AUTISM Mental Health Issues& A guidebook on mental health issues affecting individuals with Autism Spectrum Disorder Introduction to Autism& Mental Health utism is a neuro-developmen- performance and sustainability. For example, tal disorder that is typically studies have looked at students diagnosed diagnosed by age three and is with ADHD, pediatric bipolar disorder, a lifelong disability. It has an depression and anxiety, and have found simi- impact on three main areas in lar outcomes. Van Ameringen, Mancinia, Aa person’s life: social development, commu- and Farvoldenb (2003)1 found that anxiety nication skills and restricted interests. As a disorders are associated with a higher rate of spectrum disorder, autism can affect some- early school withdrawal. Pavuluri, O’Connor, one in mild to severe ways in these areas. Harral, Moss and Sweeney (2006)2 studied In addition, we see sensory and behavioral pediatric bipolar disorder and ADHD and differences that can become barriers to fully noted that no difference between these two participating in one’s education. groups of students existed when looking at academic performance. Both groups expe- Students on the autism spectrum often rienced difficulties with attention, memory, have a co-existing mental health disorder and problem solving. All of these issues that may be undiagnosed. Professionals served to contribute to poor academic per- have little information on this topic and formance. Similarly, students diagnosed with frequently miss the signs and symptoms of a depressive mood disorders have been related co-existing mental health disorder. Teachers to lower academic achievement3. There is a are left unequipped in their classrooms to high percentage of students diagnosed with determine what is motivating their stu- Pervasive Developmental Disorder Not Oth- dents with autism to behave in ways that erwise Specified who have been determined challenge their education. The assump- to have a co-existing mental health issue. tion of most people is that all behaviors are related to a student’s autism diagnosis. The information contained in this docu- This assumption will leave mental health ment is to provide the reader with signs issues that exist untreated and may, in fact, and symptoms of autism and mental health exacerbate symptoms. concerns, what educators need to know, managing a crisis, and resources that are The research indicates that mental health available to support students, their families issues have a negative impact on academic and educators. 2 ABOUT MENT A L HE A LT H SCREENING addition, the Autism Spectrum Disorder- Screening for Comorbid for Children (ASD-CC) is a 49-item informant based rating scale Mental health screening tools designed to identify emotional difficulties Comorbid that commonly occur with ASD. A mental health screening tool is a brief, Psychiatric culturally sensitive questionnaire for identify- Important steps to remember when ing individuals who may have mental health implementing and interpreting the challenges that merit further attention, Conditions in intervention, or evaluation4,5 screen 1. Obtain parental consent and student • Screening tools can serve three pri- assent before administering screening. Students with mary purposes: 2. Administer screening in a confidential 1. Assess an individual’s symptoms. area, and prioritize privacy of results. Autism Spectrum 2. Measure progress after intervention has begun. 3. Remember clinical judgment can over- ride results from a screening assessment. Disorders 3. Provide a framework for discussing an A student who does not meet a particular individual’s challenges. cut-off score on a screening tool may still • A screening tool is not a diagnostic tool need further evaluation. but rather a “triage” process. A positive 4. Notify and offer assistance in connect- screen does not necessarily mean a stu- ing parents of any student found to be in dent meets criteria for a diagnosis. Only a need of further evaluation with a local trained clinician is qualified to interpret mental health professional. screening results. 5. Immediately refer to a trained profes- First steps in implementing the sional any student who screens positive screening process6 for suicidal or homicidal ideation. • Develop a planning committee comprised of parents, educators, mental EXT TEP S health experts, primary care providers, N S and other representatives from the com- munity. The planning team will: 1. Formulate a “Planning Team” com- prised of relevant individuals from school » Develop policy ensuring confidential- ity safeguards are in place. and community to develop confidential- ity policy, formalize community liaisons, » Draft agreements between schools and make critical decisions about the and collaborating community providers screening process (e.g., when to screen clarifying responsibilities in order to facilitate the collaborative process and and what tools to use). address liability issues. 2. Ensure adequate staff training on » Ensure policies are approved by screening tool implementation, scoring, appropriate education and mental and interpretation. health boards. 3. Designate contact person within the » Determine when to administer the school to oversee the screening process. screen (e.g., transitional grades: 6th–7th, 4. Obtain parent consent and student and 9th–10th) and what tools to use. assent before administering screen. » Ensure adequate staff training and 5. Make appropriate referrals based on supervision on how to administer, screening results, including immediate score, interpret the data, and refer to referral for positive screen for suicidal or community providers, etc. homicidal ideation. » Identify a “Screening Coordinator” (e.g., guidance counselor, nurse) who assumes responsibility for the screening process. • A list of recommended screening tools can be found at http://www2.massgen- eral.org/schoolpsychiatry. The majority of these screening tools have not been stud- ied in individuals with ASD, and results should be interpreted cautiously. In 3 While the core deficits of autism have been • This policy warrants reconsideration due to Signs of Possible well-studied, a less investigated cause of the large number of individuals with clini- impairment in individuals with ASD is the cal symptoms in these areas and the impli- occurrence of comorbid psychiatric disorders. cations for treatment that this presents. Mental Health Recent epidemiological studies have suggested that nearly three out of every four individuals ADHD with ASD meet criteria for another (comor- Conditions in ADHD may be the most common co- bid) mental health disorder7. Unfortunately, occurring psychiatric disorder among chil- comorbidities are often overlooked in the ASD Persons with dren with ASD, occurring in approximately population, with serious negative consequences 50% of one sample8. on quality of life, school and family function- Autism Spectrum ing, and access to appropriate treatment. • Other studies have estimated rates as fall- ing between 28.2% and 31%7,13. Disorders • The rate increased to nearly 55% when 13 PREV A LENCE OF MENT A L HE A LT H sub-threshold cases were included . Iss UE S IN ASD • ADHD in combination with ASD may confer significantly increased risk for a more complicated symptom presentation; Research has consistently indicated that nearly 85% of individuals with comorbid persons with ASD exhibit an increased risk ASD/ADHD met criteria for an addi- of developing psychiatric disorders, when tional disorder13. compared to the general population. • Studies within the last decade reveal rates Anxiety 7,8 between 67% and 70.8% of individu- Anxiety symptoms seem to be “part and als with ASD who would meet criteria parcel” of the everyday experience of many for an additional mental health disorder individuals with ASD, with a large number described within the Diagnostic and (over 40%) meeting DSM-IV criteria for Statistical Manual of Mental Disorders- specific anxiety conditions7. The most com- 9,10 Fourth Edition (DSM-IV) . mon anxiety diagnoses appear to be: • Having a comorbid psychiatric condition significantly increases the risk of multiple • Specific Phobias or fears (44%)—fear of diagnoses. specific objects, activities, or situations (e.g., heights, insects, the dark, storms, etc.). » 41% of the entire sample had 2 or more co-occurring disorders in addition to • Social Anxiety (29.2%)—fear of being ASD, with 17% having 2 disorders and negatively evaluated in social situations. 24% having 3 or more7. • Generalized Anxiety (13.4%)—persistent, • Evidence also suggests that individu- excessive, uncontrollable anxiety/worrying. als with ASD may be twice as likely to • Panic Disorder (10.1%)—recurrent exhibit comorbid disorders when com- panic attacks that are not associated with pared to those with non-ASD intellectual any specific stimuli. or developmental disabilities11,12. • Obsessive Compulsive Disorder (OCD) is also very common, although rates in Prevalence rates for the most common individuals with ASD have varied across co-occurring psychiatric disorders: studies from approximately 8% to more One of the challenges to diagnosing comor- than 33%7,13. bid psychiatric conditions in ASD is the » However, some level of compulsive result of specific exclusionary criteria within behavior may be observed in the major- the DSM-IV diagnostic system9,10. ity (>85%) of individuals with ASD14 indicated that the vast majority (86%) • In the DSM-IV, a diagnosis of autism of their sample exhibited some level of