Autism spectrum disorder is a developmental disorder that is very different from anxiety disorders and mood disorders like depression and bipolar disorder. People on the autism spectrum can still go on to develop these other disorders. In fact, autism may increase their risk for developing these disorders.
For those with co-occurring disorders of autism and mood disorders, treatment can be complex. The presence of autism can render standard methods of pharmacology or psychotherapy ineffective or actively harmful. Clinicians are experimenting with treatment methods that combine the best of standard mood disorder therapies and recognized autism therapies.
What Are Mood Disorders?
Mood disorders is an umbrella term for a number of mental health disorders that cause disturbances to emotional balance and regulation. This can look like long periods of excessive, unshakeable sadness (the depressive stage), impulsive and unstable joy (the manic stage), or both. Depression and mania are known as the two poles of mood disorders because they represent the two extremes.
In some people, only depression develops, and this is a unipolar disorder. Bipolar disorders, on the other hand, consist of periods of depression, periods of mania, and periods of euthymia (a relatively stable period where the person is neither manic nor depressive).
There are many different kinds of mood disorders. Some of them include:
- Major depressive disorder.
- Bipolar disorder.
- Seasonal affective disorder.
- Depression related to medical illness.
- Depression brought on by substance use, abuse, or medication.
Anxiety is not generally thought of as a mood disorder, although its symptoms and effects can overlap and occur simultaneously. Anxiety disorders make up their own separate category. Some examples are:
- Generalized anxiety disorder.
- Panic disorder.
- Post-traumatic stress disorder.
- Social anxiety disorder.
- Anxiety brought on by substance use, abuse, or medication.
Autism & Mood Disorders
In 2018, the Pediatrics journal published the results of a study that found children who have autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) have a higher risk for developing mood disorders and anxiety. The researchers conducting the study found that children with co-occurring ASD and ADHD were 2.7 times more likely to have mood disorders. “Mood disorders are highly prevalent in those with ASD,” said the lead author of the study.
The Pediatrics study is an addition to a large body of research that has found that autism spectrum disorder has overlapping features with mood disorders. For example, a study in 2008 published in Clinical Practice and Epidemiology in Mental Health reported that as many as 27% of children with autism spectrum disorder display symptoms of bipolar disorder.
But Autism Speaks notes that bipolar disorder and autism have a number of common symptoms and behaviors, which leads some children with ASD to be mistakenly diagnosed with bipolar disorder. In reality, their symptoms are the result of their autism.
Bipolar Disorder & Autism
Bipolar disorder has been linked to genetic traits. A person who has a family member with bipolar disorder or depression has a higher chance of developing one or both of those conditions than a person with no such family history.
Similarly, genetic traits play a role in the development of autism, but the degree of the role they play has not been fully determined. A JAMA Psychiatry article from 2016 noted that some of the genes that are connected to the development of bipolar disorder may be linked to the development of autism spectrum behaviors. This might explain why people who have ASD have a higher chance of showing the symptoms of bipolar disorder and why some diagnoses mistake one disorder for the other.
If an autistic person has bipolar disorder, it is possible that the conditions can present together, and their respective symptoms will be different than if either condition was present on its own.
While depressive behavior is very distinct from some of the symptoms of autism, mania can be much harder to recognize in someone who has autism. A sudden or dramatic shift of behaviors may be the result of mania. Otherwise, if the behaviors have been constant and somewhat predictable since the autism presented itself, the likelihood is stronger that the symptoms are more rooted in the autism than they are in bipolar disorder.
Anxiety Disorder & Autism
The Anxiety and Depression Association of America notes that anxiety disorder is not a “core feature” of autism spectrum disorder, but anxiety disorders are very common comorbid conditions in people who have autism. As many as 40% of people with autism spectrum disorder will develop “clinically elevated levels of anxiety.” They might go on to develop at least one recognized anxiety disorder, such as obsessive-compulsive disorder.
ADAA warns that anxiety can greatly influence the course of ASD, to the point where addressing the repetitive behaviors and social withdrawal can become extremely complicated. Additionally, untreated anxiety disorder in ASD has been linked to other mood and behavioral disorders, such as depression and self-injury. This makes early recognition and treatment vital for the safety of clients and very important for their long-term treatment prognosis.
The Current Opinion in Psychiatry journal notes that many of the symptoms of anxiety disorder and autism spectrum disorder overlap, which makes early recognition a challenge. Anxiety usually presents with different manifestations at different times, often associated with different environmental and contextual demands.
- Phobias: A specific phobia (one that poses little to no real danger) can come up early in the course of autism spectrum disorder due to over-responsiveness to sensory stimulation, like a loud noise. In clients who have both ASD and anxiety, these specific phobia tend to involve unusual stimuli, like a vacuum cleaner or a toilet flushing. They can also revolve around phobias that are more commonly associated with usual stimuli, such as spiders or darkness.
- Obsessive-compulsive disorder: This disorder itself is characterized by compulsive behaviors driven by intrusive thoughts. ADAA writes that “OCD is often comorbid with ASD,” which makes recognizing obsessive-compulsive disorder in autistic individuals vitally important. The repetitive behaviors of ASD are not related to distress, but the compulsive behaviors are directly carried out to relieve anxiety.
- Social anxiety: This can increase as the person grows older and their environment becomes more demanding. The inability to communicate can drive the development of social anxiety, which can become exacerbated if the person has high-functioning autism. This point on the spectrum affords them a degree of awareness about their social limitations, which can be a pronounced source of anxiety. Social anxiety (the intense fear of being embarrassed or “found out” in a social situation) prompts avoidance of social situations. This, in turn, reduces the person’s chances of practicing social skills, which greatly heightens anxiety levels when they inevitably have to engage in social practices. As Psychology Today explains, autism spectrum disorder and social anxiety are very distinct, but also very similar.
- Separation anxiety: The social impairment described above can lead to parents overcompensating by “protecting” their children, to the point of unwittingly building up prohibitive levels of avoidance behavior in their children. When the parent and child have to separate (for example, the child has to leave for college), this can trigger intense separation anxiety.
Children who have autism spectrum disorder can experience other atypical symptoms of anxiety, such as excessive stress stemming from any deviation in their daily routine or living environment.
Treating Comorbid Autism & Anxiety Disorder
It is possible for anxiety to be treated separately from autism, but the treatments have to be adapted to serve the needs of autistic individuals in order to maximize the help and minimize the side effects.
For example, selective serotonin reuptake inhibitors (SSRIs) are usually the first line of pharmacological treatment for those with anxiety and related mood disorders in the general population. However, the use of SSRIs in people with autism is associated with only minimal effectiveness and a high rate of negative effects.
Similarly, cognitive behavioral therapy (CBT), a psychotherapeutic approach, is an established form of treatment for anxiety and related mood disorders, but people on the autism spectrum will struggle to verbally express their feelings.
CBT might maintain its effectiveness with autistic clients who are high-functioning and have appropriate verbal skills. They may be able to benefit from CBT’s method of educating clients about anxiety, developing strategies to understand negative thought patterns and improve high-level thinking, and coming up with behavioral strategies to control an anxiety attack.
As with pharmacological interventions, individuals with autism who benefit from CBT will require a highly specialized version of the therapy, in order for their comorbid autism and anxiety to be concurrently treated.
Depression & Autism
Spectrum News explains that “major depression is not unusual for people on the (autism) spectrum.”
In “Prevalence of Depressive Disorders in Individuals with Autism Spectrum Disorder,” the Journal of Abnormal Child Psychology reviewed 66 studies and found that children on the autism spectrum are four times more likely than people not on the autism spectrum (or “neurotypicals”) to experience depression throughout their lives. As with other mood disorders, there is no consensus on why this is the case.
What doctors have found is that the rates of depression in children on the autism spectrum seem to increase with age. They are higher in those who have a high-functioning form of autism. Over 70% of youth with autism have mental health conditions that include depression and anxiety, and these conditions tend to persist and worsen throughout adulthood.
Currently, there are no available studies on the best screening methods to test for comorbid autism and depression, and there is no known treatment to ease depression among people on the spectrum. Doctors are unable to tell if a person on the autism spectrum who has depression will respond differently to psychotherapy than a neurotypical person with depression.
Similarly, there is no research to determine the best way to adapt standard depression treatments, such as cognitive behavioral therapy, for autistic people. It is unlikely that talk therapy will work well for people with ASD and depression, given that one of the characteristics of autism is that individuals have difficulties with social communication and identifying their feelings.
Furthermore, the effect of medications for depression on people with autism is also unknown. Psychiatrists fear that such drugs may cause unpredictable side effects and complicate the process for managing autism. Antidepressants have been known to disrupt the sleep patterns of children with autism and make them even more impulsive.
How Do Comorbid Depression & Autism Develop?
One of the stumbling blocks is that the root causes between comorbid autism and depression have been hard to pin down. An assistant professor of psychiatry and psychology told Spectrum News that “we know alarmingly little about depression and autism,” despite the fact that the comorbidity of the conditions is well documented.
What is known is that depression for neurotypical people is usually the result of a combination of genetic and environmental factors. For some autistic people, their development of depression may occur due to similar factors. A 2018 study in the Psychiatry journal found that neurotypical siblings of people with autism have a 40% increased risk of depression compared to the general population, which suggests a genetic correlation.
For others, depression results from isolation, social problems, or being bullied because of their autism, per JAMA Psychiatry. People on the spectrum who are lonely are statistically at the highest risk for developing depression. In and of itself, loneliness is a key factor in depression, and autism can make it difficult for vulnerable people to form friendships and develop a support network.
Additionally, rumination — the compulsion to repeatedly obsess over negative experiences, thoughts, and emotions — can lead some people on the autism spectrum to a depressive episode. This can exacerbate the symptoms of autism, which can deepen the depression.
Because of the interconnected nature of the two comorbid conditions, many people who have autism never get a diagnosis of depression and never get the help they need. Many doctors and therapists will miss the nuanced signs of depression in people with autism because depression is an internalizing disorder (characterized by feelings that happen internally). A person with autism will greatly struggle to articulate or otherwise clearly communicate their internal feelings.
Muddying the waters further is that some symptoms of depression, like being socially withdrawn, are often mistaken for autism symptoms. A pediatrician in New York notes that children with depression and autism “show a range of warning signs,” but cautions that there is no template by which to diagnose such patients.
Treating Comorbid Autism & Depression
Doctors have to make difficult decisions when determining the best way to offer treatment to people on the autism spectrum who also have depression. For instance, the Evidence-Based Child Health journal notes that children with autism have a high risk of experiencing negative side effects (including aggression, hyperactivity, and agitation) when they take antidepressants.
Most doctors treating autistic individuals who are positive for depression will likely use adapted forms of psychotherapy, like cognitive behavioral therapy, to help their patients reconfigure their negative thought patterns. Because the method has enjoyed some success in treating anxiety in autistic patients, there is hope that this will also work for autistic patients who have depression, but there is yet no data on how effective this approach is. If nothing else, clinicians are optimistic, believing that “CBT is unlikely to do actual harm to treat depression in the [autistic] population.”
CBT can still be used with the basics of autism therapy, such as sticking to a predictable routine and structure for sessions, verbalizing treatment concepts often, and using visual aids, worksheets, and other tools to help a client work with more abstract concepts. Therapists can also emphasize emotion recognition in their sessions, perhaps by incorporating mindfulness training to help autistic clients focus on and improve their emotional awareness.
What Can Parents Do?
Raising a child who is autistic can be incredibly challenging for any parent. Raising such a child who also has a comorbid mood disorder can feel impossible at times. However, there are approaches and resources that parents can and should make use of, to maximize the benefits of their child’s therapy and to give their child the greatest chance of success at managing their disabilities.
What can you do to help your child? Autism Speaks suggests that you should “get your child out in the community,” even though this process can seem daunting at first. Encouraging your child to socialize can help them to build vital skills. Socialization can act as a buffer against feelings of loneliness and isolation, which drive the development of depression.
Helping your child cultivate an array of hobbies and enjoyable activities will foster a sense of self-worth and fun. This is vital in the formation of good mental health.
Be as involved as possible in your child’s education and mental health care. Get to know their teachers, therapists, and technicians. This will allow you to offer a continuity of care at home, so your child will find it easier to move from educational and therapeutic settings to the home setting. Since ABA therapy is often offered in your own home, this transition can become even more seamless.
Get to know parents of children who are autistic. As much as it is important for your child to have a community and support network, it is equally important for you to know other people in similar situations. These parents can relate to what you’re going through, and you can lean on each other for support when needed. They might know of good behavior therapists and technicians you can contact.
You can find local (and distant) support groups through public universities, community centers, houses of worship, and local school districts. Schools and community organizations will usually have a list of advocacy groups, assessment clinics, and intervention services. They can also connect you to training and research groups.
All of this will help you increase your knowledge and understanding about autism and autism-related issues. And this puts you in a better position to effectively help your child.
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