Autism and ADHD often go hand-in-hand. What’s it like to have ‘AuDHD’?

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If there’s anything this newsletter has repeatedly taught me, it’s that our minds are so much more complex than we can imagine. There’s so much we don’t know, and whatever we think we know will evolve with time.

I’m so grateful for how your questions let me poke around the largely unknown corners of the mind. For example, I read something earlier this year about how an estimated 22% to 83% of autistic children meet the criteria for ADHD and, conversely, 30% to 65% of children with ADHD (attention-deficit/hyperactivity disorder) have significant autistic traits.

The wide range of percentages here underscores how much more research needs to be done if we’re to fully grasp the depth of the connection between ADHD and autism. Still, it’s an overlap worth exploring — and one that complicates the simplistic, categorical packaging of neurodivergence we’re often handed (such as what’s presented in the DSM 5, the diagnostic handbook widely used by psychotherapists and psychiatrists in the United States).

In fact, a dual-diagnosis of ADHD and autism wasn’t permitted by the American Psychological Assn. (APA) before 2013 because practitioners believed you could only be one or the other.

For the second piece of our three-part series on neurodiversity, I spoke with three psychotherapists who specialize in working with “AuDHD” clients (folks who experience some version of both), who are all AuDHD themselves. We unpacked what ADHD and autism have in common, how AuDHD is experienced, and the likely roots of this overlap.

The latest science on ADHD

Last week, I wrote about the evolving understanding of autism and the harmful misconceptions that remain. I encourage you to read that piece if you haven’t already.

First, let’s briefly dive into the science of what we know today. Like autism, ADHD is a neurodevelopmental condition, which means it affects how the mind functions from a very young age and into adulthood. Brain scans of people with ADHD have shown structural and chemical differences; this research has led scientists to believe that ADHD could be caused by a deficiency of the neurotransmitter norepinephrine, which is made from dopamine, an integral part of the brain’s reward system that motivates us to do things that feel good.

This shortage of norepinephrine in people with ADHD is thought to create challenges in the areas of executive functioning (which enables us to plan, focus, remember and juggle multiple tasks), impulsivity, attention, organization, hyperactivity and emotional regulation. (If you’re feeling overwhelmed by the science jargon, here’s a two-minute video about ADHD that gives a nice visual of how the condition presents in the brain).

One common misunderstanding about ADHD lies in its very name, according to Dr. Edward Hallowell, a psychiatrist who treats people with ADHD and has ADHD himself. “It’s a horrible term,” Hallowell told Mashable. “We don’t have a deficiency of attention, but an abundance of it.” Hallowell compared ADHD to having “an amazingly powerful Ferrari engine of a brain with bicycle brakes. So your challenge is to control it.”

People with ADHD have what’s referred to as an “interest-based” nervous system, meaning that their attention is allocated unevenly. They can feel more focused or motivated when a task is interesting, novel, urgent or competitive in nature. As a result, people with ADHD can experience something called “hyperfocus,” or intense concentration on a particular task, so much so that they lose their sense of time.

People with ADHD can also be overcome with intense and sudden emotion, and may have trouble shifting their mindset to consider other aspects of a situation.

Just like autism, ADHD presents differently from person to person. But one thing many folks with ADHD have in common is having to exert a lot more mental energy than the non-ADHDer to complete ordinary tasks — like responding to emails or doing laundry — that might be unstimulating to the ADHD mind.

The APA recognizes three different types of ADHD, though some think there are probably many more, likening ADHD to a constellation of characteristics similar to the autism spectrum. You can read more about the kinds of ADHD here.

The ADHD and autism overlap

Though ADHD and autism are distinct from one another, they share some traits, particularly when observed from the outside.

And teasing out the overlap between ADHD and autism is complicated, said Megan Anna Neff, a clinical psychologist and neurodivergent advocate based in Portland, Ore.

“Is my desk always a mess because of my executive functioning struggles associated with autism or ADHD? Is the reason my email inbox says 1967 unread emails (most of them spam, but probably some important ones hidden in there) because of ADHD or autism? Is my impulsivity, failure to close drawers, constant restlessness, tendency to interrupt people or the fact that I’m always looking for my keys, phone, and credit cards my autism or ADHD?” she wrote in this great explainer about AuDHD.

Here are some traits that autism and ADHD can have in common, according to experts:

• Repetitive movement: Stimming (repetitive behaviors like bouncing, rocking, clapping, picking at skin, and twirling or pulling hair that help soothe intense feelings). Fidgeting caused by ADHD can resemble stimming.

• Executive functioning: Challenges may include difficulty organizing tasks, remembering things, focusing, and struggling with impulse control and decision-making.

• Sensory processing: Autistic people and ADHDers may be over- or under-sensitive to tastes, sights, noises, smells and touch. Hypo- or hypersensitivity to stimuli are not part of the formal diagnostic criteria for ADHD, but many people with ADHD often report it as part of their experience.

• Socializing: Both groups struggle with picking up on social cues, but often for different reasons, Neff said.

For autistic people, this is more often related to difficulties picking up on body language or vague speech, or knowing what is deemed appropriate in specific social settings — “like knowing that what you say in a bar or a college party doesn’t transfer to what you can see in a classroom, or someone you’re just meeting in a grocery store. Context shifting is harder for autistic brains,” Neff explained.

“In ADHD, there’s instead an underlying mechanism of ‘not having a filter’; it’s more about impulsivity than not intuitively being able to read social cues,” Neff said. “Or it’s tied to inattention in conversation, which could lead to some awkward social moments. There’s also difficulty maintaining friendships sometimes, because that takes executive functioning skills.”

• Emotional regulation: Both ADHDers and autistic people can struggle with regulating and soothing intense emotions, Neff said. This is believed to be caused by having more sensitive amygdalas (the part of the brain that processes fearful and threatening stimuli) and nervous systems.

• Divergent brain patterns: “Both tend to think more in associations or networks,” Neff said, and conversations can seem non-linear. There’s a lot of sharing through story-swapping between ADHDers and autistic people.

The experience of being autistic or having ADHD also creates some commonalities in the way that people cope with being rejected or treated poorly because of their neurodivergent minds.

Research indicates that both groups may be more likely to experience traumatic life events, particularly interpersonal trauma such as bullying and alienation. Studies have shown that autistic people and ADHDers are more likely to seek relief by using drugs and alcohol, and are at a higher risk for anxiety and depression.

Stacie Fanelli, a therapist at Equilibrium Counseling Services, a queer- and neurodiversity-affirming practice in Rancho Cucamonga, specializes in working with autistic people and ADHDers with eating disorders. “The reason why eating disorders are more common in both populations is that we’ve been told, ‘The way you do this is wrong, you’re not enough, you’re lazy’ — with all of that messaging, you’re going to find some way to be good enough,” she said.

Why the overlap between ADHD and autism?

As I mentioned up top, it’s only been 10 years since the psychiatric community acknowledged that these diagnoses can coexist in the same person; so research into why ADHD and autism often coincide is limited but growing.

Autism and ADHD are both thought to involve multiple genes, but the specific genes involved can differ from person to person.

So far, some studies have shown that the two conditions may have some common genetic roots. For example, firstborn children of women with ADHD are more than six times more likely to have ADHD themselves, and are twice as likely to be autistic compared with the general population, according to a 2014 study. And a 2018 study of almost 2 million people born in Sweden found that autistic people as well as their family members are much more likely to also have ADHD.

“The research is new, but it’s starting to show how common it is to see autism and ADHD co-occur in the same family,” Neff said.

One thing to consider about this research: People of color have historically been less likely than white people to be diagnosed with autism or ADHD. That’s for a range of reasons, including cultural differences in parenting and how childhood behavior is perceived, how costly it can be to get a diagnosis, and systemic racism. A lack of diverse experiences in research limits how much we can really know about the experiences of all people with these conditions.

To read more about this, check out this NPR story.

The AuDHD experience

I asked this week’s experts to describe what it’s like to be autistic and have ADHD, as they and their clients experience it. Again, everyone is unique, but here are some interesting AuDHD takeaways:

• They balance and support each other at times, said Jamie Roberts, AuDHD psychotherapist and founder of Equilibrium Counseling Services. “Those with ADHD may struggle with organization and initiation of tasks, while autism likes structure and routine,” she said. “Sometimes, the autistic brain can kick in and balance some of the challenges the ADHD side might be having. Sometimes ADHD is missed by clinicians because autism is helping with executive functioning.”

• Special interests and hyperfocus: Autistic people very often have special interests, or intense fascination with specific topics. “My special interest is psychology. So in school and work, I’m hyperfocused, hyperaware, super-engaged, very on top of it,” Roberts said. “Outside of that work atmosphere in which I thrive, I struggle to go to the grocery store, laundry piles up in corners. But at school at work, people would never known.”

  Neff described a similar hyperfixation on her special interest, which makes her look “incredibly focused,” they said. “When I’m not focusing on my special interest, I’m much more distractible and forgetful. My ADHD becomes much more evident.”

  In AuDHD, special interest may change more rapidly than for those who are only autistic, Neff said. “It may last only a couple of months, but the intensity of the special interest remains the same,” she added.
  

• Conflicting priorities: Being on time is very important to Fanelli, but she often isn’t — and that can be distressing, she said. “In autism, routine and sameness can be very highly valued, and ADHD can make it really hard to implement. It feels like you’re really always fighting yourself, and there’s some identity confusion that comes with that.” Fanelli also noted that novelty and newness are valued by people with ADHD, while for autistic people, such novelty can feel deeply dysregulating.
  
• Putting yourself out there: AuDHDers may seem more extroverted in social situations than someone who is only autistic, Neff said. That’s because autistic people often don’t have a strong social drive, while ADHDers may be more talkative and outgoing (though this is not always the case).

Ultimately, this shared ground between autistic people and those who have ADHD could serve as a force for community-building in a world that largely doesn’t take neurodivergence into consideration, experts told me.

“Finding a neurodivergent community is healing for many of us, because it helps us feel more seen and validated,” Neff said.” I talk a lot about neurodivergent shame, and that’s such a common and painful experience for many of us. Being in community helps us address internalized ableism and be emotionally more resilient.“

Learning about the connection between ADHD and autism has made me excited for all that’s left to be uncovered about neurodivergence and the way it shapes so many people’s lives. I have a feeling we’re really only seeing the tip of the iceberg.

Until next week,

Laura

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More perspectives on today’s topic and other resources

Decoding the overlap between autism and ADHD: The two conditions often coincide, as we wrote about in this newsletter, but the search for common biological roots turns up conflicting evidence. The connections could run deep. One team in the Netherlands has proposed that autism and ADHD are different manifestations of a single condition with a range of subtypes, each having a distinct time of onset, mix of traits and progression.

When the FDA first announced a shortage of Adderall in America in October, the agency expected it to resolve quickly. But five months in, the effects of the shortage are still making life tough for people with ADHD who rely on the drug. And the issue has revealed a troubling gap in how the condition is treated.

Other interesting stuff

L.A. County launched a suicide and crisis line last year that promised to save lives of people suffering from mental health conditions by avoiding deadly confrontations with police. But the rollout of 988 and related psychiatric emergency services has so far failed to live up to that promise, a Times investigation written by my colleague, Lila Seidman, has found.

At the heart of the latest battle over abortion access is a federal judge’s ruling that cites concern about the mental health of those who choose to end their pregnancies, writes my colleague Melissa Healy. In revoking regulatory approval of the widely used drug mifepristone, U.S. District Judge Matthew Kacsmaryk said the FDA failed to study the psychological effects of its use and ruled that it should be pulled from shelves while the drug agency conducts a comprehensive evaluation of its safety. But abortion’s aggregated mental health effects on women who have terminated their pregnancies have been studied extensively — and the most rigorous research does not support the assertions.

The denial of health insurance coverage for mental health treatment continues to be extremely common, despite federal and state parity laws that are supposed to ensure fairness. But these laws are rarely enforced and people with severe mental health challenges often must rely on their own resources to get care, according to this piece by NPR.