The Fascinating ADHD and ASD comorbidity

The fascinating comorbid ADHD + ASD... what 50 years ago was deemed as impossible, today is a fact... here we explore what may also become a fact in another 50 years?

The purpose of this article is to reflect on the presentation of comorbid ADHD and ASD which is very different to when these two conditions present separately, highlighting the challenges of diagnosing this FASCINATING COMORBIDITY whilst exploring its potential and strength, and learning on the way.

I refer to this comorbidity as fascinating as, how symptoms and traits mix, has the potential of resulting on an amazingly successful combination or, on the other hand, leading to a much greater challenge in getting through life. Individuals with the amazing trait combination of this ADHD + ASD comorbidity are likely to have successful careers and never present in Mental Health (MH services whereas those with the more challenging trait combination are more likely to present in MH services due to the comorbidity itself or secondary presentations such as depression or anxiety.

THE FASCINATING ADHD + ASD COMORBIDITY


50 years ago, comorbid ADHD and ASD was nearly unthinkable. Nowadays, not only we know they do coexist, but they actually express from the same genetic loading.

It’s been a great help that research and science have enabled the transition from ADHD and ASD not coexisting to both conditions having common genetics and often expressing as comorbid conditions… how often is debatable, and this article tries to raise awareness on this comorbid presentation being much more common than it is recognised.


Research and science did its job demonstrating comorbidity of these two conditions, but what it cannot do is enabling professionals to recognise this comorbid ADHD + ASD presentation, which, based on the symptoms/symptom clusters as described in diagnostic classifications (see below), shouldn’t be difficult, but the reality is quite different.


Diagnosing ADHD or ASD on their own, as sole conditions, can be challenging and controversial enough. There is a lot of difference of opinion about what is “normality” and what falls beyond, where is the threshold for diagnosis, how wide is the spectrum on ASD, what “significant impairment” really means, how it makes sense that greater severity in symptoms can get masked by stronger protective factors such as High IQ, special talents or very supportive educational/family environments which means that a less severe presentation would get a diagnosis but a more severe one with protective factors wouldn’t as presenting with overall better functioning…

The consequence of such diagnostic challenge is that many people are not getting a diagnosis of either ADHD or ASD when they may be actually presenting with both.


Here below is a simplified, basic summary of symptoms and symptom-cluster as shown in diagnostic classifications (DSM 5). These are only the symptoms, as there are also other essential diagnosis criteria before a diagnosis can be formulated.


DIAGNOSTIC SYMPTOMS/CLUSTER CRITERIA:

ADHD: 

-      Inattention

-       Impulsivity

-       Hyperactivity


ASD:     

-      Difficulties with Social Communication and social interaction

-       Repetitive/restricted Behaviours


And here below are some example areas showing that dichotomy in the comorbid presentation and symptom “contradiction” that leads to the diagnostic challenge:

CHALLENGING AREA ADHD ASD
Socialisation Very sociable and interactive; seeks the company of others and “action”; adapt easily to different environments and types of people; friendships are very important More comfortable in small groups or with either younger or older people, don’t get social subtle cues and relationships tend to be on their terms; prefer being on their own; need their own space and enough calmness
Peer pressure They need to fit in, to feel part of and included, to be liked, to get attention; they’ll do things just to please others They prefer to be un-noticed and don’t like attention; they don’t tend to participate in activities and have minimal social interaction
Focusing Difficulty concentrating; scattered focus, short attention span, easily distracted, Can hyperfocus and obsess on particular things/subjects; fixating
Organisation Chaotic, disorganised, no skills to plan or organise things/activities, messy, losing things Likes order, organisation, control, predictability, things “being right”
Adaptability/flexibility Very adaptable, anything goes, will try everything, attracted by new things Rigid, inflexible; thrives on routine, distress with sudden changes
Activity level Hyperactive, restless, fidgety; always fiddling and having to do something Not an issue, can stay doing something for long if hyper-focused
Impulsiveness Impulsive, impatient, doesn’t think before speaking/acting, gets in trouble for "reacting" rather than "acting"; thrives on immediate reward Not impulsive, thinking carefully, seeks control/predictability, can take too long to make a decision and sometimes, never make it; impatience is more due to fixation and not impulsivity
Risk taking Many; thrives on excitement and will not think of consequences; prone to accidents, teenage pregnancy, crime Rarely as needs to feel in control and have a sense of safety/security/predictability
Repetitive behaviours Rarely; gets bored easily, likes novelty as more exciting, change, starts things but doesn’t finish as moves to the next Typical; repetitive patterns of behaviours as part of their rigid/fixating nature and easily perpetuated as liking routine, predictability, control
Perfectionism Rarely; doesn’t have the patience to perfect anything, rushes things to finish them quick Often; fixates on things to obsession so things have to be perfect; thrives on re-assurance which leads to perfection
Verbal Communication “Chatter box”, will take part on most conversations and can talk for the sake of it, dialogue/interested on the other Tends to be literal, factual, black and white; often one-sided; conversing needs to have a purpose, usually informative so finds “small talk” difficult
Non-verbal Communication Able to recognise and communicate through gestures and facial expressions Difficulty at different level with both understanding and demonstrating non-verbal communication
Humour Class clown; naturally funny, humorous, "silly" May not get humour or humour is dry or they’re not intentionally funny
Emotion/empathy Able to recognise and express all emotions; tends to be very empathic, caring and supportive of others Has difficulty recognising and/or expressing emotions in self and/or others
Affection Can be over affectionate and tactile; Uncomfortable with overt expression of affection, mostly if invading space.
Anxiety Can be present Nearly always present
Eating Not a particular pattern Tend to have a restricted pattern, sometimes resembling an eating dis; sensitive to certain textures/flavours
Sleep Tends to be delayed Can be delayed but it’s more due to the generalised anxiety than the ASD


Well, if diagnosing these conditions separately, ADHD and ASD, is challenging enough, diagnosing their comorbid presentation is a whole other world! Whilst the symptom/symptom cluster diagnostic criteria can be reasonably clear, the combination, overlapping and interlinking of symptoms and traits can be so unique in each individual that it can make recognising the underlying neurodevelopmental condition an outstanding challenge.


As it can be seen from the table above, someone with this comorbid presentation could have some severe symptoms of one condition that would mask traits supporting the diagnosis of the other condition and so, the comorbid presentation would be missed.

For example, one individual can present with a “deficit of attention”, find it difficult to focus, tend to “scan” and yet, hyper-focus on a certain topic which they get fixated on, that way disguising the diagnosis of ADHD.

Another individual can present with an apparent like for socialisation typical of ADHD but, when explored in depth, relationships are superficial, one sided, controlling or imposing, lacking “intimacy” and yet again, disguising the comorbid diagnosis, the ASD on this occasion.


Therefore, not only there is a unique, individual combination of symptoms/traits within the ADHD + ASD comorbidity, but each of those can separately vary in degree of severity allowing infinite variations on how comorbid ADHD + ASD may present as well as why one of those would get recognised but not the other one when both are present.


Often parents are perplexed with how their child can be so chaotic with most things but so particular with others, so generally disorganised and yet so specific and fixated with others, so forgetful but have such an incredible memory with certain facts or topics.... Often these parents get frustrated with such contradictions and can't understand them.


To add to this diagnostic challenge, if the individual presents with a high IQ, ADHD is going to be masked throughout education, the higher the IQ, the longer the attention deficit is hidden for. And if the social interaction is not the most severe aspect of ASD, again the individual’s ASD is likely to get un-noticed perhaps throughout their whole life.


I believe this fascinating comorbidity is more common than ever before, and I believe one of the reasons may be “Survival of the fittest” and “theory of evolution” as I have mentioned in another previous article. It would seem as if severe presentations of ASD are becoming less common whereas the better adapted ASD is becoming quite more common.

This more adapted version of ASD seems to also express with ADHD symptoms which provide the ASD with a more balanced overall outcome placing the comorbid presentation in quite a stronger position than if isolated.


My observation is that, indeed, many successful businessmen, entrepreneurs, actors, sportsmen, and similar, do present with this fascinating ADHD + ASD comorbidity and they have a wonderful mix of symptoms and traits supporting that successful career.

Furthermore, over 80-90% of patients in my private practice who have parents with particularly successful careers (in the groups mentioned above) present with difficulties on both ADHD and ASD even if they don’t meet criteria for both diagnoses, and when exploring the family history, there is a strong suggestion of ADHD and ASD if no formal diagnoses.


I'd like to finish with some points to reflect on:

-       Are these so called “disorders” no longer such and, instead, the best adapting traits are surviving and becoming a stronger genetic version in human evolution?

-       Is it time to stop referring to them as disorders?

-       If this comorbidity is becoming more and more common, will it go from being the minority to becoming the majority one day?

-       If this comorbidity is particularly common amongst very successful people, why are they not diagnosed and what does this mean?

-       If so many of the most successful people in the world present with traits and symptoms of this ADHD + ASD comorbidity, is this a sign of Evolution?


Maybe one day we’ll know all these answers but, for now, we continue being curious, open-minded and learning.

THANK YOU.

Diagnosed of ADHD at 50: a Life Changing experience

By Luisa Sanz 21 Mar, 2024
I BELIEVE... in the bright inner diamond that we ALL have and makes us all PERFECT; do you?
By Luisa Sanz 29 Jul, 2023
"SOME" live life humbly always learning and growing with a determination to become better beings for the greater universal good. "OTHERS" struggle to learn from life and get stuck in a loop of hollow, self-centered materialism... in which do you choose to be?
By Luisa Sanz 03 Jul, 2023
Two men in their 50s receive an ADHD diagnosis which changes their lives: J’s email to myself within a week of starting medication: “I am a completely different person now Dr. The transformation is beyond comprehension. I’ve never looked forward to my life in the past, ever, and I’m 50 now.  Thank you so much!”
01 Nov, 2022
Change is the only thing that is permanent in life. Evolution is on-going continuous Change. Evolution starts with the Change in ONE being to then become two beings, then a few, and a few more to form a minority and ultimately, the majority and ALL.  ADH (Attention Deficit Hyperactivity) is slowly but surely becoming a more and more common Presentation. Therefore, should we still refer to it as a Disorder, ADHD? Perhaps, it is now time to talk about ADHP , a Presentation .
28 Oct, 2022
Should I have an assessment? Should I get a diagnosis? Should I share that I’ve got a diagnosis? Should I take medication? Should my child have an assessment, get a diagnosis or take medication? Have you ever asked yourself those questions? Are you now trying to decide what to do? Well, let’s then think about it!
12 Apr, 2022
We are so pleased to announce that Dr. Luisa Sanz has just launched her guided wellbeing journal: My Journal, MYLife . This will support you in achieving the changes you set off to make in your life whilst, effortlessly, you’ll also be changing your outlook towards a more positive one ultimately leading to a more fulfilling, happier life. This journal was written and developed by Dr. Luisa Sanz. You'll find space for reflection, introspection, learning, and growth. This is a springboard to becoming a better version of yourself through proving your inner strength and so achieving a deeper self-understanding and a greater sense of purpose. While tools like this can be extremely valuable, and we know you will benefit greatly from this journal, we wanted to explore goal setting further to help you understand the intention behind the journal and help you succeed in the goals you set out for yourself. Here is an interview with Dr. Sanz about goals. We hope you enjoy it! If you’re ready to make positive changes in your life, get your journal now! What is a Goal? A goal is anything that we aim for or want to change. When we’re setting goals and imagining those changes, one would expect that they will improve our quality of life or be beneficial somehow. So, most goals are positive in nature, either in the short term, long term, or both. Sometimes reaching one’s goals seems very difficult, and in the short term it can appear to make life harder or more of a struggle, but in the longer term, they provide a real benefit. If you are not satisfied with some aspects of your life, then you need to reflect on why you aren’t satisfied and if it would be worth putting in the effort to make a change and improve that aspect of life. If the answer is yes, then you set out to change and the goal comes from that place. What are some benefits of setting sustainable, achievable goals? Good question! Instead, I would phrase it as setting achievable goals that are then sustainable. First, you have to be able to achieve the goal that you’ve set, then you need to be able to sustain it through time. The benefit of this type of achievable and sustainable goal is, in the greatest sense, a better quality of life. You’ve likely set a goal that is going to help improve your lifestyle, when you meet this goal and elevate your lifestyle, your self-esteem will boost because you’re achieving what you’ve set out to achieve and that would also improve your confidence levels. In our journal, we have the “Cuadruple S” or “SSSS.” It stands for Sensible, Sustainable, and Safe goals to Succeed. In setting goals that meet the “SSSS,” we are more likely to benefit from those goals in the long term. Do you believe there is a direct link between goals and happiness? The straight answer would be absolutely yes. But, for deeper exploration, I’d add that people tend to misunderstand what happiness is and assume that feeling happy is being happy, but there’s an essential difference between the two. Feeling happy can be achieved by anything that temporarily brings us joy whereas being happy is a state of being, a long-term way of living; this is much harder to achieve. It is achievable, certainly, but it tends to require a longer journey. That said, goals can be used to provide both the feeling and the state of being happy. Perhaps it makes you feel temporarily happy at first, but if it’s sustained over time, it may lead you to a happier state of being. Happiness is achievable for all of us, but some of us are born with a more positive outlook which makes our journey much easier; whereas some others have a more negative predisposition and so need to make a greater effort in achieving goals to ultimately achieve the greatest goal of happiness. What are some tactics that one may use to inspire real lasting change in their lives? The greatest tactic is your mindset. You’ve got to believe in yourself, you’ve got to believe in the fact that you have a right to be happy and to achieve the goals you are setting out to. Along with the journal comes some “rules” to help you set and achieve your goals, but also to help you believe. One of the first rules is love, you must begin with love for yourself. Another rule is honesty. You’ve got to be honest with yourself as to why you are setting a specific goal and what you aim to achieve. When it comes to goals, we tend to default to excuses and outward-facing blame if we struggle to achieve what we’ve set out to. But, if you’re honest with yourself, internal reasons for struggling to achieve goals will come to the surface. Perhaps you aren’t prioritizing yourself, perhaps you’re not ready for the change. There are three rules when entering this journal and they are absolutely crucial: you have to love yourself, you have to be honest with yourself, and you have to enter with positivity. The last one begins with a positive mindset. This is not to say that you need to be so positive that you simply can’t allow mistakes, on the contrary, it is to say that despite mistakes you still stay positive as mistakes aren’t really such, instead they’re experiences to learn from… and that’s the positive outlook we’re talking about! You've got to ask yourself: “Is this goal important enough?” And “is it worth the effort that I need to put in?” These two questions can be answered by looking at the “why and the “who” of the goal: “Why do I want this change?” and “who am I doing it for?” This is where you need to exercise total honesty. If you can’t answer the “why,” it’s not important enough, therefore it will be harder to succeed. And if the answer to the “who” doesn’t include yourself, the change may happen but it’s not likely to last long as changing for others is never the right reason and so requires too much effort. Next, you need to ask if the goal is realistic and if it is sustainable. You need to be able to achieve your goal, but you also need to be able to sustain the change to improve your life and your happiness in the long term. Unsustainable goals can diminish long-term benefit rather than elevate it. So, ask yourself about why you’re doing it, who you’re doing it for, and if it’s realistic and sustainable. If you’ve got answers to all four questions, you will certainly achieve your goal. What are some unhealthy or toxic assumptions or beliefs about goals? In my opinion, the most toxic belief about goals is the need to change becoming an expectation from society. If you ever think that you need to fit in with society's expectations and this leads your change, then you won't succeed in your long-term goals, you may achieve them, but you won't sustain them. Goals like these that are set to meet others’ needs and expectations are not authentic to yourself. You've got to set a goal that you believe in, not because others want you to change in that way or expect that change in you, but because you believe in those goals. Another aspect of changing in response to social expectations leading to unsuccessful goals is comparison. When we compare ourselves to others and make changes in this way, those changes are not genuine and won’t last. Another worrisome side of goal setting is shame and fear of failing. This is why we must enter with love, honesty, and positivity. It’s okay to make mistakes, it’s okay to readjust. When we set goals for ourselves and give ourselves room for error, we’re so much more likely to succeed and, so much more likely to just get started in the first place. How is your journal different from what else is out there? What sets this journal apart is the intention behind it. This journal is different from anything that’s out there because it’s got both short-term intention and long-term purpose. It’s aiming to help people in the here and now, but it also has the long-term purpose of transformation. This journal aims to switch your mindset towards a more positive outlook in life. In changing one’s outlook, making changes, achieving goals and sustaining them becomes a much easier task. The beauty of this journal is that from the beginning of day one, it provides you with loads of tools to help you succeed, both within the journal and in your day-to-day life. It helps you rationalize your goals and lay a foundation for success. There are other things like lists of reasons to change and inspirational quotes. We provide a ton of those and also give you space to add your own. You’ll find the “Be Better Box,” daily pages and weekly reflections, and so much more. This journal is made for everyone and developed with clinical, factual background information on positive mindsetting, goal setting/succeeding and factors contributing to happiness.
Photo collage featuring Dr. Luisa Sanz's late brother, Antonio.
16 Mar, 2022
Dr. Luisa Sanz, Founder of Mind Yr Life, shares the story of her late brother, Antonio, who lived with schizophrenia from the age of 17. Dr. Sanz takes a deep dive into the impacts on her family and the societal stigmas that Antonio was forced to endure.
Woman running into the sun wearing jogging clothing.
By Kenneth Pillipow 18 Oct, 2021
In this article, Dr. Luisa Sanz interviews the mother of a patient named Miles. Miles has both autism and ADHD and in this interview, Dr. Sanz explores Lucy and Miles' story.
ADHD Video Series. This article's image is a highway with a blue sky and clouds.
By Kenneth Pillipow 18 Oct, 2021
We are pleased to share a video series on ADHD by Dr. Luisa Sanz, child and adolescent psychiatrist. The purpose of Mind Yr Life is to share information and start conversations to dismantle stigma surrounding mental health and promote an attitude of acceptance, compassion, love, and respect.
Dr. Luisa Sanz interviews Chris. The photo for this is purple flowers.
By Kenneth Pillipow 18 Oct, 2021
In this interview, Dr. Luisa Sanz talks to Chris about his struggles with mental health. They cover depression, anxiety, autism, and more.
Share by: