Injury risk and ADHD

"The results indicate that there is an elevated injury risk among Swedish schoolchildren with ADHD [attention-deficit hyperactivity disorder] but not for children with ASD [autism spectrum disorder]."

So went the findings reported by Carl Bonander and colleagues [1] providing yet more important data on how a diagnosis of ADHD might be something that confers quite a bit of additional risk for all-manner of different negative outcomes.

I've hinted at this important topic before as per some discussion a few years back on how road crossing behaviour might be 'affected' by a diagnosis of ADHD (see here). This time around Swedish researchers compared the risk of injury for those diagnosed with autism vs. risk of injury for those diagnosed with ADHD based on school nurse collected- and school-based data (survey A and B respectively). "After adjusting for confounders, ADHD was associated with a 65% increased risk of injury... in Survey A, and a 57% increased risk of injury... in Survey B" relative to data derived from "unaffected controls."

A quick look through the other peer-reviewed material on this topic reveals the extent to which a diagnosis of ADHD might increase the risk of various injuries. Take the paper by Silva and colleagues [2] who noted that in "young children who are subsequently diagnosed with attention deficit hyperactivity disorder (ADHD)" there was an increased risk of hospitalisation for all manner of different things: "head injuries, burns, poisons, all other injuries." Other studies have reported similar findings [3] including that relying on 'big data' from the big data capital that is Taiwan [4] (see here for more chatter on Taiwan).

Whilst no-one is suggesting that every visit to accident and emergency (the emergency room) is somehow the product of ADHD, there are some potentially important lessons to learn from such collected data. Timely diagnosis and appropriate management of ADHD symptoms when they affect quality of life are two points raised, bearing in mind 'management' might include several strategies (see here and see here and see here). Where also hospitals or other medical professionals are presented with children or young people who are 'regular visitors', one might also look to the possibility of preferential screening for something like ADHD too as part of additional enquiries. I might add that whilst Bonander and colleagues looked at ADHD vs. autism when it comes to injury risk, one must not forget that ADHD and autism occurring together is not an uncommon finding (see here) and accident and emergency is not necessarily an unfamiliar place to some of those on the autism spectrum (see here). There is more to do in this important area of research.

Finally, I'm also minded to reiterate that hosptial admissions for certain chronic somatic issues might also flag up preferential ADHD screening as well (see here)...

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[1] Bonander C. et al. Injury risks in schoolchildren with attention-deficit/hyperactivity or autism spectrum disorder: Results from two school-based health surveys of 6- to 17-year-old children in Sweden. J Safety Res. 2016 Sep;58:49-56.

[2] Silva D. et al. Children diagnosed with attention deficit disorder and their hospitalisations: population data linkage study. Eur Child Adolesc Psychiatry. 2014 Nov;23(11):1043-50.

[3] Hurtig T. et al. The Association Between Hospital-Treated Injuries and ADHD Symptoms in Childhood and Adolescence: A Follow-Up Study in the Northern Finland Birth Cohort 1986. J Atten Disord. 2016 Jan;20(1):3-10.

[4] Kang JH. et al. Attention-deficit/hyperactivity disorder increased the risk of injury: a population-based follow-up study. Acta Paediatr. 2013 Jun;102(6):640-3.

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Bonander C, Beckman L, Janson S, & Jernbro C (2016). Injury risks in schoolchildren with attention-deficit/hyperactivity or autism spectrum disorder: Results from two school-based health surveys of 6- to 17-year-old children in Sweden. Journal of safety research, 58, 49-56 PMID: 27620934

Mortality and autism: comorbidity counts

I don't enjoy talking about mortality and autism on this blog but once again I'm drawn to discuss this important topic based on some recent findings published by Diana Schendel and colleagues [1]. I say these are important findings on the basis of how researchers took into account the possible role played by psychiatric and neurological comorbidity occurring alongside autism when it comes to the quite alarming mortality statistics.

Drawing on the findings reported in their paper and an interview discussing the study (see here), the Schendel results are again based on the examination of one of those very useful Scandinavian registries (several in fact) based in Denmark. Following the "unique 10-digit identifier assigned to all live births and new residents in Denmark" researchers were able to track down the records of over 20,000 children and young adults diagnosed with an autism spectrum disorder (ASD) from a total population of some 1.9 million people "born in Denmark during the period from 1980 to 2010 who were alive at 1.5 years of age and followed up through 2013." The presence of "comorbid mental, behavioral, and neurologic disorders" was also deciphered from records and the rather grim process of determining death and causes of death among any cohort members was carried out.

Results: perhaps unsurprisingly there was a difference in mortality risk between those with ASD compared with those without. Those with autism had a 2-fold higher mortality risk, bearing in mind that older children and young adults were the focus of this study - "Of the 20 492 persons with ASD, 68 died (0.3%)." Most of those who had passed away also had additional comorbidity (83%). Worryingly, in about a quarter of deaths, suicide was listed as the cause; a further quarter died in accidents. Also: "The co-occurrence of ASD added no additional mortality risk for persons with neurologic... or mental/behavioral disorders...  compared with persons with these disorders and no ASD."

There is quite a bit to take from these results. First and foremost is that they provide further evidence that the risk of [early] mortality is seemingly heightened when a diagnosis of autism is received. Sixty-eight deaths out of over 20,000 might not sound a lot in cold statistical terms, but those were 68 people with 68 families and loved ones.

Next is the idea that comorbidity often plays a big role in relation to autism. I've lost count of the number of times that both medical and psychiatric comorbidity attached to autism have been discussed on this blog. Suffice to say that the label of autism is seemingly protective of nothing when it comes to other diagnoses/labels appearing (see here for example) and certain types of comorbidity carry their own early mortality risks (see here). I might also add that, on occasion, the diagnosis of autism may also represent an obstacle to receiving another appropriate medical diagnosis and where possible, intervention (see here).

The suggestion that suicide was represented in the mortality figures detailed by Schendel et al is a real worry although not entirely a new finding. Previous research has talked about levels of suicide ideation when it comes to the autism spectrum (see here) and even some extreme examples of euthanasia requests from individuals on the autism spectrum (see here). A lot more needs to be done to find out why suicide is over-represented and what we can do about it. I might suggest that preferential screening and monitoring for potential correlates of suicide (ideation or attempted) might be a good starting point (see here).

Finally, the idea that accidental death featured in the statistics is also concerning. I can't comment on the specific types of accident that may more readily feature when it comes to early mortality and autism but one only needs to look at the literature and very sad reports on the issue of wandering and autism to see what might potentially figure (see here). With this issue in mind, I'll draw your attention to some positive activities designed to counteract or mitigate such risk (see here).

And just before I leave you, I might also draw your attention to some other research from some of the authors on the Schendel paper talking about an increased mortality risk in cases of obsessive-compulsive disorder (OCD) [2] potentially also relevant in light of the topic of comorbidity and autism (see here)...

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[1] Schendel DE. et al. Association of Psychiatric and Neurologic Comorbidity With Mortality Among Persons With Autism Spectrum Disorder in a Danish Population. JAMA Pediatr. 2016 Jan 11:1-8.

[2] Meier SM. et al. Mortality Among Persons With Obsessive-Compulsive Disorder in Denmark. JAMA Psychiatry. 2016. 27 Jan.

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Schendel, D., Overgaard, M., Christensen, J., Hjort, L., Jørgensen, M., Vestergaard, M., & Parner, E. (2016). Association of Psychiatric and Neurologic Comorbidity With Mortality Among Persons With Autism Spectrum Disorder in a Danish Population JAMA Pediatrics DOI: 10.1001/jamapediatrics.2015.3935