Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder that affects a person’s social skills, communication and behaviour. The signs often appear in the first two to three years of life but may show up later.

Each person’s experience is unique and their symptoms can range from mild to severe. This is why autism is referred to as a spectrum. There is no one cause of autism and the cause is not yet well understood. However, a combination of genetic and environmental factors may play a role.

Children and youth with ASD usually experience two types of symptoms:

1. challenges with social communication and interactions
2. repetitive (repeated) and restricted (narrow or intense interests) patterns of behaviour

These symptoms cause challenges in day-to-day life. They are present at school, home, and other areas of life. The symptoms are also present across the lifespan, though they may change as individuals develop, learn new skills or find environments that are a good fit for them.

Note: The terms ‘children with autism’ and ‘autistic children’ are both used throughout the content to respect individuals’ different preferences for person-first and identity-first language.

Challenges with social-communication and interactions in ASD may include:

• delayed language or nonverbal, unusual use of language such as scripted phrases (for example: repeating words from TV, movies or stories)
• little use of gestures during conversations, gestures that don’t align with verbal language, and trouble understanding the gestures of others
• avoids eye contact, less eye contact than same-aged children, or eye contact that is not aligned with verbal language
• challenges in conversations such as not following the “rules” of conversation (for example: not taking turns speaking, focusing on own interests)
• challenges sharing interests, thoughts and feelings with others
• lack of social awareness or what’s appropriate  
• unusual facial expressions, unusual body positions
• challenges building and maintaining close relationships. Some autistic children and youth might not be interested in others. However, many children with ASD are interested in others, but they may not know how to start or maintain friendships. They may have challenges changing their behaviour to fit what others are doing or having conversations about topics they are not interested in.

Repetitive and restricted patterns of behaviour in ASD may include:

• repetitive movements or use of objects
• repeats the same words or phrases
• problems dealing  with changes in routine or environment
• rigid thinking – not able to consider other ways of doing something or other opinions
• very specific interests that are unusual and intense
• more sensitive or less sensitive than others to sensory experiences (for example: pain, temperature, texture, smell, taste, lights, or sound)

Self-Injurious Behaviour in Children with Neurodevelopmental Disorders

Some children with autism or other forms of neurodiversity engage in self-injurious behaviour (SIB), which can be defined as self-directed injury that is non-suicidal in nature and causes physical injury to the body. SIB can be difficult to understand and treat, especially in autistic children who are minimally verbal (around 30 words or so). You can learn more about supporting your child with SIB here, and hear about a parent's experience with her daughter's SIB here. 

ASD and Mental Health

Families of children with ASD may face specific challenges and stressors. These can have a big impact on your child, personal relationships and family, but treatment can help a great deal.

Why is it hard to diagnose mental illness in children with ASD?

• mental health symptoms in ASD may look different than they do in other people (for example: anxiety may look like hyperactivity or oppositional behaviour)
• it may be difficult to know what a child is feeling (for example: if they can’t tell you how they feel)
• other people may misread the child’s symptoms (for example: thinking the mental health disorder symptoms are due to autism)
• the child may not think that something is wrong
• there are less guidelines and tests that help to diagnose other mental health disorders in children with ASD
• there are fewer clinicians trained in understanding both ASD and mental health diagnoses

Some common signs of ASD are also signs of different mental health disorders. This can be confusing. It’s always a good idea to talk to your doctor if you are concerned about your child or if you notice a change in the way your child acts or feels. This is especially true if the new behaviours haven’t gotten any better under your child’s current ASD treatment program.

Your doctor may also want to see if there is a medical problem related to the behaviours. For example, behaviour such as “head banging” in a child with ASD who is non-verbal might be related to pain (for example: an ear infection, dental pain). Your doctor may also refer you to a psychologist, psychiatrist or a mental health therapist to determine if your child does have a mental health disorder. Families in BC can also self-refer to their local Child and Youth Mental Health Team.

Below are some of the mental health disorders that are more common for individuals with ASD.

• Anxiety is very common in autistic people. We are not sure why ASD and anxiety go together so often. There are a few different ideas about how they may be related. For example, the brain differences that may be present in ASD may also contribute to anxiety. Or there may be genes that link both ASD and anxiety.  Another idea is that anxiety may be related to the social skills and communication challenges of people with ASD. An autistic person may experience social anxiety and avoid social situations because of negative experiences like bullying.

  Another example of anxiety is phobias. The most common phobias in children living with ASD are needles, crowds and loud noises. Children with ASD may also have more unusual fears (for example: fears of flushing toilets, taking baths, talking on the phone) that may be related to sensory sensitivities or social anxiety. 

  In the past, we thought that people with ASD simply were not aware that they had social challenges. But current studies suggest that many young people with ASD are very aware of their differences. They want to interact with others but are not able or don’t know how to do so appropriately. As a result, young people with ASD may feel lonely, which can lead to anxiety and depression.

• Obsessive-compulsive disorder (OCD) shares some signs with ASD. For example, it can be hard to tell the difference between compulsions in OCD and the repeated or rigid patterns of behaviour that are common in ASD. The difference between the two disorders is how they make your child feel. Repeated behaviours in ASD may give comfort or pleasure, but compulsions in OCD do not.

  It can sometimes be difficult to tell the difference between the specific interests of ASD and the obsessions of OCD. One difference is that obsessions are thoughts that are frequently distressing and difficult to stop (for example: worry about germs). The specific and intense interests in ASD are often enjoyable (for example: talking and thinking about ferry schedules). It can be hard to assess this kind of behaviour in children with ASD, particularly if the child has minimal language. They may be diagnosed with OCD if they have more compulsions than are usual with ASD, or if the compulsions have recently changed and are affecting their ability to function on a daily basis.

• Attention-Deficit / Hyperactivity Disorder (ADHD) affects the way people act and interact with the world around them. Some signs of ADHD, like hyperactivity and not paying attention, are common in ASD. The symptoms of ASD and ADHD may also overlap. For example, children with ASD may have difficulty making eye contact, sharing attention with others, and responding to their name.

  For ADHD to be diagnosed in addition to ASD, symptoms need to be causing challenges in daily life and are above and beyond what would be expected for their level of intelligence and skills. For example, in ASD the lack of attention may be because they have less interest in the social situation.

• Depression is a mental health disorder that affects a child’s mood for a long time. Like anxiety disorders, there may be a link between social skills and mood challenges. Children with ASD may be more likely to have signs of depression as they become more aware of their social skills challenges. Depression can also develop because of long-standing, untreated anxiety. That is one of the reasons it is so important to get help for children with social skills challenges and anxiety.

Bringing up a child with ASD may seem overwhelming at times. It is important to remember that there is help. Many children with ASD can lead happy, fulfilling lives. Getting treatment and support can help with this. The same is true if your child is diagnosed with another mental health disorder.

There are a variety of treatments and supports for mental health disorders and for the use of these treatments with children with ASD. Researchers have studied how to effectively treat children and adolescents with ASD who also have a mental health disorder.

Here are just a few treatment options:

• Modified (CBT) cognitive-behavioural therapy (CBT) helps you understand the way your thoughts, feelings and behaviours work together. It is a helpful treatment for many different mental health conditions. There are ways to change or modify CBT for children with ASD (for example: a greater focus on behaviour). The therapist works closely with parents, caregivers and their child to help the child identify the connection between situations and feelings.

  More hands-on activities help to make thoughts and feelings more concrete. Children are taught to notice specific signs of what they are thinking, doing, saying, and feeling in their body.  Step by step they slowly learn to face situations that make them feel anxious or angry. Rewards have been found to be especially important for youth with ASD as they face their fears. In studies, children with ASD improved as much as children without an ASD when they received modified CBT.

• Social skills training is often used for children with ASD to improve their social skills and social awareness. It may lessen anxiety related to social situations and interactions with others. That may also help with feelings of sadness and depression. Social skills training may boost a child’s self-esteem and help them to connect with peers. It is important to look for social skills training programs that have been studied and found helpful in ASD.

• There is no medication for treatment of ASD itself. But some medications can help with some of the mental health challenges that are more common with ASD. These include depression, anxiety disorders, ADHD, irritability and sleep problems. It can be more difficult to see the full effects or the side effects of the medication in children living with ASD. They may find it hard to share their thoughts, feelings and physical symptoms. As a result, health providers must rely on parents and caregivers to observe and report a child’s behavioural symptoms (for example: activity level, sleep, appetite, oppositional behaviour/temper tantrums). Learn more about medications used to treat challenges associated with autism.

  Many children with autism have challenging behaviours related to mental health challenges or underlying medical conditions which can sometimes be difficult to catch. There are helpful treatments available and medicine can be one of those treatments. It is important to have a discussion with your doctor so you understand the possible risks and benefits of these medications.

• Contact Autism Information Services BC (AIS BC), a provincial information centre for autism and related disorders. AIS BC has information on assessment, diagnosis and treatment options, and you can reach them by phone, in person or via email.
• If you would like to get your child assessed for autism, your doctor can refer you to the BC Autism Assessment Network (BCCAAN) for further assessment and diagnosis.
• For a full listing of resources on autism, visit our resource library

Looking for more information on this topic? Connect with a family peer support worker at the Kelty Centre to discover additional resources, learn more about support and treatment options, or just to find a listening ear.