Distinguishing Similar Traits of Autism and ADHD - A Challenge for Science and Society
Recent research reveals that up to 80 percent of individuals diagnosed as autistic also meet the criteria for attention deficit hyperactivity disorder (ADHD), and up to 50 percent of the ADHD group meet the criteria for autism. These findings challenge previous assumptions about both and require a more nuanced approach to diagnosis.
While psychometric assessments are a valuable tool, clinicians must recognize their limitations and adopt a comprehensive approach that includes three distinct elements to accurately differentiate between autism and ADHD:
Clinician experience
Patient’s experience of their traits or symptoms
Evidence based psychometrics
Psychometric assessments are a valuable tool for diagnosing psychological conditions, but they have their limitations, especially when it comes to distinguishing between autism and ADHD. While the SAAST test is effective at identifying ADHD, it can sometimes identify individuals as having the condition when they do not, due to the shared executive skill challenges of ADHD and autism.
One key difference between the ADHD and autism is the level of experience with inattention. For some autistic individuals, attention may not be a significant challenge, whereas with ADHD, it can be a major issue. For some autistics, what is externally seen as inattention is simply an autistic person exercising their agency, choosing to focus on what they want and not what someone else wants.
As someone who has personally undergone a ton of psychometric assessments, I, like others, have found that a more holistic / personal approach is necessary to accurately diagnose these complex conditions. It is important to consider not only the test results but also the individual's experiences and tendencies, including how they answer the questions. This approach can help ensure a definitive diagnosis and effective guidance in how to best proceed with this new information (e.g., not everyone is a proper candidate for certain medicines, or certain medicines might not be available at the moment).
Again, speaking from my own strengths and deficits, including those associated with autism, ADHD, BP1, and alexithymia, I can attest to the complexity of accurately diagnosing these conditions. While psychometric assessments are useful tools, they do not always capture the full picture.
For example, my most significant executive skill challenges include losing things. My struggles with attention and focus do seem more related to my autistic system’s processing of time than to my ADHD’s influence on executive skills. In fact, throughout my life, people have marveled at my ability to focus intently - producing my latest book over a short summer break as an example.
Our own personal experiences highlight the importance of looking beyond psychometric assessments and considering our unique characteristics and tendencies when diagnosing autism and ADHD. Again, by taking a more holistic approach, clinicians can develop more accurate diagnoses, which is the point we’re making here.
If you’re a paid supporter, keep reading to discover how this all plays out in the SAAST. If you’re a free subscriber, I encourage you to lend your support.
A Practical Exercise
Over at Embrace Autism, Dr. Natalie Engelbrecht (herself autistic but not ADHD) recently deconstructed her results on the SAAST and compared them to a typical ADHD response to the same questions.
Here’s the scale for each question:
No, not at all
Yes, somewhat or a little
Yes, moderately to quite a lot
Yes, very much
Q1. I find that I make careless mistakes in work, in school, or in other activities; or I have trouble paying attention to details.
I love how Dr. Engelbrecht breaks it down. I share it here, then contrast it with my response.
Natalie:
Somewhat
First I don’t like that there are two completely separate questions.
a1. Careless mistakes: This is something I do a fair amount in my writing, but not in my head. As I have dyslexia I have problems with spelling and also with switching letters. I do not make careless mistakes in other areas. So in spelling yes, but not in other things and not other areas. My level of interest is not a factor in how much I make errors.
a2. Work, in school, or in other activities.
b. Trouble paying attention to details. I am a big picture person, so I naturally pay attention to the forest and not the trees. If I need to I can switch, but that takes a lot more brain power. That is something we know is a skill of autistics is that they can switch between bottom up or top down. I have trouble paying attention to details when I am very tired or when the information is very high level in a field I lack knowledge.
Kendall:
Moderately
a1. Careless mistakes. The less interested in something I am, the more mistakes I will make. I have to pay significant energy to not overlook things.
a2. Work, in school, or in other activities. It happens across different activities.
b. Trouble paying attention to details. If it is something I am not interested in, it is just about impossible. If someone is explaining some aspect of something to me, it is so uninteresting that it does not even go in my head. I just glaze over. For example if I go to the accountant and he starts explaining something about a form—I tell him I don’t want to understand it, there is no point in explaining it to me. I guess I don’t want to spend resources on something that is so uninteresting to me.
Differences: My errors are errors mostly due to spelling and mild dyslexia, while Kendall’s errors correlate with his interest. The more interested I am in something the more mistakes I will make due to excitement. Boredom lies behind Kendall’s errors.
I loose interest when the information is way way outside of my breadth of knowledge. Kendall has a hard time paying attention when he is not interested in the topic.
First, I share the frustration over the multi-part question.
For me, the first part of the question is answered Moderately. I do get distracted and make careless mistakes. I use my love of routine (autistic) to try and mitigate this. When I’m forced to be off of my routine, mistakes multiply. A last minute trip somewhere unexpected is an example of this break in routine. I often forget to pack important items and am left to scramble on arrival to get replacements.
The second part of the question might be Not At All. Finding important information in details, and making sense of it, might be considered one of my super strengths.
So, do I split the difference? My brain struggles in scoring this one, which increases my anxiety, which is a trigger for my BP1.
Q2. I tend to fidget with my hands or feet, or I squirm in my seat.
Here, I wonder if they’re asking about stimming, fidgeting, or squirming. These can be separate things, used to achieve different ends. Are my verbal stims a fidget, done by someone of a generation where movement-based fidgeting was physically punished?
I chose Moderate because I do stim moderately, more so under stress. It serves a calming function in me, having little to do with focus.
Q3. I often miss what is being said to me in conversations.
Auditory processing delay is one of the main reasons I initially landed on “the spectrum.” I would mark this as Very Much because I do miss a lot. It plagued my on Zoom during the beginning of the pandemic, when captions were erratic. It’s why I use captions when watching TV. But, it’s likely not due to inattention.
Q4. I prefer to run about or climb on things, even when I know it doesn’t fit the situation.
Well, of course I do. Very Much so. I’m a Solitary Forager. Because this is such a feature of autism, and can be quite dangerous, this “wandering off” is a major theme of my latest book.
Dr. Engelbrecht, however, comments that she never did, that she knew the rules. This illustrates the point that if you’ve met one autistic, you’ve met one autistic … once.
Q5. I find it difficult to organize my tasks and activities.
Not at all. Autistic brains tend towards a high degree of systemization. It’s why capitalism thinks us employable. It’s why I was able to sift through volumes of data to create my old book, Forensic Photoshop. It’s how I'm able to write books and Substacks in the first place.
Q6. I am often “on the go”; as if driven by a motor.
If this means that I feel as though I have to be moving about as I process the world, then I would say Somewhat. But, with BP1, the tendency increases and drives the moving about to full on wandering during manic episodes, so is this ADHD exclusively? Probably not.
Q7. I tend to lose things that I need for school or work.
I did, Very Much so. But, as noted in Q1, I’ve managed to mitigate this with routine. Absent routine, I’d lose most things. This also speaks to that tendency for us to want things always in the same place (e.g., why is the boy always lining up his toys?).
Q8. I can’t help but give the answer before someone has finished asking me a question.
I Very Much do this when I’m in the flow of a conversation. It’s an expression of excitement and connection. But, the presence of this question seems to imply a negative element to this, which I disagree with. I don’t see it as a negative at all. Watch two autistic people engaged in a conversation over a mutually shared interest. Neither will be able to complete a sentence. Likely, each will complete the other’s sentences. It’s a beautiful thing.
Q9. I am forgetful during my daily activities.
Somewhat. When I’m in the moment, when I’m flowing, I lose track of time. This can be seen as forgetful, especially when seen from the outside. I lose track of all of reality beyond what I’m doing when I’m flowing. Is this “forgetful?” I don’t think so in the sense that they seem to imply … like “where’s my keys.” For these types of things, my autistic routines have me placing my things in the precise place that they go … each time, every time. They’re their where I left them when I want them.
Q10. I find it difficult to keep my attention on what I am doing, whether working or playing.
Not At All. I can go off on a secant, chasing something that I may need more information about, but it is on topic.
Q11. I find it hard to stay sitting, even when I know I am expected to.
Somewhat. But, this has more to do with the fact that I’m quite tall and rarely find chairs comfortable. My literal brain has me answering this in the affirmative. I do get up during meetings when the uncomfort becomes unbearable. But, reading the responses of others to this question, the implication seems toward impulse and not comfort.
Q12. I find it hard to follow through on instructions or finish chores or duties, even though I understand what is expected of me.
Not At All. I get anxious when things remain unresolved or undone. It’s as a splinter in my mind’s eye. I have to remove it, finish the task. I can’t quite move on until then. It’s a big part of why I didn’t do well in college until I got into a “cohort” style program that only had one class at a time. It was so hard to manage those times when I had multiple classes per term.
Q13. I find it hard to engage in play or leisure activities that are quiet.
Not At All. I am prone to over-stimulation. I need my dark, quiet room during my calm down time.
Q14. I don’t like having to make a sustained mental effort.
Not At All. I actually love it. I enjoy deep dives and the flow states that happen when I do.
Q15. I tend to talk excessively.
Yes, Very Much. Not only do I love to share, and I love to flow in conversations (Q8), my stims tend towards the verbal. Verbal stims are common with Gestalt Language Processors.
Q16. I am easily distracted.
Not At All. If I’m in a flow state, or working on something of deep interest, there’s no turning my attention away.
Q17. I have trouble waiting my turn.
Somewhat. Context is key. I can queue for as long as necessary. But the time it takes for me to get test results, for example, seem like an eternity. I think if I can see what’s happening, like a postal queue, I am fine. If I can’t see into the process, like test results, the building anxiety is troublesome.
Q18. I often interrupt others.
Yes, Very Much. But, it’s part of my job as a special education teacher. I often have to interrupt when someone is off task, going down the wrong path, and so forth. Also, like Q8, this can happen in a flowing conversation and be perfectly normal.
Q19. Even before the age of 7, some of the questions above (1-18) would still have been “Yes, moderately to quite a lot” or “Yes, very much”.
Yes. We don’t usually grow out of our preferred way of being. We can, however, get better at blending them in with everyday life.
Q20. I experience problems related to some of the above in more than one context — i.e., I experience problems more than just at home, or more than just at work.
Yes. I am me, wherever I happen to be.
Q21. The kinds of problems I experience due to these experiences get to be pretty serious in my social life, my academic work, or my job.
Somewhat. When I get flowing, and obligations go to the wayside, there is consequence.
Q22. I have previously been diagnosed with a mental disorder that I have been told might account for the types of experiences above, or I believe that I may be experiencing such a disorder. This might include Pervasive Developmental Disorder, Schizophrenia or other Psychotic Disorder, or something in the class of disorders included under the headings of Mood Disorder, Anxiety Disorder, Dissociative Disorder, or Personality Disorder.
Yes. Do I consider autism to be a disorder? No. I think my autistic brain is perfectly in order. But, the system from which this survey comes considers autism to be a disorder. Thus, I answered Yes.
My Score: 26 (12-42, Significant Level of Experiences Associated With Hyperactivity-Impulsivity)
My answers indicate levels of experiences which are consistent with the hyperactivity-impulsivity component of ADHD symptoms. However, are these actually ADHD, autism, BP1, or a mix of all three?
Going back to Dr. Engelbrecht’s results (18) vs. Kendall (39), she notes:
“[The] answers indicate levels of experiences which are consistent with the hyperactivity-impulsivity component of ADHD symptoms. However, in the absence of higher levels of experiences typically associated with inattention, a diagnosis of ADHD is normally not appropriate.
And that is what I do not have, high levels of experiences of inattention.”
In conclusion, it is important to consider not only a person’s traits, but why a person has that trait, when assessing a person. This is especially important for those who can only self-assess. Without these considerations autism can be mistaken for many different conditions such as BP1, BPD, or ADHD. Or something else entirely. Mix in alexithymia and all bets are off.
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