Attention deficit hyperactivity disorder (ADHD), one of the most frequent comorbidities of autism spectrum disorder (ASD), can further compromise a child’s ability to function in a classroom or other social settings.
Although imaging studies have shown structural differences between the brains of children with either disorder and those of typical controls, few studies have compared the brains of children with ASD to the brains of children with ADHD—and only one has examined whether symptoms that co-occur across diagnoses arise from shared structural abnormalities.
That study, published in September 2017 in JAMA Psychiatry, was led by Adriana Di Martino, MD, associate professor of child and adolescent psychiatry and research director of the Autism Spectrum Disorders Clinical and Research Program at NYU Langone’s Child Study Center.
“To find better treatments for patients with complex presentations, we must uncover the neural correlates of clinical symptoms,” explains Dr. Di Martino, a pioneer in the use of innovative imaging approaches to neurodevelopmental disorders. “Instead of focusing on ASD and ADHD as categorically distinct, we need to think of each of their domains in a continuum—with some patients more impaired by autistic symptoms than by ADHD symptoms and vice versa. If we can identify biomarkers for the type of symptom and its severity, we can then develop more precisely targeted interventions for children in both diagnostic groups.”
In the study, Dr. Di Martino and colleagues used diffusion tensor imaging— which visualizes neural connectivity by measuring the diffusion of water molecules in white matter—to scan the brains of 69 children with ASD, 55 with ADHD, and 50 typically developing controls.
Regardless of the child’s diagnosis, the team found associations between the ASD symptom severity and abnormalities in white matter organization—particularly in the corpus callosum, the bundle of nerve fibers that connect the brain’s hemispheres. The total severity of ADHD traits was not associated with white matter metrics.
But when the team further analyzed the results, separating out hyperactivity from inattentive traits, they found evidence of a white matter correlation for the inattentive symptoms—again, a finding that transcended diagnosis.
These findings, Dr. Di Martino notes, point to promising avenues for further exploration. “Larger studies will help to uncover the relationships between the structural anomalies and children’s symptoms, and the mechanisms involved,” she explains. “Eventually, we hope to find proxies for these neurological patterns—perhaps using eye-tracking measurements or other inexpensive tests—so clinicians can make nuanced assessments without resorting to an MRI.”
New Autism Clinical Pathway Designed To Improve Care
An estimated 10,000 children and adolescents affected by severe forms of ASD and/or intellectual disability (ASD/ID) are hospitalized psychiatrically each year for dangerous, self-injurious, or aggressive behavior.
In a busy medical center, sensory processing, communication, and social difficulties can lead to staff injuries, excessive medication, and prolonged hospital stays, explains Sarah Kuriakose, PhD, clinical assistant professor of child and adolescent psychiatry and clinical director of the ASD Clinical and Research Program at NYU Langone’s Child Study Center. “Many hospitals cannot accommodate the needs of children with ASD/ID, but we’re helping to provide the tools needed to manage these patients,” she says.
Three years ago, Dr. Kuriakose, Beryl J. Filton, PhD, clinical assistant professor of child and adolescent psychiatry, and colleagues at the Child Study Center, part of Hassenfeld Children’s Hospital, joined with NYU Langone’s Child and Adolescent Psychiatry faculty based at NYC Health + Hospitals/Bellevue, which operates the only Children’s Comprehensive Psychiatric Emergency Program (C-CPEP) in New York State. Together they devised the nation’s first clinical pathway to manage children with ASD/ID in a general inpatient psychiatric unit.
A new clinical pathway to manage children with autism spectrum disorder and intellectual disabilities decreases hospital stays by nine days.
The pathway follows patients from intake at the C-CPEP—where caregivers complete a questionnaire detailing the child’s behavioral triggers, including stimuli that upset or calm the child— through discharge to outpatient units. Admissions information goes into each child’s binder, to which visual representations of daily tasks can be attached.
To harness the proven benefits of physical exercise, children are given “motor breaks” every two hours, and staff members carry a “coping card” with techniques to defuse meltdowns. Developmentally appropriate activities and supporting materials are also introduced in the units. At discharge, caregivers receive copies of these materials and a verbal debriefing, to prevent incidents that could lead to readmission.
Data from the pathway’s first 18 months were presented at the 2017 American Academy of Child and Adolescent Psychiatry Annual Meeting. Compared with the 18 months prior to implementation, use of restraints and seclusions declined significantly, as did total length of stay, from a mean of 22 days to 13 days.
Less easily measured, but equally important, has been the pathway’s effect on staff. “The entire attitude toward children with autism has changed,” reports Dr. Kuriakose. “Now, there’s an understanding that these are great kids; we just need the tools to help them.”
Other hospitals have begun to adopt the pathway. In May 2017, Dr. Kuriakose, Dr. Filton, and colleagues helped roll out a program at NYC Health + Hospitals/ Elmhurst, training frontline staff in the psychiatric emergency department and inpatient psychiatric units.
A modified version will be implemented in 2018 at the Children’s Center, a residence for children awaiting foster placement operated by the New York City Administration for Children’s Services, and additional partnerships across the nation are planned.