Diagnosing Autism and ADHD: Part One

There are many tools to assess Autism Spectrum Disorder (ASD) and Attention Deficit Hyperactivity Disorder (ADHD), but not any one of these should be used entirely on its own to establish diagnosis and there are many variety of clinicians who can and do diagnose autism and ADHD, yet these individuals continue to struggle to get a timely diagnosis and effective treatment.

There is a lot of controversy in this aspect of clinical practice because at one point in time, far too many children were being diagnosed with ADHD, even teachers were sending home notes from school asking parents to get their child medicated for ADHD when in fact, this wasn't the primary issue nor medication the best treatment. This caused many parents to turn away from diagnosis losing faith in this being a true disorder, fearing it was a means to sell more medications. As understanding of these disorders have evolved, primary care providers are more inclined to refer for diagnosis, but this can delay care even a few years and costs are significantly higher.

Autism, in my own opinion, has been a diagnosis reserved for those more profoundly impacted, but otherwise ignored for those who are high-functioning. That in itself though, is a misnomer, because while those identified as "high-functioning" might effectively care for their basic needs, they certainly aren't functioning well in many aspects of their daily lives.

Certainly within the healthcare industry autism is a disorder not often discussed or well understood. As a mother with children on the spectrum, I know that when I share with medical personnel that my child has autism, they ask if he can feed and dress himself. That's about the extent of their concern. They haven't any awareness that while yes, he can brush his teeth and put on his own shoes, he can't discern pain well, nor time, nor communicate his needs, and may be inappropriate or have perspectives so different from others that it may not seem based in reality. He may even have crippling anxiety that keeps him from implementing treatments or seeking support. Not only does the healthcare industry struggle to identify and diagnose individuals with autism, but they aren't very knowledgeable in how to meet their needs as clients. This holds true for ADHD as well.

Autism Spectrum Disorder

Research has found that autism spectrum disorder can sometimes be detected at 18 months of age, even younger. By the age of 2 years, a diagnosis by an experienced professional can be considered very reliable (Lord et al., 2006). Average age of diagnosis is around 4 or 5 years (Smith et al., 2025); however, many do not receive a final diagnosis until they are much older. This delay means that children with autism aren't often getting the help they need to succeed. The earlier the diagnosis, a proper diagnosis, the sooner you and your child can start to navigate and advocate how to optimizing their growth and development. Honestly, I grew up as a mother in the times where we feared labeling our child, and we certainly were opposed to medicating them to be zombies just so they weren't too active, but in hindsight, many of us have done a disservice.

There is a middle ground. Not understanding your child's challenges can lead to significant social and emotional disability so that they suffer defiance, low self-esteem, significant school challenges, learning disabilities, crippling anxiety and paranoia, even self-harm. Once diagnosed, having an understanding of where you fit on the spectrum is often a relief because many share that for so long they've known there was something very wrong, that they didn't fit in or think like others. They didn't make friends and couldn't understand what people wanted from them, or even how they were suppose to behave and respond. When individuals resonate with this diagnosis, it can help them find grounding and discover their strengths and better understand what resources might actually minimize their challenges, and maybe for the first time recognize and appreciate their place on the spectrum.

The American Academy of Pediatrics recommends that primary care providers and pediatricians evaluate for autism in each of the developmental surveillance visits, and any concerns should be promptly investigated. Specific screenings are recommended at 9 months, 18 months and at 30 months. If the child was born prematurely, had low birth weight, has a sibling or parent with autism, they should be identified as high risk and monitored. If diagnosis is offered, then chronic management should be initiated with a practitioner you trust will advocate for them. Counseling is also recommended, by myself, for both parents and the child, as it is well identified in the literature that parents who have a child with autism suffer trauma similar to soldiers in combat.

Current diagnosis process typically includes lengthy wait times and multiple appointments prior to receiving a diagnosis (MacKenzie et al., 2022; Wong et al., 2017). Recent estimates suggest up to a 2-year delay between the time of first concern and a receiving of diagnosis (MacKenzie et al., 2022; Zuckerman et al., 2017). Females are diagnosed much later than males (Begeer et al., 2013; McQuaid et al., 2024). The poor are diagnosed later still, as their access to care is limited, particularly mental healthcare. Given the association between diagnostic timing and positive clinical outcomes, careful attention must be placed on ways to lower the average age at diagnosis.

It doesn't require a psychiatrist to diagnose either ASD or ADHD, although certainly their expertise can be helpful. Your primary care provider certainly may be your best advocate and even diagnostician, although there is concern that unless they have proper expertise and experience, this may be an overreaching diagnosis and other concerns may go missed. The issue is largely lack of time in conventional medicine. Certainly, post-graduate training has the potential to enhance clinician confidence and service provision in ASD assessment and diagnosis, but there is a lack of evidence in which pathways are superior or even necessary (Curran et al., 2024).

Ultimately, there is no gatekeeping on the diagnosis of autism or ADHD, but rather clinician discernment with regards to their own expertise and resources.

Clinicians are encouraged to use the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria, expert clinical judgment, and in many cases, standardized diagnostic tools such as the Autism Diagnostic Observation Schedule-Second Edition (ADOS-2) (Lord et al., 2012) and the the Autism Diagnostic Interview-Revised (ADI-R) (Lord et al., 1994) to diagnose autism. These can take 20 minutes to 4-hours depending on the extensive nature of the consultation, and each of these tools requires extensive training and resources to reliably administer (Durkin et al., 2015). Consequently, autism diagnostic assessments are most often limited to professionals practicing in autism specialty centers or academic medical centers rather than primary care settings. It is however, the intention of the Interagency Autism Coordinating Committee to expand the autism diagnostic system's capacity to meet family's needs (IACC, 2023), as again, this is not an issue of inability of family practice providers to perform the assessment and offer the diagnosis, but more the issue of having the time within the conventional medicine model and the diagnostic tools readily available. Private practice clinicians certainly may opt to offer these services, even specialize in offering diagnostic assessments, within their own practice.

There is data demonstrating that clinicians, specifically primary care providers, can effectively be trained in their primary care practices to identify and diagnose autism spectrum disorders (Smith et al., 2025, Schieltz et al., 2023, & Guan et al., 2022) with similar outcomes to psychologists. In fact, those who do have found to have similar diagnostic accuracy of 95% using an ECHO Autism STAT assessment tool (Sohl et al., 2023), only one false-negative using the START-ED training (Swanson et al., 2014; Warren et al., 2009), and using EAE hub system, diagnostic agreement was 82% (Smith et al., 2025). Interestingly, diagnostic agreement between community-based psychologists and an expert team was determined to be 89% based on agreement on cases presented in the ECHO Autism: Diagnostic study.

Factors that relate to the appropriateness of diagnosing individuals in primary care settings related to the clinician's certainty. There are more apparent cases, clear diagnosis, which are often termed "tier one" for which primary care clinicians are unlikely to need further consultation from specialty clinicians. They may use the STAT diagnostic tool for these cases, and move forward with diagnosis and referral for necessary services (Stone et al., 2000). However, tier two can be a bit more complex and require assessment with more standardized tools, like the ADOS-2 used in the ECHO Autism: Diagnostic training for psychologists (Nowell et al., 2020). Tier 3 is more complex yet, reserved for those who require the most comprehensive diagnostic assessment, an interdisciplinary assessment of symptoms across the healthcare team, including speech and language, occupational therapy, and psychology. At each tier though, the primary care provider can certainly play a very integral role and really, to optimize care for these individuals, more really do need to expand their skillset and expertise to include autism diagnostics.

We all have our own niche, our own passions, and in these areas some dive a bit deeper into their practice, so I would suggest knowing well the comfort zone of your clinician when seeking a diagnosis for autism and ADHD. Expanding the "playing field" so to speak with regards to who can offer evaluations for diagnosis and treatment decreases time families have to endure long waitlists for specialty centers. Although psychologists may continue to be the professionals most likely to diagnose autism (MacKinzie et al., 2022), other clinicians, including nurse-practitioners, can diagnose autism with training. Just like any other area of primary care practice, clinicians may manage more obvious diagnoses in their practice and refer to a specialty clinician for more challenging cases, but that discernment lies within the practitioner recognizing their own expertise, experience, and resources as it does for every other aspect of their clinical practice. Avenues for bolstering a clinician's skill set can come from trainings, workshops, or educational opportunities (DeCorby-Watson et al., 2018 & Schieltz et al., 2023).

The standard, no matter the diagnostician, is for two main sources of information - parents or caregivers, teachers or mentors, to provide a description of the child's development and a professional observation of the child. Primary care visits are often only 6 minutes and if they occur only once a year, this is not likely the best practitioner for such diagnosis. Although that isn't exclusively true. In my own practice, individual visits are an hour, so when I meet with a family, often in their home, I can be there the entire afternoon visiting with each of the children. This absolutely does enhance my ability to make these diagnosis and if I see them year after year, and for healthcare needs in between, my time with these children is much more extensive than most primary healthcare providers, even psychologists. This is the beauty of private practice. We more often have time for building relationships with our clients.

If your primary care provider feels a referral is best for diagnosis, then they may recommend a neurodevelopmental pediatrician, a developmental-behavioral pediatrician, a child neurologist, or even a geneticist or early intervention programs. I have even worked with occupational therapists and speech therapists who have offered really extensive evaluations for ASD and ADHD as well. Either way, healthcare professionals in the United States and much of the world use the American Psychiatric Association's Diagnostic and Statistical Manual (5th edition) as the authority guide for diagnosis of mental health disorders.

The challenge here is that it takes 17 years for 30% of clinicians to update their clinical practice after a new guideline or publication is offered, advancing our clinical knowledge. It can take years, if not decades for expert panels to convene and publish recommendations, and depending on the clinician's practice model and interests, some will maintain very current, even leading the industry in their particular niche, while others remain decades behind the norm.

Autism Spectrum Disorder (DSM-5) Diagnostic Criteria

When clinicians are evaluating for autism, they are specifically looking to confirm that there are persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or historically:

• deficits in social-emotional reciprocity, ranging for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduce sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions;

• deficits in nonverbal communicative behaviors used for social interaction, ranging for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication;

• deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.

Clinicians will then identify the severity of these deficits based on social communication impairments and restricted repetitive patterns of behavior. There is also the expectation that those with autism will have restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or historically:

• Stereotyped or repetitive motor movements, use of objects, or speech such as simple motor stereotypes, lining up of toys or flipping objects, echolalia, idiosyncratic phrases;

• Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal behavior such as extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take the same route or eat food every day;

• Highly restricted, fixated interests that are abnormal of intensity or focus such as a strong attachment to or preoccupation with unusual objects, excessively circumscribed or preservative interest;

• Hyper- or hypo-reactivity to sensory input or unusual interests in sensory aspects of the environment (apparent indifference to pain and temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).

Again, the clinician will specify the current severity of these deficits, based on social communication impairments and restricted, repetitive patterns of behavior. Clinicians will expect symptoms to be present in the early developmental period, but they may not fully manifest until social demands exceed their limited capacity or they may mask these deficits because they've learned quickly to strategize ways to compensate. To meet diagnostic criteria, these deficits will impair the individual in social, occupational, or other important areas of current functioning. These deficits should also, not be better explained by intellectual disability or global developmental delay.

The essential features of autism spectrum disorder are persistent impairment in reciprocal patterns of behavior, interests and social interaction per the first criteria, and the second addresses restricted, repetitive patterns of behavior, interests, or activities. The impairments in communication and social interaction specified in the first diagnostic criteria are pervasive and sustained. Diagnoses are most valid and reliable when based on multiple sources of information, including clinician’s observations, caregiver history, and, when possible, self-reporting. Verbal and nonverbal deficits in social communication have varying manifestations, depending on the individual's age, intellectual level, and language ability, as well as other factors such as treatment history and current support. Many individuals have language deficits, ranging from complete lack of speech through language delays, poor comprehension of speech, echoed speech, or stilted and overly literal language. Even when formal language skills (e.g., vocabulary, grammar) are intact, the use of language for reciprocal social communication is impaired in autism spectrum disorder.

Deficits in social-emotional reciprocity (i.e., the ability to engage with others and share thoughts and feelings) are clearly evident in young children with the disorder, who may show little or no initiation of social interaction and no sharing of emotions, along with reduced or absent imitation of others’ behavior. What language exists is often one-sided, lacking in social reciprocity, and used to request or label rather than to comment, share feelings, or converse. In adults without intellectual disabilities or language delays, deficits in social-emotional reciprocity may be most apparent in difficulties processing and responding to complex social cues (e.g., when and how to join a conversation, what not to say). Adults who have developed compensation strategies for some social challenges still struggle in novel or unsupported situations and suffer from the effort and anxiety of consciously calculating what is socially intuitive for most individuals.

Deficits in nonverbal communicative behaviors used for social interaction are manifested by absent, reduced, or atypical use of eye contact (relative to cultural norms), gestures, facial expressions, body orientation, or speech intonation. An early feature of autism spectrum disorder is impaired joint attention as manifested by a lack of pointing, showing, or bringing objects to share interest with others, or failure to follow someone’s pointing or eye gaze. Individuals may learn a few functional gestures, but their repertoire is smaller than that of others, and they often fail to use expressive gestures spontaneously in communication. Among adults with fluent language, the difficulty in coordinating nonverbal communication with speech may give the impression of odd, wooden, or exaggerated “body language” during interactions. Impairment may be relatively subtle within individual modes (e.g., someone may have relatively good eye contact when speaking) but noticeable in poor integration of eye contact, gesture, body posture, prosody, and facial expression for social communication.

Deficits in developing, maintaining, and understanding relationships should be judged against norms for age, gender, and culture. There may be absent, reduced, or atypical social interest, manifested by rejection of others, passivity, or inappropriate approaches that seem aggressive or disruptive. These difficulties are particularly evident in young children, in whom there is often a lack of shared social play and imagination (e.g., age-appropriate flexible pretend play) and, later, insistence on playing by very fixed rules. Older individuals may struggle to understand what behavior is considered appropriate in one situation but not another (e.g., casual behavior during a job interview), or the different ways that language may be used to communicate (e.g., irony, white lies). There may be an apparent preference for solitary activities or for interacting with much younger or older people. Frequently, there is a desire to establish friendships without a complete or realistic idea of what friendship entails (e.g., one-sided friendships or friendships based solely on shared special interests). Relationships with siblings, co-workers, and caregivers are also important to consider (in terms of reciprocity).

Autism spectrum disorder is also defined by restricted, repetitive patterns of behavior, interests, or activities per the second criteria, which show a range of manifestations according to age and ability, intervention, and current supports. Stereotyped or repetitive behaviors include simple motor stereotypes (e.g., hand flapping, finger flicking), repetitive use of objects (e.g., spinning coins, lining up toys), and repetitive speech (e.g., echolalia, the delayed or immediate parroting of heard words; use of “you” when referring to self; stereotyped use of words, phrases, or prosodic patterns). Excessive adherence to routines and restricted patterns of behavior may be manifest in resistance to change (e.g., distress at apparently small changes, such as in packaging of a favorite food; insistence on adherence to rules; rigidity of thinking) or ritualized patterns of verbal or nonverbal behavior (e.g., repetitive questioning, pacing a perimeter). Highly restricted, fixated interests in autism spectrum disorder tend to be abnormal in intensity or focus (e.g., a toddler strongly attached to a pan; a child preoccupied with vacuum cleaners; an adult spending hours writing out timetables). Some fascinations and routines may relate to apparent hyper- or hyporeactivity to sensory input, manifested through extreme responses to specific sounds or textures, excessive smelling or touching of objects, fascination with lights or spinning objects, and sometimes apparent indifference to pain, heat, or cold. Extreme reaction to or rituals involving taste, smelt texture, or appearance of food or excessive food restrictions are common and may be a presenting feature of autism spectrum disorder.

Many adults with autism spectrum disorder without intellectual or language disabilities learn to suppress repetitive behavior in public. Special interests may be a source of pleasure and motivation and provide avenues for education and employment later in life. Diagnostic criteria may be met when restricted, repetitive patterns of behavior, interests or activities were clearly present during childhood or at some time in the past, even if symptoms are no longer present.

Intellectual disability and autism spectrum disorder frequently occur simultaneously, so when there is when both are diagnosed, there is social, communicative, and intellectual disability below what is expected for their general developmental level. Many though, have intellectual impairment and language impairment. They may be slow to talk or have a language comprehension that is behind their ability to produce language, and even those with average or high intelligence may have an uneven profile of abilities. Motor deficits are often present, including odd gain, clumsiness, and other abnormal motor signs, such as walking on their tiptoes. Self-injury may occur, and disruptive/challenging behaviors are more common in children and adolescents with autism than with other disorders, including intellectual disability.

Adolescents and adults with autism spectrum disorder are prone to anxiety and depression. Some individuals develop catatonic-like motor behavior (slowing and “freezing” mid-action), but these are typically not of the magnitude of a catatonic episode. However, it is possible for individuals with autism spectrum disorder to experience a marked deterioration in motor symptoms and display a full catatonic episode with symptoms such as mutism, posturing, grimacing and waxy flexibility. The risk period for co-morbid catatonia appears to be greatest in the adolescent years.

Importantly, if individuals were diagnosed previously with autism based on the DSM-IV diagnostic criteria, this should be reevaluated and confirmed. As well, if an individual identifies their diagnosis as Aspergers or pervasive developmental disorders, these too are a bit outdated and need to be reevaluated based on more recent criteria. If an individual has marked deficits in social communication, but does not otherwise meet criteria for autism spectrum disorder, then they should be evaluated for social (pragmatic) communication disorder.

Further, the diagnosis of autism spectrum disorder will be identified as being accompanied with intellectual impairment, or not, and with or without language impairment. It will also be associated with another neurodevelopmental, mental, or behavioral disorder, and with catatonia or other medical and genetic conditions or environmental factors.

Social (Pragmatic) Communication Disorder

Just to be clear, this diagnosis is one that may be confused or misdiagnosed as autism so its helpful to be aware of another, similar disorder that may better identify the challenges one is facing. According to the DSM-IV, when an individual has persistent difficulties in the social use of verbal and nonverbal communication as manifested by all of the following, then social pragmatic communication disorder is a better diagnosis:

• deficits in using communication for social purposes, such as greeting and sharing information, in a manner that is appropriate for the social context;

• impairment of the ability to change communication to match context or the needs of the listener, such as speaking differently in a classroom than on the playground, talking different to a child than to an adult, and avoiding use of overly formal language;

• difficulties following rules for conversation and storytelling, such as taking turns in conversation, rephrasing when misunderstood, and knowing how to use verbal and nonverbal signals to regulate interaction;

• difficulties understanding what is not explicitly stated, such as making inferences, and nonliteral or ambiguous meanings of language, such as idioms, metaphors, multiple meanings that depend on the context for interpretation.

These deficits result in functional limitations in effective communication, social participation, social relationships, academic achievement, or occupational performance, individually or in combination, and the onset of symptoms is in the early developmental period, but the deficits may not fully manifest until their social communication demands exceed their limited capacity. These symptoms should not be attributable to another medical or neurological condition, or to low abilities in the domains or word structure and grammar, or are not better explained by autism spectrum disorder, intellectual disability, global developmental delay, or another mental disorder.

Recommendations Regarding Universal Screening for ASD among Young Children

The U.S. Preventive Services Task Force (USPSTF) released a recommendation in 2016 regarding universal screening for young children for autism spectrum disorder, which applies to children 3 years of age and younger, who otherwise have no signs or symptoms of autism or even developmental delay. This screening is also for children whose parents have no concerns about their child's development. It's a routine safety net.

Research has identified that parents are reliable sources of information about their children's development. We can use evidence-based tools that incorporate parent's reports about their children, such as their use of the Ages and Stages Questionnaire, to better discover as clinicians if there may be underlying concerns, and these really help increase parent awareness. These screenings take anywhere from two minutes to 15 minutes, and the cost are minimal. This is about establishing relationship-based practices and promoting positive parent-child relationships, while building the strongest possible relationship between parent and provider.

Clinicians use screening tools to get directly to the indicators for any particular diagnosis and these screening tools have sometimes large amounts of scientific study to support them, while others are more in their infancy of development, but help gather more information in a short amount of time for practitioners to discern as part of their diagnostic assessment. Screening tools in themselves though, do not provide conclusive evidence of developmental delays and do not result in diagnoses just based off of this data alone. They're tools for identifying who needs a more thorough evaluation.

A two-minute screening for autism that many practitioners include as part of their diagnostic assessment is the M-CHAT-R. I offer the M-CHAT-R to parents prior to their developmental wellness checks for their little ones. This can help open conversation about concerns. The Ages and Stages Questionnaire is another general developmental screening tool addressing communication, gross motor, fine motor, problem-solving, and personal adaptive skills.

There are screening tools better for various ages and screening tools better for specific concerns within each of these diagnosis. The Communication and Symbolic Behavior Scales (CSBS DP Infant and Toddler Checklist) is yet another standardized tool for screening of communication and symbolic abilities up to 24-months, and this one is also completed by the parents. There is also the Parents' Evaluation of Developmental Status (PEDS Tools) and the Screening Tool for Autism in Toddlers and Young Children (STAT), the latter of which is used where there are suspicions for autism.

As primary care providers, we monitor growth and development, which is an ongoing process of watching a child grow and encouraging conversations between parents and ourselves about a child's skills and abilities. We want to see them play, learn, speak, how they behave and move, which is a big part of why I like to offer home visits. This is much easier done in the child's home, where they are comfortable. Parents, grandparents, early childhood education providers, and other caregivers all have a place in this developmental monitoring. As mentioned above, if your primary care provider has a particular passion for autism or ADHD and they can accommodate the time within their clinical schedule, they may dive into expanding their skill set for diagnosing these individuals, or they may refer outside their practice.

When screenings flag for concerns of autism, a more formal evaluation is then offered to determine the appropriateness of diagnosis. Depending on your primary care provider's experience and expertise, this may be a referral outside their practice, or they may conduct this evaluation themselves which allows for referral for services that will best help the individual with autism succeed. For my own son, we used social emotional groups with a local speech therapist and worked with an occupational therapist to help mature some of his fetal reflexes and work to address issues with his vestibular and proprioception, improve his connection to his core, even his eye coordination. He has many sensory issues as well, but for me as a parent, I really had no real understanding of where his disability started and what was just quirky personality, or even lack of effort or even misbehavior. It really helped me make space for him, to better understand where he needed me to show up for him, and it calmed my fight-or-flight to some degree, because I better recognized not only, his rights and how I could better advocate for him, but I understood why sometimes his own fight-or-flight caused him to target me.

Development and Course of Autism Spectrum Disorder with Age

First symptoms of autism spectrum disorder frequently involve delayed language development, often accompanied by lack of social interest or unusual social interactions (e.g., pulling individuals by the hand without any attempt to look at them), odd play patterns (e.g., carrying toys around but never playing with them), and unusual communication patterns (e.g., knowing the alphabet but not responding to own name). Deafness may be suspected but is typically ruled out. During the second year, odd and repetitive behaviors and the absence of typical play become more apparent. Since many typically developing young children have strong preferences and enjoy repetition (e.g., eating the same foods, watching the same video multiple times), distinguishing restricted and repetitive behaviors that are diagnostic of autism spectrum disorder can be difficult in preschoolers. The clinical distinction is based on the type, frequency, and intensity of the behavior (e.g., a child who daily lines up objects for hours and is very distressed if any item is moved).

Autism spectrum disorder is not a degenerative disorder, and it is typical for learning and compensation to continue throughout life. Symptoms are often most marked in early childhood and early school years, with developmental gains typical in later childhood in at least some areas (e.g., increased interest in social interaction). A small proportion of individuals deteriorate behaviorally during adolescence, whereas most others improve. Only a minority of individuals with autism spectrum disorder live and work independently in adulthood; those who do tend to have superior language and intellectual abilities and are able to find a niche that matches their special interests and skills. In general, individuals with lower levels of impairment may be better able to function independently. However, even these individuals may remain socially naive and vulnerable, have difficulties organizing practical demands without aid, and are prone to anxiety and depression. Many adults report using compensation strategies and coping mechanisms to mask their difficulties in public but suffer from the stress and effort of maintaining a socially acceptable facade. Scarcely anything is known about old age in autism spectrum disorder.

Some individuals come for first diagnosis in adulthood, perhaps prompted by the diagnosis of autism in a child in the family or a breakdown of relations at work or home. Obtaining detailed developmental history in such cases may be difficult, and it is important to consider self-reported difficulties. Where clinical observation suggests criteria are currently met, autism spectrum disorder may be diagnosed, provided there is no evidence of good social and communication skills in childhood. For example, the report (by parents or another relative) that the individual had ordinary and sustained reciprocal friendships and good nonverbal communication skills throughout childhood would rule out a diagnosis of autism spectrum disorder; however, the absence of developmental information in itself should not do so.

Risks and Prognostic Factors for Autism

The best established prognostic factors for individual outcome within autism spectrum disorder are presence or absence of associated intellectual disability and language impairment (e.g., functional language by age 5 years is a good prognostic sign) and additional mental health problems. Epilepsy, as a comorbid diagnosis, is associated with greater intellectual disability and lower verbal ability.

Environmental

A variety of nonspecific risk factors, such as advanced parental age, birth weight, or fetal exposure to valproate, may contribute to risk of autism spectrum disorder.

Genetic And Physiological

Heritability estimates for autism spectrum disorder have ranged from 37% to higher than 90%, based on twin concordance rates. Currently, as many as 15% of cases of autism spectrum disorder appear to be associated with a known genetic mutation, with different de novo copy number variants or de novo mutations in specific genes associated with the disorder in different families. However, even when an autism spectrum disorder is associated with a known genetic mutation, it does not appear to be fully penetrant. Risk for the remainder of cases appears to be polygenic, with perhaps hundreds of genetic loci making relatively small contributions.

Functional Consequences of Autism Spectrum Disorder

In young children with autism spectrum disorder, lack of social and communication abilities may hamper learning, especially learning through social interaction or in settings with peers. In the home, insistence on routines and aversion to change, as well as sensory sensitivities, may interfere with eating and sleeping and make routine care (e.g., haircuts, dental work) extremely difficult. One of my boys would absolutely panic when trying on new clothes.

Adaptive skills are typically below measured IQ. Extreme difficulties in planning, organization, and coping with change negatively impact academic achievement, even for students with above-average intelligence. During adulthood, these individuals may have difficulties establishing independence because of continued rigidity and difficulty with novelty. Many individuals with autism spectrum disorder, even without intellectual disability, have poor adult psychosocial functioning as indexed by measures such as independent living and gainful employment. Functional consequences in old age are unknown, but social isolation and communication problems (e.g., reduced help-seeking) are likely to have consequences for health in older adulthood.

More to come with regards to treatment approaches for autism, and then a deeper dive into ADHD but other diagnosis that may present similar to autism are Rett Syndrome, Selective Mutism, Language Disorders and Social (Pragmatic) Communication Disorder, Intellectual Disabilities without Autism, Stereotypica Movement Disorder, ADHD, and Schizophrenia. Of course, autism can also accompany other diagnosis, including psychiatric disorders. Upwards of 70% of autistic individuals have a psychiatric disorder and 40% may have two or more mental disorders.

If you'd like to connect to discuss your thoughts and concerns with autism or ADHD for yourself, or your child, feel free to message me at 765-335-2171. You can also sign up for a free Meet-the-Doc session listed on our homepage.

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