Ask the Expert - Depression and ASD: Why is It So Hard?
Posted on 04/25/19 in Health by Cara Marker Daily, PhD, BCBA
The unfortunate reality is that a large percentage of individuals with autism are also diagnosed with a mental health disorder. With this comes a critical need for efficient assessment and treatment for the autism community. Join us Tuesday, June 11, for our first ever Deep Dive Series at the Milestones National Autism Conference, as we delve into the complexities of depression, anxiety, and trauma, as well as assessment, diagnosis, and evidence-based treatment. Cara Marker Daily, PhD, BCBA, is one of the featured speakers lending her expertise to these sessions, and was kind enough to share a sneak peek into her topic of the relationship between depression and autism on the blog this month. Find out more about our Deep Dive sessions here.
Did you know that those diagnosed with autism spectrum disorder (ASD) are dying at a younger age than the rest of the population and that the third leading cause of their death is suicide (Hirvikoski et al., 2018)? Those with ASD are four times more likely to be depressed than those without autism, particularly those with higher IQs (Hollocks et al., 2019). Compared to the general population, adults with high functioning ASD are 10 times more likely to endorse suicidal thoughts (Cassidy et al., 2014). This is why screening and assessing individuals with ASD for depression is so important throughout their life span. Unfortunately, the research is lacking on specific tools to help us identify and medications to treat those with ASD who are depressed.
Depression can look very different in individuals with ASD, so finding a therapist or psychologist who specializes in ASD is a must. For a diagnosis of depression, individuals may feel depressed, irritable, express a loss of interest in activities, exhibit weight or appetite change, have sleep difficulties, fatigue, psychomotor agitation, difficulty concentrating, feelings of worthlessness, or recurrent thoughts of suicide. Those with ASD who are depressed may also exhibit aggression, mood changes, hyperactivity, decreased self-care, regression of previously learned skills, increased compulsiveness, fluctuations in preoccupations/restricted interests, self-injurious behavior, catatonia, or just some other significant change in behavior (Magnuson & Constantino, 2011).
Proper treatment for depression can also be challenging if you are seeking out medication and not working with a physician or psychiatrist who is knowledgeable about ASD. Research is clear that certain medications that typically work with the general population, do not work the same way with those with ASD. Those with ASD process medication differently than neurotypical individuals. For example, antidepressants, such as Selective Serotonin Reuptake Inhibitors (SSRIs), which are typically given to treat depression in the general population, are not effective in treating depression in children with ASD and may even cause more harm (Williams and colleagues, 2013). No medications have been approved by the FDA to treat depression in children with ASD. This is why therapy is so important.
Psychotherapy, which can be beneficial in treating depression, should be used, particularly those techniques of Cognitive-Behavioral Therapy (CBT). To be most effective, the therapist should modify the typical techniques of CBT to best fit the client with ASD (White et al., 2018). Due to the chronic nature of ASD, therapy should focus on the positives of the client during treatment. Use the client’s strengths during sessions and to practice strategies at homes. Inclusion of the client’s special interests should be integrated in the therapy. The core features of ASD should be addressed during treatment in developing exposure hierarchies and targeting social problems.
Additionally, group training with peers should be used to develop real-life practice skills and modeling. Furthermore, education about ASD and depression is important. The therapist should focus on helping the client develop emotional awareness and insight into ASD and their feelings of depression. With adolescent and young adults, therapy should also include increased reliance on parents.Treatment should be highly structure with clear expectations, but also slower paced so as to allow time for the client to process skills and practice repeatedly. Visual handouts should be used during sessions to assist with teaching as most individuals with ASD process information more visually than verbally. The therapist also should try to reduce the use of metaphors to avoid confusion and provide additional time for in-session practice as well as provide homework for the client to practice skills at home, at school, and/or in the work settings. Proper diet, sleep, and exercise, which also affects mood, should be addressed in sessions and self-regulation strategies, such as diaphragmatic breathing and other relaxation techniques should be taught. Increased social and vocational opportunities for the individual with ASD are also beneficial in reducing depression.
Assessing and treating depression for individuals with ASD is hard, but with the right treatment team and proper therapy, depression can be reduced and coping skills can be taught. As more research is conducted, hopefully more therapies will be found effective, including possible medications to properly treat depression. If you or someone you know is depressed, please reach out to someone, as there are professionals who can help.
Cassidy, S., Bradley, P., Robinson, J., Allison, C., McHugh, M., & Baron-Cohen, S. (2014). Suicidal ideation and suicide plans or attempts in adults with Asperger's syndrome attending a specialist diagnostic clinic: a clinical cohort study. The Lancet Psychiatry, 1(2), 142-147.
Hirvikoski, T., Mittendorfer-Rutz, E., Boman, M., Larsson, H., Lichtenstein, P., & Bölte, S. (2016). Premature mortality in autism spectrum disorder. British Journal of Psychiatry,208(3), 232-238. doi:10.1192/bjp.bp.114.160192
Hollocks, M., Lerh, J., Magiati, I., Meiser-Stedman, R., & Brugha, T. (2019). Anxiety and depression in adults with autism spectrum disorder: A systematic review and meta-analysis. Psychological Medicine, 49(4), 559-572. doi:10.1017/S0033291718002283
Magnuson, K. M., & Constantino, J. N. (2011). Characterization of depression in children with autism spectrum disorders. Journal of developmental and behavioral pediatrics : JDBP, 32(4), 332–340. doi:10.1097/DBP.0b013e318213f56c
White, S. W., Simmons, G. L., Gotham, K. O., Conner, C. M., Smith, I. C., Beck, K. B., & Mazefsky, C. A. (2018). Psychosocial treatments targeting anxiety and depression in adolescents and adults on the autism spectrum: Review of the latest research and recommended future directions. Current psychiatry reports, 20(10), 82.
Williams K, Brignell A, Randall M, Silove N, Hazell P. Selective serotonin reuptake inhibitors (SSRIs) for autism spectrum disorders (ASD). Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD004677. DOI: 10.1002/14651858.CD004677.pub3.
ABOUT THE WRITER
Cara Marker Daily, PhD, BCBA, is a licensed pediatric psychologist and board certified behavior analyst with over 20 years of clinical, research, and teaching experience with autism in the home, school, hospital, and community settings. Dr. Daily is the president and training director of Daily Behavioral Health, a leading behavioral health provider in northeast Ohio specializing in assessment, consultation, and treatment of autism, anxiety, and disruptive behavior disorders. Dr. Daily is also the founder and executive director of the Building Behaviors Autism Center, which has received numerous grants to provide free and reduced cost applied behavioral analysis services to individuals with autism. She has written several cognitive-behavioral and behavioral-based curriculums, a peer-reviewed journal article, and the book, "The Key To Autism". She presents internationally on topics of autism spectrum disorder and is regularly featured in radio, television, and other media platforms in Ohio.
This article was provided by a guest writer for Milestones Autism Resources. While Milestones has vetted this professional as an individual who practices evidence-based strategies, views and opinions expressed in this article are the writer's own.