Anxiety and Depression in Autism

Comorbidity in Autism Spectrum Disorder

There is robust research to suggest that 70 to 80 percent of children with autism spectrum disorder (ASD) meet diagnostic criteria for one or more co-occurring (comorbid) disorders and 40 to 50 percent meet criteria for two or more. A Comorbid disorder is defined as a condition that co-occurs with another diagnosis so that both share a primary focus of clinical and educational attention. The most prevalent comorbid conditions are anxiety, depression, attention-deficit/hyperactivity disorder (ADHD), disruptive behavior problems, and chronic tic disorders, all which contribute to overall impairment.

  

 Internalizing Problems

Studies have consistently reported an association between ASD and internalizing symptoms, in particular, anxiety and depression. A bidirectional association has been identified between internalizing disorders and autistic symptoms. For example, both a higher prevalence of anxiety disorders has been found in ASD and a higher rate of autistic traits has been reported in youth with mood and anxiety disorders. Although prevalence rates vary from 11% to 84%, most studies indicate that approximately one-half of children with ASD meet criteria for at least one anxiety disorder. Individuals with ASD also display more social anxiety symptoms compared to typical individuals, even if these symptoms were clinically overlapping with the characteristic social problems of ASD. In addition, there is some evidence to suggest that adolescents and young adults with ASD show a higher prevalence of bipolar disorders as compared to controls.

Depression is one of the most common comorbid conditions observed in individuals with ASD, particularly higher functioning youth. A study of psychiatric comorbidity in young adults with ASD revealed that 70% had experienced at least one episode of major depression and 50% reported recurrent major depression. Although another documented association is with obsessive-compulsive disorder (OCD), it is difficult to determine whether observed obsessive-repetitive behaviors are an expression of a separate, comorbid OCD, or an integral part of the core diagnostic features of ASD (i. e., restricted, repetitive patterns of behavior, interests, or activities).

Externalizing Problems

An association between ASD and attention-deficit/hyperactivity disorder (ADHD) and other externalizing problems (i. e., oppositional defiant disorder) have been reported. Studies have found that children with ASD in clinical settings present with co-occurring symptoms of ADHD with rates ranging between 37% and 85%. Although there continues to a debate about ADHD comorbidity in ASD, research, practice and theoretical models suggest that co-occurrence between these conditions is relevant and occurs frequently. For example, case studies suggest that ADHD is a relatively common initial diagnosis in young children with ASD. It is also important to note that a significant change in the DSM-5 is removal of the DSM-IV-TR hierarchical rules prohibiting the concurrent diagnosis of ASD and ADHD. When the criteria are met for both disorders, both diagnoses are given.

Other Comorbidities

Tourette Syndrome (TS) and other tic disorders have been found to be a comorbid condition in many children with ASD. A Swedish study showed that 20% of all school-age children with ASD met the full criteria for TS. There also appears to be a higher incidence of seizures in children with autism compared to the general population. The comorbidity of ASD and psychotic disorders has received some research attention. A study of children with ASD who were referred for psychotic behavior and given a diagnosis of schizophrenia showed that when psychotic behaviors were the presenting symptoms, depression and not schizophrenia, was the likely diagnosis. Thus, individuals with ASD may present with characteristics that could lead to a misdiagnosis of schizophrenia and other psychotic disorders. Other co-occurring conditions include physical (cerebral palsy, atypical gait), and medical (allergies, asthma, gastrointestinal) conditions. Behavior problems associated with GI distress may include sleep disturbances, stereotypic or repetitive behaviors, self-injurious behaviors, aggression, oppositional behavior, irritability or mood disturbances, and tantrums. In addition, unusual responses to sensory stimuli, chronic sleep problems, catatonia, and low muscle tone often occur in individuals with ASD. Specific learning difficulties are also common, as is developmental coordination disorder. 

Implications

Many individuals with ASD have symptoms that do not form part of the diagnostic criteria for the disorder (about 70% of individuals with ASD may have one comorbid disorder, and 40% may have two or more comorbid conditions). The most common co-occurring diagnoses are anxiety and depression, attention problems, and challenging behavior disorders. When the criteria for a comorbid disorder is met, both diagnoses should be given. Medical conditions commonly associated with ASD should also be noted.

The core symptoms of ASD can often mask the symptoms of a comorbid condition. The challenge for practitioners is to determine if the symptoms observed in ASD are part of the same dimension (i. e, the autism spectrum) or whether they represent another condition. Although various psychometric instruments, such as clinical interviews, self-report questionnaires and checklists, are widely used to assist in diagnosis, these tools are designed and standardized to identify symptoms in the general population, and may not be appropriate and valid for use with ASD. Likewise, their administration may be problematic in that individuals with ASD may have difficulties in sustaining a reciprocal conversation, reporting events, and perspective taking. Nevertheless, comorbid problems should be assessed whenever significant behavioral issues (e.g., inattention, impulsivity, mood instability, anxiety, sleep disturbance, aggression) become evident or when major changes in behavior are reported. Individuals who are nonverbal or have language deficits, observable symptoms such as changes in sleeping or eating or increases in challenging behavior should be evaluated for anxiety and depression. Co-occurring conditions should also be carefully investigated when severe or worsening symptoms are present that are not responding to intervention or treatment.

Further information on best practice guidelines for assessment and intervention is available from A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

References and Further Reading

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.) Washington, DC: Author.

Colombi, C., &  Ghaziuddin, M. (2017). Neuropsychological Characteristics of Children with Mixed Autism and ADHD. Autism Research and Treatment, 2017, 1-5. doi:10.1155/2017/5781781

Doepke, K. J., Banks, B. M., Mays, J. F., Toby, L. M., & Landau, S. (2014). Co-occurring emotional and behavior problems in children with Autism Spectrum Disorders. In L. Wilkinson (Ed.), Autism Spectrum Disorders in Children and Adolescence: Evidence-based Assessment and Intervention in Schools (pp. 125-148). Washington, DC: American Psychological Association.

Duerden, E. G., Oatley, H. K., Mak-Fan, K. M., McGrath, P. A., Taylor, M. J., Szatmari, P., & Roberts, S. W. (2012). Risk factors associated with self-injurious behaviors in children and adolescents with autism spectrum disorders. Journal of Autism and Developmental Disorders, 42:2460–2470. DOI 10.1007/s10803-012-1497-9

Leyfer, O.T., Folstein, S.E., Bacalman, S. et al. (2006). Comorbid psychiatric disorders in children with autism: Interview development and rates of disorders. J Autism Dev Disord, 36, 849–861. https://doi.org/10.1007/s10803-006-0123-0

Maenner, M. J., Arneson, C. L., Levy, S. E., Kirby, R. S., Nicholas, J. S., & Durkin, M. S. (2012). Brief report: Association between behavioral features and gastrointestinal problems among children with autism spectrum disorder. J Autism Dev Disord 42:1520–1525. DOI 10.1007/s10803-011-1379-6

Mayes, S. D., Calhoun, S. L., Murray, M. J., & Zahid, J. (2011). Variables associated with anxiety and depression in children with autism. Journal of Developmental and Physical Disabilities, 23, 325–337.

Mazurek, M. O., Vasa, R. A., Kalb, L. G., Kanne, S. M., Rosenberg, D., Keefer, A., et al. (2013). Anxiety, sensory over-responsivity, and gastrointestinal problems in children with autism spectrum disorders. Journal of Abnormal Child Psychology, 41, 165–176.

Mazurek, M. O., Kanne, S. M., & Wodka, E. L. (2013).  Physical aggression in children and adolescents with autism spectrum disorders. Research in Autism Spectrum Disorders, 7, 455–465.

Mazzone et al.: Psychiatric comorbidities in asperger syndrome and high functioning autism: diagnostic challenges. Annals of General Psychiatry 2012 11:16. doi:10.1186/1744-859X-11-16

Sikora, D. M., Vora, P., Coury, D. L., & Rosenberg, D. (2012). Attention-Deficit/Hyperactivity Disorder Symptoms, Adaptive Functioning, and Quality of Life in Children With Autism Spectrum Disorder. Pediatrics, 130, S91-97. DOI: 10.1542/peds.2012-0900G

Simonoff E., Pickles A., Charman T., Chandler S., Loucas T., Baird G. (2008). Psychiatric disorders in children with autism spectrum disorders: Prevalence, comorbidity, and associated factors in a population-derived sample. Journal of the American Academy of Child and Adolescent Psychiatry, 47, 921-929. https://doi.org/10.1097/CHI.0b013e318179964f

Strang, J. F., Kenworthy, L., Daniolos, P., Case, L., Wills, M. C., Martin, A., et al. (2012). Depression and anxiety symptoms in children and adolescents with autism spectrum disorders without intellectual disability. Research in Autism Spectrum Disorders, 6(1), 406–412.

Tureck, K., Matson, J. L., May, A., Whiting, S. E., & Davis, T. E., III. (2013). Comorbid symptoms in children with anxiety disorders compared to children with autism spectrum disorders. Journal of Developmental and Physical Disabilities. doi: 10.1007/s10882-013

Weiss, J. A., Jason K. Baker, J. K., & Butter, E. M. (2016, September). Mental health treatment for people with autism spectrum disorder (ASD). Spotlight on Disability Newsletter. 

Wilkinson, L. A. (2015). Overcoming anxiety on the autism spectrum: A self-help guide using CBT. London and Philadelphia: Jessica Kingsley Publishers.

Wilkinson, L. A. (2017).  A best practice guide to assessment and intervention for autism spectrum disorder in schools (2nd ed.). London & Philadelphia : Jessica Kingsley Publishers.

Lee A. Wilkinson, PhD, is a licensed and nationally certified school psychologist, and certified cognitive-behavioral therapist. He is author of the award-winning books, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT. He is also editor of a text in the American Psychological Association (APA) School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Multi-Tiered Screening for Autism in Schools

A Multi-Tiered Approach to Screening for Autism in Schools

There has been a worldwide increase in the prevalence of autism over the past decade. Yet, compared to population estimates, identification rates have not kept pace in our schools. It is not unusual for children with less severe symptoms of autism spectrum disorder (ASD) to go unidentified until well after entering school. As a result, it is critical that school-based support personnel (e.g., school psychologists, special educators, school counselors, speech/language pathologists, and social workers) give greater priority to case finding and screening to ensure that children with ASD are identified and have access to the appropriate programs and services. 

 Screening and Identification

Until recently, there were few validated screening measures available to assist school professionals in the identification of students with the core ASD-related behaviors. However, our knowledge base is expanding rapidly and we now have reliable and valid tools to screen and evaluate children more efficiently and with greater accuracy. The following tools have demonstrated utility in screening for ASD in educational settings and can be used to determine which children are likely to require further assessment and/or who might benefit from additional support. All measures have sound psychometric properties, are appropriate for school-age children, and time efficient (10 to 20 minutes to complete). Training needs are minimal and require little or no professional instruction to complete. However, interpretation of results requires familiarity with ASD and experience in administering, scoring, and interpreting psychological tests.

The Autism Spectrum Rating Scales (ASRS; Goldstein & Naglieri, 2009) is a norm-referenced tool designed to effectively identify symptoms, behaviors, and associated features of ASD in children and adolescents from 2 to 18 years of age. The ASRS can be completed by teachers and/or parents and has both long and short forms. The Short form was developed for screening purposes and contains 15 items from the full-length form that have been shown to differentiate children diagnosed with ASD from children in the general population. High scores indicate that many behaviors associated with ASD have been observed and follow-up recommended.

The Social Communication Questionnaire (SCQ; Rutter, Bailey, & Lord, 2003), previously known as the Autism Screening Questionnaire (ASQ), is a parent/caregiver dimensional measure of ASD symptomatology appropriate for children of any chronological age older than four years. It is available in two forms, Lifetime and Current, each with 40 questions. Scores on the questionnaire provide a reasonable index of symptom severity in the reciprocal social interaction, communication, and restricted/repetitive behavior domains and indicate the likelihood that a child has an ASD. The lifetime version is recommended for screening purposes as it demonstrates the highest sensitivity value. 

The Social Responsiveness Scale, Second Edition (SRS-2; Constantino & Gruber, 2012) is a brief quantitative measure of autistic behaviors in 4 to 18 year old children and youth. This 65-item rating scale was designed to be completed by an adult (teacher and/or parent) who is familiar with the child’s current behavior and developmental history. The SRS items measure the ASD symptoms in the domains of social awareness, social information processing, reciprocal social communication, social anxiety/avoidance, and stereotypic behavior/restricted interests. The scale provides a Total Score that reflects the level of severity across the entire autism spectrum.

A Multi-Tier Screening Strategy

The ASRS, SCQ, and SRS-2 can be used confidently as efficient first-level screening tools for identifying the presence of the more broadly defined and subtle symptoms of higher-functioning ASD in school settings. School-based professionals should consider the following multi-step strategy for identifying at-risk students who are in need of an in-depth assessment.

Tier  one. The initial step is case finding. This involves the ability to recognize the risk factors and/or warning signs of ASD. All school professionals should be engaged in case finding and be alert to those students who display atypical social and/or communication behaviors that might be associated with ASD. Parent and/or teacher reports of social impairment combined with communication and behavioral concerns constitute a “red flag” and indicate the need for screening. Students who are identified with risk factors during the case finding phase should be referred for formal screening.

Tier two. Scores on the ASRS, SCQ, and SRS-2 may be used as an indication of the approximate severity of ASD symptomatology for students who present with elevated developmental risk factors and/or warning signs of ASD. Screening results are shared with parents and school-based teams with a focus on intervention planning and ongoing observation. Scores can also be used for progress monitoring and to measure change over time. Students with a positive screen who continue to show minimal progress at this level are then considered for a more comprehensive assessment and intensive interventions as part of Tier 3.  However, as with all screening tools, there will be some false negatives (children with ASD who are not identified). Thus, children who screen negative, but who have a high level of risk and/or where parent and/or teacher concerns indicate developmental variations and behaviors consistent with an autism-related disorder should continue to be monitored, regardless of screening results.

Tier three. Students who meet the threshold criteria in step two may then referred for an in-depth assessment. Because the ASRS, SCQ, and SRS-2 are strongly related to well-established and researched gold standard measures and report high levels of sensitivity (ability to correctly identify cases in a population), the results from these screening measures can be used in combination with a comprehensive developmental assessment of social behavior, language and communication, adaptive behavior, motor skills, sensory issues, and cognitive functioning to aid in determining eligibility for special education services and as a guide to intervention planning.

Limitations

Although the ASRS, SCQ, and SRS can be used confidently as efficient screening tools for identifying children across the broad autism spectrum, they are not without limitations. Some students who screen positive will not be identified with an ASD (false positive). On the other hand, some children who were not initially identified will go on to meet the diagnostic and/or classification criteria (false negative). Therefore, it is especially important to carefully monitor those students who screen negative to ensure access to intervention services if needed. Gathering information from family and school resources during screening will also facilitate identification of possible cases. Autism specific tools are not currently recommended for the universal screening of typical school-age children. Focusing on referred children with identified risk-factors and/or developmental delays will increase predictive values and result in more efficient identification efforts.

Concluding Comments

Compared with general population estimates, children with mild autistic traits appear to be an underidentified and underserved population in our schools. There are likely a substantial number of children with equivalent profiles to those with a clinical diagnosis of ASD who are not receiving services. Research indicates that outcomes for children on the autism spectrum can be significantly enhanced with the delivery of intensive intervention services. However, intervention services can only be implemented if students are identified. Screening is the initial step in this process. School professionals should be prepared to recognize the presence of risk factors and/or early warning signs of ASD, engage in case finding, and be familiar with screening tools in order to ensure children with ASD are being identified and provided with the appropriate programs and services. 

Best practice screening and assessment guidelines are available from: Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools and A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd ed.). 

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Lee A. Wilkinson, PhD, is a licensed and nationally certified school psychologist, and certified cognitive-behavioral therapist. He is author of the award-winning books, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT. 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. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition)