Anxiety & depression in AuDHD (Part I)

Common mental health conditions, such as anxiety and depression, are challenging for all people regardless of neurocognitive ability. They can cause distressing and debilitating effects on a person’s daily functioning. However, these effects are extremely distressing for autistics and AuDHDers compared to neurotypicals.

Studies show that autistics more frequently report experiencing anxiety and depression compared to non-autistics.^[1]Heightened Anxiety and Depression Among Autistic Adolescents with ADHD: Findings From the National Survey of Children’s Health 2016–2019 (Accardo et al., 2022)^[2]Attention-deficit hyperactivity disorder traits are a more important predictor of internalising problems than autistic traits (Hargitai et al., 2023)^[3]Prevalence and Risk Factors of Anxiety in a Clinical Dutch Sample of Children with an Autism Spectrum Disorder (Wijnhoven et al., 2018) In this article, I will discuss the relationship between autism and ADHD and how they increase the risk of experiencing anxiety and depression, as well as how to mitigate those risks.

Prevalence

What do the numbers look like?

Autistics with co-occurring ADHD seem to be most affected by anxiety and depression (42% of adolescents) compared to non-autistics and people with just one condition. On their own, both autistics and people with ADHD are likely to have co-occurring anxiety during adolescence (ages 12 to 17), with some studies reporting an average of 50–70% across genders. This number is disproportionately high compared to the general population, where the rate of anxiety is ~9%.^[4]Heightened Anxiety and Depression Among Autistic Adolescents with ADHD: Findings From the National Survey of Children’s Health 2016–2019 (Accardo et al., 2022)^[5]Prevalence and Risk Factors of Anxiety in a Clinical Dutch Sample of Children with an Autism Spectrum Disorder (Wijnhoven et al., 2018)^[6]Anxiety’s Toll on Children and Adults with Autism (Sarris, 2020) | SPARK: Simons Foundation Powering Autism Research for Knowledge)

High levels of anxiety and depression tend to persist from adolescence well into adulthood. This is found in autistic and AuDHD adults who were also more likely to experience levels of anxiety (47.7%) and depression (54.1%) compared to non-autistic adults (15.7% and 17.3%, respectively).^[7]Psychiatric Co-occurring Symptoms and Disorders in Young, Middle-Aged, and Older Adults with Autism Spectrum Disorder (Lever & Geurts, 2016)

When looking at depression specifically, significantly more AuDHDers (38%) tend to report experiencing depression than autistics (20.5%) and neurotypical adolescents (6.3%).^[8]Heightened Anxiety and Depression Among Autistic Adolescents with ADHD: Findings From the National Survey of Children’s Health 2016–2019 (Accardo et al., 2022)In terms of adults, Zheng et al’s (2021) study on independent autistic adults finds this number to be higher (65.4% of autistics had a diagnosis of depression). Putting this all together, this suggests that depression persists and can even be more likely in adulthood for autistics compared to neurotypicals.

While there have been years of studies on the links between autism, anxiety, and depression, there is a noticeable lack of research on anxiety and depression in ADHD populations. Similarly, research on autistic people with ADHD (AuDHD) is limited in this field. So why is it that AuDHDers seem to have the highest rates of anxiety and depression? Well, some research suggests that ADHD traits contribute most to a person having anxiety and depression.

For example, a new study conducted by Hargitai and colleagues at the University of Bath (2023) suggested that people with ADHD are more likely to experience anxiety and depression than autistics. However, other research finds it’s the intensity of ADHD-specific traits, rather than autism-specific traits, that increases the risk of having co-occurring anxiety and depression.^[9]ADHD severity as it relates to comorbid psychiatric symptomatology in children with Autism Spectrum Disorders (ASD) (Mansour et al., 2017)

I think it could be that autism and ADHD have many overlapping characteristics that leave AuDHDers more vulnerable to experiencing anxiety and depression. For example, missing social cues by not understanding them (autism) or being unaware of them due to inattention (ADHD) can lead to difficulties in social communication and being rejected by their peers. While this is one example, I believe more research is needed in this area to understand how the combination of autism and ADHD uniquely affects anxiety and depression.

Additionally, much of this research does not reflect undiagnosed populations. I find this quite alarming, as that suggests these already high numbers are vastly underreported in the autistic/AuDHD community. The lack of anxiety and depression research in ADHD populations may contribute to AuDHDers being unable to access the care and accommodations they need. It may also lead to practitioners misattributing anxiety and depression symptoms to a person’s autism and/or ADHD (or misattributing a person’s autism to anxiety and depression) instead of looking at commonly occurring mental health conditions.

Risk factors

What factors contribute to the increasing prevalence of anxiety and depression in AuDHD?

There are many different factors that work to increase the risks of anxiety and depression in autistic and AuDHD people, including challenges with getting the right diagnosis, barriers in accessing diagnosis and support, as well as challenges with social communication.

Misdiagnosis and diagnostic overshadowing

For autistics who were diagnosed later in life, it is common to have experiences with childhood anxiety. This is understandable as there are many similarities between autistic experiences and anxiety, including having separation anxiety with a caregiver or experiencing selective mutism as children.

Similarly, people with anxiety disorders as well as autistics may have difficulty coping with changes to our reality. This is true for Dr. Natalie, who has both autism and anxiety. She was obviously born with autism, and her anxiety developed as a result of a difficult childhood, as well as a lot of change (She moved 33 times by age 13). She also struggled with social interaction, which caused her to be ostracized.

While autism and anxiety have many similar experiences, the reasons behind those experiences (like why some autistics experience separation anxiety and selective mutism) are what define autism and anxiety as separate conditions. An example of this is how autistic people’s anxiety may be centred on a specific context or location (like communicating in school) whereas non-autistic anxiety might be more generalized.^[10]Anxiety’s Toll on Children and Adults with Autism (Sarris, 2020) | SPARK: Simons Foundation Powering Autism Research for Knowledge)

The relationship between autism and anxiety is complex and different for everyone — while many autistics might not have an anxiety disorder but share similar experiences with anxiety, other autistics (diagnosed or not) may have negative social experiences as a result of their autism that trigger encounters with anxiety and depression.

One friend of mine who experienced lots of anxiety as a child, especially in social situations in school, felt they were too “different” from the other children and did not know how to maintain friendships. In early adulthood, they realized that their feelings of difference stemmed from having autistic communication traits and neurotypicals not understanding them. This is to say that their underlying autism influenced how and when their anxiety was triggered.

Similarly, anxiety and depressive symptoms might be mischaracterized by clinicians to be symptoms of people’s autism and ADHD without also providing support for the anxiety and depression. This is known as diagnostic overshadowing, where a practitioner may misattribute symptoms to someone’s present diagnosis while overlooking other co-occurring conditions that can better explain these experiences.^[11]Anxiety’s Toll on Children and Adults with Autism (Sarris, 2020) | SPARK: Simons Foundation Powering Autism Research for Knowledge)

In this way, I feel that both the misdiagnosing of autism as anxiety (and the under-diagnosing of autism and ADHD) increase the risk of experiencing anxiety and depression. Not having the right supports and accommodations that come with early, accurate diagnoses can make everyday problems extremely challenging for autistics and AuDHDers. Feeling as if no one, even mental health professionals, can understand you can be awful and may leave you feeling defeated and isolated from others.

Unfortunately, many mental health professionals are not aware enough of the nuances in autism presentations to separate autism from anxiety characteristics. This can lead to late diagnoses of autism or under-diagnoses of anxiety and depression in autistics. In addition to misdiagnosis, there are many systemic barriers to diagnosis and treatment that can increase how long (and how severely) autistics and AuDHDers experience anxiety and depression.^[12]When Autism and Depression Come Together: What We Know, How to Manage, and Key Resources (Zheng et al., 2021) | Anxiety & Depression Association of America)^[13]“I wouldn’t know where to start”: Perspectives from clinicians, agency leaders, and autistic adults on improving community mental health services for autistic adults (Maddox et al., 2020)

Lack of access to diagnosis & treatment

Going undiagnosed and untreated for disorders such as anxiety and depression can be distressing and affect people’s daily functioning if it goes unrecognized. Many autistics and people with ADHD experience being undiagnosed for much of their lives due to systemic barriers in diagnosis including, but not limited to: financial barriers and a lack of extensive research on various presentations of autism. Similarly, it is difficult for autistics and AuDHDers to get mental health support for anxiety and depression.

Firstly, getting effective treatment (including individual therapy and medication) can be expensive and time-consuming. In fact, many autistics report financial and insurance issues as their top reason for not getting treatment for anxiety and depression. This is a privilege that few people can afford to pursue; as such, many choose to cope in their own ways. This may be another reason why we see autistics reporting anxiety and depression symptoms for longer periods than neurotypicals.^[14]Depression in independent young adults on the autism spectrum: Demographic characteristics, service use, and barriers (Zheng et al., 2021)

Additionally, for autistic and AuDHD people of colour, it is even harder to access support in diagnosis and treatment for anxiety and depression. On average, autistic POC are less likely to be diagnosed with psychological conditions compared to White autistic adults. Now consider the challenges we face in first getting an autism/ADHD diagnosis. Here, the lack of research on how autism presents and/or affects health outcomes in these populations, combined with structural barriers to accessing (culturally sensitive and uplifting) mental health supports, places us at an increased risk for anxiety and depression and leaves us facing worse health outcomes into adulthood.^[15]Racial/Ethnic Differences in Psychiatric and Medical Diagnoses Among Autistic Adults (Ames et al., 2022)

The intersections of race/ethnicity and autistic/disabled identities is an example of how people of colour can be further marginalized in the health care system. In this framework of intersectionality, Dr. Kimberlé Crenshaw describes how the experiences we face due to our identities (specifically race and sex, but also ability and social class) come together to create a unique experience for the person at the intersection of those identities.^[16]Demarginalizing the intersection of race and sex: A black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics (Crenshaw, 1989)

This is why the racism that Black women experience is different than that of Black men, and why the experiences of one autistic person may be different from another when we consider their other identities. Likewise, this framework is useful in understanding how experiences of anxiety and depression can disproportionately affect historically marginalized communities.

In my personal experience, mental health issues have been taboo in Black and African cultural circles, so it can be hard to find people to talk to in our community or to find support. Additionally, as the health care system is overwhelmingly white, it can be difficult to be vulnerable with people who have such different life experiences from you (sometimes the lack of understanding from these clinicians can further trigger anxiety and depressive symptoms!). This makes it harder to advocate for ourselves in mental health spaces, as well as to trust the healthcare system to help us find affirming support.

In this way, to improve health outcomes for all autistics and AuDHDers, inequities in mental health support accessibility need to be addressed by acknowledging the historical obstacles racialized communities face in navigating the health care system. Additionally, autistics may have trouble identifying and communicating their needs and advocating for themselves, which poses another challenge in treating anxiety and depression.^[17]Demarginalizing the intersection of race and sex: A black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics (Crenshaw, 1989)^[18]Racial/Ethnic Differences in Psychiatric and Medical Diagnoses Among Autistic Adults (Ames et al., 2022)

Social communication & social isolation

Social communication can be another source of anxiety that is particularly distressing for autistics and AuDHDers. As children, trying to make friends can be scary when we do not understand neurotypical social cues. Many of us experience rejection by our peers and as a result, have fewer opportunities to practice our social skills. As adults, many autistics may camouflage their behaviours to navigate neurotypical society. It can be exhausting to use extreme amounts of energy “acting neurotypical” for the sake of fitting in. As such, masking and camouflaging can be a source of anxiety when making friends and avoiding rejection is very important to us.

Many autistics who camouflage and mask frequently may find they also experience high levels of anxiety.^[19]Looking good but feeling bad: “Camouflaging” behaviors and mental health in women with autistic traits (Beck et al., 2020) For me, this anxiety manifests when I’m working and comes from keeping my voice and facial expressions engaged and friendly towards customers and coworkers during a busy eight-hour shift. Sometimes I will have to run through a mental script of all the possible directions a conversation will go to prepare myself for making a phone call or chatting with a supervisor. However, working for long periods on my own or with a few people who have similar communication styles, makes it easier for me to be myself, making these situations bearable.

Possibly due to the difficulties associated with maintaining social interaction, many autistics differ from neurotypicals in how much time we like to spend on social interaction. In this way, what neurotypicals may see as isolating or a distressing lack of social support can be seen as normal for autistics. In my experience, a wide social network or long periods of time spent with loved ones is not needed for us to feel content and supported. However, if we perceive a lack of support (regardless of time spent or amount of people around us), it can become distressing and a trigger for feelings of loneliness and depression.^[20]When Autism and Depression Come Together: What We Know, How to Manage, and Key Resources (Zheng et al., 2021) | Anxiety & Depression Association of America

Summary

In summary, the challenges autistics and AuDHDers face on a daily basis may exacerbate the debilitating effects of anxiety and depression. These challenges, when left unsupported and unaccommodated, place autistics at an increased risk for developing co-occurring anxiety and depression, as well as experiencing high levels of these symptoms throughout their lives. Misdiagnosis, inaccessibility of diagnostic and treatment resources, and social communication difficulties all work together to increase autistic people’s risk of anxiety and depression. In Part 2 of this series, we will talk about some ways to lessen the risk of experiencing anxiety and depression.