A Clinician's Guide to Mental Health Conditions in Adults with Autism Spectrum Disorders

Assessment and Interventions

Eddie Chaplin, Jane McCarthy, Debbie Spain

• Publisher: Jessica Kingsley Publishers
• Year: 2019
• ISBN:
  9781784508005
• Topic: Psicología
• Subtopic: Trastornos del espectro autista

This comprehensive and much-needed guide addresses the issues faced by clinicians in assessing and treating the range of mental health conditions, which can affect adults with Autism Spectrum Disorder (ASD). Its particular focus on adults fills a notable gap in the ASD professional literature, with an extensive array of contributors from across the psychology and healthcare professions.

Covering a wide variety of common co-occurring mental health conditions including mood disorders, anxiety, psychosis, OCD, personality disorders, and eating disorders, this guide also explores broader issues to do with promoting positive mental health and wellbeing. Authoritative and detailed, this is an essential resource for all clinicians and professionals looking to understand and tailor their approach to mental health in autistic adults, and the need for specific methods and strategies to enhance assessment and treatment.

Section 1

Overview

CHAPTER 1

Introduction

Dr Debbie Spain, Professor Eddie Chaplin and Dr Jane McCarthy

Autism Spectrum Disorder

Since the 1700s there have been several documented case reports portraying people presenting with atypical social communication styles. However, the term ‘autism’ was not mentioned in the literature until the turn of the 20th century when Eugen Bleuler used it to describe individuals with severe forms of schizophrenia who appeared aloof and detached from reality and other people (Parnas and Bovet 1991). In 1943 Leo Kanner, a psychiatrist, described a series of case histories in an article entitled ‘Autistic Disturbances of Affective Contact’. Almost concurrently, Hans Asperger, a paediatrician, published an unrelated study about a condition called ‘autistic psychopathy’ (Frith 1991; Wing 1981). Both clinicians reported on small cohorts of children who displayed similar impairments in social interaction and relatedness, atypical methods of communication, poor understanding of others and tendencies to engage in set and repetitious activities. While Kanner noted that these impairments appeared to be associated with a developmental delay and intellectual disability (ID), Asperger stated that the children in his cohort were of average intelligence.

These two seminal studies helped to encourage interest in developmental disorders of childhood onset (prior to this, individuals with comparable clinical presentations would have been considered to have a general mental health condition or ID). Further work during the 1960s and 70s focused on the onset, course and causes of symptoms described by Kanner and Asperger, as well as the utility of behavioural interventions to target social skills impairments (Volkmar and McPartland 2014). In 1980 ‘infantile autism’ was included as a diagnosis in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) (APA 1980), shortly after having been listed in the ninth revision of the International Classification of Mental and Behavioural Disorders (ICD-9) (WHO 1977).

During the past 40 years, definitions and diagnostic criteria for autism have undergone several changes, at least in part due to clinical and attitudinal factors. First, there was a paradigm shift: rather than relying upon a categorical approach to classifying autism (and psychiatric disorders more generally), the trend moved towards using a dimensional approach (see Coghill and Sonuga-Barke 2012). This was important clinically as it had become apparent that many individuals presented with substantially impairing behaviours consistent with the initial descriptions of autism but they had fewer symptoms than required to meet the relatively stringent diagnostic criteria. Thus symptoms started to be conceptualised in terms of a spectrum of severity, that is, autism spectrum disorder(s) (ASD). Second, perceptions about the causes of ASD altered fairly considerably: parenting style, for example, was no longer thought to have a direct causal impact; instead, neurobiological and anatomical factors were considered pivotal. This may have served to reduce some of the stigma and guilt experienced by parents (e.g. D’Astous et al. 2014) and perhaps encouraged them to feel more confident about requesting formal assessment and support. This meant that more information and clinical data were generated about the clusters of ASD symptoms experienced by individuals. Finally, there was also increased standardisation of methods of assessment, which allowed for more methodologically sound comparisons between samples (Ousley and Cermak 2014).

Perhaps as a consequence of these factors, later editions of the DSM (DSM-IV; APA 2000) and the ICD (ICD-10; WHO 1992) included several disorders under the umbrella term of ASD and pervasive developmental disorder (PDD), characterised by a number of different symptoms, with or without language delay. These were notably: Asperger syndrome (AS); childhood autism or autistic disorder (AD) co-occurring with an ID; high-functioning autism (HFA) with no co-occurring ID; PDD, including atypical autism; childhood disintegrative disorder (CDD); and Rett’s syndrome.

Current diagnostic criteria for autism spectrum disorders

Historically, ASD symptoms were clustered into three categories – communication, reciprocal social interaction, and restricted and repetitive interests and behaviours – commonly known as the ‘triad of impairments’ (Wing 1981). However, symptoms have now been clustered into a dyad in DSM-5 (APA 2013): one category encapsulates difficulties associated with communication, social interaction and relatedness; the other includes restricted and repetitive behaviours, stereotyped speech and sensory sensitivities. A central premise underpinning this change is that it does not seem clinically meaningful to disentangle ways of communicating and interacting – they are inextricably linked.

A further distinction is that the DSM-5 no longer includes specific ASD subtypes, such as AS. Instead, individuals are diagnosed with an ‘autism spectrum disorder’, with clinicians assigning a rating for symptom severity along the two dimensions and the degree of support required. Severity ratings range from ‘requires support’ to requires ‘very substantial support’. Removal of specific diagnoses reflects relatively consistent empirical findings that indicate there are few notable differences in the aetiology, clinical presentations and outcomes of individuals with AS and HFA (Happé 2011). On the one hand, this seems a pragmatic approach: several individuals can have the same number and type of ASD symptoms, but the severity and impact of these differs markedly; specifying the nature of an individual’s unique symptom profile could imply that interventions are better tailored to suit their needs (Volkmar and Reichow 2013). On the other hand, this has caused some contention. In a thematic analysis of comments on online forums, Giles (2014) found that individuals diagnosed with AS (sample size unspecified) described feeling a sense of ‘acceptance’ that their symptoms were finally regarded as ‘part of’ the ASD spectrum in DSM-5, but also ‘fear and suspicion’ about the implications this could have. Clinically, we also find that the sense of relief and understanding some individuals obtain from being diagnosed in adulthood can be marred by concerns about potential future changes to ASD diagnostic criteria, contributing to uncertainty about what they ‘should’ or ‘can’ think about their diagnosis, and how best to share it with others.

Several recent studies have examined this issue from service provider perspectives. An empirical study by Wilson and colleagues (2013) comparing rates of ASD diagnoses according to the DSM-IV, ICD-10 and DSM-5 in an adult ASD sample (n=150) found that a significant proportion (22%–44%, depending on whether the comparison was according to ICD or DSM criteria) no longer met the DSM-5 ASD diagnosis. These findings reflect those reported in a systematic review, entitled ‘Impact of DSM-5 on epidemiology of autism spectrum disorder’, which included 133 international studies (Tsai 2014). In turn, this raises important questions about the right to access health and social care services, a debate that is likely to be ongoing for some time.

To meet the diagnostic threshold for an ASD, individuals must have a minimum number of qualitative and quantitative impairments in verbal and non-verbal communication, diminished reciprocity and preferences for engaging in circumscribed interests or repetitious patterns of behaviour (APA 2013; WHO 1992). Although there are now differences in the clustering and categorisation of symptoms in the DSM-5 (APA 2013) and the ICD-11 (WHO 2019), the main characteristics indicative of ASD are as follows:

• impairments in the quantity and/or quality of non-verbal communication (e.g. limited or awkward gestures, restricted affect, or avoidant or prolonged eye gaze)

• diminished reciprocity in social interaction (e.g. limited ‘to and fro’ conversation, few or inappropriate social overtures, difficulties responding to the approaches of others, or reduced sharing of information or interests)

• poor integration of speech and non-verbal gestures

• diminished capacity for social imitative play (e.g. engagement in parallel play but not imaginative or creative activities with peers) along with diminished interest in others

• difficulties developing friendships and relationships

• use of stereotyped, idiosyncratic or echolalic speech (e.g. use of repetitious words or phrases, use of neologisms or unusual speech patterns relative to age)

• circumscribed interests and hobbies (e.g. either interests that occur to an unusual degree or those that are distinctly odd)

• repetitive behaviours (e.g. motor mannerisms or ‘lining’ up of objects)

• preferences for maintaining rituals and routines (e.g. preference for ‘sameness’, rigid and concrete thinking style or adherence to routines)

• hypo- or hyper-sensory sensitivities (e.g. limited responsiveness to pain or high sensitivity to auditory or sensory stimuli).

The onset of symptoms must be in early childhood, with evidence of functional impairment. Symptoms may initially seem subtle but become more prominent or severe with age, or in less structured contexts. Finally, presenting difficulties should not be better explained by an alternative diagnosis, such as an ID or mental health condition (e.g. an anxiety disorder).

Clinical presentation of individuals with autism spectrum disorders

ASD is a markedly heterogeneous condition with variability between individuals. Socio-communication impairments can range from subtle to severe, impacting on few, several or all social interactions. Similarly, circumscribed interests can be in keeping with peer group preferences; for example, liking particular music groups or fantasy films, but to an unusual degree. Alternatively, these interests can pertain to highly unusual topics.

Characteristics such as hypo- or hyper-sensory sensitivities (Koenig and Rudney 2010) and an intolerance of uncertainty (IoU) (Boulter et al. 2014) are considered inherent to ASD, with some data indicating that these particular characteristics are interlinked (Maisel et al. 2016). Overall, ASD symptoms are considered to be relatively stable, and there is only a limited amount of evidence to suggest that they substantially improve in a minority of individuals when assessed longitudinally (Woolfenden et al. 2012b).

It is widely reported that ASD affects more males than females, with a current estimated ratio of approximately 3:1,...

Table of contents

• Cover
• Title Page
• Contents
• Section 1: Overview
• Section 2: Common Mental Health Conditions
• Section 3: Interventions
• Section 4: Understanding and Managing Risk
• Section 5: Promoting Health and Wellbeing
• The Contributors
• Subject Index
• Author Index
• Join Our Mailing List
• Copyright
• Of Related Interest