HFA or ADD?

Post Reply New Topic

We are wondering if our teenage son is "high functioning autistic" (his recent diagnosis) or "ADD - inattention" (ADHD without the hyperactivity) - which was his original diagnosis some years ago. While we are in the process of having him re-tested, I'd be interested in any comments anyone may have.

The DSM - IV criteria for "ADD - inattention" are (comments on son in brackets):

• Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities (Maybe/No)
• Often has difficulty sustaining attention in tasks or play activities (Strongly Yes)
• Often does not seem to listen when spoken to directly (Strongly Yes)
• Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions) (Strongly Yes - although can be due to failure to understand)
• Often has difficulty organizing tasks and activities (Very Strongly Yes)
• Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) (Strongly Yes)
• Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools) (Strongly Yes/Yes)
• Is often easily distracted by extraneous stimuli (Yes)
• Is often forgetful in daily activities (Strongly Yes)

So he fits most of the criteria for "ADD - inattention".

The DSM - IV for Aspergers are (comments on son in brackets):

(I) Qualitative impairment in social interaction, as manifested by at least two of the following:
(A) marked impairments in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body posture, and gestures to regulate social interaction (Maybe Somewhat)
(B) failure to develop peer relationships appropriate to developmental level (Strongly Yes)
(C) a lack of spontaneous seeking to share enjoyment, interest or achievements with other people, (e.g.. by a lack of showing, bringing, or pointing out objects of interest to other people) (Maybe)
(D) lack of social or emotional reciprocity (Maybe)

(II) Restricted repetitive & stereotyped patterns of behaviour, interests and activities, as manifested by at least one of the following:

(A) encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus (Strongly Yes)
(B) apparently inflexible adherence to specific, nonfunctional routines or rituals (Don't Think So)
(C) stereotyped and repetitive motor mannerisms (e.g. hand or finger flapping or twisting, or complex whole-body movements) (No)
(D) persistent preoccupation with parts of objects (Don't Think So)


(III) The disturbance causes clinically significant impairments in social, occupational, or other important areas of functioning. (Yes - social and schoolwork badly impaired)

(IV) There is no clinically significant general delay in language (E.G. single words used by age 2 years, communicative phrases used by age 3 years) (Yes)

(V) There is no clinically significant delay in cognitive development or in the development of age-appropriate self help skills, adaptive behavior (other than in social interaction) and curiosity about the environment in childhood. (Maybe)

(VI) Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia. (Don't think so, although mother is schizophrenic).


So he seems to fit the DSM criteria less well for autism than ADD, but does fit them to a degree. If our son is “High Functioning Autistic/Aspergers” as per latest recent diagnosis why is it he:

(a) shows almost all of the signs of “ADD inattention” including a general restlessness (accepting that some of the symptoms are similar eg lack of executive function and a degree of hyperfocussing on items of interest)

(b) shows no signs of "stimming" or other repetitive movements (although he does sometimes use a lot of repetitive wording eg would when younger would a number of times a day ask us to look at the dog)

(But on the other hand if our son's correct diagnosis is “ADD inattention”, why is it he:

(a) seemingly unable or difficult for him to form real friendships (apparently he currently gets on ok with some of the schoolkids but progressively as he moved into middle school and beyond has lost the friends he had, and virtually never gets invited out) – seems more akin to autism?

(b) had only limited special (hyperfocus) interests, as opposed perhaps to flitting from subject to subject, and seems to have real difficulty with any abstract concepts (despite apparently testing as of above average IQ) – seems more akin to autism?)

I do understand you can have both!

Thanks in advance for any pertinent comments.

My son 13yrs has been dx with both AS/ADHD, it seems your son has probably both, ADD is very common with AS I think around 60%-70% get dx with both usually ADD when younger and AS later.

I guess the issue is, which set of strategies are you going to use? The diagnosis is only a tool to help you understand behavior and apply strategies to help address it, otherwise it's just words on a piece of paper.

IMO, I'd start with the pertinent strategies for autism and see how that goes, if for no other reason than that often the strategy for ADHD involves medication. Another diagnosis to get: have his speech tested for pragmatics. We found this was the reason my son was struggling socially (although there are other reasons someone on the spectrum may struggle, for instance a lack of interest in anything other than their "special interest")

What are the strategies for autism? Check Tracker's book: http://www.asdstuff.com/works.html (no, I don't secretly work for Tracker )

Here's some strategies for ADHD that seem to be on track: http://helpguide.org/mental/adhd_add_te ... tegies.htm

Thanks Annmaria - maybe he does have both.

Momsparky - isn't the point that you start with a diagnosis and then that simplifies the task of deciding what other steps to take?

As our son was diagnosed ADD-inattention initially he was on Ritalin for some years. He said he felt it did help and he was more focused when on Ritalin. I was initially anti-medication for this sort of thing, but was convinced by a Sydney psychiatrist at an ADD convention I attended (who showed that brain scans of ADD kids were different from brain scans of NT's etc) that it was the right thing to do. (Our son's mainstream school on the whole seems to be anti-Ritalin, but it is not their decision).

As per other post our son is unfortunately now doing really badly academically in his second last year of school and we are prepared to look at anything that will at least get him though this year. We are focused primarily on his academics now given there are only a few more months in the school year (although he has no real friends and does not participate in organised sport).

Thanks for the reference to Tracker's book; both I and my wife have read most of that. Also thanks very much for the ADD link; I will check that out.

I will also raise the issue of pragmatics with the doctor when we see him. I had no idea what that was - guess "language in context" - not sure if that applies to our son, but given his lack of general communication, anything is possible.

This is only true to a certain extent, but the problem with diagnoses in general is that they are big-picture generalizations and sometimes they don't suit the individual - and there is a LOT of overlap on the spectrum. ADHD, Autism, OCD, Tourette's, Bipolar and more are all very common co-morbidities, and piecing out which part of the label applies to what can drive anybody crazy.

We started to see positive changes in our son the instant we started using the strategies that applied to Aspergers. He'd had multiple diagnoses, from mood disorder to ADHD (not formally) to Asperger's and PDD-NOS. Providing him a structured, predictable environment and visual clear instructions wasn't that hard to do, and we saw improvement right away. For us, seeing what worked was a much better indicator than the various diagnoses we got...I considered them to be only a direction to go in, but not a definitive answer.

If your son was medicated for ADHD and the meds don't work, it would indicate to me that there might be something else going on (it might also indicate that a change in meds is in order.) However, even with meds - there are still strategies to try.

A pragmatic language deficit is common in kids with autism. Pragmatics are the parts of language that are social: body language, tone, etc. http://www.asha.org/public/speech/devel ... matics.htm

momsparky - thanks for your comments.

Yeah diagnosis is a difficult issue. The more I read about differential diagnosis for ADD-inattention and HFA, the more confusing it gets. Both ADD kids and autistic kids can have failure of executive function, hyperfocus on particular issues etc. Although our boy is perhaps at the milder end of the spectrum, he seems to live in his own little world, not really understanding the world at all. That seems autism to me, as does his interest in limited areas (I don't think his brain can cope with the complexities of the world).

On the other hand he meets the criteria for ADD-inattention very well - and he did apparently benefit from Ritalin, at least to a degree (which he can get with an ADD diagnosis, but not with an HFA diagnosis).

It may be that each is an individual and as you say we need to find what works. That may be Ritalin, and it will also be a very structured environment where he gets simple instructions and then is checked on carefully to see if the work has been completed. At school he has been instructed to go to the school counselling rooms in his free periods, rather than to goof off in the library or whatever. The school counsellor (a very nice guy) is also meeting with him regularly and discussing his planning for the week. The counsellor has also told his teachers to give him help with clear instructions, and to keep us parents fully advised of exactly what needs doing. Most of them have been doing that.

At home my wife has quit her evening part time job to control his after school hours. When I have been in charge I have been setting a timer - 50 minutes of work and then 15 minutes off. He also has to write down his work so I can see he is doing it. He is not allowed to have the TV or a DVD on while working. I think we are making some progress but not sure if it will be enough as he is so behind!

We have a 15-year-old son who is both on the autism spectrum (initially diagnosed with PDD-NOS, or high-functioning autism) and since then I've felt like he has inattentive ADD. He hit the 8th grade, and our previously good student couldn't do ANYTHING. The ADD meds weren't working. We were having to reteach him everything once he got home from school, because he just couldn't pay any attention to stuff in school, AND he was taking forever to do homework. It was really hard, for both our son and us as his parents.

We are now working with a doctor who prescribes large amounts of stimulants. I am still not really sure if it's the right thing to do. Sometimes I think the stimulants are great for attention purposes, but are horrible for social life. We've had our son off of the stimulants for a few days in the summer -- and I loved it, because he was so happy and fun, back to his old self. Granted, he was also impulsive and sometimes would say the wrong thing, but he was just so happy. Then, he would go back onto the meds, and in certain situations he was just a zombie. It was awful. I was completely ready to pull him off of the meds totally -- and then he has started school, and he is doing really well, accomplishing homework with little supervision, and seems more happy and less zombie-like. I am completely baffled, but I do know that our doctor and his office really does have our son's best interests at heart, and will work with my son until he feels comfortable -- with or without meds.

@schleppenheimer

Perhaps our son was on a lower dose of ritalin, but to me he didn't really seem affected at all. However he did say it was helping him concentrate. I never considered whether there was any placebo effect here. (Our son does say what he thinks you want to hear). Rightly or wrongly we did give him ritalin holidays on weekends and the holidays. My wife (who has her own mental health issues) dealt with most of that and for some reason she stopped the ritalin about a year or so back. I can't see that the ritalin would do our son any harm and may well do him good, based on our past experience.

Obviously school gets harder as you go along. Where we live they only really start external testing in the third last year of school, and that "found our son out" as he only just scraped through the last year exams with intensive coaching in one subject. This year he does not seem to be coping academically at all.

Good that your son seems now to be better with medication - which would appear to confirm your ADD diagnosis I would think. Maybe he has just gotten used to the medication.

Well our local GP has agreed (after discussion with the psychiatrist who diagnosed him as HFA quite recently) that he go on a Ritalin trial for two weeks. If that helps he can continue; if it does not seem to help then presumably it will stop. He will start that tomorrow. The doctor pointed to the shifting sands of definition of various disorders in making this decision and agreed he seems to show signs of both HFA and ADD.

Apparently our son completed and handed in his art assignment which was due today, so that is good. Whether it will meet the required criteria is unsure, but at least it was handed in on time.

I'm hoping that the intervention steps taken together with medication can lead to some significant improvements, to allow him to meet the academic requirements for this year.

As you know, it is possible to have both AS and ADHD at the same time. It is quite common, and you fill find lots of those AS-ADHD-combo folks on the general forum.

Clearly I do not know you or your son, and don't have the right to disagree with a doctor, but I am wondering: why did he diagnose him with AS instead of ADHD? According to your comments to each of the diagnostic criteria, it seems odd he would do that. Did he or she explain themselves?

For ADHD-inattentive type, he needs 6 out of the 9 criteria. According to your comments he very strongly meets 8 of those. So WHY would the doctor switch his diagnosis? Did he kind of "revoke" the ADHD by saying something like "he has Aspergers instead of ADHD?"

Now, sometimes there are some cases of Aspergers that resemble ADHD on the surface, so a person can be mis-diagnosed as ADHD and then later corrected to Aspergers (and some just have both). But if we move on to your comments under the Aspergers section, it seems--to this non-psychologist outsider basing my opinions on your observations--that ADHD-inattentive type was likely the accurate label for him.

According to your comments, he wouldn't really fit an Aspergers diagnosis. For section I, he must have 2--you've only REALLY identified one (and the one you happened to identify is also a common occurance amongst people with ADHD as well!) For section II, he does fit the one required criteria (but if you don't pass section I, then the rest is sort of moot anyway). Section III is something that can also be found in people with ADHD. Also, section IV--people with ADHD don't usually have a language delay either (I often use my niece as an example to contrast certain things because I have moderate classic autism and no ADHD, and she has severe ADHD and no autism. She also has learning disabilities and is borderline mental retardation, while I have an above average IQ. She spoke right on time and quite well for someone later diagnosed as "BMR". I barely spoke until I was older than 5.) So, anyway my point: ADHD people--even those with learning delays--do not usually have delays in language, so while this lack of a delay is necessary for Aspergers, it doesn't imply Aspergers or disregard ADHD.)

It COULD be possible that he has PDDNOS--but according to your comments, he would not fit the Aspergers diagnosis (unless your maybes from section I were actually yeses).

Anyway, from what you wrote, I would guess it is ADHD he has. Especially because the Aspie qualities you pointed out mostly are in tune with those with severe ADHD. It might be possible that he has more severe ADHD and a mild form of a PDD, or maybe the PDD was off entirely.

Some people with ADHD are very sociable, others have difficulty forming friendships. There is a difference between ADHD and AS relationships though. It is easier for me to understand the mind of someone with an ASD, so from our perspective, we would have difficulty forming friends because we have trouble with social and nonverbal communication (basically). This is not an issue for people with ADHD, but they can still experience strained or fewer friendships than NTs. Do you know WHY you son has difficulty forming relationships? Most of the communication aspects in section I of AS had a maybe next to them, so I cannot really analyze it any further than that. I do know from my niece who has ADHD, that she REALLY wants friends. She REALLY wants to fit in with everyone. But she lacks the confidence to make the friends, and occasionally can get into disagreements due to her lack of focus and her impulsivity (she has combined type).
As for the hyperfocus, that could be a sign of an ASD, sure. Many people do not realize though, that hyperfocus can occur in people with ADHD as well. Short article:

http://www.additudemag.com/adhd/article/612.html

For abstract concepts---I have noooo idea. I have issues with abstract concepts, so does my niece (but she also has learning disabilities that could account for that).

Anyway, my unofficial guess: ADHD-inattentive. But could be both. I DEFINITELY do not believe, if he has PDD, that he JUST has PDD. He fits TOOOO well into the ADHD criteria for that to be discarded entirely. Maybe discuss this with his newer doctor, and find out why he thinks he is AS. Or perhaps even get a third opinion, just to see what a fresh set of eyes might see in your son.

Of course I posted mine before reading this! Best of luck with the medication trial!

littlelilly613

Thanks for your detailed thoughts (and well wishes on the Ritalin trial).

I guess the problem as Momsparky has previously alluded is that diagnoses don't necessarily seem to be a simple matter of ticking the boxes. I am no expert (although both my parents were psychiatrists!) but from further investigation since my original post it's noted that the definitions themselves are somewhat fluid ....

For instance I think DSM V is going to subsume Aspergers with ASD generally -
http://www.dsm5.org/ProposedRevisions/P ... spx?rid=97

Similarly while this may be more of a semantic type issue DSM V is eg currently uncertain about whether to separate out ADD (the illness with no impulsivity/hyperactivity ever present) from ADHD, or to retain them all under one head (with I suppose different subtypes).

(DSM V is eg noted to be making major changes in the whole way personality disorders are defined - http://www.dsm5.org/Newsroom/Documents/ ... hange-.pdf)

If we do use the current perhaps slightly outmoded DSM IV definitions I am inclined to think our son is ADD-inattention for the reasons you have noted. But there are elements in his personality that do seem possibly on the autistic spectrum. His mother went with our son to the psychiatrist, we thought simply to re-start his ritalin prescriptions, and accordingly I did not attend the meeting. But I understand the re-diagnosis as HFA was done on the basis of discussions with our son and his mother, checking his records and perhaps in particular noting his general presentation and somewhat slow responses and speech.

As you point out on the first of the DSM IV asperger criteria the only criteria he really met was failure to develop appropriate peer relationships, which you have indicated can happen with ADD children too. With this though I wonder if ADD kids problems in this area don't arise from unthinkingness, impulsiveness etc, rather than a lack of understanding how the world works. When our son was little, although the schools here have been in general good, he was bullied somewhat. I think kids took advantage of his naivety at that time eg telling him to get under the table after an earthquake drill because an earthquake was about to strike. As a sad aside, our son did seem to be getting on ok with kids perhaps around the end of primary school, but just started to lose it and lose his friends as he has gotten older. I am not a very social person myself (although I certainly had a number of friends at our son's current age at school) and do not fully understand why he seems unable to make friends. It may be that he simply is not picking up on cues and is simply not able to intellectually understand their conversations. He cannot understand my circumlocutory conversations (while his sister, who is intellectually able, is easily able to do so). I have to speak to him in simple, concrete terms. All this seems to me to be more likely to be autistic than ADD.

As regards Section II, while hyperfocus as you note is found with ADD also, our son's hyperfocus when little (when it may have been easier to discern) seemed more autistic to me. I get the impression ADD persons are more inclined to hyperfocus on many different things over time, whereas the hyperfocus of autistic persons is more because they have difficulty in comprehending the world so hyperfocus on limited smaller areas in which they can gain competence. For example when our son was little he drew endlessly (and with great proficiency). But he never really graduated from one limited style of cartooning, and certainly did not extend that to artistic endeavour generally (eg exploring colour, different methods of painting oils/watercolour etc, as I guess an artistic NT person would have done). With encouragement he did a series of cartoons for a local website, but seemed to have difficulty in generating the relatively simple ideas necessary for the cartoons.

Section III as you point out can apply to both ADD and ASD and section IV also does not differentiate the two.

I don't think he has PD NOS. I do think he has ADD-inattention (or some close variant of that). But I have to say, when I think about the matter, I believe he is on the autistic spectrum also.

Anyway, he started his Ritalin trial tonight. If that improves his condition (as I believe it will) it will show that he does have ADD - but I suspect he has elements of ASD as well.

That's apparently common in inattentive ADHD too. More and more, researchers are finding that social interqaction can be a major challenge for ADHD. Inattentiveness can lead to missing social cues because you weren't paying attention to them when they came, which then leads to missing opportunities to learn social skills and the kid falls further and further behind.



That's a common myth, but actually most kids react to Ritalin by getting better at concentrating. There's a reason it's sold illegally in colleges to improve exam performance. Whether or not a kid responds to Ritalin doesn't tell you whether or not they have ADHD - though it can tell you if a particular behavior is due to inattention or inability.

In a nutshell, yes. I've found it works much better to go backwards and start with best practices; the ones that work for us have this pattern: they will work famously almost immediately for the short term, then we'll plateau and struggle for a bit, and then they'll start working again.

Thanks for your comments momsparky and ettina

ettina - the point is not that improvements of concentration from Ritalin use per se will show he has ADD, given as you point out that college students use ritalin to help them study. It's that allied to our son meeting most of the DSM indicia of ADD-inattention, if he uses a medication expressly prescribed for ADD and it helps, then this would corroborate the ADD diagnosis.

The psychiatrist who had recently re-diagnosed our son with ASD rather than ADD had initially refused our request for a re-prescription of Ritalin, advising that was for ADD not ASD. (I do note some evidence though that Ritalin may benefit ASD eg http://www.physorg.com/news177846441.html )

Anyway that psychiatrist has not disagreed with our local GP's two week Ritalin trial (although he had wanted to make it a one week trial - wonder if he is not pro-medication! or wants to justify his possible mis-diagnosis by not allowing a reasonable trial!) so our son started the Ritalin yesterday and there were some possible early signs of improvement.

hoegaandit, keep us posted about your son's trial with Ritalin (again). I hope that it helps him.

I definitely feel like trying to find the right meds, and definitely the right meds in the right dosages, is a very inexact science. We tried for three years having low dosages of stimulants -- which worked initially, but in the 8th grade stopped working at all. Then we started going to this doctor who does these massive dosages. It sure does work for the concentration, but in our experience, there are side effects of depression, tics, etc. that are not so beneficial. There are pills to take care of those side effects, too -- but wow, it sure does seem like a lot of pills to be taking.

I am interested to hear if your son manages to do well on a small amount of Ritalin, as there are varying studies on the effectiveness on small dosages of stimulants for inattentive-ADD. Much of the literature says that inattentive types do BETTER on small dosages.. That has not been our experience, but I can definitely see how it may work for others.