Autism and Dual Diagnosis
Autism Spectrum Disorder (ASD) is a complex developmental disability that typically appears during early childhood and is marked by difficulties in a person’s ability to communicate and interact with others. ASD is defined as a “spectrum condition” that affects individuals differently and to varying degrees. It is characterized by developmental delays, social-emotional deficits, repetitive patterns of behavior, and difficulty establishing and maintaining relationships. Until fairly recently, it was thought that those diagnosed with Autism could only be diagnosed with ASD and not with other diagnoses. It is now clinically accepted that individuals can be diagnosed with ASD and additional diagnoses or conditions. This is called dual diagnosis, otherwise known as co-occurring, co-existing, or co-morbidity. It is defined as having more than one disability or condition at the same time. Some common related conditions that can accompany Autism Spectrum Disorders are low IQ, chronic constipation and or/diarrhea, sleep problems, seizures, sensory integration disorder, low muscle tone, high or low pain thresholds, feeding issues, and allergies/immune system problems. In addition, the most common co-occurring diagnoses include attention deficit-hyperactivity disorder (ADHD), Fragile X Syndrome, Down Syndrome, depression, mood disorders, anxiety, obsessive compulsive disorder (OCD), dissociation, and schizophrenia. It is often difficult to differentiate between similar symptoms of Autism and other co-occurring diagnoses. It requires further evaluation from other professionals such as a pediatrician, neurologist, psychiatrist, psychologist, speech pathologist, occupational therapist, physical therapist, school psychologist, or other medical professional. Research is varied in terms of the prevalence of dual diagnosis. For example, current research in the area of ADHD and Autism has found that anywhere from 11 to 84% of individuals with Autism also fit the diagnosis criteria for an Anxiety Disorder. Thankfully there is currently a lot more funding and research directed toward these areas.
For further detail on common co-occurring conditions and diagnoses, it is suggested one consult a professional and review diagnostic criteria of mental health disorders found in the Diagnostic and Statistical Manual of Mental Disorders (5 Edition, DSM-5). It is important to remember that diagnosing can only come from a professional in the particular field of the disorder or condition. Low IQ or intellectual disability is a generalized neurodevelopmental disorder typically characterized by impaired intellectual and adaptive functioning. It is defined by an IQ score under 70 in addition to deficits in at least two adaptive behaviors that affect functioning and general living. It is fairly common for individuals with Autism to have gastrointestinal issues in the form of chronic constipation or frequent diarrhea (or in some cases, leaky gut). These issues can greatly affect an individual and consult should be sought from one’s pediatrician, gastroenterologist, and nutritionist. It is also common for individuals to have significant sleep issues. These can include a reduced amount of time sleeping, irregularities in one’s circadian rhythm, excessive sleeping, issues attaining REM sleep, sleep disturbances, and issues with dreaming, nightmares, or night terrors. If a sleep issue is suspected it is recommended that one seek consult with a sleep specialist with a possible sleep study. Seizures are defined as changes in one’s brain electrical activity, which can cause significant noticeable symptoms or even no symptoms at all. There are several different types of seizures, including grand mal, absence, myoclonic, clonic, tonic, and atonic seizures. The symptoms of each can vary greatly so it is recommended that one consult the primary care doctor, who then might refer you to a neurologist or epileptologist. Sensory Integration Disorder is a neurological disorder that results from the brain’s inability to integrate certain information received from the body’s five basic sensory systems. This can affect one’s ability to process information in the areas of sight, sound, smell, taste, temperature, pain, and the position/movements of the body.
In addition a person might have low muscle tone that greatly affect their ability for gross motor and/or fine motor movements. A person could also have a high or low threshold to pain affecting their ability to tolerate pain or feel pain when one normally should. Individuals with Autism may have ritualistic behaviors or restrictive behaviors that affect their ability to eat. Some limit what they eat which causes severe nutritional deficiencies. It is important to consult a doctor between the difference between being a picky eater versus having a feeding disorder. Lastly, you will often see individuals with Autism suffering from allergy or immune system disorders. They can be very sensitive to environmental allergies and can have significant issues related to their sinuses. They can be highly susceptible to getting sick and their immune systems might have difficulty fending off viruses. Doctors might recommend different all natural supplements to help boost one’s immune system.
Full definition and symptom criteria for mental health disorders can be found in the current DSM-5, but all diagnoses must come from a medical professional and/or psychologist/psychiatrist. Attention deficit-hyperactivity disorder (ADHD) is defined as a neurodevelopmental and mental disorder characterized by problems paying attention/focusing, excessive activity, or difficulty controlling behavior which is not appropriate for one’s age. These symptoms begin between ages six and twelve and continue for more than 6 months. A child might only have a symptoms related to difficulty with attention, symptoms around hyperactivity, or a mixture of both. One should consult a pediatrician, psychologist, and/or psychiatrist if it is believed their child has significant issues. There are various methods of treatment, including medication, behavioral therapy, mindfulness, etc. Fragile X Syndrome (also known as Martin-Bell Syndrome) is a genetic condition that causes a significant range of developmental problems including cognitive impairment and learning disabilities. It is an inherited cause of intellectual disability especially among boys. Nearly half of all children with Fragile X meet the diagnostic criteria for Autism. Down Syndrome, also known as Trisomy 21, is a genetic disorder caused by the presence of all, or part of a third copy of chromosome 21. It is characterized by mild to moderate intellectual disability, physical growth delays, and characteristic facial features. The average IQ of a young adult with Down Syndrome is 50, which is around the age equivalent of an eight or nine year old. This syndrome is diagnosed with fetal testing during pregnancy. Depression is defined as a state of low or depressed mood and aversion to activity that affects a person’s behavior, thoughts, feelings/ emotional state, and sense of well-being. It is important to remember that depression will not always look the same in everyone. People with depression can feel sad, empty, hopeless, worthless, helpless, guilty, ashamed anxious, irritable, over-tired or restless. For those with high functioning Autism (formerly known as Asperger’s Syndrome), co-occurring depression can be fairly high. In addition, those suffering from mood disorders can be common. In addition to depression, these include Affective Mood Disorders, Bipolar disorder, Seasonal Affective Disorder, and self-harm. They are defined as a group of diagnoses in the DSM-5 where a disturbance in the person’s mood is hypothesized to be the underlying feature. Anxiety Disorders are characterized as twelve distinct disorders in the current DSM. Anxiety is an emotion characterized by an unpleasant state of inner turmoil, typically associated by nervous behavior, such as pacing back and forth, rumination, and somatic complaints. It is the subjective feeling of worry or dread over anticipated events. Current research shows a possible high rate of co-morbidity with Autism, although the actual number is debated. Obsessive compulsive disorder (OCD)is related to Anxiety Disorders but has its own classification. It is defined as a mental disorder where people have certain repeated thoughts, feel the strong need to check things repeatedly, or perform certain routines repeatedly. People are typically unable to control the thoughts or activities. There is currently no cure for OCD, but behavioral therapy, psychotherapy, and medication can greatly help reduce symptoms. Dissociation is a psychological term that describes a wide array of experiences from mild detachment from immediate surroundings to a more severe detachment from physical and emotional experience. This is defined as a detachment from reality, rather than a loss of reality as in psychosis/schizophrenia. There are three main types characterized in the DSM: Dissociative Amnesia, Depersonalization-derealization disorder, and Dissociative Identity Disorder. Schizophrenia is defined as mental disorder characterized by abnormal social behavior and failure to understand reality. Typical symptoms include unclear/confused thinking, hearing voices, false beliefs, reduced social engagement and emotional expression, and a lack of motivation. There has been increased research on the biological links between Autism and Schizophrenia that is quite fascinating and opens the door for further questions. In addition, there is a growing discussion in the psychological fields regarding the understanding of hearing voices and alters characterized in Dissociative Identity Disorder. There is much debate regarding our Western World understanding of psychology and mental health symptoms and a more cultural and possible spiritual view on various symptomology. It is important for professionals and families to respect different cultural understandings of what is going on with a child and pair it with current scientific research and understanding. As both a Behavior Analyst and Clinical Psychologist rooted in both the modern view of psychology and cultural view of psychology, I find it to be increasingly beneficial to view cases from multiple points of view. It is very important to work closely with the family and other professionals to help achieve the best possible outcome for the child. If you suspect your child has an additional diagnosis to Autism, it is imperative that you seek help from other professionals to better the chance of treatment for a positive prognosis.
Nicholas Golden, Psy.D., M.Ed., BCBA-D, LAPA