Diagnosing 2e: ADHD vs Asperger's?

By Emily Kircher-Morris, LPC

Because I work with many high-ability, gifted, and twice-exceptional individuals in my practice, I've noticed an interesting pattern with some of my clients. The story follows a specific path: A bright child was diagnosed with ADHD at a young age. Medication after medication had minimal benefit; often the parents abandoned medication altogether. As the child gets older, their lagging social skills cause more and more problems with friends and at school. We finally determine the appropriate diagnosis of Asperger's Disorder has been missed.

Many children compensate well for social struggles and concerns may go unnoticed by parents and educators. If the child is gifted, asynchronous development explains many of the quirks the child may show. However, one would expect that as the bright, quirky, asynchronous child grows older, some skills (such as the ability to meet typical social expectations) would balance out. However, the DSM-V says that for a diagnosis of Autism Spectrum Disorder, symptoms may not fully manifest until social demands exceed the abilities of the individual. When a child's struggles increase with age instead of balancing out, a diagnosis of Autism Spectrum Disorder (ASD)/Asperger's should be considered.

So, why are these kids given an ADHD diagnosis instead of ASD? A close look at the symptoms of ADHD through the lens of Asperger's can help understand how this misdiagnosis can be made:

• Inattentiveness - A classic symptom of ADHD is the inability to focus and pay attention. A child with ASD may indeed look like he or she can't pay attention. However, is this inattentiveness better explained by a lack of understanding of the social expectations to focus in certain situations? Is the child only motivated to engage when the topic is within his or her area of interest?
• Impulsiveness - Another symptom that leads to a diagnosis of ADHD is impulsive behavior. Again, when examined through the lens of ASD, impulsive behavior could be explained by a inability to understand the norms of typical reciprocal conversation and manifest as verbally interrupting conversations. There are social norms and hidden rules in game play and other interactions that a child with Asperger's doesn't interpret; his or her behavior can look impulsive. Intense emotions and "meltdowns" associated with ASD may also be written off as the impulsive behavior of ADHD.
• Hyperactivity - Constant movement, bouncing, or pacing could easily be more directly related to a sensory need or stimming behavior instead of true hyperactivity. Hyperactivity can also present as a need to talk constantly; a child or teen with ASD may talk about his or her areas of interest without pausing for feedback due to difficulty understanding the social rules of reciprocal conversation.

Parents, educators, and medical/mental health professionals need to be aware of the overlap of behaviors between these two diagnoses. If medications don't seem to make a difference for ADHD, it may be beneficial to consider the presence of ASD. If social skills seem to be regressing as a child enters late elementary, middle, or high school instead of balancing out, taking a look for Asperger's could help. And finally, considering each of the behaviors that was originally explained by ADHD, and whether the motivation for the behavior is better explained by traits of ASD, can help find an accurate diagnosis. 

While any mental health diagnosis for a child can be overwhelming, accurately identifying the cause of problematic behaviors allows for proactive interventions to be implemented earlier and with better efficacy.

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