Methodical/mercurial

How would it be if you woke up one morning around4 am,consumed by an idea that felt like the Best Idea You Ever Had. You spend the next two hours fervently researching said idea, watching videos, reading in-depth articles, compiling a spreadsheet comparing costs, techniques and options, then buying a whole load of books and equipment, and signing up to courses to teach you how to bring this fantastic, life-changing idea to fruition. You book a viewing for the new house in a new country that you are going to buy after investigating climate, housing options and work opportunities. You book the flights for that trip, to a Pacific island, where you will learn to scuba dive and set up a business as a dive instructor having fully understood the tourism industry and its legal implications. You sign up for that master’s programme in hypnotherapy/mushroom-growing/road-building after comparing the cost and quality of all colleges offering these courses. Your research is deep, your conclusions well justified. These are all good choices. Buzzing on your own brilliance at finding the answer to all of your problems, your true calling in life and, basically, frigging nirvana, you are desperate to wake your beloved, who is lying beside you, blissfully unaware that their world is about to be rocked. You think about waking them because you can’t contain all this excitement alone and need to share it, but it’s only6 amand you know from experience that this wouldn’t end well. So you sit, fidgeting, watching the clock until6:30 am.Surely, that’s late enough? Perhaps if you bring them coffee, they won’t be so mad. Yet how could they be mad, when what you’re about to reveal to them will make them say: ‘Why didn’t you wake me up sooner, you genius?’ But as you sit impatiently waiting for an acceptable hour to rouse your beloved and blow their mind, your whole self shifts sideways, like someone just turned the TV over to another channel or a changeling took over your mind. You suddenly realise that your previously designated Best Idea Ever is full of holes and is actually a Terrible Idea. You are puzzled that you didn’t see this sooner. What were you thinking? You can’t move house because your kids are in school here, you have a full-time job and bills to pay, and you don’t have the attention span to read your horoscope, let alone do a master’s. And you can’t even swim. What idiot thought that any of this was a good idea? Oh… it was me. OK… time to cancel it all and hope that you didn’t lose too much money and that it will all be back in the bank account before ‘they’ wake up. And hope that you don’t do the same thing again tonight. You will likely have come across the term AuDHD used as a shortcut to describe those given the dual diagnosis of autism and attention-deficit and hyperactivity disorder (ADHD). It is a relatively new label and for good reason – until recently, no one individual was clinically permitted to be given both diagnoses and therefore there was no one to whom the term ‘AuDHD’ could officially apply. In 1994, a mere 32 years ago, theDiagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), included Asperger Syndrome for the first time. In 2013, thediagnosiswas removed from the 5th edition(DSM-5)and subsumed under the broader category of ‘autism spectrum disorder’. Asperger Syndrome hadidentifiedindividuals who met the social and behavioural aspects of the diagnostic criteria for autism but who did not have intellectual disability or the language-development differences then associated with an autism diagnosis. As a result, an autistic person reading this magazine today would have been unlikely to receive an autism diagnosis in the past: there was simply no diagnostic category that fit their profile. That helps to explain the huge rise in adult diagnoses in recent decades. Autism and ADHD were long considered mutually exclusive Alongside this, diagnosis ofADHD in adultshas been a similarly recent arrival. Having been considered a predominantly childhood condition for most of itshistory, the idea that children can continue to experience ADHD features into adulthood was not seriously considered until the early 2000s. Earlierversionsof theDSMrequired that symptoms had to have been present prior to the age of seven years, and focused almost entirely on childhood behaviours to form the diagnosis. In 2013, with thepublicationof theDSM-5,the onset age of ADHD symptoms was raised to12 years,and fewer symptoms were required for adults to meet the diagnostic threshold – which took into account development changes and challenges within adult settings, such as work – thus opening up ADHD diagnosis to adults. This means that a person without intellectual disability and with relatively typical language development has been eligible for an autism diagnosis for only32 years.And the ADHD criteria have been explicitly adapted to better recognise the disorder in adults only since 2013. That history is one part of the AuDHD issue. The second part is that autism and ADHD were long considered mutually exclusive. It was thought that their apparently contradictory traits of rigidity and impulsivity effectively cancelled each other out. This meant that a person – either child or adult – could not be officially diagnosed with both conditions until13 yearsago, when theDSM-5removed this exclusion and allowed both diagnoses to be given to the same person – opening the way for what is now widely called AuDHD. At first glance, existing diagnostic criteria for each condition may look like contradictions of each other. While a stereotypical autistic person may present as socially awkward, precise and cautious in language and behaviour, requiring predictability, sameness and calm, our ADHDer looks like the complete opposite. ADHD diagnostic criteria typically present as someone socially driven, scattered and impulsive in language and behaviour, seeking novelty, variety and stimulation. How can it be that both of these seemingly opposing traits can exist in one person, and what is it like for that person whenthey do? Given the relatively recent formal recognition of this comorbid profile, research into its impact is unsurprisingly scarce and, aside from a small handful of papers, has been focused on children and adolescents. The earliest research into this overlap I could find waspublishedin 1999; those investigators concluded that autistic features were common in those with ADHD, and that a dual diagnosis should be considered in some cases, even though this was not clinically permitted at the time. This overlap has been one of the most frequently studied aspects of AuDHD. A 2023 systematicreviewidentified 9,050 articles and ultimately included 23 studies; across these, estimates of the prevalence of ADHD symptoms in autistic young people without intellectual disability ranged from2.6 percent to95.5 percent. Anotherpapersuggested that 50 to70 percent of autistic people present with comorbid ADHD. If you are reading this article with a diagnosis of autism or ADHD, you may want to think about whether you may be both, because it’s looking increasingly likely thatyou are. Of course, there have always been differing opinions and concerns about the pathologising nature of diagnosis in neurodiversity. Where does one neurodivergent condition end and another begin? Can we really separate these aspects of ourselves into neat clinical categories – often deemed necessary to permit access to a particular support service, therapy, fund or setting to meet the often-disabling needs of being neurodivergent in a neurotypical world? The reality is that no one knows the answers, so here we are with our rigid clinical diagnostic criteria, which – as we can see from the alterations in theDSM-5– are changing as understanding grows. Forgive me for working within these uncomfortable neat boxes, but they are all we have right now; and, for at least some people, they can be a helpful way of unders