Co-occurring Autism and ADHD – A Call to Action!

Ann-Marie Low

Co-occurring Autism and ADHD – A Call to Action!

by Ann-Marie Low^*

Assistant Professor, Department of Psychology University of Copenhagen Østre Farimagsgade 2A 1353 Copenhagen Denmark.

^*Corresponding author: Ann-Marie Low, Assistant Professor, Department of Psychology University of Copenhagen Østre Farimagsgade 2A 1353 Copenhagen Denmark.

Received Date: 16 February, 2024

Accepted Date: 20 February, 2024

Published Date: 23 February, 2024

Citation: Low AM (2024) Co-occurring Autism and ADHD – A Call to Action!. J Psychiatry Cogn Behav 7: 169. https://doi.org/10.29011/2574-7762.000069

Abstract

Rates of autism spectrum disorder (ASD) have increased in recent years. A substantial subgroup of autists have co-occurring ADHD; but little literature exists concerning adults with co-occurring ASD and ADHD. The aim of this letter is to (1) describe some of the complexities of co-occurring ADHD and ASD in adults from a clinical perspective, and (2) highlight the lack of research and guidelines concerning clinical treatment / management of this group, particularly for individuals with an average or above average IQ, and who do not conform to (male-dominated) prototypes. Such research is urgently needed.

Letter to the editor

Rates of autism spectrum disorder (ASD)^{^[1]} have increased in the last 5-10 years, particularly for women and those diagnosed in adulthood [1]. Co-morbidity with ADHD is relatively common; a recent meta-analysis reported a current prevalence of ADHD of up to 47.8 % in children with ASD, and 22.4% in adults [2]. Rates may be higher for some sub-groups e.g., individuals without intellectual disability.

I am a clinician working in the specialized clinic for adults with ADHD and autism at Psychiatric Centre Glostrup, Capital Region of Denmark, which annually receives 1500 referrals. In our clinic, the co-occurrence is somewhat higher – presently approximately 81% of ASD patients are also diagnosed with ADHD / ADD, the majority of whom do not have intellectual disability. The reason for the higher co-morbidity in our clinic can only be speculated upon, but its occurrence has alerted us to the lack of knowledge about this group of patients.

A very substantial body of research exists concerning children and adults with ASD or ADHD, and to an extent children with ADHD and ASD; far less literature exists concerning adults diagnosed with co-occurring ASD and ADHD. For example, it is only very recently that the first guidelines have been published regarding identification and treatment of co-occurring ASD and ADHD [3]. The goals of this letter are to (1) describe some of the complexities of co-occurring ADHD and ASD from a clinical perspective and (2) highlight the lack of research and guidelines concerning clinical treatment and management of this group of patients, particularly for individuals with an average or above average IQ, and who do not conform to the (male-dominated) prototype for these two neurodevelopmental conditions [4].

Complexities of co-occurring ADHD and ASD. Many patients in our clinic who are diagnosed with both ADHD and ASD describe both difficulties and strengths related to their co-occurring symptoms. These can possibly broadly be described in the following categories: (1) symptoms which exacerbate each other (“double-up” symptoms); (2) symptoms which complement each other advantageously (“serendipity” symptoms); (3) symptoms from each disorder which pull in the direction of different preferences and needs (“contrary” or “clash” symptoms).

An example of “double-up” symptoms is attentional symptoms, where an individual experiences both general difficulties in focusing and maintaining their attention on uninteresting or boring tasks, and also has a narrow range of interests. An example of “serendipity” symptoms is an individual who on the one hand tends to not give close attention to details and thus is vulnerable to making careless mistakes, but has a good eye for details in tasks they find relevant, thereby succeeding in their chosen occupation.

An example of “contrary” symptoms is an individual who both finds social situations tiring (due to sensory sensitivity and increased effort when reading social cues) and quickly becomes bored. This combination may relatively often lead them to seek out social situations, or situations with a high degree of sensory stimulation; this satisfies their need for input, but leaves them exhausted for days afterwards. Another is an individual who both has a strong preference / need for structured plans and “sameness”, and impulsively changes their plans.

This complexity is difficult to understand, both for the individual themselves and their significant others. It can be challenging for clinicians to provide psychoeducation / treatment, as little literature exists to describe these experiences or guide interventions. This is true for the scientific literature, particularly for adults with a higher level of daily functioning, as well as for popular scientific literature that is more accessible to patients and their relatives. Indeed, I owe a debt of gratitude to the patients I work with, for drawing my attention to this lack of literature.

Is lack of research in co-occurring ASD and ADHD particularly prominent in women and others with non-prototypical presentations? Generally, empirical literature on ASD is limited by an under-representation of gender diverse individuals [4]. Women may be under-represented for several reasons. For example, research on gender differences suggests that girls may be consistently under-identified for both ADHD and ASD due to e.g., differential presentation and referral bias. This may particularly be the case when there is no intellectual impairment, and for individuals who successfully use compensatory strategies i.e., “camouflage”; the latter may itself be more common in women [2,4,5]. To the extent that women and others with non-prototypical presentations are not diagnosed with ASD, then this will clearly impact the extent to which they are included in clinical research. Beyond this, research pertaining to life events / biological factors which are unique for some biological females, such as the menstrual cycle, pregnancy, and childbirth are relatively rarely studied. For example, the extent to which the menstrual cycle affects symptoms of ASD or ADHD has only recently become a focus of research interest, and virtually nothing is known about this area in women with co-occurring disorders.

A call to action! There is a gap in our knowledge of co-occurring ADHD and ASD in adults, particularly in women and others with non-prototypical presentations, and where there is no co-existing intellectual disability. This lack of knowledge directly affects clinicians’ ability to offer appropriate and relevant interventions, which are currently undertaken on the basis of sparse research and fewer guidelines. Such research is thus urgently needed; that many patients themselves identify such knowledge as a need in a clinical context lends weight to this argument. In our clinic, we are currently planning research in individuals with co-occurring ASD and ADHD - initially small, qualitative studies aiming to understand the phenomenology of patients’ (particularly women) experiences, and hereafter regarding experiences of individual and group psychoeducation. Hopefully, others in the research community will also take up this challenge.

Disclosure of interests

No funding was received to assist with the preparation of this manuscript.