Children and youth with ASD (Autism Spectrum Disorder) represent a variable and growing population in the K-12 school system who may be served under IDEA (The Individuals with Disabilities Education Act: 2004). ASD is, according to the DSM V (Diagnostic and Statistical Manual of Mental Disorders, 5th Ed.; American Psychiatric Association, 2013) a neurological disorder characterized by deficits, social-communication and the presence of restrictive and repetitive patterns of behavior. It is a difficult disorder to neatly classify as individuals are highly heterogeneous in their symptoms, delays and strengths. Schools may identify children to receive services under IDEA in the eligibility category of Autism at any age provided that there is evidence of an adverse educational impact. The diagnosis of ASD is often not the only issue the family and school team has to contend with. A large percentage of children, youth and adults with ASD present with one or more other disorders, termed “comorbidity,” including sleep disorders, seizures, tic disorders, ADHD, gastrointestinal disorders, obsessive compulsive disorder and others (Hanson, E., Cerban, B.M., Caccomo, L.M., Bacic, J. & Chan, E. 2013; Manion, Leader & Healy, 2014; ). The presence of one or more comorbidities is quite common in this population (Manion et al., 2014; Manion & Leader, 2014) and presents a number of issues worthy of discussion for educational teams. The focus of this particular article is on ASDs with comorbidities of mental health disorders.
The public school system is federally mandated to serve any child with a disability between the ages of 3 to 21 provided that the disability (or disabilities) present(s) such an impact that accommodations alone cannot adequately ensure progress in the general education curriculum. School systems operate under IDEA and determine an area of eligibility based upon best fit when evaluating a child for special education. Teams can and do struggle when more than one disorder is identified. Eligibility categories serve multiple purposes for educational planning and service delivery including identification of prevalence, better definitions for research purposes and deployment of resources. The child with more than one diagnosis may be the “square peg in the round hole” when it comes to identification and eligibility for services. For example, a young adult may present with diagnoses of ASD and Bipolar Disorder. In this case there are two possible IDEA eligibility categories to choose from: ASD and ED (Emotional Disturbance). Teams in this case must grapple with identifying the category that best fits the student and move beyond the label toward adequately addressing adverse educational impact and academic/behavioral needs in the IEP. In some cases a team could qualify the student under the IDEA category of MD (Multiple Disabilities). Ultimately the team should select the category for eligibility that represents the best fit and look toward creating written plans and specially designed instruction that address the multiple and varied needs of each child. The category opens the door to services and ensures the continued entitlements. The paperwork and plans that follow are the true guides to creating a package of services that address all needs related to ASD and any impairment areas that create an adverse educational impact.
Comorbidities: Addressing Needs Through Collaboration and Training
Comorbidities with ASDs in children and youth bring up a number of important issues for school teams during the educational planning and intervention phases and suggest the need for greater collaboration and training. School teams typically approach each child from a strength and needs-based perspective related to the disabilities creating the adverse educational impact. All interventions should be designed to increase functional capacity to cope with the social and academic demands of school and are tied to the underlying core symptoms of ASD within the scope of the educational professionals’ practice. These cases become complicated when more than one disorder is creating adverse educational impact and blur the lines of what educational professionals can address.
For example, consider the dilemma a school team finds themselves in with the following scenario. A teenager diagnosed with ASD presents with multiple challenges that create a barrier to successfully accessing the general education curriculum. He has a hard time getting in assignments due to disorganization, will often day dream in class, does not seek out the help of his instructors and seeks his smart phone video game apps at any opportunity. His grades have plummeted, engagement has dropped significantly and everyone is struggling to compete with the reinforcement the phone provides in all subjects. Complicating this scenario is the fact that this teenager is diagnosed with Bipolar disorder and presents with the behavior of cutting, specifically to his arms, chest and legs. This youth recruits attention from peers by showing the wounds in social settings. As school pressures mount the team notes that he engages in more cutting behavior as well as demonstrating more emotional variability in the school setting. He receives outside therapy to address cutting behavior as well as anxiety and depression. This therapy is cognitive-behavioral in nature and is delivered in tandem with medication interventions from a psychiatrist. In this complicated case there are multiple confounds and issues to work through—not all of which can be attributed solely to ASD. In this case the youth has mental health needs which also adversely impact his education and access to the general education curriculum. An approach designed to address his core deficits of ASD alone will not suffice.
School teams in a situation like this case are faced with a number of challenges. They are responsible for building skills that are required for success in school including organization, self-advocacy, staying on task and avoiding distractions in order to be engaged with academics. They are also responsible for addressing the social-emotional needs that this young man brings to the table. The outside mental health providers are addressing his cutting and internalizing behaviors both therapeutically and medically. School teams should be encouraged, in situations like this, to develop a collaborative relationship with the child’s outside therapists in order to develop a coordinated approach. This might involve securing permission to share information, meeting to exchange treatment plans, developing an understanding of therapeutic approaches and implementing generalizable strategies as appropriate. For example if the therapist is working on developing approaches for him to use when he feels like cutting, the school team can, as appropriate, implement similar strategies, cues and prompts in the school setting. Outside therapeutic and medical information can and should be a part of this child’s functional behavior assessment, behavior intervention plan and possibly as part of a health care plan if side effects from medications are an issue. Ongoing communication with all parties can assist with generalization as well as sharing of progress (or lack of) with the interventions that are put in place.
School teams can benefit from specific training to address prevention and intervention strategies for ASDs as well as comorbid mental health conditions. This training may include reviewing or learning specific hallmarks of the disorders, prevention tactics, intervention strategies and other behavioral supports. Teams need time to not only gather new ideas but to plan and work through how interventions will look in a typical school situation. They can also benefit by ongoing collaboration with outside mental health professionals by reviewing their strategies and considering how they could inform their approach in the school setting. Districts can and should support their instructional staff in ASD issues by including content covering the common comorbidities and their manifestations in children and youth as an ongoing component of professional development.
ASD as a disability category and area of special education is unfortunately not a neatly wrapped box into which we can place all children and youth. The needs of this population are highly variable and confounded by the presence of comorbidities. School teams are in a position of decision making when evaluating and finding children and youth eligible for special education under IDEA. They may struggle when determining eligibility based upon the categorical nature of the process. School teams are counseled to consider a best fit approach in order to create eligibility, to consider the MD category if needed and available, and to expand upon the child’s needs accurately within the IEP paperwork and plans. In other words, the category should not limit the team from addressing all areas of need within the IEP and behavior plans. School teams will find that interventions designed for children and youth with ASDs may not be sufficient for dealing with mental health issues that are commonly found in this population. Collaboration with outside agency professionals is critical to creating a coordinated approach that can improve service delivery and generalization of skills. Training is a necessary ongoing process in order to increase instructional staff’s knowledge and skills in ASD as well as comorbid conditions. School teams do need to remember that in most cases the ASD label does not adequately explain the intricacies of each child or youth, and to remain open to other factors including mental health needs when engaging in educational planning and service delivery.
Vanessa Tucker, PhD, BCBA-D, is Assistant Professor of Special Education at Pacific Lutheran University. For more information, please contact Dr. Tucker at firstname.lastname@example.org.
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. (5th Ed.). Arlington, VA: American Psychiatric Publishing.
Individuals With Disabilities Education Act, 20 U.S.C. § 1400 (2004).
Hanson, E., Cerban, B.M., Slater, C.M., Caccamo, L.M., Bacic, J. & Chan, E. (2013). Brief report: Prevalence of attention deficit/hyperactivity disorder among individuals with autism spectrum disorder. Journal of Autism and Developmental Disorders, 43 (6), 1459-1464.
Mannion, A. & Leader, G. (2014). Comorbidity in autism spectrum disorder: A literature review. Research in Autism Spectrum Disorders, 7 (12), 1595-1616.
Mannion, A., Leader, G., & Healy, O. (2014). An investigation of comorbid psychological disorders, sleep problems, gastrointestinal symptoms and epilepsy in children and adolescents with Autism Spectrum Disorder. Research in Autism Spectrum Disorders, 7 (1). 35-42.