A Causal and Mediation Analysis of the Comorbidity Between Attention Deficit Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder (ASD)

Clinical and functional characteristics of children and young adults with cerebral palsy and co-occurring attention-deficit/hyperactivity disorder

BACKGROUND

Emerging research shows that children and young adults (CYAs) with cerebral palsy (CP) are at higher risk for attention-deficit/hyperactivity disorder (ADHD). However, little is known about the clinical and functional characteristics of CYAs with these co-occurring disorders.

AIM

To estimate associations between a diagnosis of ADHD among CYAs with CP and clinical and functional characteristics.

METHODS

This retrospective, cross-sectional study used data from the electronic health records of CYAs (aged 4-26 years) with CP (n = 1145). We used bivariate and multivariable analyses to estimate associations between an ADHD diagnosis, CP type, Gross Motor Function Classification System (GMFCS) level, speech or language disorder, and intellectual disability.

RESULTS

18.1 % of CYAs with CP had a diagnosis of ADHD. CYAs with spastic-bilateral CP had lower odds of ADHD (adjusted odds ratio [AOR] = 0.58; 95 % confidence interval [CI], 0.35-0.96). Odds of having ADHD were significantly lower for those with GMFCS levels III-V (AOR = 0.10; 95 % CI, 0.06-0.15).

CONCLUSIONS

Our study found that a diagnosis of ADHD among CYAs with CP was associated with greater clinical and functional impairments compared to counterparts without ADHD. Findings highlight the need to screen for both conditions because of the high comorbidity rates in this population.

Object Exploration and Manipulation in Infants at Typical vs. Elevated Likelihood for ASD: A Review

The present review considers the growing body of literature on fine motor skills in infants at elevated genetic likelihood (EL) for autism spectrum disorder (ASD). This area of study aims to identify crucial motor markers associated with the disorder, facilitating earlier and more accurate identification of ASD, using various experimental methodologies, including standardized assessments, observational measures, and technological tools. The reviewed evidence revealed distinct developmental trajectories in EL infants, marked by differences in fine motor skills and exploratory behaviors compared to typically developing infants. We discuss the developmental trajectory of fine motor skills in infants and their predictive value for later ASD diagnosis, highlighting the significance of fine motor skills as early indicators of ASD risk in infants and emphasizing the need for further research to elucidate their predictive value and underlying mechanisms.

Identifying Autistic-Like Symptoms in Children with ADHD: A Comparative Study Using ADOS-2

Purpose

Recent literature has focused attention on the presence of autistic-like symptoms in children with Attention Deficit/Hyperactivity Disorder (ADHD), who often exhibit social difficulties, posing challenges for a distinct clinical diagnosis. The current study aimed to identify the specific pattern of autistic symptoms in subjects with ADHD or Autistic Spectrum Disorder (ASD), examining similarities or differences at both the domain and individual item levels.

Patients and Methods

In this study, we enrolled 43 school-age children divided into the following: the ADHD group (n=25) consisted of children initially referred for ASD symptoms but subsequently clinically diagnosed with ADHD, and the ASD group consisted of 18 children with ASD. We used the Autism Diagnostic Observation Schedule, 2nd edition (ADOS-2), to examine relative differences in the presence of symptoms such as deficits in communication and social interaction, and restricted and repetitive behaviors in these two groups. Comparison between groups was conducted to explore differences in IQ, age, ADOS-2 domains, and externalizing and internalizing problems among the groups.

Results

We found significant differences between the groups when comparing summary scores of ADOS-2 domains (Social Affect, Restricted and Repetitive Behavior, and Total Score). Interestingly, at the individual item level, the ADHD group exhibited a similar level of atypical behaviors compared to the ASD group in two items related to the social-communication area: "Pointing" and "Gestures". Additionally, the frequencies of "Stereotyped/idiosyncratic words or phrases", "Mannerisms", and "Repetitive interests and behaviors" also showed similarities between groups.

Conclusion

These findings indicate the importance of exploring and developing potential transdiagnostic domains that could be targeted for treatments specifically designed for children with ADHD.

The effect of sevoflurane exposure on cell-type-specific changes in the prefrontal cortex in young mice

Sevoflurane, the predominant pediatric anesthetic, has been linked to neurotoxicity in young mice, although the underlying mechanisms remain unclear. This study focuses on investigating the impact of neonatal sevoflurane exposure on cell-type-specific alterations in the prefrontal cortex (PFC) of young mice. Neonatal mice were subjected to either control treatment (60% oxygen balanced with nitrogen) or sevoflurane anesthesia (3% sevoflurane in 60% oxygen balanced with nitrogen) for 2 hours on postnatal days (PNDs) 6, 8, and 10. Behavioral tests and single-nucleus RNA sequencing (snRNA-seq) of the PFC were conducted from PNDs 31 to 37. Mechanistic exploration included clustering analysis, identification of differentially expressed genes (DEGs), enrichment analyses, single-cell trajectory analysis, and genome-wide association studies (GWAS). Sevoflurane anesthesia resulted in sociability and cognition impairments in mice. Novel specific marker genes identified 8 distinct cell types in the PFC. Most DEGs between the control and sevoflurane groups were unique to specific cell types. Re-defining 15 glutamatergic neuron subclusters based on layer identity revealed their altered expression profiles. Notably, sevoflurane disrupted the trajectory from oligodendrocyte precursor cells (OPCs) to oligodendrocytes (OLs). Validation of disease-relevant candidate genes across the main cell types demonstrated their association with social dysfunction and working memory impairment. Behavioral results and snRNA-seq collectively elucidated the cellular atlas in the PFC of young male mice, providing a foundation for further mechanistic studies on developmental neurotoxicity induced by anesthesia.

Sociability: Comparing the Effect of Chlorpyrifos with Valproic Acid

In recent years, exposures to organophosphate pesticide have been highlighted as a possible cause or aggravating factor of autism spectrum disorder (ASD). The present study examined if Wistar rats prenatally exposed to chlorpyrifos (CPF) at a dose of 1 mg/kg in GD 12.5-15.5 could express similar behaviors to those exposed to valproic acid (VPA, 400 mg/kg) during the same administration window, which is an accepted animal model of autism. The 3-chambered test was employed to evaluate sociability and reaction to social novelty in two experiments, the first in adolescence and the second in adulthood. The results obtained in this study show that animals prenatally treated with CPF or VPA show a similar behavioral phenotype compared to the control group (CNT). In adolescence, the CPF animals showed a negative index in the reaction to social novelty, followed closely by the VPA, while both experimental groups showed a recovery in this aspect during adulthood. This study therefore provides evidence to suggest that prenatal exposure to CPF in rats could have similar effects on certain components of sociability to those seen in autistic models.

The High Rates of Comorbidity among Neurodevelopmental Disorders: Reconsidering the Clinical Utility of Distinct Diagnostic Categories

The boundaries between neurodevelopmental disorders are often indistinct, even among specialists. But do these boundaries exist, or do experts struggle to distinguish and categorize symptoms in order to arrive at a dominant diagnosis while comorbidity continually leaves questions about where each disorder ends and begins? What should be reconsidered? The introduction of the term 'spectrum of neurodevelopmental disorders' could pave the way for a re-appraisal of the clinical continuum of neurodevelopmental disorders. This study aims to highlight the problems that emerge in the field of the differential diagnosis of neurodevelopmental disorders and propose a renegotiation of the distinctiveness criteria.

Caregiver and youth inter-rater assessment agreement in autism spectrum disorder, developmental coordination disorder, and typical development

Youth diagnosed with autism spectrum disorder (ASD) and those with developmental coordination disorder (DCD) are at heightened risk for co-occurring mental health diagnoses, especially anxiety and attention-deficit/hyperactivity disorder (ADHD). However, caregiver-child agreement on presence of related symptoms in populations with neurodevelopmental conditions is not well understood. Here, we examine the extent to which 37 ASD, 26 DCD, and 40 typically developing children and their caregivers agree on the degree of the child's symptoms of anxiety and ADHD. All caregiver-child dyads completed the Screen for Child Anxiety Related Emotional Disorders and Conners 3 ADHD Index. Across groups, intraclass correlations indicated generally poor agreement on anxiety and ADHD symptomatology. Although youth generally reported greater internalizing symptoms (i.e., anxiety), caregivers tended to report more observable externalizing behaviors (i.e., ADHD). Together, the results of this study support the need for a multi-informant approach in assessments of anxiety and ADHD in youth with neurodevelopmental disorders.

Therapeutic efficacy of probiotics for symptoms of attention-deficit hyperactivity disorder in children and adolescents: meta-analysis

BACKGROUND

The efficacy of probiotics as a therapeutic alternative for attention-deficit hyperactivity disorder (ADHD) remain unclear.

AIMS

To investigate the effectiveness of probiotics for symptoms of ADHD and identify possible factors affecting their efficacy.

METHOD

Randomised placebo-controlled trials were identified through searching major databases from inception to April 2023, using the main keywords 'probiotics' and 'ADHD' without limitation on languages or geographic locations. The outcome of interest included improvement in total symptoms of ADHD, symptoms of inattention and hyperactivity/impulsivity, and drop-out rate. Continuous and categorical data were expressed as effect sizes based on standardised mean differences (SMDs) and odds ratios, respectively, with 95% confidence intervals.

RESULTS

Meta-analysis of seven trials involving 379 participants (mean age 10.37 years, range 4-18 years) showed no significant improvement in total symptoms of ADHD (SMD = 0.25; P = 0.12), symptoms of inattention (SMD = 0.14; P = 0.3) or hyperactivity/impulsivity (SMD = 0.08; P = 0.54) between the probiotic and placebo groups. Despite non-significance on subgroup analyses, there was a large difference in effect size between studies using probiotics as an adjunct to methylphenidate and those using probiotics as supplementation (SMD = 0.84 v. 0.07; P = 0.16), and a moderate difference in effect size between studies using multiple strains of probiotics and those using single-strain regimens (SMD = 0.45 v. 0.03; P = 0.19).

CONCLUSIONS

Current evidence shows no significant difference in therapeutic efficacy between probiotics and placebos for treatment of ADHD symptoms. However, albeit statistically non-significant, higher therapeutic efficacies associated with multiple-strain probiotics or combining probiotics with methylphenidate may provide direction for further research.

Comprehensive immunoprofiling of neurodevelopmental disorders suggests three distinct classes based on increased neurogenesis, Th-1 polarization or IL-1 signaling

Neurodevelopmental disorders (NDDs) are a spectrum of conditions with commonalities as well as differences in terms of phenome, symptomatome, neuropathology, risk factors and underlying mechanisms. Immune dysregulation has surfaced as a major pathway in NDDs. However, it is not known if neurodevelopmental disorders share a common immunopathogenetic mechanism. In this study, we explored the possibility of a shared immune etiology in three early-onset NDDs, namely Autism Spectrum Disorder (ASD), Attention Deficit Hyperactivity Disorder (ADHD) and Intellectual Disability Disorder (IDD). A panel of 48 immune pathway-related markers was assayed in 135 children with NDDs, represented by 45 children with ASD, ADHD and IDD in each group, along with 35 typically developing children. The plasma levels of 48 immune markers were analyzed on the Multiplex Suspension Assay platform using Pro Human cytokine 48-plex kits. Based on the cytokine/chemokine/growth factor levels, different immune profiles were computed. The primary characteristics of NDDs are depletion of the compensatory immune-regulatory system (CIRS) (z composite of IL-4, IL-10, sIL-1RA, and sIL-2R), increased interleukin (IL)-1 signaling associated with elevated IL-1α and decreased IL-1-receptor antagonist levels, increased neurogenesis, M1/M2 macrophage polarization and increased IL-4 as well as C-C Motif Chemokine Ligand 2 (CCL2) levels. With a cross-validated sensitivity of 81.8% and specificity of 94.4%, these aberrations seem specific for NDDs. Many immunological abnormalities are shared by ASD, ADHD and IDD, which are distinguished by minor differences in IL-9, IL-17 and CCL12. In contrast, machine learning reveals that NDD group consists of three immunologically distinct clusters, with enhanced neurogenesis, Th-1 polarization, or IL-1 signaling as the defining features. NDD is characterized by immune abnormalities that have functional implications for neurogenesis, neurotoxicity, and neurodevelopment. Using machine learning, NDD patients could be classified into subgroups with qualitatively distinct immune disorders that may serve as novel drug targets for the treatment of NDDs.

Management of sleep disorders in autism spectrum disorder with co-occurring attention-deficit hyperactivity disorder: update for clinicians

AIMS

To update and examine available literature germane to the recognition, assessment and treatment of comorbid autism spectrum disorder (ASD), attention-deficit hyperactivity disorder (ADHD) and sleep disruption, with a predominant focus on children, adolescents and emerging adults.

BACKGROUND

Considerable overlaps exist among ASD, ADHD and sleep disruption. Literature and guidance for clinicians, administrators, policy makers and families have been limited, as such deliberations were rarely considered until 2013.

METHOD

This narrative review of the literature addressing sleep disruption issues among those with ASD, ADHD and comorbid ASD and ADHD involved searching multiple databases and use of reverse citations up to the end of September 2022. Emphasis is placed on secondary sources and relevant data for clinical practice.

RESULTS

Complex clinical presentations of ASD/ADHD/sleep disruption are frequently encountered in clinical practice. Prior to 2013, prevalence, clinical presentation, pathophysiology, prognosis, other sleep-related factors and interventions were determined separately for each disorder, often with overlapping objective and subjective methods employed in the process. High percentages of ADHD and ASD patients have both disorders and sleep disruption. Here, the extant literature is integrated to provide a multidimensional understanding of the relevant issues and insights, allowing enhanced awareness and better care of this complex clinical population. Database limitations are considered.

CONCLUSIONS

Assessment of ASD symptomatology in youth with ADHD, and the reverse, in cases with disrupted sleep is critical to address the special challenges for case formulation and treatment. Evidence-based approaches to treatment planning and multi-treatment modalities should consider combining psychosocial and biological interventions to address the complexities of each case.

Cortical responses to social stimuli in infants at elevated likelihood of ASD and/or ADHD: A prospective cross-condition fNIRS study

Autism spectrum disorders (ASD) and attention-deficit hyperactivity disorder (ADHD) are highly prevalent neurodevelopmental conditions that often co-occur and present both common and distinct neurodevelopmental profiles. Studying the developmental pathways leading to the emergence of ASD and/or ADHD symptomatology is crucial in understanding neurodiversity and discovering the mechanisms that underpin it. This study used functional near-infrared spectroscopy (fNIRS) to investigate differences in cortical specialization to social stimuli between 4- to 6-month-old infants at typical and elevated likelihood of ASD and/or ADHD. Results showed that infants at both elevated likelihood of ASD and ADHD had reduced selectivity to vocal sounds in left middle and superior temporal gyrus. Furthermore, infants at elevated likelihood of ASD showed attenuated responses to visual social stimuli in several cortical regions compared to infants at typical likelihood. Individual brain responses to visual social stimuli were associated with later autism traits, but not ADHD traits. These outcomes support our previous observations showing atypical social brain responses in infants at elevated likelihood of ASD and align with later atypical brain responses to social stimuli observed in children and adults with ASD. These findings highlight the importance of characterizing antecedent biomarkers of atypicalities in processing socially relevant information that might contribute to both phenotypic overlap and divergence across ASD and ADHD conditions and their association with the later emergence of behavioural symptoms.

Co-development of attention deficit hyperactivity disorder and autistic trait trajectories from childhood to early adulthood

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) and autism, defined as traits or disorders, commonly co-occur. Developmental trajectories of ADHD and autistic traits both show heterogeneity in onset and course, but little is known about how symptom trajectories co-develop into adulthood.

METHODS

Using data from a population cohort, the Avon Longitudinal Study of Parents and Children, we examined correlations between ADHD and autistic traits across development, using the Social Communication Disorders Checklist and ADHD subscale of the Strengths and Difficulties Questionnaire. We modelled joint developmental trajectories of parent-reported ADHD and autistic traits between 4 and 25 years, then characterised trajectory classes based on sociodemographic, perinatal, psychopathology, cognition and social functioning variables and tested for associations with neurodevelopmental/psychiatric polygenic scores (PGS).

RESULTS

Three classes of trajectories were identified; a typically developing majority with low-stable ADHD-autistic traits (87%), a male-predominant subgroup with child/adolescent-declining traits (6%) and a subgroup with late-emerging traits (6%). ADHD-autistic trait correlations were greatest in young adulthood for the two nontypically developing classes. There were higher rates of emotional and conduct problems, low IQ, childhood seizures and poor social functioning in the declining and late-emerging classes compared to the low-stable class. Emotional, conduct and peer problems were more prevalent during childhood in the childhood/adolescent-declining class compared to other classes, but were more prevalent in young adulthood in the late-emerging class. Neurodevelopmental/psychiatric PGS also differed: both nontypically developing classes showed elevated ADHD PGS compared to the low-stable group, and the late-emerging group additionally showed elevated schizophrenia PGS and decreased executive function PGS, whereas the declining group showed elevated broad depression PGS.

CONCLUSIONS

Distinct patterns of ADHD-autism co-development are present across development in the general population, each with different characterising factors and genetic signatures as indexed by PGS.

Pharmacological intervention for irritability, aggression, and self-injury in autism spectrum disorder (ASD)

BACKGROUND

Pharmacological interventions are frequently used for people with autism spectrum disorder (ASD) to manage behaviours of concern, including irritability, aggression, and self-injury. Some pharmacological interventions might help treat some behaviours of concern, but can also have adverse effects (AEs).

OBJECTIVES

To assess the effectiveness and AEs of pharmacological interventions for managing the behaviours of irritability, aggression, and self-injury in ASD.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, 11 other databases and two trials registers up to June 2022. We also searched reference lists of relevant studies, and contacted study authors, experts and pharmaceutical companies.

SELECTION CRITERIA

We included randomised controlled trials of participants of any age with a clinical diagnosis of ASD, that compared any pharmacological intervention to an alternative drug, standard care, placebo, or wait-list control.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Primary outcomes were behaviours of concern in ASD, (irritability, aggression and self-injury); and AEs. Secondary outcomes were quality of life, and tolerability and acceptability. Two review authors independently assessed each study for risk of bias, and used GRADE to judge the certainty of the evidence for each outcome.

MAIN RESULTS

We included 131 studies involving 7014 participants in this review. We identified 26 studies as awaiting classification and 25 as ongoing. Most studies involved children (53 studies involved only children under 13 years), children and adolescents (37 studies), adolescents only (2 studies) children and adults (16 studies), or adults only (23 studies). All included studies compared a pharmacological intervention to a placebo or to another pharmacological intervention. Atypical antipsychotics versus placebo At short-term follow-up (up to 6 months), atypical antipsychotics probably reduce irritability compared to placebo (standardised mean difference (SMD) -0.90, 95% confidence interval (CI) -1.25 to -0.55, 12 studies, 973 participants; moderate-certainty evidence), which may indicate a large effect. However, there was no clear evidence of a difference in aggression between groups (SMD -0.44, 95% CI -0.89 to 0.01; 1 study, 77 participants; very low-certainty evidence). Atypical antipsychotics may also reduce self-injury (SMD -1.43, 95% CI -2.24 to -0.61; 1 study, 30 participants; low-certainty evidence), possibly indicating a large effect. There may be higher rates of neurological AEs (dizziness, fatigue, sedation, somnolence, and tremor) in the intervention group (low-certainty evidence), but there was no clear evidence of an effect on other neurological AEs. Increased appetite may be higher in the intervention group (low-certainty evidence), but we found no clear evidence of an effect on other metabolic AEs. There was no clear evidence of differences between groups in musculoskeletal or psychological AEs. Neurohormones versus placebo At short-term follow-up, neurohormones may have minimal to no clear effect on irritability when compared to placebo (SMD -0.18, 95% CI -0.37 to -0.00; 8 studies; 466 participants; very low-certainty evidence), although the evidence is very uncertain. No data were reported for aggression or self -injury. Neurohormones may reduce the risk of headaches slightly in the intervention group, although the evidence is very uncertain. There was no clear evidence of an effect of neurohormones on any other neurological AEs, nor on any psychological, metabolic, or musculoskeletal AEs (low- and very low-certainty evidence). Attention-deficit hyperactivity disorder (ADHD)-related medications versus placebo At short-term follow-up, ADHD-related medications may reduce irritability slightly (SMD -0.20, 95% CI -0.40 to -0.01; 10 studies, 400 participants; low-certainty evidence), which may indicate a small effect. However, there was no clear evidence that ADHD-related medications have an effect on self-injury (SMD -0.62, 95% CI -1.63 to 0.39; 1 study, 16 participants; very low-certainty evidence). No data were reported for aggression. Rates of neurological AEs (drowsiness, emotional AEs, fatigue, headache, insomnia, and irritability), metabolic AEs (decreased appetite) and psychological AEs (depression) may be higher in the intervention group, although the evidence is very uncertain (very low-certainty evidence). There was no evidence of a difference between groups for any other metabolic, neurological, or psychological AEs (very low-certainty evidence). No data were reported for musculoskeletal AEs. Antidepressants versus placebo At short-term follow-up, there was no clear evidence that antidepressants have an effect on irritability (SMD -0.06, 95% CI -0.30 to 0.18; 3 studies, 267 participants; low-certainty evidence). No data for aggression or self-injury were reported or could be included in the analysis. Rates of metabolic AEs (decreased energy) may be higher in participants receiving antidepressants (very low-certainty evidence), although no other metabolic AEs showed clear evidence of a difference. Rates of neurological AEs (decreased attention) and psychological AEs (impulsive behaviour and stereotypy) may also be higher in the intervention group (very low-certainty evidence) although the evidence is very uncertain. There was no clear evidence of any difference in the other metabolic, neurological, or psychological AEs (very low-certainty evidence), nor between groups in musculoskeletal AEs (very low-certainty evidence). Risk of bias We rated most of the studies across the four comparisons at unclear overall risk of bias due to having multiple domains rated as unclear, very few rated as low across all domains, and most having at least one domain rated as high risk of bias.

AUTHORS' CONCLUSIONS

Evidence suggests that atypical antipsychotics probably reduce irritability, ADHD-related medications may reduce irritability slightly, and neurohormones may have little to no effect on irritability in the short term in people with ASD. There was some evidence that atypical antipsychotics may reduce self-injury in the short term, although the evidence is uncertain. There was no clear evidence that antidepressants had an effect on irritability. There was also little to no difference in aggression between atypical antipsychotics and placebo, or self-injury between ADHD-related medications and placebo. However, there was some evidence that atypical antipsychotics may result in a large reduction in self-injury, although the evidence is uncertain. No data were reported (or could be used) for self-injury or aggression for neurohormones versus placebo. Studies reported a wide range of potential AEs. Atypical antipsychotics and ADHD-related medications in particular were associated with an increased risk of metabolic and neurological AEs, although the evidence is uncertain for atypical antipsychotics and very uncertain for ADHD-related medications. The other drug classes had minimal or no associated AEs.

Prevalence and treatment of mental, behavioral, and developmental disorders in children with co-occurring autism spectrum disorder and attention-deficit/hyperactivity disorder: A population-based study

There is a lack of nationally representative studies examining the co-occurrence of autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) in children. This study examines comorbid mental, behavioral, and developmental disorders (MBDDs) and associated treatment modalities for children with co-occurring ASD and ADHD. Cross-sectional analyses were conducted using data from the pooled 2016-2018 National Survey of Children's Health (sample n = 102,341). Nationally representative prevalences were estimated for sociodemographic variables, comorbidities, psychotropic medication, and behavioral treatment. We assessed multivariable associations between co-occurring ASD + ADHD and MBDDs, use of psychotropic medication, and receipt of behavioral treatment after adjustment for sociodemographic confounders. Compared to children with ASD without co-occurring ADHD, children with ASD + ADHD had higher prevalence of most MBDDs, including anxiety (AOR 4.03 [95% CI 2.77, 4.87]), depression (AOR 3.08 [95% CI 1.77, 5.36]), behavior or conduct problems (AOR 4.06 [95% CI 2.72, 6.06]), and other mental health conditions. Similarly, compared to children with ADHD without ASD, children with ASD + ADHD had higher odds of anxiety (AOR 3.49 [95% CI 2.65, 4.61]), depression (AOR 1.67 [95% CI 1.21, 2.29]), behavior or conduct problems (AOR 2.31 [95% CI 1.68, 3.17]), and other mental health conditions. Children with ASD + ADHD were significantly more likely to take psychotropic medication than children with ASD without ADHD. Among children with ASD + ADHD, males had higher odds of receiving behavioral treatment, whereas older children and adolescents were more likely to take psychotropic medication. A multidisciplinary approach is necessary to support the complex needs of these children.

Psychiatric Comorbidities in Children and Adolescents with High-Functioning Autism Spectrum Disorder: A Study on Prevalence, Distribution and Clinical Features in an Italian Sample

This study investigated the prevalence and distribution of psychiatric comorbidities in a group of 472 children and adolescents with ASD aged 3-18 years. We examined differences in age, sex, IQ, adaptive skills, and ASD symptom severity by comparing participants with ASD (ASD group) with participants with ASD and a psychiatric disorder (ASD/PSY group). Overall, 32.2% of participants had a comorbid psychiatric condition. Attention deficit/hyperactivity disorder (ADHD) was the most frequent diagnosis among preschoolers (20.4%); among school-age children, ADHD and anxiety/obsessive-compulsive disorders were the most frequent conditions (21% and 10.6%, respectively); finally, adolescents exhibit higher prevalence of anxiety/obsessive-compulsive disorders (21.8%). The ASD/PSY group showed a higher percentage of males, they were older and showed lower adaptive skills than the group with ASD; moreover, their mothers exhibited higher stress levels than mothers of participants in the ASD group. The comparison between age groups in participants within ASD/PSY group revealed that preschoolers had lower IQ than school-age children and adolescents, and worse adaptive skills, more repetitive behaviors, and restricted interests than adolescents. This study highlights the importance of an accurate diagnosis of psychiatric comorbidities in children and adolescents with ASD, also considering individual and family impairment.

The regulatory role of endoplasmic reticulum chaperone proteins in neurodevelopment

The endoplasmic reticulum (ER) is the largest tubular reticular organelle spanning the cell. As the main site of protein synthesis, Ca2+ homeostasis maintenance and lipid metabolism, the ER plays a variety of essential roles in eukaryotic cells, with ER molecular chaperones participate in all these processes. In recent years, it has been reported that the abnormal expression of ER chaperones often leads to a variety of neurodevelopmental disorders (NDDs), including abnormal neuronal migration, neuronal morphogenesis, and synaptic function. Neuronal development is a complex and precisely regulated process. Currently, the mechanism by which neural development is regulated at the ER level remains under investigation. Therefore, in this work, we reviewed the recent advances in the roles of ER chaperones in neural development and developmental disorders caused by the deficiency of these molecular chaperones.

Reduced motor planning underlying inhibition of prepotent responses in children with ADHD

To flexibly regulate their behavior, children's ability to inhibit prepotent responses arises from cognitive and motor mechanisms that have an intertwined developmental trajectory. Subtle differences in planning and control can contribute to impulsive behaviors, which are common in Attention Deficit and Hyperactivity Disorder (ADHD) and difficult to be assessed and trained. We adapted a Go/No-Go task and employed a portable, low-cost kinematic sensor to explore the different strategies used by children with ADHD or typical development to provide a prepotent response (dominant condition) or inhibit the prepotent and select an alternative one (non-dominant condition). Although no group difference emerged on accuracy levels, the kinematic analysis of correct responses revealed that, unlike neurotypical children, those with ADHD did not show increased motor planning in non-dominant compared to dominant trials. Future studies should investigate whether motor control could help children with ADHD compensate for planning difficulties. This strategy might make inhibition harder in naturalistic situations that involve complex actions. Combining cognitive and kinematic measures is a potential innovative method for assessment and intervention of subtle differences in executive processes such as inhibition, going deeper than is possible based on accuracy outcomes alone.

Diagnostic and Therapeutic Challenges of Comorbid ASD, ADHD and Psychosis: A Case Report

Autism Spectrum Disorder (ASD) and attention deficit hyperactivity disorder (ADHD) comorbidity is common in clinical practice and it seems to be related to shared etiological mechanisms and genetic susceptibility. Moreover, occurrence of psychosis can further complicate these complex clinical pictures. Here, we discuss the case of a nine-years-old boy presenting with an episode of abnormal sustained posture of the upper limbs, resembling dystonia, at the age of 3. At this time, auditory and visual hallucinations, as well as obsessive thoughts and attentional lability were also present and a diagnosis of "Early onset psychosis" was initially made. Due to the worsening of clinical picture, several hospitalizations were necessary and pharmacological treatment with carbamazepine, risperidone and aripiprazole was carried out. Extensive clinic evaluation revealed a past medical and personal history of toe walking, weak social skills and stereotyped behavior observed and ADOS-2 Module 2 administration revealed severe Autism scores. Moreover, signs of attention and hyperactivity were consistent with ADHD diagnosis. This work highlights the importance of a complete diagnostic assessment in patients with complex presentation, suggesting the possible overlap diagnosis of ADHD and Autism even in presence of psychotic-like symptoms.

Annual Research Review: The transdiagnostic revolution in neurodevelopmental disorders

Practitioners frequently use diagnostic criteria to identify children with neurodevelopmental disorders and to guide intervention decisions. These criteria also provide the organising framework for much of the research focussing on these disorders. Study design, recruitment, analysis and theory are largely built on the assumption that diagnostic criteria reflect an underlying reality. However, there is growing concern that this assumption may not be a valid and that an alternative transdiagnostic approach may better serve our understanding of this large heterogeneous population of young people. This review draws on important developments over the past decade that have set the stage for much-needed breakthroughs in understanding neurodevelopmental disorders. We evaluate contemporary approaches to study design and recruitment, review the use of data-driven methods to characterise cognition, behaviour and neurobiology, and consider what alternative transdiagnostic models could mean for children and families. This review concludes that an overreliance on ill-fitting diagnostic criteria is impeding progress towards identifying the barriers that children encounter, understanding underpinning mechanisms and finding the best route to supporting them.

Pharmacological and dietary-supplement treatments for autism spectrum disorder: a systematic review and network meta-analysis

BACKGROUND

There is still no approved medication for the core symptoms of autism spectrum disorder (ASD). This network meta-analysis investigated pharmacological and dietary-supplement treatments for ASD.

METHODS

We searched for randomized-controlled-trials (RCTs) with a minimum duration of seven days in ClinicalTrials.gov, EMBASE, MEDLINE, PsycINFO, WHO-ICTRP (from inception up to July 8, 2018), CENTRAL and PubMed (up to November 3, 2021). The co-primary outcomes were core symptoms (social-communication difficulties-SCD, repetitive behaviors-RB, overall core symptoms-OCS) measured by validated scales and standardized-mean-differences (SMDs). Associated symptoms, e.g., irritability/aggression and attention-deficit/hyperactivity disorder (ADHD) symptoms, dropouts and important side-effects, were investigated as secondary outcomes. Studies in children/adolescents and adults were analyzed separately in random-effects pairwise and network meta-analyses.

RESULTS

We analyzed data for 41 drugs and 17 dietary-supplements, from 125 RCTs (n = 7450 participants) in children/adolescents and 18 RCTs (n = 1104) in adults. The following medications could improve at least one core symptom domain in comparison with placebo: aripiprazole (k = 6 studies in analysis, SCD: SMD = 0.27 95% CI [0.09, 0.44], RB: 0.48 [0.26, 0.70]), atomoxetine (k = 3, RB:0.49 [0.18, 0.80]), bumetanide (k = 4, RB: 0.35 [0.09, 0.62], OCS: 0.61 [0.31, 0.91]), and risperidone (k = 4, SCM: 0.31 [0.06, 0.55], RB: 0.60 [0.29, 0.90]; k = 3, OCS: 1.18 [0.75, 1.61]) in children/adolescents; fluoxetine (k = 1, RB: 1.20 [0.45, 1.96]), fluvoxamine (k = 1, RB: 1.04 [0.27, 1.81]), oxytocin (k = 6, RB:0.41 [0.16, 0.66]) and risperidone (k = 1, RB: 0.97 [0.21,1.74]) in adults. There were some indications of improvement by carnosine, haloperidol, folinic acid, guanfacine, omega-3-fatty-acids, probiotics, sulforaphane, tideglusib and valproate, yet imprecise and not robust. Confidence in these estimates was very low or low, except moderate for oxytocin. Medications differed substantially in improving associated symptoms, and in their side-effect profiles.

LIMITATIONS

Most of the studies were inadequately powered (sample sizes of 20-80 participants), with short duration (8-13 weeks), and about a third focused on associated symptoms. Networks were mainly star-shaped, and there were indications of reporting bias. There was no optimal rating scale measuring change in core symptoms.

CONCLUSIONS

Some medications could improve core symptoms, although this could be likely secondary to the improvement of associated symptoms. Evidence on their efficacy and safety is preliminary; therefore, routine prescription of medications for the core symptoms cannot be recommended. Trial registration PROSPERO-ID CRD42019125317.

Comorbidity of Attention-Deficit Hyperactivity Disorder and Autism Spectrum Disorders: Current Status and Promising Directions

High rates of co-occurring Attention-Deficit Hyperactivity Disorder (ADHD) and Autism Spectrum Disorders (ASD) suggest common causal pathways, which await elucidation. What is well-established, however, is the negative impact of comorbid ADHD and ASD on outcomes for everyday living, particularly in social interaction and communication and on broader psychopathology. Neurocognitive approaches suggest correlates of comorbidity are rooted in functional connectivity networks associated with executive control. There is support for familial origins, with molecular-genetic studies suggesting a causal role of pleiotropic genes. Further investigation is needed to elucidate fully how genetic risk for ADHD and ASD affects neurodevelopment and to identify structural and functional neural correlates and their behavioral sequelae. Identification of intermediate phenotypes is necessary to advance understanding, which requires studies that include the full spectrum of ASD and ADHD symptom severity, use longitudinal designs and multivariate methods to probe broad constructs, such as executive and social function, and consider other sources of heterogeneity, such as age, sex, and other psychopathology. Randomized efficacy trials targeting comorbid symptomatology are needed to mitigate negative developmental outcomes.

Latent Structure of Combined Autistic and ADHD Symptoms in Clinical and General Population Samples: A Scoping Review

Background: Many phenotypic studies have estimated the degree of comorbidity between Autism Spectrum Disorder (ASD) and Attention Deficit Hyperactivity Disorder (ADHD), but few have examined the latent, or unobserved, structure of combined ASD and ADHD symptoms. This is an important perquisite toward better understanding the overlap between ASD and ADHD. Methods: We conducted a scoping review of studies that examined the factor or latent class structure of ASD and ADHD symptoms within the same clinical or general population sample. Results: Eight studies met final inclusion criteria. Four factor analysis studies found that ASD and ADHD domains loaded separately and one found that some ASD and ADHD domains loaded together. In the three latent class studies, there were evidence of profiles with high levels of co-occurring ASD and ADHD symptoms. Conclusions: Our scoping review provides some evidence of phenotypic overlap between ASD and ADHD at the latent, or unobserved, level, particularly when using a "person-centered" (latent class analysis) vs. a "variable-centered" (factor analysis) approach.

Neurodevelopmental disorders: An innovative perspective via the response to intervention model

Neurodevelopmental disorders are a group of conditions classified together by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders which include intellectual disability, communication disorders, autism spectrum disorder, attention-deficit/hyperactivity disorder, specific learning disorder (SLD), and motor disorders. SLD is present in many students, who exhibit significant difficulties in the acquisition of reading, written expression, and mathematics, mostly due to problems with executive functions (EF). The present study is a review of the current situation of neurodevelopmental disorders and SLD focusing on the benefits of the response to intervention model (RtI), which allows the combination of evaluation and intervention processes. It also addresses the key role of EF. The importance of adapting RtI to new possibilities such as the use of virtual reality is discussed and a theoretical framework for carrying that out is provided.

Biological Bases of Empathy and Social Cognition in Patients with Attention-Deficit/Hyperactivity Disorder: A Focus on Treatment with Psychostimulants

In recent years, there has been growing interest in investigating the effect of specific pharmacological treatments for ADHD not only on its core symptoms, but also on social skills in youths. This stands especially true for ADHD patients displaying impulsive aggressiveness and antisocial behaviors, being the comorbidity with Disruptive Behavior Disorders, one of the most frequently observed in clinical settings. This systematic review aimed to synthesize research findings on this topic following PRISMA guidelines and to identify gaps in current knowledge, future directions, and treatment implications. Search strategies included the following terms: ADHD; methylphenidate and other ADHD drugs; empathy, theory of mind and emotion recognition. Full-text articles were retrieved and data from individual studies were collected. Thirteen studies were finally included in our systematic review. Ten studies assessing changes in empathy and/or theory of mind in patients with ADHD treated after pharmacological interventions were identified. Similarly, seven partially overlapping studies assessing changes in emotion recognition were retrieved. Despite a great heterogeneity in the methodological characteristics of the included studies, most of them reported an improvement in emphatic and theory of mind abilities in youths with ADHD treated with psychostimulants and nonstimulant drugs, as well as positive but less consistent results about emotion recognition performances.

Gestational diabetes mellitus, autistic traits and ADHD symptoms in toddlers: Placental inflammatory and oxidative stress cytokines do not play an intermediary role

OBJECTIVE

To evaluate whether gestational diabetes mellitus (GDM) is associated with increased risks of autistic traits and attention deficit/hyperactivity disorder (ADHD) among offspring and whether placental inflammatory and oxidative stress cytokines play an intermediary role.

METHODS

Based on a prospective cohort study from China, namely, the Ma'anshan Birth Cohort study (MABC), 3260 mother-child pairs were included. Autistic traits and ADHD symptoms among children were assessed at 18 months and 36 months, respectively. The mRNA expression levels of fourteen placental cytokines were determined using PCR. Logistic regression analysis was used to examine the associations between GDM and the risks of autistic traits or ADHD symptoms. Mediation analysis was used to assess the potential mediation effects of certain placental inflammatory factors.

RESULTS

Of the 3260 children, 419 (12.85%) were exposed to GDM. The prevalence rates of autistic traits and ADHD symptoms were 13.86% and 6.4%, respectively. A 48.6% increased risk of autistic traits was observed among offspring born to mothers with GDM [odds ratio (OR) = 1.49, 95% confidence interval (95%CI): 1.11-2.00)], while no significant association was found in terms of ADHD symptoms. There were significant positive associations between GDM and IL-10 expression and between HIF1-α and CRP mRNA expression and a significant negative association between GDM and CD206 mRNA expression. The expression of MCP-1 mRNA was negatively associated with the risk of autistic traits [adjusted OR = 0.73 (95%CI: 0.73-0.55)]. The levels of TNF-α were positively associated with the risk of ADHD symptoms [OR = 2.11 (95%CI: 1.39-3.21)], while GRP78 was inversely associated with it [OR = 0.64 (95%CI: 0.44-0.94)]. However, none of the 14 placental cytokines was involved as a key mediator.

CONCLUSION

Our findings suggest that GDM may act as a risk factor for autistic traits in offspring, while the biological mechanisms may not involve the 14 placental cytokines studied. No significant association between GDM and ADHD symptoms was observed.

Cognitive Dimensions of Learning in Children With Problems in Attention, Learning, and Memory

A data-driven, transdiagnostic approach was used to identify the cognitive dimensions linked with learning in a mixed group of 805 children aged 5 to 18 years recognised as having problems in attention, learning and memory by a health or education practitioner. Assessments included phonological processing, information processing speed, short-term and working memory, and executive functions, and attainments in word reading, spelling, and maths. Data reduction methods identified three dimensions of phonological processing, processing speed and executive function for the sample as a whole. This model was comparable for children with and without ADHD. The severity of learning difficulties in literacy was linked with phonological processing skills, and in maths with executive control. Associations between cognition and learning were similar across younger and older children and individuals with and without ADHD, although stronger links between learning-related problems and both executive skills and processing speed were observed in children with ADHD. The results establish clear domain-specific cognitive pathways to learning that distinguish individuals in the heterogeneous population of children struggling to learn.

Multidisziplinäre Diagnostik von Entwicklungsstörungen: Grundlage der „personalized precision medicine“

Das Spektrum der Entwicklungsstörungen gehört zum Alltag des Facharztes für Kinder- und Jugendmedizin. Durch den zunehmenden Einsatz von „Next-generation sequencing“-Methoden in den letzten 10 Jahren werden die genetischen Hintergründe besser verstanden. Hiermit eröffnen sich Möglichkeiten in der Routinediagnostik und auch für pathomechanismusbasierte individuelle Therapieansätze („personalized precision medicine“). Dieser Beitrag beschreibt die patientenzentrierte Einbettung einer multidisziplinären Tagesklinik („Murmeltiersprechstunde“) zu zeit- und ressourcensparender Diagnostik und Behandlung von Entwicklungsstörungen. Bei 43 an der Murmeltiersprechstunde teilnehmenden Kindern (Durchschnittsalter 4,9 Jahre) mit einer Entwicklungsstörung konnte in 24 Fällen (56 %) eine pathogene Variante in einem bereits bekannten Krankheitsgen, in 4 weiteren Fällen (12 %) in einem Kandidatengen gefunden werden und somit eine Diagnose gestellt werden. Hierdurch konnte in 6 Fällen (14 %) eine pathomechanismusbasierte Therapie erfolgreich eingeleitet werden. Die durchschnittliche Dauer zwischen der Aufnahme in der Tagesklinik und der Befundmitteilung betrug 6 Monate. Die Murmeltiersprechstunde zeigt, wie „personalized precision medicine“ in den Alltag einer Kinderklinik eingebaut werden kann und direkten Einfluss auf die Behandlung hat.

Treatment with Methylphenidate Improves Affective but Not Cognitive Empathy in Youths with Attention-Deficit/Hyperactivity Disorder

Background: Beside the core symptoms, patients with attention-deficit/hyperactivity disorder (ADHD) frequently show relevant difficulty in developing relationships with peers. Although ADHD symptoms may account for social impairment, deficits in cognitive and/or affective empathy have also been involved. Our aim was to investigate the effect of methylphenidate (MPH) treatment on affective and cognitive empathy. Methods: Sixty-one drug-naïve youths with ADHD (age range 6 to 17 years, mean 10.3 ± 2.8 years, 51 males) naturalistically treated with MPH monotherapy were followed up for 6 months for ADHD symptoms and empathy, measured with the Basic Empathy Scale. Results: After being treated with MPH, the patients showed a significant improvement in affective and cognitive empathy scores. Linear regression models showed that changes in inattention symptoms predicted changes in affective but not in cognitive empathy, while changes in the hyperactivity/impulsivity symptoms did not predict changes in affective or cognitive empathy. Conclusions: Our study provides a further contribution for a better understanding of the possible effects of the MPH on youth’s characteristics.

Differential diagnosis of autism spectrum disorder, intellectual disability and attention-deficit hyperactivity disorder (ADHD)

Purpose

Professionals working with community populations are often presented with complicated cases where it is difficult to determine which diagnosis or diagnoses are appropriate. Differentiating among neurodevelopmental disorders such as autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder and intellectual disability can be a complex process, especially, as these disorders have some overlapping symptoms and often co-occur in young children. This series of case studies aims to present commonly overlapping symptoms in children who present to clinics with developmental concerns.

Design/methodology/approach

This paper presents three case studies that were completed at a free community ASD screening clinic in Southern California.

Findings

The case studies have common presenting behaviors and symptoms (e.g. social communication difficulties) that often co-occur across diagnoses; explanations for the final diagnoses are given in each case.

Research limitations/implications

Conclusions from these three cases cannot generalize to all children being seen in clinics for neurodevelopmental concerns.

Practical implications

This series of case studies highlights commonly overlapping symptoms in children who present for differential diagnosis with social and/or behavioral concerns. Implications for educational placement and intervention are discussed.

Social implications

These cases highlight the challenges involved in the differential and dual diagnostic process for young children with developmental concerns. Diagnostic considerations can affect later educational placement and opportunities for socialization.

Originality/value

This series of case studies provide practical information for clinicians about how to effectively differentiate between commonly occurring neurodevelopmental disorders, particularly given recent changes to the Diagnostic and Statistical Manual, 5th edition (DSM-5).

The Impact of the Comorbidity of ASD and ADHD on Social Impairment

Children with autism spectrum disorder (ASD) and children with attention deficit/hyperactivity disorder (ADHD) both experience behavioral and social difficulties. Prior research has shown that when these disorders co-occur, behavioral symptoms associated with both disorders may be more severe. There is only limited research on the impact of ASD + ADHD comorbidity on social functioning. The present study investigated social impairment in 282 children diagnosed with ASD, ADHD, or ASD + ADHD. No significant differences in social impairment were found between the ASD and ASD + ADHD groups. This study contributes to extant literature indicating mixed findings in regard to social functioning amidst the ASD + ADHD comorbidity.

Mixed-effect Bayesian network reveals personal effects of nutrition

Nutrition experts know by their experience that people can react very differently to the same nutrition. If we could systematically quantify these differences, it would enable more personal dietary understanding and guidance. This work proposes a mixed-effect Bayesian network as a method for modeling the multivariate system of nutrition effects. Estimation of this network reveals a system of both population-wide and personal correlations between nutrients and their biological responses. Fully Bayesian estimation in the method allows managing the uncertainty in parameters and incorporating the existing nutritional knowledge into the model. The method is evaluated by modeling data from a dietary intervention study, called Sysdimet, which contains personal observations from food records and the corresponding fasting concentrations of blood cholesterol, glucose, and insulin. The model's usefulness in nutritional guidance is evaluated by predicting personally if a given diet increases or decreases future levels of concentrations. The proposed method is shown to be comparable with the well-performing Extreme Gradient Boosting (XGBoost) decision tree method in classifying the directions of concentration increases and decreases. In addition to classification, we can also predict the precise concentration level and use the biologically interpretable model parameters to understand what personal effects contribute to the concentration. We found considerable personal differences in the contributing nutrients, and while these nutritional effects are previously known at a population level, recognizing their personal differences would result in more accurate estimates and more effective nutritional guidance.

Clinical characteristics of children with ASD and comorbid ADHD: Association with social impairment and externalizing and internalizing behaviours

BACKGROUND

Autism spectrum disorder (ASD) and attention-deficit hyperactivity disorder (ADHD) are frequently occurring conditions that are often associated (ASD + ADHD). However, there are few comparative studies concerning the clinical presentation in patients formally diagnosed with both ASD and ADHD. Here, we aimed to 1) compare social impairment and externalizing/internalizing behavioural problems across four groups of children: ASD + ADHD, ASD alone, ADHD alone, and typical development and 2) examine their bidirectional relationship with ASD and/or ADHD symptoms.

METHODS

This study included 186 participants from 6 to 12 years of age: single ASD (n = 98), ASD + ADHD (n = 29), single ADHD (n = 28), and TD (n = 31).

RESULTS

The results showed that children in the ASD + ADHD and single ASD groups had a higher level of social impairment than those in the single ADHD group. In addition, children in the single ADHD group presented a greater attention deficit than those in the single ASD group. Externalizing /internalizing behaviours were more frequent in all groups with neuro-developmental disorders than in typical development. In addition, externalizing behavioural problems were related to ADHD severity in the ASD + ADHD and single ADHD groups, whereas internalizing behaviours were related to ASD severity.

CONCLUSIONS

These findings highlight the specific needs of children who have both ASD and ADHD and underscore the necessity of individualizing their interventions.

Evaluating atypical language in autism using automated language measures

Measurement of language atypicalities in Autism Spectrum Disorder (ASD) is cumbersome and costly. Better language outcome measures are needed. Using language transcripts, we generated Automated Language Measures (ALMs) and tested their validity. 169 participants (96 ASD, 28 TD, 45 ADHD) ages 7 to 17 were evaluated with the Autism Diagnostic Observation Schedule. Transcripts of one task were analyzed to generate seven ALMs: mean length of utterance in morphemes, number of different word roots (NDWR), um proportion, content maze proportion, unintelligible proportion, c-units per minute, and repetition proportion. With the exception of repetition proportion (p [Formula: see text]), nonparametric ANOVAs showed significant group differences (p[Formula: see text]). The TD and ADHD groups did not differ from each other in post-hoc analyses. With the exception of NDWR, the ASD group showed significantly (p[Formula: see text]) lower scores than both comparison groups. The ALMs were correlated with standardized clinical and language evaluations of ASD. In age- and IQ-adjusted logistic regression analyses, four ALMs significantly predicted ASD status with satisfactory accuracy (67.9-75.5%). When ALMs were combined together, accuracy improved to 82.4%. These ALMs offer a promising approach for generating novel outcome measures.

Potential mechanisms of the fatigue-reducing effect of cognitive-behavioral therapy in cancer survivors: Three randomized controlled trials

OBJECTIVE

Fatigue is a common symptom among cancer survivors that can be successfully treated with cognitive-behavioral therapy (CBT). Insights into the working mechanisms of CBT are currently limited. The aim of this study was to investigate whether improvements in targeted cognitive-behavioral variables and reduced depressive symptoms mediate the fatigue-reducing effect of CBT.

METHODS

We pooled data from three randomized controlled trials that tested the efficacy of CBT to reduce severe fatigue. In all three trials, fatigue severity (checklist individual strength) decreased significantly following CBT. Assessments were conducted pre-treatment and 6 months later. Classical mediation analysis testing a pre-specified model was conducted and its results compared to those of causal discovery, an explorative data-driven approach testing all possible causal associations and retaining the most likely model.

RESULTS

Data from 250 cancer survivors (n = 129 CBT, n = 121 waitlist) were analyzed. Classical mediation analysis suggests that increased self-efficacy and decreased fatigue catastrophizing, focusing on symptoms, perceived problems with activity and depressive symptoms mediate the reduction of fatigue brought by CBT. Conversely, causal discovery and post-hoc analyses indicate that fatigue acts as mediator, not outcome, of changes in cognitions, sleep disturbance and depressive symptoms.

CONCLUSIONS

Cognitions, sleep disturbance and depressive symptoms improve during CBT. When assessed pre- and post-treatment, fatigue acts as a mediator, not outcome, of these improvements. It seems likely that the working mechanism of CBT is not a one-way causal effect but a dynamic reciprocal process. Trials integrating intermittent assessments are needed to shed light on these mechanisms and inform optimization of CBT.

Operative list of genes associated with autism and neurodevelopmental disorders based on database review

The genetics of neurodevelopmental disorders (NDD) has made tremendous progress during the last few decades with the identification of more than 1,500 genes associated with conditions such as intellectual disability and autism. The functional roles of these genes are currently studied to uncover the biological mechanisms influencing the clinical outcome of the mutation carriers. To integrate the data, several databases and curated gene lists have been generated. Here, we provide an overview of the main databases focusing on the genetics of NDD, that are widely used by the medical and scientific communities, and extract a list of high confidence NDD genes (HC-NDD). This gene set can be used as a first filter for interpreting large scale omics dataset or for diagnostic purposes. Overall HC-NDD genes (N = 1,586) are expressed at very early stages of fetal brain development and enriched in several biological pathways such as chromosome organization, cell cycle, metabolism and synaptic function. Among those HC-NDD genes, 204 (12,9%) are listed in the synaptic gene ontology SynGO and are enriched in genes expressed after birth in the cerebellum and the cortex of the human brain. Finally, we point at several limitations regarding the relatively poor standardized information available, especially on the carriers of the mutations. Progress on the phenotypic characterization and genetic profiling of the carriers will be crucial to improve our knowledge on the biological mechanisms and on risk and protective factors for NDD.

Social and non-social gaze cueing in autism spectrum disorder, attention-deficit/hyperactivity disorder and a comorbid group

Recent trends in literature, along with the changes to the Diagnostic and Statistical Manual (DSM), make it imperative to study Attention-Deficit/Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder (ASD) together, in order to better understand potential aetiological commonalities between these highly comorbid disorders. The present study examines social cueing, a highly studied construct in ASD, and intra-subject variability (ISV), a potential endophenotype of ADHD, in four groups of typically developing (TD), ADHD, ASD- (ASD without ADHD), ASD+ (ASD with ADHD) participants (N = 85) aged 10-13 years. Results showed that social cueing is intact in the 'pure' ASD group when task expectations are clear. The ADHD group showed faster saccadic reaction times, no increased ISV and a pattern of viewing comparable to the TD group. However, the ASD + group showed a differences in processing style and ISV. A secondary analysis gives evidence of non-additive effects of the ASD and ADHD factors.

Motor and sensory features successfully decode autism spectrum disorder and combine with the original RDoC framework to boost diagnostic classification

Sensory processing and motor coordination atypicalities are not commonly identified as primary characteristics of autism spectrum disorder (ASD), nor are they well captured in the NIMH's original Research Domain Criteria (RDoC) framework. Here, motor and sensory features performed similarly to RDoC features in support vector classification of 30 ASD youth against 33 typically developing controls. Combining sensory with RDoC features boosted classification performance, achieving a Matthews Correlation Coefficient (MCC) of 0.949 and balanced accuracy (BAcc) of 0.971 (p = 0.00020, calculated against a permuted null distribution). Sensory features alone successfully classified ASD (MCC = 0.565, BAcc = 0.773, p = 0.0222) against a clinically relevant control group of 26 youth with Developmental Coordination Disorder (DCD) and were in fact required to decode against DCD above chance. These findings highlight the importance of sensory and motor features to the ASD phenotype and their relevance to the RDoC framework.

Poor glycaemic control is associated with increased risk of neurodevelopmental disorders in childhood-onset type 1 diabetes: a population-based cohort study

AIMS/HYPOTHESIS

The aim of this study was to investigate the effect of childhood-onset type 1 diabetes on the risk of subsequent neurodevelopmental disorders, and the role of glycaemic control in this association. We hypothesised that individuals with poor glycaemic control may be at a higher risk of neurodevelopmental disorders compared with the general population, as well as compared with individuals with type 1 diabetes with adequate glycaemic control.

METHODS

This Swedish population-based cohort study was conducted using data from health registers from 1973 to 2013. We identified 8430 patients with childhood-onset type 1 diabetes (diagnosed before age 18 years) with a median age of diabetes onset of 9.6 (IQR 5.9-12.9) and 84,300 reference individuals from the general population, matched for sex, birth year and birth county. Cox models were used to estimate the effect of HbA_1c on the risk of subsequent neurodevelopmental disorders, including attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorders (ASD) and intellectual disability.

RESULTS

During a median follow-up period of 5.6 years, 398 (4.7%) individuals with type 1 diabetes received a diagnosis of any neurodevelopmental disorder compared with 3066 (3.6%) in the general population, corresponding to an adjusted HR (HR_adjusted) of 1.31 (95% CI 1.18, 1.46) after additionally adjusting for other psychiatric morbidity prior to inclusion, parental psychiatric morbidity and parental highest education level. The risk of any neurodevelopmental disorder increased with HbA_1c levels and the highest risk was observed in patients with mean HbA_1c >8.6% (>70 mmol/mol) (HR_adjusted 1.90 [95% CI 1.51, 2.37]) compared with reference individuals without type 1 diabetes. In addition, when compared with patients with diabetes with HbA_1c <7.5% (<58 mmol/mol), patients with HbA_1c >8.6% (>70 mmol/mol) had the highest risk of any neurodevelopmental disorder (HR_adjusted 3.71 [95% CI 2.75, 5.02]) and of specific neurodevelopmental disorders including ADHD (HR_adjusted 4.16 [95% CI 2.92, 5.94]), ASD (HR_adjusted 2.84 [95% CI 1.52, 5.28]) and intellectual disability (HR_adjusted 3.93 [95% CI 1.38, 11.22]).

CONCLUSIONS/INTERPRETATION

Childhood-onset type 1 diabetes is associated with an increased risk of neurodevelopmental disorders, with the highest risk seen in individuals with poor glycaemic control. Routine neurodevelopmental follow-up visits should be considered in type 1 diabetes, especially in patients with poor glycaemic control.

Postural Control in Childhood: Investigating the Neurodevelopmental Gradient Hypothesis

Neurodevelopmental disorders (NDDs) have been suggested to lie on a gradient continuum, all resulting from common brain disturbances, but with different degrees of impairment severity. This case-control study aimed to assess postural stability against such hypothesis in 104 children/adolescents aged 5–17, of whom 81 had NDDs and 23 were healthy controls. Compared to healthy controls, Autism Spectrum Disorder (ASD) resulted in the most severely impaired neurodevelopmental condition, followed by Attention Deficit Hyperactive Disorder (ADHD) and Tourette Syndrome (TS). In particular, while ASD children/adolescents performed worse than healthy controls in a number of sensory conditions across all parameters, ADHD children/adolescents performed worse than healthy controls only in the sway area for the most complex sensory conditions, when their vision and somatosensory functions were both compromised, and performance in Tourette Syndrome (TS) was roughly indistinguishable from that of healthy controls. Finally, differences were also observed between clinical groups, with ASD children/adolescents, and to a much lesser extent ADHD children/adolescents, performing worse than TS children/adolescents, especially when sensory systems were not operationally accurate. Evidence from this study indicates that poor postural control may be a useful biomarker for risk assessment during neurodevelopment, in line with predictions from the gradient hypothesis.

Differential Diagnosis in Children with Autistic Symptoms and Subthreshold ADOS Total Score: An Observational Study

BACKGROUND

Children with autism spectrum disorder (ASD) share some symptoms with children with other neurodevelopmental disorders (ie, intellectual disability or communication disorders or language disorders). These similarities can make difficult to obtain an accurate diagnosis, which is essential to give targeted treatments to the patients. We aim to verify in our study if children with autistic traits who undergo to Autism Diagnostic Observation Schedule had specific clinical diagnosis.

PATIENTS AND METHODS

We selected 73 children tested with ADOS-G or ADOS-2, for the presence of autistic symptoms. The whole sample did not reach the cut-off of ADOS and did not receive the ASD diagnosis, according to DSM-5.

RESULTS

Results of this study showed that in order of frequency and early diagnosis, communication disorders (CD), mild intellectual disability (mID) and the attention deficit hyperactivity disorders (ADHD) represent the most common final clinical diagnosis in children with autistic traits.

CONCLUSION

Our results showed as the CD was the common diagnosis of these children and that often associated with younger age. Moreover, analyses of ADOS domains and the difference of individual items between groups did not show the capacity to differentiate between different neurodevelopmental disorders in terms of differential diagnosis, and this confirms the need for integrating multiple sources of information during the diagnostic process.

Atypical Development of Attentional Control Associates with Later Adaptive Functioning, Autism and ADHD Traits

Autism is frequently associated with difficulties with top-down attentional control, which impact on individuals’ mental health and quality of life. The developmental processes involved in these attentional difficulties are not well understood. Using a data-driven approach, 2 samples (N = 294 and 412) of infants at elevated and typical likelihood of autism were grouped according to profiles of parent report of attention at 10, 15 and 25 months. In contrast to the normative profile of increases in attentional control scores between infancy and toddlerhood, a minority (7–9%) showed plateauing attentional control scores between 10 and 25 months. Consistent with pre-registered hypotheses, plateaued growth of attentional control was associated with elevated autism and ADHD traits, and lower adaptive functioning at age 3 years.

Trait-Based Dimensions Discriminating Adults with Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Disorder (ASD) and, Co-occurring ADHD/ASD

This study assessed the co-occurrence of attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) in newly diagnosed adults of normal intelligence and the contribution of trait-based dimensions deriving from the Barkley Adult ADHD Rating Scale-IV (BAARS-IV), the Autism-Spectrum Quotient (AQ), and the Empathy Quotient (EQ) to the differentiation of patients with ADHD, ASD, and ADHD/ASD. A total of 16.1% of patients with ADHD received a co-occurring ASD diagnosis, while 33.3% of patients with ASD received an ADHD diagnosis. Subjects with ADHD or ADHD/ASD had higher scores in all ADHD traits compared to ASD subjects. Compared to the ADHD group, the ASD group had AQ scores that were significantly greater, except for attention to detail. ADHD/ASD co-occurrence significantly increased the score of attention to detail. The total EQ score was greater in the ADHD group. In the stepwise logistic regression analyses, past hyperactivity, current inattention and impulsivity, attention switching, communication, imagination, and total EQ score discriminated ADHD patients from ASD patients. Attention to detail, imagination, and total EQ score discriminated ADHD cases from ADHD/ASD cases, while past hyperactivity and current impulsivity discriminated ASD subjects from ADHD/ASD subjects. Our findings highlight the importance of particular trait-based dimensions when discriminating adults with ADHD, ASD, and co-occurring ADHD/ASD.

Look duration at the face as a developmental endophenotype: elucidating pathways to autism and ADHD

Identifying developmental endophenotypes on the pathway between genetics and behavior is critical to uncovering the mechanisms underlying neurodevelopmental conditions. In this proof-of-principle study, we explored whether early disruptions in visual attention are a unique or shared candidate endophenotype of autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD). We calculated the duration of the longest look (i.e., peak look) to faces in an array-based eye-tracking task for 335 14-month-old infants with and without first-degree relatives with ASD and/or ADHD. We leveraged parent-report and genotype data available for a proportion of these infants to evaluate the relation of looking behavior to familial (n = 285) and genetic liability (using polygenic scores, n = 185) as well as ASD and ADHD-relevant temperament traits at 2 years of age (shyness and inhibitory control, respectively, n = 272) and ASD and ADHD clinical traits at 6 years of age (n = 94).

Results showed that longer peak looks at the face were associated with elevated polygenic scores for ADHD (β = 0.078, p = .023), but not ASD (β = 0.002, p = .944), and with elevated ADHD traits in mid-childhood (F(1,88) = 6.401, p = .013, $\eta _p^2$=0.068; ASD: F (1,88) = 3.218, p = .076), but not in toddlerhood (ps > 0.2). This pattern of results did not emerge when considering mean peak look duration across face and nonface stimuli. Thus, alterations in attention to faces during spontaneous visual exploration may be more consistent with a developmental endophenotype of ADHD than ASD. Our work shows that dissecting paths to neurodevelopmental conditions requires longitudinal data incorporating polygenic contribution, early neurocognitive function, and clinical phenotypic variation.

Characteristics of child psychiatric outpatients with slow processing speed and potential mechanisms of academic impact

While slow processing speed (PS) is well documented in youth with ADHD, growing evidence suggests that this difficulty affects children with other neuropsychiatric conditions. Clarifying the relationship between slow PS and different forms of psychopathology is important clinically, given the potential impact of PS on academic functioning, and conceptually. In 751 youth, ages 6-21, consecutively referred for neuropsychiatric evaluation, we examined the association between slow PS (i.e., Wechsler PS Index < 85) and seven neuropsychiatric diagnostic groups. In 492 of these youth, we also related slow PS to eight psychopathology symptom dimensions. Finally, we modeled the relationship between PS, other cognitive functions and academic achievement. Data are from the Longitudinal Study of Genetic Influences on Cognition. Analyses included one-sample t tests, ANOVA, logistic regression, mixed modeling, and structural equation modeling (SEM), controlling for age, sex, and medication. Compared to normative data, all clinical groups showed PS decrements. Compared to referred youth without full diagnoses and accounting for other psychopathology, risk for slow PS was elevated in youth with autism spectrum disorder (OR = 1.8), psychotic disorders (OR = 3.4) and ADHD-inattentive type (OR = 1.6). Having multiple comorbidities also increased risk for slow PS. Among dimensions, inattention (OR = 1.5) associated with slow PS but did not fully explain the association with autism or psychosis. In SEM, PS had direct effects on academic achievement and indirect effects through working memory. Findings extend evidence that PS relates to multiple aspects of child psychopathology and associates with academic achievement in child psychiatric outpatients.

Investigating Gait, Movement, and Coordination in Children with Neurodevelopmental Disorders: Is There a Role for Motor Abnormalities in Atypical Neurodevelopment?

Motor abnormalities have been suggested to play a role in most neuropsychiatric disorders, as a potential generic neurodevelopmental vulnerability. However, they still represent a neglected area, with a paucity of empirical studies, especially in pediatric populations. This case-control study aimed to comprehensively assess motor functioning in children with atypical neurodevelopment and investigate whether any socio-demographic or clinical characteristics would concur with motor difficulties to distinguish children with neurodevelopmental disorders (NDD) from healthy controls. Socio-demographic (age and gender) and clinical (intelligence quotient, gait, movement, and coordination) data were collected on 114 children aged 5-15 (83 with NDD, 31 healthy controls). Male children were at significantly higher risk for NDD (OR: 13.023, p < 0.001). Furthermore, there was a statistically significant interaction between the total intelligence quotient and overall coordination such that increasing levels of total intelligence quotient appeared to protect against the likelihood of being diagnosed with an NDD, but only in the context of a preserved coordination (OR: 0.964, p = 0.038). Collectively, results may have important public health implications, as they point towards the development of new approaches to establish an early prognosis in neurodevelopment, including assessing motor difficulties and mitigating their impact on children's quality of life.

Leveraging epigenetics to examine differences in developmental trajectories of social attention: A proof-of-principle study of DNA methylation in infants with older siblings with autism

Preliminary evidence suggests that changes in DNA methylation, a widely studied epigenetic mechanism, contribute to the etiology of Autism Spectrum Disorder (ASD). However, data is primarily derived from post-mortem brain samples or peripheral tissue from adults. Deep-phenotyped longitudinal infant cohorts are essential to understand how epigenetic modifications relate to early developmental trajectories and emergence of ASD symptoms. We present a proof-of-principle study designed to evaluate the potential of prospective epigenetic studies of infant siblings of children with ASD. Illumina genome-wide 450 K DNA methylation data from buccal swabs was generated for 63 male infants at multiple time-points from 8 months to 2 years of age (total N = 107 samples). 11 of those infants received a diagnosis of ASD at 3 years. We conducted a series of analyses to characterize DNA methylation signatures associated with categorical outcome and neurocognitive measures from parent-report questionnaire, eye-tracking and electro-encephalography. Effects observed across the entire genome (epigenome-wide association analyses) suggest that collecting DNA methylation samples within infant-sibling designs allows for the detection of meaningful signals with smaller sample sizes than previously estimated. Mapping networks of co-methylated probes associated with neural correlates of social attention implicated enrichment of pathways involved in brain development. Longitudinal modelling found covariation between phenotypic traits and DNA methylation levels in the proximity of genes previously associated with cognitive development, although larger samples and more complete datasets are needed to obtain generalizable results. In conclusion, assessment of DNA methylation profiles at multiple time-points in infant-sibling designs is a promising avenue to comprehend developmental origins and mechanisms of ASD.

Examining the autistic traits in children and adolescents diagnosed with attention-deficit hyperactivity disorder and their parents

BACKGROUND

Attention-Deficit Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder (ASD) are two of the most frequently-observed neurodevelopmental disorders. Autistic traits are detected frequently in children who have ADHD. This study aimed to examine autism symptoms in children diagnosed with ADHD and their parents; and also, to investigate parental risk factors that increase autistic traits in children. Besides the risk factors related to pregnancy, birth and developmental history were examined.

METHODS

Two groups were created consisting of 66 children diagnosed with ADHD and 33 children not diagnosed with ADHD and their parents. Autism symptoms were screened with the Autism Behavior Checklist (ABC) in children, and Autism Spectrum Quotient (AQ) in parents. Also, Adult ADD/ADHD DSM-IV Based Diagnostic Screening and Rating Scale and Wender Utah Rating Scale (WURS) were used to determine ADHD symptoms in parents.

RESULTS

It was determined that there were more autism symptoms in children who were diagnosed with ADHD than in the control group without ADHD. There were more autistic symptoms in boys and the presence of Oppositional Defiant Disorder (ODD). Although there were more ADHD symptoms in the parents of children diagnosed with ADHD, it was determined that they did not differ from parents in the control group in terms of autism symptoms. It was also determined that maternal and paternal ADHD symptoms were predictive for autism symptoms in children. It was also shown that maternal smoking during pregnancy is associated with more autistic traits.

CONCLUSION

ASD and ADHD show high levels of comorbidity. The etiology remains unclear. Both ADHD and ASD show strong hereditary transition. We found that maternal and paternal ADHD symptoms predict autism symptoms in children with ADHD. However, more studies are needed to reveal the etiology.

Characterization of Clinical Manifestations in the Co-occurring Phenotype of Attention Deficit/Hyperactivity Disorder and Autism Spectrum Disorder

Comorbidity between attention deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) is a frequently reported condition. However, the clinical overlaps between the two disorders are not well characterized. The Child Behavior Checklist (CBCL) is a well-documented measure of emotional and behavioral problems in children and adolescents. The aim of the present study was to evaluate whether CBCL scales were able to detect psychopathological comorbidities as well as emotional and behavioral profiles across three groups of children with ASD, ADHD, and with the co-occurrence of both disorders. The results show that around 30% of participants with ASD exhibited internalizing problems, which was in line with previous findings. Co-occurrence condition showed a clinical intermediate phenotype: relative to ADHD and ASD, youths with co-occurrence of ADHD and ASD phenotype showed respectively lower (p < 0.000) and higher externalizing problems (p < 0.000). No differences emerged in internalizing problems (p > 0.05) across groups. CBCL is a useful measure to study the psychopathological conditions as well as emotional and behavioral profiles associated with ASD, ADHD, and the co-occurrence of ADHD and ASD. The identification of psychopathological and behavioral profiles associated with ASD and ADHD is crucial to perform specific and individualized treatments. Our preliminary findings suggested the existence of an intermediate and independent phenotype between ADHD and ASD that seems to be defined by the externalizing problems. Internalizing problems do not significantly differ between the combined phenotype and the two groups.

Processing speed as a marker to stimulant effect in clinical sample of children with high functioning autism spectrum disorder

Background: Patients with co-occurring Attention-Deficit/Hyperactivity Disorder (ADHD) and ASD might benefit from stimulants. There is a progressive increase in prescribing ADHD aimed medications for children diagnosed with Autism Spectrum Disorder (ASD), despite scarce knowledge and no distinct clinical guidelines for that matter.Aim: This study aims to analyze the effect of stimulant on processing speed performance and attention indices in children with ASD and ADHD.Methods: Forty children aged 6-18 years diagnosed with ASD who also met the criteria for ADHD were recruited. All children performed a computerized performance test for the assessment of cognitive attention performance three times: twice while they are drug naïve and once an hour after taking a single dose of 10 mg. methylphenidate (MPH). This performance was compared to a group of children diagnosed with 'ADHD only' without ASD.Results: A significant difference (p < 0.001) was found only in the parameter of measuring cognitive processing speed. This effect is significantly different from the response of the 'ADHD only' group.Conclusions: The reaction to MPH among ASD children is different than among ADHD children. In ASD, MPH significantly improved cognitive processing speed without changing other measured attention parameters. Improving processing speed, might improve every day functioning in children with ASD who also met the criteria for ADHD, in other means than expected. This unique response suggests new research targets for treatment with stimulants in ASD and ADHD children and its influence on cognitive parameters.