ASD Comorbities

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					Autism Spectrum
Disorders :
Presentations and
Co-morbidities in

Ronan Mullaney
Clinical Lecturer in Psychiatry, RCSI
   Historical famous peopleJane Austen, 1775-1817, English novelist, author of Pride and
    Prejudice Béla Bartók, 1881-1945, Hungarian composer Ludwig van Beethoven, 1770-
    1827, German/Viennese compose Alexander Graham Bell, 1847-1922,
    Scottish/Canadian/American inventor of the telephone Anton Bruckner, 1824-1896,
    Austrian composer Henry Cavendish, 1731-1810, English/French scientist, discovered the
    composition of air and water Emily Dickinson, 1830-1886, US poet Thomas Edison, 1847-
    1931, US inventor Albert Einstein, 1879-1955, German/American theoretical physicist
    Henry Ford, 1863-1947, US industrialist Kaspar Hauser, c1812-1833, German foundling,
    portrayed in a film by Werner Herzog Oliver Heaviside, 1850-1925, English physicist
    Thomas Jefferson, 1743-1826, US politician, Carl Jung, 1875-1961, Swiss
    psychoanalystFranz Kafka, 1883-1924, Czech writer Wasily Kandinsky, 1866-1944,
    Russian/French painterH P Lovecraft, 1890-1937, US writerLudwig II, 1845-1886, King of
    BavariaCharles Rennie Mackintosh, 1868-1928, Scottish architect and designer Gustav
    Mahler, 1860-1911, Czech/Austrian composerWolfgang Amadeus Mozart, 1756-1791,
    Austrian composerIsaac Newton, 1642-1727, English mathematician and physicistFriedrich
    Nietzsche, 1844-1900, German philosopherBertrand Russell, 1872-1970, British logician
    George Bernard Shaw, 1856-1950, Irish playwright, writer of Pygmalion , critic and
    SocialistRichard Strauss, 1864-1949, German composerNikola Tesla, 1856-1943,
    Serbian/American scientist, engineer, inventor of electric motorsHenry Thoreau, 1817-
    1862, US writerAlan Turing, 1912-1954, English mathematician, computer scientist and
    cryptographerMark Twain, 1835-1910, US humoristVincent Van Gogh, 1853-1890, Dutch
    painterLudwig Wittgenstein, 1889-1951, Viennese/English logician and philosopher
“Once you have seen one
 Autistic Child, you have
 seen one Autistic Child.”
 (L. Wing)
The Spectrum of Autistic
 Behaviourally defined developmental
  disorders of brain function
      1. Classical Autism
      2. Asperger Disorder
      3. Atypical Autism/PDD-NOS
      4. Childhood Disintegrative Disorder
      5. Rett Syndrome
The diagnostic umbrella -


       Behavioural Symptoms of ASD

 First described by Kanner (1943) and Asperger
 Triad of Symptom domains :

     1) Reciprocal Social Interaction

     2) Language and Communication

     3) Repetitive Behaviours and Circumscribed
    Diagnosis and Prevalence

 Apparent increase in overall prevalence of ASD
  4.1/10000 in 1966 ; 0.6% in 2005 (Fombonne,

 Increasingly recognised in adults

 Few specialist adult services for ASD and
  increasing demand on community general adult
       ASD Assessment
         IQ measures identify 2 groups :

  (1) ASP / HFA / PDD-NOS group with normal
              intellectual functioning

  (2) Autism / PDD-NOS with IQ of 70 and below

 ? Gold-standard tests (26+ different evaluations
  for ASD symptoms, 5 of these measures specific
  to identify Aspergers)
ASD Assessments
 26+ Assessment Instruments

 ADI-R = Autism Diagnosis Interview –
  Revised. A semi-structured interview with
  the caregiver

 ADOS = Autism Diagnosis Observation
  Schedule. A semi-structured play/interactive

 DISCO = Diagnostic Interview for Social and
  COmmunication disorders (Wing et al, 2002)
        Prevalence of ASD in General
        Psychiatry OPD
 Small number of studies suggest between 0.6% and
  1.4% in general psychiatry out-patient clinics for adults

 Measured using a Screening Instrument (Autism
  Quotient, Baron-Cohen et al. 2001)

 Screening Instruments may not be valid in other
  populations eg Holland, Japan - cut off points ?

 Not clear how well screening instruments can
  differentiate between other co-morbidities eg SCZ
       Diagnosis of ASD in Adults
 Lengthy assessments in clinic – at least 4 hours

 Gold Standard ? – Clinical Judgment and ADI-R
  and/or ADOS

 Use of assessment instruments requires specific
  training and expertise

 Most assessments are designed and validated
  with children in mind then converted to adult use
        Behavioural Genetics Clinic –
        SLaM NHS Trust
 Referral
 Pre-Assessment self and observer rating reports
 ADI-R +/- ADOS (preferably both)
 Psychiatric Interview with particular attention to :
     Developmental History;
     Current level of Psychosocial Functioning ;
     Symptoms suggestive of a Co-morbid mental
     health disorder
 Physical exam
 Consensus Clinical Opinion
Assessment Tools
 Autistic Spectrum Quotient (ASQ) : Self and Other
  (50 items – Likert scale, cut-0ff 32 points : 80%

 Social Responsiveness Scale (SRS) : Filled by
  parent/teacher – Likert scale – measure of ASD

 Obsessive-Compulsive Inventory – Revised (OCI-R)
  : 18 item self-report – Likert Scale – measures 6
  symptoms subtypes of OCD.

 Barkley Current and Past Behaviour Scales – Self
  and Other

 Hospital Anxiety and Depression Scale (HADS)
Treatment Recommendations
 May be a gap between
  recommendations and services available
 Mainstay for HFA and AS involves social
  and psychological interventions
 Vocational support may be available and
  is very worthwhile
 Management of comorbidities improves
  outcome and overall level of function
       ASD and Co-morbidities

 Focus on the core symptoms is necessary for
  diagnosis but may lead to overlooking co-morbid
  health problems (“diagnostic overshadowing”)

 Co-morbid conditions can exacerbate the core
  symptoms of ASD, further compromising social
  functioning, quality of life, and long-term
  outcome (Matson & Nebel-Schwalm 2006)
       Co-morbidity may reflect . . .

 Causality between the conditions
 Alternate forms of the same disorder
 Different manifestations of a single underlying
 Unique subgroups who happen to present with
  attributes of both disorders
        Co-morbidity in Adult ASD

 Difficult to evaluate in clinic

 Limited language, literal interpretations, concrete
  thinking, obsessionality, anxiety and intellectual
  disability may make assessment difficult

 Paucity of ASD specific instruments to measure
  psychopathology in this group
       Co-morbidity – Study
 Many ASD co-morbidity studies exist BUT these
  studies are variable :
 Different methodologies
 Different age ranges
 Different case selections
 Different diagnostic classifications
 Relatively small number of cases
 NO population based co-morbidity cohorts ie.
  Co-morbidity is derived from clinic samples

        Sverd J. : Journ Psych Pract , 2003
       Comorbidity in ASD - Medical

 Epilepsy (~30%)
 Sleep disorders
 Associated syndromic disorders eg Tuberous
  Sclerosis, Fragile X, Angelman Syndrome,
 Hearing and Visual Impairments
 Non-specific Gastro-intestinal symptoms
        Specific Psychopathological
        Co-morbidities in ASD
 ADHD (30-45 %)
 Intellectual Disability (30-80%)
 Depression (4-38%)
 Anxiety Disorders (11-76%)
 Obsessive-Compulsive Disorder (25-50 %)
 Schizophreniform Disorders (7-35%)
 Bipolar Affective Disorder (3-9%)
 Catatonia/Movement disorders (4.5-20%)
 Specific Reading/Writing difficulties
         Contrast between ASD-related
         symptoms and new-onset diagnoses

 Anxiety symptoms related to ASD
     Early onset of anxieties (continuous)
     Anxiety around change, simple phobias
     Rituals and compulsions that are part of interests
      and preoccupations

 New („co-morbid‟) disorder
     Meet DSM-IV criteria
     later onset or exacerbation of symptoms (episodic)
     impairment due to anxiety/mood symptoms
Co-morbidity - Diagnostic
 Formal issues in diagnostic classification
 DSM IV and ICD-10 preclude the co-
  morbid diagnosis of ASD and ADHD
 You cannot diagnose ASD and ADHD
 You cannot diagnose Schizotypal
  Personality Disorder or Simple
  Schizophrenia and Asperger syndrome.
Comorbidity in ASD follow-up
 Stahlberg et al (2004) : 129 ASD
 38% had co-morbid ADHD
 7% had BPAD Type 1
 7.8% had Schizophrenia or another
  psychotic illness
 Implies approximately 15% of ASD
  sample diagnosed with a psychotic
ASD follow-up studies (1)

 Mouridsen et al (2007) : 40 year follow-
  up of 89 adults diagnosed with Atypical
  Autism or PDD-NOS
 35% diagnosed with a Schizophrenia
  Spectrum disorder
 65% in contact with Adult Psychiatry
  Services for any reason
ASD follow-up Studies (2)

 Billstedt and Gillberg (2005) – 120 adults
  aged 18-40 were followed up for 13 -22
 Consistently poor psychosocial
  outcomes noted
 Numerous co-morbid diagnoses
          ASD and ADHD
 ASD is often characterised by hyperactivity, impulsivity
    and poor attention
   Recent studies : 31% of ASD met ADHD criteria (Leyfer
    et al., 2006) and 45% of PDD-NOS met ADHD criteria
    (de Bruin et al., 2007)
   ASD symptoms in children with ADHD exceed those in
    the general population (Reierson et al. 2007)
   Studies have shown specific attentional deficits in higher
    functioning ASD (Gillberg and Billstedt, 2000)
   Note ADHD : pragmatic language difficulties, TOM
   Different pattern of executive function deficits in each
    disorder when examined separately
Anxiety in ASD

 Common, very common
 Often unrecognised or underdiagnosed
  (Tsai et al., 2006)

 Social Anxiety disorder, Agoraphobia,
  Simple phobia, OCD
 Greater than community prevalence
        Anxiety disorders in ASD -
 Is this core to ASD ?
 ASD by definition may present with Repetitive
  Behaviours resembling those of OCD
 Unclear if different forces driving these
  behaviours in each condition
 Inability to describe thoughts interferes with the
  process of diagnosis
 25 % of HFA/Aspergers met ICD-10 OCD
  criteria (Russell et al, 2005)
ASD and OCD (1)
 Core symptom or Co-morbidity ? Restricted
  Repetitive Interests are core symptoms
 Obsessive-Compulsive symptoms also
  conceived of as being on a Spectrum
  (Hollander et al., 2006)
 Many ASD patients experience their
  symptoms as ego-syntonic and reasonable
  – Insight ?
 OCD traits seen in increased rates in first-
  degree relatives
 Higher rates of ASD traits in OCD patients
  (Ivarsson, 2008)
ASD and OCD (2)
 4/5 Symptom dimensions –
 1. Obsessions and Checking
 2. Symmetry and Ordering
 3. Cleanliness and Washing
 4. Hoarding
 Symptom dimensions more likely to involve
  symmetry/ordering/hoarding in ASD - ? ASD/OCD
  Subtype (Bejerot, 2007)
 What we know about ASD & Psychosis

Some shared common features ;

 Strange or bizarre behaviour
 Bullied at school, odd
 Cessation of promising studies
 Difficulties at work
 Limited social relationships
 Preoccupation with the internal world
 Anxiety
Psychoses in ASD
 Boundaries between Schizophrenia and
  Autism often unclear until 1970s (Kolvin, 1971)
  when differentiated by age of onset and
  development of language/cognition.

 Wide range of study findings : 7%-34%
  of ASD subjects reported to have
  Schizophrenia-spectrum disorder or
  Bipolar illness with psychotic features
  (Volkmar, 1991 ; Mouridsen, 2008)
        Depression in ASD (1)
 Wide variance in reported studies : 4 – 34 %

 Language difficulties – poor emotional

 Poor integration of non-verbal expression

 Neutral or limited range of facial and vocal
         Depression in ASD (2)
 Reliance on Third party reports due to limited self report

 Increased maladaptive behaviours

 Social withdrawal and poverty of speech may be
  interpreted as symptoms of core ASD rather than

 Mood is reported as low but worthlessness, guilt,
  diminished concentration and thoughts of suicide are
  less reported (Stewart et al, 2006)
        Depression in ASD (3)

 Risk factors : very limited literature.

 Note distress and anxiety with environmental

 Development of tailored assessment tools or
  modification of current diagnostic tools.
Independent living in ASD

 Intellectual functioning may be relatively
  well preserved which can mask failures
  in expected levels of adaptive
Future Directions
 Subtyping of ASD populations – pattern
  of core deficits, ADHD, OCD, Familial
  aggregation, Neuroimaging, Age specific

 Specific Assessment Instruments –
  designed for Adult ASD assessments eg
  Repetitive Behaviour Scale – Revised

 Specific Treatment Approaches (tailored
  to subtypes ?)
ASD and Movement Disorders

 Chronic Tics
 Stereotypies
 Tourettes Syndrome
 Catatonia
Catatonia in ASD
 Catatonia in ASD is a motor disorder
  characterised by Stereotypy, rigidity, mutism
  and posturing (Wing and Shah, 2000)
 Four features : (1) Increased slowness in
  movement and verbal response (2) Difficulty in
  action initiation and completion (3) Increased
  reliance on prompts (4) Increased
  passivity/decreased motivation
 In ASD many children have some features from
  early childhood
 Small minority develop more severe features in
  early adult life or adolescence (“Catatonia-like
  Autistic Regression”)
Catatonia in ASD (2)

 Rarely progress to full stupor and
  most make gradual improvement
 3 studies : 800 children, adolescents
  and young adults
 6 – 17 % had catatonia like
 Worsening symptoms associated with
 Is there a sub-group of ASD with
  Catatonia ? (Dhossche, 2004)
Tourettes Disorder and ASD
 TD : Chronic multiple motor and vocal tics with
    onset usually in childhood and with a
    fluctuating course
   Tics : Simple and Complex
   TD/ASD : Echolalia, Obsessive-compulsive
    symptoms, Stereotypies
   TD in ASD 6.5% in Baron-Cohen study (1999)
                                    11% of
    Canitano study (2007)
                20% in Burd Study (1987)
   Worldwide prevalence study (Freeman et al.,
    2000) showed 4.5% of ASD subjects had TD
Forensic issues -
    The literature relating to ASD and violent behaviour remains

    No firm conclusion regarding any association between ASD’s
     and violent behaviour. No evidence of higher rates of offending

    No evidence of a higher rate of offending amongst people with
     Asperger Syndrome. (Howlin, 1997)

    Ghaziuddin et al (1991) following literature review say that there
     is no clear conclusion that violence is common in Asperger’s
Personality Disorders in ASD
 Few specific studies – wide range of
  personality types but anecdotal evidence
  and case report suggest over
  representation of Schizoid and
  Obsessive-Compulsive Personality
 Increased difficulties in ASD/ADHD
  combined population – measured using
  Temperament and Character Inventory
  (Cloninger et al.)
 TCI – indicated “obsessional”, “passive-
  dependent” and “explosive”
  temperaments were highly prevalent
  (Soderstom et al., 2002)
Key points

 Considering ASD diagnosis . . . ? Comorbidity is
    very common
   Are there symptoms of ADHD ?
   Also consider Anxiety Disorders – Social phobia
    and OCD
   Also consider if there is a Mood Disorder
   Evaluate level of psychosocial function – Global
    functioning may be poor despite a superior level
    of intellectual function
       Co-morbidity in ASD – Key
       points reiterated
 Very Common – can be overlooked
 Common presentations may be Atypical in
  presentation – Core vs Co-morbid ?
 Informants but may be key in this population
  to recognise co-morbidity
 Consider Global assessment of Functioning
  which may be poor despite superior
  Intellectual Performance
End of Presentation

 The following slides give more
 information on Assessment
 Instruments for ASD and References
 for Co-morbidities
Autism Diagnostic Interview –
(ADI-R; Lord et al., 1994)
 Investigator-based interview
 Items cover social development, verbal and
  non-verbal communication and repetitive
  interests and behaviors; rated 0-3, higher
  scores for increasing degree of atypicality
 Current vs. lifetime ratings; diagnostic
  algorithm based on the latter
 Initially developed to distinguish qualitative
  impairments consistent with DSM-IV/ICD-10
  diagnosis of autism from intellectual
 Autism Diagnostic Interview –
 (ADI-R; Lord et al., 1994)
 Additional work with ADI-R measurement model
     Algorithms to distinguish autistic disorder from other ASD (Risi
      et al., 2006)
     Factor analyses to identify more empirically defined
      dimensions: social-communication, insistence on sameness,
      repetitive stereotyped motor behavior (Cuccaro et al., 2003;
      Georgiadis et al., 2007; Szatmari et al., 2006)
     ADI-R dimensions as quantitative traits
        Familiality – mainly          repetitive behavior domain (e.g.,
         Georgiadis et al., 2007)
        limited     success in genetic linkage studies (e.g., Liu et al.,
Autism Diagnostic Observation Scale (ADOS)
(Lord et al., 2000)
 Standardized activities and „presses‟ used to elicit
  communication, social interaction, imaginative play, and repetitive
 Four modules for differing language levels
      Module 1 = minimal or no language
      Module 2 = regular use of non-echoed 3-word phrases
      Module 3 = child with fluent language
      Module 4 = adolescent or adult with fluent language
 Diagnostic algorithm
      Module-specific
      Communication and social domain scores(subset of items that best
       discriminate autism/ASD from other DD), summed for overall score.
      Subscale scores for play and repetitive behavior domains not part of
       diagnostic algorithm.
Other ASD symptom rating scales
 Diagnostic Interview for Social and
  Communication Disorders (Wing et al., 2002)
     Investigator-based interview (2-4 hours)
     Good reliability and discriminant validity
     Autism and ASD criteria, lifespan perspective
 Gilliam Autism Rating Scale (Gilliam, 1995)
     Questionnaire (parent and teacher versions)
     Concerns re: reliability, sensitivity; heavily weighted to repetitive
      behaviors (South et al., 2002; LeCavalier, 2005)
 Others
Social Responsiveness Scale
(Constantino et al., 2000)
 Formerly „Social Reciprocity Scale‟, developed as a quantitative
   measure of social-communication symptoms in ASD (includes a few
   RRB items).
 Developed for 4-18 year olds; version for 3-year-olds (Pine et al.,
 Designed to measure ASD symptom expression in individuals with
   and without the diagnosis, views ASD as a continuous construct
       unrotated factor analysis identifies single factor in heterogeneous
 Can be completed in 15-20 minutes; correlates well with ADI-R
   (r=.80); parent and teacher reports also well-correlated (r=.72);
   potential for rapid quantitative assessment of ASD-related social
   impairment (Constantino et al., 2003; 2007)
 Stability over 2 time points 1-5 years apart (Constantino et al., 2009)
Social communication
 formerly ASQ (Berument et al., 1999)
 parent questionnaire, adaptation of ADI-R
 Screening criteria established in 4-40-year-
     Cut-off = 15: sensitivity=85%; specificity=75%
 Subsequently evaluated in 2-3-year-olds
     Poorer sensitivity and/or specificity (depending on cut-
      point) (Corsello et al., 2007)

 Mainly evaluated in referral samples
     Not community screening, but may have utility
      in other high-risk samples (e.g., screening for
References – General
 Matson, J. L., & Nebel-Schwalm, M. S. (2007).
  Comorbid psychopathology with autism spectrum
  disorder children: An overview. Research in
  Developmental Disabilities, 28, 341–352
 Jarbrink, K., McCrone, P., Fombonne, E., Zande´ n,
  H., & Knapp, M. (2007). Cost-impact of young adults
  with high- functioning autistic spectrum disorder.
  Research in Developmental Disabilities, 28, 94–104.
 Happe, F., Ronald, A., Plomin, R., (2006). Time to give
  up on a single definition for Autism. Nature
  Neuroscience, 10, 1218-1221.
 Woodbury-Smith & Volkmar. (2009). Asperger
  syndrome. Eur Child Adolesc Psychiatry, 18: 2-11
References - Epidemiology
 Williams JG, Higgins JP, Brayne CE. Systematic review
  of prevalence studies of autism spectrum disorders.
  Arch Dis Child 2006; 91: 8–15.
 Fombonne E. Epidemiological surveys of autism and
  other pervasive developmental disorders: an update. J
  Autism Dev Disord 2003; 33: 365–82
 Simon Baron-Cohen, Fiona J. Scott, Carrie Allison,
  Joanna Williams, Patrick Bolton, Fiona E. Matthews, and
  Carol Brayne. Prevalence of autism-spectrum
  conditions: UK school-based population study The
  British Journal of Psychiatry 2009 v. 194, p. 500-509
 Baird G, Simonoff E, Pickles A, Chandler S, Loucas T,
  Meldrum D, et al. Prevalence of disorders of the autism
  spectrum in a population cohort of children in South
  Thames: the Special Needs and Autism Project (SNAP).
  Lancet 2006; 368: 210–5
References – Core Symptoms

 Relationship Between Symptom
 Domains in Autism Spectrum
 Disorders: A Population Based Twin
 Study (2009). Katharina Dworzynski,
 Francesca Happe, Patrick Bolton,
 Angelica Ronald : J Autism Dev
 Disord. (epubl ahead of print).
References – ADHD/ASD
 A. Ronald, Emily Simonoff, Jonna
  Kuntsi, Philip Asherson and Robert
  Plomin (2008). Evidence for overlapping
  genetic influences on autistic and ADHD
  behaviours in a community twin sample.
  Journal of Child Psychology and
  Psychiatry 49:5, pp 535–542
 Mulligan A. et al (2009) Autism
  symptoms in Attention-
  Deficit/Hyperactivity Disorder: A Familial
  trait which Correlates with Conduct,
  Oppositional Defiant, Language and
  Motor Disorders. Journal of Autism Dev
  Disord 39: 197-209
       References – Anxiety in ASD
 Bonnie M. MacNeil, Vicki A. Lopes, Patricia
  M. Minnes (2009). Anxiety in children and
  adolescents with Autism Spectrum
  Disorders. Research in Autism Spectrum
  Disorders 3 : 1-21
 Bejerot, S. (2006) „Autism Spectrum
  Disorders, Autistic Traits and Personality
  Disorders in Obsessive Compulsive
  Disorder‟ in Ruthgross-Isseroff &
  Abrahamweizman (eds.) Obsessive
  Compulsive Disorder and Co-morbidity. Nova
  Science Publishers, New York
         References – ASD and OCD
 Delorme R., Gousse V., Roy I. et al. (2007) Shared
  executive dysfunctions in unaffected relatives of patients
  with autism and obsessive-compulsive disorder.
  European Psychiatry; 22 : 32-38
 Russell A., Mataix-Cols D., Anson M., (2005) Obsessions
  and compulsions in Asperger syndrome and high-
  functioning autism and high-functioning autism. BJP; 186
  : 525 -528
 Bejerot, S. (2006) „Autism Spectrum Disorders, Autistic
  Traits and Personality Disorders in Obsessive
  Compulsive Disorder‟,in RUTHGROSS-ISSEROFF &
  ABRAHAMWEIZMAN(eds) Obsessive Compulsive
  Disorder and Comorbidity. Nova Science Publishers,New
       References – Depression in
 Lainhart Jen (1999) : Psychiatric problems in
  individuals with autism, their parents and
  siblings. International Review of Psychiatry
  1999, 11:278-298
 Stewart, ME, Barnard L, Pearson J, Hasan R,
  O'Brien G (2006) : Presentation of depression
  in autism and Asperger syndrome: a review.
  Autism, 10 : 103-116
           References – Psychosis and
 Konstantareas MM, Hewitt T. Autistic disorder and
    schizophrenia: diagnostic overlaps. J Autism Dev Disord 2001;
    31: 19–28
   Stahlberg O, Soderstrom H, Rastam M, Gillberg C. Bipolar
    disorder, schizophrenia, and other psychotic disorders in
    adults with childhood onset AD/HD and/or autism spectrum
    disorders. J Neural Transm 2004; 111: 891–902
   Volkmar FR, Cohen DJ. Comorbid association of autism and
    schizophrenia. Am J Psychiatry 1991; 148: 1705–7
   Blackshaw AJ, Kinderman P, Hare DJ, Hatton C. Theory of
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   Nylander L: Autism spectrum disorders and schizophrenia
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    and some suggestions for future clinical research. Clinical
    Neuropsychiatry 2008, 5:43-54
          References - Movement
          Disorders in ASD
 Wing L, Shah A. Catatonia in autistic spectrum disorders.
    Br J Psychiatry. 2000;176:357Y362.56.
   Ghaziuddin N. Catatonia in autism: a distinct subtype? J
    Intellect Disabil Res. 2005;49:102Y105.
   Fink M, Taylor M, Ghaziuddin N. Catatonia in autistic
    spectrum disorders: a medical treatment algorithm. Int
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   Catatonia in autism: implications across the life span.
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    Issue 6, 2008, First Page 327 Kakooza-Mwesige,
    Angelina; Wachtel, Lee E.; Dhossche, Dirk M.
   Canitano R., and Vivanti G. Tics and Tourette syndrome
    in autism spectrum disorders. Autism: 11; 19-28
       References – Personality in
 Soderstrom H, Rastam M, Gillberg C (2002):
  Temperament and character in adults with
  Asperger syndrome. Autism, 6:287-297
 Tantum D (2000) : Psychological Disorder in
  Adolescents and Adults with Asperger
  Syndrome. Autism 2000, 4:47-62
 Anckarsater et al (2006): The Impact of ADHD
  and Autism Spectrum Disorders on
  Temperament, Character and Personality
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