Comorbidity refers to the presence of one or more mental or physical conditions that coincide with a primary mental or physical condition (Al-Beltagi, 2021). Research has shown that 70% of autistic children meet the criteria for one comorbid disorder and 40% meet the criteria for two or more comorbid diagnoses – ranging from skin and food allergies to headaches to mental health disorders (Isaksen et al., 2013; Mansour et al., 2017). The most common comorbid diagnoses among autistics include ADHD, mood disorders, and anxiety disorders (Mansour et al., 2017; Wilson et al., 2014).
Comorbid diagnoses can be challenging for families and therapists (Al-Beltagi, 2021; McCrimmon et al., 2014) due to the complexity of exploring and supporting multiple disorders. However, it does not have to be challenging. I encourage families and therapists to focus on the autistic rather than on separate diagnoses to gain a more descriptive picture of the behaviors.
Using a holistic approach helps for several reasons. First, the individual (child, teen, or adult) is the same person – the diagnosis label didn’t change that. Second, a holistic approach captures the complexity of the symptomatology since one disorder can exacerbate or mask another disorder. Which leads to: What is the best way to work with autistic clients who present with comorbidities?
I designed a systematic approach when working with my autistic families. I first develop a trusting relationship, followed by an assessment to identify the underlying cause of behaviors. The initial step in the assessment is identifying sensory overloads that may be causing the symptoms. Once sensory issues are addressed, the autistic’s anxiety decreases and now we can focus on the comorbidities. However, in my experience once I remedy sensory overloads most symptoms disappear.
Effective treatment begins with feeling understood and treated with respect. When working with autistics, we may be working with both the individual and their trust issues because those who came before us destroyed the trust. Trust is earned; we are not entitled to it. To show that the relationship with us will be different, enjoy being with them, talk about their interests, and show unconditional support rather than immediately asking for behavior changes.
When designing treatment plans for autistics with comorbid disorders, the first question we must ask is why is the autistic individual exhibiting these behaviors or symptoms? An effective strategy to answer this question is conducting an assessment, focusing on environment-behavior interactions.
The philosophy behind an assessment is that behaviors are not abnormalities; they are reasonable behavioral adaptations exhibited within the context of the environment. An assessment identifies factors leading up to the occurrence of behaviors. For example, I feel anxious when looking at people in the eye while talking with them. Through an assessment we can tease out that sustained eye contact is a precursor for my anxiety. Rather than focusing solely on behavior and increasing appropriate behaviors (looking at a person’s face when talking), realize that behind every behavior is a need in disguise. I look away from a person not because I don’t want to hear them, rather I look away to reduce my anxiety so I can hear them. When we meet my need rather than solely focusing on my behavior, we begin to understand the reason for my behavior. Many times, the need in disguise is a sensory sensitivity.
Environments and activities neurotypicals consider normal, autistics find painful or exhausting. The main reason is we are sensitive to sensory stimuli. Because of the sensory sensitivity, autistics live in stressful environments. Addressing sensory issues needs to be the starting point of any treatment. Why? Often behaviors we observe are a result of sensory overload.
Many autistics are in a constant state of sensory overload, which heightens their anxiety. The anxiety can then cause agitation, impulsivity, irritability, and outbursts. Not until the sensory overload is reduced do anxiety levels decrease and we begin to see more positive behaviors emerge. For example:
- Food refusal may be due to food allergies or teeth pain.
- Pulling at clothes may be due to irritating sensations.
- Crying and yelling may be due to the individual being frustrated but not able to verbalize the emotions.
- Scratching skin may be due to a skin allergy.
- Repeating memorized movie scenes or retelling stories multiple times may be how the autistic shows joy and enthusiasm about the experience.
- Fidgeting may reduce anxious feelings while in social contexts.
It is not until we address underlying sensory issues that our treatment plan can be effective. Once the autistic’s anxiety is under control, they are calmer and able to communicate and interact. So often, emphasis is placed on challenges with the social domain because that is what people see. However, it is difficult for autistics to learn new skills when they are in a constant state of anxiety or stress. Therefore, equipping autistics with strategies to prevent, or at the very least reduce, sensory overloads is a vital goal when working with comorbidities.
The primary goal of any treatment is promoting long-term positive outcomes. To meet that goal, skills taught must be consistently used by the autistic individual. A disadvantage of the clinic setting is that teaching is more passive; we hope the client will use the taught skills outside of the clinic. A more proactive and enjoyable way is through natural environment teaching.
The use of natural environments grew out of the recommendation from Stokes and Baer (1977) to teach skills in multiple settings. Teaching in natural environments provide authentic learning experiences and more opportunities to learn complex skills. Additionally, the focus is on the autistic’s understanding of the skill, rather than memorizing steps. When a client has a practical understanding of a skill, they are more likely to utilize the skill in the future. For example, how to escape an over stimulating situation or learning how to self-regulate emotions.
One benefit of working in natural environments is that the autistic individual takes the lead in deciding which behavior to work on. Autistics value opportunities to contribute to the decision-making process regarding goals and treatment. When autistics don’t have buy-in, interventions are less meaningful and ultimately less effective. Additionally, teaching within natural environments increase the chances the skills taught will maintain over time.
Using a holistic process allows us to focus on the individual when designing effective interventions. The primary focus of an assessment needs to be uncovering and addressing sensory overloads rather than merely treating symptoms. Address the sensory overloads, then address the other comorbidities. Ultimately, effective treatment occurs when autistic clients feel understood, accepted, and respected, which paves a path to a better prognosis among autistics with comorbid diagnoses.
For more information, Heidi Hillman can be reached at firstname.lastname@example.org.
Al-Beltagi M. (2021). Autism medical comorbidities. World journal of clinical pediatrics, 10 (3), 15–28. https://doi.org/10.5409/wjcp.v10.i3.15
Isaksen, J., Bryn, V., Diseth, T. H., Heiberg, A., Schjølberg, S., Skjeldal, O. (2013). Children with autism spectrum disorders: The importance of medical investigations. European Journal of Paediatric Neurology, 17, 68–76.
Mansour, R., Dovi, A. T., Lane, D. M., Loveland, K. A., & Pearson, D. A. (2017). ADHD severity as it relates to comorbid psychiatric symptomatology in children with autism spectrum disorders (ASD). Research in Developmental Disabilities, 60, 52–64.
McCrimmon, A., Altomare, A., Smith, A., Jitlina, K., Matchullis, R., & Sakofske, D. (2014). Overview of Autism Spectrum Disorder. In Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention In Schools. Wilkinson, L.E. (Ed). American Psychological Association.
Stokes, T. F., & Baer, D. M. (1977). An implicit technology of generalization. Journal of Applied Behavior Analysis, 10, 349-367.
Wilson, B., Manangan, C., Dauterman, H., & Davis, H. (2014). ADHD symptoms moderate the relation between ASD status and internalizing symptoms in 3-6- year-old children. Journal of Autism & Developmental Disorders, 44(6), 1347– 1356.