Change in the relationship between ADHD and Autism, in the DSM-5.

The DSM-5 (the updated diagnostic manual, due to come into effect next year), has made a change to the relationship between ADHD and autism. Previously, the two conditions could not officially be diagnosed together, due to an express exclusion under ADHD, which requires that the ADHD symptoms didn’t occur during the course of a Pervasive Developmental Disorder (autism). The new ADHD criteria remove that restriction.  Research (and plain good reasons) are cited for the change.

The reasons provided for the change are highly persuasive; the reasons for the initial (and continued) exclusion, are not.

Particularly noteworthy reasons for the change, are that the medications used for ADHD can be of great benefit to those with autism who have relevant issues, and that it is possible there is a specific subgroup of those with autism who present with ADHD (which appears to be about 30%) – that there may be overlapping genetic influences for both conditions. It is also possible that those who present with both ADHD and autism, have different “neurobiological and clinical correlates” than those with just autism. So the forced separation of the two diagnoses, gets in the way of potentially effective treatments, and gets in the way of truly reflecting and understanding the relationship between these two conditions, and in turn the meaningfulness of the absence of ADHD from those with only autism.

So why were they separated in the first place? Apparently a key concern was that autism would go under-diagnosed otherwise, and that those who would have benefited from autism interventions would be more likely to miss out, as the autism inattentiveness would be confused with ADHD. (One of the concerns about allowing them to now be co-diagnosed, is that the prevalence of ADHD diagnoses will increase.)

The fact is that medical professionals have already been diagnosing ADHD alongside autism (anecdotally anyway; I know of very many families who have had both diagnoses declared for their child). It’s also already widely known that some ADHD medications are helpful (and used) for the relevant issues experienced by those with an autism diagnosis. It seems that this change is just bringing autism and ADHD diagnostic rules, in line with existing clinical behaviours and the body of research in this area.

I don’t know much about ADHD, ironically what I do know about it I almost exclusively learnt through personal research into autism and through autism blogs. My own son does not appear to have ADHD from what I’ve read of the criteria. He does have many of the “inattentiveness” traits required for a diagnosis under that heading, but it is of a different qualitative sort of inattentiveness as I understand it; ways that can be, are sufficiently, and are better explained by his autism. I can clearly and easily imagine that there are cases where those ADHD criteria are met quite independently and in addition to the autism-caused behaviours. It’s an interesting distinction though, and one I intend to do further research into.

From what I understand, there is broad approval of this particular DSM-5 change. I would be interested to hear whether you think this change will impact on your own child’s diagnosis / diagnoses, and whether you think the change is a positive one. I’d be particularly interested to hear from those whose children already have both diagnoses, and what their clinicians said to them about the comorbidity when diagnosed.

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12 Responses to Change in the relationship between ADHD and Autism, in the DSM-5.

  1. usethebrainsgodgiveyou says:

    My son had an autism diagnosis from a psychiatrist, and an ADHD diagnosis from his pediatrician. I’m waiting for them to add learning disabilities to the mix (dyslexia). My son took ritalin, but he hated it and said it made him feel like a zombie. No drugs when we started homeschooling grade 9.

  2. xaraxia says:

    My eldest child was given an ADHD diagnosis, and only after changing to his younger brother’s paediatrician did the secondary PDD-NOS diagnosis pop up. ADHD is the greater challenge for him, but being aware of the PDD is incredibly useful. I wasn’t even aware that they weren’t supposed to be diagnosed together, but I certainly approve of the separation. The ASD inattentiveness of his younger brother is quite different to the ADHD behaviours. Ritalin helps immensely. It’s a stimulant, so it’s interesting that it made the person’s child above feel like a zombie. My brother had an ADHD diagnosis as a child but Ritalin didn’t make enough of a difference to justify the headaches that he got.

    • I’ve heard those mixed reactions about Ritalin before; that for some children it has the exact opposite effect than in other children. Neurological differences can have a big impact on how drugs affect each individual, I’m guessing here. Our son hasn’t been on any of these types of medications, so I can’t speak from personal experience in that regard.

  3. Bec Oakley says:

    I have one son who officially has both diagnoses, but my suspicion is that it’s the result of that diagnostician having a poor understanding of autism. So I wonder how often that happens, since it’s been my experience (and certainly throughout much of what I’ve read) that the causes of inattention and hyperactivity in autistic kids is not well understood by clinicians and researchers.

    • I think that’s a fair and very real concern here. I suppose the question for those writing the Manual is whether including or excluding the co-diagnosis significantly impacts on those concerns, and whether those concerns then outweigh the arguments going in the other direction. Thanks for your thoughts and experiences Bec.

  4. mrsstone says:

    I have some concerns about these two diagnosis as co occurring. Prior to better Autism awareness many ASD kids were mis diagnosed with ADHD/ADD and medicated, perhaps unnecessarily. And I am certain my son would receive that dx today if he went to a Dr who was ignorant about Autism. When you consider some of the primary neurological/behavioural impacts of autism such executive function problems, impulse control issues, emotional regulation issues and so on, they mirror in many ways what ADHD looks like. But do we have two separate diagnosis or is it just that autism can manifest in those ways because similar parts of the brain to ADHD are affected? Which is perhaps why some improvement can be seen with medications in some cases.
    If Drs use behaviours rather than diagnosis alone to determine whether medication may be helpful (which I am sure they must do) then a diagnosis of Autism alone should not preclude the use of any pharmaceutical intervention. But I’d hate to think drugs become the first port of call in the treatment of ASD for kids who struggle to focus, with attention to task or impulse control. My son clearly has these struggles, but I see that very much as part of his autism. And with intervention tailored to meet those struggles, alongside the maturing process I see no need at this stage to consider any additional diagnosis. Of course this is just my experience, but like Bec above, reading and talking to so many other parents about this issue, I have some concerns about how people think about and understand autism.
    I do think this is a really interesting topic and the science is obviously continually evolving. I am aware of many children having the co occurring diagnosis, despite what the current DSM states. So clearly many professionals feel that co occurring diagnosis is warranted.

    • Really interesting thoughts Sharon.

      I used to think it made a lot of sense to keep the two separate, and was initially concerned about the co-diagnosis, but was swayed by the arguments presented by the groups working of the DSM-5 and various other organisations that have welcomed the changes. But you make some powerful points in response to those arguments. I do wonder though on the point of misdiagnosis, whether keeping the two separate would make any difference to those more ignorant doctors; just because they can’t co-diagnose right now, doesn’t mean they know it’s actually autism. I wonder too whether a good way to address remaining concerns wouldn’t be a strong reminder in the diagnostic manual to doctors to consider autism alongside or instead of ADHD, rather than the more simple removal of the barrier that currently exists. I suppose at some point we simply have to trust that the professionals in this field will do their research and make proper enquiries, and listen to the parents when the parents feel the diagnosis is wrong or inaccurate in some sense.

      Thanks for your comment, definitely food for thought there.

      • mrsstone says:

        When reading this comment from your link above,

        “Many kids with autism do have attention issues,” he says. However, the nature of the problem is different than in ADHD. It’s difficult to get the attention of children with ADHD or to keep them on task. In contrast, children with autism have trouble shifting attention away from their narrow range of interests.”

        It highlights my concerns. I think this statement alone reflects a narrow idea of what autism looks like as neither of my kids have narrow range of interests, but both struggle with focus on task and attention. The only different intervention we could apply in their cases is medication, which would not resolve the issues with executive function that I suspect are responsible for a lot of their focus issues. Along with fear of failure, impulse control, emotional lability etc. My daughter is no trouble in class so I see no benefit for her with medication and my son is very difficult in a classroom, but this is motivated by his need to control his environment (a common autistic trait) but it would be so easy to dismiss his behaviours as attention deficit and hyperactive, because if you don’t understand autism, that’s what it looks like.

        I suppose I cant argue that ASD and ADHD cant co occur, because I don’t know that. However when I ask parents what behaviours their child exhibited to get the additional ADD diagnosis they always sound to me like behaviours that could be attributed to the neurology of autism. Which leaves me wondering how they tease out the two? Anyway I find this an interesting topic and I thank you for raising it. People far wiser than I obviously disagree with my thoughts on this 🙂

  5. grahamta says:

    I woke up this morning, told my husband that I really think my child’s biggest issue right now is she needs to slow down and he agreed. I searched for adhd and autism and found your great post.

    Her inability to “slow down” is impacting everything…from cutting paper (she rushed through it and can’t even stop long enough to cut a line that curves slightly at the end), to puzzles, to new language learning, to the ability to stop and look at buttons on her talker to make the best choice, etc. Her sensory stuff drastically reduced at home (I am homeschooling), she is stimming less now, she is not extremely restrictive with her interests like some kids with autism I have seen, so we are left with this adhd-like problem as the biggest hurdle at the moment. We did not have adhd as a co-diagnosis. I wish we had, because it may have made me look at the problem differently. Yes, everything is overlapping, but if you look at adhd-like symptoms as the PRIMARY issue with learning (especially at home), it is helpful to me.

  6. Pingback: Musings on Autism and Attention-Deficit/Hyperactivity Disorder (ADHD) | Fumbling Thru Autism

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