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

2. 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

3. 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

4. Autism Spectrum Disorder

5. 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

6. Diagnosis
Epidemiology
Etiology
Treatment

7. 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

8. 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

9. 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

10. Diagnosis
Epidemiology
Etiology
Treatment

11. 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

12. Diagnosis Epidemiology Etiology Treatment Neurobiology
Environmental Factors
Treatment

13. 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

14. 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

15. Diagnosis
Epidemiology
Etiology
Treatment
Intensive Behavioural Intervention
Pharmacotherapy

16. 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

17. 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

18. 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

19. Attention-Deficit/Hyperactivity Disorder

20. 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

21. Diagnosis
Epidemiology
Etiology
Treatment

22. 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

23. 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

24. 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

25. 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%

26. Diagnosis
Epidemiology
Etiology
Treatment

27. 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

28. 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

29. Diagnosis Epidemiology Etiology Treatment Neurobiology
Environmental Factors
Treatment

30. 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%

31. 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

32. Diagnosis
Epidemiology
Etiology
Treatment

33. 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

34. 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

35. 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

36. 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

37. 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