ADHD is a condition that makes a person inattentive, impulsive and hyperactive. An increasing number of children are diagnosed as having both ADHD and autism, and many parents are understandably confused about the links between the two. Can a child have both conditions and if they do, how can you best support them?
There are many reasons for the two conditions being confused in young children. Many children with autism display signs of hyperactivity and inattention when they start school. However, experts are very clear that as the child becomes older the apparent similarities between the two conditions will separate out. The child with autism may become more withdrawn and given the right environment their hyperactivity should wane and their difficulties with social skills will emerge. Children with ADHD on the other hand are unlikely to become calmer with age unless they receive medication or high-quality therapeutic interventions. They still develop social and communication skills and are unlikely to have the anxiety levels of a child with autism.
DSM-IV stipulates that a diagnosis of ADHD can only be made if the child has shown signs of the condition before the age of seven and has been experiencing symptoms of inattention, impulsivity or hyperactivity to an extent which is developmentally deviant and for a period of at least six months.
The condition cannot be diagnosed if it occurs solely within the context of a pervasive developmental disorder such as autism. That is not to say that a child cannot have both conditions. For the reasons mentioned above, it is possible that the child with autism will display signs of ADHD but that this should not be considered as an additional diagnosis until their needs relating to their autism are addressed first.
The following hints and tips are intended to be of use whether your child has been diagnosed with both ADHD and autism or just autism. If you are still not sure why your child has received the diagnosis they have, then you should go back to the specialist who gave you the original diagnosis for further clarification. You may also wish to contact some of the parents' groups listed at the end of this page for more information about ADHD specifically.
The causes of ADHD appear to be remarkably similar to those alleged to cause autism. This may be largely because we know so little about both of these conditions. The key similarities are that until recently many professionals thought that ADHD only occurred as a result of poor parenting. The range of factors thought to cause ADHD today range from the biological, such as genetics and brain damage during pregnancy, to the environmental, such as sensitivity to certain foodstuffs. It is likely that the causes are actually bioenvironmental, that is the result of an interaction between both biological and environmental causes.
Some people have suggested that ADHD belongs on the autism spectrum as children with the condition have so much in common with those with autism. However, many children with ADHD have no difficulties with communication and social skills except where these are the result of their limited functioning in other areas. That is, children with ADHD may appear to have difficulty interacting with other children at school, but this has more to do with their low self-esteem and their difficulty settling to playing or working together in a constructive way rather than an inherent problem with relating to others.
However, there are still links between autism and ADHD. It is clear from the genetic histories of some families that some parents are only diagnosed with ADHD after their children have been diagnosed with autism. And the two conditions are often confused at the time of diagnosis as well.
Coping with ADHD and autism
The actual diagnosis that your child has received is irrelevant here. Some children with autism will also display hyperactive behaviours and some children with ADHD will demonstrate autism traits. As a result they will need behavioural and other interventions that recognise this combination of needs.
Firstly you can examine what might be causing any hyperactive behaviours.
Food and drink
If your child has caffeinated drinks, such as tea, coffee or cola, this might affect their behaviour or disturb their sleep. Some people with ASD or ADHD also have gastrointestinal problems, so they may experience discomfort during or after eating, such as wind or constipation, which might affect their behaviour or disturb their sleep.
Changing routines can be stressful and if your child is used to having certain drinks or snacks, suddenly switching to something different may be counterproductive. However, you could try changing to decaffeinated tea, coffee and cola, or reducing the amount of the food which could be causing wind or constipation.
Alternatively, you could try gently phasing certain foods out over a period of days or weeks so that less and less is consumed overall without anything suddenly being taken away. For example, you could offer one biscuit instead of two, or mix decaffeinated and caffeinated drinks together.
Some people advocate making radical changes to a child’s diet like completely eliminating caffeine. We suggest that this is only worth doing if you have already tried a more moderate approach. We also suggest that you visit a dietician before introducing any major changes just to check that you’re continuing to offer your child a balanced diet.
If your child is especially sensitive to sensory stimuli such as lights, sounds and textures then environments where many of these factors interact could be extremely distracting and disturbing for them. If your child is frequently calm and only occasionally hyperactive or disruptive then it may be worth charting when and where these incidents occur to see if there is any pattern to their behaviour. Good examples of places that might over-stimulate a child include swimming pools, supermarkets and fast-food restaurants and trips to places like these may need careful planning as a result.
The most widely known drug used to treat ADHD is Ritalin. This is a stimulant drug that acts to reduce electrical activity in the brain, which in turn reduces hyperactivity. It is widely recognised as useful for children with ADHD and has also been shown to be of some limited benefit for children with autism.
However, there are many people who advocate against the use of Ritalin. They argue that Ritalin is used to prevent families and schools addressing the real issues of providing appropriate support and education. This is a very valid argument particularly for children who have Asperger syndrome. Many parents have expressed concern that their children have been mis-diagnosed with ADHD when in fact they are showing hyperactive behaviours as a way of coping with their frustration at school where their needs are not being met.
Some parents opt to use Ritalin as a way of controlling their child's symptoms for a short time whilst they address some of the behavioural issues affecting their child. This breathing space way of using medication can be very effective provided people are clear that that is what they are looking for from the outset.
If you are attempting this it is important to bear the following points in mind
- Start administering the drug at the lowest dose possible and only increase it after you have found it doesn't work at that level. In this way you can establish the optimum dose, ie the lowest dose with the best results.
- Set target dates for reducing the dose. If your doctor doesn't provide you with a diary or some other monitoring form for improvements then make one yourself. Note down any aberrant or new behaviours on the chart.
- Keep your child involved in administering and monitoring the medication. Allow them to see this as just a straightforward medical treatment.
Firstly it is important to remember that when your child misbehaves in public it is often the result of their own stress and not a desire to be naughty. It can be very hard to keep calm and avoid getting angry even if you know your child is in distress. Planning ahead can reduce some of that stress. However, it is important to remember that long trips are always going to be difficult to manage and the chances are that if you find something stressful then your child probably feels the same way. That should not discourage people from going out, and carefully managed short trips may help your child learn the skills to cope with longer trips later on.
For the more able child you can probably work with them to plan the trip so that they are aware of what incentives there are to keep calm and in control at every stage. Try talking through before each trip exactly what you are planning to do and what you expect; this will make the trip much more predictable for your child, which can in turn reduce their anxiety levels. You can also write down your plans so that your child can keep them to look at and refer back to. If you write down each stage of the trip on a separate card or sheet of paper then they can then be used as visual prompts to remind your child of what is happening.
An example of a series of flash cards for planning a trip to a swimming pool could be:
- We will go to the swimming pool at a time when there won't be lots of other people there.
- In the car on the way there you can relax and we'll play some quiet music.
- When we get there we have to buy tickets to get in. This won't take more than two or three minutes and then we can go through to the changing rooms.
- The changing rooms can be noisy but we will sit down to relax for a minutes before we get changed.
- While I put our clothes and bags in the lockers you can sit down and wait quietly for me. This will only take a minute.
- We will hold hands while we walk out to the pool.
- I will get into the pool first and then I will help you get in.
- If you want to go then just tell me and we will leave.
Think about the worst possible outcome
This sounds strange but often people get absorbed by thinking about how difficult the whole trip will be without focusing on the specifics of what might go wrong. For example, in the case of going on the bus:
Don't think: "This will be so difficult. My child might behave appallingly, and it'll be in public. People might start staring or commenting."
Instead, look at what is the worst thing that could happen: "My child could have a tantrum whilst we are on the bus."
- If you make sure that your child is next to the window and that you sit next to them, then they won't be able to get out and annoy the other passengers.
- If you take your child's favourite toy or treat with you, then this can be used to placate them when necessary.
- If they do make a lot of noise and people do look, then try to have a stock phrase ready to reply to any comments with. Something like "Joe has autism/ADHD. Lots of stimulation makes him feel anxious. Making these noises helps him to feel calmer".
- If two of you go with the child then you can share responsibility for looking after them. This in turn will make the experience less intense and exhausting and leave you more able to cope with difficult situations should they arise.
If you can think of coping strategies
for the worst thing you can imagine happening then you can probably cope with any other problems that occur.
Motivating your child
If you have a child with a very keen interest in one subject, whatever that is, it is worth encouraging the interest. This can be a valuable motivational tool. It can also help your child to learn concentration skills and once they have developed the ability to focus on an enjoyable activity they can begin generalising it out to other areas.
Encourage your child to discuss their needs with you. They may lose interest in an activity and begin wandering after 20 minutes because they do not know how to explain what has made them lose interest. Children with autism may not realise that their teacher or parent doesn't know how bored they are. Let them know that you are happy for them to move on to something else, but that they have to tell you why they want to do this. This need to explain could be very frustrating for them and it is important to avoid putting pressure on them to give a detailed and abstract explanation for their behaviour, a simple 'Don't understand' or 'Bored' is still something to work on.
Coping with frustration
Hyperkinetic activity may occur when a child with autism is unusually frustrated or wound up about something. Under these circumstances it is probably not desirable to attempt to contain the activity as they may then choose to let off steam somewhere else and in a destructive or aggressive way. Even children with low levels of functioning can be supported to do exercises, bounce on a trampoline, punch a punch bag and run around the garden in order to relieve tension. For more able children, encouraging them to go for a jog or a cycle ride in order to cool off and release some of that surplus energy might be helpful. This could also be tied in with doing a useful activity like picking up some shopping or doing a paper round so that the need to use up this energy is turned into a useful skill and something your child can feel positive about.
Remember that there are lots of positive things about having plenty of energy provided that it is channelled in the right directions. However, for families it can also have serious disadvantages. Fundamentally a child with hyperactive behaviours will need certain types of behavioural support whether or not they have autism as well. Their families may also need plenty of respite and support, and it is important that families have their support needs addressed even if there are question marks hanging over the diagnosis.