Navigating Co-Occurring Conditions: What Autism Families Should Know
Overview: This article describes conditions that commonly co-occur with autism spectrum disorder. The conditions are separated into biological and psychiatric conditions and are discussed in terms of their impact on overall well-being. Please note that specific treatment is discussed in other articles and not covered herein.
Introduction
Individuals on the autism spectrum frequently seek treatment for maladies not central to their autism diagnosis, such as stomach aches, depression, learning difficulties, and anxiety. In fact, research over the last few decades has shown that these types of complaints are reported more frequently by individuals on the autism spectrum than those who are not. These correlations can create diagnostic and treatment confusion highlighting the necessity for awareness and understanding of the physiological and psychiatric conditions that most often co-occur with autism to provide accurate assessment and care.
Assessment
The assessment of co-occurring conditions with autism is as complex as it is important. The complexity comes from the wide variation of how autism symptoms manifest, because after all, if you’ve met one autistic person, then you’ve only met one autistic person. The assessment is important because treatment of co-occurring conditions is often essential to improve the individual’s quality of life. Simply stated, it is crucial for caregivers to attune to individual symptoms as well as to the entire, bigger picture of the person’s functioning. For example, consider the autistic person who suffers from stomach aches whenever they’re in social situations. A care provider or parent may attribute social avoidance to poor social skills, when in fact the person may struggle with social anxiety and a separate digestive issue. Instead of assuming that they are just socially aloof, they may benefit from help with improving social skills and help with regulating anxiety, as well as medical/dietary support for their stomach aches. High quality assessment can help to ensure that these conditions receive their due attention rather than assuming that one condition supersedes all others.
The importance of assessing and differentiating conditions for an autistic person requires a unique and nuanced approach. Kerns et al. (2016) suggests a multistep assessment process that seeks to compare non-asd symptoms (such as anxiety symptoms) to those of similar autistic peers instead of to a neuro-typical (non-asd) standard. This helps to contextualize the baseline that an autistic person may be operating from in a way that ultimately helps to provide a better understanding of what someone is capable of. Regardless of the approach, it is critical that people on the autism spectrum receive assessments that capture the entirety of their presenting issues in order to receive the highest quality care.
Physiological Co-occurring Conditions
There are many physiological conditions that may co-occur with autism, each of which require specific forms of support and medical care. While the etiology of the different conditions are unique to themselves, it is probable that some of the genetic and environmental factors that contribute to autism also contribute to these different physical conditions.
The most common physical conditions that impact autistic people are motor skill issues (79% of autistic people), gastrointestinal problems (up to 70% of autistic people), epilepsy (up to 30% of autistic people) and sleep disorders (50–80% of autistic people) (Lai, Lombardo, and Baron-Cohen, 2014). Each of these conditions have their own impact on an individual and may require the support of medical professionals. Fine motor skill deficits have been found to correlate with social skill deficits (Ohara et al., 2019) in a way that suggests they share some similar neural structures. In treatment, it is often noticed that improvement in fine motor skills (manipulating objects and nuanced use of hands) correlates with improved social skills. While this growth may not be causal, research suggests that it may be a potential treatment approach for people on the autism spectrum. It is also recommended that medical intervention, when needed, be provided for people on the autism spectrum with gastrointestinal problems and epilepsy since these conditions may exacerbate proficiency in daily life skills.
Sleep issues unfortunately plague a large percentage of modern society, but the percentage is even higher in the autistic population. Things like regular exercise, avoiding screen time before bed, a regular diet and eating times, and sleep routines all have a positive impact on sleep. Given the significant emotional toll that poor sleep can have, this is especially important for people who already struggle with emotion regulation. For more on sleep in general, the following books are recommended:
“Why We Sleep” by Matthew Walker
“Say Good Night to Insomnia” by Gregg Jacobs
A final common co-occurring condition is intellectual disability. It is estimated that between 30% and 45% of autistic people have a co-occurring intellectual disability (Lai, Lombardo, & Baron Cohen, 2014; Christensen et al., 2016). An intellectual disability is broadly described by below average cognitive skills –the ability to take in, process, and retain information – and adaptive skills, which are the skills necessary for daily living. These disabilities can manifest themselves as dyscalculia (difficulty with learning and comprehending arithmetic), dysgraphia (difficulty with written expression), dyslexia (difficulty with reading), dyspraxia (difficulty with motor movements and coordination), and others. Intellectual struggles can cause anxiety and self-doubt and require a separate individualized care plan. People with intellectual disabilities may qualify for additional public support through an individualized educational program (IEP), a 504 plan, or disability services. These services and others are discussed in more detail in the article “Support for Autism”.
Psychiatric Co-Occurring Conditions
Because it is so difficult to disentangle autistic symptoms from the symptoms of other disorders, many young autistic people go undiagnosed with ASD for years and are instead diagnosed with a plethora of other psychiatric disorders. This is especially true for Level 1 or “needing low support” autistic people. It is essential that treatment providers understand which psychiatric disorders most commonly co-occur with autism so that an accurate diagnosis can be made.
One of the most common psychiatric disorders that co-occurs with autism is attention deficit hyperactivity disorder (ADHD). Both conditions are neurodevelopmental – meaning that they are caused in part by changes in brain development – and they frequently present similarly in young people. Yerys et al. (2017) found that care providers often struggle to distinguish these two diagnoses because kids with either or both diagnoses can appear distracted, avoidant, and easily overwhelmed. Farhat et al. (2022) completed a thorough review of both diagnoses and identified the significant differences in each diagnosis and their assessment (for example, having a restricted range of interests is unique to autism). The research demonstrates how critical it is to analyze every layer of behavior in order to arrive at the correct diagnosis. Treatment for ADHD often includes pharmacological (medication) care, while treatment for ASD symptoms may include a whole host of other approaches. This alone makes it critical to distinguish the two.
Mood disorders and anxiety disorders are also very common among people on the autism spectrum. Mood disorders, such as depression, tend to increase the later someone is diagnosed with autism (Hosozawa, Sacker, & Cable, 2021). This is likely due to the fact that social demands increase as people age, and without proper care and coaching an undiagnosed autistic person is likely to fall further and further behind their more social peers. Depression can lead to self-doubt, low self-esteem, feelings of isolation, or even and more significant depressive symptoms such as self-harm and suicidal ideation. Anxiety also commonly co-occurs with autism due to the tendency for autistic individuals to become overwhelmed and overstimulated in hectic and demanding environments (Lever and Geurts, 2016). Recall that autistic individuals frequently view the world in a very systematized manner and when things fall outside of those established systems it can be anxiety provoking. These common mental health diagnoses are often the first reason an autistic person seeks care and should garner significant attention from care providers given how crippling they can be.
People on the autism spectrum also experience elevated rates of obsessive-compulsive disorder (OCD), oppositional defiant disorder (ODD), and thought disorders such as schizophrenia (Lever & Geurts, 2016; Levy et al., 2010; Vaquerizo-Serrano et al, 2022). There is a growing belief that changes in neurological development that cause Autism may also contribute to these co-occurring conditions. Given the relative severity of each of these conditions, it is critical that people be assessed and treated for presenting symptoms as early in life as possible. Medications, therapeutic approaches, and other mental health interventions may stave off the most debilitating symptoms of the conditions if it is diagnosed and addressed before disruptive patterns become too entrenched.
Diagnosing and treating co-occurring psychiatric disorders is a critical part of any treatment plan for an autistic person. It is possible, if not likely, that many autistic people will experience more disturbance and difficulty from the co-occurring diagnosis than from autism. The fact that these issues co-occur makes it even more critical to identity and adequately treat the conditions as effectively as possible.
Conclusion
People with autism are more likely to be challenged by a myriad of medical and mental health conditions in addition to their autism. Some of these conditions are likely caused by similar biological mechanisms,such as brain development, and some of them can be a byproduct of autism itself, such as anxiety. It is critical for individuals, families, and caregivers to attune to these different conditions and to provide evidence-based treatment for each.
References
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