The primary condition is ASD and intellectual disabilities. In this cohort ADHD is up to 70% prevalent.
In the previous iterations of DSM ADHD was not diagnosed if there was a different condition explaining the symptoms of ADHD however presently an ADHD diagnosis can be made.
I find that the prevalences are representations of what people are looking for.
For instance at an autism diagnostic clinic, there will be a higher prevalence of kids getting diagnosed with autism. Likewise for an ADHD assessment chances are of a greater ADHD prevalence.
It is also true that 10 - 15 years down the road these kids may look entirely different.
The practice of child psychiatry is over 80% off label both on the medication side and often on the diagnosis side.
Before we jump up and down and call it lack of evidence based, these children have been observed in two different settings or more, known to have symptoms, symptoms interfering with everyday activities, especially not meeting their expected milestones socially or developmentally or educationally. They are meeting severity criteria for needing treatment above and beyond psychosocial treatment. These children are not doing well at home or school.
They're not helped by diagnostic conundrums as much as they're helped by symptomatic management and in that respect the diagnosis of autism, intellectual disability, adhd, disruptive behavior disorder, intermittent explosive disorder are often seen as descriptors of what's being treated.
Thankfully development is a beautiful thing and 10 years 20 years down the road these children will either be out of the developmental or psychosocial limitations when they were younger or firmly and clearly having conditions that will persist into adulthood. Either way the treated outcomes are better than the untreated outcomes.
I'm all for treatment in childhood, but perhaps there should be more general understanding about how a diagnostic and treatment picture can and should change ten and twenty years later? Not a message to you, so much as to society at large.
Thanks for your input!
>Thankfully development is a beautiful thing and 10 years 20 years down the road these children will either be out of the developmental or psychosocial limitations when they were younger or firmly and clearly having conditions that will persist into adulthood.
The tricky thing about this is that in the case of ADHD in adulthood, other symptoms tend to be at the forefront (depression, anxiety and addiction) compared to children, which blurs the lines even more!
Absolutely agreed. So the usual course of action is to treat the bigger more sustained conditions as depression, bipolar, anxiety before looking at ADHD because all of these conditions will impact attention and sustaining attention
Obviously it's harder to diagnose ADHD when there are co-morbid conditions present. But say the anxiety/depression is caused directly by unmanaged ADHD symptoms (e.g. low self-esteem due to failing academics, anxiety due to not being able to complete school work on time) wouldn't an ADHD diagnosis be helpful in treating the anxiety/depression?
So there is this concept where we timeline the conditions to see which one happened first however when you are out to treat them some people may have more anxiety with stimulants
medications.
If the anxiety and depressive symptoms are impairing everyday activities an SSRI for anxiety and depression should be started earlier. If the anxiety and depressive symptoms are not severe I have done it the other way around as well explained to the parents that in the interest of keeping minimal medications let's try a stimulant and if there's worsening we'll will have to rejigger this, and start an SSRI
In this respect, I have repeatedly spoken to the diagnosticians to stop doing diagnostic ADHD assessments on kids who have uncontrolled anxiety, uncontrolled social anxiety, depression etc. An autism assessment should be conducted before an ADHD assessment.
It's kind of like talking to the abortion doctors about treating psychosocial conditions of their patients. That's not what they do. Hence we get all these vanderbilts sent over alongside teachers observations etc this kid now has ADHD. If the parents want assessment for an ADHD appointment they get an ADHD appointment.
It does come down to the psychiatric prescribers to tease this out because at the end we are responsible for the outcomes. Not those diagnosticians who send cases to us.
:-) fasten your seatbelts
The idea is to catch other impairing conditions first. Such as mood disorders, anxiety disorders and autism. A lot of things look like ADHD especially in kids. Not every kid will need a full workup tho.
I'm out of my area of competence in commenting on diagnostics accuracy thru neuropsychological testing. I'm talking about more pedestrian ASD via ADOS (https://www.childrensresourcegroup.com/a-brief-overview-of-the-ados-2-an-assessment-for-autism-spectrum-disorder/)
Anywhere from 30% to 80% of children with autism also meet the criteria for ADHD. Conversely, 20% to 50% of children with ADHD may also have autism spectrum disorder (ASD).
Can I get more information about this thought process? At what age do you recommend the difference? For the “easy ADHD” kids (the pre 3rd grade ones, where anxiety/depression is less prevalent), I assume this doesn’t apply because there isn’t as much uncontrolled anxiety/depression at that age.
But doesn’t this still cause the same problem we’ve been facing with inattention type girls/women? Misdiagnosed with anxiety and not ADHD?
And maybe I’m just missing something, but where is the “test for autism first” coming into this?
Med student with a prior Master's in a mental health field, not psychiatrist, but:
I can't answer for the person you asked this of, but my take on this is partially going back to:
"The practice of child psychiatry is over 80% off label both on the medication side and often on the diagnosis side."
I think there are a lot of ideas and assumptions placed on diagnosing young girls with anxiety now (or often anything other than ADHD and Autism) that come from perhaps an overreaction to older sexist assumptions and diagnostic bias, but run the risk of making the same mistake in a different direction.
Which is to say - OurPsych101 has a great point in saying "how can you assess for ADHD with significant overlying anxiety without first assessing or addressing that?" Anxiety can look a lot like ADHD, for sure, especially in kids, and can lead to similar problems in functioning.
I think the problem here comes in assuming that the motive (or even the outcome regardless of motive) is
1. to "deny" a diagnosis of ADHD or invalidate the child being diagnosed
2. rather than to investigate and progress and work with the child & the family to figure out what's going on and try and treat it effectively.
And I get that partially that comes from some older sexism in psychology/psychiatry, and partially from overworked mental health care resources that means what should look like 2) can look more like a brief dx and then a family doctor handling med renewals for a decade, but taking a step back and thinking about the actual purpose of evaluation & working with kids & families in psychiatry, it's not that.
And getting "the right diagnosis" or a certain diagnosis within a short period of time isn't always the concern - yes, that matters if you have a kid with leukemia, and with some mental health conditions as well, but in terms of working with a kid who has maybe-anxiety maybe-ADHD maybe-depression it may really not, and the process of working through that can be helpful.
Again, as OurPsych101 said, child & adolescent psychiatry means working with a lot of uncertainty, but I'd add that the good part of that is that often working together with kids & families in good faith means that whether you're "right" or "wrong" that work is probably still progressing in a way that's somewhat helpful - unlike misdxing childhood leukemia.
I also will add that I think there's been a lot of social media talk and awareness for girls with inattentive or """quiet""" ADHD (see quotation marks) that ends up being somewhat pejorative or stigmatizing towards girls & women with less """quiet""" ADHD, or stigmatizing towards girls & women with anxiety as being somehow in lesser need of attention or having a more insignificant problem.
Not to say diagnosis or working diagnosis doesn't matter at all, but it shouldn't matter THIS much - it should be about working with kids & families to treat and improve whatever's going on that's disrupting functioning or causing distress, not about finding a true "perfect" answer that likely doesn't exist, or would differ depending on point in time, specialist seen (ADHD clinic biased towards ADHD, anxiety clinic looking for anxiety, etc), etc. And that's not always going to be the same answer for every kid.
//again, not a psychiatrist! Med student with prior degree thinking on what I knew prior to medical school, and what I've experienced so far in child & adolescent psychiatry as a med student.
My only issue with the misdiagnosis for women is the huge differences in medication efficacy. We have stimulants- they work for ADHD. Caught early enough, we effectively block a lot of anxiety from occurring. But once on the anxiety bandwagon, we begin to use the incorrect treatment for the underlying problem.
Yes, there often needs to be real CBT for that anxiety. It may be old school of me, but there’s some great REBT/CBT stuff missing in a lot of anxiety treatment I see with therapists today. I care far less about the validation of feelings and more about “is this a problem where etiology matters for treatment, and seriously impacts treatment outcomes?” ADHD is one of those diagnoses, especially if it isn’t overlapping with ASD.
Ruling out anxiety first or working on it if present and having continuing follow-up with a psychiatrist or a psychiatrist + therapist, social worker, psychologist, isn't the same as dismissing ADHD though, and it doesn't prevent revisiting or addressing later. Often this isn't something that can be instantly solved with a correct answer, or a definitive answer.
And there are also other approaches than CBT for anxiety, and probably being more flexible with those would likely do kids who may fall in less definite categories (so - many/most) much better than assuming there's a circle that goes through a circle hole, and a square that needs to go through the square hole.
Let me put it this way - do you think there's an instantaneous and very valid/reliable way to diagnose ADHD in kids? Because it sounds like you're suggesting that there is one, and it's intentionally or wilfully harmful to miss it it. I disagree with that, and I think research on ADHD and childhood mental health does as well (to a certain extent), and that may be the gap here - I'm not sure there's a way to just "know" that anxiety or depression or something else is hiding ADHD in many children without a more involved assessment & process that may also include addressing anxiety. If this is a misreading or mischaracterization of what you're saying, then apologies, I may be missing something.
The context of testing for autism first is for symptoms where there is mixed autistic, difficulty connecting with others, or externalizing behaviors towards other kids.
Girls do tend to get more ADHD inattentive type diagnosis. Or misdiagnosed as anxiety. However as you have mentioned this is more predominant after the elementary schools.
Say for instance there is someone grades one through four or five, who is viewed as withdrawn, not interacting and difficulty sustaining friendships. Playing alone, eating alone. This would need to be discerned between communication issues, anxiety issues or ADHD issues.
This. If symptoms of depression are affecting cognitive domains of attention/concentration, treat the depression before exploring ADHD. Of course, if social anxiety is the result of severe, debilitating ADHD symptoms, you’ll likely get a lot out of addressing the ADHD first. Context of the diagnosis/treatment is key, and it’s usually not super complicated to tease this out in practice. That said, there will always be a lot of overlap and at least some degree of trial and error.
Why would the prevalence of 2 neurodevelopmental disorders being present together be expected to be low? If something went wrong with neurodevelopment, shouldn't we expect multiple disorders? It's like how having one autoimmune disorder makes having others more likely. None of this is to say that they are likely or that they're related, just that our prior expectations should be high, not low.
Exactly. Learning disabilities, ADHD, developmental coordination disorder, auditory processing disorder, autism, etc are all disabilities that tend to come packaged together. If you have, you are more likely to have co-morbid disabilities in the neurodevelopmental cluster than not.
If anything, when I see someone coming in with six psychiatric diagnoses and they're not all hilariously wrong, the underlying connection is semi-often an autism spectrum disorder. The increased frequency comorbidity of ASD/ADHD/tic disorder/OCD is well established.
I work at a high school which is specifically tailored to students with learning disabilities and behavioural disorders, and I've gotta agree, a very significant portion of them exhibit signs of both at the same time. Some of them have a diagnosis for one or the other, some have a diagnosis for both, and some aren't diagnosed at all (a lot of parents tend to be in denial and refuse to get their child help that will improve their quality of life, but that's an entirely other conversation lol).
As both a physician who does primary care for children and refers a lot for nonspecific symptoms where parents have questions about both AND as the caregiver for a child with ADHD, I sometimes wonder how much of the apparent comorbidity is caregiver overwhelm with symptom severity. As the number of parents requesting ADHD evaluations has increased, I feel like I'm frequently diagnosing primarily inattentive, relatively non-disruptive kids who are presenting with primarily anxiety related to achievement while in younger kids with hyperactivity there's a lot more parental anxiety around how disruptive symptoms cannot "just" be ADHD. I see this with the child in our home also--he's been evaluated by multiple professionals and no one evaluating him formally has felt that ASD was a fitting explanation for his behaviors or needs, but lay people around us love to opine that he must have ASD because this loud, disruptive, frankly immature kid seems more severe than what they imagine ADHD alone would explain. We have been pushed by random moms at activities to have him see even more professionals until someone gives him an ASD diagnosis.
I can absolutely see how these things appear as a spectrum or difficult to differentiate at the more severely hyperactive ends of ADHD, and I think sometimes the addition of ASD helps to validate the challenges of managing behaviors. I've also been told by developmental pediatricians I rotated with that having that diagnosis opens up more resources, so they find themselves sometimes utilizing that diagnosis to improve access to therapies while subjectively they're not confident that there's truly a distinct ASD presentation at play.
>they find themselves sometimes utilizing that diagnosis to improve access to therapies
This is much more common than people realize. Sometimes there's a kid with a clear developmental delay, and they need some sort of diagnosis to begin therapy, with the understanding that the diagnosis can be revised later. Often resources are gated behind an ASD diagnosis specifically, ex: the local school has a sensory gym that is available for ASD kids, but not ADHD kids. I've also seen kids be kicked out of therapeutic programs when their diagnosis changes from ASD to fragile X or some other non-ASD condition.
The developmental gap between the top and bottom of the Kindergarten class has also widened considerably in the last 5-10 years, especially for boys. It's becoming common for developmentally typical kids to start kindergarten a year late because it gives them an academic and athletic edge. In my district, 65% of the boys and 40% of the girls start late. The kindergarten curriculum has also gotten more advanced, including a lot of what used to be 1st grade curriculum, and it's pushing the younger kids past their neurodevelopmental capacity.
The problem that arises is when you get a kid with ADHD who just turned 5 in the same classroom with 6.9 year olds. If the ADHD kid is on the lower end of the emotional maturity bell curve for their chronological age, and some of those 6.9 year olds are on the upper end for their age, there can easily be a 3+ year gap in maturity in the same classroom. That makes the ADHD kid's behaviors look much more severe than they would be otherwise. It shouldn't surprise anyone that the kid who is developmentally a 4 year old struggles in a classroom of 7 year olds.
I'm general peds, and while most of my patients who meet DSM 5 criteria for ADHD are not even remotely autistic, the reverse situation seems complicated. Most of the kids who are able to communicate tell me that they are getting sensory overwhelm rather than the type of distraction I see in ADHD-only patients. Or they are getting sucked into an obsessive thought or compulsion. If you don't dig into it, it's easy to miss causes of symptoms that might have a more specific management.
Someone correct me with I'm wrong but, many kids with autism also have adhd. I do not believe the reverse is as true, even though there is substantial comorbidity. I think the amount of kids with adhd who also have autism is more like 10%ish.
ADHD/ASD were always on my MR and never treated until I was in my 40's. The depression caused by never having been able to finish law school or anything else for that matter, was always more important to MDs than treating the root causes, ADHD/ASD.
For all those ADHD/ASD patients being told they are just "depressed" please, at the very least, treat the ADHD and the rest will follow.
Something worth asking is whether ADHD is truly a genuine comorbidity of ASD and ID, or if ADHD is so broadly defined that any set of executive and attention deficits from any etiology (ID, ASD, mood, NCD, anxiety, SUD, OCD, BPD) COULD be interpreted as ADHD as long as an evaluator would like to imagine the possibility of some internal separation, or an earlier and more subtle onset.
If the latter were NOT the case, then there would be clear rules about how ADHD can specifically be differentiated from cognitive deficits inherent to ID or ASD. (If those cognitive deficits are the same, then the entity would not be separately defined.)
Read the criteria and ask if this is the case.**
This is not to say that I don't think there's some core Primary Disorder of Vigilance (that is, whatever entity that *should* be captured by the ADHD construct) which is unique and separate from other neurodevelopmental impairments. The Primary Disorder of Vigilance also would be expected to have higher comorbidity with other ND disorders given the likelihood of genetic contribution.
The point I'm making is that there does not appear to be any significant attempt to rigorously define the borders of these conditions in the field. I think you're right to wonder about it. I don't think there's any enthusiasm from the experts to find out or create any separation beyond a few prevalence studies. Speaking about the degree of comorbidity is meaningless if the core constructs have not been separated through a scientifically informed process.
**The problem, as I see it, is that the DSM has never made any significant attempts to formally differentiate any disorder from another except in select explicit cases. Instead, it insinuates that some entities are a Thing In Itself, and that others are linked and not fully separate, and others are caused by this and that. The lack of specific separation leaves room for professional judgment but also allows poorly trained clinicians to go wild in their diagnostic process. Wild diagnosis is then taken as real, rather than clinical. This is a failure of the etiology neutral approach, the dictionary function of the manual, and the professional consensus method of construction.
Thanks for sharing!
>**The problem, as I see it, is that the DSM has never made any significant attempts to formally differentiate any disorder from another except in select explicit cases. Instead, it insinuates that some entities are a Thing In Itself, and that others are linked and not fully separate, and others are caused by this and that. The lack of specific separation leaves room for professional judgment but also allows poorly trained clinicians to go wild in their diagnostic process. Wild diagnosis is then taken as real, rather than clinical. This is a failure of the etiology neutral approach, the dictionary function of the manual, and the professional consensus method of construction.
So this is interesting. When I did my CAP rotations, I was supervised by a specialist who worked in one of the university hospitals. He basically saw everything and anything, self referrals included.
Bear in mind we're in a country that doesn't use the DSM for coding purposes but we do keep it in mind in terms of criteria. ICD is the way here.
He'd seen thousand upon thousand kids from diverse backgrounds, ASD was a pretty common reason. Which makes sense. I'm somewhat convinced he was very "biased" towards ASD but one thing he and his colleagues told me is that they barely had ANY ADHD diagnoses, whether requested by the parents or simply discovered upon assessment.
What I do notice in the DSM (iirc) is how recurrent ADHD is as a differential diagnosis. It's almost suspicious at times. I'm wondering if this explains why there are so many ADHD prevalence gaps between countries.
I sometimes wonder if “AuDHD” could be considered a separate condition to ADHD and autism in that due to the overlapping and sometimes mitigating effects of the two conditions patients present features of both conditions but may not reach the full criteria of either. PDA profile autism could be another avenue to look down regarding this as well.
Makes perfect sense a whole body connective tissue disorder that often has neurological and Autonomic issues thrown in the mix too being co morbid with neurodivergence makes perfect sense since collagen is key in brain formation and development.
Don't get why you're downvoted
Among other myriad immune dysregulations and neurodivergences, such as being transgender. I wonder what it is that links collagen, immunity, and the nervous system.
I was forced to research the POTS/MCAS/EDS triad because it was becoming more obvious my headaches weren't simply primary, chronic migraine, but rather POTS. It takes time piece together the excessive sweating, feeling sick after hot showers, with the whole picture without digging with a PCP who is willing to refer you around to different -ologists. I wasn't surprised to read that there's theoretical autoimmune components to at least POTS, and obviously MCAS, give that I have diagnosed eczema which comes and goes together with everything else.
Regarding that some symptoms appear to contradict each other, I have seen it suggested that the combination changes the presentation of both, but I don't know if there is actual research for that.
I mean fair enough, that's basically 99% of my caseload, though in addictions we kind of have to broaden the scope and work towards encompassing ADHD more thoroughly in our assessments. Not as easy as it sounds unfortunately.
Removed under rule #1. This is not a place to share experiences or anecdotes about your own experiences or those of your family, friends, or acquaintances.
Self-diagnosis primarily. I just don’t believe that everyone suddenly developed ADHD and ASD. Can people have difficulty focusing in boring work and school tasks and also be socially awkward? Yes but that does not warrant a legitimate diagnosis.
Self-diagnosis primarily. I just don’t believe that everyone suddenly developed ADHD and ASD. Can people have difficulty focusing in boring work and school tasks and also be socially awkward? Yes but that does not warrant a legitimate diagnosis.
The primary condition is ASD and intellectual disabilities. In this cohort ADHD is up to 70% prevalent. In the previous iterations of DSM ADHD was not diagnosed if there was a different condition explaining the symptoms of ADHD however presently an ADHD diagnosis can be made.
Thing is, we don't use the DSM in many countries (usually ICD instead). Yet prevalences are completely different in comparison to the US.
I find that the prevalences are representations of what people are looking for. For instance at an autism diagnostic clinic, there will be a higher prevalence of kids getting diagnosed with autism. Likewise for an ADHD assessment chances are of a greater ADHD prevalence. It is also true that 10 - 15 years down the road these kids may look entirely different.
Perhaps the most irresponsible choice made in the move from IV to 5, and there are a lot of choices to choose from...
I’m curious as to why you say that?? Do you think they’re not comorbid conditions?
The practice of child psychiatry is over 80% off label both on the medication side and often on the diagnosis side. Before we jump up and down and call it lack of evidence based, these children have been observed in two different settings or more, known to have symptoms, symptoms interfering with everyday activities, especially not meeting their expected milestones socially or developmentally or educationally. They are meeting severity criteria for needing treatment above and beyond psychosocial treatment. These children are not doing well at home or school. They're not helped by diagnostic conundrums as much as they're helped by symptomatic management and in that respect the diagnosis of autism, intellectual disability, adhd, disruptive behavior disorder, intermittent explosive disorder are often seen as descriptors of what's being treated. Thankfully development is a beautiful thing and 10 years 20 years down the road these children will either be out of the developmental or psychosocial limitations when they were younger or firmly and clearly having conditions that will persist into adulthood. Either way the treated outcomes are better than the untreated outcomes.
I'm all for treatment in childhood, but perhaps there should be more general understanding about how a diagnostic and treatment picture can and should change ten and twenty years later? Not a message to you, so much as to society at large.
Thanks for your input! >Thankfully development is a beautiful thing and 10 years 20 years down the road these children will either be out of the developmental or psychosocial limitations when they were younger or firmly and clearly having conditions that will persist into adulthood. The tricky thing about this is that in the case of ADHD in adulthood, other symptoms tend to be at the forefront (depression, anxiety and addiction) compared to children, which blurs the lines even more!
Absolutely agreed. So the usual course of action is to treat the bigger more sustained conditions as depression, bipolar, anxiety before looking at ADHD because all of these conditions will impact attention and sustaining attention
Obviously it's harder to diagnose ADHD when there are co-morbid conditions present. But say the anxiety/depression is caused directly by unmanaged ADHD symptoms (e.g. low self-esteem due to failing academics, anxiety due to not being able to complete school work on time) wouldn't an ADHD diagnosis be helpful in treating the anxiety/depression?
So there is this concept where we timeline the conditions to see which one happened first however when you are out to treat them some people may have more anxiety with stimulants medications. If the anxiety and depressive symptoms are impairing everyday activities an SSRI for anxiety and depression should be started earlier. If the anxiety and depressive symptoms are not severe I have done it the other way around as well explained to the parents that in the interest of keeping minimal medications let's try a stimulant and if there's worsening we'll will have to rejigger this, and start an SSRI
Interesting thanks!
Which is kind of why I'm questioning all these diagnostic trends we're seeing.
In this respect, I have repeatedly spoken to the diagnosticians to stop doing diagnostic ADHD assessments on kids who have uncontrolled anxiety, uncontrolled social anxiety, depression etc. An autism assessment should be conducted before an ADHD assessment. It's kind of like talking to the abortion doctors about treating psychosocial conditions of their patients. That's not what they do. Hence we get all these vanderbilts sent over alongside teachers observations etc this kid now has ADHD. If the parents want assessment for an ADHD appointment they get an ADHD appointment. It does come down to the psychiatric prescribers to tease this out because at the end we are responsible for the outcomes. Not those diagnosticians who send cases to us. :-) fasten your seatbelts
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The idea is to catch other impairing conditions first. Such as mood disorders, anxiety disorders and autism. A lot of things look like ADHD especially in kids. Not every kid will need a full workup tho. I'm out of my area of competence in commenting on diagnostics accuracy thru neuropsychological testing. I'm talking about more pedestrian ASD via ADOS (https://www.childrensresourcegroup.com/a-brief-overview-of-the-ados-2-an-assessment-for-autism-spectrum-disorder/) Anywhere from 30% to 80% of children with autism also meet the criteria for ADHD. Conversely, 20% to 50% of children with ADHD may also have autism spectrum disorder (ASD).
Can I get more information about this thought process? At what age do you recommend the difference? For the “easy ADHD” kids (the pre 3rd grade ones, where anxiety/depression is less prevalent), I assume this doesn’t apply because there isn’t as much uncontrolled anxiety/depression at that age. But doesn’t this still cause the same problem we’ve been facing with inattention type girls/women? Misdiagnosed with anxiety and not ADHD? And maybe I’m just missing something, but where is the “test for autism first” coming into this?
Med student with a prior Master's in a mental health field, not psychiatrist, but: I can't answer for the person you asked this of, but my take on this is partially going back to: "The practice of child psychiatry is over 80% off label both on the medication side and often on the diagnosis side." I think there are a lot of ideas and assumptions placed on diagnosing young girls with anxiety now (or often anything other than ADHD and Autism) that come from perhaps an overreaction to older sexist assumptions and diagnostic bias, but run the risk of making the same mistake in a different direction. Which is to say - OurPsych101 has a great point in saying "how can you assess for ADHD with significant overlying anxiety without first assessing or addressing that?" Anxiety can look a lot like ADHD, for sure, especially in kids, and can lead to similar problems in functioning. I think the problem here comes in assuming that the motive (or even the outcome regardless of motive) is 1. to "deny" a diagnosis of ADHD or invalidate the child being diagnosed 2. rather than to investigate and progress and work with the child & the family to figure out what's going on and try and treat it effectively. And I get that partially that comes from some older sexism in psychology/psychiatry, and partially from overworked mental health care resources that means what should look like 2) can look more like a brief dx and then a family doctor handling med renewals for a decade, but taking a step back and thinking about the actual purpose of evaluation & working with kids & families in psychiatry, it's not that. And getting "the right diagnosis" or a certain diagnosis within a short period of time isn't always the concern - yes, that matters if you have a kid with leukemia, and with some mental health conditions as well, but in terms of working with a kid who has maybe-anxiety maybe-ADHD maybe-depression it may really not, and the process of working through that can be helpful. Again, as OurPsych101 said, child & adolescent psychiatry means working with a lot of uncertainty, but I'd add that the good part of that is that often working together with kids & families in good faith means that whether you're "right" or "wrong" that work is probably still progressing in a way that's somewhat helpful - unlike misdxing childhood leukemia. I also will add that I think there's been a lot of social media talk and awareness for girls with inattentive or """quiet""" ADHD (see quotation marks) that ends up being somewhat pejorative or stigmatizing towards girls & women with less """quiet""" ADHD, or stigmatizing towards girls & women with anxiety as being somehow in lesser need of attention or having a more insignificant problem. Not to say diagnosis or working diagnosis doesn't matter at all, but it shouldn't matter THIS much - it should be about working with kids & families to treat and improve whatever's going on that's disrupting functioning or causing distress, not about finding a true "perfect" answer that likely doesn't exist, or would differ depending on point in time, specialist seen (ADHD clinic biased towards ADHD, anxiety clinic looking for anxiety, etc), etc. And that's not always going to be the same answer for every kid. //again, not a psychiatrist! Med student with prior degree thinking on what I knew prior to medical school, and what I've experienced so far in child & adolescent psychiatry as a med student.
My only issue with the misdiagnosis for women is the huge differences in medication efficacy. We have stimulants- they work for ADHD. Caught early enough, we effectively block a lot of anxiety from occurring. But once on the anxiety bandwagon, we begin to use the incorrect treatment for the underlying problem. Yes, there often needs to be real CBT for that anxiety. It may be old school of me, but there’s some great REBT/CBT stuff missing in a lot of anxiety treatment I see with therapists today. I care far less about the validation of feelings and more about “is this a problem where etiology matters for treatment, and seriously impacts treatment outcomes?” ADHD is one of those diagnoses, especially if it isn’t overlapping with ASD.
Ruling out anxiety first or working on it if present and having continuing follow-up with a psychiatrist or a psychiatrist + therapist, social worker, psychologist, isn't the same as dismissing ADHD though, and it doesn't prevent revisiting or addressing later. Often this isn't something that can be instantly solved with a correct answer, or a definitive answer. And there are also other approaches than CBT for anxiety, and probably being more flexible with those would likely do kids who may fall in less definite categories (so - many/most) much better than assuming there's a circle that goes through a circle hole, and a square that needs to go through the square hole. Let me put it this way - do you think there's an instantaneous and very valid/reliable way to diagnose ADHD in kids? Because it sounds like you're suggesting that there is one, and it's intentionally or wilfully harmful to miss it it. I disagree with that, and I think research on ADHD and childhood mental health does as well (to a certain extent), and that may be the gap here - I'm not sure there's a way to just "know" that anxiety or depression or something else is hiding ADHD in many children without a more involved assessment & process that may also include addressing anxiety. If this is a misreading or mischaracterization of what you're saying, then apologies, I may be missing something.
The context of testing for autism first is for symptoms where there is mixed autistic, difficulty connecting with others, or externalizing behaviors towards other kids. Girls do tend to get more ADHD inattentive type diagnosis. Or misdiagnosed as anxiety. However as you have mentioned this is more predominant after the elementary schools. Say for instance there is someone grades one through four or five, who is viewed as withdrawn, not interacting and difficulty sustaining friendships. Playing alone, eating alone. This would need to be discerned between communication issues, anxiety issues or ADHD issues.
This tracks. Thank you.
This. If symptoms of depression are affecting cognitive domains of attention/concentration, treat the depression before exploring ADHD. Of course, if social anxiety is the result of severe, debilitating ADHD symptoms, you’ll likely get a lot out of addressing the ADHD first. Context of the diagnosis/treatment is key, and it’s usually not super complicated to tease this out in practice. That said, there will always be a lot of overlap and at least some degree of trial and error.
Are you a child psychiatrist
Yes.
Why would the prevalence of 2 neurodevelopmental disorders being present together be expected to be low? If something went wrong with neurodevelopment, shouldn't we expect multiple disorders? It's like how having one autoimmune disorder makes having others more likely. None of this is to say that they are likely or that they're related, just that our prior expectations should be high, not low.
Exactly. Learning disabilities, ADHD, developmental coordination disorder, auditory processing disorder, autism, etc are all disabilities that tend to come packaged together. If you have, you are more likely to have co-morbid disabilities in the neurodevelopmental cluster than not.
If anything, when I see someone coming in with six psychiatric diagnoses and they're not all hilariously wrong, the underlying connection is semi-often an autism spectrum disorder. The increased frequency comorbidity of ASD/ADHD/tic disorder/OCD is well established.
We work with a lot of young people who have a diagnosis of one, the other, or both. I think of it more like an extended spectrum.
I work at a high school which is specifically tailored to students with learning disabilities and behavioural disorders, and I've gotta agree, a very significant portion of them exhibit signs of both at the same time. Some of them have a diagnosis for one or the other, some have a diagnosis for both, and some aren't diagnosed at all (a lot of parents tend to be in denial and refuse to get their child help that will improve their quality of life, but that's an entirely other conversation lol).
As both a physician who does primary care for children and refers a lot for nonspecific symptoms where parents have questions about both AND as the caregiver for a child with ADHD, I sometimes wonder how much of the apparent comorbidity is caregiver overwhelm with symptom severity. As the number of parents requesting ADHD evaluations has increased, I feel like I'm frequently diagnosing primarily inattentive, relatively non-disruptive kids who are presenting with primarily anxiety related to achievement while in younger kids with hyperactivity there's a lot more parental anxiety around how disruptive symptoms cannot "just" be ADHD. I see this with the child in our home also--he's been evaluated by multiple professionals and no one evaluating him formally has felt that ASD was a fitting explanation for his behaviors or needs, but lay people around us love to opine that he must have ASD because this loud, disruptive, frankly immature kid seems more severe than what they imagine ADHD alone would explain. We have been pushed by random moms at activities to have him see even more professionals until someone gives him an ASD diagnosis. I can absolutely see how these things appear as a spectrum or difficult to differentiate at the more severely hyperactive ends of ADHD, and I think sometimes the addition of ASD helps to validate the challenges of managing behaviors. I've also been told by developmental pediatricians I rotated with that having that diagnosis opens up more resources, so they find themselves sometimes utilizing that diagnosis to improve access to therapies while subjectively they're not confident that there's truly a distinct ASD presentation at play.
>they find themselves sometimes utilizing that diagnosis to improve access to therapies This is much more common than people realize. Sometimes there's a kid with a clear developmental delay, and they need some sort of diagnosis to begin therapy, with the understanding that the diagnosis can be revised later. Often resources are gated behind an ASD diagnosis specifically, ex: the local school has a sensory gym that is available for ASD kids, but not ADHD kids. I've also seen kids be kicked out of therapeutic programs when their diagnosis changes from ASD to fragile X or some other non-ASD condition. The developmental gap between the top and bottom of the Kindergarten class has also widened considerably in the last 5-10 years, especially for boys. It's becoming common for developmentally typical kids to start kindergarten a year late because it gives them an academic and athletic edge. In my district, 65% of the boys and 40% of the girls start late. The kindergarten curriculum has also gotten more advanced, including a lot of what used to be 1st grade curriculum, and it's pushing the younger kids past their neurodevelopmental capacity. The problem that arises is when you get a kid with ADHD who just turned 5 in the same classroom with 6.9 year olds. If the ADHD kid is on the lower end of the emotional maturity bell curve for their chronological age, and some of those 6.9 year olds are on the upper end for their age, there can easily be a 3+ year gap in maturity in the same classroom. That makes the ADHD kid's behaviors look much more severe than they would be otherwise. It shouldn't surprise anyone that the kid who is developmentally a 4 year old struggles in a classroom of 7 year olds.
I'm general peds, and while most of my patients who meet DSM 5 criteria for ADHD are not even remotely autistic, the reverse situation seems complicated. Most of the kids who are able to communicate tell me that they are getting sensory overwhelm rather than the type of distraction I see in ADHD-only patients. Or they are getting sucked into an obsessive thought or compulsion. If you don't dig into it, it's easy to miss causes of symptoms that might have a more specific management.
Someone correct me with I'm wrong but, many kids with autism also have adhd. I do not believe the reverse is as true, even though there is substantial comorbidity. I think the amount of kids with adhd who also have autism is more like 10%ish.
ADHD/ASD were always on my MR and never treated until I was in my 40's. The depression caused by never having been able to finish law school or anything else for that matter, was always more important to MDs than treating the root causes, ADHD/ASD. For all those ADHD/ASD patients being told they are just "depressed" please, at the very least, treat the ADHD and the rest will follow.
You may be interested in this article that tackles the very question of splitting vs grouping ADHD and ASD: https://pubmed.ncbi.nlm.nih.gov/38822588/
Thanks!! Will read
Something worth asking is whether ADHD is truly a genuine comorbidity of ASD and ID, or if ADHD is so broadly defined that any set of executive and attention deficits from any etiology (ID, ASD, mood, NCD, anxiety, SUD, OCD, BPD) COULD be interpreted as ADHD as long as an evaluator would like to imagine the possibility of some internal separation, or an earlier and more subtle onset. If the latter were NOT the case, then there would be clear rules about how ADHD can specifically be differentiated from cognitive deficits inherent to ID or ASD. (If those cognitive deficits are the same, then the entity would not be separately defined.) Read the criteria and ask if this is the case.** This is not to say that I don't think there's some core Primary Disorder of Vigilance (that is, whatever entity that *should* be captured by the ADHD construct) which is unique and separate from other neurodevelopmental impairments. The Primary Disorder of Vigilance also would be expected to have higher comorbidity with other ND disorders given the likelihood of genetic contribution. The point I'm making is that there does not appear to be any significant attempt to rigorously define the borders of these conditions in the field. I think you're right to wonder about it. I don't think there's any enthusiasm from the experts to find out or create any separation beyond a few prevalence studies. Speaking about the degree of comorbidity is meaningless if the core constructs have not been separated through a scientifically informed process. **The problem, as I see it, is that the DSM has never made any significant attempts to formally differentiate any disorder from another except in select explicit cases. Instead, it insinuates that some entities are a Thing In Itself, and that others are linked and not fully separate, and others are caused by this and that. The lack of specific separation leaves room for professional judgment but also allows poorly trained clinicians to go wild in their diagnostic process. Wild diagnosis is then taken as real, rather than clinical. This is a failure of the etiology neutral approach, the dictionary function of the manual, and the professional consensus method of construction.
Thanks for sharing! >**The problem, as I see it, is that the DSM has never made any significant attempts to formally differentiate any disorder from another except in select explicit cases. Instead, it insinuates that some entities are a Thing In Itself, and that others are linked and not fully separate, and others are caused by this and that. The lack of specific separation leaves room for professional judgment but also allows poorly trained clinicians to go wild in their diagnostic process. Wild diagnosis is then taken as real, rather than clinical. This is a failure of the etiology neutral approach, the dictionary function of the manual, and the professional consensus method of construction. So this is interesting. When I did my CAP rotations, I was supervised by a specialist who worked in one of the university hospitals. He basically saw everything and anything, self referrals included. Bear in mind we're in a country that doesn't use the DSM for coding purposes but we do keep it in mind in terms of criteria. ICD is the way here. He'd seen thousand upon thousand kids from diverse backgrounds, ASD was a pretty common reason. Which makes sense. I'm somewhat convinced he was very "biased" towards ASD but one thing he and his colleagues told me is that they barely had ANY ADHD diagnoses, whether requested by the parents or simply discovered upon assessment. What I do notice in the DSM (iirc) is how recurrent ADHD is as a differential diagnosis. It's almost suspicious at times. I'm wondering if this explains why there are so many ADHD prevalence gaps between countries.
Indeed. Conceptualization is the foundation of prevalence...
I sometimes wonder if “AuDHD” could be considered a separate condition to ADHD and autism in that due to the overlapping and sometimes mitigating effects of the two conditions patients present features of both conditions but may not reach the full criteria of either. PDA profile autism could be another avenue to look down regarding this as well.
Not sure about in general, but I know the Ehlers-Danlos syndrome folks commonly get both
Makes perfect sense a whole body connective tissue disorder that often has neurological and Autonomic issues thrown in the mix too being co morbid with neurodivergence makes perfect sense since collagen is key in brain formation and development. Don't get why you're downvoted
Among other myriad immune dysregulations and neurodivergences, such as being transgender. I wonder what it is that links collagen, immunity, and the nervous system.
I was forced to research the POTS/MCAS/EDS triad because it was becoming more obvious my headaches weren't simply primary, chronic migraine, but rather POTS. It takes time piece together the excessive sweating, feeling sick after hot showers, with the whole picture without digging with a PCP who is willing to refer you around to different -ologists. I wasn't surprised to read that there's theoretical autoimmune components to at least POTS, and obviously MCAS, give that I have diagnosed eczema which comes and goes together with everything else.
What has that got to do with being trans?
I don't know. I'm just saying the association exists; transgender people report hypermobility at much higher rates than the general population.
Sorry, I interpreted your response as "being trans is a form of neurodiversity", which it isn't really.
Regarding that some symptoms appear to contradict each other, I have seen it suggested that the combination changes the presentation of both, but I don't know if there is actual research for that.
If the presentation ends up radically different, we might want to think about better fleshed out criteria.
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I mean fair enough, that's basically 99% of my caseload, though in addictions we kind of have to broaden the scope and work towards encompassing ADHD more thoroughly in our assessments. Not as easy as it sounds unfortunately.
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Removed under rule #1. This is not a place to share experiences or anecdotes about your own experiences or those of your family, friends, or acquaintances.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8918663/#:~:text=According%20to%20the%20scientific%20literature,deficit%20hyperactivity%20disorder%20(ADHD).
That's the article I cited! Thanks for sharing it again though.
So diplomatic lol
I mean it, people are more likely to click on the link than Google my citation! 😂
About 100% on TikTok
Self-diagnosis primarily. I just don’t believe that everyone suddenly developed ADHD and ASD. Can people have difficulty focusing in boring work and school tasks and also be socially awkward? Yes but that does not warrant a legitimate diagnosis.
Self-diagnosis primarily. I just don’t believe that everyone suddenly developed ADHD and ASD. Can people have difficulty focusing in boring work and school tasks and also be socially awkward? Yes but that does not warrant a legitimate diagnosis.