By Dr Emily Jackson 1, Dr Eleanor Smith 1,2 and Dr Aditya Sharma 1,2
1: Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
2: Translational and Clinical Research Institute, Newcastle University
The autism community identified mental health as their top research priority in 2016.¹ Autistic children and adolescents are more likely than their general population counterparts to have psychiatric disorders.² For bipolar disorder, rates of 7% are seen in autistic children and adolescents versus 1% in their general population peers.³ Rates for depression are also increased ranging from 0.9% – 29% compared to 2.1% in the general population.⁴,⁵
Are there differences in the way mood disorders present in autistic children and adolescents?
ASD impacts on how mood disorders present which can make the diagnosis more challenging.⁶ One of the difficulties is the common assumption that ASD is the cause of symptoms, a phenomenon known as diagnostic overshadowing.⁴ Knowledge of each individual’s euthymic profile and baseline functional ability are essential to allow clinicians to notice changes necessary to diagnose mood disorders. For example, social isolation can be a feature at baseline in ASD⁴ but if it is increased or a new feature, depression should be considered. Furthermore, ASD may impact an individual’s ability to describe emotions such as irritability, elation, guilt or worthlessness.⁴,⁷,⁸
Behavioural changes associated with depression in ASD include a rise in aggressive and self-injurious behaviours and the emergence of gloomy content in art and writing.⁸ Increased agitation and loss of temper have also been identified,⁶ as well as classical depression symptoms⁹ such as changes in sleep, appetite, and concentration.⁴
Behavioural changes associated with mania in autistic children and adolescents can include irritability, increase in goal-directed behaviour, distractibility, increased risk-taking, psychomotor agitation, decreased need for sleep, increased stereotypic behaviour and increased obsession.¹⁰
If a child’s developmental progress slows, plateaus or regresses, then an explanation should be sought. It is vital that healthcare professionals maintain a high index of suspicion for mood disorders in context of episodic change in functioning e.g. changes in self-care or degree of communication.⁴ Remembering mania may present as an apparent improvement from baseline due to features such as over talkativeness.¹⁰
Adapting approach to assessment and intervention
Approaches that can be helpful include adding structure to sessions, keeping to time and taking a collateral history. Collateral history is even more important for this population as there is evidence that autistic children and adolescents will under report symptoms compared to their caregivers.¹¹ When examining mental state, remember that ASD can impact affect, which can be restricted at baseline.⁶
It is crucial to check comprehension and experience of concepts like guilt, hopelessness and self-esteem. This avoids enquiring for symptoms that may not be in that individual’s repertoire as the level of understanding will differ between individuals.
Seemingly small changes can be very significant in ASD¹² so always enquire for changes in circumstances e.g. change in routine, caregivers, etc. Such change in circumstances can be a factor in precipitating a depressive episode⁶ and have been associated with increased risk of suicide in autistic children and adolescents.¹²
The varied symptoms of mood disorders highlight the importance of being aware of differentials to avoid misdiagnosis and inappropriate medication. For example psychomotor agitation driven by mania could be misinterpreted as hyperactivity in context of Attention Deficit Hyperactivity Disorder. Subsequent treatment with methylphenidate may further increase the risk of mania in children and adolescents in the first three months if not on a mood stabiliser.¹³ Similarly mistaking the impact of mania on frequency of repetitive behaviours as obsessive compulsive disorder¹⁴ may lead to use of use of selective serotonin reuptake inhibitors (SSRIs) which in turn may exacerbate mania.¹⁰
There are few validated instruments both to screen for and measure severity of mood disorders in autistic children and adolescents, which may contribute to the variation in prevalence statistics.¹⁴ Where interviews are used, few studies modify these for an autistic sample and there is little data on the impact of using adapted interviews.¹¹ It is also notable that many studies investigating mood disorder exclude autistic individuals.¹⁴
Psychological therapies such as Cognitive Behavioural Therapy and relapse prevention work can be used for children and adolescents but these may need to be adjusted to take the person’s ASD into account.⁷
– Mental health clinicians have a vital role in considering mood disorders as a differential when autistic young people present with a change in behaviour.
– At interview: ask caregivers for a collateral history, use accessible language when enquiring for symptoms relating to mood, enquire for change of circumstances and stressors, leave more time for the interview and ensure good time-keeping.
– Refer when needed: bipolar disorder and depression in autistic children and adolescents should only be diagnosed by clinicians experienced in making these diagnoses for this population.
– Remember that recognising mood disorders positively impacts quality of life and functionality with prompt diagnosis and treatment.¹⁰
¹ James Lind Alliance (2016). Your Priorities For Autism Research. James Lind Alliance; p. 4.
² Mayes SD, Calhoun SL, Murray MJ, Ahuja M, Smith LA (2011). Anxiety, depression, and irritability in children with autism relative to other neuropsychiatric disorders and typical development. Res Autism Spectr Disord. 5(1):474–85.
³ Sharma A, Neely J, Camilleri N, James A, Grunze H, Le Couteur A (2016). Incidence, characteristics and course of narrow phenotype paediatric bipolar I disorder in the British Isles. Acta Psychiatr Scand. Dec;134(6):522–32.
⁴ Skokauskas N, Frodl T (2015). Overlap between Autism Spectrum Disorder and Bipolar Affective Disorder. Psychopathology. 48(4):209–16.
⁵ Vizard T, Pearce N, Davis J, Sadler K, Ford T, Goodman A, Goodman R, McManus S (2018). Mental Health of Children and Young People in England, 2017: emotional disorders. NHS Digital. https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-england/2017/2017
⁶ Chandrasekhar T, Sikich L (2015). Challenges in the diagnosis and treatment of depression in autism spectrum disorders across the lifespan. Dialogues Clin Neurosci. Jun;17(2):219–27.
⁷ Barkla X, Sharma A (2015). Bipolar disorder in children and young people on the autism spectrum. Network Autism (July). http://network.autism.org.uk/knowledge/insight-opinion/bipolar-disorder-children-and-young-people-autism-spectrum
⁸ Rosen TE, Mazefsky CA, Vasa RA, Lerner MD (2018). Co-occurring psychiatric conditions in autism spectrum disorder. Int Rev Psychiatry. Jan 2;30(1):40–61.
⁹ Semple D, Smyth R (2013). Oxford Handbook of Psychiatry. Third. Vol. 67, The Journal of Clinical Psychiatry. Oxford Medical Publications.
¹⁰ Sapmaz D, Baykal S, Akbaş S (2018). The Clinical Features of Comorbid Pediatric Bipolar Disorder in Children with Autism Spectrum Disorder. J Autism Dev Disord. Aug 21;48(8):2800–8.
¹¹ Hudson CC, Hall L, Harkness KL (2019). Prevalence of Depressive Disorders in Individuals with Autism Spectrum Disorder: a Meta-Analysis. J Abnorm Child Psychol. 47(1):165–75.
¹² Richa S, Fahed M, Khoury E, Mishara B (2014). Suicide in Autism Spectrum Disorders. Arch Suicide Res. 18(4):327–39.
¹³ Atkin T, Nuñez N, Gobbi G (2017). Practitioner Review: The effects of atypical antipsychotics and mood stabilisers in the treatment of depressive symptoms in paediatric bipolar disorder. J Child Psychol Psychiatry. Aug;58(8):865–79.
¹⁴ Leyfer OT, Folstein SE, Bacalman S, Davis NO, Dinh E, Morgan J, et al. (2006). Comorbid psychiatric disorders in children with autism: Interview development and rates of disorders. J Autism Dev Disord. 36(7):849–61.
Eleanor Smith is a Consultant Child and Adolescent Psychiatrist with Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust and an Associate Clinical Lecturer at Newcastle University. She is the Consultant Psychiatrist for the Complex Neurodevelopmental Disorders Service, a specialist Autism Spectrum Disorder Clinical Academic Team.
Dr Adi Sharma is a Clinical Senior Lecturer and Hon Consultant in child and adolescent psychiatry at Newcastle University (Translational and Clinical Research Institute) and Cumbria, Northumberland Tyne and Wear NHS Foundation. After medical and psychiatry training in India he moved to the United Kingdom in 2002 to pursue further clinical research training and was awarded a PhD in 2013 by Newcastle University. His clinical academic interests include the identification of factors (including psychiatric comorbidities) that impact on and improve psychosocial outcomes in early onset (<25 years) mood disorders across the world.
Dr Emily Jackson is a CT1 psychiatry trainee at Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust. She graduated from Queen’s University of Belfast in 2016 in Northern Ireland before returning to the North East of England. She has interests in child mental health, psychosis and bipolar disorder.