Cindy Lopez: Welcome. My name is Cindy Lopez, the host of this CHC podcast, Voices of Compassion. We hope you find a little courage, feel connected and experience compassion every time you listen.  

Today we’re talking about something that can be really confusing for parents, and that’s what it looks like when a child has both ADHD and autism. A lot of families notice that something’s going on, but it’s not just one thing, maybe their child is constantly in motion or struggles with focus or has big emotional reactions or seems overwhelmed by things other kids handle more easily. Maybe social situations are hard and routines are hard and school is hard, but it’s not in a way that’s really easy to explain. And for many parents, that leads to a lot of second guessing. Is this ADHD? Is it autism? Is it anxiety? Is this just a phase or am I overthinking it?

So, today I’m joined by CHC expert, Dr. Melanie Hsu, to help us better understand what happens when ADHD and autism overlap – how that can show up in everyday life – and what parents need to know if they’re trying to make sense of their child’s behavior and needs.

Dr. Hsu, we’re so glad that you could join us today and share some of your experience and expertise with us. Before we jump into the conversation, could you tell our listeners just a little bit more about you?

Melanie Hsu, PhD: I am a licensed clinical psychologist, and I am the Medi-Cal Director and the Evaluation Program Manager at CHC.

Cindy Lopez: And that doesn’t nearly describe Dr. Hsu and what she does because she wears many hats and does a lot and has very deep expertise. So, I really appreciate, Dr. Hsu, you being here talking on topics that you are deeply familiar with and have expertise in. So ADHD, and autism. So, what is ADHD, what is autism?

Melanie Hsu, PhD: So, ADHD and autism are both neurodevelopmental disorders. These are disorders that affect individuals throughout their lifetime and are present from early childhood and throughout the life. And it affects you differently at different stages. And with ADHD, you’re looking at difficulties with regulating emotions and impulses, behaviors, and with autism, there are difficulties with social communication and understanding the social rules that are inherent in social interactions with others.

Cindy Lopez: So, you said neurodevelopmental. Could you talk a little bit more about what that is exactly?

Melanie Hsu, PhD: So neurodevelopmental basically refers to how this is a disorder that starts in the nervous system, and it affects the way that our nervous system develops. This is something that is present before you’re born. And so sometimes parents, for example, will not have concerns until later, but this is something that an individual starts off life with. It doesn’t develop later in life.

Cindy Lopez: Yeah, it might show up in different ways later in life. And as with anything, there are strengths and challenges. You described some of the challenges. Maybe could you describe perhaps some of the strengths that come with ADHD and / or autism?

Melanie Hsu, PhD: Individuals with ADHD, again, it’s a regulation disorder, so it’s harder to regulate attention. This also means though that individuals with ADHD sometimes can do a very good job of paying a lot of attention to things that are very interesting, and so this kind of hyper-focus can be very helpful when you are going on a deep dive into something, becoming a specialist in something and really can give the individual an edge over others because they can really focus their attention on something that may be harder for others to really be that interested in. Individuals with ADHD also, because they have a tendency to make connections in ways that are different than people without ADHD can also seem very creative, very excitable, and can see things again from a different perspective. And that different perspective is very useful in general, the diversity of experiences and the diversity of perspectives is what makes the world really interesting. And so that can definitely be a strength of ADHD as well.

For autism, it is also similar so that we do see that individuals with autism can have a tendency to hyperfocus on things, which means that they can become experts in certain areas. You can make the argument that anyone with an advanced degree has a tendency to hyperfocus a bit, but you do need that hyper focus to be able to really get into something, to really become knowledgeable or an expert in something as well. Individuals with autism can also do a better job in pattern recognition as well, or in noticing small, subtle differences in things that other individuals may not be paying attention to. There are some jobs, for example, that specifically look for individuals with autism because they are so good at noticing patterns, being able to find small differences and being very exact and detail oriented.

Cindy Lopez: I know a student of mine–it was a long time ago, but looking at a field of those three leaf clovers, within minutes, he could find a four leaf. Like you just said, he could just see those differences and the patterns. It was amazing. And so when we say a child has ADHD and autism, what are we actually talking about?

Melanie Hsu, PhD: So, we’re seeing both of those neurodiversity traits. There is overlap between ADHD and autism, but when you see that an individual has those difficulties with regulating behaviors and attention more so than the social aspects that we would expect to be impacted by autism – when it’s harder for them to regulate their bodies, when it’s harder for them to regulate their behaviors. For example, sometimes the difficulties can be due to the fact that the individual doesn’t understand that now is the time to pay attention to the teacher rather than this book that I’m interested in – whereas an individual with autism, even if they want to pay attention to something or they understand that’s expected of them, it’s still harder to regulate those behaviors.

Cindy Lopez: So, you talked about some of the aspects of ADHD and autism, how they’re alike or how they overlap, and I wonder in addition to overlapping or how they’re alike, can ADHD sometimes mask autism or vice versa? Could autism sometimes mask ADHD?

Melanie Hsu, PhD: Absolutely. So, it’s not uncommon for children when they’re young for their parents to think my child might have ADHD. And so then they seek an assessment, and what they’re usually saying is they’re not paying attention when other people are talking to them. They seem to only be interested in what they’re interested in. So when a child has a lot of symptoms of ADHD, you can look like you have a social difficulty on top of it. It can be hard to tell whether or not the social issues that are presenting are due to difficulties with regulating emotions, behavior, and attention. Sometimes, for example, a family will come to me for an evaluation and I’ll say we need to get the ADHD more under control so that we can see what are the social issues that still exist, if any, after we’ve regulated the behavior and the attention.

So ADHD can absolutely mask autism because a child who’s not paying attention isn’t going to make eye contact, isn’t going to be having deep conversations and may have trouble with social interactions because they’re not paying attention. However, once you control for those things, once you can help with the attention, with the behaviors, if there are still social issues, then you become more concerned about autism. The reverse is also true. So, if you have a child that is more affected by autism and has more difficulty with understanding when to pay attention to things, what is more socially acceptable or expected in the situation, they may look inattentive, they may look impulsive, but it’s more due to the social misunderstandings or misses. And so again, you want to look at “what situations these happen in” and then there’s also specific testing that we can do to differentiate between what might be causing some of these problems.

Cindy Lopez: Yeah. So, if you’re a parent or educator, you might be observing some behaviors that seem like one or the other. My background is education, so as an educator to always ask, “What’s causing that behavior?” So, and I think that’s what you’re saying here too, is like, “what is causing the behavior?” They’re not paying attention, why?

Melanie Hsu, PhD: Exactly.

Cindy Lopez: So, that’s interesting because I think a lot of parents can feel confused because their child might look different in different settings.

Melanie Hsu, PhD: And with different people.

Cindy Lopez: Yeah, they might struggle at home, but they hold it together at school or the other way around. Is that kind of common when both ADHD and autism are in the picture?

Melanie Hsu, PhD: Absolutely. When you have both ADHD and autism, what happens is there’s two factors that are draining your energy. So, not only are you having more difficulty with regulating your own behaviors, but you’re also trying on top of it to make sense of the social interactions. And so it’s a double whammy in some ways. Children can do it, individuals can do it, but it always comes at a cost, and that cost is usually energy. What parents will say, especially when a child has both, is that their child comes home and it’s basically like, ‘restraint collapse,’ right? They’ve been holding it together so tightly and they’ve been, you know, running their engine in the red for the entire day. And so when they get home, they’re just toast.

Cindy Lopez: Yeah. Yeah. And I definitely have heard that from parents where at school it’s like, teachers reporting, “He’s doing great, has lots of friends,” but then parents say, well, that’s great, but when he gets home it’s total meltdown. Sometimes the worst time of day is that transition from school to home and as you said, so much energy. They’ve been applying so much energy to just kind of holding it together. So, do you have any tips for parents to help mitigate that and help the child transition?

Melanie Hsu, PhD: Absolutely. So, this is why we recommend working with your child’s educational team to see what can we do during the day to lessen the amount of energy needed to get through the day? Because we’ve just been talking about energy and we haven’t even talked about learning, right? And so the amount of energy it takes to learn a new thing on top of, you know, trying to navigate the social situation and trying to manage your behaviors and pay attention and be good, all of those things just take a lot of energy. So what can we do to help the child not have to be running into the red every day and because some of those things, especially for example, for our quieter or shyer children, for our girls, or those assigned female at birth, these children who are taught to be good and to really not make trouble are the ones that we often see running out of energy. So, what can we do to make sure that we’re not waiting for them to be in trouble and running out of energy before they get support. Another thing to do is to think about that transition time. So, you know, a lot of times again families when they’re picking up their child from school or when they’re just coming home off of the bus, immediately like, “How was your day? What did you do?” And they want to talk, right? And it’s great. It makes sense. You want to connect with your child, you’re interested in what’s going on, but what can be very helpful is to give the child transition time to decompress. It’s like us after a long day of work, right? Like sometimes it’s like, “Please don’t talk to me for 30 minutes until I’ve had a chance…” to listen, you know, and this is why commutes sometimes are nice. We get to listen to something on the radio or listen to our favorite music and kind of process what happened to us during the day before we’re ready to talk about it with someone else. I recommend that families think about how do we create like a good decompression time for their child? What’s helpful in those circumstances? So again, for some children it’s putting on noise canceling headphones and listening to some soothing music, getting a good snack. Our OTs [occupational therapists] talk a lot about some of the sensory things that you can do to get your body to unwind. So either doing some heavy work or applesauce through a straw or eating something crunchy and so there’s a lot of sensory strategies that can help as well. Turning the lights down and minimizing, again, questions until the child has had some time to decompress. I would also recommend talking with the child. Just being like, when I’ve had a hard day, these are the things that helped me get ready for what I need to do at home. What do you think would help for you? And giving the child the language to say, “I need a break. I need this.” And for them to help understand themselves as well, so that they can advocate for those things.

Cindy Lopez: And I think for so many kids too, they go from school immediately to another thing, whether it’s like a team sport or piano practice or even tutoring.

Melanie Hsu, PhD: Yeah. Tutoring.

Cindy Lopez: All of those things. From what I hear you saying, those would just be prolonging like having to keep it together. And the energy that it takes to do that. So, do you have any advice for parents around that – like those extracurricular things that tend to happen right after school?

Melanie Hsu, PhD: Yeah, there’s usually still the commute there. And so taking that time to be mindful about refilling the gas tank. And so again, getting some noise canceling headphones, getting a nice crunchy snack, like having a weighted blanket for them, having a fidget. Any of those types of things to reset the nervous system, and again, not asking a ton of questions, and then letting the child have at least 15 to 30 minutes to decompress and to get ready for the next thing. This all depends on the child as well. Some children don’t need as much time. Some children need more time. Some children, for example, who go straight to aftercare, you can also maybe advocate with the aftercare to say, can they have 30 minutes again with their headphones before they have to join any group activities. And so just building it in mindfully so that there is some sort of a break.

Cindy Lopez: I can even remember when I was growing up, no ADHD or autism, but I needed that time. So, it’s really about being curious and listening to your child about what they need. And as you said, Dr. Hsu, like they might not have the language to say what they need, but you can be curious with them.

What are times when you feel like you don’t have to do what somebody else wants you to do or I’m not sure what all the questions are, but it’s kind of just thinking about those things with your child and observing, like nature, being outdoors, that seems to provide some regulation for them. So observing those things and being curious I hear that over and over again from all of our experts at CHC: be curious and listen. So I think it applies to this too.

Melanie Hsu, PhD: I think it’s a good family exercise as well because children observe a lot, right? It’s really good for parents who themselves may also be neurodivergent to reflect with the child to say, “This is what’s happening for me. This is what I’ve noticed helps. I’m wondering if this would be helpful for you, too.” And for them to be able to hear their parents’ stories of struggle, but then of triumph, I think is really, really powerful and a really great way to bond as a family and it brings context to it, and it’s just another way to connect with your child as well over some possible shared insights or shared struggles and that can be very powerful for a family.

Cindy Lopez: That’s really important too, that connection with your child. 

I think also, some parents might be seeing these things, like their child is coming home from school and having these meltdowns or they’re noticing in social situations that there’s some inappropriate responses or no responses, or there’s this hyperfocus on some things, but inability in other things. So, if they’re seeing those kinds of things, I wonder at what point would you say to a parent or would a parent think to themselves, maybe I need some input on this. Is it an evaluation, and what is it that would key them into thinking they might need some more help?

Melanie Hsu, PhD: I would say as parents you have great instincts about your child, and one of the great things is that CHC does offer free 30 minute consults with a licensed clinician to talk about any concerns to determine whether or not it would make sense to do an evaluation, to just do a consult, either with a psychologist, a neuropsychologist, an occupational therapist, a speech and language pathologist or to consider therapy. And so that could be a really good place to start to talk through what parent concerns are and then to get a professional opinion on what might be good next steps.

As an evaluator, I am very biased towards doing a full assessment because that is how I understand a child. It’s a really good way to break things apart, to really look very carefully at lots of different areas. But we do understand that it’s a stressful and long process for children. It’s also quite expensive and it can take a long time. Starting off with a consultation is always helpful. And then sometimes the specialist may recommend, I think therapy might be helpful, just to explore some of these things a little bit more. There are also questionnaires that we can give to families and to teachers, but in general, if a parent is concerned about these things, taking some observations, talking with teachers, talking with the child, and then thinking through it either with a professional or together as a family can be really helpful in deciding next steps.

Mike Navarrete: CHC’s Voices of Compassion podcast is made possible by the generosity of people like you. To learn more about supporting CHC, go to chconline.org/donate. Also make sure to follow us on social media for more inspiring and educational content from CHC.

Cindy Lopez: So, from my impression, you can tell me if I’m right or wrong, but the autism tends to be diagnosed at a younger age than ADHD. And so you might have a child with an autism diagnosis and you’re still seeing some things. It’s like, this isn’t quite adding up. I’m imagining that getting that dual diagnosis, whether it’s autism and ADHD or any kind of dual diagnosis can be shocking or even overwhelming to parents. So, I just wonder how important that evaluation is for parents and for the child?

Melanie Hsu, PhD: Absolutely. So, we want to make a diagnosis of autism as soon as possible, honestly. So we like to see children as early as possible if there’s a suspicion of autism. Usually at younger ages there are more concerns. So, it’s autism, speech, disruptive behaviors, and what the research shows over and over again is that early intervention is key. I love to see children before the age of two, if possible. However, you would not be making a diagnosis of ADHD at the age of two. What’s really important for me as an early childhood specialist and an assessor is to see children with developmental concerns, including autism as soon as possible, so that they can benefit from really intense, rich early intervention services before the age of three. And so at that point, if I’m seeing a child, for example, an 18 month old child, a 24 month old child, I’m going to be concentrating on development and on possible autism and the question of ADHD is going to be looked at later after we’ve addressed the developmental issues, but parents do come in with those concerns about, well, but he’s also really hyperactive. He’s also really impulsive, but early intervention addresses those issues even without a formal diagnosis of ADHD. So we always recommend if you have a concern about autism don’t wait. Seek help early, advocate for your child, get in, and get seen.

A diagnosis of ADHD usually comes significantly later, more like 5, 6, 7. We can’t really do more specific neuropsychological testing until the child is a little bit older, around seven or so. But you can make a diagnosis of ADHD just based on behavioral observations. You don’t need neuropsych testing, but it can be helpful again, especially if the presentation isn’t as clear to be able to do testing, which isn’t available as much until the child is older.

Cindy Lopez: Right. And with autism, you’re seeing some things really early in young children. With ADHD, as you noted, a diagnosis comes later and there’s probably certain pressure points that you’re seeing over and over again. So things like transitions, impulsivity, emotional regulation, and when I think about those things, I often think about executive functioning. Can you talk a little bit about that in relation to ADHD?

Melanie Hsu, PhD: Absolutely. So executive functioning is what we are looking at in a lot of ways with ADHD. So, executive functions are your ability to plan, to initiate, to follow through with tasks, sequencing – a lot of those tasks are what we call higher order. So these are things that you develop as you get older. So these are not things that we would expect a 2-year-old to be able to do, which is why we really can’t look specifically at some of these things as much until they get a little bit older, but yes, so all of those executive functions are things that we’re going to be looking at as they develop, as they start going through school. These are things that help you be successful when there are demands placed on you to be able to be independent, to be able to plan, to be able to understand consequences of your behavior, and then also understand and plan how to get to a destination. And again, you don’t expect this of younger children, which is why we don’t look at those things in younger children.

Cindy Lopez: Yeah, and we’ve talked about this, the child holding it together during the school day and coming home and just having the meltdown and and sometimes you know when it’s going to happen, and so you can be prepared for it and sometimes you don’t. So, for those parents and those who are listening in today to this episode, for those who are in those hard moments every day, the meltdowns, shut downs, explosive reactions, that kind of pervasive dysregulation, what helps and maybe even what doesn’t really help?

Melanie Hsu, PhD: Prevention helps. I like to think of it like a gas tank. So, you need fuel to run the engine. And so think about all the things throughout the day that drain the gas tank. Again, if your engine isn’t as efficient, so if we’re talking about a Chevy Suburban  versus a Toyota Prius, right, if you have ADHD, if you have autism, your engine isn’t as efficient. You need more gas to get through the day compared to your classmates. And so that drains your energy source. It drains your resources. This is why we were talking about taking breaks, doing things that refill the gas tank. So, when a child is having a meltdown, when they are having a really hard time, it’s because their gas tank is depleted. So, what can we do throughout the day to make sure that either we’re sprucing up their engine to make them more efficient, or we’re preventing things from draining them as much and we’re giving them opportunities to refuel because a child will also, as they grow, start to see that other children don’t need to take as much effort and that leads to, again, questions about themselves, maybe unkind thoughts about themselves, and that also drains their energy as well. And so helping them understand themself, and also having accommodations and supports to help them become more efficient and also to make sure that we have those opportunities for refueling can be really helpful in reducing the amount of dysregulation that we see and hopefully circumventing some of those outbursts.

Cindy Lopez: And this comes from my time in the classroom, but breaking tasks down, so they’re not overwhelmed by, okay, if it were happening in the classroom, can you write a paragraph on, we’re studying frogs, write a paragraph on the lifecycle of a frog or whatever. That’s really hard. Most students don’t know how to approach that, but especially kids with autism and ADHD. And also, you mentioned OT, occupational therapy, and there’s some sensory strategies, regulating the body before the emotions. What does all that look like in practice? What would you be helping your children do or teaching them to do?

Melanie Hsu, PhD: Absolutely. And I definitely want to go back to what you just said about breaking tasks down, because that’s exactly it. So, there’s a social component in demands, right? So when we say do this, this usually has 30 embedded steps, and some of those are socially mediated, right? And so it’s very difficult with an individual, with executive functioning deficits, like with ADHD and with social deficits, like with autism, to break down a task in a way that’s logical and efficient. Exactly what you said, breaking it down. What I often see in testing in individuals with autism and ADHD separately and together is that they don’t take the most efficient route. They kind of attack it by will and energy instead. So, instead of looking at a list of words and organizing it or grouping it, they’re just like, I’m just going to try really hard and that fails at a certain point, you kind of can’t just attack things with will alone. And so teaching them shortcuts, teaching them mnemonics, those things don’t often come naturally to these individuals, but they can do it once they’ve been taught. So, exactly as you said, breaking that task down to say, so when I say, “Clean your room,” what I mean is, this. This is what the goal is and these are the steps to the goal, and this is how we generated those steps. That can be really helpful to give them the context, to give them a goal, and then to break it down so that they learn the script for it, and then they can hopefully apply it to other situations. So, then you can call it out to say, so do you remember we broke it down this way? So, this is also for: clean up your backpack. This is also for: et cetera, et cetera. And so giving them those scripts, those mnemonics can be very helpful in lots of different circumstances because we often take for granted if we use, say, “Clean your room.” I know what that means. That means the floor needs to be cleaned. That means the clothes need to be put away. It means the bed needs to be made. But again, that’s five different tasks embedded within one sentence. So, definitely that breakdown.

Cindy Lopez: One of the things I know that when I was teaching, like taking photos, everyone, clean out your desks and to have a photo of what, like a clean and organized desk looked like helpful or even to say, if they had a locker, organize your locker, to have a photo of what that looks like. So, if you’re doing that at home, take a photo of the clean room or even some aspect of it, show the clothes all put away in the drawers or whatever. I don’t know what that would look like, but I think that helping them picture what it looks like is important because like you just said, they just don’t, and they’re visual. And typically, you know, visual individuals really learn from that.

Melanie Hsu, PhD: And having it broken down, like you said, into each individual tasks. So first this, then this. And each thing in a visual format can be really helpful. Everybody nowadays has a supercomputer, right? Everyone has a phone. Even having, let’s say a parent do it first and recording it and being like, and then I’m doing this step, and then this step, and then this step, and then they can refer to it as a reference later.

Cindy Lopez: Yeah. And another thing you have talked about a little bit is, sensory breaks or sensory exercises and could you talk about maybe what that could look like both at school and at home?

Melanie Hsu, PhD: So some common accommodations for children who have a tendency to get overwhelmed are things like noise canceling headphones, preferential seating, being able to take tests in separate locations. So those kinds of things where they don’t need to regulate their hearing as much. So again, we can take for granted that after a while in a noisy situation, we can start to tune it out. Individuals who are neurodivergent can’t turn it off. It’s like an alarm that keeps tripping which means that you have to attend to the alarm and then get back to what you’re doing, attend to the alarm and get back to your doing – that takes a lot of energy and so what we see is things like noise canceling headphones. There’s also discreet earplugs that can be used. So Vybz, for example, is a good one. Loop makes some really good noise reducing headphones as well that are nice and quiet and discreet because sometimes children don’t like to stand out. And with Vybes you can wear them all day and it just reduces the noise without causing any problems with still being able to hear. Other things would be to not have to attend assemblies because again, a lot of kids in a classroom can be a lot or adaptive PE would be another one. And then, some other sensory accommodations we see is access to fidgets, for example, for them to get that stimulation that they need, and then sensory breaks. So again, an opportunity to go take a walk outside or to bring the books to the library so that they get to carry something heavy while getting away from the classroom, while still doing something that’s helpful to the school and doesn’t make them stand out.

Cindy Lopez: Yeah, even things like adjustable desks where a student can stand at a desk or even seating, like they could sit on a ball that moves – those kinds of things really kind of help. It doesn’t perhaps look like it because they’re moving all the time. But that helps ground them. So, it’s something to remember because as a parent you might think that does not seem like it would be that helpful. That’s just going to wind them up more. When in effect, it really has the opposite outcome for them. So, Dr. Hsu, as we wrap it up today, thinking about parents who might be listening, who might be feeling overwhelmed, exhausted or even worried about what this ADHD, autism diagnosis means for their child long-term, what would you most want them to hear?

Melanie Hsu, PhD: You’re not alone. There’s a lot of people who understand this – both together. It’s a pretty common comorbidity, so we do see it a lot. This also means there’s a lot of families that are going through it, just like you are and also a lot of families that have seen a lot of success. So there’s a lot of really great parent support groups out there. There’s a lot of professionals who have great suggestions for how to support your family as well. It can feel very overwhelming. And so we recommend, again, reaching out for support and having patience with the systems that you have to navigate. But knowing that there are a lot of supports, things that we can do to help support both the individual and the family that’s affected.

Cindy Lopez: We have experts just like Dr. Hsu at CHC, so please reach out to us. You can find our website at chconline.org. You can email our care team to find out more or set up one of those free parent consultations that Dr. Hsu referenced. You can reach out to the care team via email at [email protected] or you can call 650-688-3625. So, thank you Dr. Hsu so much for joining us today, for your wealth of experience and insight and sharing that with us and to our listeners, we thank you for joining us today.

Melanie Hsu, PhD: Thank you for having me.

Cindy Lopez: Visit us online at podcasts.chconline.org. Make sure to subscribe to Voices of Compassion so you never miss an episode, and we’d love it if you’d leave us a rating and review. Have a question? Send us an email or a voice memo at [email protected]. We’re here for you when you need us.