Asperger's versus AD/HD

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I recently went to a new psychologist and psychiatrist with my daughter who is 8.5 years old and diagnosed with AS and Developmental Dyspraxia. Her behaviors have improved (mostly) but her anxiety is at an all time high as far as her engaging in inappropriate and debilitating coping mechanisms/manifestations. I wanted to see about safe, simple medications to help her with her self-isolation yet extreme neediness lately.

The psychiatrist wanted to prescribe an AD/HD med. She brought up some compelling behavior “traits” associated with AD/HD that my daughter has. When I went to research the medication, I also pulled out The Complete Guide to Asperger’s by Tony Atwood to see what it says about anxiety. When I read through the Attwood book, I can completely understand the anxiety in the context of Asperger’s. However, while my daughter is diagnosed with Asperger’s clearly by the DSM criteria (and by a reputable Univ Medical Center neropsych), she lacks fulfilling the criteria related to sharing enjoyment and interests and lacking social and emotional reciprocity. With people she is comfortable with and when she is not anxious she can carry on appropriate and functional conversations, with no apparent issues with speech, prosody, or tone. She might have flat affect at times and speak monotone but sometimes she speaks elatedly and passionately.

I then pulled out a book called Understanding Girls with AD/HD by Nadeau, Littman, & Quinn. In a chapter about girls with AD/HD this is how they describe them:
Tactile sensitivity
Sound sensitivity
Obsessional Behaviors
Emotional Neediness
Oral Fidgeting
Sleep Disturbance
Missing Social Cues
Executive Functioning issues with:
Initiate organize and prioritize tasks
Focus and sustain attention
Sustain alertness, effort and processing speed
Manage Emotion and Frustration
Access Memory Reliably
Monitor and control speech and behaviors
Writing Issues
Reading Issues

The above is basically a perfect description of my daughter.

So, my question is what is the difference between AS and AD/HD? What is the distinguishing factor between the two? Does it matter to distinguish between the two?
My daughter did a trial of Ritalin a few years ago and it made her skin crawl. It was the opposite of how it should have affected her-she became fidgety and agitated.

I am interested in any thoughts on this. Could my daughter be mis-diagnosed?

I was diagnosed with ADHD before I was diagnosed with AS. My doctor still prescribes traditional ADHD meds to deal with my focus issues.

My son was diagnosed with ADHD 3 years before Aspergers. Now he has both diagnoses and still takes ADHD meds that really help. I read a great book about this subject, I highly recommend it. It's called The ADHD-Autism Connection: A step toward more accurate diagnoses and effective treatments By Diane Kennedy. It helped me make sense of all of this. READ IT!! !

I don't know if the specific diagnosis really matters, right? At issue right now is whether or not to treat your daughter with ADHD meds, which can be very helpful to some kids, and don't work at all for others. You may also want to see if ADHD techniques work or not.

Ritalin is obviously out. You might see if other stimulants work better; the one good thing I've heard about this class of drugs is that when they aren't right, it takes very little time for your body to rid itself of them, unlike many other psychiatric medications, so a trial run isn't as serious as it otherwise might be. (Obviously, I am not a physician, so please verify this with a professional.)

My DS6 has AS and ADHD. With him, the ADHD-type executive function issues seem to predominate. His repetitive behaviors are very minor, and he barely qualifies as having fixated or unusual interests. A year ago he only qualified for the AS dx, but now that he is having more trouble in kindergarten than he did in preschool (most likely due to a bigger class and being required to actually do school work), he meets the criteria for ADHD as well. He started ADHD meds recently, and so far it has helped.

The dev-psychologist who diagnosed AS said there is a triad of impairments they look for to make the AS diagnosis: motor skill issues, communication issues, and social issues.

I suspect this may qualify her under the communication portion. I've never seen the symptoms of flat affect and speaking in a monotone in an ADHD description.

Does her anxiety result in a lot of rigidity in play -- needing to control the game or the way a story plays out?

As momsparky said, more important than the label is figuring out whether and which meds are helpful to your daughter. I think the docs like to try ADHD meds first because they act so quickly and can be discontinued so quickly. The anxiety meds take longer to build up and clear out.

Try generic Dexedrine (the "good" part of Adderall). IMHO, on its own, it's much "softer" and "nicer" than methylphenidate (the active ingredient in Ritalin and Concerta).

Or, consider combining a small amount of a TCA like Anafranil/Clomipramine with Concerta. TCAs + methylphenidate have long been known to be a good combination. I personally took Desipramine + Concerta for more than 10 years, and still hate my doctor for taking the Desipramine away from me (he refused to prescribe it anymore after the mfr. said it might be cardiotoxic in small children. Grrrrrr.) Nothing has ever been as good for me as Concerta + Desipramine was. Concerta alone wears off too fast, and leaves me feeling "raw", and the only drug I've found that comes remotely close to being comparable to Desipramine is Reboxetine (which officially doesn't exist in the US, and is hard to get from overseas).

You'll notice I said "Concerta", and not "Ritalin". Concerta is absolutely and unambiguously better than all other forms of methylphenidate -- hands down, no contest. When you're talking about a drug with a 2.5-hour half life (like methylphenidate), the delivery system is almost more important than the drug itself. Concerta has it nailed down almost perfectly.

The truth is, it doesn't really matter all that much whether she has ADD, AS, or both. Stim meds work for AS, too. The only catch with AS is that there's a very fine line between focus and perseveration, and if you're relying on stim meds alone, it seems like the minimum dose for focus is at least slightly past the minimum required to trigger perseveration. This is why TCAs are so helpful when combined with methylphenidate for AS. Back when I took Desipramine + Concerta, I had *nowhere* near the problem with perseveration I do now. I was able to easily get my focus up to where it had to be, without always getting locked into 'perseveration' mode on almost a daily basis.

My post isn't about the differences between ADHD and AS, it's about the meds.

My oldest was dx'd with ADHD when he was young and we gave him Ritalin. It worked but it had too many bad side effects so it was discontinued. There wasn't much else back then that wouldn't have given him the same side effects, so he had to learn to do the best he could without the meds.

My youngest son was dx'd with ADHD a few years ago. We tried several of the meds with him. Adderall XR made him too anxious and he was afraid because of the increased heart rate, etc. Concerta did nothing. Strattera made him very negative and mean. We tried Vyvanse as a last resort and it works great.

It's a stimulant, but it's a prodrug. It lasts about 15 hours, and has a slow onset. An hour to feel the effects of one of the meds, and three hours to feel the full effects. I give it to him at 5am when I get up and let him go back to sleep for an hour. WHen he gets up then, it's easier for him to get ready in the mornings and it kicks in right around the time school starts. He has no loss of appetite, no increased heart rate, and it doesn't cause insomnia. He gets hungry at his usual times and has even napped after school before while on it. I couldn't give it a better reccomendation. I believe it's meant for children 6 and up. 20mg is the smallest dose, and he's on that. They do titrate it up over time, but I told them that as long as this dose is working, I don't want to increase it. The dr was fine with that, and so far he's still doing good on 20mg.

She wanted to prescribe strattera.

To be honest, when she prescribed it and eluded to the fact that perhaps grace has ad/hd instead of as really upset me. I've done some thinking since then about why it upset me and I think it's because I've just gotten to the point where I feel I understand my daughter. Coming to terms with the diagnosis meant a complete change in how I viewed her behaviors. I felt that an ad/hd diagnosis meant that her behaviors were willful and that she is cognitively able to not meltdown. Maybe I don't understand ad/hd, my only experience is that my cousin was diagnosed with it and he has none of the same issues that my daughter has-his were mainly concentration and hyperactivity. He was actively social, played sports, was in boy scouts, etc. he displays none of the anxiety and sensory issues my daughter struggles with.

I refused the strattera and ended up accepting vistaril. It is only to help with the anxiety. She has constant fears and rituals as well as perseveration on what bad things may happen. I theorized that many of her behaviors were anxiety induced. It is only as needed when she is having an excessively anxious time.

But if the behaviors are related to ad/hd I need to research what that means and perhaps open my mind to ad/hd meds.

My daughter states that she "needs to keep the pictures in her head to keep the bad things from happening". Whenever anything remotely unpredictable happens she has extremely emotional reactions and becomes very upset. To compensate for this, she has begun refusing to go anywhere or do anything.

My son dx with ADHD, OCD & ASD takes strattera & prozac! he had been taking strattera for ADHD for some time and he found it really helpful as in concentration, not getting distracted, and also not moving to one activity to the other. The prozac helps with the repetitive behaviours we still have huge difficulties with school but nothing to compare if my son is not taking these medication, its actually woeful.

I hate giving him medication still not reside to it but feel I have to its so hard!

I think there is a lot of overlap between many of these labels, and doctors are doing the best they can. I also think that doctors tend to get comfortable with a certain diagnosis and view many kids through that lens, even considering the wide range of diagnoses out there.

I think you are most likely right that your daughter's meltdowns aren't wilful - I would trust a mother's judgement over a doctor's on that. This is not to say that it isn't worth looking at meds. When we first brought my son in for diagnosis, the psych recommended some ADHD meds even though he didn't fit the criteria, because sometimes they help other kids, too, particularly with anxiety.

We were really on the fence with medication and finally opted not to use them, which I think was the right decision for us - DS was able to pull it together when both we and the school had a better understanding of how best to help him. We may revisit this decision in the future.

Hmmm. If perseveration and rituals are an issue, I'd lean strongly towards low-dose Anafranil with Concerta. Anafranil is known to be very good for controlling OCD and reducing perseveration. I've been doing a lot of research over this exact topic for the past few days, and from what I've read, the general consensus so far is that newer SNRIs that work well for depression just don't pack quite the same punch as older TCAs when it comes to treating the symptoms of ASD and ADD. Nobody really knows *why* yet, but it's obvious that there's a lot going on behind the scenes with TCAs that has never been fully explored up to now... but CAN be, now that it's possible to clone human neurons & directly experiment upon them in ways that would have been unthinkably unethical (or impossible) 10-20 years ago.

I'm not sure about combining a TCA with amphetamines. I'm trying Adderall with Reboxetine (a norepinephrine-specific reuptake inhibitor) right now. I remember what it was like to add Reboxetine to Concerta - even on day one, the effect was immediate and positive. With Adderall, the addition of Reboxetine is more ambiguous. It does seem to have reduced the severity of both the bruxism and hyperventilation I was experiencing daily with Adderall (but didn't experience with Dexedrine), but it doesn't seem to have helped much with my perseveration (I've burned the whole day so far on WP instead of working on a home improvement project I was supposed to be doing today).

For what it's worth, I tried Vyvanse a few months ago, and didn't like it AT ALL. It gave me HORRIBLE problems with tolerance that I've never had with either Dexedrine or Adderall. With Vyvanse, I was crashing & burning early in the evening, and IR dexedrine just bumped the crash a few hours closer to my normal bedtime. However, every single night, I was going to bed in a dizzy "crashed" state, and every morning, after supposedly sleeping for 8-10 hours, I was waking up feeling like total death. In contrast, with both Adderall & Dexedrine, I fall asleep fairly normally around 12:30 or so, and wake up at 7 for work feeling groggy, but no worse than I'd classify as "normal".

Here's an example of the difference: when the alarm goes off after taking dex or Adderall the previous day, I go through the usual morning struggle to get up, but I can do it. When I was taking Vyvanse, I literally fell back asleep sitting on the edge of the bed.

There are a few theories, but the most sensible one I've seen is that Vyvanse has a very "long metabolization tail". 90-95% of it gets metabolized immediately & acts like IR dexedrine with 2-hour startup delay, but that last 5-10% sticks around and keeps kicking in for several hours afterward. It's not enough to have any therapeutic benefit, or even cause insomnia, but it IS enough to keep the neurons from resetting themselves overnight and losing the previous day's tolerance. Over at addforums.com, some users have reported that a very small (half of a 25mg tablet) dose of Seroquel before bed can undo the lingering tolerance by basically neutralizing effect of the amphetamine residue and pulling the dopamine that was blocked back into the neurons. I was about to try it, but then I thankfully ran out of Vyvanse, replaced it with Adderall, and the problem solved itself.

IMHO, there's really nothing good to say about Vyvanse or recommend it over generic IR dexedrine. It doesn't last any longer (once you factor in the 2-hour startup delay), it arguably has more side effects (the lingering tolerance I described), and it costs about 5 times as much as generic IR dexedrine. The worst thing for me was the 2-hour delay, because I usually remember to take a dose when I feel the previous dose wearing off. With Vyvanse, if you wait until you feel the previous dose wearing off, it's too late. By the time the next dose kicks in, you'll have firmly splattered face-first into the ground and crashed beyond salvation for the day.

My knowledge of ADHD comes from my experience with little boys who can't sit still, can't control their impulses, don't mind, don't remember what you tell them, and continually get in trouble for the same type of behavior, so admittedly my knowledge on the subject might be limited. I've never read the book concerning girls, and I don't know why hypersensitivity would be a trait of ADHD, however I can point out some differences between those with AS and those who might have ADHD according to the traits you listed.

A person with ADHD might have executive dysfunction issues because they have difficulty paying attention and remembers.

A person with AS might have executive dysfunction issues because they parse information differently and process information differently in their head.

A person with ADHD might miss social cues because they are not paying attention due to be distracted by something else..

A person with AS might miss social cues because they are simple difficult for the person to spot, despite the person paying attention, or they might not miss the social cues but might have trouble interpreting them.

So I believe the reasons behind the actions would be different.

^^^ You forgot category III --ASD plus ADD

Somebody with both will be oblivious to social cues because they're distracted, but wouldn't be likely to notice or interpret them EVEN IF they were paying attention.

Somebody with both might express executive dysfunction by focusing on something appropriate, then get derailed by a delay (say, going to save a file that takes an eternity because the network is so slow) or some interruption (phone call, text message, program crash, whatever), then slide into his preferred perseverative interest and be unable to disengage and return to the original task for hours. Or get distracted by something, and go off on a 6-hour knowledge adventure tangential to the interruption. Wikipedia's homepage is exceptionally dangerous to me, as are news portal sites. When Microsoft released IE5 with MSN news as the default homepage, they destroyed months of my free time because I got sidetracked & distracted every time I launched IE.

Was the psychiatrist questioning the AS diagnosis, or just justifying why she wanted to try ADHD meds? If the former, you have to think about how much time the psychiatrist has spent observing and testing your daughter versus how much time the neuropsych spent. Also look into how much ASD experience the psychiatrist has. I have heard that sometimes medications affect ASD folks differenently than NT, so I looked for a developmental clinic that has a lot of ASD experience.

My sister-in-law recently completed her training to be a child psychiatrist. Before we told her and my brother about DS's dx, I probed a little bit to find out how she would go about diagnosing AS and how much training on AS she received. It didn't sound like much -- she said she just talked to them for awhile and didn't even mention the ADOS.

The psychiatrist spent very little time with my daughter and it was the psychologist who seemed to infer that my daughter *might* be mis-diagnosed. We spent 1 hr on 2 separate occasions with her. After the first visit she concurred with the as diagnosis. After the 2nd visit, which quite frankly was awful, she decided that my daughter's behaviors "seemed more willful" than what she believes occurs in someone with as. She stated a person with as does not have the theory of mind to be manipulative, which my daughter seemed to be. However, in that visit the psychologist pushed my daughter behaviorally past what we have ever encountered with a therapist before. She refused to allow my daughter to play with her toys because she didn't ask and then proceeded to make her stand on an 11 x 8 piece of paper because she wouldn't listen to the psychologist and kept putting her feet on the couch. It was a very strange experience for me and I left feeling that the psychologist really didn't get an accurate picture of my daughter's behavior. However, she called me in a few days later and that is when she inferred my daughter did not have as.

Because of how the psychologist acted and some black and white things she said about as, I don't believe her to be credible. However, the entire experience got me thinking, after I cooled down, about ad/hd and uncovered the list above which seems compelling.

By the way, we spent 7 cumulative hours with the univ getting the as diagnosis. A full ados was done as well as extensive cognitive testing, which the psychologist would not review because she stated she likes to make her own conclusions.

I also want to add that my daughter can have amazing concentration on something she likes. She can put together a 300 piece puzzle which makes me question whether ad/hd is relevant. However, she stated ad/hd kids can also have concentration when they *want* to.

Wow. Perhaps this psychologist has some control issues?

I am sure this is not how you deal with your daughter's behavior at home. In fact, you are likely to be more supportive towards your daughter and a bit more creative in going about getting her to do things you want her to do (like not putting her feet on the couch). I don't think this psychologist COULD get an accurate picture of your daughter's behavior, because she was subjecting her to a completely unfamiliar (not to mention, inappropriate [if you ask me]) behavioral approach. I used to be a behavioral consultant. If I had ever presented a behavior plan that included that consequence, I wouldn't have been employed for very long...

My son an ADHD diagnosis, which we are constantly challenging, and one thing that he loves is to learn new board games and card games. The more complicated the better! Over the holidays he learned a new card game that takes 2 hours to play (think Big Bang Theory and all their cards and expansion packs lol). He was fully engaged the whole time, in fact, I do believe he won that round! We go for ASD assessment tomorrow, I plan on asking the psychologist about this particular issue, because it is one that confuses me completely. I'll let you know if I find anything out.

cutiecrystalmom