Following ADHD long-term: "a persistence rate of 27.8%"

Studies such as the one published by Michel Lecendreux and colleagues [1] always catch my attention. Research that follows a group of people over a period of years makes for interesting reading; not least because one gets a flavour for what *could* happen when such findings are applied to a larger population.

The Lecendreux findings focused on a few important issues pertinent to a diagnosis of attention-deficit hyperactivity disorder (ADHD) specifically related to (a) the persistence of ADHD, and (b) the idea that signs and symptoms of ADHD not meeting the thresholds for a diagnosis of ADHD might be rather important. Indeed, that they may merit "a subthreshold diagnostic category" of their own.

So, based on a starting participant sample of just over a thousand families including a child in the "6-12 years age range", interviews were conducted covering various aspects of ADHD and beyond: "symptoms of ADHD, conduct disorder, and oppositional defiant disorder as well as family living situation, school performance, sleep disturbance, eating habits, use of supplemental iron, and history of ADHD treatment." Approaching half of the original sample (492 / 1012) were followed up some 9 years later where "the persistence of ADHD and its impairments and the emergence of new conditions were assessed."

Results: "At follow-up, 16.7% of the children diagnosed with ADHD at baseline met full criteria for ADHD and 11.1% met criteria for subthreshold ADHD, yielding a persistence rate of 27.8%." Diagnosis of ADHD was, by the way, based on DSM-5 criteria (see here). That figure of 27.8% in terms of ADHD persistence from childhood to early adulthood is potentially an important one. It tells us that for a majority of children diagnosed with ADHD in childhood, their symptoms of inattention, hyperactivity and impulsivity will reduce to such a degree that they are no longer considered clinically significant or at least not reaching thresholds for a diagnosis of ADHD. Whether such a reduction in symptoms is through processes such as maturation or the timely implementation of intervention/management strategies needs quite a bit more work. Whether also ADHD potentially 'morphs' into something else as people age also needs further exploration (see here).

Another important detail was also mentioned by Lecendreux et al: "Among children not diagnosed with ADHD at baseline, 1.1% met criteria for ADHD at follow-up." Such a figure is important in relation to the concept of adult-onset ADHD [2] and the question of whether ADHD is a diagnosis with foundations always rooted in infancy. The Lecendreux findings suggest that for some people, this might not be the case and opens the door to possible talk about acquired ADHD for examples. This also sounds very familiar (see here).

Insofar as the issue of a possible 'subthreshold diagnostic category' for ADHD, I find myself agreeing with the "dimensional conceptualization" mentioned by the authors. Several other conditions / states / diagnoses have recognised 'lite versions' of the label. In autism for example, one might see this as social communication disorder (SCD) or mention of the broader autism phenotype (BAP). I'm even minded to place the label known as pathological demand avoidance (PDA) in a similar bracket given recent opinions (see here). Such chatter about 'lite' does not and should not downplay the effects of such sub-threshold labels. It merely acknowledges that there may be a wider spectrum of issues / difficulties experienced outside of the receipt of a core diagnosis.

So it should perhaps be the same with ADHD too, given what is beginning to emerge on the long-term 'effects' that a diagnosis of ADHD and subthreshold ADHD might bring (see here and see here).

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[1] Lecendreux M. et al. A 9-Year Follow-Up of Attention-Deficit/Hyperactivity Disorder in a Population Sample. J Clin Psychiatry. 2019 May 7;80(3). pii: 18m12642.

[2] Cooper M. et al. Investigating late-onset ADHD: a population cohort investigation. J Child Psychol Psychiatry. 2018 Oct;59(10):1105-1113.

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"two in five young people scoring above thresholds for emotional problems, conduct problems or hyperactivity"

The quote titling this post - "two in five young people scoring above thresholds for emotional problems, conduct problems or hyperactivity" - comes from the eye-opening findings published by Jessica Deighton and colleagues [1] (open-access available here).

It's based on a study of over 28,000 adolescents here in Blighty: "51.2% of whom were in Year 7 (age 11–12) and 48.8% of whom were in Year 9 (age 13–14) in 97 state-maintained secondary schools across six geographical locations in England."

Said young people were given the "child self-report Strengths and Difficulties Questionnaire (SDQ)" to complete, and the received data were analysed alongside other information collected by the authors "from the National Pupil Database: SEN status; FSM eligibility; child in need status (CIN, this is a child who either (a) is unlikely to achieve/maintain a reasonable standard of health and development without local authority provision; (b) is likely to be impaired without local authority provision; or (c) is disabled); and ethnicity (Asian, Black, Chinese, Mixed, White or any other ethnic group)."

In more detail: "18.4% scored above the abnormal threshold for emotional symptoms, 18.5% for conduct problems, 25.3% for inattention/hyperactivity and 7.3% for peer-relationship problems." Going back to the title of this post, researchers mention how "around two in five young people scoring above ‘abnormal’ thresholds for three of the four problem areas measured (emotional problems, conduct problems and hyperactivity)." They also observed that:

• SEN - special educational needs - status played a role in those figures (those with SEN were consistently more likely to provide an above-threshold response to all the areas measured, particularly peer-relationship problems). 
• Entitlement to free school meals (FSM), a potential marker of deprivation, was also associated with an above-threshold response to all areas.
• "Being male significantly increased the odds of scoring above threshold for behavioural problems and inattention/hyperactivity, whereas being female significantly increased the odds of experiencing emotional symptoms."

There are caveats attached to the Deighton findings; not least the sole reliance on "child self-report data from a very brief assessment tool" without any accompanying further analysis on the presence (or not) of diagnosable psychopathology. But, in the context of the large participant number included for study and that most adolescents aren't likely to 'lie' about their positive responses to items such as "I get very angry and often lose my temper" or "I take things that are not mine from home, school or elsewhere" I'd be inclined to view the Deighton findings as a pretty accurate representation of their 'in the thousands' cohort.

So where next? Well, if we're talking about findings observing that "42.5% scored above threshold for any one of the first three problem scales (emotional symptoms, conduct problems or inattention/hyperactivity)" we have to talk about what services are in place (and should be in place) to support this large group. This, on the basis that, such 'problems' can potentially lead to various other 'adverse' outcomes both in later childhood and beyond. And when I talk about 'support', I mean both support and intervention to help those young adults to manage such issues. All of this set in the context of a continually squeezed financial and resource position (at least here in Blighty).

The other question has to be 'why'? Why have so many young people reported as they have? Deighton et al talk about various factors as potentially being important: "the impact of austerity, increasing experience of academic pressures, reduced rates of sleep and increased use of social media", to a large extent talking about the social environment as playing a significant role. I don't doubt that these external factors and other related variables will play a role in how young people are reporting, but I'm not convinced that the social environment is the only important factor to consider. It's not, for example, beyond the realms of possibility that other genetic and non-genetic variables (i.e. in the physical environment) could also play a role; something I say in the context of a 'growth' in the number of children and young adults being diagnosed with all-manner of different behavioural and/or psychiatric labels (see here and see here for examples).

Something important seems to be going on with our young people (see here and see here). We have to assume that such an issue is not going to resolve itself and may even increase in terms of numbers as time goes on. We really need to find out what factors are behind this and start taking action... like now.

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[1] Deighton J. et al. Prevalence of mental health problems in schools: poverty and other risk factors among 28 000 adolescents in England. Br J Psychiatry. 2019 Jan 30:1-3.

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More welcomed (and interesting) research on pathological demand avoidance (PDA)

Pathological demand avoidance (PDA) [syndrome] is a label that currently occupies an unusual place in psychiatric and developmental circles. Defined by "obsessive non-compliance, distress, and florid challenging and socially inappropriate behaviour", PDA has seemingly found a place (somewhere) on the autism spectrum, but at the time of writing, does not actually occupy any unique position in any of the current systems of diagnostic classification mentioning autism (e.g. DSM, ICD). The National Autistic Society (NAS) here in Blighty talk about PDA in the context of "a behaviour profile within the autistic spectrum" but that's just one description among others.

The rise and rise of the term PDA as a specific diagnosis is firmly rooted (geographically) here in Blighty. This is probably as a result of the first description of PDA emanating from the late Elizabeth Newson during her time at the Early Years Diagnostic Centre (now called the Elizabeth Newson centre). Not everyone however is totally convinced that PDA is an independent syndrome (see here) or indeed, whether it is deserving of its specific and exclusive link with the autism spectrum at the cost of other labels... I'll be touching on that last point again in this post.

After that long introduction, I bring the findings reported by Vincent Egan and colleagues [1] to the blogging table, and some more welcome research in this area. The name of the research game for Egan et al was to adapt the Extreme Demand Avoidance Questionnaire (EDA-Q) "an informant-rating instrument" into a self-report version - the Extreme Demand Avoidance Questionnaire—Adult version (EDA-QA). Two studies are reported on in this context: "In Study 1, we use this measure to examine the relationship between PDA traits, ASD [autism spectrum disorder] traits, and other psychopathology dimensions, in a community sample of adults reporting self-identified psychopathology" and: "The second study examined the EDA-QA in a community sample and measured ASD traits more thoroughly, using the full ASQ." Yes, that's ASQ as in AQ (the Autism Spectrum Quotient) "used to quantify cognitive and behavioural features associated with ASD" and all the baggage that goes with it (see here and see here).

Results: yes, the EDA-QA was "reliable, univariate, and correlated with negative affect, antagonism, disinhibition, psychoticism, and ASQ score." This bearing in mind that the nearly 350 people who took part in study 1 were all self-reporting on the various instruments used, were "recruited from a variety of specialist on-line blogs and community forums focusing on the needs and concerns of persons with ASD" and were described as "a highly educated group." I also note that the words 'self-identifying' were also used extensively during the study write-up, specifically: "29 individuals reporting self-identified ASD also reported having PDA, 44 persons claimed to have PDA alone, and a further 19 self-identified PDA alongside depression or anxiety; separately, 59 persons claimed to have formally diagnosed ASD." Even the authors acknowledge that "self-reported ASD is not without it’s difficulties." No arguments from me there (see here and see here) and others have similar opined.

When it came to study 2 results, we are told that: "A path analysis to fit the data indicated that ASQ and EDA-QA scores were positively related." Irrespective of my various musings on how the ASQ (AQ) is not seemingly 'specific' when it comes to traits being 'linked to autism', this is an encouraging result. But there was more too... "The EDA-QA measure was associated with lower agreeableness, lower emotional stability, and higher scores on the ASQ. The effects were stronger for personality traits than for ASQ scores, suggesting it may be personality that differentiates how ASD traits are expressed, with more emotionally unstable and antagonistic persons with ASD expressing PDA-type qualities." One of the thoughts I had about this finding - 'personality that differentiates how ASD traits are expressed' - is the 'tie up' between the expression of autistic traits in relation to something like borderline personality disorder (BPD) (see here and see here) that has become more frequent in the peer-reviewed science arena recently. Yet more evidence perhaps that 'self-identifying' or 'self-diagnosis' when it comes to autism is not necessarily the most accurate measure?

The authors conclude that their instrument has promise and "could be easily integrated into assessment packages currently used with prisoners, mentally disordered offenders, and homeless people, where PDA may be suspected." Minus any big headlines regarding those particular groups (see here for example), I think examination of PDA in some of those contexts could be rather revealing. The link, for example, between PDA and offending behaviour (see here) in the context that SRED (Self-Report Early Delinquency Scale) scores - indicating "higher overall self-reported delinquency" -  significantly positively correlated with EDA-QA is an intriguing finding. That also AQ scores showed no such association with SRED scores might also suggest that PDA is not as necessarily well suited to an all-encompassing link to autism (autistic traits) as many people might think...

Let's hope that there is more research to come on the topic of PDA.

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[1] Egan V. et al. The Measurement of Adult Pathological Demand Avoidance Traits. J Autism Dev Disord. 2018 Aug 23.

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ALSPAC examines... pregnancy risk factors and oppositional-defiant disorder (ODD) and conduct disorder

ALSPAC mentioned in the title of this post refers to the Avon Longitudinal Study of Parent and Children, something of quite a regular feature on this blog by all accounts (see here and see here for examples). On this blogging occasion, I'm talking about ALSPAC in relation to the research paper published by I. Hyun Ruisch and colleagues [1] who reported that: "Common and potentially preventable pregnancy risk factors were independently related to both offspring ODD [oppositional-defiant disorder] and CD [conduct disorder] symptomatology in children from the general population."

ODD and CD represent a couple of the most prevalent 'disruptive behavioural' conditions seen nowadays. Whilst subtly different from one and another both in scope and severity, both represent conditions where control and in particular, self-control in accordance with cultural rules and norms, is perhaps not as it should be. I've mentioned one or other of these conditions in previous posts on this blog (see here for example) and the heightened risk of future adverse outcomes seemingly associated with them.

As with many (nay, all) behavioural and psychiatric conditions, science is still at a bit of a loss as to how they come about, accepting that they all probably [variably] include genetic and non-genetic factors working differently in different people. Ruisch et al set about utilising data from ALSPAC to ascertain if and whether "a broad range of pregnancy factors" might play some [statistically significant] role. Their results are quite revealing...

So: "Higher ODD symptom scores were linked to paracetamol use... and life events stress... during pregnancy." Further: "Higher CD symptom scores were linked to maternal smoking..., life events stress... and depressive symptoms... during pregnancy."

It should be noted that ODD and CD symptoms scores were gathered via the Development and Well-Being Assessment (DAWBA) as per other ALSPAC research occasions (see here). Researchers also quizzed both mothers and teachers of their children; thus providing two potentially different snapshots of functioning and their related factors.

In relation to that sentence on "Common and potentially preventable pregnancy risk factors were independently related to both offspring ODD and CD symptomatology in children" my eye was immediately drawn to two variables reported as being connected to said diagnoses: pregnancy paracetamol use and maternal smoking; both of which have appeared with increasing regularity in relation to adverse offspring developmental outcomes.

First, paracetamol also known as acetaminophen to our cousins across the Pond and other parts of the world. What can I say? It seems to be going from bad to worse for this go-to over-the-counter medicine with regards to pregnancy use *associations* and offspring developmental factors (see here). Yes, I appreciate that more studies need to be done on the possible pregnancy effects of this medicine, but the emerging peer-reviewed science is starting to look quite consistent. And many of the studies pointing the finger at paracetamol, like ALSPAC, are not to be under-estimated in size or power...

Second, maternal tobacco smoking during pregnancy. Again, something that has been talked about before on this blog (see here) in the context of related clinical labels. We can't yet say that 'pregnancy smoking causes offspring CD' because proof of cause-and-effect are rarely established by such observational studies. But much like the paracetamol story, the data is becoming more and more consistent for a possible effect of pregnancy smoking on child development. And for various other reasons, smoking during pregnancy is generally not thought of being a great thing for the developing child.

More investigations are indicated but clues are starting to emerge.

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[1] Ruisch IH. et al. Pregnancy risk factors in relation to oppositional-defiant and conduct disorder symptoms in the Avon Longitudinal Study of Parents and Children. J Psychiatr Res. 2018 Feb 23;101:63-71.

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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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Low birth weight and autism: rise of the population attributable risk

RIP Cheggers.

"LBW [low birth weight] accounted for 6.0% of all ASD [autism spectrum disorder] cases, 2.4% of BCD [behaviour and conduct disorder], and 6.8% of LD [learning disability] among the study population."

Those were the observations made by Sandie Ha and colleagues [1] and with it, another example of the use of the population attributable risk/fraction in the context of autism (see here for another occasion). Published in 2014 but only recently appearing on PubMed, Ha et al report results based on data from the 2011 (US) National Survey of Children’s Health, (NSCH) - a "random-digit-dial phone survey conducted between February 2011 and June 2012" - where data on birth weight and receipt or not of a diagnosis of "attention deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), behavior and conduct disorder (BCD) and learning disability (LD)" were available. As an aside, I've talked about the other studies arising from the NSCH program before on this blog (see here and see here for examples).

Including data pertinent to around 81,000 children aged between 2 and 17 years of age, researchers reported that around 9% of the cohort were "born with a LBW as reported by their parent" in response to the question: "What was [sampling child’s] birth weight?" There were some interesting correlates alongside those responses regarding LBW status: "children who were female, non-Hispanic black, had single mothers, had less educated mothers, were poorer, lacked insurance, were exposed to in-home smoking, or born prematurely were more likely to have LBW compared to those with normal BW."

Insofar as 'neurobehavioural disorders' (ND) also asked about: "The weighted prevalence of parent-reported ND among children ages 2 to 17 was approximately 9.9% for ADHD, 2.3% for ASD, 4.1% for BCD, and 10.6% for LD." Yes, this was a telephone-based survey where "both exposure and outcome are based on parental reporting, and thus the information may not represent actual diagnoses" but with the size of the participant numbers included, these prevalence/frequency figures still make for important reading.

Then to the main event - the population-attributable risk percentage (PAR%) and the finding headlining this post: "LBW [low birth weight] accounted for 6.0% of all ASD [autism spectrum disorder] cases, 2.4% of BCD [behaviour and conduct disorder], and 6.8% of LD [learning disability] among the study population." The authors caution that "maternal age at delivery, gestational age, and pregnancy complications could be important confounders" and were not taken into account in their analyses and could be "potential reasons for LBW" alongside undetected "congenital anomalies or genetic disorders." Caution is required.

It's not new news that birth weight might impact on something like autism risk (see here and see here). One also has to bear in mind that something like LBW may not necessarily appear in isolation to other pregnancy or birth events (see here) so a wider research agenda perhaps needs to be followed. But the size of the PAR% talked about by Ha and colleagues is not easily ignored. Taking into account that LBW for some may very well have some 'genetic' influences, one is left asking whether those more 'social' variables linked to LBW might be to some degree 'influenced' with a corresponding effect on neurodevelopmental 'consequences' reported. I say this in the context that poverty as a variable, has already been linked to some diagnoses included in the Ha study (see here)...

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[1] Ha SU. et al. Population attributable risks of neurobehavioral disorders due to low birth weight in US children. Adv Pediatr Res. 2014;1. pii: 2.

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Bullying and autism: stating the bleedin' obvious...

A short post today to reiterate the 'bleedin' obvious': children diagnosed as being on the autism spectrum are far more likely to be the victim of bullying than perpetrator (see here for a previous blog post on this topic).

This conclusion comes from the paper by Hwang and colleagues [1] based on responses to the Behavior Assessment System for Children: Second Edition (BASC-2) (parental report version). The authors initially reported that "children with ASD [autism spectrum disorder] showed significantly increased risk for bullying involvement compared to community children" potentially indicating that a diagnosis of autism does not somehow shield someone from either being bullied or indeed, participating in bullying behaviour (perpetrator). But... "after controlling for comorbid psychopathology and other demographic factors, increased risks for being perpetrators or victim-perpetrators disappeared while risk for being bullied/teased continued to be significantly elevated." Said 'comorbid psychopathology' included aggression and conduct problems as well as the signs and symptoms of depression potentially accompanying a diagnosis of autism. Indeed, aggression was pretty much linked to every type of bullying behaviour in both autism and control groups...

What's more to say on this topic? Well, further recognition that school in particular, can be a significant source of stress and anxiety for children on the autism spectrum is one thing (and potentially contributory to the stats on school refusal in the context of autism). Indeed, without trying to armchair diagnose nor artificially inflating the seriousness of bullying, I wonder whether quite a few more children on the autism spectrum need to be screened for possible post-traumatic stress disorder (PTSD) in the context of how traumatic bullying can be for a person (see here). In relation also to the point made about aggression being a common variable predicting bullying across the Hwang cohort, I wonder whether more needs to be done more generally in relation to reducing aggression in places like school and thus potentially reducing bullying behaviour more generally?

And whilst on the topic of bullying, it appears that some of the longer term effects of bullying for some might be countered by some kind of resilience (whatever 'resilience' might mean)...

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[1] Hwang S. et al. Autism Spectrum Disorder and School Bullying: Who is the Victim? Who is the Perpetrator? J Autism Dev Disord. 2017 Sep 21.

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Various childhood psychiatric disorders may be risk factors for later substance abuse

"Childhood ADHD [attention-deficit hyperactivity disorder], ODD [oppositional defiant disorder], CD [conduct disorder], and depression increase the risk of developing substance-related disorders."

So concluded the results of the meta-analysis published by Annabeth Groenman and colleagues [1] surveying the peer-reviewed research literature between 1986 and 2016. Drawing on data from nearly 40 studies covering over three quarters of a million people that "included 22,029 participants with ADHD, 434 participants with ODD or CD, 1,433 participants with anxiety disorder, and 2,451 participants with depression" researchers looked at the risk in relation to "later alcohol-, nicotine-, or drug-related disorders or substance use disorders (SUDs)."

The level of risk identified concerning childhood psychiatric disorders and later substance abuse were not by any means borderline. Risk for SUD, substance use disorder, was particularly marked for all diagnoses and confirms the authors' conclusions about their findings that "emphasize the need for early detection and intervention to prevent debilitating substance-related disorders in later life." I say that, bearing in mind that one other diagnosis or set of diagnoses - anxiety disorder - did not seem to be related to later risk of substance-related disorder ("although the findings are highly heterogeneous").

As part of a growing pattern of research exploring the risk of future adversity associated with a diagnosis of something like ADHD or CD (see here) I share the author's sentiments that 'early detection' and 'intervention' are worthwhile ventures when it comes to such diagnoses. If one also assumes that ADHD and/or CD in particular, might also increase the risk for future psychopathology (see here), the case becomes even stronger to try and intervene early and improve future quality of life for both the individual and also on a more societal level. Guidance on this topic already exists [2].

But there are other factors to consider with such research. SUD reflects a complicated set of conditions in terms of how-and-why people arrive at such a diagnosis. Factors such as the role of peers and social issues such as poverty and homelessness [3] can all influence risk of SUD as can a variety of other variables that need to be taken on board. Whilst zooming in on individuals is a big part of the strategy to minimise any excess adverse risk of SUD in relation to ADHD, CD, ODD or depression, it should not be the only focus.

Finally, allied to the Groenman results, I might also draw your attention to those published by Clarissa Bauer-Staeb and colleagues [4] talking about how "substance misuse history conveys the greatest risk in all BBV [blood-borne viruses]" in relation to those diagnosed with a severe mental illness as a further undesirable outcome potentially stemming from certain substance abuses. And with it, yet more action is required...

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[1] Groenman AP. et al. Childhood Psychiatric Disorders as Risk Factor for Subsequent Substance Abuse: A Meta-Analysis. J Am Acad Child Adolesc Psychiatry. 2017 Jul;56(7):556-569.

[2] Harstad E. et al. Attention-Deficit/Hyperactivity Disorder and Substance Abuse. Pediatrics. 2014; 134:

[3] Tompsett CJ. et al. Peer Substance Use and Homelessness Predicting Substance Abuse from Adolescence Through Early Adulthood. American journal of community psychology. 2013;51(0):520-529.

[4] Bauer-Staeb C. et al. Prevalence and risk factors for HIV, hepatitis B, and hepatitis C in people with severe mental illness: a total population study of Sweden. Lancet Psychiatry. 2017 Jul 4. pii: S2215-0366(17)30253-5.

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Conviction for violence and autism: comorbidity counts

I tread carefully when discussing the results published by Ragini Heeramun and colleagues [1] on the topic of "whether autism is associated with convictions for violent crimes" and "the associated risk and protective factors." Carefully because, as I've indicated on other occasions (see here), people commit crimes not labels, and sweeping generalisations about labels, specific types of crime and/or the concept of 'dangerousness' tend to do very little to help anyone in the long term.

Still, I do think it is important that issues such as offending in the context of autism spectrum disorder (ASD) are not brushed under the carpet. I say this bearing in mind that a few high profile cases where autism has been mentioned alongside have been highlighted in the media recently here in Blighty (see here and see here). Indeed, in these days of cyber-terrorism linked to extremism for example, I'd like to see quite a bit more scientific investigation into the ways of protecting those on the autism spectrum from being lured into such activities alongside studies on the possible hows-and-whys of people entering into such behaviours.

Heeramun et al relied on data from the Stockholm Youth Cohort where some 5,700 participants had a recorded ASD diagnosis. Data was cross-referenced with that from the Swedish National Crime Register to ascertain how many people were charged with offences where violence was a factor. Comparing those with autism with those with not-autism, researchers concluded that: "Individuals with autism, particularly those without intellectual disability, initially appeared to have a higher risk of violent offending." They do temper that finding with the observation that "these associations markedly attenuated after co-occurring attention-deficit/hyperactivity disorder (ADHD) or conduct disorder were taken into account" suggesting that comorbidity might count. Indeed, this data tallies with other independent findings suggesting that a range of 'adverse' life events can be a significant feature of ADHD and conduct disorder in the long-term (see here) and for example, that autism and ADHD in the prison population should considered (see here).

Alongside, authors talked about how various other factors might also influence risk of violent offending ("parental criminal and psychiatric history and socioeconomic characteristics") and importantly, how: "Better school performance and intellectual disability appeared to be protective." That intellectual (learning) disability accompanying autism seems to be protective against conviction for a violent crime with autism in mind is probably due in part to the increased supervision given to such individuals. This is a point that has been raised in previous peer-reviewed research too (see here).

The take-away messages are once again, sweeping generalisations about all autism being *linked to* violent crime are not needed and that comorbidity might count (as it seems to on many occasions) when it comes to variables being linked to autism (see here for another example). As with such crime in the general population, there are a myriad of often quite individual factors contributing to such behaviours, but alongside: "Better understanding and management of comorbid psychopathology in autism may potentially help preventive action against offending behaviors in people with autism."

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[1] Heeramun R. et al. Autism and Convictions for Violent Crimes: Population-Based Cohort Study in Sweden. JAACAP. 2017. April 3.

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Heeramun, R., Magnusson, C., Gumpert, C., Granath, S., Lundberg, M., Dalman, C., & Rai, D. (2017). Autism and Convictions for Violent Crimes: Population-Based Cohort Study in Sweden Journal of the American Academy of Child & Adolescent Psychiatry DOI: 10.1016/j.jaac.2017.03.011

Psychiatric disorders among male juvenile detainees in South Korea

"Juvenile detainees evidence high rates of psychiatric disorders and comorbidities. Assessment of and intervention in psychiatric disorders, especially alcohol use disorder and comorbid alcohol use disorder with disruptive behavior disorders, may help prevent further offenses."

So concluded Johanna Inhyang Kim and colleagues [1] (open-access) following their investigation into the prevalence of DSM-IV psychiatric criteria in a sample of 173 male juvenile detainees aged between 15-19 years old held at a "male juvenile detention center in Seoul, South Korea, during the period of December 2015 to January 2016." Most of the detainees were held in relation to crimes against property (49%) but violent crimes (39%), traffic offences (24%) and sexual offences (19%) also featured in offending patterns.

The presence of a psychiatric diagnosis was made using the Mini International Neuropsychiatric Interview (MINI) screening for various groups of disorders: disruptive behavioural disorders (DBDs), substance use disorder (SUD) and "any anxiety disorder." Researchers also looked for the presence of psychotic disorder and major depression too, alongside collecting various demographic data and information about recidivism (repeat offending).

Results: "In total, 157 (90.8%) participants had at least one psychiatric diagnosis" is the standout figure from the paper compared with other independent data from this part of the world "of 15–38% among the general adolescent population." Alcohol use disorder was the most frequently mentioned label mentioned in the study, but 'comorbidity seems to be the rule' as we are told that: "Alcohol use disorder with DBDs was the most common combination, accounting for 46.2% of the detainees, followed by DBDs with anxiety disorders (22.5%)."

When it came to the important issue of repeat offending, researchers also report some interesting patterns. Dropping out of school, present in about a quarter of the total cohort, was reported to be a factor in relation to recidivism (present in about 90% of detainees). The presence of two psychiatric disorders also showed a notable connection to repeat offending particularly where an alcohol use disorder was one of them. The message seems to be that keeping kids/young adults in school and away from alcohol might be an important combination in relation to affecting repeat offending rates.

There is quite a lot of other data included in the Kim study and I would encourage interested parties to take a more detailed look. One thing that struck me about the Kim data was the apparent lack of results when it came to attention-deficit hyperactivity disorder (ADHD) in relation to offending and repeat offending outcomes. Minus any sweeping generalisations, I've talked before on this blog about how a diagnosis of ADHD might elevate the risk of contact with law enforcement agencies (see here) for whatever reason(s) and how a combination of ADHD and conduct disorder in particular, might be tied into a range of long-term adverse outcomes including 'risk of criminality' (see here). Kim and colleagues paint a slightly different clinical picture whereby a different combination of psychiatric factors might be specifically related to this group of people in this part of the world.

More investigations are implied including reference to what potential nutritional changes might do to [some] behaviour in this population (see here).

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[1] Kim JI. et al. Prevalence of psychiatric disorders, comorbidity patterns, and repeat offending among male juvenile detainees in South Korea: a cross-sectional study. Child Adolesc Psychiatry Ment Health. 2017 Jan 18;11:6.

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Kim JI, Kim B, Kim BN, Hong SB, Lee DW, Chung JY, Choi JY, Choi BS, Oh YR, & Youn M (2017). Prevalence of psychiatric disorders, comorbidity patterns, and repeat offending among male juvenile detainees in South Korea: a cross-sectional study. Child and adolescent psychiatry and mental health, 11 PMID: 28115987

ADHD and conduct disorder long-term

Today I'm once again blogging about peer-reviewed research suggesting that when it comes to the long-term effects of attention-deficit/hyperactivity disorder (ADHD) on a person, there is some pretty solid evidence that addressing symptoms early could "potentially avert a wide range of future adverse outcomes."

The paper making such a conclusion is the one from Holly Erskine and colleagues [1] who conducted a systematic review and meta-analysis pertinent to this topic; also taking into account the potential effects of a diagnosis of conduct disorder (CD) in the long-term. Including nearly 100 studies "linking ADHD and CD with a range of health and psychosocial outcomes" authors were able to say with some degree of confidence that issues with academic achievement, risk of comorbid "mental and substance use disorders", employment prospect likelihood and risk of criminality (i.e. being arrested) were all seemingly linked to a diagnosis of ADHD. Similar findings were also reported for CD. I know this is kind of research is not exactly great PR for ADHD (or CD) but it is nonetheless important.

Accepting that (i) sweeping generalisations about ADHD/CD do no-one any good and (ii) there may be multiple variables attached to the 'adverse' outcomes detailed outside of just diagnosis, there are some important points to be acted upon following the Erskine review. I might for example, advocate the position that academic achievement is a particularly important area when it comes to the symptoms of ADHD (see here) and moves to address the impact of ADHD on education should perhaps be a priority.

Minus any medical and/or clinical advice being dished out on this blog (I don't do that), there are several intervention options that have been discussed in the collected science literature to think about. Medication is one possibility as per what is known about the effectiveness of something like methylphenidate on ADHD signs and symptoms (see here). Sleep training is something else that appears to be quite useful when it comes to [some] ADHD (see here) too and could probably tie into research looking at physical activity levels and ADHD (see here). And then we have the collected literature pointing to dietary elements as possibly showing some connection to some facets of ADHD as per the whole fatty acid story (see here) and even something potentially linked to milk allergy for at least some (see here). This nutrition research building on the almost forgotten studies on a few foods diet and ADHD (see here) for example, which seems to have ground to a shuddering halt in research strategy terms. The list is long and getting longer (immune system, nutritional supplements, etc) of where to look when it comes to potentially important intervention routes for something like ADHD. Discussions with physicians need to be had and further investment in research is needed.

And perhaps one might also be inclined to take more note of the research suggesting that various 'somatic disease' might also be more likely when a diagnosis of ADHD is received [2] and how, for a start, preferential screening might be undertaken?

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[1] Erskine HE. et al. Long-Term Outcomes of Attention-Deficit/Hyperactivity Disorder and Conduct Disorder: A Systematic Review and Meta-Analysis. J Am Acad Child Adolesc Psychiatry. 2016 Oct;55(10):841-50.

[2] Instanes JT. et al. Adult ADHD and Comorbid Somatic Disease: A Systematic Literature Review. J Atten Disord. 2016 Sep 22. pii: 1087054716669589.

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Erskine HE, Norman RE, Ferrari AJ, Chan GC, Copeland WE, Whiteford HA, & Scott JG (2016). Long-Term Outcomes of Attention-Deficit/Hyperactivity Disorder and Conduct Disorder: A Systematic Review and Meta-Analysis. Journal of the American Academy of Child and Adolescent Psychiatry, 55 (10), 841-50 PMID: 27663939