ADHD and autism together: when novelty and routine pull in two directions

“I want something new. As long as nothing changes.”

It is half a joke, but the person saying it isn’t laughing. It describes something very concrete: a Saturday when he would love to go somewhere he has never been, because the walls at home are suffocating him with boredom — while knowing that a new route, a new café, new food and the noise of strangers will have squeezed everything out of him by evening. So he stays at home. And is bored. And is angry with himself for being bored.

People who live with both ADHD and autism often describe contradictions like this as a constant pull in two directions. One part seeks novelty, stimulation and spontaneity; the other needs predictability, calm and clear rules. Neither is the “real me” — both are real. In this article I will try to explain what we know about how ADHD and autism intertwine, why the combination is so hard to recognise, and what can help when you live with both.

For a long time it was one or the other

Until 2013, the American diagnostic manual, the DSM, did not allow a person to have both diagnoses at once. If someone was autistic, ADHD could not be diagnosed — their attention difficulties were simply assumed to “belong to the autism”. The fifth edition of the manual (DSM-5) removed this exclusion. Since then it has been possible for someone to have both officially recognised.

The change was not merely administrative. Research had long shown that these two ways of functioning occur together more often than chance would predict. In 2019 Meng-Chuan Lai and colleagues carried out a large meta-analysis of how often autistic people have other diagnoses as well. ADHD was the most common: they estimated that around 28 per cent of autistic people have it — roughly one in four to one in three. Estimates vary between studies, depending on who was included and how things were measured, but the message is clear: the combination is not a rare exception.

Twin and family studies suggest that ADHD and autism partly share hereditary roots. As early as 2008, Angelica Ronald and colleagues found in twins that autistic traits and ADHD traits overlap genetically as well. A Swedish register-based study by Laura Ghirardi and colleagues in 2018 showed that ADHD occurs more often among relatives of autistic people, and vice versa. This doesn’t mean they are the same thing, but it does mean it makes sense to find them together — sometimes in the same person, sometimes spread across a family.

In neurodivergent communities an informal term has taken hold for the combination: AuDHD. It is not a diagnostic term, but many people find it helpful, because it finally names an experience that neither diagnosis describes well on its own.

Where they meet and where they part

The intertwining is easiest to understand if you look at what the two have in common and what is typical of only one. Of course, everyone has their own picture and no diagram describes everyone — but some features recur both in the professional literature and in people’s own accounts.

What they often share are difficulties with executive functions — planning, starting tasks, switching between them and holding information in mind. They can share sensory sensitivity: noise, light, clothing, smells that others barely notice. They can share emotional overwhelm, when a feeling rises faster than a person can catch it. And they can share a deep, absorbing immersion in something that interests the person.

Where they often part is in what drives a person. ADHD often means a hunger for novelty and stimulation — boredom is not just unpleasant but almost painful. Autism often means a need for predictability — a change of plan is not just annoying but can wreck the whole day. In someone who has both, these two needs don’t dissolve into each other. They live side by side and often argue.

The same behaviour, a different reason

One of the biggest difficulties in recognising the combination is that ADHD and autism can look very similar from the outside, even though they come from different reasons. A few examples:

• Interrupting in conversation. With ADHD, often because the thought arrives too fast and will vanish if not said immediately. With autism, it may be because the person doesn’t pick up the unspoken signal that the other person still has the floor.
• Withdrawing from company. With ADHD, perhaps because the conversation has become boring. With autism, perhaps because the sensory and social load is too much.
• A messy desk. With ADHD, because tidying is never interesting enough to get started. With autism, mess is less often the problem — unless an ordered system has been disrupted and can’t be rebuilt.
• Resistance to a task. With ADHD, because of a lack of drive. With autism, often because of vagueness — it isn’t entirely clear what exactly is expected.

When both are present, the reasons add up and sometimes overlap. That is why, as Kevin Antshel and Natalie Russo wrote in a 2019 review, professionals assessing someone don’t just ask “is this behaviour present”, but also “why does it happen”. The answer to the second question is often what tells one from the other.

A pull in two directions

People with the combination often describe life as a constant negotiation between two inner needs. Routine soothes the autistic part, but the ADHD part soon begins to experience it as a prison. Novelty wakes up the ADHD part, but the autistic part pays for it with exhaustion. A plan is essential so that the day doesn’t fall apart — but the ADHD part doesn’t stick to plans, and the autistic part then experiences every departure from the plan as a small catastrophe.

This is how a conversation between partners might sound (composed, not a real person):

“You said you wanted to go on a trip on Saturday. Now you don’t?”
“I do. It’s just that you said Kamnik, and all week I’d been picturing Bled.”
“But it doesn’t matter, they’re both lovely.”
“It doesn’t matter to you. I’d already worked it all out in my head — the car park, the route, where we’d eat. Now I have to start again.”
“But yesterday you said you were bored because we always go to the same places.”
A long pause. “I know. Both are true.”

That “both are true” is exactly what confuses people around them most. From the outside it looks like fickleness or inconsistency. From the inside, it is two real needs that have to fit into the same day. And once that becomes clear to both partners, the argument is often easier to resolve: it isn’t about whether he wants to go on the trip or not, but about needing novelty and time to prepare for it.

How it shows up in everyday life

Everyday life with the combination has a few characteristic tensions that are worth knowing, because people often experience them as personal failure.

Routines you can’t keep up. Many people with ADHD and autism deeply need structure, but find it hard to build and maintain. The autistic part longs for a morning ritual; the ADHD part forgets it after three weeks. When the routine falls apart, what is left is a sense of chaos that the autistic part tolerates poorly — and the cycle turns again.

Interests that burn differently. Autistic interests are often long-lasting and deep, while ADHD enthusiasms can flare up and die out quickly. With the combination there can be both: a few topics that stay with a person for life, and a pile of started projects that have been left lying. I wrote about how this drive can also become a strength in ADHD and entrepreneurship: a gift and a burden at once.

The sensory paradox. Some people with the combination both seek and avoid stimulation. They need music to concentrate, but the noise in a shop breaks them. Movement calms them, but a stranger’s touch is unbearable. The difference isn’t in the amount of stimulation, but in whether the person controls it themselves.

The emotional peak. When too much builds up in the same day — a change of plan, a loud room, a forgotten deadline — it can end in an outburst or a complete shutdown. It helps to understand this as an exceeded window of tolerance, not as bad character or a lack of willpower.

Why the combination is so hard to recognise

When both are present, they can partly hide each other. The autistic need for order can partly cover ADHD disorganisation — a person builds rigid systems that keep them upright, and nobody notices what it costs them. ADHD sociability and impulsivity can cover autistic social difficulties — the person is talkative and makes contact quickly, so nobody thinks of autism, even though every conversation exhausts them afterwards.

It often happens that one is recognised first and the other years later. Someone gets an ADHD diagnosis and much becomes clearer, but something remains unexplained — for example, why a change of plan knocks them over so badly, or why socialising drains them more than it does others. Or the other way round. If you are interested in how ADHD otherwise shows up in adults, I wrote about it in ADHD in adults: signs we have put down to character for decades.

In women the picture is even more complicated, because they often learn to hide both. I wrote about how masking affects the recognition of autism in Autism in women and the masking that wears you out.

A diagnosis of ADHD or autism — or both — is made by a psychiatrist or clinical psychologist after a thorough assessment. If you don’t know where to turn, you may find Clinical psychologist or psychotherapist: two roles we keep confusing helpful. As a therapist in training under supervision in marriage and family therapy, I do not make diagnoses myself.

On medication — just briefly

People with the combination often ask whether ADHD medication can help them. The answer is a matter for a doctor — a psychiatrist who knows their whole picture. Reviews, including the one by Antshel and Russo, point out that the response to medication in people with both diagnoses can differ from the response in people with ADHD alone, and that dosing calls for caution and ongoing monitoring. There is no medication for autism itself, because autism is not an illness to be cured.

Medication can help with some of the difficulties, but it doesn’t answer the question of how to live with two needs pulling in opposite directions. What helps there is understanding, adjustments to your surroundings, and relationships in which you don’t have to explain yourself all the time.

Exercise: two lists for balance

This exercise helps you find what each of the two parts needs, and how to give both room in the same week. It is not diagnostic — it is also useful if you have only one of the two, or neither.

1. Write a list of “what wakes me up”. Everything that gives you energy, drive, a sense of being alive: a new way home, a new recipe, a spontaneous call to a friend, a new project. At least five things.
2. Write a list of “what calms me”. Everything that gives you a sense of safety and predictability: the same morning coffee, familiar music, quiet, a schedule known in advance. At least five things.
3. Next to each item, write how much preparation it needs. Some things on the first list can happen spontaneously; others require you to know in advance. That is often the key.
4. For next week, choose one thing from the first list and plan it in advance — with all the details you need. Novelty, prepared to suit the autistic part.
5. After the week, write down how it went — not just whether it worked, but how much energy it cost you and what you would do differently next time.

Where this explanation doesn’t hold

Not everyone who recognises themselves has both. Many of the traits in this article are familiar to people without either diagnosis. Anxiety, depression, trauma, lack of sleep or long-term stress can also cause attention difficulties, sensory oversensitivity and a need to withdraw. That is why a professional assessment is essential — and why it makes no sense to diagnose yourself on the basis of an online test.

A diagnosis is not a goal in itself. For some people, recognition is a relief that opens the way to understanding and support. For others it matters less — they adapt their lives and manage well without a name. Both paths are legitimate. I wrote about what a diagnosis can and cannot tell you in A diagnosis is a map, not a name for you: what the ICD says and what it does not.

Not everything is the “ADHD part” or the “autistic part”. Dividing into two parts is a useful metaphor, but a person is a whole. Some things come from personality, history, relationships, surroundings — and not from neurological functioning. If we attribute everything to the two diagnoses, we may overlook what is happening in relationships and in life.

The research is still young. Because a joint diagnosis was officially excluded until 2013, there is relatively little research on adults with both. Much of what we know today comes from people’s own accounts and from research on children. That is no reason for distrust, but it is a reason for modesty in what we claim.

What therapy can offer

Therapy can’t change how a person functions, and it shouldn’t try to. But it can help two needs that pull in opposite directions start talking to each other instead of arguing. It can help you understand when it is ADHD drive, when it is the autistic need for safety, and when it is something else altogether — an old family pattern, for example.

In relational family therapy, in which I am training, there is a particular emphasis on relationships. With the combination of ADHD and autism, these are often crucial. A partner who understands why a change of plan wrecks the day responds differently from a partner who takes it personally. Parents who understand why their child is both bored and resistant to change can create a home that gives both needs room.

Therapy can also be a place where you learn to observe your own state without judging it. When am I close to the edge? What drained me today? What do I need to come back? These are questions that help with emotion regulation — not as control, but as care for yourself.

And not least, therapy can be a place where you don’t have to explain why you are the way you are. Where “both are true” is allowed to be the starting point, not something that has to be resolved. I also work with English-speaking clients, in person in Ljubljana.

What to remember

• ADHD and autism occur together more often than chance — a meta-analysis estimated that around 28 per cent of autistic people have ADHD.
• Until 2013 a joint diagnosis wasn’t possible; the DSM-5 removed the exclusion.
• The combination often means a pull in two directions: novelty versus routine, spontaneity versus a plan, stimulation versus quiet.
• The same behaviour can have different reasons, so in assessment the question “why” matters, not only “what”.
• A diagnosis is made by a psychiatrist or clinical psychologist; therapy helps both needs find room in the same life.