Friday, January 20, 2017

Restricted, Repetitive Patterns of Behavior (RRBs) and Comorbid Symptoms in Children on the Autism Spectrum

Children with autism spectrum disorder (ASD) frequently have co-occurring (comorbid) psychiatric symptoms, with rates significantly higher than would be expected from the general population. Research indicates that the most common co-occurring diagnoses are anxiety and depression, attention problems, and disruptive behavior disorders. Previous studies also suggest that restricted, repetitive patterns of behavior, interests, or activities (RRBs) are associated with the symptoms of co-occurring psychiatric conditions in individuals with ASD. 

The criteria for the new DSM-5 category of Autism Spectrum Disorder (ASD) continue to include RRBs as a core diagnostic feature, together with the domain of social communication and social interaction deficits. According to the DSM-5, restricted, repetitive patterns of behavior, interests, or activities are defined by the presence of at least two of the following:
  • Stereotyped or repetitive speech, motor movements, or use of objects; (such as simple motor stereotypies, echolalia, repetitive use of objects, or idiosyncratic phrases).
  • Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change; (such as motoric rituals, insistence on same route or food, repetitive questioning or extreme distress at small changes).
  • Highly restricted, fixated interests that are abnormal in intensity or focus; (such as strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).
  • Hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment; (such as apparent indifference to pain/heat/cold, adverse response to specific sounds or textures, excessive smelling or touching of objects, fascination with lights or spinning objects.
RRBs have been shown to cause significant challenges for both the individual with ASD and his or her family. Likewise, they can impede learning and socialization by decreasing the likelihood of positive interactions with peers and adults. Parents of individuals with ASD also report that RRBs are one of the most challenging features of ASD due to their significant interference with daily life. In contrast with the core domain of social/communication deficits, RRBs have only recently been the focus of systematic research efforts.
Stratis and Lecavalier (2013) investigated the relationship between RRBs and co-occurring depressive, anxiety, attention-deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) symptoms, while considering level of functioning. Participants in the study were 72 parents of children and youth diagnosed with ASD (ages 5–17). Children’s co-occurring diagnoses included: Attention-Deficit/Hyperactivity Disorder (ADHD), Anxiety Disorders, Mood Disorders, Behavioral Disorders, and Intellectual Disability. Frequency and severity of RRBs were assessed across five domains: Stereotypic Behavior, Self-Injurious Behavior (SIB), Compulsive Behavior, Ritualistic/Sameness Behavior, and Restricted Interests. Ratings by parents were used to quantify co-occurring symptom severity for each of the following four domains: ADHD, ODD, anxiety disorders and depressive disorders. Data analyses were completed to determine which RRBs were most predictive of co-occurring symptom severity.
Children with high levels of ritualistic and sameness behavior tended to show more severe symptoms of anxiety and depression. This appears consistent with the high co-occurrence of depressive and anxiety symptoms in the general population. This finding also suggests that ritualistic and sameness behaviors may be implicated in the development and maintenance of anxiety in individuals with ASD. Interestingly, high levels of restricted interests were associated with less severe symptoms of depression, suggesting that restricted interests may be a protective factor against the development of depression. Although restricted interests frequently have a negative impact on interpersonal relationships, they might also have a positive effect by providing a feeling of self-validation and a means of occupying one’s time, while also serving as an incentive to increase knowledge. 
Inconsistent with previous research, all psychiatric symptom domains appeared unrelated to children’s level of functioning. However, level of functioning moderated the relationship of SIB and depressive and anxiety symptoms. For higher functioning children and youth, elevated levels of SIB were predictive of more severe depressive and anxiety symptoms whereas higher levels of SIB were predictive of less severe depressive and anxiety symptoms for lower functioning individuals. For lower functioning individuals, high levels of ritualistic and sameness behaviors predicted more severe depressive symptoms while there was no significant relationship for higher functioning individuals.
The results of this study may help clarify the presentation of ASD phenotypes, suggesting that different types of RRBs may be predictive of co-occurring psychiatric disorders. This has implications for genetic and neurobiological research. For example, differences underlying genetic and neurobiological factors may be identified based on symptom presentation, including RRBs and co-occurring psychiatric symptoms. Moreover, if RRBs and psychiatric symptoms do share common etiologies, interventions for psychiatric symptoms may help ameliorate RRBs in individuals with ASD. The possibility that RRBs such ritualistic and sameness behaviors may be involved in development and maintenance of anxiety or that restricted interests protect against the development of depressive symptoms has significant implications for treatment and should be explored in future research. Given that RRBs continue to be a core feature of ASD in DSM-5, clinicians and practitioners should give increased attention to the assessment and presence of RRBs and their impact on common co-occurring disorders and psychological well-being of individuals with ASD.
Stratis, E. A., & Lecavalier, L. (2013).  Restricted and repetitive behaviors and psychiatric symptoms in youth with autism spectrum disorders. Research in Autism Spectrum Disorders, 7, 757–766.

Monday, January 2, 2017

Mothers of Children on the Autism Spectrum Experience High Levels of Fatigue and Mental Distress

Studies indicate that the demands placed on parents caring for a child with autism contribute to a higher overall incidence of parental stress, depression, and anxiety and adversely affects family functioning and marital relationships compared with parents of children with other intellectual, developmental, or physical disabilities. Mothers of children with ASD, in particular, appear to face unique challenges that potentially have an impact on their health and wellbeing.

Parents of children with an autism spectrum disorder (ASD) are increasingly involved in the provision of early intervention and learning activities to promote positive outcomes for their children. However, several studies have documented that parental stress as well as a lack of time and energy are barriers to providing early intervention activities. Because autism impairs social relatedness and adaptive functioning, parent stress can decrease helpful psychological processes and directly influence the parent or caregiver’s ability to support the child with disabilities. Consequently, understanding factors, such as lack of energy or fatigue that may limit the capacity of the parent to assist in promoting their child’s development is critical.

A study published in the journal Autism examined the extent to which parents experience fatigue and its relationship to other aspects of wellbeing and parenting. Fifty mothers of children ages 2-5 years with ASD participated in the study and completed questionnaires assessing level of fatigue, parenting self-efficacy (belief about the ability to parent successfully), children’s behavioral and emotional problems, sleep quality, parent support needs, and overall physical activity. The study found that compared with mothers of typically developing children, mothers of children with ASD reported significantly higher fatigue, with overall scores in the moderate range. Factors associated with high levels of fatigue were poor maternal sleep quality, a high need for social support and poor quality of physical activity. Fatigue was also significantly related to other aspects of wellbeing, including stress, anxiety and depression, and lower parenting efficacy and satisfaction.

These findings were somewhat expected given the additional caregiving demands, parenting challenges and pressures of managing family life when raising a child with an ASD. Likewise, It is also probable that symptoms of depression, anxiety, stress and worry (body tension, increased heart rate and rumination) can be mentally taxing and contribute to, or exacerbate fatigue. The researchers also note that it was not surprising that poor sleep quality was associated with higher levels of fatigue given the large amount of research indicating that inadequate sleep and poor sleep quality is associated with a range of physical health and wellbeing difficulties. Parents of children with ASD are at particular risk of sleep disruption and poor sleep quality owing to the high rate of sleep problems in their children. Parents reported that their child waking was the primary reason for sleep disruption. For other parents in the study, stress, anxiety and not being able to wind down were stated reasons for sleep disruption.


What are the implications of this study? The findings clearly indicate the need for interventions to specifically target parental fatigue and its impact on families affected by ASD both in the present and longer term. In addition to interventions targeting child sleep problems, parents are likely to benefit from psycho-education about fatigue and its potential effects on wellbeing, parenting and caregiving. This includes information about strategies to minimize and/or cope with the effects of sleep disruption, increase health and self-care behaviors, and strengthen opportunities for social support. It is well established that social support is protective of optimal parent wellbeing and, therefore, is an important component of any intervention to address fatigue and wellbeing of parents of children with an ASD. Parents with limited assistance to share the daily demands of caregiving and family life are likely to be at greater risk of fatigue than parents with more support. For parents with limited support, there might also be fewer opportunities to engage in self-care behaviors that are likely to alleviate or protect them from fatigue.

From a clinical perspective, professionals working with families of children with an ASD should be aware of negative effects of fatigue in addition to other wellbeing difficulties, such as stress and anxiety. An assessment of the presence and severity of the physical, cognitive and emotional symptoms of fatigue, as well as the perceived impact on daily functioning, mood, relationships, parenting and other aspects of caregiving is important. Lastly, future work in this area should involve the development and evaluation of information resources and intervention approaches to assist parents of children with an ASD to manage fatigue and promote their overall wellbeing. The longer-term benefits for parents in terms of strengthening their overall health, wellbeing and parenting should also be a focus of research.

Giallo, R., Wood, C. E., Jellett, R., & Porter, R. (2013). Fatigue, wellbeing and parental self-efficacy in mothers of children with an Autism Spectrum Disorder. Autism, 17, 465-480. DOI: 10.1177/1362361311416830

Lee A. Wilkinson, PhD, CCBT, NCSP is author of the award-winning book, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools, published by Jessica Kingsley Publishers. He is also editor of a text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools and author of the book, Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

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