Signs of ASD in Children
Autism Spectrum Disorder (ASD) is a developmental condition affecting a person's ability to socialize and communicate with others. It can also present with restricted and/or repetitive behavior patterns, interests, or activities. ASD is considered a “spectrum” because some people diagnosed with this disorder are mildly affected while others are severely disabled.[1]
Approximately 1-in-100 people are on the autism spectrum[2] and the CDC reports that roughly 1-in-36 children has been identified with ASD.[3] People with ASD typically get diagnosed in their early years since symptoms of ASD often begin to appear during the first three years of life.[4] Some symptoms of ASD in children may include:[5,6]
Difficulty engaging in everyday human interactions
Intense specific interests
Different ways of interacting with others
Failing to make eye contact
Not responding to their name
Playing with toys in unusual, repetitive ways
Severe tantrums or non-compliance
Destructiveness
Self-injurious behavior
They may sleep less or are awake frequently during the night
Co-Morbid Mental Health Conditions in Children with ASD
Autism Spectrum Disorder is one of the most common disabilities affecting children and has drawn many researchers to investigate the well-being of children affected by ASD’s well-being. Studies show children with ASD are at higher risk of developing a mental health condition; Melissa (2021) notes that it is reported that more than three-quarters of children with ASD have at least one co-morbid mental health condition. Based on the statistic, children with ASD are likely to develop a mental health condition which is more than children with an intellectual disability, special health care needs, or the general population.[7]
The most common mental health conditions children with ASD experience, in order, are behavioral/conduct problems, attention-deficit/hyperactivity disorder (ADHD), anxiety, and depression.[8] Research has found certain factors have been tied to an increased likelihood of specific mental health conditions compared to others. For example:
Females with ASD are more likely to have anxiety;
Children with ASD and intellectual impairments are more likely to have behavioral problems;
Children with ASD who experience multiple adverse childhood experiences have greater odds of anxiety and ADHD.[9]
Age is yet another factor that affects how mental health conditions present in children, as emotional, behavioral, and social difficulties can influence the timing of an autism diagnosis. Early childhood diagnoses usually present with greater emotional, conduct, hyperactivity, and social difficulties. Meanwhile, late-diagnosed children often have mental health and social difficulties before diagnosis that become more severe as they enter adolescence.[10]
Multiple reasons contribute to children with ASD's high risk of developing mental health conditions. The Mental Health Foundation (2022) notes that children with ASD may struggle in trying to fit into or make sense of the world, which can lead them to have feelings of depression and anxiety.[11] The act of camouflaging or strategizing to hide autistic traits also contributes to higher levels of depression, anxiety, and stress in adolescents and adults with ASD.[12] Children with ASD are more likely to face stigma and discrimination because of their disorder,[13] and those with internalizing problems (e.g., feelings of guilt, fear, worry, depression or anxiety) are more likely to be victimized by bullying.[14] Lastly, children with ASD may face difficulties receiving the proper care for their mental health conditions, including delays in diagnosis and lack of appropriate support available (e.g., therapists trained to work with autistic children).[15]
Co-Morbid Condition Effects
Categorized as an internalizing behavior of ASD, anxiety is an excessive feeling of worry about a variety of events and activities over a long period. Perihan, et al., (2021) and Shea et al., (2018) found that internalizing problems may predict externalizing problems (e.g., aggression, conduct issues, and hyperactivity) in children with ASD.[16,17] Children with ASD and ADHD have been found to express a more substantial severity of autistic symptoms than patients with ASD alone; this increase in symptoms may result from inattention, impulsivity and hyperactivity.[18] Greene & Sherrel (2022) report that obsessive-compulsive disorder (OCD) is also found comorbidity with ASD.[19] Repetitive behaviors and hoarding are common in mild forms of autism, and Bejerot (2007) has shown that a combination of ASD and OCD results in a more severe and treatment-resistant form of OCD.[20]
Example of visualized language cards.
Mental health treatment options
Treatment for mental health conditions in autistic children often has to be tailored to accommodate how they individually communicate and make sense of the world around them. For example, existing clinical anxiety programs for neurotypical children use communication and the relationship between clients and therapists to treat the condition. However, since children with ASD experience social and communication difficulties, they may experience difficulty interacting with their therapists and understanding the therapeutic social and emotional contexts that foster successful treatment. Research has found visualization to be one of the most effective treatment strategies in promoting effective social interaction and communication in children with ASD and utilizing visualized language significantly improves the success of anxiety treatment in children with ASD.[21]
Cognitive behavioral therapy (CBT) is another treatment option for children with autism spectrum disorder and mental health conditions (e.g., anxiety, depression and ADHD) and works by teaching children how to alter their beliefs or behaviors to avoid negative emotions.[22] The cognitive component of the therapy helps children change how they think about a situation, while the behavioral component helps change how they react.[23] Modifications to CBT techniques are often needed to provide a more successful treatment to children with ASD and therapists may include concrete, repetitive, and visual tactics and focus on the child's unique interests to hold their focus. Additionally, a therapist may have to incorporate frequent movement breaks or sensory activities for children with attention or sensory under- or over-reactivity.[24]
The role of community
The mental health of children with ASD has been shown to improve as a result of community support. Caregivers of children with autism should be aware that feeling tired or hungry can increase the severity of the child’s mental health condition(s).[25] Additionally, families should be aware that accommodating anxiety by removing the source of anxiety in response to a child's outburst is not as beneficial as one would imagine it should be. Storch et al. (2015) studied the effects of family accommodation on anxiety levels of children with ASD and found that lower levels of family accommodation can actually lead to lower levels of anxiety.[26] It is also important that caregivers take care of their own physical and psychological needs since raising a child with ASD can be difficult to navigate; this will benefit the caregiver as well as the child as levels of parental psychological stress have also been positively correlated to anxiety symptoms in children and adolescents with ASD.[27]
Further, O'Connor et al., (2022) note that young people with ASD who have more positive friendship features present with fewer signs of depression.[28] Supporting children with ASD to have healthy, positive relationships can improve their overall mental health. Additionally, O’Connor et al. recommend teaching non-autistic children how to be supportive friends to their autistic peers in order to help more autistic children experience the positive effects of friendship.[29]
If you are the parent or caregiver of a child with ASD and are experiencing signs of significant stress, anxiety and/or depression, please reach out to a licensed mental health provider who can help you navigate through the nuances of this disorder as well as any stressors you may be experiencing.
Contributed by: Maria Karla Bermudez
Editor: Jennifer (Ghahari) Smith, Ph.D.
References
1 Autism. NAMI. (n.d.). Retrieved February 27, 2023, from https://www.nami.org/Learn-More/Mental-Health-Conditions/Related-Conditions/Autism#:~:text=Children%20with%20autism%20can%20also,conditions%20than%20children%20without%20autism.
2 Autism and mental health. Mental Health Foundation. (2022, February). Retrieved February 27, 2023, from https://www.mentalhealth.org.uk/explore-mental-health/a-z-topics/autism-and-mental-health
3 Data & Statistics on Autism Spectrum Disorder. Centers for Disease Control and Prevention. (2023, April). Retrieved August 23, 2023, from https://www.cdc.gov/ncbddd/autism/data.html
4 NAMI
5 Ibid.
6 Payakachat, N., Tilford, J. M., Kovacs, E., & Kuhlthau, K. (2012, August). Autism spectrum disorders: A review of measures for clinical, health services and cost-effectiveness applications. Expert review of pharmacoeconomics & outcomes research. Retrieved February 27, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3502071/
7 Melissa J. (2021, March). Mental health conditions seen in 78% of children with autism. Retrieved February 27, 2023, from https://publications.aap.org/aapnews/news/11976?autologincheck=redirected
8 Ibid.
9 Ibid.
10 Mandy, W., Midouhas, E., Hosozawa, M., Cable, N., Sacker, A., & Flouri, E. (2022). Mental health and social difficulties of late-diagnosed autistic children, across childhood and adolescence. Journal of child psychology and psychiatry, and allied disciplines, 63(11), 1405–1414. https://doi.org/10.1111/jcpp.13587
11 Mental Health Foundation (2022)
12 Bernardin, C. J., Lewis, T., Bell, D., & Kanne, S. (2021). Associations between social camouflaging and internalizing symptoms in autistic and non-autistic adolescents. Autism : the international journal of research and practice, 25(6), 1580–1591. https://doi.org/10.1177/1362361321997284
13 Mental Health Foundation (2022)
14 Cappadocia, M. C., Weiss, J. A., & Pepler, D. (2012). Bullying experiences among children and youth with autism spectrum disorders. Journal of autism and developmental disorders, 42(2), 266–277. https://doi.org/10.1007/s10803-011-1241-x
15 Mental Health Foundation (2022)
16 Perihan, C., Bicer, A., & Bocanegra, J. (2022). Assessment and Treatment of Anxiety in Children with Autism Spectrum Disorder in School Settings: A Systematic Review and Meta-Analysis. School mental health, 14(1), 153–164. https://doi.org/10.1007/s12310-021-09461-7
17 Shea, N., Payne, E., & Russo, N. (2018). Brief Report: Social Functioning Predicts Externalizing Problem Behaviors in Autism Spectrum Disorder. Journal of autism and developmental disorders, 48(6), 2237–2242. https://doi.org/10.1007/s10803-017-3459-8
18 Banaschewski, T., Poustka, L., & Holtmann, M. (2011). Autismus und ADHS über die Lebensspanne. Differenzialdiagnosen oder Komorbidität? [Autism and ADHD across the life span. Differential diagnoses or comorbidity?]. Der Nervenarzt, 82(5), 573–580. https://doi.org/10.1007/s00115-010-3239-6
19 Greene N, Sherrell Z.(2022, March). ADHD vs. OCD: Differences, symptoms, treatment, and more. Medical News Today. Retrieved February 27, 2023, from https://www.medicalnewstoday.com/articles/adhd-vs-ocd
20 Bejerot S. (2007). An autistic dimension: a proposed subtype of obsessive-compulsive disorder. Autism : the international journal of research and practice, 11(2), 101–110. https://doi.org/10.1177/1362361307075699
21 Perihan et al., (2022)
22 Cognitive behavioral therapy for autism spectrum disorder in children. Patient Care at NYU Langone Health. (n.d.). Retrieved February 27, 2023, from https://nyulangone.org/conditions/autism-spectrum-disorder-in-children/treatments/cognitive-behavioral-therapy-for-autism-spectrum-disorder-in-children#:~:text=Cognitive%20behavioral%20therapy%20may%20be,behaviors%20to%20avoid%20negative%20emotions
23 Ibid.
24 Schorr, B. (2021, April 28). Cognitive behavioral therapy for autism. Hidden Talents ABA. Retrieved February 27, 2023, from https://hiddentalentsaba.com/cognitive-behavioral-therapy-for-autism/
25 Behavioral Innovations. (2023, January 5). Autism and impact on mental health. Behavioral Innovations - ABA Therapy for Kids with Autism. Retrieved February 27, 2023, from https://behavioral-innovations.com/blog/autism-and-impact-on-mental-health/
26 Storch, E. A., Zavrou, S., Collier, A. B., Ung, D., Arnold, E. B., Mutch, P. J., Lewin, A. B., & Murphy, T. K. (2015). Preliminary study of family accommodation in youth with autism spectrum disorders and anxiety: Incidence, clinical correlates, and behavioral treatment response. Journal of anxiety disorders, 34, 94–99. https://doi.org/10.1016/j.janxdis.2015.06.007
27 Guerrera, S., Pontillo, M., Tata, M. C., Di Vincenzo, C., Bellantoni, D., Napoli, E., Valeri, G., & Vicari, S. (2022). Anxiety in Autism Spectrum Disorder: Clinical Characteristics and the Role of the Family. Brain sciences, 12(12), 1597. https://doi.org/10.3390/brainsci12121597
28 O'Connor, R. A. G., van den Bedem, N., Blijd-Hoogewys, E. M. A., Stockmann, L., & Rieffe, C. (2022). Friendship quality among autistic and non-autistic (pre-) adolescents: Protective or risk factor for mental health?. Autism : the international journal of research and practice, 26(8), 2041–2051. https://doi.org/10.1177/13623613211073448
29 Ibid.