Guidance for Identification and Treatment of Individuals With Attention Deficit/Hyperactivity Disorder and Autism Spectrum Disorder Based Upon Expert Consensus
BMC Medicine
Young, S., Hollingdale, J., et al. (2020).
BMC Medicine, 18(1), 1-29.
This consensus-based guideline provides recommendations for the identification and treatment of children, adolescents, and adults on the autism spectrum with co-existing attention-deficit/hyperactivity disorder (ADHD). Interventions outside of the scope of audiology and speech-language pathology (e.g. pharmacological interventions) are not included within this article summary.
United Kingdom ADHD Partnership
<div>Due to the complexity of assessing individuals on the autism spectrum with comorbid ADHD, assessments should only be conducted by healthcare practitioners with appropriate training and skills.</div>
<div>Due to the fact that symptom presentation may vary over time for both autism and ADHD, comprehensive assessment should include detailed information regarding the individual's development and functioning across various settings spanning many years.</div>
<div>Semi-structured clinical interviews with explicit mapping onto diagnostic criteria may assist in conducting a comprehensive developmental and clinical interview. Prior to any interview, it is helpful to ask parents or care partners, as applicable, to look at childhood developmental health records, photographs, and school reports and/or to think about key transitions in the child’s life.</div>
<div>Assessors should take a conservative approach, and should not double count symptoms that are present in both ADHD and autism spectrum disorder (ASD).</div>
<div>Assessors must consider the extent to which the individuals' functioning is age appropriate. They should obtain examples of how difficulties interfere with the individuals' functioning and development in various settings. Assessors should also consider the potential cultural impact on various behaviors (e.g., eye contact, play).</div>
<div>When possible, information should be obtained from independent sources (e.g., parents, care partners, teachers, observation, and school, college, and/or employment records). Assessors should remember that informants who are family members may have diagnosed or undiagnosed ADHD or ASD, which may impact upon their judgement of the client's behavior.</div>
<div>Assessment should attempt to identify whether co-existing comorbid disorders are present with ASD and/or ADHD. Young children presenting with an initial diagnosis of ASD should be continually monitored throughout development for ADHD, particularly given differences in the average age of diagnosis for the two conditions.</div>
<div>Comprehensive evaluation should include a risk assessment (e.g., assessment for risk of substance abuse) together with an assessment of dysfunctional strategies.</div>
<div>Capacity assessment may be warranted for adults on the autism spectrum with severe impairments requiring substantial support.</div>
<div>Rating scales should not be considered diagnostic instruments. They are tools to aid in diagnosing and monitoring clinical progress. If used as screening tools, individuals with borderline scores should not be excluded as candidates for comprehensive assessment. Likewise, observational assessments are non-diagnostic and should be used to provide insight into an individual's functioning and augment clinical decision-making alongside other assessment measures.</div>
<div>Given that norms for many screening tools are based predominantly on male samples, clinicians should be aware of the disadvantage of their use in females.</div>
<div>Visual reporting tools (e.g., visual representations of mood states, visual analogue scales) can help obtain subjective information from individuals who have difficulty identifying or describing their thoughts, feelings, and/or sensations.</div>
<div>Clinicians should have a low threshold for administering intellectual assessments and assessments of adaptive functioning. Intellectual assessments may assist in goal setting, determining cognitive strengths and weaknesses, and selecting interventions for children and young people in school or higher education.</div>
<div>Assessment outcomes should include both diagnostic and etiological information with protective, predisposing, precipitating, and perpetuating factors that inform a comprehensive care plan. This care plan should include a positive behavioral support plan and take into account of the needs of the individual and how these needs may be met across settings. With client and care partner consent, the care plan should be shared with all relevant parties, including educational establishments as appropriate.</div>
<div>The following recommendations were made regarding client and family education:</div>
<ul>
<li><span style="color: #333333;">Using a lifespan approach, clinicians should provide psychoeducation to both the client and their care partners whenever possible. </span></li>
<li><span style="color: #333333;">Follow-up sessions are essential to provide information and support and key points of transition. </span></li>
<li><span style="color: #333333;">Psychoeducational programs should differ for children and adolescent populations, with education for adolescents including issues relating to educational and work transitions, sexuality, and risk.</span></li>
<li><span style="color: #333333;">Clinicians should ensure that clients and their care partners have realistic expectations of the child’s abilities and what may be achieved by interventions.</span></li>
<li><span style="color: #333333;">Clinicians should acknowledge the difficulties experienced by care partners in coping with the daily care of children with complex needs. They should provide education and content that will help the care partners manage their own feelings of isolation, stress, anxiety, and depression.</span></li>
</ul>
<div>Functional Behavioral Analysis (FBA) is helpful to provide insight into the triggers of challenging behavior and factors that maintain the behavior. Information achieved through FBA may inform the method and goals of treatment.</div>
<div>Cognitive approaches may be more suitable for adolescents than younger children. A greater emphasis on behavioral interventions with supplemental cognitive intervention components may be needed when treating younger children.</div>
<div>A greater total amount of therapy with more frequent sessions, shorter duration of sessions, a slower pace, and mid-session breaks may be needed in treating individuals on the autism spectrum with comorbid ADHD. Increased structure and adherence to a clear agenda will may reduce uncertainty and client anxiety. Environmental adaptations should be considered, as needed, to minimize sensory discomfort and distractions (e.g. sensitivity to light, smells and sounds).</div>
<div>Parents, care partners, and teachers should be included in the therapy process as appropriate to support the client in applying techniques learned in therapy across different contexts.</div>
<div>Transition planning should occur at least 1 year before the client moves from child to adult services so that appropriate supports may be identified and the child is not lost to follow-up. A successful transition should involve everyone the client’s support circle.</div>
<div>Any selected treatment approaches should be integrated into the client's comprehensive care plan. A positive behavioral support plan should be included. The care plan should be shared with all relevant parties, with appropriate consent.</div>
The following recommendations were made regarding the provision of school services to children and adolescents on the autism spectrum with comorbid ADHD:<br />
<ul>
<li><span style="color: #333333;">Specific training should be given to school staff regarding how ADHD and ASD impact the way that children and adolescents learn in the classroom and interact with their peers.</span></li>
<li><span style="color: #333333;">If anxiety becomes a barrier to social inclusion and learning, isolation and distress may lead to refusal to participate. When this occurs, educational services should develop comprehensive coordinate support plans to help the child and pre-empt refusals.</span></li>
<li><span style="color: #333333;">School staff should have the knowledge and understanding about the social and sensory needs of these individua, enabling staff to make necessary adjustments (e.g. avoidance of congested spaces, loud noises) to reduce stress and promote learning and engagement.</span></li>
<li><span style="color: #333333;">The achievement gap between these students' chronological age and their developmental age needs to be clearly stated and addressed in the child’s legal education care plan (i.e., Individualized Education Plan) to ensure that curricular demands are appropriate. The IEP should be created and regularly updated with input from all those involved in the child's care, including parents and caregivers.</span></li>
<li><span style="color: #333333;">Individualized transition planning should occur proactively and with input from all those involved in the child's care, as appropriate, in order to minimize the stress and negative impacts associated with transitions from primary to secondary education.</span></li>
<li><span style="color: #333333;">Personalised education plans [PEPs] should be developed and shared with members of the healthcare team in order to aid in the development of the individual’s care plan. This care plan should be shared with all relevant parties, with appropriate consent.</span></li>
</ul>
<div>Associated learning difficulties (e.g., dyslexia, dyscalculia, dysgraphia, language and communication deficits) should be addressed as early as possible. Referral to allied health professionals (e.g. occupational therapists) should be conducted, as needed, to introduce appropriate interventions before they significantly impact on learning, social functioning, and/or development.</div>
The following recommendations were made specifically for adults on the autism spectrum with comorbid ADHD:<br />
<ul>
<li><span style="color: #333333;">The impact of consent and capacity on individual's decision-making and legal rights should be carefully considered for individuals with intellectual disability. Any information shared with care partners must be done with the individual’s knowledge and consent.</span></li>
<li><span style="color: #333333;">Support to care partners should be provided, when indicated, to help connect them with reputable services to learn about guardianship and the potential need for any long-term financial planning arrangements.</span></li>
<li><span style="color: #333333;">Provide additional support and guidance, as needed, to clients who become parents.</span></li>
<li><span style="color: #333333;">Psychoeducational interventions should be provided to both the individual and carers. </span></li>
<li><span style="color: #333333;">Peer group support interventions may be helpful to adults on the autism spectrum with comorbid ADHD.</span></li>
<li><span style="color: #333333;">Cognitive approaches (e.g., cognitive remediation therapy and cognitive behavioural therapy) are likely to be effective interventions for adults with ADHD and ASD given adaptations for social communication and intellectual deficits.</span></li>
<li><span style="color: #333333;"> Group treatments with specific adaptations (e.g., lower client to clinician ratios) may be more helpful for adults than children and adolescents.</span></li>
<li><span style="color: #333333;">Support strategies and transition planning should be provided for individuals transitioning between child and adult services. Additional transition planning should be provided in the instance of significant life events (e.g., parental death, relocation, major relationship changes). </span></li>
<li><span style="color: #333333;">Interventions should be integrated into the collaborative care plan, including a Positive Behavioural Support plan to increase consistency between different caregivers and staff. The care plan should be shared with all relevant parties, with appropriate consent.</span></li>
</ul>
The following recommendations were made regarding educational and occupational supports for adults on the autism spectrum with comorbid ADHD: <br />
<ul>
<li><span style="color: #333333;">Career officers, special educational needs coordinators, and therapists should collaborate in order to ensure young adults are directed appropriately towards realistic career and independent living goals. </span></li>
<li><span style="color: #333333;">Members delivering educational support services should be aware of the potential challenges for students in higher education (e.g., anxiety, sleep disruptions, social isolation, substance abuse, difficulties in living independently).</span></li>
<li><span style="color: #333333;">Supervised mid-point breaks may be more effective than extra time to complete an examination for these individuals in a tertiary education setting. </span></li>
<li><span style="color: #333333;">Support should be provided to aid with job applications, interviews, and navigating the recruitment process.</span></li>
<li><span style="color: #333333;">The attainment of voluntary and supported work placements will help individuals to gain an understanding about the expectations of being in a work setting.</span></li>
<li><span style="color: #333333;">Staff in educational and employment establishments should receive training in neurodiversity to improve general understanding among colleagues.</span></li>
<li><span style="color: #333333;">As needed, support and coaching should be provided regarding the management of personal finances and planning for financial commitments. </span></li>
<li><span style="color: #333333;">A personalized education plan should be developed and shared with the healthcare team for inclusion in the individual’s care plan. With consent, this care plan should be shared with all relevant parties. </span></li>
</ul>
