Module 2—Presentation 2 - VCU RRTC
Virginia Commonwealth University Autism Center for Excellence (VCU-ACE)
Foundations of Autism Spectrum Disorder
Module 2
Presentation 2: There’s more to it! Co-morbid conditions
By: Taryn Goodwin, M.Ed., BCBA
Slide 1: Introduction
Taryn Goodwin, M.Ed., BCBA
Slide 2: Introduction
Transcript:
In this presentation we will look at another very important issue—co-morbid conditions. Individuals with ASD often live with other neurological and medical conditions. If left untreated, these conditions can affect a person’s quality of life. In this presentation, we will discuss the most common conditions associated with ASD.
Slide 3: Introduction
Transcript:
When we think of ASD, it’s important to understand not only a spectrum of abilities and challenges for each individual, but also a wider spectrum of neurological disorders or even medical conditions. There are times when an individual may have more than one condition. This is called co-morbidity. Co-morbid means that in addition to the primary disorder the individual has one or more other diagnosed disorders. There are several disorders that individuals might have in addition to ASD. Some of the more common co-morbidities include:
• ADHD
• Generalized Anxiety Disorder
• Depression
• OCD
• Seizure Disorders
• Sleep Disorders
• Gastrointestinal Disorders
Slide 4: Why co-morbidity is important
Transcript:
An important thing to remember about ASD is that co-morbidities can make life far more complex for the individual with ASD and his or her family. While we know that many of the most common co-morbid neurological conditions share many similarities to ASD, such as OCD, it’s important to realize that the intensity of the characteristic may be the biggest challenge. Diagnosing other conditions is no easy task. It takes a skilled clinician to understand the intricacies of ASD or ASD plus other complicating factors.
Due to the primary characteristics of ASD, it may be difficult to distinguish pain or illness related behaviors from other types of repetitive behaviors or from sensory processing problems. Individuals with ASD, even those with formal language and advanced vocabularies may not be able to explain pain, illness, or other symptoms no matter their age. Some individuals may use behaviors, such as self-injury, to express and manage pain or illness. Once treated, though, the individual with ASD may be able to function on a different level than before. When we feel better, we do better!
Slide 5: Individuals with ASD
Transcript:
Individuals with ASD may have challenges with attending which can, of course, affect every part of life. There are several reasons why they might get distracted easily. They might have sensory processing difficulties and be hypersensitive or hyposensitive to the sensory information that is around them. An individual with ASD might also be easily distracted by their area of interest and find it hard to concentrate on anything else! For example, Ben is always arranging his magnetic letters into words and Emily is always ready to talk about Anime. Another reason for difficulty with attending may be due to a co-morbid diagnosis of ADHD.
Slide 6: Attention Deficit Hyperactivity Disorder
Transcript:
Attention Deficit Hyperactivity Disorder is often referred to as ADHD. There are subtypes of ADHD—Hyperactivity and Inattentive. Individuals can be diagnosed with either being Hyperactive or Inattentive - or a combination of the two. In terms of hyperactivity, most of us think of a person in constant motion. Often these individuals are described as bring ‘driven by a motor’ since they are constantly moving, squirming, wiggling, and tapping. This individual often feels restless and acts impulsively. Other challenges with impulsivity might include blurting out answers, impatience, or interrupting excessively. This person would be described as ADHD, predominantly hyperactive-impulsive.
Now, let’s talk about the person who is inattentive. Not all people with ADHD are hyperactive or impulsive, though, and many are only inattentive. This was previously described as ADD, but is now described as ADHD primarily inattentive. Individuals with an inattentive type of ADHD may sit quietly but have tremendous problems paying attention. This individual may seem distracted or forgetful and may even switch topics often. Many people might describe this person as a daydreamer. Emily’s teachers often report that she appears distracted during class and have asked her grandparents to talk to their doctor about ADHD.
As you can see, distinguishing between the characteristics of ASD and difficulties related to ADHD is a real challenge!
Slide 7: Generalized Anxiety Disorder
Transcript:
Generalized Anxiety Disorder (GAD) is a condition characterized by excessive and uncontrollable worry about everyday things. Most of us worry about something. How much money is in our account, why our friend is late for dinner, or how we’ll ever get to work on time when the traffic is really bad. It’s normal to worry and feel anxious from time to time. However, it becomes a problem when the frequency, intensity, and duration of the worry are disproportionate to the actual source of worry, and such worry often interferes with daily functioning. People with general anxiety disorder often have a variety of symptoms such as tension, being startled easily, restlessness, hyperactivity, worrying, and fear. In individuals with ASD, general anxiety disorder can lead to lower levels of social supports and poor academic outcomes.
Slide 8: Depression
Transcript:
Depression is a serious medical problem for many people. Most of us have felt a little ‘blue’ from time to time. Some of us can be sad due to loneliness, family circumstances, or the loss of a job. Feeling sad at different times in our lives is completely normal. However, depression is different. Those suffering from depression may feel hopeless, restless, or they may lose interest in activities they once found enjoyable or have changes in appetite. We’ve all heard the phrase, “Depression hurts.” People with depression also feel both physical and emotional pain. All of these feelings can interfere with a person’s ability to function, and may even drive some people to suicidal thoughts.
Slide 9: Individuals with ASD
Transcript:
People with ASD may experience depression, especially in late adolescence and their twenties. Depression lowers an individual’s desire to interact socially with others and those individuals with ASD who suffer from depression are at a greater risk of social isolation due to pre-existing social difficulties in the areas of social communication.
As you know, individuals with ASD have difficulty with communication. This means people with ASD often have trouble communicating feelings of anxiety or distress and it is common for these to go undiagnosed until the effects are very evident. As with any comorbid disorder, it is important to work with a medical professional to determine whether depression may be present. Emily’s classmate, Paul, enjoyed fixing computers and playing games online. Over the period of a few months, he started eating less and less at lunch, sitting by himself and he stopped finding enjoyment in computers. His parents discussed the possibility of depression with their family doctor and followed him closely for other signs and symptoms. Individuals with ASD who suffer from clinical depression may require medication and therapy to improve.
Slide 10: Obsessive Compulsive Disorder
Transcript:
You may have heard someone use the term obsessive-compulsive in joking manner to describe someone who is very organized and likes to keep a very clean desk or someone who talks about a particular topic a lot. However, these terms and jokes should not be confused with Obsessive Compulsive Disorder, or OCD. OCD is a very specific and well-defined condition that is described as recurrent obsessions and compulsions and persistent thoughts, impulses, or images that are intrusive and inappropriate. These thoughts, impulses, or images cause the individual with OCD considerable distress.
Compulsions can be described as repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession. These acts are aimed at preventing or reducing distress or preventing some dreaded event or situation. These behaviors or mental acts either are not connected realistic or are excessive in nature. Most individuals with OCD realize that they really don't have to repeat the behaviors over and over again, but the anxiety can be so great that they feel that repetition is "required" to get rid of that uncomfortable feeling
Slide 11: Individuals with ASD
Transcript:
While ASD and OCD can occur together, it is more common for individuals with ASD to display behaviors that are similar to those of OCD, but that are in fact a part of ASD and not a separate case of obsessive compulsive disorder. The key is knowing that the obsessions or compulsions are excessive that makes it OCD. Another factor is the individual with ASD often finds intense joy in their interests and significant relief in their repetitive actions, whereas the individual with OCD experiences significant distress at their intrusive thoughts and compulsive actions. It’s important to understand that the two disorders are separate but can occur together in some individuals as some may need to seek other types of intervention for relief from intrusive thoughts and compulsive actions than what might be provided for only a person diagnosed with ASD.
Slide 12: Did you know?
Transcript:
Up to 1/3 of people diagnosed with ASD will also have a seizure disorder.
Slide 13: Seizure disorder
Transcript:
One of the most common co-morbid conditions associated with ASD is seizure disorder. Some individuals with ASD will present with seizure activity early on in childhood, whereas others may not begin to exhibit seizure activity until adolescence. We aren’t sure why seizures develop in some individuals with ASD and not in others. It is also unknown as to why we see an increase in the possibility of seizures developing during adolescence.
Seizures are caused by abnormal electrical activity in the brain. There are seizures where a person’s muscles might stiffen (tonic seizures) or where a person’s muscles might jerk (clonic seizures). There are also seizures where a person’s muscle do both (tonic clonic seizures). These types of seizures are what most people think of when they hear the words seizure disorder and are sometimes called a grande mal type of seizure. There are also seizures where a person loses muscle control and falls down (atonic seizure).
Symptoms of seizure activity might include episodes with:
• Jerking movements
• Loss of consciousness
• Extreme fatigue
• Loss of bowel or bladder control
• Confusion or weakness
Slide 14: Seizure disorders
Transcript:
Another type of seizure is known as an absence seizure. An absence seizure is characterized by brief episodes of unresponsive staring. These episodes usually last about 10 seconds but can last as long as 20-30 seconds. During an absence seizure, the individual generally cannot be redirected by tapping their shoulder or by calling their name. Untreated absence seizures can contribute to educational and behavioral problems.
If you have any concerns about any type of seizure activity, it is important to discuss these concerns with your doctor and consider a referral to a neurologist. Further testing may be required and medication a necessary part of treatment.
Slide 15: Gastrointestinal disorders
Transcript:
Gastrointestinal, or GI, disorders are common among all types of people. Most of us have seen the commercials for reflux medications, constipation, and yes, even diarrhea! GI issues, no matter how difficult they are to talk about, happen to all of us at one time or another. However, in some individuals, reflux happens more often than after a spicy meal and the cramps of GI pain happen more often than after a bad burrito.
Slide 16: Individuals with ASD
Transcript:
People with ASD and their families often report GI disorders that are more obvious but also other pain related behaviors that aren’t as obvious. While there is a lot of misinformation about what role GI disorders play in the development of ASD, we do know that people with ASD are like anyone else—they can and will have common medical conditions such as reflux and bathroom problems. It’s important to remember that due to sensory processing issues, many people with ASD have difficulty eating a balanced diet. Subsisting on a limited diet doesn’t really help a person’s GI health! For example, Ben only eats Ritz crackers and drinks white grape juice. His parents are worried that this may be related to some of his bathroom habits.
It’s also possible that some individuals with ASD may also have more complex issues; however, there is no one GI condition that is currently known to exist in every person with ASD. Remember, every person with ASD is different—some may have GI issues and others may not. Talking with your family doctor and seeking a referral to a gastroenterologist may be necessary for individuals with symptoms such as feeding aversion, excessive constipation or diarrhea, excessive hoarseness or throat clearing, excessive vomiting, difficulty swallowing, weight loss or failure to thrive, obvious pain in the chest or abdomen, and other symptoms.
Slide 17: Sleep disorders
Transcript:
Most of us have had a time in our life where we just didn’t sleep well. We’ve all had a lousy night’s sleep in a hotel or had a noisy neighbor wake us in the middle of the night. Some of us may have even experienced trouble sleeping for many weeks in a row due to a stressful event in our lives. However, individuals with ASD may have difficulties sleeping from a very early age and may continue to have difficulty falling asleep, staying asleep, or with early morning waking throughout their entire life.
Sleep is an important part of life and serves a very real function for the brain—rest and recuperation. Without sleep, learning and functioning in everyday life can be difficult if not impossible! Some symptoms of sleep disorders might include:
• Prolonged difficulty falling asleep
• Difficulty staying asleep or repeated waking throughout the night
• Early morning waking such as 3 am
• Excessive daytime sleepiness
Ben’s parents have many concerns about Ben’s lack of sleep. He only sleeps about three hours every night. Ben’s pediatrician has ordered a sleep study to find out more information. If there’s any concern about a child’s sleep, a sleep study may be necessary and / or a follow up with a neurologist for treatment such as medications to help the individual fall asleep and stay
asleep.
Slide 18: Other health considerations
Transcript:
It’s also important to remember that people with ASD are much like anyone else—they can and will get sick. This means that more common ailments can also be a problem. This includes dental pain from cavities, headaches including migraines, allergies, asthma, and diabetes. These are all health considerations for everyone else today and may be the source of pain, discomfort, behavior, or even self-injury in the individual with ASD. It’s important that every person with ASD have access to quality preventative health care including dental screenings, vision screenings, and yearly check-ups with a pediatrician or family doctor to discuss other concerns besides ASD related concerns. If at any time there is any concern about pain or illness, it’s important to consider the social communication, behavioral, and sensory challenges that may prevent the individual with ASD from accessing quality medical care and treatment. After all, even those with very formal language and advanced vocabularies cannot always adequately describe if they are in pain or where that it hurts. Stereotypical behaviors may be related to pain or illness and sensory processing problems can make identifying pain and illness difficult. Ben’s parents have started using a pain scale with him to identify how bad common scrapes and bruises hurt. Oliver’s family have role-played going to the doctor and discussing pain to help him be more comfortable in a medical setting.
Slide 19: Video: Co-morbidity
Transcript:
In this video, you will notice a physician discussing the most common co-morbidities associated with ASD.
Video transcript:
Hello, I’m John Harrington, general academic pediatrician at Children’s hospital of the King’s Daughter and professor of pediatrics at Eastern Virginia Medical School, here to talk to you about co-morbid concerns for children with autism spectrum disorder. Co-morbid, or a second diagnosis, I like to think about this as a mneumonic, A SECOND, so a for anxiety, s for sleep, e for eating and nutritional problems, c for constipation, o for obsessive compulsive disorder, n for neurological, seizures and neurodevelopmental problems, and d for depression and disruptive behaviors. Let’s look at each one separately.
Anxiety, this generally may manifest early as a separation problem between the parent and the child. It can become more generalized to not only a person but also specific places like the school, the store, or even the playground. It may be part of an insistence on routines that get so ingrained that the child becomes anxious when once the routines are not followed. Usually behavior strategies teach coping skills with transitions can be extremely helpful. Medications are rarely needed but a selective serotonin reuptake inhibitor, such as Prozac, in low doses can be helpful.
Sleeping problems, are very important. They start early in most cases, generally even in the infancy. Parents will get too little or interrupted sleep, as their child has trouble falling asleep, staying asleep, and maintaining a prolonged sleep. Poor sleep hygiene like this can get reinforced. This can worsen the child’s behaviors in all areas. Parents need to develop a fairly rigid bedtime routine. This can also be assisted with a medication called melatonin. Generally, I like to give three milligrams of melatonin one hour before bedtime to assist in these sleep hygiene routines.
Eating problems. Usually occurs within the first year or toddler years. Toddlers can be extremely restricted but children with autism are restricted to textures, colors, and may only eat one or two foods. They can actually develop nutritional deficiencies in vitamin d and vitamin c. We’ve actually seen two cases of scurvy which is a vitamin c deficiency at CHKD. Parents can continue to offer multiple food trials. IN regular children, 10-20 trials are needed, but in children with autism, you may need as much as 100 trials of the same food in order to get them to eat it. I tell parents to introduce a multivitamin early so that becomes a routine and the child is getting their vitamins.
Constipation. Constipation probably coincides with a limited diet. Some can have diarrhea initially at first and can be the reason for increased irritability and outbursts. If the child is constipated, they are not happy. You can try and add fiber foods or pills. Miralax powder, which is over the counter, but can be gotten as prescription, works well also. Taking one scoop and putting in 8 ounces of water once a day.
Obsessive Compulsive Disorder is generally an early defining behavior, lining things up and an insistence on routines, and unable to transition from one thing to another. Children with autism may play with water or light switches, not just for minutes but for hours. You need to work on behavior modification that practices transitions in order to help children through these obsessive compulsive disorders. Sometimes a low dose of SSRI, or the Prozac may help.
Neurological or neurodevelopmental problems such as seizures in preschool and adolescence usually see some type of regression in development. Neurodevelopmental problems such as ADHD, or Attention Deficit Hyperactivity Disorder, is sometimes the first diagnosis given to children with autism. In these children may actually be higher functioning. This disorder, ADHD, is found in 50% of children with autism, and is very common and treatable. Low doses of medication should be started due to sensitivity to the side effects. The mantra is start low and go slow.
Depression and disruptive behaviors can become important as the child gets older. It’s very important to recognize depression. It generally occurs as kids get older and more cognizant of differences. Pressure to conform in middle school is one of the reasons. Counseling is probably the best therapy for children. Disruptive behaviors are the number one reason for difficulties in school and out of school suspensions. Behavior therapies that target the antecedent, behaviors, and consequences of the behaviors work best. Medications like Risperdal or Abilify are sometimes used in these cases.
Co-morbid problems in children are important. Although autism spectrum disorder is the unifying diagnosis for the child, the treatment of the co-morbid problems can sometimes be more important for the health and well-being of the child and family. Thank you.
Slide 20: Conclusion
Transcript:
Individuals with ASD may have co-morbid conditions that, if left untreated, can affect a person’s quality of life. These include conditions such as ADHD, Generalized Anxiety Disorders, OCD, seizure disorders, sleep disorders, and gastrointestinal disorders. It’s important to remember that people with ASD are much like anyone else, they can and will get sick with more common ailments as well. As you’ve learned throughout this course, individuals with ASD have trouble communicating with others. This can include asking for help, saying no, or having a conversation. Many individuals, even those with formal language and advanced vocabularies, can have difficulty expressing emotions, feelings, and pain. This can make diagnosing co-morbid conditions difficult and increases the importance of well-child visits and yearly check-ups for adolescents and adults.
Information for this presentation is from Virginia Commonwealth University's Autism Center for Excellence (VCU-ACE) that is funded by the Virginia State Department of Education (Grant # 881-61172-H027A100107). Virginia Commonwealth University is an equal opportunity/affirmative action institution providing access to education and employment without regard to age, race, color, national origin, gender, religion, sexual orientation, veteran's status, political affiliation, or disability. If special accommodations or language translation are needed contact (804) 828-1851 VOICE -- (804) 828-2494 TTY
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