and Differences Dr. Lindsay Bates, Registered Clinical Child - - PDF document

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Understanding ADHD and ASD: Similarities and Differences

• Dr. Lindsay Bates, Registered Clinical Child Psychologist

ASD Team Leader, Erica Baker Psychological Services

• Ms. Melissa Gendron, Psychologist (Candidate Register)

Erica Baker Psychological Services

What IS Autism Spectrum Disorder anyway?

Most people are familiar with the terms AUTISM or ASPERGER’S, but the term, AUTISM SPECTRUM DISORDER is not as widely recognized

• r

understood Most people are familiar with the terms AUTISM or ASPERGER’S, but the term, AUTISM SPECTRUM DISORDER is not as widely recognized

• r

understood In 2013, a revised version

• f

the Diagnostic and Statistical Manual of Mental Disorders (DSM) was released, the DSM-5. This (controversial) revision changed the way autism is classified and diagnosed. In 2013, a revised version

• f

the Diagnostic and Statistical Manual of Mental Disorders (DSM) was released, the DSM-5. This (controversial) revision changed the way autism is classified and diagnosed. Although the ‘official’ diagnosis of ASD has changed, the ‘old terms’ do still continue to be used (e.g., Asperger’s syndrome, HFA, Autism). Although the ‘official’ diagnosis of ASD has changed, the ‘old terms’ do still continue to be used (e.g., Asperger’s syndrome, HFA, Autism).

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Past & Current Terminology

PERVASIVE DEVELOPMENTAL DISORDERS Asperger’s Disorder Autistic Disorder PDD-NOS Childhood Disintegrative Disorder

Autism Spectrum Disorder (ASD)

DSM-5 (2013) DSM-IV-TR (2000)

The ‘basics’ re: ASD …

ASD is a lifelong, neurodevelopmental disorder that affects how people communicate and relate to others. The range and intensity of disability varies, but all people affected by ASD have difficulty with communication, social interaction, and restricted or repetitive interests and behaviours Autism is referred to as a ‘spectrum disorder’ because the symptoms and characteristics can present themselves in a variety of combinations and degrees of severity, ranging from mild to severe. ASD is reported to occur in all racial, ethnic, and socioeconomic groups and the overall incidence rate is relatively consistent around the globe.

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The ‘basics’ re: ASD …

Social-Emotional reciprocity: difficulty with back-and-forth conversation, reduced sharing of interests, emotions, difficulty initiating and responding to social interactions Nonverbal Communication: poorly integrated verbal and nonverbal communication; abnormalities in eye-contact and body language; lack of use and understanding of gestures; lack of facial expressiveness Relationships: difficulty developing, maintaining, and understanding relationships; difficulty adjusting behaviour to suit various social contexts, challenges in imaginative play, absence of interest in peers Restricted/Repetitive Behaviour: repetitive motor movements, use of

• bjects, or speech; insistence on sameness, inflexible adherence to

routines; Highly restricted/fixated interests; Hyper/Hypo-reactivity to sensory input ASDs show a striking male bias in prevalence, with approximately 4 affected males for every 1 affected female. This prevalence difference has been consistent over time and populations, strongly implicating the involvement

• f sex-specific biological factors in ASD etiology.

A male preponderance is not unique to ASD - studies have reliably documented greater prevalence of ADHD and other developmental conditions in males compared to females. Current research suggests that prevalence rates may be less striking than

• nce believed (at least 2:1–3:1)

The 4:1 male bias may be partly due to the under-recognition of females (particularly higher-functioning who tend to show increased functional social behaviour and less obvious repetitive behaviours), sampling bias, and issues of diagnostic instruments.

Sex differences in ASD

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A brief note re: causes of ASD…

A definitive cause of ASD is not known. There are no established biomarkers for ASD, although there is evidence to support shared biochemical markers with other disorders, such as ADHD. Current research indicates that ASD likely develops from an interaction between genes and the environment, resulting in a disruption to typical brain development early in life. Twin studies suggest 60 – 90% heritability. Recurrence risk in siblings is about 2 - 10% (although as high as 20% when considering broader ASD phenotypes)

What DOESN’T cause ASD

You can’t catch ASD ‘bad parenting’ poor nutrition cable tv / cell phones / videogames car seats pollution pesticides

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Side note… Celebrity mom and (previously vocal anti- vaxxer), Jenny McCarthy, retracted her claims that vaccines cause autism in 2014 … but the damage was already done 

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Other myths re: ASD …

the ‘rainman’ myth ASD is a disorder

• f childhood

individuals with ASD are not social individuals with ASD are intellectually disabled individuals with ASD are violent ASD can be

• utgrown

and/or cured

Prevalence rates

This year the National Autism Spectrum Disorder Surveillance System (NASS) released a first reporting of national data and information of Autism Spectrum Disorder (ASD) in Canada. The findings of the 2015 NASS report focuses on those aged 5– 17 years, from six provinces and

• ne territory: Newfoundland and

Labrador, Nova Scotia, Prince Edward Island, New Brunswick, Quebec, British Columbia and the Yukon.

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Key findings …

Among children and youth 5–17 years old, the combined prevalence of ASD for the year 2015 was 1 in 66 (15.2 per 1,000). Males were diagnosed with ASD four times more frequently than females. NASS found that 1 in 42 males and 1 in 165 females aged 5–17 years old were diagnosed with ASD. Among those diagnosed by 17 years of age, 56% had received their diagnosis by 6 years of age; 72% had been diagnosed by 8 years of age; and less than 10% were diagnosed after 12 years of age. The 2015 overall prevalence of ASD in Nova Scotia was 1 in every 68 (of 5–17 year olds).

What IS ADHD anyway?

ADHD stands for: Attention-Deficit/Hyperactivity Disorder ADHD stands for: Attention-Deficit/Hyperactivity Disorder Most people are familiar with the terms ADHD and ADD, but the official term, ADHD is what is used today. Most people are familiar with the terms ADHD and ADD, but the official term, ADHD is what is used today. In 1987, a revised version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) was released, the DSM-III. This revision dropped the hyperactivity distinction. In 1987, a revised version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) was released, the DSM-III. This revision dropped the hyperactivity distinction. Then subsequent DSM’s added subtypes/presentations: ADHD - Inattentive, ADHD - Hyperactive, and ADHD - Combined. Then subsequent DSM’s added subtypes/presentations: ADHD - Inattentive, ADHD - Hyperactive, and ADHD - Combined. Although the ‘official’ diagnosis of ADHD has changed, ‘old’ language continues to be used (e.g., ADD - Attention-Deficit Disorder). Although the ‘official’ diagnosis of ADHD has changed, ‘old’ language continues to be used (e.g., ADD - Attention-Deficit Disorder).

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The ‘basics’ re: ADHD …

ADHD is a persistent pattern of inattention and/or hyperactivity that interferes with functioning or development. Inattention: lacking persistence, difficulty staying focused, disorganization, etc. Hyperactivity: excessive motor activity when inappropriate, talkativeness, etc. Impulsivity: hasty actions that occur in the moment without forethought that have the potential for harm to the individual; social intrusiveness (e.g., interrupting, disruptive behaviour) Symptoms have to be persistent (more than 6 months) to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities. Symptoms cannot be due to defiance,

• ppositional behaviour, or failure to understand tasks/instructions.

ADHD is a neurodevelopmental disorder that begins in childhood. Several symptoms must be present before age 12. Symptoms vary depending on the context within a given setting. Symptoms may be minimal when the individual is receiving frequent rewards, under close supervision, in a novel setting, engaged in especially interesting activities, has consistent external stimulation (e.g., screens), or interacting one-on-one. Associated features may include low frustration tolerance, irritability, and/or mood lability. ADHD is more frequently diagnosed in males than females (approximately 2:1 in children, 1.6:1 in adults). The prevalence is about 5% in children and 2.5% in adults.

Additional information re: ADHD

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Risk Factors

• f ADHD

Current research indicates that ADHD likely develops from an interaction between genes and the environment resulting in a disruption to typical brain development early in life. Very low birth weight conveys a 2-3x risk for

• ADHD. Smoking during

pregnancy has been strongly linked, as well as pregnancy and birth complications, brain damage, toxins, and infections. The heritability of ADHD is substantial. ADHD is elevated in first-degree biological

• relatives. ~50% risk

parent to offspring. Twin Studies show 60- 80% heritability. Twin studies of children with ADHD show that the family environments of the children contribute very little to their individual differences in ADHD symptoms

Myths re: ADHD …

ADHD is not a real disorder

(Cases date back to 1775 and since over 10,000 research studies have been published)

ADHD is a disorder

• f childhood

(Long-term studies of children diagnosed with ADHD show that ADHD is a lifespan disorder)

Children with ADHD are

• ver-medicated

(Most evidence from research studies suggest that levels of treating ADHD with medication are either appropriate or that ADHD is undertreated)

Poor Parenting causes ADHD

(Twin studies of children with ADHD show that the family environments

• f the children contribute very

little to their individual differences in ADHD symptoms)

Girls have less severe ADHD than boys

(Research studies are reporting on the substantial impairments girls experience, often to the same extent as boys)

ADHD is over- diagnosed

(The vast majority (9 out of 10) of children have been diagnosed by practitioners using best practice guidelines)

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ASD & ADHD: Diagnostics

According to DSM-IV-TR, an individual could not be diagnosed with ADHD if they had a diagnosis of a Pervasive Development Disorder (PDD). One of the reasons for the prohibition of a comorbid diagnosis of autism and ADHD was that the severity of ASD placed it above ADHD in the diagnostic hierarchy. Epidemiological, clinical, and neuroimaging findings led to a revision of the ADHD exclusion criteria in the DSM-5 (2013). Now, ASD is no longer an exclusion criteria - both ASD and ADHD can be diagnosed together. 30 - 60% youth with ASD also meet criteria for ADHD – ADHD has been described as the most common occurring diagnosis with ASD.

ASD & ADHD: Diagnostics

30 - 80% youth with ASD also meet criteria for ADHD – ADHD has been described as the most common occurring diagnosis with ASD. 20 – 50% of youth with ADHD also show features of ASD

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ASD & ADHD: Diagnostics

It is not uncommon for children to first be diagnosed with ADHD. Studies have found that an initial diagnosis of ADHD may be associated with delayed ASD diagnosis (older than 6 years of age). This delay persists across age and severity

• f the ASD.

It has been suggested that symptoms of ADHD may overshadow or mask symptoms of ASD. ASD that goes unrecognized until the child is older may negatively affect their long- term prognosis.

ASD & ADHD: Similarities

Although ASD and ADHD are unique neurobiological conditions, they have been shown to share genetic factors and neural pathways as per findings from family and twin studies ASD and ADHD share many similar impairments that can complicate differential diagnosis, including attention deficits, social vulnerabilities, sensory over- responsivity, emotion regulation problems, and behavioural challenges. Both disorders are characterized by reduced performance on tasks of executive function and information processing.

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ASD & ADHD: Differences

A major distinction between ASD and ADHD is that in ASD there is a marked impairment to initiate and sustain connection with others. Individuals with ASD often have difficulties reading and/or demonstrating nonverbal behaviors that help regulate social interaction - such as eye contact, facial expression, vocal inflection, and gestures. ASD and ADHD share many similar impairments that can complicate differential diagnosis, including attention deficits, social vulnerabilities, and behavioural challenges. Both disorders are characterized by reduced performance on tasks of executive function and information processing.

Implications of Comorbidity: ASD/ADHD

Frequently associated with greater level of impairment, including higher rates of tantrums, irritability, depressed mood, avoidance, and conduct behaviours Children with ADHD and ASD symptoms, compared with those with ADHD only, tend to be prescribed more medications Can have a large negative impact on the daily life of affected individuals and their families Associated with a lower quality of life and poorer adaptive functioning than in any one of these conditions

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Comorbidity in Neurodevelopmental Disorders

Neurodevelopmental disorders, such as ASD, intellectual disability, ADHD, epilepsy, etc. are characterized by strong clinical comorbidity, which suggests a common genetic etiology across the diverse group of disorders. Recent studies have found that inheritance of one neurodevelopmental disorder also confers an increased risk for other disorders within the same family. For example, twins have been found to be more likely to develop ADHD or a learning disability if their co-twin had ASD. Therefore, it is increasingly clear that the genetic underpinnings for these disorders do not conform to the current singular diagnostic criteria/classifications

Commonalities between ASD & ADHD

ASD ADHD

• inattentiveness
• Behaviour

difficulties

• emotional

dysregulation

• social

challenges

• intense focuses
• inconsistent

eye contact

• impulsivity
• sensory issues
• executive

dysfunction

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Symptom : difficulties conversing with others

More ASD-ish…

 ‘monologuing’  talking at, versus talking to  Lack of interest or

acknowledgement of others’ comments

 Oblivious to ‘social rules’ in

conversation – e.g., turn-taking

 Correcting conversation partner –

irrespective of age or authority

More ADHD-ish

 Impulsive interrupting – as if

can’t wait to share

 ‘zones out’ and misses parts of

the conversation

 Loses train of thought and/or

forgets what they were going to say

 Responds before thinking

Symptom: social difficulties

More ASD-ish…



Frequently cannot initiate social interactions (and friendships)



Awkward/uncomfortable in social interactions



Social dysfunction due to social disengagement and indifference to social cues



may show little if any interest in interacting socially, or if they do, they may be completely socially

• blivious and even offensive at

times

More ADHD-ish…



Infrequently by choice



Can make friends, but often not keep them



Social dysfunction due to impulsive behaviour



Kids with ADHD can be overly aggressive in trying to be noticed, they may lack basic conversational skills and often interrupt, talk too much or let emotions get the best

• f them.

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Symptom : overactivity

More ASD-ish…



Repetitive movements – flapping, pacing, spinning



Repetitive movement seems necessary



• ften a way to release the tension

that comes from the stress of extreme sensory sensitivity or anxiety that comes from a break in their routine.

More ADHD-ish



Restlessness



Fidgetiness



Making excuses to move



Overactivity seems necessary

Symptom: Inattention

More ASD-ish…

 Hypervigilent attention and

internal distractibility

 Can appear withdrawn (‘in

their own world’) to the exclusion of of more salient environmental stimuli

 Hyperfocused on details –

missing the ‘big picture’

More ADHD-ish…

 lack of focus and distractibility

by external stimuli

 Poor persistence – shifting

quickly from one activity to the next

 Poor sustained attention

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Symptom: Intense Interests

More ASD-ish…



Can have socially isolating effects due to their intensity or unusual nature.



Unusually intense – knowing every detail about interest and spending most free time engaging in, learning about it, etc.



Interest can be outside of developmental norm (e.g., a teenager intensely interested in Lego, a child very interested in politics, etc.)



Can follow similar themes across people with ASD (e.g., Titanic, etc.)



Can be quite unusual (e.g., eggs, metal

• bjects, etc.)

More ADHD-ish…

 Becoming hyperfocused –

Difficulty regulating attention

 Continuing to engage in a

preferred activity for long periods and having difficulty ‘shifting’ away

 Interests are often typical for

developmental stage

Implications

The de-emphasis on specific clinical categories and a greater focus on dimensions

• f

behavioral and neurobiological measures may have future implications. This approach may… The de-emphasis on specific clinical categories and a greater focus on dimensions

• f

behavioral and neurobiological measures may have future implications. This approach may… Inform treatments that extend beyond classic diagnostic boundaries, resulting in use of more integrated approaches. Inform treatments that extend beyond classic diagnostic boundaries, resulting in use of more integrated approaches. Increase recognition

• f

co-occurring neurodevelopmental disorders and the genetic and biological factors that underlie them, which may help reframe societal opinions on causality. Increase recognition

• f

co-occurring neurodevelopmental disorders and the genetic and biological factors that underlie them, which may help reframe societal opinions on causality. Lead to a better understanding of the bio- psycho-social complexity of challenges faced by these individuals and their families. Lead to a better understanding of the bio- psycho-social complexity of challenges faced by these individuals and their families.

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Questions?