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Adults with autism 1

Psychopathology in Adults with Autism and Intellectual Disability


Elias Tsakanikos, Helen Costello, Geraldine Holt, Nick Bouras, Peter Sturmey & Tim Newton

Abstract There ha e !een "ew studies o" #sycho#atholo$y in adult with autism% This study e&amined #sychiatric co'mor!idity in 1() adults with intellectual disa!ility *+,- and autism and ./0 adults with +, !ut without autism% A"ter controllin$ "or the e""ects o" $ender, a$e, #sychotro#ic medication and le el o" +,, #eo#le with autism and +, were no more likely to recei e a #sychiatric dia$nosis than #eo#le with +, only% Peo#le with autism were less likely to recei e a dia$nosis o" #ersonality disorder% These "indin$s cast dou!ts on the hy#othesis that adults with +, and autism are more ulnera!le to certain #sychiatric disorders than non'autistic adults with +,% Keywords1 Autism2 intellectual disa!ility2 #sychiatric co'mor!idity2

Autism o"ten co'e&ists with +ntellectual ,isa!ility *+,- *3om!onne, 4a5au!run, Cans & Grand6ean, 177)2 Gill!er$, 1777-% Althou$h the increased incidence o" #sychiatric disorders in +, has !een well documented *,e!, 4athews, Holt & Bouras, 8//12 ,e!, Thomas, & Bri$ht, 8//1- it is unclear whether #eo#le with +, and autism are more #rone to #sychiatric disorders than #eo#le with +, only% +t has !een o"ten su$$ested that #eo#le with autism are more ulnera!le to certain #sychiatric disorders% 3or e&am#le, common inter#ersonal and co$niti e im#airments in autism and schi5o#hrenia ha e historically contri!uted to a contro ersy on whether the two disorders were the same *Eisen!er$ & 9anner, 170:- or whether autism per se is a risk "actor "or later #sychosis *Clarke, ;ittle<ohns, Cor!ett & <ose#h, 17:72 Petty, =rnit5, 4ichelman & >immerman, 17:(-% This hy#othesis has not recei ed em#irical su##ort *4ouridsen, ?ich & +sa$er, 17772 @olkmar & Cohen, 1771-% A lar$e study !y @olkmar & Cohen *1771- "ound the schi5o#hrenia rate in #eo#le with autism to !e similar to that e&#ected in the $eneral #o#ulation% Corres#ondin$ly, 4ouridsen et al *1777- in a 88'year "ollow'u# study o" A: #eo#le with autism "ound no one to ha e schi5o#hrenia or any other #sychotic disorder% There is some emer$in$ e idence that a""ecti e disorders, es#ecially de#ression, are the most common #sychiatric disorders in #eo#le with autism% ?ates o" de#ression ha e !een "ound to
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This is an author'created ersion o" the "ollowin$ article1 Tsakanikos, E%, Costello, H%, Holt, G%, Bouras, N%, Sturmey, P%, & Newton T% *8//0-% Psycho#atholo$y in adults with autism and intellectual disa!ility% Journal of Autism and Developmental Disorders *in #ress-% The ori$inal #u!lication is a aila!le at www%s#rin$erlink%com

Adults with autism 8 !e increased amon$ close relati es o" #eo#le with autism *Pi en & Palmer, 1777- and a num!er o" studies ha e shown an increased rate o" a""ecti e disorders and an&iety amon$ "irst'de$ree relati es o" #eo#le with autism com#ared to #eo#le with ,own syndrome *Bolton, Pickles, 4ur#hy & ?utter, 177:2 ;ainhart, 1777-% Bolton et al% *177:- "ound that !oth autistic'like sym#toms and a""ecti e disorders were ele ated amon$ the relati es o" #eo#le with autism com#ared to the relati es o" #eo#le with ,own syndrome% Howe er, there was no correlation !etween measures o" the !roader autistic #henoty#e and a""ecti e disorders su$$estin$ that a""ecti e disorders mi$ht not !e #art o" the !roader autistic #henoty#e% +ncreased carer !urden cannot !e e&cluded as #otential contri!utin$ "actor, es#ecially considerin$ emotional and #sychosocial as#ects o" raisin$ a child with autism% ?ates o" de#ression are also increased amon$ children and adolescents with autism *Cha5iuddin & Greden, 177:-, and with As#er$er syndrome *Cha5iuddin, Cha5iuddin & Greden, 8//82 Gill!er$ & Billstedt, 8///-% A systematic re iew o" "ollow'u# studies "rom childhood to adulthood *Howlin, 8///- has concluded that de#ression, o"ten associated with se ere an&iety, is the most common #sychiatric disorder in hi$h'"unctionin$ adults with autism% +t is #ossi!le that hi$h'"unctionin$ adults with autism mi$ht !e more #rone to such disorders, in #art #erha#s !ecause o" their $reater insi$ht into their de"icits and $reater sensiti ity to social sti$ma, handica# and discrimination% ?ecently, 4or$an, ?oy and Chace *8//A- re#orted the #re alence o" #sychiatric disorders !ased on +C,'1/ criteria in a lar$e sam#le o" adults with +, and autism% ,e#ressi e disorders were more common in adults with +, and autism as com#ared to adults with +, !ut without autism, althou$h there were no other #sycho#atholo$y di""erences% These results su$$est an increased ulnera!ility to de#ression in #eo#le with autistic s#ectrum disorders and +,% Bn"ortunately, #otentially con"oundin$ aria!les such as a$e, $ender, le el o" +,, and #sychotro#ic medication were not controlled "or% As a result, it remains unclear whether the o!tained le els o" #sychiatric comor!idity in the autistic sam#le were due to true di""erences or due to some con"oundin$ aria!les% Bradley, Summers, Cood and Bryson *8//(- studied #sycho#atholo$y in adolescents with +, and autism and "ound that not only de#ression !ut most #sychiatric disorders were ele ated in #eo#le with autism com#ared to a matched control $rou#, althou$h in this study the sam#le si5e was small *N D 18-% These studies ha e su$$ested that #eo#le with +, and autism are at $reater risk "or #sycho#atholo$y, and #erha#s es#ecially de#ression, than #eo#le with +, alone% Howe er, the studies were limited !y small sam#le si5es and "ailure to control "or #otential con"oundin$ aria!les% There"ore, the aims o" the #resent study were "irst, to e&amine whether a ariety o" #sychiatric disorders or de#ression alone are increased in #eo#le with +, and autism2 second, to assess the #ossi!le contri!ution o" other aria!les, such as $ender, a$e, le el o" +,, #sychotro#ic medication, that could account "or any relationshi# !etween #sycho#atholo$y !etween autism% Method Participants There were 1() #eo#le with autism and +, and ./0 #eo#le with +, and without autism !etween 1. and :( years old *mean D AA%A, S, D 1A%8-, ./E were males and (/E "emales They were re"erred "or assessment to a S#ecialist 4ental Heath Ser ice o" South' East ;ondon !etween 17:A and 8//1 *Bouras et al%, 8//A- and re#resented 17%0E o" the total re"errals to the Ser ice "or that #eriod% The lar$est #ro#ortion o" re"errals came "rom Primary Care *()%0E- "ollowed !y Generic 4ental Health Ser ices *A)%(E- and Social Ser ices *10%8E-% The de$ree o" +, was coded on +C,'criteria into mild *3)/-, moderate *3)1- or 8

Adults with autism A se ere *3)8')A-% The dia$nosis o" #er asi e de elo#mental disorder *3:(, +C,'1/- was made !y a #sychiatrist "ollowin$ clinical inter iews with key in"ormants and the #atients as #art o" deli erin$ clinical ser ice% Two e&#erienced #sychiatrists a$reed on the dia$nosis !y usin$ +C,'1/ clinical criteria% Historical details o" early social and communication #ro!lems were o!tained "rom #ast medical records% The same #rocedure was "ollowed "or the assessment o" #sycho#atholo$y% The eli$i!ility criteria "or the study were identical with the re"erral criteria, i%e% +F !elow )/ and si$ni"icant social im#airment% The ser ice includes out#atient clinics, outreach work, in#atient assessment and treatment, and consultation with community a$encies% The clinical team consists o" #sychiatrists, community #sychiatric nurses and administrati e sta"", and has a re$ular inter"ace with clinical #sycholo$ists and !eha ioural su##ort #ractitioners% There are three #hases in #ro idin$ clinical ser ices1 assessment, inter ention and "ollow'u#% Thera#eutic inter entions are !ased on multidisci#linary work and include medication and en ironmental mani#ulation, as well as #sycholo$ical treatments such as an&iety mana$ement and co$niti e !eha iour thera#y% Data recording and analysis The data were recorded at initial assessment usin$ a s#ecially de ised assessment and in"ormation ratin$ #ro"ile and were then entered in a s#readsheet% The si& aria!les that were recorded were a$e, $ender, #sychiatric dia$nosis, e#ile#sy, de$ree o" intellectual disa!ility, and medication% Psychiatric dia$nosis was coded to the "ollowin$ ma6or +C,'1/ cate$ories1 schi5o#hrenia s#ectrum disorder *38/'8)-, #ersonality disorder *3./'.7-, an&iety *3(/'(:-, de#ressi e disorder *3A8'A7-, ad6ustment reaction *3(A-, and dementia *3//'/A-% The two #atient $rou#s were de"ined on the !asis o" the #resence or a!sence o" #er asi e de elo#mental disorder *3:(-% The data were analysed !y chi'sGuare tests to e&amine whether there were any statistically si$ni"icant di""erences !etween the autistic and non' th autistic $rou#% ,ata were analysed usin$ the Statistical Packa$e "or Social Sciences, 11 @ersion *SPSS 11-% Multi-variate analyses +n order to control statistically "or the contri!ution o" #otentially con"oundin$ demo$ra#hic aria!les, while assessin$ each dia$nostic cate$ory as an inde#endent #redictor o" autism, a !inary lo$istic re$ression was #er"ormed usin$ a ste#wise "orward method% The aria!les were added successi ely accordin$ to their ma$nitude o" the correlation with the de#endent aria!le, and then were successi ely remo ed until the #redicti e a!ility o" the re$ression model, inde&ed !y the model chi'sGuare, was not si$ni"icantly im#ro ed% Be"ore the analysis, dummy aria!les were created where there were more than one cate$ory "or each aria!le, coded as #resence or a!sence% The #resence o" autism was the de#endent measure% The #arameters $ender, a$e *H A0 or IA0-, +, le el *se ereJnon'se ere-, medication *#resenceJa!sence-, as well as the #sychiatric cate$ories, *schi5o#hrenia s#ectrum disorder, #ersonality disorder, an&iety, de#ressi e disorder, ad6ustment reaction, and dementia-, each coded as a !inary aria!le, were entered in the eGuation as #redictor aria!les%

Adults with autism (

PAS -ADD sample A su!'$rou# o" 88( #artici#ants, 00 o" whom were dia$nosed with autism s#ectrum disorders +, and 1)8 were dia$nosed with +, only were also assessed with the Psycho#atholo$y Assessment Schedule "or adults with ,e elo#mental ,isa!ilities checklist *PAS'A,, Checklist-% The PAS'A,, Checklist is a relia!le measure o" #sycho#atholo$y "or #eo#le with +, *4oss, Prosser, Costello, Sim#son, & Patel, 177:-% A key in"ormant, such as a "amily or sta"" mem!er com#leted the PAS'A,, Checklist "or each indi idual% The assessin$ #sychiatrist was !lind to the PAS'A,, Checklist score at assessment, and the key in"ormant was !lind to the #sychiatric dia$nosis% The PAS'A,, Checklist has 87 items *scored "rom / to 8- ta##in$ a ran$e o" #sychiatric sym#toms, and $i es three total scores1 A""ecti eJNeurotic, Possi!le =r$anic and Psychotic ,isorders% Results Ta!le 1 #resents the #ro#ortion o" #artici#ants !y $ender, a$e, and le el o" +, "or the two $rou#s% Peo#le with autism and +, were youn$er than #eo#le with +, only *Chi'sGuare D A%(1, df D 0, p I %///1-, and were more likely to ha e moderate or se ere +, *Chi'sGuare D AA%((, df D 8, p I %///1-% The $ender di""erences !etween the two $rou#s did not reach si$ni"icance *Chi'sGuare D A%(1, df D 1, p = /%/.-% Ta!le 1 Number and percentages of patients with and without autism by gender, age, and level of Intellectual Disability (ID) Autism @aria!le No n *EKes n *E77 *.)%A(: *A8%).. () 8/ 7 0 *((%7*A8%/*1A%.*.%1*A%(Total n *E-

Gender 4ale 3emale A$e *yearsI8( 80'A( A0'(( (0'0( 00 L ;e el o" +, 4ild *3)/4oderate *3)1Se ere *3)8')AA0) *07%/8(: *(1%/1:A 10A 1A( )7 0. *A/%8*80%A*81%1*1A%1*7%A(0. *./%.87. *A7%(8(7 *AA%18// *8.%.10( *8/%0:: *11%).1 *:%1(). *.A%11.7 *88%11/) *1(%8-

(1A *.:%118/ *17%:)8 *11%7-

.A *(8%:(7 *AA%AA0 *8A%:-

Adults with autism 0

The #ro#ortion o" #sychiatric dia$nosis and e#ile#sy is #resented in Ta!le 8% Psychiatric disorder were less "reGuent in the autistic $rou# *Chi'sGuare D 8/%/), df D ., p I %//1% There were no si$ni"icant di""erences !etween the two $rou#s in the rate o" e#ile#sy (p M %A/Ta!le 8 Number and percentages of patients with and without autism by type of psychiatric diagnosis and presence of epilepsy Autism @aria!le No n *EKes n *ETotal n *E-

Psychiatric dia$nosis Schi5o#hrenia s#ectrum *38/'8)Personality disorder *3./'.7An&iety *3(/'(:,e#ressi e disorder *3A8'A7Ad6ustment reaction *3(A,ementia *3//'/ANo dia$nosa!le disorder E#ile#sy A!sent Generalised ;ocalised

1/7 *1:%00A *7%/(: *:%10A *7%/A: *.%080 *(%88.A *((%)()0 *):%01/. *1)%08( *(%/-

8A *1.%(( *8%7. *(%A7 *.%() *0%/8 *1%(:7 *.A%.181 *:8%A88 *10%/( *8%)-

1A8 *1:%10) *)%:0( *)%(.8 *:%0(0 *.%88) *A%)A08 *(:%A07. *)7%A18: *1)%/8: *A%)-

The #ro#ortion o" #eo#le with autism and +,, and those with +, only, !y ty#e o" medication is #resented in Ta!le A% There were si$ni"icant di""erences in the #ro#ortion o" #atients with autism who were in recei#t o" medication *Chi'sGuare D 81%((, df D 0, p I %//1-% S#eci"ically, #eo#le with autism were more likely to take #sychotro#ics *Chi'sGuare D 1A%/., df D 1, p I %//1- and less likely to take anti'con ulsants *Chi'sGuare D .%1(, df D 1, p I %/1-% Ta!le A Number and percentages of patients by type of medication Autism

Adults with autism .

@aria!le

No n *E-

Kes n *E-

Total n *E-

Ty#e o" medication Psychotro#ics Sedati es Anti'con ulsants P?N only Com!inations None

1A: *88%:81 *A%0:8 *1A%0(( *)%171 *1/%)800 *(8%1-

0( *A.%): *0%(7 *.%1: *0%(88 *10%/(. *A1%A-

178 *80%087 *A%771 *18%108 *.%7:) *11%.A/1 *(/%/-

Multi-variate analyses Ta!le ( summarises the lo$istic re$ression model "or the a!sence or #resence o" autism% This model was si$ni"icant *Chi'sGuare- D00%0., df D 0, p I/%//1, '8 lo$ likelihood D .:)%/08 accountin$ "or a!out 11E o" the ariance *? -% The hi$hest odds ratio was "or +, le el, with #artici#ants with se ere +, !ein$ almost twice more likely to !e autistic than #artici#ants with mild or moderate +,% The lowest odds ratio was "or #atients with #ersonality disorders who were less than hal" as likely to !e autistic as someone with any other #sychiatric dia$nosis% 4ale #atients, and those who took medication, were also 1%. times more likely to !e autistic, as com#ared to "emale #atients, and those without recei in$ medication% 3inally, #artici#ants who were under A0 were more likely to !e dia$nosed as autistic than the older #atients% Ta!le ( !egression model predicting presence or absence of autism

Predictor aria!le Age *H A0"e# *maleID level *se ere$ersonality disorder *#resence%edication *#resenceConstant

B '1%11 /%(7 /%(7 '1%88 /%(7 '1%)8

SE /%88 /%8/ /%8( /%0A /%8/ /%88

E&# *B/%A1 1%.( 1%:A /%87 1%.( /%1:

70E C+ /%81 ' /%01 1%11 ' 8%(( 1%1( ' 8%7A /%1/ ' /%:( 1%1/ ' 8%(0

P I %//1 I %/1 I %/1 I %/0 I %/1

Adults with autism )

Analysis of PAS-ADD sample +n an e""ort to alidate the dia$noses o" autism s#ectrum disorder the means o" PAS' A,, Checklist on the "ollowin$ autism'related items were com#ared1 item . *!epeated actions, such as chec&ing over and over that a door has been loc&ed, or having to do thin&s in a particular order) and item 8: *'dd gestures and mannerisms)% =n item . the means *and SE s- were /%(. *SE D 1%11- and /%1. *SE D /%/(- which was a si$ni"icant di""erence *t = 8%77, p I %/1-% =n item 8: the means *and SE s- were /%80 *SE D/%/.- and /%1A *SE D /%/8which was also a si$ni"icant di""erence *t = 8%1(, p I %/1-% Thus, the $rou#s did di""er in terms o" autism'related sym#toms% The $rou#s were then com#ared in terms o" scores on non'autistic #sycho#atholo$y on the PAS'A,, Checklist% There were no di""erences on the three su!'scales scores *all ps M %/0-% The numerical di""erences in the mean PAS'A,, scores !etween autistic *Affective(Neurotic D (%.8, $ossible 'rganic D 1%7/, $sychotic Disorders D1%/8- and non' autistic #artici#ants *Affective(Neurotic D (%87, $ossible 'rganic D1%./, $sychotic Disorders D %:)- were not statistically si$ni"icant, all ts I 1% This result su$$ests an a$reement !etween #sychiatric dia$noses, made !y the two clinicians, and #sycho#atholo$y, as assessed !y the PAS'A,,, which was com#leted !y key in"ormants% Discussion This study com#ared #sycho#atholo$y as measured !y #sychiatric dia$nosis and !y the PAS'A,, Checklist in a lar$e $rou# o" adults with +, and autism and #eo#le with +, alone% Both $rou#s did indeed di""er in the #resence o" autistic sym#toms as measured !y the PAS'A,, Checklist% Howe er, !oth multi ariate analysis o" #sychiatric disorders and uni ariate analyses o" the PAS'A,, Checklist data re ealed "ew di""erences !etween the $rou#s% The multi ariate analysis o" #sychiatric dia$nosis demonstrated that, althou$h the $rou#s di""ered in that those with autism were youn$er, more likely to !e male, more likely to !e dia$nosed with se ere +,, more likely to take #sychotro#ic medication, the only #sychiatric dia$nosis that distin$uished !etween the $rou#s was that #eo#le with autism s#ectrum disorders were less likely to !e dia$nosed with #ersonality disorders% Thus, in contrast to some other research *Bradley et al%, 8//(2 4or$an et al%, 8//A- we "ound little e idence o" increased rates o" #sycho#atholo$y% Ce also re#licated early "indin$s that there was no increased risk o" #sychoses *4ouridsen et al, 17772 @olkmar & Cohen, 1771- in #eo#le with autism and +,% The male'to'"emale ratio was "ound to !e ele ated in the autistic $rou# in accord with most #re ious studies showin$ a male #redominance in autism *"or a re iew see Baron'Cohen, 8//A-% The "ailure to "ind di""erences in #sycho#atholo$y !etween these two $rou#s reGuires some comment% This study took #lace in a naturalistic clinical en ironment, and the sam#le si5e was Guite lar$e, i" not lar$er than most #re ious studies, includin$ also standardised methods o" data collection usin$ the PAS'A,, checklist% Thus, sim#le lack o" #ower is a #ossi!le e&#lanation, !ut not a likely one% =ne methodolo$ical e&#lanation is that in this study we used multi ariate analyses that controlled "or #ossi!le con"ounds !etween the $rou#s% Hence, it is #ossi!le that in some #re ious studies the o!ser ed di""erences !etween #eo#le with autism and #eo#le with +, only were due to other uncontrolled aria!les% Another methodolo$ical e&#lanation "or the a!sence o" di""erences mi$ht !e that the )

Adults with autism : measures used in this study were insensiti e to di""erences !etween the $rou#s% The PAS' A,, did indeed detect di""erences !etween the $rou#s in autism sym#toms% Howe er, it may !e the case that the PAS'A,, scales are too short and hence insensiti e to detect more su!tle di""erences !etween the $rou#s% 4or$an et al% *8//A- collected their data retros#ecti ely, !y re iewin$ case notes o er a #eriod o" time% Ce collected data at one #oint in time as #art o" deli erin$ clinical ser ice% Hence the "i$ures re#orted !y 4or$an et al may !e closer to #eriod #re alences o" #sycho#atholo$y, and hence may ha e !een more sensiti e measures o" #sycho#atholo$y% =ur data were collected at one #oint in time, and hence may !e closer to #oint #re alence measures and hence !e less sensiti e measures o" di""erences !etween the $rou#s% Another #ossi!ility is that !ecause nearly )/E o" #eo#le with autism s#ectrum disorders were takin$ #sychotro#ic medication that any #sycho#atholo$y was well controlled% Alternati ely, there may !e measures o" other as#ects o" #sycho#atholo$y, such as social !eha ior and lan$ua$e "unctionin$, and challen$in$ !eha iors, that mi$ht detect di""erences !etween #eo#le with and without autism% Psychotro#ic medication was "ound to !e more "reGuent in the autistic $rou#, a result that concurs with #ast e idence *Posey & 4c,ou$le, 8///-, des#ite the "act that #sychiatric disorders were less "reGuent in this $rou#% +t is #ossi!le that the ele ated medication le els in #eo#le with +, and autism may re"lect an e""ort to reduce autism'related !eha iours, such as stereoty#y and a$$ression% This result may also re"lect #ressures to #rescri!e medication in cases o" $reater com#le&ity, des#ite the a!sence o" o ert clinical #sycho#atholo$y% Bnlike 4or$an et al% we "ound no increased rates o" de#ression in #eo#le with autism s#ectrum disorders% The sam#le em#loyed the 4or$an et al% consisted #redominantly *0)Eo" #atients with se ere disa!ility, althou$h the #resent sam#le consisted mainly *:0E- o" #atients with mild and moderate disa!ility% +t could !e su$$ested, "or e&am#le, that increased le els o" de#ression mi$ht !e limited to #eo#le with se ere +,% Howe er, analysis o" the #resent data showed that no case with se ere +, and autism recei ed a dia$nosis o" de#ression */%/E-, althou$h some de#ression rates were o!ser ed in moderate *(%1E- and mild +, *11%1E-% +n #eo#le with +, !ut no autism s#ectrum disorder a similar #attern was o!ser ed in terms o" the de#ression rates as a "unction o" the +, le el% The #ro#ortion o" #eo#le with de#ression was se ere */%/E- moderate *0%:E- and mild +, *11%1E-% Hence, these di""erences !etween 4or$an et al and the #resent study are unlikely to account "or the re#orted di""erences% Peo#le with autism were more likely to ha e se ere +, than their non' autistic counter#arts% This may re"lect an o er'dia$nosis o" autism in low "unctionin$ indi iduals due to assessment di""iculties% Another #ossi!ility would !e that the de elo#mental co'e&istence o" autism with +, is likely to ha e a $radually detrimental e""ect on co$niti e "unctionin$, increasin$ the likelihood o" se ere +,% ConseGuently, "urther research is needed to elucidate the relationshi# !etween autism and le els o" +,% =ur sam#le contained mostly adolescents and youn$ adults, !ut did contain a##ro&imately 8/E o" adults a$ed o er A0 years% =ur multi#le re$ression model identi"ied a$e as the aria!le that !est #redicted autism *See also Ta!le 1-% =ther research has re#orted trends to dia$nosin$ autism s#ectrum disorders in children and adolescents more "reGuently than in adults *3om!onee, 17772 Sturmey & <ames, 8//1%- There is e idence that certain autism'related !eha iours are more likely to im#ro e in older #atients, as com#ared to youn$er #atients *Selt5er, 9rauss, Shattuck, =rsmond, Swe & ;ord, 8//A-% A$e di""erences may #artly re"lect a #articular neuro'de elo#mental #attern in autism% Brain de elo#ment in autism "ollows an a!normal #attern, with accelerated $rowth in early li"e *resultin$ in !rain enlar$ement- and su!seGuent decrease in !rain olume in later li"e, as a #art o" a maturationJnormali5ation #rocess *Aylward et al%, 8//8-% ConseGuently, such a neuro' de elo#mental #rocess could account "or the "act that autism was "ound to !e more "reGuent :

Adults with autism 7 in youn$er *I A0- than in older #atients% The cumulati e e""ects o" education and en ironmental o##ortunity to learn alternati e non'#atholo$ical !eha iors o er the li"es#an may also !e an im#ortant aria!le in"luencin$ the course o" de elo#ment in adults with autism% The rates o" e#ile#sy were rou$hly eGui alent !etween the autistic and non'autistic $rou#, des#ite the well'know association !etween autism and sei5ure disorders *e%$% Gill!er$, 17712 Gio anardi'?ossi, Posar & Parme$$iani, 8///2 @olkmar & Nelson, 177/-% There seems to !e a !imodal a$e distri!ution o" sei5ures in autism, as one #eak occurs in in"ancy and the other in adolescence *@olkmar & Nelson, 177/-% There"ore, the #resent results #ro!a!ly re"lect the a$e ran$e o" the sam#le, as the ma6ority was older than 80 years% +n addition, considerin$ that the ma6ority o" the #resent sam#le consisted o" cases with mild and moderate +,, it is #ossi!le that the association !etween e#ile#sy and autism may e&ist mainly "or cases with se ere +,% Gi en that in many cases #re ious dia$noses were a aila!le "rom #ast medical records, it could !e ar$ued that such in"ormation would !ias the assessin$ clinicians towards con"irmin$ #re ious dia$noses% Such a #ossi!le !ias would !e #articularly likely "or older cases, due to a likelihood o" historic misinter#retation o" autistic sym#toms as e idence o" Nschi5o#hrenia s#ectrumO or N#ersonality disorderO% Howe er, the e&#erience o" two o" the co' authors *NB & GH-, who were also assessin$ clinicians "or the #resent sam#le, was somehow di""erent% All the cases were re"ereed "rom Primary Care, Social Ser ices and 4ainstream 4ental Health Ser ices to a S#ecialist Ser ice% The assessin$ clinicians, s#ecialists in +, and autism, sometimes reconsidered an old dia$nosis o" Nschi5o#hrenia s#ectrumO or N#ersonality disorderO to ha e !een in "act a misdia$nosis o" autism% =ne #otential limitation o" the study is that !oth #sychiatric dia$nosis and autism was assessed !y clinical inter iews% The dia$nosis o" autism durin$ concurrent clinical assessment, des#ite !ein$ more relia!le than retros#ecti e assessment, may ha e o ershadowed other #sychiatric dia$noses% Takin$ into account communication #ro!lems in autism *Howlin, 177)-, cou#led with the #resent "indin$ that #ersonality disorder was "ound less likely in the autistic $rou#, the #ossi!ility o" such an under'dia$nosis mi$ht constitute a challen$e "or "uture in esti$ations to o ercome% 3urthermore, the #resent study in esti$ated only one su!$rou# o" the autistic s#ectrum *low "unctionin$ $rou#-, and there"ore the "indin$s mi$ht not a##ly to those with normal intelli$ence% Hi$h sel"'awareness o" autism' related social #ro!lems and limitations may!e an im#ortant contri!utin$ "actor to mental health in #eo#le with autism and normal intelli$ence% +n summary, the #resent results seem to cast dou!ts on the su$$estion that #eo#le with +, and autism may ha e an increased risk "or #sychiatric disorders% Howe er, althou$h #eo#le with autism may not "ul"ill the con entional +C,'1/ criteria, they still may su""er "rom #sychiatric sym#toms and malada#ti e !eha iors% 3irm conclusions on the relationshi# !etween low'"unctionin$ autism and #sychiatric co'mor!idity may !e #remature in li$ht o" the dia$nostic di""iculties, inherent methodolo$ical #ro!lems, and #ossi!le o erla# !etween autistic !eha iours and those relatin$ to other disorders% +n this res#ect, dia$nostic tools desi$ned to address the s#eci"ic needs o" #eo#le with autism could contri!ute su!stantially% +n terms o" mental health #olicy #lannin$, a stron$er e idence !ase is needed #rior to committin$ resources "or clinical ser ices%

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