Q&A: Autism and Mental Health

Up Close: Autism Spectrum Disorder and Mental Health in the Classroom
Volume 42 Issue 4

 
2014 Convention News
Washington DC, February 18–21
Up Close: Autism Spectrum Disorder and Mental Health in the Classroom

 

 

The third installment in our “Up Close” series of Q&As with 2014 convention presenters takes a closer look at some key factors related to autism spectrum disorder (ASD), an increasingly prevalent diagnosis among school-age children. Convention workshop presenter James Coplan, MD (Neurodevelopmental Pediatrics of Main Line, Rosemont, PA) discusses some of the issues concerning comorbid mental health problems in children with ASD. This is the primary focus of the workshop he will present at the convention, WS021: Mental Health Issues in ASD on Thursday, February 20, 8:30–11:30 a.m. Specific registration is required for workshops, which provide documented NASP- and APA-approved CPD. Relevant Domains of Practice (NASP Practice Model): 1, 3, 4, 7, and 8.

 

Seventy years have passed since Leo Kanner added “autism” to the medical lexicon. His seminal article from 1943, “Autistic Disturbances of Affective Contact,” remains the best description of what we now refer to as ASD. To access this original article, go www.drcoplan.com and click on Related Links.

 

Coplan: The leading confirmed causes of ASD are all genetic. There are 30,000 genes in the human genome; half of these genes are expressed in the brain, and hundreds of individual gene defects have been identified in persons with ASD. Some of these defects are common; others are rare. Collectively, however, genetic factors account for the overwhelming proportion of cases in which a cause can be identified. Despite much publicity in the lay press, there is no convincing evidence that immunizations cause ASD.

 

Coplan: There is no proof that we are experiencing an epidemic (i.e., actual increased incidence) of ASD. On the other hand, the proportion of children identified as having ASD (the “administrative prevalence”) has increased sharply in the past decade, but most of this increase probably reflects changes in federal law (prior to 1990, autism was not a federally recognized educational disability) and broadening of diagnostic criteria.

 

Coplan: Mental health disorders occur frequently in children with ASD. Internalizing behaviors (anxiety, obsessive thinking, and perfectionism) are extremely common. Depression probably goes underdiagnosed, but is also common (at least, among adults with ASD). Given the highly genetic nature of ASD, it is not surprising that one or both parents of a student with ASD often have mental health issues themselves—typically anxiety, but sometimes depression, obsessive–compulsive disorder, or bipolar disorder. Mental health issues in a parent often impede the parent's ability to respond to the child's needs in an adaptive fashion. The combination of mental illness in a parent plus ASD (with or without mental health issues) in the child is a potentially catastrophic combination.

 

Coplan: Students with ASD frequently experience anxiety, and the use of selective serotonin reuptake inhibitors (SSRIs such as fluoxetine) is an accepted mode of treatment for childhood anxiety disorders. The SSRIs do not treat ASD per se, but they can substantially reduce the burden of anxiety and cognitive rigidity, and enable the child to benefit more fully from behavioral interventions.

 

Dysregulation of attention is also common in children with ASD. As in children with garden-variety attention deficit hyperactivity disorder, pharmacologic intervention (stimulants, alpha-2 agonists) is often beneficial. Some children with ASD have neurologically driven disruptive behavior, which may lead to spontaneous periods of aggression. This is different from the disruptive behavior seen as a direct consequence of anxiety, rigidity, and perfectionism, where there is a clear antecedent (e.g., inability to complete a task perfectly). In these situations, treatment with one of the atypical neuroleptics (risperidone, aripiprazole, etc.) may be helpful.

 

Coplan: Virtually all children with ASD would benefit from a positive behavior support plan for internalizing behavior. Importantly though, functional behavioral assessments (FBAs) should more regularly take internalizing problems into account. FBAs rarely list anxiety or perfectionism as antecedent conditions, and usually fail to consider that disruptive or task-avoidant behavior may be serving the function of anxiety reduction rather than simple escape from task. As a result, behavior plans often overfocus on compliance, rather than anxiety reduction. This is another area where active collaboration between school psychologists (who have a broader concept of child development) and behavioral psychologists (who traditionally disregard “private mental events”) would be of tremendous value in terms of reorienting the underlying premises and basic thrust of the behavior plan.

 

Coplan: At present, ASD remains a condition defined by its symptoms rather than by its underlying biology, although we have a few pieces of the puzzle in place. In the coming decade, we can look forward to a more biologically based definition, taking advantage of rapid developments in neuroscience and behavioral genetics. A firm understanding of the underlying biology of ASD will, in turn, lead to rationally based medical and developmental interventions. Services for adults with ASD—especially those with high functioning ASD who are capable of living independently—will begin to receive the attention they deserve. This will require the creation of service systems not now in existence.