In the JournalsPerspective

Autism diagnosis should be considered in children with ADHD

Diagnostic consideration for autism spectrum disorder is required when making a diagnosis of attention-deficit/hyperactivity disorder, due to the prevalence of detrimentally late diagnosis of ASD in children with concurrent disorders, according to recent data in Pediatrics.

“Our study supports the hypothesis that receiving a diagnosis of [attention-deficit/hyperactivity disorder (ADHD)] before [autism spectrum disorder (ASD)] may delay the diagnosis of ASD, and that this delay persists across age and severity of the ASD,” Amir Miodovnik, MD, MPH, of the division of developmental medicine at Boston Children’s Hospital and Harvard Medical School, and colleagues wrote. “Furthermore, if ADHD is diagnosed first, the ASD diagnosis has a higher probability of occurring late. ASD that goes unrecognized and untreated until the child is older may negatively affect their long-term prognosis.”

Amir Miodovnik

The researchers gathered data from the 2011-2012 National Survey of Children’s Health, and they recorded the ages at which parents reported their children initially were diagnosed with ADHD or ASD. Criteria for confirming a survey respondent had a child with ASD was done through a series of questions, including: “Has a doctor or other health care professional ever told you that your child had autism?” Other survey questions were analyzed to determine whether an ADHD diagnosis was made before, concurrently, or after ASD diagnosis.

Ultimately, 1,496 children, aged 2 to 17 years, with confirmed ASD were included in the final study population, of which 705 also had an ADHD diagnosis. Almost 45% of participants with coinciding ADHD and ASD reported that an ADHD diagnosis was made first. The researchers noted that the group of children who had ADHD diagnosed before ASD contained fewer children with speech problems, compared with children diagnosed first with ASD or simultaneously with ADHD (P = .009). Children in this group also were aged about 4 years older than those diagnosed with ASD before or simultaneously with ADHD (P < .001). Later ASD diagnosis due to earlier ADHD diagnosis resulted in 81% of children in this group not receiving a diagnosis of ASD until after they were aged 6 years (P <.001).

There were 745 children in the study group diagnosed only with ASD, while 392 children were diagnosed with ADHD at the same time or after an ASD diagnosis.

The investigators said that a diagnosis of ADHD before ASD caused at least a 3.2-year delay in a diagnosis of ASD. This delay has the potential to negatively impact the long-term symptoms and quality of life associated with ASD, they said.

Children that presented with speech problems resulted in an ASD diagnosis occurring 1.2 years earlier, the researchers said. Children with mild to moderate ASD also were diagnosed later than children with severe ASD.

“Diagnostic criteria and screening measures for ASD may need to reflect the overlapping symptomatology between ASD and ADHD,” Miodovnik and colleagues wrote. “For now, clinicians should consider ASD when evaluating young children presenting with ADHD symptoms.” – by David Costill

Disclosures: Miodovnik reports no relevant financial disclosures. Another author reports receiving grants from SynapDx.

Diagnostic consideration for autism spectrum disorder is required when making a diagnosis of attention-deficit/hyperactivity disorder, due to the prevalence of detrimentally late diagnosis of ASD in children with concurrent disorders, according to recent data in Pediatrics.

“Our study supports the hypothesis that receiving a diagnosis of [attention-deficit/hyperactivity disorder (ADHD)] before [autism spectrum disorder (ASD)] may delay the diagnosis of ASD, and that this delay persists across age and severity of the ASD,” Amir Miodovnik, MD, MPH, of the division of developmental medicine at Boston Children’s Hospital and Harvard Medical School, and colleagues wrote. “Furthermore, if ADHD is diagnosed first, the ASD diagnosis has a higher probability of occurring late. ASD that goes unrecognized and untreated until the child is older may negatively affect their long-term prognosis.”

Amir Miodovnik

The researchers gathered data from the 2011-2012 National Survey of Children’s Health, and they recorded the ages at which parents reported their children initially were diagnosed with ADHD or ASD. Criteria for confirming a survey respondent had a child with ASD was done through a series of questions, including: “Has a doctor or other health care professional ever told you that your child had autism?” Other survey questions were analyzed to determine whether an ADHD diagnosis was made before, concurrently, or after ASD diagnosis.

Ultimately, 1,496 children, aged 2 to 17 years, with confirmed ASD were included in the final study population, of which 705 also had an ADHD diagnosis. Almost 45% of participants with coinciding ADHD and ASD reported that an ADHD diagnosis was made first. The researchers noted that the group of children who had ADHD diagnosed before ASD contained fewer children with speech problems, compared with children diagnosed first with ASD or simultaneously with ADHD (P = .009). Children in this group also were aged about 4 years older than those diagnosed with ASD before or simultaneously with ADHD (P < .001). Later ASD diagnosis due to earlier ADHD diagnosis resulted in 81% of children in this group not receiving a diagnosis of ASD until after they were aged 6 years (P <.001).

There were 745 children in the study group diagnosed only with ASD, while 392 children were diagnosed with ADHD at the same time or after an ASD diagnosis.

The investigators said that a diagnosis of ADHD before ASD caused at least a 3.2-year delay in a diagnosis of ASD. This delay has the potential to negatively impact the long-term symptoms and quality of life associated with ASD, they said.

Children that presented with speech problems resulted in an ASD diagnosis occurring 1.2 years earlier, the researchers said. Children with mild to moderate ASD also were diagnosed later than children with severe ASD.

“Diagnostic criteria and screening measures for ASD may need to reflect the overlapping symptomatology between ASD and ADHD,” Miodovnik and colleagues wrote. “For now, clinicians should consider ASD when evaluating young children presenting with ADHD symptoms.” – by David Costill

Disclosures: Miodovnik reports no relevant financial disclosures. Another author reports receiving grants from SynapDx.

    Perspective
    Susan Kabot

    Susan Kabot

    It is critically important for young children with autism spectrum disorder (ASD) to receive appropriate intervention as early as possible to achieve the best outcomes. This study found that children with ASD, who were first diagnosed with attention-deficit hyperactivity disorder (ADHD), were correctly diagnosed with ASD approximately 3 years later (at age 6 years) than children who were originally diagnosed with ASD or both ASD and ADHD. Although many children with ASD have attention problems, and many with severe enough problems to warrant an additional diagnosis, interventions for ADHD may miss the critical area of social communication that is a cornerstone of the autism diagnosis and intervention. Building early communication skills in young children with ASD will prevent the development of many challenging behaviors that are secondary to deficits in communication.

    • Susan Kabot, EdD, CCC-SLP
    • Executive director of the Autism Institute Nova Southeastern University Mailman Segal Center

    Disclosures: Kabot reports no relevant financial disclosures.

    Perspective

    This study highlights the subtleties of diagnosing young children with autism, especially those presenting with symptoms on the milder end of the spectrum. The authors imply that children may be diagnosed with ADHD either in lieu of ASD or that the ASD diagnosis is missed. If reliable, these findings suggest that children diagnosed with ADHD may need to be either monitored closely for symptoms of ASD or sent to a specialist for differential diagnosis.

    • MaryLouise E. Kerwin, PhD, BCBA-D
    • Department of Biomedical Sciences Cooper Medical School Director, Center for Behavior Analysis Rowan University

    Disclosures: Kerwin reported no relevant financial disclosures.

    Perspective

    This recent publication in Pediatrics presents data showing that diagnosis of ADHD prior to ASD is linked to an approximately 3 year lag in diagnosis of ASD. The children with ADHD diagnosed first were nearly 30 times more likely to receive their ASD diagnosis after age 6.  This finding is concerning for several reasons. First of all, early diagnosis is fundamental in ASD because early intervention in autism with evidence-based techniques such as applied behavior analysis is linked to major improvements in functioning, and, in a small portion of cases, to “optimal outcomes” in which children no longer meet criteria for an autism diagnosis (Orenstein et al, 2014).

    The findings are also concerning because of known disparities in the diagnosis of autism linked to minority status, and lower levels of parent education and income. It is fundamental in autism that all children must be identified as early as possible so that they can receive intensive early intervention. The recommendation of the Pediatrics article that, “To avoid potential delays in ASD diagnosis, clinicians should consider ASD in young children presenting with ADHD symptoms” is appropriate and important.

    Lauren Kenworthy, PhD
    Director, Center for Autism Spectrum Disorders
    Children’s National Health System

    Laura Anthony, PhD
    Center for Autism Spectrum Disorders
    Children’s National Health System

    Disclosures: Kenworthy and Anthony reported no relevant financial disclosures.