Dr Jane McCarthy MB ChB MD MRCGP FRCPsych

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1 Dr Jane McCarthy MB ChB MD MRCGP FRCPsych Consultant Psychiatrist in Intellectual Disability, East London NHS Foundation Trust and Visiting Senior Lecturer, Institute of Psychiatry, Psychology & Neuroscience, King s College London

2 Diagnosis Prevalence Co-occurrences in clinic & forensic settings

3 1. Deficits in Social Communication & Social Interaction 2. Restricted & repetitive behaviour, interests or activities

4 Affects 1 per 100 Boys more than girls. Spectrum of conditions

5 1. A significantly reduced ability to understand new or complex information or to learn new skills (impaired intellectual functioning with IQ of 70 +/-5) 2. A reduced ability to cope independently (impaired adaptive functioning) 3. Onset during developmental period

6 Onset in the developmental period Impairments of personal, social, academic or occupational functioning Symptoms of excess as well as deficits Include ID, ADHD, ASD, Communication disorders, Specific learning disorder

7 Difference in brain structure ADHD boys had grey matter volume reduction in right posterior cerebellum ASD boys had grey matter volume enlargement in left MTG/STG (Lim et al., 2015, Psych Med, 45, ).

8 Difference in neurobiological functioning ASD: glutamate/gaba imbalance ADHD:catecholamine/dopamine/ nicotine imbalance

9 Social dysfunction Inattention Behavioural problems

10 ASD have abnormalities of attention (overly focused or easily distracted) ASD individuals show hyperactivity Attention or Hyperactivity exceeds that typically seen in those of comparable mental age

11 Overactivity and inattention may impair general performance and contribute to lower IQ scores Buchmann et al (2011) suggested it is not possible to diagnose ADHD with certainty in individuals with an IQ below 85

12 DSM-V and ICD-10 ADHD/HKD criteria advise that the observed behaviour must be inconsistent with the developmental level Similar symptom picture and developmental course of ADHD symptoms for young children and adults with and without ID (Simonoff et al, 2007; Xenitidis et al, 2010)? Poorer outcome in adult life

13 70% of ASD children have one comorbid condition 28% have ADHD (Simonoff et al., 2008)

14 Prevalence rates vary widely from 14 to 60% in children (Ruedrich,2010) ADHD prevalence 8 x higher in children with ID (Secondary analysis of for National Statistics survey of the Mental Health of Children and Adolescents in Great Britain) (Emerson 2003) About 15% of adult with ID have ADHD

15 Genetic heritability Up to 80% + for ASD (narrow criteria) Up to 70% + for ADHD For ID will find genetic cause in about 50% Polygenetic conditions Environmental Smoking, drug and alcohol use during pregnancy Early brain infections

16 6 item screening tool for ADHD: WHO Adult ADHD self-report scale (Kessler et a., 2005) DIVA (Diagnostic Interview for ADHD in Adults) (Kooik, 2010)

17 ASD (N = 137) No ASD ( N= 383) ADHD 6.6% 2.1% p = Anxiety 13.1% 5.5% p = Bipolar 15.3% 11.7% n.s. Depression 18.2% 20.6% n.s. Psychotic 35.8% 43.3% n.s PD 0% 5% p = Dementia 0.7% 6% P = 0.012

18 Total Prison population is male prisoners recruited 45% from BME background Aged 20 to 72 (mean = 34)

19 Co-occurring ND in a Prison Population (N=87)

20 61% of prisoners with ID had ADHD 26% of prisoners with ADHD had ID Current Mental Health Problems: ID only: 13% ID & ADHD: 54% ADHD only: 66%

21 No NDD ASD + p value High alcohol use in last 12 months 20% (14) 35% (13) (10 ADHD) Any drug use in last 12 months 30% (21) 40% (15) (12 ADHD) 0.295

22 Methylphenidate, amphetamine and risperidone have proven efficacy in children Atomoxetine reduces symptoms in children (Harfterkamp et al., 2012) Less evidence for adults: Follow NICE guidelines

23 ADHD is the rule rather than exception in people with ASD & ID Why is this so? General genetic susceptibility to neurodevelopmental disorders But different trajectory in terms of brain development Should emphasis be on symptom co-occurrence rather than co-occurrence of comorbid disorder?

24 Screening and diagnostic assessment of neurodevelopmental disorders in a male prison. (2015). McCarthy J, Chaplin E, Underwood L, Forrester A, Hayward H, Sabet J, Young S, Asherson P, Mills R & Murphy D. Journal of Intellectual Disabilities and Offending Behaviour, 6(2), Lai MC et al., (2014). Autism. Lancet, 383, Lim L et al., (2015). Disorder-specific grey matter deficits in ADHD relative to ASD. Psychological Medicine, 45, Attention-Deficit Hyperactivity Disorder (ADHD) (2014). Xenitidis K, Maltezos S & Asherson P. In: Handbook of Psychopathology in Adults with Developmental and Intellectual Disability: Research, Policy and Practice. Eds: E Tsakanikos and J McCarthy. New York, NY: Springer Science.

25 Dr Lisa Underwood, Dr Eddie Chaplin, Dr Andrew Forrester, Hannah Hayward, Professor Philip Asherson, Professor Declan Murphy, Institute of Psychiatry, Psychology & Neuroscience King s College London Professor Susan Young, Imperial College London & Richard Mills, Research Autism

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