To Örebro University

Introduction: Individuals with ADHD are at higher risk of being bullied than individuals without ADHD 1,2,3 Over the past decades, there has been a shift from a categorical to a dimensional conceptualization of ADHD 4. It remains unknown if the association between ADHD and bullying also extends to non-clinical popula-tions.

Objectives: To assess if subclinical ADHD symptoms associates with bully victimization in childhood and adolescence.

Methods: 1557 non-clinical adults completed the 6-item Adult Self-Report Scale Screener (ASRS) and answered questions concerning bully victimization. ADHD and ASD diagnoses served as exclusion criteria. Prevalence rates of bully victimization (defined as bullied ≥twice monthly) were compared at different time periods between those with- and without a positive ASRS-screener (cut-off score ≥4/6) by chi-square tests. Moreover, logistic regression evaluated the association while adjusting for candidate covariates age and sex.

Results: Out of the total sample 1332 individuals (mean age=42, 60% female) scored negative and 217 individuals (mean age=36, 70% female) scored positive on the ASRS-screener while 8 had missing data on age or sex. Prevalence rates of bully victimization comparing those with- and without a positive score were as following; 20% vs 11%, p<.001 at 7-9 years, 26% vs 15%, p<.001 at 10-12 years, 20% vs 13%, p=.005 at 13-15 years and 6% vs 2%, p=.002 at 16-18 years. The statistically significant associations seen in the prevalence comparisons up until working life remained in thelogistic regression models.

Conclusions: More pronounced subclinical ADHD symptoms were associated with approximately twice as high prevalence of bully victimization in childhood and adolescence. Thus, ADHD characteristics appear to have serious consequences across the full clinical and non-clinical parts of the spectrum.

Autism spectrum disorder (ASD) and generalised joint hypermobility (GJH) share a number of clinical manifestations including proprioceptive impairment, motor difficulties, sensory hypersensitivity, and autonomic dysfunction. Clinical observations suggest that GJH is overrepresented in ASD. However, there are currently few systematic studies available. Knowledge about comorbidities may unfold common aetiopathological pathways underlying the association and improve the clinical management. The aim of this large, cross-sectional comparative study is to evaluate the relationship between ASD and GJH in adults. Data on joint hypermobility, symptoms associated with both hypermobility spectrum disorders (HSD) and hypermobile Ehlers-Danlos syndrome (hEDS), lifetime psychiatric diagnoses, psychiatric rating scales for ASD and attention deficit hyperactivity disorder (ADHD), and socio-demographics was collected for 199 individuals with ASD and 419 non-ASD community controls. Logistic regression models adjusting for covariates (age, sex, ethnicity) revealed a significant relationship between ASD and GJH and between ASD and symptomatic GJH, with adjusted odds ratios of 3.1 (95% CI: 1.9, 5.2; p < 0.001) and 4.9 (95% CI: 2.6, 9.0; p < 0.001), respectively. However, the high prevalence of comorbid ADHD in the study sample reduces the generalizability of the results among individuals with ASD without comorbid ADHD. Possibly, an additional ADHD phenotype is the primary driver of the association between ASD and GJH. Furthermore, GJH with additional self-reported symptoms, suggestive of HSD/hEDS, showed a stronger association with ASD than did non-specified GJH, indicating that symptomatic GJH plays a greater role in the relationship than non-specified GJH does. Therefore, the current study underscores the need of careful sample subclassifications. ASD with GJH may represent a novel subgroup of ASD in terms of aetiopathology and clinical presentation. Future research should elucidate the aetiological factors behind the association between ASD and GJH and evaluate how the comorbidity of GJH affects ASD outcomes.

Knowledge about comorbidities is important since they often can affect the diagnoses, treatment and outcome of a patient. Moreover, it may provide an insight to biological underpinnings contributing to the association. Generalised joint hypermobility (GJH) has recently been suggested to be a common, yet unrecognized, comorbidity amongst individuals with NDDs. In the present thesis we aimed to evaluate the relationships between GJH and ADHD and GJH and ASD across the full clinical and non-clinical spectra. Moreover, we aimed to make available a simple screening tool for GJH for Swedish speakers.

In study I we translated the five-part questionnaire on hypermobility (5PQ) into Swedish and tested psychometric properties in a non-clinical adult population (n=315). The Swedish 5PQ showed good psychometric properties in the general adult population with a sensitivity of 91%, a specificity of 75%, and an AUC of 0.87. Thus, it is a promising measure for GJH screening in adults. 

In studies II and III we measured GJH in large cohorts of adults with ADHD (n=431), ASD (n=199) and general population controls (n=419). We evaluated the associations between GJH and ADHD and GJH and ASD by using logistic regression models, while adjusting for age, sex and ethnicity. GJH was associated with ADHD and ASD with adjusted odds ratios of 4.7 and 3.1, respectively.

In study IV a large cohort of adults from the general population (n=887) completed a survey form comprising the 5PQ and questions regarding symptoms and traits of ADHD, ASD and motor impairment. Responses were compared between GJH and non-GJH individuals. We found that sub-syndromal neurodevelopmental symptoms were not affected by GJH. Thus, the association between GJH and NDDs appears to be limited to clinical populations. However, the hypothesis needs to be tested with a physical assessment of GJH before any firm conclusions can be drawn.

Introduction: There is growing evidence that generalised joint hypermobility (GJH) is associated with several psychiatric conditions. There are no previous studies on adult ADHD.

Objectives: To evaluate, in a large Swedish sample, if generalised joint hypermobility and adult ADHD are associated.

Methods: 431 adults with ADHD and 417 controls were included. GJH was assessed by the Beighton Score, a physical examination, and the 5PQ, a self-report screening tool. Exploratively, reported musculoskeletal symptoms and abnormal skin manifestations suggestive of symptomatic GJH (e.g. Ehlers-Danlos syndrome), were assessed to differentiate this group from the general GJH group. Logistic regressions determined the influence of an ADHD diagnosis and known covariates (age, sex and ethnicity) on GJH and symptomatic GJH respectively.

Results: ADHD was associated to GJH, as defined by the Beighton Score and the 5PQ, with adjusted odds ratios of 4.65 (CI 95% 3.01-7.18, p<.005) and 1.86 (CI 95% 1.39-2.48, p<.005), respectively. Likewise, ADHD and symptomatic GJH were associated withadjusted odds ratios of 6.94 (CI 95% 4.05-11.89, p<.005) and 2.66 (CI 95% 1.94-3.66, p<.005).

Conclusions: GJH and adult ADHD are associated conditions. Symptomatic GJH, defined as additional symptoms of pain and/or skin manifestations, has a considerably stronger link to adult ADHD than unspecific GJH has. GJH may represent a marker of an underlying systemic disorder with physical manifestations in connective tissue as well as behavioural manifestations including hyperactivity, impulsiveness and inattentiveness. Future studies should investigate if this represents a novel subtype of ADHD and if symptomatic GJH affects the ADHD management.

Growing evidence suggests an unexpected association between generalised joint hypermobility (GJH) and several psychiatric conditions, and a shared pathophysiology has been proposed. No previous studies on adult attention-deficit/hyperactivity disorder (ADHD) are available. This study aimed to evaluate the association between adult ADHD and GJH. A total of 431 adults with ADHD and 417 non-ADHD controls were included in this cross-sectional comparative study. GJH was assessed by physical examination following the Beighton scoring system (BSS). Furthermore, musculoskeletal symptoms and skin abnormalities were queried to create a proxy for symptomatic GJH (e.g., Hypermobility spectrum disorders and Ehlers-Danlos syndrome) to differentiate this from non-specified GJH defined by BSS only. Logistic regression examined the influence of ADHD and candidate covariates (age, sex, ethnicity) on GJH and symptomatic GJH, respectively. ADHD was significantly associated with GJH, as defined by the BSS, with adjusted odds ratios of 4.7 (95% confidence interval [CI] 3.0-7.2, p < .005). Likewise, ADHD was significantly associated with symptomatic GJH, as defined by the BSS and additional symptoms, with adjusted odds ratios of 6.9 (CI 95% 4.1-11.9, p < .005). Our results suggest that GJH may represent a marker for an underlying systemic disorder involving both connective tissue and the central nervous system. GJH with additional musculoskeletal symptoms and/or skin abnormalities has a considerable stronger link to adult ADHD than non-specified GJH has, and may need awareness in ADHD management. Future studies should investigate the mechanisms behind this association and how comorbid GJH affects ADHD outcome.

While no European country has legalized recreational use of cannabis, several countries, but not Sweden, have decriminalized it. Although we hitherto have a relatively low prevalence of users compared to other countries, Swedish policy is criticized. Strong voices advocate legalization. It is hypothesized that a legalization would minimize adolescent access, ensure quality control, make consumption safer and raise tax revenue. Furthermore, it is assumed to diminish the illicit drug market and drug related crimes. However, the legalization in the US and Canada has instead made cannabis more available to users by innovative marketing and product development, while the illegal market persists. Meanwhile the price of cannabis decreases and potency, which are related to many of the risks, increases. Cannabis-related harms include e.g. cognitive impairment, psychosis and psychosocial problems. The long-term effects from legalization is yet to be seen.

Background: Individuals with generalised joint hypermobility (GJH, present in 10–20% of the general population) are at increased risk of being diagnosed with a range of psychiatric and rheumatological conditions. It is unknown whether Paediatric acute-onset neuropsychiatric syndrome (PANS), characterised by childhood onset obsessive-compulsive disorder or restricted eating and typically associated with several comorbid neuropsychiatric symptoms, is associated with GJH. It is also unknown whether extensive psychiatric comorbidity is associated with GJH.

Method: This is a case-control study including 105 participants. We compared three groups: Individuals with PANS, individuals with other mental disorders and healthy controls. Joint mobility was assessed with the Beighton scoring system, psychiatric comorbidity with the M.I.N.I. or MINI-KID interview and symptoms of PANS with the PsychoNeuroInflammatory related Signs and Symptoms Inventory (PNISSI).

Results: Hypermobility was similar across groups, and high rates of psychiatric comorbidity was not associated with higher Beighton scores.

Conclusion: Although GJH is associated with several psychiatric conditions, such as ADHD and anxiety, this does not seem to be the case for PANS according to this preliminary study.

BACKGROUND: The conventional way to identify generalised joint hypermobility is by a physical examination according to the Beighton Score. However, a physical examination is time-consuming in clinical practise and may be unfeasible in population-based studies. The self-assessment five-part questionnaire on hypermobility (5PQ) offers a more practicable way to identify GJH. The aim of this study was to test validity and reliability of the five-part questionnaire on hypermobility (5PQ) translated into Swedish on a non-clinical adult population.

METHODS: A structured procedure was used for the translation of the 5PQ into Swedish. The Beighton Score was used as reference standard for generalised joint hypermobility. Test-retest reliability was tested in a separate group who filled in the questionnaire twice with a ten-week interval. Participants consisted of a convenience sample recruited in Stockholm, Sweden (2017).

RESULTS: A total of 328 participants were included in the study, 297 participants in the validity group and 31 participants in the reliability group. When evaluated against a present Beighton Score with an age-dependent cut-off, the Swedish 5PQ attained a sensitivity of 91%, a specificity of 75% and an area under the curve of 0.87. The Swedish 5PQ showed substantial to almost perfect test-retest reliability.

CONCLUSIONS: The Swedish 5PQ is a valid and reliable instrument to screen for or to identify generalised joint hypermobility.

BACKGROUND: Generalised joint hypermobility (GJH) is reportedly overrepresented among clinical cases of attention deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD) and developmental coordination disorder (DCD). It is unknown if these associations are dimensional and, therefore, also relevant among non-clinical populations.

AIMS: To investigate if GJH correlates with sub-syndromal neurodevelopmental symptoms in a normal population.

METHOD: Hakim-Grahame's 5-part questionnaire (5PQ) on GJH, neuropsychiatric screening scales measuring ADHD and ASD traits, and a DCD-related question concerning clumsiness were distributed to a non-clinical, adult, Swedish population (n=1039).

RESULTS: In total, 887 individuals met our entry criteria. We found no associations between GJH and sub-syndromal symptoms of ADHD, ASD or DCD.

CONCLUSIONS: Although GJH is overrepresented in clinical cases with neurodevelopmental disorders, such an association seems absent in a normal population. Thus, if GJH serves as a biomarker cutting across diagnostic boundaries, this association is presumably limited to clinical populations.