ADHD is a mild form of Asperger

similarities and differences

Patients with attention deficit hyperactivity disorder (ADHD) and / or autism spectrum disorder (ASD) often come to their doctor with unspecific symptoms. It is not uncommon for them to complain. B. about stress and exhaustion or excessive demands and are often noticed by communication problems. The differential diagnosis is particularly difficult due to the overlap of various symptoms of these two diseases.

A 21-year-old physics student comes to our outpatient clinic for the treatment of depressive symptoms. As early as the social anamnesis, he reports difficulties when asked about social support - such as when deciding who is a friend and who is an acquaintance. Difficulties in social interaction: It would be ideal for him if he could conclude a contract with the person at the beginning of a new encounter that defines exactly what is appropriate in this relationship and what is not. However, it is also clear to the patient that this could appear strange to other people. On closer exploration, a difficulty in establishing social contacts emerges. In the course of his life he had occasional individual friends, but never a very close bond. During his school days he had a stable class community in the small village in which he lived. They were always the same classmates, and he was slowly able to find his way into the social fabric. His otherness was accepted by everyone. His classmates left him alone, but also respected him for his special talent in the world of numbers ("he is extremely good at mental arithmetic"). During his studies, however, he did not find a connection with his fellow students. The transition to university was also difficult for him because he had to leave the familiar surroundings of his parents' home. In the dormitory he felt overwhelmed by the constant change of roommates. He is currently two semesters behind in his studies because he failed some exams - often because of the sheer volume of learning content. This was not a problem at school: he passed his Abitur with a grade of 1.0. Back then, however, he was often told that he was too easily distracted in class. Nevertheless, he always wrote good exams. At the university I developed depressive symptoms due to the anamnestic and because of the repeated setbacks. He also reports that he can no longer carry out his hobby, painting, which he still pursued at home, in his dorm room due to lack of space. All in all, due to the flexible timetable, he has scaled back his activities further and further. Now he doesn't get up until noon. And he no longer goes to voluntary lectures because the excessive overstimulation affects him. Instead, he prefers to surf the Internet at home.Diagnosis: An autism spectrum test and an ADHD test were carried out for diagnosis. These showed a high level of conspicuousness in the area of ​​autism and also ADHD traits. The diagnosis was a considerable relief for the student, since in many areas of life in which he had previously considered himself insufficiently capable, autistic peculiarities could explain the problems. The parents were also able to develop an understanding of the special habits of their son in discussions with relatives.

ADHD and ASD are both included in the developmental disorder category. That means: The first abnormalities or symptoms must appear and become suspicious in childhood, at the latest in adolescence, in order to be able to make the diagnosis (see case report). Symptoms often become visible at the beginning of school because after the familiar kindergarten a significantly higher level of adaptation is required. Occasionally, there can be a delay in diagnosis if the environment does not pay attention to the symptoms or classifies them as special personality traits and pays a lot of attention to the peculiarities.

It is characteristic that the abnormalities occur in several areas of life and not specifically in a singular situation or only in a single area of ​​life or temporarily. Signs of ASD that may show up in routine medical contacts include difficulties in social communication and interaction: Concrete language (e.g. to the question "How many hours do you sleep per day?" the patient answers with: "None" - since people only sleep at night), difficulty maintaining eye contact, reduced understanding of social indicators (e.g. in the case of indirect call terminators such as: "Do you have any other questions?") and a reduced transmission of non-verbal communication (e.g. gesturing). The occurrence of special interests, as usually communicated via the media, can occur, but is not essential for the diagnosis. Often, however, certain routines and rituals (e.g. always the same order when getting dressed) can be determined. Sometimes contact with people affected by autism is perceived by the neurotypical counterpart as strange, strange and awkward.

Signs of ADHD are inattentiveness, hyperactivity, and impulsiveness. The possible manifestations and consequences include academic and professional difficulties, such as the repeated occurrence of careless mistakes, difficulties in organizing oneself, forgetfulness and easy distraction by external stimuli as well as dreaminess and "foulness". It is not uncommon for ADHD patients to be noticed by forgetting appointments, misplacing prescriptions, appearing stressed and chaotic and reporting in detail to rambling, erratic or disordered, sometimes fighting with a lot of "power" for their concerns or entering into conflicts.

Diagnostics in the family doctor's practice

A diagnosis of both ADHD and an autism spectrum disorder assumes that symptoms begin to show up in childhood. Above all, the external anamnesis is important here, be it through the parents, through (primary) school reports or through accompanying doctors. A summary of the symptoms observed so far by the family doctor, who has often been with the family for a long time, can therefore be very helpful. He is often well informed about domestic problems, worries and not infrequently also conflicts that arise in daily life with the affected family members.

If there is a suspicion of ADHD or ASD, the family doctor should refer to a specialist for the diagnosis and, according to the guideline [2], he should prepare the treatment plan himself, based on a detailed psychoeducation, together with the person concerned.

According to a study [3], about 30% of patients with an autism spectrum disorder have a comorbid ADHD disease. This means that the incidence of ADHD in ASD is significantly higher than in the general population. However, around 20% of children with ADHD also seem to suffer from ASD [5]. As is known, as with most diseases, people with multiple comorbidities present more often than with just one of the diagnoses. However, this harbors the risk that one of the comorbidities will be overlooked. The differential diagnosis can be difficult here and should be transferred to the specialist.

Overlapping symptoms

Symptoms and compensatory mechanisms overlap in ADHD and autism. In the area of ​​symptoms, an uninterrupted flow of speech can be noticeable in both diseases. Autistic people lack recognition of social indicators that signal that it is time to stop talking. In ADHD patients, the fluency of speech is attributed to the impulsive symptoms. The motor hyperactivity typical of ADHD can be distinguished from repetitive motor behavior in ASD, because in the stereotypical movement disorders as they can occur here, the motor behavior is generally fixed and repetitive, while the fidgety and restlessness in ADHD generalized and not repetitively stereotyped occurs.

Inattentiveness, difficulties in social interaction, rejection from others and behavior that is difficult to control are characteristic of autism spectrum disorders, just as they are for ADHD. However, the social dysfunction and peer rejection in ADHD must be distinguished from the possible decreased social interest, social withdrawal, and neglect of facial and vocal communication signals or the inability to read social and emotional signals that are common in people with autism spectrum. Malfunctions occur. Children with ASD may experience tantrums due to an inability to tolerate deviations from expected course of events. In children with ADHD, inappropriate behaviors and tantrums are more likely to result from impulsiveness or a lack of self-control.

Routines and rituals

A build-up of routines can be observed in the compensation mechanisms for both diseases. There is an important need for routines and rituals in people on the autism spectrum. In ADHD patients, building routines can be seen as a compensation mechanism for coping with everyday life. With both diseases, the elimination of external structuring (e.g. in the transition from school to university) can often lead to decompensation. The sensitivity to irritation in ADHD and the overstimulation in autism can also make a similar impression.

1. Tebartz van Elst L. Autism and ADHD between norm variant, personality disorder and neuropsychiatric illness. 2nd Edition. Stuttgart: W. Kohlhammer GmbH. 2018
2. Long version of the guideline "ADHD in children, adolescents and adults". AWMF registration number 028-045. AWMF online 2017
3. Simonoff E, Pickles A, Charman T, Chandler S, Loucas T, Baird G. 2008. Psychiatric disorders in children with autism spectrum disorders: prevalence, comorbidity, and associated factors in a population-derived sample. J Am Acad Child Adolesc Psychiatry, 47 (8): 921-9.
4. Taurines R, Schwenck C, Westerwald E, Sachse M, Siniatchkin M, Friday C. 2012, ADHD and autism: differential diagnosis or overlapping traits? A selective review. ADHD Attention Deficit and Hyperactivity Disorders Volume 4, Issue 3, pp 115-139.
5. Hollingdale J, Woodhouse E, Young S, Fridman A, Mandy W. 2019. Autistic spectrum disorder symptoms in children and adolescents with attention-deficit / hyperactivity disorder: a meta-analytical review. Psychol Med, 18: 1-14. doi: 10.1017 / S0033291719002368. [Epub ahead of print]

PD Dr. med. Swantje Matthies
university hospital Freiburg

Conflicts of Interest: The authors have not declared any.

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