"Maternal infection during pregnancy may be responsible for some portion of autism..."

The quote heading this post - "Maternal infection during pregnancy may be responsible for some portion of autism..." - comes from the paper published by Benjamin al-Haddad and colleagues [1]. They continue a research theme observing that pregnancy infection may have some quite far-reaching effects on the unborn child and their subsequent risk for various conditions / labels / diagnoses (see here for example).

So: "A total of 1 791 520 Swedish children born between January 1, 1973, and December 31, 2014, were observed for up to 41 years using linked population-based registries." As per use of the term 'population-linked registries', this was another study originating in Scandinavia (this time in Sweden) and their important research registries (see here). The important variables being analysed were the presence of "fetal exposure to any maternal infection while hospitalized during pregnancy" and "diagnosis of autism, depression, bipolar disorder, or psychosis among offspring."

Results: "fetal exposure to any maternal infection increased the risk of an inpatient diagnosis in the child of autism... or depression" but not seemingly for bipolar disorder or psychosis. The magnitude of the risk could be described as 'notable' but perhaps not exceptional. 'Urinary tract infection' (UTI) is mentioned as one infection that seemed to increase the risk of offspring diagnosis; something that has been kinda hinted at in other research literature [2] outside of the classic 'acute psychosis and UTI' research that appears in the peer-reviewed literature (see here).

Mechanisms? Well, it doesn't take a genius to figure out that most infection has a bearing on immune system functions and onward concepts like inflammation. There's quite a long history of immune system 'issues' and inflammatory processes being potentially connected to labels like autism and depression (see here and see here respectively) that provide a template for further investigation. This, bearing in mind, that pregnancy is already a time of 'reprogrammed' immune function so that a mothers body can 'tolerate' the developing fetus. As good as any place to start for further investigations...

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[1] al-Haddad BJS. et al. Long-term Risk of Neuropsychiatric Disease After Exposure to Infection In Utero. JAMA Psychiatry. 2019. March 6.

[2] Hadjkacem I. et al. Prenatal, perinatal and postnatal factors associated with autism spectrum disorder. J Pediatr (Rio J). 2016 Nov - Dec;92(6):595-601.

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Constipation in kids with autism: financial as well as health implications

I've always be a little perplexed about the response to gastrointestinal (GI) issues appearing alongside autism. Time after time after time, the peer-reviewed science domain serves up evidence that both functional and more pathological bowel issues are over-represented in autism (see here and see here for examples) and cause considerable suffering. Yet some parts of the lay and research community seemingly 'gloss over' such findings. It's almost as if the acceptance that 'some' autism seems to be 'bowel-related' would shatter some people's view of autism. Perhaps it's also because there would have to be some [partial] acceptance of other related uncomfortable findings too (see here)...

The findings reported by Brandon Sparks and colleagues [1] continue the theme that functional bowel issues such as constipation are part and parcel of some autism. And not only do they have often severe health implications for the person concerned, but there may also be wider economic implications too. So, researchers concluded that: "ED [emergency department] visits by children with ASD [autism spectrum disorder] were more likely to be constipation-related compared with visits by children with other chronic conditions or children with no chronic conditions." Further: "Hospital charges were higher in children with ASD than in those without chronic conditions."

Based on data derived from the Nationwide Emergency Department Sample (NEDS), a US initiative that records diagnostic trends in ER (also known as Accident & Emergency here in Blighty) visits, authors looked for those with and without a diagnosis of autism (ASD). They observed that constipation was an important variable in those ER visits when it came to autism and continued to be important when ER visits turned into hospital admissions. They conclude by saying that there may be a need for "developing more effective outpatient therapies for constipation in children with ASD."

Constipation might not sound like a condition that requires an ER visit. But if and when it does, I guess you could probably say that it's something quite serious. Just as reports in relation to those with a learning disability have highlighted how constipation is (a) over-represented, and (b) has actually been cited as a cause of death (see here), so perhaps you can see why there should be a lot more urgency in this area of the autism research and practice landscape.

I added in the 'financial as well as health implications' bit to the title of this post to stress how, even if someone chooses to ignore the pain and physiological effects that constipation can cause, such symptoms are also placing quite a burden on resources and finances. I personally don't much like the idea of talking too much about 'how much autism costs' but if that's the only way to make people listen and actually do something about bowel issues in relation to autism, then I'm quite willing to continue to talk money and strains (no pun intended) on resources...

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[1] Sparks B. et al. Constipation in Children with Autism Spectrum Disorder Associated with Increased Emergency Department Visits and Inpatient Admissions. The Journal of Pediatrics. 2018. June 1.

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Vitamin D deficiency in adult patients admitted to a psychiatric ward: same as before

The 'same as before' part of the title of this post refers to the observation that vitamin D deficiency is not an uncommon feature for those admitted to psychiatric hospitals (see here and see here).

This time around I present the results published by Dipen Patel & Manjunath Minajagi [1] who reported that: "49% (N = 51) of participants were vitamin D deficient (serum 25(OH)D <30 nmol/L), and a further 42% (N = 44) were vitamin D insufficient (<50 nmol/L); 8.7% (N = 9) of participants were vitamin D sufficient (>50 nmol/L)."

'Participants' mentioned by Patel & Minajagi, referred to 104 adults (average age of 40) admitted to a psychiatric hospital who provided written consent to participate in their study and were diagnosed with a range of psychiatric disorders including "depressive episode", "bipolar affective disorder", "schizophrenia" and/or "personality disorder". We are told that: "Vitamin D levels were requested alongside standard admission blood tests on serum samples collected by venepuncture." Sounds like a good call by all accounts.

Alongside noting those quite important numbers/percentages of vitamin D deficiency and insufficiency (see here for more information about the distinction), authors also reported that: "There were no statistically significant differences noted in mean serum 25(OH)D associated with gender, age or primary diagnosis." They did however mention that: "Mean serum 25(OH)D was higher in participants of White British ethnicity compared with those of other ethnic backgrounds" indicating that skin colour probably plays a role in vitamin D production/levels. A shocker indeed [2].

"At the current time, there is insufficient evidence to draw any firm conclusions regarding an association between vitamin D deficiency and non-musculoskeletal health outcomes, including mental illness. More research in the form of larger epidemiological and intervention studies are needed to investigate the association between vitamin D and mental health outcomes; indeed, randomised controlled trials are planned that will hopefully shed more light on this intriguing area in the future." Sorry about the large text grab noted in that last sentence, but the authors said it better than I ever could in terms of (a) being cautious about making any specific connections between vitamin D deficiency/insufficiency and 'mental illness' and (b) the value of supplementation (see here and see here) outside of just restoring vitamin D levels to where they should be.

That being said, there is a further scheme of work to look at drawing on data from other labels (see here for example). Remembering also that, minus too many sweeping generalisations, some of the other health issues that seem to follow a psychiatric label *might* also show some involvement with vitamin D [3] too...

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[1] Patel D. & Minajagi M. Prevalence of vitamin D deficiency in adult patients admitted to a psychiatric hospital. BJPsych Bull. 2018 May 2:1-4.

[2] Bonilla C. et al. Skin pigmentation, sun exposure and vitamin D levels in children of the Avon Longitudinal Study of Parents and Children. BMC Public Health. 2014;14:597.

[3] Lu L. et al. Association of vitamin D with risk of type 2 diabetes: A Mendelian randomisation study in European and Chinese adults. PLoS Med. 2018 May 2;15(5):e1002566.

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Various symptoms cluster around psychosis but...

The findings reported by Abigail Livny and colleagues [1] provide some [brief] blogging fodder today. Looking to "characterize the symptoms of patients later hospitalized for psychotic disorders in primary mental health outpatient settings" researchers found several variables seemed to be *correlated* in their target population (N=1092).

So: "thought disorder, perceptual abnormalities, poor orientation, and suicidality was associated with an increased risk for hospitalization for nonaffective psychotic disorder" as a function of various time periods. The hazard ratios (HRs) produced were not to be sniffed at. The authors concluded however that: "Despite the increased risk, the positive predictive values of this symptom cluster were low" suggesting that looking for such a symptom cluster does not necessarily guarantee prediction of "later hospitalization for nonaffective psychotic disorder."

It remains the holy grail of psychiatry to be able to 'predict' who might go on to develop something like a clinical diagnosis of psychosis or other related condition and onward, target those vulnerable groups/people with appropriate screening and other required services. Whilst there is seemingly no end of potential 'behaviours to watch for' (indeed, conditions/labels to watch for too), the fact of the matter is that we still don't [reliably] know who will or won't go to develop psychosis. And I doubt that position will change very much without some greater focus on biological 'risk' markers also added to the mix (see here and see here for examples)...

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[1] Livny A. et al. A Population-Based Longitudinal Study of Symptoms and Signs Before the Onset of Psychosis. Am J Psychiatry. 2017 Nov 28: appiajp201716121384.

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From limp to scurvy in the context of autism

"A panel of nutritional markers was sent, and a presumptive diagnosis of scurvy was made."

So said the case report detailed by Adam Yan and colleagues [1] as, yet again (see here and see here), the topic of scurvy in the context of autism appears in the peer-reviewed science literature. Scurvy, a condition affecting various tissues of the body, comes about as a result of a lack of adequate vitamin C in the diet. It's thought of as a rare disease nowadays, following on from some 'limey' historical observations (see here).

I say that scurvy is a rare disease, but as per the other blogging occasions when it's received attention, for those diagnosed on the autism spectrum it's not as rare as it should be. Indeed, even Yan et al note that "scurvy is increasingly identified in children with ASD [autism spectrum disorder] and developmental delay who consume restrictive diets, often lacking in fruits and vegetables." Their case report highlights how clinicians need to be observant...

The subject of the Yan case report was a young boy diagnosed with autism who was described as non-verbal. He came to clinical attention following "a 2-week history of limp and oral mucosal bleeding." Unfortunately, his first contact with medical professionals resulted in less-than-revealing typical test results that meant he was discharged with "a referral to dentistry to address the oral mucosal changes." Things did not improve. He presented again to hospital, this time "with new onset of fevers for 1 week, ongoing limp that had progressed to complete refusal to weight bear, and persistent bleeding from his oral mucosa." This second time a few more investigations were ordered and a very (VERY) low level of vitamin C (ascorbic acid) was detected: "The low ascorbic acid level confirmed the diagnosis of scurvy with a concomitant diagnosis of anemia." Treatment in the form of vitamin C and an iron supplement (alongside a multivitamin) did the trick in terms of the limp/leg problem and bleeding gums.

What are the lessons from this case report? Well, yet again, the realisation that issues such as those related to feeding problems present quite widely in relation to autism (see here) and can very much impact on health is paramount. Indeed, it should really be part of standard medical care to monitor and keep monitoring children in particular, with a diagnosis of autism to ensure that their nutritional needs are being met in many areas (see here). If they're not, supplement (under appropriate medical guidance) and don't be afraid to do so, keeping in mind that each person/child is different (see here).

I'm also minded to mention that when medical and other allied healthcare practitioners are faced with a child/adult with autism that is non-verbal and presenting with 'symptoms', the onus really should be on medicine to turn investigator to find out 'hows-and-whys' rather than discharging with a 'we don't know' sentiment. I say this in the context that a diagnosis of autism is seemingly not protective against any other condition/label/disease occurring, and noting other, more catastrophic, examples where this has happened (see here). And minus any sweeping generalisations, a few correctly framed questions can sometimes be enlightening [2] for all-manner of different issues pertinent to autism...

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[1] Yan A. et al. Limp in a Child With Autism Spectrum Disorder. Global Pediatric Health. 2017. Nov 30.

[2] Cohen S. et al. Sleep patterns predictive of daytime challenging behavior in individuals with low-functioning autism. Autism Res. 2017 Dec 1.

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"Medical history was associated with increased risk of CFS/ME"

The paper by Berit Feiring and colleagues [1] (open-access) is the source blogging material today covering an area that I was previously unaware of: "to study the association between HPV [human papillomavirus] vaccination and risk of CFS/ME [chronic fatigue syndrome/myalgic encephalomyelitis] among girls eligible for HPV vaccination in the national immunisation programme in Norway."

A quick trawl of PubMed to look-see whether there was any previous peer-reviewed science in this area revealed some inklings about a possible *association* between use of the HPV vaccine and some symptoms that may follow a diagnosis of ME/CFS [2] but not much to say that risk of an actual diagnosis of CFS/ME was significantly heightened [3] following HPV immunisation. On the topic of postural tachycardia syndrome (PoTS) and HPV vaccination, I had been aware of some, limited peer-reviewed discussions (see here).

As it happens, Feiring et al did not observe any population-wide links between HPV vaccination and increased risk of CFS/ME based on their analysis of "176,453 girls born 1997–2002 [who] were eligible for HPV vaccination." They tempered their conclusions slightly given that they "did not have access to patient records for verification of the CFS/ME diagnoses" derived from the Norwegian Patient Registry (NPR) but for all intents and purposes, their data is compelling based on sample size and how well Scandinavian countries tend to treat their population data.

A few other, rather interesting aspects to the Feiring data are also apparent: "we observed an increase in the incidence of CFS/ME among adolescents aged 10–17 in Norway, during 2009–2014" and: "Medical history was associated with both increased risk of CFS/ME and lower uptake of HPV vaccine." The idea that numbers of cases of CFS/ME is on the up in Norway is an interesting one and perhaps contrasts with other data from here in Blighty for example (see here) bearing in mind the age groups analysed. I was however specifically drawn to the idea that: "The risk of CFS/ME increased with increasing number of previous hospital contacts."

Looking at hazard ratios (HRs) for a diagnosis of CFS/ME based on how many times a girl had had hospital contact, a rather interesting dose-dependent pattern emerged. So, examining the entire follow-up period, the (adjusted) HR for CFS/ME diagnosis for those with only one hospital contact was 1.64 (1.22–2.19). For those with seven or more hospital contacts, the HR jumped to 5.23 (3.66–7.49). Also potentially important were the possible reason(s) for hospital contact and risk of CFS/ME: "According to ICD-10 diagnoses, the highest risk of CFS/ME was found among girls with diagnoses in chapters I00-I99 (Diseases of the circulatory system)..., A00-B99 (Certain infectious and parasitic diseases)... and R00-R99 (Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified)."

Other discussions on data also from Norway (indeed, from some of the same authors) has talked about medical history around CFS/ME and what conditions seem to be 'over-represented' (see here). On that research occasion [3] they concluded that: "Children with CFS/ME were frequently diagnosed with infections, supporting the hypothesis that infections may be involved in the causal pathway." Said previous findings are not so dissimilar from the current ones reported by Feiring and colleagues.

Insofar as the next steps on from the Feiring data, well one might - assuming independent replication and the like - see a way forward where a potential early warning system for possible CFS/ME screening might be put in place on the basis of patterns of hospital visits and the types/patterns of diagnosis that are given. I appreciate that there is quite a lot of heterogeneity when it comes to CFS/ME (possibly even another label ripe for pluralisation or spectrum-ing?) so I don't want to get too ahead of myself here but there is potential. Whilst HPV vaccination did not seem to be connected to later CFS/ME diagnosis in the Feiring cohort, the question about what factors could be driving the increase in cases remains open: "The reasons for the increase in CFS/ME in Norway are unknown."

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[1] Feiring B. et al. HPV vaccination and risk of chronic fatigue syndrome/myalgic encephalomyelitis: A nationwide register-based study from Norway. Vaccine. 2017. June 23.

[2] Brinth LS. et al. Orthostatic intolerance and postural tachycardia syndrome as suspected adverse effects of vaccination against human papilloma virus. Vaccine. 2015 May 21;33(22):2602-5.

[3] Donegan K. et al. Bivalent human papillomavirus vaccine and the risk of fatigue syndromes in girls in the UK. Vaccine. 2013 Oct 9;31(43):4961-7.

[4] Bakken IJ. et al. Comorbidities treated in primary care in children with chronic fatigue syndrome / myalgic encephalomyelitis: A nationwide registry linkage study from Norway. BMC Family Practice. 2016; 17: 128.

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Infections treated with anti-infective agents linked to schizophrenia?

Identify everyone born in Denmark between 1985-2002. Identify those treated "in the primary care setting" for an infection. Identify those diagnosed with schizophrenia and affective disorders. Look-see whether there is an overlap between infection or treated infection and schizophrenia / affective disorders. Report results.

That's basically the study published by Köhler and colleagues [1] (a name that has appeared on this blog before) who concluded that: "Infections treated with anti-infective agents and particularly infections requiring hospitalizations were associated with increased risks of schizophrenia and affective disorders, which may be mediated by effects of infections/inflammation on the brain, alterations of the microbiome, genetics, or other environmental factors."

Mention of Denmark as being the source material for such a discovery means, yet again, that those various Scandinavian population registries are proving their 'big data' scientific worth. Indeed, such resources really do put countries such as Blighty to shame insofar as tracking the health of the Nation and at the same, providing science with lots and lots of research nuggets.

Taking into account various "confounders", authors report that alongside a possible connection between infection or treatment for infection being 'associated' with schizophrenia / affective disorders there was "a dose-response and temporal relationship" further substantiating their findings. Indeed, those who had to be hospitalised for infection (a serious infection then) were at much greater risk of subsequently being diagnosed with schizophrenia or affective disorders. This tallies with other research on this topic (see here).

One more thing: "The excess risk was primarily driven by infections treated with antibiotics, whereas infections treated with antivirals, antimycotics, and antiparasitic agents were not significant after mutual adjustment." Interesting. This suggests that bacterial infections or their treatments, e.g. antibiotics seem to be important factors in relation to the subsequent risk of schizophrenia and/or affective disorders. Again, this is not the first time that this point has been raised (see here and see here) and provides some corroborative evidence as to why the microbiome was mentioned by authors in relation to possible mechanisms to account for their findings.

I could start talking about how this research is further evidence for a role for the immune system and/or inflammatory processes in relation to psychiatric labels (see here for example) but you've probably heard it all before I'm sure. What we are also starting to understand with some confidence, is that infection and the effects of it's treatment might go way beyond just the somatic...

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[1] Köhler O. et al. Infections and exposure to anti-infective agents and the risk of severe mental disorders: a nationwide study. Acta Psychiatr Scand. 2016 Nov 21.

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Köhler O, Petersen L, Mors O, Mortensen PB, Yolken RH, Gasse C, & Benros ME (2016). Infections and exposure to anti-infective agents and the risk of severe mental disorders: a nationwide study. Acta psychiatrica Scandinavica PMID: 27870529

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

"Paediatricians are seeing more children with developmental-behavioural conditions"

The findings reported by Harriet Hiscock and colleagues [1] are brought to the blogging table today, specifically that suggestion that paediatricians, at least in Australia, might be encountering an increased number of "developmental/behavioural conditions" as part of their workload.

Looking at the clinical experiences of some 180 paediatricians who took part in the study in late 2013 and comparing them with data from 2008, researchers probed a number of practices relating to "(i) conditions seen; (ii) consultation duration; (iii) imaging and pathology ordered; and (iv) prescribing." The details associated with seeing an increasing number of children "with developmental-behavioural conditions" included: "More paediatricians reported diagnoses of autism spectrum disorder... attention-deficit/hyperactivity disorder... and intellectual disability... in first consultations."

Whilst being slightly careful that 'seeing more children with developmental-behavioural conditions' is not necessarily equated with there 'being' more children with such issues, I'm inclined to suggest that such data is important. Quite a few times in the British media at least, stories have emerged about long waiting times for developmental assessments (see here for one example) and how an already stretched National Health Service (NHS) is seemingly struggling in some parts, to cope with the number of referrals coming through (see here).

As part of a wider peer-reviewed and 'other' evidence base suggesting that (a) the estimated prevalence rates for autism have increased (see here) and (b) there may be a 'real' increase in 'rates of behaviour' associated with an autism spectrum disorder (ASD) (see here) I am becoming more and more convinced that old arguments about 'better awareness' or 'diagnostic switching' are becoming less relevant to the debate about the increasing numbers of cases of autism (see here for example).

I don't doubt that as a society we are far more aware of autism than we ever were (we've even started 'screening for it' during early infancy here in Blighty) and where decades ago someone for example, might have been diagnosed with a learning disability even though they presented with autistic features so things are a little different nowadays. But the sorts of stresses and strains being placed on developmental screening and diagnostic services (particularly paediatric services) in comparison to times gone by are seemingly not comparable anymore. Even taking into account population increases and changes to the organisation of screening and diagnostic services, talk of a growing tide of children being diagnosed, or waiting to be assessed, as being on the autism spectrum is something that really should be prompting a lot more urgency and action. I might also add that arguments about better clinical awareness - did they really miss all those children? - really do a disservice to those who have been skillfully diagnosing autism for many years. Value our experts!

And alongside the talk about children being diagnosed, adult services too are also under a lot more pressure these days...

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[1] Hiscock H. et al. Trends in paediatric practice in Australia: 2008 and 2013 national audits from the Australian Paediatric Research Network. J Paediatr Child Health. 2016 Sep 4.

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Hiscock H, Danchin MH, Efron D, Gulenc A, Hearps S, Freed GL, Perera P, & Wake M (2016). Trends in paediatric practice in Australia: 2008 and 2013 national audits from the Australian Paediatric Research Network. Journal of paediatrics and child health PMID: 27594610

Reasons for visiting ER by those with autism

ER - Emergency Room - or as we call it here in Blighty Accident & Emergency (A & E), is never a particularly desirable place to visit given the emphasis on illness or injury of yourself or loved one. That being said, staff there do a sterling job sometimes under very stressful circumstances, responding to all-manner of complaints, some of which are life-threatening.

The paper by Dorothea Iannuzzi and colleagues [1] sought to identify some of the medical reasons why ER visits were made by people on the autism spectrum. They concluded that, depending on age, epilepsy or seizure-type disorders and "psychiatric conditions" were well represented in cases of autism based on data derived from the US 2010 National Emergency Department database.

Realising that epilepsy / seizure-type disorders seem to have more than a passing connection to quite a few cases of autism (see here) and can, in some cases, lead to that most extreme of outcomes (see here), I'm not going to focus any further on this part of the Iannuzzi findings. Rather the finding that: "Psychiatric conditions were primary among ASD individuals aged 12-15 years, accounting for more than 11 % of all visits" merits some further analysis.

The findings reported by Kalb and colleagues [2] documenting that: "Thirteen percent of visits among children with ASD [autism spectrum disorder] were due to a psychiatric problem, as compared with 2% of all visits by youths without ASD" provides further evidence for the extent of the Iannuzzi finding. Whilst treading carefully in this area of autism research, one detail stuck out from the Kalb report, whereby ER visits due to psychotic disorders seemed to be increased in likelihood compared to visits by asymptomatic children/youths. This seemed to tie in well with my recent discussions on the observations of Maibing and colleagues [3] and the risk/onset of schizophrenia spectrum disorders following a previous child or adolescent psychiatric diagnosis.

Unfortunately, my discussions on the research literature on ER visits and autism do not get any happier as I turn to the body of work looking at suicide attempts and autism, and as per the conclusion from Kato and colleagues [4], "ASDs should always be a consideration when dealing with suicide attempts in adults at the emergency room". Again, I've covered the very sensitive topic of suicide (ideation and attempts) and autism previously on this blog (see here and see here) and as we speak further research has emerged pertinent to this topic [5]. Though sometimes quite uncomfortable to discuss, this collected work emphasises how we all really need to be talking a lot more about this issue and what can be done to divert people away from this most extreme type of behaviour. Admission to the ER - which will often be the first point of contact after such behaviour - could be a good place to start having those discussions.

In amongst the literature talking about the ER and autism, there are other details which provide a rather more positive discussion about this topic. Take for example, the paper by Giarelli and colleagues [5] looking at the ways and means ER might be made more comfortable to [some of] those on the autism spectrum. Similarly, the guidance supplied by McGonigle and colleagues [6] talking about ways of managing agitation in the ER for those on the autism spectrum might also be better referenced in this clinical setting. Oh, and a bit more knowledge about medical comorbidities potentially affecting people with autism would probably not go amiss more generally.

I should conclude that whilst I've focused on some of the more frequently reported reasons why people with autism might present to the ER, one shouldn't forget that all the other reasons why the general population go to the ER are similarly as pertinent to those on the spectrum. That being said, I very much doubt that "help with removing false nails" would feature on most people's reasons to attend hospital...

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[1] Iannuzzi DA. et al. Brief Report: Emergency Department Utilization by Individuals with Autism. J Autism Dev Disord. 2014 Sep 27.

[2] Kalb LG. et al. Psychiatric-related emergency department visits among children with an autism spectrum disorder. Pediatr Emerg Care. 2012 Dec;28(12):1269-76.

[3] Maibing CF. et al. Risk of Schizophrenia Increases After All Child and Adolescent Psychiatric Disorders: A Nationwide Study. Schizophr Bull. 2014 Sep 5. pii: sbu119.

[4] Kato K. et al. Clinical features of suicide attempts in adults with autism spectrum disorders. Gen Hosp Psychiatry. 2013 Jan-Feb;35(1):50-3.

[5] Takar K. & Kondo T. Comorbid atypical autistic traits as a potential risk factor for suicide attempts among adult depressed patients: a case–control study. Annals of General Psychiatry 2014, 13:33.

[6] Giarelli E. et al. Sensory stimuli as obstacles to emergency care for children with autism spectrum disorder. Adv Emerg Nurs J. 2014 Apr-Jun;36(2):145-63.

[7] McGonigle JJ. et al. Management of agitation in individuals with autism spectrum disorders in the emergency department. Child Adolesc Psychiatr Clin N Am. 2014 Jan;23(1):83-95.

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Iannuzzi DA, Cheng ER, Broder-Fingert S, & Bauman ML (2014). Brief Report: Emergency Department Utilization by Individuals with Autism. Journal of autism and developmental disorders PMID: 25261249