In a recently released article in Pediatrics(10.1542/peds.2017-1377), Dr. Gordon-Lipkin and colleagues use an internet-based parent-report research registry, Interactive Autism Network (IAN), to examine the occurrence of anxiety and mood disorders among youth ages 6-17 years who have both Autism Spectrum Disorder (ASD) and Attention-Deficit/Hyperactivity Disorder (ADHD) compared to those with ASD alone. Prior to the 2013 release of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), ASD and ADHD could not be diagnosed as co-occurring, even though many clinicians believed that the diagnoses had considerable overlap. This study is part of ongoing clinical research aiming to better understand children with dual diagnosis of ASD and ADHD who are burdened by multiple behavioral and emotional difficulties.1
Certainly the use of a “family-centered” database which shares de-identified information for research purposes is intriguing. IAN participants must have a professional diagnosis of ASD; information in the registry has been clinically validated by scores on the Social Communication Questionnaire-Lifetime (SCQ-Lifetime) and verified by medical record review. To assess for ADHD and anxiety and mood disorders, the authors utilized parent report, and asked, “Has [CHILD NAME] ever been diagnosed with or received treatment for____?”- Depression; Bipolar Disorder; ADHD; Anxiety Disorder?” They were able to compare responses for 3319 children with ASD, of whom 1503 (45.3%) also had ADHD by parent report. This high proportion of children with a dual diagnosis could be considered surprising given that clinicians previously were “not allowed” to co-diagnosed. The authors also found parents self-reported that 41.1% of their children also demonstrated anxiety and 18.9% mood disorders in their diagnosis and treatment. Increasing age was associated with increasing risk for diagnosis or treatment of these behavioral and emotional co-morbidities. The authors review the many possible clinical, biological and study methodology-related reasons for their findings in a thought provoking Discussion.
What does this mean for clinicians? My take is that we have an enormous responsibility to fully evaluate children with emotional and behavioral troubles as early as possible, and to refer promptly if the constellation of symptoms is beyond our own level of expertise. Don’t wait. Rather than hoping entry to preschool or school will magically mitigate troubles, and rather than ascribing challenging or worrisome behaviors to autism alone or even to ADHD and autism together, we can support referral to appropriate psychological help. Was the relationship of diagnosis to older age noted here due to late diagnosis or to the natural history of these conditions? The study of Dr. Gordon-Lipkin et al does not purport to answer this question, but as the authors note, both mood disorders and anxiety are highly treatable with psychotherapy and medications, and if untreated can negatively impact relationships, quality of life and functioning.2-4 This study is a call to action!
References
1. Sokolova E, Oerlemans AM, Rommelse NN, et al. A Causal and Mediation Analysis of the Comorbidity Between Attention Deficit Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder (ASD). Journal of Autism and Developmental Disorders. 2017;47(6):1595-1604. doi:10.1007/s10803-017-3083-7.
2. Birmaher B, Brent D; AACAP Work Group on Quality Issues, Bernet W, Bukstein O, Walter H, Benson RS, Chrisman A, Farchione T, Greenhill L, Hamilton J, Keable H, Kinlan J, Schoettle U, Stock S, Ptakowski KK, Medicus J. Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry. 2007 Nov;46(11):1503-26.
3. Connolly SD, Bernstein GA; Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry. 2007 Feb;46(2):267-83.
4. Mojtabai R, Olfson M, Han B. National Trends in the Prevalence and Treatment of Depression in Adolescents and Young Adults. Pediatrics. 2016;138(6):e20161878. doi:10.1542/peds.2016-1878.
