How can autistic adults be supported in primary care?

Elizabeth O’Nions; Douglas GJ McKechnie; Cathie Long; Will Mandy; Joshua Stott

doi:10.3399/bjgp23X735525

Published eLetters

eLetter submission guidelines

Submit a Response to This Article

Compose eLetter

Title *

Author Information

Contributors

First Name and Middle Initial *

First or given name, e.g. 'Peter'.

Last Name *

Your last, or family, name, e.g. 'MacMoody'.

Email Address *

Your email address, e.g. higgs-boson@gmail.com. PLEASE NOTE: your email address will be published.

Occupation *

Your role and/or occupation, e.g. 'Orthopedic Surgeon'.

Affiliation *

Your organization or institution (if applicable), e.g. 'Royal Free Hospital'.

Statement of Competing Interests

Competing interests? *

Yes

Please describe the competing interests

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

Vertical Tabs

Jump to comment:

Supporting adults with autism - don’t forget comorbid ADHD
Laurence Leaver, Sally Cubbin and Allyson Parry

Published on: 29 October 2023

Published on: (29 October 2023)
Page navigation anchor for Supporting adults with autism - don’t forget comorbid ADHD
Supporting adults with autism - don’t forget comorbid ADHD
Laurence Leaver, Hon Senior Clinical Lecturer in General Practice, Green Templeton College, Oxford
Other Contributors:
Sally Cubbin, Consultant psychiatrist, Adult ADHD Clinic, The Manor Hospital, Oxford

Allyson Parry, Consultant neurologist, John Radcliffe Hospital, Oxford
O’Nions et al’s recent analysis of autism¹ helpfully highlights how primary care can help and the problem of under-diagnosis of autism. However, we were disappointed that the article does not mention the importance of screening autistic patients for attention deficit hyperactivity disorder (ADHD). They mention that the presence of ADHD should be one factor that may trigger the clinician to consider the presence of autism but not vice versa: indeed, Ronald et al² found that 22% of those with suspected ADHD met the criteria for ASD; but more relevantly, they also found that 41% of individuals with ASD had suspected ADHD. A recent systematic review³ found that studies at low risk of bias, found 26.7% to 95.5% of those with ASD had ADHD. DSM-5 recognised in 2013 that ADHD symptoms are common in people with ASD, with estimated prevalence of 30-50%⁴. Ghirardi et al⁵ in 2018 also found that individuals with ASD were more likely to have ADHD (odds ratio 22.33).

We already know that difficulties with attention are common in people with ASD⁶: difficulties with listening and concentrating are also common features of ADHD and could exacerbate social problems experienced by autistic patients, and further add to social anxiety. Difficulties with executive function can also reinforce low self-esteem and low mood. ADHD benefits from highly effective pharmacological treatments recommended by NICE^7...
Show More

O’Nions et al’s recent analysis of autism¹ helpfully highlights how primary care can help and the problem of under-diagnosis of autism. However, we were disappointed that the article does not mention the importance of screening autistic patients for attention deficit hyperactivity disorder (ADHD). They mention that the presence of ADHD should be one factor that may trigger the clinician to consider the presence of autism but not vice versa: indeed, Ronald et al² found that 22% of those with suspected ADHD met the criteria for ASD; but more relevantly, they also found that 41% of individuals with ASD had suspected ADHD. A recent systematic review³ found that studies at low risk of bias, found 26.7% to 95.5% of those with ASD had ADHD. DSM-5 recognised in 2013 that ADHD symptoms are common in people with ASD, with estimated prevalence of 30-50%⁴. Ghirardi et al⁵ in 2018 also found that individuals with ASD were more likely to have ADHD (odds ratio 22.33).

We already know that difficulties with attention are common in people with ASD⁶: difficulties with listening and concentrating are also common features of ADHD and could exacerbate social problems experienced by autistic patients, and further add to social anxiety. Difficulties with executive function can also reinforce low self-esteem and low mood. ADHD benefits from highly effective pharmacological treatments recommended by NICE⁷. Diagnosing and treating ADHD could make a dramatic difference to many patients with ASD. Given the lack of treatments for ASD, we believe that early identification and intervention for ADHD should be a priority. It is easy to screen for ADHD using a simple six question scoring tool, available free of charge, as recommended by the WHO: the ASRS⁸.

References

1. O'Nions E, McKechnie DG, Long C, Mandy W, Stott J. How can autistic adults be supported in primary care? Br J Gen Pract. 2023; 73(736):518-521. doi: 10.3399/bjgp23X735525.

2. Ronald A, Simonoff E, Kuntsi J, Asherson P, Plomin R. Evidence for overlapping genetic influences on autistic and ADHD behaviours in a community twin sample. J Child Psychol Psychiatry. 2008; 49(5):535-42. doi: 10.1111/j.1469-7610.2007.01857.x.

3. Eaton C, Roarty K, Doval N, Shetty S, Goodall K, Rhodes SM. The Prevalence of Attention Deficit/Hyperactivity Disorder Symptoms in Children and Adolescents with Autism Spectrum Disorder Without Intellectual Disability: A Systematic Review. J Atten Disord. 2023; 27(12):1360-1376. doi: 10.1177/10870547231177466.

4. Leitner Y. The co-occurrence of autism and attention deficit hyperactivity disorder in children - what do we know? Front Hum Neurosci. 2014; 8:268. doi: 10.3389/fnhum.2014.00268.

5. Ghirardi L, Brikell I, Kuja-Halkola R, Freitag CM, Franke B, Asherson P, Lichtenstein P, Larsson H. The familial co-aggregation of ASD and ADHD: a register-based cohort study. Mol Psychiatry. 2018; 23(2):257-262. doi: 10.1038/mp.2017.17.

6. Corbett BA, Constantine LJ, Hendren R, Rocke D, Ozonoff S. Examining executive functioning in children with autism spectrum disorder, attention deficit hyperactivity disorder and typical development. Psychiatry Res. 2009; 166(2-3):210-22. doi: 10.1016/j.psychres.2008.02.005.

7. National Institute for Health and Care Excellence (NICE). Attention deficit hyperactivity disorder: diagnosis and management. 2019. www.nice.org.uk/guidance/ng87

8. Kessler RC, Adler L, Ames M, Demler O, Faraone S, Hiripi E, Howes MJ, Jin R, Secnik K, Spencer T, Ustun TB, Walters EE. The World Health Organization Adult ADHD Self-Report Scale (ASRS): a short screening scale for use in the general population. Psychol Med. 2005; 35(2):245-56. doi: 10.1017/s0033291704002892.
Show Less

Competing Interests: Drs Leaver, Parry and Cubbin are affiliated with the UK Adult ADHD Network (UKAAN). Dr Cubbin works in private practice in an ADHD clinic.