There are many reasons why an autistic or ADHD person might go
missed for years. If you're an adult who's only
recently started making sense of your own neurodivergence, then
you've lived through multiple cultural and diagnostic shifts.
Changes to the diagnostic criteria.
A growing emphasis on lived experience, more recognition of
what autism and ADHD looks like in adults, and much deeper
awareness of nuanced presentations and masking.
One of the other things that can complicate or delay a diagnosis,
especially an autism diagnosis, is when both ADHD and autism are
present. That's what we're looking at
today, how the overlap between autism and ADHD can lead to
misdiagnosis, late diagnosis, and a lot of self doubt.
Along the way, we'll unpack what diagnostic overshadowing is, the
research we do have about a delay in diagnosis, and we'll
walk through six ways that ADHD can over shadow autism.
I'm Doctor Megan Ananieff. I'm an autistic ADHD clinical
psychologist, founder of Neurodivergent Insights, the
author of self-care for Autistic People, and the Autistic Burnout
Workbook. I'm currently deep in the
research and writing phase of my next book, Audi HD Unlocked, and
this video series gives you a window into some of what I'm
finding and thinking along the way.
Now, the statistics range quite a bit depending on which study
you look at, but estimates suggest that roughly 30 to 80%
of autistic people also meet criteria for ADHD, and about 20
to 50% of people with ADHD are also autistic.
Unfortunately, diagnostic systems are built on an either
or categorical framework, and so when overlap happens, that can
create some unique problems. It sets the stage for what's
called diagnostic overshadowing. That's when 1 diagnosis hides
another condition that is also present.
What that means for our lives is that many of us don't slot
neatly into autism or ADHD alone.
We're often living at that complex intersection where it
treats blend, blur, and sometimes hide each other.
Now, the diagnostic tools that we have available to us are
often built around neat list of check boxes or more of that
categorical thinking. So if you're autistic and ADHD,
you might not fit cleanly into the autism boxes and you also
might not fit cleanly into the ADHD boxes either.
So you can end up falling through the cracks between these
two categories. Now, across multiple studies, a
clear pattern has been shown that when ADHD is first
identified for someone who's both autistic and ADHD, it
results in a delay in identification of the autism.
So, for example, one large European study found that
children who had an ADHD diagnosis before the autism
diagnosis, on average it took 1.8 years longer for the autism
to be identified. Now, when researchers broke this
down by gender, boys with prior ADHD received an autism
diagnosis about 1.5 years later, while girls waited closer to 2.6
years. And then clinical reports and
case studies and lived experience also echo this
pattern. Many describe children and teens
who first carried an ADHD diagnosis, and only after years
of unmet needs and struggle and often mental health challenges
did autism finally make it into the conversation.
And then these numbers, these also sit on top of other
disparities that we know about. For example, we know that black
and brown children tend to receive both autism and ADHD
diagnosis later and after more clinical encounters than white
children. So it's reasonable to assume
that when ADHD is picked up first in these communities that
the delay and recognition of the autism likely stretches even
further for them. So then when it comes to an
autism recognition, there are at least 4 overlapping delays that
Audi HD ERS may experience. First of all, a delay tied to
ADHD being recognized 1st and then diagnostic overshadowing
happens. There can also be a delay tied
to gendered expectations. And then a lot of the tools that
we have available to us were built and designed around the
experiences of boys, a delay that is tied to racial
inequality and unequal access to assessment and care.
And then across the gender spectrum, masking adds another
layer where a lot of autistic and ADHD traits tend to fly just
under the threshold or under the radar of what clinicians are
looking for. So for many Audi HD adults, this
helps explain why our diagnostic story feels so fragmented.
Perhaps you received a childhood ADHD diagnosis and then maybe
anxiety or depression was added in adolescence and only much
later does autism enter the conversation.
And then of course for others, both ADHD and autism were
completely missed in childhood and only entered the
conversation in adulthood. This is what we often refer to
as the lost generation of autistic adults or the lost
generation of ADHD adults. Now, if we look at the
diagnostic shadowing when ADHD is overshadowing the autism,
then here are six ways that ADHD can hide the autism from the
outside. ADHD can be pretty loud and
colorful, and that can quickly drown out the autism.
So while this certainly isn't an exhaustive list, here are six
ways that this can happen. First, social behavior can look
ADHD enough that autism is never even considered.
So, for example, a child might be struggling socially.
Maybe they interrupt their peers or talk over others or blurt out
responses in class, and this is often seen as part of a broader
pattern of ADHD. And so maybe the person is
struggling socially or they're struggling to connect with their
peers, but it's interpreted and read as impulsive.
So on top of the ADHD, they might also be missing social
cues or context cues and struggling to interpret other
people's emotions or signals. But all of that gets framed as
part of ADHD in attention or ADHD impulsivity.
And then once ADHD seems to fit, clinicians, parents and teachers
might stop asking those deeper questions.
So some of those more subtle social communication
differences, they're again flying under the radar.
Or all the social struggles that that person is having is getting
attributed to ADHD alone. Now a second thing that can
happen is where movement and sensory seeking often get framed
as hyperactivity or restlessness.
So fidgety and pacing or just being in constant motion.
This can easily be understood as hyperactivity.
And when that happens the underlying sensory drivers.
So perhaps stimming or needing movement to regulate or seeking
certain repetitive sensations, those go unnoticed.
So a child might be spinning or cluing or seeking deep
proprioceptive pressure, and that all might get interpreted
as the person being overactive rather than as someone who is
seeking proprioceptive input. Or maybe they have some unmet
vestibular sensory needs, which is why they're spinning.
So all of this which we see in autism can be hidden under the
framework of hyperactivity and ADHD.
A third one is when executive functioning struggles are
attributed solely to ADHD. So difficulties with planning,
transitioning, or shifting our attention all rely on executive
functioning. And these are classic
experiences in the ADHD experience, but they can also be
connected to autism, but often for different reasons.
For example, autistic people tend to be bottom up processors,
meaning that we absorb a lot of details and so we can easily get
cognitively overwhelmed and overloaded, which make a lot of
those decisions or shifting of attention more difficult, but
for slightly different reasons. Additionally, when we are
sensory overloaded, that's also going to impact our executive
functioning. And so again, that aspect of
executive functioning struggle or decision fatigue or
difficulty with planning might get chalked up to ADHD executive
functioning when actually there are autistic drivers in the mix.
Again, if ADHD is already on the chart, then those struggles are
going to get explained through executive functioning and the
ways that bottom up processing or are sensory processing are
contributing to that are going to remain unseen.
Fourths, the need for security, predictability, and routine can
get interpreted through an an ADHD emotional lens.
So for autistic people, it's really common to have a lot of
distress around sudden change or unpredictability, things we
weren't expecting. However, these responses can get
interpreted as emotional reactivity or quote UN quote,
poor frustration tolerance. These are things that we often
see coming along the picture for ADHD, and so these reactions to
routine disruptions or distress might get interpreted as simply
ADHD emotion regulation difficulties.
Again, when ADHD is the first label, then shutdowns a person
might be having during transitions or distress they
might be showing in response to routine disruption or schedule
changes. All of that can get misread as
behavioral issues rather than an artistic response to uncertainty
or unexpected change or routine disruption.
Similarly, sensory distress could also be interpreted
through that same emotional lens.
So for example, a child might have a meltdown when a parent
tries to brush their hair or brush their teeth or help them
get dressed and they might be having a sensory response.
However, if that child is known to be ADHD, the parent might
interpret that as difficult behavior in the context of ADHD.
A fifth way that ADHD can hide the autism is when special
interests get missed and folded into ADHD interest patterns.
So deep focused interests is a huge part of the autistic
experience. However, ADHD it's also common
to have hyper focus and have passions and so special
interests can get chalked up to hyperfocus and then less
attention might get paid to how narrow or immersive or
regulating those interests are. A clinician might write gets
very absorbed in preferred activities, ADHD hyperfocus.
But if they never ask how those interests function socially,
emotionally, or sensory wise, which are key to understanding
their role in the autistic experience, then that's another
part of the person's experience that can easily get missed and
attributed to the ADHD. And finally, masking can hide
what's underneath. Many Audi HD years become pretty
skilled at using their ADHD traits.
So things like humor or playfulness or quick speech or
storytelling to kind of perform sociability, and that can smooth
over some of the autistic social anxiety or confusion that we
often see in the autistic experience.
On paper, this can look like the person's really friendly and
talkative and they look like talkative ADHD, but the autistic
person beneath it is often carefully scripting or
rehearsing or collapsing afterward.
Now in each of these scenarios, the ADHD explanation isn't
completely wrong, but it isn't complete.
And when it becomes the whole story, that's when the autism is
overshadowed. And when this happens, that's
what we call diagnostic overshadowing, where the
autistic traits get attributed to the ADHD.
In audio HD, it is more common for the ADHD to over shadow the
autism. However it can go both ways.
So overshadowing between autism and ADHD can show up in several
different ways. Autistic sensory overload can be
labeled ADHD overwhelmed or emotion dysregulation, and the
sensory and predictability needs underneath are never named or
going the other way when the autism is known but the ADHD is
not. Forgetfulness and time
perception struggles could get framed as autistic rigidity or
autistic shutdowns or autistic cognitive overload, and then the
ADHD related executive functioning differences go
unseen. And then on top of all of that,
global experiences like shutdowns or meltdowns or
burnout are often explained through 1 lens alone.
Like that's just the autism or that's just the ADHD rather than
seeing them as a cumulative effect of both interacting
together. So in this kind of diagnostic
overshadowing happened, support can miss the mark, especially
when the underlying neurology and the support needs that flow
from that are never fully seen and supported.
Diagnostic overshadowing is one of the main reasons that so many
of us wait so many years before we have a full story to actually
understand ourselves and all of our complexity.
And so it can delay identification.
It also tends to delay the ability to set up the
appropriate accommodations that we need.
That could make life feel a lot more possible and doable.
And it can deepen shame as many of us repeatedly internalize
some form of the message. I should be able to do this when
the truth is the support that we perhaps have received or built
around us was never fully designed with all of our
neurology in mind. In the next video we'll look at
how autism can over shadow or hide the ADHD.
And while that is a less common experience, that was actually my
experience. And so I'm excited to talk about
that in the next video. And we'll talk about how
understanding our combined neurology can bring more clarity
to our audio HD stories. Until then, be gentle with
yourself, stay curious, and thanks so much for being here.
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