Rachel Loftin, Ph.D. Autism Assessment, Research & Treatment Services (AARTS) Rush University Medical Center Comorbidity Medical comorbidity Seizures GI (24% in one study) Infections Feeding Issues Etc. Psychiatric Comorbidity More than one psychiatric diagnosis Complications for diagnosis Complications for treatment Complications for research 1
Challenges to Studying Comorbidity in ASD Symptoms often attributed to intellectual or social disabilities Symptom overlap or complicated symptom attribution may lead to viewing problems in multiple contexts (one person s oppositionality is another s rigidity or insistence on sameness) Is there comorbidity in ASD? Yes & at a higher rate than in the general clinical population 70 80% of people with ASD meet criteria for additional diagnoses 57% had more than one additional diagnosis (Leyfer = 50%) ADHD Old DSM criteria versus new Over 80% in one study; others much lower Extremely high in general clinic population Problem of diagnosis- social attention & motivation General relationship to social behavior 2
Anxiety Phobias Overall w/any Anxiety Disorder: 41.9% Social Anxiety Disorder: 29.2 Generalized Anxiety Disorder: 13.4% Panic Disorder: 10.1% Obsessive Compulsive Disorder: 8.2% * (Simonoff, et al., 2008) * = lower than others have found (Leyfer, 2006 = 37.2%); diagnostic tool used requires purposeful quality to obsess/compuls Oppositional Defiant Disorder Old criteria, comorbidity was about 28% DSM-5 has three groups of symptom types angry/irritable mood, argumentative/defiant behavior vindictiveness May not fit as well Mood Disorders Estimated 1-12% Hard to diagnose because of withdrawal, lack of interest, etc. Rate thought to be higher in HFA, AS Suicide risk higher than in general population Role of psychotic symptoms unclear 3
Bipolar Disorder Some studies have identified bidirectional overlap (~30% in on BPD study) Certainly observed in clinical practice Can be difficult to tease apart Psychosis Some studies report slightly higher than general clinical population for AH, VH, del Inconsistent finding Problem with assessment Threshold for dx should be high in ASD Treatments General considerations For people with ASD, environment is crucial Psychoeducation is key for individual and parents Communication of internal experience can be a problem Social contact Healthy habits Sleep Diet Exercise 4
General considerations Our kids set themselves up for psychiatric problems Effective Interventions: Adult-led Goal-directed Measurable objectives Homework General Supports Safe address Clear guidelines Consistency in expectations and routines Advance warning of changes Written or picture supports Physical activity Minimize over-stimulating and unstructured times Watch for negative peer interactions ADHD Treatments Pharmacology Behavior management Stop and think interventions Problem solving Motor breaks Alternating activities Self-monitoring, self-reinforcing Social skills instruction 5
Anxiety Treatments Social Anxiety Cognitive Behavioral Therapy Exposures Relaxation techniques Group formats Skills training Insistence on school attendance is critical Anxiety Treatments Generalized Anxiety Disorder Acceptance and Commitment Therapy Cognitive behavioral therapy Relaxation training Cognitive restructuring Behavioral activation Coordination with classroom teachers is key Gentle pushing and gradual exposures Anxiety Treatments Specific Phobias Is it worth it? Behavior therapy (exposures) Flooding (CAUTION) Systematic desensitization Counter-Conditioning Kids do this to themselves with special interests 6
Anxiety Treatment Panic Disorder Environmental manipulation Prevention Cognitive behavioral therapy Relaxation training Cognitive restructuring Anxiety Treatments Obsessive-Compulsive Disorder Cognitive Behavior Therapy Exposure with Response Prevention Parent education piece crucial Coordination with all adults who interact with child is critical if response prevention is attempted ODD Treatment Oppositional Defiant Disorder Behavior management from adults Set plan Consistency Support for plan from home is key Home-based services likely required Collaborative Problem Solving Skills-building focus 7
Depression Treatment Acceptance and Commitment Therapy Cognitive behavioral therapy Healthy habits Pleasant events Cognitive restructuring Participation in activities at school Support accomplishments, capacities Physical activity Bipolar Disorder Treatment Some responsiveness to CBT Psychoeducation about nature of disease Adult structure and support Secure environment Coordination among team Data collection; antecedent management Consistent behavior plan 8