This article is to serve as a review of the diagnoses of Autism, Asperger’s and PDD NOS. You can refer to other articles as to how these relate to ADD/ADHD here: Autism, Aspergers and ADD/ADHD, ADHD Medication and Autism/ Asperger’s.

The Autistic Spectrum includes two major disorders; Autism and Asperger’s disorder and a third one called Pervasive Developmental Disorder Not Otherwise Specified (or PDD NOS).

The main characteristics of the Autistic Spectrum are individuals: 1) who have trouble relating to other people, there are social difficulties, 2) there are behavioral difficulties, things like ritualized behavior and obsessive types of behavior and 3) there is trouble with speech and communication.

Now if someone has all three major categories they would have the diagnosis of Autism. If they have the social issues and the behavioral issues but no trouble with speech or communication they would have Asperger’s disorder. And if they had enough criteria that the doctor is concerned about the pervasive developmental disorders but not enough to meet one of the diagnoses they would have PDD not otherwise specified.

It’s also very important to note that individuals with PDD or autism have a very wide range in functioning. There are some individuals with autism who are developmentally delayed; they can be adolescents or adults and have trouble with toilet training and communication; may only speak three or five words or none and there are individuals with high functioning autism or Asperger’s who go on to get University education, they are professionals, they are “successful” in society and they have families. So there is a very wide range in functioning.

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This article about Autism and ADHD stems from the following question from a subscriber: ‘My son is diagnosed with PDD Autism - we have put him on Ritalin for behaviors and hyperactivity. Our family doctor feels that since the Ritalin has helped that he must also be ADHD. Could that be correct?’

As I wrote about in a previous article: Autism, Aspergers and ADHD, yes it could be correct that a child can have Autism and ADHD. In fact there is about a 50 to 60% chance of kids with autism having an ADHD diagnosis.

I do want to caution you about this kind of logic. I don’t like making a diagnosis because a medicine worked.

In other words just because Ritalin settled down some of the behavioral problems that your son was experiencing doesn’t necessarily mean that for sure your son has ADHD.

If you are concerned about the possibility of ADHD, go to a clinician who can do a thorough assessment, such as a paediatrician, psychiatrist, or psychologist. Have a thorough assessment done and see what the results are.

The medication treatments in child psychiatry are symptom specific not disease specific. This means that the medications treat symptoms, not disorders.

So if he had some hyperactivity related to Autism that may be settled by the Ritalin as Ritalin and other stimulants (like Adderall, Concerta, Metadate, Focalin, Daytrana, etc) have a clear history of helping hyperactivity and inattention in ADHD.

However, based on my experience as a Child Psychiatrist, I think it is possibe if the Ritalin is working then there may actually be a diagnosis of ADHD. However, the best practice of medicine would be to go and get a thorough assessment. This is the proper way, rather than just saying: ‘well the pill worked so it must be so’.

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This article comes from a subscriber’s question about ADHD and Autism.

The question is: “what is the prevalence rate of ADHD when the child has been diagnosed with Autism?”

This is a very good question. In fact this is a question that led me to do a lot of homework. I pulled out the textbooks, I pulled out notebooks from conferences I’ve been to. I pulled out journals, I searched online etc. and I finally have an answer for you. It was a very smart question.

First of all I need to go back to the DSM which as you will recall is the Diagnostic and Statistic Manual of the American Psychiatric Association that has the diagnostic criteria for the psychiatric disorders.

In the diagnostic criteria for ADHD which is covered in a previous article, there are exclusionary criteria.

Criterion E is ‘the symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia or other psychotic disorder etc.”

Now for those of you who are not aware a Pervasive Developmental Disorder (PDD) is another term for autism or another disorder on the autistic spectrum (such as Asperger’s Disorder).

Thus, by strict interpretation of the DSM-IV-TR criteria, when someone has a diagnosis of Autism or a Pervasive Developmental Disorder, then they technically shouldn’t be diagnosed with ADHD.

Coming back to the question: ‘what’s the prevalence rate of ADHD when the child has been diagnosed with autism?’

According to the DSM-IV-TR, it is zero, because it is not possible.

Now the reason why I spent so much time looking for the answer is because I see it in my office a lot; kids who have Autistic Spectrum Disorders (another term for PDD, Autism or Asperger’s) and seem to have ADHD type symptoms and benefit from ADHD treatments.

I was able to find somewhat of an answer in an article published by Goldstein and Schwayback in the Journal of Autism and Developmental Disorders published in June 2005.

In that article they looked at 57 kids with an Autistic Spectrum Disorder and they reviewed all of the data available in what was called a retrospective chart review - that’s looking back at children that had already been assessed. They found that they had sufficient data in 27 children to see whether they actually had ADHD symptoms to the level that they could meet a diagnosis for ADHD. Of the 27, 7 of them or 26 % met enough criteria to reach a diagnosis of ADHD combined type. Nine of them or 33% had enough criteria to meet the ADHD inattentive type and 11 of them or 41% didn’t have any ADHD type symptoms.
In this very small sample, what I would call a preliminary study, about 26% of these Autistic kids had ADHD combined type and 33% had ADHD inattentive type; 41% didn’t have ADHD at all.

Now as I said this is a very preliminary study and it’s not conclusive at all and certainly a lot more needs to be done.

I will tell you that in my clinical practice I do see kids with Autistic Spectrum Disorders who do have symptoms of ADHD, or meet the full diagnostic criteria.

Perhaps I should have prefaced this article with the fact that I can’t do a comprehensive review of Autism in this article. Frankly, a whole blog can be written about autism because of its complexity and the struggles that families have in dealing with children (and teens and adults) with Autism. For an overview, please visit this article on Autism and Asperger’s.

So coming back to our question I guess we can say that according to a preliminary study 26% of kids with autism had ADHD combined type and 33% had ADHD inattentive type suggesting about 50 to 60 percent of kids with autistic spectrum may have ADHD. As I say take this with a big grain of salt because it’s a preliminary study.

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A subscriber sent in this question: “when I was a child I was diagnosed with ADD. Although I was never on medication I didn’t actively seek much help. I’m beginning to realize that perhaps now at age 26 it is related to my depression and anxiety issues as well as motivation. I’m still struggling to get through a degree and not quite sure where to turn. I think I should go see someone about this but I’m not sure who the best person to turn to is”.

This question is a very important one. This is an adult who is describing having been diagnosed with ADD early in life and now has depression and anxiety issues. It sounds as if the depression and anxiety are the main concern - however, let’s remember that this person sent his/her question in to The ADHD Doctor! So, obviously there is some concern there about the impact of the ADD or ADHD as well.

This question is very important along the lines of comorbidity of ADD and ADHD, particularly in adults.

I’m going to assume that the individual who diagnosed the ADD early on was accurate, and that a thorough and complete assessment was done.

Is ADD still a problem for this individual?

I don’t have a lot of information to go on, but it seems that it likely still is. He or she is struggling with motivation, and completion of a degree. That said, this could be completely related to the depression and anxiety that is going on.

It would be important for this person to have a thorough assessment with a psychiatrist with expertise in adult ADD or ADHD. The problem is that they can be hard to find. Also, often it is the child psychiatrist who are better at ADD or ADHD. All child psychiatrists train in adult psychiatry first, and we learn about ADD and ADHD, and how it can change through the course of the lifespan.

Comorbidity in adult ADD is very common. Only 14% of adults with ADD don’t have a second disorder. In other words, comorbidity is the rule, not the exception.

It is very common for an adult with ADD or ADHD to have comorbidity with depression and anxiety.

Sometimes, it is minor depression or anxiety - somewhat of a self esteem issue. This can relate to all of the years of people saying:
“you would do better if you would only live up to your potential, or try harder or keep more organized, I know you can do better etc.”

Eventually a person with ADD can start to feel, “well I must be that kind of loser that everybody’s talking about.”

Then, depression and anxiety can develop.

Coming back to the specific question, the main issue for this person is figuring out if the depression and anxiety are the main problem, or whether the ADD is still active and is the main problem.

If the depression and anxiety are the main problem (or the dominant problem, even if ADD is still there), then they have to be treated first, with therapy plus or minus medication. After these are more stable, it would be important to review if ADD is still there and if it needs treatment.

If the ADD is the main problem, then it will need treatment - with therapy, coaching, plus or minus medication. If the ADD improves, most likely minor depression and anxiety would improve as well.

It can be very complicated for adults with ADD or ADHD, because there aren’t that many doctors who are comfortable and competent in adult ADD.

Start with your primary care doctor (family doctor), ask questions, and seek referrals until you have the answers you need. Also, consider a psychologist who may be able to help with the diagnosis and therapy, though he or she couldn’t prescribe the medication.

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There is a very important concept in ADHD called comorbidity. Comorbidity means that there is a co-existing disorder that causes more ‘morbidity’, or in other words difficulties in one’s life.

It is very common for people with ADHD to have comorbid (or co-existing) conditions. Only about 25-40% of kids and teens with ADHD have ADD or ADHD alone. Most of the time (i.e. 60-75% of the time), there is a second, or third diagnosis as well.

The most common comorbid conditions with ADD or ADHD in kids and teens are: Learning Disabilities, Behavior Disorders (including Oppsitional Defiant Disorder and Conduct Disorder), Anxiety Disorders, Mood Disorders (commonly Depression, rarely Bipolar Disorder), tic disorders (like tourette’s), etc.

In adults - comorbidity in ADHD is very common. Research has shown that only about 14% of adult ADHD is simple ADHD, meaning that 86% of adults with ADD or ADHD actually have a second or third disorder.

While the list of comorbid conditions in adults is similar to the one in kids, it is important to note that there are some significant additions. These include: substance abuse and dependences (i.e. drug and alcohol addiction/dependence), and personality disorders. Adults still have high rates of Learning Disabilities, Behavior Disorders, Anxiety Disorders, Depression and even Bipolar disorder.

The reason that comorbidity in ADD or ADHD is so important relates to the fact that often times, the comorbid condition can be so important that it can completely dominate or change the treatment for the whole condition.

For example, if one has ADHD and an Anxiety disorder, there is research that shows that the response to medication may be different. For example, some studies show that the use of a stimulant (like Concerta, Ritalin, Adderall, Biphentin or Metadate CD) may actually worsen the anxiety. There are other studies that show that they don’t worsen the anxiety, but don’t help it. However, Strattera, the non stimulant for ADHD, has been shown to help the anxiety and the ADHD at the same time.

Another example is if a child has ADD and a Learning Disability. If this occurs, one needs to treat both in order to get a good effect. If one were to only treat the concentration, then there could still be problems with processing information (i.e. the learning disability). If there were academic supports and treatment put in place for the learning disability, but there was not effective treatment in place for the ADHD, then the child could struggle to pay attention in order to benefit from the help in place for academics.

The bottom line: a thorough assessment for ADD or ADHD will review whether there are any comorbid (or co-existing) conditions present. Knowing about these comorbid conditions is crucial because it can actually affect the primary treatment of the ADD or ADHD.

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