with Amandeep Jutla, MD, Usman Ghumman, MD, and Adriana Di Martino, MD

Many children with autism spectrum disorder (ASD) have co-occurring problems in addition to the core ASD features of impaired social communication and restricted, repetitive behavior. The risk of also developing psychosis and ADHD is increased in someone with ASD, but it can often be difficult to determine when their symptoms are a function of ASD and when they represent a specialized condition.

Experts presenting at the October 2020 American Academy of Child and Adolescent Psychiatry (AACAP) virtual annual meeting dove into these topics.


Psychosis and Autism Spectrum Disorder

Children with ASD are three to four times more likely than their neurotypical peers to eventually be diagnosed with schizophrenia (SCZ) , a chronic mental illness with a deteriorative course. As SCZ, unlike ASD, tends to be associated with poor long-term outcomes, predicting which youth with ASD are likely to develop SCZ has important prognostic implications. Emerging evidence suggests that in at least some youth with ASD, psychotic symptoms present with a characteristic pattern that, if recognized, can be managed earlier.

In his AACAP presentation, Understanding Psychosis in Autism Spectrum Disorder: Conceptual and Practical Challenges, Amandeep Jutla, MD, Child & Adolescent Psychiatry, Columbia University, New York, discussed the prevalence, predictors, and potential ramifications of psychotic-like symptoms in autism spectrum disorder and provided practical techniques to identify and appropriately manage these symptoms when they are present.

ASD, which is generally diagnosed in childhood, typically has a stable, longitudinal course that is characterized by social communication deficits and restricted or repetitive behaviors. SCZ, typically diagnosed in late adolescence or early adulthood, is characterized by a loss of contact with reality and delusional beliefs or hallucinatory experiences. The repeated psychotic breaks in SCZ cause a progressively worsening deterioration in function. “Because of this, there has been an emphasis on early identification of those at risk for psychotic disorders. The more days of untreated psychosis someone has, the worse the functioning becomes,” said Dr. Jutla.

“The elephant in the room,” he told the AACAP virtual audience, “is the overlap between autism and the negative symptoms of schizophrenia, such as withdrawing from friends and family, showing less emotion, having a flat affect, and having social communication deficits. There is also overlap between language use and the perception and understanding of self and others,” he explained.

Dr. Jutla and his team studied 9,130 youth, 151 of whom had a reported ASD diagnosis, and found that children and adolescents with ASD endorsed disproportionately more psychotic-like symptoms regarding hallucinatory phenomena and had more difficulty separating fantasy from reality on a prodromal psychosis screening questionnaire than typically developing youth. The researchers concluded that these specific symptoms could be more important than others in identifying which youth with ASD are at risk of SCZ.  Specifically, he noted, “a focus on specific psychotic-like symptoms in middle childhood may help identify who is at risk. Until more is known about how and why ASD and SCZ converge, clinicians treating youth with ASD will need to be thoughtful in their approach to recognizing psychosis.” (More on schizophrenia and overlapping psychiatric disorders, such as PTSD.)

Dr. Jutla advises that clinicians, parents, and other caregivers “take potential psychotic behaviors in ASD youth seriously and avoid the temptation to assume symptoms are ‘just’ a function of autism. Most prodromal youth do not go on to develop full-blown schizophrenia but there is a greater overall risk with ASD.” He also recommends chromosomal microarray testing in anyone with ASD of unknown etiology, which in most cases, probing the boundary between repetitive/perseverative behavior and psychosis to determine whether the paranoia and other negative thoughts indicative of psychosis may be present. This testing can also help to monitor changes in symptoms over time.

When Autism and ADHD Overlap

Autism spectrum disorder and attention deficit hyperactive disorder (ADHD) are both neurodevelopmental disorders (NDDs) that show impairment in growth, development, and function of the brain, and, thus, have negative impacts on memory, learning ability, and emotions. Both have an increased prevalence in boys, interact with similar neurotransmitters, and are characterized by difficulties in social communication, stereotyped behavior, and aberrations in brain structures.

Usman Ghumman, MD, and his team at Texas Tech University Health Sciences Center at El Paso, presented results of a cross-sectional study to determine the prevalence of ADHD presentations with comorbid ASD among children in their AACAP panel titled: Can Autism Spectrum Disorder (ASD) and ADHD Be on the Same Spectrum: Cross-Sectional Study Analyzing the Subtypes of ASD With Comorbid Subtypes of ADHD.

Patients at the Texas Tech Child Psychiatry Clinic from 2010 to 2018 were included in the study. A review of 1,203 patient charts was performed to determine findings of mental health interviews and scores on the Social Communication Questionnaire (SCQ), the Autism Diagnostic Observation Schedule, 2nd edition (ADOS-2), and the Vanderbilt ADHD Diagnostic Rating Scale.

The review yielded 31 patients (23 males and 8 females) who had a combined diagnosis of ADHD and ASD. These patients showed comparable scores for both ADHD and ASD on their respective assessment instruments.

Given the higher prevalence of ADHD and ASD in males, higher scores in the sections evaluating restricted and repetitive behavior (RRB) in females could indicate they have more severe forms of ADHD and ASD. In addition, the similarities between ADHD and ASD led Dr. Ghummam’s team to consider the possibility that they (ie, either ASD or ADHD) can be viewed as a different presentation of the same illness. However, the determination of ADHD in the ASD population is challenging, they observed, with prevalence estimates varying widely.

While this retrospective review included only a small number of patients who were tested for Autism spectrum disorders, Dr. Ghummam said they believe youth with ASD and ADHD may be more difficult to treat than typically developing children with ADHD alone, and the rate of reported side effects when both occur together may be higher. (More on differentiating the two disorders below. See also, our data slideshow on other overlapping psychiatric comorbidities and ADHD.)


When Differentiating ASD and ADHD, Know the Limitations of Screening Tools

While ASD and ADHD are defined as distinct neurodevelopmental conditions, they often present with overlapping symptoms, which can delay an accurate diagnosis and add challenges to clinical care.

According to Adriana Di Martino, MD, of the Child Mind Institute in New York City, the “increasing evidence of overlapping ADHD and ASD presentations underscores our clinical and research challenges” as a field. She pointed to stats showing that 20 to 30% percent of children with ADHD are reported to display symptoms of ASD, and 20% to 85% of children with ASD are reported to display symptoms of ADHD. Her AACAP talk was titled “The Utility of Parent-Report Screening Tools in Differentiating Autism Spectrum Disorder vs ADHD in School-Age Children.”

Accurate diagnosis of the overlapping disorders can be delayed by as much as 3 years, especially in females, leading to greater functional impairment, increased rates of medication use, and increased hospitalizations. In children with ASD, ADHD can add to their symptoms by affecting organizational and social skills, which then present daily challenges for parents, healthcare providers, and educators.


Professional Takeaways

  • Females who showed higher rates of restricted and repetitive behavior (RRB) could indicate more severe forms of ADHD and ASD
  • Psychotic behaviors in children and adolescents with autism should be taken seriously; avoid the temptation to assume symptoms are a function of the spectrum disorder.
  • Accurate and valid clinical measures for identifying ASD and ADHD exist but they do not fully capture the heterogeneous presentation of these disorders


While the recognition of ADHD symptoms in children with ASD is increasingly accepted, there is still a large percentage of children with ADHD who do not meet ASD criteria – although that percentage is not known for certain. Having reliable and objective assessment tools is, therefore, crucial, especially given that comprehensive evaluations can be time-consuming and costly, noted Dr. Martino.

She and her colleagues assessed the performance of three well-known parent-report measures used to differentiate ASD from ADHD-only in verbal and intelligent school-aged children. Using the Autism Symptom Interview (ASI), School-Age, a recently validated brief interview of ASD, along with widely used parent questionnaires, including the Social Responsiveness Scale-2nd Edition (SRS-2) and the Social Communication Questionnaire (SCQ)-Lifetime, they analyzed data from a sample of 176 children (74 with ASD and 102 with ADHD; all aged 6-11 years) enrolled in an ongoing neuroimaging study.

All three screening tools yielded moderate-to-high accuracy for identifying ASD. The accuracy of the SCQ was larger relative to both ASI and SRS-2 and reached a statically significant difference relative to the SRS-2. Dr. Di Martino and her team concluded that, while all three assessments correctly classified ASD versus ADHD-only, the SCQ may be preferable in clinically complex presentations. “At the end of the day, the knowledge of the instruments and your clinical judgment will guide your decision,” she said.

However, she cautioned, clinicians need to remember that parent ratings may be biased. Parent ratings were more severe for children who tested false positive for ASD and less severe for those who tested false negative for ASD. “Given the degree to which parent concerns impacted the classification accuracy of these instruments, soliciting multiple independent sources of information is essential to best characterize children with ASD and ADHD,” she said. (See also, Psycom Pro’s special report on the external factors that can impact an ADHD diagnosis, including family and culture).

Another tool that may be helpful in a differential diagnosis is functional magnetic resonance imaging (fMRI), which, Dr. Di Martino noted captures functional connectivity and offers clinicians a noninvasive way to study the brain at rest. (ASD and ADHD are both characterized by abnormal functional connectivity and may show overlaps in structural brain connection abnormalities as well.)

“Accurate and valid clinical measures exist but they do not fully capture the heterogeneous presentation of these disorders. They are diagnosis-specific but also have transdiagnostic atypicalities,” she concluded.


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Last Updated: Aug 27, 2021