Michael J. Murray

Attention-deficit/Hyperactivity Disorder in the Context of Autism Spectrum Disorders

Autism spectrum disorders (ASD) are frequently marked by symptoms consistent with attention-deficit/hyperactivity disorder (ADHD), namely inattention, hyperactivity, and impulsivity. Recent work has established that about half of the ASD population also meets diagnostic criteria for ADHD, although the comorbid diagnoses are precluded by the DSM-IV-TR. Individuals with co-occurring ASD and ADHD symptoms are more severely impaired, with significant deficits seen in social processing, adaptive functioning, and executive control. Children with ASD and ADHD symptoms are also prone to motor problems, which lead to especially poor outcomes. Recent work has also demonstrated high rates of ASD symptoms in a subset of children with ADHD. Medication studies have demonstrated the efficacy of methylphenidate, atomoxetine, and guanfacine, among others, in treating ADHD symptoms co-occurring with ASD. However, these effects were not as great as those seen when treating primary ADHD, and they are less well-tolerated in the ASD population.

Comparison of Scores on the Checklist for Autism Spectrum Disorder, Childhood Autism Rating Scale, and Gilliam Asperger’s Disorder Scale for Children with Low Functioning Autism, High Functioning Autism, Asperger’s Disorder, ADHD, and Typical Development

Reliability and validity for three autism instruments were compared for 190 children with low functioning autism (LFA), 190 children with high functioning autism or Asperger’s disorder (HFA), 76 children with attention deficit hyperactivity disorder (ADHD), and 64 typical children. The instruments were the Checklist for Autism Spectrum Disorder (designed for children with LFA and HFA), Childhood Autism Rating Scale (CARS) for children with LFA, and Gilliam Asperger’s Disorder Scale (GADS). For children with LFA or ADHD, classification accuracy was 100% for the Checklist and 98% for the CARS clinician scores. For children with HFA or ADHD, classification accuracy was 99% for the Checklist and 93% for the GADS clinician scores. Clinician–parent diagnostic agreement was high (90% Checklist, 90% CARS, and 84% GADS).

Brief Report: Excellent Agreement between Two Brief Autism Scales (Checklist for Autism Spectrum Disorder and Social Responsiveness Scale) Completed Independently by Parents and the Autism Diagnostic Interview-Revised.

Agreement between the Autism Diagnostic Interview-Revised (ADI-R) and two brief scales completed by parents was 93.1% for the Checklist for Autism Spectrum Disorder (CASD) and 89.7% for the Social Responsiveness Scale (SRS) in a sample of adolescents with suspected autism spectrum disorders. Our study is consistent with others showing that brief scales like the CASD and SRS have strong psychometric support and compare favorably with the ADI-R. The CASD and SRS are each completed and scored in 15xa0min, whereas the ADI-R takes over 2xa0h to administer and score. The CASD and SRS offer a valid and cost effective alternative to lengthy and expensive measures and, by virtue of their brevity and simplicity, could facilitate diagnosis, access to treatment, and research.

Use of the Childhood Autism Rating Scale (CARS) for Children with High Functioning Autism or Asperger Syndrome.

The authors of the Childhood Autism Rating Scale (CARS) state in the manual that the best cutoff score for distinguishing low functioning autism (LFA) from intellectual disability is 30 for children and 28 for adolescents and adults. This study determined that a cutoff score of 25.5 was most accurate in differentiating between high functioning autism or Asperger syndrome (HFA; n = 197) and ADHD (n = 74) in a sample of 1- to 16-year-olds with IQs of 80 or higher. Classification accuracy was 96% using clinician scores and 72% using parent scores. Children with LFA (n = 193) had significantly higher clinician and parent scores than children with HFA, and scores were negatively correlated with IQ. None of the typical children (n = 64) earned parent scores greater than 21.

A Profile on Emergency Department Utilization in Adolescents and Young Adults with Autism Spectrum Disorders

There has been an increase in utilization of the Emergency Department (ED) in individuals with autism spectrum disorder (ASD) which may reflect a deficit of services (Green et al., Journal of the American Academy of Child and Adolescent Psychiatry 40(3):325–332, 2001; Gurney et al., Archives of Pediatric and Adolescent Medicine 160:825–830, 2006; Leichtman et al., American Journal of Orthopsyhciatry 72(2):227–235, 2001). The current study examined the rates of ED utilization between 2005 and 2013 in ASD youth 12- to 21-years-old. Adolescents with ASD accessed ED services four times as often as adolescents without ASD. Older adolescents and those living in rural areas showed a significant increase in ED visits over time. Post hoc analysis revealed increased ED utilization for females and behavioral health ED services over time. Better access to and greater understanding of services for adolescents with ASD is a critical need.

Assessing adolescent social competence using the Social Responsiveness Scale: Should we ask both parents or will just one do?:

There is a paucity of instruments designed to measure social competence of adolescents with autism spectrum disorders. The Social Responsiveness Scale is one of a few that can be used. This study compared differences between mother and father reports of social competence of adolescents. Data were collected from parents of 50 adolescents with and without an autism spectrum disorder diagnosis between the ages of 12 and 17 years. The Social Responsiveness Scale demonstrated high interrater reliability between parents. These results suggest that the Social Responsiveness Scale is an efficient and valuable tool for researchers and clinicians to obtain a more comprehensive understanding of an individual’s social skills deficits. Additionally, given the extremely high agreement between mothers and fathers on the ratings of their children’s social competence, obtaining data from either parent is sufficient to provide an accurate reflection of social competence at home.

Use of Gilliam Asperger's disorder scale in differentiating high and low functioning autism and ADHD.

Little is known about the validity of Gilliam Aspergers Disorder Scale (GADS), although it is widely used. This study of 199 children with high functioning autism or Aspergers Disorder, 195 with low functioning autism, and 83 with Attention Deficit Hyperactivity Disorder (ADHD) showed high classification accuracy (autism vs ADHD) for clinicians GADS Quotients (92%), and somewhat lower accuracy (77%) for parents Quotients. Both children with high and low functioning autism had clinicians Quotients (M = 99 and 101, respectively) similar to the Aspergers Disorder mean of 100 for the GADS normative sample. Children with high functioning autism scored significantly higher on the Cognitive Patterns subscale than children with low functioning autism, and the later had higher scores on the remaining subscales: Social Interaction, Restricted Patterns of Behavior, and Pragmatic Skills. Using the clinicians Quotient and Cognitive Patterns score, 70% of children were correctly identified as having high or low functioning autism or ADHD.

Comparison of self-and other-report of symptoms of autism and comorbid psychopathology in adults with autism spectrum disorder

While the presentation of autism-related symptoms is variable across individuals with ASD, there is growing evidence that many of these symptoms may be further complicated or exacerbated by comorbid symptoms of psychopathology. Some individuals with ASD may also have difficulty reflecting and reporting on their own behavioral and emotional symptoms, which can interfere with diagnosis and treatment. The current study compared selfand other-ratings of the behavior of 47 young adults with ASD in the home environment, to identify areas of rater agreement and discrepancy across symptoms of both ASD and general pathology. For ASD symptoms, nominated reporters rated the participant’s behavior as significantly more impaired regarding social communication symptoms, but no significant difference was found for restricted and repetitive behavior. For symptoms of psychopathology, only attention problems, depression problems, avoidant personality problems, and total problems were reported by others as significantly higher when compared to self-report. While this provides increased confidence for assessing most comorbid symptoms of psychopathology via one reporter, results suggest obtaining collateral reports for ASD symptoms may be important for comprehensive assessment. The results from this study may inform the future of the clinical field regarding the use of a more efficient assessment of individuals with ASD’s behavior and comorbid psychopathology. Correspondence to: Amanda M. Pearl, PhD, Assistant Professor of Psychiatry, Division of Autism Services, Penn State Hershey, 500 University Drive Hershey, PA 17033, USA, E-mail: apearl@pennstatehealth.psu.edu

Children of migrant parents may be at greater risk of low-functioning autism spectrum disorder, but lower risk of high-functioning autism spectrum disorder.

ED FROM Magnusson C, Rai D, Goodman A, et al. Migration and autism spectrum disorder: population-based study. Br J Psychiatry 2012;201:109–15. Correspondence to: Cecilia Magnusson, Department of Public Health Sciences, Karolinska Institutet, Norrbacka, Stockholm 171 76, Sweden; cecilia.magnusson@ki.se Sources of funding: The Stockholm County Council and the Swedish Council for Working Life and Social Research. CO M M EN TA RY Magnusson and colleagues examined the prevalence of autism spectrum disorders (ASDs) in a Swedish sample of migrant families. The investigators utilised the Stockholm Youth Cohort which captures all children between the ages of 0 to 17 residing in Stockholm County between 2001 and 2007. The researchers identified 4592 individuals with ASDs: 2855 children with highfunctioning autism and 2097 children with lowfunctioning autism. Children of migrant parents were found to be at increased risk of suffering from low-functioning autism with comorbid intellectual disability. This risk was increased if the parents migrated from a region of low human development index and if the migration occurred in the year prior to the child’s birth. The authors postulated that these increased rates of low-functioning autism in children born to mothers who migrated during their pregnancies might be caused by increased stress induced by the move. This stress may possibly lead to dysregulation of fetal neurodevelopment or epigenetic mechanisms resulting in the clinical presentation. This sample demonstrated no increased risk of suffering from high-functioning autism for children of migrant parents. The authors suggest that more subtle presentations of autism, especially in the absence of intellectual disability, may not be recognised as being of concern and instead may be mistakenly attributed to cultural differences or a potential language barrier. This study reinforces the importance of effective screening for ASDs in vulnerable populations such as migrant families. This study’s finding of migration during pregnancy as a risk factor for autism is intriguing and could argue for closer surveillance of children born under these circumstances. It also points to a possible risk factor for low-functioning autism which could be impacted by better psychosocial supports for families. The suspicion that the lack of increased risk of high-functioning autism in these families is a failure to recognise the social deficits marking this condition, pointing to the need for better training for clinicians to recognise these symptoms in culturally diverse populations and for better education for families to be aware of typical social development in infants and young children.