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and Disorder in ChildrenEliza Gordon-Lipkin, MD,a,​ b​ Alison With R. Marvin, PhD,Autismc​ J. Kiely Law, MD, MPH, Spectrumb,​ ​c Paul H. Lipkin, MDa,​b,​c

OBJECTIVES: Disorder and ADHD abstract

Autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) frequently co-occur. Understanding the endophenotype of children with both ASD and ADHD may impact clinical management. In this study, we compare the of METHODS: anxiety and mood disorders in children with ASD, with and without ADHD. We performed a cross-sectional study of children with ASD who were enrolled in the Interactive Network, an Internet-mediated, parent-report, autism research registry. Children ages 6 to 17 years with a parent-reported, professional, and questionnaire-verified diagnosis of ASD were included. Data were extracted regarding parent-reported diagnosis and/or treatment of ADHD, anxiety disorder, and . RESULTS: ASD severity was measured by using Social Responsiveness Scale total raw scores. P There wereP 3319 children who met inclusion criteria. Of these, 1503 (45.3%) had ADHD. Comorbid ADHD increased with age ( < .001) and was associated with increased ASD severity ( < .001). A generalized linear model revealed that children with ASD and – ADHD had an increased risk of anxiety disorder (adjusted relative risk 2.20; 95% confidence – interval 1.97 2.46) and mood disorder (adjusted relative risk 2.72; 95% confidence interval 2.28 3.24) compared with children with ASD alone. Increasing age was the most significant CONCLUSIONS: contributor to the presence of anxiety disorder and mood disorder. Co-occurrence of ADHD is common in children with ASD. Children with both ASD and ADHD have an increased risk of anxiety and mood disorders. Physicians who care for children with ASD should be aware of the coexistence of these treatable conditions.

WHAT’S KNOWN ON THIS SUBJECT: disorder (ASD) and attention-deficit/hyperactivity a c Departments of Neurology and Developmental Medicine and Medical Informatics, Kennedy Krieger Institute, disorder (ADHD) frequently co-occur. Recently, Baltimore, Maryland; and bDepartment of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, Maryland researchers have explored the endophenotype of individuals with both ASD and ADHD. Whether these Dr Gordon-Lipkin conceptualized and designed the study and drafted the initial manuscript; Dr individuals are more prone to other psychiatric Marvin conceptualized and designed the study, contributed to the registry development and than those with ASD alone is unknown. survey design, performed data acquisition and statistical analyses, and reviewed and revised the manuscript; Dr Law conceptualized and designed the study, contributed to the registry WHAT THIS STUDY ADDS: We report that children development and survey design, and critically reviewed the manuscript; Dr Lipkin conceptualized with both ASD and ADHD have higher ASD severity and designed the study and critically reviewed the manuscript; and all authors approved the final scores and have an increased risk for anxiety and manuscript as submitted and agree to be accountable for all aspects of the work. mood disorders when compared with children with DOI: https://​doi.​org/​10.​1542/​peds.​2017-​1377 ASD alone. Accepted for publication Jan 2, 2018 Address correspondence to Eliza Gordon-Lipkin, MD, Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, 707 N Broadway, Baltimore, MD 21205. E-mail: lipkine@ kennedykrieger.org PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). To cite: Gordon-Lipkin E, Marvin AR, Law JK, et al. Anxiety Copyright © 2018 by the American Academy of Pediatrics and Mood Disorder in Children With Autism Spectrum Disorder and ADHD. Pediatrics. 2018;141(4):e20171377

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 141, number 4, April 2018:e20171377 ARTICLE ∼

Autism spectrum disorder are more prone to other psychiatric 80% white, 4% African American, (ASD) and attention-deficit/ comorbidities than those with ASD 2% Asian American, and 10% hyperactivity disorder (ADHD) are alone has not yet been studied. The Hispanic. Parents are primarily neurodevelopmental disorders that identification of treatable psychiatric college educated (85%). IAN content begin during childhood with long- comorbidities in this population is in English only. Every state in term clinical and social implications is important because they may 16 the United States is represented. for affected individuals, their families, impact therapeutic interventions,​ IAN has provided recruitment and ∼ and the community. According to the short- and long-term outcomes, and data services for >500 studies. The ∼ 17 most recent 1data, ASD affects 1 in quality of life. Our objective in IAN registry has been clinically 68 children,​ and ADHD affects 1 2 this study was to compare children validated for children with a Social in 10 children in the United States. with ASD with and without ADHD Communication– Questionnaire-

It has long been recognized that these by the prevalence of comorbidity Lifetime (SCQ-Lifetime)19 21 total score disorders may have overlapping 3 and clinical characteristics. We cutoff of 12,​ ‍ ‍ and it has been features and often occur together. hypothesized that children with both verified by a review of parent- and

Before 2013, research on these 2 ASD and ADHD have an increased professional-provided22 medical disorders was primarily focused on prevalence of other psychiatric records. the comparison of the behavioral comorbidities. The primary outcome We included individuals in the IAN and psychologicalDiagnostic profiles 3and of the measures were professional registry ages 6 to 17 years who had 2Statistical disorders Manual individually of Mental. However, Disorders, diagnoses or treatment of anxiety completed the IAN Child with Autism Fifthwith theEdition new disorder and mood disorder Spectrum Disorder Questionnaire by parental report. Secondary (CAQ) (a baseline questionnaire ≥ , ASD and ADHD can be outcome measures were population with demographic and core clinical diagnosed as co-occurring disorders. demographics, report of intellectual information), had a total score 12 ≥ 20 There has subsequently been disability (ID), and ASD severity on the SCQ-Lifetime,​ and had increased interest in understanding score by standardized questionnaire. a total T-score 60 on the Social the etiology and clinical4, 5​implications METHODS Responsiveness23 Scale (SRS)-Parent of their co-occurrence. ‍ Report with no more than 6 missing responses. Children outside of the There is evidence that together, – This study was approved by the Johns age range and/or with incomplete ASD and ADHD may negatively 6 8 Hopkins University Institutional questionnaires and/or with reported impact behavioral development,​ ‍‍ 9 ParticipantsReview Board. diagnosis of were attentional performance,10,11​ ​ adaptive excluded.Measures behavior, and sleep. ‍ Psychiatric IAN CAQ comorbidities, including anxiety and mood disorders,– are also We performed a cross-sectional, common in both5,12​ ASD15 and ADHD network-based study of children independently. ‍ ‍‍ Up to 70% of with ASD who were enrolled in The CAQ is a baseline questionnaire for children with ASD that asks children with ASD may be affected14,15​ the Interactive Autism Network, ’ by other psychiatric disorders. ‍ referred to as IAN, between 2006 parents questions about their Of those with ASD who have 1 and 2013. IAN is a family-centered, children s birth, ASD diagnosis, comorbidity, 45% had > 2. Similarly, online registry and research database development, and additional medical 1 study of ADHD revealed that 52% that was created to accelerate ASD history. of individuals had at least 1 comorbid research by linking participants with Parent report of additional diagnoses “ psychiatric13 disorder, and 26% had studies and by sharing18 deidentified was obtained from the following 2 or more. Given that both ASD data for analysis. Children and questions on the CAQ: Has [child ” and ADHD each have an increased adults with ASD may register for name] ever been diagnosed with risk of comorbidities (and that the IAN along with parents and siblings. or received treatment for____? co-occurrence of these disorders To register with IAN, participant Options included , has negative developmental, probands must have a professional , ADHD, and anxiety cognitive, behavioral, and functional diagnosis of ASD. Approximately disorder. In this study, parent- implications), it follows that ASD and 60000 people have consented reported mood disorder was defined ADHD co-occurrence may compound to participate, including >18500 as a positive response to the above the risk of further comorbidity. children and 7500 adults with ASD. question for depression and/or However, to our knowledge, whether Children with ASD are 80% boys a positive response to the above individuals with both ASD and ADHD with an ethnic and racial profile of question for bipolar disorder. Downloaded from www.aappublications.org/news by guest on September 24, 2021 2 GORDON-LIPKIN et al TABLE 1 Subject Characteristics and Differences by the Presence or Absence of Comorbid ADHD “ Variable Total ASD ASD (−) ADHD ASD (+) ADHD P Effect ID was defined as a positive response (n = 3319) (n = 1816; 54.7%) (n = 1503; 45.3%) Size to the question, Has [child name] ever been diagnosed with intellectual Demographic data ” a disability (also known as mental Age, y, mean (SD) 10.3 (3.08) 9.9 (3.06) 10.8 (3.0) <.001 0.30 “ Boys, No. (%) 2753 (83.0) 1481 (81.6) 1272 (84.6) .019 0.04b retardation)? and/or an IQ score ’ White race, No. (%) 2894 (87.2) 1574 (86.7) 1320 (87.8) .348 NA <70 on the question, What was ” Hispanic race and/ 254 (7.7) 150 (8.3) 104 (6.9) .150 NA [child name] s most recent IQ test or ethnicity, No. score? (%) Phenotypic data For the purposes of this study, ID, No. (%) 649 (19.6) 381 (21.0) 268 (17.8) .023 0.04b children with autism spectrum SRS total raw score, 112.60 (26.10) 110.04 (26.22) 115.70 (25.63) <.001 0.22a disorder with parent-reported mean (SD) Psychiatric attention-deficit/hyperactivity comorbidities, No. disorder are referred to as ASD (%) (+) ADHD, and children with Anxiety disorder 1025 (30.9) 345 (19.0) 680 (45.2) <.001 0.28b autism spectrum disorder without Mood disorder 532 (16.0) 146 (8.0) 386 (25.7) <.001 0.24b parent-reported attention-deficit/ NA, not applicable. − hyperactivity disorder are referred to a Cohen’s d. b Phi. as ASD ( ) ADHD. Age was calculated by using the date of birth and the date on which the 145, and T-scores are standardized and mood disorder for the entire CAQThe SCQ-Lifetime was completed. ≥ for sex. A T-score on the SRS- cohort are presented in Table 1 in − Parent Report 60 is considered addition to a comparison between The SCQ-Lifetime is a 40-item, abnormal and associated with ASD. the ASD (+) ADHD and ASD ( ) parent-report questionnaire that The SRS has strong psychometric ADHD groups. Survey completion properties, including an interrater was near contemporaneous, with is designed20 as a screening test for ASD. It is validated for ages 4 years reliability of 0.9 between parents, 92.2% completing both the CAQ and and older. Scores range from 0 to an internal consistency of >0.9, and the SRS within 1 calendar year and 39 with a cutoff of 15 for ASD in a discriminant validity between other 96.5% within 2 calendar years. The general population, and a cutoff as developmental behavioral disorders, cohort was primarily male (82.9%), low as 11 is recommended for a high- including ADHD, mood disorders,23, 25​ white (87.2%), and non-Hispanic , and . ‍ (92.4%), with a mean age of 10.3 risk population to24 optimize the area under the curve. In this study, we It has been validated against clinical years. Of the children, 649 (19.6%) used a cutoff of 12 as 1 of several evaluation and the Autism Diagnostic were reported to have ID, 1025 ’ inclusion criteria in the IAN registry Interview with a sensitivity24,26​ of 0.75 (30.8%) were reported to have a per the manual s recommendation andData a Management specificity of 0.96and .Analysis diagnosis of or treatment for an anxiety disorder, and 532 (16.0%) to use a lower threshold20 if there are additional risk factors because were reported to have a diagnosis of registrants of the IAN are considered Detailed methodology regarding or treatment for a mood disorder. A high risk for ASD given that they have data management and data analysis statistically significant difference in received a professional diagnosis may be found in the Supplemental the sex proportion and prevalence of parent-reported ID was found of ASD per parent report. In the Information. − IAN registry, the SCQ-Lifetime total RESULTS when comparing the ASD (+) ADHD and ASD ( ) ADHD groups. The ASD score cutoff of 12 has been validated − against the Autism Diagnostic 19 (+) ADHD group was older than the InterviewThe SRS-Parent with Report99% accuracy. There were 3319 children who met ASD ( ) ADHD group and had higher inclusion criteria for this study, of ASD severity per the SRS-Parent whom 1503 (45.3%) reported a Report total raw score. We found no The SRS-Parent Report consists diagnosis of or treatment for ADHD. significant difference in either race or of 65 items and is designed to Demographics, the prevalence of ethnicity between the groups. identify the presence and severity23 parent-reported ID, mean SRS- of social impairment in ASD. The Parent Report total raw scores, In Table 2, we provide the results27 of questionnaire is validated in ages 4 and the presence of comorbid generalized linear model (GLM) to 18 years. Scores range from 0 to parent-reported anxiety disorder analyses in which we compare Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 141, number 4, April 2018 3 TABLE 2 Rates and Relative Risks of Psychiatric Conditions in Children With ASD: A Comparison of Those With to Those Without ADHD Age 6–11 y Age 12–17 y All ASD (−) ASD (+) Adjusted Risk ASD (−) ASD (+) Adjusted Risk ASD (−) ASD (+) Adjusted Risk ADHD, ADHD Ratioa n (95% ADHD, ADHD Ratioa n (95% ADHD, ADHD Ratioa n (95% CI) Reference (n = 973), CI) Reference (n = 530), CI) Reference (n = 1503), (n = 1381), n (%) (n = 435), n (%) (n = 1816), n (%) n (%) n (%) n (%) Anxiety 205 (14.8) 400 (41.1) 2.65 (2.26–3.05) 140 (32.2) 280 (52.8) 1.65 (1.41–1.94) 345 (19.0) 680 (45.2) 2.20 (1.97–2.46) disorder Mood 64 (4.6) 184 (18.9) 3.59 (2.73–4.73) 82 (18.9) 202 (38.1) 2.00 (1.60–2.49) 146 (8.0) 386 (25.7) 2.72 (2.28–3.24) disorder a GLM analysis by using ASD without ADHD as reference and adjusted for sex (male or female), ethnicity (Hispanic or non-Hispanic), race (white or people of color), age (continuous), and the presence of ID (yes or no).

P P the presence of anxiety or mood disorder only (school-aged: = .041; independent of ADHD, which is disorders with the presence or adolescent: = .001). Neither sex, nor unsurprising given that the CAQ asks absence of ADHD. The ASD (+) race, nor ethnicity were significant in if a child has ever been diagnosed ADHD group had an increased risk of any of the GLM analyses. with these conditions, leading to an reported anxiety disorder (adjusted DISCUSSION inevitable cumulative diagnosis with – relative risk 2.20; 95% confidence time. Additionally, both groups follow interval [CI] 1.97 2.46) and mood the same trajectory as typically – disorder (adjusted relative risk 2.72; developing peers in that the onset − To our knowledge, this is the largest 95% CI 2.28 3.24) compared with study in which researchers compare of symptoms consistent with mood the ASD ( ) ADHD group. Increasing comorbidities in individuals with ASD and anxiety disorders is most often seen in adolescence, which may age was the most significantP alone and ASD with ADHD. It is also contributor for both anxiety disorder 1 of the largest in which researchers explain the higher prevalence of and mood disorder (both < .001), compare the clinical phenotypes these disorders in the older cohort. In contrast, the relative risks of anxiety and the absenceP of report of ID was of these populations. We found an a significant contributor for mood extremely high prevalence of parent- and mood disorders are greater in disorder only ( < .001). Given the reported ADHD among children with the younger, school-aged children association between increasing ASD, with ADHD affecting 45.2% of than in the older adolescents for those with ADHD compared with age and parent-reported ADHD, the children, which is commensurate– those without ADHD. This suggests we also analyzed relative risks by with previous studies that reveal28 31 age subgroups (school-aged and a 31% to 95% co-occurrence. ‍ ‍ that ADHD may make children with adolescent) to better appreciate Previous studies reveal that there ASD more vulnerable to an earlier onset of the symptoms of anxiety a clinical practice perspective. As may be a genetic or3, 32​symptom overlap or mood disorders or more likely to expected, we found an increased of these disorders. ‍ Nonetheless, exhibit detectable symptoms at an prevalence of both anxiety disorder this should not invalidate either earlier age. and mood disorder in the adolescent diagnosis, especially when diagnosis- group compared with the school- specific treatments are available. − The specific etiology behind the aged group for both the ASD (+) Our primary study findings were relationships among these conditions ADHD and ASD ( ) ADHD groups; that children with both ASD and is unclear at this time. It is possible however, there were higher relative ADHD are at an increased risk for that there is a genetic basis for an risk ratios for the school-aged group being diagnosed with or treated for increased risk of multiple psychiatric compared with the adolescent group anxiety and mood disorders when disorders, as has32 been found with for both anxiety disorder and mood compared with those with ASD alone. ASD and ADHD. Alternatively, it disorder. Within the age subgroups, These are supported by a 2011 study is possible that 1 syndrome is an we also found the same pattern as in of adolescents in special education early manifestation of the other, the full data set that increasing age that revealed increased rates of or the development of 1 syndrome was the most significant contributor and/or antianxiety increases the risk for the other. One to the presence of bothP anxiety and use among children may also consider that children with mood disorders (for both age groups with ASD and ADHD33 in comparison ADHD and ASD are at an increased8,10​ and both conditions: < .001), with ASD only. Furthermore, the risk for behavioral problems,​ ‍ and and absence of report of ID was a prevalence of reported anxiety and these behaviors may contribute to significant contributor for mood mood disorders increases with age, anxiety or mood symptoms. This may Downloaded from www.aappublications.org/news by guest on September 24, 2021 4 GORDON-LIPKIN et al ∼ also contribute to the differences were not assigned a diagnosis children with ASD and ADHD have in SRS scores between the groups, because symptoms may overlap SRS scores 3 points higher than which is discussed below. but were prescribed medication children38 with ASD who do not have Referral bias may explain an for hyperactivity, anxiety, or mood ADHD. There is also evidence increased risk for reported anxiety symptoms in the absence of a formal suggesting that children with ADHD and mood disorders in children with diagnosis. With this in mind, our alone may have higher SRS scores39 ASD and ADHD in comparison with rates of ADHD, anxiety, and mood than the normative population,​ ASD alone because practitioners who disorders may reflect the rate of suggesting that a behavioral overlap diagnose ADHD may be more likely symptoms that are consistent with between ASD and other psychiatric to also diagnose anxiety or mood these disorders rather than formal disorders exists. The clinical disorders. However, this question diagnosis. Frequently still, diagnoses implication of a small increase in ASD are not used until intervention is symptom severity in children with was addressed in12 a previous study of the IAN registry,​ in which children needed, which suggests that our both ASD and ADHD is unclear. Six sample may be underidentifying points on the SRS may not translate with both ASD and ADHD were ’ less likely to have a third diagnosis these comorbidities if the children to appreciable differences in an – than to not (odds ratio 0.1, 95% CI are not being medically treated. individual child s outcome, but such a difference may have a broader 0.1 0.2), implying that referral bias is Recognizing the increased risk social or economic impact among unlikely in this sample. Registration for psychiatric disorders in this this population. It is possible that the bias may also influence the findings population has implications SRS is not an adequately sensitive or if parents of children with multiple for clinical practice. This may specific tool to assess ASD function in comorbidities are more likely to be challenging in ASD because this setting, and additional studies of participate in IAN. symptoms of anxiety and mood ASD symptomatology in the context disorders may present differently EvolvingDiagnostic diagnostic and Statistical criteria may Manual also of ADHD are needed. in these children than in typically ofinfluence Mental population-basedDisorders, Fifth Edition, studies.​ The developing children. Unfortunately, We also found a difference in the has information regarding how anxiety rates of ID among those children with broadened the construct of autism and mood disorders were diagnosed ASD with and without ADHD. In our toward a spectrum and narrowed and/or treated was not available cohort, those with ADHD had slightly the diagnostic criteria for ASD, for this study. Further research is lower rates of ID. It may be that although the definitions of ADHD needed to better understand how ADHD symptoms are more easily or and mood disorders are similar mood and anxiety disorders present frequently detected in children with to those outlined in the previous in both ASD and ADHD populations to normal intellect or that the genetic edition. The evolution of definitions optimally assess and diagnose these phenotype associated with ASD and and allowing the coexistence of disorders. Importantly, both anxiety ADHD is also associated with normal multiple psychiatric diagnoses and mood disorder symptoms are intellect. Differential rates of ID acknowledges and may affect medical treatable medical35 conditions through36 among those children with ASD with recognition and treatment. The high and medication. and without ADHD may also be a Recognizing and treating the function of diagnostic overshadowing rates of comorbidity in thisDiagnostic study symptoms can impact quality of (eg, ascribing inattention and/ andmay S thustatistical reflect Manual changing of Mental practice 37 life and improve other short- and or to ID rather than Disorderswith the evolution of the long-term outcomes, with further ADHD). Researchers in future studies . knowledge also being needed about examining this question may help effective, evidence-based treatments clarify whether this association Pharmacotherapy may also for these comorbidities in ASD. is replicable and what its clinical contribute to our findings because implications may be. ADHD, anxiety, and mood disorders We found that the presence of all have treatments that are widely ADHD has a small association with The diagnosis of ASD has been available and34 increasingly used greater ASD symptom severity, as validated in the19, IAN21​ database with in practice. Notably, IAN asks reflected in the SRS score, suggesting 98% accuracy,​ ‍ but similar whether a child has ever been that children with increased ASD data are not available for the diagnosedDiagnostic with or treated and Statistical for these severity are either more likely to other diagnoses in this study. Manualcomorbidities, of Mental acknowledging Disorders, Fourth that be diagnosed with ADHD, or a dual Although performing standardized, Editionwith the diagnosis of ASD and ADHD impacts comprehensive psychiatric ASD symptoms. Researchers in assessment is the gold standard , many children with ASD another study found similarly that for diagnosis, participant report Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 141, number 4, April 2018 5 is efficient in sampling a large information, and we did not assess symptoms, particularly in those with population, with data for other individuals longitudinally. Therefore, ADHD. diagnoses supporting that such report our trends in age groups are based ACKNOWLEDGMENTS is valid with equal accuracy (S. Terry, on prevalence rather than incidence.

MA, personal40 communication, Longitudinal data may help clarify 2017). Furthermore, the parent- the relationships between these We acknowledge the individuals with reported diagnoses in this study conditions and age. ASD, their families, the researchers, are supported by similar rates – Because computer and Internet and the care professionals of comorbidity with ASD28,30,​ in31,​ large33,​ 41​ 43 access are required to complete who make IAN possible through the epidemiologic studies. ‍ ‍ ‍ ‍ the IAN questionnaires, there is generous contribution of their time However, we do acknowledge that and effort. bias toward participants50 of higher participant-reported data may be socioeconomic status. We have ABBREVIATIONS susceptible to recall or reporting bias. assumed that this bias is constant Self- and parent-report data have also throughout the sample, although demonstrated statistical44 validity in this sample is not precisely ADHD: attention-deficit/hyperac - the social sciences and is frequently tivity disorder 45 representative of the general − relied on for the diagnosis46 of ADHD population. ASD: autism spectrum disorder and anxiety disorders. Furthermore, CONCLUSIONS ASD ( ) ADHD: childre n with there is similar precedent for the autism spectrum use of parent-reported diagnoses in disorder without other large epidemiologic– studies of ADHD affects nearly half of the parent-reported children, such as the47 49 National Health children with ASD. This subgroup of attention-deficit/ Interview Survey,​ ‍ in which the individuals with ASD may represent hyperactivity language is identical to that used in a distinct clinical phenotype, with disorder the IAN questionnaire. Incorporating different diagnostic and therapeutic ASD (+) ADHD: children with psychiatric diagnostic questionnaires implications. Better understanding autism spectrum may help validate this report in the the differences between children disorder with future. with ASD with and without ADHD parent-reported Both ADHD and ID may be is crucial to designing effective attention-deficit/ hyperactivity underreported in this cohort, as is 48 interventions. disorder seen with chronic health conditions. Our study supports that anxiety CAQ: Child with Autism For ID specifically, parents may be and mood disorders, although ’ Spectrum Disorder underinformed or misinformed of highly prevalent in those with ASD Questionnaire their children s intellectual skills. alone, are even more prevalent in CI: confidence interval We further acknowledge that our individuals who have ADHD. They are GLM: generalized linear model Diagnosticdefinition of and ID Statistical(parent report Manual or IQof also more prevalent with increasing IAN: Interactive Autism Network Mental<70) does Disorders not conform to the current age. The identification of psychiatric ID:  conditions in children with ASD is SCQ-Lifetime: Social definition because important because these disorders Communication it does not incorporate adaptive are treatable and affect quality of Questionnaire- functioning. life. Physicians who treat children Lifetime This study represents a cross- with ASD should be vigilant about SRS: Social Responsiveness Scale sectional sample of lifetime screening for anxiety and mood

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: The Interactive Autism Network is funded by the Simons Foundation and the Patient-Centered Outcomes Research Institute. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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Downloaded from www.aappublications.org/news by guest on September 24, 2021 8 GORDON-LIPKIN et al Anxiety and Mood Disorder in Children With Autism Spectrum Disorder and ADHD Eliza Gordon-Lipkin, Alison R. Marvin, J. Kiely Law and Paul H. Lipkin Pediatrics originally published online March 30, 2018;

Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/early/2018/03/28/peds.2 017-1377 References This article cites 45 articles, 0 of which you can access for free at: http://pediatrics.aappublications.org/content/early/2018/03/28/peds.2 017-1377#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Developmental/Behavioral Pediatrics http://www.aappublications.org/cgi/collection/development:behavior al_issues_sub Attention-Deficit/Hyperactivity Disorder (ADHD) http://www.aappublications.org/cgi/collection/attention-deficit:hyper activity_disorder_adhd_sub Autism/ASD http://www.aappublications.org/cgi/collection/autism:asd_sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on September 24, 2021 Anxiety and Mood Disorder in Children With Autism Spectrum Disorder and ADHD Eliza Gordon-Lipkin, Alison R. Marvin, J. Kiely Law and Paul H. Lipkin Pediatrics originally published online March 30, 2018;

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/early/2018/03/28/peds.2017-1377

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