Comorbidities and Co-occurring Conditions

By Gillian Feit

According to the American Psychological Association, “Autism spectrum disorder (ASD) can impact functioning across multiple domains (e.g., social, cognitive, adaptive), and individuals with ASD are also at an increased risk for comorbid disorders. Comorbidity refers to the co-occurrence of two or more disorders in the same individual. The co-occurrence of ASD and other disorders can further exacerbate impairments in functioning” (Matson & Burns, 2019). Additionally, in an article written by Mannion and Leader, they found from prior research that children diagnosed with ASD had more severe comorbid symptoms than atypically developing toddlers. Younger children had fewer problems, and there was an increasing trend as the older age groups displayed the most severe problems across all classes of behavior, demonstrating, that those with ASD face co-occuring conditions however, the earlier that you notice that your loved on may have comorbidities, the sooner you should seek treatment, which will make for a more manageable and successful individuals battling multiple conditions (Mannion & Leader, 2024).

Furthermore, in an article titled ‘Prevalence of Autism Spectrum Disorder and Co-morbidities in Children and Adolescents: A Systematic Literature Review’ researchers found “Substantial heterogeneity in prevalence of co-morbidities was observed: ADHD (0.00–86.00%), anxiety (0.00–82.20%), depressive disorders (0.00–74.80%), epilepsy (2.80–77.50%), ID (0.00–91.70%), sleep disorders (2.08–72.50%), sight/hearing impairment/loss (0.00–14.90%/0.00–4.90%), and GI syndromes (0.00–67.80%). Studies were heterogeneous in terms of design and method to estimate prevalence. Gender appears to represent a risk factor for comorbid ADHD (higher in males) and epilepsy/seizure (higher in females) while age is also associated with ADHD and anxiety (increasing until adolescence)” which is extremely interesting (Bougeard et al., 2021). The statistics of which conditions the individuals have, suggest that there are high chances for any autistic individual to be diagnosed with such conditions. Also, the fact that gender and age play a role, in impacting the separate populations, should make loved ones more attentive to their autistic individuals’s symptoms. 

Although ASD impacts different domains of functioning, some common comorbid conditions include ADHD (attention-deficit hyperactivity disorder), anxiety, depression, OCD (obsessive-compulsive disorder), learning disabilities, and many more (Khachadourian et al., 2023). 

Specifically, individuals with ADHD may have trouble staying focused, following instructions, sitting still, or waiting their turn. When ADHD co-occurs with autism, these symptoms can exacerbate difficulties in communication and social interactions. 

Those with anxiety disorder encounter excessive fear, worry, or nervousness that can interfere with daily activities. In individuals with autism, anxiety can manifest as intense concern about changes in routine, social situations, or specific fears, contributing to heightened stress and avoidance. 

Next, depression, a common anxiety disorder that is characterized by persistent feelings of sadness, hopelessness, and lack of interest or pleasure in activities, makes it more difficult to recognize in individuals diagnosed with autism due to overlapping symptoms such as social withdrawal and difficulties in expressing emotions. Nevertheless, depression significantly impacts the quality of life. 

OCD, a disorder characterized by unwanted, intrusive thoughts and repetitive behaviors or mental acts, can be very disruptive to anyone’s daily lifestyle. In individuals with autism, OCD-like behaviors might include rigid routines, repeated checking, or specific rituals that can interfere with and be bothersome to daily functioning. 

Additionally, autism spectrum disorder is not a learning disability; however, it can significantly affect learning. Learning disabilities are neurological disorders that affect the ability to process and respond to information, which can impact skills. Those diagnosed with both autism and learning disabilities may face challenges in academic settings and require specialized educational support and interventions.

Next, there are multiple different types of tests to diagnose individuals for comorbidities. “The Baby and Infant Screen for Children with aUtIsm Traits (BISCUIT), Part II (Matson, Boisjoli & Wilkins, 2007) was developed to screen for comorbid psychopathology in infants aged 16-37 months and has been psychometrically validated (Matson, Fodstad, Mahan & Sevin, 2009). The Autism Spectrum Disorders Comorbidity-Child Version (ASD-CC) (Matson & González, 2007) is another instrument used to diagnose comorbid psychopathology in children. Leyfer, Folstein, Bacalman, Davis, Dinh, Morgan et al., (2006) modified the existing instrument The Kiddie Schedule for Affective Disorders and Schizophrenia for use with children and adolescents with ASD. The modified instrument, the Autism Comorbidity Interview-Present and Lifetime Version (ACI-PL) was used to research prevalence rates of specific disorders” (Mannion & Leader, 2024). Also, the individual's psychiatrist or specialist may diagnose them with other disorders. 

Although there are many different tests and resources, there are some challenges that come with having co-occurring conditions. “Symptoms of comorbidities in ASD may be atypical and are often difficult to recognize (14). A major culprit propitiating these diagnostic difficulties is communication problems. In ASD, 25–50% of individuals are unable to speak (15). Furthermore, 90% of ASD toddlers are unable to point protodeclaratively or protoimperative (16). Indeed, many individuals with ASD are incapable of pointing to the source of their discomfort, find it difficult to attend to or detect bodily sensations (17), have poor integration of body scheme representation, and have atypical sensory perceptions or reports of pain (18). This inability to communicate pain or discomfort to other people may propitiate the enactment of inappropriate behaviors as a way for patients to express themselves and attract attention to their plight” (Casanova et al., 2020). Furthermore, many of these disorders have been largely ignored, due to the challenges involved in conducting a meaningful medical history and physical examination in a frequently nonverbal patient whose behavior may interfere with a lengthy assessment (Bauman, 2010). 

Managing ASD comorbidities may be challenging at first but, there are many ways to help individuals deal with multiple diagnoses. To begin, understanding the importance of medication is crucial. “Although pharmacological intervention is not intended to reverse ASD-related disabilities, medications can treat symptoms of ASD and co-occurring conditions, including intellectual disabilities, language delays, attention-deficit/ hyperactivity disorder (ADHD), anxiety, depression, agitation, irritability, disruptive behavior, and sleep disorders” which can make a significant difference in the individual’s everyday life (Feroe et al., 2021). Despite medication being an extremely effective way to help individuals manage co-occuring conditions with ASD, other ways to make the situation easier include, “engaging in shared decision-making with patients and families to develop the medical home and support” (Feroe et al., 2021). Having a secure support system will make individuals feel more comfortable, at ease and better cared for. 

Ultimately, it is vital to identify comorbid, health-related medical conditions associated with ASD. First, many of these medical conditions are treatable, and if identified and managed, will result in an improved sense of well being, more engagement in educational and therapeutic programs, and improved quality of life for the patient and his family. Second, identification of medical disorders involving specific organ systems may help us to identify phenotypic and genetic clusters of ASD persons, which may possibly define meaningful subtypes that may result in a better understanding of subsets of causative and biological mechanisms (Bauman, 2010).

Understanding your loved one’s ASD and their co-occuring conditions, helps to make a successful ASD individual that will receive the support and help needed.

References

Matson, J. L., & Burns, C. O. (2019). Comorbidity and the need for interdisciplinary treatments. In R. D. Rieske (Ed.), Handbook of interdisciplinary treatments for autism spectrum disorder (pp. 29–47). Springer Nature Switzerland AG. https://doi.org/10.1007/978-3-030-13027-5_3

Mannion, A., & Leader, G. (2024). Comorbidity in autism spectrum disorder: A literature review. Research in Autism Spectrum Disorders. https://www.lenus.ie/bitstream/handle/10147/559386/MannionLeader2013b.pdf?sequence=1 

Bougeard, C., Picarel-Blanchot, F., Schmid, R., Campbell, R., & Buitelaar, J. (2021). Prevalence of Autism Spectrum Disorder and Co-morbidities in Children and Adolescents: A Systematic Literature Review. Insights in Autism: 2021, 12. https://www.frontiersin.org/journals/psychiatry/articles/10.3389/fpsyt.2021.744709/full 

Khachadourian, V., Mahjani, B., Sandin, S., Kolevzon, A., Buxbaum, J. D., Reichenberg, A., & Janecka, M. (2023). Comorbidities in autism spectrum disorder and their etiologies. Translational Psychiatry, 13. https://www.nature.com/articles/s41398-023-02374-w

Casanova, M. F., Frye, R. E., Gillberg, C., & Casanova, E. L. (2020). Editorial: Comorbidity and Autism Spectrum Disorder. Comorbidity and Autism Spectrum Disorder, 11. https://www.frontiersin.org/journals/psychiatry/articles/10.3389/fpsyt.2020.617395/full 

Feroe, A. G., Uppal, N., Gutierrez-Sacristan, A., Mousavi, S., Greenspun, P., Surati, R., Kohane, I. S., & Avillach, P. (2021). Medication Use in the Management of Comorbidities Among Individuals With Autism Spectrum Disorder From a Large Nationwide Insurance Database. JAMA Pediatrics, 175(9), 957-965. https://watermark.silverchair.com/jamapediatrics_feroe_2021_oi_210029_1630088716.57398.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAAzQwggMwBgkqhkiG9w0BBwagggMhMIIDHQIBADCCAxYGCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQMOdkmOqpWVWKGcmniAgEQgIIC57K 

Bauman, M. L. (2010). Medical Comorbidities in Autism: Challenges to Diagnosis and Treatment. Neurotherapeutics: The Journal of the American Society for Experimental NeuroTherapeutics, 10(3). https://link.springer.com/content/pdf/10.1016/j.nurt.2010.06.001.pdf