An update on the comorbidity of ADHD and ASD: a focus on clinical management

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.

Slow but Steady: Similarities and Differences in Executive Functioning Between Autistic and Non-Autistic Adults

Prior research has established differences between autistic and non-autistic individuals across the domains of executive function (EF). While some early theories portrayed these differences as universal to the autism spectrum, recent findings have been quite mixed. Factors like small samples, the components of EF being measured, and the age and intelligence quotient (IQ) of those being compared may contribute to this diversity in results. Moreover, research suggests performance over time might fluctuate in different patterns for autistic and non-autistic individuals. To test EF differences and the possible influence of these factors upon them, we recruited a sample of over 900 autistic and non-autistic participants (with generally average/above average IQ levels) from 18 to 77 years of age. They completed a battery of tasks measuring inhibition, cognitive flexibility, working memory, and attentional orienting to social and nonsocial cues. We found that performance was similar between groups in our primary measures of EF, although autistic participants were consistently slower, more susceptible to the effects of spatial cueing, and more prone to certain errors in the working memory task. Differences between groups were generally not influenced by participants' age, gender, or IQ. Performance over time varied only in the working memory task. While autistic adults may still face related challenges in real life, these findings suggest that being autistic does not necessarily imply executive dysfunction on a basic cognitive level, contradicting theories assuming universal impairments therein. Moreover, the lack of influence of included demographic factors suggests that explanations for discrepancies in the literature lie elsewhere.

Anhedonia as a Transdiagnostic Symptom Across Psychological Disorders: A Network Approach

Background

Anhedonia is apparent in different mental disorders and is suggested to be related to dysfunctions in the reward system and/or affect regulation. It may hence be a common underlying feature associated with symptom severity of mental disorders.

Methods

We constructed a cross-sectional graphical Least Absolute Shrinkage and Selection Operator (LASSO) network and a relative importance network to estimate the relationships between anhedonia severity and the severity of symptom clusters of major depressive disorder (MDD), anxiety sensitivity (AS), attention-deficit hyperactivity disorder (ADHD), and autism spectrum disorder (ASD) in a sample of Dutch adult psychiatric patients (N = 557).

Results

Both these networks revealed anhedonia severity and depression symptom severity as central to the network. Results suggest that anhedonia severity may be predictive of the severity of symptom clusters of MDD, AS, ADHD, and ASD. MDD symptom severity may be predictive of AS and ADHD symptom severity.

Conclusions

The results suggest that anhedonia may serve as a common underlying transdiagnostic psychopathology feature, predictive of the severity of symptom clusters of depression, AS, ADHD, and ASD. Thus, anhedonia may be associated with the high comorbidity between these symptom clusters and disorders. If our results will be replicated in future studies, it is recommended for clinicians to be more vigilant about screening for anhedonia and/or depression severity in individuals diagnosed with an anxiety disorder, ADHD and/or ASD.Appeared originally in Psychol Med 2023; 53:3908-3919.

Vitamin D insufficiency and sleep disturbances in children with ADHD: a case-control study

Introduction

Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorders often co-occurring with sleep problems and other physical disorders. Vitamin D regulates sleep and supports normal brain function. Regrettably, no studies have looked at whether vitamin D insufficiency exacerbates sleep problems in ADHD children and further affects ADHD symptoms.

Objective

This study aimed to examine whether vitamin D insufficiency exacerbates sleep problems and ADHD symptoms in children aged 6-14 years.

Methods

This is a case-control study, 260 ADHD children (aged 6-14 years) were enrolled in, of whom 95 had vitamin D insufficiency and 165 had sufficiency. Collected all ADHD symptom severity and functional impairment scales, including Swanson, Nolan and Pelham (SNAP) scale, Integrated Visual and Auditory Continuous Performance Test (IVA-CPT), Conners parents symptom questionnaire (PSQ) and Weiss Functional Impairment Rating Scale-Parent Form (WFIRS-P). All guardians of children with ADHD complete the Children's Sleep Habits Questionnaire (CSHQ).

Results

The CSHQ total scores of the ADHD children in both groups were significantly higher than 41, which means that ADHD children overall have sleep problems. Compared to ADHD children with vitamin D sufficiency group, we observed significantly higher sleep duration and sleep disordered breathing scores in ADHD children with vitamin D insufficiency group (all p< 0.05). However, there was no direct effect of vitamin D insufficiency on the type of ADHD, symptoms or functional impairment (all p> 0.05). Further analyses showed a correlation between the CSHQ and symptoms, functional impairment scores in children with ADHD.

Conclusion

Sleep problems are highly prevalent in children with ADHD. Vitamin D insufficiency has a significant impact on both sleep duration and sleep disordered breathing, but no notable direct effects on ADHD symptoms or functional impairment. Our findings underscore the importance of screening for vitamin D insufficiency in children with ADHD, particularly given its association with sleep disturbances, which may indirectly affect symptom severity.

Challenges for neurodiverse children in acute medical hospitals and opportunities for the new National Children's Hospital to be 'neurodiversity-friendly'

Neurodiversity refers to the variation in human cognitive, sensory, and communication experiences and reframes deficits as differences. Rates and duration of hospitalisation in neurodiverse children are higher compared to their neurotypical peers. Despite increased admissions, paediatric medical hospitals are poorly equipped to adequately support their unique cognitive, sensory, behavioural, and communication needs, which can have negative impacts on the experiences of patients, families, and staff. The literature supports several innovative and inclusive strategies, which present exciting opportunities for Ireland's new National Children's Hospital (NCH) to become a 'neurodiversity-friendly paediatric hospital'.

Effect of comorbid allergic diseases on attention-deficit hyperactivity disorder symptoms and sleep: A cross-sectional study

INTRODUCTION

Recent studies have shown a close relationship between attention-deficit hyperactivity disorder (ADHD) and allergic diseases in children. Regrettably, few studies have investigated the effect of comorbid allergies on ADHD symptoms and sleep, in particular, it is unclear whether comorbid allergic conditions further exacerbate sleep problems in children with ADHD.

OBJECTIVE

To investigate the effect of comorbid allergic on symptoms and sleep in children with ADHD.

METHODS

This was a cross-sectional study, 222 ADHD children (aged 6-14 years) were enrolled in, of whom 93 had allergic diseases and 129 without allergic diseases. Collected all ADHD symptom severity and functional impairment scales, including: Swanson, Nolan and Pelham (SNAP) scale, Integrated Visual and Auditory Continuous Performance Test (IVA-CPT), Conners Parents Symptom questionnaire (PSQ) and Weiss Functional Impairment Rating Scale-Parent Form (WFIRS-P). Every guardian of children diagnosed with ADHD is required to complete the Children's Sleep Habits Questionnaire (CSHQ).

RESULTS

Compared to ADHD children without allergic diseases, we observed significantly higher hyperactivity and impulsivity scores on the SNAP-IV, higher hyperactivity index and impulsivity index on the PSQ, and higher risky activities on the WFIRS-P in ADHD children with comorbid allergic diseases (all p < 0.05). CSHQ total score and sleep disordered breathing were particularly prominent in ADHD children with comorbid allergic diseases (all p < 0.05), and changes in CSHQ correlate with ADHD symptoms and functional impairment. Further analyses revealed that ADHD symptoms and sleep did not worsen with increasing number of comorbid allergic diseases (all p > 0.05). The primary influence on ADHD symptoms and sleep was the type of allergic diseases, where food allergies predominantly influence ADHD symptoms, including attention deficit disorder and hyperactivity disorder (all p < 0.05); allergic rhinitis notably impacts parasomnias, sleep disordered breathing (all p < 0.05); and allergic asthma significantly affects sleep anxiety, daytime sleepiness, and sleep disordered breathing in children with ADHD (all p < 0.05).

CONCLUSION

The presence of comorbid allergic diseases affects both the hyperactivity and impulsivity symptoms of ADHD and sleep disordered breathing, predominantly influenced by the type of the allergic diseases.

Behavioral characteristics of toddlers later identified with an autism diagnosis, ADHD symptoms, or combined autism and ADHD symptoms

BACKGROUND

Autism commonly co-occurs with attention-deficit/hyperactivity disorder (ADHD), but less is known regarding how ADHD symptoms impact the early presentation of autism. This study examined early behavioral characteristics of a community sample of toddlers later identified with autism diagnosis, ADHD symptoms, combined autism and ADHD symptoms, or neither condition.

METHODS

Participants were 506 toddlers who were part of a longitudinal study of children's behavioral development. Parents completed questionnaires about their children's behavior at two time points. Four groups were identified based on study measures or medical record: autism diagnosis (n = 45), elevated ADHD symptoms (n = 70), autism and ADHD symptoms (n = 30), or neurotypical development (n = 361). Relationships between early parent report of autism- and ADHD-related behaviors, social-emotional and behavioral functioning, and caregiver experience and subsequent group designation were evaluated with adjusted linear regression models controlling for sex.

RESULTS

Significant group differences were found in measures of autism-related behaviors, ADHD-related behaviors, externalizing and internalizing behaviors, and parent support needs (p < .0001). Pairwise comparisons indicated toddlers later identified with combined autism diagnosis and ADHD symptoms had higher levels of autism-related behaviors, externalizing and internalizing behaviors, and autism-related parent support needs compared to the other groups. Toddlers with subsequent elevated ADHD symptoms or combined autism diagnosis and ADHD symptoms exhibited similar levels of ADHD-related behaviors, while both groups displayed more ADHD-related behaviors than toddlers subsequently identified with autism or those with neither condition.

CONCLUSIONS

In this community sample, toddlers for whom combined autism diagnosis and ADHD symptoms were subsequently identified showed a distinct presentation characterized by higher early autism-related behaviors, broader behavioral concerns, and higher parent support needs. Presence of ADHD symptoms (alone or in combination with autism) was associated with higher parent-reported ADHD-related behaviors during toddlerhood. Results indicate that ADHD-related behaviors are manifest by toddlerhood, supporting screening for both autism and ADHD during early childhood.

Mapping the landscape and evidence of cross-sectoral collaboration models targeting individuals referred for assessment of attention-deficit hyperactivity disorder or autism spectrum disorder: protocol for a scoping review

INTRODUCTION

Neurodevelopmental disorders, notably attention-deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD), present substantial challenges in mental health. Individuals referred for assessment in a psychiatric unit experience complex needs. This implies that their needs necessitate coordination across multiple sectors. Cross-sectoral collaboration models have emerged as essential strategies for addressing the complexities of these disorders. However, evidence of their existence, implementation and success remains limited. This protocol aims to outline a scoping review where we will explore existing collaboration models, evaluate their implementation and gain an understanding of how cross-sectoral collaboration models can be developed to ultimately benefit individuals referred for assessment of ADHD or ASD.

METHODS AND ANALYSIS

This proposed scoping review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. A comprehensive search will be conducted across PubMed, CINAHL, Embase, PsycINFO and Google Scholar, as well as grey literature sources, between 1 December 2024 and 1 January 2025. Inclusion criteria will encompass studies focusing on cross-sectoral collaboration for individuals referred for assessment of ADHD or ASD, published in English, Danish, Norwegian or Swedish. The search will use a three-block search string, with iterative refinement guided by familiarity with the evidence base. Data extraction will involve study characteristics and implementation details, using the Consolidated Framework for Implementation Research in combination with Proctor et al's implementation outcomes framework. Results will be synthesised into descriptive tables, providing a comprehensive mapping of existing models and emphasising implementation feasibility.

ETHICS AND DISSEMINATION

Ethical approval is not required for this protocol since it involves the review of existing literature without the involvement of human participants or personal data. Findings will be disseminated at national and international conferences and will be integrated into future efforts to develop cross-sectoral collaboration models in Denmark.

The Daydream Spectrum: The Role of Emotional Dysregulation, Internalized Stigma and Self-Esteem in Maladaptive Daydreaming Among Adults With ADHD, ASD, and Double Diagnosis

OBJECTIVE

Maladaptive daydreaming (MD) is characterized by vivid, excessive fantasy activity that becomes prioritized over other activities and may result in avoidant coping strategies. Little is known about the relationship between MD and internalized stigma in the neurodivergent sample. The current study aimed to examine emotional dysregulation, escapism and self-perception (self-esteem and internalized stigma) as potential determinants of MD in three groups: adults on the autism spectrum, with ADHD, and both diagnoses ("AuDHD"), including their neurodivergent symptoms (autistic traits, empathizing, ADHD symptoms).

METHODS

A sample of 293 persons (139 with ADHD, 74 on the autism spectrum, and 80 with both diagnoses) completed self-report scales concerning ADHD symptoms, autism spectrum symptoms, empathizing, self-esteem, daydreaming as escapism, emotional dysregulation, maladaptive daydreaming, and internalized stigma. A correlation analysis was implemented. Additionally, a group comparison and quantile regression for the 25th, 50th, and 75th percentile of maladaptive daydreaming in the three groups were executed.

RESULTS

The results showed that internalized stigma, emotional dysregulation, escapism, and self-esteem have significant associations with MD in the neurodiverse sample. The ADHD group achieved the lowest scores in emotional dysregulation, discrimination experience, and social withdrawal. The groups did not vary in MD rates, stereotype endorsement, stigma resistance, nonacceptance of emotional responses, and impulse control difficulties. The AuDHD group achieved higher results than the ASD group only in the ADHD symptoms. Quantile regression revealed differences in the predictors of maladaptive daydreaming in the three groups. ADHD symptoms and self-suppression escapism were significant predictors for the higher levels of MD in persons with singular autism or ADHD diagnosis.

CONCLUSION

The results showed no differences in MD rates, although there were significant variations in predictive features among the three samples. The role of internalized stigma and self-esteem was highlighted in the results as significant associates of MD prevalence. These outcomes expand the current knowledge in the context of maladaptive daydreaming, internalized stigma, self-esteem and emotional dysregulation in a neurodiverse sample and allow for proposing clinical applications and further research directions.

Peer Problems and Prosocial Behavior Among Icelandic Children and Adolescents with ADHD and/or Autism: Gender and Age Differences

Children with neurodevelopmental disorders tend to have more social difficulties than typically developing children. The aim of the current study was to examine parent and teacher-reported effects of age and gender on social functioning in a large clinical sample of children and adolescents with ADHD, autism, or co-occurring ADHD and autism using a cross-sectional study design. This nationwide clinical sample included 2132 Icelandic children and adolescents (35% girls, 65% boys) aged 5-18 years referred for a neurodevelopmental diagnostic assessment (ADHD and/or autism) in Iceland. Social functioning was measured using the Prosocial behavior and Peer problem subscales on the Strengths and Difficulties Questionnaire (SDQ) completed by parents and teachers. Results revealed that autistic youth and youth with co-occurring ADHD and autism experienced more peer problems and showed less prosocial behavior than youth with ADHD only. According to parents and teachers, girls were found to experience more social difficulties compared to boys. Interaction for age and gender, although only significant for teacher reports, indicated that younger girls with neurodevelopmental disorders experience more peer problems and show less prosocial behavior than older girls. In contrast, boys with neurodevelopmental disorders experience similar issues at all ages. The results suggest different patterns of social difficulties for boys and girls with neurodevelopmental disorders. Future research should examine different developmental pathways of social challenges for boys and girls. Implications for developing and providing clinical interventions appropriate developmental stages are discussed.

Connectome-based symptom mapping and in silico related gene expression in children with autism and/or attention-deficit/hyperactivity disorder

Clinical, neuroimaging and genomics evidence have increasingly underscored a degree of overlap between autism and attention-deficit/hyperactivity disorder (ADHD). This study explores the specific contribution of their core symptoms to shared biology in a sample of N=166 verbal children (6-12 years) with rigorously-established primary diagnoses of either autism or ADHD (without autism). We investigated the associations between inter-individual differences in clinician-based dimensional measures of autism and ADHD symptoms and whole-brain low motion intrinsic functional connectivity (iFC). Additionally, we explored their linked gene expression patterns in silico. Whole-brain multivariate distance matrix regression revealed a transdiagnostic association between autism severity and iFC of two nodes: the middle frontal gyrus of the frontoparietal network and posterior cingulate cortex of the default mode network. Across children, the greater the iFC between these nodes, the more severe the autism symptoms, even after controlling for ADHD symptoms. Results from segregation analyses were consistent with primary findings, underscoring the significance of internetwork iFC interactions for autism symptom severity across diagnoses. No statistically significant brain-behavior relationships were observed for ADHD symptoms. Genetic enrichment analyses of the iFC maps associated with autism symptoms implicated genes known to: (i) have greater rate of variance in autism and ADHD, and (ii) be involved in neuron projection, suggesting shared genetic mechanisms for this specific brain-clinical phenotype. Overall, these findings underscore the relevance of transdiagnostic dimensional approaches in linking clinically-defined phenomena to shared presentations at the macroscale circuit- and genomic-levels among children with diagnoses of autism and ADHD.

Sleep problems and circadian rhythm functioning in autistic children, autism with co-occurring attention deficit hyperactivity disorder, and typically developing children: A comparative study

LAY ABSTRACT

Sleep problems are common in autism spectrum disorder (ASD) and different factors can contribute to its occurrence in this population. Misalignment of the biological clock (our circadian system) has been described as one possible explanation. While there is a body of research on sleep problems, relatively less is known about circadian functioning and the specific population of autistic children with co-occurring attention deficit hyperactivity disorder (ADHD). Using an ambulatory circadian monitoring (ACM) system, which resembles a common watch, we gathered sleep parameters and the different rhythms obtained from measuring motor activity, light exposure and distal temperature in 87 autistic children and adolescents, 27 of whom were diagnosed with co-occurring ADHD, and 30 neurotypical children and adolescents as a comparison group. Autistic children and, especially, those with co-occurring ADHD showed greater motor activity during sleep which would be worth studying in future projects which could better define this restless sleep. Of note, we observed an atypical pattern of wrist temperature, with higher values in neurotypical children, followed by autistic children and, ultimately, those with co-occurring ADHD. Temperature is one of the most valuable factors evaluated here as it is closely connected to sleep-wakefulness and the hormone melatonin. Its special pattern during day and nighttime would support the hypothesis of an atypical secretion of melatonin in autistic individuals which would also link with the higher presence of sleep problems in this neurodevelopmental condition.

Prevalence Trends and Treatment Patterns of Autism Spectrum Disorder Among Children and Adolescents in the United States from 2017 to 2020

BACKGROUND

Autism spectrum disorder (ASD) poses a significant challenge due to its diverse impact on individuals, emphasizing the need for personalized treatment plans. The financial burden of ASD-related healthcare is substantial, necessitating a comprehensive understanding of its prevalence and evolving trends.

METHODS

This study aims to analyze the prevalence and trends of ASD, treatment patterns, gender differences, and racial-ethnic disparities in the United States from 2017 to 2020, utilizing nationally representative data from the National Survey of Children's Health (NSCH). The NSCH, a leading annual national survey, provided rich data on child health. A total of 108,142 participants aged 3-17 years were included, with ASD prevalence assessed based on self-reported diagnoses.

RESULTS

Between 2017 and 2020, ASD prevalence in children aged 3-17 was 2.94% (95% confidence interval: 2.68-3.18). Significant disparities were observed: older age and male gender correlated with higher prevalence, while family income-to-poverty ratio and insurance coverage influenced prevalence. Racial/ethnic disparities existed, with Hispanics showing the highest prevalence. Treatment trends showed stability overall, but age influenced behavioral and medication interventions. The prevalence remained stable from 2017 to 2020, with variations in age groups and a significant increase among non-Hispanic Whites.

CONCLUSIONS

This study highlights a higher but stable overall ASD prevalence, with nuanced disparities among different demographic groups. Gender differences persist, emphasizing the need for tailored interventions. Racial-ethnic disparities call for targeted healthcare strategies. The stability in treatment trends underscores the persistent challenge of addressing core ASD symptoms.

Response inhibition as a critical executive function in differentiating attention-deficit/hyperactivity disorder from autism spectrum disorder: a comprehensive attention test study

Background

Autism Spectrum Disorder (ASD) and Attention-Deficit/Hyperactivity Disorder (ADHD) are both associated with impairment in executive function, particularly in complex attention. Although previous studies using clinical assessments have attempted to delineate differences between these disorders, the findings have been inconclusive. Our study aims to elucidate the differences of endophenotype between ASD, ADHD, and their co-occurring condition utilizing a uniform computerized test.

Methods

The study included children diagnosed with ASD, ASD co-occurring with ADHD (ASD+ADHD), or ADHD who completed the comprehensive attention test (CAT) at Severance Hospital between October 2013 to May 2023. We excluded children with intellectual disability and comorbid major psychiatric or neurologic disorders possibly affecting attention measurement. The participants were categorized into three groups for the comparative analysis of CAT measures: (a) ASD (n=112), (b) ASD+ADHD (n=155), and (c) ADHD (n=104). The study also conducted an exploratory analysis utilizing multivariate linear regression analysis to examine the association between the CAT measures and parent-reported scales.

Results

Notably, the ASD+ADHD and ADHD groups exhibited higher frequency of commission errors (CE) and perseveration errors (PE) compared to the ASD group. In the exploratory analysis, a significant negative association was observed between reaction time (RT) and both the social communication questionnaire (SCQ) and the child behavior checklist (CBCL) externalization scores in the ASD+ADHD and ADHD groups. The ASD+ADHD group tended to show higher standard deviation of reaction time (RTSD) compared to the ASD group.

Conclusions

Our findings suggest that impaired response inhibition is more pronounced in ADHD compared to ASD. We propose altered visual attention, reflecting response inhibition, may serve as potential endophenotypic markers differentiating ADHD from ASD in attentional assessment. Elevated RTSD in the ASD+ADHD group demonstrates additive pathology, suggesting that the neurological mechanisms underpinning impaired sustained attention may differ between the two conditions.

Heterogeneity and convergence across seven neuroimaging modalities: a review of the autism spectrum disorder literature

Background

A growing body of literature classifies autism spectrum disorder (ASD) as a heterogeneous, complex neurodevelopmental disorder that often is identified prior to three years of age. We aim to provide a narrative review of key structural and functional properties that differentiate the neuroimaging profile of autistic youth from their typically developing (TD) peers across different neuroimaging modalities.

Methods

Relevant studies were identified by searching for key terms in PubMed, with the most recent search conducted on September 1, 2023. Original research papers were included if they applied at least one of seven neuroimaging modalities (structural MRI, functional MRI, DTI, MRS, fNIRS, MEG, EEG) to compare autistic children or those with a family history of ASD to TD youth or those without ASD family history; included only participants <18 years; and were published from 2013 to 2023.

Results

In total, 172 papers were considered for qualitative synthesis. When comparing ASD to TD groups, structural MRI-based papers (n = 26) indicated larger subcortical gray matter volume in ASD groups. DTI-based papers (n = 14) reported higher mean and radial diffusivity in ASD participants. Functional MRI-based papers (n = 41) reported a substantial number of between-network functional connectivity findings in both directions. MRS-based papers (n = 19) demonstrated higher metabolite markers of excitatory neurotransmission and lower inhibitory markers in ASD groups. fNIRS-based papers (n = 20) reported lower oxygenated hemoglobin signals in ASD. Converging findings in MEG- (n = 20) and EEG-based (n = 32) papers indicated lower event-related potential and field amplitudes in ASD groups. Findings in the anterior cingulate cortex, insula, prefrontal cortex, amygdala, thalamus, cerebellum, corpus callosum, and default mode network appeared numerous times across modalities and provided opportunities for multimodal qualitative analysis.

Conclusions

Comparing across neuroimaging modalities, we found significant differences between the ASD and TD neuroimaging profile in addition to substantial heterogeneity. Inconsistent results are frequently seen within imaging modalities, comparable study populations and research designs. Still, converging patterns across imaging modalities support various existing theories on ASD.

Gray matter asymmetry alterations in children and adolescents with comorbid autism spectrum disorder and attention-deficit/hyperactivity disorder

Despite the high coexistence of autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) (ASD + ADHD), the underlying neurobiological basis of this disorder remains unclear. Altered brain structural asymmetries have been verified in ASD and ADHD, respectively, making brain asymmetry a candidate for characterizing this coexisting disorder. Here, we measured the gray matter (GM) volume asymmetry in ASD + ADHD versus ASD without ADHD (ASD-only), ADHD without ASD (ADHD-only), and typically developing controls (TDc). High-resolution T1-weighted data from 48 ASD + ADHD, 63 ASD-only, 32 ADHD-only, and 211 matched TDc were included in our study. We also assessed brain-behavior relationships and the effects of age on GM asymmetry. We found that there were both shared and disorder-specific GM volume asymmetry alterations in ASD + ADHD, ASD-only, and ADHD-only compared with TDc. This finding demonstrates that ASD + ADHD is neither an endophenocopy nor an additive pathology of ASD and ADHD, but an entirely different neuroanatomical pathology. In addition, ASD + ADHD displayed altered GM volume asymmetries in the prefrontal regions responsible for executive function and theory of mind compared with ASD-only. We also found significant effects of age on GM asymmetry. The present study may provide structural insights into the neural basis of ASD + ADHD.

Visual and auditory attention in individuals with DYRK1A and SCN2A disruptive variants

This preliminary study sought to assess biomarkers of attention using electroencephalography (EEG) and eye tracking in two ultra-rare monogenic populations associated with autism spectrum disorder (ASD). Relative to idiopathic ASD (n = 12) and neurotypical comparison (n = 49) groups, divergent attention profiles were observed for the monogenic groups, such that individuals with DYRK1A (n = 9) exhibited diminished auditory attention condition differences during an oddball EEG paradigm whereas individuals with SCN2A (n = 5) exhibited diminished visual attention condition differences noted by eye gaze tracking when viewing social interactions. Findings provide initial support for alignment of auditory and visual attention markers in idiopathic ASD and neurotypical development but not monogenic groups. These results support ongoing efforts to develop translational ASD biomarkers within the attention domain.

Relationships between Sensory Processing and Executive Functions in Children with Combined ASD and ADHD Compared to Typically Developing and Single Disorder Groups

The prevalence of autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) is increasing, with a tendency for co-occurrence. Some studies indicate a connection between atypical sensory processing and executive function. This study aims to explore the distinctive etiology of executive function deficits in children with ASD+ADHD by investigating the relationship between sensory processing and executive function, comparing children with ASD, ASD+ADHD, ADHD, and typically developing children (TD).

METHOD

Sensory Profile 2 (SP-2) and Behavior Rating Inventory of Executive Function 2 (BRIEF-2) were measured in 120 school-aged children. The results of the above scales were compared across these four groups, and correlation and regression analyses between BRIEF2 and SP2 were conducted.

RESULTS

Our research revealed varying levels of atypical sensory processing and executive function anomalies across the three neurodevelopmental disorder groups compared to the TD group. The ASD+ADHD group showed particularly significant differences. The heightened emotional problems observed in ASD+ADHD children may be associated with more prominent atypical sensory processing. Variance analysis of inhibitory function revealed differences between ASD+ADHD and ADHD children, suggesting distinct etiological mechanisms for attention issues between ASD+ADHD and ADHD.

CONCLUSIONS

ASD+ADHD represents a phenotype distinct from both ASD and ADHD. Special consideration should be given to interventions for children with ASD+ADHD. The results of this study may offer a new perspective on understanding the occurrence of ASD+ADHD and potential individualized intervention methods.

The distribution of parent-reported attention-deficit/hyperactivity disorder and subclinical autistic traits in children with and without an ADHD diagnosis

Background

Autistic traits are often reported to be elevated in children diagnosed with attention-deficit/hyperactivity disorder (ADHD). However, the distribution of subclinical autistic traits in children with ADHD has not yet been established; knowing this may have important implications for diagnostic and intervention processes. The present study proposes a preliminary model of the distribution of parent-reported ADHD and subclinical autistic traits in two independent samples of Australian children with and without an ADHD diagnosis.

Methods

Factor mixture modelling was applied to Autism Quotient and Conners' Parent Rating Scale - Revised responses from parents of Australian children aged 6-15 years who participated in one of two independent studies.

Results

A 2-factor, 2-class factor mixture model with class varying factor variances and intercepts demonstrated the best fit to the data in both discovery and replication samples. The factors corresponded to the latent constructs of 'autism' and 'ADHD', respectively. Class 1 was characterised by low levels of both ADHD and autistic traits. Class 2 was characterised by high levels of ADHD traits and low-to-moderate levels of autistic traits. The classes were largely separated along diagnostic boundaries. The largest effect size for differences between classes on the Autism Quotient was on the Social Communication subscale.

Conclusions

Our findings support the conceptualisation of ADHD as a continuum, whilst confirming the utility of current categorical diagnostic criteria. Results suggest that subclinical autistic traits, particularly in the social communication domain, are unevenly distributed across children with clinically significant levels of ADHD traits. These traits might be profitably screened for in assessments of children with high ADHD symptoms and may also represent useful targets for intervention.

Social Functioning in Children and Adolescents with ADHD and Autism Spectrum Disorder: A Cross-Disorder Comparison

OBJECTIVE

Social functioning can be defined according to three main components: social perception, social performance, and social knowledge. Although they are important in daily life relationships and in children's adaptation, these components have never been tested together in children and adolescents with Attention Deficit/Hyperactivity Disorder (ADHD) or with Autism Spectrum Disorder (ASD) using lab-based tasks. The present study used a cross-disorder approach to compare the performance of children with ADHD and ASD and non-diagnosed (ND) peers utilizing a task that involves these three fundamental social functioning components.

METHODS

Two hundred and twenty-five Italian children (86% boys) aged between 8 and 16 (66 with a clinical diagnosis of ADHD; 51 with a clinical diagnosis of ASD, level 1; 108 ND children) were enrolled. The three groups were matched for age, gender, and IQ. Social functioning was assessed using a lab-based task, including videos of problematic interactions among peers, created ad hoc for the study, and a semi-structured interview based on the Social Information Processing model.

RESULTS

Data were analyzed using one-way ANOVAs and multinomial mixed effects models. Our findings suggested that both groups with ADHD and ASD presented social functioning difficulties in comparison to ND children. However, a different pattern of performance emerged. Children with ADHD showed higher difficulties in social performance than those with ASD, whereas autistic children revealed more difficulties in social perception and in some aspects of social knowledge.

CONCLUSIONS

Our findings have important clinical implications for assessment, intervention, and differential diagnosis, and should encourage clinicians to investigate different aspects of social functioning and identify specific strengths and weaknesses in each social profile.

The effectiveness of a dialogical family guidance intervention regarding child treatment response in families with a child with neurodevelopmental disorders

BACKGROUND

Children with neurodevelopmental disorders (NDD) can have emotional and behavioral symptoms affecting not only the child, but the whole family. Since family members have a strong impact on each other, studies highlight the need to offer effective family interventions to strengthen the wellbeing of the family. The aim of the current study is to clarify whether there is a difference between parents` opinions regarding their child`s emotional and behavioral condition immediately after Dialogical Family Guidance (DFG) has ended and after a three and six month follow-up.

METHOD

Fifty families with a child with NDD were randomized into two groups. Group 1 received DFG with an immediate starting point, and Group 2 received DFG after a three-month waiting period. Parent experiences of treatment response regarding their children`s emotional and behavioral symptoms were estimated before and after DFG using the parent version of the Strengths and Difficulties Questionnaire (SDQ-p) at baseline, and after three and six months. Additionally, comparisons between boys and girls, and the age of the child were analyzed.

RESULTS

The total difficulties score between Group 1 and Group 2 showed no difference immediately after DFG, or after three months. Regarding subdomains boys had more peer problems than girls, and at baseline, children between 3 and 6 years appeared to have more conduct problems than children between 7 and 13 years. Subdomain prosocial behavior increased statistically significantly during the study period in Group 1. Other SDQ-p subdomains remained constant in both groups between baseline and three and six month follow-up.

CONCLUSIONS

The result does not show any differences between parents` opinions regarding their child immediately after or three months after DFG regarding SDQ-p total difficulties scores in either group. The difference between younger and older children regarding conduct problems at baseline, and the difference between boys and girls regarding peer problems is worth paying attention to in the clinical setting. Because of the small sample, it is not possible to draw relevant conclusions regarding the intervention`s effect regarding the child`s mental health dimensions, gender, or age. Nevertheless, Dialogical family Guidance represents one intervention that can be used.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04892992 (retrospectively registered May 18th 2021).

Enhancing emotion recognition in young autistic children with or without attention-deficit/hyperactivity disorder in Hong Kong using a Chinese App version of The Transporters

TRIAL REGISTRATION

This study was registered with the German Clinical Trials Register - Deutschen Register Klinischer Studien (DRKS) on 23 December 2018. The Trial Registration Number (TRN) is DRKS00016506.

LAY ABSTRACT

The Transporters App is an intervention programme with 15 animated episodes that teach emotion recognition skills to autistic children between 4 and 6 years of age. Each episode contains a story depicting social interactions between characters in the form of a vehicle, with human faces grafted on to each of them. Each episode teaches a specific emotion in a story context. Autistic children watched at least three episodes at home for about 15 min daily for a month, with parental guidance. Its automated, home-based format is cost-saving and readily accessible. This study translated The Transporters to a Cantonese-Chinese version. Results showed a significant improvement in emotion recognition following viewing The Transporters in a group of Hong Kong Chinese autistic children, between 4 and 6 years of age, with and without attention-deficit/hyperactivity disorder (n = 48) relative to a control group (n = 24). A non-autistic group (n = 23) showed that the autistic children scored lower in emotion recognition pre-intervention. Post-intervention, the autistic children had improved in emotion recognition to the level of the non-autistic children. The autistic children in the intervention groups also generalized their learning to novel situations/characters not taught within The Transporters. There was no dosage effect, with the standard recommended number of episodes viewed being sufficient to achieve significant improvement. This study confirms the effectiveness of The Transporters for Chinese autistic children and contributes to the literature/practice by expanding the range of applicability of The Transporters to autistic children with attention-deficit/hyperactivity disorder, which is important given the high rate of co-occurrence between autism and attention-deficit/hyperactivity disorder.

Parental Experiences of Distance Learning in Families with and without an Adolescent with ADHD/ASD: A Large Qualitative Survey Study

One of the greatest COVID-19-related challenges for children and their families was managing distance learning due to school closures. We also know from previous research that families with a child with a neurodevelopmental disorder such as ADHD or ASD were struggling more than others but also experienced some positive effects. However, few qualitative studies have been conducted. The present study therefore aimed to investigate parental experiences of the negative and positive effects of distance learning during the COVID-19 pandemic in a large sample of families with an adolescent with ADHD and/or ASD and a matched comparison group (n = 682). Data were collected through open-ended questions as part of a larger survey study. Five main themes with different sub-themes were identified for both negative and positive effects: (1) Teaching, (2) Social, (3) Support, (4) Child factors, and (5) Home environment. In addition, the main theme "Technical problems" was identified for negative effects. Families with a child with ADHD/ASD reported negative effects related to "Child factors" and "Support" more frequently than the controls, as well as negative effects related to some aspects of "Teaching" and "Technical problems". Regarding positive effects, significant group differences were primarily found for the theme "Child factors". These findings are discussed both in terms of how to best prepare for possible future pandemics, but also of how to best provide educational support for children with ADHD and/or ASD when schools are open.

Heightened Anxiety and Depression Among Autistic Adolescents with ADHD: Findings From the National Survey of Children's Health 2016-2019

Data from the National Survey of Children's Health 2016-2019 was used to examine the co-occurrence of autism and ADHD and the impact on anxiety and depression among adolescents age 12-17. Rates of anxiety and depression were up to ten-fold the prevalence of adolescents not diagnosed with autism or ADHD. Over half of autistic females (57%) and nearly half of autistic males (49%) are also diagnosed with ADHD. Autistic females with ADHD had the highest co-occurrence of anxiety at 72% followed by autistic males with ADHD at 69%. The prevalence of depression was highest among autistic adolescents with ADHD yet was consistent across genders (male/female) at 38-39%. Adolescents diagnosed with autism and/or ADHD are at heightened risk for anxiety and depression.

Could Sensory Differences Be a Sex-Indifferent Biomarker of Autism? Early Investigation Comparing Tactile Sensitivity Between Autistic Males and Females

Sensory differences are highly prevalent in autistic individuals. However, few studies have compared their presentation between autistic males and autistic females. We used psychophysics to assess and compare tactile perceptual sensitivity between autistic and non-autistic boys and girls aged between 8 and 12 years of age. While there were sex-differences of amplitude discrimination, frequency discrimination and order judgement thresholds, these sex-differences were not autism-specific. Mean RTs and detection thresholds were elevated in autism but were comparable between the sexes. Tactile sensitivity measures that are elevated in autism but are otherwise comparable between autistic males and autistic females suggest the possibility that certain sensory features could be used as sex-indifferent markers of autism. Further investigation with larger and more representative samples should be conducted before any stronger conclusions are made.

Management of sleep disorders in autism spectrum disorder with co-occurring attention-deficit hyperactivity disorder: update for clinicians

AIMS

To update and examine available literature germane to the recognition, assessment and treatment of comorbid autism spectrum disorder (ASD), attention-deficit hyperactivity disorder (ADHD) and sleep disruption, with a predominant focus on children, adolescents and emerging adults.

BACKGROUND

Considerable overlaps exist among ASD, ADHD and sleep disruption. Literature and guidance for clinicians, administrators, policy makers and families have been limited, as such deliberations were rarely considered until 2013.

METHOD

This narrative review of the literature addressing sleep disruption issues among those with ASD, ADHD and comorbid ASD and ADHD involved searching multiple databases and use of reverse citations up to the end of September 2022. Emphasis is placed on secondary sources and relevant data for clinical practice.

RESULTS

Complex clinical presentations of ASD/ADHD/sleep disruption are frequently encountered in clinical practice. Prior to 2013, prevalence, clinical presentation, pathophysiology, prognosis, other sleep-related factors and interventions were determined separately for each disorder, often with overlapping objective and subjective methods employed in the process. High percentages of ADHD and ASD patients have both disorders and sleep disruption. Here, the extant literature is integrated to provide a multidimensional understanding of the relevant issues and insights, allowing enhanced awareness and better care of this complex clinical population. Database limitations are considered.

CONCLUSIONS

Assessment of ASD symptomatology in youth with ADHD, and the reverse, in cases with disrupted sleep is critical to address the special challenges for case formulation and treatment. Evidence-based approaches to treatment planning and multi-treatment modalities should consider combining psychosocial and biological interventions to address the complexities of each case.

The Paradoxical Clinical Course of Persons with Gambling Disorder and Comorbid Attention-Deficit/Hyperactivity Disorder (ADHD)

The co-occurrence of gambling disorder (GD) and attention-deficit/hyperactivity disorder (ADHD) has been widely reported. In this study, we aimed to investigate the social background, clinical characteristics, and clinical course of initial-visit GD patients with and without ADHD in a Japanese psychiatric hospital. We recruited 40 initial-visit GD patients and collected comprehensive information by self-report questionnaires, direct interviews, and medical records. 27.5% of the GD patients had comorbid ADHD. Compared to the GD patients without ADHD, those with ADHD had significantly higher comorbidity rates of autism spectrum disorder (ASD), lower rates of marriage, slightly less years of education and marginally lower employment rates. On the other hand, the GD patients with ADHD showed higher treatment retention rates and participation rates in the mutual support group. Despite presenting with disadvantageous characteristics, GD patients with ADHD exhibited a more favourable clinical course. Therefore, clinicians should be mindful of the possibility of ADHD comorbidity and the potential for better clinical outcomes among GD patients with ADHD.

Changes in Anxiety following Taste Education Intervention: Fussy Eating Children with and without Neurodevelopmental Disorders

Despite the surge in studies on fussy eating in recent years, anxiety as an associated factor is generally not considered, even though children with fussy eating and those with neurodevelopmental disorders, including Autism Spectrum Disorder or Attention Deficit/Hyperactivity Disorder (ADHD) often have higher levels of anxiety than typically developing children. The current study investigated changes in anxiety scores during a Taste Education intervention, a seven-week school-based intervention for 71 children with fussy eating. Comparisons were made based on neurodevelopmental status (between children with (n = 30) and without (n = 41) neurodevelopmental disorders). Participants were paired based on age, sex, and neurodevelopmental disorder. The Multidimensional Anxiety Scale for Children (MASC) was administered at delayed intervention (for those waiting 7 weeks before starting the intervention), pre-intervention, post-intervention, and at six-month follow-up. Results did not indicate elevated anxiety based on mean MASC T-scores. MASC Total T-scores ranged from slightly elevated to average, decreasing significantly between pre-intervention and post-intervention, plateauing at six-month follow-up. Significant reductions between measurement points were seen for the physical symptoms, social anxiety, and separation anxiety subscales, but not for harm avoidance. Repeated measures analysis of variance with neurodevelopmental disorders as between-subjects factors did not reveal a significant interaction effect between neurodevelopmental disorders and changes in MASC Total score or subscales. The results indicated that our food-based intervention did not elevate MASC scores in fussy eating children, with or without neurodevelopmental disorders.

A systematic review and meta-analysis on the ocular characteristics in children and adolescents with neurodevelopmental disorders

To conduct a systematic review and meta-analysis of the association between children and adolescents with attention deficit hyperactivity disorder (ADHD) or autism spectrum disorder (ASD) and ocular characteristics. Systematic review with meta-analysis. Six databases (PubMed, Scopus, APA PsycInfo, Embase, EBSCOhost, and Cochrane library) were selected for a systematic literature search from database inception to July 2022. The observational studies assessing and reporting at least one outcome regarding ocular characteristics in children and adolescents with ADHD or ASD aged 6-17 were included. Studies in languages other than English, studies of adult or elderly human populations, and animal studies were excluded. The results were analyzed following the PRISMA guideline 2020. The findings of 15 studies, including 433 participants with ADHD, 253 participants with ASD, and 514 participants with typical development (TD), revealed that there were no significant differences in retinal nerve fiber layer, ganglion cell complex, and macular thickness between the ADHD group and the TD group. In subgroup analysis, significant differences in inferior ganglion cell (MD = - 3.19; 95% CI = [- 6.06, - 0.31], p = 0.03) and nasal macular thickness (MD = 5.88; 95% CI = [- 0.01, 11.76], p = 0.05) were detected between the ADHD group and the TD group. A significant difference in pupillary light reflex (PLR) was also observed between the ASD group and the TD group (MD = 29.7; 95% CI = [18.79, 40.63], p < 0.001). Existing evidence suggests a possible association between children and adolescents with ADHD or ASD and ocular characteristics. Given the limited number of studies, further research on a larger cohort is necessary to claim a possible diagnosis of ADHD or ASD through ocular characteristics.

Sex as a Moderator Between Parent Ratings of Executive Dysfunction and Social Difficulties in Children and Adolescents with Autism Spectrum Disorder

Girls and boys might differ in autistic symptoms and associated cognitive difficulties such as executive function (EF). We investigated sex differences in the relationship between parent rated EF and autistic symptoms in 116 children and adolescents (25 girls) aged 5-19 years with an intelligence quotient above 70 and an autism spectrum disorder (ASD) diagnosis. They were rated with the behavior rating inventory of executive function (BRIEF) and the autism diagnostic interview revised (ADI-R). We found a positive association between EF and the ADI-R domains of reciprocal social interaction (p < 0.001) and communication (p = 0.001) in girls, while these relationships were small and non-significant in boys. Our results provide a greater understanding of the sex-specific characteristics of children and adolescents with ASD.

Probing the overarching continuum theory: data-driven phenotypic clustering of children with ASD or ADHD

The clinical validity of the distinction between ADHD and ASD is a longstanding discussion. Recent advances in the realm of data-driven analytic techniques now enable us to formally investigate theories aiming to explain the frequent co-occurrence of these neurodevelopmental conditions. In this study, we probe different theoretical positions by means of a pre-registered integrative approach of novel classification, subgrouping, and taxometric techniques in a representative sample (N = 434), and replicate the results in an independent sample (N = 219) of children (ADHD, ASD, and typically developing) aged 7-14 years. First, Random Forest Classification could predict diagnostic groups based on questionnaire data with limited accuracy-suggesting some remaining overlap in behavioral symptoms between them. Second, community detection identified four distinct groups, but none of them showed a symptom profile clearly related to either ADHD or ASD in neither the original sample nor the replication sample. Third, taxometric analyses showed evidence for a categorical distinction between ASD and typically developing children, a dimensional characterization of the difference between ADHD and typically developing children, and mixed results for the distinction between the diagnostic groups. We present a novel framework of cutting-edge statistical techniques which represent recent advances in both the models and the data used for research in psychiatric nosology. Our results suggest that ASD and ADHD cannot be unambiguously characterized as either two separate clinical entities or opposite ends of a spectrum, and highlight the need to study ADHD and ASD traits in tandem.

Effects of Intersectionality Along the Pathway to Diagnosis for Autistic Children With and Without Co-occurring Attention Deficit Hyperactivity Disorder in a Nationally-Representative Sample

Children with complex behavioral profiles (e.g., ASD + ADHD) may experience delays in obtaining a final diagnosis. Low-resource or underrepresented groups may be at even greater risk for delayed diagnosis. We assessed the effect of sociodemographic factors, symptom complexity and co-occurring conditions, and identifier of first symptoms on diagnostic trajectories among children aged 3-17 years diagnosed with ASD (n = 52) or ASD + ADHD (n = 352) from a nationally-representative sample. Race/ethnicity and gender disparities were evident in both groups. Race, symptom complexity, and co-occuring conditions predicted age of final diagnosis and wait time between first concern and final diagnosis, both of which were staggeringly high. Results suggest a complex influence of sociodemographic factors on the diagnostic pathway, and risk of health disparities as a function of intersectionality.

Anhedonia as a transdiagnostic symptom across psychological disorders: a network approach

BACKGROUND

Anhedonia is apparent in different mental disorders and is suggested to be related to dysfunctions in the reward system and/or affect regulation. It may hence be a common underlying feature associated with symptom severity of mental disorders.

METHODS

We constructed a cross-sectional graphical Least Absolute Shrinkage and Selection Operator (LASSO) network and a relative importance network to estimate the relationships between anhedonia severity and the severity of symptom clusters of major depressive disorder (MDD), anxiety sensitivity (AS), attention-deficit hyperactivity disorder (ADHD), and autism spectrum disorder (ASD) in a sample of Dutch adult psychiatric patients (N = 557).

RESULTS

Both these networks revealed anhedonia severity and depression symptom severity as central to the network. Results suggest that anhedonia severity may be predictive of the severity of symptom clusters of MDD, AS, ADHD, and ASD. MDD symptom severity may be predictive of AS and ADHD symptom severity.

CONCLUSIONS

The results suggest that anhedonia may serve as a common underlying transdiagnostic psychopathology feature, predictive of the severity of symptom clusters of depression, AS, ADHD, and ASD. Thus, anhedonia may be associated with the high comorbidity between these symptom clusters and disorders. If our results will be replicated in future studies, it is recommended for clinicians to be more vigilant about screening for anhedonia and/or depression severity in individuals diagnosed with an anxiety disorder, ADHD and/or ASD.

The Role of Choline in Neurodevelopmental Disorders-A Narrative Review Focusing on ASC, ADHD and Dyslexia

Neurodevelopmental disorders appear to be rising in prevalence, according to the recent Global Burden of Disease Study. This rise is likely to be multi-factorial, but the role of certain nutrients known to facilitate neurodevelopment should be considered. One possible contributing factor could be attributed to deficits in choline intake, particularly during key stages of neurodevelopment, which includes the first 1000 days of life and childhood. Choline, a key micronutrient, is crucial for optimal neurodevelopment and brain functioning of offspring. The present narrative review discusses the main research, describing the effect of choline in neurodevelopmental disorders, to better understand its role in the etiology and management of these disorders. In terms of findings, low choline intakes and reduced or altered choline status have been reported in relevant population subgroups: pregnancy (in utero), children with autism spectrum disorders, people with attention deficit hyperactivity disorder and those with dyslexia. In conclusion, an optimal choline provision may offer some neuronal protection in early life and help to mitigate some cognitive effects in later life attributed to neurodevelopmental conditions. Research indicates that choline may act as a modifiable risk factor for certain neurodevelopmental conditions. Ongoing research is needed to unravel the mechanisms and explanations.

Immersive and maladaptive daydreaming and divergent thinking in autism spectrum disorders

Little is known about the internal mental experiences of individuals with ASD. While some research suggests a limited capacity for imagination, other studies show heightened interest in fantasy and unique forms of creative thinking in ASD. This study explored daydreaming experiences in adults with ASD, with a focus on immersive daydreaming and its relation to divergent thinking abilities. Individuals with and without a diagnosis of ASD were surveyed on their daydreaming habits and completed a divergent thinking task. Experiences of immersive daydreaming were identified in 42% of adults with ASD and were related to broad ASD traits in those without a diagnosis of ASD. However, ASD diagnosis was unrelated to originality of divergent thinking, which was negatively associated with immersive daydreaming. Moreover, daydreaming experiences in ASD were diverse. A more nuanced understanding of the mental experiences in ASD may assist in the development of interventions and support for this population.

Anxiety, mood, and substance use disorders in adult men and women with and without Attention-Deficit/Hyperactivity Disorder: a substantive and methodological overview

Knowledge on psychiatric comorbidity in adult ADHD is essential for prevention, detection, and treatment of these conditions. This review (1) focuses on large studies (n> 10,000; surveys, claims data, population registries) to identify (a) overall, (b) sex- and (c) age-specific patterns of comorbidity of anxiety disorders (ADs), major depressive disorder (MDD), bipolar disorder (BD) and substance use disorders (SUDs) in adults with ADHD relative to adults without ADHD; and (2) describes methodological challenges relating to establishing comorbidity in ADHD in adults as well as priorities for future research. Meta-analyses (ADHD: n=550,748; no ADHD n=14,546,814) yielded pooled odds ratios of 5.0(CI:3.29-7.46) for AD, 4.5(CI:2.44-8.34) for MDD, 8.7(CI:5.47-13.89) for BD and 4.6(CI:2.72-7.80) for SUDs, indicating strong differences in adults with compared to adults without ADHD. Moderation by sex was not found: high comorbidity held for both men and women with sex-specific patterns as in the general population: higher prevalences of ADs, MDD and BD in women and a higher prevalence of SUDs in men. Insufficient data on different phases of the adult lifespan prevented conclusions on developmental changes in comorbidity. We discuss methodological challenges, knowledge gaps, and future research priorities.

The contribution of copy number variants to psychiatric symptoms and cognitive ability

Copy number variants (CNVs) are deletions and duplications of DNA sequence. The most frequently studied CNVs, which are described in this review, are recurrent CNVs that occur in the same locations on the genome. These CNVs have been strongly implicated in neurodevelopmental disorders, namely autism spectrum disorder (ASD), intellectual disability (ID), and developmental delay (DD), but also in schizophrenia. More recent work has also shown that CNVs increase risk for other psychiatric disorders, namely, depression, bipolar disorder, and post-traumatic stress disorder. Many of the same CNVs are implicated across all of these disorders, and these neuropsychiatric CNVs are also associated with cognitive ability in the general population, as well as with structural and functional brain alterations. Neuropsychiatric CNVs also show incomplete penetrance, such that carriers do not always develop any psychiatric disorder, and may show only mild symptoms, if any. Variable expressivity, whereby the same CNVs are associated with many different phenotypes of varied severity, also points to highly complex mechanisms underlying disease risk in CNV carriers. Comprehensive and longitudinal phenotyping studies of individual CNVs have provided initial insights into these mechanisms. However, more work is needed to estimate and predict the effect of non-recurrent, ultra-rare CNVs, which also contribute to psychiatric and cognitive outcomes. Moreover, delineating the broader phenotypic landscape of neuropsychiatric CNVs in both clinical and general population cohorts may also offer important mechanistic insights.

Emotional problems in preschool and school-aged children with neurodevelopmental disorders in Spain: EPINED epidemiological project

BACKGROUND

Children with neurodevelopmental disorders (NDD) are often at risk of developing emotional problems.

AIMS AND METHODS

The co-occurrence of anxiety and depression with ASD and/or ADHD was determined by exploring the association with children's clinical and neuropsychological functioning and their parent's mental health. To this end, we assessed 295 preschoolers (PRE; 4-5 years old) and 486 school-aged children (SCH; 10-11 years old) in Tarragona, Spain. NDD diagnoses were based on DSM-5. Emotional problems were assessed using Achenbach's scales.

RESULTS

Emotional problems (PRE: 36%-78%; SCH: 32%-81%) were more common and more severe in participants with NDD than in controls and children in the ASD + ADHD school-aged group were the most affected. In ADHD, emotional problems were associated with more severe symptoms of attention deficit (PRE) and hyperactivity/impulsivity (SCH). In ASD + ADHD, emotional problems showed a trend of association with more severe ASD repetitive behaviours and impaired working memory, whereas in ASD were associated with greater overall ASD severity.

CONCLUSIONS AND IMPLICATIONS

Children with NDD are vulnerable to emotional problems, which become more prevalent and interfering with age. Early detection and intervention aimed at tackling emotional problems can improve NDD prognosis.

Bacterial gut microbiome differences in adults with ADHD and in children with ADHD on psychostimulant medication

Recent evidence suggests that there is a link between neurodevelopmental disorders, such as attention deficit hyperactivity disorder (ADHD), and the gut microbiome. However, most studies to date have had low sample sizes, have not investigated the impact of psychostimulant medication, and have not adjusted for potential confounders, including body mass index, stool consistency and diet. To this end, we conducted the largest, to our knowledge, fecal shotgun metagenomic sequencing study in ADHD, with 147 well-characterized adult and child patients. For a subset of individuals, plasma levels of inflammatory markers and short-chain fatty acids were also measured. In adult ADHD patients (n=84), compared to controls (n=52), we found a significant difference in beta diversity both regarding bacterial strains (taxonomic) and bacterial genes (functional). In children with ADHD (n=63), we found that those on psychostimulant medication (n=33 on medication vs. n=30 not on medication) had (i) significantly different taxonomic beta diversity, (ii) lower functional and taxonomic evenness, (iii) lower abundance of the strain Bacteroides stercoris CL09T03C01 and bacterial genes encoding an enzyme in vitamin B₁₂ synthesis, and (iv) higher plasma levels of vascular inflammatory markers sICAM-1 and sVCAM-1. Our study continues to support a role for the gut microbiome in neurodevelopmental disorders and provides additional insights into the effects of psychostimulant medication. However, additional studies are needed to replicate these findings and examine causal relationships with the disorder.

Human generalization of internal representations through prototype learning with goal-directed attention

The world is overabundant with feature-rich information obscuring the latent causes of experience. How do people approximate the complexities of the external world with simplified internal representations that generalize to novel examples or situations? Theories suggest that internal representations could be determined by decision boundaries that discriminate between alternatives, or by distance measurements against prototypes and individual exemplars. Each provide advantages and drawbacks for generalization. We therefore developed theoretical models that leverage both discriminative and distance components to form internal representations via action-reward feedback. We then developed three latent-state learning tasks to test how humans use goal-oriented discrimination attention and prototypes/exemplar representations. The majority of participants attended to both goal-relevant discriminative features and the covariance of features within a prototype. A minority of participants relied only on the discriminative feature. Behaviour of all participants could be captured by parameterizing a model combining prototype representations with goal-oriented discriminative attention.

A longitudinal study on cognitive aging in autism

Longitudinal studies on cognitive aging in autism are scarce, and largely underpowered, yet essential to obtain more conclusive results on cognitive changes in autism during adulthood. In the largest longitudinal study on cognition thus far, we aimed to get more insight into cognitive aging in autism. As pre-registered, we computed reliable change indices (RCIs) and multilevel models to estimate cognitive changes in 128 autistic, and 112 non-autistic adults (range: 24-85 yrs.) over two to three timepoints (average interval: 3.5 yrs.). Participants were tested on 15 outcome measures, covering verbal memory, visual (working) memory, prospective memory, theory of mind, fluency, response speed, inhibition, planning, and switching. RCIs showed no significant differences between groups (autism/no-autism) in changes over time. Using multilevel models, most tasks showed sensitivity to cross-sectional age-related effects, and/or longitudinal changes, with worse performance at older age, and later timepoints. However, effects were not significantly different between the autism and no-autism group. This lack of group differences was substantiated by additional Bayesian analyses. In sum, the current study provides evidence for parallel (similar) cognitive aging in autism. Specifically, autistic individuals diagnosed in adulthood, without intellectual disability, do not seem at risk for accelerated cognitive decline.

Bibliometric Analysis of Research Themes and Trends of the Co-Occurrence of Autism and ADHD

Background

In recent years, there has been a growing body of research suggesting that ASD and ADHD are two disorders that often co-exist. Despite the rapid development of research, little is known about their etiology, diagnostic markers, and interventions, which has led us to review and summarise the development of the field in the hope that this will provide an opportunity to look for future directions.

Methods

A bibliometric approach was used to analyse papers in the field of ASD co-morbidities in ADHD on Web of Science from 1991-2022, using CiteSpace and VOSview to map the country/institution, journal, author, co-citation, and keyword networks in the field and to visualise the results.

Results

A total of 3284 papers were included, showing an increasing trend in terms of posting trends. Research on co-morbidities of ASD has proven to be mainly focused on universities. The USA (1662) published the most relevant literature in this area, followed by the UK (651) and Sweden (388). Lichtenstein P is the most published author (84), and research into the pathogenesis of ASD co-occurring ADHD and related clinical diagnostics is currently at the forefront of the field.

Conclusion

This analysis identifies the most influential institutions and countries, cited journals, and authors in the field of ASD co-morbid ADHD research. The future direction of ASD co-occurring ADHD should be based on improving case identification, discovering the etiological and diagnostic markers of ASD and ADHD, and finding more effective clinical interventions.

C-Reactive Protein (CRP): A Potent Inflammation Biomarker in Psychiatric Disorders

An increasing number of studies have investigated the role of inflammation in psychiatric disorders, by demonstrating how an altered/dysfunctional immunological and inflammatory system may underpin a psychiatric condition. Particularly, several studies specifically investigated the role of a neuroinflammatory biomarker, named C-reactive protein (CRP), in psychiatric disorders. Overall, even though scientific literature so far published still does not appear definitive, CRP is more likely reported to be elevated in several psychiatric disorders, including schizophrenia, mood disorders, anxiety disorders and post-traumatic stress disorder. Moreover, a low-grade inflammation (CRP >3 mg/L) has been more likely observed in a subgroup of patients affected with a more severe psychopathological symptomatology, more treatment resistance and worst clinical mental illness course, strengthening the hypothesis of the need for a different clinical and prognostic characterization based on this concomitant neuroinflammatory predisposition. However, even though further research studies are needed to confirm this preliminary evidence, CRP may represent a potential clinical routine biomarker which could be integrated in the clinical routine practice to better characterize clinical picture and course as well as address clinicians towards a personalized treatment.

Reliability and validity of the Chinese version of the kiddie-schedule for affective disorders and schizophrenia-present and lifetime version DSM-5 (K-SADS-PL-C DSM-5)

BACKGROUND

As the Diagnostic and Statistical Manual of Mental Disorders fifth version (DSM-5) was published, the Kiddie-Schedule for Affective Disorders and Schizophrenia-Present and Lifetime version (K-SADS-PL) was modified to adapt the new version (K-SADS-PL DSM-5). We translated it to Chinese (K-SADS-PL-C DSM-5) and described its reliability and validity.

METHODS

A total of 154 groups of 6 to 18-year-old children and their guardians were included. Trained interviewers interviewed subjects using the K-SADS-PL-C DSM-5. Interrater reliability was assessed by audio recording. Parent-reported scales, like child behavior checklist (CBCL), the Chinese version of Swan-son Nolan and Pelham, version IV scale-parent form (SNAP-IV), social responsiveness scale (SRS-1), and children-reported scales like depression self-rating scale for children (DSRSC) and the screen for child anxiety related emotional disorders (SCARED) were used to examine the validity of depressive disorder, ADHD, ASD, and ODD.

RESULTS

The K-SADS-PL-C DSM-5 had fair to excellent interrater (0.537-1.000) and test-retest (0.468-0.885) reliability of affective disorder and neurodevelopment disorder. The convergent validity of affective disorder and neurodevelopment disorder was good, and their divergent validity was acceptable.

LIMITATIONS

i) Clinical questionnaires were insensitive in classifying disorders and had limitations in derived diagnoses. ii) Samples only came from clinical environment, iii) covered limited disease species, and iv) were small.

CONCLUSION

The K-SADS-PL-C DSM-5 can support reliable and valid diagnoses for children with affect, neurodevelopmental, and behavioral disorders in China.

Diagnostic and Therapeutic Challenges of Comorbid ASD, ADHD and Psychosis: A Case Report

Autism Spectrum Disorder (ASD) and attention deficit hyperactivity disorder (ADHD) comorbidity is common in clinical practice and it seems to be related to shared etiological mechanisms and genetic susceptibility. Moreover, occurrence of psychosis can further complicate these complex clinical pictures. Here, we discuss the case of a nine-years-old boy presenting with an episode of abnormal sustained posture of the upper limbs, resembling dystonia, at the age of 3. At this time, auditory and visual hallucinations, as well as obsessive thoughts and attentional lability were also present and a diagnosis of "Early onset psychosis" was initially made. Due to the worsening of clinical picture, several hospitalizations were necessary and pharmacological treatment with carbamazepine, risperidone and aripiprazole was carried out. Extensive clinic evaluation revealed a past medical and personal history of toe walking, weak social skills and stereotyped behavior observed and ADOS-2 Module 2 administration revealed severe Autism scores. Moreover, signs of attention and hyperactivity were consistent with ADHD diagnosis. This work highlights the importance of a complete diagnostic assessment in patients with complex presentation, suggesting the possible overlap diagnosis of ADHD and Autism even in presence of psychotic-like symptoms.

Maternal Western-style diet reduces social engagement and increases idiosyncratic behavior in Japanese macaque offspring

Recent evidence in humans and animals indicates an association between maternal obesity and offspring behavioral outcomes. In humans, increased maternal body mass index has been linked to an increased risk of children receiving a diagnosis of early-emerging neurodevelopmental disorders such as Attention Deficit/Hyperactivity Disorder (ADHD) and/or Autism Spectrum Disorder (ASD). However, a limited number of preclinical studies have examined associations between maternal Western-Style Diet (mWSD) exposure and offspring social behavior. To our knowledge, this is the first study to investigate relationships between mWSD exposure and social behavior in non-human primates. Since aberrant social behavior is a diagnostic criterion for several neurodevelopmental disorders, the current study focuses on examining the influence of maternal nutrition and metabolic state on offspring social behavior in Japanese macaques (Macaca fuscata). We found that mWSD offspring initiated less affiliative social behaviors as well as proximity to a peer. Using path analysis, we found that the association between mWSD consumption and reduced offspring social engagement was statistically mediated by increased maternal interleukin (IL)-12 during the third trimester of pregnancy. Additionally, mWSD offspring displayed increased idiosyncratic behavior, which was related to alterations in maternal adiposity and leptin in the third trimester. Together, these results suggest that NHP offspring exposed to mWSD exhibit behavioral phenotypes similar to what is described in some early-emerging neurodevelopmental disorders. These results provide evidence that mWSD exposure during gestation may be linked to increased risk of neurodevelopmental disorders and provides targets for prevention and intervention efforts.

A Case of Priapism in a Child With Autism Spectrum Disorder, Possibly Due to Risperidone Treatment With Addition of Atomoxetine

OBJECTIVES

Risperidone is an effective drug used for the treatment of irritability in children with autism spectrum disorder (ASD). Atomoxetine (ATX) is a well-tolerated drug used in first-line therapy in children with attention-deficit/hyperactivity disorder (ADHD). However, uncommon adverse effects of risperidone and ATX are a concern among mental health professionals. To our knowledge, this is the first case report of priapism after addition of ATX upon existing treatment with risperidone.

METHODS

Written informed consent for publication was obtained from the patient and his parents, and their identities were concealed for ethical reasons.

RESULTS

Here, we report a case of priapism as an adverse effect of ATX and risperidone treatment in a 7-year-old boy with ASD and comorbid ADHD. In this case, priapism was not observed with risperidone until ATX was added.

CONCLUSIONS

Priapism is a condition viewed as a medical emergency. Although risperidone-induced priapism is a rare phenomenon, it is advised for clinicians to consider the drug interactions in treatment of ASD and ADHD in terms of early diagnosis and intervention.

The relationship between executive function, neurodevelopmental disorder traits, and academic achievement in university students

Difficulties with executive function have often been identified in individuals with various neurodevelopmental disorders such as Autism Spectrum Disorder (ASD), Attention-Deficit Hyperactivity Disorder (ADHD), and Developmental Co-ordination Disorder (DCD). Additionally, in childhood and adolescence, executive functioning is an important predictor of academic achievement. However, less research has explored these relationships in adult students, and those with a high level of neurodevelopmental disorder traits but no clinical diagnosis. Therefore, the current study aimed to assess whether ASD, ADHD, and DCD traits can predict academic achievement in university students, and whether traits of these neurodevelopmental conditions moderate the relationship between executive function and academic achievement. Both neurotypical students and those with a clinical diagnosis of a neurodevelopmental disorder were able to participate, with the majority being neurotypical. Participants completed four self-report questionnaires and provided a measure of academic achievement based on their university assignment results. Traits of ASD, ADHD, and DCD alone did not predict achievement, however, traits of ADHD and DCD significantly moderated the relationship between executive function and academic achievement. ASD traits did not significantly moderate this relationship. Implications and suggestions for future research are also discussed.