1. 1. Research Data Repository 3. Environmental Risk Factors 5. Behavioural Research 6. Autism Research across the Lifespan 2. Genetic and Stem Cell Research 7. Policy Change 4. Neuroimaging Research

2. Dr. Geraldine Leader & Ms Arlene Mannion Irish Centre for Autism and Neurodevelopmental Research National University of Ireland, Galway

3. What is Comorbidity? Comorbidity is defined as the co-occurrence of two or more disorders in the same person (Matson & Nebel- Schwalm, 2007). A comorbid condition is a second order diagnosis which offers core symptoms that differ from the first disorder.

4. Why is it important to study comorbidity in ASD? Comorbidity in ASD is a topic that has been infrequently addressed and requires more research. Important that one disorder is diagnosed as the primary disorder and the other(s) as secondary. Design and implementation of effective treatment plans.

5. Why is it important to study comorbidity in ASD? Comorbid conditions result in a more complex diagnostic treatment picture. Comorbidity can make the overall problems more severe and treatment resistant.

6. Why is it important to study comorbidity in ASD? There are considerable differences in symptoms of ASD. What are the core symptoms of ASD? How are those symptoms different to symptoms of comorbid disorders?

7. Mannion, Leader & Healy (2012) An investigation of comorbid psychological disorders, sleep problems, gastrointestinal symptoms and epilepsy in children and adolescents with autism spectrum disorder. Participants were 89 children and adolescents with a diagnosis of ASD. The mean age of the sample was 9 years, ranging from 3 to 16 years. 83% (n = 74) were males and 17% (n = 15) were female.

8. Mannion, Leader & Healy (2012) Comorbid disorder (including intellectual disability) 78.7% (n = 70) Comorbid disorder (excluding intellectual disability) 46.1% (n = 41) Epilepsy 10.1% (n = 9) Attention deficit/hyperactivity disorder (AD/HD) 17.9% (n = 16) Anxiety disorder 15.7% (n = 14) Oppositional defiant disorder (ODD) 4.5% (n = 4)

10. What are Gastrointestinal Symptoms? Gastrointestinal (GI) symptoms include: Nausea Bloating Abdominal pain Constipation and Diarrhoea

11. Why is it important to study GI symptoms? They can cause pain and discomfort to individuals with ASD. Can have an effect on challenging behaviour. Can interfere with learning.

12. Why are GI symptoms difficult to diagnose in ASD? Many individuals with ASD are non verbal and cannot express pain or discomfort through speech. Cannot communicate symptoms as clearly as their typically developing peers. Those who can verbally communicate may have difficulty describing subjective experiences or symptoms.

13. Why are GI symptoms difficult to diagnose in ASD? Insistence on sameness can lead individuals to demand stereotyped diets, that may result in inadequate intake of fibre, fluids and other foods, which can cause gastrointestinal symptoms. If medication is administered, it can influence gut function.

14. Prevalence of GI symptoms The prevalence of gastrointestinal abnormalities in individuals with ASD is incompletely understood. The reported prevalence in children with ASD has ranged from 9 to 84%. It is an area that is in need of future research.

15. Mannion, Leader & Healy (2013) Used the Gastrointestinal Symptom Inventory (Autism Treatment Network, 2005). Measured nausea, abdominal pain, bloating, constipation and diarrhoea. 79.3% of children/adolescents had at least 1 GI symptom. 23% had 2 symptoms. 13.8% had 3 symptoms. 14.9% had 4 symptoms. 6.9% had all 5 GI symptoms.

16. Mannion, Leader & Healy (2013) Of those with GI issues, most common symptoms were: Abdominal pain (51.7%) Constipation (49.4%) Diarrhoea (45.9%) Nausea (29.9%) Bloating (25.3%)

17. We identified a link between gastrointestinal symptoms problem behaviour. An emerging literature suggests that individuals with ASD and GI symptoms may be at higher risk for problem behaviours than those with ASD who do not have GI symptoms. We also found a link between gastrointestinal symptoms and sleep problems.

19. What are sleep problems? Insomnia Parasomnias Sleep related breathing disorders (e.g. Obstructive Sleep Apnea, OSA) Circadian rhythm sleep disorders

20. Why is it important to study sleep problems in autism? Sleep disturbance is one of the most common concerns voiced by parents of children with autism. Sleep affects not only children, but families. Sleep problems are especially important comorbidities to identify in children with ASD. The sleep community has identified autism as a priority population for targeting interventions for sleep disorders.

21. Why is it important to study sleep problems in autism? Poor sleep impacts on the individual’s health, and daily functioning, as well as the family unit. Sleep disorders are highly treatable. However, evidence-based standards of care for the surveillance, evaluation and treatment of sleep disturbance in the ASD population are greatly needed.

22. Mannion, Leader & Healy (2012) Used the Children’s Sleep Habits Questionnaire (CSHQ) (Owens, Nobile, McGuinn & Spirito, 2000). CSHQ is a parental report sleep screening instrument. It is not intended to diagnose specific sleep disorders, but rather to identify sleep problems and the possible need for further evaluation.

23. Mannion, Leader & Healy (2012) Score of 41 is clinical cut-off for identification of probable sleep problems. Subscales: Bedtime resistance Sleep onset delay Sleep duration Sleep anxiety Night wakings Parasomnias Sleep disordered breathing Daytime Sleepiness.

24. Mannion, Leader & Healy (2013) 80.9% of children presented with a sleep problem (Score of 41 or over on the CSHQ). Study also examined the predictors of sleep problems. Investigated whether age, gender, comorbid disorders (including intellectual disability), Autism Spectrum Disorder-Comorbid for Children (ASD-CC) score or gastrointestinal symptoms predicted sleep problems.

25. Mannion, Leader & Healy Avoidant behaviour (ASD-CC subscale), Under-eating (ASD-CC subscale) and total GI symptoms predicted sleep problems. Specifically, abdominal pain predicted sleep anxiety. Future research needs to examine the link between sleep problems and gastrointestinal symptoms.

26. Treatment of Sleep Problems Behavioural interventions-1 st approach Visual Schedules for bedtime routines Reinforcement: Stickers, Tokens, Basket of presents. Bedtime Pass-A token system for minimizing bedtime resistance and night wakings.

27. Autism Treatment Network (ATN) Sleep Tool-kit Informational booklet designed to provide parents with strategies to improve sleep in their children affected by autism spectrum disorders. Suggestions based on both research and clinical experience of sleep experts. Can be downloaded for free. www.autismspeaks.org

28. In summary: 79.3% of children had at least one gastrointestinal symptom within the last 3 months. 80.9% had sleep problems. 67.8% of children had both gastrointestinal symptoms and sleep problems.

29. In summary: We found a link between gastrointestinal symptoms and behaviour problems. We found a link between gastrointestinal symptoms and sleep problems..

30. Take Home Messages: It is important to diagnose comorbid disorders in order to provide the best possible treatment for a child with autism. It is essential that we distinguish between the symptoms of autism and the symptoms of comorbid disorders. Communication impairments in autism may lead to unusual presentations of gastrointestinal symptoms, including sleep disturbances and challenging behaviour. Sleep problems are highly treatable.

31. Take Home Messages: We need parents to get involved in research, even if their children are not presenting with comorbid symptoms. By comparing children with autism with and without comorbid symptoms, we can understand a lot more about comorbidity. When we understand comorbidity better, we can then focus on establishing the most effective treatment for children with autism.

32. 1. Research Data Repository 3. Environmental Risk Factors 5. Behavioural Research 6. Autism Research across the Lifespan 2. Genetic and Stem Cell Research 7. Policy Change 4. Neuroimaging Research