulties, they differ in nature. Here are some things to be considering:
What are the underlying mechanisms behind social difficulties? Sokolova et al., 2017 found that difficulty socializing was more connected to impulsivity and inattention in the context of ADHD. While for Autistics, social challenges are connected to difficulty interpreting allistic social cues. ADHDers will be able to read social cues when they can focus. Autists have more inherent difficulty with doing this intuitively (although they may do it through the use of their prefrontal cortex and analytical skills).
Other social differences may include: ADHDers are more likely to talk excessively, interrupt others and not listen to what is being said, while Autistics are more likely to struggle with back-and-forth conversation and use language repetitively or robotically (Sokolova et al., 2017).
Social Motivation: On average ADHDers tend to have more social motivation than Autistic people.
Assess How the Person Navigates Disruptions to Routine
Many of the items in Criteria B for Autism can look like ADHD (sensory sensitivities, special interests can look like hyper-fixation and repetitive movement can look like hyperactivity. One thing distinguishing Autism from ADHD is how the person adapts to change (criteria B item 2).
To understand this better, consider observing how an individual copes with unexpected alterations to their routine. It's essential to differentiate between self-initiated changes (where the individual decides to modify their own routine) versus externally imposed changes (those that are unexpected or forced upon them).
For Autistic people, unanticipated alterations stemming from external sources often lead to intense emotional responses, including heightened irritability, anxiety, and stress. Therefore, gauging a person’s response to disruptions can provide valuable insight into their unique neurodivergent profile.
Repetitive Behaviors vs. Hyperactive
Repetitive behaviors can, at times, be mistaken for hyperactivity. Differentiating between repetitive behaviors and hyperactivity requires understanding the underlying function and the individual's internal experience (Sokolova et al., 2017).
Rule out Autism/Autistic Traits
When conducting assessments for either ADHD or Autism, it is essential to include routine screeners for both conditions. Surprisingly, Autism screeners are often overlooked in ADHD assessments, despite the substantial overlap of Autism and ADHD. In my assessments for ADHD, I always include the AQ, RAADS, and CAT-Q to capture a comprehensive picture. I recommend incorporating routine screeners for both conditions into your practice to ensure a thorough evaluation. By doing so, you can effectively identify and address the presence of Autistic traits in individuals with ADHD.
Screeners
Autism Screeners
AQ : Autism Spectrum Quotient
Alexithymia Questionnaire (not technically an autism screener, but Alexithymia is common among Autistics).
The Ritvo Autism Asperger Diagnostic Scale-Revised (RAADS-R) is a self-report questionnaire designed to identify adult autistics who “escape diagnosis” due to a subclinical level presentation.
EQSQ: Combined version of Baron-Cohen's Empathizing Quotient (EQ) and Systemizing Quotient (SQ)
The Adult Repetitive Behaviors Questionnaire-2 (RBQ-2A) is a self-administered questionnaire that measures restricted and repetitive behaviors in adults.
The Camouflaging Autistic Traits Questionnaire (CAT-Q) is a self-report measure of social camouflaging behaviors in adults. It may be used to identify autistic individuals who do not currently meet diagnostic criteria due to their ability to mask their autistic proclivities.
ADHD Screeners
There are fewer online options for routine ADHD screeners. However, the ASRS or Wender Utah can provide a data point/sense of whether further evaluation is warranted.
Future Reading:
For clinicians working with ADHD/ASD: Executive Functions by Russell Barkley or check out my book recommendations for Neurodivergent Clinicians (#affiliatelinks)
ADHD Reads: Outside the Box, Women with ADHD
My Favorite Autism Reads: Divergent Minds, Aspergirls and Neurotribes, Unmasking Autism
· Footnote: Interoception and ADHD have more mixed results: Kutscheidt et al. found impairment of interoception among ADHDers, Wiersema and Grodefroid, 2016 found interoception remained intact in the context of ADHD)
Book Recommendations
Citations
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Barkley, R. A., Murphy, K., & Fischer, M. (2008). ADHD in adults: What the science says. New York, NY: Guilford Press.
Biederman, J.; Ball, S.W.; Monuteaux, M.C.; Surman, C.B. MD; Johnson, J.L; Zeitlin, S (2007). Are Girls with ADHD at Risk for Eating Disorders? Results from a Controlled, Five-Year Prospective Study. Journal of Developmental & Behavioral Pediatrics. 28(4). https://doi.org/10.1097/DBP.0b013e3180327917
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Older Versions Of The Venn Diagram