AD/HD and autism spectrum disorders in adults Hofvander, Björn 2009 Link to publication Citation for published version (APA): Hofvander, B. (2009). AD/HD and autism spectrum disorders in adults. Department of Clinical Sciences, Lund University. 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LUND UNIVERSITY PO Box 117 221 00 Lund +46 46-222 00 00 Forensic Psychiatry, Department of Clinical Sciences, Malmö, Lund University; doctoral thesis AD/HD and autism spectrum disorders in adults Björn Hofvander Malmö 2009 Cover drawing by Pia Moberg ISSN 1652-8220 ISBN 978-91-86253-84-4 Lund University, Faculty of Medicine Doctoral Dissertation Series 2009:96 In theory there is no difference between theory and practice. In practice there is. Jan L. A. van de Snepscheut/ Yogi Berra To Ebba and Truls Contents Abstract 7 Svensk sammanfattning 8 Acknowledgements 9 List of papers 11 Abbreviations 13 Introduction 15 Nosology 15 Comorbidity and the borders of disorders 16 Categories or dimensions? 17 Course and continuity of disorders 17 Psychopathology across the lifespan 18 Childhood conditions in adults 18 Neurodevelopmental disorders 19 Attention Deficit Hyperactivity Disorder 19 The heterogeneity of AD/HD 21 Neuropsychological correlates 21 Psychiatric and psychosocial outcome 22 Autism spectrum disorders 22 Autistic disorder 23 Asperger´s disorder 24 High functioning autism 25 Pervasive developmental disorder – not otherwise specified 25 The broader autism phenotype 26 Neuropsychological correlates 26 Mental retardation and the ASDs 27 Complications and outcome 27 Personality 28 Cloninger´s biopsychosocial model 29 Neuropsychology 29 Intelligence 30 Sex aspects 30 Aims of the present thesis 32 General aims 32 Specific aims 32 Methods 33 Subjects 33 Review data (Paper I) 33 NPG study group: adult psychiatric outpatients (Paper II and III) 33 P.A.R.I.S. study group (Paper III) 34 FNP study group: pre-trial forensic psychiatric investigees (Paper II) 34 AN study group: research subjects with anorexia and comorbid ASDs (Paper IV) 34 Measures 35 Diagnostic interviews 35 Developmental history 36 The Wechsler scales 37 Neuropsychological testing 37 Measures of aggression 38 Self-report instruments 38 Other assessments 39 Medical examination 39 Exclusion criteria 39 Analytical methods 39 Response rate 40 Power 40 Multiple comparisons 40 Ethical aspects 41 Results 42 AD/HD in adulthood 42 Paper I: Longitudinal studies of hyperactivity 42 Paper II: AD/HD and aggression in adults 42 ASDs and co-occurring problems in adult age 43 Paper III & IV: Clinical characterization and psychosocial adversities in adults with ASDs 43 Clinical autistic features 43 AD/HD comorbidity 44 Other axis I disorders 45 Personality disorders 46 Personality dimensions 46 Neuropsychological functioning 47 Psychosocial complications 47 Summary of findings 48 Discussion 49 Limitations 49 Comments to main findings 51 Clinical implications and future research directions 54 References 55 Abstract Background: Attention deficit/hyperactivity disorder (AD/HD) and autism spectrum disorders (ASDs) are early-onset, but often life-time impairing, neurodevelopmental disorders. They are highly overlapping and seem to carry considerable risks of negative outcomes, psychiatrically and psychosocially. Childhood hyperactivity is a known risk factor for early-onset conduct disorder (CD), but details concerning the associations between neurodevelopmental problems, aggression, and antisocial personality disorder (ASPD) in adult age are still uncertain. The current diagnostic subdivision of the ASDs is based on children, while the adult characteristics, including patterns of comorbidity and psychosocial adversities, have been less studied, especially in subjects without concomitant intellectual disability. Objectives: The overall aim of this thesis was to describe the adult outcome of AD/HD and ASDs. Specific aims were to: (1) review prospective, longitudinal studies of the adult outcome of childhood hyperactivity, equivalent to AD/HD, with special regard to ASPD, (2) investigate the relationships between AD/HD, ASDs, and different types of aggressive behaviours, (3) describe the clinical presentation, including personality development and psychosocial outcome, in normal- intelligence adult subjects with ASDs. Method: The first paper is a systematic meta-analysis of published studies. The subsequent studies are descriptive analyses of common clinical assessment protocols from consecutive groups of adults either referred for clinical evaluations of childhood-onset neuropsychiatric disorders, for forensic psychiatric investigations, or recruited to a population-based, longitudinal study of teenage-onset anorexia nervosa (AN). Results: Childhood hyperactivity increases the risk for CD, which is found in at least one-third of all hyperactive children, forming the starting point for the development of aggressive antisociality in adulthood in about half of cases with the combination of hyperactivity and CD in childhood. Support for the hypothesis that childhood hyperactivity, in the absence of early CD, carries a risk for adult ASPD, is still lacking (Paper I). Both conditions are, however, predictors of aggression in adults, together with substance-related disorders and poor development of the character trait Cooperativeness. ASD traits or symptoms did not generally predict aggression but may be associated with unique violent offences (Paper II). Among subjects with normal- intelligence ASDs, life-time psychiatric comorbidity was very high, and measures of outcome indicated low psychosocial functioning. AD/HD was common in all ASD subject categories studied with the notable exception of subjects with AN, none of whom had AD/HD. ASPD and substance-related disorders were more common in patients with an atypical ASD as compared to Asperger´s disorder or autistic disorder. Among all adults diagnosed with an ASD, less than half led an independent life and comparatively few had ever had a long-term relationship. Female subjects more often reported having been bullied at school than male subjects (Paper III and IV). Discussion and conclusions: Childhood-onset neuropsychiatric conditions such as AD/HD and ASDs are relevant for adult psychiatric phenotypes but insufficiently studied. Current classifications suffer from the hiatus between child- and adolescent psychiatry and adult psychiatry and future diagnostic concepts ought to be longitudinal with a life-time perspective on cognitive and emotional development and a patient-centred focus rather than fragmented into complex patterns of “comorbidities”. Key Words: AD/HD; Autism spectrum disorders; Comorbidity; Behaviour disorders; Outcome 7 7 Svensk sammanfattning Bakgrund: Uppmärksamhetsstörning med hyperaktivitet och impulsivitet (AD/HD) och autismspektrumstörningar (ASDs) är neuroutvecklingsrelaterade psykiatriska tillstånd som debuterar tidigt i livet och påverkar individens fungerande genom livet. Dessa diagnosgrupper överlappar påtagligt sinsemellan och med andra psykiatriska tillstånd. Hyperaktivitet i barndomen är en känd bakgrundsfaktor till uppförandestörning i barndomen (CD), medan det fortfarande är oklart vilken roll neuroutvecklingsrelaterade problem i övrigt spelar för aggressivitet och antisocial personlighetsstörning (ASPD) i vuxen ålder. Kunskapen om hur ASDs ter sig i vuxna kliniska grupper och hur de förhåller sig till viktiga utfallsmått som aggressivitet och psykosocialt fungerande är fortfarande begränsad. Syfte: Det övergripande syftet för denna avhandling har varit att undersöka det psykiatriska och psykosociala utfallet av AD/HD och ASDs. Specifika målsättningar var att: (1) genomföra en litteraturöversikt över prospektiva, longitudinella studier där hyperaktivitet i barndomen, motsvarande AD/HD, följts upp i vuxen ålder, med särskilt fokus på utvecklingen av ASPD, (2) undersöka förhållandet mellan AD/HD, ASDs och olika former av aggressiva beteenden, (3) beskriva den kliniska bilden, inklusive psykosocialt fungerande, hos vuxna normalbegåvade personer med ASDs. Metod: Avhandlingens första arbete (Paper I) utgår från en systematisk meta-analys av den vetenskapliga litteraturen. De därpå följande arbetena (Paper II, III och IV) är deskriptiva analyser av kliniska data, insamlade antingen i konsekutiva, vuxenpsykiatriska grupper där forskningspersonerna remitterats till neuropsykiatriska utredningar alternativt rättspsykiatriska undersökningar eller ingått i en longitudinell, populationsbaserad grupp bestående av individer med tonårsdebuterande anorexia nervosa (AN). Resultat: Minst en tredjedel av alla hyperaktiva