The Triple A’s
When a doctor, therapist, or counselor works with a child diagnosed with autism, they should also consider the possibility of the “Triple A’s”. No, not AAA the auto insurance company, but the Triple A’s, meaning autism, ADHD, and anxiety.
These three things often overlap. 27% of adults and about 70% of children with autism will also meet the criteria for attention deficit hyperactivity disorder (ADHD). That is ten times higher than the general population for adults with autism. Children with autism also have a 40-70% chance of also having anxiety. This chance increases with age, and if a child has been diagnosed with both autism and ADHD, their risk for anxiety is even higher. This results in the common finding of the Triple A’s.
ADHD and autism share several overlapping symptoms, including inattention, social difficulties, and challenges with behavior regulation. Having both ADHD and autism can further impact adaptive functioning, social skills, and overall quality of life.
Autism and anxiety also overlap in important ways. Common shared symptoms include social withdrawal and avoidance, repetitive behaviors and insistence on sameness, restlessness or agitation, distractibility, and sleep disturbances.
Anxiety and ADHD share similar features as well, including inattention, difficulty focusing, restlessness, emotional dysregulation and irritability.
Determining whether a child has one, two, or all three of the Triple A’s can be challenging to diagnose but obtaining a good history from the family and patient, utilizing screening forms, and rating scales from parents/teachers is a great place to start.
When providers are choosing an ADHD medication, they can consider a stimulant or non-stimulant. Children with autism can be more sensitive to stimulant medication and are more likely to experience behavioral activation (restlessness and disinhibition), which is why non-stimulants may be tried first. If a stimulant medication is used, providers are likely to start at a low dose and slowly increase to find the safest and most effective dose for that child.
Managing anxiety in a child with autism and/or ADHD can be trickier, as stimulant medication used for ADHD can sometimes worsen anxiety. Because of this, providers may try a non-stimulant medication first. Cognitive-behavioral therapy (adapted) is the first-line treatment for anxiety, but having uncontrolled ADHD and cognitive impairments associated with autism can limit the ability to engage a child with anxiety, ADHD, and autism during therapy.
If anxiety is significantly impacting a child, the Selective Serotonin Reupdate Inhibitors (SSRIs) like Prozac, Zoloft, and Lexapro are often tried. However, research supports that up to half of children with autism and anxiety will not tolerate the SSRI medications due to side-effects, such as behavioral activation. Antipsychotic medications are rarely used in children with autism and for aggression and may have some benefit for anxiety and ADHD symptoms.
If I child has the Triple A’s, the most impairing illness is addressed first, which may be the symptoms of autism. In that case, utilizing Applied Behavioral Analysis (ABA), speech, occupational, and physical therapies should be first-line approaches. School supports, including an appropriate IEP, and behavioral plans at home are also vital. After these supports are in place, providers may focus on the next most significant symptoms of the A’s, either anxiety or ADHD. It is not uncommon for children with the Triple A’s to benefit from a combination of therapies, school supports, behavioral strategies, and prescribed medication.
The keys to a successful treatment plan for the Triple A’s include:
- A provider who listens and seeks the data to support a correct diagnosis
- A therapy team that works together (physician, nurse practitioner, counselor, therapists)
- Patience with both counseling and medication trials
- Focus on goals that help the child and family thrive while building on the child’s strengths
Authored by: Dr. Kyle John