Slide 1: Introduction s1

This lecture was produced for the VCU-ACE Foundations of ASD Course. The transcript is intended for use by participants in the online course. Please do not disseminate this material without the permission of VCU-ACE staff.

Introduction

Hi my name is Joy Engstrom. I am the Training and Technical Assistance Coordinator at the VCU Autism Center for Excellence. I will be presenting on comorbidity.

Comorbidity

 Comorbid means that in addition to the primary disorder the individual has one or more other diagnosed disorders.

 The purpose of this module is to bring to your attention some of the common characteristics of the comorbid disorders and the importance of observing behavior.

Autism alone is a complex developmental disability when coupled with another disorder it can create additional challenges for the person, family, and those who support them whether it’s a teacher, therapist or other service provider. Let’s start by defining comorbid. Comorbid means that in addition to the primary disorder the individual has one or more other diagnosed disorders. There are several disorders that individuals might have in addition to autism. Some of the more common ones are; Sensory processing disorder, Attention Deficit Hyperactivity Disorder (ADHD), Seizure Disorder, Generalized Anxiety Disorder (GAD), Depression, Tourette syndrome, Obsessive Compulsive Disorder (OCD), and Bipolar Disorder. As I talk about the disorders you may notices some overlap between the characteristics of Autism and the characteristics of the comorbid disorders. The purpose of this module is to bring to your attention some of the common characteristics of the comorbid disorders and the importance of observing behavior. It is important to know what “typical” behavior is for the individual with ASD so that you can identify when something is different. As we review the characteristics of some of the comorbid disorders I would like for you to think about how the disorders overlap and how they are different. In the next few slides I will give a brief overview of the different disorders and talk about what they might look like with an individual with ASD. Slide 3: Sensory processing

 Many individuals with ASD also have a sensory processing disorder.

 They may be hypersensitive which means that they are extremely sensitive to items in the environment.

 They may be hyposensitive which means that they require the sensation to be stronger in order to react to it.

 Sensory processing disorder might also present in individuals with autism as trouble with movement, coordination or sensing where one’s body is in space.

It should be noted that sensory processing disorder is not a disorder that is currently found in the diagnostic and statistical manual, it is however a term that is synonymously used for sensory integration dysfunction. During this presentation we will use the term sensory processing disorder. As we discussed earlier, many individuals with ASD also have a sensory processing disorder. This affects how they experience the world around them. The way that an individual’s brain process sensory information is often either hypersensitive or hyposensitive. Let’s take a second to revisit these two terms. Hypersensitive means that they are extremely sensitive to items in the environment. For example the scratching tags in their shirt, or the flicker of florescent lights. I worked with one student with Asperger’s syndrome who reported being able to hear the electricity running through underground electrical lines. Or they may be hyposensitive to certain sensations. As we talked about in the previous section, hyposensitive means that the individual requires the sensation to be much stronger in order for them to have a reaction to it. For example, Tomika, a teenager with autism likes to eat spicy foods. She puts hot sauce on everything and often complains that there is no taste if it is not spicy. Often, the child's reactions to sensory input whether hypo or hyper sensitive may be viewed as misbehavior. Picture if you will a student walking in line down the hall. They are getting bumped and jostled from behind and get agitated. This would be a child who is hypersensitive. Or you may have the reverse, a student who is in line but stands too close to the student in front of them, walking right on their heels. This is an example of a student who is hyposensitive. You can see how this might be misinterpreted as misbehavior when in fact it is a student communicating that they are having difficulty processing the sensory information in this situation.

Sensory processing disorder might also present in individuals with autism as trouble with movement, coordination and sensing where one’s body is in space. This often leads to clumsiness and difficulty with tasks such as dressing, navigating crowded hallways, and playing sports. An example that some of you might be familiar with is, a teacher directs students to come and sit on the rug at the front of the room. Bobby, a student with ASD , while trying to make his way to his spot, steps on the hands of two of his classmates and knocks a third child over. None of this is intentional but without the proper supports you can see how this can be difficult for Bobby as well as for his classmates.

Attention Deficit Hyperactivity Disorder (ADHD)

 The characteristics that impact functioning in the classroom the most are inattention, distractibility, inability to sit still, and difficulty taking turns.

 The second subtype is inattentive or what was commonly known as ADD.

 The characteristics that impact functioning in the classroom the most are inattention, distractibility, inability to sit still, and difficulty taking turns.

Another disorder you might see co-diagnosed is Attention Deficit Hyperactivity Disorder often referred to as ADHD. There are subtypes of ADHD, Hyperactivity and/or Inattentive. Children can be diagnosed with either subtype or combined. For example, Mark, 7 years old boy with autism, spends some of his educational day in a 2nd grade class and part in a special education classroom. When he is in his 2nd grade class, he has a hard time staying in his seat. He fidgets while in large group activities and often plays with the threads in the rug when he is sitting on the front carpet for group activities. People who are hyperactive always seem to be in motion. They can't sit still. Like Mark, they may dash around or talk incessantly. Sitting still through a lesson can be an impossible task. Hyperactive children squirm in their seat or roam around the room. Or they might wiggle their feet, touch everything, or noisily tap their pencil. Hyperactive children and teens may feel intensely restless. The second subtype is inattentive or what was commonly known as ADD. Lisa is five years old with ASD and has a difficult time taking turns during center time both at school and in after school care. She often blurts out answers to questions or random thoughts during art activities or small group reading. People who are overly impulsive seem unable to curb their immediate reactions or think before they act. As a result, like Lisa, they may blurt out inappropriate comments. Or like Mark, they may run into the street without looking. Their impulsivity may make it hard for them to wait for things they want or to take their turn in games. They may grab a toy from another child or hit when they're upset. The characteristics that impact functioning in the classroom the most are inattention, distractibility, inability to sit still, and difficulty taking turns. Jessie, a girl with Asperger’s syndrome, has been given a quiz to complete. She continues to talk to the other students around her, she gets out of her seat several times, and takes several minutes to just write her name on the paper. Based on what we have talked about in the sensory presentation and on the previous slide, I’m sure you can see how it might be difficult to really tease out the differences between sensory processing disorder, or ADHD coupled with Autism based on symptoms alone. Whatever the cause, ADHD, Autism, or sensory processing disorder, it is important to provide the necessary supports to help the individual be successful. That can look like visual supports, proximity control (so that you stand closer to the student during difficult times), or other systems that are worked out with the educational team.

General anxiety disorder

 General anxiety disorder (GAD) is characterized by excessive and uncontrollable worry about everyday things.

 People with general anxiety disorder experience symptoms such as tension, being startle easily, restlessness, worrying, fear, and rumination.

 In individuals with ASD, general anxiety disorder often leads to lower levels of social supports, and poor academic outcomes.

General anxiety disorder (GAD) is characterized by excessive and uncontrollable worry about everyday things. It is normal to worry and feel anxious from time to time. It becomes a problem when the frequency, intensity, and duration of the worry are disproportionate to the actual source of worry, and such worry often interferes with daily functioning. People with general anxiety disorder often have a variety of symptoms such as tension, being startle easily, restlessness, hyperactivity, worrying, fear, and rumination. For example, John a young man with Asperger’s syndrome had a conversation with his teacher about changes that he needed to make to the story he wrote during English class. He is upset and spends the day thinking about the conversation over and over in his head. He cannot get any work done the rest of the day and continues to worry that his paragraph was not good. Another example is Sammy a boy with ASD, who also has a diagnosis of GAD. Sammy is easily frightened by fire drills and will catastrophize the meaning of the fire drill thinking that the school will burn down and he will lose his desk and that people will be hurt. In individuals with ASD, general anxiety disorder often leads to lower levels of social supports, and poor academic outcomes in addition to a lack of understanding of whether the anxiety is truly anxiety or a “behavior” that needs to be addressed behaviorally. General anxiety disorder differs from other anxiety disorders in the sense that there is no clear “trigger” that elicits anxiety or was associated with its onset.

Depression  Mood symptoms in autism have been described since the earliest description of the disorder.

 A person with ASD may face a range of difficulties across three broad areas: social communication, social understanding and imagination.

 People’s experience of depression usually occurs on a continuum ranging from very mild to very severe.

People with ASD are prone to depression especially in late adolescence and their twenties. In fact mood symptoms in autism have been described since the earliest descriptions of the disorder. But they often have trouble communicating these feelings of disturbance, anxiety or distress and it is common for these to go undiagnosed until the effects are very evident. A person with ASD may face a range of difficulties across three broad areas and they may experience these difficulties to varying degrees. The three broad areas of functioning that are directly impacted by depression include: social communication, social understanding and imagination. Depression lowers an individual’s desire to interact socially with others and those individuals with ASD who suffer from depression are at a greater risk of social isolation due to pre-existing social difficulties in the areas of social communication and social understanding. The person can have increased difficulty in initiating and maintaining appropriate social interaction with others, establishing and maintaining friendships and being able to anticipate what will happen in given situations. As you may remember we talked about this in detail in the social skills presentation in module one. People’s experience of depression usually occurs on a continuum ranging from very mild to very severe and include changes in mood, change in behavior, and changes in eating and sleeping patterns. Paul, a 7 year old with autism, enjoyed playing kickball at recess and would look forward to doing so every day after lunch. Over the period of about a week, he started eating less and less at lunch, sitting by himself and not talking to his friends. At recess his teacher notices that he does not play kickball, but instead sits under a tree picking at the grass. What used to be fun for him does not seem to interest him any longer.

Obsessive compulsive disorder  Obsessive compulsive is sometimes used in an offhand comment.

 Obsessions and compulsions are recurrent and persistent thoughts, impulse or images that are intrusive and inappropriate and that cause noticeable distress.  Most individuals with OCD realize that they don’t have to repeat the behaviors over and over again.

 It is believed that autism and OCD based repetitive thoughts and behaviors are quite similar in the early stages of development, but become dissimilar over time.

“Obsessive-Compulsive” is often used in an offhand comment to describe someone who is particular or engrossed in an activity or thought. You probably know someone who you think may be excessive about something, like organizing their desk for example. You may think “boy that person is obsessive” which may or may not be true. These informal references should not be confused with obsessive-compulsive disorder which is a specific and well-defined condition. The DSM describes these obsessions and compulsions as recurrent and persistent thoughts, impulses, or images that are intrusive and inappropriate and that cause noticeable distress.

Compulsions can be described as repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession. These acts are aimed at preventing or reducing distress or preventing some dreaded event or situation. These behaviors or mental acts either are not connected realistic or are excessive in nature. Most individuals with OCD realize that they really don't have to repeat the behaviors over and over again, but the anxiety can be so great that they feel that repetition is "required" to neutralize the uncomfortable feeling. And often the behavior does decrease the anxiety- but only temporarily. For example, if a child is obsessed with germs or dirt, he may develop a compulsion to wash their hands over and over again. Another example is a student who writes his name, erases it, writes it again, and erases it again, repeating these steps several times before he can move on to the rest of his worksheet.

While autism and OCD can occur comorbidly, it is more common for individuals with autism to display behaviors that are similar to those of OCD, but that are in fact a part of their autism symptom disorder and not a separate case of obsessive compulsive disorder. The key is knowing that the obsessions or compulsions are excessive that makes it OCD. Nonetheless, it is believed that autism and OCD based repetitive thoughts and behaviors are quite similar in the early stages of development, but become dissimilar over time as they often serve different functions within the two disorders. I once taught Tommy, a young man with ASD, who had a compulsion that people could not cross their arms or legs. This affected him in all environments. He could not concentrate at school if one of his classmates crossed their arms or legs in class or in the hallway. One time when he was out shopping with his mom, they were in the checkout line at his favorite store and the man in front of them had his arms crossed. Tommy yelled “arms down” several times and then attempted to uncross the man’s arms. Without knowing Tommy you might attribute this to challenging behavior when in fact it was his OCD.

Tourette syndrome  Tourette syndrome is a neurological disorder that is characterized by the person exhibiting repetitive involuntary movements or vocalizations.  Simple motor tics are sudden, brief, repetitive movements.  Complex tics are coordinated patterns of movements involving several muscle groups.  Tics are often worse with excitement or anxiety and better during calm, focused activities. Tourette syndrome is a neurological disorder that is characterized by the person exhibiting repetitive involuntary movements or vocalizations. These are referred to as tics. Tics are classified as either simple or complex. Simple motor tics are sudden, brief, repetitive movements that involve a limited number of muscle groups. Some of the more common simple tics include eye blinking and other vision irregularities, facial grimacing, shoulder shrugging, and head or shoulder jerking. Simple vocal tics may include throat-clearing, sniffing/snorting, grunting, or barking. Kathie, a girl that I taught with Asperger’s syndrome, would make clicking noises with her tongue when she engaged in silent reading Complex tics are coordinated patterns of movements involving several muscle groups. Complex motor tics might include facial grimacing combined with a head twist and a shoulder shrug. Other complex motor tics may actually appear purposeful, including sniffing or touching objects, hopping, jumping, bending, or twisting. More complex vocal tics include words or phrases.

Tics are often worse with excitement or anxiety and better during calm, focused activities. Certain physical experiences can trigger or worsen tics, for example tight collars may trigger neck tics, or hearing another person sniff or throat-clear may trigger similar sounds. Some with TS will describe a need to complete a tic in a certain way or a certain number of times in order to relieve the urge or decrease the sensation. Tommy, the boy mentioned in the section about OCD also has Tourette syndrome, and when he is excited or anxious he rubs his hands together in a rapid back and forth motions and shouts “I’m ready” “I’m ready”. This complex constellation of symptoms is secondary to his primary diagnosis of autism.

Seizure disorder  Another common comorbid disorder is seizure disorder.

 There are several different types of seizures some of which are; Absence, Tonic, Atonic and Clonic.  Atonic seizures are often revered to as “drop seizures.”

Another common comorbid disorder that we need to be aware of when supporting individuals with ASD is seizure disorder. It is estimated that about 1 in 4 individuals with ASD will be diagnosed with a seizure disorder. Often times the person will not begin to exhibit seizures until adolescence. It is unknown as to why we see an increase in the possibility of seizures developing during adolescences but one theory is changes in hormonal levels. Seizures are caused by abnormal electrical activity in the brain. There are several different types of seizures some of which are; Absence, Tonic, Atonic and Clonic. An absence seizure is characterized by brief episodes of unresponsive starring. They usually last about 10 seconds but can last as long as 20 seconds. Tonic seizures usually occur when the person is asleep. They last on average 20 seconds and is characterized by increased muscle tension in the body, arms and legs. Atonic seizures are often revered to as “drop seizures.” They typically last anywhere from 10 to 20 seconds. They are called drop seizures because the individual loses consciousness and muscle tone and drops to the floor. The last seizure we will talk about as part of this presentation is a Clonic seizure. A Clonic seizure varies in length and is characterized by rapid alternation of the individual’s muscles from contracted to relaxed resulting in a jerking motions. It is important to know that you cannot stop this motion by restraining the person. Instead you should ensure the safety of the individual by protecting the individuals head. Is should also be noted that seizures required medical treatment and can be controlled through medication.

Intellectual Disability

 Intellectual Disability was recently adopted to replace the term mental retardation.

 While it was once believed that 75% of individuals with ASD also had ID, we are finding that to no longer be the case.

 Some individuals with ASD also have ID.

 What is evident from current research is that those with ID and ASD are distinctly different from persons with ID or with normal IQ and ASD. Intellectual Disability was recently adopted to replace the term mental retardation. Intellectual Disability or ID is a term for a pattern of persistently slow learning of basic motor and language skills ("milestones") during childhood, and a significantly below-normal global intellectual capacity as an adult. ID is diagnosed though standardized IQ testing resulting in a score of less than 70. Additionally, there is a significant delay in adaptive functioning or the skills needed to live independently. Certain skills are important to adaptive behavior, such as: daily living skills, such as getting dressed, using the bathroom, and feeding oneself ; communication skills, such as understanding what is said and being able to answer social skills with peers, family members, spouses, adults, and others. While it was once believed that 75% of individuals with ASD also had ID, we are finding that to no longer be the case. As educator we are coming to realize that that scores achieved by giving an IQ test are not representative of the individuals IQ. According to the National Research Council, in order for an individual with ASD to demonstrate their true ability on an IQ test, they must be able to quickly respond to verbal questions, have well developed motor skills and be able to communicate what you know to a stranger. While some individuals with ASD also have ID, it is important that they not be defined by their IQ score but rather it should be considered one component of the individuals learning profile. The study of ASD and comorbidity with ID is a relatively new phenomenon. The possibility of ID has not been factored into the diagnostic profile and we have not yet developed assessment tools sophisticated enough to help us to understand who may have ASD, who may have ID, and who may indeed have both. What is evident from current research is that those with ID and ASD are distinctly different from persons with ID or with normal IQ and ASD.

Conclusion

 Many individuals with ASD have or will have a comorbid disorder.

As we have discussed throughout this presentation, ASD alone is a complex developmental disability. But when coupled with another disorder it can create additional challenges for the person, family and those who support them throughout their life, whether it’s a teacher, therapist or other service provider. As many individuals with ASD have or will have a comorbid disorder, it is important to be familiar with the typical behavior of the individual with ASD so that one can identify when something is different and assist the person with ASD in obtaining assistance as it is needed.