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Learning Center Experience
By Rebecca K Arvans-Feeney, PhD, BCBA-D, Faculty, Kaplan University
Children on the autism spectrum often also meet diagnostic criteria for other common childhood diagnoses, including attention deficit hyperactivity disorder, oppositional defiant disorder, conduct disorder, anxiety disorders, mood disorders, tic disorders, enuresis, encopresis, and schizophrenia. These individuals are not more likely to receive additional services to address these concerns, even though comorbidity with other diagnoses is likely to affect overall treatment outcomes (Mukaddess et al., 2012). Providers for children with autism should be aware of best practices so they can systematically treat all relevant mental health concerns or refer to those in their area who can provide such services.
Autism Spectrum Disorders and Comorbid Diagnoses: How Common Are They and Why Should We Care About Them?
Stan enters my office for the first time. He is a young adult, about 13 years old, with significant delays in communication and social impairments. He appears shy and distracted until I ask about video games and Star Wars, at which point he talks incessantly. Unfortunately, he does not appear to notice when I am no longer participating in the conversation and, despite my attempts to change the topic, he continues on with excitement. At some point, I'm able to redirect him back to our initial interview. He notes that he is aware he has difficulties with peers; that he is often bullied; that he feels sad; that he experiences suicidal thoughts; that he often worries; that he has no friends; and that he does poorly in school. Stan is a fairly typical child on the autism spectrum who presents in my clinical practice. He not only qualifies for an autism spectrum disorder, but he may also meet diagnostic criteria for depression, anxiety, and other mental health concerns.
In my clinical experience, it is not uncommon to interact with a child on the autism spectrum who also meets diagnostic criteria for other common childhood diagnoses. Children on the autism spectrum have significant deficits in communication and social impairments, along with significant repetitive or stereotypical behaviors. However, they often also experience depressive symptoms, significant anxiety, and behavior problems outside of the typical diagnostic criteria relevant to a diagnosis of an autism spectrum disorder. Such symptoms are not always accounted for by the autism spectrum disorder diagnosis.
Comorbidity With Autism Spectrum Disorders
Several studies have found a high prevalence of comorbidity amongst individuals with autism spectrum disorders and other mental health diagnoses. For example, Mukaddess, Herguner, and Tanidir (2010) found rates of comorbidity amongst individuals on the spectrum were very high in their sample, ranging from 93-100 percent. In their study, attention deficit hyperactivity disorder (ADHD) was the most common comorbid diagnosis. Additional common diagnoses included oppositional defiant disorder (ODD) and conduct disorder (CD), anxiety disorders (especially obsessive compulsive disorder [OCD] and specific phobias), mood disorders, tic disorders, enuresis, encopresis, and schizophrenia. Gjevik, Eldevik, Fjaeran-Granum, and Sponheim (2011) also found ADHD and anxiety to be highly prevalent in children with autism spectrum disorders. Additionally, they found comorbidity in at 72 percent of those included in their study; again a very high rate.
In addition to the types of comorbid diagnoses often encountered, Hess, Matson, and Dixon (2010) found that children with autism spectrum disorders endorsed more psychiatric symptoms than their typical peers while Storch et al., (2012) found that children who met diagnostic criteria for both autism and a behavior disorder experienced more severe symptoms, were more likely to be prescribed antipsychotic medications, and experienced significantly more functional impairment. Additionally, they were not more likely to receive additional services to address these concerns.
Importance of Understanding Comorbidity
These additional diagnoses become important when one begins to consider empirically supported treatment options for their clients. Comorbidity with other diagnoses is likely to affect overall treatment outcomes (Mukaddess et al., 2012). For example, a child with significant behavior problems and autism may benefit not only from traditional empirically supported autism interventions (e.g., applied behavior analysis), but also from other empirically supported interventions meant to specifically address behavioral issues (e.g., parent training). A child with OCD and autism may also benefit from other empirically supported interventions meant to address OCD symptoms (e.g., habit reversal, exposure protocols, medication management). A child with depression and autism may benefit from other empirically supported interventions meant to address depressive symptoms (e.g., cognitive-behavior therapy, medication management). Obviously, the list goes on and on here in terms of possible empirically supported approaches that may be relevant to any one client who enters the therapy room.
Additionally, this also means that providers for children with autism should be aware of best practices for commonly occurring comorbid diagnoses. If providers are not comfortable providing the services meant to address these additional mental health concerns, they should at least be aware of and refer to those in their area who can provide such services. In doing so, they are likely to see more therapeutic benefits and better outcomes for their clients.
In summary, children with autism spectrum disorders are highly likely to also meet diagnostic criteria for many additional mental health disorders. Without providers being aware of this, many of these individuals never receive additional mental health services that could greatly benefit the client and result in better treatment outcomes.
Gjevik, E., Eldevik, S., Fjaeran-Granum, T., & Sponheim, E. (2011). Kiddie-SADS reveals high rates of DSM-IV disorders in children and adolescents with autism spectrum disorders. Journal of Autism and Developmental Disorders, 41, 761-769.
Hess, J.A., Matson, J.L., & Dixon, D.R. (2010). Psychiatric symptom endorsements in children and adolescents diagnosed with autism spectrum disorders: A comparison to typically developing children and adolescents. Journal of Developmental and Physical Disabilities, 22, 485-496.
Mukaddess, N.M., Herguner, S., & Tanidir, C. (2010). Psychiatric disorders in individuals with high-functioning autism and Asperger's disorder: Similarities and differences. The World Journal of Biological Psychiatry, 11, 964-971.
Storch, E.A., Arnold, E.B., Jones, A.M., Ale, C.M., Wood, J.J., Ehrenreich-May, J., ... Murphy, T.K. (2012). The roles of co-occurring disruptive behavior in the clinical presentation of children and adolescents with anxiety in the context of autism spectrum disorders. Child Psychiatry Human Development, 43, 734-746.
Rebecca K Arvans-Feeney, Kaplan University
Correspondence concerning this article should be addressed to Rebecca Arvans, 10399 Double R Blvd #102, Reno, NV 89521 Email: firstname.lastname@example.org
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