Autisme: Mellem 59-83% af alle med Autisme, lider også af ADHD

Seneste videnskabelige evidens (Mayes et al., 2020) påviser, at mellem 59% og 83% af alle med Autisme, samtidigt også lider af ADHD. For tiden er Sundhedsstyrelsen ved at opdatere NKR for børn og unge med Autismespektrumlidelser, og af den senest offenligtgjorte høringsversion fremgår det, at ”SVAG ANBEFALING MOD: Førstevalget til behandling af irritabilitet, aggression og udadreagerende adfærd hos børn og unge med autisme er nonfarmakologiske pædagogiske og psykologiske tiltag.”. Dette er signifikant i modstrid til hvad seneste videnskabelige evidens netop har dokumenteret. I denne artikel forklarer jeg hvorfor, og forklarer ligeledes hvorfor medicinering af børn med Autisme bør være ligeså naturligt, som medicinering af børn med Diabetes i dag er.

Autisme kan (og bør) medicineres!

Som det fremgår af seneste høringsversion af NKR for børn og unge med Autismespektrumforstyrrelse fra Sundhedsstyrelsen, så er viden omkring mulig medicinering af Autisme her i Danmark, desværre signifikant forældet, og er præget af en (mis)forståelse af hvad Autisme er, gør og betyder – i virkeligheden.

Autisme er en gennemgribende udviklingsforstyrrelse. Dette medfører, at personen er grundlæggende dysfunktionel på de helt centrale perceptionelle, sensoriske og emotionelle funktioner, eller sagt med andre ord – Autismesymptomerne er langt mere fysiologiske end psykologiske i deres oprindelse.

En godt eksempel på en fysiologisk betinget lidelse er Blindhed. Her taler vi om, at noget i personens fysiologiske system ikke virker, hvilket medfører at personen dermed bliver blind. Diabetes er ligeledes en fysiologisk lidelse, hvor dysfunktionen medfører at kroppen ikke selv kan regulere personens blodsukker, uden at der tilføres insulin udefra.

Hverken en person med blindhed, diabetes, ADHD eller Autisme –KAN ikke udvise den ønskede adfærd, fordi vores krop er født dysfunktionel – det handler ikke om hvorvidt vi VIL udvise den ønskede adfærd … Det er som at påstå, at en der er blind, ikke kan se, fordi vedkommende simpelthen ikke selv VIL kunne se!

Ligesom vi allerede for snart 30 år siden (Barkley, 1997) lærte, så handler ADHD ikke om manglende evne til at udvise opmærksomhed, evnen til at kunne sidde stille, samt evnen til at tænke før man taler eller handler.

ADHD handler om manglende alderssvarende udvikling af Hæmningskontrollen (verbal og nonverbal adfærdsregulering), som dermed skaber en dysfunktionel Motorkontrol (verbal og nonverbal adfærd), da Hæmningskontrollen (som skal styre Motorkontrollen) er forsinket i sin udvikling, hvilket derved fører til den adfærd som kendetegner ADHD; Hyperaktivitet/impulsivitet og Uopmærksomhed.

Da Autisme er en gennemgribende (altså grundlæggende og omfangsrig) udviklingsforstyrrelse, og da nyeste forskning nu påviser, at 59-83% af alle med Autisme også lider af samtidig ADHD (der er en specifik udviklingsforstyrrelse), så er der videnskabelig konsensus for (og evidens på), at Autisme er en somatisk, fysiologisk lidelse (præcis som ADHD primært ligeledes er), og at man bør betragte Autisme og ADHD med samme forståelse, som man ville betragte og forstå – Diabetes – nemlig som en fysiologisk defekt der medfører psykologiske og adfærdsmæssige problemer, hvis den fysiologiske dysfunktion, ikke er medicinsk behandlet, og at denne lidelse kan og bør behandles med medicin der kan afhjælpe de symptomer som denne lidelse, Autisme, medfører.

Hvorfor skal man medicinere Autisme?

Svaret er egenligt såre simpelt:

At vi overhovedet overvejer hvorvidt medicinering af Autisme er nødvendigt eller ej, bygger udelukkende på den sociale/pædagogiske/psykologiske forståelsesramme som er fremherskende her i Danmark. Man anser den adfærd man oplever ved Autisme som værende “dysfunktionel adfærd” som bør rettes ved at tilføre ny viden, adfærdsregulering, samt pædagogisk støtte.

Forestil dig, at man brugte samme (mis)forståelse hvis dit barn havde Diabetes! Og forestil dig så, hvordan dette barns livskvalitet vil blive forringet og medfører yderligere sen-følger, fysiske såvel som psykiske? Vi ved i dag, at medicinsk ubehandlet ADHD (alene), medfører en 50% overdødelighed (Dalsgaard et al., 2015), 3x højere risiko for at lide en “unaturlig tidlig død” inden man fylder 46 år (Barkley, 2020), samt at ens forventede middellevetid er – 13 år kortere – (Barkley et al. 2019).

Autisme handler på ingen måde om at personen ikke VIL udvise den ønskede adfærd, det handler primært og grundlæggende om, at personen ikke KAN udvise den ønskede adfærd!

Derfor har det ingen blivende effekt eller værdi, at tilføje mere viden om ønsket adfærd (Pædagogik/Forældretræning), træne med repetitiv adfærdsregulering (ABA), eller forsøge at tale personen i stand til at udvise den ønskede adfærd (Psykoterapi, CBT).

Tankeeksperimentet

Prøv at gennemgå nedenstående tankeeksperiment, så vil du sikkert nok erkende, at visse problemer udelukkende kan løse ved at tilføre en konkret løsning.

Min idé er, at dette er en metafor for den (mis)forståelse som i dag præger den professionelle danske perception af hvad Autisme er, gør og betyder, og jeg forsøger her at illustrere, hvorfor denne perception af Autisme, bygger på en grundlæggende videnskabelig Fallacy (falsk sandhed), som medfører, at vi der lever med Autisme, ikke få adgang til den videnskabeligt anbefalede behandling: Medicin …

LAMPEN

Opgavebeskrivelse:

Forestil dig en lampe. Lampen har en pære, som er helt ny og som vi ved virker, når der bliver sat elektricitet til lampen. Lampen har en ledning, og denne ledning har et stik. Ledningen sidder fast i lampen, i den ene ende, og i den anden ende af ledningen, sidder der et stik. Stikket er sat i en stikkontakt. Lampen har ingen tænd og sluk knap.

Opgave:

Hvordan får du lys i lampen?

Løsning:

Man tænder for stikkontakten, så der kommer elektricitet til ledningen, som føres gennem ledning til lampen, der sender elektriciteten op til pæren og pæren begynder derefter at lyse.

Problemstilling:

Hvordan kommer der lys i pæren?

• For at få lys i pæren, kræves en energikilde: elektricitet

Hvordan kommer der elektricitet til lampen og dermed lys i pæren?

• Der kan kun komme lys i lampen, vis der tilføres en energi kilde der skaber den elektricitet der får pæren til at lyse.

Hvordan skaber man denne energi?

• Energien skabes ved at tilføre en energikilde der skaber den elektricitet, der er nødvendig for at pæren kan lyse.

Hvorfra kommer denne energikilde?

• Energikilden kan være et batteri eller et strømstik.

Hvad er resultatet af at aktivere energikilden?

• At der kommer strøm til lampen og pæren begynder at lyse

Er der nogle alternativer måder at få lys i pæren?

• Nej

Konklusion

Uanset hvor meget man forsøger at forklare lampen hvordan den bør kunne lyse, sætter den samme med andre lamper der lyser for at vise Lampen hvor fint alle de andre lamper kan lyse, bruger timevise dagligt på at træne hvordan man kommer til at lyse, eller bruger uendelige timer på at tale om hvordan lampen også kan kom til at lyse – hvis den virkeligt og oprigtigt blot ville … SÅ KOMMER DER SGU DA IKKE LYS I LAMPEN – FØR DER KOMMER STRØM TIL PÆREN, VEL?

Opfordring

Hvis du er enig i ovenstående konklusion, så burde du nu have fået den nødvendige viden til at du nu kan træffe en informeret beslutning om, hvorvidt du mener at man kan tale sig til at fjerne fysiologisk betingede symptomer, eller om man er nød til at tilføre “strøm” til behandlingen af Autisme, i form af medicin, for at afhjælpe disse fysiologisk betingede symptomer, særligt i forhold til sanserne, følelserne og ikke mindst – tankerne …

Hvis du ikke er enig, så er det din ret, jeg har ingen intention om at prædike eller påvirke din overbevisning – jeg påpeger blot, hvad videnskabelig evidens (helt blottet for holdninger, følelser og alternative agendaer) påviser, og tilbyder en måde for dig at udvide din forståelse og indsigt i Autisme. Valget er dit, ønsker du at have ret til at mene om Autisme hvad du nu vælger, eller er du i stand til at korrigere din (mis)forståelse og dermed forsøge at skabe et bedre liv for personer med Autisme?

/ADDspeaker

Videnskabelig evidens for ovenstående følger her …

Symptom scores and medication treatment patterns in children with ADHD versus autism

Mayes, S. D., Waxmonsky, J. G., Baweja, R., Mattison, R. E., Memon, H., Klein, M., … Waschbusch, D. (2020). Symptom Scores and Medication Treatment Patterns in Children with ADHD versus Autism. Psychiatry Research, 112937. doi:10.1016/j.psychres.2020.112937

Abstract

Most children with autism have ADHD, and children with ADHD-Combined and children with autism have high rates of irritable, oppositional, and aggressive behavior. Despite similar symptoms, prescribing practices may differ between autism and ADHD, which has not been examined in a single study. 1407 children with autism and 1036 with ADHD without autism, 2–17 years, were compared with 186 typical peers. Symptom scores were maternal Pediatric Behavior Scale ratings in eight areas (ADHD, oppositional/aggressive, irritable/angry, anxious, depressed, and social, writing, and learning problems). Psychotropics were prescribed to 38.0% with ADHD-Combined, 33.3% with autism, and 20.2% with ADHD-Inattentive, most often an ADHD medication (22.1% stimulant, 2.3% atomoxetine), antipsychotic (7.8%), SSRI (5.5%), and alpha agonist (4.9%). 

Key Points

• ADHD medications were more often prescribed than other medications in all diagnostic groups.
• Compared to autism, children with ADHD-Combined were more likely to be prescribed an ADHD medication, whereas antipsychotics and SSRIs were more likely to be prescribed in autism than in ADHD-Combined.
• Children with ADHD-Inattentive were least impaired and least likely to be medicated. More severely impaired children were more often medicated regardless of diagnosis.
• Symptom scores were far worse for treated and untreated children with ADHD and with autism than for typical peers.
• Studies show most children with autism have attention deficit hyperactivity disorder (ADHD).
• 59% to 83% of children with autism had ADHD and ADHD percentages were even higher in clinically referred children with autism.
• Children with ADHD-Combined presentation (ADHD-C) and autism both have high rates of irritable, oppositional, and aggressive behavior.
• In controlled trials of children with autism or ADHD, alpha agonists (clonidine or guanfacine) decreased ADHD symptoms, oppositional behavior, and irritability.
• In children with autism or ADHD, antipsychotics decreased ADHD symptoms, irritability, oppositional behavior, tantrums, aggression, self-injurious behavior, and anxiety.
• Children with ADHD-C and children with autism are at risk for comorbid ODD, aggression, irritability, and tantrums. In contrast, children with ADHD-I did not differ from typical controls in behavior problems, and they had significantly lower irritability/anger maternal ratings than children with autism or ADHD-C.
• Research also demonstrated that most children with autism have ADHD.
• Given the similarities in behavioral, mood, and ADHD symptoms in ADHD-C and autism (and differences from ADHD-I), it might be expected that medication classes prescribed to these children and the use of polypharmacy are similar for ADHD-C and autism and different for ADHD-I.
• Most previous studies relied on medical record reviews or parent report, which may not yield reliable diagnoses and may indicate an obvious diagnosis (e.g., ADHD) without considering additional possible diagnoses (e.g., autism). This is important because many children with autism are initially diagnosed with only ADHD (Miodovnik et al., 2015), and parent survey data show a high frequency of autism symptoms in children diagnosed with ADHD, suggesting that autism may have been missed in some cases.
• Children with autism were significantly more impaired on the irritable/angry, anxious, social problems, and poor writing subscales than children with ADHD-C, and children with ADHD-C were more impaired than children with ADHD-I on these measures.

As shown in Table 3, 69.2% of children with autism had severe ADHD symptoms (rated as often or very often a problem), but, as shown in Table 4, only 21.5% of children with autism were treated with an ADHD medication (3.2:1). 

Likewise, 87.6% of children with ADHD-C had severe ADHD symptoms, but only 33.0% of children with ADHD-C were treated with an ADHD medication (2.7:1). 

Analyzing inattention ratings only (excluding impulsivity and hyperactivity), 67.9% of children with ADHD-I had severe attention problems, but only 13.9% were treated with an ADHD medication (4.9:1).

• Prior studies showed that antipsychotics were more commonly prescribed in autism than stimulants. In our study, the reverse was true and children with autism were prescribed ADHD medications twice as often (22%) as antipsychotics (11%).
• Primary care providers may have appropriately treated the obvious ADHD symptoms without recognizing that the child also had autism.
• Results suggest that within the ADHD and autism samples, medication was generally prescribed based on symptom type and severity.
• Children with ADHD-C (who had more severe ADHD maternal ratings than children with autism) were more likely than children with autism to be treated with an ADHD medication, and children with autism (who had more severe irritability/anger/tantrums and anxiety than children with ADHD-C) were more likely to be treated with an antipsychotic or SSRI than children with ADHD-C
• Studies show that ADHD medications can improve academic performance, including seatwork productivity and accuracy, grades, and achievement test scores (Baweja et al., 2015). Despite this, children with ADHD-I in our study were least likely to be treated with an ADHD medication, even though they had greater learning problems than children with autism and a similar degree of learning problems as children with ADHD-C.
• Attention deficit (excluding impulsivity and hyperactivity) was rated as often to very often a problem by mothers for 68% of children with ADHD-I, yet only 14% were treated with an ADHD medication.
• This imbalance may indicate that medication is prescribed primarily to treat behavior problems and not attention deficit and associated learning problems.
• Attention problems may impede learning and classroom performance, but without impulsivity and hyperactivity, they may not be disruptive to others or classroom, home, and community environments, possibly explaining why attention problems may be tolerated and untreated.
• Interestingly, within the autism sample, ADHD, irritability/anger/tantrums, and anxiety were rated by mothers as more problematic than social problems.
• Several factors determine which children will and will not be treated with medication, aside from diagnoses and symptom scores. Especially important are parents’ attitudes regarding the use of medication (Waschbusch et al., 2011) and physicians’ attitudes.
• Multiple studies reviewed in the introduction show that, in children with ADHD and autism, ADHD medications and antipsychotics can both decrease ADHD symptoms, aggression, irritability, and behavior problems (symptoms common in both ADHD-C and autism), but that ADHD medications are most often prescribed for children with ADHD and antipsychotics for children with autism.
• Irritability is also common in autism (63% of children with autism in our study were rated by their mothers as often or very often irritable and angry), and a controlled trial showed that an SSRI can decrease irritability in children with autism.
• Children with ADHD-C were more likely than children with autism to be treated with an ADHD medication and children with autism were more likely than children with ADHD-C to be treated with an antipsychotic.
• Joshi et al. (2017) found that 76% of the children with autism in their study had ADHD, but were significantly less likely to receive medication and counseling for their ADHD than children with ADHD without autism.

Referencer

Barkley, R. A. (1997). Behavioral inhibition, sustained attention, and executive functions: Constructing a unifying theory of ADHD. Psychological Bulletin, 121(1), 65–94. https://doi.org/10.1037/0033-2909.121.1.65

Barkley, R. A., & Fischer, M. (2019). Hyperactive Child Syndrome and Estimated Life Expectancy at Young Adult Follow-Up: The Role of ADHD Persistence and Other Potential Predictors. Journal of attention disorders, 23(9), 907–923. https://doi.org/10.1177/1087054718816164

Dalsgaard, S., Østergaard, S. D., Leckman, J. F., Mortensen, P. B., & Pedersen, M. G. (2015). Mortality in children, adolescents, and adults with attention deficit hyperactivity disorder: a nationwide cohort study. Lancet (London, England), 385(9983), 2190–2196. https://doi.org/10.1016/S0140-6736(14)61684-6

Mayes, S. D., Waxmonsky, J. G., Baweja, R., Mattison, R. E., Memon, H., Klein, M., … Waschbusch, D. (2020). Symptom Scores and Medication Treatment Patterns in Children with ADHD versus Autism. Psychiatry Research, 112937. doi:10.1016/j.psychres.2020.112937