ADHD and "criminogenic cognitions": is inattention a key issue?

"These results indicate that in community-recruited adults, inattention rather than hyperactivity is related to criminogenic cognitions."

That was a key conclusion reached in the paper by Paul Engelhardt and colleagues [1] who set out to put some further scientific flesh on the bones of the finding of a "strong link between ADHD [attention-deficit hyperactivity disorder] and criminal behaviour." They were specifically interested in some of the cognitive processes behind such a correlation, and whether specific facets of ADHD might be more strongly related to criminal behaviour.

OK, first things first, although there is more than a passing connection between ADHD and risk of incarceration for example (see here and see here) I do need to point out that not every person diagnosed with ADHD is a criminal or would-be criminal. Sweeping generalisations about the effects of behavioural and/or psychiatric labels have done more than enough damage down the years, and I don't want to add to any stigma. That being said, I don't think it's unfair to point out that there is a body of peer-reviewed research evidence out there observing that ADHD certainly seems to increase the risk of contact with law-makers and law enforcers alongside a host of other events (see here).

Engelhardt et al provided a sample of adults (N=198) aged between 18-65 years with a package of questionnaires designed to assess 'criminal thinking styles' and ADHD-related traits. Questionnaires were of the self-report kind. The results suggested that various variables/items on the ADHD questionnaire and more general demographic information *correlated* with criminogenic cognitions. So: "higher age and being female were negatively related to criminogenic cognitions" indicating that such variables were associated with lower criminogenic cognitions. Further, and as mentioned at the start of this post: "inattention/memory problems were more strongly associated with criminogenic cognitions than was impulsivity/emotional lability." In total, age, sex/gender and ADHD symptoms accounted for "between half and two-thirds of the variance in criminogenic cognitions."

The authors mention how their results differ from other data talking about hyperactivity as being linked to criminality, and whether their use of a non-criminal participant group and focus on criminogenic cognitions rather than criminality might be important. I'd agree that the Engelhardt results are important but require further investigations to be carried out to assess their validity. Having said that, the results as they stand do perhaps offer another avenue for intervention, based on the the idea that managing inattention (if that is possible) *could* be have some really important effects.

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[1] Engelhardt PE. et al. The Relationship between Adult Symptoms of Attention-Deficit/Hyperactivity Disorder and Criminogenic Cognitions. Brain Sci. 2019 Jun 2;9(6). pii: E128.

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"The Camouflaging Autistic Traits Questionnaire (CAT-Q)"

There are quite a few reasons why the findings from Laura Hull and colleagues [1] are to be welcomed. Their report detailing the development and validation of the The Camouflaging Autistic Traits Questionnaire (CAT-Q) covers an important area of autism research and practice that has hitherto been quite extensively discussed in lay circles but not readily quantified in scientific ones.

So: "Social camouflaging is defined as the use of strategies by autistic people to minimise the visibility of their autism during social situations." Further: "Camouflaging is driven by the desire to ‘fit in’ so as to appear non-autistic, and to form relationships with others, which may be harder to achieve when the person presents autistic behaviour." Discussions about camouflaging/masking in the context of autism have figured in some peer-reviewed research already; stretching from some worrying data on the risk of suicidality (see here) to discussions about friendship experiences (see here) to potentially hindering assessment and diagnostic outcomes (see here). The difficulty so far however, is a lack of instruments able to accurately quantify camouflaging...

Hull et al set out to develop their questionnaire to fill the gap between lay reports and science, and perhaps eventually provide some data pertinent to questions like: "Who, among the many different autistic people, camouflages their autism? Do autistic girls and women camouflage more than boys and men, and does this partly account for gender disparities in the rate and timing of diagnosis? What is the relationship between camouflaging and mental health outcomes?"

I won't bore you with psychometric details of how the CAT-Q was developed and validated. Suffice to say that it was developed from "autistic adults’ experiences of camouflaging" combined with initial testing results from several hundred people both on and off the autism spectrum. That's not to say there aren't issues to consider with for example, the use of an on-line survey or that "the self-report CAT-Q only measures individuals’ own reflections/perceptions of their camouflaging behaviours, and is thus limited in its use to those who are able to reflect on their own behaviours and provide insight to their motivations." But it does represent a good first effort to look into this important area. I'd also hat-tip the researchers for another part of their study protocol: "Those who reported being self-diagnosed were automatically excluded from the study and did not complete any further questions." I support this on the basis that self-diagnosis does not necessarily mean accurate diagnosis (see here and see here) no matter how many people would wish it to be so.

I was also interested to read about the authors' findings breaking down camouflaging into some smaller units. So: "Compensation (strategies used to actively compensate for difficulties in social situations), Masking (strategies used to hide autistic characteristics or portray a non-autistic persona), and Assimilation (strategies that reflect trying fit in with others in social situations)." Such descriptions are important insofar as putting some scientific flesh onto the bones of social camouflaging and the possible processes/motivations behind it.

What else? Well, there is a need for more investigation in this area. The authors have already highlighted some of the areas that need more study (who, males vs females, mental health outcomes). Minus any sweeping generalisations and without trying to furrow any brows, I'd also add that study on camouflaging might also be something to consider in another autism-related context: those presenting with so-called 'optimal outcome' where some people who were previously diagnosed and presented as autistic, no longer do so (see here and see here). I'm not saying this to somehow imply that all those who have experienced a 'loss of diagnosis' are somehow all camouflaging their symptoms. But it would be interesting to look-see whether this could explain a proportion of cases and indeed whether some camouflaging might not be as negative as some people might think (see here)...

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[1] Hull L. et al. Development and Validation of the Camouflaging Autistic Traits Questionnaire (CAT-Q). J Autism Dev Disord. 2018. Oct 25.

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"no evidence of any beneficial effect of monthly vitamin D3 supplementation on mood-related outcomes"

The quote titling this post - "no evidence of any beneficial effect of monthly vitamin D3 supplementation on mood-related outcomes" - comes from the paper published by Maria Choukri and colleagues [1] (open-access available here). Their study represents an important continuation of research looking at whether supplementing with vitamin D (the sunshine vitamin/hormone) may affect depression or depressive symptoms (see here). The authors in this case observed that their study "did not provide evidence for the benefit of single monthly dose of vitamin D3 supplementation over autumn and winter on depression and other mood outcomes in healthy pre-menopausal women."

Just before heading further into the Choukri findings, it's worthwhile mentioning some of the history in this area. So, vitamin D is an essential part of maintaining good bone integrity as per the connection between deficiency of the stuff and conditions like rickets (see here). More recently, scientific and clinical eyes have turned to other possible roles for vitamin D in light, for example, of 'deficiency' connections to various developmental and/or behaviourally-defined labels such as autism, schizophrenia and depression (see here and see here and see here respectively). When deficiency (or insufficiency) is detected, people supplement with vitamin D to correct the deficiency, following Government guidance (see here). Speculation then turned to whether supplementation might also 'impact' on the presentation of some of those developmental/clinical labels as well as just correcting any biological deficiency. The results have tended to be mixed so far (see here and see here) with some important biological caveats (see here)...

"This study was a double-blind, placebo-controlled, randomised clinical trial conducted from February 2013 to October 2013 in Dunedin, New Zealand (45° 52′0 S, similar to the latitude of Montreal, Canada; or Lyon, France in the northern hemisphere)." The latitude information is important to various studies mentioning vitamin D because geography influences sun exposure which then influences vitamin D production (see here). Importantly too, the Choukri study was focused on 'healthy' women who were not currently diagnosed with a variety of exclusionary conditions/labels. "A total of 152 healthy women (18–40 years) in Dunedin, New Zealand were randomly assigned to receive 50 000 IU [international units] (1·25 mg) of oral vitamin D3 or placebo once per month for 6 months" we are told, and measures covering anxiety, depression, 'flourishing' and positive and negative mood were utilised before and after.

Results: first and foremost measured vitamin D levels did what they were expected to do as a function of vitamin D or placebo receipt. There was for example, no significant baseline difference in vitamin D levels between the groups (vitamin D vs placebo). At the end of the study, those in the placebo group showed "the expected seasonal pattern in terms of a decline in absolute level and change over the seasonal periods" in vitamin D levels, whilst the supplemented group did not.

But alongside... "There were no statistically significant differences between the vitamin D and placebo groups in any of the outcome measures – depression, anxiety, flourishing, or positive and negative mood, controlling for the baseline measures and the covariates." Indeed, across the various measures, there wasn't even anything close to a statistically significant difference reported between the groups. Ergo, in healthy women "over the winter period", vitamin D supplementation did not seemingly impact on mood-related outcomes despite altering biological vitamin D levels.

I could mention about some possible caveats attached to this study such as the fact that this was a study carried out on an already healthy population "with no vitamin D deficiency or high depressive symptoms." But this is not the first time that vitamin supplementation has 'failed' to show a demonstrable connection to improving mood and probably won't be the last either...

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[1] Choukri MA. et al. Effect of vitamin D supplementation on depressive symptoms and psychological wellbeing in healthy adult women: a double-blind randomised controlled clinical trial. J Nutr Sci. 2018 Aug 23;7:e23.

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"maternal pre-pregnancy obesity is associated with autism-like behaviors in offspring"

The results reported by Kandice Varcin and colleagues [1] concluding that "maternal pre-pregnancy obesity is associated with autism-like behaviors in offspring" continue and extend a research theme (see here and see here). A research theme that highlights a potentially important relationship between maternal weight (and/or related parameters) and offspring development across various, potentially intertwined, variables (see here).

Including the notable name of Andrew Whitehouse on the authorship team (see here and see here for some examples of his other research), researchers set about to explore whether "pre-pregnancy weight was related to autistic-like traits among offspring not diagnosed with ASD [autism spectrum disorder]." I added the bold highlight to the word 'not' to emphasise how this work was set slightly apart from the other research that has observed an *association* between maternal weight before or during pregnancy and a risk of a formal diagnosis of autism in offspring. Pregnant women in their second trimester of pregnancy were recruited and "had their height measured." They also "reported their pre-pregnancy weight" which combined with the height measurements to give the measure known as the body mass index (BMI). And also: "At 19-20 years of age, 1238 offspring of these women completed a measure of autistic-like traits, the Autism-Spectrum Quotient (AQ)." Keep those issues in mind for now.

Results: "Regression analyses identified a positive association between increasing maternal pre-pregnancy BMI and increasing AQ Total Score amongst offspring; this association was maintained even after controlling for a range of variables including maternal/obstetric factors (age at conception, education, smoking, alcohol consumption, hypertensive diseases, diabetes, threatened abortion), paternal BMI at pregnancy, and child factors (parity, sex)." Sorry for the large quote, but the authors said it better than I ever could. Authors also reported that those women defined as being obese before pregnancy, according to their BMI measurement, were quite a bit more likely to "have offspring with high scores (≥26) on the AQ." This then lead them to conclude that "maternal pre-pregnancy obesity is associated with autism-like behaviors in offspring."

Caveats? Well, yes, a few. Height measured in the second trimester but participants "reported their pre-pregnancy weight"? I can see a few complications there in terms of accuracy of recall and perhaps the possibility of some bias creeping in. Having said that, many mums-to-be do have records of their weight during that 'special time' and some probably before as part of their regular clinical care or just as a result of how health conscious everyone is being these days. That and the fact that most people roughly know their typical weight (outside of pregnancy).

But also the AQ... the AQ. Regular readers probably already know that I have some qualms about the AQ and it's 'specificity' when it comes to autism and autistic traits (see here and see here). I know it's often seen as one of the internet's premier 'are you autistic?' instruments, but sometimes I think it's done more harm than good by way of it's probable link to the rise and rise of the 'self diagnosis' (see here) for example. I could go on about this, but I won't. Instead I'll just mention that 'autism-like' behaviours as judged by the AQ is probably the correct phrase to use in the context of the Varcin paper. Indeed, one might easily suggest that in a non-clinical population, AQ might also be tapping into other labels and traits [2]: "Higher AQ scores were associated with higher scores of loneliness, social anxiety, depression, and anxiety, as well as with lower scores of quality of life (QoL)." So unless one accepts that depression and/or anxiety might potentially be core features of autism (see here and see here), AQ might be picking up other things other than autism.

Still, I can't argue with the *association* talked about by Varcin et al, and what it might mean for the quite spectacular rise and rise in the numbers of people being diagnosed with an autism spectrum disorder (see here). No, not by any means the only factor to account for the increase in diagnoses, but potentially an important part of the story...

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[1] Varcin KJ. et al. Maternal pre-pregnancy weight and autistic-like traits among offspring in the general population. Autism Res. 2018 Sep 19.

[2] Reed P. et al. Loneliness and Social Anxiety Mediate the Relationship between Autism Quotient and Quality of Life in University Students. Journal of Developmental and Physical Disabilities. 2016; 28: 723-733.

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

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

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

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

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

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

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

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

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ALSPAC says... frequency of depression during pregnancy has increased over time

Yes, it's yet another 'ALSPAC [Avon Longitudinal Study of Parents and Children] says...' post today, and the findings reported by Rebecca Pearson and colleagues [1] observing that "prenatal depression is on average 51% more common among young mothers in the current generation of the ALSPAC cohort than during their mothers’ generation 25 years ago."

Having already attracted some media attention (see here), the aim of the current study was to "compare prenatal depression prevalence in young women across time." Because ALSPAC is a longitudinal study (following participants across some quite long periods of time) also involving several generations of the same families, it was ideally placed to compare depressive symptoms during pregnancy across different temporal cohorts.

And compare it did, as responses to the Edinburgh Postnatal Depression Scale (EPDS) were analysed from those in the original ALSPAC cohort participating in the early 1990s (N=2390) compared with those second-generation ALSPAC participants (G1: 2012-2016, N=180), including "66 mother-offspring pairs." All participants were aged between 19-24 years of age at the time of pregnancy assessment and, to reiterate, all "had the same measure of prenatal depression assessed at approximately the same time in pregnancy."

Results: well, alongside some potentially important differences between the two cohorts - "ALSPAC-G1 women were more likely to have achieved A-Levels and were less likely to smoke, but were more likely to take antidepressants" - the study suggested that reaching cut-off scores on the EPDS (≥13) was about 50% more likely in the G1 (younger) cohort. The strength of this 'association' actually increased when researchers took into account other variables potentially likely to affect the study results such as "age, BMI, smoking, parity, and education." They also noted that: "Restricting the analyses to the 66 mother-offspring pairs and accounting for clustering of pairs, we found a virtually identical association, but with wider a confidence interval."

Caveats? Well, one needs to remember that this was a study based on one self-report questionnaire which includes 10 questions answered on a scale from 'not at all' to 'most of the time' (or something similar). It's useful in the context of depression over the course of pregnancy but, as per the instructions for completion, only provides a snapshot (over the past 7 days), so please keep that in mind. The authors are also quite specific in their discussion about the applicability of their results, bearing in mind the age of their cohort(s) and the fact that: "The ALSPAC population largely consists of white European individuals."

That all being said, the findings are interesting and certainly worthy of further inspection and study. The authors go through the possible hows-and-whys of their findings; heading down the path that something(s) in the environment has changed over the decades and could be related to mechanisms. So: "This [younger] generation of young women has also experienced rapid change in technology, internet, and social media use, which has been associated with increased feelings of depression and social isolation and changes to social relationships." They also mention words like 'chronic stress' and 'sedentary lifestyle' as perhaps influencing the wider increase in depression that seems to be present these days. Whilst important (see here for example), I'm not totally convinced that the rise in depression or depressive symptoms is necessarily just a product of such modern living. Take 'chronic stress' for example; are we saying that young mothers-to-be are more stressed now than during the 1990s? I'm also minded to point out that the physical environment has also changed somewhat in the intervening years, as per the comment by the authors about G1 women being "more likely to take antidepressants." I don't doubt that there have been other 'chemical' changes too; some of which might be important.

Oh, there's another possibility too: I've talked about research using the EPDS before on this blog (see here). On that particular research occasion [2] an observation was made suggesting that "pregnant women with broader autism phenotype (BAP) showed an increased risk for developing postpartum depression (PPD)." Not to try and make connections where none may exist, but I'm wondering whether Pearson et al or someone else from ALSPAC might want to have a look-see whether this could be relevant to their current findings. Well, it's not as if ALSPAC don't have data on autistic traits for example (see here) and set against more recent ALSPAC research findings (see here), there's another hypothesis to be tested.

And as if to prove a point, the findings reported by Hirokawa and colleagues [3] observing that the BAP and postpartum depression might be *linked* should also be [carefully] introduced as part of the research conversation...

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[1] Pearson MR. et al. Prevalence of Prenatal Depression Symptoms Among 2 Generations of Pregnant Mothers. JAMA Network Open. 2018; 1: e180725.

[2] Asano R. et al. Broader autism phenotype as a risk factor for postpartum depression: Hamamatsu Birth Cohort (HBC) Study. Research in Autism Spectrum Disorders. 2014; 8: 1672-1678.

[3] Hirokawa K. et al. Associations between broader autism phenotype (BAP) and maternal attachment are moderated by maternal postpartum depression when infants are one month old: A prospective study of the Japan environment & children's study. J Affect Disord. 2018 Sep 19;243:485-493.

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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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"The Importance of Adolescent Self-Report in Autism"

The findings reported by Jessica Keith and colleagues [1] provide the blogging fodder today and a rather important message about the value of self-report in the context of autism, but also with one or two caveats too.

The name of the research game was to investigate the "consistency of adolescent and parent reports of anxiety and auditory sensitivity in individuals with ASD [autism spectrum disorder]" as well as examine "their validity via comparisons with sympathetic arousal at baseline and in response to an auditory challenge." This, on the basis that anxiety is not an uncommon diagnostic bedfellow when it comes to autism (see here for example) and alongside, auditory sensitivity also having quite a long established relationship with some autism (see here).

As per the title of this post taken from the Keith paper - "The Importance of Adolescent Self-Report in Autism" - an important focus of the study was to look-see whether parental reports of anxiety and auditory sensitivity 'matched up' with self-reports from adolescents with autism themselves. Authors reported that they did to a degree, but that also self-report might also provide some greater depth: "demonstrating greater self-reported (than parent-reported) anxiety and sensory symptoms." Indeed authors concluded: "adolescents with ASD have a unique perspective on their internal experience, which can complement parent reports and provide a more comprehensive assessment of symptoms in research and clinical settings."

I don't think anyone should be too surprised that asking adolescents about their own experiences of anxiety, sensory issues or anything else is probably going to yield far more accurate results than proxy reporting or second-hand accounts alone. Indeed, in these days where more and more people diagnosed as being on the autism spectrum are offering up their own first-hand accounts of their experience of autism, this represents a good thing in terms of 'getting it right' when it comes to diagnosing and managing important and often life-affecting symptoms or clinical diagnoses such as anxiety.

Caveats? Well, yes. I'm all in favour of people self-reporting and providing valuable insight into their own experiences. What is slightly less appealing however is that such self-reporting is not a luxury shared by all on the autism spectrum. The lack of self-report coming say, from some under-represented parts of the autism spectrum (see here) can sometimes mean that 'autistic experiences' are skewed towards more 'able' (or should that be 'vocal') parts of the autism spectrum; this despite the oft-used phrase: if you've met one autistic person, you've met one person with autism (or words to that effects). A solution? How about devoting more research and clinical resources to 'enabling' those traditionally not thought to have the capacity for complicated self-report to do so? Indeed, a participatory solution would perhaps be the best step forward I think (see here).

Oh, and also bear in mind that it needn't be self-report versus parent-report when it comes to something like anxiety in the context of autism. Both viewpoints can provide something important [2] on the basis that individuals know themselves but parents also have quite a unique viewpoint of their children and their behaviour across their formative years...

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[1] Keith JM. et al. The Importance of Adolescent Self-Report in Autism Spectrum Disorder: Integration of Questionnaire and Autonomic Measures. J Abnorm Child Psychol. 2018 Aug 2.

[2] Adams D. et al. Parent descriptions of the presentation and management of anxiousness in children on the autism spectrum. Autism. 2018 Aug 16:1362361318794031.

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What factors potentially predict quality of life in adults with autism?

"The study findings are that autistic people on average have lower QoL [quality of life] than the general population in the UK." Further: "Three main characteristics were predictive of lower QoL in almost all domains: being female, having a current mental health diagnosis and higher severity of autism symptoms." By contrast: "Significant positive predictors of QoL were: being employed (physical QoL), receiving support (social and environment QoL), and being in a relationship (social QoL)."

So said the findings reported by David Mason and colleagues [1] describing the results of a study that examined "quality of life (QoL) of a large sample of autistic adults in the UK and investigates characteristics that may be predictive of QoL." This is a vitally important topic because perceived quality of life IS important and has been discussed before in the peer-reviewed research arena with autism in mind (see here).

This time around the focus was on 'self-reported' quality of life for autistic adults who submitted data as part of a research initiative "into the life experiences of autistic adults, the Adult Autism Spectrum Cohort‐UK." Some 370 people (mostly) formally diagnosed with an autism spectrum disorder (ASD) completed the WHOQoL‐BREF, a quality of life assessment schedule developed by the World Health Organisation, as well as the Social Responsiveness Scale (SRS) and a initiative-specific questionnaire that collected various information including that about "everyday life including relationship status; home life including living alone or with family members (family of origin or spouse/partner); employment including paid employment, volunteering, or retired; education including type of school and qualifications achieved; support including who supports the adult and how often support is needed; mental health/neurological conditions including current diagnoses and type of medication/therapy; physical health conditions; and autism spectrum in other family members." Acquired data was put into the statistical 'measuring' machine and trends were reported.

So, a large proportion of participants were aged between 41 and 60 years old (~40%). The sex/gender ratios were fairly evenly split (males: 54% vs. females: 43% vs. 'prefer not to say' ~3%). The vast majority of respondents reported either a mental health issue as being concurrent to their autism diagnosis/status (~70%) or a physical health issue as being present (70%). I don't think we were actually told all the specific diagnostic categories that were included under 'a mental health issue' or 'a physical health issue' but some clues are provided in the text: "most commonly depression and/or anxiety" and "sleep problems, or hypertension." The WHOQoL‐BREF, by the way, provides information on QoL in various domains: physical, psychological, social and environment. Authors therefore report that: "Reported QoL for autistic adults was lower across all four domains than UK norms."

Then to those potential predictors of 'poorer' or 'better' quality of life, as some further statistical analysis was actioned on the collected data. Quite consistently - in the physical, psychological and environment domains - the same three elements cropped up as potentially predicting poorer quality of life: being female, having a comorbid mental health diagnosis and total scores on the SRS (an instrument that "measures autism characteristics" with a focus on social aspects). Looking at the statistical strength of the various factors observed, I'd have to say that the SRS score (total) - that measure of 'autism characteristics' - was the one that seemed to be most strongly related to QoL. Yes, the implications are that the [social] manifestation of autism itself *could* be an important driver of poorer QoL. Insofar as the factors potentially related to a more positive (better) quality of life, being employed, receiving support and being in a relationship were all mentioned, but certainly not as consistently across all the various WHOQoL‐BREF domains as noted in those negative predictors.

The authors highlight a few positives and negatives in relation to their study: use of a "robust measure of QoL is a strength", pretty large sample size and the collection of some good quality 'complete' results. That being said, they also note that a general QoL questionnaire might not gather all the important information relevant to QoL in the context of autism (I do wonder if all that ICF core sets of autism work might help matters on future research occasions). And then there's the issue of representativeness to consider, when it comes to the applicability of Mason results to the (very) wide autism spectrum (see here)...

Recommendations - 'implications' - aplenty spring from the Mason results. Focus in on better screening and treatment/management of mental health (and physical health) issues when concurrent to an autism diagnosis (see here and see here for examples). Make employment - long-term employment - work better for those on the autism spectrum (see here). Devote greater resources to discovering what factors surrounding female autism might lead to poorer quality of life. All noble sentiments worth pursuing. Alongside, are those results about autism severity also seemingly impacting on QoL. Does this perhaps also imply that moves to 'intervene' on core autistic symptoms might also be a target too? Y'know, on the understanding that 'core autism features' have also been *correlated* to some other, rather extreme endpoints also significantly affecting quality of life (see here)?

Addition: 10 May 2018. Y'know I mentioned that SRS scores - "measures autism characteristics" - might be an important variable when it comes to quality of life? Well, it seems another cohort came to similar conclusions [2] (click here for a larger view of figure b and those self SRS scores)...

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[1] Mason D. et al. Predictors of quality of life for autistic adults.  Autism Res. 2018. May 7.

[2] Oakley B. et al. Why Is Quality of Life Reduced in Individuals with Autism Spectrum Conditions? Investigating the Impact of Core Symptoms and Psychiatric Comorbidities on Quality of Life in the EU-AIMS LEAP Cohort. INSAR 2018.

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Autistic traits and risk of suicidality: ALSPAC opines...

The findings reported by Iryna Culpin and colleagues [1] observing that: "Social communication impairments are an important autistic trait in relation to suicidality" return me back to a topic that features much too frequently on this blog: suicide risk and autism.

Drawing on data from the Avon Longitudinal Study of Parents and Children (ALSPAC) initiative, that continues to provide some important insights on labels like autism (see here for example), researchers sought to answer a couple of important research questions: "1. Is an autism diagnosis and/or autistic traits associated with suicidal ideation (suicidal thoughts and plans) and suicidal behaviour (self-harm with and without suicidal intent) by age 16 years? 2. Are any of the observed associations explained by depressive symptoms in early adolescence?"

The question of whether autism or autistic traits are *associated* with suicide (ideation and/or behaviour) is something that has entered the peer-reviewed research psyche quite a bit in recent times. I've talked for example, about data from 'big data' Taiwan on this topic (see here) who concluded that: "ASD [autism spectrum disorder] was an independent risk factor of attempted suicide" [2] based on the analysis of over 5000 young people diagnosed with autism and some 22, 000 not-autism controls.

The numbers included in the Culpin study were a little less impressive - "5,031 members of the UK-based birth cohort study-the Avon Longitudinal Study of Parents and Children" - but ALSPAC does have the advantages of "long-term follow-up, the availability of data on several outcomes, as well as rich data on confounders, and longitudinal design that enables to examine mediating pathways." Indeed, as well as focusing on a diagnosis of autism, Culpin et al also had some 'rich data' on the presence of "four dichotomised ASD traits (social communication, pragmatic language, repetitive behaviour, sociability)." This enabled them to both observe any findings based on a diagnosis / label of autism or ASD and also traits pertinent to a diagnosis of autism or ASD. Issues such as self-harm and/or suicidal thoughts or plans were similarly sought from participants at age 16 years based on answers to questions such as "Have you ever hurt yourself on purpose in any way (e.g., by taking an overdose of pills or by cutting yourself?)" and "On any of the occasions when you have hurt yourself on purpose, have you ever seriously wanted to kill yourself?"

Results: as per the opening sentence, authors observed that "social communication difficulties may be important in relation to suicidality." They interpret this by suggesting that their results tally with others where "social impairments and difficulties in establishing interpersonal relationships are triggers for suicidal behaviour."

But... when it came to examining the diagnosis of autism or ASD in relation to suicidality, they reported that there was: "no evidence of an association between ASD diagnosis and any of the outcomes." They caution however that the numbers of those with a diagnosis were "very low and confidence intervals wide." I also note that data on the numbers of those with a diagnosis of ASD with self-harm with or without suicidal intent are shown as 'censored' to "prevent disclosure due to small cell counts."

Finally, it's worthwhile noting another part of the Culpin study analysis looking at a role for depressive symptoms on the observations made. We are told that "data from the Short Mood and Feelings Questionnaire (SMFQ), a 13-item instrument used to evaluate core depressive symptomatology in children aged 8 to 18 years" was also analysed. Authors report on "evidence of an indirect pathway from impaired social cognition to self-harm via depressive symptoms" but such depressive symptoms only accounted for about a third of the "total estimated association between impaired social cognition and self-harm." Enough however for them to conclude that "addressing the mental health needs of children with autism" *might* offset some risk in this area. Who would argue with that?

There are issues with the Culpin study insofar as the focus on self-report over clinical diagnosis for something like depression or depressive symptoms and "limitations in establishing suicidal intent accompanying self-harm, particularly using self-reports which could be influenced by fluctuations in mood or change over time." I will, once again, reiterate that the report of no evidence of of an association between a diagnosis of autism or ASD and suicidality is also likely to be "imprecise due to small numbers."

A final question: by tackling and hopefully influencing "impairments in social communication" alongside other interventions, is it possible that the risk of suicidality in relation to autism can be reduced? I say this bearing in mind that future studies in this area might want to take a larger view of autism (see here) on the basis that a diagnosis of autism rarely exists in a diagnostic vacuum (see here). How also, issues such as depression like various other quality-of-life-draining facets that seem to be over-represented in relation to autism (see here), may very well be a lot more 'core' over 'comorbidity' (see here) at least for some.

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[1] Culpin I. et al. Autistic Traits and Suicidal Thoughts, Plans and Self-Harm in Late Adolescence: Population-Based Cohort Study. J Am Acad Child Adolescent Psychiatry. 2018. March 14.

[2] Chen MH. et al. Risk of Suicide Attempts Among Adolescents and Young Adults With Autism Spectrum Disorder: A Nationwide Longitudinal Follow-Up Study. J Clin Psychiatry. 2017 Nov/Dec;78(9):e1174-e1179.

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Autistic traits + borderline personality disorder traits = enhanced risk of suicide ideation?

Following some quite recent discussions on this blog about how autism-related dimensions are not necessarily always autism-specific dimensions (see here) in the context of Borderline Personality Disorder (BPD), I'm talking today about the findings reported by Henri Chabrol & Patrick Raynal [1].

They detail some still emerging evidence that, alongside "significant comorbidity between ASD [autism spectrum disorder] and BPD", there could be some rather important outcomes arising from possessing both significant autistic traits and borderline personality disorder traits in the more general population when it comes to risk of suicide ideation. Further, that such data could also cast some light on that important issue for both clinical conditions and contribute to the pressing need to reduce any excess risk(s).

I've covered the issue of suicide - ideation, attempted and completion - on this blog a few times (see here). It's a topic that requires careful handling (see here) and something that, in respect of the core blogging material here, requires important continued attention (see here and see here).

Chabrol & Raynal detail results following the self-report of several parameters: autistic and BPD traits, thoughts of suicide and "depressive symptomatology" in a cohort of college students (N=474). They reported that, whilst BPD traits and autistic traits were only "weakly correlated", those participants who presented with both high BPD and high autistic traits (approaching 20% of their total sample) were the ones who expressed "the highest level of suicidal ideation."

Bearing in mind that this was research carried out with a 'non-clinical' population and a population that might not be necessarily completely representative of everyone else, additional investigations are warranted. Whether for example, the clinical combination of autism and BPD might elevate the risk of suicide ideation or beyond is one issue to be explored, particularly given research observing that suicide risk is not unknown to the diagnosis of BPD. I might also add that given the possibility of even greater complexity in behavioural/psychiatric presentation [2] coinciding with other observations in relation to some autism (see here), quite a wide research view might need to be taken. This coinciding with more and more evidence to suggest that autism is not typically a stand-alone diagnosis (see here).

And if anyone needs to talk to someone, organisations like the Samaritans are only an email or phone call away...

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[1] Chabrol H. & Raynal P. The co-occurrence of autistic traits and borderline personality disorder traits is associated to increased suicidal ideation in nonclinical young adults. Comprehensive Psychiatry. 2018. Feb 15.

[2] Fan AH. & Hassell J. Bipolar disorder and comorbid personality psychopathology: a review of the literature. J Clin Psychiatry. 2008 Nov;69(11):1794-803.

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Carefully: effect of SSRI use on "rating-scale-assessed suicidality in adults with depression"

I stress the word 'carefully' in the title of this post discussing the findings reported by Jakob Näslund and colleagues [1] because it covers the very sensitive idea that "selective serotonin reuptake inhibitors (SSRIs) have been claimed to elicit or aggravate suicidal ideation."

I think it's sensible to begin this post by stressing that (a) NO medical or clinical advice is given or intended on this blog, and (b) anyone with concerns about their taking this class of medicines really needs to speak to their physician BEFORE making any changes to their prescribed medication routine. I know that point (b) sounds like me giving medical / clinical advice but it's common sense to talk to your medical professional first who's spent years studying and probably years practising medicine, rather than tinker around yourself...

There is always a balancing act to consider when discussing research such as this. A medicine indicated for various clinical conditions, that is taken by many, many people, and quite successfully treating / treated (nay, very successfully [2]) a condition that can, without treatment, have life-limiting consequences. No-one wants to rock the boat and scare or deter people from accessing such a treatment. At the same time however, one needs to know everything about that medicine; not least whether for some, there may be side-effects to possibly consider...

It's been a quite a long running saga talking about the possible additional effects of SSRI use for some (see here). It's drawn heavily on often harrowing individual stories and perspectives and not also been helped by the seeming (in)actions of some of the manufacturers of such medicines (see here). Näslund et al decided to approach this delicate topic from the point of view of analysing "the effect of [SSRI] treatment on rating-scale-assessed suicidal ideation in individual patients." This is distinct from other work that has focused on actual suicides or "suicide-related adverse events" that have been carried out before. The authors suggested that their approach might have the advantages of measuring the "net influence of treatment on suicidality at a group level" as well as the ability to "detect individual cases of emergence or aggravation of suicidal ideation." To this end, scores on the Hamilton Rating Scale for Depression (HRSD) particularly focused on "item 3 of the HRSD" covering suicidal ideation/attempts, was a core feature of their study covering "young adults (18–24) (n = 537) and adults (≥25) (n = 7725)." Said participants were derived from "all industry-sponsored, HRSD-based, FDA-registered placebo-controlled studies undertaken to explore the effects of citalopram, paroxetine or sertraline in major depression in adults."

Results: "In patients above the age of 24, SSRIs were found to reduce the mean rating of the HRSD suicidality item from week 1 until study end-point and also to reduce the risk for aggravation of suicidal ideation and emergent suicidal behaviour." This is very good news. It provides "strong support for the view that the net effect of SSRI treatment is beneficial rather than harmful" when it comes to suicide ideation/contemplation bearing in mind the specific focus on on item on the HRSD. I will again link to the recent findings by Cipriani and colleagues [2] reporting that: "All antidepressants were more efficacious than placebo in adults with major depressive disorder." It doesn't, as Näslund et al suggest, rule out rare cases of 'adverse effects', but does suggest that any such extreme side-effects are not likely to be encountered by most people who take such medicines.

When however it came to those younger adults (aged 18-24 years), the results were a little less straight-forward. So: "In young adults, those given an SSRI were at enhanced risk for worsening of suicidal ideation (in the unadjusted analysis) or emergent suicidality (loose but not strict definition) during the late (weeks 3–6) but not the early phase (weeks 1–2) of treatment." You'll see from the number of brackets used in that last quote that the authors provide some caveats to such findings; but this shouldn't take away from the trends observed. Indeed, bearing in mind such findings and also that "both SSRIs and placebo resulted in an end-point rating of suicidality equal to that observed in adults given an SSRI and lower than that observed in adults given placebo" you kinda get the impression that further investigations are needed to ascertain for example, whether depression and/or suicidality in the 25 and overs is somehow 'different' from depression in the younger age group. At least, different insofar as what treatment choices might be primarily made available. No, I'm not saying that this is evidence enough that SSRIs should have some sort of age restriction, just that cost/benefit ratios might perhaps have to be a little more 'age-sensitive' as well as individual-sensitive.

And, if anyone needs someone to talk to, there are resources available.

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[1] Näslund J. et al. Effects of selective serotonin reuptake inhibitors on rating-scale-assessed suicidality in adults with depression. Br J Psychiatry. 2018 Feb 5:1-7.

[2] Cipriani A. et al. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. Lancet. 2018. Feb 21.

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Sexual orientation as a function of autistic traits? Not so fast...

I was in two minds as to whether or not I should blog about the findings reported by Christiane Rudolph and colleagues [1] describing results observing that: "Autistic traits are associated with minority sexual orientation, and perhaps with uncertain self-identification and/or a defiance of traditional ways of categorizing sexual identity."

Two minds because (a) I'm not a great fan of sweeping generalisations in the context of autism or 'autistic traits' or anything related, and (b) although autism and sexual attraction preference(s) is a growing area of research interest (see here for example), I did wonder what the aim of the Rudolph study was, being as it was, based on 'autistic traits in the general population'. Was it trying to make a case for autistic traits as somehow being related to a person's sexual preference or just adding to the existing autism literature based on non-clinical population findings? As per this entry that you're reading, I did decide to take on the Rudolph findings because peer-reviewed science is peer-reviewed science. Also, how one has to exercise some degree of caution with the current results as they stand for various reasons...

So, the aim of the research game was to examine "autistic traits and sexual orientation" and whether one might be *associated* with the other. Over 47,000 adults were initially invited to participate; the cohort self-completed the Autism Spectrum Quotient (AQ) (the AQ-10) to measure 'autistic traits' and were also asked about their sexual orientation (hetero-, homo-, bisexual, none of the above). You'll immediately note that researchers were looking at two primary variables, albeit in quite a large sample group.

Results: "Participants with autistic traits were more likely to identify as bisexual (OR 1.73; 95% CI 1.01–2.9) and to feel that their sexual orientation could neither be described as hetero-, homo- nor bisexual (OR 3.05; 95% CI 2.56–3.63), compared to individuals without autistic traits." I say all that accepting that if one looks closely at the confidence intervals (CIs) particularly for the association with bisexuality - "95% CI 1.01–2.9" - you'll see that it comes ever so close to crossing 1 (1.01) which typically translates as no statistical difference between the groups.

The findings do kinda accord with what has been noted in other 'diagnosed autism' research literature. 'Uncertainty in attraction' and bisexuality, for examples, have been mentioned before (see here) as being potentially over-represented when examined in the context of the autism spectrum and continue to do so [2]. One might also opine that the presence of certain autistic traits (AQ measured of course) might also mean that 'honesty' in relation to some very personal questioning on sexual identity/preference(s) might be more likely among this group when extrapolating from other findings [3]. Indeed, greater honesty and also greater tolerance [4] it seems...

But... the AQ, the AQ... Regular readers of this blog probably already know what I think about the AQ as one of the premier 'are you autistic?' schedules (see here). It's most definitely measuring something, but I'm minded to suggest that that 'something' is not always exclusively autism or autism spectrum disorder (ASD) (see here and see here). In the context of using AQ with a supposed non-clinical population, I'll refer you to the findings reported by Phil Reed and colleagues [5] for example, who similarly noted that: "Higher AQ scores were associated with higher scores of loneliness, social anxiety, depression, and anxiety, as well as with lower scores of quality of life (QoL)." It's not outside the realms of possibility that the 'autistic traits' being measured by Rudolph et al may have also included facets of these states/conditions/labels, particularly if one assumes that issues like anxiety and depression are very much over-represented in the context of autism (see here) and given the large participant numbers included for study. At this point I'll also add in my view that when we talk about depression and anxiety as being 'comorbid' to autism, I don't think we're actually doing justice to how pervasive such issues can be for a person and whether they should instead be considered as something more than just comorbidity à la Mildred Creak and colleagues...

Insofar as other research *linking* elevated AQ scores in some 450,000 people to STEM (science, technology, engineering and mathematics) career choices (see here), or AQ scores being "significantly positively correlated with eating disorder psychopathology" [6] or even AQ scores potentially being associated with lower income [7] I'll leave you to debate/argue what the implications may or may not be in light of the Rudolph findings and why we should perhaps be rather cautious about any sweeping generalisations.

It's not that I don't 'accept' the Rudolph results for what they are, but I'm still however unsure about what the final aim of the study was...

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[1] Rudolph CES. et al. Brief Report: Sexual Orientation in Individuals with Autistic Traits: Population Based Study of 47,000 Adults in Stockholm County. Journal of Autism & Developmental Disorders. 2017. Oct 30.

[2] George R. & Stokes MA. Sexual Orientation in Autism Spectrum Disorder. Autism Res. 2017. Nov 21.

[3] de Schipper E. et al. Functioning and disability in autism spectrum disorder: A worldwide survey of experts. Autism Res. 2016 Sep;9(9):959-69.

[4] Dewinter J. et al. Sexuality in adolescent boys with autism spectrum disorder: self-reported behaviours and attitudes. J Autism Dev Disord. 2015 Mar;45(3):731-41.

[5] Reed P. et al. Loneliness and Social Anxiety Mediate the Relationship between Autism Quotient and Quality of Life in University Students. Journal of Developmental and Physical Disabilities. 2016; 28: 723-733.

[6] Tchanturia K. et al. Characteristics of autism spectrum disorder in anorexia nervosa: A naturalistic study in an inpatient treatment programme. Autism. 2017 Nov 1:1362361317722431.

[7] Skylark WJ. & Baron-Cohen S. Initial evidence that non-clinical autistic traits are associated with lower income. Molecular Autism. 2017; 8: 61.

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With great [intellectual] power comes enhanced health risks?

"Intelligence research most often focuses on the flashes of lightning seen in this rare population, however in order to serve this group of individuals fully, we must not neglect to acknowledge the rumbles of thunder that follow in the wake of their brilliance."

There was something rather poetic in the above sentence concluding the paper by Ruth Karpinski and colleagues [1] talking about "high IQ [intelligence quotient] as being a potential risk factor for affective disorders, ADHD [attention-deficit hyperactivity disorder], ASD [autism spectrum disorder], and for increased incidence of disease related to immune dysregulation." The idea being that "those with a high intellectual capacity (hyper brain) possess overexcitabilities in various domains that may predispose them to certain psychological disorders as well as physiological conditions involving elevated sensory, and altered immune and inflammatory responses (hyper body)."

I have to say that I was/am slightly unimpressed with the terms 'hyper brain' and 'hyper body' - it sounds like something from a movie I watched a while back - but am genuinely interested in the possibility of an intersection between the brain and other body functions particularly in the context of risk for specific health-related labels.

So, examining some 3700 members - "the majority of participants were older, male, and European American" - of American Mensa, Ltd. researchers sifted through responses to various questions about psychological and somatic health answered by participants. The on-line questionnaire used as the self-report tool (yes, self-report tool) included items covering both "diagnosed and suspected" in terms of various diagnoses, and results were compared against national average data covering quite a bit of clinical ground.

Results: an interesting pattern of both suspected and diagnosed comorbidities emerged from the high IQers [self-report] data. I've already quoted the authors in terms of an over-representation of autism, ADHD and affective disorders (mood and anxiety disorders). The degree of over-representation of such diagnoses was not insignificant: for autism for example "When comparing diagnosed patients, there was 1.2 times the risk within the high intelligence group compared with national averages (a 20% increase). However, an additional 5.1% suspected that they should be diagnosed with ASD, for a total combined risk of 6.3 times the national average, an increase of 530%." This perhaps ties into other independent research too (see here) bearing in mind that diagnosing autism is probably best left to the professionals (see here).

But alongside, there was also a somatic angle to consider: for 'environmental' allergies for example we are told that: "Overall, there was 3.13 times the risk of being diagnosed with an environmental allergy, an increase of 213%, for those with high cognitive ability. When included self-diagnoses, there was 4.33 times the risk, for an increase of 333%." Asthma and autoimmune diseases also registered. The same caveat about caution in self-report and self-diagnosing coming into play too.

There is quite a bit of data to absorb in the Karpinski paper and I would encourage readers to plough through it. One detail that particularly struck me in their "Hyper Brain/Hyper Body: a theoretical framework" diagram was where the authors chose to place autism - in the hyperbody side of things - and their comments: "that one such plausible genetic component to consider is that of high IQ which may be responsible for a hyper physiological response to these insults and a resulting development of ASD." I can't say if they're right or wrong about this but certainly the connections made between [some] autism and things like neuroinflammation (see here) and immune function (see here) are not to be forgotten or glossed over. More so when one considers what something like [acute] inflammation *might* be able to do in the context of psychological processes (see here).

So what implications do the Karpinski results have for clinical practice for example? Again, harking back to the opening sentence, an appreciation that with great intellectual power may come the potential for enhanced health risks is worthwhile reflecting on and what it means for preferential screening for example, alongside healthcare planning. I say this bearing in mind that correlation and causation are not one and the same, and also that the reliance on self-report used in the Karpinski study is, by no means, to be put to one side. If one however assumes that a measure like IQ has a significant genetic loading behind it, one might also speculate that the same genes (or expression of genes) governing any such association might also have the ability to affect parameters such as autistic and/or ADHD traits, the presence of depression and anxiety and also immune function in relation to things like 'environmental' allergies or autoimmune conditions. In the same way that autism genes are probably not just 'genes for autism' (see here) so a wider picture seemingly emerges with IQ potentially in mind...

To close, and without trying to trivialise the subject matter today, I wonder if people like Stan Lee and other 'Marvel'ous folk had it right when they portray great power often being balanced with a seeming lack of power?

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[1] Karpinski RI. et al. High intelligence: A risk factor for psychological and physiological overexcitabilities. Intelligence. 2017. Oct 8.

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ADHD and law enforcement contact: not a straight-forward relationship

Several times on this blog I've talked about how a diagnosis of attention-deficit hyperactivity disorder (ADHD) seems to place the recipient at quite a bit of excess risk for various unfavourable outcomes (see here). I've tried hard not to make too many sweeping generalisations on this issue; mindful that behind every statistic in every peer-reviewed bit of science there are real people and real lives. But the data is becoming quite compelling on this matter...

The paper by Mark van der Maas and colleagues [1] makes an important contribution to the idea that the relationship between a diagnosis of ADHD and contact with law enforcement 'systems' is perhaps not as straight-forward as many might believe. Concluding that: "The observed connection between ADHD and criminality may be better understood through their shared relationships with indicators of poor social bonds", researchers suggest that social factors may very well come into play.

OK, based on a sample of over 5300 adults "representative of the general population of Ontario, Canada" researchers asked participants about their "self-reported arrest on criminal charges" history alongside examining ADHD-linked symptoms via the Adult Self Report Scale (ASRS-v1.1). They also interviewed/questioned about various social bonds - household size, education level, drug and substance abuse, etc.

They observed that: "screening positive for ADHD was twice as likely... and past use of medications for ADHD three times as likely... to be associated with ever having been arrested." But... when statistical modelling took into account the data on social bonds, things started to get a little more fuzzy. So: "In the best fitting statistical model, ever having been arrested was not associated with ADHD, but it was significantly associated with indicators of strong and weak social bonds." So things like anti-social behaviour, not progressing well in educational terms and substance use (abuse) might have some important influences on contact with law enforcement agencies. A shocker, I know.

I do have to point out a few important things about this research before anyone gets too immersed in the idea that ADHD is completely off the hook. First was the reliance on self-report when it comes to both ADHD signs and symptoms and also arrest record. The ASRS might very well be a nice rough-and-ready measure of ADHD symptoms but it is no substitute for a thorough assessment for a diagnosis of ADHD. Similarly, people may not always be completely truthful when it comes to their arrest record under several circumstances including research conditions...

Second is the concept of cause-and-effect. As easy as it is to say that ADHD was not itself linked to arrest record(s), it is important not to interpret the findings to say that there is 'no connection' between ADHD and 'having been arrested'. Minus sweeping generalisations, facets of ADHD - such as impulsivity and inattention - can and do perhaps account for some of the heightened risk for various types of offending behaviour [2]. It's fine to say that these facets of ADHD might be exacerbated under conditions of substance use/abuse for example, but one could easily then ask whether ADHD might have actually been involved in facilitating such substance use/abuse in the first place. Certainly, there is (peer-reviewed) evidence that a diagnosis of ADHD - if left untreated - may very well impact on educational outcomes for example [3] which could be one of several factors in determining other life choices.

The idea however that ADHD as a sole risk factor for adverse outcomes such as law enforcement contact does not exist in some sort of social vacuum is an important one to come from data such as that presented by van der Maas et al. It is perhaps the issue of 'vulnerability' that comes to the forefront, and how an ADHD diagnosis should perhaps be explored with that tenet in mind...

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[1] van der Maas M. et al. Examining the effect of social bonds on the relationship between ADHD and past arrest in a representative sample of adults. Crim Behav Ment Health. 2017 Jul 5.

[2] Berryessa CM. Attention, reward, and inhibition: symptomatic features of ADHD and issues for offenders in the criminal justice system. Atten Defic Hyperact Disord. 2017 Mar;9(1):5-10.

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

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