Tuesday, 26 August 2014

76% of youths with autism meet ADHD diagnostic criteria?

Autism is not normally a stand-alone diagnosis. I've mentioned that point a few times on this blog, stressing how a clinical diagnosis of autism appears to increase the risk of various other behavioural, psychiatric and somatic diagnoses also [variably] being present over a lifetime. Part of that comorbidity has been talked about in discussions about ESSENCE (see here) and the excellent document produced by Treating Autism on medical comorbidities occurring alongside autism (see here) for example. Prof. Gillberg's recent scientific publication called 'Autism Plus Versus Autism Pure' [1] kinda adds to this notion and his very strongly worded sentiments: "It is high time that the comorbidities, sometimes even more important than the autism, came back on the diagnostic agenda".
Cheeky... @ Wikipedia 

Outside of the more traditional comorbidities mentioned in the same breath as some autism, such as learning disability (intellectual disability) and epilepsy or seizure-type disorders, quite a lot of attention is being focused on the overlap between autism and attention-deficit hyperactivity disorder (ADHD). Indeed, the paper by Gagan Joshi and colleagues [2] very much thrusts ADHD into the autism diagnostic arena with their assertion of: "A high rate of comorbidity with ADHD was observed in psychiatrically referred youth with ASD [autism spectrum disorder], with a clinical presentation typical of the disorder".

The Joshi paper sought to "compare the clinical presentation of ADHD between youth with autism spectrum disorder (ASD) and ADHD and a sample of youth with ADHD only". What they found is something remarkably similar to the typical presentation of ADHD (without autism) insofar as age of onset and "distribution of diagnostic subtypes, the qualitative and quantitative symptom profile, and symptom severity". I might add that their participant group was classified as "High-Functioning" (their words not mine) so one needs to be mindful that only one part of the autism spectrum was surveyed.

What is perhaps slightly worrying from the Joshi results was the finding that: "a significant majority of ASD youth with ADHD failed to receive appropriate ADHD treatment". ADHD treatment, as I've mentioned in previous posts, normally implies pharmacotherapy but can also include other intervention options as per discussions on things like dietary changes potentially being useful for some (see here). Indeed, I've talked about the some of the results from things like the use of a gluten- and casein-free (GFCF) diet when applied to autism and how ADHD-type symptoms might be the more important targets for intervention (see here). The idea also that outside of just affecting ADHD symptom profiles, intervention might also have knock-on effects for other areas as per the review by Daley and colleagues [3] is similarly important.

I don't want to linger further on this issue aside from reiterating that the presentation of autism is, more often than not, part of a complex tapestry of presentation which can cover various other diagnostic categories. ADHD or sub-threshold ADHD-type symptoms are being realised as fairly frequent companions to a diagnosis of autism. The changes to the diagnostic criteria for ADHD (see here) will no doubt further expand the link between autism and ADHD, placing yet more emphasis on how autism is not normally a stand-alone diagnosis.

Music to close. Ray Charles and You Don't Know Me.

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[1] Gillberg C. & Fernell E. Autism Plus Versus Autism Pure. J Autism Dev Disord. 2014 Jun 24.

[2] Joshi G. et al. Symptom Profile of ADHD in Youth With High-Functioning Autism Spectrum Disorder: A Comparative Study in Psychiatrically Referred Populations. J Atten Disord. 2014 Aug 1. pii: 1087054714543368.

[3] Daley D. et al. Behavioral Interventions in Attention-Deficit/Hyperactivity Disorder: A Meta-Analysis of Randomized Controlled Trials Across Multiple Outcome Domains. J Am Acad Child Adolesc Psychiatry. 2014 Aug;53(8):835-847.e5.

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ResearchBlogging.org Joshi G, Faraone SV, Wozniak J, Tarko L, Fried R, Galdo M, Furtak SL, & Biederman J (2014). Symptom Profile of ADHD in Youth With High-Functioning Autism Spectrum Disorder: A Comparative Study in Psychiatrically Referred Populations. Journal of attention disorders PMID: 25085653