Co-occurrence of Autism Spectrum Disorder and Attention Deficit Hyperactivity Disorderand the Intersection of Transgender, Non-Binary and Gender Expansiveness
Erin Plew Lyles
Department of Counseling: Art Therapy
AT/CN 663-2: Theory & Practice of Family Art Therapy/Counseling
Jessi Cross, MA, LPAT, ATR-BC, LPCC
March 13, 2024
Population
This research paper investigates the high degree of clinical overlap in Autism SpectrumDisorder (ASD) and Attention-Deficit Hyperactivity Disorder (ADHD), and the extent to whichboth conditions are pathologized by society. Additionally, there are many women with ASD andADHD that either remain undiagnosed or receive their diagnosis much later in life due to thesymptoms presenting much differently in people assigned female at birth (AFAB). This isprimarily due to diagnostic criteria centering around the white male experience. There also existsa large population at the intersection of neurodiversity and transgender, nonbinary, and genderexpansive (TNBGE), all of which have been systematically marginalized by the dominantculture. As clinicians, it is important that we work to advocate for and depathologize thebehavior, experience, personality, and perspectives of ASD, ADHD and TNBGE people(McConnell & Minshew, 2023).
Overlap of Autism Spectrum Disorder and Attention Hyperactivity Deficit Disorder
ASD and ADHD are neurodevelopmental conditions that most often begin in childhoodand persist into adulthood. People with ADHD are defined as having “impairments infunctioning in cognitive, academic, familial, and social domains of everyday life”, with coresymptoms of “inattention, hyperactivity and impulsivity (Ragnarsdottir, et al., 2018).” AutismSpectrum Disorder is a neurodevelopmental disorder in people who experience persistentimpairments of social interaction and communications. ASD also includes limited, narrowpatterns of repetitive behaviors and atypical fixed interests (McConnell & Minshew, 2023; Liuet.al, 2023). According to Liu et. al. (2023), both autism and ADHD share the symptoms of“attention deficit, hyperactivity and impulsivity and difficulties with social interaction” and are“strongly associated with genetic factors.” Research has shown that 37%-85% of children withautism also have an ADHD diagnosis and 13% of children with ADHD also have an ASDdiagnosis (Liu, et.al., 2023). It has only been in the last ten years that the Diagnostic andStatistical Manual of Mental Disorders (5th ed., text rev.) (DSM-5-TR) (APA, 2022) recognizedASD and ADHD as a dual diagnosis (Craddock, 2024), and since then, AuDHD is the term thathas been adopted by those experiencing this overlap. Despite their frequent co-occurrence,autism and ADHD are often treated in isolation and practitioners rarely consider that onediagnosis would likely indicate the other. This disparity in the consideration of this overlapfurther indicates that clinicians are also unlikely to consider the “wider intersections of sex,ethnicity, class, age and disability” (Craddock, 2024).
Both ASD and ADHD are often pathologized realms of neurodivergence, not onlysocietally and medically, but also according to DSM-5-TR (APA, 2022) and to cliniciansproviding these diagnoses. Pathologizing diagnostic language associated with autism and ADHDare often words such as: skill deficits, impairments, restricted, disruptive, limitations, attentionproblems, social deficits, difficult behaviors, serious delinquency, defiance, problemsmaintaining relationships, peer rejections, and poor outcomes. These are words that comedirectly from many peer-reviewed academic articles researched for this paper, and from theDSM-5-TR (Ragnarsdottir, et al., 2018; APA, 2022). The DSM 5-TR tends to focus primarily onthe deficits in individuals with ASD and ADHD and lacks emphasis on important areas such asthe heightened sensorial and internal experiencing. Rejection Sensitivity Dysphoria (RSD), forexample, is a condition in which one is hyper-sensitive to perceived criticism and rejection, another prominent feature in both ASD and ADHD (Craddock, 2024), that is not mentioned inthe DSM 5-TR.
Autism and ADHD are still being treated as problems to be solved, behaviors to becorrected, in order to make neurotypical people feel comfortable, rather than being viewed as aneurological difference offering unique perspectives. Activists supporting the autistic communitymake the argument about the language of the diagnostic criteria, “insisting that autism should notbe considered a disorder, but rather simply part of a spectrum of diversity, and should only be“diagnosed” as is useful for helping autistic people access appropriate resources (McConnell &Minshew, 2023).”
Treatment Methods & Clinical Approaches
Evidence-based approaches such as Cognitive Behavioral Therapy (CBT), AppliedBehavioral Analysis (ABA), and Parent-Child Interaction Therapy (PCIT) are often used asbehavior modification therapies for people with autism and ADHD. Parent-Child InteractionTherapy in an attachment and social learning theories-based therapy that focuses on the behaviorof the adult and what they can do to better accommodate their child with neurological differences(Vetter, 2018). PCIT takes the focus off of the child’s behaviors and helps the parent to developstrategies for supporting the existing behaviors and neurological differences of their child.
However, because ADHD and autism are still considered “disorders,” or problems to besolved, they are still predominantly being treated with medication (Craddock, 2024) orbehavioral modification therapies. The primary treatment for autism is Applied BehavioralAnalysis therapy which works to diminish “problematic” behaviors in people with autism. Asstated by McConnell & Minshew (2023), ABA therapy was allegedly co-created by the person who created conversion therapy for non-heteronormative people. The goal in both therapies isto decrease the behaviors in people with diverse experiencing in order to increase the comfort ofneurotypical (allistic) and heteronormative people. Though this statement about the co-creator ofABA may be a bit sensationalist, it does stand to reason that ABA therapy is a disservice to thosewith neurodiversity that would benefit from instead being offered resources and supports in theircommunity. The current treatment models for autism and ADHD push people with thesediagnoses to further mask themselves, rather than to live with and adapt to their symptoms.
Gender Differences in AuDHD
Craddock (2024) asserts that neurodivergent women and girls have been overlooked bythe medical profession because ADHD and autism have until recently been considered only asconditions, “with diagnosis being 4 times more likely for males than females (Craddock, 2024).”The diagnostic criteria in the DSM 5-TR on the combined diagnosis of ASD and ADHD has beencritiqued because it is based only on the male experience and presentation of symptoms. Boysare more likely to receive ADHD diagnosis than girls, because the way that it presents in girlsappears very different (Ragnarsdottir, et al., 2018). As with many medical diagnoses, the whitemale body is the primary example that has been studied for autism and ADHD, to the exclusionof other genders, races, and ethnicities (McConnell & Minshew, 2023).
Girls are more likely to observe the way that they “should” act according to societalgendered expectations and “mask” their behaviors accordingly to fit in. Their “self-knowledgemay become clouded, suppressed, or managed to avoid negative consequences and reactionsfrom others (McConnell & Minshew).” AFAB women and girls tend to internalize the implicitmessages of how they should be versus their internal experiencing, which leads to poor mental health and trauma (Craddock, 2024). Because women become so efficient at the masking of theirASD and ADHD symptoms, they are often not recognized as being neurodiverse and continue tointernalize beliefs that something is wrong with them into adulthood.
Intersectionality between Autism and TNBGE
“Neurodivergent individuals are a neuro-minority in the general population, and thus face structural barriers living in a world designed by and for neurotypicals. These barriers arecompounded by gendered structures of oppression (Craddock, 2024).” Transgender, nonbinaryand gender expansive (TNGBE) people are more likely to experience neurodivergence andAuDHD people are more likely to be TNBGE. TNBGE have been historically pathologized andmarginalized by society and adding a layer of neurodivergence causes them to face furthersystemic inequities. Those who are at the intersection of AuDHD and TNGBE tend to be evenfurther ostracized by a system which does not consider their experience of AuDHD traits in thediagnostic criteria. It is no surprise that AuDHD TNGBE individuals experience high rates ofdepression and anxiety (McConnell & Minshew, 2023). Typically, practitioners that specialize intreating people experiencing TNGBE lack training in assessing for autism or ADHD and viceversa (Craddock, 2024). Clinicians that are informed in both areas can be better prepared thatone condition may overlap with the other. Further, the clinician can then address the AuDHDTNBGE intersecting identities by aiding these clients in understanding the trauma and distressthat comes from systematic oppression, and supporting them in deconstructing shame andinternalized stigma.
Feminist therapy moves to depathologize neurodiversity and those with TNGBE byempowering and re-centering their voices. “The neurodiversity movement asserts that difference is a naturally occurring feature ofhumanity and that all individuals are equal, although they might not be treated as such. Itseeks to move away from a deficits-based model that positions those with neurologicaldifferences as ‘abnormal’ in contrast to the ‘norm’ – those without neurologicalconditions (Craddock, 2024).” Rather than pathologizing symptoms and behaviors, feminist therapists see these ascoping strategies that have allowed people with AuDHD to exist in a world that was notstructured for them. For example, recognizing that an autistic inclination is to “stim,” or self-stimulate, a recommendation a therapist might make is to spend time with others who stim orthose who recognize it as a necessary coping mechanism. Therapists can challenge people withAuDHD to ask for their needs to be met such as dimming the lights and turning down loudsounds in public places. I hope to become and advocate, researcher, and a voice for a group of people that have been marginalized by a society not createdfor them, demanding our rights to be seen as equal individuals who have much to contribute.
“The neurodiversity movement argues for a paradigm shift that recognises difference asnaturally occurring and all neurotypes as equal. To fully achieve this requires a radicaloverhauling of society, institutions, and behaviour to remove the privileging ofneurotypical ways of thinking and being. (Craddock, 2024)”
References
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Craddock, E. (2024). Raising the voices of AuDHD women and girls: Exploring the co-
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Liu, A., Lu, Y., Gong C. , Sun, J., Wang, B., & Jiang, Z. (2023). Bibliometric analysis of
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McConnell, E. A., Minshew, R. (2023). Feminist therapy at the intersection of gender diversity
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Ragnarsdottir, B., Dagmar, K. H., Halldorsson, F., & Njardvik, U. (2018). Gender and agedifferences in social skills among children with ADHD: Peer problems and pro-socialbehavior. Child & Family Behavior Therapy, 40(4), 263-278. DOI:10.1080/07317107.2018.1522152
Vetter, J. A. (2018). Parent-child interaction therapy for autism spectrum and attention-deficit/hyperactivity disorders: A review of the literature. Child & Family BehaviorTherapy, 40(3), 204-232. DOI: 10.1080/07317107.2018.1487740