I recently wrote a chapter for a textbook related to counseling children with disabilities. My chapter focused on children with autism and co-occurring disabilities. “Co-occurring” means that there is another type of problem that the child is experiencing in addition to autism. The Centers for Disease Control and Prevention (CDC, 2014) state that about 1 in 68 children have been identified with autism. Many are unaware of the fact that autism often co-occurs with other “developmental, psychiatric, neurologic, or medical diagnoses” (Levy, Giarelli, Lee, Schieve, Kirby, Cunniff, Nicholas, Reaven, & Rice, 2010, pp. 267) and that the co-occurrence of one or more non-autism developmental diagnosis is an alarming 83% (CDC, 2014). Yes, you read that correctly: 83%! While I was aware that many of the young people with whom I work suffer from other disabilities, it stunned me to know that the number was so high. As I did more research for the chapter, I was alarmed to find that the rate of occurrence of each disability is several times higher than for those in the general population. Here are some of the co-occurring disabilities and the rates at which they occur.
Cognitive Delays, Neurological Issues, and Epilepsy
A high percentage of children with autism, especially more severe forms of autism, experience cognitive delays and problems with reasoning and intellectual functioning. Neurological development is disrupted because of delays in brain development or due to certain areas not developing at all. Epilepsy is common among children with autism. Tuchman (2011) found that a person diagnosed with autism is 10 to 30 times more likely to have epilepsy than those in the general population and that the long-term outlook for a person with autism and epilepsy is poor.
Gastro-intestinal and Eating Problems
Gastro-intestinal (GI) problems and eating problems co-occur with autism. Wang, Tancredi, & Thomas (2011) conducted a large study and found that 42% of children with autism had GI issues, as opposed to only 12% of their neurotypical siblings. Eating problems such as refusing certain foods, craving other foods, as well as acting out during mealtimes are problems that many parents of autism children report (Durand, 2014). Stress, which is a common part of the autism child’s world due to the triggering of the sympathetic nervous system (Bodenach & Bogdan, 2012), is believed to be a factor in GI problems, while sensory issues and hypersensitivity to texture are a factor in children with autism having difficulty tolerating new and different foods.
Anxiety and mood disorders co-occur with autism at an alarming rate. Durand (2014) states that “roughly 50-80%” can be diagnosed with an anxiety related disorder (p. 58). The activation of the “fight-flight-freeze” response and release of neurotransmitters such as cortisol and adrenaline create a sense of disorder and danger, leaving the child feeling unsteady and unsafe. The behaviors that result in an anxiety related diagnosis (obsessive-compulsive disorder, separation anxiety, phobias, etc.) are all connected to the child’s attempt to restore a sense of safety and equilibrium. Depression occurs at rates of between 25 to 34% (Ghaziuddin, Ghaziuddin, & Greden, 2002) in individuals diagnosed with autism. Problems from social situations, family stress, and trips to therapists, doctors, and special school classes, leave children with autism feeling overwhelmed and many turn their negative feelings inward resulting in overwhelming sadness and self-rejection. Many children with autism have difficulty understanding emotions and due to an inability to put feelings into words, the child buries it all deep within resulting in a sense of despair and hopelessness.
Attention-Deficit-Hyperactivity-Disorder (ADHD) is yet another co-occurring diagnosis with autism. When one considers the constant triggering of the sympathetic nervous system and the upheaval that results in high levels of anxiety, it seems logical that ADHD is part of the landscape for a child diagnosed with autism. The demands of joining a confusing, fast-paced world often outweigh the child’s psychological resources. In my experience, nearly every child diagnosed with autism usually receives an additional diagnosis of ADHD or is mis-diagnosed with ADHD instead of autism. I believe that the reason for this is that the intellectual intensity and the inability to tolerate negative emotions creates a constant triggering of the sympathetic nervous system (“fight-flight-freeze”) which makes the child appear to have severe impairments in the areas of impulse control and self-regulation.
A final problem that often plagues the child with autism are issues with sleep (Durand, 2014). Trouble falling asleep, sleeping too much, as well as insomnia are all characteristics of those diagnosed with autism. Sleep problems affect the mental and emotional functioning of the child as well as academic performance and overall coping skills (Staples & Bates, 2011). From a family perspective, sleep problems of the child with autism can create stress on the family system and the bed time routine is often a major problem area that is mentioned during the initial counseling intake session.
What Does All This Mean?
This information has several implications for families with a child with autism. First, parents should not feel shocked when they discover that their child has something else going on in addition to autism. For whatever reason, the rate of a co-occurring disability is high, and knowing this can help parents be prepared to find coping skills and strategies to keep stress at a minimum. Second, investigating the co-occurring disability and finding effective treatment will be helpful to lessen the effects of stress and anxiety on the child and everyone involved. Third, routine and structure as well as building relationship are of utmost importance. It is hard enough to parent a child with autism but for those parents who have a child with autism and a co-occurring disability, it is an overwhelming task. However, creating routine and structure with a clearly defined system of rewards and consequences, in addition to making time for play and relationship minimizes stress and allows the child to stay on track developmentally.
The Role of Counseling Children with Autism and a Co-Occurring Disability
Counseling for children with autism who have a co-occurring disability has many benefits. Learning to put feelings and thoughts into words, developing a sense of self-understanding and self-worth, as well as learning coping techniques to deal with stress are just a few of the benefits. Play therapy and relationship-based therapy provides the child with an affirming environment wherein the child uses play to express thoughts and feelings which helps manage stress and anxiety. Play therapy can be tailored to address a specific problem such as low self-worth or anxiety, and it can be taught to parents in family therapy sessions so that they can take the techniques and implement those in the home environment. Play helps build self-worth and create a sense of identity and self-understanding.
A Final Word…
Autism and co-occurring disabilities occur together at an alarmingly high rate. Children with autism who have a co-occurring disability face immense challenges in daily living. Families with a child with autism who have a co-occurring disability experience high levels of stress and many parents carry a sense of despair at being unable to help their child and to meet the child’s developmental needs. Counseling offers a safe haven for children with autism and co-occurring disabilities and their families. Play therapy and relationship based therapy are ways to help children with autism and a co-occurring disability deal with stress and increase self-worth and self-understanding. Family therapy is useful to teach parents coping skills and learn effective ways to manage stress, create routing and structure, and build relationship with their child.
Badenoch, B. & Bogdan, N. (2012). Safety and connection: The neurobiology of play. In L.Gallo-Lopez and L. C. Rubin (Eds.), Play-Based Interventions for Children and Adolescents with Autism Spectrum Disorders (pp. 3-18). New York, NY: Routledge/Taylor & Francis Group.
Centers for Disease Control and Prevention. (2014). Autism. Retrieved from http://www.cdc.gov/ncbddd/autism/data.html.
Durand, V. M. (2014). Autism spectrum disorder: A clinical guide for general practitioners (First Edition.). Washington, DC: American Psychological Association.
Ghaziuddin, M., Ghaziuddin, N., & Greden, J. (2002). Depression in persons with autism: Implications for research and clinical care. Journal of Autism and Developmental Disorders, 32(4), 299-306. doi:10.1023/A:1016330802348
Levy, S. E., Giarelli, E., Lee, L. C., Schieve, L. A., Kirby, R. S., Cuniff, C., Nicholas J., Reaven, J., & Rice, C. E. (2010). Autism spectrum disorder and co-occurring developmental, psychiatric, and medical conditions among children in multiple populations of the United States. Journal of Developmental and Behavioral Pediatrics, 31(4), 267–275.
Staples, A. D., & Bates, J. E. (2011). Children’s sleep deficits and cognitive and behavioral adjustment. In M. El-Sheikh (Ed.), Sleep and development: Familial and socio-cultural considerations (pp. 133–164). New York, NY: Oxford University Press.
Tuchman, R. (2011). Epilepsy and encephalography in autism spectrum disorders. In D. G. Amaral, G. Dawson, & D. Geschwind (Eds.), Autism spectrum disorders (pp. 381–394). New York, NY: Oxford University Press. doi:10.1093/med/9780195371826.003.0026
Wang, L. W., Tancredi, D. J., & Thomas, D. W. (2011). The prevalence of gastrointestinal problems in children across the United States with autism spectrum disorders from families with multiple affected members. Journal of Developmental and Behavioral Pediatrics, 32, 351–360. doi:10.1097/DBP.0b013e31821bd06a