Monday 6 May 2013

The ESSENCE of autism comorbidity?

Like Charlie Bucket looking through the sweet shop window at the delicious chocolates produced by the workforce of a certain Mr Willy Wonka (the candyman no less), I am always quite interested in the goings-on at the IMFAR autism research conference.
  The candyman can... @ Wikipedia  

This year (2013) proved to be a bit of a vintage, as once again the great and the good presented their Wonka bars of autism research; thus hinting at the direction of future autism research and what you can expect to read on this blog in the coming months. Oh, and something about poodles(?) (thanks Carol).

I've been hearing quite a bit of chatter about the keynote speech given by Prof. Christopher Gillberg which seemed to quite strongly hint that the autism research community should be paying rather more attention to the add-ons which seem to accompany a diagnosis of autism, rather than seeing autism as just existing stand-alone in a diagnostic vacuum.

Far be it from me to say 'I told you so', but comorbidity and overlap, and the often far-reaching effects on quality of life of certain comorbidity, has been a theme running through many posts on this blog and not just the more behaviourally-defined type of comorbidity. So for example the question of 'significantly over-represented' and all that autism's' chatter (note the plural) immediately come to mind. Indeed I don't actually believe that many people in the know would view the autisms as just being the total sum of the triad (very soon to be dyad). Or would they?

Mention of the word ESSENCE - Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations* - has apparently been made in Prof. Gillberg's address denoting "the reality of children (and their parents) presenting in clinical settings with impairing child symptoms before age 3 (-5) years in the fields of (a) general development, (b) communication and language, (c) social inter-relatedness, (d) motor coordination, (e) attention, (f) activity, (g) behaviour, (h) mood, and/or (i) sleep". Before proceeding, I would perhaps suggest that Gillberg seems to have some interest in the use of acronyms in autism research and beyond as per the example of DAMP and MBD**.

Anyhow, a quick scan of the peer-reviewed research literature does indeed see a small but growing body of work discussing ESSENCE and its use in autism research circles. I note for example this paper by Prof. Brian Neville*** who highlights an essential part of the use of ESSENCE: that the presentation of behaviour in infants and young children is often complex, and the "problems are their multiplicity". Common sense perhaps?

Perhaps one of the best (so far) papers discussing the concept of ESSENCE in a real-world clinical setting is this one from Lotta Höglund Carlsson and colleagues**** (open-access) (which includes Gillberg as part of the authorship team). The paper is free for all to read so no great dissection required from me. That being said, I would highlight the fact that based on examination of just over 100 children diagnosed with an autism spectrum disorder (ASD), "a mean of 3.2 coexisting disorders or problems" were reported, including a third of children presenting with "severe hyperactivity/ADHD".

I was particularly interested in this autism-ADHD link given some other recent research on the overlap*****. That and the fact that additional reports have indicated even higher levels of overlap between autism and ADHD (see this post) calls into question whether the two labels may intersect even more than we perhaps have appreciated.

One of the potential implications of the co-occurrence of autism and ADHD is with regards to intervention and therapeutic options. Without trying to hijack the association with my dietary mumbo-jumbo, I would draw your attention to a previous post I published a while back on food and ADHD and some potential lesson for autism (see here). The suggestion there - and it was only a suggestion - was that some of the observations made when looking at the impact of a dietary intervention for autism actually working on some of the symptoms associated with ADHD might imply that targeting such comorbidity might eventually impact on more core autism presentation. A shocker I know that children being described as less impulsive and attending better might actually have better outcome.

I'm finishing shortly but before I do, I want to draw your attention to another ESSENCE mention in the paper by Stephanie Plenty and colleagues****** (open-access) who looked at the retrospective application of the concept in cases of adult ASD and ADHD. They similarly reported: "Although differences were observed between ADHD and ASD patients in the core diagnostic areas, these syndromes also shared a number of childhood difficulties".

The wave of research and opinion which is seemingly directing everyone to this idea that autism is not a stand-alone label is growing. Add into the mix the recent announcement that even before the introduction of DSM-V the NIMH prefer an even broader view of behaviour and psychiatry (RDoC) ('reorienting' apparently) and that autism-ADHD-[insert other] spectrum is starting to feel more and more like a giant tapestry.

To close, for the second time in this post I'm going to direct you to the genius of Sammy Davis Jnr - the Candyman can y'know.


* Gillberg C. The ESSENCE in child psychiatry: Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations. Res Dev Disabil. 2010; 31: 1543-1551.

** Gillberg C. Deficits in attention, motor control, and perception: a brief review. Arch Dis Child 2003; 88: 904-910.

*** Neville B. Role of ESSENCE for preschool children with neurodevelopmental disorders. Brain Dev. 2013; 35: 128-132.

**** Höglund Carlsson L. et al. Coexisting disorders and problems in preschool children with autism spectrum disorders. Scientific World Journal. 2013: 213979.

***** Cooper M. et al. Autistic traits in children with ADHD index clinical and cognitive problems. Eur Child Adolesc Psychiatry. April 2013.

****** Plenty S. et al. Applying an ESSENCE Framework to Understanding Adult Autism Spectrum Disorder and ADHD: Retrospective Parent Reports of Childhood Problems. Scientific World Journal. 2013: 469594.

---------- Höglund Carlsson, L., Norrelgen, F., Kjellmer, L., Westerlund, J., Gillberg, C., & Fernell, E. (2013). Coexisting Disorders and Problems in Preschool Children with Autism Spectrum Disorders The Scientific World Journal, 2013, 1-6 DOI: 10.1155/2013/213979

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