AAA

(All about Autism …continuing ..)

Dr.P.Sudhakar
Developmental Pediatrician
Autism spectrum disorder (ASD) has a broad spectrum of comorbid conditions, such
as attention-deficit/hyperactivity disorder (ADHD), anxiety disorder, depression,
bipolar disorder, obsessive-compulsive disorder and many more non psychological
conditions.
In this article we discuss about the comorbidity of ASD and ADHD and the
difficulties in differentiating both.
Confusion in day to day practice :
In our clinical practice we often come across very naughty children, always on the
move loaded with motor driven energy . Parents used to be in a confusion about the
hyperactive behavior and we ourselves too may be in a dilemma in labeling it as
age appropriate hyperactive state or inappropriate behavior as an early signs of
ADHD or any other behavioral problems. Any child under the age of 3 to 3.6 years
can have simple hyperactivity with age appropriate development in all five domains
of child development. And a simple hyperactivity doesn’t need an evaluation or
therapy whereas a wrong labeling will lead to unnecessary hardships for the child and
family.

Where we struggle to differentiate :

It is very difficult to differentiate look alike conditions - simple age appropriate
hyperactivity , Attention deficit hyperactivity disorder  (ADHD) and Autism
spectrum disorder by simple observation and history taking. Both ADHD and ASD
share many symptoms even though they are two distinct conditions.
There is no diagnostic test, standardised observation or questionnaire that is specially
designed to distinguish between ADHD and ASD. It needs an adequate exposure and
experience to differentiate these two conditions . Among all the comorbid conditions
attention-deficit/hyperactivity disorder (ADHD) is the most common and even being
a reason for worsening the developmental trajectory of Autism spectrum disorder

Autism spectrum disorder is a communicative behavioural disorder with deficit in

communication / language skills, behavior, socializing, and the ability to learn
whereas ADHD is a condition with deficit in attention or focus and hyperactivity
with difficulty in completing a task . Increasing evidence suggests that the co-
occurrence of ADHD symptoms may exacerbate the adverse outcomes of ASD
patients. For instance, ASD in children with ADHD may be identified at a later age
than those with only ASD which may hinder the early diagnosis and treatment of
ASD. Where as the correct diagnosis of ASD with ADHD at an early stage helps
children get the right treatment so they don't miss out on important development and
learning. People with these conditions can have successful, happy lives if managed
properly on time .

Where we can’t differentiate ASD and ADHD

There used to be Overlap in risk factors and early signals (0–4 years of age) and thus
do not give a direction for differential diagnosis between ASD and ADHD.
1. Birth complications like asphyxia, low birth weight, prematurity,etc..
2. Self-regulation problems ,excessive crying ,easily upset
,overstimulated/irritated ,hard to soothe/calm down, eating problems, sleep
problems, speech delay , and cleanliness (although some of the children with
ASD may maintain over cleanliness )
3. Difficulties in social interaction with peers from toddler- and preschool age:

Where we can differentiate of ASD and ADHD.

Attention :
Look at the child’s attention or focus on any task.
Children with autism are very focused on details and do often not miss details. In
activities, an insistence on sameness and repetition is commonly seen, leading to
fewer sloppy errors in children with ASD  . Children with ASD also struggle to focus
on things which they don't like, such as reading a book but at the same time they
may fixate on things that they do like, such as playing with a particular toy.

Children with ADHD often fails to give close attention to details or makes careless
errors in schoolwork, at work or during other activities and often dislike and avoid
things they'll have to concentrate on.

An unique situation is TV viewing -- Children with ADHD and ASD both can
generally focus their attention for longer periods of time when gaming or watching
television. These are activities that require relatively little patience and sustained
attention, as stimuli and response are alternate and very quick for maintaining an
attention ( practically very little attention span is needed).

Socialness:
Children with either condition may struggle to interact with other people, but those
with autism can have less social awareness of others around them. They often have a
hard time putting words to their thoughts and feelings. And they may not be able to
point to an object to give meaning to their speech. They find it hard to make eye
contact. Whereas Children with ADHD used to be very good in socializing and they
maintain eye contact may be lesser than other typical children which is due to
inattention not as a core symptom.

Language :
Usually both may have speech delay but a child with ADHD, on the other hand may
be talkative. They try to interrupt when someone else is speaking or butt in and try to
monopolize a conversation but it used to be relevant to the topic on discussion .
Here a point to be noted is some children with autism also look talkative, they can
talk for hours but only about a particular topic that they're interested in. A child with
ADHD will stop when asked and restart the discussion process instructions whereas
a child with ASD won’t be able to understand the need to stop on request they will
stick on to their idea and keep on saying about it .

Repetitive Behavior :
A child with autism usually loves order and repetition we can call them Mr.Perfect .
But a child with ADHD find it difficult , even after knowing it helps them can be
called as Mr.Imperfect on a lighter side.
The child with ASD have excessive interest in organizing of toys (instead of playing),
dominance of sensory play that is not in line with developmental level such as
mouthing/putting things into mouth, rhythmical moving (parts of) toys (such as
turning the wheels of a car without meaning in play), echolalia ( both early and
delayed ) and idiosyncratic phrases .

Insistence on sameness and inflexibility :

A child with autism might want the same type of food at a favorite restaurant, for
instance, or become over attached or focused to one particular toy or shirt or colour
or any material. They can become upset when routines change. Children with ASD
like a fixed place for their belongings and ritualized ways of, for instance, packing
their school bag .
A Child with ADHD on the other way doesn't like doing the same thing again and
changes are never a problem for them although children with ADHD without ASD
can also become unsettled in new situations.

The difference, however, appears to be in the nature/direction of the disruption.

In ADHD children due to impulsive action/reward focus that quickly may change
into impatience and frustration is often seen . Whereas fearful tension for new action
is leading to avoidance is often seen in children with ASD.

Nonverbal communicative behaviors used for social interaction :

 
The use of gestures and meaningful eye contact is present in children with ADHD
and sometimes they may be over smart and spontaneous .
However, ASD should be considered when poorly integrated verbal and nonverbal
communication, atypical eye contact and body language, deficits in understanding
and use of gestures, or lack of facial expressions and nonverbal communication are
present.
Reactivity to sensory inputs :
A child with ASD may show indifference to pain/temperature, shows unusual
responses to specific sounds or textures , excessively smells or touches objects and/or
has a visual fascination for lights or movement especially spinning movement
whereas these are usually not seen in ADHD.

 
How Are They Diagnosed?
The greatest challenge in diagnosis of either condition is when they coexist as a
comorbid condition.

Conclusion
The article tries to offer some guidance in approaching whether the problems of a
child with a mixed ASD+ADHD symptom profile can best be explained from an
‘ADHD perspective’ or an ‘ASD perspective’ or whether a co-morbid diagnosis
offers the best fitting description.
Finally we need to accept that an exclusive ‘ADHD/ASD’ perspective is too limited:
in this way, many behaviors may be categorized as belonging to ASD and/or ADHD,
making these diagnostic categories rapidly expanding construct.
Management :
The management needs a multidisciplinary approach involving Developmental
Pediatrician , Pediatric Psychiatrist , ABA therapist and Clinical psychologist
The management should be focused on the broad profile of a child’s core symptoms,
cognitive characteristics, stimuli processing, emotional and behavior problems and
regulaion, as well as adaptive functioning.

We will continue to discuss more and more about comorbid conditions in future
editions……………….