Behavioural and Cognitive Profiling in ASD and ADHD - escap

142 Pages·2014·3.43 MB·English

Behavioral and Cognitive Profiling in
Autism Spectrum Disorder and
Attention-Deficit/Hyperactivity Disorder
Jolanda Maria Johanna van der Meer
Behavioral and Cognitive Profiling in
Autism Spectrum Disorder and
Attention-Deficit/Hyperactivity Disorder
Een wetenschappelijke proeve op het gebied van de Medische Wetenschappen
Academisch Proefschrift
Cover design
Hartebeest
Cover photo (back side)
ter verkrijging van de graad van doctor
Charelle Fotografie
aan de Radboud Universiteit Nijmegen
Layout and print
op gezag van de rector magnificus prof. mr. S.C.J.J. Kortmann,
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volgens besluit van het college van decanen

in het openbaar te verdedigen op woensdag 3 september 2014
om 14.30 uur precies
Support
This PhD project was supported by Karakter Child and Adolescent Psychiatry, and
door
the Netherlands Organisation for Scientific Research (NWO) by grants assigned
to Buitelaar (05613015) and Rommelse (91610024).
Jolanda Maria Johanna van der Meer
Geboren op 6 september 1983 te Enschede.
Copyright
© J.M.J. van der Meer, 2014. All rights reserved.
No part of this thesis may be reproduced, stored in a retrieval system or transmitted
in any form or by any means without prior written permission of the author.
Promotor
Prof. dr. J.K. Buitelaar
Copromotoren
Dr. N.N.J. Lambregts-Rommelse
Dr. C.A. Hartman (Rijksuniversiteit Groningen)
Manuscriptcommissie
Prof. dr. M. Willemsen (voorzitter)
Prof. dr. H. Bekkering
Prof. dr. H. Roeyers (Universiteit Gent, België)
Now nature never deals in black or white.
It is always some shade of grey.
She never draws a line without smudging it.
Winston S. Churchill
Winston And Clementine: The Personal Letters Of The Churchills
Table of Contents
Chapter 1
General introduction, aims and outline of the thesis 11
Chapter 2
Are high and low extremes of ASD and ADHD trait continua
pathological? A population-based study using the AQ and SWAN
rating scales 35
Chapter 3
Are autism spectrum disorder and attention-deficit/hyperactivity
disorder different manifestations of one overarching disorder?
Cognitive and symptom evidence from a clinic and population-based sample 61
Chapter 4
How ‘core’ are motor timing difficulties in ADHD? A latent class
comparison of pure and comorbid ADHD classes 91
Chapter 5
Homogeneous combinations of ASD-ADHD traits and their cognitive
and behavioral correlates in a population-based sample 111
Chapter 6
Using cognitive profiles to examine the relationship between
ASD and ADHD 133
7
Chapter 7
A randomized, double-blind comparison of atomoxetine and placebo
on response inhibition and interference control in children and
adolescents with autism spectrum disorder and comorbid attention-
deficit/hyperactivity disorder symptoms 161
Chapter 8
General discussion, summary, discussion, key findings, limitations,
future directions and clinical implications 183
Chapter 9
Samenvatting in het Nederlands (Summary in Dutch) 211
Chapter 10
References 223
Chapter 11
Dankwoord (Acknowledgements in Dutch) 267
Chapter 12
About the author 275
8 9
General introduction
10
This thesis focuses on the shared and unique behavioral and cognitive profiles
of Autism Spectrum Disorder (ASD) and Attention-Deficit/Hyperactivity Disorder
(ADHD). Studying ASD and ADHD together may provide the most optimal
strategy in examining both shared and unique substrates, ultimately translating
into differential prognoses and susceptibility towards treatment. The current
research approach steps away from the Diagnostic and Statistical Manual
of Mental Disorders (DSM) defined heterogeneous group comparisons, and
acknowledges the continuously distributed nature of the ASD and ADHD trait
within the population, as well as the etiological and symptomatic heterogeneity
within both disorders. In this general introduction, the co-occurrence, etiology
and treatment of ASD, ADHD and related cognitive profiles are discussed. Then,
the research approach used to reduce heterogeneity on both the behavioral and
cognitive level is described. Finally, the outline of the chapters is provided.
ASD and ADHD
With prevalence rates of about 1% for ASD and 5% for ADHD, these disorders are
among the most commonly diagnosed psychiatric developmental disorders in
children and adolescents (Baird et al., 2006; Polanczyk, de Lima, Horta, Biederman
& Rohde, 2007). ASD is characterized by impaired social interaction skills and
verbal and nonverbal communication, as well as restricted and repetitive behavior
and interests, while ADHD is characterized by severe inattention, hyperactivity
and impulsivity (American Psychiatric Association, 2013). Symptom presentations
of both disorders are rather heterogeneous, as described in the DSM (American
Psychiatric Association, 2013), see Box 1.1. The DSM-IV and previous psychiatric
classification schemes prevented a diagnosis of ADHD in the context of ASD. This
prohibition was based on the assumption that ASD is an overarching disorder
that mimics or even causes symptoms of ADHD. As a consequence, patients
were diagnosed with either ASD or ADHD, disregarding possible co-occurring
symptoms. The heterogeneous symptom presentation on the one hand and the
prohibited comorbid diagnosis of ASD and ADHD on the other hand may explain
13
Chapter 1
the not-to-be-ignored proportion of children that have been alternatively given
Box 1.1 DSM-5 diagnostic criteria for ASD and ADHD
a diagnosis of one or the other disorder throughout development (Fein, Dixon,
Autism Spectrum Disorder (ASD)
Paul & Levin, 2005). In the current DSM-5, a comorbid diagnosis of ASD and
Diagnostic Criteria
ADHD can be made (American Psychiatric Association, 2013). This step forward
A. Persistent deficits in social communication and social interaction across multiple
contexts, as manifested by the following, currently or by history (examples are
will boost research on the shared and specific underlying mechanisms related to
illustrative, not exhaustive):
ASD and ADHD, and can inform us on the association between both disorders. 1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social
approach and failure of normal back-and-forth conversation; to reduced sharing of
Even though the diagnostic criteria appear to show little overlap,
interests, emotions, or affect; to failure to initiate or respond to social interactions.
symptoms of ASD and ADHD may be entangled. For example, inattention can 2. Deficits in nonverbal communicative behaviors used for social interaction, ranging,
for example, from poorly integrated verbal and nonverbal communication; to
easily be mistaken for social inattention, and stereotyped behaviors (such as
abnormalities in eye contact and body language or deficits in understanding and use
body rocking and hand flapping) may be mistaken for hyperactivity. Although of gestures; to a total lack of facial expressions and nonverbal communication.
3. Deficits in developing, maintaining, and understanding relationships, ranging,
such entangled symptoms may result in inflated ASD-ADHD comorbidity rates, 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
factor analyses found no overlapping diagnostic criteria, which supports the
peers.
independence of ADHD and ASD diagnostic criteria (Ghanizadeh, 2010; Martin, Specify current severity level 1 / 2 / 3, see below.
Hamshere, O’Donovan, Rutter & Thapar, 2014; see for review Rommelse, Franke, B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested
by at least two of the following, currently or by history (examples are illustrative,
Geurts, Hartman & Buitelaar, 2010). Hence, the co-occurrence of ASD and ADHD not exhaustive):
1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple
is unlikely to be largely due to mistaken symptom interpretations. In clinic based
motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).
samples, the majority of comorbidity estimates reported for ADHD in ASD fall 2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of
verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with
within the range of 30% to 80%, whereas the presence of ASD is estimated in 20%
transitions, rigid thinking patterns, greeting rituals, need to take same route or eat
to 50% of the patients with ADHD (e.g. Ames & White, 2011; Leyfer et al., 2006; for same food every day).
3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g, strong
review see Rommelse et al., 2010; Ronald, Simonoff, Kuntsi, Asherson & Plomin,
attachment to or preoccupation with unusual objects, excessively circumscribed or
2008). perseverative interest).
4. Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of
The importance of comorbidity in taxonomic questions forms the basis
the environment (e.g., apparent indifference to pain/temperature, adverse response
to specific sounds or textures, excessive smelling or touching of objects, visual
of critical hypotheses in both research and clinical practice, as was already
fascination with light or movement).
described decades ago (Caron & Rutter, 1991; Neale & Kendler, 1995). Provided Specify current severity level 1 / 2 / 3, see below.
that comorbidity is not due to artifacts such as chance, sampling bias, population C. Symptoms must be present in the early developmental period (but may not
become fully manifest until social demands exceed limited capacities, or may
stratification or symptom overlap, perhaps the most fundamental issues are at be masked by learned strategies in later life).
the nosological level: Are the two disorders distinct, or do they reflect an arbitrary D. Symptoms cause clinically significant impairment in social, occupational, or
other important areas of current functioning.
division of a single syndrome (Neale & Kendler, 1995). True comorbidity may be E. These disturbances are not better explained by intellectual disability (intellectual
developmental disorder) or global developmental delay. Intellectual disability
due to either shared or related risk factors, to a comorbid pattern constituting
and autism spectrum disorder frequently co-occur; to make comorbid diagnoses
a meaningful syndrome, or to one disorder creating an increased risk for the of autism spectrum disorder and intellectual disability, social communication
should be below that expected for general developmental level.
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Chapter 1
Box 1.1 Continued. DSM-5 diagnostic criteria for ASD and ADHD Box 1.1 Continued. DSM-5 diagnostic criteria for ASD and ADHD
Severity is based on social communication impairments (A) and restricted, repetitive Attention-Deficit/Hyperactivity Disorder (ADHD)
patterns of behavior (B):
A. Either (1) or (2):
Severity level Social communication Restricted, repetitive
behaviors (1) Six or more symptoms of inattention for children up to age 16; symptoms of
inattention have been present for at least 6 months, and they are inappropriate
Level 3 Severe deficits in verbal and nonverbal Inflexibility of behavior,
for the developmental level:
“Requiring very social communication skills cause severe extreme difficulty coping
substantial impairments in functioning, very limited with change, or other
Inattention
support” initiation of social interactions, and restricted/repetitive
a. Often fails to give close attention to details or makes careless mistakes in schoolwork,
minimal response to social overtures from behaviors markedly
at work, or with other activities.
others. For example, a person with few interfere with functioning
b. Often has trouble holding attention on tasks or play activities.
words of intelligible speech who rarely in all contexts. Great
c. Often does not seem to listen when spoken to directly.
initiates interaction and, when he or she distress/difficulty d. Often does not follow through on instructions and fails to finish schoolwork, chores,
does, makes unusual approaches to meet changing focus or or duties in the workplace (e.g., loses focus, side-tracked).
needs only and responds to only very action. e. Often has trouble organizing tasks and activities.
direct social approaches f. Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long
period of time (such as schoolwork or homework).
Level 2 Marked deficits in verbal and nonverbal Inflexibility of behavior,
g. Often loses things necessary for tasks and activities (e.g. school materials, pencils,
“Requiring social communication skills; social difficulty coping with
books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
substantial impairments apparent even with supports change, or other
h. Is often easily distracted.
support” in place; limited initiation of social restricted/repetitive
i. Is often forgetful in daily activities.
interactions; and reduced orabnormal behaviors appear
responses to social overtures from others. frequently enough to be
(2) Six or more symptoms of hyperactivity-impulsivity for children up to age 16;
For example, a person who speaks simple obvious to the casual
symptoms of hyperactivity-impulsivity have been present for at least 6 months
sentences, whose interaction is limitedto observer and interfere
to an extent that is disruptive and inappropriate for the developmental level:
narrow special interests, and who has with functioning ina
markedly odd nonverbal communication. variety of contexts.
Hyperactivity
Distress and/or difficulty a. Often fidgets with or taps hands or feet, or squirms in seat.
changing focus or b. Often leaves seat in situations when remaining seated is expected.
action. c. Often runs about or climbs in situations where it is not appropriate (adolescents or
adults may be limited to feeling restless).
Level 1 Without supports in place, deficits in Inflexibility of behavior
d. Often unable to play or take part in leisure activities quietly.
“Requiring social communication cause noticeable causes significant
e. Is often “on the go” acting as if “driven by a motor”.
support” impairments. Difficulty initiating social interference with
f. Often talks excessively.
interactions, and clear examples of functioning in one or
atypical or unsuccessful response to more contexts. Difficulty
Impulsivity
social overtures of others. May appear switching between
g. Often blurts out an answer before a question has been completed.
to have decreased interest in social activities. Problems
h. Often has trouble waiting his/her turn.
interactions. For example, a person who of organization and
i. Often interrupts or intrudes on others (e.g., butts into conversations or games).
is able to speak in full sentences and planning hamper
engages in communication but whose independence.
In addition, the following conditions must be met:
conversation with others fails, and whose
B. Several inattentive or hyperactive-impulsive symptoms were present before age 12
attempts to make friends are odd and
years.
typically unsuccessful. C. Several symptoms are present in two or more settings (e.g., at home, school or work;
with friends or relatives; in other activities).
D. There is clear evidence that the symptoms interfere with, or reduce the quality of,
social, school, or work functioning.
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