Conditions comorbid to autism spectrum disorders
Autism spectrum disorders (ASD), including Asperger syndrome, are neurological disorders that begin in early childhood, persist throughout adulthood, and affect three crucial areas of development: communication, social interaction and restricted patterns of behavior. There are many conditions comorbid to autism spectrum disorders, such as fragile X syndrome and epilepsy. In medicine and in psychiatry, comorbidity describes the effect of other diseases an individual patient might have other than the primary disease of interest. About 10–15% of autism cases have an identifiable Mendelian (single-gene) condition, chromosome abnormality, or other genetic syndrome, and ASD is associated with several genetic disorders, perhaps due to an overlap in genetic causes.
Distinguishing between ASDs and other diagnoses can be challenging because the traits of ASDs often overlap with symptoms of other disorders and the characteristics of ASDs make traditional diagnostic procedures difficult.
- 1 Comorbid conditions
- 1.1 Anxiety
- 1.2 Attention-deficit hyperactivity disorder
- 1.3 Bipolar disorder
- 1.4 Bowel disease
- 1.5 Developmental coordination disorder
- 1.6 Epilepsy
- 1.7 Fragile X syndrome
- 1.8 Intellectual disability
- 1.9 Neuroinflammation and immune disorders
- 1.10 Nonverbal learning disorder
- 1.11 Obsessive-compulsive disorder
- 1.12 Tourette syndrome
- 1.13 Sensory problems
- 1.14 Tuberous sclerosis
- 1.15 Sleep disorders
- 1.16 Other mental disorders
- 2 See also
- 3 References
Anxiety disorders are common among children with ASD, although there is no firm data. Symptoms are likely affected by age, level of cognitive functioning, degree of social impairment, and ASD-specific difficulties. Many anxiety disorders, such as social anxiety disorder, are not commonly diagnosed in people with ASD because such symptoms are better explained by ASD itself, and it is often difficult to tell whether symptoms such as compulsive checking are part of ASD or a co-occurring anxiety problem. The prevalence of anxiety disorders in children with ASD has been reported to be anywhere between 11% and 84%; the wide range is likely due to differences in the ways the studies were conducted.
Attention-deficit hyperactivity disorder
Previously, the diagnosis manual DSM-IV did not allow the co-diagnosis of ASD and attention-deficit hyperactivity disorder (ADHD) . However, following years of clinical research, the most recent publication (DSM-5) in 2013 removed this prohibition of co-morbidity. Thus, individuals with autism spectrum disorder may also have a diagnosis of ADHD, with the modifiers of inattentive, hyperactive, combined-type, or not otherwise specified. Clinically significant symptoms of these two conditions commonly co-occur, and children with both sets of symptoms may respond poorly to standard ADHD treatments. Individuals with autism spectrum disorder may benefit from additional types of medications or from behavioral or other therapies, such as applied behavior analysis and neuro-feedback.
Pediatric bipolar disorder, or manic-depression, is a highly controversial diagnosis and is itself often claimed to be comorbid with a number of conditions, including autism. Autism includes some symptoms commonly found in mood and anxiety disorders.
Some children with autism also have gastrointestinal (GI) symptoms, but there is a lack of published rigorous data to support the theory that autistic children have more or different GI symptoms than usual. It has been claimed that up to fifty percent of children with autism experience persistent gastrointestinal tract problems, ranging from mild to moderate degrees of inflammation in both the upper and lower intestinal tract. This has been described as a syndrome, autistic enterocolitis, by Dr. Andrew Wakefield; this diagnostic terminology, however, has been questioned by medical experts, and Wakefield's 1998 paper has since been shown to be fraudulent. Constipation, often with overflow, or encopresis, is often associated with developmental disorders in children, and is often difficult to resolve, especially among those with behavioral and communication problems.
Developmental coordination disorder
The initial accounts of Asperger syndrome and other diagnostic schemes include descriptions of developmental coordination disorder. Children with ASD may be delayed in acquiring motor skills that require motor dexterity, such as bicycle riding or opening a jar, and may appear awkward or "uncomfortable in their own skin". They may be poorly coordinated, or have an odd or bouncy gait or posture, poor handwriting, or problems with visual-motor integration, visual-perceptual skills, and conceptual learning. They may show problems with proprioception (sensation of body position) on measures of developmental coordination disorder, balance, tandem gait, and finger-thumb apposition.
ASD is also associated with epilepsy, with variations in risk of epilepsy due to age, cognitive level, and type of language disorder. One in four autistic children develops seizures, often starting either in early childhood or adolescence. Seizures, caused by abnormal electrical activity in the brain, can produce a temporary loss of consciousness (a "blackout"), a body convulsion, unusual movements, or staring spells. Sometimes a contributing factor is a lack of sleep or a high fever. An EEG can help confirm the seizure's presence. Typically, onset of epilepsy occurs before age five or during puberty. and is more common in females and individuals who also have a comorbid intellectual disability.
Fragile X syndrome
Fragile X syndrome is the most common inherited form of intellectual disability. It was so named because one part of the X chromosome has a defective piece that appears pinched and fragile when under a microscope. Fragile X syndrome affects about two to five percent of people with ASD. It is important to have a person with autism checked for Fragile X, especially if the parents are considering having another child. If one child has Fragile X, there is a 50% chance that boys born to the same parents will have Fragile X (see Mendelian genetics). Other members of the family who may be contemplating having a child may also wish to be checked for the syndrome.
The fraction of autistic individuals who also meet criteria for intellectual disability has been reported as anywhere from 25% to 70%, a wide variation illustrating the difficulty of assessing autistic intelligence. For example, a 2001 British study of 26 autistic children found about 30% with intelligence in the normal range (IQ above 70), 50% with mild to moderate retardation, and about 20% with severe to profound retardation (IQ below 35). For ASD other than autism the association is much weaker: the same study reported normal intelligence in about 94% of 53 children with PDD-NOS. Estimates are that 40–69% of individuals with ASD have some degree of intellectual disability, with females more likely to be in severe range of intellectual disability. Learning disabilities are also highly comorbid in individuals with an ASD. Approximately 25–75% of individuals with an ASD also have some degree of learning disability, although the types of learning disability vary depending on the specific strengths and weaknesses of the individual.
A 2006 review questioned the common assumption that most children with autism have ID. It is possible that the association between intellectual disability and autism is not because they usually have common causes, but because the presence of both makes it more likely that both will be diagnosed.
The CDC states that based on information from 11 reporting states 46% of people with autism have above 85 IQ 
Neuroinflammation and immune disorders
The role of the immune system and neuroinflammation in the development of autism is controversial. Until recently, there was scant evidence supporting immune hypotheses, but research into the role of immune response and neuroinflammation may have important clinical and therapeutic implications. The exact role of heightened immune response in the central nervous system (CNS) of patients with autism is uncertain, but may be a primary factor in triggering and sustaining many of the comorbid conditions associated with autism. Recent studies indicate the presence of heightened neuroimmune activity in both the brain tissue and the cerebrospinal fluid of patients with autism, supporting the view that heightened immune response may be an essential factor in the onset of autistic symptoms. A 2013 review also found evidence of microglial activation and increased cytokine production in postmortem brain samples from people with autism.
Nonverbal learning disorder
The prevalence of Tourette syndrome among individuals with autism is estimated to be 6.5%, higher than the 2% to 3% prevalence for the general population. Several hypotheses for this association have been advanced, including common genetic factors and dopamine, glutamate or serotonin abnormalities.
Unusual responses to sensory stimuli are more common and prominent in autistic children, although there is no good evidence that sensory symptoms differentiate autism from other developmental disorders. Sensory processing disorder is comorbid with ASD, with comorbidity rates of 42–88%.
Tuberous sclerosis is a rare genetic disorder that causes benign tumors to grow in the brain as well as in other vital organs. It has a consistently strong association with the autism spectrum. One to four percent of autistic people also have tuberous sclerosis. Studies have reported that between 25% and 61% of individuals with tuberous sclerosis meet the diagnostic criteria for autism with an even higher proportion showing features of a broader pervasive developmental disorder.
Sleep disorders are commonly reported by parents of children with ASDs, including late sleep onset, early morning awakening, and poor sleep maintenance; sleep disturbances are present in 53–78% of children with ASD. Unlike general pediatric insomnia, which has its roots in behavior, sleep disorders in children with ASD are comorbid with other neurobiological, medical, and psychiatric issues.
If not addressed, severe sleep disorders can exacerbate ASD behaviors such as self-injury; however, there are no Food and Drug Administration-approved pharmacological treatments for pediatric insomnia at this time. Some evidence suggests that melatonin supplements improve sleep patterns in children with autism but robust, high-quality studies are overall lacking.
Other mental disorders
The presentation of depression in ASDs can depend on level of cognitive functioning, with lower functioning children displaying more behavior issues and higher functioning children displaying more traditional depressive symptoms. Depression is thought to develop and occur more in high-functioning individuals during adolescence, when they develop greater insight into their differences from others.
- Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.). Washington, D.C.: American Psychiatric Association. 2000.
- Folstein SE, Rosen-Sheidley B (2001). "Genetics of autism: complex aetiology for a heterogeneous disorder". Nat Rev Genet 2 (12): 943–55. doi:10.1038/35103559. PMID 11733747.
- Zafeiriou DI, Ververi A, Vargiami E (2007). "Childhood autism and associated comorbidities". Brain Dev (Review) 29 (5): 257–72. doi:10.1016/j.braindev.2006.09.003. PMID 17084999.
- Cuthbert, Bruce (March 1, 2013). "Overlap Blurs Diagnostic Categories – NIH-funded Study". http://www.nimh.nih.gov/. NIMH. Retrieved May 26, 2015.
National Institutes of Health-funded researchers discovered that people with disorders traditionally thought to be distinct – autism, ADHD, bipolar disorder, major depression and schizophrenia – were more likely to have suspect genetic variation at the same four chromosomal sites. These included risk versions of two genes that regulate the flow of calcium into cells.
- Johnny L. Matson and Peter Sturmey, ed. (2011). International Handbook of Autism and Pervasive Developmental Disorders. New York: Springer. pp. 53–74.
- Underwood L, McCarthy J, Tsakanikos E (September 2010). "Mental health of adults with autism spectrum disorders and intellectual disability". Curr Opin Psychiatry (Review) 23 (5): 421–6. doi:10.1097/YCO.0b013e32833cfc18. PMID 20613532.
- White SW, Oswald D, Ollendick T, Scahill L (2009). "Anxiety in children and adolescents with autism spectrum disorders". Clin Psychol Rev 29 (3): 216–29. doi:10.1016/j.cpr.2009.01.003. PMC 2692135. PMID 19223098.
- Reiersen AM, Todd RD (2008). "Co-occurrence of ADHD and autism spectrum disorders: phenomenology and treatment". Expert Rev Neurother 8 (4): 657–69. doi:10.1586/14737220.127.116.117. PMID 18416666.
- DSM 5 ADHD Fact Sheet
- Luby J, Navsaria N (October 1, 2011). "Pediatric bipolar disorder: evidence for prodromal states and early markers". J Child Psychol Psychiatry. 51 (4): 459.471. doi:10.1111/j.1469-7610.2010.02210.x. PMC 3184298. PMID 20085607.
- McElroy SL (2004). "Diagnosing and treating comorbid (complicated) bipolar disorder". The Journal of clinical psychiatry. 65 Suppl 15: 35–44. PMID 15554795.
- Towbin KE, Pradella A, Gorrindo T, Pine DS, Leibenluft E (2005). "Autism spectrum traits in children with mood and anxiety disorders". Journal of child and adolescent psychopharmacology 15 (3): 452–64. doi:10.1089/cap.2005.15.452. PMID 16092910.
- Erickson CA, Stigler KA, Corkins MR, Posey DJ, Fitzgerald JF, McDougle CJ (2005). "Gastrointestinal factors in autistic disorder: a critical review". J Autism Dev Disord 35 (6): 713–27. doi:10.1007/s10803-005-0019-4. PMID 16267642.
- Encopresis, University of Iowa Health Care, Center for Disabilities and Development, accessed August 17, 2006
- McPartland J, Klin A (2006). "Asperger's syndrome". Adolesc Med Clin 17 (3): 771–88. doi:10.1016/j.admecli.2006.06.010 (inactive 2015-01-01). PMID 17030291.
- Ehlers S, Gillberg C (1993). "The epidemiology of Asperger's syndrome. A total population study". J Child Psychol Psychiat 34 (8): 1327–50. doi:10.1111/j.1469-7610.1993.tb02094.x. PMID 8294522. "Truncated version". Archived from the original on 2008-07-19. Retrieved 2008-06-15.
- Klin A (2006). "Autism and Asperger syndrome: an overview". Rev Bras Psiquiatr 28 (suppl 1): S3–S11. doi:10.1590/S1516-44462006000500002. PMID 16791390.
- Tuchman R, Rapin I (2002). "Epilepsy in autism". Lancet Neurol 1 (6): 352–8. doi:10.1016/S1474-4422(02)00160-6. PMID 12849396.
- "A Parent’s Guide to Autism Spectrum Disorder". National Institute of Mental Health. Retrieved 17 October 2013.
- Canitano R (February 2007). "Epilepsy in autism spectrum disorders". Eur Child Adolesc Psychiatry (Review) 16 (1): 61–6. doi:10.1007/s00787-006-0563-2. PMID 16932856.
- "Autism and Fragile X Syndrome". National Fragile X Foundation. Retrieved 3 November 2013.
- Dawson M, Mottron L, Gernsbacher MA (2008). "Learning in autism" (PDF). In Byrne JH (ed.-in-chief), Roediger HL III (vol. ed.). Learning and Memory: A Comprehensive Reference 2. Academic Press. pp. 759–72. doi:10.1016/B978-012370509-9.00152-2. ISBN 0-12-370504-5. Retrieved 2013-02-16.
- Chakrabarti S, Fombonne E (2001). "Pervasive developmental disorders in preschool children". JAMA 285 (24): 3093–9. doi:10.1001/jama.285.24.3093. PMID 11427137.
- Mash EJ, Barkley RA (2003). Child Psychopathology. New York: The Guilford Press. pp. 409–454.
- O'Brien G, Pearson J (June 2004). "Autism and learning disability". Autism (Review) 8 (2): 125–40. doi:10.1177/1362361304042718. PMID 15165430.
- Edelson MG (2006). "Are the majority of children with autism mentally retarded? a systematic evaluation of the data". Focus Autism Other Dev Disabl 21 (2): 66–83. doi:10.1177/10883576060210020301. Retrieved 2007-04-15.
- Skuse DH (2007). "Rethinking the nature of genetic vulnerability to autistic spectrum disorders". Trends Genet. 23 (8): 387–95. doi:10.1016/j.tig.2007.06.003. PMID 17630015.
- Pardo CA, Vargas DL, Zimmerman AW (2005). "Immunity, neuroglia and neuroinflammation in autism". International review of psychiatry (Abingdon, England) 17 (6): 485–95. doi:10.1080/02646830500381930. PMID 16401547.
- Gesundheit B, Rosenzweig JP, Naor D et al. (August 2013). "Immunological and autoimmune considerations of Autism Spectrum Disorders". J. Autoimmun. 44: 1–7. doi:10.1016/j.jaut.2013.05.005. PMID 23867105.
- Russell, A. J.; Jassi, A.; Fullana, M. A.; Mack, H.; Johnston, K.; Heyman, I.; Murphy, D. G.; Mataix-Cols, D. (2013). "Cognitive Behavior Therapy for Comorbid Obsessive-Compulsive Disorder in High-Functioning Autism Spectrum Disorders: A Randomized Controlled Trial". Depression and Anxiety 30 (8): 697–708. doi:10.1002/da.22053. PMID 23389964.
- Rogers SJ, Ozonoff S (2005). "Annotation: what do we know about sensory dysfunction in autism? A critical review of the empirical evidence". J Child Psychol Psychiatry 46 (12): 1255–68. doi:10.1111/j.1469-7610.2005.01431.x. PMID 16313426.
- Baranek GT (October 2002). "Efficacy of sensory and motor interventions for children with autism". J Autism Dev Disord (Review) 32 (5): 397–422. doi:10.1023/A:1020541906063. PMID 12463517.
- Ming X, Brimacombe M, Wagner GC (2007). "Prevalence of motor impairment in autism spectrum disorders". Brain Dev 29 (9): 565–70. doi:10.1016/j.braindev.2007.03.002. PMID 17467940.
- Smalley, S. L. (1998). "Autism and tuberous sclerosis". Journal of autism and developmental disorders 28 (5): 407–414. doi:10.1023/A:1026052421693. PMID 9813776.
- Harrison JE, Bolton, PF (1997). "Annotation: Tuberous sclerosis". Journal of Child Psychology and Psychiatry 38 (6): 603–614. doi:10.1111/j.1469-7610.1997.tb01687.x. PMID 9315970.
- Malow BA, Byars K, Johnson K et al. (1 November 2012). "A Practice Pathway for the Identification, Evaluation, and Management of Insomnia in Children and Adolescents With Autism Spectrum Disorders". Pediatrics 130 (S2): S106–S124. doi:10.1542/peds.2012-0900I. PMID 23118242.
- "Poor sleep in children with autism associated with problematic behavior during the day.". Truthly. Retrieved 5 February 2015.
- Johnson, Kyle P.; Malow, Beth P. (1 October 2008). "Assessment and Pharmacologic Treatment of Sleep Disturbance in Autism". Child and Adolescent Psychiatric Clinics of North America 17 (4): 773–785. doi:10.1016/j.chc.2008.06.006. PMID 18775369. Retrieved 5 February 2015.
- "Melatonin supplementation associated with improved sleep and behavior in children with autism". Truthly. Retrieved 5 February 2015.
- "More Evidence that Melatonin Eases Autism-Associated Insomnia". Autism Speaks. Retrieved 5 February 2015.
- Matson JL, Nebel-Schwalm MS (2007). "Comorbid psychopathology with autism spectrum disorder in children: an overview". Res Dev Disabil 28 (4): 341–52. doi:10.1016/j.ridd.2005.12.004. PMID 16765022.