Autism and ADHD occurring simultaneously in adult

women: A literature review on AuDHD

According to the World Health Organization [WHO](WHO, 2022)mental health “is a state of mental
wellbeing that enables people to cope with the stresses of life”. It is not just the absence of psychiatric
disorders or mental health disease but is individualistic with different difficulties and day to day distress
(WHO, 2022)
Many factors, including biological factors, environmental factors etc. affect mental health and clinical
outcomes. These manifest in the form of disorders which are temporary or permanent.

Attention-Deficit Hyperactivity disorder (ADHD) is one such disorder that might have implications for
the individual in their day-to-day lives. The Diagnostic and statistical manual of mental disorders, DSM,
is a classification of mental disorders developed by the American Psychiatric Association. According to
the DSM 5, ADHD “is a neurodevelopmental disorder defined by impairing levels of inattention,
disorganization, and/or hyperactivity-impulsivity"(American Psychiatric Association, 2013). The Mayo
Clinic states that this causes instability in relationships, difficulties in school and in the workplace and
social problems(Mayo Clinic : ADHD Symtoms, 2023)
Autism also known as autism spectrum disorder (ASD) another neurodevelopmental disorder which,
according to the WHO is “characterized by some degree of difficulty with social interaction and
communication” (Autism, 2023)(WHO, 2023). WHO states that Autism has multiple etiological factors
such as genetic and environmental factors.

According to Hours. et al. individuals with Autism and simultaneously occurring ADHD are 50-70% of
the population (Hours, 2022). This is a high rate of comorbidity and the physiopathology of both the
disorders needs to be investigated.
The DSM-5 also lists both the disorders in each other's differential diagnosis leading to the question of
how often these occur simultaneously.

According to the National Autistic Society of the United Kingdom, women and girls face even greater
challenges for diagnosis and support (Autistic Women and Girls, n.d.)(NAS, 2024). The same was
reported by Attoe.D and Climie. E. (2023) regarding ADHD diagnosis and support in women. But how
often do ADHD and Autism occur simultaneously in Adult Women?

More than a decade ago, Grzadzinski, R., et.al.(Grzadzinski et al., 2011) found in their study that a large
number of parents of children with ADHD also reported autistic traits. This was genetically confirmed
earlier by Smalley, S. L. (2002),when they found overlapping genes.

Grzadzinski’s study, though, relied largely on parental opinions and did not employ any diagnostic
criteria.
In 2014 Chantiluke, K., et al, claimed that children with the comorbidity of ADHD and Autism showed
significantly higher traits and symptoms of the secondary disorder when diagnosed with a primary
disorder between the two disorders. They hypothesized that since their findings showed elevated
symptoms in comorbid patients than the “pure” disorders, a significant etiological difference might be
present.(Chantiluke et al., 2014)

Green, J. L., also found that Children with ADHD also commonly showed certain ASD symptoms. (J. L.
Green et al., 2015)

A 59% comorbidity was found by Stevens and Peng in 2016 (Stevens et al., 2016). They studied a sample
of the population of the United states of America and also interpreted the age of diagnosis of primary and
secondary disorders. They claimed that comorbid patients received delayed diagnosis and medical
support. Infact, the earlier editions of the Diagnostic and Statistical Manual of Mental Disorders; DSM-5
(American Psychiatric Association, 2013) does not permit comorbid diagnosis. This heavily limited the
ability to diagnose as exclusionary criteria were more prevalent in the diagnosis of the neuropsychiatric
disorders.(Stevens et al., 2016)
Lyall 2016 found through the Charge study (CHildhood Autism Risk from Genetics and the
Environment), California, USA, which is a large analysis that there were significant associations between
ADHD traits in children with ASD.(Lyall et al., 2017)

One research team conducted causal modeling of an observed data set and came up with three pathways
in which ADHD and ASD are associated. These include associations between hyperactivity, impulsivity,
inattention to social ineptness, stereotyped ASD behavior and verbal IQ. (Sokolova et al., 2017)

Manohar et al. found that interventions performed early in comorbid neurodevelopmental disorders can
increase the control of symptoms and outcome of the other (Manohar et al., 2018). The same year,
Salunkhe found that the Intrasubject Variability(ISV) of reaction times which is an abnormality in ADHD
Phenotype was higher in Patients with comorbid ASD and absent in “pure” ASD. They also point to an
exclusive profile of Comorbid ASD and ADHD and not just an addition of the two disorders (Salunkhe et
al., 2021).

This was refuted by Antshel in 2019 who believe that the overlapping symptoms and deficits are additive
in nature. (Antshel & Russo, 2019)

A recent research team also found strong associations that can lead to dual diagnosis between attention-
related autism and ADHD traits . According to their research paper, an important potential transdiagnostic
process involved attention control. (Waldren et al., 2024) With this new information it is only imperative
to consider Autism and ADHD as differential Diagnoses as suggested by the DSM-5, or consideration be
given to a dual diagnosis in a clinical setting.

ASD and ADHD in Women:

Some studies concluded that differences exist within genders and a developmental approach might be
useful for distinguishing them. They also observed main differences in social and communication skills
between these disorders (Mahendiran et al., 2019). Here, gender refers to the social construct and
commonly accepted norms.

Underdiagnosis of both these disorders also disproportionately affects women and girls. This was
reported by many researchers and clinicians but also confirmed by the Diagnostic and
Statistical Manual of Mental Disorders, fifth edition; DSM-5 (American Psychiatric Association,
2013) which reported a 4:1 male to female ratio for Autism.

Hull (2020) explains that this may be due to expression of symptoms where females are less likely to
express their Autism symptoms than males which might be missed in a clinical setting (Hull et al., 2020)
It is also due to the development of the diagnostic criteria largely based on male symptoms (R. M. Green
et al., 2019). Masking of symtoms has also been attributed to this underdiagnosis (Craddock, 2024)
Underdiagnosis or late diagnosis has various social and mental implications for the affected women.
As claimed by Attoe and Climie, late diagnosis or miss diagnosis can have severe effects of mental health,
relationships, social wellbeing and emotional wellbeing (Attoe & Climie, 2023).
A large number of women also report reduced Health related quality of life(HRQoL) with or without
diagnosis (Asztély et al., 2019)

Emma Craddock (2024) who is herself a late diagnosed AuDHD (Autism and ADHD) referred to this
phenomenon of underdiagnosis and effects on mental health of women in her research paper. She claimed
that this is the healthcare experience of most women and calls it a “trauma of a lifetime of misdiagnoses”.
She also addressed the criticism of diagnostic criteria and stated that the criteria does not cover lived
experiences of neurodivergent individuals. (Craddock, 2024)

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Reports, 21(5), 34. https://doi.org/10.1007/s11920-019-1020-5

Asztély, K., Kopp, S., Gillberg, C., Waern, M., & Bergman, S. (2019). Chronic Pain And

Health-Related Quality Of Life In Women With Autism And/Or ADHD: A Prospective

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