Symptom Profile of ADHD in Youth With High-Functioning Autism Spectrum Disorder: A Comparative Study in Psychiatrically Referred Populations

Self-reported symptoms of attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), and affective lability in discriminating adult ADHD, ASD and their co-occurrence

BACKGROUND

To diagnose and manage adults with Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Disorder (ASD), or their co-occurrence (ADHD + ASD), clinicians must identify specific features that differentiate these diagnostic categories. Self-report questionnaires targeting specific features are widely used and, together with clinical assessments, provide reliable diagnoses. Although affective lability is present in various psychiatric disorders, it lacks specificity when screening for ADHD in the general population, and its discriminant value for ADHD, ASD, and ADHD + ASD has not been studied.

METHODS

This study involved 300 adults without intellectual developmental disorder (188 male) who received an ADHD (n = 174), ASD (n = 68), or ADHD + ASD (n = 58) diagnosis after a multidisciplinary consensus decision according to DSM-5 criteria. Before clinical assessment, all patients requesting evaluation for one of these diagnoses completed questionnaires on an online platform. The assessment instruments included a modified version of the Barkley Adult ADHD Rating Scale (BAARS IV) for ADHD, the Autism Spectrum Quotient (AQ) and the Empathy Quotient (EQ) for ASD features, and the Affective Lability Scale (ALS) for affective lability. Total scores and sub-scores of the instruments were compared among the three groups. Additionally, stepwise logistic regression analyses were conducted to identify specific measures that contribute to group discrimination.

RESULTS

Results revealed distinct patterns in symptomatology as expected. The ADHD and the ADHD + ASD groups presented significantly higher ALS total score compared to ASD. Stepwise logistic regression analyses identified specific measures contributing to group differentiation. ASD vs. ADHD + ASD discrimination included BAARS IV current total score and EQ total score. The subscale anger from ALS in addition with BAARS IV past total score and AQ total score were the factors that discriminated ADHD diagnosis from the co-occurrence of ADHD and ASD. Finally, BAARS IV past total score, BAARS IV current inattention, AQ total score, and EQ total score were found to differentiate ADHD from ASD.

CONCLUSIONS

The study highlights the significance of incorporating emotional dimensions in diagnostic frameworks and may contribute valuable insights for clinicians differentiating neurodevelopmental conditions.

Cognitive Disengagement Syndrome (CDS) (Formerly Sluggish Cognitive Tempo), Autism, and Insomnia Symptoms in Childhood Predict CDS in Adolescence: A Longitudinal Population-Based Study

Our study is the first using multiple variables to compare concurrent with longitudinal predictors of cognitive disengagement syndrome (CDS). The population-based sample comprised 376 youth (mean baseline age 8.7 and follow-up 16.4 years) rated by parents on the Pediatric Behavior Scale. The baseline CDS score was the strongest predictor of follow-up CDS. Baseline autism and insomnia symptoms also predicted follow-up CDS above and beyond baseline CDS. Autism, insomnia, inattention, somatic complaints, and excessive sleep were concurrently related to CDS at baseline and follow-up. Additionally, follow-up depression was associated with follow-up CDS, and baseline hyperactivity/impulsivity was negatively associated with baseline CDS. Oppositional defiant/conduct problems and anxiety were nonsignificant. Age, sex, race, and parent occupation were unrelated to CDS, and correlations between baseline CDS and 15 IQ, achievement, and neuropsychological test scores were nonsignificant. Results indicate childhood CDS is the strongest risk factor for adolescent CDS, followed by autism and insomnia symptoms.

Differentiating Functional Connectivity Patterns in ADHD and Autism Among the Young People: A Machine Learning Solution

OBJECTIVE

ADHD and autism are complex and frequently co-occurring neurodevelopmental conditions with shared etiological and pathophysiological elements. In this paper, we attempt to differentiate these conditions among the young people in terms of intrinsic patterns of brain connectivity revealed during resting state using machine learning approaches. We had two key objectives: (a) to determine the extent to which ADHD and autism could be effectively distinguished via machine learning from one another on this basis and (b) to identify the brain networks differentially implicated in the two conditions.

METHOD

Data from two publicly available resting-state functional magnetic resonance imaging (fMRI) resources-Autism Brain Imaging Data Exchange (ABIDE) and the ADHD-200 Consortium-were analyzed. A total of 330 participants (65 females and 265 males; mean age = 11.6 years), comprising equal subgroups of 110 participants each for ADHD, autism, and healthy controls (HC), were selected from the data sets ensuring data quality and the exclusion of comorbidities. We identified region-to-region connectivity values, which were subsequently employed as inputs to the linear discriminant analysis algorithm.

RESULTS

Machine learning models provided strong differentiation between connectivity patterns in participants with ADHD and autism-with the highest accuracy of 85%. Predominantly frontoparietal network alterations in connectivity discriminate ADHD individuals from autism and neurotypical group. Networks contributing to discrimination of autistic individuals from neurotypical group were more heterogeneous. These included language, salience, and frontoparietal networks.

CONCLUSION

These results contribute to our understanding of the distinct neural signatures underlying ADHD and autism in terms of intrinsic patterns of brain connectivity. The high level of discriminability between ADHD and autism, highlights the potential role of brain based metrics in supporting differential diagnostics.

Pre-K-12 Teachers' Views on ASD+ADHD: Prevalence Estimates and Teaching Preparedness

BACKGROUND/OBJECTIVES

Teachers play a significant role in the identification and intervention of neurodevelopmental disorders such as ASD and ADHD. However, their perceptions of ASD+ADHD comorbidity remain underexplored. This study investigates teachers' estimates of ASD+ADHD prevalence and their perceived preparedness to teach students with co-occurring diagnoses, exploring key predictors of both outcomes.

METHODS

Pre-K-12 teachers (N = 199) completed demographic questions and four additional questionnaires assessing ASD- and ADHD-specific knowledge, neurodiversity attitudes and overall teaching self-efficacy. Participants estimated the prevalence of ASD+ADHD comorbidity and rated their preparedness to instruct students with ASD+ADHD, ASD-only, and ADHD-only. Regression analyses examined factors predicting prevalence estimates and preparedness.

RESULTS

Teachers underestimated the lifetime prevalence of ASD+ADHD, though current prevalence estimates were more aligned with meta-analytic findings. Personal experience and current teaching of comorbid students predicted higher prevalence estimates, whereas greater ASD knowledge was associated with lower estimates. Preparedness to teach ASD+ADHD was rated lower than for ASD-only or ADHD-only students. Self-efficacy, neurodiversity attitudes, and professional training were predictors of preparedness. Current teaching of comorbid students, disorder-specific knowledge, and total years of teaching experience showed inconsistent associations across conditions.

CONCLUSIONS

Findings suggest that while direct experience and training enhance both awareness and preparedness, disorder-specific knowledge alone does not consistently translate to confidence in supporting students with co-occurring diagnoses. Implications for teacher training and the need for comorbidity-focused professional development are discussed.

Available Treatments for Autism Spectrum Disorder: From Old Strategies to New Options

Autism spectrum disorder (ASD) is a condition that is gaining increasing interest in research and clinical fields. Due to the improvement of screening programs and diagnostic procedures, an increasing number of cases are reaching clinical attention. Despite this, the available pharmacological options for treating ASD-related symptoms are still very limited, and while a wide number of studies are focused on children or adolescents, there is a need to increase research about the treatment of ASD in adult subjects. Given this framework, this work aims to review the available literature about pharmacological treatments for ASD, from older strategies to possible new therapeutic targets for this condition, which are often poorly responsive to available resources. The literature, besides confirming the efficacy of the approved drugs for ASD, shows a lack of adequate research for several psychopharmacological treatments despite possible promising results that need to be further investigated.

Injury Rates Among Children With Autism Spectrum Disorder With or Without Attention-Deficit/Hyperactivity Disorder

Importance

Injuries are a major cause of morbidity and mortality among children with neurodevelopmental conditions. Identifying injuries associated with this vulnerable population could inform specific preventive actions.

Objective

To compare the injury risk among children with autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD), or coexisting ASD and ADHD with children with typical development (TD).

Design, Setting, and Participants

This population-based cohort study involved 325 412 children born between 2005 and 2009, followed up until the end of 2021. Data analysis was conducted from February 2 to November 14, 2023. The study data were extracted from the Clalit Health Service (CHS) database, which contains comprehensive clinical and sociodemographic data on all members of the CHS admitted to the emergency departments (EDs) of all hospitals in Israel during the study period. Children who were members of CHS born between 2005 and 2009 were classified into 4 groups: ASD, ADHD, ASD and ADHD, and TD (control).

Main Outcomes and Measures

Negative binomial regression models were used to assess incidence rate ratios (IRRs) of ED visits between the study groups and the control group. These models were adjusted for birth year, sector, and socioeconomic status. IRRs for specific injuries were also assessed. The statistical significance of IRRs was assessed using 95% CIs.

Results

A total of 325 412 children (163 183 boys [50%]) were included in the study. Children with ASD, ADHD, or both had significantly higher ED visit rates than children with TD (IRR, 1.48 [95% CI, 1.42-1.55], 1.45 [95% CI, 1.39-1.52], and 1.29 [95% CI, 1.28-1.30], respectively). Children with ADHD had also higher rates of ED visits due to physical injuries compared with controls (IRR, 1.18 [95% CI, 1.16-1.20]), whereas children with ASD with or without ADHD did not (IRR, 0.96 [95% CI, 0.89-1.05] and 0.91 [95% CI, 0.83-1.00], respectively). A focused analysis of the injury profiles revealed that children with ASD or comorbid ASD and ADHD had higher rates of ingestion and inhalation injuries (IRR, 1.57 [95% CI, 1.06-2.25] and 1.80 [95% CI, 1.28-2.48], respectively) and lower rates of orthopedic injuries (IRR, 0.78 [95% CI, 0.69-0.89] and 0.83 [95% CI, 0.74-0.93], respectively), and animal-inflicted injuries (IRR, 0.44 [95% CI, 0.22-0.79] and 0.92 [95% CI, 0.60-1.35], respectively) than controls.

Conclusions and Relevance

In this large cohort study, different types of injury were associated with children with ASD and ADHD. The causes underlying these associations should be further investigated to develop effective approaches for injury reduction among these children.

Cognitive Disengagement Syndrome and Autism Traits are Empirically Distinct from each Other and from Other Psychopathology Dimensions

Recently, an association between cognitive disengagement syndrome (CDS), formerly sluggish cognitive tempo, and autism has been documented, but it is not known if the association is due to overlapping autism and CDS traits or if CDS is empirically distinct from autism. Mothers rated 2,209 children 4-17 years (1,177 with autism, 725 with ADHD-Combined type, and 307 with ADHD-Inattentive type) on the Pediatric Behavior Scale. Factor analysis of the Pediatric Behavior Scale items indicated that CDS and autism traits are empirically distinct from each other without cross-loading and are distinct from eight other factors (attention deficit, impulsivity, hyperactivity, oppositional behavior, irritability/anger, conduct problems, depression, and anxiety). CDS total scores were significantly higher in the autism + ADHD-Inattentive and autism + ADHD-Combined groups than in the autism, ADHD-Combined, and ADHD-Inattentive only groups with a nonsignificant difference between the latter three groups. CDS and autism are empirically distinct from each other and from other psychopathology dimensions. Overlapping traits do not explain the association between autism and CDS. Autism in combination with ADHD-Combined or ADHD-Inattentive increases the likelihood of CDS relative to youth who have autism, ADHD-Combined, or ADHD-Inattentive only. Because of the known associations between autism, CDS, and ADHD, both autism and ADHD must be assessed in CDS research and clinically to better understand and explain research findings and provide targeted clinical intervention.

Rare Variant Analyses in Ancestrally Diverse Cohorts Reveal Novel ADHD Risk Genes

Attention-deficit/hyperactivity disorder (ADHD) is a highly heritable neurodevelopmental disorder, but its genetic architecture remains incompletely characterized. Rare coding variants, which can profoundly impact gene function, represent an underexplored dimension of ADHD risk. In this study, we analyzed large-scale DNA sequencing datasets from ancestrally diverse cohorts and observed significant enrichment of rare protein-truncating and deleterious missense variants in highly evolutionarily constrained genes. This analysis identified 15 high-confidence ADHD risk genes, including the previously implicated KDM5B. Integrating these findings with genome-wide association study (GWAS) data revealed nine enriched pathways, with strong involvement in synapse organization, neuronal development, and chromatin regulation. Protein-protein interaction analyses identified chromatin regulators as central network hubs, and single-cell transcriptomic profiling confirmed their expression in neurons and glial cells, with distinct patterns in oligodendrocyte subtypes. These findings advance our understanding of the genetic architecture of ADHD, uncover core molecular mechanisms, and provide promising directions for future therapeutic development.

Pharmacological treatment in autism: a proposal for guidelines on common co-occurring psychiatric symptoms

BACKGROUND

The prevalence of autism spectrum disorder (ASD) has surged, with an estimated 1 in 36 eight-year-olds in the United States meeting criteria for ASD in 2020. Autistic individuals face elevated rates of co-occurring medical, psychiatric, and behavioral conditions compared to non-autistic individuals. The rising ASD-patient demand is increasingly outpacing the capacity of ASD-specialty clinics, resulting in urgent need for autism-competent providers in general practice settings. This work aims to empower healthcare providers, especially primary care providers (PCPs), with guidelines for the recognition and safe pharmacologic management of common co-occurring psychiatric and behavioral conditions in ASD.

METHODS

Lurie Center for Autism medical providers, who have extensive experience in ASD care, delineated approaches for recognition and pharmacological treatment of sleep disturbances, attention-deficit/hyperactivity disorder (ADHD), anxiety, depression, and irritability tailored to ASD patients. Pharmacological guidelines were iteratively refined until consensus was reached. Treatment differences relative to standard of care (SOC) of non-autistic individuals are noted. Key literature and clinical trial results were reviewed to supplement clinical experience.

RESULTS

The pharmacological treatment pathways reflect how appropriate medication options for ASD patients can depend on many factors unique to the patient and can differ from established non-autistic SOC. Key takeaways include: For sleep disturbances in ASD, initial strategies align with non-autistic SOC, emphasizing sleep hygiene and melatonin use. First-line recommendations for treating ADHD, anxiety, and depression in ASD differ from non-autistic SOC; α2-adrenergic agonists are more suitable than stimulants for some ASD-ADHD patients, buspirone and mirtazapine are preferred to selective serotonin reuptake inhibitors (SSRIs) for anxiety, and duloxetine, mirtazapine, bupropion, and vortioxetine are recommended ahead of SSRIs for depression. Addressing irritability in ASD requires interdisciplinary evaluation of contributing factors, and guanfacine, risperidone, or aripiprazole may be appropriate, depending on severity.

CONCLUSIONS

Recognition and treatment of co-occurring psychiatric and behavioral conditions in autistic patients must account for differences in clinical presentation and medication effectiveness and tolerability. Drawing on evidence-based clinical insights, these guidelines seek to support PCPs in making informed decisions when prescribing medications for ASD patients with co-occurring psychiatric and behavioral conditions, ultimately enhancing access to timely, comprehensive care for all individuals with ASD.

Developmental and Psychiatric Conditions Among 5-7 Year Old Children with Non-persistent and Persistent Autism

To describe the types and frequency of developmental and psychiatric conditions (DPCs) in early school-age children who were diagnosed with ASD as toddlers and to compare rates of DPCs in children whose ASD persists ("persistent ASD") versus those in whom it does not ("non-persistent ASD"). Children with a clinical ASD diagnosis at 12-36 months old underwent a research assessment at 5-7 years old. Research assessments included measures of ASD symptoms and cognitive and adaptive functioning. A research psychologist assigned an ASD diagnosis (yes or no) based on the child's current functioning. Information about DPCs was obtained from parent and/or research psychologist report. Intellectual disability was defined as cognitive standard score < 70. Of the 213 children diagnosed with ASD at initial clinical assessment, at the research assessment 134 (62.6%) had persistent ASD and 79 (37%) had non-persistent ASD. Overall, the most common DPCs were ADHD (n = 58; 27.2%); speech disorder (n = 46; 21.6%); and intellectual disability (n = 46; 21.6%). Of children with non-persistent ASD, 29.1% had ≥ 1 DPC, and 19% had ADHD. Children with persistent ASD were over 5 times more likely (OR = 5.72) to have an additional DPC, compared to those with non-persistent ASD. Children with non-persistent ASD may manifest several different DPCs, with an increased rate of ADHD compared to population norms. Children with persistent ASD have higher rates of DPCs than those with non-persistent ASD. Follow-up care for children diagnosed with ASD at a young age should include assessment for other DPCs.

A conditional multi-label model to improve prediction of a rare outcome: An illustration predicting autism diagnosis

OBJECTIVE

This study aimed to develop a novel approach using routinely collected electronic health records (EHRs) data to improve the prediction of a rare event. We illustrated this using an example of improving early prediction of an autism diagnosis, given its low prevalence, by leveraging correlations between autism and other neurodevelopmental conditions (NDCs).

METHODS

To achieve this, we introduced a conditional multi-label model by merging conditional learning and multi-label methodologies. The conditional learning approach breaks a hard task into more manageable pieces in each stage, and the multi-label approach utilizes information from related neurodevelopmental conditions to learn predictive latent features. The study involved forecasting autism diagnosis by age 5.5 years, utilizing data from the first 18 months of life, and the analysis of feature importance correlations to explore the alignment within the feature space across different conditions.

RESULTS

Upon analysis of health records from 18,156 children, we are able to generate a model that predicts a future autism diagnosis with moderate performance (AUROC=0.76). The proposed conditional multi-label method significantly improves predictive performance with an AUROC of 0.80 (p < 0.001). Further examination shows that both the conditional and multi-label approach alone provided marginal lift to the model performance compared to a one-stage one-label approach. We also demonstrated the generalizability and applicability of this method using simulated data with high correlation between feature vectors for different labels.

CONCLUSION

Our findings underscore the effectiveness of the developed conditional multi-label model for early prediction of an autism diagnosis. The study introduces a versatile strategy applicable to prediction tasks involving limited target populations but sharing underlying features or etiology among related groups.

The Brunswik Lens Model: a theoretical framework for advancing understanding of deceptive communication in autism

Due to differences in social communication and cognitive functioning, autistic adults may have greater difficulty engaging in and detecting deception compared to neurotypical adults. Consequently, autistic adults may experience strained social relationships or face increased risk of victimization. It is therefore crucial that research investigates the psychological mechanisms that are responsible for autistic adults' difficulties in the deception process in order to inform interventions required to reduce risk. However, weaknesses of extant research exploring deception in autism include a heavy focus on children and limited theoretical exploration of underlying psychological mechanisms. To address these weaknesses, this review aims to introduce a system-level theoretical framework to the study of deception in autistic adulthood: The Brunswik Lens Model of Deception. Here, we provide a comprehensive account of how autism may influence all processes involved in deception, including: Choosing to Lie (1), Producing Deception Cues (2), Perceiving Deception Cues (3), and Making the Veracity Decision (4). This review also offers evidence-based, theoretical predictions and testable hypotheses concerning how autistic and neurotypical adults' behavior may differ at each stage in the deception process. The call to organize future research in relation to a joint theoretical perspective will encourage the field to make substantive, theoretically motivated progress toward the development of a comprehensive model of deception in autistic adulthood. Moreover, the utilization of the Brunswik Lens Model of Deception in future autism research may assist in the development of interventions to help protect autistic adults against manipulation and victimization.

Prevalence and Correlates of Poor Safety Awareness and Accidental Injury in ASD, ADHD, ASD + ADHD, and Neurotypical Youth Samples

The purpose of the present study is to compare risk and predictors of poor safety awareness and accidental injuries in ASD, ADHD, and neurotypical samples. Neurodivergent groups (ADHD-I n = 309; ADHD-C n = 747; ASD-only n = 328; ASD + ADHD n = 1,108) were 2-17 years old. The neurotypical group (n = 186) was 6-12 years of age. Maternal ratings on the Pediatric Behavior Scale examined safety awareness, accidental injury, and psychological problems. Children with ASD + ADHD had significantly poorer safety awareness and accidental injury ratings than all other groups. Predictors of poor safety awareness in the total ASD and/or ADHD sample were: impulsivity, younger age, lower IQ, and hyperactivity. Predictors of accidental injuries were: incoordination, hyperactivity, and conduct problems. Clinicians working with children who have ASD and ADHD are encouraged to screen for poor safety awareness, discuss child safety measures, and provide evidence-based intervention to improve safety awareness and mitigate the risk of injury.

Early Childhood Aggression in Autistic and Non-Autistic Preschoolers: Prevalence, Topography, and Relationship to Emotional Reactivity

Objective

Despite heightened rates of aggressive behaviors among older autistic youth relative to non-autistic peers, less is known about these behaviors during early childhood. This study included 3 objectives to address this gap: (1) to establish the prevalence and topography (frequency, severity, type, context) of aggressive behaviors in a large sample of preschool-aged children using a developmentally sensitive parent-report measure; (2) to identify clinical correlates of aggression; and (3) to investigate whether different subgroups of autistic children can be identified based on their profiles of aggression, emotional reactivity, and autism traits.

Method

Data were analyzed from parents of 1,199 children 2 to 5 years of age (n = 622 autistic children) who completed the Multidimensional Assessment Profiles Scales (MAPS) aggression subscale and the Emotion Dysregulation Inventory-Young Child (EDI-YC) reactivity subscale.

Results

Autistic preschoolers had 2 to 6 times higher odds of experiencing frequent aggression (more days than not) compared with non-autistic preschoolers. Hierarchical multiple regression analyses revealed that autism diagnosis, traits, and suspected and diagnosed attention-deficit/hyperactivity disorder (ADHD) were positively associated with aggression; however, heightened emotional reactivity explained the greatest degree of added variance in aggression total scores. Machine learning clustering techniques revealed 3 distinct subgroups of autistic preschoolers, with cluster membership driven primarily by aggression and reactivity scores, and less so by autism traits.

Conclusion

Autistic preschoolers display more frequent parent-reported aggressive behaviors, and emotional reactivity may play an important role in aggressive behavior presentation. Future developmental screening and early intervention tailoring for aggression may benefit from assessing reactivity early in development.

Diversity & Inclusion Statement

One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented sexual and/or gender groups in science. One or more of the authors of this paper self-identifies as living with a disability. The author list of this paper includes contributors from the location and/or community where the research was conducted who participated in the data collection, design, analysis, and/or interpretation of the work.

Exposure to Bisphenol F and Bisphenol S during development induces autism-like endophenotypes in adult Drosophila melanogaster

Bisphenol F (BPF) and Bisphenol S (BPS) are being widely used by the industry with the claim of "safer substances", even with the scarcity of toxicological studies. Given the etiological gap of autism spectrum disorder (ASD), the environment may be a causal factor, so we investigated whether exposure to BPF and BPS during the developmental period can induce ASD-like modeling in adult flies. Drosophila melanogaster flies were exposed during development (embryonic and larval period) to concentrations of 0.25, 0.5, and 1 mM of BPF and BPS, separately inserted into the food. When they transformed into pupae were transferred to a standard diet, ensuring that the flies (adult stage) did not have contact with bisphenols. Thus, after hatching, consolidated behavioral tests were carried out for studies with ASD-type models in flies. It was observed that 1 mM BPF and BPS caused hyperactivity (evidenced by open-field test, negative geotaxis, increased aggressiveness and reproduction of repetitive behaviors). The flies belonging to the 1 mM groups of BPF and BPS also showed reduced cognitive capacity, elucidated by the learning behavior through aversive stimulus. Within the population dynamics that flies exposed to 1 mM BPF and 0.5 and 1 mM BPS showed a change in social interaction, remaining more distant from each other. Exposure to 1 mM BPF, 0.5 and 1 mM BPS increased brain size and reduced Shank immunoreactivity of adult flies. These findings complement each other and show that exposure to BPF and BPS during the development period can elucidate a model with endophenotypes similar to ASD in adult flies. Furthermore, when analyzing comparatively, BPS demonstrated a greater potential for damage when compared to BPF. Therefore, in general these data sets contradict the idea that these substances can be used freely.

In Memoriam: Professor Joseph Biederman's Contributions to Child and Adolescent Psychiatry

OBJECTIVE

To provide an overview of Joe Biederman's contributions to child and adolescent psychiatry.

METHOD

Nine colleagues described his contributions to: psychopharmacology, comorbidity and genetics, pediatric bipolar disorder, autism spectrum disorders, Tourette's and tic disorders, clinical and neuro biomarkers for pediatric mood disorders, executive functioning, and adult ADHD.

RESULTS

Joe Biederman left us with many concrete indicators of his contributions to child and adolescent psychiatry. He set up the world's first pediatric psychopharmacology clinic and clinical research program in child adolescent psychiatry. As a young faculty member he began a research program that led to many awards and eventual promotion to full professor at Harvard Medical School. He was for many years the most highly cited researcher in ADHD. He achieved this while maintaining a full clinical load and was widely respected for his clinical acumen.

CONCLUSION

The world is a better place because Joe Biederman was here.

Dr. Joseph Biederman's Enduring Legacy: Illuminating the Path to Addressing Autistic Traits in Attention Deficit Hyperactivity Disorder With Transcranial Photobiomodulation

OBJECTIVE

To review the existing literature on transcranial photobiomodulation (tPBM) treatment effects on Autism Spectrum Disorder (ASD), in search for an effective treatment of a symptom cluster identified largely by contributions from late Dr. Biederman who asserted that they frequently present with Attention Deficit Hyperactivity Disorder (ADHD).

METHOD

A survey of two databases, PubMed and PsycINFO, for clinical trials reporting on tPBM treatment in ASD was performed. Identified manuscripts that met eligibility criteria were then reviewed.

RESULTS

Three original manuscripts reporting findings on a heterogenous group of study methods met the eligibility criteria. Despite the heterogenous nature of study designs, findings from all three studies reported tPBM treatment to be associated with improvements in ASD symptoms. No serious or treatment limiting adverse events were reported.

CONCLUSIONS

A nascent body of research suggests further clinical studies investigating efficacy of tPBM in treatment of ASD symptoms should be supported.

Caregiver and youth inter-rater assessment agreement in autism spectrum disorder, developmental coordination disorder, and typical development

Youth diagnosed with autism spectrum disorder (ASD) and those with developmental coordination disorder (DCD) are at heightened risk for co-occurring mental health diagnoses, especially anxiety and attention-deficit/hyperactivity disorder (ADHD). However, caregiver-child agreement on presence of related symptoms in populations with neurodevelopmental conditions is not well understood. Here, we examine the extent to which 37 ASD, 26 DCD, and 40 typically developing children and their caregivers agree on the degree of the child's symptoms of anxiety and ADHD. All caregiver-child dyads completed the Screen for Child Anxiety Related Emotional Disorders and Conners 3 ADHD Index. Across groups, intraclass correlations indicated generally poor agreement on anxiety and ADHD symptomatology. Although youth generally reported greater internalizing symptoms (i.e., anxiety), caregivers tended to report more observable externalizing behaviors (i.e., ADHD). Together, the results of this study support the need for a multi-informant approach in assessments of anxiety and ADHD in youth with neurodevelopmental disorders.

Identifying subgroups of attention-deficit/hyperactivity disorder from the psychopathological and neuropsychological profiles

The Research Domain Criteria (RDoC) advocates the dimensional approach in characterizing mental disorders. We followed RDoC to characterize children with ADHD using profiling based on the cognitive and psychopathological domains. We aimed to identify and validate ADHD subtypes with different clinical characteristics and functional impairments. We recruited 362 drug-naïve children with ADHD and 103 typically developing controls. The cluster analysis was used to identify subgroups based on the Child Behaviour Checklist (CBCL) and the Behaviour Rating Inventory of Executive Function (BRIEF). The subgroups' clinical characteristics and functional impairments were assessed using the WEISS Functional Impairment Rating Scale-Parent Report (WFIRS-P) and the Conners Parent Symptom Questionnaire (PSQ). The cluster analysis yielded four subgroups: (1) ADHD with severe impairment in psychopathology and executive functions (EF), (2) ADHD with mild executive dysfunctions and normal-level psychopathology, (3) ADHD with severe externalizing problems and (4) ADHD with severe executive dysfunctions. These subgroups showed different clinical characteristics and degrees of functional impairment. The EF impairment group displayed more serious learning problems and worse life skills than the externalizing group. The two groups with externalizing problems (i.e. the severe impairment group and the externalizing group) both exhibited higher rates of the combined subtype of ADHD and higher rates of comorbid ODD. Different subtypes of ADHD displayed different profiles of internalizing and externalizing problems and levels of executive dysfunctions. In particular, the subtype with severe impairment in EF exhibited more learning problems and worse life skills, suggesting EF is a critical target for intervention in children with ADHD.

Potential Mechanisms Underlying Suicidality in Autistic People with Attention Deficit/Hyperactivity Disorder: Testing Hypotheses from the Interpersonal Theory of Suicide

Background

Autistic people with co-occurring attention deficit/hyperactivity disorder (ADHD) appear to be at heightened risk of suicide. To understand why, we explored two explanatory mechanisms from the interpersonal theory of suicide: first, that co-occurring ADHD might be associated with greater risk through greater thwarted belongingness and perceived burdensomeness and, secondly, that hyperactive/impulsive features might incur additional risk through their association with painful and provocative events, which are suggested to create "capability" for suicide.

Methods

Autistic adults (n = 314) completed an online survey including measures of thwarted belongingness, perceived burdensomeness, painful and provocative events, acquired capability for suicide, and ADHD features. Creating an overall index of likely ADHD, we examined associations between likely ADHD, suicide ideation, and lifetime suicide attempts through the parallel mediators of thwarted belongingness, perceived burdensomeness, anxiety, and depression. In several models, we then examined hyperactive, impulsive, and inattentive features as predictors of exposure to painful and provocative events and subsequent capability for suicide, and examined whether these two variables, sequentially or individually, mediated an association with lifetime suicide attempts.

Results

Likely ADHD was associated with past-year suicide ideation through greater depression and perceived burdensomeness, which also mediated its association with more suicide attempts. Hyperactive and impulsive features were associated with exposure to painful and provocative events and through this acquired suicide capability. Both features were associated with more numerous suicide attempts through these two mediators sequentially, and through exposure to painful and provocative events alone.

Conclusions

These data suggest that suicidality in autistic people with ADHD may be partially related to perceived burdensomeness and to acquired suicide capability after exposure to painful and provocative events. However, as we observed a pathway to suicidality associated with painful and provocative events alone, it is likely that there are also other explanatory mechanisms for the influence of traumatic events on suicide risk.

Comorbidity of autism spectrum and attention deficit/hyperactivity disorder symptoms and their associations with 1-year mental health outcomes in adolescents and young adults

Autism spectrum (ASD) and attention deficit/hyperactivity disorders (ADHD) share genetic, neurological, and behavioural features. However, related research in Asia is limited. We collected self-reported ASD and ADHD symptoms from 2186 Hong Kong adolescents and young adults aged 15-24 years, among whom, 1200 provided 1-year data on mental health-related outcomes. Comparative and network analyses were performed. Rating scale cutoff scores were used to divide participants into ASD, ADHD, comorbid, and control groups. The prevalence rates of ASD, ADHD, and comorbidities in Hong Kong were 13.3 %, 10.6 %, and 2.7 %, respectively. Compared with the control group, the comorbid group experienced more psychotic-like experiences (PLEs), the ASD group had poorer functioning, and the ADHD group had higher depression and anxiety symptoms and a lower quality of life after 1 year. The ability to switch attention, preference for routines and difficulty with change, and problems with organisation and planning were positively associated with depressive symptoms, forgetfulness and working memory issues with anxiety symptoms, and heightened sensory input and difficulties in sustaining attention and task completion with PLEs after 1 year. Our findings provide insight into support strategies to address the needs of young Asians to improving their well-being and long-term outcomes.

Fifty years of executive control research in attention-deficit/hyperactivity disorder:What we have learned and still need to know

For 50 years, attention-deficit/hyperactivity disorder (ADHD) has been considered a disorder of executive control (EC), the higher-order, cognitive skills that support self-regulation, goal attainment and what we generally call "attention." This review surveys our current understanding of the nature of EC as it pertains to ADHD and considers the evidence in support of eight hypotheses that can be derived from the EC theory of ADHD. This paper provides a resource for practitioners to aid in clinical decision-making. To support theory building, I draw a parallel between the EC theory of ADHD and the common gene-common variant model of complex traits such as ADHD. The conclusion offers strategies for advancing collaborative research.

Cortical responses to social stimuli in infants at elevated likelihood of ASD and/or ADHD: A prospective cross-condition fNIRS study

Autism spectrum disorders (ASD) and attention-deficit hyperactivity disorder (ADHD) are highly prevalent neurodevelopmental conditions that often co-occur and present both common and distinct neurodevelopmental profiles. Studying the developmental pathways leading to the emergence of ASD and/or ADHD symptomatology is crucial in understanding neurodiversity and discovering the mechanisms that underpin it. This study used functional near-infrared spectroscopy (fNIRS) to investigate differences in cortical specialization to social stimuli between 4- to 6-month-old infants at typical and elevated likelihood of ASD and/or ADHD. Results showed that infants at both elevated likelihood of ASD and ADHD had reduced selectivity to vocal sounds in left middle and superior temporal gyrus. Furthermore, infants at elevated likelihood of ASD showed attenuated responses to visual social stimuli in several cortical regions compared to infants at typical likelihood. Individual brain responses to visual social stimuli were associated with later autism traits, but not ADHD traits. These outcomes support our previous observations showing atypical social brain responses in infants at elevated likelihood of ASD and align with later atypical brain responses to social stimuli observed in children and adults with ASD. These findings highlight the importance of characterizing antecedent biomarkers of atypicalities in processing socially relevant information that might contribute to both phenotypic overlap and divergence across ASD and ADHD conditions and their association with the later emergence of behavioural symptoms.

Testing the triple network model of psychopathology in a transdiagnostic neurodevelopmental cohort

AIM

The triple network model of psychopathology posits that altered connectivity between the Salience (SN), Central Executive (CEN), and Default Mode Networks (DMN) may underlie neurodevelopmental conditions. However, this has yet to be tested in a transdiagnostic sample of young people.

METHOD

We investigated this in 175 children (60 girls) that represent a heterogeneous population who are experiencing neurodevelopmental difficulties in cognition and behavior, and 60 comparison children (33 girls). Hyperactivity/impulsivity and inattention were assessed by parent-report. Resting-state functional Magnetic Resonance Imaging data were acquired and functional connectivity was calculated between independent network components and regions of interest. We then examined whether connectivity between the SN, CEN and DMN was dimensionally related to hyperactivity/impulsivity and inattention, whilst controlling for age, gender, and motion.

RESULTS

Hyperactivity/impulsivity was associated with increased functional connectivity between the SN, CEN, and DMN in at-risk children, whereas it was associated with decreased functional connectivity between the CEN and DMN in comparison children. These effects replicated in an adult parcellation of brain function and when using increasingly stringent exclusion criteria for in-scanner motion.

CONCLUSION

Triple network connectivity characterizes transdiagnostic neurodevelopmental difficulties with hyperactivity/impulsivity. We suggest that this may arise from delayed network segregation, difficulties sustaining CEN activity to regulate behavior, and/or a heightened developmental mismatch between neural systems implicated in cognitive control relative to those implicated in reward/affect processing.

Rhythmic attentional sampling in autism

Individuals diagnosed with autism often display alterations in visual spatial attention toward visual stimuli, but the underlying cause of these differences remains unclear. Recent evidence has demonstrated that covert spatial attention, rather than remaining constant at a cued location, samples stimuli rhythmically at a frequency of 4-8 Hz (theta). Here we tested whether rhythmic sampling of attention is altered in autism. Participants were asked to monitor three locations to detect a brief target presented 300-1200 ms after a spatial cue. Visual attention was oriented to the cue and modified visual processing at the cued location, consistent with previous studies. We measured detection performance at different cue-target intervals when the target occurred at the cued location. Significant oscillations in detection performance were identified using both a traditional time-shuffled approach and a new autoregressive surrogate method developed by Brookshire in 2022. We found that attention enhances behavioral performance rhythmically at the same frequency in both autism and control group at the cued location. However, rhythmic temporal structure was not observed in a subgroup of autistic individuals with co-occurring attention-deficit/hyperactivity disorder (ADHD). Our results imply that intrinsic brain rhythms which organize neural activity into alternating attentional states is functional in autistic individuals, but may be altered in autistic participants who have a concurrent ADHD diagnosis.

The Prevalence of Attention Deficit/Hyperactivity Disorder Symptoms in Children and Adolescents With Autism Spectrum Disorder Without Intellectual Disability: A Systematic Review

OBJECTIVE

ADHD commonly co-occurs with ASD without ID in young people. It has been difficult to obtain accurate prevalence estimates of ADHD in this population, as a dual-diagnosis was not permitted until DSM-V. We systematically reviewed the literature on the prevalence of ADHD symptoms in young people with ASD without ID.

METHOD

9,050 articles were identified through six databases. Articles were reviewed against inclusion and exclusion criteria and 23 studies were included.

RESULTS

ADHD symptom prevalence varied from 2.6% to 95.5%. We discuss these findings according to the ADHD assessment measure, informant, diagnostic criteria, risk of bias rating and recruitment pool.

CONCLUSION

ADHD symptoms are common in young people with ASD without ID, but there is substantial variance in study reporting. Future studies should recruit participants from community sources, provide information on key sociodemographic sample characteristics and assess ADHD with standardized diagnostic criteria, using both parent/carer and teacher report.

Effects of a Nonwearable Digital Therapeutic Intervention on Preschoolers With Autism Spectrum Disorder in China: Open-Label Randomized Controlled Trial

BACKGROUND

Autism spectrum disorder (ASD) is a neurodevelopmental disorder that can cause difficulty with communication and social interactions as well as complicated family dynamics. Digital health interventions can reduce treatment costs and promote healthy lifestyle changes. These therapies can be adjunctive or replace traditional treatments. However, issues with cooperation and compliance prevent preschool patients with ASD from applying these tools. In this open-label, randomized controlled trial, we developed a nonwearable digital therapy called virtual reality-incorporated cognitive behavioral therapy (VR-CBT).

OBJECTIVE

The aim of this study was to assess the adjunctive function of VR-CBT by comparing the effects of VR-CBT plus learning style profile (LSP) intervention with those of LSP-only intervention in preschool children with ASD.

METHODS

This trial was performed in China on 78 preschool children (age 3-6 years, IQ>70) diagnosed with ASD who were randomized to receive a 20-week VR-CBT plus LSP intervention (intervention group, 39/78, 50%) or LSP intervention only (control group, 39/78, 50%). The primary outcome was the change of scores from baseline to week 20, assessed by using the parent-rated Autism Behavior Checklist (ABC). Secondary outcomes included the Childhood Autism Rating Scale (CARS), Attention-Deficit/Hyperactivity Disorder Rating Scale-IV (ADHD-RS-IV), and behavioral performance data (accuracy and reaction time) in go/no-go tasks. All primary and secondary outcomes were analyzed in the intention-to-treat population.

RESULTS

After the intervention, there was an intervention effect on total ABC (β=-5.528; P<.001) and CARS scores (β=-1.365; P=.02). A similar trend was observed in the ABC subscales: sensory (β=-1.133; P=.047), relating (β=-1.512; P=.03), body and object use (β=-1.211; P=.03), and social and self-help (β=-1.593; P=.03). The intervention also showed statistically significant effects in improving behavioral performance (go/no-go task, accuracy, β=2.923; P=.04). Moreover, a significant improvement of ADHD hyperactivity-impulsivity symptoms was observed in 53 children with comorbid ADHD based on ADHD-RS-IV (β=-1.269; P=.02). No statistically significant intervention effect was detected in the language subscale of ABC (β=-.080; P=.83). Intervention group girls had larger improvements in ABC subscales, that is, sensory and body and object use and in the CARS score and accuracy of go/no-go task (all P<.05) than the control group girls. Statistically significant intervention effects could be observed in hyperactivity-impulsivity symptoms in the intervention group boys with comorbid ADHD compared with those in the control group boys (β=-1.333; P=.03).

CONCLUSIONS

We found potentially positive effects of nonwearable digital therapy plus LSP on core symptoms associated with ASD, leading to a modest improvement in the function of sensory, motor, and response inhibition, while reducing impulsivity and hyperactivity in preschoolers with both ASD and ADHD. VR-CBT was found to be an effective and feasible adjunctive digital tool.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2100053165; http://www.chictr.org.cn/showproj.aspx?proj=137016.

Autism Spectrum Disorder in Children with an Early History of Paediatric Acquired Brain Injury

Autism spectrum disorder (ASD) is a neurodevelopmental condition that arises from a combination of both genetic and environmental risk factors. There is a lack of research investigating whether early acquired brain injury (ABI) may be a risk factor for ASD. The current study comprehensively reviewed all hospital records at The Brain Injury Service, Kids Rehab at the Children's Hospital at Westmead (Australia) from January 2000 to January 2020. Of the approximately 528 cases, 14 children with paediatric ABI were subsequently given an ASD diagnosis (2.7%). For this ASD sample, the mean age at the time of the ABI was 1.55 years, indicating a high prevalence of early ABI in this diagnostic group. The mean age of ASD diagnosis was, on average, 5 years later than the average ASD diagnosis in the general population. Furthermore, 100% of children had at least one medical comorbidity and 73% had three or more co-occurring DSM-5 diagnoses. Although based on a small data set, results highlight early paediatric ABI as a potential risk factor for ASD and the potential for a delayed ASD diagnosis following early ABI, with comorbidities possibly masking symptoms. This study was limited by its exploratory case series design and small sample size. Nonetheless, this study highlights the need for longitudinal investigation into the efficacy of early screening for ASD symptomatology in children who have sustained an early ABI to maximise potential intervention.

Human pluripotent stem cell (hPSC) and organoid models of autism: opportunities and limitations

Autism spectrum disorder (ASD) is a complex neurodevelopmental disorder caused by genetic or environmental perturbations during early development. Diagnoses are dependent on the identification of behavioral abnormalities that likely emerge well after the disorder is established, leaving critical developmental windows uncharacterized. This is further complicated by the incredible clinical and genetic heterogeneity of the disorder that is not captured in most mammalian models. In recent years, advancements in stem cell technology have created the opportunity to model ASD in a human context through the use of pluripotent stem cells (hPSCs), which can be used to generate 2D cellular models as well as 3D unguided- and region-specific neural organoids. These models produce profoundly intricate systems, capable of modeling the developing brain spatiotemporally to reproduce key developmental milestones throughout early development. When complemented with multi-omics, genome editing, and electrophysiology analysis, they can be used as a powerful tool to profile the neurobiological mechanisms underlying this complex disorder. In this review, we will explore the recent advancements in hPSC-based modeling, discuss present and future applications of the model to ASD research, and finally consider the limitations and future directions within the field to make this system more robust and broadly applicable.

Reduced inferior fronto-insular-thalamic activation during failed inhibition in young adults with combined ASD and ADHD compared to typically developing and pure disorder groups

Autism spectrum disorder (ASD) often co-occurs with attention-deficit/hyperactivity disorder (ADHD) and people with these conditions have frontostriatal functional atypicality during motor inhibition. We compared the neural and neurocognitive correlates of motor inhibition and performance monitoring in young adult males with "pure" and combined presentations with age-and sex-matched typically developing controls, to explore shared or disorder-specific atypicality. Males aged 20-27 years with typical development (TD; n = 22), ASD (n = 21), combined diagnoses ASD + ADHD (n = 23), and ADHD (n = 25) were compared using a modified tracking fMRI stop-signal task that measures motor inhibition and performance monitoring while controlling for selective attention. In addition, they performed a behavioural go/no-go task outside the scanner. While groups did not differ behaviourally during successful stop trials, the ASD + ADHD group relative to other groups had underactivation in typical performance monitoring regions of bilateral anterior insula/inferior frontal gyrus, right posterior thalamus, and right middle temporal gyrus/hippocampus during failed inhibition, which was associated with increased stop-signal reaction time. In the behavioural go/no-go task, both ADHD groups, with and without ASD, had significantly lower motor inhibition performance compared to TD controls. In conclusion, only young adult males with ASD + ADHD had neurofunctional atypicality in brain regions associated with performance monitoring, while inhibition difficulties on go/no-go task performance was shared with ADHD. The suggests that young people with ASD + ADHD are most severely impaired during motor inhibition tasks compared to ASD and ADHD but do not reflect a combination of the difficulties associated with the pure disorders.

Prevalence and treatment of mental, behavioral, and developmental disorders in children with co-occurring autism spectrum disorder and attention-deficit/hyperactivity disorder: A population-based study

There is a lack of nationally representative studies examining the co-occurrence of autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) in children. This study examines comorbid mental, behavioral, and developmental disorders (MBDDs) and associated treatment modalities for children with co-occurring ASD and ADHD. Cross-sectional analyses were conducted using data from the pooled 2016-2018 National Survey of Children's Health (sample n = 102,341). Nationally representative prevalences were estimated for sociodemographic variables, comorbidities, psychotropic medication, and behavioral treatment. We assessed multivariable associations between co-occurring ASD + ADHD and MBDDs, use of psychotropic medication, and receipt of behavioral treatment after adjustment for sociodemographic confounders. Compared to children with ASD without co-occurring ADHD, children with ASD + ADHD had higher prevalence of most MBDDs, including anxiety (AOR 4.03 [95% CI 2.77, 4.87]), depression (AOR 3.08 [95% CI 1.77, 5.36]), behavior or conduct problems (AOR 4.06 [95% CI 2.72, 6.06]), and other mental health conditions. Similarly, compared to children with ADHD without ASD, children with ASD + ADHD had higher odds of anxiety (AOR 3.49 [95% CI 2.65, 4.61]), depression (AOR 1.67 [95% CI 1.21, 2.29]), behavior or conduct problems (AOR 2.31 [95% CI 1.68, 3.17]), and other mental health conditions. Children with ASD + ADHD were significantly more likely to take psychotropic medication than children with ASD without ADHD. Among children with ASD + ADHD, males had higher odds of receiving behavioral treatment, whereas older children and adolescents were more likely to take psychotropic medication. A multidisciplinary approach is necessary to support the complex needs of these children.

Identifying activity level related movement features of children with ASD based on ADOS videos

Autism spectrum disorder (ASD) is a neurodevelopmental disorder that affects about 2% of children. Due to the shortage of clinicians, there is an urgent demand for a convenient and effective tool based on regular videos to assess the symptom. Computer-aided technologies have become widely used in clinical diagnosis, simplifying the diagnosis process while saving time and standardizing the procedure. In this study, we proposed a computer vision-based motion trajectory detection approach assisted with machine learning techniques, facilitating an objective and effective way to extract participants' movement features (MFs) to identify and evaluate children's activity levels that correspond to clinicians' professional ratings. The designed technique includes two key parts: (1) Extracting MFs of participants' different body key points in various activities segmented from autism diagnostic observation schedule (ADOS) videos, and (2) Identifying the most relevant MFs through established correlations with existing data sets of participants' activity level scores evaluated by clinicians. The research investigated two types of MFs, i.e., pixel distance (PD) and instantaneous pixel velocity (IPV), three participants' body key points, i.e., neck, right wrist, and middle hip, and five activities, including Table-play, Birthday-party, Joint-attention, Balloon-play, and Bubble-play segmented from ADOS videos. Among different combinations, the high correlations with the activity level scores evaluated by the clinicians (greater than 0.6 with p < 0.001) were found in Table-play activity for both the PD-based MFs of all three studied key points and the IPV-based MFs of the right wrist key point. These MFs were identified as the most relevant ones that could be utilized as an auxiliary means for automating the evaluation of activity levels in the ASD assessment.

Delayed recognition of autism spectrum disorder and attention-deficit/hyperactivity disorder in a girl with ornithine transcarbamylase deficiency: A case report

RATIONALE

Ornithine transcarbamylase (OTC) deficiency, a urea cycle disorder, is a rare congenital metabolic error that leads to hyperammonemia. Psychiatric symptoms of hyperammonemia are nonspecific and can cause autism spectrum disorder (ASD)-like symptoms and attention-deficit/hyperactivity disorder (ADHD)-like symptoms. Some studies report that OTC deficiency is often initially diagnosed as ASD or ADHD. However, there are no reports of OTC deficiency comorbid with ASD and ADHD.

PATIENT CONCERNS

The patient is 17-year-old girl diagnosed with OTC deficiency at 3 years of age. She had behavioral problems since childhood, including depressed mood, irritability, and impulsive behavior; however, they were considered OTC-mediated nonspecific psychiatric symptoms. Therefore, the patient had not been appropriately assessed for ASD and ADHD. She presented with depressed mood and self-harm at 17 years of age.

DIAGNOSES

We diagnosed her with ASD and ADHD based on her medical history and semistructured interviews.

INTERVENTIONS

We focused her ASD and ADHD traits and discussed strategies with her for better adaptive living.

OUTCOMES

Our interventions resulted in her better social adjustment.

LESSONS

Physicians should consider the possibility of comorbid ASD and ADHD in individuals with OTC, facilitating appropriate and intervention for better outcomes.

Clinician factors related to the delivery of psychotherapy for autistic youth and youth with attention-deficit hyperactivity disorder

LAY ABSTRACT

Autistic children and youth often experience mental health problems, such as anxiety, depression and behavioural challenges. Although there are therapy programmes that have been found helpful in reducing these issues, such as cognitive behaviour therapy, autistic children often struggle to receive adequate mental health care. Clinicians' knowledge, attitudes, confidence and beliefs about treating mental health problems in autistic people may be related to their choices in providing psychotherapy. Across Ontario, Canada, 611 mental health clinicians, working in publicly funded agencies, completed an online survey about their experiences and opinions on delivering therapy for autistic clients compared to those with attention-deficit hyperactivity disorder. Clinician knowledge was associated with their intention to treat autistic clients or clients with attention-deficit hyperactivity disorder, partly because of their attitudes and the social pressures or values they felt. Clinicians reported feeling less intent on providing therapy to autistic youth compared to youth with attention-deficit hyperactivity disorder because of differences in their attitudes, social pressures and knowledge. This research can inform the training and educational initiatives for mental health practitioners.

Distinct and shared white matter abnormalities when ADHD is comorbid with ASD: A preliminary diffusion tensor imaging study

Attention deficit/hyperactivity disorder (ADHD), a common neurodevelopmental disorder, is the most frequent comorbid condition seen in children with autism spectrum disorder (ASD). This high comorbidity between ADHD and ASD worsens symptom manifestations and complicates disease treatment and prognosis. It remains unclear whether individuals suffering with both ADHD and ASD, compared to individuals with ADHD only, share overlapping neural correlates associated with ADHD neuropathology, or exhibit a distinct neuropathological profile. Answering this question is critical to the understanding of treatment outcomes for the challenging comorbid ADHD symptoms. To identify the shared and the differentiated neural correlates of the comorbidity mechanisms of ADHD with ASD, we use diffusion tensor imaging (DTI) to characterize white-matter microstructure integrity in youth diagnosed with ADHD+ASD and youth with ADHD-only (excluding both the diagnosis and symptoms of ASD) compared with a healthy control group. Results show that the ADHD-only cohort exhibits impaired microstructural integrity (lower fractional anisotropy, FA) in the callosal-cingulum (CC-CG) tracts compared to the control cohort. The ADHD+ASD comorbid cohort shows impaired FA in an overlapping region within the CC-CG tracts and, additionally, shows impaired FA in the frontolimbic tracts including the uncinate fasciculus and anterior thalamic radiation. Across all participants, FA in the CC-CG showed a significantly negative relationship with the degree of ADHD symptom severity. Findings of this study suggest a specific role of CC-CG underlying ADHD neuropathology and symptom manifestations, and when comorbid with ASD a shared ADHD profile with a shift toward an anterior-brain, frontal impact. Results of this study may facilitate future targeted therapeutics and assist in diagnostic precision for individuals suffering with differing levels of comorbid ADHD with ASD, and ultimately contribute to improve prognostication and outcomes for these two highly prevalent and comorbid neurodevelopmental disorders.

Comparison of the Cognitive Disengagement and Hypoactivity Components of Sluggish Cognitive Tempo in Autism, ADHD, and Population-Based Samples of Children

An international Sluggish Cognitive Tempo (SCT) Work Group proposed a new term for SCT, "cognitive disengagement syndrome," that more accurately describes the syndrome than does SCT. According to the Work Group, symptoms of SCT represent a cognitive dimension (cognitive disengagement) and a motor dimension (hypoactivity). Our study determined (1) if distinct factors representing cognitive disengagement and hypoactivity emerged when SCT items were factor analyzed and (2) the degree of differences in cognitive disengagement and hypoactivity within diagnostic groups. Mothers rated 1,177 children with autism, 725 with ADHD-Combined, and 307 with ADHD-Inattentive (4-17 years) and 665 elementary school children (6-12 years) on the Pediatric Behavior Scale (PBS). SCT prevalence rates were autism 32%, ADHD-Inattentive 27%, ADHD-Combined 18%, and elementary school students 7%. Factor analysis of the SCT items yielded two factors reflecting cognitive disengagement (in a fog/confused and stares/preoccupied/in own world) and hypoactivity (sluggish/slow moving/low energy, drowsy/sleepy/not alert, and tires easily) in all diagnostic groups. Cognitive disengagement prevalence rates and scores were significantly higher than hypoactivity in the autism and ADHD-C groups and in the autism and ADHD-C subgroups of children with SCT (but not in the ADHD-I and elementary school total groups and SCT subgroups). Our findings factor analyzing five SCT items support two SCT subfactors: cognitive disengagement and hypoactivity.

Autism Spectrum Disorder and Attention-Deficit/Hyperactivity Disorder: Shared or Unique Neurocognitive Profiles?

Attention-deficit/hyperactivity (ADHD) and autism spectrum (ASD) disorders are commonly co-occurring conditions characterized by neurocognitive impairments. Few studies have directly compared neurocognitive profiles in ADHD and ASD and fewer still have controlled for comorbidity of ADHD and ASD. All direct comparisons have been in clinic samples, leaving the question of generalizability of results unaddressed. We compared neurocognitive performance in clinically ascertained ASD (n = 261) and ADHD (n = 423) cases and controls (n = 162), 6.0-17.9 years of age. We also compared ASD (n = 190) and ADHD (n = 926) cases ascertained in the community with controls (n = 14,842) of similar age. Using the stop-signal task (SST), we measured response inhibition (stop-signal reaction time-SSRT), sustained attention (defined as reaction time variability-RTV), and reaction time (RT). We controlled for comorbidity using ADHD and ASD trait scores and categorically-defined ADHD. Compared with controls, both clinic ADHD and ASD had significantly longer SSRT and RTV than controls and did not differ from each other. ADHD traits accounted for neurocognitive impairment in ASD, but not vice versa. There were no group differences for RT. Similar patterns of neurocognitive impairment were observed in the community sample. In the largest direct comparison of ADHD and ASD to date, we found impaired response inhibition and sustained attention in both disorders. However, neurocognitive impairment in ASD was almost completely accounted for by comorbid ADHD. Results generalized in the community sample indicating that referral bias alone did not drive results. Response inhibition and sustained attention likely play a role in ADHD and ASD.

Genetic Relationships between Attention-Deficit/Hyperactivity Disorder, Autism Spectrum Disorder, and Intelligence

INTRODUCTION

Attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) commonly co-occur; both traits exert an influence on intelligence scores. Genetic relationships between these three traits are far from being clear.

METHODS

The summary results of genome-wide association studies of ADHD (20,183 cases and 35,191 controls), ASD (18,381 cases and 27,969 controls), and intelligence (269,867 participants) were used for the analyses. Local genetic correlation analysis and polygenic overlap analysis were used to explore the shared genetic components between ADHD, ASD, and intelligence. Mendelian randomization (MR) analysis was used to examine the causal associations between ADHD, ASD, and intelligence. A cross-trait meta-analysis was performed to identify pleiotropic genetic variants across the three traits.

RESULTS

Our results showed that intelligence has a positive and negative genetic correlation with ASD and ADHD, respectively, including three hub genomic regions showing correlated genetic effects across the three traits. Polygenic overlap analysis indicated that all the risk variants contributing to ADHD are overlapped with half of those for intelligence, and the majority of the shared variants have opposite effect directions between them. The majority of risk variants (80%) of ASD are overlapped with almost all the risk variants of intelligence (97%). Notably, some ASD/intelligence overlapping variants displayed opposing effects on these two conditions. MR analysis showed that the genetic liability to higher intelligence was associated with an increased risk for ASD (OR = 1.12) and a decreased risk for ADHD (OR = 0.78). Cross-trait meta-analyses identified 170 pleiotropic genomic loci across the three traits, including 12 novel loci. Functional analyses of the novel genes support their potential involvement in neurodevelopment.

CONCLUSION

Our results suggest that ADHD is associated with inheriting a reduced set of low-intelligence alleles, whereas ASD results from incongruous effects from a mixture of high-intelligence and low-intelligence contributing alleles summed up with additional, ASD-specific risk variants not associated with intelligence.

Shared genetics between autism spectrum disorder and attention-deficit/hyperactivity disorder and their association with extraversion

BACKGROUND

Deciphering the genetic relationships between autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) may uncover underlining shared pathophysiology as well as inform treatment.

METHODS

The summary results of genome-wide association studies on ADHD, ASD, and extraversion were utilized for the analyzes. Genetic correlations between ADHD, ASD, and extraversion were tested using linkage disequilibrium score regression. Causal relationships between ADHD, ASD, and extraversion were investigated using Mendelian randomization (MR) analysis. Novel pleiotropic genomic loci shared by ADHD and ASD were identified using a cross-trait meta-analysis.

RESULTS

Extraversion was positively correlated with ADHD (r_g = 0.205) and negatively correlated with ASD (r_g = -0.193). The MR analysis showed that ADHD confers a causal effect on ASD (OR: 1.35, 95% confidence interval (CI):1.20-1.52) and vice versa (1.46, 1.38-1.55). Extraversion exerts a causal effect on ADHD only (1.19, 1.05-1.33). The cross-trait meta-analysis identified three novel pleiotropic genomic loci for ADHD and ASD, involving two pleiotropic genes, LINC00461 and KIZ.

CONCLUSIONS

Our study provides new insights into the shared genetics of ADHD and ASD and their connections with extraversion.

Pharmacotherapy of Attention-Deficit/Hyperactivity Disorder in Individuals with Autism Spectrum Disorder

Attention-deficit/hyperactivity disorder (ADHD) is the most frequent comorbid disorder that is observed at a higher rate and with greater morbidity in higher intellectually functioning populations with autism. Up to 85% of the populations with autism and 15% of individuals with ADHD suffer from a reciprocal comorbidity that is highly under-recognized in intellectually capable populations. Limited empirical evidence is available on the response of anti-ADHD agents in autism populations with ADHD. In autism spectrum disorder (ASD) populations, response to methylphenidate for the treatment of hyperactivity is worse than typically expected in the presence of the intellectual disability. The anti-ADHD response to atomoxetine in autism populations is worse than typically expected although tolerability is similar to that observed in the typicals. The hyperactivity response to guanfacine treatment in predominantly intellectually impaired populations with ASD is as robust as observed in the typicals although tolerability was worse than typically expected. Further trials are warranted to document the extent of atypical anti-ADHD response in intellectually capable populations with autism.

Annual Research Review: The transdiagnostic revolution in neurodevelopmental disorders

Practitioners frequently use diagnostic criteria to identify children with neurodevelopmental disorders and to guide intervention decisions. These criteria also provide the organising framework for much of the research focussing on these disorders. Study design, recruitment, analysis and theory are largely built on the assumption that diagnostic criteria reflect an underlying reality. However, there is growing concern that this assumption may not be a valid and that an alternative transdiagnostic approach may better serve our understanding of this large heterogeneous population of young people. This review draws on important developments over the past decade that have set the stage for much-needed breakthroughs in understanding neurodevelopmental disorders. We evaluate contemporary approaches to study design and recruitment, review the use of data-driven methods to characterise cognition, behaviour and neurobiology, and consider what alternative transdiagnostic models could mean for children and families. This review concludes that an overreliance on ill-fitting diagnostic criteria is impeding progress towards identifying the barriers that children encounter, understanding underpinning mechanisms and finding the best route to supporting them.

Age of Diagnosis for Co-occurring Autism and Attention Deficit Hyperactivity Disorder During Childhood and Adolescence: a Systematic Review

Early identification and intervention are recognised as important elements of the clinical pathway for autism spectrum disorder (ASD). Children with ASD and attention deficit hyperactivity disorder (ADHD) may be diagnosed at a different age than children who only have one of these diagnoses. This systematic review aimed to identify the age at which children were diagnosed with both ASD and ADHD. Of the 9552 articles screened, 12 were included in the review. The findings suggest that ASD is typically diagnosed later when ADHD is present, and ADHD is typically diagnosed earlier when ASD is present. Further research is needed to understand the factors impacting a delayed ASD diagnosis and an earlier ADHD diagnosis when the two conditions co-occur.

The effect of autistic traits on response to and side-effects of pharmacological ADHD treatment in children with ADHD: results from a prospective clinical cohort

Background

Attention deficit hyperactivity disorder (ADHD) is a common childhood behavioral condition that globally affects an average of around 5% of children and is associated with several adverse life outcomes. Comorbidity with autism spectrum disorder (ASD) is highly prevalent. Pharmacological treatment for ADHD symptoms has been shown to be effective. However, the prevailing perception is that children with ADHD and concomitant ASD symptoms report poorer efficacy and more side effects. This has been supported by studies on this population, but prospective studies directly comparing children with ADHD and different levels of ASD symptoms are lacking. We aimed to assess if children with ADHD and concomitant ASD symptoms differ regarding effects and side-effects of pharmacological ADHD treatment compared to children with ADHD without ASD traits. This is to our knowledge the second study to directly compare the effect of ADHD medication between ADHD patients with different levels of ASD symptoms.

Methods

In a non-randomized, observational, prospective cohort study, 323 patients aged 6 to 17 years who were diagnosed with ADHD and starting pharmacological treatment were divided into two groups: one with high level of ASD symptoms (ASD group, N=71) and one with low level of ASD symptoms (non-ASD group, N = 252). Treatment outcome was measured as ADHD symptoms, and evaluated using the Swanson, Nolan and Pelham Teacher and Parent ADHD rating scale-version IV (SNAP-IV). Side-effects were evaluated using the Pediatric Side Effects Checklist (P-SEC), at 3 months follow-up.

Results

From baseline to 3 months, there was no significant difference in neither treatment effect nor number of clinically significant adverse events experienced between the ASD group and the non-ASD group.

Conclusions

Our results did not implicate that ADHD patients with concomitant ASD symptoms have decreased treatment effect of ADHD medication than patients with ADHD without concomitant ASD symptoms. Neither did the results support that ADHD patients with ASD symptoms experienced significantly more side-effects than ADHD patients without ASD symptoms. Although, we did not analyze different medications separately, this is in line with the only previous study directly comparing methylphenidate treatment in children with or without ASD.

Trial registration

NCT02136147, May 12, 2014.

Inpatient Care Unit in Children and Adolescents With Autism Spectrum Disorder: Benefits, Difficulties, and Conditions of Hospitalization

ABSTRACT

Autism spectrum disorder (ASD) is a complex neurodevelopmental disorder that affects social interactions and behavior. The number of children and adolescents with ASD treated in mental health services has been growing in recent years. Knowing clinical and familial characteristics of hospitalized patients with ASD and multidisciplinary approach are crucial for children and adolescents mental health professionals. In this study, 253 Turkish children and adolescents, with and without ASD, treated in psychiatry inpatient care unit were examined. Applied approaches such as medical consultation areas, psychiatric management of mothers, and pharmacological treatment during hospitalization, were studied. In addition to familial and clinical characteristics of patients with ASD, the benefits and the hospitalization conditions were evaluated. Patients with ASD showed a higher tendency on having relatives with a psychiatric disorder than the patients without ASD. A significant difference was found in terms of age, sex, and intellectual functioning, whereas length of stay did not differ drastically. Also, suicide attempts were significantly higher in patients without ASD than in patients with ASD. This study eases the management of hospitalized ASD patients with giving important information of clinical and familial characteristics.

Evaluation of peripheral inflammatory markers, serum B12, folate, ferritin levels and clinical correlations in children with autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD)

AIM

The aim of the current study is to compare serum B12, folate, and ferritin levels and peripheral inflammatory indicators between children with Autism Spectrum Disorders (ASD), Attention Deficit Hyperactivity Disorder (ADHD), and healthy controls (HC) and to evaluate the correlation of those with symptoms.

MATERIALS AND METHODS

A total of 203 children were evaluated (ASD = 72; ADHD = 61; HC = 70). Diagnoses of ASD and ADHD were ascertained according to Schedule for Affective Disorders and Schizophrenia for School-Age Children - Present and Lifetime Version (K-SADS-PL). Control group was chosen among the healthy children who applied to general pediatrics outpatient clinic. Gilliam Autism Rating Scale-2 is used to assess autistic symptoms and Atilla Turgay DSM-IV Based Child and Adolescent Behavior Disorders Screening and Rating Scale is used for ADHD symptoms.

RESULTS

Neutrophil levels (p = 0.014) and neutrophil/lymphocyte ratio (NLR) (p = 0.016) were higher in the ADHD and ASD groups compared to HC. Neutrophil values explained 70.1% of the variance across groups while NLR explained a further 29.9% of the variance. NLR significantly correlated with social interaction problems in ASD (r = 0.26, p = 0.04). There were no significant differences between groups in terms of vitamin B12, folate and ferritin levels.

CONCLUSION

Our results may support involvement of inflammation in the underlying pathophysiology of neurodevelopmental disorders. However, these parameters should be analyzed in a wider population to clarify the effect on the etiology and symptomatology of neurodevelopmental disorders.

Consortium neuroscience of attention deficit/hyperactivity disorder and autism spectrum disorder: The ENIGMA adventure

Neuroimaging has been extensively used to study brain structure and function in individuals with attention deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) over the past decades. Two of the main shortcomings of the neuroimaging literature of these disorders are the small sample sizes employed and the heterogeneity of methods used. In 2013 and 2014, the ENIGMA-ADHD and ENIGMA-ASD working groups were respectively, founded with a common goal to address these limitations. Here, we provide a narrative review of the thus far completed and still ongoing projects of these working groups. Due to an implicitly hierarchical psychiatric diagnostic classification system, the fields of ADHD and ASD have developed largely in isolation, despite the considerable overlap in the occurrence of the disorders. The collaboration between the ENIGMA-ADHD and -ASD working groups seeks to bring the neuroimaging efforts of the two disorders closer together. The outcomes of case-control studies of subcortical and cortical structures showed that subcortical volumes are similarly affected in ASD and ADHD, albeit with small effect sizes. Cortical analyses identified unique differences in each disorder, but also considerable overlap between the two, specifically in cortical thickness. Ongoing work is examining alternative research questions, such as brain laterality, prediction of case-control status, and anatomical heterogeneity. In brief, great strides have been made toward fulfilling the aims of the ENIGMA collaborations, while new ideas and follow-up analyses continue that include more imaging modalities (diffusion MRI and resting-state functional MRI), collaborations with other large databases, and samples with dual diagnoses.

Cognitive, social, and behavioral manifestations of the co-occurrence of autism spectrum disorder and attention-deficit/hyperactivity disorder: A systematic review

LAY ABSTRACT

This work aimed to review recent research on the characteristics of individuals who have both autism spectrum disorder and attention-deficit/hyperactivity disorder due to their high co-occurrence. Thirty-four studies were analyzed and main findings summarized in two content domains focusing on areas that could enhance our understanding of the cognitive and behavioral characteristics of individuals with autism spectrum disorder + attention-deficit/hyperactivity disorder (ASD+). Most of the results suggested that ASD+ is a co-occurring condition associated with more severe impairments in cognitive functioning, adaptive behavior, and increased likelihood to present more emotional/behavioral problems. These results will be helpful to provide improved care plans for individuals with both attention-deficit/hyperactivity disorder and autism spectrum disorder.

Data-driven analysis of gaze patterns in face perception: Methodological and clinical contributions

Gaze patterns during face perception have been shown to relate to psychiatric symptoms. Standard analysis of gaze behavior includes calculating fixations within arbitrarily predetermined areas of interest. In contrast to this approach, we present an objective, data-driven method for the analysis of gaze patterns and their relation to diagnostic test scores. This method was applied to data acquired in an adult sample (N = 111) of psychiatry outpatients while they freely looked at images of human faces. Dimensional symptom scores of autism, attention deficit, and depression were collected. A linear regression model based on Principal Component Analysis coefficients computed for each participant was used to model symptom scores. We found that specific components of gaze patterns predicted autistic traits as well as depression symptoms. Gaze patterns shifted away from the eyes with increasing autism traits, a well-known effect. Additionally, the model revealed a lateralization component, with a reduction of the left visual field bias increasing with both autistic traits and depression symptoms independently. Taken together, our model provides a data-driven alternative for gaze data analysis, which can be applied to dimensionally-, rather than categorically-defined clinical subgroups within a variety of contexts. Methodological and clinical contribution of this approach are discussed.

Autistic Traits and Empathy in Children With Attention Deficit Hyperactivity Disorder, Autism Spectrum Disorder and Co-occurring Attention Deficit Hyperactivity Disorder/Autism Spectrum Disorder

Attention Deficit Hyperactivity Disorder (ADHD) and Autism Spectrum Disorders (ASD) are two of the most represented neurodevelopmental conditions in childhood. The diagnostic shift introduced by the DSM-5, allowing a combined diagnosis of ADHD and ASD, poses different clinical challenges related to diagnostic overshadowing, accuracy of clinical judgment and potential delay in an ASD diagnosis in children presenting with ADHD. Here we tried to disentangle the clinical phenotype and specificity of the two co-occurring conditions in relation to autism traits and empathy, by comparing children with ASD with and without comorbid ADHD with children presenting ADHD only and children with typical development. The child versions of the Autism Quotient (C-AQ) and Empathy Quotient (C-EQ) were administered to a total sample of 198 male children between 6 and 14 years old with age appropriate language skills and normal intelligence. Univariate analysis demonstrated no significant differences in the C-AQ total and subscale scores as well as the C-EQ between children with ASD and children with ASD + ADHD, while children with ADHD alone presented an intermediate phenotype between ASD and TD. Furthermore, a receiver operating characteristic (ROC) analysis was applied to discriminate among the different phenotypes. We found that the C-AQ and C-EQ were accurate at distinguishing with satisfactory reliability between: (a) ASD vs. non- ASD (N-ASD) groups comprising both ADHD and TD children (Area Under the Curve AUC 88% for C-AQ and 81% for C-EQ); (b) ASD and TD (AUC 92% for C-AQ and 95% for C-EQ); (c) ASD and ADHD (AUC 80% for C-AQ and 68% for C-EQ). Our data confirm the reliability of the C-AQ and C-EQ as behavioral markers to differentiate ASD (regardless of comorbid ADHD) from an ADHD condition and TD. Interestingly, in our sample an ADHD condition does not increase the severity of the clinical phenotype in terms of autism traits distribution and empathy, suggesting that the psychological measures detected by the two quantitative instruments are independent of ADHD traits. This evidence will contribute to the translational efforts in developing better tailored treatments and preventive strategies.

Inclusivity for children with autism spectrum disorders: Parents' reflections of the school learning environment versus home learning during COVID-19

Whilst attendance in mainstream school helps encourage inclusivity, these environments are recognised as being particularly challenging for young people with an autism spectrum disorder (ASD). The COVID-19 pandemic brought a novel transition as young people moved from school to home-learning. This study compared the experiences of parents of children with ASD and co-occurring health difficulties of school-learning environments with their home-learning environments during COVID-19 lockdown. An interpretative phenomenological analysis was conducted on semi-structured interviews from six parents of children (aged 8-15 years old) with ASD. Four superordinate themes were generated: Interactions between Health, ASD and Learning Environments; School Support and Managing Health Needs; Seeking Solutions; and Learning from COVID-19 Lockdown. The study highlighted the impact of ASD and co-occurring health difficulties on learning where parents found ways to provide positive home-learning environments which could be used and/or transferred back into school environments. These results hold real-world implications where educators could treat sensory and ASD friendly environments as standard and include genuine adjustments for children with ASD and additional needs. A flexible home-learning approach using parental knowledge around environmental adjustments that support learning, wellbeing and a sense of inclusion should be prioritised for children's overall development and wellbeing in these unprecedented times, and beyond.