Autism Spectrum Disorder (ASD) is a 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. The symptoms can range from mild to severe. ASD is thought to be caused by a combination of genetic and environmental factors.

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

1) Problems with social communication and interactions, and

2) Repetitive (repeated) and restricted patterns of behaviour

These symptoms are present at school, home, and other areas of life. They cannot be explained by the child or youth’s age. For example, some children become more shy and self-aware during puberty. The symptoms cause difficulty in day-to-day life.

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

• Delayed language or nonverbal, unusual use of language such as scripted phrases (repeating words from TV, movies, commercials, stories)
• Difficulties in conversations such as not following the “rules” of conversation (not taking turns speaking, focusing on own interests)
• Problems sharing interests, thoughts and feelings with others
• Lack of social awareness or what’s appropriate  
• Unusual facial expressions, avoids eye contact, unusual body positions
• Little use of gestures during conversations and trouble understanding the gestures of others
• Problems with building close relationships. Children and youth with ASD might not be interested in others. They may not know how to initiate or maintain friendships. They may have problems changing their behaviour to fit what others are doing.

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 (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 trauma. SIB can be difficult to understand and treat. 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 other challenges and stressors. This can have a big impact on your child and family, but treatment can help a great deal.

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

• Symptoms of one disorder can look like another disorder
• Symptoms of one disorder can hide symptoms of another disorder
• Mental health symptoms in ASD may look different than they do in most people (for example - anxiety may look like hyperactivity or oppositional behaviour)
• It may be difficult to tell what a child is feeling
• They may not be able to tell you how they feel
• Other people may misread the child’s symptoms
• The child may not think that something is wrong
• There are only a few guidelines and tests that help to diagnose other mental illnesses in children with ASD

An important note on ASD studies

Many studies on mental health and ASD include children with “high-functioning” autism. These children do not have as many challenges with cognitive or intellectual abilities. There are fewer studies on the mental health of children who are considered “lower functioning” or more affected by ASD symptoms. These children may also have mental illness and help is available for them. But, it is important to know that some studies may not include certain groups of children.

Some common signs of ASD are also signs of different mental illnesses. 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 (ear infection, dental pain).

Here are some of the mental illnesses that are more common to individuals with ASD.

Anxiety disorders

Anxiety is very common in people with ASD. A child with an anxiety disorder will be very worried or afraid for no good reason.  Children who are “higher-functioning” are more likely to also have an anxiety disorder.

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 changes that cause ASD may also cause 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 problems of people with ASD. A person with ASD may experience social anxiety and avoid social situations because of negative experiences like bullying. In the past, we thought that people with ASD simply were not aware that they had social problems. 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 and this can also lead to anxiety and depression.

The anxiety disorders that are most common in children with ASD are:

• obsessive-compulsive disorder 
• generalized anxiety disorder 
• social anxiety disorder
• specific phobia
• separation anxiety disorder.

Obsessive-compulsive disorder or OCD is made up of two different parts: obsessions and compulsions. Obsessions are thoughts, ideas or urges that are usually distressing and can be difficult for a child to control. They may seem very strange or have to do with things a child would not normally think about doing. Obsessions can cause a lot of anxiety for a child and the family.

Compulsions are things that a child keeps doing to lessen their feelings of anxiety. For example, if a child has obsessions about getting very sick, they might wash their hands a lot. Compulsions take up a lot of time and affect the way a child lives. They may avoid things or situations that trigger obsessions or compulsions. Children living with OCD may not see that their obsessions or compulsions are unreasonable.

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, ritual-like behaviours that are common in ASD. These repetitive behaviours can include body movements and the rigid behaviour includes the need for sameness or routine. The difference between the two disorders is how they make your child feel. Repeated behaviours or rituals in ASD may give comfort or pleasure, but compulsions in OCD do not. Also, 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 (example: worry about germs).  The specific and intense interests in ASD are often enjoyable (example: talking and thinking about ferry schedules). It can be hard to assess this kind of behaviour in children with ASD. 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.

Generalized anxiety disorder or GAD makes a child feel very worried about everyday things for a long time. The child may feel like they cannot control or stop their worry, and it affects their life in a big way. GAD can affect concentration and memory. You cannot always tell when a child worries, but there are many other signs of GAD. Common signs include headaches, stomach aches, sore muscles, irritability, restlessness and fatigue, as well as avoiding things or situations. If your child shows physical signs, it is always important to talk to your doctor. Your doctor can make sure there isn’t a medical problem causing the symptoms.

Phobia (sometimes called simple or specific phobia) is the fear of a certain thing or situation. This fear lasts a long time and causes a lot of distress. It also changes the way a child lives because they work hard to avoid what they fear. The most common phobias in children living with ASD are shots (injections), crowds and loud noises. Children with ASD may also have more unusual fears (fears of flushing toilets, hand dryers, taking baths, talking on the phone) that may be related to sensory sensitivities or social anxiety. Young children may not see that their fear is unreasonable.

Separation anxiety disorder makes children feel very anxious when they leave home or separate from caregivers like parents or siblings. Of course, it is normal for children to feel some anxiety when separated from caregivers especially at a young age. But, with separation anxiety disorder, a child may feel much more anxious or scared than you would expect. This disorder can last for a long time and make it hard to take part in everyday activities such as preschool, school and extracurricular activities. It may also make a child feel scared that something terrible will happen to their caregiver or to themselves when separated.  They may refuse to go to school, feel very scared of being left alone or have nightmares about being separated.

Attention-deficit/hyperactivity disorder (ADHD)

ADHD affects the way your child acts or behaves. It has two different groups of symptoms: hyperactivity (over-activity) and inattention (difficulty paying attention)

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. The difference between ADHD and ASD is the reason for their inattention. For example, in ASD the lack of attention may be because they have less interest in the social situation. It can be harder for children to go about daily life when they have both ASD and signs of ADHD.

Depression

Depression is a mental illness that affects a child’s mood for a long time. The child might feel very sad, guilty, irritable or hopeless.  They may have a hard time concentrating and enjoying things they used to like. Depression can also make them feel very tired and affect the way they sleep and eat.

Like anxiety disorders, there may be a link between social skills and mood problems.  Children with ASD are more likely to have signs of depression as they become more aware of their social skills challenges. Depression can develop because of long-standing social anxiety.  That is one of the reasons it is so important to get help for children with social skills problems and anxiety.

Schizophrenia

This mental illness affects the way a child thinks. 

Signs of schizophrenia include:

• hallucinations (sensing something that is not there)
• delusions (strongly believing in something that isn’t true)
• disorganized thoughts
• disorganized speech
• problems expressing emotions
• difficulty carrying-on a conversation
• not enjoying activities they enjoyed before

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, productive lives if they have early treatment and supports. The same is true if your child is diagnosed with another mental illness. There are a variety of treatments and supports for mental illness and for the use of these treatments with children with ASD. 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 illnesses. There are ways to change or modify CBT for children with ASD (example: a greater focus on behaviour). The therapist works closely with parents 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. In studies, children with ASD improved as much as children without an ASD when they received modified CBT.

Social skills training

This type of 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.

Medication

There is no medication for treatment of an 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 report on their thoughts, feelings and physical symptoms. As a result, health providers must rely on their parents to observe and report a child’s behavioural symptoms (example: activity level, sleep, appetite, oppositional behaviour/temper tantrums). Learn more about medications used to treat problems associated with autism.

Many children with autism have challenging behaviours related to mental illness. 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.