Friday, 17 August 2018

Even more on wandering and autism

I don't know if it's just me being more attentive but I seem to be more regularly seeing media reports of children and adults diagnosed with autism or autism spectrum disorder (ASD) wandering from their family/caregiver home or other place. Some of these media reports end happily insofar as the person being found safe and unharmed to then be reunited with their loved ones; on occasion, using some important previously learned survival skills. Other reports however, don't have such a happy ending...

The paper by Laura McLaughlin and colleagues [1] brings the topic of wandering (elopement) back into research view, observing that in their cohort of nearly 1500 parents talking about their children diagnosed with an ASD: "22.4% of the children wandered from their home or yard and 24.6% from a public place more than monthly." Such research continues a theme down the years illustrating how wandering is an important issue when it comes to autism (see here) and how for some, wandering can lead to a very, very final outcome (see here).

Researchers distributed their anonymous on-line questionnaire about various aspects related to wandering through several autism-related organisations, encouraging parents of children diagnosed with autism/ASD to respond. This wasn't your typical 'does your child wander?' questionnaire, but instead also incorporated several related items such as "the use of electronic tracking devices,... use of restraints and/or seclusion to prevent wandering at school, and receipt of guidance about wandering."

About a quarter of parents said their child wanders (and wanders quite routinely) and the effects of such behaviour seemed to be quite wide-ranging. Not only did wandering reflect a worry for many parents - "48.6% and 58.7% of parents were moderately/very worried about their child wandering from home or yard or a public place" - but almost three-quarters of parents reported that wandering concerns affected "decisions to let their child spend time with friends or family in their absence." With such sentiments being expressed, it's not difficult to see why some parents with children with autism have to announce 'why I can never die' (see here). Perhaps also surprisingly, McLaughlin et al reported that only a third of parents in their cohort "had previously received any counseling about wandering."

I still maintain that wandering represents one of the most important 'issues' linked to autism (see here). Lots more resources need to be dedicated to the hows-and-whys of such behaviour (see here) and what can be done to reduce risks all round. I also think more needs to be done to talk about wandering in the context of autism and provide parents/caregivers with the information and tools ('best available evidence') about wandering. Given also the seemingly important relationship between wandering and water safety in particular (see here), I'm minded to again vocalise the (preferential) need to teach water and swimming skills as and when a child is diagnosed...


[1] McLaughlin L. et al. Wandering by Children with Autism Spectrum Disorder: Key Clinical Factors and the Role of Schools and Pediatricians. J Dev Behav Pediatr. 2018 Jul 6.


Thursday, 16 August 2018

"aggressive behaviour is not a choice for children with autism": a legal decision with implications...

The quote heading this post - "aggressive behaviour is not a choice for children with autism" - reflects a legal ruling rather than a piece of peer-reviewed research that more typically appears on this blog. The ruling, which was reported in several media outlets (see here and see here), concerns an appeal over "a 13-year-old boy with special educational needs who had been excluded from school because of aggressive behaviour that was linked to his autism."

The details of the case concern various incidents where the boy - referred to as 'L' - struck a teaching assistant with a ruler as well as pulling her hair and punching her. As a result, the school gave L a one-and-a-half day exclusion. The exclusion was challenged on the basis that L was being denied an education as a result, in contravention of his human rights. The judge agreed and deemed the exclusion discriminatory on the basis that the presentation of such aggression was 'not a choice' but instead his "behaviour in school is a manifestation of the very condition which calls for special educational provision to be made." The National Autistic Society (NAS) here in Blighty was involved in bringing this appeal and have highlighted what it means: "all schools must make sure they have made appropriate adjustments for autistic children, or those with other disabilities, before they can resort to exclusion."

Of course this is all good news for children on the autism spectrum and their parents. It stresses that school exclusion should always be a tool of last resort as enshrined in law. It means that such 'challenging behaviours' should always be investigated as a 'sign of unmet need' and appropriate provision put in place to 'work through and manage' rather than exclude as a first reaction. This is really important and will influence many, many futures; hopefully also reversing a worrying trend (see here). It also means that schools excluding pupils or trying to exclude pupils perhaps on the basis of "their results not counting against the school" or similar sentiments, have been given notice...

But there is another side to this coin, and one that may also have equally important long-term repercussions for autism and the autism spectrum: aggression or aggressive behaviour is now inextricably *linked* to autism. And the removal of the word 'choice' from such 'tendency to physical abuse' behaviour - "through no fault of their own... akin to a spasmodic reflex" - starts to place such actions and behaviours in law in a similar position to that of various other developmental and psychiatric labels. 'Vulnerability' it seems, continues to retain it's relevance to autism (see here).

Not to carry on with casting a dark cloud over such a ruling, there is another group of people often forgotten in such cases for whom such a judgement will also likely have an important effect: teachers and teaching assistants who are often working at the 'sharp end'. Indeed, in one of the news reports on this case, there are some important points made by a union representative: "school staff members are attacked at work on a daily basis - from verbal abuse, to being spat at, kicked and punched. But they love their jobs, love the kids and want to carry on doing their best for the children. They understand these pupils can lash out and violent incidents can occur. All they ask is their school backs them up when it does happen - and takes the common sense steps needed to protect them." Such a ruling is unlikely to aid in the recruitment and retention of teaching and support staff who, just as anyone else in any other profession, also have enshrined rights at work when it comes to their health, safety and wellbeing. And without an appropriate intake of such often under-paid, under-appreciated staff, the education system, including that relevant to special educational needs, can only be put under even more stress and strain coupled to the current funding issues. A vicious cycle continues and is only likely to accelerate (see here).

Further research aplenty [1] is required on this important topic. Research on how to make school a more welcoming place for all is the primary objective and already implied. Every child deserves a decent education, and school should also be a place where happy memories are made and remembered for a lifetime. It's not an impossible task by any means; there are schools out there catering for various different needs and doing it well, if not in an 'outstanding' capacity. Good practice needs to be shared and shared widely. Minus any 'blame game' indications, such a ruling also means that some further calm and objective discussions and investigations about ways to reduce and minimise acts of physical aggression should at the same time, also be prioritised (see here and see here and see here for some possible research directions). Minus that is any psychobabble explanations, sweeping generalisations or 'one-size-fits-all' sentiments being expressed...


[1] Brede J. et al. Excluded from school: Autistic students’ experiences of school exclusion and subsequent re-integration into school. Autism. 2017. Nov 9.


Wednesday, 15 August 2018

On the question of suicide risk and chronic fatigue syndrome / myalgic encephalomyelitis continued

The paper by Andrew Devendorf and colleagues [1] brought me back to a complicated and sensitive topic previously discussed on this blog (see here) regarding the issue of suicide risk in the context of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Specifically, the Devendorf findings provide some potentially important information about the possible reasoning behind suicide risk in the context of ME/CFS: "(1) feeling trapped and (2) loss of self, loss of others, stigma and conflict."

Based on discussions with 29 people diagnosed with ME/CFS "who endorsed suicidal ideation but did not meet depression criteria" researchers, including one Leonard Jason (see here), discussed some of the hows-and-whys of such suicidal ideation. As per the 'did not meet depression criteria' sentiments of the research, this work was less about 'mental health diagnoses affecting suicide risk' and more about how thoughts, feelings and situational factors might play a role. And as per the two variables highlighted by the study - 'feeling trapped' and 'loss of self & others and the stigma and conflict' generated by this incapacitating condition(s), some clear areas for further research and clinical attention emerged.

I've covered the sensitive issue of suicide (risk, ideation, completion) quite a few times on this blog for all-manner of different reasons (see here and see here for examples). In the most part, my musings have been on research into suicide where a specific label/condition/disorder has been diagnosed, and how facets of such labels/conditions/disorders *might* at least partially, 'intrinsically' elevate the risk of suicide ideation or beyond. The Devendorf findings kinda deviate from such 'intrinsic' sentiments, insofar as examining the implications of an acquired physical disability (see here and see here) and the onward the physical (and mental) restrictions of a condition seemingly elevating the risk of suicidality. By saying all that, I'm not making any sweeping generalisations...

I don't think anyone should really be surprised by the Devendorf results. With ME/CFS you have a condition that literally steals life from people; for example, rendering previously fit and active people to sometimes being bed-bound for days and days (or even longer) at a time. Add in a 'boom-bust' pattern of symptoms (see here) and the various 'environmental' effects (to employment, finances, social life, etc) of the condition, and well, I'm often surprised how resilient people with ME/CFS are.

I noted also how the words 'stigma' and 'conflict' were also detailed in the Devendorf study, and what implications this might have for quite a few areas of current research and clinical practice in relation to ME/CFS. I'm thinking specifically about the whole 'biopsychosocial (BPS) thing' that seems to have pervaded ME/CFS thinking down the years (see here), and how psychology in particular, seems to have over-stepped it's usefulness in relation to ME/CFS. It's kind of a coincidence that as I write this post, another article including Keith Geraghty [2] on the authorship list, is published discussing how some ME/CFS patients and patient groups have been labelled as 'militant' (or similar words and phrases) on the basis of them pushing back against medical dogma as a function of their own experiences of BPS-backed 'intervention' for example (see here). Militant is one word that has been used, 'vexatious' is another (see here).

"Participants emphasized that they were not depressed, but felt trapped by the lack of treatments available." This sentence serves to reiterate that suicidality in the context of ME/CFS is perhaps not something that should necessarily be thought of as intrinsic to the condition(s). It emphasises how issues like 'hopelessness' at the state of medical knowledge about ME/CFS, about the lack of biological explanation for the condition, and the lack of intervention options (not BPS guided I might add) may play a role in thoughts and feelings related to suicidality. It also provides another rather pressing reason why less 'psychologising' and more biological science needs to be dedicated to the hows-and-whys of ME/CFS and the search for a cure...


[1] Devendorf AR. et al. Suicidal ideation in non-depressed individuals: The effects of a chronic, misunderstood illness. J Health Psychol. 2018 Jul 1:1359105318785450.


Tuesday, 14 August 2018

Autistic traits carrying a 'cognitive cost' into old age?

I don't think anyone should be too alarmed at the findings reported by Gavin Stewart and colleagues [1]. But their observation that "autism traits as measured by the BAPQ [Broad Autism Phenotype Questionnaire] may confer additional risk of cognitive decline in aging" represents something that requires quite a bit of further investigation.

Some twenty 'older' adults who were questioned and deemed to have met criteria for the broader autism phenotype (BAP) were tested on skills related to executive function alongside episodic memory. Their results were compared with twenty 'older' adults who did not reach criteria for the BAP. Authors reported that: "Despite no differences in age, sex ratio, educational history or IQ, the BAP group demonstrated poorer performance on measures of executive function and episodic memory compared to the COA [control older adults] group." They interpret this in the context of that 'additional risk of cognitive decline in aging'.

The numbers of participants in the Stewart study were low and imply that one has to be quite careful about making any sweeping generalisations as a result. Bear also in mind that the BAP does not necessarily equal autism or autism spectrum disorder (ASD) as a function of it describing sub-threshold autistic traits (sub-threshold for a diagnosis). Traits, I might add, that are seemingly not just potentially representative of autism (see here for one example).

But set within a 'gap' in the research base looking at autism in older adults (see here), there is a scheme of work to follow. If for example, the Stewart 'trend' does overlap with the experiences of older adults on the autism spectrum in terms of 'cognitive decline', there is a whole barrage of potentially important implications to consider. More so when one considers that the autism prevalence data continues to head in only one direction (see here) and what this means for societal financial and resource planning.

Just before I go, one more detail was revealed in the Stewart paper: "Older adults who met the BAP criteria also reported higher levels of depression and anxiety." Continuing a theme on this blog that various over-represented issues/diagnoses in relation to autism might not be best described as just being 'comorbid' (see here and see here and see here), I believe that this finding adds further weight to the notion that autistic traits (clinical and sub-clinical) might have some important 'direct' relationships with other psychopathology. Not necessarily a welcome opinion in some quarters, but something that also requires a lot more investigation.


[1] Stewart GR. et al. Aging with elevated autistic traits: Cognitive functioning among older adults with the broad autism phenotype. Research in Autism Spectrum Disorders. 2018; 54: 27-36.


Monday, 13 August 2018

Participatory research in autism: some good ideas but who gets to participate?

I was genuinely pleased to read the article published by Sue Fletcher-Watson and colleagues [1] talking about how the incorporation of views and opinions from people with autism / autistic people can hopefully improve the relationship between autism research and clinical practice. Pleased because, as autistic voices become more prominent in many walks of life including important research agencies, so such voices can help both guide research priorities and also aid in the the important translation of research findings from dusty science books/journals to [positively] affecting real lives.

The Fletcher-Watson paper recalls the results of a "shaping autism research seminar series" held here in Blighty. We are told that the "overarching goal was to examine how autism research could become more participatory in nature" where the 'target group' aids in making research "more meaningful – that is, relevant to the community, consistent with their values, and not tokenistic in delivery." 'Nihil de nobis, sine nobis' so the [important] saying goes.

Some key themes emerged from the initiative: "Respect, Authenticity, Assumptions, Infrastructure and Empathy." All of these points serve to enhance autism research and move it away from issues like 'research solely for the benefit of researchers careers' and/or 'research for the benefit of just getting further research grants/money' which probably feature in at least some circumstances. Instead the message is about moving towards a research strategy that has tangible real life impact for those on the autism spectrum, also trying to be sensitive to the numerous wants, needs and desires. All those sweeping psychobbable explanations of autism from yesteryear really haven't served anyone well in terms of enhancing quality of life and so people want something different...

The authors accept that alongside the strengths of such an approach there are also challenges. So for example, we are told that under the category of 'authenticity' where "autism communities can shape a research agenda", one challenge is going to be that "merging perspectives of a diverse group into homogeneous outcomes can result in under-specified priority research topics." Indeed it can, and it has been talked about before in the context of consumers/producers of autism research (see here).

Whilst noble in sentiment, I have some cautions and caveats about this area; not least around the question of exactly how participatory such initiatives truly are and can be when it comes to the very heterogeneous autism spectrum and the multitude of voices to be included (see here). Are voices from the autism spectrum who for example, are critical of the concept of neurodiversity likely to be invited to participate? What about those who don't see their autism or its effects in as positive a light as others? Who are the gatekeepers deciding who is involved in "shaping autism research through meaningful participation" and what is the criteria for participating aside from a diagnosis of autism? What happens also when there are disagreements in research direction between 'professionals' and the communities they serve?

The oft-used term 'if you've met one person with autism, you've met one autistic person' always figures in my mind. It denotes that within such a heterogeneous label/diagnosis, there is huge variation in the presentation of autism and the impact that core and related symptoms have on day-to-day living, alongside lots of different views and opinions about autism and what the label means to people. And in this context, terms like 'relevant to the community' and 'consistent with their values' are difficult concepts to entertain in any universal sense because there really is no single 'autistic community' or universally shared values. Remember: if you met one person with autism... Indeed, their meaning may also likely be something slightly different to the 'under-studied' parts of the autism spectrum for example (see here), where voices seem to be currently less well heard in many different scenarios (see here).

I was also a little confused to read the word 'allies' multiple times in the Fletcher-Watson paper, denoting those who are not autistic but share the various views and opinions of those on the spectrum particularly included in the article. 'Allies' is typically a word used in the context of combat and warfare. I appreciate that there are debates/arguments on-going in the autism 'community' that sometimes look and feel like warfare. But the implication from the use of such a 'them-and-us' term, particularly in the context of a research paper, is that if you're 'for' participatory research of the specific type highlighted by the authors, you're an ally. If you're not, or if your opinion differs in terms of possible research priorities (whether you are autistic or not), then by definition, you're not an ally. This is important. Words matter, particularly in the context of 'participatory' research. I say all this also acknowledging that science should really be allegiance-free...

Without wishing to continue too much with the cautions and caveats when such inclusion efforts have noble goals, I have further points. Appreciating that some important research goals have already been published (see here) and with the rapid development of the ICF core sets for autism (see here), there are already plenty of research directions that need to be taken which prioritise people with autism / autistic people and the day-to-day challenges they face; all already including input from people on the autism spectrum. In this respect, participatory research is nothing new to autism.

Insofar as that research 'relevant to the community' (or should that be 'communities') opinion, I'd also advance the idea that 'life-saving' should perhaps represent the first tier of autism research importance to any participatory strategy, as issues such as wandering, suicide risk and early mortality (see here, see here and see here respectively) continue to remain ever-present and significantly impact on many peoples' lives - again, particularly among those who perhaps fall into that 'under-represented' categorisation of autism (see here). The alleviation of pain and suffering, whether physical (see here for one example) or otherwise (see here), should probably form the next tier of research importance. And perhaps another tier of participatory research could be devoted to giving those with autism who seemingly don't have a voice, the means to communicate their wants, needs and desires and thus enable themselves to participate further in such participatory schemes. Just my observations...

A final question I have for such participatory research is an ethical one in the context of some likes and dislikes voiced by some on the autism spectrum: if for example, by tackling such primary issues such as depression and anxiety that plague many people on the autism spectrum and often severely impact on quality of life, it actually means having to intervene on the core presentation of autism (see here and see here for other research in these areas), would such participatory research 'alliances' be brave enough to take on such an option? If for example, it mean't that something like the presence of social-communication issues showed a *connection* to the experience(s) of depression for example (see here), would such participatory research look to evidence-based strategies and possibilities to try and 'change' such core issues and behaviour? Or would the conversations just revert back to something like the tenets of the social model of disability as being the primary reason for such issues as per other examples (see here)?


[1] Fletcher-Watson S. et al. Making the future together: Shaping autism research through meaningful participation. Autism. 2018 Aug 10:1362361318786721.


Friday, 10 August 2018

"Risk markers for suicidality" and autism: masking or insight as a feature?

The findings reported by Sarah Cassidy and colleagues [1] continue an important research theme in relation to risk of suicide and autism (see here). The value-added bit to their research on this occasion was the observation that "there are unique factors associated with autism and autistic traits that increase risk of suicidality" and that some of these factors may be potentially modifiable.

Members of this research team have some important research history [2] when it comes to looking at suicidality and autism. This time around they report the results of an on-line survey completed by over 160 adults on the autism spectrum and a similar number of not-autistic controls. Prior to the delivery of this survey we are told that a steering group of autistic adults / adults with autism helped to target the research towards what factors might be relevant, including: "non-suicidal self-injury, mental health problems, unmet support needs, employment, satisfaction with living arrangements, self-reported autistic traits (AQ), delay in ASC [autism spectrum condition] diagnosis, and ‘camouflaging’ ASC."

"Results are consistent with previous findings that autistic adults are at significantly increased risk of suicidality compared to the general population." As worrying as that finding is, the observation that suicidality is elevated in relation to autism is nothing new. Indeed, as far back as the late 1990s, there were rumblings of 'under-reporting' of suicidality in relation to autism and related developmental disorders.

Continuing: Various psychiatric labels/conditions were identified as being present in those with autism at a greater frequency than controls. This included various 'comorbidities' previously discussed with autism in mind (see here and see here). Several of those conditions have also been identified as key risk variables when it comes to suicidality. I was also particularly drawn to the rate of personality disorder (PD) identified in this sample: 18% in females with autism compared with 3-4% in control females for example. This is interesting in light of other research explored on this blog (see here) and again, some evidence of an enhanced risk for suicide alongside such a condition. And mention of 'Myalgic encephalopathy' I assume akin to Myalgic Encephalomyelitis (ME), another mainstay topic of this blog, perhaps taps into an area that requires lots more study on the possible overlap between autism and ME/CFS (chronic fatigue syndrome) (see here). Indeed, in future posts I'll be [again] covering research on the issue of suicide in relation to ME/CFS [3] that could also be relevant to autism and ME/CFS when co-occurring, reiterating that ME/CFS is not a psychiatric or mental health diagnosis...

Onward: "These results suggest that autism diagnosis and autistic traits explain significant additional variance in suicidality beyond a range of known risk factors, and are therefore independent risk markers for suicidality." So 'autistic traits as being independent risk markers for suicidality'. This is not the first time that such peer-reviewed sentiments have been reported (see here) and probably won't be the last. The logical implications from such a finding is that a reduction in autistic traits may well impact on suicidality. This is not a sentiment that some people will find palatable, but that's the logical implication stemming from such a finding.

Finally, quite a lot has been made (on social media at least) about the issue of camouflaging (masking) and a possible connection to suicidality in relation to autism. Masking reflects the idea that some on the autism spectrum actively camouflage signs and symptoms "in order to cope in social situations." The authors report that: "Camouflaging and unmet support needs appear to be risk markers for suicidality unique to ASC [autism spectrum conditions]." I'm however slightly cautious of this at the moment when wearing my objective science hat. One has to remember that, at present, there aren't many (any?) well validated tools for objectively assessing masking in relation to autism. In this study, Cassidy and colleagues mention how: "A brief set of four questions were designed to quantify tendency to camouflage." The answers to such a small set of open questions are subject to considerable bias (particularly if the individual is active on social media and perhaps privy to all the discussions around masking on there). One also cannot discount the idea that having the fundamental ability of 'insight' to be able to mask/camouflage may itself be a risk factor for suicidality. I say this on the basis of other research talking about how a higher cognitive capacity in relation to autism seems to increase the risk of vulnerability to depression (see here) as a function of the link between depression and suicidality. Simple answers to complex questions are likely to be few and far between.

So, where next? Well, being careful not to fall into any sweeping generalisations or psychobabble explanations of suicide risk in relation to autism, it strikes me that there are a few things to think about in terms of harm reduction. Screening for something like depression and/or non-suicidal self-injury (NSSI) should be much more widespread in the context of autism. Obviously, such behaviours / diagnoses are not just 'locked in' over a lifetime, so such screening needs to be done quite regularly. I would also mention that other comorbidity seemingly over-represented when it comes to autism might also exert an important effect too (see here). Tackling 'unmet support needs' also looks to be important. I'm slightly less sure of how to go about affecting this, given that the availability of many services are seemingly at the whim of finances and resources, which continue to be in short supply in these austere times (see here). But where there's a will, there's a way. I'll also reiterate that if certain autistic traits are themselves independent risk factors for suicidality, it surely follows that moves to reduce such behaviours would impact on suicidality. Indeed, in this context, the active process of masking could be seen as a double-edged sword when it comes to suicidality and autism.

And I'm also minded to bring in some important literature where autism is talked about in the context of euthanasia and assisted suicide (see here) and what lessons could be learned from some of the accounts detailed there. It's another difficult topic to discuss but something that is becoming increasingly relevant (see here).

As always, if you need someone to talk to (or text), there are organisations available. Please use them.


[1] Cassidy S. et al. Risk markers for suicidality in autistic adults. Mol Autism. 2018 Jul 31;9:42.

[2] Cassidy S. et al. Suicidal ideation and suicide plans or attempts in adults with Asperger's syndrome attending a specialist diagnostic clinic: a clinical cohort study. Lancet Psychiatry. 2014 Jul;1(2):142-7.

[3] Devendorf AR. et al. Suicidal ideation in non-depressed individuals: The effects of a chronic, misunderstood illness. J Health Psychol. 2018 Jul 1:1359105318785450.


Thursday, 9 August 2018

On postpartum paracetamol metabolites and risk of offspring ADHD: details matter

The findings reported by Yuelong Ji and colleagues [1] provide the blogging fodder today, as once again the topic of acetaminophen (a.k.a paracetamol) use during pregnancy and offspring risk of attention deficit hyperactivity disorder (ADHD) is in the spotlight. I say 'once again' because this topic has cropped up time and time again on this blog (see here for example).

On this research occasion, the starting point was the Boston Birth Cohort (a cohort that has been mentioned before) and specifically, an analysis of "maternal plasma acetaminophen metabolites levels measured within a few days after delivery and ADHD diagnosis in the offspring" as a measure of paracetamol exposure. The metabolites in question were "unchanged acetaminophen, acetaminophen glucuronide, and 3-(N-Acetyl-l-cystein-S-yl) acetaminophen." All were measured in blood plasma using one of the gold-standard chemical analytical techniques: mass spectrometry. A diagnosis of ADHD was extracted from medical records on the basis of ICD-9 and/or ICD-10 definitions.

Results: taking into account other potential confounding variables, authors reported finding "a significant positive association between maternal blood acetaminophen metabolite levels measured within 1–3 days postpartum and ADHD diagnosis in offspring." It's perhaps however important to understand how such a finding was arrived at, bearing in mind that ADHD was not the only diagnostic fruit examined in the Ji study. So: "The main exposures analyzed in this study were maternal acetaminophen metabolite levels, which were inverse normal transformed to approximate the normal distribution." What this means is that rather than reporting the specific levels of each paracetamol metabolites across different diagnoses and a 'neurotypical group' ("Children without any diagnosis of ASD [autism spectrum disorder], ADHD, developmental delays, or intellectual disabilities were classified as neurotypical (NT)"), authors chose to covert the raw values into groupings. Groupings were based around "no detection, below median, above median of detected values." I'm not altogether sure that this is the best way to report results; certainly I would have liked to have seen the raw values for each metabolite according to group as a comparator; but that's just my research preference. Researchers mention that they did not see any association between paracetamol metabolites and any other diagnostic label, and also stressed how the association remained when other potentially confounding variables were taken into account. And when it comes to ADHD, there are a few (see here for example).

How much weight can we give these results? Well, this is probably the first time that someone has looked at actual paracetamol metabolites in mums rather than just relying on maternal or doctor records of paracetamol usage during pregnancy, and that's a good thing. Authors also mention that their study was "further strengthened by the diagnosis of ADHD by both general pediatricians and developmental specialists." Add in the prospective design of the study, and you have some potentially important evidence for a *relationship* between paracetamol use and subsequent offspring development.

But... "this study only included a one-time measurement of maternal acetaminophen metabolite levels within 1–3 days postpartum." The authors rightly acknowledge that paracetamol is pretty quickly metabolised in the body so, at best, their study really only looked at recent paracetamol use immediately during or after birth. Maybe further study of archived samples during pregnancy (at multiple points during pregnancy) would provide some further information? And comments from the authors like "women with detectable levels of acetaminophen biomarkers are likely to be more regular users" really don't have any place in a scientific paper without supporting evidence. Particularly when pain relief is going to be pretty important when it comes to the process of childbirth.

Also: "our metabolite measurement method did not include acetaminophen sulfate, which accounts for 30–44% of the total metabolites of acetaminophen under the normal dosage." I don't want to go into the nitty-gritty of paracetamol metabolism, but just going back to the research looking at sulphation (sulfation) in the context of autism (see here), it would have been useful to examine both paracetamol sulphate and paracetamol glucuronide at the same time. Certainly it would have provided a more complete picture of typical paracetamol metabolism.

Don't get me wrong, I am interested in the Ji findings and their addition to the literature on paracetamol use and offspring outcomes. This still remains an important area of investigation. I'm not however completely convinced that the evidence presented by Ji and colleagues counts as particularly strong evidence despite the important measurement of paracetamol metabolites in this context...


[1] Ji Y. et al. Maternal Biomarkers of Acetaminophen Use and Offspring Attention Deficit Hyperactivity Disorder. Brain Sci. 2018 Jul 3;8(7). pii: E127.