Associations between domains of health-related quality of life and co-occurring emotional and behavioral problems in youth with autism spectrum disorder

BackgroundHealth-related quality of life (HRQoL) can be used as a measure of the impact of a particular disorder on one’s daily functioning. Previous studies have found that comorbid psychiatric disorders in children and adolescents with autism spectrum disorder (ASD) are associated with poorer HRQoL than ASD alone. Less is known about potential associations between specific symptoms of co-occurring psychopathology (i.e., emotional and behavioral problems) and domains of functioning or HRQoL in youth with ASD.MethodParticipants were 470 children with ASD 2–14 years old recruited from one of three sites. Hierarchical multiple regressions were conducted with Pediatric Quality of Life Inventory 4.0 (PedsQL; Varni, Seid, & Kurtin, 2001) HRQoL domains of physical functioning, emotional functioning, school functioning, and social functioning as the dependent variables. Covariates were entered at step 1, followed by the independent variables of interest at step 2: irritability, social withdrawal, stereotypic behavior, hyperactivity/noncompliance, and inappropriate speech.ResultsThe study found that increased irritability was associated with poorer emotional and physical functioning and that greater social withdrawal was associated with worse social functioning. Furthermore, findings showed that more hyperactivity/noncompliance was associated with worse school functioning.ConclusionsResults demonstrated that certain emotional and behavioral symptoms are differentially associated with domains of HRQoL. This indicates that emotional and behavioral problems should be considered when measuring HRQoL in children with ASD. It also suggests that treating co-occurring emotional/behavioral problems could improve HRQoL and functioning in certain domains for this population.     

Children with psychiatric disorders who are frequent attenders to primary care

Child psychiatric disorder has been found to be linked to enhanced primary care attendance. We studied the somatic and psychological associations of psychiatric disorder amongst frequent (four or more consultations a year) primary care attending school children. We compared 32 children aged 7–12 years with a psychiatric disorder with 77 non-disordered (also frequently attending) children. Psychiatric disorder was not associated with type of presenting complaint at the surgery nor with chronic physical illness. However disordered children were more likely to be described by their mothers as handicapped by existing physical problems, in poor health, with low energy levels and likely to experience physical symptoms under stress. Problems in social relationships and educational difficulties were reported in more disordered children; more of them came from broken homes and had mothers who reported other psycho-social and health stresses and showed characteristic health beliefs. The findings indicate that knowledge about the child's general physical well-being and relationships and about maternal mental health may assist in the primary care identification and management of psychiatric disorders of frequently attending school children. Accepted: 17 September 1998     

The Heavy Burden of Psychiatric Comorbidity in Youth with Autism Spectrum Disorders: A Large Comparative Study of a Psychiatrically Referred Population

The objective of the study was to systematically examine patterns of psychiatric comorbidity in referred youth with autism spectrum disorders (ASD) including autistic disorder and pervasive developmental disorder not otherwise specified. Consecutively referred children and adolescents to a pediatric psychopharmacology program were assessed with structured diagnostic interview and measures of psychosocial functioning. Comparisons were made between those youth satisfying diagnostic criteria for ASD and age and sex matched youth without ASD referred to the same clinical program. 9.3% (217/2323) of the referred youth (age range: 3–17 years) met DSM-III-R criteria for ASD. ASD youth suffered from significantly higher number of comorbid disorders than comparisons (6.4 ± 2.7 vs. 5.2 ± 2.9; p < 0.001). Ninety-five percent of the youth with ASD had three or more comorbid psychiatric disorders and 74% had five or more comorbid disorders. ASD youth were also more functionally impaired and required extra-assistance in school and therapeutic interventions at higher rates than age and sex matched non-ASD referred youth. Youth with ASD have high levels of psychiatric comorbidity and dysfunction comparable to the referred population of youth without ASD. These findings emphasize the heavy burden of psychiatric comorbidity afflicting youth with ASD and may be important targets for intervention.     

Onset of maternal psychiatric disorders after the birth of a child with intellectual disability: A retrospective cohort study

Mothers of a child with intellectual disability (ID) have more psychiatric disorders after the birth of their child than other mothers. However, it is unclear if this is because they have more psychiatric disorders before the birth or if the increase is related to the burden of caring for the child. We aimed to calculate the rate of new psychiatric disorders in mothers after the birth of their eldest child with ID born between 1983 and 2005 and to compare these with rates in women with a child with no ID or autism spectrum disorder (ASD) born during the same period. By linking data from Western Australian population-based registries, we selected women with no psychiatric history who survived the birth of their live-born child (N = 277,559) and compared rates of psychiatric disorders for women with a child with ID and women without a child with or ASD. Negative binomial regression with STATA 12 was used for all analyses. Mothers of children with mild–moderate ID of unknown cause had around two to three and a half times the rate of psychiatric disorders of mothers of children without ID or ASD. Mothers of children with Down syndrome and no pre-existing psychiatric disorder showed resilience and had no impairments in their mental health. Interventions and services are needed for mothers of other children with ID to improve their mental health. Further research is implicated to explore the mental health of mothers of children with ID and a pre-existing psychiatric disorder.     

The role of family cohesion in the psychological adjustment of non-Hispanic White and Hispanic mothers of children with autism spectrum disorder

The current study utilizes a process-oriented approach to understand both personal and family factors influencing the development of depressive symptoms among non-Hispanic White and Hispanic mothers of children with ASD. Family cohesion was hypothesized to mediate the associations between the personal factors (optimism, benefit finding, social support) and depressive symptoms. Mothers of 117 children with ASD (Hispanic n = 73; non-Hispanic White n = 44) completed measures of depressive symptoms, family cohesion, social support, optimism, and benefit finding. Results from this study indicate that optimism, benefit finding, and social support are important predictors of positive maternal adjustment. Furthermore, these factors contribute to better family functioning, namely family cohesion. The mediation models containing optimism, benefit finding, partner and family support were significant for both Hispanic and non-Hispanic White mothers, suggesting a similar mediation process for both racial/ethnic groups. However, family cohesion was a significant mediator of the relationship between friend support and depressive symptoms for Hispanic mothers only. The results of this study complement and extend previous research examining family functioning among mothers of children with ASD and have implications for the development of interventions aimed at increasing maternal well-being.     

Interaction of neurodevelopmental pathways and synaptic plasticity in mental retardation,autism spectrum disorder and schizophrenia: Implications for psychiatry

Objectives. Schizophrenia (SCZ), autism spectrum disorder (ASD) and mental retardation (MR) are psychiatric disorders with high heritability. They differ in their clinical presentation and in their time course of major symptoms, which predominantly occurs for MR and ASD during childhood and for SCZ during young adult age. Recent findings with focus on the developmental neurobiology of these disorders emphasize shared mechanisms of common origin. These findings propose a continuum of genetic risk factors impacting on synaptic plasticity with MR causing impairments in global cognitive abilities, ASD in social cognition and SCZ in both global and social cognition. Methods. We assess here the historical developments that led to the current disease concepts of the three disorders. We then analyse, based on the functions of genes mutated in two or three of the disorders, selected mechanisms shared in neurodevelopmental pathways and synaptic plasticity. Results. The analysis of the psychopathological constructs supports the existence of three distinct clinical entities but also elaborates important associations. Similarly, there are common mechanisms especially in global and social cognition. Conclusions. We discuss implications from this integrated view on MR, ASD and SCZ for child & adolescent and adult psychiatry in pathophysiology and research perspectives.     

Comparison of Children with Autism Spectrum Disorder with and Without Schizophrenia Spectrum Traits: Gender, Season of Birth, and Mental Health Risk Factors

Children with autism spectrum disorder (ASD) with and without co-occurring schizophrenia spectrum traits (SST) were examined for differences in co-occurring psychiatric symptoms, background characteristics, and mental health risk factors. Participating mothers and teachers completed a DSM-IV-referenced rating scale and a background questionnaire (mothers only) describing 147 children (6-12?years) with ASD. There was a clear pattern of group differences in co-occurring psychiatric symptom severity (+SST?>?SST-) and background characteristics. Children with impairing SST had more mental health risk factors. Girls were more likely to be classified SST according to mothers' ratings. Children born in spring-summer were more likely to be classified non-SST by teachers' ratings. Findings provide tentative evidence that SST may be a useful marker of behavioral heterogeneity within the ASD clinical phenotype.     

Immigrant children: psychiatric disorder, school performance, and service utilization

Data from the Ontario Child Health Study were used to examine the strength of association between child immigrant status and child psychiatric disorder, poor school performance, and use of mental health/social services. Bivariate results indicate that immigrant children are not at increased risk for psychiatric disorder or poor school performance and that they use mental health and social services significantly less often than do their nonimmigrant peers. Implications of the findings are explored.     

Women's posttraumatic stress symptoms and autism spectrum disorder in their children

Maternal posttraumatic stress disorder (PTSD) may be associated with autism spectrum disorder (ASD) in offspring through multiple pathways: maternal stress may affect the fetus; ASD in children may increase risk of PTSD in mothers; and the two disorders may share genetic risk. Understanding whether maternal PTSD is associated with child's ASD is important for clinicians treating children with ASD, as PTSD in parents is associated with poorer family functioning. We examined the association of maternal PTSD with offspring ASD in a large US cohort (N ASD cases = 413, N controls = 42,868). Mother's PTSD symptoms were strongly associated with child's ASD (RR 4–5 PTSD symptoms = 1.98, 95% CI = 1.39, 2.81; RR 6–7 symptoms = 2.89, 95% CI = 2.00, 4.18). Clinicians treating persons with ASD should be aware of elevated risk of PTSD in the mother. Genetic studies should investigate PTSD risk alleles in relation to ASD.     

A pilot study examining the use of the autism diagnostic observation schedule in community-based mental health clinics

Community-based mental health (CMH) services play an important, but relatively understudied role in the identification and treatment of youth with autism spectrum disorder (ASD) who may be receiving care for other psychiatric conditions. Little is known about the role of standardized ASD assessment measures administered by providers working in generalist community-based mental health (CMH) settings. This pilot study extracted data from three CMH clinics to examine the use of the Autism Diagnostic Observation Schedule (ADOS) by 17CMH providers who received ASD assessment training with 62 youth (Mean = 10.69 years) referred for an ASD diagnostic evaluation. Results indicated that 57% of youths assessed ultimately received an ASD diagnosis. All cases given a final ASD diagnosis were classified as “Autism” or “ASD” on the ADOS. Seventy percent of youth who did not receive a final ASD diagnosis were classified as “Non-Spectrum” on the ADOS. In these false positive cases, report narratives indicated that social communication difficulties identified on the ADOS were explained by symptoms of other mental health conditions (e.g., ADHD, anxiety). Future research is needed to examine the utility of the ADOS when used by CMH providers to facilitate CMH capacity to identify ASD.     

An Examination of Treatment Completers and Non-Completers at a Child and Adolescent Community Mental Health Clinic

This study examined sociodemographic and clinical characteristics of treatment completers (N = 114) and non-completers (N = 136) at a child and adolescent community mental health clinic. Results indicated that children who completed treatment significantly differ from those who prematurely drop out of treatment. Non-completers presented with considerably more impairment in functioning and psychiatric symptoms, and their caregiver reported experiencing significantly more parenting stress and depressive symptoms. Results suggest that mental health treatment is not readily provided to the most difficult to reach and most at-risk youth and their families.     

Autistic spectrum disorder,attention deficit hyperactivity disorder,and psychiatric comorbidities: A nationwide study

Attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) are both frequently comorbid with other psychiatric disorders, but the comorbid effect of ASD and ADHD relative to the comorbid risk of other psychiatric disorders is still unknown. Using the Taiwan National Health Insurance Research Database, 725 patients with ASD-alone, 5694 with ADHD-alone, 466 with ASD + ADHD, and 27,540 (1:4) age-/gender-matched controls were enrolled in our study. The risk of psychiatric comorbidities was investigated. The ADHD + ASD group had the greatest risk of developing schizophrenia (hazard ratio [HR]: 95.89; HR: 13.73; HR: 174.61), bipolar disorder (HR: 74.93; HR: 19.42; HR: 36.71), depressive disorder (HR: 17.66; HR: 12.29; HR: 9.05), anxiety disorder (HR: 49.49; HR: 50.92; HR: 14.12), disruptive behavior disorder (HR: 113.89; HR: 93.87; HR: 26.50), and tic disorder (HR: 8.95; HR: 7.46; HR: 4.87) compared to the ADHD-alone, ASD-alone, and control groups. Patients with ADHD + ASD were associated with the greatest risk of having comorbid bipolar disorder, depressive disorder, anxiety disorder, disruptive behavior disorder, and tic disorder. The diagnoses of ASD and ADHD preceded the diagnoses of other psychiatric comorbidities. A comprehensive interview scrutinizing the psychiatric comorbidities would be suggested when encountering and following patients with both ASD and ADHD in clinical practice.     

Children's sleep problems are associated with poorer student–teacher relationship quality

ObjectiveChildren's sleep problems are associated with poorer student functioning in the school environment, including impairment in peer relationships; yet, no studies have examined sleep functioning in relation to the student–teacher relationship. The objective of this study was to examine whether child-rated total sleep problems or specific sleep problem domains (bedtime problems, nighttime problems, or daytime sleepiness) were associated with teacher-rated student–teacher closeness and conflict after controlling for student mental health symptoms known to be associated with both greater sleep problems and poorer student–teacher relationship quality. The study also examined whether age moderated the relation between sleep problems and student–teacher relationship quality.ParticipantsParticipants were 175 children (81 boys and 94 girls) in the first to sixth grades (age = 6–13 years) and their teachers.MethodsChildren completed the Sleep Self-Report. Teachers completed a measure of student mental health symptoms (ie, attention-deficit/hyperactivity disorder, oppositional defiant disorder, conduct disorder, and anxiety/depression) and a measure of their relational closeness and conflict with each student.ResultsTotal sleep problems were associated with greater student–teacher conflict, after controlling for child mental health symptoms and demographic factors. This association was moderated by age such that sleep problems were associated with conflict for younger children but not older children. Notably, daytime sleepiness specifically was associated with less student–teacher closeness.ConclusionsThis is the first study to demonstrate a relation between student sleep functioning and the student–teacher relationship. Results of the study suggest that sleep may be an important component of school-based screening and evaluation efforts, as sleep is an important malleable factor related to school success.     

Caregiver-Teacher Concordance of Challenging Behaviors in Children with Autism Spectrum Disorder Served in Community Mental Health Settings

Children with autism spectrum disorder (ASD) exhibit high rates of challenging behaviors that impair functioning and represent the primary presenting problem in mental health (MH) services. Obtaining symptom reports from multiple informants is critical for treatment planning. This study evaluated caregiver-teacher concordance of ratings of the intensity of challenging behaviors in children with ASD receiving MH services, and identified child clinical factors associated with concordance. This sample included 141 children (M?=?9.07 years), their caregivers, and teachers. Caregiver-teacher concordance of challenging behaviors was low and impacted by the degree and type of child psychiatric comorbidity. Findings support need for increased attention to the range of psychiatric problems children with ASD present to tailor treatment recommendations and service delivery.     

Quality of life and risk of psychiatric disorders among regular users of alcohol,nicotine, and cannabis: An analysis of the National Epidemiological Survey on Alcohol and Related Conditions (NESARC)

Research is limited on the effects of regular substance use on mental health-related outcomes. We used a large nationally representative survey to examine current and future quality of life and risk of psychiatric disorders among past-year regular (weekly) users of alcohol, nicotine, and cannabis. Data on psychiatric disorders and quality of life from two waves (Wave 1 N = 43,093, Wave 2 N = 34,653) of the National Epidemiological Survey on Alcohol and Related Conditions (NESARC) were used to test study aims. In cross-sectional analyses, regular nicotine and cannabis use were associated with higher rates of psychiatric disorder, though regular alcohol use was associated with lower rates of disorders. Prospective analyses found that regular nicotine use predicted onset of anxiety, depressive, and bipolar disorders. Regular alcohol use predicted lower risk of these disorders. Regular cannabis use uniquely predicted the development of bipolar disorder, panic disorder with agoraphobia, and social phobia. Lastly, regular alcohol use predicted improvements in physical and mental health-related quality of life, whereas nicotine predicted deterioration in these outcomes. Regular cannabis use predicted declines in mental, but not physical health. These data add to the literature on the relations between substance use and mental and physical health and suggest increased risk of mental health problems among regular nicotine and cannabis users and better mental and physical health among regular alcohol users. Examination of mechanisms underlying these relationships is needed.     

Kiddie-SADS Reveals High Rates of DSM-IV Disorders in Children and Adolescents with Autism Spectrum Disorders

Prevalence of current comorbid DSM-IV disorders was assessed in a special school population of children and adolescents with ASD (N = 71, age 6.0–17.9 years), representing all cognitive levels and main ASD subgroups. Symptoms were assessed through parent interview and association to child characteristics was explored. Seventy-two percent was diagnosed with at least one comorbid disorder. Anxiety disorders (41%) and attention deficit/hyperactivity disorder (31%) were most prevalent. Obsessive–compulsive disorder was more common in older children, and oppositional defiant disorder/conduct disorder more prevalent in pervasive developmental disorder, not otherwise specified. Our results show high rates of comorbid DSM-IV disorders and underscore the importance of such evaluation in children ASD. However, diagnostic challenges are present and future research on the diagnostic validity of comorbid psychiatric disorders is needed.     

The link between emotion regulation,social functioning,and depression in boys with ASD

PurposeSymptoms of depression are common in children and adolescents with an autism spectrum disorder (ASD), but information about underlying developmental factors is limited. Depression is often linked to aspects of emotional functioning such as coping strategies, but in children with ASD difficulties with social interactions are also a likely contributor to depressive symptoms.MethodologyWe examined several aspects of emotional coping (approach, avoidant, maladaptive) and social functioning (victimization, negative friendship interactions) and their relation to depression symptoms in children with ASD (N = 63) and typically developing (TD) peers (N = 57). Children completed a battery of self-report questionnaires.ResultsLess approach and avoidant, but more maladaptive coping strategies, and poor social functioning were uniquely associated with more symptoms of depression in children with ASD. Only less approach and more maladaptive coping were uniquely associated with depression severity in TD boys.ConclusionsUnlike TD boys, boys with ASD who report using avoidant strategies to deal with stressful situations report fewer symptoms of depression, suggesting that this may be an adaptive emotion regulation strategy. However, understanding the role of over-arousal in this process, inferences about long-term effects of this strategy, its causality and direction of effects will require additional research.     

Psychiatric symptoms in children and adolescents with higher functioning autism spectrum disorders on the Development and Well-Being Assessment

The Development and Well-Being Assessment (DAWBA) parent interview was used to assess psychiatric symptoms in children and adolescents with higher functioning autism spectrum disorders (ASD) (n = 60; age range 6.5–16.7) and in typically developing (TD) children and adolescents (n = 60; age range 6.9–16.2). Psychiatric symptoms were reported in the ASD group (68%) significantly more compared to the TD group (12%). Specifically, emotional disorders, attention deficit hyperactivity disorder/hyperkinesis, and tic disorders were significantly more frequent in the ASD group compared to the TD group. Routine screening and early identification of these symptoms could have important implications for planning interventions and thus outcome in individuals with higher functioning ASD. The DAWBA would be a useful interview for this purpose, since it can also be easily and quickly administered in clinics not specialized in psychiatry.     

Group-based Cognitive Behavioural Therapy for Anxiety Disorder in Children with Autism Spectrum Disorder: a feasibility study

Abstract

Purpose: Autism spectrum disorder (ASD) includes core symptoms that affect general and social development. High risk of developing comorbid disorders such as anxiety is prominent. Up to 60% of children with ASD suffer from anxiety disorders which can negatively influence educational, social and general development together with quality of life. This study is the first to investigate the feasibility of the manualised cognitive behavioural therapy (CBT) group programme 'Cool Kids ASD' for anxiety adapted for children with ASD in a general hospital setting.

Methods: Nine children, aged 9–13 years, with ASD and anxiety recruited from a public child psychiatric health clinic were enrolled in the study. Outcome measures were collected from both child and parent pre- and post-treatment and at 3-month follow-up and included scores from a semi-structured anxiety interview, together with questionnaires on anxiety symptoms, life interference, children's automatic thoughts and satisfaction with the programme.

Results: Eight out of nine families found the programme useful and would recommend it to other families in a similar situation. Six families attended all 12 sessions in the programme, two missed one session and one family only managed to attend eight sessions. At follow-up, five children were free of all anxiety diagnoses and a further two out of the nine children no longer met the criteria for their primary anxiety diagnosis.

Conclusions: This study suggests that the transition of the group programme 'Cool Kids ASD' from University Clinics to standard child psychiatric clinical settings is feasible. Further randomised studies are needed to confirm the efficacy of the programme in a larger sample.     

Brief Report: Emotion Regulation and Respiratory Sinus Arrhythmia in Autism Spectrum Disorder

Emotion regulation (ER) may be an important transdiagnostic factor for understanding mental and behavioral health given its association with several psychiatric disorders, including autism spectrum disorder (ASD). However, there is limited research on ER in ASD, particularly using biomarkers such as respiratory sinus arrhythmia (RSA). The aim of the current study was to examine RSA among school-aged children with ASD in relation to symptoms of anxiety, executive functioning, and adaptive socialization skills. Results showed decreased RSA in children with ASD (relative to typically developing controls), reflecting decreased parasympathetic nervous system activity. In addition, decreased RSA was associated with increased symptoms of anxiety and lower socialization skills. These findings emphasize the need for interventions targeting emotional and arousal regulation in ASD.