rachel brooks. what we mean by co-morbidity what diagnoses do we see along with asd? how commonly do...
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Rachel Brooks
What we mean by co-morbidityWhat diagnoses do we see along with ASD?How commonly do these occur?What does that mean for our assessment and
management of the child or young person?
Co morbidityTwo or more diagnoses occurring together
Causal
Associated
Random/Co-incidental
Tuberose sclerosis1:10,000 Autosomal dominantLearning difficulties 50%Epilepsy >80%Skin lesionsBrain lesions
40-60% ASD Infantile spasms predispose to
ASDM:F ratio not like ASD
?Why a pathway to ASD•Frontal or temperoparietal lesions•Genetic pathway
PhenylketonuriaUntreated PKUPicked up and treated following newborn blood spot
screening test (Guthrie)Significant subgroup meet ASD criteriaShould not be an issue in WalesOther rare inborn errors of metabolism
Congenital RubellaAll young women vaccinated to prevent Rubella
infection in pregnancyLearning difficultiesDeafness
Visual problemsOcular problems are
common in ASDRefractive error and
visual functionSkilled assessment of
vision and visual function is important
Congenital BlindnessCan have presentation
fulfilling criteria for ASDNot specific to one
medical diagnosis
Foetal Alcohol SyndromeCharacteristic
featuresBehavioural
phenotypeDose response effect Some reach ASD
diagnostic criterion?Co-incidence
AssociatedDiagnoses where ASD occurs more than by chanceNeuro-developmental
Co morbid psychiatric disorders112 children 10-14 with ASD 70% had 1 diagnosis40% had 2 or more
Social anxiety disorder 29%ADHD 28%Oppositional defiant disorder 28%24% Tourettes, chronic tics, Trichotillomania, enuresis etc
Simonoff et al 2008
Co morbid psychiatric disordersLD and psychiatric disordersIn Simonoff study no relationship with IQ
BUTOvershadowing Diagnostic difficultiesRequires special skills from CAMHS
ASD and ADHDCommon co morbidity~ 28% *Can confuse diagnosis Poor attention and
hyperactivity influence social development
Can overshadow
*Simonoff E J Am Acad Adolesc Psychiatry 2008 47(8) 921-9
4 year old boy Very hyperactive Running, climbing and
impossible to keep safeStarted on stimulants
earlyProfound ASD then
apparent
Fragile XMore than by chance1,2500-1,4000Gaze aversionLang delay and echolaliaPerseverationHypersensitivity to sensory
stimuliStereotypiesNeed for samenessSocial anxiety
15-30% ASD
EpilepsyMore common in ASD than
general population17%Partly due to the causal and
associated diagnoses which predispose to epilepsy
E.g. Tuberose sclerosis
Angelmans
Fragile X
Increases with the severity of underlying brain dysfunction
•Any kind of Epilepsy can occur in ASD
Epilepsy 2 Most commonly
appears in first 3 years of life
Another peak at puberty
Landau-Kleffner
Infantile spasms (West Syndrome)
Now add in the random diagnoses coexisting with ASD28 genetic3 endocrine4 infective5 toxic3 syndromes with multiple aetiologies18 single case reports Gillberg and Coleman 2000
And I can add more ……
ASD is common 0.6 – 1% of the population
Beware of diagnostic overshadowing
Boy with Down syndrome (1:800)
Challenging behaviourFamily situation
breaking downASD diagnosed by
tertiary teamDown and ASD need
ASD management
Medical problems overshadow tooBoy ~ 8Severe Congenital heart defectLife saving surgery as a small childMonths in hospitalDevelopmental progress and ‘oddities’ put down to
hospitalisation and surgeryDiagnosis of ASD and LDs
Not a simple equation!A combination of
conditions doesn’t just have a simple additive effect
It can be more than that
You need to unpick a child's strengths and difficulties to understand this and meet their needs
Children with ASD are not just their ASDASD is commonIt will occur more
commonly with other common diagnoses
Some, particularly neuro-developmental disorders occur more commonly with ASD
Children with ASD can have almost anything else
Beware of overshadowing
Be aware of common co-morbidities
Children with co morbidity need assessment not assumptions