Depressive symptoms in ADHD: "comparing child and parent reports"

I was drawn to blogging about the results published by Annie Fraser and colleagues [1] for a few reasons. Their observation that: "Young people with ADHD [attention-deficit hyperactivity disorder] are at high risk of experiencing symptoms of depression but may under‐report the severity of their symptoms" was interesting. It potentially ties into some other important observations about 'happiness' in the context of ADHD (see here) and also how there is an elevated risk of suicidality when ADHD is part of the clinical picture (see here). Similarly, it fits the narrative that various developmental and/or behavioural labels/conditions/disorders are typically never really stand-alone diagnoses...

So: "This study used a subsample of children originally recruited as part of the Cardiff University Study of ADHD Genes and Environment (SAGE)." As per the 'comparing child and parent reports' part of the Fraser paper, both parents and children completed the Mood and Feelings Questionnaire (MFQ) to measures depressive signs and symptoms in participating children/young adults ("mean age was 14.6 years (range 8–20 years)"). The MFQ "is a widely used depression screening instrument" according to the authors, and has some pretty good backing. Results from the MFQ were compared with a non-ADHD (I assume?) general population sample from a similar part of the United Kingdom (UK) and statistics were applied.

Having already alluded to the observation that depression scores on the MFQ were higher (indicative of more depressive symptoms) in the ADHD group than the population control group (N=1460), there are some further details to mention. Both parent- and child-rated MFQs showed the trend of more depressive symptoms in participants with ADHD. And when it came to clinical cut-off points for suspected depression, quite a few more of those diagnosed with ADHD reached them compared with controls (parent‐report 54.5% vs. 10.6%... child‐report 32.4% vs. 10.5%).

"Amongst the most common depression symptoms found in our ADHD sample were difficulty concentrating, restlessness and feeling grumpy with parents. These symptoms overlap with those of ADHD, so it is unsurprising that they were common in our sample." Think of those last sentences in one particular context: the rise and rise of the term 'ESSENCE' (Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations) and all the chatter about how behavioural symptoms across various different labels seem to 'overlap' with one and another. How also, developmental and behavioural labels rarely exist alone or in some sort of diagnostic vacuum (see here for example). And add them to another sentence from the authors: "This could suggest that depression scores in this sample are artificially elevated by symptoms which overlap with ADHD symptoms." Indeed.

"Suicidal thoughts and symptoms of psychomotor and cognitive retardation (i.e. talking more slowly than usual, moving and walking more slowly than usual, and sleeping more than usual) were the lowest scoring symptoms on both parent‐ and child‐report." Having already mentioned those quite worrying statistics on how a diagnosis of ADHD seems to elevate the risk of suicidality, this might initially seem like better news from the Fraser paper. Items such as "S/he thought about death or dying.... S/he thought his/her family would be better off without him/her... S/he thought about killing him/herself" were not, in the majority, reported on with great fervour. But one needs to be cautious. I say that because the authors also added: "symptoms of suicidality (‘I thought about killing myself’) were present in 20%–25% of the ADHD sample, according to both parent‐report and child‐report, compared to 2%–7% of the population sample." This is a more worrying way of looking at the findings.

So to conclude: depression or depressive symptoms are no stranger to ADHD, the symptoms of ADHD probably overlap with some of the symptoms of depression (at least according to the MFQ), and an enhanced risk of suicidality seems to be confirmed as and when ADHD is diagnosed. There's more than enough further investigations to be done on those topics; perhaps also drawing on a few other important observations too (see here and see here and see here).

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[1] Fraser A. et al. The presentation of depression symptoms in attention‐deficit/hyperactivity disorder: comparing child and parent reports. Child and Adolescent Mental Health. 2018;23(3):243-250.

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"a high rate of physical problems in children with NDDs"

NDDs mentioned in the title of this post refers to neurodevelopmental disorders, pertinent to the important results published by Setareh Alabaf and colleagues [1] on how autism and various other NDDs rarely appear in some sort of diagnostic vacuum (see here).

Including a notable ESSENCE-related name on the authorship list (see here), authors focused on various physical (somatic) diagnoses - "epilepsy, migraine, asthma, cancer, diabetes, psoriasis, lactose intolerance, celiac disease, diarrhea, constipation, daytime enuresis, encopresis" - and their frequency in a nationwide population cohort of twins that has been mentioned before on this blog (see here). The participant number totalling data on some 28,000 twins (parent reported) is not to be sniffed at, including over 1000 children categorised as having a NDD.

Results: "The results indicate a high rate of physical problems in children with NDDs, particularly in those with indications of the presence of combinations of several NDDs." I was particularly drawn to a couple of the results mentioned by Alabaf et al that tally with other independent findings. So: "asthma had the highest prevalence (14.2%)" following other peer-reviewed results (see here and see here). The authors also highlight another important physical comorbidity as being important to some: "Of the GI [gastrointestinal] problems, the most prevalent was constipation (8.4%) and lactose intolerance (5.9%)" which again aligns with other findings (see here and see here). I should mention that the study relied on telephone interviews with parents of children asking specifically whether particular physical problems were diagnosed. Yet again also responses to a questionnaire were "used as clinical proxies for ASD [autism spectrum disorder], ADHD [attention-deficit hyperactivity disorder] and LD [learning disorders], which are included in the NDD group" so one has to bear this in mind.

Another aspect to the Alabaf findings is also noteworthy: "children with different constellations of NDDs more often had coexisting physical problems as compared to children with a single NDD." This is important. It suggests that alongside the idea that a diagnosis like autism or ADHD typically do not exist in some sort of diagnostic vacuum when it comes to other psychiatric and developmental psychopathology, so the frequency of physical or somatic issues seems also to cumulative. The first thing that sprung to my mind when reading about this was the idea that 'autism genes' are probably not just 'genes for autism' (see here). And that probably goes for the presentation of somatic issues too. By saying that I don't belittle the contribution of the 'functional' immune system to autism and the various links that have been made there too [2] in a 'non-genetic' capacity.

It also means that yet again, as and when a diagnosis of something like autism or ADHD is given, professionals should be mindful that other 'preferential' screening should also be provided alongside...

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[1] Alabaf S. et al. Physical health in children with neurodevelopmental disorders. J Autism Dev Disord. 2018 Jul 24.

[2] 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

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Selective mutism and autism

The findings reported by Hanna Steffenburg and colleagues [1] make for potentially important reading reporting: "In this study of a clinical group of children who were diagnosed with SM [selective mutism] and assessed at a center for neurodevelopmental disorders, 63% also met criteria for ASD [autism spectrum disorder]."

Selective mutism (SM) refers to an anxiety disorder typically manifesting during early childhood that affects the use of spoken language in certain social situations such as at school. 'Literally being unable to speak' is a phrase that follows SM in certain contexts, where speech and language skills are not typically affected when and where family or close friends are around. It's not surprising that there is 'overlap' between SM and autism given the characterisation of SM in terms of being "nervous, uneasy or socially awkward" and "stiff, tense or poorly co-ordinated" (minus any sweeping generalisations). And just before you question it, 'poorly-coordinated' is perhaps an under-rated aspect for many people diagnosed as being on the autism spectrum (see here).

Steffenburg and colleagues - including the notable ESSENCE-related name of Christopher Gillberg - sought to examine the possible 'overlap' of SM and autism on the basis that various diagnoses/labels can occur alongside SM; quite a few of them also recognised in relation to autism (see here). Approaching 100 children/young adults diagnosed with selective mutism were assessed at the premier 'autism spectrum conditions' clinic in Gothenberg, Sweden. The clinical assessment undertaken of course covered the diagnosis of autism but also various cognitive functions too.

Almost two-thirds of those with SM who were assessed also met criteria for an autism spectrum disorder (ASD). Added to that: "A further 20% (n=19) had autistic features that were “subclinical”, but, nevertheless, sufficiently marked to have an impact on everyday life." Only 17% were described as having no ASD symptoms. Those are pretty interesting percentages.

Authors also mention how: "The level of cognitive function was average in more than half of the study group but more than one-third of the study group had a borderline IQ or an ID [intellectual disability]." They use such a finding in the context of the ESSENCE term - Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations - where overlapping diagnoses/labels is the rule not the exception.

The implications? Well, screen and keep a continual eye open for autism in cases of SM seems to be an important first implication. That also includes keeping in mind those 'subclinical' signs and symptoms, which could be relevant to discussions about the broader autism phenotype (BAP) (see here) and also that curious DSM-5 diagnostic category known as social communication disorder (SCD) (see here). The focus on 'anxiety' in relation to SM might also be important given the pretty well-established connection between autism and anxiety (see here for example) following in the footsteps of some often forgotten autism research history (take a bow Mildred Creak and colleagues for including the term "acute, excessive and seemingly illogical anxiety"). I'm also minded to mention that given the pretty high rate of autism described in SM by Steffenburg and other researchers, further investigations perhaps need to be directed towards shared biology/genetics as well as shared behavioural presentation? Y'know, along the lines of whether 'comorbidity' might be something more 'core' (see here)?

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[1] Steffenburg H. et al. Children with autism spectrum disorders and selective mutism. Neuropsychiatr Dis Treat. 2018 May 7;14:1163-1169.

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Treating anxiety and depression in the context of autism: is 'talk therapy' cutting the mustard?

The findings reported by Brenna Maddox and colleagues [1] caught my eye recently, talking about "community treatment" patterns for co-occurring anxiety or depression in the context of autism.

Researchers concluded that talking therapy such as cognitive behavioural therapy (CBT) typically indicated for such mental health issues, is utilised in the context of autism but perhaps not as frequently as experienced in a not-autistic group. That finding covered various types of talk therapy such as individual therapy for anxiety/depression and case management. Alongside: "Adults with ASD [autism spectrum disorder] are more likely to be prescribed multiple medications concurrently."

Drawing on "Pennsylvania Medicaid claims data", researchers were able to identify adults with ASD who also presented with defined depression and/or anxiety. They matched this group (numbering about 270) with other adults presenting with depression and/or anxiety but not diagnosed with autism (N=1072). They then compared psychiatric treatment experiences between the groups.

"Adults without ASD were more likely to receive talk therapy for anxiety/depression." I added the bolding to the text so that we are clear that the Maddox results suggested that talking therapies for co-occurring depression and/or anxiety were less likely to be used when autism was mentioned. The authors further explain that these results are consistent with the idea that "they [those diagnosed with autism] often experience difficulty accessing mental health services." That being said, when talk therapy was accessed by adults with autism, researchers reported that they "averaged more individual talk therapy visits per month than did adults without ASD." I'll come back to this point in a moment...

Going back to the experiences of pharmacotherapy for those with and without autism, Maddox et al observed that: "the ASD group had a significantly higher number of days per month prescribed for all medication classes" covering medicines such as antidepressants, antipsychotics, benzodiazepines (anxiolytic) and CNS stimulant. Polypharmacy - where more than one medicine is dispensed - was also a more frequent occurrence for autistic adults too (nearly half were taking two or more psychotropic medicines).

What could all this mean? Well, going back to the observation that when they were able to access talk therapy, more visits per month were noted for the adults with autism, there is one possibility entertained by the authors to account for this: "talk therapy in the community is less effective with adults with ASD, who therefore stay in therapy for a longer period in pursuit of greater symptom relief." That possibility alongside the higher rates of 'multiple medicine use' noted in that group, adds weight to the idea that whilst talking therapy is useful for some cases of anxiety and depression, in the context of autism it might not necessarily be 'cutting the mustard'. The words "having more “treatment refractory” or complex constellations of symptoms" are also mentioned by Maddox and, well, have been discussed before (see here for example).

Further research is required on this issue before any sweeping generalisations are made by me or anyone else. For the record, I'm not adverse to the idea that talking therapy could be useful for depression/anxiety in the context of autism, but am open to the idea that the presentation of such mental health issues alongside autism might not be the same in form or for the same reason(s) as that in other non-autistic contexts. Indeed, in these days of ESSENCE and 'autism plus', I'm fast coming around to the idea that anxiety and depression could well be a core part of [some] autism (see here) as per what other - often forgotten names - had previously suggested (see here). Contrary then to the idea being promulgated among some (mainly psychological) quarters of the autism research and practice scene, that anxiety and depression develop in the most part as a consequence of external sources (see here for some chatter on 'social acceptance'), such mental health issues could be more fundamental characteristics of autism [2]. By saying that, I'm not discounting *some* influences like the contributions of loneliness and self-esteem (see here) but would also look to more intrinsic (biological and genetic) variables as also exerting something of a powerful effect. Similar sentiments have also been voiced when it comes to some other extremes of behaviour and their possible 'core' link to autism (see here).

"Our results suggest the need both for more granular and sophisticated assessment of community treatment for adults with ASD and anxiety/depression, and for better training for clinicians working with this population." I don't think many people would disagree with such conclusions. What I would like to see, under scientifically controlled circumstances, is some further comparisons of talking therapy for anxiety/depression in autism vs. not autism. I'm not talking about CBT vs no CBT with autism in mind [3] but rather research comparisons taking into account whether a diagnosis of autism might mean rethinking particularly talking therapy strategies for managing such quality-of-life-draining issues such as depression and anxiety.

The implication is also, yet again, that to really positively impact on the presentation of such issues, one needs to consider 'targeting' the core symptoms of autism themselves, as per what other research has similarly hinted at (see here). I can see conflicts arising following such sentiments...

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[1] Maddox BB. et al. Treatment utilization by adults with autism and co-occurring anxiety or depression. Research in Autism Spectrum Disorders. 2018; 51: 32-37.

[2] Spain D. et al. Social anxiety in autism spectrum disorder: A systematic review. Research in Autism Spectrum Disorders. 2018; 52: 51-68.

[3] Kilburn TR. et al. Rationale and design for cognitive behavioral therapy for anxiety disorders in children with autism spectrum disorder: a study protocol of a randomized controlled trial. Trials. 2018 Apr 2;19(1):210.

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How much does it cost to assess a child for autism?

In answer to the question titling this post - 'How much does it cost to assess a child for autism?' - the results published by Mark Galliver and colleagues [1] provide some important findings, at least pertinent to the diagnostic experience here in Blighty.

Authors concluded that assessment for autism "typically takes 13 hours of professional time" and costs somewhere in the region of "£650–£1000 ($975–$1500) per child." Importantly too, the staff costs of around £800 per assessment do not cover "costs of intervention, parent psychological education, investigation and assessment and management of comorbidities."

I appreciate that talking about 'financial costs' associated with autism (assessment) is not a topic everyone will enjoy discussing. Much like other 'bean counter' discussions (see here and see here), everyone [rightly] aspires to providing this, that and t'other to improve facilities with regards to diagnosis and indeed, post-diagnostic services. The financial reality however, particularly in these days of continued austerity, is that such services are often under-funded, under-resourced and headlines including words like 'two year wait' for diagnostic assessment (see here) are not uncommon. People rightly get angry about this but the services themselves and the people delivering them are not to blame.

Galliver et al started out with some important premises. First, there are a growing number of referrals for assessment for autism. Second, such an 'increase in demand' naturally puts greater pressure on diagnostic services resulting in longer waiting times. Third, there are recognised pathways for referral and assessment for autism, but the resourcing of such pathways might not always be optimal either in form or amount. All of this is set in the context of the National Health Service (NHS) providing clinical and medical services here in the UK, free at the point of need and all that.

Researchers therefore decided to ask various local child development centres (CDC) in England about their diagnostic experiences in terms of resources and costs. Various questions were asked pertinent to the pathway used to deliver assessments and professional time typically allocated to said assessments. They report on responses from 60% of the CDC - no, not that CDC - initially questioned, covering a range of services in different geographic locations.

I don't need to rehash the financial findings again. I will however mention a couple of associated points that might be relevant. First, autism rarely exists in some sort of diagnostic vacuum (see here). The authors make the point that their figures did not cover the "investigation and assessment and management of comorbidities" something important in these days of greater realisation of 'autism plus' and ESSENCE (see here). In this respect, the figures provided by Galliver are likely to be an underestimate of the true financial cost of assessment.

Second, the issue of growing numbers of referrals and "increasing demand" for diagnostic services is highlighted in various parts of the reported findings. I have my own opinions as to why this is happening (see here and see here) but the one thing that is becoming increasingly clear is that such an increase is probably not just due to better recognition of autism or issues such as diagnostic switching (see here and see here). Yes, these points were probably relevant about 10-20 years ago, but now, I'd have to say not as much as [clinical] awareness must have peaked by now. At some point the question of 'why the increase' is going to have to be properly faced up to if it's not going to be all about just assessing and diagnosing in a catch-up sense.

Finally, although more funding would help, such demands on assessment services are probably not going to be met by just 'throwing a few quid' at them. The NHS is moving with the times in other areas; and the rise and rise of technology to potentially assist with autism assessments is becoming increasingly important. I'm thinking about work such as that being done at the Duda-Wall laboratory (see here and see here) where technology such as machine learning is being used in the context of autism screening. And things like autism screening triage via YouTube (see here) *might* also [eventually] become more commonplace. Technology can potentially ease the burden on assessment services.

Whatever does or does not happen as a result of findings such as those by Galliver and colleagues, the underlying messages are that autism assessment is (a) not an inexpensive process and (b) either significant funds need to be poured into the service or services need a revamp on the basis of current funding schedules and as national finances allow. Either way, I don't see assessment waiting times improving much in the near future despite the important work provided by our fantastic NHS and the desperate need for timely autism assessment.

And I've not even mentioned about adult diagnostic services...

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[1] Galliver M. et al. Cost of assessing a child for possible autism spectrum disorder? An observational study of current practice in child development centres in the UK. BMJ Paediatr Open. 2017 Nov 30;1(1):e000052

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"evidence does not support the validity of pathological demand avoidance as an independent syndrome"

Pathological Demand Avoidance (PDA) mentioned in the title of this post represents "a behaviour profile within the autism spectrum" according to one authoritative source.

As I mentioned in a blogpost a few years back discussing PDA (see here), the label encompasses quite a few characteristics that overlap with facets of autism. Importantly however, it also includes a few other elements, including 'resisting and avoiding the ordinary demands of life' and the 'active use of various strategies to resist demands via social manipulation', not readily associated with autism (see here for further information). The late Prof. Liz Newson talked quite a bit about PDA [1] and I was honoured to see her speak so passionately about this topic on a few occasions.

As per the UK National Autistic Society (NAS) entry on PDA, the label is "increasingly, but not universally, accepted as a behaviour profile that is seen in some individuals on the autism spectrum." Such a description sets the scene for how things stand at the moment with regards to PDA and it's current lack of formal acceptance in the various diagnostic manuals despite relatively common usage, at least here in Blighty. The viewpoint article published by Jonathan Green and colleagues [2] is likely to provoke reactions on both sides of the debate of whether PDA is an "independent syndrome" or merely reflects "an important known range of co-occurring difficulties for many children with autism spectrum disorder." Green et al suggest the latter.

This is a difficult topic to talk about. Not least because there are quite a few children and adults who have been diagnosed with PDA. The idea that these people may have been 'mis-diagnosed' or perhaps even given the label on the basis of a diagnostic 'fad' has the potential to cause quite a bit of distress both to them, their parents / caregivers and various other people who have an interest in their education and development. I make no value judgements on the Green paper aside from looking at the quality of the [current] peer-reviewed science upon which it is based.

On the topic of the peer-reviewed science on PDA, well, the term 'limited in quantity' probably best describes it so far, which is a bit surprising given the increasingly popularity of the label. I daresay that this point probably impacted on the conclusion reached by Green and colleagues, but there are some important things to highlight so far.

The paper by Elizabeth O'Nions and colleagues [3] talking about the possibility of identifying PDA via the use of the DISCO (Diagnostic Interview for Social and Communication Disorder) covered some important issues. First: "the sense that identifying PDA features in individuals within the autism spectrum may serve an important clinical function in providing tailored educational and support strategies" is mentioned. In these times when autism is increasingly being talked about in the plural sense ('the autisms') and rarely as a 'stand-alone' diagnosis (see here), PDA perhaps represents a first important step in categorising or sub-categorising part of the autism spectrum. It's perhaps no coincidence that the name Gillberg also appears on quite a bit of the literature talking about PDA, with his interest in the overlapping concept of ESSENCE including autism (see here). I might add that this is not the first time that efforts have been made with regard to formulating a diagnostic instrument for PDA [4].

Second, O'Nions and colleagues both in their adapting DISCO to diagnosis paper and other peer-reviewed publications [5] make reference to how data suggest that "a number of the traits characteristic of PDA are not very specific to the PDA phenotype and may be relatively common across the autism and problem behaviour phenotypes." They observed for example that: "Outrageous acts and lack of concern for their effects draw parallels with conduct problems and callous-unemotional traits" and even that: "The pathological demand avoidance group displayed comparable levels of autistic traits and peer problems to the autism spectrum disorders group and anti-social traits approaching those seen in the conduct problems and callous-unemotional traits group." This is important in any debate about whether PDA is deserving of a stand-alone diagnosis status or something more 'comorbid'. It should also be viewed alongside the idea that autistic traits are not seemingly just autism-specific (see here) but also occur across various different labels and diagnoses (see here). Going back to the idea for example, that callous-unemotional and anti-social traits seem to be part and parcel of some PDA, I'll draw your attention to a group of conditions where such issues are also seemingly 'over-represented' (see here) and how such conditions are themselves over-represented when it comes to the autism spectrum [6] (see here also). In short, it's [clinically] complicated.

Finally, although by no means a specific gender-linked diagnosis, I note that there are facets of the description of PDA that could 'overlap' with issues that are 'rising' when it comes to autism and in particular, female autism. So, again from the NAS description, the phrase "appears social at first and to be people-orientated" is mentioned in connection to PDA; complemented by observations on the use of 'role-play' with regard to obtaining needs and wants. I've specifically mentioned female autism in this context because of the growing interest in how the female presentation of autism might be subtly different (camouflaged) from the male presentation (see here), bearing in mind the need not to make too many sweeping generalisations (see here).

To reiterate, I remain neutral as to the current position of PDA as a distinct entity or something more 'co-occurring' symptom-wise. I do think the Green findings should be a 'call to action' for more research on this topic in terms of symptom comparisons and importantly, symptom presentation more longitudinally. With my interest in all-things 'comorbidity' in relation to autism (see here) I'd also like to see more investigations done on how the comorbidity profile may be similar/different in relation to more classical presentations of autism. And then there's biology to consider, and whether PDA notably 'differs' across any physiological measure(s) compared with other manifestations of the autism spectrum?

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[1] Newson E. et al. Pathological demand avoidance syndrome: a necessary distinction within the pervasive developmental disorders. Arch Dis Child. 2003 Jul;88(7):595-600.

[2] Green J. et al. Pathological Demand Avoidance: symptoms but not a syndrome. The Lancet Child & Adolescent Health. 2018. March 23.

[3] O'Nions E. et al. Identifying features of 'pathological demand avoidance' using the Diagnostic Interview for Social and Communication Disorders (DISCO). Eur Child Adolesc Psychiatry. 2016 Apr;25(4):407-19.

[4] O'Nions E. et al. Development of the 'Extreme Demand Avoidance Questionnaire' (EDA-Q): preliminary observations on a trait measure for Pathological Demand Avoidance. J Child Psychol Psychiatry. 2014 Jul;55(7):758-68.

[5] O'Nions E. et al. Pathological demand avoidance: exploring the behavioural profile. Autism. 2014 Jul;18(5):538-44.

[6] Gordon-Lipkin E. et al. Anxiety and Mood Disorder in Children With Autism Spectrum Disorder and ADHD. Pediatrics. 2018 Mar 30. pii: e20171377.

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ADHD and non-suicidal self-injury (NSSI)

I've covered the growing literature observing a link between a diagnosis of attention-deficit hyperactivity disorder (ADHD) and risk of unintentional injury a few times on this blog (see here and see here). The quite consistent picture emerging from that body of peer-reviewed research is that yes, a diagnosis of ADHD does seem to increase the risk of injury for whatever reason(s). Further, that pharmacotherapy utilising some of the various medicines indicated for ADHD, seems to have something of a 'reducing' effect on that elevated injury risk (see here).

Today I'm extending that ADHD-injury risk work to include the findings reported by Judit Balázs and colleagues [1] who concluded that: "ADHD symptoms are associated with an increased risk of NSSI [non-suicidal self-injury] in adolescents." Further that: "the symptoms of affective disorders and alcohol abuse/dependence psychotic symptoms" seem to be important 'mediators' of that risk of NSSI in the context of ADHD symptoms.

Based on the examination of adolescents who "were inpatients in the Vadaskert Child and Adolescent Psychiatric Hospital and Outpatient Clinic, Budapest, Hungary between 25.02.2015 and 09.05.2016", researchers reported that some 50 adolescents met the full criteria for ADHD and a further 70-odd "showed symptoms of ADHD at the subthreshold level." They employed the "Hungarian version of the modified Mini International Neuropsychiatric Interview Kid" to assess for various psychiatric symptoms, alongside the Deliberate Self-Harm Inventory (DSHI) to provide details on self-injury and some further questioning on suicidality. The aim was to investigate rates of NSSI in their cohort but also "how the symptoms of comorbid psychiatric conditions influence this [relationship], and whether there is a difference between girls and boys at this age."

Results: alongside the finding that at the very least, ADHD or ADHD symptoms are not protective against non-suicidal self-injury (NSSI), authors also observed that "people with ADHD have a higher risk than those without of developing comorbid psychiatric problems, both externalizing and internalizing ones" and "there is no direct association between the symptoms of ADHD and the prevalence of NSSI in a clinical sample of adolescents in any sex." On that last point, authors further opine that: "Comorbidities fully mediate the association between these conditions." In other words, clinicians should be screening for various psychiatric comorbidities - major depressive episode, dysthymic disorder, hypo/manic episode, psychotic disorders, substance-related dependence/abuse - and treating said comorbidities to potentially offset the risk of NSSI appearing alongside ADHD or subclinical ADHD.

In these days of ESSENCE - Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations - where the rule seems to be that various labels do not appear in some sort of diagnostic vacuum (see here for example), the Balázs findings fit well. The implication being that before grand associations are made on the basis of one variable = one condition/label/diagnosis (see here for example), one should perhaps consider a wider clinical picture. Indeed, to further extend the Balázs findings talking about NSSI, and based on the idea that autism and ADHD seem to be an important clinical combination (see here), I would perhaps encourage a greater depth of screening in future research (see here). That also might apply to the delicate issue of suicidality too (see here)...

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[1] Balázs J. et al. Attention-deficit hyperactivity disorder and nonsuicidal self-injury in a clinical sample of adolescents: the role of comorbidities and gender. BMC Psychiatry. 2018; 18:34.

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A quarter of prison inmates screen positive for ADHD (and beyond)

This is not the first time that I've talked about neurodevelopmental diagnoses such as attention-deficit hyperactivity disorder (ADHD) in the context of the prison population (see here and see here) on this blog and I doubt that it will be the last.

Without making any excuses or condoning / justifying any behaviour(s), I believe it is important to talk about such labels in the context of offending and incarceration because, as in the case of ADHD, there seems to be some real risk(s) attached to such a diagnosis/behaviour(s) that may well be reduced by timely assessment and management/treatment. There may also be some intervention options to be instigated in prisons too [1] in light of other evidence (see here)...

This time around, the findings from Susan Young and colleagues [2] provide the starting research material and their analysis of nearly 400 male prison inmates who "underwent an assessment that included the Diagnostic Interview for ADHD in Adults 2.0, the Autism Quotient, the Learning Disability Screening Questionnaire, the Brief Symptom Inventory (BSI), and measures of disruptive behaviours and attitudes towards violence."

Researchers reported that a quarter of their prisoner population screened positive for ADHD. They also observed that nearly 10% of their population screened positive for autism and a similar percentage for intellectual disability (ID). As is the case in these days of overlapping labels (ESSENCE?), various diagnostic label combinations seemed to occur; some of these combinations also *correlated* with various behavioural patterns. So, for example: "the combined ADHD/ID group had significantly higher scores of behavioural disturbance than the ADHD-only group."

Whilst interested in the Young results, I do have one tiny issue with one of the instruments used: the Autism Quotient (AQ). It's quite a long running thing I have with regards to the AQ and the important question: what does it actually measure? (see here) I know for some, it's their 'go to' self-report 'are you autistic?' instrument (see here) but I'm rather less enthralled by it's specific autism diagnostic potential. Indeed, other (much more important) people have similarly voiced peer-reviewed concerns [3] about the utility of the AQ (see here too). In that respect, I don't think Young et al can conclusively claim that approaching 10% of their prison cohort had autism on the basis of the AQ screen alone. I might also at this point, refer you to a post I wrote some time back on whether autism was in fact under-diagnosed among prisoners that concluded 'probably not' (see here)...

Still, the ADHD findings are important and add to a growing body of work concluding that various long-term adverse events [4] are potentially over-represented when a diagnosis is given alone or in combination with other labels (see here and see here). And medication, whilst providing one important intervention option for ADHD (see here), may not be the only course available to potentially reduce symptoms and onward mitigate any heightened adverse risks (see here and see here)...

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[1] Gesch CB. et al. Influence of supplementary vitamins, minerals and essential fatty acids on the antisocial behaviour of young adult prisoners. Randomised, placebo-controlled trial. Br J Psychiatry. 2002 Jul;181:22-8.

[2] Young S. et al. Neurodevelopmental disorders in prison inmates: comorbidity and combined associations with psychiatric symptoms and behavioural disturbance. Psychiatry Res. 2017 Dec 15;261:109-115.

[3] Allely C. A systematic PRISMA review of individuals with autism spectrum disorder in secure psychiatric care: prevalence, treatment, risk assessment and other clinical considerations. Journal of Criminal Psychology. 2018; 8: 58-79.

[4] Luderer M. et al. Prevalence Estimates of ADHD in a Sample of Inpatients With Alcohol Dependence. J Atten Disord. 2018 Jan 1:1087054717750272.

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Yet more 'the label of autism rarely exists in a diagnostic vacuum' research

Two papers are served up for your reading delight today: the first is by Maj-Britt Posserud and colleagues [1] and concluded that: "Co-occurring problems were common in ASD [autism spectrum disorder] screen positive children and contributed strongly to both impairment and to contact with services." The second paper was by Anne-Katrin Kantzer and colleagues [2] and, in a similar vein, observed that: "The vast majority of children with ASD fitted the concept of “Autism Plus”."

The commonality between the two papers, aside from both including a notable researcher and author (see here), was the assertion once again, that the diagnosis of autism rarely exists in some sort of diagnostic vacuum.

Both papers are open-access so require only limited discussion from myself. Each research project followed a slightly different methodological track insofar as their participant numbers, how autism was assessed for and other, related details. There are also a few other nuggets of important information included in each paper.

Posserud et al relied on a pretty large participant group, all part of the Bergen Child Study (BCS). The aim of the study was to examine the "prevalence of co-occurring problems, impairment and service use in a population-based sample of children defined as screen positive on the Autism Spectrum Screening Questionnaire (ASSQ)." Of course 'screen positive' on the ASSQ does not necessarily mean 'diagnosed with autism' but there you go. Alongside, researchers also screened for a range of other behavioural and mental health issues in their cohort using both parents and teachers as informants.

Results: "A total of 226 children were defined as ASD screen positive (3.6%), 66 girls (2.1% of all girls) and 160 boys (5.1% of all boys)." A large proportion of those who screened positive for autism (over 90%) also screened positive for various other co-occurring issues including attention-deficit hyperactivity disorder (ADHD) and/or learning (intellectual) disability. Indeed: "Only 2% of children could be characterised as having “autism only”, i.e. having no other problems in this population-based sample."

Kantzer et al by contrast, relied on a data from a much smaller participant sample (N=96) who were prospectively 'followed' from first contact for assessment - having previously "been identified with autistic symptoms in a general population child health screening program" - for a further two years (T2). We are told that "assessment included a broad neurodevelopmental examination, structured interviews, a cognitive test and evaluations of the child́s adaptive and global functioning" across the different testing occasions.

Results: 76 of the 96 children included for study initially met the diagnostic criteria for ASD at initial assessment rising to 79 at T2. What this tells us is that not everyone referred for an autism assessment will hit autism diagnostic thresholds (something noted on a previous blogging occasions). Although diagnostic stability (i.e. maintaining a diagnosis at both time points) was pretty good across the study, that's not to say things were 100% consistent either (see here)...

"One, two or more ESSENCE related problems other than ASD were found in 98% (48/49) of the children with T2 AD [autistic disorder], in 87% (20/23) of the children with T2 PDD-NOS [pervasive developmental disorder - not otherwise specified] and in 71% (5/7) of the children with T2 Asperger syndrome." ESSENCE - Early Symptomatic Syndrome Eliciting Neurodevelopmental Clinical Examinations - is basically an umbrella term for the range of overlapping conditions that seem to accompany a diagnosis of autism. A bit more information about the concept can be found here.

To reiterate the observations from these collected data, the label of autism rarely exists in a diagnostic vacuum. Do you really need any more evidence? And, as one keen observer pointed out on social media (see here) the 'screening out' of these other 'autism plus' or ESSENCE traits to make various study results more 'autism-specific' might in fact, limit any research sample to something remarkably unlike 'real-life' autism if one assumes that autism plus or ESSENCE is the norm...

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[1] Posserud M. et al. Autism traits: The importance of “co-morbid” problems for impairment and contact with services. Data from the Bergen Child Study. Research in Developmental Disabilities. 2018; 72: 275-283.

[2] Kantzer A-K. et al. Young children who screen positive for autism: Stability, change and “comorbidity” over two years. Research in Developmental Disabilities. 2018; 72: 297-307.

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Is the word 'comorbid' accurate when describing emotional and behavioural issues occurring alongside autism?

The findings reported by Per Normann Andersen and colleagues [1] observing that: "The amount of autism symptoms and degree of attention problems at baseline significantly predicted EBP [emotional and behavioral problems] at follow-up" potentially taps into a wider discussion in the context of autism.

EBP refers to feeling "anxious/depressed, withdrawn/depressed, somatic complaints, social problems, thought problems, attention problems, rule-breaking behavior, and aggressive behavior." The wider discussion is framed around a question on whether use of the term 'comorbid' - comorbid EBP for example - is accurate when it comes to such 'issues' appearing alongside the core features of autism? Should instead we be thinking and talking about comorbid issues/symptoms such as depression and anxiety as being something rather more central to at least 'some' autism? Y'know, is there a lot more than just the the triad/dyad of core features for some at least?

It's a discussion that has emerged before on this blog (see here and see here) and continues in the peer-reviewed science arena [2]. It has some potentially profound implications for things like autistic identity, the distinction between autism as a developmental condition as opposed to a psychiatric disorder, talk about the 'disabling aspects' of autism (and 'where they potentially come from') and the often polarised topic of intervention specifically 'for autism'...

Andersen et al report results based on analysis of children and adolescent diagnosed with autism - 'high-functioning' autism (HFA) (their term not mine) - where "levels of EBP, autism symptoms, inattention problems, and verbal IQ" were assessed at baseline and 2 years later.  The aim was to see whether symptoms such as autism "can predict EBP 2 years later."

Interestingly, the authors opted for the use of the Autism Spectrum Screening Questionnaire (ASSQ) as one of their study instruments, [partly] devised by a researcher who I have a lot of time for on this blog (see here) and his equally pertinent concept of ESSENCE (Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations). This was complemented by "the Schedule for Affective Disorders and Schizophrenia for School Age Children/Present and Lifetime version-2009 (K-SADS-PL)" covering questions on possible "affective disorders, psychotic disorders, anxiety disorders, behavioral disorders (ADHD), substance abuse disorders, eating disorders, tic disorders and ASD [autism spectrum disorder]" and the ADHD rating scale IV among others research tools.

Results: "the level of autism symptoms at baseline were the best predictor of EBP in our group of children with HFA." The authors also observed that "attention problems had an independent impact on EBP" but noted that whilst autism and attention issues correlated at baseline, the role of attentional issues on EBP was "considerably less compared to the level of autism symptoms." Authors also stated that verbal IQ did not seemingly predict EBP, which is perhaps at odds with other independent research on a similar topic (see here). They conclude by suggesting that "interventions aimed at improving ASD symptoms may positively affect the prevalence of EBP in children with HFA."

Of course the Andersen study was not perfect and one has to be careful not to extrapolate too much. As the authors note, their study: "focused on symptoms of autism and attention, and we cannot generalize these findings to those with ASD and clinical diagnoses of ADHD" representing one important limitation. They add that their focus on those with an IQ above 70 and their investigating a very 'male-orientated' sample group also limited the generalisability of their findings to the entire autism spectrum; particularly some of the 'under-studied' people of the autism spectrum (see here). And before you mention it, yes, IQ still needs quite a bit more research work done on it when it comes to autism...

Nevertheless, I believe that these findings do add to an increasingly vocal peer-reviewed research evidence base suggesting that the term 'comorbidity' might not be the most 'useful' description when it comes to chatter about a range of labels/conditions/symptoms that are seemingly over-represented in relation to autism. Indeed, as per more historical mentions - yes, Mildred Creak yet again - set within the context of the plural 'autisms' (see here), many issues described today as 'comorbid' may eventually turn out to be rather more central to [some] autism...

The idea also discussed by Andersen et al about 'intervening' in/on the traditional 'core symptoms' of autism as potentially 'offsetting' some of the effects of those EBP is, no doubt, going to be a bit of a hot potato. We do have a few other examples showing how a reduction/dissipation of core autism symptoms does seem to impact on 'comorbid' signs and symptoms as per some of the discussions on the term 'optimal outcome' (see here). In the example recorded by Gillberg et al [3] observing that "The minority of the AS [Asperger syndrome] group who no longer met criteria for a full diagnosis of an autism spectrum disorder were usually free of current psychiatric comorbidity", we see how there could be quite a bit more to a diagnosis of autism (AS) than has traditionally been recognised. Other research from Andersen and colleagues [4] talking about the same cohort as being discussed today with depression and autism presentation again in mind likewise adds to such 'intervening' sentiments.

I have one final point to make just in case the idea of intervening does not sit well with some: if one assumes that something like depression is in fact, a core part of some autism and could be 'modified' by intervention(s) targeting core autism symptoms, there is a potentially important impact to be made on one of the primary issues affecting the autistic population: risk of suicide. I say that on the basis that depression or related psychiatric disorder (see here) is an all-too-frequent companion when it comes to suicidal behaviour(s) and therefore represents a potentially modifiable variable. Exactly how and where intervention on core autism symptoms is done is another question for another day; also bearing in mind that 'current' core autism symptoms themselves, might be an important risk factors when it comes to suicidal thoughts/behaviours (see here).

Lots more research is indicated, minus hype and minus too much politics...

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[1] Andersen PN. et al. Severity of Autism Symptoms and Degree of Attentional Difficulties Predicts Emotional and Behavioral Problems in Children with High-Functioning Autism; a Two-Year Follow-up Study. Frontiers in Psychology. 2017; 8: 2004.

[2] Nah Y-H. et al. Brief Report: Screening Adults with Autism Spectrum Disorder for Anxiety and Depression. J Autism Dev Disord. 2017. Dec 2.

[3] Gillberg IC. et al. Boys with Asperger Syndrome Grow Up: Psychiatric and Neurodevelopmental Disorders 20 Years After Initial Diagnosis. J Autism Dev Disord. 2016 Jan;46(1):74-82.

[4] Andersen PN. et al. Associations Among Symptoms of Autism, Symptoms of Depression and Executive Functions in Children with High-Functioning Autism: A 2 Year Follow-Up Study. J Autism Dev Disord. 2015 Aug;45(8):2497-507.

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Sleep and gut issues in autism: a clinically relevant subtype?

"Autistic children with gastrointestinal or/and sleep problems may represent clinically relevant subtypes of ASD [autism spectrum disorder], for which targeted treatments may be needed."

That was one of the conclusions reached by Xiao-Lei Yang and colleagues [1] looking at an interesting combination of symptoms/conditions that have featured before on this blog (see here and see here): gastrointestinal (GI) and sleep issues with autism in mind.

Surveying around 170 children diagnosed with an autism spectrum disorder (ASD) and a similar number of "healthy children" (authors words, most definitely not mine), researchers sought to estimate the prevalence of GI and sleep issues among their cohort(s). Perhaps unsurprisingly "GI and sleep problems were prevalent in Chinese ASD children." Interestingly too: "ASD children with GI symptoms reported more severe ASD core symptoms than others." Those with sleeping issues also showed "lower performance in daily living skills, social cognition, social communication and intellectual development" than the children with ASD who did not present with sleeping issues.

The implications of such observations? Several. Not least that when one talks about GI issues  - whether functional or more pathological - being over-represented in relation to autism, one has some confidence that such 'over-representation' seems to cross different ethnicities and different countries and is not just derived from or based on Western research findings. This adds further weight to the notion that at least some types/phenotypes of autism may have a significant bowel-related component to them for whatever reason(s).

Next, the suggestion that children with autism who also present with GI symptoms might present with a more 'severe ASD core symptoms' profile provides some truly tantalising clinical and research opportunities. Not least that said bowel symptoms might be able to affect some aspects of behaviour and onward the question: what happens when bowel symptoms are effectively treated? I know such sentiments are not necessarily welcomed in some quarters ('autism symptoms are lifelong and immutable' so the saying goes) but for others, particularly those suffering with bowel symptoms (yes, I did say suffering), there are some potentially interesting consequences following intervention. Assuming also that pain and discomfort are key parts of 'suffering' from bowel issues in autism as they are when present in not-autism, we arrive at a situation whereby certain autistic traits may be at least 'heightened' when pain is present. Such a proposition is not necessarily new news to the peer-reviewed autism research (see here and see here). And if one was to assume that something like 'inflammation' might be part and parcel of said GI issues and pain in relation to autism, we arrive at yet another testable hypothesis (see here)...

Finally, sleep issues in relation to the autism spectrum. What's more to say? They are pretty prevalent throughout children and adults on the autism spectrum and probably contribute to the various 'quality of life' disparities that have been shown in relation to autism (see here). There are things that can be 'tried' in relation to intervention (see here and see here for examples) but by no means is there some 'magic wand' that helps every single sleep issue for every single person. The idea that sleep issues, like GI issues, might also impact on certain behavioural aspects linked to autism is probably not unexpected but I would like to see a lot more research done in this area before any grand sweeping generalisations are made. Not least recognising that certain over-represented behavioural comorbidity such as attention-deficit hyperactivity disorder (ADHD) is rising through the sleep research ranks (see here) and what that might mean for autistic traits in these ESSENCE-like times...

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[1] Yang X-L. et al. Are Gastrointestinal and Sleep Problems Associated with Behavioral Symptoms of Autism Spectrum Disorder? Psychiatry Research. 2017. Oct 24.

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Completing the set: features of ADHD in childhood epilepsy

'Completing the set' used in the title of this post refers to the idea that a diagnosis of epilepsy rarely(?) seems to exist in some sort of diagnostic vacuum as per previous discussions whereby features of autism (see here) and dyspraxia / developmental coordination disorder (DCD) (see here) seem to be over-represented in cases of epilepsy.

This time around the focus was on attention-deficit hyperactivity disorder (ADHD) and the findings reported by Isabell Brikell and colleagues [1] suggesting that: "Individuals with epilepsy had a statistically significant increased risk of ADHD." Researchers arrived at their conclusions on the basis of examining some of those wonderful Scandinavian population registries that are providing all-manner of interesting details on possible trends and patterns in various areas: "We identified 1,899,654 individuals born between 1987 and 2006 via national Swedish registers..." Said data were actually used to look at "the familial coaggregation of epilepsy and ADHD and to estimate the contribution of genetic and environmental risk factors to their co-occurrence" but also served the purpose of looking at ADHD prevalence alongside epilepsy. Indeed it was also interesting to note the authors' conclusions about familial liability to the "cross-disorder overlap": "The genetic correlation was 0.21 (95% CI = 0.02-0.40) and explained 40% of the phenotypic correlation between epilepsy and ADHD, with the remaining variance largely explained by nonshared environmental factors." Mmm...

Such research - although requiring quite a bit more independent investigation [2] - follows an important trend in recent times observing how stand-alone developmental and/or psychiatric diagnoses often 'clump together' in seemingly at-risk patient groups. I've for example, talked about the important concept of ESSENCE - Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations [3] on this blog and how "co-existence with other conditions was the rule" (see here) rather than the minority perspective in the area of childhood psychiatry. Now we seem to be able to add ADHD to the list of comorbidity potentially over-represented alongside a diagnosis of epilepsy (bearing in mind that epilepsy covers quite a lot of diagnostic ground).

Mechanisms? Well, far be it from me to speculate too much, but an important starting point is the nature of epilepsy and how it affects brain function. It's not inconceivable that particular alterations to the functioning of the brain as a result of epilepsy (or even during some prodromal phase) might be enough to *induce* other behaviours/symptoms to be pronounced. Equally, one might subscribe to the the idea that changes to brain function due to other events or factors that may be connected to conditions such as autism or ADHD or DCD could be enough to induce the onset of epilepsy (this hypothesis draws support from the onset patterns typically seen in cases of autism and epilepsy). I don't doubt that relationships are likely to be complicated.

Much more needs to be done on this topic, not least in ensuring appropriate screening services when cases of epilepsy are diagnosed, particularly in childhood. With no medical or clinical advice given or intended (don't mess with epilepsy), I do wonder whether some of the peer-reviewed data talking about dietary changes being used to manage certain types of epilepsy also potentially impacting on presented symptoms of *some* other labels (see here) might also provide some clues as to potential shared mechanisms between epilepsy and other developmental/psychiatric labels?

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[1] Brikell I. et al. Familial Liability to Epilepsy and Attention-Deficit/Hyperactivity Disorder: A Nationwide Cohort Study. Biol Psychiatry. 2017 Aug 12. pii: S0006-3223(17)31858-9.

[2] Caplan R. ADHD in Pediatric Epilepsy: Fact or Fiction? Epilepsy Curr. 2017 Mar-Apr;17(2):93-95.

[3] Gillberg C. The ESSENCE in child psychiatry: Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations. Res Dev Disabil. 2010 Nov-Dec;31(6):1543-51.

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Epilepsy (or comorbidity?) impacts on academic achievement

The results of the systematic review from Wo and colleagues [1] highlight something of an important trend in the peer-reviewed science domain looking at how epilepsy may have various important implications for all manner of different issues outside of just the presence of seizures. This time around the focus was on academic achievement.

Drawing on data from 20 studies that "assessed the prevalence of academic difficulties in children with epilepsy (CWE) of normal intelligence, and its associating factors" researchers concluded that nearly three-quarters of studies found that CWE "had significantly lower academic achievement scores" compared with controls or population norms. The authors added that despite improvements in seizure frequency for some, issues with academic achievement still remained.

There were also some more positive points to take from the Wo findings: "Higher parental education and children with higher IQ, and [who] had better attention or had a positive attitude towards epilepsy, were associated with higher academic achievement score." I can't readily explain how (and indeed whether) a 'positive attitude' towards ones epilepsy might influence academic achievement but one might see how children with a high IQ, nurtured under the right circumstances, might have somewhat more protection against 'lower academic achievement scores'.

I think it is important to take a step back here before any sweeping generalisations are made. Not every study included for review by Wo et al indicated a relationship between epilepsy and academic achievement. This is an important point, and stresses how under the very heterogeneous label of epilepsy - some types more readily associated with conditions such as learning (intellectual) disability - not everyone is going to be potentially 'disadvantaged' in an academic sense as a result. This also bearing in mind that academic achievement is not always a great 'marker' when it comes to what one might define as a successful life; plenty of people do alright / make it big without great academic achievement scores.

Added to the Wo study, I also want to introduce the findings reported by Gillberg and colleagues [2] providing something of an example of how many other factors might potentially affect academic achievement in the context of epilepsy. Gillberg et al once again refer to their ESSENCE description - early symptomatic syndromes eliciting neurodevelopmental clinical examinations - to denote how diagnoses affecting behaviour and development rarely appear in isolation to one and another. They observed that: "The rate of ESSENCE in febrile seizures and epilepsy was significantly higher than in the total population without seizures" based on the examination over 27,000 parent reports of twins. I might venture further into their suggestion that: "Febrile seizures alone could be seen as a marker for a broader ESSENCE phenotype in some cases" specifically in the context of autism on a separate blogging occasion (see here) but for now, the message is that epilepsy probably does not appear (diagnostically) alone and said comorbidity *might* also be important to academic achievement and no doubt, other outcomes too.

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[1] Wo SW. et al. The impact of epilepsy on academic achievement in children with normal intelligence and without major comorbidities: A systematic review. Epilepsy Res. 2017 Jul 20;136:35-45.

[2] Gillberg C. et al. Febrile Seizures and Epilepsy: Association With Autism and Other Neurodevelopmental Disorders in the Child and Adolescent Twin Study in Sweden. Pediatr Neurol. 2017 Jun 8. pii: S0887-8994(17)30178-9.

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"medical disorders in children with ASD and ADHD appear to be widespread"

The quote titling this brief post is taken from the results of the systematic review undertaken by Jet Muskens and colleagues [1] (open-access) who surveyed the peer-reviewed science literature "on medical comorbidity in the two major developmental disorders autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD)."

Continuing an important theme (see here), the authors concluded that various categories of conditions - "immunology, neurology and gastroenterology" - are over-represented in relation to autism and ADHD and that "future studies should not only focus on psychiatric symptoms, but provide a broader evaluation of medical disorders" when it comes to those labels.

Minus too much chatter, I was impressed to see that many of the research articles covered on this blog down the years had made it into the Muskens review. So, the likes of Harumi Jyonouchi gets a well-deserved mention (see here and see here) and the focus on how the immune system might be doing so much more than just protecting us from the odd pathogen or two. The authors also bring in some of the very convincing scientific evidence that various gastrointestinal (GI) issues are over-represented in relation to autism (see here). There's even mention of how useful that Taiwanese research database has been down the years to autism and ADHD research (see here).

What's more to say? Well, preferential screening for various medical conditions in the context of an autism diagnosis yet again, receives more support. As does the idea that when a medical diagnosis is received by a person diagnosed on the autism spectrum, that medical diagnosis deserves the same healthcare management and/or treatment as it does in the context of not-autism save any further health inequalities potentially appearing (see here). The days for example of 'blaming autism' for every single physical complaint are also to be consigned to the historical dustbin. And with it, recognition that concepts such as ESSENCE or 'autism plus' (see here and see here) really need to include the somatic as well as the behavioural/psychiatric...

Whilst welcoming the Muskens review, it's important to note that others have already 'primed' for the importance of medical comorbidity in relation to a diagnosis of autism...

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[1] Muskens JB. et al. Medical comorbidities in children and adolescents with autism spectrum disorders and attention deficit hyperactivity disorders: a systematic review. European Child & Adolescent Psychiatry. 2017. July 3.

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1 in 8 kids diagnosed with ADHD also diagnosed with autism

"Approximately one in eight children currently diagnosed with ADHD [attention-deficit hyperactivity disorder] was also diagnosed with ASD [autism spectrum disorder]."

So said the findings reported by Benjamin Zablotsky and colleagues [1] derived from results obtained from the US 2014 National Survey of the Diagnosis and Treatment of ADHD and Tourette Syndrome covering some 2500 participants. Based on parental responses via telephone interviews, researchers compared "children diagnosed with ADHD and ASD with children with ADHD, but not ASD" to arrive at their headline figure. They further observed that: "Children diagnosed with both disorders had greater treatment needs, more co-occurring conditions, and were more likely to have a combined hyperactive/impulsive and inattentive ADHD subtype."

It's not necessarily new news that autism and ADHD have more than a passing connection to one and another (see here). Indeed, the idea that those diagnosed with ADHD might also need to be preferentially assessed for autism too has been suggested before (see here and see here) and under more controlled scientific conditions. All very ESSENCE like if you ask me (see here).

I'm also struck by the suggestion that those with ADHD plus autism might also be more likely to have 'greater treatment needs' and 'more co-occurring conditions'. This rings particularly true when it comes to adulthood and the enhanced risks facing those with such dual diagnoses (see here). I might also add that 'co-occurring conditions' does not necessarily imply just the behavioural or psychiatric as per other findings [2]. Indeed, the observations reported by Anna Lamanna and colleagues on allergic disease potentially being something to consider when it comes to the comorbidity of ADHD and autism ties in with other findings covered on this blog (see here). The immune system might be doing so much more than just defending the body against the odd pathogen...

And to close, in keeping with today's subject matter, it appears that medications indicated for ADHD might also have some added value alongside the management of core ADHD symptoms [3].

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[1] Zablotsky B. et al. The Co-Occurrence of Autism Spectrum Disorder in Children With ADHD. J Atten Disord. 2017 Jun 1:1087054717713638.

[2] Lamanna AL. et al. Risk factors for the existence of attention deficit hyperactivity disorder symptoms in children with autism spectrum disorders. Neuropsychiatr Dis Treat. 2017 Jun 15;13:1559-1567.

[3] Lu Y. et al. Association Between Medication Use and Performance on Higher Education Entrance Tests in Individuals With Attention-Deficit/Hyperactivity Disorder. JAMA Psychiatry. 2017 Jun 28.

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