Tuesday, 18 September 2018

On Cochrane and 'facts' and 'politics' in evidence-based medicine

The controversy surrounding the reported expulsion of Peter Gøtzsche from the Cochrane Collaboration (or should that just be Cochrane?) is something that I've been following for a few days now (see here). Cochrane, under the heading "Trusted evidence. Informed decisions. Better health", represents one of the premier go-to sources for evidence-based healthcare advice on a range of topics. Some of those topics have been previous fodder for this blog too (see here and see here for examples).

I don't profess to have any unique insight into the various goings-on leading to the reported expulsion of Gøtzsche and resignations of fellow members beyond that which has been discussed in various sections of the science media (see here and see here and see here). From what I gather, things look like they've been 'brewing' for a while with regards to Cochrane and the views and opinions expressed by some of those who are seemingly departing. Such a public spat however, is unlikely to be good for science or evidence-based medicine, and indeed may have some wider implications for some fundamentals of science and science communication...

One of the possible [late] precipitating events mentioned around the Gøtzsche saga was the publication of a quite scathing article by Lars Jørgensen and colleagues [1] (including Gøtzsche as an author) questioning the published results of a recent Cochrane review [2] titled: "Prophylactic vaccination against human papillomaviruses [HPV] to prevent cervical cancer and its precursors". The original review by Marc Arbyn et al garnered media headlines when published (see here) as per conclusions such as: "There is high‐certainty evidence that HPV vaccines protect against cervical precancer in adolescent girls and young women aged 15 to 26." A comforting finding by all accounts. Accompanying such efficacy data were other statements made by the authors on the basis of the evidence reviewed that: "The vaccines do not increase the risk of serious adverse events, miscarriage or pregnancy termination."

Jørgensen and colleagues however put forward their [peer-reviewed] view that the Arbyn paper fell short of the expected standards from Cochrane: "We do not find the Cochrane HPV vaccine review to be ‘Trusted evidence’, as it was influenced by reporting bias [3] and biased trial designs." They highlighted several 'issues' with the original review stretching from trial selection for the review, to the assessment of "serious and systemic adverse events" to potential "conflicts of interest." Similar sentiments had been voiced about other Cochrane reviews too that were subsequently pulled from the scientific literature. Feathers were inevitably ruffled (see here) by the Jørgensen paper, even as far as prompting a response from the journal that published the paper [4] about the peer-review process leading to publication of the critique. Things are getting serious when a journal has to defend its publication of a paper.

Without wishing to reduce this saga to any one event, I don't think it would be unreasonable to assume that the Jørgensen paper might have influenced matters quite considerably; perhaps even bringing them to a head. As per involvement on the Boesen paper [5] Gøtzsche is no stranger to calling out Cochrane reviews that seemingly don't make the grade, alongside also voicing opinions on various other matters down the years. To quote: "... in another book, [he] likened the pharmaceutical industry to "organized crime""; such forthright statements stretching back some years are unlikely to have made too many friends in certain circles.

As per the title of this post mentioning the words 'facts' and 'politics', one particular write-up of this saga I think hits the nail on the head. The opinion piece from Trish Greenhalgh [6] presents the two sides to this 'dispute': on the one hand is that the “crisis” is "philosophical (relating to the nature of facts)" and on the other, "political (relating to organisational governance)." The philosophical side of things is pretty evident as per the publication of the Jørgensen paper as a counter to the Arbyn paper. Greenhalgh mentions about how "Gøtzsche might be classified as an evidence-based medicine purist" given his views and sizeable contribution to various "statements on how to undertake and publish research." In this respect, his published views on the original Arbyn paper (and similarly in other reviews) seem to detail scientific standards not being met, or at least not being met to his and his co-authors standards. And certainly on points such as access to trial results and data, he's seemingly not alone in his concern (see here).

On the political side of things, well, at the time of writing we just don't know enough to reasonably comment. Greenhalgh mentions that: "The political explanation for Cochrane’s crisis relates to the tension between governing an organisation and respecting individual members’ academic freedom to express dissent." The fact that such dissent has over the years covered various important public health topics - "cast doubts about the safety of a vaccine against human papillomavirus (HPV), a cause of cervical cancer, and says psychiatry has “gone astray” by coercing patients into taking medication, such as antidepressants, they don’t want to use and that cause “brain damage” over the long run" - is likely to have really stretched those organisational relationships with Gøtzsche. Not least because immunisation and antidepressant use reflect important pillars of modern public healthcare and, historically, uptake of such medicines is very, very susceptible to differences in scientific views, opinions and beyond.

As to the idea mentioned by Greenhalgh that: "We should cut it [Cochrane] some slack while it gets its house in order", I'm not exactly sure how it's going to approach this 'house in order' requirement and what this means for the future credibility of Cochrane. Based solely on the 'facts' side of this saga, it strikes me that organisations like Cochrane actually need people like Peter Gøtzsche and their "evidence-based medicine purist" beliefs. They need them in order to critically (really critically) boil down the ever-growing research literature into scientifically sound statements for public and policy consumption without fear or favour. Minus such voices, it's more likely that evidence-based messages originating from such initiatives are perhaps going to be weakened, which in turn means that population healthcare is potentially going to suffer. Moreover, I assume also that just because Gøtzsche is reportedly not part of Cochrane any more does not mean that he won't be heard from again in the peer-reviewed domain...

----------

[1] Jørgensen L. et al. The Cochrane HPV vaccine review was incomplete and ignored important evidence of bias. BMJ Evidence-Based Medicine. 2018. July 27.

[2] Arbyn M. et al. Prophylactic vaccination against human papillomaviruses to prevent cervical cancer and its precursors. Cochrane Database Syst Rev. 2018 May 9;5:CD009069.

[3] Jørgensen L. et al. Index of the human papillomavirus (HPV) vaccine industry clinical study programmes and non-industry funded studies: a necessary basis to address reporting bias in a systematic review. Syst Rev. 2018 Jan 18;7(1):8.

[4] Heneghan C. & Onakpoya I. Editors’ response to concerns over the publication of the Cochrane HPV vaccine review was incomplete and ignored important evidence of bias. BMJ Evidence-Based Medicine. 2018. Sept 12.

[5] Boesen K. et al. The Cochrane Collaboration withdraws a review on methylphenidate for adults with attention deficit hyperactivity disorder. Evid Based Med. 2017 Aug;22(4):143-147.

[6] Greenhalgh T. The Cochrane Collaboration—what crisis? BMJ. 2018. Sept 17.

----------

Thirty fold future risk of bipolar disorder if ADHD and anxiety are diagnosed together

"The combination of ADHD [attention-deficit hyperactivity disorder] and anxiety increased the risk of bipolar disorder 30-fold... compared with those with no prior ADHD or anxiety."

That was the conclusion reached in the study results published by Sandra Meier and colleagues [1] following their examination of one of those oh-so-useful Scandinavian population registries.

Drawing on data for over 2.4 million people born in Denmark between 1955 and 1991 and followed "from their sixteenth birthday or from January 1995 to their first clinical contact for bipolar disorder or until December 2012", researchers came to a attention-grabbing observation with some potentially profound implications when it comes to 'risk' and screening. The magnitude of the risk - "30-fold" - when ADHD and anxiety were joined in terms of bipolar disorder being diagnosed represents something that is difficult to brush under the scientific carpet.

Am I surprised by these latest findings? Well, no. For quite a while now, it's been 'known' that a diagnosis of ADHD alongside other developmental labels might be a risk factor for all-manner of psychiatric disorders (see here for example). This added to other literature indicating an *association* between ADHD and other, potentially life-limiting behaviours (see here) that compliments evidence discussing suicide attempts in relation to bipolar disorder [2] for example. All set in an age of increasing realisation that behavioural and psychiatric conditions rarely exist in a diagnostic vacuum (see here).

I'm also minded to point out that ADHD and anxiety are pretty common 'comorbidities' when it comes to a label/condition of specific interest to this blog: autism or autism spectrum disorder (ASD) (see here and see here for examples). Following this logically, the implication is that alongside a diagnostic combination of autism, ADHD and anxiety, there may be implications for the identification of a heightened risk of bipolar disorder there too. Indeed, it's been mentioned before in the peer-reviewed research literature that bipolar disorder *might* be a feature of some autism (see here) albeit not necessarily presenting in a 'classical' fashion (which could be a significant factor in under-diagnosis).

There is another implication from such shared, overlapping diagnostic sentiments: successfully tackle one or other element (ADHD or anxiety) and perhaps modify the subsequent risk of bipolar disorder being diagnosed... Some food for thought.

----------

[1] Meier SM. et al. Attention-deficit hyperactivity disorder and anxiety disorders as precursors of bipolar disorder onset in adulthood. Br J Psychiatry. 2018 Jun 21:1-6.

[2] Novick DM. et al. Suicide attempts in bipolar I and bipolar II disorder: a review and meta-analysis of the evidence. Bipolar Disord. 2010 Feb;12(1):1-9.

----------

Monday, 17 September 2018

Maternal tobacco smoking and offspring ADHD risk again

"ADHD [attention-deficit hyperactivity disorderand movement disorders were found to be more common in hospitalized children of smoking mothers."

That was one of the details recorded in the research findings published by Gil Gutvirtz and colleagues [1] adding to a growing research 'trend' suggesting that maternal tobacco smoking during pregnancy seemingly does little for mum's health and also probably not a great deal for her offspring's health and wellbeing either (see here).

Based on results analysing "all deliveries of mothers who reported smoking during pregnancy and non-smoking mothers between 1991 and 2014 at a single tertiary medical center" researchers included almost 250,000 children in their study. Quite a small proportion - "2861 (1.2%)" - were children of mothers who smoked during pregnancy. When researchers looked at these children they noted "higher rates of movement, eating and developmental disorders as well as attention deficit hyperactive disorder" as compared with the larger non-smoking group. "Maternal smoking during pregnancy is an independent risk factor for long-term neurological morbidity of the offspring" was the conclusion.

Allowing for the fact that observational studies, even population-based ones, aren't great for 'proving' cause-and-effect, the volume of such studies independently reaching the conclusion that maternal smoking during pregnancy *might* have an important connection to risk of offspring ADHD is growing. Indeed, alongside all the other adverse outcomes seemingly connected to smoking during pregnancy (see here) I don't think it would be out of place for regulators and health-related agencies to start informing the population at large that ADHD or ADHD-related behaviours as an outcome is at least possible; as some agencies seem to be doing (see here)...

Another research step could be some further investigations actually looking at something like cotinine levels (and important marker of tobacco smoke exposure) in both mums and offspring to see whether 'the dose makes the poison' as other recent studies have hinted at [2].

Tobacco smoking ain't good for anyone it seems, and children seem to be particularly vulnerable to its effects.

----------

[1] Gutvirtz G. et al. Maternal smoking during pregnancy and long-term neurological morbidity of the offspring. Addictive Behaviors. 2018. Aug 16.

[2] Kim KM. et al. Associations between urinary cotinine and symptoms of attention deficit/hyperactivity disorder and autism spectrum disorder. Environ Res. 2018 Jun 26;166:481-486.

----------

Friday, 14 September 2018

Statistically significant group differences in self-reported repetitive movements between diagnosed and self-identifying autism

One needs to remember that, at the time of writing this post, the article posted by Joost Wiskerke and colleagues [1] suggesting that "camouflaging of RMs [repetitive movements] may contribute to under diagnosis of autism, at least in females and transgender people" is just a preprint ("a version of a scholarly or scientific paper that precedes publication in a peer-reviewed scholarly or scientific journal"). It has not been through formal peer-review yet, but rather the authors have bravely 'put it out there' for old farts like me to pore over.

Having glanced through the abstract first and discovered the use of the words "self-identified as autistic" my brow furrowed somewhat. Upon further reading of the paper in its entirety, the furrowing brow furrowed a little less as I understood why the authors mentioned use of a cohort that was "56% formally diagnosed participants and 44% who self-identified as autistic." But that's not to say that I was completely enamoured with the study write-up as it currently stands...

Before continuing and in order to repel any accusations that come my way, I'll mention that I don't have any particular issue with people without a formal diagnosis of autism thinking/believing they are on the autism spectrum. It's their right to do so and indeed, such self-realisation is often an important step towards getting a professional assessment for autism. For some people, their hunch about being autistic eventually turns out to be correct as per them reaching defined clinical cut-off points for autism on the various instruments of assessment that are available during said professional assessment. But that's not to say that every person who self-identifies as being autistic/having autism is always going to be right. As we are starting to realise from the wealth of peer-reviewed science on this topic, the label autism does not seemingly have any exclusive rights to the presentation of autistic traits (see here and see here for examples). And it is for that reason why we have so many good and knowledgeable diagnosticians when it comes to such professional assessments, combined with an important focus on: "Symptoms caus[ing] clinically significant impairment in social, occupational, or other important areas of current functioning" in order to receive a diagnosis. Access to such autism assessments is another issue, but shouldn't be used as an excuse...

Onward:

Wiskerke et al started from the premise that repetitive movements (RMs) are common in autism but there are some potentially important differences in the expression of such issues between the genders. This follows other independent findings in this area (see here) detailing how stereotyped and repetitive behaviours may be less frequently observed in females [2] minus any sweeping generalisations. Researchers then moved on to suggesting that one of the reasons why such RMs may be less frequently observed is because they are actively being masked or camouflaged, and this could eventually lead to an under-diagnosis of autism among certain groups. 'Masking' or camouflaging in the context of autism is a bit of a hot [social media] topic at the moment (see here and see here).

"In this exploratory study, we took a first step... by using self-report measures from a large number of female and transgender adults, using recruitment on social media to an on line questionnaire." Ah yes, the on line questionnaire, which seems to becoming more and more popular in certain autism research circles [3] (see here also for another example). There's nothing wrong with using such tools for asking about opinions and the like, but they are typically open to anyone and everyone (who has access to the internet!), and not exactly great for authenticating complicated things like clinical diagnoses, behaviours and comorbidity for example. As for the incorporation of data from transgender adults, well, again this follows a theme in autism research recently (see here) where 'autistic identity' and sexual identity seem to be converging for some people/groups (see here).

"We assessed current RMs using a combination of visual analog scales for specific behaviors and textboxes for free-text responses." There's mention of using some of the DSM-5 criteria for autism in this section. Authors also talk about testing for camouflaging "using the matrix multiple-choice question “Did/do you hide these behaviors from others…” 1) “…as a child?”, 2) “…as an adolescent?”, 3) “…as an adult?”" Yet again (see here) a research priority needs to be the formulation of a valid and reliable questionnaire pertinent to 'measuring' masking/camouflaging with autism in mind. And finally there was the use of an old favourite  - the autism spectrum quotient (AQ) - by the authors, but with some added caveats...

Results:  "We found high rates of RMs in both diagnosed and self-identifying participants, and a striking prevalence of camouflaging" was one of the headlines. But... there were also some other important details observed too. So: "Higher scores in the diagnosed group were found for object fidgeting, repetitive hand movements, rocking, object spinning and hand flapping." I think most people would agree that such behaviours represent some of the more 'classical' manifestations included in the RM categorisation of autism. By contrast, other RMs such as scratching/rubbing skin, walking in circles and 'banging head' were not different between the diagnosed and self-identifying groups.

Based also on the strength of the camouflaging data presented by Wiskerke et al I have to say that I'm not yet altogether convinced by the evidence presented. It's not that I don't believe that 'self-inhibition' plays a role in such masking, nor that: "There were many references (47 participants) to having been bullied or disciplined for childhood RMs." It's just that methodologically speaking, offering up one question on such a complicated issue does not make for a scientifically compelling argument. As I previously said, autism science needs to invest in some high quality research on how to assess masking in the context of autism; perhaps including some important measure of self-monitoring for example. And one also needs to control for things like intellectual ability too and perhaps be open to other reasons why the presentation of autism between the genders/sexes might be subtly different.

I was also a little dismayed that the discussion of results by the authors did not seem to fully 'tally' with their findings. So: "The striking similarities between diagnosed and undiagnosed participants are consistent with a clinically relevant prevalence of autism in the undiagnosed group." As I've mentioned, the picture of 'striking similarities' was far from consistent when comparing RMs across the groups and those statistically significant differences reported on between diagnosed and self-identifying autism. Added to the fact that authors zoomed in on RMs without too much clinical focus on the other elements to autism, and the 'clinically relevant' picture is also far from complete based on this study alone. Indeed, other text in the discussion provide further clues as to the probable inclination of the authors: "We believe that this study in part reached the “lost generation” of autistic adults... many of whom appear to have turned to social media for support and kinship, sometimes after many disappointing encounters with clinicians and scientists." Emotive language such as 'Lost generation' really shouldn't be in a science paper without [strong] corresponding evidence.

What else? Well the authors did acknowledge some shortcomings in their study: "the on line format limited our ability to ascertain that robust diagnostic procedures had been used in all cases" and: "The self-report format also makes it possible that some participants erroneously reported an official diagnosis" (erroneously?) but perhaps more is needed to be said about participants ("the vast majority were indeed very cognitively able") and onward the applicability of results to other parts of the autism spectrum. It would also have been useful to include a few other (self-report) measures of other conditions/labels where autistic characteristics overlap, just to see...

I do think Wiskerke et al have tapped into a increasingly important research 'need' for some of those on the autism spectrum - masking - and how such behaviour does seem to impact on quality of life for quite a few people. We need a lot more research on this topic, and yes, there also needs to be some further analysis of what social accommodations could be made too, bearing in mind such understanding needs to come from lots of different quarters of society (see here). I'd also like to acknowledge the fact that one of the authors on the Wiskerke took the time to converse (on Twitter) with me about their paper, which was rather encouraging.

But still, I can't shake the idea that the methodological shortcomings of this study and the sweeping interpretations imply caution before any generalisations are made as a result. The fact also remains that self-identifying as being autistic/having autism is not the same as receiving a formal diagnosis of autism, however much people might want this to be true or find 'kinship' with the autism spectrum...

----------

[1] Wiskerke J. et al. Camouflaging of repetitive movements in autistic female and transgender adults. bioRxiv. 2018. Sept 10.

[2] Mandy W. et al. Sex differences in autism spectrum disorder: evidence from a large sample of children and adolescents. J Autism Dev Disord. 2012 Jul;42(7):1304-13.

[3] Kupferstein H. Evidence of increased PTSD symptoms in autistics exposed to applied behavior analysis. Advances in Autism. 2018; 4: 19-29.

----------

Thursday, 13 September 2018

"The Importance of Adolescent Self-Report in Autism"

The findings reported by Jessica Keith and colleagues [1] provide the blogging fodder today and a rather important message about the value of self-report in the context of autism, but also with one or two caveats too.

The name of the research game was to investigate the "consistency of adolescent and parent reports of anxiety and auditory sensitivity in individuals with ASD [autism spectrum disorder]" as well as examine "their validity via comparisons with sympathetic arousal at baseline and in response to an auditory challenge." This, on the basis that anxiety is not an uncommon diagnostic bedfellow when it comes to autism (see here for example) and alongside, auditory sensitivity also having quite a long established relationship with some autism (see here).

As per the title of this post taken from the Keith paper - "The Importance of Adolescent Self-Report in Autism" - an important focus of the study was to look-see whether parental reports of anxiety and auditory sensitivity 'matched up' with self-reports from adolescents with autism themselves. Authors reported that they did to a degree, but that also self-report might also provide some greater depth: "demonstrating greater self-reported (than parent-reported) anxiety and sensory symptoms." Indeed authors concluded: "adolescents with ASD have a unique perspective on their internal experience, which can complement parent reports and provide a more comprehensive assessment of symptoms in research and clinical settings."

I don't think anyone should be too surprised that asking adolescents about their own experiences of anxiety, sensory issues or anything else is probably going to yield far more accurate results than proxy reporting or second-hand accounts alone. Indeed, in these days where more and more people diagnosed as being on the autism spectrum are offering up their own first-hand accounts of their experience of autism, this represents a good thing in terms of 'getting it right' when it comes to diagnosing and managing important and often life-affecting symptoms or clinical diagnoses such as anxiety.

Caveats? Well, yes. I'm all in favour of people self-reporting and providing valuable insight into their own experiences. What is slightly less appealing however is that such self-reporting is not a luxury shared by all on the autism spectrum. The lack of self-report coming say, from some under-represented parts of the autism spectrum (see here) can sometimes mean that 'autistic experiences' are skewed towards more 'able' (or should that be 'vocal') parts of the autism spectrum; this despite the oft-used phrase: if you've met one autistic person, you've met one person with autism (or words to that effects). A solution? How about devoting more research and clinical resources to 'enabling' those traditionally not thought to have the capacity for complicated self-report to do so? Indeed, a participatory solution would perhaps be the best step forward I think (see here).

Oh, and also bear in mind that it needn't be self-report versus parent-report when it comes to something like anxiety in the context of autism. Both viewpoints can provide something important [2] on the basis that individuals know themselves but parents also have quite a unique viewpoint of their children and their behaviour across their formative years...

----------

[1] Keith JM. et al. The Importance of Adolescent Self-Report in Autism Spectrum Disorder: Integration of Questionnaire and Autonomic Measures. J Abnorm Child Psychol. 2018 Aug 2.

[2] Adams D. et al. Parent descriptions of the presentation and management of anxiousness in children on the autism spectrum. Autism. 2018 Aug 16:1362361318794031.

----------

Wednesday, 12 September 2018

Maternal and child immune disease and autism or other developmental disorder

The paper by Lisa Croen and colleagues [1] provides the brief blogging fodder today and some further results from the Study to Explore Early Development (SEED) initiative based in the United States. Whilst SEED has already produced quite a bit of peer-reviewed research data (see here), this time around the focus was on "the role of family history of autoimmune diseases, asthma, and allergies in autism spectrum disorder (ASD) as well as other developmental disorders (DD)." Yep, immune function yet again (see here).

Researchers mention how following their analysis of some 660 children with ASD, nearly a thousand children with DD and over 900 not-autism, not-DD population (POP) controls, they turned up some potentially important *associations* pertinent to immune system related conditions potentially elevating the risk of autism and/or DD. So: "Maternal history of eczema/psoriasis and asthma was associated with a 20%-40% increased odds of both ASD and DD" and "children with ASD were more likely to have a history of psoriasis/eczema or allergies than POP controls." Conversely, they did not detect any statistically significant associations between "paternal history or family history of these immune conditions for either ASD or DD."

I'm gonna leave things there for now on this topic. The immune system seems to be related to at least 'some' autism. There's nothing particularly new or novel about that sentiment but it does cover an awful lot of ground. A lot more research is required on the 'hows-and-whys' (see here for one example research route) and whether intervening on various immune system related conditions, one *might* also impact on the presentation of behaviour too...

And on the topic of intervention, may I also draw your attention to the mammoth paper by Marchezan and colleagues [2] reviewing the many and varied (evidence-based) intervention methods that are available as and when immune system issues crop up in the context of autism?

----------

[1] Croen LA. et al. Family history of immune conditions and autism spectrum and developmental disorders: Findings from the study to explore early development. Autism Res. 2018 Aug 10.

[2] Marchezan J. et al. Immunological Dysfunction in Autism Spectrum Disorder: A Potential Target for Therapy. Neuroimmunomodulation. 2018. Sept 5.

----------

Tuesday, 11 September 2018

Specific learning disorder in mathematics: prevalence, overlap and autism

I'm not going to spend too long discussing the findings reported by Kinga Morsanyi and colleagues [1] on the topic of specific learning disorder in mathematics (SLDM) but they are potentially important. Important because, alongside some [DSM-5] diagnostic definition changes to the issue of learning disorder with maths in mind (see here), something stood out from the Morsanyi results: "About half of the children with an SLDM profile had some form of language or communication difficulty. Some of these children also had a diagnosis of autism, social, emotional, and behavioural difficulties or attention deficit and hyperactivity disorder."

Surveying some 2400 primary school children here in Blighty, researchers analysed results based on various "standardized tests of mathematics, English, and IQ." They also looked at "several demographic factors over the primary school years" and subsequently applied the DSM-5 diagnostic criteria for specific learning disorder (SLD) to their cohort.

The found that about 6% of children met the diagnostic thresholds for SLDM. Sex/gender didn't seem to make any difference to the findings, but as with many things these days (see here), SLDM was typically not a 'stand-alone' diagnosis.

The 'language or communication difficulty' bit to the Morsanyi findings is perhaps not unexpected; I'll mention that again in a bit. The 'lumping' together of various SLDs covering reading, writing and maths skills in the DSM-5 is perhaps justified to this extent. Of more interest to this blog is the idea that developmental disorders, particularly autism, are also not uncommon alongside SLDs.

Without wishing to conflate a diagnosis of SLD with anything else, I'd like to take readers back to a post I wrote some time ago on how maths ability - particularly maths problem solving ability - in the context of autism is as varied as the label itself (see here). The sweeping generalisation that many/all those on the autism spectrum somehow have some savant ability when it comes to maths is brought crashing down by cold, objective science [2]. Science that observed that nearly a quarter of those on the autism spectrum "evidenced a mathematics learning disability" compared with around 4% who "exhibited mathematical giftedness." That's quite a disparity.

What can we learn from such data? Well, preferential screening is perhaps the first lesson to be learned. Ensuring that sweeping generalisations and stereotyping about autism in particular ("what's his/her special ability?") are replaced by appropriate objective testing to determine strengths and weaknesses in areas such as maths ability. Next, a greater appreciation that SLDs can overlap with one and another [3] might also be useful. So, issues with reading and writing might also be over-represented among those with an SLD in relation to maths ability as per what the Morsanyi data implied. Finally, intervention needs to be further examined: what can we do to aid a learner with autism presenting with SLDM? I'm no expert in this area, but understand that there are groups looking at this issue (see here). Obviously such interventions need to be mindful of the diagnosis of autism and other potential comorbidities and what that could mean for learners, but I'm assuming that there are going to be individualised strategies that work as well for those on the autism spectrum as they do for those not on the autism spectrum. This includes ensuring that maths anxiety is tackled too.

Oh, and just before I go, a friendly reminder: maths is probably not just a systemising-linked ability (see here and see here).

----------

[1] Morsanyi K. et al. The prevalence of specific learning disorder in mathematics and comorbidity with other developmental disorders in primary school-age children. Br J Psychol. 2018 Jul 5.

[2] Oswald TM. et al. Clinical and Cognitive Characteristics Associated with Mathematics Problem Solving in Adolescents with Autism Spectrum Disorder. Autism Res. 2016 Apr;9(4):480-90.

[3] Moll K. et al. Specific learning disorder: prevalence and gender differences. PLoS One. 2014 Jul 29;9(7):e103537.

----------

Monday, 10 September 2018

Internet addiction and suicidal behaviours meta-analysed

"This meta-analysis provides evidence that internet addiction is associated with increased suicidality even after adjusting for potential confounding variables including depression."

That was the research bottom line reported on by Yu-Shian Cheng and colleagues [1] following their meta-analysis of the peer-reviewed research literature looking at 'internet addiction' ("internet addiction OR internet gaming disorder OR internet use disorder OR pathological internet use OR compulsive internet use OR problematic internet use") and suicidality.

Researchers, with some experience of meta-analysis it has to be said (see here and see here), trawled through the pertinent literature and settled on the analysis of some 25 studies, including over a quarter of a million participants, that looked at internet addiction and suicidal ideation, planning, and attempts. Boiling the data down, they observed some important *associations* that even held when important variables linked to suicidal behaviours - depression for example - were adjusted for. Children it seems, were also more 'vulnerable' to the link between internet addiction and suicidality. The authors caution that cause-and-effect were not proven from their analysis of the collected data, bearing in mind "the evidence was derived mostly from cross-sectional studies" but call for further investigations in this area.

This is an important area of research. As per some of the previous studies conducted on internet overuse and suicidality [2], there are some important further investigations to be undertaken on for example, the various types of online activity that might increase the risk of suicidality: "online gaming, chatting, watching movies, shopping, and gambling were associated with an increased risk of suicidal attempt." This in the context that social media use in particular, is under the spotlight when it comes to various different health issues (see here). Alongside gambling disorder, so it looks like gaming disorder is set to enter the diagnostic texts too (see here), where 'lack of control' and causing "significant impairment in personal, family, social, educational, occupational or other important areas of functioning" are key features. And minus any sweeping generalisations, 'control' *could* actually be a key element to consider when it comes to suicidal behaviours in certain circumstances.

Bearing in mind that this blog is predominantly concerned with autism research, I couldn't help but think about how the Cheng findings *might* relate to [some] autism. How for example, a diagnosis of autism also seems to elevate the risk of suicidality (see here) and how issues like depression are not uncommon in the context of autism (see here). I'm also minded to mention how compulsive internet use *might* show some important connections to the presentation of autistic traits [2] and how videogame use, in particular (see here), might have both positives and negatives in the context of autism [3].

By saying all that, I don't want to make any sweeping generalisations; the label of autism has had enough of those down the years. I don't also want to demonise the wonderful resource that is the internet, particularly when pastimes like gaming and social media use can be a good 'social' outlet for many people on the autism spectrum and beyond when used in moderation. Certainly the internet, through things like social media, provides an important voice and potentially quite a lot more to those whose voices might previously not have been heard...

But perhaps when it comes to the next stage of any research plan looking at internet overuse / addiction and suicidal behaviours it might be worth considering whether some of the features of autism or other, related labels [4] (see here) *might* also moderate any relationship. Whether there are some relevant lessons to be learned that *might* reduce the very worrying statistics on suicide and autism, and whether activities other than those done on online, could perhaps be seen as 'protective factors' when it comes to suicide risk (see here for example)?

Bear all that in mind by all means. But remember also that the paths that take someone to such suicidal behaviours are often numerous and individual. Internet overuse is probably only a small part of an often bigger and more complicated picture.

And in case anyone needs to talk or text, there's always someone who will listen (see here).

----------

[1] Cheng YS. et al. Internet Addiction and Its Relationship With Suicidal Behaviors: A Meta-Analysis of Multinational Observational Studies. J Clin Psychiatry. 2018 Jun 5;79(4). pii: 17r11761.

[2] Lin IH. et al. The association between suicidality and Internet addiction and activities in Taiwanese adolescents. Compr Psychiatry. 2014 Apr;55(3):504-10.

[3] Mazurek MO. & Wenstrup C. Television, video game and social media use among children with ASD and typically developing siblings. J Autism Dev Disord. 2013 Jun;43(6):1258-71.

[4] Wang B. et al. The association between attention deficit/hyperactivity disorder and internet addiction: a systematic review and meta-analysis. BMC Psychiatry. 2017;17:260.

----------