Shirah Vollmer MD

The Musings of Dr. Vollmer

Is it Severe ADHD or is it Asperger’s? The Case for a Good Assessment

Posted by Dr. Vollmer on April 25, 2010

Charlie is seven years old. He hates school; he has no friends. Charlie is aggressive and angry most of the time, but particularly when his parents set a limit. A pediatric neurologist diagnosed him with Asperger’s syndrome and told the parents that he was an “odd duck.” Charlie was then evaluated in a tertiary care setting (a medical school). They agreed. Charlie was put on Risperdal, an antipsychotic. Charlie got “better” according to the parents, but he still did poorly in school and he still had no friends.

Charlie’s parents were reluctant to pursue educational testing. Not only was the price high, they did not want Charlie to think that his entire life was about going from one medical appointment to another. I understood that, but I said this is the most important step you can take in terms of understanding Charlie’s brain. Reluctantly, the parents agreed. Meanwhile, I explored the family history. Charlie’s dad, Tony, never did well in school either. Now, he works as a fire fighter. Charlie’s mom, Gaby, was a good student, as were her six siblings. I wondered about Charlie’s attention span. Gaby explained to me that “he could never sit on the circle, like the other kids could in preschool. He was always running around.”

The neuropsychological evaluation confirmed my suspicion. Charlie had severe ADHD. He could not focus; he has no frustration tolerance. Hence, he could not engage in a dialogue with other children, so he had no friends. He could not wait his turn in games. He blurted out what he was thinking. He had no ability to inhibit his thoughts, so other kids found him to be a “a bit strange” according to Gaby. I stopped the Risperdal, gave him a stimulant (Concerta), and within days, he was doing his work at school, he was no longer a behavior problem and he was getting along with other children. As Charlie said “that medicine really makes my friends nice to me.”

Social skills are dependent on attention. In order for Charlie to make friends, he has to be able to listen, wait, and think before he speaks. If his ADHD makes it so that he has no control over his brain, he will come across as odd, intrusive, and uncooperative. On the other hand, if he takes a stimulant, he will then be able to ponder his next move and thereby prevent the embarrassing moment of saying something that other kids will laugh about. In other words, he will have a space between thought and action. This space is critical for social success.

Untreated ADHD looks like Asperger’s Disorder. That is a simple, yet often missed, truth. The treatment for ADHD is stimulants. The treatment for Asperger’s Disorder ranges from special education to antipsychotic medication. These are very different paths. Diagnosis is essential. A comprehensive approach to assessment demands that the clinician consider all conditions, factoring in the statistics which reinforce the obvious; common diseases are common. ADHD is one out of twenty kids. Asperger’s is hard to pinpoint, but it is roughly one in a hundred kids. Those numbers alone make it so that ADHD should be a leading contender in the mystery of Charlie’s behavior. Adding on, Charlie has a potential family history of ADHD, as his dad might have it as well. This data, combined with the neuropsychological testing, combined with Charlie’s long history of hyperactivity makes the diagnosis straight-forward.

Charlie’s parents have gone through what so many parents suffer from. Charlie has behavior problems. Who should he see? A pediatrician? A pediatric neurologist? A child psychiatrist? Who should pay? Insurance? Out-of pocket? Should they go to a University for an “expert” opinion? There is no road map for these questions. Parents are understandably confused. Child psychiatrists are the experts at diagnosing behavior problems in children, yet the public does not understand that; pediatricians do not understand that either. Universities can be very helpful, but because the patient sees someone in training, there is variability in quality. Once again, the fault lies in my profession. We have not presented our expertise to the public in such a way that it is clear how we can be helpful. Shame on us for not helping more kids like Charlie. Shame on us for putting families through multiple evaluations with confusing answers.

Child psychiatrists need a public relations firm to announce our skill set. We should use the money from our dues in the American Academy of Child and Adolescent Psychiatry  Association to pay for this public education.  Maybe we can figure out a way to make it happen. For the sake of our “children” we must.

See also…. and

68 Responses to “Is it Severe ADHD or is it Asperger’s? The Case for a Good Assessment”

  1. Shelly said

    What a great piece–timely and certainly a “hot issue” right now. If Asperger’s is manifested by “social issues” and ADHD by an inability to wait one’s turn and focus and concentrate, then how can a child learn overnight the skills necessary to be functional in a social setting simply by switching from Risperdal to Concerta? What is the Concerta doesn’t help–does that mean that Charlie does not have ADHD? What behaviors did the pediatric neurologist call “odd”? What if the child is given both a stimulant and an antipsychotic and is still an “odd duck”? What kind of diagnosis would you give then? You say that “untreated ADHD looks like Asperger’s.” In what way? Should a child with Asperger’s be in a special education environment? What if the young adult with the Asperger’s is a high school student and has spent his entire life without friends? How can one teach him the skills necessary to interact? What if the young adult doesn’t care? What is the prognosis for the young adult as he grows into adulthood? What are adults with Asperger’s like? Since Asperger’s ‘came into being’ in 1994, most psychiatrists who attended medical school before this time know little or nothing about the disorder. Whose job is it to educate them? Are there various degrees of Asperger’s patients (i.e. are some patients’ symptoms far worse than others)? If “ADHD is caused by bad or weak parenting” (as stated on tv, radio, or in other newspapers), what is Asperger’s caused by?

    • Thanks Shelly and Zac. For some kids, social skills are intuitive. It is possible that Charlie does not have “learn” how to have friends, but he does need to control his impulses. For other kids, social skills have to be taught since they are not intuitive. If Concerta does not help, then other stimulants are worth trying. If no stimulant helps, then it does not mean he does not have ADHD, but it does make one question the diagnosis. Such a child would require further assessment. The “odd” behaviors were leaving circle time as a preschooler, saying inappropriate things, interrupting other kids in the middle of their conversation. Antipsychotics do not make kids less odd, only calmer. An “odd duck” is a neuroatypical kid who has a brain which is so far outside the bell curve that he cannot find people who “get” him. I am saying that untreated ADHD may look like Asperger’s. It is just something to think about. A child with Asperger’s should be in special education if he has associated learning issues. Social skills can always be taught, but the child/adult needs to be motivated. Without motivation, it is nearly impossible. Psychiatrists need to keep up on the literature throughout their career. They should be educated by experts, but the issue of continuing medical education is complicated and it might be the subject of a fture blog. Yes, Asperger’s exists on a continuum-like everything else. ADHD is never casued by bad or weak parenting, but strong parenting can help an ADHD child. Asperger’s is a neuroatypical brain. There are probably strong genetic links. In essence, it is a wiring problem. Thanks for all your thoughtful questions-as always!

  2. Zac Taylor said

    What a great case to show the importance of having a solid assessment — especially with children. You saved this kid’s life, and that’s no joke.

    Shelly — that’s a lot of great questions and would probably take a book or two to answer, and there are some good ones out there. I think the point of Shirah’s post was to point out the need for good clinical assessment before we diagnose and drug children into oblivion.

  3. Thanks again Zac. I appreciate your comments.

    • Zac Taylor said

      Thanks. It’s tough to ever blame parents, if blame is even the right word, for ADHD. At the same time, we know that environmental factors affect and exacerbate ADHD and that a large part of a kid’s environment is at home with parents.

      From an attachment and social learning theory perspective, and in my humble opinion, parenting and attachment styles can (not always, but can) have a profound affect on a child’s ability to concentrate and in the onset and exacerbation of ADHD. I think this is one reason why Parent-Child Interaction Therapy (PCIT) has been so successful.

      Again, I want to emphasize each situation is unique and it’s not all parents, all environment, or all genetics. It’s a messy combination, so saying that “ADHD is never caused by bad or weak parenting” is just as inaccurate as saying it’s “always caused by bad or weak parenting.” It’s a mix, and I think in the treatment of ADHD we need to coach parents on how to be with their kids and meet their attachment needs because that is often a part of the solution.

  4. […] Is it Severe ADHD or is it Asperger's? The Case for a Good … […]

  5. AA said

    As one who has a condition similar to AS, I am absolutely stunned that Risperdal would even be considered for that condition except in very extreme cases with all the side effects it has. Folks like us are already neurologically compromised. The last thing we need are drugs that over time will worsen things for us.

    As far as stating that kids/adults with AS have to be motivated to learn social skills, that is kind of like stating that someone who is blind should be motivated to learn how to read.

    I know your intentions are good but think of the area that you are weakest in and that feels like Greek to you. Now picture someone saying to you, what is the matter Dr. Vollmer, you can learn this, you’re just not motivated. How would you feel?

    And by the way, when you’re teaching social skills to people with AS, you’re asking them to learn things that people learn unconsciously at a very young age. That is darned hard.

    I am not saying it can’t be done by the way. I am just trying point out that learning social skills is alot more involved than just having motivation.

    • Thank you for your comments.

      Risperdal can be helpful or harmful, like any medication. The decision to use it is done on a case by case basis. I certainly agree that sometimes it is prescribed inappropriately.

      I think people with AS can learn social skills and they can be motivated. It is not a black and white situation.

      I understand that people with AS do not necessarily want friends, but some do, but they do not know how to make them. Perhaps I should have been more clear about that. I will try to address this issue in a future blog.

      I agree that social skills are intuitive to most people, and someone with AS does not have that kind of intuition. I agree it is hard. I am sorry if I did not make it clear that I understand that.

      Yes, learning social skills is a slow process. Motivation is only the beginning. I did not mean to imply that once someone with AS had motivation, then they would be on easy street. It is a rough road. However, without motivation, it is hard to even get started.

  6. What a thought provoking case study. To think children with ADHD are mistakenly being diagnosed with Aspergers and hence not given the proper course of treatment is outright scary. Paying attention is indeed vital for forming good social skills and friendships; think about how vital listening skills in adults are.

    Thanks for a great post.

  7. Hi Mendel,
    Thanks for your comments. Shall we link our websites? SV

  8. […] should pay? Insurance? Out-of pocket? Should they go to a University for an “expert” opinion? Dr. Shirah Volmer makes the case for the importance of getting a good assessment for a child with behavioral difficulties. She […]

  9. Annette said

    Great information. Charlie sounds like my son, who is now 16 and is would be flunking out of school if not for my help. His severe adhd has been treated with everything from stimulants to tenex back to sitmulants then to risperdal etc. He is presently on the daytrana patch 15mg, which is not helping. He is 6’6 and 135 pounds. We need a medicine that will work. Severe ADHD is inhibiting his academic, social, and emotional growth. We are seeing a new physician in a month and are hoping for help. At this juncture, no one seems to know what to do. Any feedback on Vyvanse? I am hoping that we will have better success with stimulants now that he is older with more body mass. Perhaps there will be less side effects.

    • Shirah Vollmer said

      Thanks for your comments. Vyvanse is a reasonable choice, but basically it sounds like your son needs a careful trial and error approach using both mixed amphetamine salt drugs (Adderall) and then methylphenidate drugs (Ritalin). I hope that your new physician is a board certified child psychiatrist. Good luck.

  10. Diagnois of social skills problems is never easy. But now when Asperger’s youth need help with their social skills, they can use a new online application to rehearse a face-to-face conversation. These social skills simulations show the facial reaction of the person you’re talking to, plus expert advice on what you said. There are many free courses (plus other low-cost resources) at

  11. T Castellon said

    Hi Dr. Vollmer,

    My 3 year-old son just received a diagnosis of AHDH and mild Asperger’s, but he doesn’t have any of the ‘classic’ symptoms of Asperger’s, so I don’t really understand the diagnosis.

    Note: I have ADHD-Inattentive Type that does not respond to stimulant medication, Depression & social anxiety(well controlled with Zoloft), motor tics that come and go, a few rule-based ritualized behaviors (e.g., systems for getting dressed, selecting food, etc.), no serious academic problems, but difficulties with spelling and math.

    My son’s main problems are that he is emotionally volatile and has very low tolerance for frustration. He insists on being in charge during play activities, and cannot tolerate being contradicted or told no. He seems immature compared to other children his age, but he easily learns how to do things that interest him (e.g., working the DVD player, putting together his train tracks, etc.). He has a few symptoms that could be seen as vaguely autistic, but nothing that is clear-cut… He is very social, his speech was a bit delayed but, with therapy, he is catching up and shows no signs of a language disorder. He has good eye contact and good joint attention. He has normal body language and appropriate facial expressions. He didn’t make eye contact as an infant, but by 2 months eye contact was normal. He was a very difficult baby, cried constantly and was difficult to console. He had no feeding problems. He wasn’t interested in toys when he was a toddler, but played with toys appropriately after about 2 years old,. He had a very narrow range of interests for about a year – he played almost exclusively with Thomas the Train and Cars from the Pixar movie, often acting out scenes from his videos, but now he has a broader range of interests and normal imaginative play. He is affectionate with me, but hates to be grabbed and kissed by my husband, which my husband does incessantly, making it worse… He has very mild motor-skill delays (doesn’t yet hold his pencil properly, doesn’t peddle a tricycle). He seemed slightly insensitive to pain and cold when he was younger, but now he doesn’t seem to have any sensory issues. He does not demand structure or routine.
    So, Dr. Vollmer, what is your opinion about his diagnosis?

    • Of course, I cannot comment on a diagnosis without my own evaluation, but generally speaking, Asperger’s tends to be overdiagnosed, so I would suspect that ADHD is the primary problem. Was he diagnosed by a board certified child psychiatrist?

      • traci castellon said

        Thanks Dr. Vollmer,
        I didn’t realize you had responded to my question… My son has now been diagnosed with “classic autism” based on his ADOS score, which is absurd… if he is on the spectrum, it’s very mild Asperger’s. He was diagnosed by a developmental pediatrician. She said mild autism and ADHD from interacting with him, but revised it to classic autism after his ADOS. She also diagnosed my friend’s child with autism, but another developmental pediatrician says no way, so I think she may over diagnose autism. Either that, or else she is right, and just extremely perceptive… But, whatever he has, he is doing really well. he is on zoloft now, and he is a different child. at the last visit the doctor said she didn’t see any symptoms of autism, but she still thinks he has it… from my perspective, a SSRI shouldn’t have “cured” his autism symptoms, which suggests to me that it might be a misdiagnosis. I doubt I will ever know for sure what he really has.

        • Shirah said

          I agree with you that generally speaking, an SSRI does not “cure” autism. I would encourage a second opinion. Thanks for your comments.

  12. Camille said

    I have a serious problem with my son and people telling me all sorts of things. I need for him to be able to be managed. I really need help.
    It started when he was a baby always crying. He was my first I thought it normal. His daycare provided told me that it wasnt normal. He would cry when he was around the other kids, and be fine when he was alone where it was quiet. I took him the doctor. They said he was fine, nothing wrong, no ear infections, no fever, nothing they could see. This was happening around 12 months
    He started to freak out when ever he heard a sudden noise, the alarm clock, the dryer, the phone and ect. He would scream as if he were terrified, even the toliet flushing. Noises really got to him, and interested him. It seemed he could hear every siren ever little noise in the store, even every fan blowing. This all happen around 18 months.
    At 2 and a half I looked for answers, my family was on the brink of falling apart. He would scream so much. He had behavior problems. It was really bad. They diagnosed him with PDD-NOS, and told me he should grow out of it with help, supports but no one offered me any help.
    He started preschool the first year we had to switch him schools to a half day preschool he would have behavior problem, and he refused to eat there food. He is very picky still. So they thought a half day would help, less stress and he could eat at home.
    He started medications for his behaviors the summer before his second year of preschool. They got better for a little while but then the medication seemed to stop working. The doctor at this point did not want to mess too much with the meds because she was only a peditrian. She referred him to a Child psychiatrist after his preschool teacher wrote a “journal” of his behaviors. He would run kids over with the tricylce, he was sieverly “stuck” on certian things. He even bite the teacher.
    The psychiatrist diagnosed him with AS and changed his meds.
    He is now in kindergarten, and the meds help a lot with the “cycling”
    The doc told me that AS comes with other problems, it was like an umbrilla diagnoses, and manic depressed is a normal “mood disorder” that they might have. And he has siever ADHD.
    At school he get into trouble because he hits kids and cant sit down. They are not helping him more tollerating him.
    As of now, I can not go anywhere with him, he throws offeal tantrums. I have to have two hands on him at all times. He throws himself down and I have to constantly pick him up. I am honestly afriad I am going to hurt him when I have to constantly hold him still, or pick him up and carry him. He seems to get over stimulated and act horrifically worse when we are around a lot of people or noise. He is constanly constantly moving, or blurting things out, any noise he can. He is increadably impulsive, kicking me and his sisters, making noises, running out in the parking lot. He pretty much does the opposite of everything I say. And I feel like I have to shout to get him to hear me, he wont sit still or look at me.
    I feel like it would help a ton to get the ADHD under control, it causes a lot of his behaviors. The doctor said it was more important to get his behaviors under control first. Righht now he takes 5 pills a day. But I seriously need one full person on him. If he mellowed out a bit maybe he wouldnt be so hard to take care of.
    He does have kids he likes to be around. He cant communicate like they can, but maybe its because he cant pay attention to learn, or figure things out. Even my two year old can look around and see why you said certain things, or understand whats going on. I dont know if AS is the problem or if he really cant figure it out because of how wired he is.
    I dont know what to do. Its been areally long road. A lot of meds, doc, assessments. But I really need to help get him under control, not just for us, but for him. He might be able to have friends, or tell me about his day if he could remember. But no one wants to change his meds. I feel like I am venting. I have never ever seen a kid that couldnt for min stop moving as much as he does. He gets so tired and he still cant stop.
    Do things really go together. Do you think that the ADHD meds could help him slow down then we could work on the behaviors when he is able to listen. Which is more important. Which drugs are more dangerous. Do kids really get the wired on ADHD or could there be soemthing else thats wrong.
    I dont know. I know he seems to be okay in the back yard.. in public he really can handle it. I have to hang on him at all times he is screaming, kicking, crying, throwing things. I dont know if he can help it or if its stimulation or ODD( which he as had one of the many ppl who looked at him said he has), because he is bad at home, way worse out in public. I dont know if its AS but he has always been borer line. Are the behavior meds helping him that much. Its been years now, and I dont know.

    • Shirah said

      Hi Camille,
      As I suggested to Traci, maybe another opinion is in order. SV

    • amanda said

      Camille, my son sounds exactly like yours and we are just now finding that it may be severe ADHD, we did a trial of concerta and for two days my husband and I were in shock over how normal things were. I cried several times because I was so happy. Unfortunately, the concerta gave him some side effects and we are waiting to meet this week to find out what is next. I hope you try something for the can’t hurt to find out how he does – quick results.

    • Mike Pone said

      This sounds like a Sensory Processing Disorder to me. My kids suffer from the same thing, but not quite as bad as what you describe. Occupational Therapy has been very helpful. What tips me off is that he seems overstimulated and that sounds, touch, smell, taste all bother him. It is very easy to confuse with ADHD. I recommend you talk to a child therapist that specializes in Sensory issues.

  13. Michelle said

    Thank you so much for this article. I found it late tonight after a particularly difficult day with my SEVERE ADHD son. He is a definite combo type and we’ve run a gamut of meds; Concerta, Vyvanse, Adderall XR, and now Adderall with Abilify. He’s at the max dosage for his weight with the Adderall and everyone can tell the medication regime is no longer working. My husband has even said that maybe we do need to consider an Aspergers diagnosis. After reading this, I am reassured that it is just his ADHD showing through a medication that is possibly no longer working. Thank you for giving me the hope that I can help him, together, with his Dr. Thank you

    • Shirah said

      You are welcome. Yes, severe ADHD can be just that. Maturation sometimes helps a great deal. Once he calms down then he can relate to others and the diagnosis of Aspergers might be able to be put to rest. Thanks, Michelle for your comments.

  14. ed reilly said

    My 17y/o son began showing symptoms of Asperger’s. His Dx was ADHD. The stimulant medication prescribed resolved most symptoms within the first hour of use. But he is still in the process of reworking and learning many social skills. His first year GPA is a 3.98 in Honors Biomedical engineering.

    I am 62 y/o and was Dx Severe ADHD. Stimulant medication prescribed have had a profound effect on my life, social interaction and my general feeling of satisfaction with life. It is the first time in my life with a quiet brain. I wish I had found this treatment 50 years ago. My life would have been much different.

    Although it may not be a 1:1 correlation, I believe that children with Severe ADHD become adults with Severe ADHD. My Father has 7 brothers and sisters. Of the eight, four show evidence of ADHD and their life histories show the scars. The other four appear to be free of symptoms, and have led much more successful lives. I have nine 1st cousins from my fathers family. And again, about half show symptoms of moderate to severe ADHD. Interestingly, about 50% of the children of each family were affected.

    The sad part of this story is that my cousins who were raised by parents with active ADHD behaviors seem to have less successful lives, when compared to those raised by parents not showing symptoms.

    Thus, what if encouraging adults to seek and maintain treatment is equally important as treating children with Severe ADHD. My caution to anyone with ADHD in their extended family is to become aware that others in their extended family may be affected and encourage their seeking treatment.

    • Shirah said

      Thank you Ed for sharing your story. I agree that ADHD parents have a more difficult time creating a child friendly environment because children are in desperate need for structure and routine. Treating adults with ADHD is vital to the function of a healthy family. Thank you again for your comments.

  15. Amy Boyden said

    I found this interesting. I have been the parent searching for answers about my now 8 yo son. I completely agree that parents of complicated kids (me) have no idea where to start. The best thing we have had so far was the neuropsych, which was very informative. But my kiddo is now seeing a child psychiatrist (if you can call it that at 15 minutes once a month)as well as a therapist. So I am curious what will come of it. He certainly has the attention piece and social issues. He also has a very high IQ with very high creative problem skills. It is diff to find a person who understands how all this fits together. Our first psych consult (diff psych) resulted in speculation of bipolar. . . oy what a crazy ride this has been.

    • Shirah said

      Understanding your child is critical to helping him develop. This is true for you as a parent, and it is also true for the treatment team. Although I understand that it is difficult to find someone that can embrace his complexity, the search for such people is well worth the effort. Thank you for your comments.

  16. Linda S. said

    This is great information. I found it while searching for ways to describe my child. i.e. Is it severe or moderate ADHD. Knowing how to describe my child to teachers and medical professionals is important and helps me convey the information in a factual/grounded way. My husband has ADHD (inattentive) and takes meds. My 9 year ol twin daughters have ADHD and OCD, one is hyper and the other is inattentive. The hyper child is on meds. This article describes her (except for the aggressive/angry/defiant). Both are in therapy right now for their symptoms. It is a journey and I pray I’m doing the things to set them up for future success.

    • Shirah said

      Hi Linda,
      Thanks for sharing. It certainly is a journey-a very difficult one. Patience, along with appropriate interventions, is the way to go. Stay the course. Shirah

  17. Amy Boyden said

    I should have said in my previous post- Thank you.
    After giving this piece a little time to settle in, and reading further comments, I realize how dead on you are. In my 8yo son’s case, attention turned out to be the most significant piece of the puzzle. What has had people, me included, questioning that -has been the severe social skills deficit that remains. His problems haven’t all dissolved since the adderral was added to the picture-therapy, patience, teaching is still on the menu for that piece. I think now that it makes sense that the lagging social skills are more a result of asynchronous development (he has very high verbal, reading, and problem solving skills-139 IQ) than an ASD. This article helped me see the pieces more clearly, and have confidence in my son’s diagnosis.

    • Shirah said

      Hi Amy,
      Nicet o hear from you again. Asynchronous development is such an important concept. It is hard to watch, but with patience, all the lines of development can catch up with one another, hence the term “blossomed” is so often applied to these kids. Keep me posted. Shirah

  18. Julie said

    My 7 yr old twin boys are being seen soon by FDLRS MDTP (through University of Florida) for whatever is causing their difficulties. They were premies and have been in different therapies since 2. At 6, their developmental delay label was dropped in FL (in school) and they were retained in K because they were way behind socially and academically. Now they are going into 1st and one of the twins is closer to being able to hold his own…maybe in first. The other well I’m very concerned. They both react to certain decibels and cry that it hurts their ears yet their only vocal tone is loud and louder. They still hide in the cafeteria because they are afraid people are looking at them. They cry if you mention their name in a conversation at all because they do not want you saying anything good or bad about them. They cry if you laugh at something they do that is funny even after they tell you they are telling a joke because then they say you are laughing at them. They barely sleep because they say their brains won’t shut off. We give them meletonin to get them to actually fall asleep but that only last for around 5 hours – 7 if we are lucky. They can’t focus on conversations all the time and will sometimes scream “I can’t hear you” or “what” when really they do not comprehend you. The jump from activity to activity except on computers Oh they are computer game geniuses. They master high level combat games but can’t read, tell you letters, or most sight words but can add numbers in their head even though they can’t identify them. Please don’t think they are always “bad”. On positive notes, they are very loving and sweet. They love to snuggle and try to help. They will try to help each other not cry (even though they don’t transfer past each other). They are very smart. They can learn our computer pass codes just from watching our hands even though we do 10-12 letter & number combos. They can type in and manipulate through Youtube better than me. They can also retell stories and tell why characters are felling certain ways when asked.

    I’m so torn. I just want the right support for my boys. My husband and I are at our wits end. Treatment is only as good as a correct diagnosis. Should we take whatever the MDTP center says? Are they gurus in the field? I just don’t know what to believe even when they give me an answer. They did think my husband was Autistic when he was young because he didn’t speak at all until he was 4 (but dismssed it because he started talking) and his only friends to this day are ones he has known since childhood. He prefers to be alone and if he isn’t interested in the topic being discussed, he will just walk away from any conversation. My husband said he always felt “odd” so at a young age he self-medicated to feel normal and fit in. Though the years he has been told he had severe ADHD, ADD, depression, bi-polar, etc. He has bee on everything from ritalin to risperdal. Nothing has worked as well as just good old fashion serious counseling for him to get in tune with himself. We have a fear that our boys might eventually turn to drugs if we don’t support them now.

    Sorry for hte long story, but without having the opportunity to assess them, what do you suggest?


    • Hi Julie,
      You are right that without being able to assess them, I am limited in what I can say. In general, a second opinion is a good idea. Further, although again, I am limited, there are situations where “good old fashion serious counseling” is the way to go. Good luck. Shirah

    • Mike Pone said

      “They both react to certain decibels and cry that it hurts their ears yet their only vocal tone is loud and louder.”
      Here too I wonder if it’s a Sensory Processing Disorder. My kids responded very well to sensory therapy. Try to find a therapist specializing in sensory processing issues. Sight, sounds, smell, touch all probably bother them.

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  21. pamela said

    My daughter is a aspie,she is almost 9 come jan.Just figuring this out last year. Her star testing is very high mostly in the 90% until it comes to words with 2 meanings and the ” what if” questions. I am going to a revised IEP meeting today, She is in 3rd grade and alot of her social skills or lack of are becoming more apparent by the day. In her IEP some of her weaknesses are limited flexible thinking,knew discriptions of daily playmates without knowing names, inappropriate comments,”shut down” when frustrated/confused,limited ability to express herself in these situations,limited ability to read non verbal cues, resonding “off topic” or atypically just to point out some. I have e-mails from the L.S.H specialist saying that she has impulses that she cant controll,and feels like she is “not connecting her choices to consequences or impact on others and her feelings.” I have told the staff in IEP meetings that I know she can tell you “never go with a stranger,even if they offer with candy or have a dog. When put in the situation she will go. She will try to hide from me in the store and if she gets out of my sight and I call her she will not respond, after I have a heart attack and find her she has a smile on her face. Some of my problems are, I went to school to pick her up one day and nobody knew where she was, after I frantically ran all over campus n checked all the bathrooms ( one of her favorite places to play) i went to the office and asked them to call her over the loud speaker, then checked campus again,Nobody from the school was helping me look for her and when I was running around asking if anyone saw my daughter they casually said no, then I remembered the week prior she asked if another childs mom could give her a ride home, told her no I did not know the parent. So I had to go to the office at this point I was scared out of my mind and told them they had a minute to find this other girls mothers phone number and call her to see if my daughter was with them or I was calling the police. So they then looked up the mother and called sure enough my daughter convince the mother that I told her it was fine that she give her a ride home. Mind you I don’t know what this parent was thinking I would never give a child a ride home not knowing or speaking to the parent. Another situation having know my daughter the speach teacher gave her a citation becuse she decided to go play in the bathroom instead of returning to class, mind you after just e-mailing me the week before about the “uncontrollable impulses”, and when I confronted her she said she has been going to this class for a while now and she should know better. Hmm ? Another citation she got was because she “threw her lunch garbage on the floor and gave the lunch lady a hard time or took to long to pick it up. So the lunch lady made her stay in for her recess and clean the cafiteria, and when she got off track and started playing the lunch lady gave her a citation for defying authority. And the principle took away her field trip that we were supposed to go on the next day. After speaking with the principle and explaining what happened she still felt that she needed to take away her field trip even though my daughter would not put the two together. My daughter gets teased on the playground (heard that from my older daughter, and some of her classmates when a went to the school to have lunch and see what was going on.) Her teacher says she cannot stay on task,”if she drops her pencil she can be under her desk for 10 min. in a whole nother world” ” has yet to finish a in class assignment”, I had addressed a few of these issues, asking can she have an aid to help her stay on task or help with social behavior? and was told there are way worst students that dont have an aid. I have asked if she could have a peer or a buddy at lunch and recesses ( because she just play’s with the rough boys,because some girls make fun of her) they said ” they dont want to burden another child” I brought up the fact they let her go missing and I am concerned for her safty( the school is not gated,and I have seen many people just walk on and off campus) And there response was ” some times we have to let them make mistakes before we can teach them appropriate social skills” I don’t know what to do my gut say’s PULL HER OUT OF THAT SCHOOL??? And I have called the school district with no response….

    • Beth said

      Pamela, I know this is a more of a child psychology blog than an educational system blog, but hopefully you will receive this message. The way the school is responding to you is sooooo wrong. IEP stands for INDIVIDUALIZED Education Plan. Whether they feel there are children that are “way worse” than her is of no consequence to their responsibility to provide for HER what SHE needs to access the curriculum. As a parent whose child has literally run away from school multiple times, there is no way I would accept losing track of a child being on par with the child making mistakes before they can teach her social skills. My son got lost in the woods behind the school before they agreed to get him an aide, and thank heavens he was not injured.

      Please find an advocate that can help represent your child’s needs at the IEP meetings and can help you understand your child’s rights to a FAPE.

  22. inherited autism…

    […]Is it Severe ADHD or is it Asperger’s? The Case for a Good Assessment « Shirah Vollmer MD[…]…

  23. coping anxiety, coping panic, coping phobias, coping fear…

    […]Is it Severe ADHD or is it Asperger’s? The Case for a Good Assessment « Shirah Vollmer MD[…]…

  24. I really need some advice. My boyfriend has been diagnosed with borderline asperger’s syndrome but this just doesn’t make sense to me because he has all the traits of ADHD. His family (I mean mother’s aunts and uncles) are convinced he is “insane” and has asperger’s syndrome but he looks me in my eyes, is able to have friends though they do think he “has something”, he is constantly talking, repeating himself alot, when he says things he can’t always remember what he has just said. He is only calmer around me but around his family, he gets very stressed and when he gets stressed he becomes very moody, non stop chatter and he relies too much on alcohol to be able to deal in stressful situations. He is unable to cope with a job so is now living on benefits and works on “permitted work” at his mother’s company but even this he finds far too stressful. He couldn’t cope with university or applying himself and he is always on the move, walking or cycling. He has bought prescription tranquilisers off the internet because he suffers with extreme insomnia and no sleeping pills help. He needs me to give him massages and back rubs to calm down before he goes to sleep. I am appalled that his family have never considered it being severe ADHD but when I have mentioned it to them they have become extremely condescending towards me and have said he has Asperger’s end of. They treat him like a child, always telling him off and he swears, suffers with mood swings, and talks again non stop. His family tell him to stop swearing, and yet they swear too. He finds boundaries difficult amongst his family but when he is around me or my friends, who are much calmer and do not talk to him like he is a child, then he does not get stressed, does not over-chatter or interrupt either. I have noticed that his family and social situations can stress him if the company is not supportive of him or listening to him. It has got to the point where his family are dismissive of him and his behaviour, stressing him out more and then he starts swearing more and really can’t stop speaking or interrupting.It’s getting to the point where I have told my boyfriend I no longer want to see his family because they make me feel like I’m a psychotherapist (which I am) dating a patient, or an adult dating a child. But when I am with him, he does not act like this at all. I really need advice now on what to do because my boyfriend is really suffering and because his family are so determined that he has asperger’s but I desperately think he has the wrong diagnosis. Once on the right treatment I know this will improve his quality of life so he doesn’t continue to feel like a failure. I love my boyfriend but it’s exhausting and I really need some help. Thank you for any advice.

  25. Momof4 said

    Thank you for this article. My 6yr old is severe ADHD. I personally would have balked had anyone suggested Aspergers. Because my Step-son is more along those lines. One distinct difference that a mother can use for her own peace of mind is to look at the imaginative play of the child. If the child mimics TV and other things he has seen or read, Then I would look more towards the spectrum, if the child makes up his own play, ADHD.

    I’ll give an example. My stepson has been diagnosed as on the spectrum PDD-NOS. When he was 8, my first son was about 4. The both of them were on the floor playing with race cars. My step son lined them all up and began recounting the last race that was on TV. My 4yr old bunched up the carpet runner and raced two cars over “mountains” and flipped them and crashed them, while saying they were on mars.

    That was the moment I “saw” the difference.

    Severe ADHD is very difficult. Right now we are experimenting with Strattera, but I am concerned as it is not suppose to be a long term treatment.

    my 6yr old ADHD son was on focalin xr, and was doing great in school, but that seems to be the only focus of his treatment is his school. By 5pm there was no medication in his system and he was literally a dangerous ping-pong ball in the house, climbing and jumping and no way to control his dangerous activities. We are noticing a difference on straterra (right now combined with the focalin until the Straterra gets into his system. But I worry we won’t find something to help him in the long run to help him through the whole day.

    Do you have other suggestions that I can look into? He processes meds quickly like I do, So I worry he we will constantly be messing with the meds. Other consideration is he is very skinny and doesn’t eat much. He is very picky. So I don’t need a medicine that makes him aggressive, not want to eat and definitely one that doesn’t affect his sleep. He has previously tried Metadate (that made him aggressive and he lost tons of weight). Any suggestions to look at and discuss with my doctor would be awesome.

    • Hi Momof4,
      Tenex is something to think about, in terms of other medications for ADHD. Thank you for sharing your story.

      • Three Mom said

        My son was on Straterra and it seemed to be working okay in the beginning. After taking it for a while he developed a lot of sleep issues and would wake up every night and would never go back to sleep. His dreams were extremely vivid and disturbing. Also, he was a lot more moody than normal. His pediatrician also said that they were looking into no longer giving this medication to children, due to the side effects. My son was 8 years old at the time.

        It has been recommended to us to give him a mood stabilizer first and then add a stimulant like adderrall or vyvanse. It has been a long road into finding something that will work. More importantly is to find a good Child Psychiatrist who knows what they are doing and has good experience with medications and their side effects. This eliminates a lot of time, money, and heart ache. Our son is now 13 and we FINALLY found a doctor who knows how to treat children and he is succeeding in school, etc.

        Good luck!

  26. Aspergers said

    My son was dx with ADHD when he was 2 after a 15 minute appointment with a developmental ped and checklist. Later after further evaluation by the mental health agency ( a year total) that included teacher/family/friends input, they said there was no way he had ADHD but rather they felt he had Aspergers syndrome. They referred to a multidisciplinary team at our local childrens hospital who dx with PDDNOS (language was delayed, so Aspergers could not be given). Later a doctor who does genetic testing watched him and said, no its aspergers syndrome. The schools psych at the time thought he had Bipolar possible schizophrenia (???), she was sure that he was not on the spectrum at all but then later decided that he had both aspergers and bipolar disorder. Bipolar and Schiz was completely ruled out by both the local mental health agency and the multidisciplinary team. After this he was given a dx of sensory integration problems fine/gross motor, and dyspraxia. Later he got a dx of a Receptive/Expressive Language Disorder. Later even yet he got the dx of Dyscalculia. In other words, the world of psychology is so subjective I can not see how these higher functioning dx can even been given?

    Im just wondering, how do you dx children who may have BOTH a PDD and ADHD. What characteristics present in this case?

    • Thank you for sharing your story. Unfortunately, it is a common one, because, as you say, our diagnostic system is very subjective. The issue of ADHD is mostly concerned with focus and hyperactivity and the issue of PDD is mostly concerned with social communication. The idea is to try to tease out these different aspects of the developmental problems. It is not always clear, which to my mind, means that we should tell families that we are not sure and that we have to do more observations and interventions to determine what is going on. Quick assessments do not help anyone. Thanks again.

  27. hocd said

    There is notmuch in the way of comprehensive information like this over the
    net. I have run a similar OCD web site for quite some time myself.

    Anytime I see information in relation to Is it Severe ADHD
    or is it Aspergers? The Case for a Good Assessment Shirah Vollmer MD as you have done I
    do like to make a comment in support. The truth is if you suffer with obsessive-compulsive disorder then you are searching for
    solutions to your desires – It is my opinion as much practical knowledge is obtainable the

  28. Christine said

    Dr., I see this article was posted a few years ago. Do you have any new info for 2013, or any new articles you can direct me to? I have a 6 yr. old who has been called a “complicated case” and has a school (by school psychologists) dx Asperger’s though not a medical dx of Asperger’s, but he has a medical dx of ADHD. I have always said that he has some unnamed version of something that combines the two or is between the two, but we have struggled with finding a correct diagnosis or any professional who understands him. Thank you.

  29. Misdiagnosed? said

    I was diagnosed as an adult with Aspergers Disorder when being assessed in university. None of the treatments for Aspergers had helped. Recently, I went for an ADHD assessment and was diagnosed with ADHD combined type. I am also a female with a high IQ and a history of trauma and depression.

    It seems to me that the ADHD diagnosis makes the most sense and I am responding well to the medication. I don’t see any indication that my social difficulties are caused by Aspergers disorder after being treated for trauma, depression and ADHD. If I just have ADHD, I am surprised an appalled that I could have gone through life with an incorrect diagnosis and this unfair stigma (I have a successful job in a dynamic social environment) without even being treated for the underlying problem. Thank you for this literature. This seems to be a topic that needs more research. Please keep us updated on any advances.

    • Hello!
      Thank you for sharing your story. Yes, you are not alone. One of the themes of my blog is that misdiagnosis causes a great deal of emotional suffering, and as such, the loosely thrown around diagnosis of Asperger’s Disorder needs to be reined in. Thanks again.

  30. Vito said

    Hi there colleagues, its great post about teachingand fully
    explained, keep it up all the time.

  31. high School in

    Charlie is seven years old. He hates school; he has no friends. Charlie is aggressive and angry most of the time, but particularly when his parents set a limit. A pediatric neurologist diagnosed him with Asperger

  32. Adrienne Baldwin said

    Great, article! My son suffers from severe ADHD which is very similar to the genetic component you were talking about. We see our 7 year old as a high-functioning Autistic that slips through all tests. His stimming is off the charts without medicine. His language score is at a 73 and his motor planning is in the tank. Barely pedaling or jumping like the other kids. However, he is extremely social with children his age and he is sensitive.

    So, we stay confused on where he fits in, but after waiting 7 years to do the ADOS test and thousands of dollars spent on therapy, We have come to conclusion that he has severe ADHD that can make it look and act like autism.

    Now, my goal is to move forward with confidence that we have done all we can, but also to decide what education environment is right for someone who can conform with medication, but has significant language struggles.

    No one, can answer this for me because there are very few severe ADHD cases that present themselves this way.

    Thoughts from your experience with patients like this?

    • Thank you Adrienne. My thoughts are that a combination of medication and a specialized learning environment, where the student teacher ratio is very low, and the teachers have master’s level degrees in special education, can help him thrive. In Los Angeles, schools like Park Century and Frostig, are good examples of a good educational environment for students like your son. Best Wishes, SV

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