Topic 7 - Comorbidity in ADHD and Autism 2010

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Autism, Asperger’s & ADHD (6PS048)

ADHD, Autism & Asperger’s (6PS052)

Simon Bignell

Psychology, School of Science

Comorbidity in ADHD and Autism

Lecture 7

Spring 2010

Simon Bignell – Module Leader

(6PS048 / 6PS052)

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Simon Bignell


Introduction to the Lecture

• A refresher: DBDs & PDDs.• Why is comorbidity important?• Are ADHD And Autism Really That

Different?• Comorbid conditions.• What might this overlap of symptoms

suggest?

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Learning Outcomes Of This Lecture.On completion of the lecture and with independent

study you should be able to:

1. Understand what disorders and symptoms commonly exist alongside Autistic Disorder, Asperger’s Disorder and Attention-Deficit/Hyperactivity Disorder.

2. Be able to describe why it is important to look at comorbid disorders.

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Simon Bignell


DisorderOnly

DisorderAnd Other

OtherOnly

What is Comorbidity?

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• Developmental Delay motor

• Mental Retardation cognitive

• Cerebral Palsy motor

• Autism/PDD social

• Learning Disability learning

• ADHD/DBD focus

Some Terminology.

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Conceptualisation of Developmental Disabilities.

Central Nervous System

Motor Cognitive Social

Cerebral Palsy

Mental Retardation

AutismSpectrum

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Prenatal Perinatal Postnatal


Cerebral Palsy

Mental Retardation

AutismSpectrum

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“Disability”:

Function:

Aetiology:


Prenatal Perinatal Postnatal


Cerebral Palsy

Mental Retardation

AutismSpectrum


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Simon Bignell


The DSM-IV includes five types of disorder under the term ‘Attention-Deficit and Disruptive Behavioural Disorders’.

1) Attention-Deficit/Hyperactivity Disorder. Predominantly Inattentive Type. Predominantly Hyperactive-Impulsive Type. Combined Type.

2) Conduct Disorder.3) Oppositional Defiant Disorder.4) Attention-Deficit/Hyperactivity Disorder Not

Otherwise Specified.5) Disruptive Behaviour Disorder Not Otherwise

Specified.

Attention-Deficit and Disruptive Behavioural Disorders.

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The DSM-IV includes five types of disorder under the term ‘Pervasive Developmental Disorder’ PDD.

1) Autistic Disorder*.2) Rett’s Disorder.3) Childhood Disintegrative Disorder.4) Asperger’s Disorder*.5) Pervasive Development Disorder Not

Otherwise Specified*.* Mainly these form the Autistic spectrum (ASD).

Pervasive Developmental Disorder.

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Major Classes Of Childhood Psychiatric Disorders.

• Developmental Disorders– Autism (ASD); Pervasive Developmental Disorders (PDD).– Language and learning disorders.

• Disruptive Behaviour Disorders (“externalizing”)– Attention Deficit Hyperactivity Disorder (ADHD).– Oppositional Defiant Disorder (ODD); Conduct Disorder (CD).

• Affective Disorders (“internalizing”)– Anxiety Disorders.– Depression; Bipolar Disorder.

• Other Disorders – Tic Disorders/Tourette’s Disorder; Eating Disorders; Substance Use;

Schizophrenia.

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Normal vs. Pathological?

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Are ADHD And Autism Really That Different?

• A large number of medical conditions, psychiatric disorders and behavioural and motor control problems are very often associated with ADHD and/or Autism.

• ADHD and Autism are generally described as separate disorders with separate genetic aetiologies.

• Most genetic studies exclude cases of Autism from studies on ADHD and vice versa.

• Comorbidity: one condition may “mask” another.

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Are ADHD And Autism Really That Different?• More symptoms of Autism in children with ADHD than

in their siblings who do not have ADHD.• A great need for in-depth research into this area.• As many as one-third of children diagnosed with

ADHD also have a co-existing diagnosed condition.

• See review by Gillberg and Billstedt (2000).

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Symptoms of ADHD.

High Impulsiveness

Poor Attention

High Hyperactivity

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• Frequent comorbid psychiatric diagnoses include:• Oppositional Defiant Disorder (35%).• Conduct Disorder (25%).

• Tics.• OCD (part of the triad?).• Anxiety (often strong environmental factors).

Comorbidity In ADHD.

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• Depression/Bipolar disorder.

• Selective mutism.

• Eating disorders (including anorexia nervosa).

• Sleep disorders.

• Learning disabilities occur in about 25% of ADHD children especially receptive language problems (spoken instructions) and expressive language (written output).


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• Substance use disorders in adults with ADHD.– Alcohol abuse (15%).– Alcohol dependence (41%).– Substance abuse (45%).– Substance dependence (31%).– Any abuse or dependence (69%).

(Millstein, et al, 1997).


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• Mood and anxiety disorders in adults with ADHD.– Major depression (63%).– Dysthymia (23%).– Bipolar (17%).– Panic disorder (11%).– Simple phobia (12%).– Generalized anxiety (21%).– Obsessive compulsive disorder (7%).

(Millstein, et al, 1997).


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• Personality disorders in adults with ADHD– Anti-social personality (22%)– Passive aggressive personality (19%)– Borderline personality (14%)– Histrionic personality disorder (11%)– Avoidant (anxious) (11%)

(Barkley et al, 1998)


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Symptoms of Autistic Disorder.

Restricted, repetitive and stereotyped patterns of behaviour.

Impairment in social interaction.

Impairment in verbal and non verbal communication.

Wing, L., & Gould, J. (1979). Severe impairments of social interaction and associated abnormalities in children: epidemiology and classification. Journal of Autism and Developmental Disorders, 9, 11-29.

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• Overlap/comorbidity (see Gillberg & Billstedt 2000).

• High overlap with ADHD symptoms.• Depression.• Mania/bipolar disorder.• Tic disorders.• “Personality disorders.”• Selective mutism.• Eating disorders.• Substance use disorders.

Comorbidity In Autism.

AUTISTICSPECTRUM

CONDITIONSATTENTION

DEFICIT/HYPER-

ACTIVITY

SEIZURES/TOURETTE’S

DEPRESSION/BIPOLAR

DISORDER

LEARNINGDISABILITIES

OBSESSIVE-COMPULSIVE

DISORDER

OPPOSITIONALDEFIANCEDISORDER

ANXIETY

Comorbidity of ASD.

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Some features of Autism can be misinterpreted as signs of schizophrenia.

• Often get disorganised thinking.• Focus on inner life/fantasy.• Talking past the point.• Perseveration.• Neologisms/colloquialisms.• Pseudo-philosophical talk.• Often speak thoughts out loud.

Example: Similarities Between Autism And Schizophrenia.

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• Imaginary friends.• Produce fantastic stories.• Complex visual hallucinations.• Thoughts described concretely sound like auditory

hallucinations.• Genuine altered perceptions.• Teasing and persecution.• Catatonia common.• Often improve with neuroleptics.


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• Early studies suggested association between SZ and ASD.• Kanner (1949) “I do not believe that there is any likelihood

that early infantile autism will at any future time have to be separated from the schizophrenias.”

• Clarke et al (1999) suggest that Autism may increase vulnerability to psychosis.

• Fitzgerald: “it is often asked where the patients with autism and Asperger's syndrome were 40 years ago and what diagnosis they received. It is likely that they were classified in adult psychiatric hospitals as having simple Schizophrenia.”


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• Bender & Faetra (1972) claimed 90 per cent of Autistic children developed Schizophrenia in adulthood.

• Dahl (1976) claimed 50 per cent of Autistic children developed Schizophrenia in adulthood.

• Wolff & Mcguire (1995) claimed 4 out of 49 patients with possible Asperger's developed Schizophrenia.


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UndiagnosedDisorder

CorrectlyDiagnosedDisorder

Misd

iagn

osed

As D

isord

er

Has DisorderDiagnosed with Disorder

Diagnosis, Misdiagnosis, And “Undiagnosed.”

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Overlap Of ‘Symptoms’ In Autism, Asperger’s And ADHD.

• Naïve remarks, faux pas, too honest.• Can only be with others on own

terms.• Poor at games, scores “own goals.”• Unaware of social conventions.• Indifferent to peer

pressure/crazes/fashion.• Pedantic, corrects other students.• Genuine poor empathy may lead to

aggression.• Good at some things/poor at others.• Same with everybody.• No language adjustment to fit social

context.• Expect others to know their thoughts.• Take things literally.

•Poor motivation/Lack of spontaneity.•Eye for detail, but fail to see big picture.•Autodidact, struggle to follow teachers.•Perfectionist.•Everything black/white, all or nothing•Catatonic symptoms.•Sensory sensitivities (noise, pain threshold).•Special interests•Odd “flapping” gait when running.•Tics, facial grimacing.•Prefer non-fiction to fiction.•Exceptional memory for facts/dates.•Exceptional isolated ability.

•May seem immature.

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• ADHD is (almost) always an indication that there will be other problems and disorders, not just ADHD.

• Autism Spectrum Disorders can present with severe hyperactivity and attention problems (Gillberg 1992).

• Extreme hyperactivity is a common presenting problem in pre-school children with Autism.

• Many individuals with ADHD also have mild Autism Spectrum Disorder (Gillberg et al 1987).

Overlap Of ‘Symptoms’ In Autism, Asperger’s And ADHD.

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ADHD / Autism Overlap: Theoretical Questions.

• Could it be that ADHD comprises a mixture of other syndromes (e.g. Tourette’s, bipolar, depression and variants of Autism Spectrum Disorder) that all present with some “ADHD” symptomatology?

• Could any dopamine/noradrenaline dysfunction syndrome with early onset present as ADHD or a “shadow syndrome” of ADHD?

• Could Autism, Asperger’s and ADHD fall on the same continuum?

Education

Topic 7 - Comorbidity in ADHD and Autism 2010