Autism should be approached as a chronic health condition, scientists recommend
Children and adults with autism spectrum disorder (ASD) have a variety of medical and psychiatric conditions and an increased use of health care services
Most medical and psychiatric conditions are significantly more prevalent in autism than in ADHD or healthy controls
In the most recent study on this problem a group of researchers analysed medical records of Kaiser Permanente Northern California members who were 14 to 25 years old. Individuals with ASD (n = 4123) were compared with peers with attention-deficit/hyperactivity disorder (n = 20 615), diabetes mellitus (n = 2156), and typical controls with neither condition (n = 20 615).
After controlling for sex, age, race, and duration of Kaiser Permanente Northern California membership, most psychiatric conditions were significantly more common in the ASD group than in each comparison group, and most medical conditions were significantly more common in the ASD group than in the attention-deficit/hyperactivity disorder and typical control groups, but were similar to or significantly less common than the diabetes mellitus group.
The most commonly reported medical conditions in ASD group included infections (42%), obesity (25%), neurologic conditions (18%), allergy and/or immunologic conditions (16%), musculoskeletal conditions (15%), and gastrointestinal (11%) conditions.
Based on their findings the authors conclude that although more research is needed to identify factors contributing to this excess burden of disease in autism, there is a pressing need for all clinicians to approach ASD as a chronic health condition requiring regular follow-up and routine screening and treatment of medical and psychiatric issues.
“…there is a pressing need for all clinicians, particularly general pediatricians and adult physicians, to approach ASD as a chronic health condition requiring regular follow-up and routine screening and treatment of medical and psychiatric issues, as is the standard of care for other chronic medical conditions.” (Davignon et al. 2018)
Early childhood health problems override genetics, can be used to spot children at high risk of autism
The findings from several recent studies provide further evidence of poor health being intrinsically linked to the emergence of autism in early life. A team of Swedish researchers investigated the role of environmental factors in the development of autism looked at the medical histories of monozygotic twins (MZ) where only one genetically identical sibling has symptoms and a diagnosis of autism.
The researchers found significantly higher rates of autism in siblings with a history of early medical events compared to their genetically identical siblings who were not exposed to such adverse events. These non-shared environmental factors included delivery and neonatal problems (e.g. foetal distress, hypoxia), minor and frequent infections (e.g. ear infections), allergy and epilepsy.
The authors therefore suggested that early medical adversity factors and infant dysregulation (excessive crying and worrying, feeding and sleeping problems) during the first year of life could be serve as early red flags for autism screening and detection.
Findings from several other large scale studies also point towards early childhood physical health issues being used to differentiate babies and toddlers who are at high risk of developing autism. Two of those studies that utilised large-scale longitudinal population data showed that early-life physical health issues could be used to differentiate babies and toddlers who are at high risk of developing autism and attention deficit and hyperactivity disorder (ADHD) later on (1, 2, 3, 4, 5, 6, 7, 8).
Relative to these results, a British study that utilized data from a large-scale longitudinal general population survey of children born in the year 2000 (i.e. the Millennium Cohort Study; MCS; n = 18 522) also concluded that pre-diagnostic data showed early health problems differentiated children later diagnosed with autism from non-diagnosed peers.
Allergies in babies and toddlers point to high autism risk
A large case-control study by Zerbo at al. noted that allergies and autoimmune diseases, especially psoriasis, are diagnosed significantly more often among children with autism than among controls.
The analysis of a large amount of health data held by the National Health Insurance Research Database (NHIRD) in Taiwan showed that toddlers who suffer from atopic dermatitis at less than three years of age are at a higher risk of developing autism and attention-deficit hyperactivity disorder during later childhood. The risk was even higher for those babies and toddlers who suffered asthma and allergic conjunctivitis alongside atopic eczema, and for those with early onset and severe atopic dermatitis.
In addition to providing an opportunity for early diagnosis and interventions, the observed increased risks of autism associated with conditions such as allergic dermatitis in infancy “suggest that a disordered immunologic response may exert effects on neurodevelopment and have implications for research into etiology and treatment strategies”.
Relationship between allergies, neurological functioning and behaviours in children has been indicated by smaller studies going back several decades. A recent follow up study from China confirmed earlier observations that symptoms in children can be improved with allergic rhinitis treatment. Both oral antihistamines, and topical steroid administration in children with allergic rhinitis lead to improved scores in inattentiveness, hyperactivity and impulsivity.
“In conclusion, our observations collectively suggest that immune factors measured at birth could provide early markers of aberrant neurodevelopmental changes associated with ASD.” (Krakowiak et al. 2017)
Davignon M.N., Qian Y., Massolo M., Lisa A. Croen (2018). Psychiatric and Medical Conditions in Transition-Aged Individuals With ASD. Pediatrics Apr, 141 (Supplement 4) S335-S345; doi: 10.1542/peds.2016-4300K.
Dillenburger K, Jordan JA, McKerr L, et al. (2015) The Millennium child with autism: early childhood trajectories for health, education and economic wellbeing. Dev Neurorehabil. Feb;18(1):37-46. doi: 10.3109/17518423.2014.964378.
Lee CY, Chen MH, Jeng MJ et al. (2016) Longitudinal association between early atopic dermatitis and subsequent attention-deficit or autistic disorder: A population-based case-control study. Medicine, 95 (39) doi: 10.1097/MD.0000000000005005.
Willfors C., Carlsson T., Anderlid B.M., et al. (2017) Medical history of discordant twins and environmental etiologies of autism. Transl Psychiatry. Jan 31;7(1):e1014. doi: 10.1038/tp.2016.269.
Yang MT, Chen CC, Lee WT, et al. (2016) Attention-deficit/hyperactivity disorder-related symptoms improved with allergic rhinitis treatment in children. Am J Rhinol Allergy. May;30(3):209-14. doi: 10.2500/ajra.2016.30.4301.
Barnevik Olsson M., Carlsson L.H., Westerlund J., et al. (2013) Autism before diagnosis: crying, feeding and sleeping problems in the first two years of life. Acta Paediatr. Jun;102(6):635-9. doi: 10.1111/apa.12229.
Billeci L., Tonacci A., Tartarisco G., et al. (2015) Association Between Atopic Dermatitis and Autism Spectrum Disorders: A Systematic Review. Am J Clin Dermatol. Oct;16(5):371-88. doi: 10.1007/s40257-015-0145-5.
Getahun D., Fassett M.J., Peltier M.R., et al. (2017) Association of Perinatal Risk Factors with Autism Spectrum Disorder. Am J Perinatol. Feb;34(3):295-304. doi: 10.1055/s-0036-1597624.
Hallmayer J., Cleveland S., Torres A., (2011) Genetic heritability and shared environmental factors among twin pairs with autism. Arch Gen Psychiatry. 2011 Nov;68(11):1095-102. doi: 10.1001/archgenpsychiatry.2011.76.
Jyonouchi H. (2015) Marked improvement of neuropsychiatric symptoms following control of allergy symptoms with the use of humanized murine anti-IgE antibody (omalizumab) in 2 patients with severely limited expressive language. Allergy, Asthma & Clinical Immunology. 11: 38. doi: 10.1186/s13223-015-0105-x.
Logan J.W., Dammann O., Allred E.N., et al. (2017) Early postnatal illness severity scores predict neurodevelopmental impairments at 10 years of age in children born extremely preterm. J Perinatol. Jan 12. doi: 10.1038/jp.2016.242.
Losh M., Esserman D., Anckarsäter H., (2012) Lower birth weight indicates higher risk of autistic traits in discordant twin pairs. Psychol Med. May;42(5):1091-102. doi: 10.1017/S0033291711002339.
Krakowiak P., Goines P.E., Tancredi D.J., et al. (2017) Neonatal Cytokine Profiles Associated With Autism Spectrum Disorder. Biol Psychiatry. Mar 1;81(5):442-451. doi: 10.1016/j.biopsych.2015.08.007.
Miller K.M., Xing G., & Walker C.K. (2017) Meconium exposure and autism risk. J Perinatol. Feb;37(2):203-207. doi: 10.1038/jp.2016.200.
Santos I.S., Matijasevich A., Capilheira M.F., et al. (2015) Excessive crying at 3 months of age and behavioural problems at 4 years age: a prospective cohort study. J Epidemiol Community Health. Jul;69(7):654-9. doi: 10.1136/jech-2014-204568.
Weber RJ, Gadow KD. (2016) Relation of Psychiatric Symptoms with Epilepsy, Asthma, and Allergy in Youth with ASD vs. Psychiatry Referrals. J Abnorm Child Psychol. Oct 11. doi: 10.1007/s10802-016-0212-2.
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