ACQUIRED AUTISM IN ADHD

Of late there has been some correspondence about the occurrence of co-morbid Autistic Spectrum Disorder (ASD), and Attention Deficit Hyperactivity Disorder (ADHD). After more than 40 years of treating these populations intensively, I can assert that there is a relationship between ASD and ADHD. In some cases, it is clearly a genetic overlap. However in many cases the "ASD" is acquired. This will be elucidated below.

There is the difference in the evaluation of a child with ASD and the later diagnosis of ADHD in contradistinction to the evaluation of a child with ADHD, and the findings of symptoms of ASD. If one looks one often finds. The ADHD symptoms may not be florid and may not meet the unhelpful criteria of DSM-V but the child with ASD has many signs, symptoms and characteristics of a child with ADHD.

A large number of children with ADHD manifest ASD-like symptoms, but do not really have an Autistic Spectrum Disorder. The additional diagnosis of ASD in these patients is harmful because it's incorrect.

Children with ADHD have a totally different set of brain operations than children without ADHD. They perceive, process, and express differently. The majority of these children are alienated from the popular group of children who coalesce together. What is happening here?

The popular crowd, which of course is a majority of individuals who see things the same way, cognate the same way and express the same way. Children with ADHD just think differently. They tend to have an extremely high speed nonlinear processor. They often blurt out answers before the teacher has completed, asking the question. They cannot explain how they do it. Simultaneously they have difficulty trying to think and learn and respond the way a teacher wants because it makes absolutely no sense to them. This can be observed in preschoolers (which, as a parent and grandparent I have had my share of experience with that population).

Often these children are derided, chastised and marginalized. They have absolutely no idea why this happens. They can be very smart little kids at five or six or seven but they are still very concrete, without insight and self-awareness. They feel defective and do not know why.  But by the middle of first grade, they are outsiders. This contributes mightily to low self-esteem, depression, and other psychosocial problems.

Ostrasizem from the crowd dramatically impacts the child's ability to socialize. Besides being teased and taunted and made fun of they are excluded in painful ways. They are not invited to events.  They are not picked for teams and clubs.  No one wants to partner up with them for projects.  Then someone diagnoses them with ASD, which is a useful excuse to many teachers and counselors. They appear to be autistic-ish or Asperger’s-ish.  They are not.

This is a sort of acquired anaclitic ASD. Children with ASD have difficulty picking up social cues and developing relationships. Children with ADHD who have been deprived of the opportunity to learn social skills, interpersonal interactions and the like appear to be ASD. Many of them will succeed nonetheless, but will have paid a  price along the way. Many others are permanently affected. They are socially awkward and uncomfortable.  They misread cues, or are not even aware of them. They expect to be ignored, teased or taunted. These are symptoms and characteristics of ASD but they are not biological.  They are acquired.

Beside the intrinsic issues identified above, the problem is magnified exponentially by the anti-ADHD people. There are a series of mistakes made. First is the failure to make the diagnosis, or to deny the diagnosis. Second is the refusal to treat. Third is maltreatment. The vast majority of patients that I have seen who have been diagnosed at some point in their lives and treated in someway have had suboptimal outcomes. If the patient and family are not educated thoroughly about ADHD; if proper, age-appropriate, cognitive, behavioral therapy is not applied; and if prudent psycho-pharmacotherapy is not initiated and monitored closely the results are not great.

Indeed there is an association between ASD and ADHD that has  a genetic/biological basis. Yet it is very important to diagnose correctly acquired "autism" in ADHD children and help them properly. Another label does not mean a better outcome.

A CONNECTION BETWEEN OCD & PANDAS/PANS

 New finding in the PANDAS/PANS spectrum.

This is a report of three interesting patients with post-infectious, Obsessive, Compulsive Disorder (OCD), anxiety, and depression. Curious diagnostic findings and a novel and new effective treatment implemented.

PANDAS/PANS is not a single distinct entity. Indeed, it is a post infectious neuropsychiatric syndrome with a myriad of presentations. There is not a single diagnostic test for every patient with symptoms and problems of a post infectious problem. This lack of a single entity with a single symptom cluster, and a single metabolic profile is a source of great annoyance to those in a profession who require absolutism and who abhor the need to stop and think about the complexities of this syndrome.

In the past three months, I and a colleague have encountered three cases of individuals with severe OCD  coupled with anxiety, panic, and various degrees of depression. Two of the individuals could recall that their symptoms occurred directly after a significant infection. One was severe colitis another a strep infection.  All had been treated with a panoply of SSRI’s and atypicals.  None had been treated with Anafranil or other tricyclics or a benzodiazepine.  Nor had they been evaluated for PANDAS.

At my direction all three patients had a comprehensive metabolic survey for evidence of acute or chronic infection, as well as the status of their immune systems. All three patients showed evidence of acute inflamation. In all three cases, the immunologic survey showed inconsistent results. In all three cases, there were significant abnormalities of the Pneumococcal. Subtypes, 23 valent. The precise significance of these markers have not been established. Nonetheless, each patient received a standard dose of Pneumovax 23.

Within 36 hours each patient, showed dramatic improvement. The patients were told ahead of time that the vaccine could affect their OCD and other symptoms. They were advised that there was a deficiency in their pneumonia antibodies and vaccination was advised. All accepted that.

Patients and family members were amazed that patient's circumstances had turned around. There was dramatic improvement in physical and emotional manifestations of their problems. Obsessions and compulsions diminished by greater than 90% in each case. Anxiety diminished similarly. The one patient with profound depression for several years suddenly was able to smile, laugh and enjoy life.

This data is important in many ways. It suggests that true medical/metabolic evaluation of psychiatric patients who have many different complaints is actually a proper baseline for care and treatment. It suggests that while there is no one thing that can be called PANDAS/PANS it is, nonetheless a reality.

Naysayers may say that this information is meaningless, not from a controlled study nor by sycophants from  various “experts” at centers of supposed self-proclaimed excellence. It is old-fashioned, clinical empiricism that happens when the doctors actually examine the patients, diagnose and treat them, without external rules about what they can and cannot think, say, or do.

This information is presented as it is, and without the  review of those who have no idea and/or no belief in what we write about.

                                                     Jory F Goodman, MD