The different presentations of ASD and ADHD discussed

ADHD (attention-deficit-hyperactive disorder) and ASD (autism spectrum disorder) are the topics at the centre of discussion in one of our latest informative articles. Here, revered London-based consultant psychiatrist, Dr Samr Dawood, tells us what both conditions are, and how they both differ from each other.

What is ASD and how does it differ from ADHD?

Both ASD and ADHD are lifelong neurobiological conditions, but each one has a different clinical presentation. ASD is characterised by impaired verbal and non-verbal communication, compromised social skills, and repetitive or restricted patterns of behaviours.

The first description of autism spectrum disorders (ASD) emphasised emotional impairments, characterising children with ASD as indifferent to other people, self-absorbed, emotionally cold, distanced, and retracted. Subsequently, it was depicted that they have difficulties in perspective taking, deficits in recognition of others’ emotions, and misread social cues.

They have difficulty understanding themselves and others’ thoughts and feelings. They have difficulty in sharing enjoyment, emotions, interests, or achievements with other people, and have a lack of emotional reciprocity. They struggle to recognise visual expressions of emotions from faces and body postures, and also struggle in the processing of emotional language.

Nevertheless, people with ASD are very likely to be focused, hardworking, honest, enthusiastic, polite, respectful, kind, and caring. Those qualities not only make them good employees, but also great friends and reliable partners.

ADHD, meanwhile, is characterised by persistent inattention and/or hyperactivity/impulsivity. Many symptoms of ADHD are, typically, behaviours that are not desirable in modern societies, and people with ADHD can find it difficult to ‘fit in’, and can typically suffer from overactive thinking, finding it hard to be organised, acting quickly before thinking, being physically over-active, as well as feeling restless or fidgety.

This will lead to difficulties in school, at work, and in relationships with friends and family. Individuals with ADHD don’t know where and how to start, since they can’t find the beginning. They jump into the middle of a task and work in all directions at once.

The ADHD nervous system is rarely at rest. It wants to be engaged in something interesting and challenging. Attention is never a “deficit.” It is always excessive, constantly occupied with internal reveries and engagements. Behavioural difficulties can be numerous, however, and they typically include: not following social rules, acting impulsively, being overly silly, or disrupting situations in different ways. They have chronic challenges with organisation and planning.

However, people with an ADHD-style nervous system tend to be great problem-solvers. They wade into problems that have stumped everyone else and jump to the answer. They are affable, likeable, with a sense of humour, and have relentless determination. When they get hooked on a challenge, they tackle it with one approach after another until they master the problem.

How difficult are ASD and ADHD to diagnose?

There are diagnostic challenges for both conditions, especially for those with subtle or ‘mild’ presentations, when difficulties are masked by other comorbid conditions or camouflaged by compensatory strategies.

It is actually very common that specialists misdiagnose these illnesses with other psychiatric disorders such as learning disabilities or even bipolar disorder, or pay attention to comorbid psychiatric illnesses like depression and anxiety, and ignore the diagnoses of ASD and ADHD.

Symptoms of both ADHD and ASD may be masked by coping strategies, and by the time individuals reach adulthood, it is not uncommon for such techniques to have been developed and established. These usually facilitate the individual to behave in an appropriately acceptable manner in public for a short time and/or in specific settings.

For example, adults with ADHD and ASD may select occupations that maximise their opportunity to overcome their difficulties. Some individuals may seek to obtain a social network by forming damaging relationships such as joining a gang, or making themselves sexually available, which could divert the attention away from the primary problems (ADHD or ASD) toward other diagnoses like an antisocial personality disorder or addiction.

What are the different presentations of ASD and ADHD?

The diagnostic criteria of ADHD will typically see symptoms of inattention, hyperactivity, and impulsivity, while those of ASD comprise of difficulties in social interaction, communication, and stereotyped behaviours. However, in many situations, the distinction between autism and ADHD is not black and white.

In practice, inattentive and hyperactive symptoms are often reported in individuals with ASD, and people with ADHD often suffer from problems in social interaction with peers. The key trait that distinguishes ADHD from autism is the ability to comprehend the social world naturally.

They know the social rules, but they cannot stick to them. They struggle socially, but their social perceptive knowledge is present. Also, they are hyperactive, impulsive, easily distracted, and have difficulty sticking to a task and following classroom routines. People with ASD, on the other hand, have difficulties interacting and communicating effectively with other people. They also develop ritualistic and repetitive behaviours and find it hard to adjust to changes in their daily routine.

It is now well accepted that core features of both ADHD and ASD (in particular inattention and social deficits) overlap, and that some, but not all, overlapping patterns are found in cognitive and behavioural traits associated with ADHD and ASD. Difficult behaviours such as aggression, poor rule-regulated behaviours, inability to delay gratification, behavioural disinhibition, learning difficulties, poor impulse control, and low motivation, are common in both illnesses. An overlap has also been noted in the cognitive deficits found in these disorders, including emotion recognition dysfunction and social cognition. The current diagnostic guidelines of the DSM‐5 allow for overlap between ADHD and ASD.

In terms of management and treatment, is the approach the same for both?

Treatments and management for ASD and ADHD include counselling, education, psychotherapy, social interventions, and medications.

There are pharmacological treatments available for ADHD in children and adults, while there is no orthodox pharmacological treatment for ASD. In the UK, the National Institute for Health and Care Excellence (NICE) guidelines should be followed for the pharmacological treatment of ADHD.

Psychotropic medications have been used widely to treat ASD symptoms in certain countries. However, the evidence base supporting its use in this population is negligible and the risk of adverse effects is unfortunately quite high. Psychological interventions are very important for both illnesses. We should provide psychoeducation interventions and psychotherapies that improve symptoms of ADHD and ASD, and enhance the social abilities hindered by them.

How can these conditions affect an individual's quality of life?

People with ASD and ADHD are at a significant risk of suffering from numerous emotional difficulties, social problems, and academic and occupational underachievement. They often show unfortunate school performance, and their professional success is often impaired.

They also suffer from significant impairments in interpersonal relations in the family and peer context. Attention deficit/hyperactivity disorder (ADHD) and ASD can affect several areas of an individual's personal and social development, including sexual health. They suffer from reduced stability in romantic relationships and less satisfaction within partnerships.

People with ADHD live in a permanent present and have a hard time learning from the past or looking into the future to see the inescapable consequences of their actions. “Acting without thinking” is the definition of impulsivity, and one of the reasons that individuals with ADHD have trouble learning from experience.

Many people with ADHD find that the feedback they get from other people is different from what they perceive. They find out, many times (and often too late), that the other people were right all along. It isn’t until something goes wrong that they can see and understand what was obvious to everybody else. Then, they come to believe that they can’t trust their perceptions of what is going on. They make mistakes and leave tasks half complete. Subsequently, they lose self-confidence.

Individuals with ASD tend to have difficulties conceptualising or verbalising their understanding of what constitutes a friendship, a partnership, and a social collaboration. Friendship and social contacts are critical for human development. It is an important variable in moral, social, and emotional growth.

To book a consultation with Dr Samr Dawood, simply visit his Top Doctors profile today.