What Is AuDHD?

AuDHD is a new term that’s being used to describe people who have both autism and ADHD. It’s not an official diagnosis but is meant to draw attention to the combined effect of having the two disorders.

Having both autism and ADHD is very common — studies estimate that 50 to 70 percent of people with autism spectrum disorder also have ADHD (though most people with ADHD do not also have autism).

It’s only since 2013 that the possibility of having both was recognized in the DSM-5, the guide to mental health disorders. Before that the two diagnoses were considered mutually exclusive. But mounting evidence of how common it is to have symptoms of both, and more recognition of the frequency with which people have several related developmental disorders, led to a change in the guidance.

Since the combination has only been recognized so recently, there is a limited amount of research on how people are affected by having both disorders, says Conner Black, PhD, associate director of the Autism Center at the Child Mind Institute. The term AuDHD was coined by autism advocates to highlight the experience of having symptoms of both, because they can interact in confusing ways.

Autism and ADHD are both neurodevelopmental disorders, and each involve issues with attention, social challenges, and difficulty regulating emotions. To understand the experience of a dual diagnosis, we must examine the behaviors associated with autism vs. ADHD — and how they might interact.

Autism: Kids with autism tend to focus intense attention on their specific interests, and they have difficulty shifting attention between tasks or on demand. “Inattention in autistic kids,” says Dr. Black, “is more because the child is self-directed and more interested in what they want to do at that time.”

ADHD: ADHD makes it unusually difficult for kids to concentrate and follow directions. “Kids with ADHD are inattentive because it’s hard for them to focus on a specific task or specific activity,” Dr. Black says.

AuDHD: Attention challenges are exacerbated in kids with both. They may be inflexible about what they will pay attention to — wanting to focus on a special interest at the cost of something else, for example — and also genuinely struggle to pay attention to things that aren’t of personal interest.

Autism: Kids with autism have trouble reading nonverbal cues and having back-and-forth conversations.

ADHD: Kids with ADHD can struggle socially because they are impulsive, tend to interrupt, and have trouble listening to others and taking turns.

AuDHD: “Kids with both can have trouble reading social cues and understanding the natural flow of conversation,” says Dr. Black. “But then they also might have difficulties with impulsivity, waiting for their turn to talk. Their social challenges can be compounded.”

Autism: Kids on the autism spectrum can have difficulty managing big emotions, which can lead them to act out. They may experience emotional distress as a result of sensory overload, unexpected change, or social confusion, which can cause them to melt down. The outbursts may seem sudden, but that’s often “because they’re not cued into their own emotions or how their body is affected by them, so they don’t know how to recognize their emotional reaction building up,” Dr. Black says.

ADHD: Kids with ADHD can also have difficulty managing big emotions, but the outbursts are often the result of frustration or impulsivity. “In ADHD, you often see these extreme emotional reactions, where kids seem to go immediately from zero to 100 as a reaction to an event,” adds Dr. Black.

AuDHD: For kids with autism and ADHD, “we often see big behavioral episodes,” Dr. Black explains, “whether that’s being aggressive or having some kind of meltdown. The two of them together exacerbates some of those challenges.”

Having both autism and ADHD can mean having traits that pull in different directions. For instance, autistic people are often more comfortable with a reliable routine; change can be challenging. But people with ADHD are often impulsive — they tend to enjoy change and seek out new experiences. These conflicting tendencies can be difficult to navigate.

“I see kids who say things like, ‘I know I have clothes all over my floor and I really want them gone, but my executive function issues won’t allow me to do that,’” says Dr. Black. “It’s like the two pieces can work against each other.”

Another example is in social situations, which can become very complicated for kids with a dual diagnosis, according to Dr. Black. “A child who has ADHD and autism might act impulsively and then hyper-analyze the social situation they were in: ‘Did I speak too much? Did I say something wrong? Did I jump in when I shouldn’t have?’” For an autistic child who already finds social situations hard to read, their impulsivity can make them even more uncomfortable.

Dr. Black notes that kids with ADHD or autism alone are already at higher risk for anxiety and depression than other kids. While the research is not robust, studies indicate that this risk may be elevated in kids who have both, he says.

Dr. Black hypothesizes that heightened risk could stem from those compounded social challenges — producing social anxiety, for example — or feeling misunderstood. “Individuals with both ADHD and autism talk about how they feel misunderstood. They haven’t found people that are similar to them. They really feel like they are different than the others around them,” he says. “I think that can lead to identity challenges and also mood difficulties. There are multiple pathways that could potentially exacerbate anxiety and depression symptoms.”

Dr. Black notes that autism can be reliably diagnosed at a younger age than ADHD. So children tend to be diagnosed with autism first, and ADHD symptoms are recognized later, leading to the second diagnosis.

Autism can be diagnosed in children as young as 18 months, while ADHD is typically diagnosed when children are in school, and they have trouble paying attention, staying in their seats, or managing impulsivity.

When a preschooler comes into his office and fits the criteria for autism, Dr. Black says, they could be screened for hyperactivity and attention challenges. But it’s often too early, since kids that age are typically very active and distractable. “In really young kids we often don’t give a co-occurring diagnosis,” Dr. Black explains. “That would be at a future assessment or when additional challenges arise — it becomes clearer once they get to that school age where there are more expectations that you sit in your seat and attend to what a teacher is saying.”

It’s not uncommon for preschoolers who are autistic to be first diagnosed with ADHD, and then years later, with autism — one study shows an average delay of three years between one diagnosis and the other. In some cases, these kids are misdiagnosed with ADHD. In other cases, they have both disorders, but their autism was overlooked — as sometimes, combined autism and ADHD can be interpreted as severe ADHD.

One reason for missing the autism symptoms may be that ADHD is more than twice as common as autism, and far more familiar to pediatricians who see young children. “ADHD is often a diagnosis that’s given first because the providers are using an ADHD lens,” says Dr. Black. An autism diagnosis may be delayed until it’s clear that the treatment for ADHD isn’t working. “Whether they try medication or go to therapy for ADHD, if it doesn’t improve then they land on that autism diagnosis.”

Early signs of autism are also more difficult to recognize when you’re not an expert, and an accurate autism diagnosis can’t be given in one short office visit. The standard assessment tool, called the ADOS — the Autism Diagnostic Observation Schedule — takes 45 minutes, and it’s meant to be paired with a structured interview with parents about current and past symptoms, which takes several hours.

Treatment for children with both ADHD and autism often involves both therapy and medication.

Therapy involves parents and other caregivers as well as the school, if possible, working with the child to develop structured routines and schedules and consistent responses to behaviors, Dr. Black explains. It also involves helping the child or adolescent develop an understanding of their emotions and the coping skills to manage them, he adds. “It’s really taking a 360-degree approach to working with that individual to help set them up for success.”

For kids with ADHD, stimulant or other ADHD medication can play multiple roles. ADHD medication can minimize symptoms and help kids function better in school and other activities. It can also help kids be able to focus on their therapy and learning important skills. “When kids are really inattentive, maybe hyperactive, it can be hard for them to engage in a therapy session, so medication might be a good start,” says Dr. Black.

In children and adolescents with autism, antipsychotic medications like risperidone (Risperdal) or aripiprazole (Abilify) may be used to help manage big behaviors like emotional outbursts or aggression — the goal is to keep kids safe and able to function at school and at home. For kids with ADHD, antipsychotic medications can be used along with ADHD medications when stimulants alone aren’t effective in controlling outbursts.

Dr. Black likes to think of antipsychotic medications, as a psychiatrist he worked with once put it, as extending the length of the fuse on the emotional outburst.

“I think that’s a great way to think about it,” he says, “because for some of the kids that I’ve worked with, one minute they’re happy as can be, and the next they’re so angry they’re throwing something across the room. Sometimes pharmaceutical help is really needed to give that kid the time to use the coping skills they learned in therapy. I’ve definitely seen kids where these medications have allowed for better therapeutic intervention.”