Autism and ADHD in Children: The Complete Playbook for Social Challenges

Understanding key differences between the social challenges of ADHD and autism is often the key to effective support  

By Mark Bertin, M.D.

 

All parents want their children to get along, play, and interact well with their peers. Usually, these social abilities develop intuitively. For children who struggle socially, the earlier the interventions start, the quicker kids catch up. Since both autism and ADHD affect relationships, finding the “why” behind social difficulties is a critical first step.


Autism and Social Development

Autism is a neurobiological disability in which social skills do not develop as expected. More severe impairment affects children who barely interact with others around them and have limited language or are nonverbal. On the other end of the spectrum, some extroverted autistic children seek out others and get along with adults but have a hard time getting along with children their age.

The ability to socialize and communicate begins in infancy and progresses as children move down developmental paths. While autism presents other behaviors, what distinguishes it from ADHD and other developmental disorders are differences in social development. Autism is diagnosed by looking for social delays, along with communication differences and behavioral markers.

SOCIAL CHALLENGES: Children with autism lag their peers in social skills. Social and behavioral signs could appear as early as six months old. Still, most medical professionals do not attempt a diagnosis until a child is at least 18 months old. Before the age of two, behaviors can change – some continue to emerge, and others disappear. For example, some children have delayed language skills, but when they do appear, they quickly catch up with their peers. It can also be confusing because some autistic children seem to develop within normal ranges, such as saying their first word at around 12-15 months and then suddenly regress, and at about 18 months to two years, they lose those skills and stop speaking.

At one year, most children respond to their name, engage in back-and-forth interaction, and understand gesture language, such as pointing and waving. The ability to interpret facial expressions, understand humor, and demonstrate empathy happen on their own during typical development, as does a desire to share interests, play with others, and to seek comfort when upset. Early signs of autism include:

  • Poor eye contact
  • Limited facial affect
  • Delays in imaginative play and self-help skills
  • Not engaging in social play
  • Doesn’t respond to parent’s smile or other facial expressions
  • Doesn’t look at objects parent is looking at or pointing to

COMMUNICATION CHALLENGES: Most autistic children have early delays in language and speak later than their peers. A few never speak at all. Others develop large vocabularies and the ability to form sentences but may be challenged by the non-verbal aspects of communication. Their speaking might seem scripted, repetitive, or awkward. They may struggle to read facial expressions, understand tone and humor, and initiate or follow a conversation. Early signs include:

  • Doesn’t say any words by 16 months
  • Doesn’t point at objects
  • Doesn’t respond to name
  • Doesn’t seem to have a desire to communicate

BEHAVIOR CHALLENGES: Autism can manifest in other behaviors as well, including repetitive physical motions, special interests, or overly rigid thinking. Many autistic people have sensory challenges as well. However, behavioral symptoms alone are not enough for a diagnosis; a child must demonstrate social and communication differences as well. Some early signs include:

  • Rocks, spins, flaps hands
  • Doesn’t adjust well to changes in routine
  • Repeatedly engages in one or two activities
  • Plays with parts of toys instead of the whole toy

ADHD and the Social World

ADHD symptoms affect social interactions, cause communication differences, and can lead to behavior challenges. The best one-line description of ADHD comes from Russell Barkley, Ph.D., 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 distinguish ADHD from autism: Children with ADHD typically know the “social rules”; they just don’t know how to follow them.

SOCIAL CHALLENGES: Children with ADHD usually understand what they’re supposed to do socially, but they can’t yet show it in everyday life. Being distracted, impulsive, and off-task affect interactions. Children with ADHD miss social cues they would otherwise understand — if only they noticed them.

COMMUNICATION CHALLENGES: One often-overlooked aspect of ADHD is the relatively high risk of language delays. Yet even in the absence of an actual delay, ADHD undermines communication. Children lose track of details, are overly talkative, interrupt, stray off-topic, and have a hard time keeping track of information. They may speak and process information more slowly than peers, which is not a measure of intelligence. Unlike kids with autism, children with ADHD typically understand the pragmatic part of language, but ADHD itself gets in the way.

BEHAVIOR CHALLENGES: Behavioral concerns frequently, but not always, occur with ADHD. They involve not following social rules, such as acting impulsively, being overly silly, or disrupting situations in other ways. When peers prefer sticking to one activity, a short attention span is disruptive. The chronic challenges with organization and planning related to executive functioning that occur with ADHD are not linked to autism. If a child with autism struggles with attention or executive functions, ADHD could also be present.

The key trait that distinguishes ADHD from autism is the ability to comprehend the social world intuitively. Delays and differences in this skill are the common thread among all diagnoses of autism, regardless of how it presents. Children with ADHD alone may also struggle socially, but their intuitive understanding is present.

 

Distinguishing & Treating Autism and ADHD

In many situations, the distinction between autism and ADHD is not black and white. As challenging as it is for a professional to know whether ADHD, autism, or both are present, receiving appropriate intervention matters most for a child. Often, developing a plan helps sort out whether either diagnosis — or neither — is appropriate. Most social and communication interventions benefit children, whether they have ADHD or autism.

Ask your child’s school to evaluate their development, including language pragmatics, play, and self-help skills. Or seek a private, comprehensive evaluation outside of your school district. Having a secondary condition frequently occurs with both ADHD and autism, so screening for these disorders is essential.

Some common coexisting conditions with autism include:

For ADHD, common coexisting conditions include:

  • Disruptive behavior disorders, such as oppositional defiant disorder (ODD)
  • Depression
  • Bipolar disorder
  • Anxiety
  • Learning disorders
  • Sleep problems
  • Substance abuse

Interventions that improve symptoms of ADHD usually enhance the social abilities hindered by it. Comprehensive care for ADHD can include individual or parent-based behavioral therapy, social skills groups, medication, and other evidence-based treatment. (As a side note, misbehavior without remorse doesn’t always mean a child lacks empathy. Children with ADHD are often emotionally overwhelmed and immature and might not know how to express remorse when they’ve done something wrong.)

With autism, the foundation of intervention is behavioral therapy. One of the primary tools is applied behavioral analysis (ABA) therapy, which employs the Antecedent-Behavior-Consequence (ABC) theory to improve behaviors. Simplistically this can be explained as, A) you make a request, B) your child complies, and C) you reward the desired action. When you repeat this approach, you increase the positive behaviors and reduce potentially challenging ones.

Depending on need, children with autism may receive intensive behavioral services in a self-contained classroom, or may participate in mainstream, general education classrooms. All children with autism, however, can benefit from consistent behavioral therapy— one of the best predictors of outcome. Think of it this way: If you want your child to be a concert pianist or a professional athlete, they should practice each day. The same goes for social skills. As skills strengthen and grow, therapies need not be so intensive, but the interventions should continue until skills become fluent.

If a child has autism, they have communication challenges. However, it is challenging to measure language pragmatics through testing. Therefore, regardless of test scores, a child with autism benefits from language services. With ADHD, consider the possibility of language delays, and intervene when appropriate.

If progress slows, it might be helpful to look for co-existing conditions, such as the frequent comorbidity of autism and ADHD. When children have compromised social and language abilities, adding ADHD to the mix makes it much harder for them to succeed. Addressing ADHD allows a child to focus, act less impulsively, access the skills they developed through intervention, and improve social skills.

Autism at School

Schools work toward placing children in mainstream classrooms whenever possible. Some kids prefer it, but others thrive in a more supportive setting. Keeping up with main- stream demands and typically developing peers can be stressful. Contained classrooms also allow for more intensive social work, which can make mainstream placement easier down the road.

Language and pragmatic delays often affect the necessary skills in school. Reading comprehension, making inferences, and writing are all affected by ADHD or autism. Home- work and in-class assignments frequently require supports or modifications.

While social plans often focus on the classroom, unstructured time (such as recess or gym) is often challenging for kids with autism and ADHD. In class, the rules are usually “sit quietly and raise your hand.” On the playground, social mores are more fluid and less understood, especially for children with autism. Children with autism are 63 percent more likely to be bullied than neurotypically developing children, according to the Autism Society. Children with ADHD are more likely to be bullied and somewhat more likely to bully others, according to StopBullying.gov. Bullied children and children who bully others can have serious, lasting problems and are more likely to develop depression and anxiety.

ADHD and autism stress parents and strain marriages, especially when there are young children with ADHD in the household. Parents of children with ADHD under the age of eight are twice as likely to divorce as parents of children without ADHD. The good news is that this lessens as the child ages, with parents of children with ADHD over the age of eight having no difference in divorce rates than parents of children without ADHD. As far as raising a child with ASD, many parents report less marital satisfaction, according to the American Psychological Association (APA). However, parents who do stay together indicate their marriage is “highly satisfying.”

 

High protein breakfast foods help boost focus and mood all day long. Use these recipe ideas to help your child shine from the first bell to the last. 

By Laura Stevens, M.S., Susan McQuillan

Maryanne knows that breakfast is the most important meal of the day, but getting her 8-year-old son, who has attention deficit disorder (ADHD), to eat in the morning is difficult. Getting his clothes on, teeth brushed, and backpack filled leaves Maryanne little time to prepare a serious morning meal, let alone something Steve will eat. When it comes to breakfast, 8-year-old Madeline, diagnosed with ADHD last year, knows what she likes: carbohydrates. Her meal of choice is toast with jelly or waffles topped with fruit or, as her mother puts it, “anything made with white flour.”

While there’s nothing wrong with eating carbohydrates in the morning, an all-carb breakfast, or no breakfast at all, is a recipe for inattention. Carbs won’t steady a child’s blood sugar throughout the morning, help her stay alert, or prevent the energy dips that cause her to lose focus in the classroom. High-protein breakfast foods are ideal.

Research suggests a direct correlation between breakfast and academic success. A 1998 study, published in the Archives of Pediatrics & Adolescent Medicine, showed that children who ate breakfast regularly had higher reading and math scores, lower levels of anxiety, and hyperactivity, better school attendance, improved attention spans, and fewer behavior problems.

For children with ADHD, the menu matters, too. In a 1983 study published in the Journal of Psychiatric Research, researchers at George Washington University tested three breakfast types (high-carbohydrate, high-protein, and no breakfast at all) on 39 children with ADHD and 44 kids without the condition. For the hyperactive children, performance on several tests, including a test for attention, was significantly worse after eating the high-carbohydrate breakfast, as compared with the scores of the children who ate the high-protein breakfast.

Why is this? Research out of Orebro University in Sweden shows that children with ADHD have nearly 50 percent lower levels of an amino acid called tryptophan. Tryptophan is one building block of the neurotransmitters in your brain that carry important information; it is needed for attention, learning, and self-control. It is also generated by eating high-protein foods. In other words, a diet rich in protein jump-starts better learning and behavior.

Seeking Balance at Breakfast

Like most children with ADHD, Madeline has very specific preferences and she will reject any food she’s not fond of. Her mother knows what foods to keep on hand and which to serve first thing in the morning to ensure that breakfast goes smoothly. She tries to balance these foods in ways that give her daughter as many calories and as much high-quality protein as possible, especially on school days.

“When you’re thinking about your child’s eating habits, or any other behavior, you have to recognize his unique temperament and behavioral traits, and work around them,” says Dr. Stanley Greenspan, M.D., author of The Challenging Child. A balanced breakfast — high in protein and carbohydrates from whole grains, fruits, and/or vegetables — ensures a varied supply of nutrients along with enough calories to sustain mental and physical energy until the next meal.

“If you don’t eat properly, you can become distracted, impulsive, and restless,” says Ned Hallowell, M.D., founder of the Hallowell Center for Cognitive and Emotional Health in Andover, Massachusetts, and author of Delivered from Distraction. “Skipping breakfast or self-medicating with food can sabotage the best of ADHD treatment plans. In treating the condition, you must consider a balanced, healthy diet an essential component of a proper regimen.”

Protein Power

“Protein helps keep your child’s blood sugar levels steady and prevents the mental and physical declines that inevitably come from eating an unbalanced breakfast containing too many carbs,” says Hallowell.

Combining protein with complex carbs that are high in fiber and low in sugar will help your child manage ADHD symptoms better during the day. The sugars from the carbohydrates are digested more slowly because eating protein and fat along with fiber results in a more gradual and sustained blood sugar release.

For your morning menu, try scrambled eggs with whole-grain toast; or natural peanut butter on whole-grain bread. Make sure to skip sugary cereals, which can cause spikes in blood sugar and increase hyperactivity in ADHD kids.

Children need more calories and protein per pound of body weight than adults do, to ensure normal growth and development and to maintain good health. The average daily amounts of calories and protein recommended by government health experts for normal-weight children and adolescents are as follows:

  • Ages 1-3: 1300 calories, 16 grams protein
  • Ages 4-6: 1800 calories, 24 grams protein
  • Ages 7-14: 2000 calories, 28 – 45 grams protein

A varied diet that supplies enough calories will generally supply enough protein. Children with ADHD who are strictly vegetarian and those who avoid meat or dairy can get enough protein from a diet rich in whole grains, legumes (dried beans and lentils), and the many meat and dairy substitutes made from soy protein and wheat gluten.

Protein in a Pinch

Here are some quick, easy, and tasty ways to get enough protein into your carb-lover’s diet without turning your kitchen or dining room into a battlefield. The idea behind all of them is to start with her favorite carbohydrates, such as waffles, toast, jam, or fruit. Then add in high-protein foods you know your child likes, such as eggs, meat, peanut butter, yogurt, cheese or other dairy products, or beans. Combine these foods in creative ways:

  • Top waffles with melted cheese or ham and cheese, instead of syrup or fruit.
  • Spread peanut butter on apple slices, a halved banana, or celery sticks.
  • Fill a breakfast burrito with scrambled eggs, black beans, and cheese.
  • Spread a toasted, whole-grain bagel or toast with natural peanut butter or another nut butter, such as almond or hazelnut. Adding a dab of all-fruit jam is just fine.
  • Wrap a slice of turkey bacon around a firm-ripe banana; broil or grill until the bacon is thoroughly cooked.
  • Sauté lean, breakfast sausage patties with pieces of diced apples.
  • Swirl crushed fruit or all-fruit jam into plain yogurt and top with dry, whole-grain cereal or chopped nuts.
  • Fill an omelet with chopped or sliced fresh fruit or spreadable fruit.
  • Serve tuna or chicken salad, sloppy joes, chili, or baked beans over toast.
  • Offer eggs and a smoothie. To save time, make hard-boiled or deviled eggs the night before.
  • Toast a slice of whole-grain bread and add a little whipped butter or margarine and a dab of all-fruit jam; milk.
  • Serve whole-grain cereal with low-fat milk, lean meat from last night’s dinner (pork chop, chicken), and orange sections.
  • Top plain yogurt with fresh fruit or mix in oatmeal.
  • Offer a grilled-cheese sandwich made with whole-grain bread and two-percent cheese.
  • Blend up a homemade instant breakfast shake or make sausage patties (see recipes, left sidebar).
  • Serve a veggie omelet with a bran muffin.
  • Offer mixed nuts, fresh fruit, and a glass of milk — a great breakfast for kids that graze.

What works best for Madeline, her mother says, is to eat a small breakfast at home and to have a second breakfast on the way to school. Madeline takes her medication with her first meal, so by the time she’s heading out the door, it’s beginning to take effect and she’s better able to focus on eating. To fill in the protein gaps, her mom may send along some scrambled eggs with cheese in a tightly wrapped tortilla, a high-protein cereal bar, or a bottled yogurt smoothie.

Maryanne discussed Steve’s breakfast problems with her doctor, and they developed some strategies. He suggested that Maryanne and Steve get up 15 minutes earlier, to give her more time to prepare breakfast, and advised that Steve take his medication with his meal rather than just after waking up, to delay the appetite suppression.

The doctor gave them a list of possibilities get more high-protein foods into her son’s diet. Their list included lean meats and poultry, eggs, unprocessed nuts and seeds, and milk products, as well as complex carbohydrates, such as whole-grain cereals and bread and fresh fruits.

ADHD Friendly Recipes

Instant Breakfast Shake
– 3 ounces low-fat milk
– 3 ounces plain yogurt
– 1 tablespoon ground flax seed
– 3 tablespoons soy or rice protein isolate
– 1/2 cup blueberries, strawberries, or peach slices, fresh or frozen

Process all ingredients in blender on high until smooth. Serve immediately. If your child doesn’t find the shake sweet enough, add a teaspoon of sugar or half a packet of artificial sweetener.

Homemade Sausage Patties
– 2 pounds coarsely ground lean pork, beef, or turkey
– 4 teaspoons sage
– 1/2 teaspoon thyme
– 1/2 teaspoon marjoram
– 1/2 teaspoon basil
– 1 1/2 teaspoons black pepper
– 2/3 cup water

Combine all ingredients in large mixing bowl. Shape into 8 patties. Fry in a non-stick skillet until fully cooked and slightly browned, or package for freezing and use patties as needed.

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