Being a mum of two ADHD kids, having a work role that has me working with neuro-diverse children every day and being ADHD myself, means that I have plenty of opportunity to observe ADHD behaviour.
And over the past few years (and months in particular) an idea has been nagging at me that I think needs exploring.
I wonder if ADHD, as a separate, independent disorder, actually exists. I wonder if perhaps we aren’t just all on the ASD spectrum, whether ADHD (in varying degrees) isn’t just co-morbid with ASD but part of it, and those of us diagnosed with ADHD are just at the ‘high-functioning ‘ end of this spectrum with more ADHD traits than Autism ones.
The current medical perspective is that ADHD is not part of the Autism. My response is, why not? Maybe we need to redefine this condition and maybe ADHD should be included as a characteristic of Autism Spectrum Disorder.
Hear me out.
I’m well aware that the current thinking is that there is overlap between the two disorders and that there are lots of lists which highlight the supposed clear distinctions between them. However, when I look at those lists, my children and I don’t fit neatly into only one of those lists, and neither do many of the individuals with ASD I know. So the ‘distinction’ making list, fails.
In fact, the distinctions only seem to hold up if we compare an ADHD individual with an individual who presents with significant Autism traits. So, what of those who are at the ‘high functioning’ end of the Autism spectrum? At this point, the distinctions become far less apparent, even blurred.
To explain, let’s look at this table from Understood.org (a generally wonderful site, I should add)
At first glance, this seems clear and simple. But watch as I highlight a few issues (see green text)
|What is it?||A neurodevelopmental condition that makes it hard for kids to concentrate, pay attention, sit still and curb impulsivity.||A range of neurodevelopmental conditions that causes challenges with social skills, communication and thinking. Repetitive behaviors are also part of autism spectrum disorder (ASD).|
|Signs you may notice, depending on your child||
Let’s look at these ‘distinct’ Autism Spectrum Disorder traits.
- Challenges with social skills – it would be fair to say that the ADHDers I’ve encountered all have difficulties with social skills to some degree. Some act silly for the sake of engaging their peers in a bid to ‘win’ friendship, unaware that they are missing key social cues which would otherwise alert them to the fact that the bystanders are laughing at them, not with them, and might be entertained but have not had their respect won.
Others, retreat because the anxiety and drain of dealing with people when the individual already has a low social thermostat, is tiring and difficult.
As adults, we learn to ‘fake’ it and hope we get by without being too conspicuous but the ‘challenges with social skills’ are ever present.
ADHDers talk too much, missing the cues that tell us we’ve gone too long or reacted too much. We’re described as very honest and loyal, anxious, hypersensitive and emotional – well, in my experience this is because we think everything is going swimmingly, miss the cues that tell us people aren’t genuine and find it hard to replicate that level of deception (ADHDers ‘wear their hearts on their sleeve’ is the romanticised interpretation of this) and so we’re shocked and upset when this finally (and by then often less than subtly) does become apparent.
We try too hard to work at better interactions and come across as ‘odd’ or feel to exhausted by the prospect and withdraw because because people are just too much hard work to be around.
- Repetitive behaviours (mentioned again lower in the list as repeats words or phrases) – it needs to be noted, that not all ASD individuals are seen to do this, and the same can be said for those diagnosed with ADHD, but what of the repetitive behaviours that go un-noticed by a clinician or people in general? Surely repetitive behaviours are only identified if they are significantly overt?
As an ADHDer, I’m now aware of a repetitive motion I make in the back of my throat, opening and closing the airway to my nasal cavity. It was my husband that pointed it out to me when we were first together because he could hear me doing it very quietly when we’d watch TV, completely unaware. Since then, I’ve caught myself doing this constantly and stop when I notice, but it is a repetitive thing that I just do. I also rub the side of my thumb nail against my middle or ring finger nail, and I bite the inside of my cheek when I’m stressed and when my ADHD medication is wearing off – a compulsive thing which I tell myself to stop (because eating anything salty or acidic later will hurt) but find myself doing again seconds later.
No-one else would notice these behaviours. They’re subtle and internal. And that brings me to another point. ADHDers suffer chronically with ‘ear worms’ – pieces of music, text, conversation (ie: repetitive words and phrases..) , sounds that we play over and over and over in our heads, sometimes initially deliberately because we’re ‘playing with them’ but they stay long after, unintentionally and frustratingly. This is partly why we feel as though the world is quieter when medicated, as this diminishes.
I’ve watched my children closely and they both also have subtle repetitive behaviours, neck clicks, nail biting, etc and they’ve shared that they have the same internal patterns of repetitive thought as I’ve described also. A clinician probably wouldn’t spot them.
It seems strange that things like nail-biting, tooth-grinding or the very noticeable jiggling of the leg exhibited by many ADHDers when they have to sit still, aren’t noted as repetitive behaviours. These urges are the reason why ADHD kids were the first to take up, and the last to lay down their fidget spinners (long after the craze had ended and it was ‘cool’ to have them). We recognise their need for these things and provide tools to manage them, and yet they are labelled as ‘fidgeting’ not repetitive. By contrast things like hand flapping or finger flicking are noted as ASD repetitive behaviours. Why the distinction? The only difference appears to be the degree of visibility of the repetitive behaviour, not its existence alone.
- Avoids eye contact/physical contact – ADHDers will hold your gaze while they are interested in what you’re saying (if they’re trying) though more often than not they’ll be fidgeting while listening and will do so intermittently when telling you something they’re interested in. But watch what happens if they don’t really like the person or have been hurt or disappointed in them, the eye contact becomes nearly impossible. It feels physical, the inability to lift your head and have your face level with theirs. Doing so brings on a feeling of seriously uncomfortable exposure, maybe because we ‘wear our hearts on our sleeve’ and feel the person will know the depth of how we’re feeling before we’re ready to share it with them. We can’t cover up our hurt/rage – we’re absolute rubbish at faking being happy/pleasant so we avoid having to do so.
The only exception to this is when we’re angry and ready to say so. Then you’ll get more eye contact than you probably have had ever from the ADHDer!
As for physical contact, catch a relaxed ADHDer (it happens occasionally) and they’re more likely to want and appreciate physical contact, but, to an already irritated, fidgety and agitated ADHDer, anything more than a quick hug can feel like restraint and it’s infuriating. We’re like ferrets – on the go (and wrestling out of embraces after what feels like a polite amount of time – 3 seconds) , or floppy and snuggly. No in-between. Understandably, people don’t always see us as warm and affectionate if they aren’t around us a lot and miss the opportunity to see us in floppy mode.
- Is prone to meltdowns (due to sensory processing issues, anxiety, frustration or communication difficulties) Oh, look. this one appears in both though at first glance it appears for different reasons, with the ASD child melting down to sensory processing issues…. but wait, look further down the ADHD column and we see, ‘May overreact to sensory input, like the way things sound, smell, taste, look or feel’. (also known as having sensory issues!!!!!!)
Next it mentions anxiety. Anxiety is the most common co-morbid condition in ADHDers, so again – highly likely to be melting down for the same reason. Frustration can also be the cause of ADHD meltdowns, when the child has missed social cues and got into trouble, can’t fathom why someone has done X, can’t disengage quickly from a task they’ve hyperfocused on etc. And as for communication, ADHDers are really poor at self-regulating, and when any individual (ADHD or not) is highly aroused (upset, angry etc) the first thing to go is our ability to use our verbal/linguistic skills. So, yes, communication at this point becomes especially difficult for an ADHDer and meltdowns are likely. In an ASD child this may mean a complete shutdown of verbal/linguistic skills and what looks like a refusal to speak and running away/hiding, in an ADHD child, you might get a few choice words as they exit themselves in looks like angry defiance. Again, the difference is in the degree of this characteristic, but is shared by both.
- Gets upset by changes in routine – Interestingly, the ASD list doesn’t explain why, but this is a trigger for ADHDers too, partly for the shared reason of generalised anxiety, but also because of the ADHDer’s struggle with executive functioning. We take a long time to gouge out routines (which support our executive functioning – organising and time management) so a change or disruption to this can really send us into a flap as we risk losing control and facing the consequences that often follow (being late to a place or for a deadline, forgetting something important etc).
- Struggles with social skills (on both lists)
- Uses excessive body movements to self-soothe (e.g., rocking, flapping hands) Not all ASD individuals exhibit ‘excessive’ body movements, but what is interesting is that the very same strategies employed to aid self-soothing in ASD children, are recommended for ADHDers. They like to be wrapped up and cocooned under heavy, weighted blankets, in swinging hammocks, in dark cosy tents etc.
An upset ADHD boy is easy to spot when you walk into a classroom. They’re the one hidden deep within their hoodie, with their hands in their pockets tugging down to increase the sensation of pressure all around them. Ask them to remove it, and you’ll get a meltdown.
I also wonder if fidgeting – a response to needing to move and not being able to, isn’t a way to ‘self-soothe’ that uncomfortable feeling away. The difference here appears to be only the size of the movement, not the function behind the behaviour.
- Has obsessive interests and experiences perseveration. Just like ASD individuals, speak to an ADHDer and they’ll have something they are completely interested in to talk your ear off about – for weeks at a time if you let them. They will be experts in anything they find more than mildly interesting. The ADHD tendency to focus and fixate gets called ‘hyperfocus’ and left to their own devices they are happy to ‘persevere’ with the activity/idea as though it is an obsession. The only difference seems to be that the ASD individual maintains their interest in a limited amount of interests, whilst the ADHDer will be completely obsessed until the next obsession presents itself. The intensity is the same, just not the duration.
- Is constantly “on the go” or moving; fidgets and needs to pick up and fiddle with everything (ADHD much?)
- Is very advanced verbally, but struggles with nonverbal cues – Dealt with non-verbal cues above and somehow this sounds just like the chatterbox ADHDer, who misses the ‘you’re boring me’ cues.
- Reacts strongly to the way things sound, smell, taste, look or feel (sensory processing issues) Again a repeat of what was mentioned earlier, and surely very similar to the ADHD descriptor of ‘ May overreact to sensory input, like the way things sound, smell, taste, look or feel’. To be fair, it isn’t a given that every ASD individual will ‘react strongly’ or ‘over-react’ – there are variations of the response to this trigger, just as there are amongst ADHDers.
- Has trouble with safety and danger awareness – As do ADHDers thanks to their lack of impulse control and executive functioning. Statistically ADHD teen boys are recognised as being in the highest risk category for ‘risky behaviours’ and early mortality. In many cases, the ADHDer knows the dangers but is vulnerable because of their impulsivity, and in other cases, poor executive functioning impedes the individual’s ability to plan, think ahead and spot potential dangers. Again, the distinction made is one of relative difficulty/impairment, of which there is a range in both parties.
Which leaves us with just 1 descriptor which seems to be the big, all-defining one for Autism – and it is one which is now disputed. The one relating to empathy and self-awareness. Has trouble showing understanding of other people’s feelings and his own. Recognised as being very empathic, this one isn’t replicated in the ADHD side of the list, however; nearly every ADHD child I know, has had support from a counsellor or psychologist recommended at one point or another to help them with the other aspect of this descriptor, navigating the intense emotional responses they have to everyday situations. Alongside, this, the long-founded view of Autistics lacking empathy is now being reconsidered, as Autistic individuals begin to voice their own interpretations of these observations and share that on the contrary, many sense that they ‘feel too much,’ a striking similarity to an ADHDers experience.
And so, as an ADHDer myself – experiencing so many of the above traits and seeing them in varying but consistent examples amongst the many, many individuals I work and interact with, irrespective of which banner they come under – I am less and less convinced that these are two separate disorders.
Instead, I am inclined to query whether ADHD symptoms/traits are in fact symptoms/characteristics of Autism, presenting in each individual in greater or lesser amounts (as is the nature of spectrum disorders) and in which, for cases where the current ‘ADHD traits’ dominate as measurable and significant impairments, medication appears to ‘fix’ the condition.
We are perhaps nearing a time when fMRI scans may be closer to giving a definitive answer to these thoughts, but so long as diagnoses of these conditions are based so strongly on subjective observations, I will not be convinced of their accuracy.