topic 7 - comorbidity in adhd and autism 2010
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Autism, Asperger’s & ADHD (6PS048)
ADHD, Autism & Asperger’s (6PS052)
Simon Bignell
Psychology, School of Science
Comorbidity in ADHD and Autism
Lecture 7
Spring 2010
Simon Bignell – Module Leader
(6PS048 / 6PS052)
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Autism, Asperger’s & ADHD (6PS048)
ADHD, Autism & Asperger’s (6PS052)
Simon Bignell
Psychology, School of Science
Introduction to the Lecture
• A refresher: DBDs & PDDs.• Why is comorbidity important?• Are ADHD And Autism Really That
Different?• Comorbid conditions.• What might this overlap of symptoms
suggest?
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Autism, Asperger’s & ADHD (6PS048)
ADHD, Autism & Asperger’s (6PS052)
Simon Bignell
Psychology, School of Science
Learning Outcomes Of This Lecture.On completion of the lecture and with independent
study you should be able to:
1. Understand what disorders and symptoms commonly exist alongside Autistic Disorder, Asperger’s Disorder and Attention-Deficit/Hyperactivity Disorder.
2. Be able to describe why it is important to look at comorbid disorders.
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Autism, Asperger’s & ADHD (6PS048)
ADHD, Autism & Asperger’s (6PS052)
Simon Bignell
Psychology, School of Science
DisorderOnly
DisorderAnd Other
OtherOnly
What is Comorbidity?
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Autism, Asperger’s & ADHD (6PS048)
ADHD, Autism & Asperger’s (6PS052)
Simon Bignell
Psychology, School of Science
• Developmental Delay motor
• Mental Retardation cognitive
• Cerebral Palsy motor
• Autism/PDD social
• Learning Disability learning
• ADHD/DBD focus
Some Terminology.
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Autism, Asperger’s & ADHD (6PS048)
ADHD, Autism & Asperger’s (6PS052)
Simon Bignell
Psychology, School of Science
Conceptualisation of Developmental Disabilities.
Central Nervous System
Motor Cognitive Social
Cerebral Palsy
Mental Retardation
AutismSpectrum
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Autism, Asperger’s & ADHD (6PS048)
ADHD, Autism & Asperger’s (6PS052)
Simon Bignell
Psychology, School of Science
Conceptualisation of Developmental Disabilities.
Central Nervous System
Prenatal Perinatal Postnatal
Motor Cognitive Social
Cerebral Palsy
Mental Retardation
AutismSpectrum
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Autism, Asperger’s & ADHD (6PS048)
ADHD, Autism & Asperger’s (6PS052)
Simon Bignell
Psychology, School of Science
“Disability”:
Function:
Aetiology:
Central Nervous System
Prenatal Perinatal Postnatal
Motor Cognitive Social
Cerebral Palsy
Mental Retardation
AutismSpectrum
Conceptualisation of Developmental Disabilities.
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Autism, Asperger’s & ADHD (6PS048)
ADHD, Autism & Asperger’s (6PS052)
Simon Bignell
Psychology, School of Science
The DSM-IV includes five types of disorder under the term ‘Attention-Deficit and Disruptive Behavioural Disorders’.
1) Attention-Deficit/Hyperactivity Disorder. Predominantly Inattentive Type. Predominantly Hyperactive-Impulsive Type. Combined Type.
2) Conduct Disorder.3) Oppositional Defiant Disorder.4) Attention-Deficit/Hyperactivity Disorder Not
Otherwise Specified.5) Disruptive Behaviour Disorder Not Otherwise
Specified.
Attention-Deficit and Disruptive Behavioural Disorders.
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Autism, Asperger’s & ADHD (6PS048)
ADHD, Autism & Asperger’s (6PS052)
Simon Bignell
Psychology, School of Science
The DSM-IV includes five types of disorder under the term ‘Pervasive Developmental Disorder’ PDD.
1) Autistic Disorder*.2) Rett’s Disorder.3) Childhood Disintegrative Disorder.4) Asperger’s Disorder*.5) Pervasive Development Disorder Not
Otherwise Specified*.* Mainly these form the Autistic spectrum (ASD).
Pervasive Developmental Disorder.
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Autism, Asperger’s & ADHD (6PS048)
ADHD, Autism & Asperger’s (6PS052)
Simon Bignell
Psychology, School of Science
Major Classes Of Childhood Psychiatric Disorders.
• Developmental Disorders– Autism (ASD); Pervasive Developmental Disorders (PDD).– Language and learning disorders.
• Disruptive Behaviour Disorders (“externalizing”)– Attention Deficit Hyperactivity Disorder (ADHD).– Oppositional Defiant Disorder (ODD); Conduct Disorder (CD).
• Affective Disorders (“internalizing”)– Anxiety Disorders.– Depression; Bipolar Disorder.
• Other Disorders – Tic Disorders/Tourette’s Disorder; Eating Disorders; Substance Use;
Schizophrenia.
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Autism, Asperger’s & ADHD (6PS048)
ADHD, Autism & Asperger’s (6PS052)
Simon Bignell
Psychology, School of Science
Normal vs. Pathological?
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Autism, Asperger’s & ADHD (6PS048)
ADHD, Autism & Asperger’s (6PS052)
Simon Bignell
Psychology, School of Science
Are ADHD And Autism Really That Different?
• A large number of medical conditions, psychiatric disorders and behavioural and motor control problems are very often associated with ADHD and/or Autism.
• ADHD and Autism are generally described as separate disorders with separate genetic aetiologies.
• Most genetic studies exclude cases of Autism from studies on ADHD and vice versa.
• Comorbidity: one condition may “mask” another.
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Autism, Asperger’s & ADHD (6PS048)
ADHD, Autism & Asperger’s (6PS052)
Simon Bignell
Psychology, School of Science
Are ADHD And Autism Really That Different?• More symptoms of Autism in children with ADHD than
in their siblings who do not have ADHD.• A great need for in-depth research into this area.• As many as one-third of children diagnosed with
ADHD also have a co-existing diagnosed condition.
• See review by Gillberg and Billstedt (2000).
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Autism, Asperger’s & ADHD (6PS048)
ADHD, Autism & Asperger’s (6PS052)
Simon Bignell
Psychology, School of Science
Symptoms of ADHD.
High Impulsiveness
Poor Attention
High Hyperactivity
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Autism, Asperger’s & ADHD (6PS048)
ADHD, Autism & Asperger’s (6PS052)
Simon Bignell
Psychology, School of Science
• Frequent comorbid psychiatric diagnoses include:• Oppositional Defiant Disorder (35%).• Conduct Disorder (25%).
• Tics.• OCD (part of the triad?).• Anxiety (often strong environmental factors).
Comorbidity In ADHD.
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Autism, Asperger’s & ADHD (6PS048)
ADHD, Autism & Asperger’s (6PS052)
Simon Bignell
Psychology, School of Science
• Depression/Bipolar disorder.
• Selective mutism.
• Eating disorders (including anorexia nervosa).
• Sleep disorders.
• Learning disabilities occur in about 25% of ADHD children especially receptive language problems (spoken instructions) and expressive language (written output).
Comorbidity In ADHD.
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Autism, Asperger’s & ADHD (6PS048)
ADHD, Autism & Asperger’s (6PS052)
Simon Bignell
Psychology, School of Science
• Substance use disorders in adults with ADHD.– Alcohol abuse (15%).– Alcohol dependence (41%).– Substance abuse (45%).– Substance dependence (31%).– Any abuse or dependence (69%).
(Millstein, et al, 1997).
Comorbidity In ADHD.
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Autism, Asperger’s & ADHD (6PS048)
ADHD, Autism & Asperger’s (6PS052)
Simon Bignell
Psychology, School of Science
• Mood and anxiety disorders in adults with ADHD.– Major depression (63%).– Dysthymia (23%).– Bipolar (17%).– Panic disorder (11%).– Simple phobia (12%).– Generalized anxiety (21%).– Obsessive compulsive disorder (7%).
(Millstein, et al, 1997).
Comorbidity In ADHD.
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Autism, Asperger’s & ADHD (6PS048)
ADHD, Autism & Asperger’s (6PS052)
Simon Bignell
Psychology, School of Science
• Personality disorders in adults with ADHD– Anti-social personality (22%)– Passive aggressive personality (19%)– Borderline personality (14%)– Histrionic personality disorder (11%)– Avoidant (anxious) (11%)
(Barkley et al, 1998)
Comorbidity In ADHD.
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Autism, Asperger’s & ADHD (6PS048)
ADHD, Autism & Asperger’s (6PS052)
Simon Bignell
Psychology, School of Science
Symptoms of Autistic Disorder.
Restricted, repetitive and stereotyped patterns of behaviour.
Impairment in social interaction.
Impairment in verbal and non verbal communication.
Wing, L., & Gould, J. (1979). Severe impairments of social interaction and associated abnormalities in children: epidemiology and classification. Journal of Autism and Developmental Disorders, 9, 11-29.
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Autism, Asperger’s & ADHD (6PS048)
ADHD, Autism & Asperger’s (6PS052)
Simon Bignell
Psychology, School of Science
• Overlap/comorbidity (see Gillberg & Billstedt 2000).
• High overlap with ADHD symptoms.• Depression.• Mania/bipolar disorder.• Tic disorders.• “Personality disorders.”• Selective mutism.• Eating disorders.• Substance use disorders.
Comorbidity In Autism.
AUTISTICSPECTRUM
CONDITIONSATTENTION
DEFICIT/HYPER-
ACTIVITY
SEIZURES/TOURETTE’S
DEPRESSION/BIPOLAR
DISORDER
LEARNINGDISABILITIES
OBSESSIVE-COMPULSIVE
DISORDER
OPPOSITIONALDEFIANCEDISORDER
ANXIETY
Comorbidity of ASD.
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Autism, Asperger’s & ADHD (6PS048)
ADHD, Autism & Asperger’s (6PS052)
Simon Bignell
Psychology, School of Science
Some features of Autism can be misinterpreted as signs of schizophrenia.
• Often get disorganised thinking.• Focus on inner life/fantasy.• Talking past the point.• Perseveration.• Neologisms/colloquialisms.• Pseudo-philosophical talk.• Often speak thoughts out loud.
Example: Similarities Between Autism And Schizophrenia.
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Autism, Asperger’s & ADHD (6PS048)
ADHD, Autism & Asperger’s (6PS052)
Simon Bignell
Psychology, School of Science
• Imaginary friends.• Produce fantastic stories.• Complex visual hallucinations.• Thoughts described concretely sound like auditory
hallucinations.• Genuine altered perceptions.• Teasing and persecution.• Catatonia common.• Often improve with neuroleptics.
Example: Similarities Between Autism And Schizophrenia.
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Autism, Asperger’s & ADHD (6PS048)
ADHD, Autism & Asperger’s (6PS052)
Simon Bignell
Psychology, School of Science
• Early studies suggested association between SZ and ASD.• Kanner (1949) “I do not believe that there is any likelihood
that early infantile autism will at any future time have to be separated from the schizophrenias.”
• Clarke et al (1999) suggest that Autism may increase vulnerability to psychosis.
• Fitzgerald: “it is often asked where the patients with autism and Asperger's syndrome were 40 years ago and what diagnosis they received. It is likely that they were classified in adult psychiatric hospitals as having simple Schizophrenia.”
Example: Similarities Between Autism And Schizophrenia.
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Autism, Asperger’s & ADHD (6PS048)
ADHD, Autism & Asperger’s (6PS052)
Simon Bignell
Psychology, School of Science
• Bender & Faetra (1972) claimed 90 per cent of Autistic children developed Schizophrenia in adulthood.
• Dahl (1976) claimed 50 per cent of Autistic children developed Schizophrenia in adulthood.
• Wolff & Mcguire (1995) claimed 4 out of 49 patients with possible Asperger's developed Schizophrenia.
Example: Similarities Between Autism And Schizophrenia.
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Autism, Asperger’s & ADHD (6PS048)
ADHD, Autism & Asperger’s (6PS052)
Simon Bignell
Psychology, School of Science
UndiagnosedDisorder
CorrectlyDiagnosedDisorder
Misd
iagn
osed
As D
isord
er
Has DisorderDiagnosed with Disorder
Diagnosis, Misdiagnosis, And “Undiagnosed.”
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Autism, Asperger’s & ADHD (6PS048)
ADHD, Autism & Asperger’s (6PS052)
Simon Bignell
Psychology, School of Science
Overlap Of ‘Symptoms’ In Autism, Asperger’s And ADHD.
• Naïve remarks, faux pas, too honest.• Can only be with others on own
terms.• Poor at games, scores “own goals.”• Unaware of social conventions.• Indifferent to peer
pressure/crazes/fashion.• Pedantic, corrects other students.• Genuine poor empathy may lead to
aggression.• Good at some things/poor at others.• Same with everybody.• No language adjustment to fit social
context.• Expect others to know their thoughts.• Take things literally.
•Poor motivation/Lack of spontaneity.•Eye for detail, but fail to see big picture.•Autodidact, struggle to follow teachers.•Perfectionist.•Everything black/white, all or nothing•Catatonic symptoms.•Sensory sensitivities (noise, pain threshold).•Special interests•Odd “flapping” gait when running.•Tics, facial grimacing.•Prefer non-fiction to fiction.•Exceptional memory for facts/dates.•Exceptional isolated ability.
•May seem immature.
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Autism, Asperger’s & ADHD (6PS048)
ADHD, Autism & Asperger’s (6PS052)
Simon Bignell
Psychology, School of Science
• ADHD is (almost) always an indication that there will be other problems and disorders, not just ADHD.
• Autism Spectrum Disorders can present with severe hyperactivity and attention problems (Gillberg 1992).
• Extreme hyperactivity is a common presenting problem in pre-school children with Autism.
• Many individuals with ADHD also have mild Autism Spectrum Disorder (Gillberg et al 1987).
Overlap Of ‘Symptoms’ In Autism, Asperger’s And ADHD.
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Autism, Asperger’s & ADHD (6PS048)
ADHD, Autism & Asperger’s (6PS052)
Simon Bignell
Psychology, School of Science
ADHD / Autism Overlap: Theoretical Questions.
• Could it be that ADHD comprises a mixture of other syndromes (e.g. Tourette’s, bipolar, depression and variants of Autism Spectrum Disorder) that all present with some “ADHD” symptomatology?
• Could any dopamine/noradrenaline dysfunction syndrome with early onset present as ADHD or a “shadow syndrome” of ADHD?
• Could Autism, Asperger’s and ADHD fall on the same continuum?
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