How Does School Work When a Child Has Both Autism and ADHD?

A parent goes to RAM (the Guidance and Research Center) and the file holds two diagnoses at once. In the committee room the question that is asked most often is: which one is more dominant?

The question is well meant but wrongly framed. The two diagnoses do not stand in for each other, and neither is a milder version of the other. School planning has to take both into account at once.

This article is about how to make that plan.

The two diagnoses can exist together

For many years it was not possible to diagnose autism and ADHD together. With DSM-5 that restriction was lifted, and it was accepted that the two conditions can exist in the same person.

In the literature this co-occurrence is called AuDHD. On the site I covered the general framework in the AuDHD article and the shared area of difficulty in the article on executive functions.

On the school side, what matters about this co-occurrence is that the two conditions work in the same direction at some points and collide at others.

Where they work in the same direction

Executive functions. In both conditions, starting, sequencing, switching and planning are difficult. This is the shared area most visible in the classroom.

Sensory load. Sound, light and crowds use up capacity in both conditions. I wrote about this in detail in the article on sensory differences.

Transitions. Moving from lesson to break and from break to lesson is hard in both conditions, and the moments of the day with the most trouble are usually these transitions.

An adjustment made in these three areas helps both at once. Starting the planning here is the most efficient way.

Where they collide

This is where the real difficulty begins, and parents often live through this conflict without being able to name it.

Routine. The autism side wants predictability. A program that does not change, an order that stays the same, a teacher who proceeds in the same sequence all produce a sense of safety. The ADHD side experiences low arousal in monotony, and repeating the same thing makes attention slip away.

Change. On the autism side a sudden change causes distress. On the ADHD side novelty gathers attention.

Social setting. The autism side wants to reduce the social load. The ADHD side can struggle when working alone, because the level of arousal drops.

A plan prepared without seeing this conflict eases one side while upsetting the other.

The approach that resolves the conflict

The solution that works in practice is simple and can be summed up in one sentence: keep the frame fixed, change the content.

The concrete forms of this are as follows.

The program stays fixed, the method changes. The math lesson is at the same time every day. Within that lesson the work is sometimes written, sometimes done at the board, sometimes done standing. Predictability is kept and monotony is broken.

Changes are announced in advance. If the program is going to change, the child learns about it in the morning. A change that has been announced produces far less distress on the autism side.

Choice is kept limited. "Do what you like" feels bad to both. "Choose one of these two ways" feels good to both.

Movement is built into the routine. Getting up to wipe the board or hand out papers meets the ADHD side's need without breaking the routine. I wrote with the evidence about how movement supports performance in some tasks in the article on moving while sitting.

What should be written in the RAM file

This is where parents make mistakes most often. When only one diagnosis goes into the file, the plan that is prepared does not see the needs of the other condition.

The information that should go into the file is as follows:

• Doctors' reports showing both diagnoses.
• Concrete observations of how the child behaves in transitions.
• In which settings sensory difficulty appears.
• What happens when the routine is disrupted.
• What happens in a monotonous lesson.

The last two items are the most often skipped, and they are exactly the information that shows the conflict. When the sentences "the child cries when the program changes" and "the child can't stay in their seat when the same type of exercise goes on for ten minutes" are written side by side, the committee sees a picture that cannot be explained by a single diagnosis.

I described the whole RAM process in the article on the RAM report.

How IEP goals should be written

When an Individualized Education Program (IEP, or BEP in Turkish) is prepared, the goals need to be measurable. In AuDHD there is one more condition: it has to be clear which condition the goal serves.

To give an example. The goal "will increase participation in the lesson" cannot be measured, and it is unclear which need it meets. By contrast the goal "will complete the transition within five minutes when given a written schedule at the start of the lesson" is both measurable and clear about which difficulty it corresponds to.

I wrote in detail about how the IEP is prepared and how the parent takes part in the process in the IEP article.

When talking to the teacher

Explaining both diagnoses to the teacher often turns the conversation into a debate about diagnosis. A more productive way is to talk from behavior.

These three sentences work:

"When it is said ahead of time that the program is going to change, the transition becomes much easier."

"When the same type of exercise goes on too long, their attention drifts; if the method changes in between, they recover."

"In a noisy setting their capacity runs out quickly."

All three are concrete, all three can be applied, and none of them opens a debate about diagnosis. I described how to prepare for the meeting in the article on meeting the teacher.

What is left to me

The most tiring thing about the two conditions together is having to translate all the time. The school hears one diagnosis and acts on it; the needs of the other diagnosis are left hanging.

The parent's job is to name the conflict. The sentence "they want routine but fall apart in monotony," said in the committee room or in a meeting with the teacher, changes the planning. Because the person who hears that sentence understands that a single solution will not be enough.

The information here is a general framework. Decisions about diagnosis and treatment are made with your doctor, and decisions about education with RAM and your school.