Photo Credit : Steven Libralon on Unsplash
Authors: David Nicholas, PhD (1), Adam McCrimmon, PhD (2), Emma Climie, PhD (2)
(1) Faculty of Social Work, University of Calgary
(2) Werklund School of Education, University of Calgary
Contents:
- Introduction
- What is Autism?
- What is Attention Deficit/Hyperactivity Disorder (ADHD)?
- Reflections of Dr. Climie and Dr. McCrimmon about ADHD
- The Overlap of Both Autism and ADHD
- Supports for Autism and ADHD
- Recommendations
- Some Concluding Remarks
- Additional Autism and ADHD Information
- References
1. Introduction
Autism and Attention Deficit/Hyperactivity Disorder (ADHD) are neurodevelopmental conditions that may be experienced by youth or adults. We recently spoke to two researchers in the fields of ADHD and autism: Dr. Emma Climie who focuses on ADHD, and Dr. Adam McCrimmon who focuses on autism. Before describing their comments about autism and ADHD, we start by introducing what is autism and ADHD. For a more detailed research review of ADHD and autism, see https://aidecanada.ca/resources/learn/asd-id-core-knowledge/considering-the-co-occurrence-of-autism-and-attention-deficit-hyperactivity-disorder .
Photo by Glenn Carstens-Peters on Unsplash
2. What is Autism?
The two main features of autism are challenges in social communication and the presence of restricted and repetitive behaviours and interests1. Some examples of social and communication challenges in Autistic individuals include differences or challenges in shared conversation; social interactions; and understanding of facial expressions, emotions, or gestures. Restricted and repetitive behaviours can take the form of maintaining routine and sameness, sensory over- or under-stimulation, having passionate areas of interest, or engaging in repetitive movements or speech1.
3. What is Attention Deficit/Hyperactivity Disorder (ADHD)?
ADHD has two main features of inattention and hyperactivity-impulsivity1, 2. These features lead to three different ways of being: 1) both inattentive and hyperactive/impulsive, 2) mostly inattentive, and 3) mostly hyperactive/impulsive1. It is important to note that there are differences in ADHD and autism.
4. Reflections of Dr. Climie and Dr. McCrimmon about ADHD
In terms of what ADHD looks like, Dr. Climie says, “One important feature of ADHD is that there is no typical profile. If you have met one child with ADHD, you have met one child with ADHD because 100 different kids with ADHD will have 100 different symptom presentations. This is important to keep in mind, especially when you are considering intervention and supports. These is not going to be a ‘one size fits all’ type of approach.”
Dr. Climie further explains, “We often see more of the hyperactive behaviors in younger children. We see an inability to sit down; they may be always moving, are not able to focus, and may be up and down, and all over the place. It is when they get into school that the more inattentive behaviours tend to show themselves. So, while they may be able to sit in a chair, they are still not able to sit and focus on the work that they are doing.” An AIDE Canada reviewer reflected and added, “But how would this change if the child was asked to spend all day outside helping their parent on their farm? Would the child still be unable to focus and learn? Probably not. So perhaps we need to emphasize that the environmental demands of the regular classroom are not particularly well-aligned to the needs of the child’s neurodivergent brain.”
Considering strategies for support, Dr. Climie comments: “Gradually, strategies are developed, interventions are put into place. As individuals move into the teenage years and into adulthood, there is usually less hyperactivity, and we see more of that inattentive piece. Individuals with ADHD certainly are able to develop strategies, but in a bit of a different way.” She adds, “ADHD certainly does persist into adulthood. It is not a condition that once you hit 18 or 19 years, it magically disappears.”
ADHD, like autism, is overrepresented in males compared to females. “We see about three boys for every girl that is diagnosed, although I think that there is certainly an underdiagnosis for females. In moving into adulthood, we see the male/female ratio becoming closer to one-to-one. That gives us an indication that maybe we are not as good at identifying females when they are younger” notes Dr. Climie.
5. The Overlap of Both Autism and ADHD
Commenting on autism and ADHD, Dr. Climie states: “Now it has become more recognized that neurologically there are overlaps between autism and ADHD. But there are also distinctions between ADHD and autism.” Dr. McCrimmon adds, “There are more people with an autism diagnosis that also have an ADHD diagnosis in comparison to people that have an ADHD diagnosis that also have an autism diagnosis. It seems to be a more unidirectional than bidirectional relationship.”
6. Supports for Autism and ADHD
Individuals with both autism and ADHD may have academic struggles in school or daily life. A few recommendations for support are: education about autism and ADHD and learning strategies for school staff and teachers, better recognizing and accommodating the sensory needs of individual students, and creating a personalized education plan (PEP)3. Dr. Climie explained that for a child with both autism and ADHD, “having a teacher that they feel listens to them or likes them” is important. She also recommends “making school a welcoming place where the student feels like they are accepted, no matter what kind of day they are having.”
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Photo by Arthur Krijgsman on Pexels
Dr. McCrimmon highlights the importance of employment support because, “individuals with autism and/or ADHD can be very successful and valuable employees, if only employers and organizations would understand and recognize the strengths they have, and make adaptations to enable them to be successful.”
In terms of offering support, Dr. Climie comments, “It is really hard to teach kids with ADHD skills when they are dysregulated.” She adds that medications can help “bring them down a notch” for caregivers to “work on some of the skills that need support such as social skills for children with autism.” Dr. McCrimmon adds that “medication for ADHD can help kids be primed to learn new skills, but the medication itself does not teach them skills.”
While research suggests that individuals with a dual diagnosis may experience challenges, Dr. Climie notes, “there are a lot of children on the autism spectrum with ADHD that are doing really well in aspects of their life.” She emphasizes the importance of individuals with these two diagnoses, “finding their path and recognizing things that they do well.” She advocates for a “strengths” focus as “continually focusing on the deficits can be very difficult whereas also focusing on what individuals with autism and ADHD are passionate about and strong at, will bring more balance in their lives.” This is echoed by Dr. McCrimmon who says, “there are a lot of individuals that I have either diagnosed with autism or both (autism and ADHD) that are considered quite successful.” He describes instances of, “[individuals] thriving and things that people could do very well, and how they could be successful.” He adds that now there seems to be, “more appreciation for what success means and how we can support people to get there.”
7. Recommendations
Dr. McCrimmon and Dr. Climie were asked to provide recommendations for (a) parents of individuals with suspected or confirmed dual diagnoses of autism and ADHD, (b) adults with these two conditions, and (c) service providers who work with this group.
a) Parents
Dr. McCrimmon: “Unfortunately, the reality is regardless of which province or territory you are in, systems are not designed in a way to be easily navigated by parents – especially when you are working with two or more different diagnoses. But there are many community-based support agencies that may be helpful. And that will likely depend upon where is the closest major urban centre, and the kind of supports you are looking for. There are specific organizations that can help navigate services because parents can get overwhelmed in the search for services.”
Dr. Climie: “Keep fighting. Keep going. Do not accept the first ‘No’. Parents have to fight for services, but certainly they are their child's best advocate. All the time and effort they put in early on, will help as they move forward. So keep at it.”
b) Adults with Autism and ADHD
Dr. McCrimmon: “Adult diagnosis of autism is a very emergent topic/issue right now. Research suggests that the most frequently diagnosed population are adults on the autism spectrum. A lot of that is because when they were younger the diagnosis did not fit for them, or perhaps, when they were younger, that diagnosis did not exist. Most autism diagnoses are made in childhood, or even in adolescence, so it is not common to find clinicians that work with adults. As a result, fewer clinicians work with that population. It is not uncommon for people to have a two to three-year waitlist to try and see a clinician or a clinical team to get an autism diagnosis. This can be a big barrier to just get that one diagnosis much less try to look at autism and ADHD together…. If you are going to get a diagnosis, who you get it from can be very important.”
Dr. Climie: “There is certainly an increase in adult women who are being identified with ADHD right now, again because 30 to 40 years ago, there was much less identification of ADHD in general, and girls can slide under the radar a little bit more. They are not up running around, they are more quiet and ‘daydream-y’, if they are on the ADHD side. We are finding that there are quite a few university-aged and older women who are recognizing that they are having difficulties in some areas. Often times, it is because their kids are being diagnosed with ADHD, and they reflect back, ‘Well wait, they are just like me. So, if my child has ADHD, what does that mean for me?’”
c) Service Providers
Dr. Climie: “One of the big pieces that needs to be addressed is sharing of relevant information between practitioners, not about individual clients, but rather about the research and this area in general. Psychoeducation has been found to be a really critical component for parents; for instance, to be able to understand ‘what is autism?’, ‘what is ADHD?’. But the same can be said about medical professionals and psychologists. They need to have greater awareness that first of all, autism and ADHD do co-occur. I am sure that they would be aware of that, but what does that look like and how might a combination of autism and ADHD be experienced? And what is a little bit different in how the various conditions present?
That also extends to the schools. With the prevalence of autism and ADHD, in a class of 20-25 kids, you are going to have one, two or three of them who likely will have these challenges whether they have a single or dual diagnosis. It is important for the teachers to be able to understand how these children’s minds work, what works for them, what ADHD and autism are, and how they can provide supports in the classroom so that they are best able to not only teach to academic success, but also support behavioral management, classroom management, and needed social skills. Another important piece that comes with that is ‘neurodiversity’ (recognition and appreciation of differences in how people’s brain functions). While this is acknowledged, it may not be as much in the forefront as it could be. I certainly think that ensuring teachers have opportunity for such professional development is really important.”
Dr. McCrimmon: “Even though somebody might be within a prominent discipline in this area and have a lot of practice experience, that does not mean that they have sufficient knowledge in this area. Guidelines evolve and therefore change your understanding of relevant issues and topics.”
8. Some Concluding Remarks
Thank you to Drs. Climie and McCrimmon for their reflections.
For more information and resources, contact your local autism society or visit the Canadian Mental Health Association in your area (https://cmha.ca/find-help/find-cmha-in-your-area), or visit their site (https://cmha.ca) to find information or access the provincial/territorial site. AIDE Canada also offers related toolkits and other educational tools and a listing of various resources in communities across Canada at: https://aidecanada.ca/resources/locate/asset-maps. Below is some online information about ADHD and Autism.
9. Additional Autism and ADHD Information
Autism:
Autism Alliance of Canada: https://autismalliance.ca
AIDE Canada: https://www.aidecanada.ca
National Autistic Society (UK): https://www.autism.org.uk/advice-and-guidance/what-is-autism
Autism Societies in your province or territory
ADHD:
Centre for ADHD Awareness Canada (CADDAC): https://caddac.ca/
The Canadian ADHD Resource Alliance (CADDRA): https://www.caddra.ca/
Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD): https://chadd.org/
Totally ADD: https://totallyadd.com/
10. References
1American Psychiatric Association. (2022). Neurodevelopmental disorders. In Diagnostic and statistical manual of mental disorders (5th ed., text rev.).
2Abraham, A., Hui, J., Moloney, F. (2022). Psychiatry. In Y. Lytvyn & M.A. Qazi (Eds.), Toronto notes: Comprehensive medical reference and a review for the Medical Council of Canada Qualifying Exam (MCCQE) (38th ed.). Toronto Notes for Medical Students, Inc.
3Young, S., Hollingdale, J., Absoud, M., Bolton, P., Branney, P., Colley, W., Craze, E., Dave, M., Deeley, Q., Farrag, E., Gudjonsson, G., Hill, P., Liang, H. L., Murphy, C., Mackintosh, P., Murin, M., O'Regan, F., Ougrin, D., Rios, P., Stover, N., … Woodhouse, E. (2020). Guidance for identification and treatment of individuals with attention deficit/hyperactivity disorder and autism spectrum disorder based upon expert consensus. BMC medicine, 18(1), 146. https://doi.org/10.1186/s12916-020-01585-y
