Autism Hidden Behind ADHD: Recognizing the Signs Your Child's Complete Story

When Autism and PDA Remain Hidden Behind ADHD: A Parent's Guide to Seeing the Full Picture

Image Courtesy of shutterstock.com

It happens more often than many realize – a child receives an ADHD diagnosis, but years later, another important piece of the puzzle emerges: autism that was there all along, hidden behind more visible ADHD symptoms. This phenomenon isn't rare. In fact, it happens to thousands of children whose autism goes unrecognized because their ADHD symptoms take center stage. The hyperactivity, impulsivity, and attention challenges are so visible that they overshadow the subtler signs of autism hiding beneath.

Have you ever had that nagging feeling that there's more to your child's struggles than just ADHD? That's exactly where I found myself three years ago with my daughter. We had the ADHD diagnosis, we were following all the recommended strategies, but something still felt... incomplete. It was like we were reading only half the book about who she truly was.

If you're nodding along right now, this post is for you. Because what I didn't understand then – but wish I had – was that autism can often be hidden behind ADHD, especially in girls. For many children, Pathological Demand Avoidance (PDA), a profile of autism characterized by an anxiety-driven need to avoid demands and maintain control, can further complicate the picture. These conditions frequently overlap, with ADHD symptoms sometimes overshadowing the more subtle signs of autism and PDA.

Our Family's Journey: Looking Beyond the First Diagnosis

My daughter was diagnosed with ADHD at age six. She was bright, talkative, and endlessly energetic. Her impulsivity and difficulty focusing were textbook ADHD. But as she grew older, I noticed patterns that didn't quite fit the ADHD profile.

Social situations that should have been fun left her completely drained. She developed intense interests that went far beyond typical hyperfocus, spending months learning everything possible about ancient Egypt, complete with creating detailed hieroglyphic charts that covered her bedroom walls. And while she could talk at length about her interests, she struggled with the back-and-forth rhythm of casual conversation.

What really confused me was her seemingly contradictory behavior. Some days, she would eagerly participate in activities, but other days, she would refuse the same activities with an intensity that went beyond typical ADHD resistance. When a demand was placed on her – even something fun like going to a birthday party – she would sometimes experience overwhelming anxiety and shut down completely.

When meltdowns continued despite our best ADHD management strategies, I started researching. That's when I first encountered the concepts of autism hidden behind ADHD and the PDA profile of autism. Suddenly, everything began to click into place – especially her extreme resistance to demands and need for control, which wasn't just ADHD-related oppositional behavior but actually anxiety-based PDA responses.

Understanding the Overlap: Why ADHD, Autism, and PDA Often Co-exist

ADHD, autism, and PDA frequently occur together – studies suggest that about 30-50% of children with autism also meet the criteria for ADHD, and about 15-25% of children with ADHD also meet the criteria for autism. The PDA profile is increasingly recognized as a distinct presentation of autism that can co-occur with ADHD as well. This isn't just a coincidence; there appear to be shared genetic factors and brain differences that contribute to these overlapping conditions.

However, the way we typically think about these conditions can make one harder to spot than the other. ADHD tends to present with more obvious behavioral challenges that quickly draw attention in classroom settings – hyperactivity, interrupting, and difficulty staying on task. Autism, especially in its more subtle presentations, might show up as social awkwardness, sensory sensitivities, or rigid thinking patterns that can be misinterpreted or attributed to ADHD.

The PDA profile can be even more challenging to identify, as the demand avoidance can look like ADHD-related task refusal or oppositional behavior when it's actually anxiety-driven. For many families like ours, this means getting the ADHD diagnosis first, only to discover later that autism and potentially PDA were there all along, hiding in plain sight.

Signs Your Child's Autism and PDA May Be Hidden Behind Their ADHD

Looking back, there were clues I missed. If any of these sound familiar, it might be worth exploring whether your child with ADHD also has autism and potentially PDA:

Social differences that go beyond ADHD-related challenges: While children with ADHD might be impulsive or miss social cues because they're distracted, children with autism often struggle with the fundamental back-and-forth of social interaction. My daughter could talk endlessly about her interests, but rarely asked questions about others. She wanted friends but couldn't figure out how to maintain friendships beyond the initial connection.

Intense sensory responses: My daughter's meltdowns in crowded, noisy places weren't just ADHD overwhelm – they were sensory processing differences common in autism. She couldn't tolerate certain clothing textures and would only eat foods of specific consistencies. I initially thought this was just being "picky," but it was actually sensory sensitivity.

Special interests that go beyond hyperfocus: Both ADHD and autism can involve intense focus, but there's a qualitative difference. My daughter's fascination with transportation systems wasn't just passing hyperfocus; it was a deep, encyclopedic interest that remained consistent for years and came with an amazing attention to detail most people would never notice.

Need for predictability and routine: While ADHD often comes with difficulty following routines, autism involves a need for routines. My daughter would become extremely distressed when plans changed unexpectedly, even for something fun. This went beyond typical ADHD flexibility challenges.

Literal language understanding: My daughter often missed jokes, idioms, and sarcasm, taking everything at face value. When I said, "It's raining cats and dogs," she looked outside expecting to see animals falling from the sky. I thought she was just being playful, but this literal thinking is common in autism.

Difficulty with transitions: Yes, transitions are hard for kids with ADHD, too, but for different reasons. My daughter's transition troubles weren't about being distracted or impulsive – they stemmed from needing to mentally prepare for changes and difficulty shifting her attention from preferred to non-preferred activities.

Stimming behaviors: My daughter's finger-flicking when excited, intense rocking when stressed, and hair-twirling during concentration weren't just fidgeting from ADHD. These repetitive movements (stimming) were self-regulatory behaviors common in autism.

Extreme demand avoidance: While children with ADHD might avoid tasks they find boring, children with the PDA profile of autism experience intense anxiety around demands of any kind – even things they enjoy. My daughter would eagerly agree to activities but then become overwhelmingly anxious when it was time to participate. This wasn't willful defiance; it was a genuine fight-or-flight response to perceived pressure that's characteristic of PDA.

Why Girls Often Get Missed: The Gender Factor

If your child is a girl, the chances of autism hiding behind an ADHD diagnosis are even higher. Girls with autism often present differently than boys, showing strengths in:

Masking (hiding their difficulties), social mimicry (copying others' behaviors), developing coping mechanisms that make their challenges less obvious, having special interests that seem more socially acceptable (like animals or literature rather than train schedules)

My daughter became a master at what researchers call "social camouflaging" – observing and copying the social behaviors of popular girls at school. She would come home exhausted from this constant performance, often leading to meltdowns that we initially attributed solely to ADHD-related emotional dysregulation.

As one expert explained to me, "Girls don't necessarily have less autism; they just have more social pressure to hide it." This masking can lead to anxiety, depression, and a profound sense of being different without understanding why.

The Diagnostic Journey: Finding the Complete Picture

Getting to an accurate understanding of your child means looking at the complete picture, not just the most visible challenges. Here's what helped us:

Comprehensive evaluation: We found a neuropsychologist experienced in both ADHD and autism who could tease apart the overlapping symptoms. This was game-changing.

Documenting patterns: I started keeping notes about specific situations that seemed to trigger difficulties, which revealed patterns pointing to sensory and social challenges beyond ADHD.

Seeking multiple perspectives: Teachers, family members, and therapists all saw different aspects of my daughter. Putting these perspectives together helped complete the puzzle.

Trusting my parental instinct: That persistent feeling that "there's something more going on" was ultimately validated. Parents often sense things about their children that even experts might initially miss.

One developmental pediatrician told me something I'll never forget: "ADHD tells us how your child's attention works. Autism helps us understand how they experience and interact with the world. Both pieces matter for the complete picture."

The Relief of Understanding: What Happened After Diagnosis

Discovering that my daughter had autism and PDA in addition to ADHD wasn't about adding more labels. It was about finally seeing her completely and being able to support her fully.

With this understanding came:

More effective supports: We adapted her environment to address sensory needs and provided clear social guidelines that went beyond ADHD strategies. Most importantly, we changed our approach to demands – using indirect language, offering genuine choices, and reducing unnecessary pressure in ways that specifically support children with PDA.

Self-understanding: As we carefully explained all three conditions to her (in age-appropriate ways), my daughter experienced profound relief. "So that's why school parties make me feel sick inside even though I want to go!" she said. "That's why I can focus for hours on drawing but can't sit through a movie everyone else enjoys." And crucially: "So that's why I sometimes really want to do something but then feel like I can't when it's time to actually do it."

Better educational plans: Her school could now address both the ADHD needs (like movement breaks and help with organization) and autism-related needs (like social skills support and sensory accommodations). We also helped teachers understand that her resistance to certain tasks wasn't defiance, but PDA-related anxiety requiring a different approach.

Finding her community: Connecting with other kids who have similar overlapping conditions helped my daughter feel less alone. "They get me, Mom," she said after her first meeting with a social group for neurodivergent kids. "I don't have to pretend."

A friend whose son was diagnosed with autism, PDA, and ADHD put it perfectly: "Getting the complete picture didn't change who my son was. It just helped us all understand him better – including himself."

Parenting the Whole Child: Strategies That Address All Conditions

Once we understood that my daughter had ADHD, autism, and PDA, we developed approaches that honored her complete neurodivergent profile:

Clear, concrete communication with less demanding language: Children with these overlapping conditions benefit from direct, explicit instructions rather than vague directions, but delivered without pressure. Instead of "Clean your room," we might say, "I wonder if the books would like to go back on their shelf?" or "When you're ready, the clothes are waiting for their home in the hamper." This indirect approach respects her PDA need for autonomy while providing the clarity her ADHD and autism require.

Sensory-aware environments: We identified her sensory triggers (certain sounds, crowded spaces, specific food textures) and found accommodations – noise-canceling headphones, designated quiet spaces at events, and flexibility around foods.

Structured flexibility: This sounds contradictory, but it's about finding the balance between the routine needs of autism and the novelty-seeking of ADHD, while honoring the autonomy needs of PDA. We maintain predictable daily rhythms while building in choices and variety within that structure, always allowing her agency in how activities unfold.

Interest-based motivation: We leverage her intense interests to build bridges to necessary tasks. Math homework becomes more approachable when it involves calculating how long it would take different dinosaurs to travel certain distances based on their estimated speeds. When her PDA anxiety spikes around schoolwork, connecting it to her special interests can transform a "demand" into an opportunity.

Emotional regulation support: All three conditions affect emotional regulation but in different ways. We use visual tools to help her identify emotions, teach specific calming strategies for different situations, and validate that her feelings make sense, given how her brain works. For PDA-specific anxiety, we've found that acknowledging her need for control and finding ways to genuinely give her that control is essential.

Collaborative problem-solving: Rather than imposing solutions, we actively involve her in figuring out what works. "This is tricky for both of us. How could we make this work better?" This approach respects her autonomy (essential for PDA) while teaching problem-solving skills that help with both ADHD and autism challenges.

Self-advocacy training: Perhaps most importantly, we're teaching her to understand and articulate her own needs. At nine years old, she can now explain to adults: "I have ADHD, autism, and something called PDA. That means I might need to move around more than other kids, sometimes loud noises hurt my brain, and I need to feel like I have choices about things."

Finding Professional Support That Addresses All Conditions

Finding professionals who understand the ADHD-autism-PDA overlap was challenging but essential. Here's what helped us:

Seeking integrated treatment approaches: We found therapists who understand neurodevelopmental conditions as interconnected rather than separate silos. The most helpful professionals recognized that PDA requires different approaches than traditional autism or ADHD interventions.

Looking beyond behavior: The most helpful professionals were those who looked past surface behaviors to understand the underlying reasons – recognizing that similar behaviors can stem from different causes in ADHD versus autism versus PDA. For example, task refusal might be ADHD distraction, autistic rigidity, or PDA anxiety – each requiring a different support approach.

Prioritizing sensory processing support: Occupational therapy focusing on sensory integration has been remarkably effective in addressing challenges that medication for ADHD couldn't touch. This helped with both autism-related sensory issues and the sensory aspects of PDA anxiety.

Building a collaborative team: Our daughter's pediatrician, therapist, and teachers now communicate regularly, sharing insights about which supports work best in different environments. We've educated everyone about the PDA profile specifically, as it's still less widely understood than ADHD or autism.

Finding PDA-knowledgeable support: This was perhaps the most challenging aspect. We specifically sought out professionals familiar with the PDA profile of autism, as traditional behavioral approaches that might work for ADHD or classic autism can backfire dramatically with PDA.

Embracing Your Child's Complete Neurodivergent Identity

One of the most beautiful outcomes of understanding all these conditions has been watching my daughter develop a positive sense of her neurodivergent identity.

Like many children with overlapping conditions, she initially felt confused about who she was. "Am I my ADHD, or am I autistic, or am I PDA?" she once asked us. We've worked to help her understand that she isn't any of these conditions – she is herself, a wonderful, complex person whose brain works in unique ways that bring both challenges and remarkable strengths.

Now, when she hyperfocuses on creating intricate artwork, spots patterns others miss, or approaches problems with outside-the-box thinking, she recognizes these as her "superpowers" – the flip side of the same neurodivergent traits that sometimes make life challenging. We've helped her understand that her PDA-related need for autonomy also contributes to her strong sense of justice and her ability to think for herself.

A mom in our support group shared that her son, diagnosed with all three conditions, told her: "My ADHD is like a rocket engine, my autism is like the navigation system, and my PDA is like the safety measures making sure I don't go places that feel dangerous to me. Together, they can take me to amazing places, but sometimes they don't sync up perfectly."

What a beautiful way to understand the intersection of these conditions – not as deficits but as different operating systems that sometimes need specific support to work together smoothly.

The Community Connection: You're Not Alone

If you're nodding along to this post, please know you're part of a growing community of parents navigating this same terrain. The recognition of how frequently ADHD, autism, and PDA co-occur is relatively recent in the medical community, which means many of us became accidental pioneers in understanding our children's complex neurodevelopmental profiles.

Connecting with other parents through support groups – both online and in person – has been invaluable for our family. There's something powerful about talking with others who immediately understand your daily joys and challenges without lengthy explanations. This is especially true for families navigating the PDA profile, which still isn't as widely recognized or understood as ADHD or autism.

Moving Forward with Understanding

If you suspect your child with ADHD might also have autism and possibly PDA that has gone unrecognized, here are some practical next steps:

1. Start documenting specific examples of behaviors that don't seem to fit the typical ADHD profile, particularly in the areas of social interaction, sensory responses, need for routine, and demand avoidance. Look especially for patterns of refusing activities they actually enjoy when those activities become expectations or demands.

2. Consider seeking a comprehensive reevaluation with a professional experienced in identifying autism and PDA in children who have ADHD. This might be a developmental pediatrician, neuropsychologist, or psychologist specializing in neurodevelopmental conditions. Be sure to ask about their familiarity with PDA specifically.

3. Visit our website, practicalparentsguide.com, for more detailed resources on supporting children with overlapping neurodevelopmental conditions, including specific strategies for children with the PDA profile of autism.

4. Consider reading "A Practical Parent's Guide to PDA and Autism," which addresses the complex intersection of different neurodevelopmental profiles and offers concrete strategies for supporting children with overlapping conditions.

Next Steps

Parenting a child with autism and PDA is both challenging and rewarding. If you're looking for more practical strategies and insights, I've compiled extensive research and personal experience in my book, "A Practical Parent's Guide to PDA and Autism."  This resource provides concrete approaches tailored specifically to parents and caregivers of children who experience both autism and PDA.

As a parent juggling therapy appointments, IEP meetings, and the daily challenges of raising a child with PDA, I know you barely have time to sit down, let alone read a book. That's exactly why I've made "A Practical Parent's Guide to PDA and Autism" available as an audiobook you can listen to during school drop-offs, while making dinner, or during those precious few minutes alone in the car. Transform your "lost time" into learning time by grabbing the audiobook here: US, UK, Australia, Canada, France, and Germany.

I wrote this book because I needed it myself and couldn't find anything like it. It offers practical, parent-to-parent advice based on both research and my own real-life experience raising a child with PDA, with specific chapters dedicated to understanding and preventing burnout. The strategies I share have helped thousands of families reduce stress and build more harmonious relationships with their neurodivergent children. As parents walking this path, we need real solutions from someone who truly understands—not just theory, but practical approaches that work in everyday life with our wonderful, complex daughters and sons.

Your Turn

Remember, recognizing that autism and PDA may be hidden behind your child's ADHD isn't about adding problems – it's about gaining a more complete understanding that leads to better support, greater acceptance, and a clearer path forward. Your child is the same wonderful person they've always been. You're just getting to know them even better.

I'd love to hear your experiences in the comments. Did you notice signs of autism and PDA in your child with ADHD that were initially overlooked? What strategies have been most helpful in supporting your child's complete neurodevelopmental profile? What questions do you have about navigating the overlap between ADHD, autism, and PDA?

References

1. American Academy of Pediatrics. (2022). Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of ADHD in Children and Adolescents. Pediatrics.

2. Antshel, K. M., & Russo, N. (2019). Autism Spectrum Disorders and ADHD: Overlapping Phenomenology, Diagnostic Issues, and Treatment Considerations. Current Psychiatry Reports.

3. Christie, P., Duncan, M., Fidler, R., & Healy, Z. (2022). Understanding Pathological Demand Avoidance in Autism: A Guide for Parents and Professionals. Jessica Kingsley Publishers.

4. Demetriou, E. A., et al. (2022). Autism spectrum disorder and attention-deficit/hyperactivity disorder in children with cerebral palsy: results from screening studies. Developmental Medicine & Child Neurology.

5. Eaton, J. (2023). A Guide to Understanding PDA in Children: Dimensions of Pathological Demand Avoidance. Jessica Kingsley Publishers.

6. Lai, M. C., & Baron-Cohen, S. (2023). Identifying autism in girls and women: advances in recognition and presentation differences across gender. Current Opinion in Psychiatry.

7. Leitner, Y. (2021). The Co-Occurrence of Autism and Attention Deficit Hyperactivity Disorder in Children – What Do We Know? Frontiers in Human Neuroscience.

8. O'Nions, E., & Noens, I. (2023). Pathological demand avoidance: What and why? Autism Research.

9. PDA Society. (2024). Understanding PDA in the context of autism. Retrieved from https://www.pdasociety.org.uk.

10. Rommelse, N. N., et al. (2021). How should ADHD with comorbid autism spectrum disorder be classified in the new ICD-11? Journal of Clinical Psychiatry.