"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.

----------

[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.

----------

The headline: "One in nine young people in Scotland have attempted suicide"

I have to say that I drew a sharp intake of breath when I read the media headline titling this post - "One in nine young people in Scotland have attempted suicide" - based on the findings reported by Rory O'Connor and colleagues [1]. The idea that, from a sample of some 3500 young people in Scotland, some 10% and 15% of respondents to the questions: "Have you ever made an attempt to take your life, by taking an overdose of tablets or in some other way?’ and ‘Have you ever deliberately harmed yourself in any way but not with the intention of killing yourself? (i.e. self-harm)" answered in the affirmative, seemed pretty important. Not least with the question 'why?' in mind.

OK, media headlines aside, the O'Connor findings require some dissection. The reasoning behind studying this issue was not only to look at the very complicated topic of suicide in a part of the UK (Scotland) that authors write "has a higher suicide rate than England", but also to try and understand how non-suicidal self-injury (NSSI) or non-suicidal self-harm (NSSH) presents in young adults and whether there is something important linking NSSH and suicidal thoughts and/or attempts.

The participant group was drawn from "a representative sample of young people aged 18–34 years from across Scotland" who were recruited to the Scottish Wellbeing Study. Lots of measures were completed by participants as part of the wider study initiative but we are told that "only the prevalence of NSSH and suicide attempts information is reported" in the O'Connor article on this occasion. I might also add that participants were compensated to the tune of £25 (pounds sterling) for their time and participation.

Alongside those headline findings on self-reported attempted suicide and self-harm, a few other important trends were observed. So: "More than 20% reported lifetime suicidal thoughts, 2.4% reported that they last thought about suicide in the past week and 10.4% reported they last thought about suicide in the past 12 months." Around 6% of respondents reported that they had both attempted suicide and also engaged in self-injury suggesting that professionals should "routinely enquire about history of self-injurious behaviour, especially as past behaviour is such a strong predictor of suicide." Also: "Earlier age at NSSH or suicide attempt onset was associated with more frequent lifetime NSSH and suicide attempts." And finally: "The prevalence of NSSH and suicide attempts was significantly higher among those classified as unemployed... and economically inactive... compared with those who were employed." Age, societal and environmental factors seem to play some roles too.

Then to another important set of questions: (a) why? and (b) what can be done to reduce these headline-grabbing statistics? Well, there are no easy answers to such questions I'm afraid. The authors do note that: "From a public health perspective, the unemployment and economic inactivity findings are noteworthy" and perhaps suggest that there are some modifiable variables that could influence suicidal thoughts and/or actions focused on getting people into employment and the benefits that this brings (wide-ranging benefits by all accounts). But this probably only covers one side of the issue, as discussions inevitably turn to what role psychiatric and/or behavioural comorbidity might play in such reporting (see here and see here and see here) and whether there may be a need for (a) something like enhanced screening for suicidal thoughts or other 'risks' among selected populations and/or (b) the [careful] use of 'preventative' strategies in such cases (see here and see here). I say all that accepting that diagnoses around mental health probably play an important role in suicide-related behaviours but are not necessarily a pre-requisite...

As always, there is always someone to talk to if needed...

----------

[1] O'Connor RC. et al. Suicide attempts and non-suicidal self-harm: national prevalence study of young adults. BJPsych Open. 2018; 4: 142-148.

----------

Estimated autism prevalence in Northern Ireland: 2.9% for 2017-2018

Consider this post discussing the publication: "The Prevalence of Autism (including Aspergers Syndrome) in School age Children in Northern Ireland 2018" an extension of other musings on previous figures to come out of Northern Ireland (see here).

On my last blogging occasion on this topic, the report (see here) covered the period 2015/2016 and detailed an estimated prevalence rate of autism spectrum disorder ("including Asperger syndrome") in Northern Ireland of 2.3%. I actually missed a report that covered the period 2016/2017 (see here) that detailed an estimated rate of 2.5%. This latest report covering 2017/2018 sets the rate at 2.9%. You can perhaps see the direction of the trend, mirroring other population estimated data (see here)...

The report(s) are open-access for anyone to see, but I'm going to pick out a few choice snippets of information.

So: the last blogging time I talked about the Northern Ireland (NI) report, I mentioned that the [estimated] prevalence rate for boys was approaching 4% based on those 2015/2016 figures. Well, that's been well and truly surpassed and is now heading towards 5% of boys in NI "identified with autism." How are they identified I hear you ask? Well, school data is the answer, "from the ‘Northern Ireland School Census’" where schools are legally obliged by the Department of Education in NI to provide information about registered pupils. Further: "The data only captures those children identified with autism, at any time there may be additional children who may be progressing through the full assessment process and it is possible that a number of children may be identified as having autism at a later date." That last point is important in the context that NI has a bit of a history of 'long-waiting lists' for autism assessments (see here). Oh, I should also mention that the National Health Service (NHS) functions in Northern Ireland just as it does in other parts of the United Kingdom (UK) meaning that healthcare (including autism assessment and diagnosis) is free at the point of need. This does not mean that things are going to be 'fast or rapid' temporally, but does mean that people don't have to typically pay extra for such clinical services.

Next: the 4:1 male:female ratio for diagnosis seems to be holding true (as it did in the latest CDC report on 'estimated' autism prevalence in the United States). I know that quite a few people talk about this ratio figure being 'inaccurate' in view of how autism may/may not present slightly 'differently' in females (see here for example), but, at the moment at least, that's what the statistics are telling us. One thing I perhaps am slightly cautious about in the latest report with regards to the sex/gender ratio thing is the phrase: "Autism could therefore be considered to be an extreme of the normal male profile." Hmm...

Also: autism prevalence by school year shows some interesting patterns. Take a look at the screen grab I've added observing that 3.4% of children in Year 9 were "identified with autism." Just in case you're not up to speed with what Year 9 translates as in age terms, have a look at this link which covers England. I think things are slightly different in NI (see here) but generally speaking, Year 9 covers somewhere between 12-14 years of age.

Finally, something else potentially quite important: "The Northern Ireland urban population has a statistically significant higher prevalence rate than the rural population." Note those words 'statistically significant', inferring that chance alone, is probably not the driver of such disparity. It's been a while since I've blogged about 'urban vs. rural' in the context of autism (see here) and I'm sure there are 101 different explanations for the mismatch. Combined however with some other observations on a possible influence of deprivation and poverty on the recent figures ("In 2017/18, the rate of autism in the most deprived MDM [Multiple Deprivation Measure] decile was 31% higher than the Northern Ireland average") one could argue that any explanation is going to be multi-factorial.

I look at these most recent figures and cannot help but think that 'increased awareness' and/or other 'artificial' explanations are (yet again) unable to entirely account for the sorts of increase in diagnosed autism being noted (see here). Were schools and other professionals 'so bad at recognising and/or recording autism' just a few years ago? No, they weren't. And to infer they were is bit a slur on the professionalism of many teachers and other associated professionals, many of whom have seen literally generations of schoolchildren pass through their educational doors.

There's also another important question to attend to on the basis of the recent figures: are the resources currently and in the future, in place to cope with the rising demands on things like education, health and social care following the increase in the numbers of children being diagnosed with autism? I say this in the context that if there are already insufficient resources to cope with the numbers requiring assessment for autism (assessments that are typically not inexpensive [1]), how can we hope that there will be sufficient resources in place over a lifetime of potential need?

----------

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

----------

On recognising "the disabling effects of ME/CFS"

The findings reported by Caroline Kingdon and colleagues [1] observing that "Using SF-36v2™ scores as a proxy, people with ME/CFS [myalgic encephalomyelitis/chronic fatigue syndrome] were measurably more disabled than PWMS [people with multiple sclerosis] or HCs [healthy controls] in this study population" didn't really surprise me.

Although I'm always a little cautious about making sweeping 'who's the more disabled' comparisons when it comes to various diseases / conditions / labels, I've previously talked about how truly quality-of-life-sapping a diagnosis of ME/CFS can be (see here). Indeed, from previous results published by Falk Hvidberg and colleagues [2] for example, the message was pretty clear: "The ME/CFS study population is more disabled and socially marginalized than the average population with regards to the subjects of long-term illness, number of illnesses, proportion of disability pensioners and relationships." Indeed on that research occasion, ME/CFS beat the likes of lung cancer, depression and schizophrenia in terms of measured severity of health-related quality of life.

The Kingdon results add to such sentiments; on this occasion comparing the "impact of disability" associated with ME/CFS with reports from PWMS and asymptomatic (so-called 'healthy') controls. Multiple sclerosis (MS) by the way, refers to an autoimmune condition that affects many different parts of the body "including problems with vision, arm or leg movement, sensation or balance."

The results, based on data "collected as part of the UK ME/CFS Biobank" included reports from over 50 people diagnosed with ME/CFS and similar numbers diagnosed with MS or asymptomatic. We are told that the SF-36v2™ is an instrument that "uses 36 questions to collect information about functional status and well-being from respondents" and covers various domains.

One figure in particular (see here) provides a good visual representation of how disabling ME/CFS was on this [group] study occasion. Median scores from participants with ME/CFS were 'consistently below' scores from the other groups on every domain, indicative of greater disability. I should also note that despite median [group] scores on the mental health domain also being lower for the ME/CFS group than the comparators, they were at least 'nearer' to the other groups than scores on the other domains examined. I say this in the context that mental health is almost certain to be affected by a diagnosis of ME/CFS, but does not need any psychobabble (i.e. psychosomatic / biopsychosocial) explanations thank you very much (see here).

There are a couple of other important trends noted in the Kingdon data worth noting. So: "Disease onset had a greater impact on employment among people with ME/CFS than among PWMS" and "Post disease onset, 83% of people with ME/CFS earned below £20,000, compared with 59% of PWMS and 54% of HCs." ME/CFS it seems, is not only a condition that hits people hard in a physical sense, it also represents an important route to financial hardship too. Further: "Unemployment costs are borne by both the individual and society." So not only does it make good sense to cure ME/CFS (yes, that's cure as in complete recovery) for the people concerned, but society also benefits. I'm also minded to suggest that when and where people with ME/CFS are disabled to such an extent by their symptoms, we (society) owe it to them to ensure that they are properly supported both medically and also, financially (see here).

Any questions?

----------

[1] Kingdon CC. et al. Functional Status and Well-Being in People with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome Compared with People with Multiple Sclerosis and Healthy Controls. PharmacoEconomics. 2018. March 13.

[2] Falk Hvidberg M. et al. The Health-Related Quality of Life for Patients with Myalgic Encephalomyelitis / Chronic Fatigue Syndrome (ME/CFS). PLoS One. 2015 Jul 6;10(7):e0132421.

----------

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)...

----------

[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.

----------

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...

----------

[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.

----------

Poverty status and autism, ADHD and asthma

The paper by Christian Pulcini and colleagues [1] talking about poverty status potentially influencing "parent-reported lifetime prevalence and comorbidities" when it comes to three target conditions (autism, attention-deficit hyperactivity disorder [ADHD] and asthma) should have been a call to action. Concluding that "poor and near poor children had a higher lifetime prevalence of asthma and ADHD, but not ASD [autism spectrum disorder]" [2], some of the findings have instead attracted criticism based on the content of the abstract (see here); specifically the line: "the lifetime prevalence of ASD rose almost 400%."

Poverty and diagnosis is a topic that I've covered before on this blog (see here for example) and how not every research study has linked poverty (measures of poverty) to something like autism and/or ADHD. At least that is, when taking into account "elevated emotional problems among children with ASD + ADHD" [3].

On this most recent occasion, Pulcini et al drew on data derived from the "National Survey of Children's Health [NSCH] for years 2003, 2007, and 2011-2012" and specifically "trends in parent reported lifetime prevalence and comorbidity among children with asthma, ADHD, and ASD" taking into account variables like poverty status. The NSCH initiative has again, been talked about previously on this blog (see here and see here) in terms of parent-reported prevalence of autism and parent-reported epilepsy appearing alongside autism. It's a good rough-and-ready measure of what estimated prevalence rates might look like (with the need for further, more detailed study).

This time around the authors illustrated that - yet again - the only way is up when it comes to estimated prevalence rates for all the 'target' conditions examined. I don't think anyone should be too surprised at such findings given data from other studies in other geographic areas (see here) specifically with the autism spectrum in mind. I'm not going to head into the debate about whether the 400% increase figure is right or wrong but will note previous findings [4] that suggested that: "differential survey measurement error over time was not a major contributor to observed changes in the prevalence of parent-reported ASD. Rather, much of the prevalence increase from 2007 to 2011–2012 for school-aged children was the result of diagnoses of children with previously unrecognized ASD." This for when data from the 2007 and 2011-2012 surveys were contrasted (not the 2003 survey).

The contribution of poverty or near poverty was not to be sniffed at when it comes to those ADHD and asthma diagnoses. This is perhaps even more important when one considers that these two labels might be rather more 'entangled' than many people might have previously realised (see here). That a poverty and ADHD link might also generalise to somewhere like here in the UK is also worth noting (see here) and implies that quite a bit more research is needed to answer the question: why? With regards to autism (ASD), the observation that the "rise in ASD was associated with being nonpoor"adds to an on-going debate, with some studies saying yes, we agree, and other studies saying no, we don't (see here). In short, it is slightly more complicated when it comes to how social factors might affect autism rates.

Music: Three steps to heaven.

----------

[1] Pulcini CD. et al. Poverty and Trends in Three Common Chronic Disorders. Pediatrics. 2017 Feb 13. pii: e20162539.

[2] Dreyer BP. Congress Should Adopt a “Do No Harm to Children” Standard in Changes to Public Health Insurance. Pediatrics. 2017. Feb 2017.

[3] Flouri E. et al. Poverty and the Growth of Emotional and Conduct Problems in Children with Autism With and Without Comorbid ADHD. J Autism Dev Disord. 2015 Sep;45(9):2928-38.

[4] Blumberg SJ. et al. Changes in Prevalence of Parent-reported Autism Spectrum Disorder in School-aged U.S. Children: 2007 to 2011–2012. Natl Health Stat Report. 2013 Mar 20;(65):1-11.

----------

Pulcini CD, Zima BT, Kelleher KJ, & Houtrow AJ (2017). Poverty and Trends in Three Common Chronic Disorders. Pediatrics PMID: 28193790

ADHD in the UK

I don't want to keep you too long today but thought it worthwhile to bring the paper by Adrian Hire and colleagues [1] to your attention and the suggestion that "socioeconomic deprivation" may play a role when it comes to ADHD (attention-deficit hyperactivity disorder).

Based on data derived from the "Clinical Practice Research Datalink (CPRD)" - a UK based resource "providing anonymised primary care records for public health research since 1987" - researchers set about looking at those children/young adults diagnosed with ADHD between 2004 and 2013. This information was stratified according to the region where the general practice (GP) surgery was based added to which a measure of deprivation status was calculated ("Practice Index of Multiple Deprivation (IMD) score").

The results: well, aside from something of quite a stable incidence (that's incidence not prevalence) of ADHD apart from the last 2 years studied (interestingly), Hire et al also reported that: "In almost every year studied, incidence rates were highest among the most deprived patients and lowest among the least deprived patients." They concluded that there may be quite a bit more to see when it comes to socioeconomic deprivation (i.e. poverty etc.) and the label ADHD.

Obviously one has to be a little guarded in making too many sweeping generalisations from this data (including the use of "a surrogate measure" for deprivation status) but there is quite a bit more work to do in this area. Other statistics for example, have come to similar conclusions about socioeconomic disparities and ADHD diagnosis [2] crossing different geographies as well. That and the suggestion that ADHD + other diagnoses might show important effects as a function of societal variables such as poverty (see here) and one has some intriguing hypotheses to test with some potentially important conclusions reflective of lots of variables including social policy.

Music: Coldplay - Adventure Of A Lifetime (and a great video).

----------

[1] Hire AJ. et al. ADHD in the United Kingdom: Regional and Socioeconomic Variations in Incidence Rates Amongst Children and Adolescents (2004-2013). J Atten Disord. 2015 Nov 23. pii: 1087054715613441.

[2] QuickStats: Percentage of Children Aged 5-17 Years with Diagnosed Attention Deficit/Hyperactivity Disorder (ADHD),by Poverty Status and Sex - National Health Interview Survey, 2011-2014. MMWR Morb Mortal Wkly Rep. 2015 Oct 16;64(40):1156.

----------

Hire AJ, Ashcroft DM, Springate DA, & Steinke DT (2015). ADHD in the United Kingdom: Regional and Socioeconomic Variations in Incidence Rates Amongst Children and Adolescents (2004-2013). Journal of attention disorders PMID: 26604267

Poverty affects autism + ADHD?

A brief post for you today to bring to your attention the paper by Eirini Flouri and colleagues [1] who suggested that although socio-economic disadvantage (SED) was probably not a risk factor for autism spectrum disorder (ASD) and attention-deficit hyperactivity disorder (ADHD) when comorbid, "it was associated with elevated emotional problems among children with ASD + ADHD."

Based on data derived from "209 children with ASD who took part in the UK's Millennium Cohort Study", an initiative that has appeared on this blog before (see here), researchers examined developmental trajectories across ages 3, 5 and 7 years. Aside from observing a possible detrimental effect from SED on aspects of ASD + ADHD, they also reported that ASD + ADHD seemed to be associated with a consistently 'high trajectory' when it came to conduct issues compared with those with ASD only.

Continuing the ideas that (a) autism appearing alongside ADHD (or should that be the other way around) is not an uncommon situation (see here), and (b) said association potentially increases the risk of various other issues coming about (see here), the suggestion that SED might impact on the presentation of autism + ADHD is an important one. Other work from this group [2] had hinted that family poverty may be one factor "associated with broad and specific (emotional and conduct problems) psychopathology" in the context of autism. I say this acknowledging that poverty has a range of effects when it comes to autism including the potential timing of diagnosis [3].

Other, independent work, has not been so quick to drop the idea that poverty and deprivation may be a risk factor for autism [4] or at least, referral rates for autism (and on more than one occasion [5]) so I'd perhaps be a little guarded about removing this aspect from the autism + ADHD grouping altogether at the present time. The next question then needs to be how, in these times of continued austerity, can society deliver something that might mitigate the impact of autism + ADHD?

Music: Morrissey - Everyday Is Like Sunday.

----------

[1] Flouri E. et al. Poverty and the Growth of Emotional and Conduct Problems in Children with Autism With and Without Comorbid ADHD. J Autism Dev Disord. 2015 Apr 25.

[2] Midouhas E. et al. Psychopathology trajectories of children with autism spectrum disorder: the role of family poverty and parenting. J Am Acad Child Adolesc Psychiatry. 2013 Oct;52(10):1057-1065.e1.

[3] Mandell DS. et al. Age of diagnosis among Medicaid-enrolled children with autism, 2001-2004. Psychiatr Serv. 2010 Aug;61(8):822-9.

[4] Campbell M. et al. Autism in Glasgow: cumulative incidence and the effects of referral age, deprivation and geographical location. Child Care Health Dev. 2013 Sep;39(5):688-94.

[5] Li X. et al. Neighborhood deprivation and childhood autism: a nationwide study from Sweden. J Psychiatr Res. 2014 Jun;53:187-92.

----------

Flouri E, Midouhas E, Charman T, & Sarmadi Z (2015). Poverty and the Growth of Emotional and Conduct Problems in Children with Autism With and Without Comorbid ADHD. Journal of autism and developmental disorders PMID: 25911306