President of MSSA Prof. Dr. Vladimir Trajkovski has presented topic: Screening for comorbid psychiatric conditions in #ASD at III-rd pediatric medical conference at university in Saint Petersburg at 30.05.2019

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ScreeningScreening
forfor ComorbidComorbid PsychiatricPsychiatric ConditionsConditions
inin Persons withPersons with AutismAutism
SpectrumSpectrum DisordersDisorders
Prof. Dr. med. VladimirProf. Dr. med. Vladimir TrajkovskiTrajkovski
Saint Petersburg, May 30th 2019
UniversityUniversity ““St. Cyril and MethodiusSt. Cyril and Methodius””
Faculty of PhilosophyFaculty of Philosophy
Institute of Special Education and RehabilitationInstitute of Special Education and Rehabilitation
Macedonian Scientific Society for AutismMacedonian Scientific Society for Autism

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DSM-5 Autism Spectrum Disorder
• Criteria for ASD
– Two clinical domains (instead of the 3 in DMS-IV)
• A-Deficits in social communication and social
interaction (blends social with communication)
• B-Restricted, repetitive patterns of behavior (includes
insistence on sameness)
– Symptoms must be present in early childhood
– Symptoms must impair functioning
Definition

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PREVALENCE
1975: 1/5000
1985: 1/2500
1995: 1/500
2000: 1/150
2004: 1/125
2006: 1/110
2008: 1/88
2010: 1/68
2018: 1/59
CDC, 2018

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Autism Comorbidity
Genetic
Conditions
Neurological
Conditions
Psychiatric
Conditions
Autism

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OverviewOverview
Epidemiological studies suggest that between 54 and 70%Epidemiological studies suggest that between 54 and 70%
of people with autism also have one or more other mentalof people with autism also have one or more other mental
health conditions (Romero, 2016).health conditions (Romero, 2016).
Like autism, ADHD, schizophrenia and bipolar disorderLike autism, ADHD, schizophrenia and bipolar disorder
areare neurodevelopmentalneurodevelopmental conditions that appear to haveconditions that appear to have
roots in early brain development.roots in early brain development.
Among people with autism, anxiety and depression mayAmong people with autism, anxiety and depression may
stem, at least in part, from autismstem, at least in part, from autism--related impairments thatrelated impairments that
increase daily stress and social isolation and decreaseincrease daily stress and social isolation and decrease
overall quality of life (overall quality of life (VasaVasa et al., 2016).et al., 2016).
Untreated mental health conditions can profoundly worsenUntreated mental health conditions can profoundly worsen
autismautism’’s behavioral challenges.s behavioral challenges.

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Psychiatric Comorbidities
Communication
Disorders Attention Deficit Hyperactivity
(Thought Disorder,
Disordered
Pragmatics)
(Executive Dysfunction, Hyperactivity,
Impulsivity, Inattention)
Mood Disorders
(Mood Dysregulation,
Anxiety, Depression, Mania)
Anxiety Disorders
(Social Interaction/“Empathy”:
?Shyness/Social Phobia,
Disinterest/Schizoid,
“Hostile Intent”/Schizotypal)
Asperger’s
Obsessive Compulsive Disorder
Autism (Restricted interests
Rigid behavior
Stereotypic behavior
Compulsions)

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Mental health screening tools
A mental health screening tool is a
brief, culturally sensitive questionnaire
for identifying individuals who may
have mental health challenges that
merit further attention, intervention, or
evaluation.

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Screening tools can serve three
primary purposes
1. Assess an individual’s symptoms.
2. Measure progress after intervention
has begun.
3. Provide a framework for discussing
an individual’s challenges.
A screening tool is not a diagnostic tool but
rather a “triage” process. A positive screen does
not necessarily mean a person meets criteria for
a diagnosis. Only a trained clinician is qualified
to interpret screening results.

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First steps in implementing the
screening process (1)
Develop a planning committee comprised of parents,
educators, mental health experts, primary care providers,
and other representatives from the community. The
planning team will:
• Develop policy ensuring confidentiality safeguards are in
place.
• Draft agreements between schools and collaborating
community providers clarifying responsibilities in order to
facilitate the collaborative process and address liability
issues.
• Ensure policies are approved by appropriate education
and mental health boards.

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First steps in implementing the
screening process (2)
• Determine when to administer the screen (e.g.,
transitional grades: 6th–7th, and 9th–10th) and
what tools to use.
• Ensure adequate staff training and supervision
on how to administer, score, interpret the data,
and refer to community providers, etc.
• Identify a “Screening Coordinator” (e.g.,
guidance counselor, nurse) who assumes
responsibility for the screening process.

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Important steps to remember when
implementing and interpreting the screen
1. Obtain parental consent and student assent before
administering screening.
2. Administer screening in a confidential area, and prioritize
privacy of results.
3. Remember clinical judgment can override results from a
screening assessment. A student who does not meet a
particular cut-off score on a screening tool may still need
further evaluation.
4. Notify and offer assistance in connecting parents of any
student found to be in need of further evaluation with a
local mental health professional.
5. Immediately refer to a trained professional any student
who screens positive for suicidal or homicidal ideation.

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Next Steps
1. Formulate a “Planning Team” comprised of relevant
individuals from school and community to develop
confidentiality policy, formalize community liaisons, and
make critical decisions about the screening process
(e.g., when to screen and what tools to use).
2. Ensure adequate staff training on screening tool
implementation, scoring, and interpretation.
3. Designate contact person within the school to oversee
the screening process.
4. Obtain parent consent and student assent before
administering screen.
5. Make appropriate referrals based on screening results,
including immediate referral for positive screen for
suicidal or homicidal ideation.

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Prevalence of Mental Health Issues in
ASD
Studies within the last decade reveal rates between 67%
and 70.8% of individuals with ASD who would meet
criteria for an additional mental health disorder described
within the DSM-IV.
Having a comorbid psychiatric condition significantly
increases the risk of multiple diagnoses.
41% of the entire sample had 2 or more co-occurring
disorders in addition to ASD, with 17% having 2 disorders
and 24% having 3 or more.
Evidence also suggests that individuals with ASD may be
twice as likely to exhibit comorbid disorders when
compared to those with non-ASD intellectual or
developmental disabilities.

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Autism and ADHD
ADHD may be the most common co-occurring psychiatric
disorder among children with ASD, occurring in
approximately 50% of one sample.
Other studies have estimated rates as falling between
28.2% and 31%.
The rate increased to nearly 55% when sub-threshold
cases were included.
ADHD in combination with ASD may confer significantly
increased risk for a more complicated symptom
presentation; nearly 85% of individuals with comorbid
ASD/ADHD met criteria for an additional disorder.

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Autism and anxiety disorders
Between 11 and 42% of people with autism struggle with
one or more anxiety disorder (Vasa et al., 2016).
Specific Phobias or fears (44%) - fear of specific objects,
activities, or situations (e.g., heights, insects, the dark,
storms, etc.).
Social Anxiety (29.2%) - fear of being negatively evaluated
in social situations.
Generalized Anxiety (13.4%) - persistent, excessive,
uncontrollable anxiety/worrying.
Panic Disorder (10.1%) - recurrent panic attacks that are
not associated with any specific stimuli.
Obsessive Compulsive Disorder (OCD) is also very
common, although rates in individuals with ASD have
varied across studies from approximately 8% to more than
33%.

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Autism and OCD
OCD is an anxiety disorder. If someone has OCD, it means that
they experience repetitive thoughts and behaviours that are
upsetting to them.
OCD occurs in about 2-3% of people who are not autistic and is
more common in people who are autistic.
It is thought that our genes (DNA) and our psychological
predisposition can make us vulnerable to developing OCD,
which can run in families.
OCD can be distressing, exhausting and can get in the way of
everyday life for the person who has it and their families.
However, it is treatable.
There are two main parts to OCD: obsessions (thoughts) and
compulsions (behaviours). OCD can be overlooked in people
on the autism spectrum as it may be mistaken for repetitive
behaviour.
It is still under-recognised and therefore under-treated.

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Autism and depression
Depression affects an estimated 7% children and 26% of
adults with autism (Croen, 2015).
This compares to 2% of children and close to 7% of adults
in the general U.S. population. A recent report in the
journal Pediatrics found that the rate of depression among
children with autism rose dramatically with age, from just
under 5% in grade-schoolers to just over 20% in
teenagers.
It likewise rose with intellectual ability (IQ), as well as the
presence of one or more of the medical conditions that
commonly accompany autism – particularly seizures and
gastrointestinal issues.

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Comorbid disorderComorbid disorder SchizophreniaSchizophrenia
Positive Symptoms
Delusions
Hallucinations
Thought disorder
Abnormal movement
• catatonia
• stereotypies
Negative Symptoms
Withdrawal (autism)
Emotional change
• inappropriate
• blunted / apathy

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Autism and bipolar disorder
Bipolar disorder is a mood disorder also known as “manic
depression”. People with bipolar disorder tend to alternate
between a frenzied state known as mania and episodes of
depression.
While some people experience only the manic episodes, most
alternate between these two states and can show extreme
irritability.
Research shows that children and adults with autism are at
increased risk for bipolar disorder.
Studies vary widely in estimating the prevalence of bipolar
disorder among people with autism, ranging from 6 to 27%.
The antipsychotics risperidone and aripiprazole can treat
irritability in children with autism, though both tend to produce
significant weight gain and diabetes risk (Autism Speaks, 2017).

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Factors which may increase risk for
comorbidity (1)
Associated medical conditions & syndromes
Individuals with ASD have additional comorbid
medical conditions that are associated associated
with psychiatric comorbidity.
Examples include Fragile X syndrome
(associated with hyperactivity and social anxiety),
Prader-Willi syndrome (associated with
compulsive behavior) and seizure disorders
(which can be associated with aggression and/or
anxiety).

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Factors which may increase risk for
comorbidity (2)
Familial genetic factors
There is increasing evidence that the incidence of
autism and mood disorders seem to cluster in
families.
Bipolar disorder might be more common in first-
and second-degree relatives families with
Asperger syndrome.
An association between symptoms of OCD in
parents of children with autism and repetitive and
restricted behaviors in their children has also
been observed.

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Factors which may increase risk for
comorbidity (3)
Psychosocial factors
Individuals may be at increased risk for encountering these
psychosocial factors due to their social and communication
deficits and behavioral patterns.
Cognitive and processing limitations (such as problem-
solving/coping skills) are often less well-developed in
persons with ASD, which further increases their risk of
adverse psychosocial experiences.
Many individuals with ASD are aware of their difficulties and
this awareness often increases during puberty. Awareness
of one’s “differentness” may underlie the development of
anxiety and depression.

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Treatment of mental co-morbidities
Medication treatment is favored by clinicians
Studies of psychosocial and behavioral treatment
effectiveness are more complicated and difficult to do even
in the non-autistic population.
Many psychosocial treatments such as psychotherapy are
communication-based.
Children with autism typically have already received other
non-medication interventions before they come to
psychiatric treatment.
Autism is seen as a “biological” disorder, which biases
clinicians towards “biological treatment.”
However, there is a growing literature on the benefits of
cognitive-behavioral therapy for anxiety in high-
functioning people with autism.

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Medications
THERE ARE NO MEDICATIONS THAT TREAT
THE CORE SYMPTOMS OF AUTISM
Medications used to treat psychiatric symptoms in
autism:
Antipsychotics
Antidepressants
Sleep Medications
Psychostimulants
Alpha-Adrenergic Agonists

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ConclusionsConclusions
Autism is frequently accompanied by mental healthAutism is frequently accompanied by mental health
conditions including anxiety, depression, and ADHD.conditions including anxiety, depression, and ADHD.
AutismAutism--associated health problems extend across the lifeassociated health problems extend across the life
spanspan –– from young children to senior citizens.from young children to senior citizens.
Identification and treatment of psychiatricIdentification and treatment of psychiatric disorders anddisorders and
symptoms may substantiallysymptoms may substantially improve the overall quality ofimprove the overall quality of
life in autismlife in autism spectrum disorders.spectrum disorders.
Specialists at autism care centers are working withSpecialists at autism care centers are working with
patients and their families to improve the health andpatients and their families to improve the health and
quality of life of all those with ASD by developing andquality of life of all those with ASD by developing and
disseminating evaluation and treatment guidelines fordisseminating evaluation and treatment guidelines for
healthcare providers.healthcare providers.
Psychiatric treatment should always bePsychiatric treatment should always be offered within anoffered within an
integrated, multiintegrated, multi--disciplinary treatment plandisciplinary treatment plan..

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Hotel Contiental

27. 2727
THANK YOU!THANK YOU!
+389+389--22--31163116--520 (234)520 (234)
+389+389--22--31183118--143143
vladotra@fzf.ukim.edu.mkvladotra@fzf.ukim.edu.mk
http://vladotra68.blogspot.comhttp://vladotra68.blogspot.com
Prof. Dr. VladimirProf. Dr. Vladimir TrajkovskiTrajkovski
@@vladotravladotra
ttp://www.linkedin.com/profile/ttp://www.linkedin.com/profile/VladimirTrajkovskiVladimirTrajkovski