ADHD, schizophrenia, bipolar disorders and autism are neurodevelopmental conditions that appear to have roots in early brain development. (Munesue 2008, Sikora 2012, Rapoport 2012) Anxiety and depression may stem, at least in part, among people with autism-related impairment that increases daily stress and social isolation, and decreases overall quality of life. (Vasa 2016, Greenlee 2016)

Epidemiological studies suggest that between 54 and 70 percent of people with autism also have one or more other mental health conditions.  (Simonoff 2008, Hofvander 2009, Croen 2015, Romero 2016)

For people with autism, untreated mental health conditions can profoundly worsen behaviour.  The challenging part is the overlapping symptoms, which is more difficult to identify in people with autism. (Levy 2010, Sikora 2012, Miodovnik 2015)  Social withdrawal associated with depression or schizophrenia, for example can be difficult to distinguish from autism-related social impairment.  Expressing the emotions and other internal feelings makes it more difficult to identify in people with autism.

In order of estimated prevalence:

  • Attention deficit and hyperactivity disorder (ADHD) affects an estimated 30 to 61 percent of people with autism. (Goldstein 2004, Lee 2006, Gadow 2006, Romero 2016)
  • Anxiety disorders affect an estimated 11 to 42 percent of people with autism. (Vasa 2016, White 2009, Croen 2015, Romero 2016)
  • Depression affects an estimated 7 percent of children and 26 percent of adults with autism. (Greenlee 2016, Croen 2015)
  • Schizophrenia affects an estimated 4 to 35 percent of adults with autism. (Chisolm 2015)
  • Bipolar disorder affects between 6 and 27 percent of people with autism. (Munesue 2008, Rosenberg 2011, Vannucchi 2014, Guinchat 2015, Croen 2015)

Autism and Attention Deficit and Hyperactivity Disorder (ADHD)

The Centers for Disease Control and Prevention (CDC) estimates that ADHD affects 6-7% of the general population (Perou 2013).  Studies from the last decade suggest that between 30-60% of people with autism also have symptoms of ADHD. (Goldstein 2004, Lee 2006, Gadow 2006, Romero 2016)

Geneticists have found that many of the gene variations that increase autism risk also the increase risk for ADHD. (Lionel 2011)

Hyperactivity, inattention and / or impulsivity that interferes with daily life, social development and learning are few persistent patterns of symptoms of ADHD.  Close attention to detail and careless mistakes at school or work often occur among people with ADHD.  Inattention is often observed, they don’t appear to listen when spoken to or have trouble organizing tasks and do not follow through with the instructions and assignments, especially those which require sustained attention. (DSM- 5 2013)

More than 3,000 patients, aged between 2-18 were observed deeply for autism and ADHD symptoms in Autism Speaks Autism Treatment Network. (Sikora 2012)  Multiple symptoms of ADHD were found in more than half these children and teens with autism.  Further evaluation showed that a combination of ADHD and autism symptoms resulted in significantly worse health, daily function and overall quality of life.

In 2013, the American Psychiatric Association specified that a person could be diagnosed with either autism or ADHD, but not both. (DSM-IV 2004) Later in 2013, the association changed its guidelines to allow diagnosis of both conditions in one person. (DSM-5 2013). Diagnosis of either one of these disorders tends to significantly delay the treatment of the other. (Miodovnik 2015) Impaired social development and difficulties with attention, learning and communication remains challenging to distinguish among people with autism and ADHD.

The journal Pediatrics published the first guidelines on the evaluation of ADHD among children and teens with autism, together with guidance on selecting and evaluating the best ADHD medication for those patients. (Mahajan 2012) It includes evaluating the benefits and side effects of ADHD medication depending on their dosages, in consultation with the family.  The emphasis here is on the highly personal nature of such medication, and the necessity of involving the individual and / or parents in evaluating goals and needs.

Autism and anxiety

One or more anxiety disorders is seen in 11-42% people with autism, as per the studies. (Vasa 2016, White 2009, Croen 2015, Romero 2016)  By contrast, CDC estimates that anxiety disorders affect 3% of children and 15% of adults in the general population. (Perou 2013, Kessler 2009)  Disorders include separation anxiety, panic disorders and phobias (extreme fear of certain noises, places and so on).

For many children with autism, anxiety increases in adolescence.  Social anxiety or extreme fear of meeting new people, crowds and social gatherings/ situations is especially seen amongst people with autism.  (Bellini 2006) Case studies suggest that anxiety remains high throughout life. (Gillott 2007, Moss 2015)

It is also seen that though symptoms of anxiety disorders may be absent in many people with autism, they have difficulty in controlling anxiety once something triggers it.  Anxiety is wrapped around autistic behaviour such as difficulty in navigating social situations and extreme sensory sensitivity to loud noises, lights, certain tastes and smells.  “Anticipatory anxiety”, produced when simply anticipating or otherwise thinking about an anxiety, can also trigger extreme anxiety.  Another reason or source of anxiety involves the need for routine or sameness.  Lack thereof can produce anxiety in the face of changes in schedule or familiar people – for example a new teacher aide or even store clerk.

Research on anxiety in autism has been focused on children and adults who are verbal and have normal to high intelligence.  Experts agree that there is need for more studies among people with autism who are non-verbal or minimally verbal and / or have intellectual disability.

Identifying and treating anxiety

It is known that people with autism have trouble assessing and expressing how they feel. Their behaviour often provides the best clues to underlying anxiety.  The impact of anxiety can trigger strong internal sensations of tension that include a racing heart, muscle tightness and stomachache.  These strong feelings can prompt an increase in self soothing, repetitive behaviour (flapping, rocking, spinning, etc.) and / or destructive or self-harming behaviour (shredding clothing, head banging etc).  Anxiety can be cause of new resistance to what had been an enjoyed activity (a trip, a birthday party, school, etc.).

The first guidelines were published in 2016, in the journal Paediatrics.  The treatment must be personalized depending on the level of the patient, which may also include language level and intellectual ability, which influences cognitive behaviour therapy. (Wood 2009, Drahota 2011, Wood 2015)

Cognitive behavioural techniques include challenging negative thoughts with logic, role playing, modelling courageous behaviour and gradual exposure to feared situations.  Gradual exposure can start with looking at a related picture.  This approach includes the use of visual aids, which have a strong impact on people with autism.  The therapist may use a favourite cartoon character to model coping skills.  It is also seen that people with autism respond strongly to the logic in cognitive behavioural therapy.  This therapy has proven effective, especially among those who are verbal and have normal to high intelligence. (Wood 2009, Wood 2015, Hepburn 2016)  Researchers are working on modifying the approach for those with intellectual disability with little or no verbal language. (Danial 2013)

Autism and depression

It is estimated that 7% of children and 26% of adults are affected with depression. (Greenlee 2016, Croen 2015) The journal of Pediatrics found that depression rose dramatically with age from just under 5% in a grade schooler to just over 20% in teenagers. (Greenlee 2016) Likewise with intellectual ability (IQ) – the presence of one or more medical conditions accompany autism, particularly seizures and gastrointestinal issues.  Depression has a profound effect on overall quality of life which rise with age and medical conditions.  Screening for depression as a routine part of care for people with autism particularly those with normal to high IQ and also with those who have additional medical issues.

Identifying depression

Chronic feelings include, sadness, hopelessness, worthlessness, emptiness and / or irritability.  Social isolation, moving or talking slowly, feeling restless and having trouble sitting still or concentrating are a few other common things identified in depression.  Thoughts about death and / or suicide is at most serious in depression.

As it is well known, identifying depression is a challenge among people with autism. (Gotham 2015) Having a “flat” or unemotional, facial expression for example, is a common trait of both autism and depression. So too is irritability and social isolation.  Difficulty in identifying and expressing how they feel, is the most challenging part for people with autism.  Specialists have been developing and testing revised methods for identifying depression among people in the autism spectrum. (Streling 2015)

autism-depression-anxiety

Treating depression

Cognitive-behavioral therapy has shown promise for treating depression in people with autism. (Kuroda 2013) This work builds on a much larger body of research using an autism-modified version of cognitive behavioral therapy for extreme and chronic anxiety. There are no FDA-approved medications specifically for depression in patients who have autism, so psychiatrists typically prescribe those used for the general population. More research may be warranted given a 2011 study suggesting that patients with autism are more likely to experience antidepressant side effects. (Boyd 2011) The most common of these include sleepiness, agitation, increased irritability, restless leg syndrome and gastrointestinal problems.

Autism and schizophrenia

In the 1960s, psychiatrists referred to autism as a subtype of childhood schizophrenia. (DSM II 1968) A clear distinction between the two conditions was made in the year 1990. (Rapoport 2009) Interestingly they share many biological similarities. Both appearing to have roots in prenatal brain development. They share similar prenatal risk factors including maternal inflammation and infection as well as advanced parental age at the time of conception. (Patterson 2009, Menon 2011, Insel 2010) Research has also identified many common genetic risk factors. In other words, many of the same gene changes are known to increase autism risk also increase the risk of schizophrenia.  (Guilmatre 2009, McCarthy 2014)

Autism and schizophrenia both involve impairments in processing language and understanding other people’s thoughts and feelings.  Clear differences include the schizophrenia’s hallmark psychosis, which often involves hallucinations.  Autism core symptoms emerge between 1-3 years, schizophrenia is in early adulthood.

The studies found schizophrenia in 4-35 % of adults who have autism and found autism in 4-60% of those who have schizophrenia. By contrast, schizophrenia affects an estimated 1.1 percent of the general population, and autism affects an estimated 1.5 percent. (NIMH/Regier 1993, Baio 2014)

Autism and bipolar disorder

Bipolar disorder is a mood disorder once known as “manic depression.” People with bipolar disorder tend to alternate between a frenzied state known as mania and episodes of depression. While some people experience only the manic episodes, most alternate between these two states and can show extreme irritability.

People with autism are at increased risk of bipolar disorder as per the researchers. (Munesue 2008,  Rosenberg 2011, Vannucchi 2014, Guinchat 2015) Prevalence of bipolar disorder ranges from 6-27%  among people with autism.  Bipolar disorder affects 4% of the general population (Kessler 1994)

Some leading experts propose that bipolar disorder may be over-diagnosed in those who have autism, due to overlapping symptoms such as hyperactivity, irritability and disturbed sleep. (Witwer 2014) For example, a child with autism may be consistently high-energy and socially intrusive through childhood. As such, her tendency to talk to strangers and make inappropriate comments are likely a consistent part of her autism, not symptoms of a manic mood swing.

 

Treatment of bipolar disorder in autism

Some bipolar disorder medications can be problematic and even dangerous in someone who has difficulty recognizing and expressing feelings – as is common with autism. Lithium, for example, can in rare cases produce life-threatening toxicity. Anti-seizure, mood-stabilizing medication such as valproic acid may be a safer treatment for those with autism. (Witwer 2014) In addition, the antipsychotics risperidone and aripiprazole are both FDA-approved to treat irritability in children with autism, though both tend to produce significant weight gain and diabetes risk.

 

Sri Lakshmi H A  (Senior Nutritionist)