Double Diagnosis, ADHD and Autism

Beau Baldassari, 8, part of a military family, showed his parents early on that he didn’t respond well to the frequent moves that are part of a military career. “One month before the move, he became angry all the time, defiant, just the definition of a behavior problem,” said Beau’s mother, Ally Baldassari. She didn’t know it at the time, but Beau was showing the first indications that he was suffering from both autism and Attention Deficit/Hyperactivity Disorder, or ADHD.

Medical guidelines regarding autism, ADHD, and attention deficit disorder (ADD) have changed in recent years. Previously, psychiatrists were unable to diagnose a child as having autism or autism spectrum disorders (such as Asperger’s), as well as ADHD or ADD. But a study published in the June 2013 edition of the journal Autism has found that nearly one in three children with autism also have some form of ADHD symptoms. Faced with this, the latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM), which lays out guidelines for diagnosing psychiatric disorders, now allows doctors to issue a joint diagnosis of autism and ADHD.

“Now families are going to be able to more effectively work with their physician, who will be at liberty to look at a child’s behavior more objectively and say that not all behavioral problems are related to their autism,” said Rebecca Landa, PhD, director of the Center for Autism and Related Disorders at Kennedy Krieger Institute in Baltimore and co-author of the study on autism and ADD/ADHD.

Autism and ADHD: Beau’s Story

Beau had been a ball of fire all his life. “Ever since he was born, he was a very active, loud, hard-to-tame child,” recalled Baldassari, 39. She didn’t suspect anything was wrong until the family’s first big move, which took place in June 2011, while Beau was in kindergarten. He was upset before the move and didn’t settle down in the months following it, either. “He’d go his whole day angry and defiant, and yelling and upset,” she said. “It just seemed like he was so unhappy. I’d never see smiles out of him.”

Baldassari took Beau to a psychiatrist at the new base, who diagnosed him with an unspecified mood disorder and put him on risperidone (Risperdal), an antispsychotic medication. “It lengthens his short fuse, I was told at the time,” she said. But problems persisted, and in March 2012, doctors finally diagnosed Beau with ADHD.

Beau seemed to do well on ADHD medications, but another move in the summer of 2012 exposed his dark side again. “It was even worse than the first. Just the most outrageously terrible behavior,” Baldassari said. “Three months without a smile — he was just angry all day, explosively angry.”

It all came to a head at a meeting between Beau’s parents and school officials in March 2013. Even though the medication had helped reduce his hyperactivity and impulsiveness, Beau still continued to have meltdowns at school. School officials suggested he might have autism.

It made a lot of sense, Baldassari said. It explained why he grew so upset regarding the moves. “Autistic children really need structure and routine. We took his whole world away when we moved,” she said. “In his mind, he couldn’t make a plan about how to make friends again or make his life normal again. He didn’t have the skills to do that.”

It also explained why Beau couldn’t concentrate in school even with his ADHD under control. Some autistic children are hypersensitive to sensory input — the hard chairs, the flickering fluorescents, the kids chattering. “School is a very unfriendly place to autistic children with sensory disorders,” Baldassari explained. “He was being more adversely affected by sensory input than he ever had been.”

Managing Autism and ADHD

Landa’s study is a landmark because now specialists can investigate the best ways to simultaneously treat ADHD and autism spectrum disorders. The situation is currently a work-in-progress for parents and doctors. Psychiatrists diagnosed Beau with autism in May 2013 and, since then, Baldassari and her husband have been sorting out how to best deal with his dual conditions. It comes down to a combination of medication and therapy — medication for the ADHD and therapy for the autism.
Beau is taking two different types of ADHD medications: a stimulant and non-stimulant, Baldassari said. He also is on an antidepressant. Together, the medications have been effective in controlling his symptoms without any significant side effects.

For his autism, Beau is undergoing a series of different therapies to help him deal with his social deficits. He is in psychotherapy and occupational therapy for managing issues involving sensory overload. Beau also is taking part in applied behavioral analysis, which is “one of the most common treatments you’ll see in autism,” Baldassari said. “It breaks down where the behavior is going wrong. There are good reasons behind it. When he’s having trouble, he’s literally melting down and not in control of his behavior.”

As far as parenting goes, Baldassari has had to completely alter her approach. Typical discipline doesn’t work because “that assumes you have a child who is really able to plan their behavior,” said Baldassari. “None of his behavior turned out to be a choice for him. He was not in control of his behavior.”

Instead, she takes a problem-solving approach. “I hold him accountable for his behavior, but I have to figure out what is causing the problem,” Baldassari said. “I will watch for the early cues that he’s getting angry and is about to become out of control, and I will help him calm down and take him out of the environment.”

In a way, Beau has provided his parents with good practices. His younger brother, Julien, also has been diagnosed with ADHD and autism. “You really have to be an absolute super-parent. You practically have to have a degree in psychology yourself,” Baldassari said. “I studied their particular things so intensely myself that I may be much more current and up to date than these doctors.”