ADHD & ASD

Attention-Deficit/Hyperactivity Disorder (ADHD)

Overview

Definition: A neurodevelopmental disorder characterized by persistent patterns of inattention and/or hyperactivity-impulsivity that interfere with functioning or development.

Prevalence:

• Approximately 5-7% of children
• 2.5-4% of adults
• More common in males (ratio 2:1 in children, closer to 1:1 in adults)

Key Features:

• Onset in childhood (before age 12)
• Symptoms present in multiple settings (home, school, work)
• Interferes with functioning
• Not better explained by another disorder

Three Presentations

1. Predominantly Inattentive Presentation:

• Difficulty sustaining attention
• Easily distracted
• Forgetful in daily activities
• Appears not to listen
• Difficulty organizing tasks
• Often loses things
• More common in girls
• May go undiagnosed (“daydreamers”)

2. Predominantly Hyperactive-Impulsive Presentation:

• Fidgets, squirms
• Difficulty remaining seated
• Excessive talking
• Interrupts others
• Difficulty waiting turn
• Acts without thinking
• More common in younger children

3. Combined Presentation:

• Both inattentive and hyperactive-impulsive symptoms
• Most common presentation
• Typically most impairing

Common Characteristics

Inattention:

• Poor attention to details, careless errors
• Difficulty sustaining focus on tasks
• Mind seems elsewhere during conversations
• Fails to finish work
• Avoids tasks requiring sustained mental effort
• Loses necessary items
• Forgets appointments, obligations

Hyperactivity:

• Constant motion, “driven by motor”
• Restlessness (in adults, may be internal)
• Difficulty engaging in quiet activities
• Excessive talking
• Inappropriate running/climbing (children)

Impulsivity:

• Blurts out answers
• Difficulty waiting
• Interrupts conversations or games
• Makes decisions without considering consequences
• Risk-taking behavior

Associated Features

Cognitive:

• Executive function deficits (planning, working memory, inhibition)
• Variable attention and performance
• Time management problems

Academic/Occupational:

• Underachievement relative to ability
• Higher risk of school failure
• Difficulty completing projects
• Job performance issues

Social:

• Peer rejection
• Difficulty maintaining friendships
• Relationship problems
• Interrupting, dominating conversations

Emotional:

• Low frustration tolerance
• Mood swings
• Emotional dysregulation
• Low self-esteem (from repeated failures)

Behavioral:

• Disorganization
• Procrastination
• Difficulty following through
• Risk-taking

Comorbidity

Very high rates of co-occurring disorders:

• Learning disorders (30-50%)
• Oppositional Defiant Disorder (40-60%)
• Conduct Disorder (15-20%)
• Anxiety disorders (25-35%)
• Depression (15-20%)
• Substance use disorders (higher in adolescence/adulthood)

Developmental Course

Preschool: Excessive activity, impulsivity School-Age: Inattention becomes more problematic Adolescence: Hyperactivity decreases, inattention and impulsivity persist Adulthood: 50-65% continue to have significant symptoms; hyperactivity often internalized as restlessness

Autism Spectrum Disorder (ASD)

Overview

Definition: A neurodevelopmental disorder characterized by persistent deficits in social communication and interaction, plus restricted, repetitive patterns of behavior, interests, or activities.

Prevalence:

• Approximately 1 in 36 children (recent CDC data)
• Increasing prevalence (better detection, broader criteria)
• 4:1 male to female ratio
• Occurs across all racial, ethnic, socioeconomic groups

Key Features:

• Present from early childhood
• Lifelong condition
• Wide range of severity (spectrum)
• Strengths and challenges vary greatly

Core Deficits

A. Social Communication and Interaction:

Social-Emotional Reciprocity:

• Abnormal social approach
• Difficulty with back-and-forth conversation
• Limited sharing of interests/emotions
• Failure to initiate or respond to social interactions

Nonverbal Communication:

• Abnormal eye contact
• Limited or unusual facial expressions
• Difficulty understanding gestures
• Limited use of gestures
• Difficulty interpreting body language

Relationships:

• Difficulty forming age-appropriate friendships
• Lack of interest in peers
• Difficulty adjusting behavior to social contexts
• Limited imaginative play
• Preference for solitary activities

B. Restricted, Repetitive Behaviors:

Stereotyped Movements/Speech:

• Hand flapping, rocking, spinning
• Repetitive use of objects (lining up toys)
• Echolalia (repeating words/phrases)
• Idiosyncratic phrases

Insistence on Sameness:

• Rigid adherence to routines
• Distress at small changes
• Ritualized patterns
• Difficulty with transitions
• Inflexible thinking

Restricted Interests:

• Highly focused interests (intensity or focus is abnormal)
• Preoccupation with unusual objects or topics
• Perseverative on specific subjects
• Encyclopedic knowledge in narrow areas

Sensory Issues:

• Hyper- or hypo-sensitivity to sensory input
• Unusual interest in sensory aspects
• Adverse response to sounds, textures, smells
• Indifference to pain/temperature
• Excessive smelling/touching of objects

Severity Levels (DSM-5)

Level 3 - Requiring Very Substantial Support:

• Severe deficits in communication (minimal verbal)
• Extreme difficulty coping with change
• Greatly limited initiation of social interaction
• Behaviors significantly interfere with functioning

Level 2 - Requiring Substantial Support:

• Marked deficits in communication
• Limited initiation of social interaction
• Difficulty coping with change
• Restricted behaviors obvious to casual observer

Level 1 - Requiring Support:

• Noticeable social difficulties without support
• Difficulty switching activities
• Problems with organization and planning
• May function adequately with supports

Common Characteristics

Communication:

• Delayed or absent speech (25-30% nonverbal)
• Difficulty with conversation (turn-taking, topic maintenance)
• Literal understanding (miss sarcasm, idioms)
• Unusual prosody (tone, rhythm)
• Difficulty understanding others’ perspectives

Social Understanding:

• Theory of mind deficits (understanding others’ thoughts/feelings)
• Difficulty reading social cues
• Miss subtle social signals
• Challenges with humor, teasing

Behavior:

• Need for predictability
• Meltdowns when overwhelmed
• Stimming (self-stimulatory behavior) for regulation
• Attention to detail
• Pattern recognition skills

Strengths (vary by individual):

• Strong memory for details
• Visual thinking
• Honesty and directness
• Focus and concentration in interest areas
• Pattern recognition
• Rule-following

Associated Features

Intellectual Functioning:

• Wide range (profound disability to superior intelligence)
• About 30-40% have intellectual disability
• Many have “spiky” profiles (uneven abilities)

Comorbidity:

• Intellectual disability (30-40%)
• ADHD (40-70%)
• Anxiety disorders (40-50%)
• Depression (especially in adolescence/adulthood)
• Epilepsy (20-30%)
• Sleep problems (50-80%)
• Gastrointestinal problems (common)

Developmental Course

Early Signs (12-24 months):

• Limited eye contact
• No response to name
• Delayed language
• Limited gestures (pointing, waving)
• Loss of previously acquired skills (regression)

Preschool:

• Social deficits become more apparent
• Repetitive behaviors emerge
• Language delays or differences evident

School-Age:

• Academic challenges may emerge
• Social difficulties with peers
• Behavioral issues may increase

Adolescence/Adulthood:

• Some improvement in symptoms possible
• Social challenges persist
• Independence varies widely
• Many can live independently with support; some need substantial care

Historical Note

DSM-5 Changes:

• Unified several disorders (Autistic Disorder, Asperger’s, PDD-NOS) into one spectrum
• Eliminated Asperger’s as separate diagnosis
• Two core domains instead of three (combined social/communication)
• Added sensory issues
• Severity levels introduced

Comparing ADHD and ASD

Similarities

• Both neurodevelopmental disorders
• Early onset (childhood)
• More common in males
• Can co-occur (high comorbidity)
• Genetic components
• Executive function difficulties
• Lifelong conditions
• Require comprehensive assessment

Key Differences

Co-occurrence

• 40-70% of individuals with ASD also have ADHD symptoms
• DSM-5 now allows dual diagnosis
• Complicates treatment planning
• Both sets of symptoms need to be addressed

Key Points for Exams

ADHD:

• Three presentations: Inattentive, Hyperactive-Impulsive, Combined
• Core symptoms: Inattention, hyperactivity, impulsivity
• Must be present before age 12 and in multiple settings
• Executive function deficits common
• High comorbidity with learning disorders, ODD, anxiety
• Medications often effective

ASD:

• Two core domains: Social communication deficits + restricted/repetitive behaviors
• Wide spectrum of severity (Levels 1-3)
• Present from early development
• Sensory issues part of criteria
• Theory of mind deficits common
• 30-40% have intellectual disability
• Lifelong condition but early intervention improves outcomes

Both:

• Neurodevelopmental disorders with early onset
• Can co-occur
• Require comprehensive, individualized treatment
• Early intervention important