Childhood Social Difficulties: The ADHD/Autism Relationship

One of the basic wishes most parents share is that their children get along, play, and interact well with others. Most often, these social abilities develop intuitively. But for children who instead struggle with peers, the earlier interventions start, the earlier they catch up. Since both ADHD and autism impact relationships, sorting out the 'why' behind social difficulties is often a first step towards figuring out how to best support this vital area of development.
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One of the basic wishes most parents share is that their children get along, play, and interact well with others. Most often, these social abilities develop intuitively. But for children who instead struggle with peers, the earlier interventions start, the earlier they catch up. Since both ADHD and autism impact relationships, sorting out the 'why' behind social difficulties is often a first step towards figuring out how to best support this vital area of development.

Autism and Social Development

Autism is a disorder of child development in which social skills do not develop as expected. More severe impairment involves children who may barely interact with others around them, and have quite limited language. On the other end of the spectrum are fairly extroverted children who seek out others and often relate well with adults, yet have a hard time understanding how to get along with children.

Both social and communication abilities progress from infancy forward along predictable developmental paths. While there is much more to autism, what distinguishes it from ADHD and other developmental disorders are differences in social development. Autism is diagnosed by looking for these social delays along with communication differences and behavioral symptoms. Common findings include:

Social: Children with autism lag behind socially, with differences documented in some studies down to six weeks of age. By one year, without ever being taught, most children respond to name, engage in back and forth interaction, and understand gesture language such as pointing and waving -- so delays in these traits are red flags for autism. The ability to understand facial expressions, humor, and empathy all happen on their own during typical development, as does a desire to share interests, play with others, and to seek comfort when upset. Other common red flags include poor eye contact, limited facial affect, and delays in imaginative play and self-help skills. When development does not meet these milestones, social development should be evaluated by a professional.

Communication: Most children with autism have early delays in language, speaking later than peers; a few never speak much at all. Others develop more concrete language abilities well, such as a large vocabulary and the ability to form sentences. However, they lack the ability to understand 'pragmatics,' the non-verbal aspects of communication, and speaking may seem overly scripted, repetitive, or awkward. Pragmatics include details like reading facial expression, understanding tone and humor, and initiating and following along in conversation, as well as adapting how to speak across social situations (like teachers versus parents versus peers).

Behavior: Autism is also characterized by quirks in behavior, including repetitive physical motions, such as hand flapping or spinning in place, obsessive, and often unusual, interests or overly rigid thinking. Many have sensory concerns as well. However, a diagnosis of autism is made based on social and communication differences, not this type of behavioral symptom alone.

ADHD and the Social World

ADHD symptoms also impact social interactions, cause communication differences, and may lead to behavioral challenges. The best one-line description of ADHD may come from Dr. Russell Barkley who said, "ADHD is not a disorder of not knowing what to do, it is a disorder of not doing what you know." This concept also helps separate ADHD from autism, as children with ADHD typically know the social rules, they just don't know how to follow them yet.

Social: Children with ADHD usually recognize what they're supposed to do socially but in everyday life they don't yet have the ability to show it. Symptoms such as being distracted, impulsive and off task impact interactions directly. They may also cause kids to miss social cues they would otherwise understand - if only they could notice them in the first place. They don't attend to the details of the social world because ADHD gets in the way.

Communication: One often overlooked aspect of ADHD is a relatively high risk of language delays. Yet even in the absence of an actual delay, ADHD may undermine communication. Children lose track of details, are overly talkative, interrupt, stray off topic, and have difficulty keeping track of information. They also may both speak and process information more slowly than peers - not a measure of intelligence, only of pacing. Unlike with autism, children with ADHD typically understand the pragmatic part of language; ADHD itself gets in the way.

Behavior: While not always, behavioral concerns frequently occur with ADHD. They involve not following social rules, such as acting impulsively, being overly silly or in other ways disrupting situations. When peers prefer sticking to one activity, having a short attention span for play may be disruptive all on its own. Lastly, the chronic challenges with organization and planning related to executive function that occur with ADHD have not been as clearly linked to autism alone. If a child with autism struggles significant with attention or executive function, ADHD may also be present.

Taking Action to Better Social Skills

The bottom line that distinguishes ADHD from autism is the ability to intuitively comprehend the social world. Delays in this area are the common thread among all diagnoses of autism, regardless of severity. Children with ADHD alone may struggle socially, but their intuitive understanding is intact - even if they cannot show it yet.

There are many situations where the distinction between ADHD and autism is not black and white, and a recent study suggests that an early diagnosis of ADHD sometimes delays recognition of autism. Challenging as it is not to know for certain whether ADHD, autism or both are present, from a child's perspective receiving appropriate intervention matters most. Often, getting started with a plan in and of itself helps sort out whether either diagnosis - or neither - is most appropriate. Thankfully, most social and communication interventions benefit children regardless of the diagnosis.

Seek comprehensive evaluation. Ask your school to evaluate your child's development, including language pragmatics, play and self-help skills. Or seek out a comprehensive evaluation outside of your school district. In addition to looking for developmental delays, having a secondary condition is common with both ADHD and autism (such as anxiety or motor delays), so screening for these 'comorbid' disorders is also important.

Understand the impact of ADHD. Any intervention that improves the symptoms of ADHD will also improve social abilities hindered by it. Comprehensive care for ADHD may mean individual- or parent-based behavioral therapy, social skills groups, medication, or various other evidence-based details. As a side note, misbehavior without seeming remorse doesn't always mean a child lacks empathy. Children with ADHD are often emotionally overwhelmed and immature, and don't know how to express remorse or react when they've done something wrong.

Start behavioral therapy and continue as long as symptoms persist. For autism, the foundation of intervention is behavioral therapy, often for far longer than happens in the real world. Behavioral programs do not only address disruptive behaviors; interventions such as applied behavioral analysis (ABA) therapy are the primary tools for teaching social skills.

Children with severe autism typically get intensive behavioral services, frequently in a self-contained classroom. With milder symptoms, children move into the mainstream or inclusion style classrooms, and behavioral interventions may become quite minimal. Yet one of the best predictors of outcome is when children receive ongoing behavioral therapy, regardless of severity of symptoms.

Think of it this way: If you want your child to be a concert pianist or a professional athlete, you'd have them practice hours a day. The same goes for social skills. As symptoms become milder therapies need not be so intensive, but the interventions continue until skills become fluent.

Add speech language therapy, if needed. By definition, if a child has autism they have communication challenges. However, it is difficult to measure language pragmatics through testing. Therefore, regardless of test scores, a child with autism will benefit from language services until proven otherwise by his own social success. With ADHD, also think about the possibility of language delays, and intervene when appropriate.

Address related conditions. As already noted, look out for coexisting conditions if progress slows. In addition, one common 'comorbidity' is having both autism and ADHD. When children already have compromised social and language abilities, adding ADHD to the mix makes it that much harder for them to succeed. Addressing ADHD may allow a child to focus, act less impulsively, and better access the skills they have developed through intervention, and goes a long way towards getting along with peers.

Consider academic placement. Mainstream classroom placement is always the goal, but not always best for everyone. Some kids prefer it, but others thrive in a more supported setting. Keeping up with mainstream demands and typically developing peers can be very stressful. Contained classrooms also allow for more intensive social pragmatic work, which may make mainstream placement easier down the road.

Academically, language and pragmatic delays often affect basic skills. For example, reading comprehension, making inferences, and writing can be impacted by ADHD or autism. Homework and in class assignments frequently require supports or modifications.

Lastly, while social plans often focus on the classroom, unstructured time (such as recess or gym) is often most challenging. In class, social rules are basically "sit quietly and raise your hand when it's time to talk." On the playground social mores are far more fluid. Children may struggle or even be subject to bullying, and planning may require social interventions more during down time than during academics.

Offer full family support. ADHD and autism stress parents and strain marriages. Take the time to take care of yourself and your relationship. Seek out help where needed -- from other family members, from friends, or with a professional if necessary. Seek out support groups. And consider practicing mindfulness, one of the more proven interventions for managing stress, to build the strength and stability needed to manage when life feels challenging.

A version of this blog posting by Dr. Bertin also appeared in Additude Magazine.

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