ADHD and Autism Spectrum Disorder

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Attention Deficit Hyperactivity Disorder (ADHD) :

learning objective : describe the symptoms of neurodevelopmental disorders (ADHD and Autism) and describe the diagnostic controversies associated with these neurodevelopmental disorders

• adults can be diagnosed with both disorders

• most often these disorders are diagnosed for the first time when the individual is a child

Attention Deficit / Hyperactivity Disorder :

• symptoms first described by Hans Hoffman in the 1920s

• while he was taking care of his son while his wife was giving birth, he noticed that his son had trouble concentrating on his homework

• it was later discovered that many hyperactive children (those who are fidgety, restless, socially disruptive, and have trouble with impulse control) also display short attention spans, problems with concentration, and distractibility

• by the 70s, it had become clear that many children who display attention problems often also exhibit signs of hyperactivity

• the DSM - III (published in 1980) included attention deficit disorder without hyperactivity but is now known as ADHD

• a child with ADHD shows a constant pattern of inattention or hyperactive and impulsive behavior that interferes with normal functioning

• some of the signs of inattention include : great difficulty with and avoidance of tasks that require sustained attention, failure to follow instructions, disorganization, lack of attention to detail, becoming easily distracted, and forgetfulness

hyperactivity : characterized by excessive movement, and includes fidgeting or squirming, leaving on’es seat in situations when remaining seated is expected, having trouble sitting still, running about and climbing on things, blurting out responses before another person’s question or statement has been completed, difficulty waiting one’s turn for something, and interrupting and intruding on others

• frequently the hyperactive child comes across as noisy and boisterous

• the child’s behavior is hasty, impulsive, and seems to occur without much forethought

• these characteristics may explain why adolescents and young adults diagnosed with ADHD receive more traffic tickets and have more automobile accidents than do others

• ADHD occurs in about 5% of children

• boys are 3 times more likely to have ADHD than girls

• such findings might reflect the greater propensity of boys to engage in aggressive and antisocial behavior and thus incur a greater likelihood of being referred to psychological clinics

• children with ADHD have lower grades and standardized test scores and higher rates of expulsion, grade retention, and dropping out

• those with ADHD are less well-liked and more often rejected by their peers

• ADHD was thought to fade away by adolescence, but studies show that it can persist into adulthood

• 29.3% of adults who have been diagnosed with ADHD still showed symptoms

• nearly 81% of those whose ADHD persisted into adulthood had experienced at least one other comorbid disorder

• ADHD can remain problematic in adults, up to 7% of college students are diagnosed with ADHD

• the symptoms of ADHD in adults includes : forgetfulness, difficulty paying attention to detail, procrastination, disorganized work habits, and not listening to others

Controversy

• the diagnosis of ADHD has quadrupled over the past 20 years

• ADHD is diagnosed in about 1 out of every 20 American children

• ADHD is the most common psychological disorder among children int he world

• ADHD is also being diagnosed much more frequently in adolescents and adults

• some believe that drug companies contribute to the rate of diagnosis of the disorder, because ADHD is often treated with a prescription medication

• research suggests that ADHD is a real disorder that is caused by a combination of genetic and environmental factors

• studies have found that ADHD is heritable

• neuroimaging studies have found that people with ADHD may have structural differences in areas of the brain that influence self-control and attention

• other studies have pointed to environmental factors, such as mothers smoking and drinking alcohol during pregnancy and the consumption of lead and food additives by those who are affected

• social factors such as family stress and poverty also contribute to ADHD

Autism Spectrum Disorder

learning objective : describe the symptoms of neurodevelopmental disorders (ADHD and Autism) and describe the diagnostic controversies associated with these neurodevelopmental disorders

• A seminal paper published in 1943 by psychiatrist Leo Kanner described an unusual neurodevelopmental condition he observed in a group of children

• He called this condition early infantile autism

• he characterized early infantile autism mainly by an inability to form close emotion ties with others, speech and language abnormalities, repetitive behaviors, and an intolerance of minor changes in the environment and normal routines

• what the DSM-5 now refers to as autism spectrum disorder today is a direct extension of Kanner’s work

• autism spectrum disorder is referred to as autism

• the qualifier “spectrum” disorder is used to indicate that individuals with the disorder can show a range, or spectrum of symptoms that vary in their magnitude and severity.

• the previous edition of the DSM included a diagnosis of Asperger’s Disorder, generally recognized as a less severe form of autistic disorder; individuals diagnosed with Asperger’s disorder were described as having average or high intelligence and a strong vocabulary, but exhibiting impairments in social interaction and social communication

• because research has failed to demonstrate that Asperger;s disorder differs qualitatively from autistic disorder, the DSM-5 does not include it

• some individuals with autism, particularly those with better language and intellectual skills can live and work independently as adults

• most do not because the symptoms remain sufficient to cause serious impairment in many realms of life

• nearly 1 in 88 American children has autism spectrum disorder

• the disorder is 5 times more common in males than in females

• the difference in diagnosis of autism spectrum disorder could be due to gender differences

• females with autism may not even be diagnosed until adulthood due to increased societal awareness of the disorder

• there is research that autism affects males and females differently

• rates of autism have increased dramatically since the 80s

• California saw an increase of 273% from 1987 to 1998

• between 2000 and 2008 the rate of autism diagnoses in the U.S increased 78%

• it is possible that the rise in prevalence is the result of the broadening of the diagnosis, increased efforts to identify cases in the community, and greater awareness and acceptance of the diagnosis

• mental health professionals are now more knowledgeable about autism spectrum disorder and are better equipped to make the diagnosis, even in subtle cases

DSM-5 Criteria for Autism Spectrum Disorder

Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive, see text):

• Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.

• Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.

• Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.

Specify current severity: Severity is based on social communication impairments and restricted repetitive patterns of behavior (see Table 2).

Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive; see text):

• Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).

• Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat food every day).

• Highly restricted, fixated interests that are abnormal in intensity or focus (e.g, strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interest).

• Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).

Specify current severity: Severity is based on social communication impairments and restricted, repetitive patterns of behavior (see Table 2).

Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life).

Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.

These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.

Note: Individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger’s disorder, or pervasive developmental disorder not otherwise specified should be given the diagnosis of autism spectrum disorder. Individuals who have marked deficits in social communication, but whose symptoms do not otherwise meet criteria for autism spectrum disorder, should be evaluated for social (pragmatic) communication disorder.

Severity levels for autism spectrum disorder