Autism Spectrum Disorder and Attention-Deficit/Hyperactivity Disorder Rob Nicolson, M.D. Department of Psychiatry, Western University

I have not had in the past 2 years a financial interest or arrangement or affiliation with one or more organizations that could be perceived as a direct or indirect conflict of interest in the content of the subject of this or any other program

Learning Objectives By the end of this session you will : Have a greater understanding of the challenges associated with Autism Spectrum Disorder (ASD) and Atttention-Deficit/Hyperactivity Disorder (ADHD) Be familiar with current important issues pertinent to ASD and ADHD

Autism Spectrum Disorder

Case: Connor 5 year old male Does not speak or communicate using gestures Seems disinterested in playing with peers at daycare; wiggles fingers in front of eyes; often looks our of corner of eyes at objects Significant tantrums with aggression and self-injurious behaviour Parents recently separated and don’t have formal parenting agreement Lives with mother, sees dad on weekends Very different approaches to his tantrums; doctor has expressed concerns about the inconsistency in parental approaches

Diagnosis Epidemiology Etiology Treatment

Diagnosis of (ASD): Social Interaction and Communication Persistent deficits in social communication and social interaction, manifested by all three of the following: Deficits in social-emotional reciprocity Deficits in nonverbal communicative behaviors used for social interaction Deficits in developing, maintaining, and understanding relationships appropriate to developmental level

Diagnosis of (ASD): Repetitive Behaviour Restricted, repetitive patterns of behaviour, interests, or activities, as manifested by at least two of the following: Stereotyped or repetitive motor movements, use of objects, or speech. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behaviour. Highly restricted, fixated interests that are abnormal in intensity or focus Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment

Diagnosis of ASD Must have all three social-communication symptoms and at least 2 of the repetitive behaviour symptoms Symptoms must be inconsistent with the person’s developmental level Symptoms must be present in early childhood Symptoms together limit and impair everyday functioning

Diagnosis Epidemiology Etiology Treatment

Epidemiology of Autism Spectrum Disorder Prevalence among 8 year olds: 1.47% (1/68) Male:female ratio: 4.5:1 Intellectual Disability occurs in 31% 20% have seizures, typically beginning early in life or in adolescence

Diagnosis Epidemiology Etiology Treatment Neurobiology Environmental Factors Treatment

Neurobiology of ASD Considered a “neurodevelopmental disorder” (i.e., caused by abnormal development of the brain rather than degeneration or specific lesion) 5-10% of patients have detectable chromosome abnormalities Sibling recurrence rate is 5-10% Heritability about 90% “Unaffected” relatives have increased rates of social, language, and behavioural problems

Environmental Factors in ASD Much has been written in recent years about vaccinations being a “cause” of autism, either directly from MMR vaccine or from mercury being used as preservative Epidemiological studies indicate that there is absolutely no relationship between autism and vaccinations

Diagnosis Epidemiology Etiology Treatment Intensive Behavioural Intervention Pharmacotherapy

Intensive Behavioural Intervention (IBI) An intensive intervention (at least 20 hours per week) for children with ASD Goal of IBI is to increase children's developmental trajectories, or rate of learning, and to prepare them to learn in other, more natural, environments Several studies indicate that IBI can be beneficial for a group of children with ASD

Pharmacotherapy of ASD There are no pharmacological treatments for ASD per se Treatment therefore aimed at reduction of behaviours which interfere with daily functioning (typically aggression and hyperactivity/inattention) Goal of medication should be to enhance other treatments (behaviour modification, education, speech therapy,…) Some medications have been shown to reduce interfering behaviours but should be used judiciously and in conjunction with other interventions

Case: Connor After assessment, diagnosed with ASD Eligible for provincial-funded IBI program (waiting list about 1 year) Mom: Quit work to be able to care for John Wants him in privately funded, home-based IBI program Feels medication is necessary to reduce aggression and self-injury Dad: Wants John to receive IBI program through provincial-funded program and to attend daycare until IBI funding is available Often unable to attend parenting seminars Is strongly against the use of any medications

Attention-Deficit/Hyperactivity Disorder

Case: Spencer 7 year old male, just finishing grade 1 Parents divorced two years ago and have joint custody of he and younger sister Since JK, teachers have commented that he: Does not listen or follow directions, doesn’t seem to pay attention Restless, frequently out of his seat, speaks out of turn and interrupts often Disruptive, defiant, frequent fights (sent home numerous times) Mother (who had problems with attention when she was a child) reports he is “exhausting”: argumentative, difficult to manage due to tantrums, needs constant supervision Dad denies similar problems at his house

Diagnosis Epidemiology Etiology Treatment

Diagnosis of ADHD The essential feature of ADHD is a persistent pattern of inattention and/or hyperactivity–impulsivity which is inconsistent with the individual’s developmental level Clear evidence of significant impairment in social or academic functioning in at least two settings Must have at least 6 inattentive symptoms AND/OR at least 6 hyperactive symptoms Some symptoms must be present before the age of 12

Inattentive Symptoms Lack of attention to details or makes careless errors Difficulty sustaining attention Does not seem to listen Difficulty following instructions Difficulty organizing tasks Avoids work requiring sustained attention Often loses things Easily distracted Often forgetful

Hyperactive/Impulsive Symptoms Often fidgets or squirms Often leaves seat in class Runs or climbs excessively Difficulty playing quietly Often “on the go” Talks excessively “Blurts” out answers Difficulty awaiting turn Often interrupts

Disorders Comorbid with ADHD Up to 65% of patients with ADHD have a comorbid psychiatric disorder Disruptive behaviour disorders (oppositional defiant disorder or conduct disorder): 50% Anxiety disorders: 25% Learning disorders: 25% Mood disorders: 20% Tourette Syndrome: 7%

Diagnosis Epidemiology Etiology Treatment

Epidemiology of ADHD Prevalence about 3% to 5% of school aged children Male:female ratio about 4:1 (9:1 in clinical samples) Females less likely to have problems with hyperactivity and impulsivity 10% of behaviour problems seen in general pediatrics are due to ADHD Children with ADHD account for up to 50% of referrals to child psychiatrists

Epidemiology of ADHD For most, persists into adulthood, although overt hyperactivity may decrease In long-term follow-up, people with ADHD have: Increased school difficulties Increased social and relationship difficulties Increased substance use problems Increased job difficulties and unemployment Increased arrests and incarceration Increased serious car accidents

Diagnosis Epidemiology Etiology Treatment Neurobiology Environmental Factors Treatment

Neurobiology of ADHD Patients with ADHD (on average) have reductions of: brain volume, particularly in the frontal lobes Changes are independent of medication treatment Long-term stimulant treatment appears not to change developmental trajectory Genetics seems to play a very significant role Relatives of children with ADHD have higher rates of ADHD than relatives of control subjects Heritability about 70%

Environmental Factors in ADHD Obstetrical complications Tend to be complications leading to chronic low oxygen Maternal cigarette smoking during pregnancy Psychosocial adversity Low SES, low maternal education, single parenthood, chronic family conflict, reduced family cohesion

Diagnosis Epidemiology Etiology Treatment

Treatment of ADHD Behavioural interventions Education about ADHD and associated difficulties Training in behavioural change strategies (reward positive behaviour, ignore unacceptable behaviour) Parent stress management Generally dependent upon appropriate medication to be of value, particularly in more severely affected children

Pharmacological Treatment of ADHD Stimulants methylphenidate (Ritalin, Concerta, Biphentin), dextroamphetamine (Dexedrine, Vyvanse), mixed amphetamine salts (Adderall) First line medications for ADHD in the vast majority of cases Can be extraordinarily effective, with 70% - 80% of participants in clinical trials showing significant improvement Abuse liability with oral formulations is low and tolerance does not typically develop to cognitive effects

Pharmacological Treatment of ADHD Atomoxetine (Strattera) Second line (or perhaps 1a) treatment Non-stimulant May help with comorbid anxiety Alpha Agonists guanfacine (Intuniv), clonidine (Catapress) Third line treatment Effective in treatment of tics Other Treatments

Case: Spencer Diagnosed with attention-deficit/hyperactivity disorder and learning disorder (reading) Parents and school have collaboratively started a behavioural program in all three environments, although consistency in parental homes is uncertain Mother would like to start him on Biphentin as she has seen it work in other children Father would like to wait until he’s older as “he’s just being a kid” and wants to see if school improves with behaviour program

Conclusion ASD and ADHD are common and present in diverse ways For many people, both conditions result in lifelong challenges and disabilities Having a child with ASD or ADHD can be very challenging and stressful for families Informed parenting approaches and involvement are critical for optimal outcome