Why autism and ADHD so often occur together in athletes, how sport hides both, and why diagnosing both helps performance, fame, coaching and later life.
By Dr Hossein Rostamipour, Consultant Psychiatrist and Dr Chris Kalafatis, Consultant Psychiatrist · Eton ADHD Clinic
Why we have written this. This is for athletes who are autistic and have ADHD, sometimes called AuDHD, and for the parents, coaches, clubs and team doctors around them. It explains why the two conditions so often occur together, why sport can hide both of them for years, and why recognising both, rather than one, matters so much: for performance, for the professional years, for the move into coaching or another career, and for coping with public life without being changed by it. It is general information, not personal medical advice, and nothing here is a reason to start, stop or change any medication yourself. Our companion articles on ADHD in athletes and on autistic athletes cover each condition on its own; this one is about what happens where they meet.
Some athletes never quite fit either explanation they are given.
They need their routine to be exactly right, and they are bored by it within a week. They notice everything on the pitch, the angle of a run, the sound of a strike, the smell of the grass after rain, and they are exhausted by the noise of the changing room. They can train with ferocious focus on the one skill that fascinates them and cannot get out of the door with the right kit. They want every session done perfectly, and on some days they cannot start at all.
If they have been assessed, they may have been told they have ADHD, or that they are autistic. The diagnosis helped, but only partly. Something was still missing.
Often what is missing is the other half.
One athlete, two conditions
Autism and ADHD occur together far more often than was once believed. For many years the diagnostic manuals did not allow the two to be diagnosed in the same person, so the apparent lack of overlap in older research was partly a product of the rules. When the American Psychiatric Association removed that restriction in DSM-5 in 2013, the picture changed.
A meta-analysis of 63 studies found that around 38.5% of autistic people currently meet criteria for ADHD, and around 40.2% do at some point in their lives. A separate meta-analysis in The Lancet Psychiatry, using a broader set of studies, put the figure at around 28%. Estimates vary with age, setting and method, but even the lower figures mean that for a large share of autistic people, understanding autism without ADHD is understanding half the picture.
The two conditions share more than they are usually given credit for, including differences in sensory processing and in executive function, the mental skills of planning, starting, switching and organising. Where they occur together, they produce difficulties that neither diagnosis predicts or treats on its own.
There is very little research on AuDHD in athletes specifically. The International Olympic Committee's 2026 consensus statement on mental health in elite athletes notes that young elite athletes with neurodevelopmental conditions remain under-represented in the research. Much of what follows therefore draws on the wider evidence and on our clinical experience, and we have tried to be clear about which is which.
Why the labels fit AuDHD athletes poorly
Part of the difficulty is the word autism itself.
The autism spectrum, as currently defined, uses one term to cover two very different clinical realities. At one end is a person with profound intellectual disability who may never speak or live independently and who needs round-the-clock care. At the other is an adult of typical or high intelligence who holds down a demanding career, and in the case of an athlete may be competing at the highest level of their sport.
In 2022 the Lancet Commission on the future of care and clinical research in autism proposed "profound autism" as a separate administrative category for autistic people with the greatest support needs. The proposal is contested. Autistic-led responses warned that any severity category risks reviving functioning labels and a hierarchy of who counts as properly autistic, and that objection deserves to be taken seriously. Our view is that clarity about need does not require a hierarchy of worth, and that the present arrangement serves neither end well.
For an athlete, the practical consequence is this. The label they receive carries a public image drawn largely from the profound end, and an assumption of incapacity that bears no relation to their life. Many find it hard to explain to a coach, a club or a sponsor what the diagnosis means for them. Some decide not to seek assessment at all, because they fear what the word will do to how they are seen.
We would argue that for many athletes of typical or high ability, autism is better understood alongside ADHD, as one combined profile that shapes how they think, perceive and perform, rather than as two parallel diagnoses that were never designed to sit together.
How sport hides both conditions
Sport can conceal AuDHD more thoroughly than almost any other setting.
Structured training suits the autistic side: clear rules, fixed routines, measurable progress and endless repetition of something that genuinely interests them. Physical activity suits the ADHD side: movement, immediate feedback and the rise in dopamine and noradrenaline that comes with exercise. A young athlete with both conditions can look settled and focused on the training ground and quietly struggle everywhere else.
The two conditions also hide each other. Autistic need for routine can impose an external order that masks ADHD disorganisation. ADHD restlessness and sociability can make autistic traits look like ordinary shyness or intensity. And athletes who leave mainstream schooling early for academies or sports schools miss the classroom comparisons that often prompt a first referral.
Then there is camouflaging. Many autistic people learn to hide their differences, rehearsing conversations, copying others and suppressing what feels natural. Research has shown that camouflaging is common in adults, particularly in women, and that it can lower scores on conventional autism measures. The Camouflaging Autistic Traits Questionnaire, the first validated measure of it, was only published in 2019, and it is still not routinely built into assessment pathways.
Compensation adds a further layer. Many athletes with both conditions limit the impact on their lives through intelligence, sheer effort and a career they chose precisely because they love it. They survive, and often excel. That is exactly why they are hard to identify: most screening tools measure the failure to compensate, not the underlying way a person's brain works.
Where the two conditions meet in sport
Sensory experience. Heightened sensitivity to sound, light, touch and smell is usually filed under autism, but it is common in ADHD too. For an AuDHD athlete it cuts both ways. A finer grain of perception can support reading play, judging distance and timing, and feeling the physics of a movement. The same sensitivity makes crowds, floodlights, whistles, strong smells and uncomfortable kit draining, and when the distress is misread as anxiety or a bad attitude, the athlete is blamed for something they cannot switch off.
Organisation. This is where the combination is sharpest. ADHD disorganisation is about starting and sustaining: the athlete knows what needs doing and cannot begin, or begins and loses the thread. The usual advice is to cut corners and do a good-enough version. Autistic rigidity makes that advice impossible, because a good-enough version feels wrong: the task is done properly or not at all. Put the two together and the athlete can neither start the recovery plan nor do it imperfectly. It is not twice as disorganised. It is disorganised in a way neither framework predicts, and the standard ADHD strategies fail outright.
Routine and novelty. The autistic side needs sameness; the ADHD side needs novelty. A training block that is too repetitive becomes unbearable within weeks, and one that changes too often becomes distressing. Getting that balance right, deliberately and with the athlete, can make a real difference to consistency.
Restlessness without hyperactivity. Many AuDHD athletes show nothing that looks conventionally hyperactive. Instead they are restless, anxious and never internally calm, and outside sport they struggle to switch off. The traditional division of ADHD into inattentive and hyperactive presentations fits these athletes badly, and research had already questioned how stable those subtypes are over time.
Defeat and feedback. High personal standards, black-and-white thinking and intense emotional reactions can combine to make a defeat, a selection decision or a piece of vague criticism feel catastrophic. What looks like overreaction from the outside is often an athlete who has been trying to meet an impossible standard for years.
Why diagnosing both releases the whole athlete
When only one condition is recognised, support is aimed at half the person, and it can make things worse.
Psychological work built on an ADHD model alone tends to push for flexibility, shortcuts and tolerating imperfection, which the autistic side cannot accept. Work built on an autism model alone builds routine and structure that the ADHD side cannot sustain. The athlete leaves feeling more at fault, not less. The same applies to coaching: a plan that suits one condition may actively work against the other.
A combined diagnosis changes that. Athletes who receive it often describe a further level of relief beyond a single diagnosis. It makes sense of their past, explains why earlier help only partly worked, and lets them see their strengths, detail, focus, pattern recognition, honesty and persistence, as part of the same profile rather than as lucky accidents.
It also makes treatment more precise. ADHD medication, where it is appropriate, can help with starting, sustaining attention and regulating impulse and emotion. It does not create ability an athlete did not have; it removes a disadvantage so they can use what they already have. Autism has no medication and does not need curing, but understanding it shapes the environment, the communication and the adjustments around the athlete. Both together allow a plan that fits.
In our experience this is what releases an athlete's full personal and professional capacity: not a new ability, but the end of years spent fighting their own profile without knowing what it was.
Preparing for the professional years
A professional career asks a great deal of executive function and sensory tolerance at exactly the age when the structure of youth sport falls away. Early recognition gives an athlete time to prepare for it.
In practice that means building systems before they are needed: written schedules and checklists that suit how the athlete actually works; agreed routines for travel days and match days; quiet space before and after competition; clear, specific communication with coaches; and a plan for what happens when routines are disrupted. It means a team doctor who understands both conditions and how they interact with sleep, appetite, heat and travel.
For athletes who take ADHD medication, it also means sorting out the paperwork early. Stimulants are prohibited in competition without a therapeutic use exemption, and controlled-drug rules differ widely between countries. Our article on ADHD in athletes covers exemptions and travel in detail. A thorough specialist assessment that documents both conditions makes an exemption application considerably more straightforward.
Fame without being changed by it
Public life is hard on both sides of an AuDHD profile. The autistic side finds unscripted interviews, crowds, sponsor events and constant attention socially and sensorially exhausting. The ADHD side is vulnerable to impulsive comments, the pull of social media, and a diary that fills faster than it can be managed.
Autistic athletes are sometimes labelled cold, arrogant or difficult with the media when they are coping with a load others do not experience. Athletes with ADHD can say something in the heat of a moment that follows them for years. And many AuDHD athletes take criticism literally and personally, reading thousands of comments as a verdict on who they are.
Understanding the profile allows an athlete and their team to plan: predictable media formats, preparation for likely questions, clear limits on social media, a trusted person who manages the diary, and protected recovery time. The aim is not to change who the athlete is to suit public life, but to set up public life so that it does not change who the athlete is.
After playing: coaching and beyond
Retirement from sport is a vulnerable point for any athlete, and the IOC highlights athletes leaving sport as a group whose mental health needs are under-studied. For an AuDHD athlete, the structure that quietly held everything together disappears overnight.
Many move into coaching, and many are well suited to it. An AuDHD coach may bring deep technical knowledge, an eye for detail and pattern that others miss, honesty in feedback, and a real commitment to doing things properly.
The same traits can create friction. Autistic people are often deeply committed to the work itself and want the best idea to win on its merits. Clubs, federations and academies run partly on timing, alliances and compromise, and an AuDHD coach may find that side of organisational life baffling or unfair. Their sense of time and priority may also run differently from the organisation's. None of this is a deficit in the usual sense, but it is a predictable source of conflict, and knowing about it in advance allows a coach to choose roles, structures and working relationships that suit them.
Diagnosis before retirement, rather than after a crisis, makes that transition far easier to plan.
Contentment
The end goal of recognising both conditions is not only better performance. It is an athlete who understands themselves.
Many AuDHD athletes have spent their careers believing they were talented but difficult, gifted but inconsistent. Understanding the combined profile allows them to set that story down: to see why some things were always harder, why other things came so naturally, and why their achievements were earned against a disadvantage no one had named. That understanding is, in our experience, one of the most protective things an athlete can take into life after sport, and part of what allows them to be content with who they are rather than defined by the next result.
Measuring cognition objectively
Assessments of ADHD and autism rely heavily on history, informants and questionnaires. Those remain essential. But camouflaging and compensation can distort self-report, and athletes often have limited time and unusual lives that questionnaires were not designed for.
Objective cognitive testing offers another view. Dr Kalafatis has worked on the development of the Integrated Cognitive Assessment, a five-minute computerised test in which people categorise rapidly presented images, measuring the speed and accuracy of visual processing. In a study published in Scientific Reports in 2019, performance on this kind of rapid visual categorisation task correlated with established measures of cognitive performance. A later validation study in 230 people, published in Frontiers in Psychiatry in 2021, found that the test detected cognitive impairment with an accuracy (AUC) of 81% in mild cognitive impairment and 88% in mild Alzheimer's disease. Because it does not depend on language, its results were much less influenced by years of education than conventional pen-and-paper tests, and it showed no significant practice effect on repeated testing.
We want to be precise about what this does and does not mean. The test was validated in memory conditions, not in athletes, and it is not a test for ADHD or autism. What those properties suggest is a role alongside a full assessment: objective cognitive measurement that is not skewed by language, education or masking, and that can be repeated over time. For athletes in contact sports, where research has linked ADHD with a greater history of concussion, a reliable personal baseline and repeatable follow-up are worth thinking about. That use has not yet been formally studied in athletes, and we would present it only as a supplement to clinical judgement.
In the interests of transparency, Dr Kalafatis has served as Chief Medical Officer of Cognetivity Ltd, the company that developed the Integrated Cognitive Assessment.
What coaches, clubs and parents can do
- Ask about both conditions. If an athlete has one diagnosis and support is only partly working, consider whether the other is present.
- Give clear, specific instructions, in writing as well as spoken, and check understanding rather than assuming it.
- Balance routine and variety deliberately, and agree changes to training blocks with the athlete in advance.
- Do not rely on the usual ADHD advice to "just do a quick version"; for an AuDHD athlete it may be impossible. Break tasks down into defined, finishable steps instead.
- Provide a quieter space before and after competition, and flexibility with kit where the rules allow.
- Explain selection and tactical decisions rather than leaving them implied.
- Plan media commitments with predictable formats and protected recovery time.
- Start conversations about life after sport, including coaching, well before retirement.
How we approach AuDHD in athletes at the Eton ADHD Clinic
We assess ADHD and autism together, because in athletes they so often occur together and because treating one without recognising the other can leave an athlete worse off. Our children's and adolescents' service assesses and treats ADHD and autism in London and in Manchester at Alderley Edge, as well as online, which matters in sport, where the question so often arises in an academy-age athlete. Our assessments take account of camouflaging and compensation, gather information from home, education and sport where the athlete agrees, and take a developmental history thorough enough to support a therapeutic use exemption if one is needed.
Treatment and recommendations are planned around training, competition, travel and public life, and written to be practical for coaches, clubs and families. Eton Psychiatrists provides in-house Consultant Cardiology, so the cardiovascular questions that arise before stimulant treatment in a highly trained athlete are answered within the same service.
Six reasons athletes choose the Eton ADHD Clinic
- ADHD and autism assessed together, with attention to how they interact.
- Assessment that allows for masking and compensation, so high-achieving athletes are not missed.
- Documentation built for exemption applications, with the evidence anti-doping bodies expect.
- Treatment planned around competition, travel and media, not in spite of them.
- In-house Consultant Cardiology, for athletes considering stimulant treatment.
- Support for the whole career, from academy years to coaching and life beyond sport.
Where to go next
If you are an athlete who recognises yourself in this article, or a parent, coach or team doctor of one, an assessment of both conditions can bring clarity, and with it support that finally fits.
Sources
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th edn (DSM-5). Arlington, VA: American Psychiatric Publishing (2013).
- Antshel, K.M. & Russo, N. Autism spectrum disorders and ADHD: overlapping phenomenology, diagnostic issues, and treatment considerations. Current Psychiatry Reports 21(5), 34 (2019). https://doi.org/10.1007/s11920-019-1020-5
- Hull, L., Petrides, K.V., Allison, C. et al. "Putting on my best normal": social camouflaging in adults with autism spectrum conditions. Journal of Autism and Developmental Disorders 47(8), 2519–2534 (2017). https://doi.org/10.1007/s10803-017-3166-5
- Hull, L., Mandy, W., Lai, M.C. et al. Development and validation of the Camouflaging Autistic Traits Questionnaire (CAT-Q). Journal of Autism and Developmental Disorders 49(3), 819–833 (2019). https://doi.org/10.1007/s10803-018-3792-6
- Iverson, G.L., Wojtowicz, M., Brooks, B.L. et al. High school athletes with ADHD and learning difficulties have a greater lifetime concussion history. Journal of Attention Disorders 24(8), 1095–1101 (2020). https://doi.org/10.1177/1087054716657410
- Kalafatis, C., Modarres, M.H., Apostolou, P. et al. Validity and cultural generalisability of a 5-minute AI-based, computerised cognitive assessment in mild cognitive impairment and Alzheimer's dementia. Frontiers in Psychiatry 12, 706695 (2021). https://doi.org/10.3389/fpsyt.2021.706695
- Khaligh-Razavi, S.M., Habibi, S., Sadeghi, M. et al. Integrated Cognitive Assessment: speed and accuracy of visual processing as a reliable proxy to cognitive performance. Scientific Reports 9, 1102 (2019). https://doi.org/10.1038/s41598-018-37709-x
- Lai, M.C., Kassee, C., Besney, R. et al. Prevalence of co-occurring mental health diagnoses in the autism population: a systematic review and meta-analysis. The Lancet Psychiatry 6(10), 819–829 (2019). https://doi.org/10.1016/S2215-0366(19)30289-5
- Lai, M.C., Lombardo, M.V., Ruigrok, A.N.V. et al. Quantifying and exploring camouflaging in men and women with autism. Autism 21(6), 690–702 (2017). https://doi.org/10.1177/1362361316671012
- Lord, C., Charman, T., Havdahl, A. et al. The Lancet Commission on the future of care and clinical research in autism. The Lancet 399(10321), 271–334 (2022). https://doi.org/10.1016/S0140-6736(21)01541-5
- Pukki, H., Bettin, J., Outlaw, A.G. et al. Autistic perspectives on the future of clinical autism research. Autism in Adulthood 4(2), 93–101 (2022). https://doi.org/10.1089/aut.2022.0017
- Reardon, C.L., Gouttebarge, V., Kroshus-Havril, E. et al. Mental health in elite athletes: International Olympic Committee consensus statement (2026). British Journal of Sports Medicine 60(15), 1083–1130 (2026). https://doi.org/10.1136/bjsports-2025-111514
- Rong, Y., Yang, C.J., Jin, Y. & Wang, Y. Prevalence of attention-deficit/hyperactivity disorder in individuals with autism spectrum disorder: a meta-analysis. Research in Autism Spectrum Disorders 83, 101759 (2021). https://doi.org/10.1016/j.rasd.2021.101759
- Willcutt, E.G., Nigg, J.T., Pennington, B.F. et al. Validity of DSM-IV attention deficit/hyperactivity disorder symptom dimensions and subtypes. Journal of Abnormal Psychology 121(4), 991–1010 (2012). https://doi.org/10.1037/a0027347
Frequently Asked Questions
This article was written by Dr. Hossein Rostamipour for Eton Psychiatrists and first published at etonpsychiatrists.co.uk. © 2026 Eton Psychiatrists. All rights reserved.
