Perspective

In recent years, awareness of mental health concerns has grown, coinciding with an increased understanding of the co-occurrence of autism and mental health difficulties. New research by the University of British Columbia and the A.J. Drexel Autism Institute at Drexel University reported that nearly 78% of autistic children have at least one mental health condition, with nearly half having two or more (2021). Therefore, it is critical to notice the signs and be prepared to help support loved ones to ensure they are getting the care they deserve.

Co-Occurring Mental Health Conditions and Autism: Prevalence and Challenges

Mental health difficulties, such as anxiety, depression, obsessive-compulsive disorder (OCD), and eating disorders, are prominent in autistic populations. According to current research, the co-occurrence of autism and depression has a lifetime prevalence of 14.4% (Hudson et al., 2019), meaning that 14.4% of autistic people will experience depression at some point in their lives. Research also shows that 39.6% of autistic children experience at least one anxiety disorder (Vasa & Mazurek, 2015). Regarding OCD, Hollocks et al., (2019) reported a lifetime prevalence of 22%, with rates varying between 9% to 22% in research since 2011. Eating disorders are also more prominent among the autistic population, and as of 2019, the prevalence of eating disorders among autistic people ranges between 1.4% and 7.9% (Lugo-Marin et al., 2019; Nickel et al., 2019).

It can be challenging to untangle autism and co-occurring mental health conditions. For example, some autistics with co-occurring depression reported that they had always felt different from their peers and that their sense of awareness of these differences has had “a negative impact on their beliefs about themselves, and their mood” (Jordan et al., 2021). Others expressed low mood in regard to not fitting in with society’s expectations, leading to negative self-perceptions for social “failings.” Autistic people’s low moods have also been linked to difficulties in building relationships, which has left many to feel lonely or isolated. As a result, many find themselves “trying to act normal,” a process known as camouflaging. Camouflaging often leads to lower mood levels because autistic people are not being their true selves.

The co-occurrence of mental health disorders among autistic individuals can complicate how clinicians understand the individual’s behaviors, evaluate interventions they are participating in, and provide strategies for supporting them. When an individual is showing signs of distress, knowing the cause of the symptoms can be rather challenging. For example, an autistic child in the classroom may begin to engage in disruptive behavior, such as ripping up their paper. The teacher or other support staff may assume this behavior is a result of autism; however, the child may actually be displaying an anxious behavior because they do not understand the task at hand.

Eating behaviors may also require a careful evaluation. Autistic individuals often have food preferences or a limited range of food interests. However, their eating habits can also signify eating disorder behaviors. If an autistic individual appears to be a “picky eater,” it is necessary for their family and professionals who work with them to determine whether this behavior stems from an eating disorder, which can be life-threatening if untreated, or simply represents the individual’s sensory sensitivity or need for predictability. On the other hand, other autistic people may engage in excessively eating a preferred food to the point of bloating or nausea, which can signify binge eating disorder or may lead to the use of unhealthy behaviors to purge themselves.

How to Support Autistic Youth with Co-Occurring Mental Health Conditions

Recognize emotions. Research has shown that autistic youth with co-occurring anxiety, depression, OCD, and/or eating disorders often have difficulties in regulating emotions. Emotional dysregulation is the inability to adjust or control one’s emotions, making calming down and/or identifying one’s feelings much harder. Cognitive behavioral therapy (CBT) has shown positive results for assisting autistics to understand their emotions and develop the skills to manage their emotions. It is important for parents to have a positive and open communicative relationship with their children to help them navigate intense emotions and recognize when they are feeling a particular way.

Understand triggers. Professionals and family members are encouraged to monitor and evaluate situations in which an autistic individual becomes distressed in order to identify their triggers. Instead of making assumptions, it is imperative to communicate with the individual, ask them questions, dig deeper into what the root cause of the behavior is, and teach them strategies to support themself during times of distress.

Evidence-based treatments. Because of emotional dysregulation, autistic individuals are more likely to use maladaptive and involuntary emotional regulation methods, such as rumination or shutting down (Vasa & Mazurek, 2015), and they may resort to these methods when they are experiencing anxiety. If an individual’s triggers have been addressed and supported yet the individual still demonstrates symptoms of anxiety, professionals should consider evidence-based treatments to provide the individual with healthier regulation methods. For example, CBT is a highly effective treatment for anxiety, depression, OCD, and eating disorders.

Self-acceptance and peer acceptance. Because depression can stem from camouflaging or feeling isolated, supports for autistic youth with depression should counteract these forces. Getting an autism diagnosis and developing a better understanding of themselves has helped many autistic individuals with depression. Families, teachers, and professionals can promote their child’s self-acceptance. Also, families and teachers can work on implementing social skills and getting children involved in extracurricular activities to support peer interactions. Joining clubs or teams that fit their interests can help a child find like-minded peers with whom to enjoy activities.

When an autistic person has one or more co-occurring mental health conditions, it is important to consider the interactions among these conditions in order to determine how to best support that person. Additionally, as not every strategy, treatment, support, or program is going to work the same for everyone, it is important to explore different options and strategies to find the ones that work best for the individual.

Resources for More Information

• 30 Activities, Teaching Strategies, and Resources for Teaching Children with Autism, Waterford.org
• Anxiety, National Autism Society (UK)
• Anxiety in Autism Spectrum Disorder, Anxiety and Depression Association of America
• The Deep Emotional Ties Between Depression and Autism, Spectrum
• Eating Disorders – a Guide for Autistic Adults, National Autism Society (UK)

Brittany Lorentz is currently pursuing a Master of Science degree in school and child psychology at the University of Calgary, Canada. She is passionate about exploring the lived experiences of autistics throughout different life events, the association of autism and mental health difficulties, and finding new ways to support and educate the community about autism. Prior to beginning graduate school, she worked with autistic youth in various settings, including individuals with mental health difficulties and co-occurring disorders, and hopes to continue to work with this population post-graduation. She has published journal articles on evolutionary psychology and written various book chapters on topics from depression to childhood development.