Even more on wandering and autism

I don't know if it's just me being more attentive but I seem to be more regularly seeing media reports of children and adults diagnosed with autism or autism spectrum disorder (ASD) wandering from their family/caregiver home or other place. Some of these media reports end happily insofar as the person being found safe and unharmed to then be reunited with their loved ones; on occasion, using some important previously learned survival skills. Other reports however, don't have such a happy ending...

The paper by Laura McLaughlin and colleagues [1] brings the topic of wandering (elopement) back into research view, observing that in their cohort of nearly 1500 parents talking about their children diagnosed with an ASD: "22.4% of the children wandered from their home or yard and 24.6% from a public place more than monthly." Such research continues a theme down the years illustrating how wandering is an important issue when it comes to autism (see here) and how for some, wandering can lead to a very, very final outcome (see here).

Researchers distributed their anonymous on-line questionnaire about various aspects related to wandering through several autism-related organisations, encouraging parents of children diagnosed with autism/ASD to respond. This wasn't your typical 'does your child wander?' questionnaire, but instead also incorporated several related items such as "the use of electronic tracking devices,... use of restraints and/or seclusion to prevent wandering at school, and receipt of guidance about wandering."

About a quarter of parents said their child wanders (and wanders quite routinely) and the effects of such behaviour seemed to be quite wide-ranging. Not only did wandering reflect a worry for many parents - "48.6% and 58.7% of parents were moderately/very worried about their child wandering from home or yard or a public place" - but almost three-quarters of parents reported that wandering concerns affected "decisions to let their child spend time with friends or family in their absence." With such sentiments being expressed, it's not difficult to see why some parents with children with autism have to announce 'why I can never die' (see here). Perhaps also surprisingly, McLaughlin et al reported that only a third of parents in their cohort "had previously received any counseling about wandering."

I still maintain that wandering represents one of the most important 'issues' linked to autism (see here). Lots more resources need to be dedicated to the hows-and-whys of such behaviour (see here) and what can be done to reduce risks all round. I also think more needs to be done to talk about wandering in the context of autism and provide parents/caregivers with the information and tools ('best available evidence') about wandering. Given also the seemingly important relationship between wandering and water safety in particular (see here), I'm minded to again vocalise the (preferential) need to teach water and swimming skills as and when a child is diagnosed...

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[1] McLaughlin L. et al. Wandering by Children with Autism Spectrum Disorder: Key Clinical Factors and the Role of Schools and Pediatricians. J Dev Behav Pediatr. 2018 Jul 6.

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The "experiences and perspectives of people who have severe autism and are minimally verbal"

I'm not going to formulate some sort of mammoth, long-read post on the paper by Christie Welch and colleagues [1] but I did want to bring their findings to your attention. My reasoning: the authors include a quite 'under-represented' group (see here) when it comes to the public view of the autism spectrum: those who "have severe autism and are minimally verbal."

Presenting the results of a qualitative study whereby "three memoirs written by youths who have severe autism and are minimally verbal were examined using inductive thematic analysis", authors observed several important themes emerging. Principal among them: "regarding the youths' concern that the way they are perceived from the outside does not match the people they are on the inside."

"These youths emphasize concepts of embodiment and physical control as central to their experiences of autism" said Welch et al, as the message seems to be that more should be done to 'tackle' these experiences and ensuring that sweeping generalisations about language use or non-use for example, are not seen as a proxy for cognitive and intellectual abilities. Just because someone cannot speak verbally, does not mean that they have nothing to say, and vice-verse.

I'm careful not to fall into the trap of 'autism severity' on the basis of the Welch findings, where terms like 'high' and 'low' functioning unduly simplify people in a binary fashion and seemingly without regard for the complexity of how autism affects various aspects of a person's life. I do however like the idea that more effort needs to go into things like the development of communication systems for those who are minimally verbal; both for clinical and research purposes but perhaps more importantly, day-to-day purposes, given also some catastrophic examples where communication issues have severely impacted on autistic lives (see here and see here).

And to the question of 'how common is 'minimally verbal' in the context of autism', well, another recent paper [2] has come up with an estimate: about a third...

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[1] Welch C. et al. Autism inside out: lessons from the memoirs of three minimally verbal youths. Disabil Rehabil. 2018 Apr 23:1-9.

[2] Bacon EC. et al. Naturalistic language sampling to characterize the language abilities of 3-year-olds with autism spectrum disorder. Autism. 2018 May 1:1362361318766241.

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Is screen time a risk factor for ADHD?

The findings reported by Vivien Suchert and colleagues [1] observing that "screen time, but not other non-screen-based sedentary activities should be considered as being a risk factor for ADHD [attention-deficit hyperactivity disorder]" taps into long-running debates on whether our societal obsession with watching, clicking and swiping might not be 'a totally positive thing' when it comes to psychological development, health and wellbeing.

Yes, I know this is a complicated area full of big personalities, sweeping generalisations, half-truths and soundbites (see here for example). But I talk about peer-reviewed science on this blog, and am dealing with presented evidence specifically looking at the issue of screen time and ADHD on this particular occasion.

So, taking a not insignificant sample number of over 900 young adults aged 13-17 years old, researchers assessed various parameters in relation to "screen-based and non-screen-based sedentary behavior and ADHD symptoms." When I say 'assessed', immediately one potentially big issue stands out when it comes to measures of sedentary behaviour used in the study and the inclusion of the questionnaire method over and above the use of more objective measures such as physical activity monitors (see here). No mind, researchers analysed the collected data and determined a few key observations not least that: "Screen time was related to the total ADHD score (p < 0.001) as well as to the subscales inattention (p ≤ 0.016) and hyperactivity/impulsivity (p ≤ 0.008)." Further: "Sedentary time without screens was virtually not associated with ADHD."

OK, to reiterate sweeping generalisations are not required on the basis of these results alone. There are a myriad of other methodological issues outside of just objective measures of sedentary behaviour that could skew the Suchert results and these should be taken into consideration. But set in the context that this is not the first time that screen use has been *corrrelated* with something like ADHD or ADHD-type behaviours [2] (or indeed the second time [3]) I'm minded to suggest that quite a more investigation is indicated. Of course, there are other factors to include in the research mix. The findings reported by Tong and colleagues [4] are potentially pertinent: "children with ADHD symptoms were likely to spend more time using a computer during school days; they were also more likely to eat while using a computer." This implies that ADHD or ADHD-type behaviours might predispose to increased screen time rather than the other way around. The relationship is likely to be complex.

In terms of the potential 'hows and whys' of any connection between screen time and ADHD-type behaviours, well, there are already some clues. I'd perhaps suggest that the effects of screen time on sleep could be a good place to start given other peer-reviewed research clues [5]. The relationship between sleep and ADHD is a complicated one, but it is known that sleep interventions can [modestly] affect the presentation of some ADHD behaviours (see here). There are no doubt other research avenues worth looking into also.

Should anyone act on the Suchert findings as they stand? Well, I don't do medical or clinical advice on this blog but I'm minded to suggest that some sensible advice provided by others might come into play: "No screens in the child’s bedroom. Pay attention to the content of the games, especially to violence. Set limits on screen time, and look for other ways to manage family interactions." With my 'what if' research hat on, I am also wondering whether the rise and rise of screens and screen time in the context of autism might also need some particular research examination, in light of the idea that autism and ADHD is not an unfamiliar diagnostic combination (see here)...

To close, although perhaps most famous as a 'rat tickler', the passing away of Jaak Panksepp a few days back deserves mention given his notable ideas about autism and the influence they had and continue to have...

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[1] Suchert V. et al. Relationship between attention-deficit/hyperactivity disorder and sedentary behavior in adolescence: a cross-sectional study. Atten Defic Hyperact Disord. 2017 Apr 4.

[2] Chan PA. & Rabinowitz T. A cross-sectional analysis of video games and attention deficit hyperactivity disorder symptoms in adolescents. Ann Gen Psychiatry. 2006 Oct 24;5:16.

[3] Montagni I. et al. Association of screen time with self-perceived attention problems and hyperactivity levels in French students: a cross-sectional study. BMJ Open. 2016 Feb 26;6(2):e009089.

[4] Tong L. et al. Attention-Deficit/Hyperactivity Disorder and Lifestyle-Related Behaviors in Children. PLoS One. 2016 Sep 22;11(9):e0163434.

[5] Engelhardt CR. et al. Media use and sleep among boys with autism spectrum disorder, ADHD, or typical development. Pediatrics. 2013 Dec;132(6):1081-9.

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Suchert V, Pedersen A, Hanewinkel R, & Isensee B (2017). Relationship between attention-deficit/hyperactivity disorder and sedentary behavior in adolescence: a cross-sectional study. Attention deficit and hyperactivity disorders PMID: 28378132

Detecting stereotypic behaviours through technology

"We have designed an Internet-of-Things (IoT) framework named WearSense that leverages the sensing capabilities of modern smartwatches to detect stereotypic behaviors in children with autism."

So said the paper by Amir Mohammad Amiri and colleagues [1] (open-access available here) and, I have to say, something that really piqued my [research] attention. Describing how authors managed to design and construct a smartwatch with the ability to "detect three behaviors, including hand flapping, painting, and sibbing [hitting themselves on the top of their head] that are commonly observed in children with autism" they report some preliminary findings.

When I say these are preliminary findings, I do indeed mean preliminary, as a two-phase preliminary trial included data from "12 healthy subjects aged between 23–33" and "two subjects (ages 15 and 16) diagnosed with autism." Aside from the implication that young adults with autism are somehow 'not healthy' (I think the correct terminology should be 'not diagnosed with autism/autism spectrum disorder'), you can perhaps see that much of the data for this study came from artificial, induced behaviours not necessarily produced by those on the spectrum - "The tasks that the subjects were invited to do included three different types for 20 s." I do have some other quibbles about the write-up of this study as per very generalised sentences like: "These stereotypic behaviors happen when a child is trying to regulate the sensory input from their surrounding environment."

But I don't want to take anything away from the potential of this kind of research and where, with a bit more study and refinement, it could take many areas of autism research and practice. Accepting the argument that stereotypic behaviours that can accompany autism are not always something that needs to be tinkered with, I can perhaps see a use for this technology when it comes to screening and assessment. If for example, this kind of technology could be applied to something like an ADOS assessment, you could perhaps see how there may be additional information to be garnered (and indeed, built up coincidental to the 'objectivity' linked to such an exam). Coupled with other technology in relation to things like gaze monitoring for example, the potential gets even more exciting. And then also are the potentials of this kind of tracking software in relation to monitoring physical activity and autism (see here for example) or even in the context of epilepsy occurring alongside autism (see here for another WearSense use). There may be lots more to see when it comes to such technology and autism...

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[1] Amiri AM. et al. WearSense: Detecting Autism Stereotypic Behaviors through Smartwatches. Healthcare (Basel). 2017 Feb 28;5(1).

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Amiri AM, Peltier N, Goldberg C, Sun Y, Nathan A, Hiremath SV, & Mankodiya K (2017). WearSense: Detecting Autism Stereotypic Behaviors through Smartwatches. Healthcare (Basel, Switzerland), 5 (1) PMID: 28264474

The force is strong with autism?

"Tablet and phone games could help diagnose autism, study suggests" went the BBC headline covering the paper by Anna Anzulewicz and colleagues [1] (open-access). The idea being that the way that touch screens are used on tablet and smart phones could potentially 'separate out' those with autism from those with not-autism.

Based on a small participant number of "37 children 3–6 years old with autism and 45 age- and gender-matched children developing typically" researchers set about examining "autism-specific motor patterns in the gameplay of children as they engaged with a smart tablet computer (iPad mini) under natural conditions and with minimal instructions." Motor issues accompanying autism are something gaining some renewed (and welcomed) research attention in recent times (see here). Specifically, researchers were utilising the astounding technology that goes into all those swipes and taps that we're also used to these days, and whether under 'serious' game conditions, aspects like force impact and gesture pressure could differentiate the two groups.

As per the headline and the rather cheesy title to this post, there were some differences picked up between the autism and control groups based on touch and swiping responses being put through their machine-learning paces (something else that has a growing following in autism research circles). So: "The inertial data indicate children with autism engaged in gameplay with greater force of impact than those developing typically." This and other potential differences led researchers to conclude that: "children with autism applied a significantly different distribution of forces into the device during gameplay than the typically developing children did."

Whilst interesting research there is quite a bit more to do before anyone starts using taps and swipes as a means to diagnose autism (or anything else). I don't really need to say that this was a study including a relatively small participant group nor that whilst "All participants had normal or corrected-to-normal vision and no other sensory or motor deficits" this does not preclude the possibility that subtle issues might also be at work (see here). That also recent discussions have suggested moving away from the singular diagnosis of autism as a research starting point is also worth reiterating (see here).

Still, I can see some opportunities arising from this area of research and how perhaps combined with other innovative areas of screening and diagnosis there may be much more to see including how subtle differences in movement might also influence variables such as interaction [2]. Yes indeed, "smart tablet technology offers an attractive, new paradigm for clinical autism assessment and bio-behavioural research of pre-school children, enabling engaging, ecological testing of children’s motor behaviour in a fun, accessible format fit for precise computational analysis of neuropsychological function."

To close: Danny Boy (from the Proms 2013 although this years version was pretty good too).

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[1] Anzulewicz A. et al. Toward the Autism Motor Signature: Gesture patterns during smart tablet gameplay identify children with autism. Scientific Reports. 2016; 6: 31107.

[2] Edey R. et al. Interaction Takes Two: Typical Adults Exhibit Mind-Blindness Towards Those With Autism Spectrum Disorder. J Abnorm Psychol. 2016 Sep 1.

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Anzulewicz A, Sobota K, & Delafield-Butt JT (2016). Toward the Autism Motor Signature: Gesture patterns during smart tablet gameplay identify children with autism. Scientific reports, 6 PMID: 27553971

Toddler language and autism risk

I'm not going to keep you too long today as I introduce the paper by DeWayne Lazenby and colleagues [1] and some rather interesting data on whether early language use might help predict those toddlers who are at subsequent risk of being diagnosed on the autism spectrum.

Based on the prospective analysis of over 300 infants - "some of whom were at high risk for developing ASD [autism spectrum disorder]" - authors went about analysing various aspects of language using among other things, the MacArthur-Bates Communicative Developmental Inventories (CDI). They reported a few potentially interesting details including: "lower receptive and expressive language scores in infants who later were diagnosed with ASD" based on their testing round about 12 months of age. Further: "a Rasch analysis indicated that infants who later developed ASD had a higher degree of statistically unexpected word understanding and production." They concluded that there may indeed be more to see when it comes to language use in early childhood as a potential marker of subsequent autism diagnosis. Such findings accord with other data from some of the authors [2].

Accepting that within the very wide and heterogeneous autism spectrum probably better defined by the plural autisms (see here) there may be lots of factors influencing first presentation including the variable of regression (see here), these are important findings. Notwithstanding the notion that autism seems not to be protective against other language-related issues being potentially comorbid [3] and the effect that might have on early presentation of language, the idea that speech patterns might direct a child towards preferential early screening for autism is useful in light of the emphasis on early screening [4] and the 'clear benefits' of early intervention [5].

As part of the growing interest in aspects of telemedicine and mobile health, the recent news about ResearchKit being applied to autism (see here) might well provide something of an important platform whereby information about facial expressions is further combined with assessment of speech patterns and production (including aspects such as intonation [6] etc). This does not mean that every single early presentation of autism will be 'picked up' by such technology, but it does perhaps offer a way that technology can ease some of the significant pressures on clinical resources pertinent to identifying autism early and accurately.

And whilst we're on the topic of language and autism, I can recommend another article by Tager-Flusberg [7] worth a read...

Music: PJ Harvey - C'mon Billy.

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[1] Lazenby DC. et al. Language Differences at 12 Months in Infants Who Develop Autism Spectrum Disorder. J Autism Dev Disord. 2015 Oct 17.

[2] Talbott MR. et al. Diary Reports of Concerns in Mothers of Infant Siblings of Children with Autism Across the First Year of Life. J Autism Dev Disord. 2015 Jul;45(7):2187-99.

[3] Tager-Flusberg H. Defining language impairments in a subgroup of children with autism spectrum disorder. Sci China Life Sci. 2015 Sep 2.

[4] Zwaigenbaum L. et al. Early Screening of Autism Spectrum Disorder: Recommendations for Practice and Research. Pediatrics. 2015 Oct;136 Suppl 1:S41-59.

[5] Zwaigenbaum L. et al. Early Intervention for Children With Autism Spectrum Disorder Under 3 Years of Age: Recommendations for Practice and Research. Pediatrics. 2015 Oct;136 Suppl 1:S60-81.

[6] Nakai Y. et al. Speech intonation in children with autism spectrum disorder. Brain Dev. 2014 Jun;36(6):516-22.

[7] Tager-Flusberg H. Risk Factors Associated with Language in Autism Spectrum Disorder: Clues to Underlying Mechanisms. J Speech Lang Hear Res. 2015 Oct 20.

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Lazenby DC, Sideridis GD, Huntington N, Prante M, Dale PS, Curtin S, Henkel L, Iverson JM, Carver L, Dobkins K, Akshoomoff N, Tagavi D, Nelson CA 3rd, & Tager-Flusberg H (2015). Language Differences at 12 Months in Infants Who Develop Autism Spectrum Disorder. Journal of autism and developmental disorders PMID: 26476738

Physical activity and sleep in autism

Sleep issues are not an uncommon feature for quite a few people on the autism spectrum (see here).

Autism research has provided some pretty strong evidence to support that last sentence and how sleep, or a lack of it in terms of quality and/or quantity, might not be optimal for people on the autism spectrum (as it isn't for those not on the spectrum).

The hows and whys of sleep affecting the behavioural presentation of autism are still a little in the air outside of what is known more generally about temperament and behaviour following poor sleeping patterns and routines. That being said, the relationship between sleep and behaviour specifically with the autism spectrum in mind has been the topic of some discussion [1] (open-access).

The findings reported by David Wachob & David Lorenzi [2] add to that literature with their suggestion that: "though over half of the children were identified as having at least one sleep-related problem, their activity levels were significantly related to their sleep patterns."

I was really quite interested in the idea that activity levels and sleep are sharing some research airtime when it comes to autism. Looking at a (very) small group of children/young adults (N=10) with autism who "were asked to wear accelerometer devices for 7 days in order to track objective measures of activity and sleep quality" researchers set about looking at any relationship. They concluded that over 7 days "the more physically active children had overall higher sleep quality."

I could quibble that the authors "included children who have a parent-reported diagnosis of ASD [autism spectrum disorder]" or that there were some gaps in the data as a result of breaks in the time that the "Actigraph GT3X+" were worn but I would be just quibbling. Particularly so following the tide of research on how accurate parent report can be when it comes to autism (see here for example). It's also worthwhile noting that other groups have also reported similar findings [3] to that of Wachob & Lorenzi.

Regular readers of this blog might have understood my specific interest in research on physical activity and autism as per posts on topics such as obesity (see here) and how movement issues might be one potential barrier to physical activity participation when it comes to autism (see here). I'm minded to suggest that there are various solutions to increasing a person's physical activity which might also have some interesting secondary effects too (see here) (although recognising that the martial arts are not for everyone).

The Wachob/Lorenzi results add an interesting dimension to the proposed benefits of physical activity when it comes to autism which requires some important follow-up. Their [objective] use of accelerometer devices also taps into increasing moves toward technology assisting in such research (see here). The paper from David Kennaway [4] advising some caution on one of the treatments of choice for sleep issues in relation to pediatric autism - melatonin - might also be dropped in at this point.

And just one more thing... one might also think about what physical activity might also do for parts of an important comorbidity in autism as per the preliminary findings from Silva and colleagues [5] on ADHD (attention-deficit hyperactivity disorder) and 'intense' physical activity...

Music: Madonna - Material Girl. (no capes).

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[1] Cohen S. et al. The relationship between sleep and behavior in autism spectrum disorder (ASD): a review. J Neurodev Disord. 2014;6(1):44.

[2] Wachob D. & Lorenzi DG. Brief Report: Influence of Physical Activity on Sleep Quality in Children with Autism. J Autism Dev Disord. 2015 Mar 20.

[3] Tatsumi Y. et al. Daytime physical activity and sleep in pre-schoolers with developmental disorders. J Paediatr Child Health. 2014 Sep 3.

[4] Kennaway DJ. et al. Potential safety issues in the use of the hormone melatonin in paediatrics. Journal of Pediatrics & Child Health. 2015. Feb 3.

[5] Silva AP. et al. Measurement of the Effect of Physical Exercise on the Concentration of Individuals with ADHD. PLoS One. 2015 Mar 24;10(3):e0122119.

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Wachob D, & Lorenzi DG (2015). Brief Report: Influence of Physical Activity on Sleep Quality in Children with Autism. Journal of autism and developmental disorders PMID: 25791123

FC is a technique that has no validity

FC, by the way, refers to Facilitated Communication, a controversial technique which as the name suggests relies on a facilitator to support "the hand or arm of a communicatively impaired individual while using a keyboard or other devices with the aim of helping the individual to point and thereby to communicate." The quote for the title of this post comes from the paper by Ralf Schlosser and colleagues [1] who following systematic review, found "unequivocal evidence for facilitator control" and that "messages generated through FC are authored by the facilitators rather than the individuals with disabilities."

It's funny how sometimes the people we remember
the least make the greatest impression on us.

I wouldn't normally be minded to talk about FC if it wasn't something (a) which has appeared alongside the word 'autism' down the years and (b) had not cropped up in various conferences I'd attended, specifically after having watched people such as Dr Andy Grayson talk about the great authorship debate with regards to FC and autism as per some of his publications in this area [2]. I'm by no means an expert on FC and autism and certainly am voicing no opinion beyond that of the peer-reviewed evidence on its usefulness or not.

What does strike me about this area though is the quite large weight of evidence coming down on 'facilitator control' as forming the lion's share of authorship in FC. I remember the paper from Edelson and colleagues [3] (including the late Bernie Rimland on the authorship team) who, quite ingeniously, talked about evaluating a "specially designed hand-support device" as an aid in the "transition from facilitated communication (FC) to independent typing" with autism in mind. They concluded: "Postassessment measures did not reveal any evidence of independent communication with or without the device." Even the American Academy of Pediatrics (AAP) has an opinion on FC with autism in mind [4]: do not use "except within research protocols".

On the basis of this and accounts of where FC can go so terribly wrong, I'd be inclined to follow the recommendations of the Schlosser paper. Even in these times of phones and tablets potentially making FC a whole lot easier, 'consumer beware' is perhaps an appropriate phrase to be derived from the collected research literature in this area...

Music to close: Empire State of Mind.

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[1] Schlosser RW. et al. Facilitated Communication and Authorship: A Systematic Review. Augment Altern Commun. 2014 Nov 11:1-10.

[2] Grayson A. et al. Hidden communicative competence: Case study evidence using eye-tracking and video analysis. Autism. 2012; 16: 75-86.

[3] Edelson SM. et al. Evaluation of a mechanical hand-support for facilitated communication. J Autism Dev Disord. 1998 Apr;28(2):153-7.

[4] Committee on Children With Disabilities. Auditory integration training and facilitated communication for autism. American Academy of Pediatrics. Committee on Children with Disabilities. Pediatrics. 1998 Aug;102(2 Pt 1):431-3.

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Schlosser RW, Balandin S, Hemsley B, Iacono T, Probst P, & von Tetzchner S (2014). Facilitated Communication and Authorship: A Systematic Review. Augmentative and alternative communication (Baltimore, Md. : 1985), 1-10 PMID: 25384895

ADHD and a sunny disposition

'Light it up blue' is probably a familiar phrase to many of those involved with autism as being the message championed by Autism Speaks on World Autism Awareness Day (2 April). The intention is noble enough: to bring autism to the attention of the world at large and importantly, keep their attention and resources focused on autism. I might add that awareness is one thing; actually 'doing something about autism' - whether that means improving prospects or modifying the course of autism or just levelling the playing field - is quite another thing.

Light it up @ Wikipedia  

By a funny twist of Internet fate, I stumbled upon a review of the study published by Arns and colleagues* looking at the possibility of a link between solar intensity (SI) and the prevalence of attention-deficit hyperactivity disorder (ADHD). The very tentative light it up blue connection was a sentence or two in the study write-up which suggested that the sleep problems which apparently come with a diagnosis of ADHD might result from "exposure to blue-light during the evening" and that strong sunlight during the day "might reset the biological clock and act as an antidote to the evening exposure to artificial blue-light causing sleep onset problems". Yes, I know it isn't a great blue light pun, sorry about that.

It should be noted that the Arns paper appears in a pretty good journal (Biological Psychiatry) so whilst you might be thinking, 'solar intensity... eh?' this is a correlation which has passed what one would expect to have been quite a rigorous peer-review battlefield. I could at this point offer you some more detailed description of the paper but it seems that the authors have already done that on their website (see here - no endorsement given or intended).

In effect, they mapped the prevalence figures for ADHD across various parts of the US and beyond and cross-referenced them with official figures relating to SI. Yes, prevalence of ADHD were partly based on "self-report of professional diagnoses" but this was to some degree countered by the use of more formal assessment data in other sites. They found a correlation (negative correlation) between ADHD prevalence and SI when controlling for various potential confounders: "a lower prevalence of ADHD in areas with high SI for both U.S. and non-U.S. data".

Bearing in mind the issue of correlation/causation (see here), one could construe this data several ways. If for example you work for the tourist boards of Arizona, Nevada or California you have a potentially interesting advert: 'Come live here, we've got lots of solar resource and potentially less risk of your children developing ADHD'. Or words to that effect. And indeed, the CDC figures do seem to suggest that those high SI states might have a lower prevalence of ADHD (assuming that this doesn't reflect other issues such as awareness, identification, etc). On a more serious note are the suggestions that (a) ADHD might be related to circadian clock disturbances, and (b) that exposure to the various new-fangled technologies we are surrounded by might be part and parcel of those circadian clock disturbances.

Just before you reach for the click away button, like I almost did, mumbling 'blame it all on technology', there are a few papers to bring to your attention. Yes, sleep issues are associated with ADHD** and indeed if the recent paper from Blesch and Breese McCoy*** is anything to go by, we might also assume that ADHD - some cases of ADHD - could be mistaken for things like sleep apnoea. True also that issues with circadian function seem also to be tied into cases of ADHD as per studies like this one from Gamble and colleagues****. On balance, sleep seems to show some connection with ADHD.

That the part of the light spectrum labelled blue emanating from various technology use is the primary cause or significant contributor to the sleep issues noted even in some cases of ADHD is the slightly more difficult proposition for me to whole-heartedly (hoof hearted!) accept from this work. I don't doubt that many children and adults with ADHD use this kind of technology. But I have to ask whether their use and exposure to the artificial blue light is really any more significant than that of everyone else? Indeed, without being an expert on the different ranges or wavelengths of light and their physiological effects, are we just talking blue or are we talking other parts of the light spectrum too?

There are details from this study which I would like to see further explored given the potential for a relationship between SI and ADHD prevalence. Readers for example, might know that I am more than a little intrigued by another sun related variable, vitamin D, and its various connections (or not) to conditions like autism or chronic fatigue syndrome among others. The question would have to be whether the sunshine vitamin / steroid hormone might also show some relationship to the latest findings? Are vitamin D levels likely to be greater / the same / reduced in cases of ADHD dependent on the specific geography and SI? Vitamin D receptors all in good working order*****? No significant drug interactions where medication is being used? Indeed, whether other correlates such as altitude - which also seem to map onto the SI exposure plots - might come into play?

There are questions which require some follow-up from this work but for now, and with all caveats in good working order when it comes to population studies of association - as with other recent results too, I'm intrigued by the Arns data and the suggested overlap. And also that ADHD might not be the only condition being looked at with a sun-related variable (see this study by Davis & Lowell******, full-text).

To close, after recently watching the quite brilliant film 'Rock of Ages' which satisfied all my 1980s rock needs, a taste of Sheffield's finest.

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* Arns M. et al. Geographic Variation in the Prevalence of Attention-Deficit/Hyperactivity Disorder: The Sunny Perspective. Biol Psychiatry. March 2013.

** Yürümez E. & Kiliç BG. Relationship Between Sleep Problems and Quality of Life in Children With ADHD. J Atten Disord. March 2013.

*** Blesch L. & Breese McCoy SJ. Obstructive Sleep Apnea Mimics Attention Deficit Disorder. J Atten Disord. March 2013.

**** Gamble KL. et al. Delayed Sleep Timing and Symptoms in Adults With Attention-Deficit/Hyperactivity Disorder: A Controlled Actigraphy Study. Chronobiol Int. February 2013.

***** Malik S. et al. Common variants of the vitamin D binding protein gene and adverse health outcomes. Crit Rev Clin Lab Sci. 2013; 50: 1-22.

****** Davis GE. & Lowell WE. Variation in ultraviolet radiation and diabetes: evidence of an epigenetic effect that modulates diabetics' lifespan. Clinical Epigenetics. 2013; 5: 5.

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Arns M, van der Heijden KB, Arnold LE, & Kenemans JL (2013). Geographic Variation in the Prevalence of Attention-Deficit/Hyperactivity Disorder: The Sunny Perspective. Biological psychiatry PMID: 23523340