Treatment for Associated Psychiatric Conditions
What Psychiatric Disorders Are Associated with Autism? How Are They Diagnosed and Treated?
As a group, children and adults with autism spectrum disorder (ASD) have a higher rate of psychiatric disorders than that of the general population. Research suggests that autism shares a genetic basis with several major psychiatric disorders. These include attention deficit and hyperactivity disorder (ADHD), depression, bipolar disorder and schizophrenia. Other research suggests that just over two-thirds of children with autism have been diagnosed with one or more psychiatric disorders. The most common include anxiety, obsessive compulsive disorder (OCD) and ADHD.
At the same time, some specialists caution that healthcare professionals not deeply familiar with autism tend to over-diagnose psychiatric problems in this group. This may be due to overlap between autism symptoms and those associated with psychiatric disorders. For example, socially inappropriate comments are common among those with autism. However, they are likewise hallmarks of bipolar disorder, Tourette's and schizophrenia. Similarly, an emotional meltdown in a person with autism may stem from difficulty communicating frustration. Without understanding this, it can be easily mistaken for a symptom of bipolar disorder or oppositional-defiant disorder.
Clearly, accurate diagnosis of mental health issues can be challenging in individuals with ASD. Yet appropriate treatment is particularly crucial. Psychiatric disorders can worsen autism symptoms, interfere with education and reduce the benefits of behavioral therapies. Conversely, effective behavioral therapy and, if appropriate, medication can dramatically improve function and quality of life.
Advancing Understanding and Treatment
For these reasons, Autism Speaks Autism Treatment Network (AS-ATN) continues to develop guidelines for the diagnosis and treatment of psychiatric conditions in individuals with autism. In a recent special supplement to the journal Pediatrics, AS-ATN physicians published several related reports. They included findings from a study on the use of psychoactive medicines in children and teens with ASD and two studies on the impact and treatment of ADHD in those with ASD.
Decisions on whether to use psychoactive medications in children can be particularly difficult. Autism Speaks ATN/AIR-P Medication Decision Aid is designed to help families work with their physicians to sort through the pros and cons in the context of their goals and values. Learn more about this tool kit and download a free copy here. Also look for the April 2013 release of the ATN/AIR-P tool kit Autism and Medicine for Challenging Behaviors: Safe and Careful Use, here.
Thanks to the generosity of its supporters, Autism Speaks continues to fund research to deepen understanding and improve treatment of psychiatric disorders in children and adults with autism.
In the following sections, you’ll find more information on the psychiatric disorders most commonly associated with autism.
Without question, anxiety is a serious problem for many people on the autism spectrum. Research suggests that around 30 percent of those affected by ASD also have an anxiety disorder. These include social phobia, separation anxiety, panic disorder and specific phobias – for instance, of spiders or loud noise.
Research suggests that adolescents with autism may be particularly prone to anxiety disorders. At the same time, the rate among younger children with ASD may not differ from the norm. Some studies suggest that high-functioning individuals with autism experience particularly high rates of anxiety disorders – perhaps because they’re more aware of “not fitting in.”
Even in the absence of an anxiety disorder, many individuals with autism have difficulty controlling anxiety once something triggers it. It’s important to remember that anxiety can range from occasional, mild and completely understandable to unremitting, severe and irrational. Mild anxiety can actually be a positive, motivating force. By contrast, extreme anxiety interferes with success in school, work and social situations.
Recognizing anxiety in someone with autism
Children with autism express anxiety or nervousness in many of the same ways as typically developing children do. However, social anxiety – or a fear of new people and social situations – is especially common among children and adults with autism.
Someone suffering from anxiety may experience strong internal sensations of tension. This can include a racing heart, muscular tensions and stomachache. In someone with autism these feels can prompt an increase in self-soothing and repetitive behaviors. These can include destructive behaviors such as shredding paper or clothing.
Understandably, many individuals with ASD have trouble communicating how they feel. Outward manifestations may be the best clues. In fact, some experts suspect that outward symptoms of anxiety – such as sweating and acting out – may be especially prominent among those with ASD.
Behavioral treatments for anxiety in those with autism
Several types of cognitive behavioral therapy (CBT) have been developed to address anxiety in children and teens with ASD. Studies suggest that CBT is particularly helpful for verbal individuals and those without intellectual disability. Techniques include challenging negative thoughts with logic, role-playing and modeling of courageous behavior, and step-by-step exposure to feared situations.
Many anxiety therapies for children with autism incorporate special interests to encourage participation. For example, the therapist may use a child’s favorite cartoon characters to model coping skills. She might intersperse conversations about a child’s special passion throughout the treatment session.
Depending on the program, weekly treatment sessions typically last 60 to 90 minutes and continue for several months. Most programs include parent involvement and practice-at-home assignments.
For more information on treating and easing anxiety in persons with autism, see these related blogs by autism researchers and clinicians.
Medications for Anxiety
Medicines for relieving anxiety are best used in combination with counseling or other behavioral interventions. The Food and Drug Administration (FDA) has not approved any medication expressly for the treatment of anxiety in persons with autism. However some drugs approved to treat anxiety disorders in the general population are commonly used to help individuals with autism. These include selective serotonin reuptake inhibitors (SSRIs) such as Prozac and Zoloft.
Some studies suggest that anti-anxiety medications are less effective, overall, in those with autism than with other groups. It may be that the biological root of autism-associated anxiety may be different from that of anxiety in the general population. As such, individuals with autism may respond best to tailored treatments.
Also see this related blog post by Autism Speaks Vice President for Translational Research Rob Ring, Ph.D.
Attention Deficit and Hyperactivity Disorder (ADHD)
Parents and autism specialists have long noticed that many children with autism also struggle with ADHD. Recent studies have helped deepen our understanding of why this is so and how it affects families. One study found common genetic factors in individuals with ADHD, autism or both. Researchers are using such findings to improve understanding, diagnosis and treatment of these interrelated disorders.
Another study looked at how commonly parents reported ADHD-related problems in their children with autism. The findings made clear that these problems are common and seriously affect children’s function and quality of life. The same study found that just 1 in 10 children with autism and ADHD were receiving medication to relieve the ADHD symptoms.
Recognizing ADHD in someone with autism
The classic symptoms of ADHD include chronic problems with inattention, impulsivity and hyperactivity. However, these or similar symptoms can likewise result from autism. For these reasons it’s important that evaluation be made by someone with expertise in both disorders.
Helping someone with ADHD and autism
While medicines can have a place in treatment, experts stress that they work best in combination with autism-specific behavioral therapies. In addition, all ADHD medicines have side effects.
Medicines used to ease ADHD include stimulants such as methylphenidate (Ritalin, Metadate, Concerta, Methylin, Focalin, Daytrana), mixed amphetamine salts (Adderall), dextroamphetamine (Dexedrine) and lisdexamfetamine (Vyvanse). Other available options include so-called alpha agonists such as guanfacine (Tenex, Intuniv) and clonidine (Catapres, Catapres TTS, Kapvay).
Stimulants tend to produce side effects such as decreased appetite, irritability, emotional outbursts and difficulty falling asleep. Common side effects of alpha agonists include sleepiness and irritability. Importantly, if a person responds adversely to one of these medicines, another may prove less problematic. On a practical level, this can require trials of several different medicines – each carefully monitored for benefits and side effects.
Please also see Autism Speaks ATN/AIR-P Medication Decision Aid (described above).
Individuals with ASD may be particularly prone to depression as they enter adolescence and adulthood. Here again, research suggests that depression can be particularly difficult to diagnose in those with autism. In part, this may stem from communication difficulties. Compared to other depressed individuals, those with autism may be less likely to express the feelings typically used to diagnose depression. These include saying one feels depressed, worthless, unable to concentrate or suicidal. In the absence of such statements, tell-tale signs can include neglect in personal hygiene and other self-care activities.
Because depression can be so difficult to diagnose in those with ASD, it’s important to see a mental health professional who has expertise with autism. The importance of seeking help is underscored by recent findings that suicidal tendencies among children and teens with ASD may be more common than in the general population.
Treatment for depression in those with autism
Cognitive behavioral therapy has shown promise for treating depression in those with autism. (See “Anxiety” section above for more on CBT.) None of the medications approved to treat depression have been tested rigorously among children or adults with ASD. Some research suggests that individuals with ASD are at increased risk of side effects from antidepressants. The most common side effects include sleepiness, agitation, increased irritability, restless leg syndrome and gastrointestinal problems. Physicians can reduce the risk of side effects by starting with a low dose for several weeks and then gradually increasing it as needed. As with anyone suffering from depression, it may take several trials of different medications to find one that works well with minimal side effects. Dosing needs to be carefully tailored to the individual as well. A dose effective for one child may be too much or too little for another, even after accounting for age and weight.
Also see "What's the Connection between Autism and Depression?" by psychiatrist Christopher McDougle, M.D., of the Lurie Center for Autism; and "Eight Critical Measure to Counter Suicide," by Sallie Bernard.
Bipolar disorder was once commonly called manic-depression. It involves episodes of abnormally high-energy alternating with depression over a period of time. A manic episode is characterized by a variety of symptoms, including feeling elated, irritable or angry or fluctuating between happy and irritable throughout the day. Among individuals with autism, the symptoms of bipolar disorder commonly include abrupt increases in “pressured speech” (rapid, loud and virtually nonstop talking), pacing, impulsivity, irritability and insomnia. Some individuals with bipolar disorder alternate between mania and depression. Others never or seldom experience depression. In other words, they exhibit manic behaviors alternating with calmer, or “normal,” periods.
As with many other psychiatric conditions, studies suggest that bipolar disorder may be relatively common among children and adults with autism. Some studies have found that as many as 27 percent of those with autism may have bipolar disorder. By contrast, its prevalence in the general population is around 4 percent.
However, some experts see evidence that bipolar disorder is mistakenly over-diagnosed in those with autism. In part this is because of overlapping and similar symptoms.
In a recent study of children and teens with autism, researchers found that nearly a third had frequent episodes of “elevated mood.” Just over 60 percent could be described as “very irritable.” Just over half talked excessively. In nearly half, they noted a tendency to “get in trouble” (47 percent), engage in excessive activity such as pacing (43 percent), accident proneness (44 percent) and distractibility (43 percent). Sleep disturbances were also common.
All these behaviors could be considered symptoms of bipolar disorder, they noted. However the vast majority of these children did NOT have bipolar disorder. In most cases, these symptoms were simply aspects of their autism.
The researchers also found that they could tease apart the symptoms of true bipolar disorder from those of autism by looking carefully at when the symptoms appeared and how long they lasted. For example, a teenager with autism shouldn’t be labeled manic just because she tends to make inappropriate comments and talk freely with strangers –if these are longstanding habits. By contrast, if the same teenager abruptly started going without sleep for days while having more tantrums than usual, this may represent a true manic episode.
Treatment of bipolar disorder in those with autism
Psychiatrists often prescribe psychoactive medications to treat bipolar disorder. Lithium is one of the most common. Unfortunately, lithium can produce significant side effects. They include thirst, excessive drinking and bed wetting, shakiness and even life-threatening toxicity. This is of particular concern for individuals with autism because they may have difficulty alerting caregivers to the effects they’re experiencing.
Studies suggest that anti-seizure, mood-stabilizing medications such as valproic acid may be safer treatments for those with autism. The atypical antipsychotics risperidone and aripiprazole are both FDA-approved to treat irritability in children with autism age 6 or older. They may help bipolar symptoms. However both medicines tend to produce significant weight gain and diabetes risk. Therefore, their use requires close monitoring. (For further guidance, please see “Behavioral Medication Side Effects.”)
Researchers at Autism Speaks AS-ATN center at Ohio State University are evaluating a family treatment intervention that combines education and psychotherapy. Early results suggest that this type of intervention decreases mood severity in children, while improving family interactions and access to appropriate healthcare.
Obsessive Compulsive Disorder (OCD)
Repetitive behaviors and restricted interests are among autism’s core symptoms. A doctor or therapist unfamiliar with autism may mistake these symptoms for those of obsessive compulsive disorder (OCD). But they are different. A distinguishing hallmark of OCD is that the compulsive thoughts or behavior cause anxiety. By contrast, persons with autism are not generally bothered by their repetitive behaviors and restricted interests. Just the opposite, these behaviors and interests tend to bring comfort and enjoyment. This is very different from the classic OCD thoughts and behaviors such as compulsive handwashing for fear of germs, rechecking locks for fear of intruders, etc.
Still, OCD may be more common among teens and adults with ASD than in the general population. The estimated prevalence of OCD in those with ASD ranges from 8 to 33 percent, depending on the study. The prevalence of OCD in the general population is about 2 percent.
However, OCD appears to be uncommon among young children. Typically, the disorder first develops in adolescence or young adulthood. In some children, compulsive “tics” may result from an autoimmune condition triggered by strep infection. This is known as pediatric autoimmune neuropsychiatric disorders after streptococcus (PANDAS). Autism Speaks is currently funding research on PANDAS in children with autism. You can read more about this study here.
Treatment for OCD
A few small clinical studies suggest that cognitive behavioral therapy can help ease OCD symptoms in high-functioning adolescents and adults with autism. Medications for OCD have not been well studied in children or adults with autism. In the general population, OCD is most commonly treated with SSRI antidepressants such as Prozac, Luvox, Paxil and Zoloft. Typically these medications take several weeks to work. When one medication does not achieve good results, another may.
Research suggests that schizophrenia affects around 2 percent of those with ASD. This is around double schizophrenia’s prevalence in the general population. The symptoms of schizophrenia tend to appear in early adulthood. Childhood schizophrenia is rare.
Considerable research indicates that autism and schizophrenia share prenatal risk factors such as maternal infection with fever during pregnancy. In addition, recent research shows that autism and schizophrenia share some of the same risk genes. Together, these findings suggest that the two disorders may arise from related disruptions in early brain development.
Although the two disorders are distinct, they share certain features such as social withdrawal and impaired communication. This can lead to problems in diagnosing schizophrenia in individuals with autism. As with anxiety, the underlying basis for symptoms tends to differ between the two disorders. For this reason, it’s important to seek screening and care from appropriate specialists.
The following information is solely for educational purposes and not intended as medical advice. Autism Speaks is not engaged in the delivery of healthcare advice or services. For individual advice about care and treatment, please consult your physician.