He was five, wiry, and fast, so fast his mother looped her purse strap around his wrist in the waiting room. She spoke softly, in Spanish, explaining that he could not sit still, could not sleep, could not stop. As she described his meltdowns, he interrupted with nonsense sentences, unrelated to her words, untethered from context. It was not defiance; it was overflow.

I and my team of CNA Spanish interpreters saw children like him every week in our cross-cultural evaluation clinic in Phoenix. Hispanic families navigating stigma, language barriers, and a diagnostic process that demanded either/or answers. But this boy was not either/or. He was both.

He flapped when excited, bolted when overwhelmed, and fixated on spinning objects. His eye contact flickered. His play was solitary and repetitive. But he also climbed furniture, interrupted constantly, and could not follow two-step directions. He was textbook ADHD. He was textbook autism. He was AuDHD, before the term existed. The questionnaires we sent to the family in Spanish and to the teachers in English confirmed the clinical picture perfectly. What we saw in the exam room and playroom was mirrored in both languages, across both settings. The diagnosis was not a guess. It was a pattern.

We explained the dual diagnoses (autism and ADHD) and gave the mother handouts in Spanish on both conditions. We walked her through how to advocate for her son under existing special education law and discussed the possibility of medication. We scheduled a follow-up so other family members could attend and ask questions directly. Two weeks later, the mother returned with the child’s father and a cousin who was more fluent in English. I explained the treatment options. Two drugs were available. Since the child was not excessively disruptive, I ruled out risperidone, despite its efficacy. Methylphenidate would likely kill his appetite and only worked for a maximum of 12 hours. The drug of choice was atomoxetine, a norepinephrine reuptake inhibitor that worked for 24 hours and had the fewest side effects. The family agreed to a trial, and I sent home follow-up questionnaires for both the family and the teachers.

Two weeks later, the mother hugged me and said: “Usted es un hacedor de milagros.” “You are a miracle worker.” The questionnaires showed clear improvement. In a handwritten note, the teacher reported that the school’s special education consultants had observed the child was more responsive to behavioral approaches for his autism over the past two weeks.

The DSM-IV and DSM-5 are flawed. It was a taxonomy built for bureaucrats, not clinicians. The manual’s architecture discouraged nuance and punished pattern recognition. It was a diagnostic silo masquerading as science. But in our Phoenix clinic, we saw children who defied those silos. We called it “dual diagnosis,” not to be provocative, but because it was true. They flapped and fixated, they bolted and interrupted, they were rigid and impulsive, and they were both.

Now, the same institutions that dismissed it call AuDHD “emerging,” a trendy hybrid, a diagnostic fashion statement. They publish papers and act like they discovered fire. But we were flying before they even built the runway.

Our clinic was a crucible of improvisation. We translated handouts into Spanish, adapted behavioral strategies to cultural norms, and used medication not as a panacea but as a scaffold. We did not treat disorders; we treated children. And when the system could not see them clearly, we adjusted the lens.

Before DSM-5 caught up, before “AuDHD” became a hashtag, there was the late L. Eugene Arnold, MD, M.Ed., the guru of ADHD psychopharmacology. He chaired the NIH-funded Multimodal Treatment of ADHD (MTA) Study, a landmark trial that reshaped how clinicians approached ADHD. The MTA proved that combination treatment (medication plus behavioral therapy) was superior to either alone, and it became the gold standard for care.

Together, we worked on Risperidone (2002) and Methylphenidate (2005) studies, exploring their effects on children with autism and disruptive behaviors. I was also aware of Gene’s Atomoxetine (2015) study, published in 2015, which showed promising results for hyperactivity in children with autism spectrum disorders. That study validated what I had already seen in Phoenix: Atomoxetine was often the drug of choice for children with dual diagnoses, longer-acting, fewer side effects, and better tolerated than stimulants.

Gene and his colleague Dr. Michael Aman, PhD, invited me to join the NIMH Research Units on Pediatric Psychopharmacology (RUPP) Autism Network at Ohio State. They wanted a strong pediatrician voice among a team dominated by psychiatrists and psychologists. They were right to do so. I conducted side studies on the nutritional intake of children with ASD, including the return of weight to its proper isobar after discontinuation of risperidone, both published as first-author papers. These studies added depth to the pharmacologic findings and gave families real-world guidance on managing side effects. I was listed as an author on eight RUPP Network publications. Not a token pediatrician, but a full voice among psychiatrists and psychologists. My edits were not cosmetic; they clarified the message, sharpened the impact, and honored the real-world care we were trying to model.

We were not waiting for permission. We were building the future while the system clung to the past.

What the system still does not see

The DSM-5’s eventual recognition of dual diagnosis was a step forward, but it did not fix the architecture. The manual still struggles to accommodate complexity. Insurance systems still reward simplicity. And clinicians are still pressured to choose a lane, even when the child is clearly driving across them. The Phoenix model was not just about diagnosis; it was a prototype for culturally responsive care, for bilingual documentation, and for medication as scaffold rather than solution. It was a system that saw children first, not codes.

A call to remember what we already know

The children have not changed. The science has not changed. What has changed is the willingness to name what has always been.

Ronald L. Lindsay is a pediatrician.