By Dr. Charles Cartwright and Victoria Bein

Based on clinical and community studies, there is strong evidence that up to 70 percent of people with autism meet diagnostic criteria for at least one emotional or behavioral disorder.

The presence of co-existing disorders can have a dramatic impact on the lives of individuals with autism, their families and caregivers. It is important for clinicians and families to watch for emotional and behavioral changes that may indicate a disorder.

Emotional Dysregulation

Emotional dysregulation is a commonly used term when discussing emotional and behavioral issues in those diagnosed with an autism spectrum disorders (ASD). The symptoms and behaviors can include irritability, temper tantrums, hyperactivity and self-injurious behaviors.

It is important to understand whether these symptoms reflect underlying mood, anxiety, impulse control and psychotic disorders, or if they are behaviors that are part of the autism spectrum. Some clinicians prefer to avoid making a psychiatric diagnosis because of this overlap.

However, to understand patterns of symptoms and behavioral presentations, and to develop effective treatments targeting these clinical issues, clinicians should be rigorous in their efforts to accurately diagnose and disentangle the mental health issues that pose so many challenges for seven out of 10 people with ASD.

Diagnosing Co-Existing Disorders

In order to diagnose an emotional or behavioral disorder, a comprehensive psychiatric evaluation is necessary. These evaluations should be performed by professionals with specific expertise in the assessment and diagnosis of autism spectrum disorders with co-occurring psychiatric disorders.

Common co-morbid diagnoses in children, adolescents and adults with ASD include disorders described in the following vignettes.

Attention Deficit Hyperactivity Disorder (ADHD affects 20-35 percent of individuals with ASD):  Brian is a 4-year-old with a history of significant language delay. He started using single words at age 3 and a year later began repeating what others said to him. He is extremely active and unable to sit still. When in an enclosed space, he pushes furniture over, throws things, runs from one corner of the room to the other, or attempts to dart out of the room. He becomes easily frustrated and has frequent tantrums when limits are set. He also appears to be oppositional and defiant, which may reflect his frustration with his inability to communicate.

Obsessive Compulsive Disorder
(affects 10-25 percent of people with ASD): 
Maria is a 13-year-old who abruptly insisted that her family’s home be arranged a certain way: with chairs in the exact same position next to the dining table, all the TVs in the house on and all the doors closed. She has an intense need to watch the exact same TV show from beginning to end repeatedly. If this routine is disrupted she becomes extremely upset. These ritualistic behaviors were not present six months earlier, before Maria and her family moved to a new neighborhood and she was placed in a new school.

Social anxiety (affects 10-20 percent of people with ASD): 
Elijah is a socially isolated 16-year-old who has a diagnosis of Asperger’s syndrome. Over the past three months, he has found it progressively harder to be with unfamiliar people without becoming markedly anxious. He now avoids all social situations, even gatherings of family and close friends. Making eye contact upsets him, so he finds relief looking down or past people.

Mood disorder (affects 5-15 percent of individuals with ASD):  At the age of 15, Nigel presented with a sudden onset of irritability,  which lasted more than a  month. He also began having difficulty falling asleep and staying asleep through the night. His irritability alternated with periods of giddy happiness along with brief intense periods of sadness, with no apparent reason for the sudden shift. Nigel’s symptoms are consistent with a mood disorder, possibly of a bipolar type.

Tic disorders (affect 5-10 percent of individuals with ASD): 
Jenny is a 9-year-old with a two-year history of an increasing frequency of throat clearing sounds, and a six-month history of jerking movements involving her head and neck. These movements have fluctuated in intensity and frequency. More recently, they have been accompanied by obsessive compulsive behaviors.

Treatment Professional treatment, including cognitive-behavioral and behavioral interventions and the careful use of psychotropic medication, can significantly reduce the severity of these issues and improve the quality of life of the individual with ASD, as well as his or her family or caregiver. 

Charles Cartwright, M.D., is Director of the YAI Autism Center and Chief of the Premier HealthCare Autism Research and Treatment Institute. Victoria Bein, M.A., M.S., is Coordinator at the Premier HealthCare Autism Research and Treatment Institute. Premier HealthCare is a member of the YAI Network.

The full version of this story appeared in Autism Spectrum News, Winter 2011.