DOUBLE WHAMMY: ADHD AND AUTISM

DOUBLE WHAMMY:ADHD AND AUTISM

Learning Objectives Understand the evolution of autism conceptualization Understand symptom distinctions in adults with Autism SpectrumDisorder and Attention Deficit Hyperactivity Disorder Understand the limited research for treatment of concurrent adultADHD and ASD

Autism Spectrum Disorder As of 2018, it appeared that ASD risk is heritablebetween 74% and 93% Males are diagnosed four times more often than females According to the latest CDC prevalence reports, 1 in 59children (1.7%) in the United States had a diagnosis ofASD in 2014, reflecting a 2.5-fold increase from theprevalence rate in 2000 From the 1940s to 2016, there has been a 15-foldincrease in the prevalence of ASDLord C, Elsabbagh M, Baird G, Veenstra-Vanderweele J. Autism spectrum disorder. Lancet 2018;392(10146):508-20; Comer RJ. Fundamentals of Abnormal Psychology. New York: Worth /Macmillan Learning 2016;457;Baio J et al. Prevalence of Autism Spectrum Disorder Among Children Aged 8 Years—Autism andDevelopmental Disabilities Monitoring Network, 11 Sites, United States, 2014. MMWR Surveill Summ2018;67(6):1-23.

Prevalence ofAutism Spectrum Disorder BUT, it is important to note that these numbers from both 2016and 2018 are not the result of direct observation of the children Instead they are the result of parental surveys in which theywere asked whether a child in the family has been diagnosedwith autism So, the diagnostic accuracy may come into questionBaio J et al. Prevalence of autism spectrum disorder among children aged 8 years—Autism and Developmental Disabilities MonitoringNetwork, 11 sites, United States, 2014. MMWR Surveill Summ 2018;67(6):1-23. doi :10 .15 5 85 I mmwr. ss6 706a1; Christensen DL etal. Prevalence and characteristics of autism spectrum disorder among children aged 8 years—Autism and Deve lopmental DisabilitiesMonitoring Network, 11 sites, United States, 2012. MMWR Surveill Summ 2016;65(3);1-23. doi:10.15585/mmwr. ss6513al.

Comorbidity:Childhood ADHD and ASDADHD22–83%ASD (M F)ASD30–65%ADHD (M F)Van Steijn DJ el al. J Child Psychol Psychiatry 2012;53(9):954-63.

History of Autism“Our capacity for deceiving ourselves about the operation ofour brain is almost limitless ”Francis Crick, 1979

Paul Eugen Bleuler:Autism in Schizophrenia Autism is a word based on Greek “autos” or “self” to describe “selfabsorption” or “withdrawal from reality” Eugen Bleuler used the term as one of the pathognomonicfeatures of schizophrenia In 1911, he introduced this term to describe the “most severeschizophrenics who live in the world of their own”Bleurer E. Dementia Praecox or the Group of Schizophrenias 1911.

Leo Kanner:“Autistic Disturbances of Affective Contact” In 1943, Leo Kanner, “the father of child psychiatry,”recounted eleven case studies in his seminal paper, “AutisticDisturbances of Affective Contact.” He described thesechildren as being born without the ability to make socialrelationships and used the term “autism.” Phenotypic elements that he identified included profoundinability to develop relationships, obsessive desire forsameness, fascination with inanimate objects, aloofness, lackof imagination, and language that did not serve the purposeof adequate communication with others.Kanner L. Autistic disturbances of affective contact. Nervous Child 1943;2(3):217-50.Kanner L. Problems of nosology and psychodynamics of early infantile autism. Am J Orthopsychiatry1949;19(3):416-26.

Hans Asperger:“Autistic Psychopathy” In 1944, Hans Asperger, an Austrian pediatrician, described asimilar set of symptoms in the children from his clinic that he called“little professors.” He described a form of autism that wasdifferent from what was noted by Kanner. Asperger's children shared some of the similar symptoms,including communication difficulties, repetitive behaviors, inabilityto make friends, and unusual sensory responses. BUT symptoms did not include cognitive disabilities or symptomsof schizophrenia. He reported that the syndrome is not particularly rare, as he hadseen more than 200 children with a similar set of criteria in hisclinic. He named this condition “autistic psychopathy.”Asperger H. Die Autistisehen Psychopathenim Kindesalter. Arch Psych Nervenkrankh 1944;117:76136.doi:10.1007/BF0183 7709.

Leo Kanner:“Early Infantile Autism" In 1958, Kanner used the term “early infantile autism” to describethe same set of characteristics However, the use of the word “autism,” which was initially used todescribe adult schizophrenia, caused significant confusionKanner L, Lesser LI. Early infantile autism. Pediatr Clin North Am 1958;5(3):711-30. doi;l0.1016/S0031·3955(16)30693·9; Kanner L. The birth of early infantile autism. J Autism Child Schizophr 1973;3(2):93-5.

Lorna Wing:“Asperger’s Syndrome” In 1981, Lorna Wing, an English psychiatrist, describedher work in the seminal article “Asperger's Syndrome: AClinical Account” She advocated a “neutral” term “Asperger's syndrome”over “autistic psychopathy” Wing is also widely credited with considering autism as aspectrum disorder instead of a single entityWing L. Asperger's syndrome: a clinical account. Psychol Med 1981;11(1):115-29.

Psychoanalysis Perspective Sigmund Freud’s death in 1939 The emphasis was placed on the mother's role in fosteringego development Autism were thus attributed, directly or indirectly, to maternalnegligence or transgression during the early childhood period

Bruno Bettelheim:“Refrigerator Mother” Bruno Bettelheim is usually considered responsible for theintroduction of the “refrigerator mother” The concept of “schizophrenogenic mother” by Fromm-Reichmann Autism is an emotional disorder that is caused by the psychologicalharm brought upon some children by their own mothers; he wasinfluenced by his own 10-month experience at Dachau concentrationcamp in WWII His theories were widely accepted by the general public during the1950s and 1960sBettelheim B. Feral children and autistic children. Am J Sociol 1959;64(5):455-67; Bettelheim B. Joey: a mechanical boy. Sci Am1959;200(3):116-20.

Bernard Rimland:Autism As Neurologic Illness In 1965, Bernard Rimland, a psychologist, founded the AutismSociety of America and the Autism Research Institute in 1967;he was critical of Bettelheim’s theories and stressed thatautism had a neurologic basis He published a book, Infantile Autism: The Syndrome and ItsImplications for a Neural Theory of Behavior, in 1964, with aforeword by Leo Kanner Rimland was concerned about the increase in the prevalenceof autism and hypothesized that vaccinations, especially thosecontaining thimerosal, might be the cause of this increase

Thimerosal Disproven Popular scientific and parental views that vaccines andthimerosal are the cause of autism have been discredited"Frequently Asked Questions about Thimerosal" cdc.gov. Centers for Disease Control and Prevention.Retrieved 21 February 2017; Wakefield AJ et al. Heal-lymphoid-nodular hyperplasia, non-specific colitis, andpervasive developmental disorder in children [retracted in: Lancet. 2010;375(9713):445]. Lancet 1998.Wakefield AJ et al. Retraction--Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasivedevelopmental disorder in children [retraction of: Wakefield AJ et al. Lancet 1998;351(9103):637·641.] Lancet.2010;375(9713);445.

Autism: From Schizophrenia to a SpectrumDisorder In the Diagnostic and Statistical Manual of Mental Disorders(DSM)-I (1952) and DSM-II (1968), autistic-like symptoms werelabeled under “childhood schizophrenia” By 1979, the idea that autism is an early form of “childhoodschizophrenia” was abandonedWolff S. The history of autism. Eur Child Adolesc Psychiatry 2004;13(4):201-8.

Autism Redefined: DSM-III DSM-III (1980): There was a consensus that social deficits,resistance to change, speech and language problems, and onsetduring early years characterized autism Autism was included under the broader category of PervasiveDevelopmental Disorder (PDD) as “Infantile autism” (LeoKanner’s term)

Autism Operationalized Formalized in DSM-III-R (1987), the separation of coresymptoms of autism into three domains of impairment Reciprocal social interaction Communication Restricted or repetitive behaviors

Asperger’s SyndromeIncluded in DSM-IV DSM-IV (1994): Three disorders—Rett's disorder, childhooddisintegrative disorder, and Asperger's disorder—were included Another major achievement was the alignment of diagnosis amongDSM-IV and the International Classification of Mental andBehavioral Disorders (ICD-10) Autism Diagnostic Observation Scale, the Autism DiagnosticInterview, and the Childhood Autism Rating Scale

Autism Redefined Again: DSM-5 DSM-5 (2013) took a more restrictive approach First, a dimensional approach to the diagnosis was chosen over thecategorical approach Second, the name of the class of disorders was changed from“Pervasive Developmental Delay” to “Autism Spectrum Disorder”because, after reviewing the research data, a decision was made tocollapse the social and communication symptom clusters into onecategory (Autism Spectrum Disorder) and add symptoms of sensorysensitivities. And so, multiple disorders in DSM-IV under PDD were removed in favorof a single term—“autism spectrum.” A controversial move was toremove the diagnosis of Asperger's disorder Third, a new disorder, social communication disorder, was added In addition, diagnosis of attention-deficit/hyperactivity disorder can bemade with ASD in DSM-5, which was not allowed in DSM-IV

ASD Scales and ADHD The Autism Spectrum Disorder-Observation for Children(ASD-OC)- only for children The Developmental, Dimensional, and Diagnostic Interview(3di) Childhood Autism Rating Scale (CARS) The Autism Diagnostic Interview—Revised (ADI-R) The Asperger Syndrome (and High-Functioning Autism)Diagnostic Interview (ASDl) The Diagnostic Interview for Social and CommunicationDisorders (DISCO) The Autism Spectrum Disorder—Diagnosis Scale forIntellectually Disabled Adults (ASD-DA)

Diagnosis of AutismSpectrum Disorder inAdults

Symptom Confusion inAdults:ADHD vs. ASD

Seeming Symptom Overlap:Asperger’s vs. ADHDSymptomOverlap?Roy M et al. Asperger Syndrome: A frequent comorbidity in first diagnosed adult ADHD patients?Psychiat Danub 2013;25(2):133-41.

Seeming Symptom Overlap:Asperger’s vs. ADHDSymptomOverlap?Roy M et al. Asperger Syndrome: A frequent comorbidity in first diagnosed adult ADHD patients?Psychiat Danub 2013;25(2):133-41.

Asperger’s Syndrome inADHD Adults First ADHD diagnosis N 53 (17 females, 36 males) Range of age: 18–56 years, average age: 33.2 years 14 patients had a current psychotropic medication ADHD: Conners Adult ADHDS Rating Scales and Structured Diagnostic interview (DIVA; Kooij& Francken, 2009) Asperger’s : Asperger’s Spectrum Quotient Empathy QuotientRoy M et al. Asperger Syndrome: A frequent comorbidity in first diagnosed adult ADHD patients?Psychiat Danub 2013;25(2):133-41.

Autism Spectrum Quotient Scale Two self-assessment instruments for screening autism disordersin adults:1. “Autism-spectrum quotient” (AQ) is an instrument; Continuum from normality to autism A higher score indicates more pronounced autistic traits Its 50 items are divided into five subscales: “social skill,” “attention switching,” “attentionto detail,” “communication,” and “imagination” The AQ has been shown to strongly predict Asperger Syndrome in a clinical sampleBaron-Cohen S et al. The autism-spectrum quotient (AQ): Evidence from Asperger-Syndrome/high functioningautism, males and females, scientists and mathematicians. J Autism Dev Disord 2001; 31:5-17.