Schizophrenia in autistic people with intellectual disabilities: Symptom manifestations and identification.

BACKGROUND: The assessment of schizophrenia in autistic people with intellectual disabilities is challenging. This study aimed to explore the identification of schizophrenia in this population. METHODS: Using data from a clinical multi-centre study, reported symptoms in 26 autistic individuals with intellectual disabilities diagnosed with co-occurring schizophrenia were explored. Scores on two checklists (Psychopathology in Autism Checklist [PAC], Aberrant Behaviour Checklist [ABC]) were compared with two comparison groups: autistic individuals with intellectual disabilities and other mental disorders (94), or no mental disorder (63). RESULTS: Reported symptoms of schizophrenia in this population met the formal diagnostic criteria. For PAC/ABC scales, only PAC psychosis differed for the schizophrenia group. Among participants with schizophrenia, two were diagnosed with additional mental disorders. Elevated scores for anxiety and depression were common. CONCLUSIONS: Emphasising core symptoms seems necessary when assessing co-occurring schizophrenia in autistic people with intellectual disabilities. The PAC may serve as a helpful screening tool.

Bias in assessment of co-occurring mental disorder in individuals with intellectual disabilities: Theoretical perspectives and implications for clinical practice.

Influence from bias is unavoidable in clinical decision-making, and mental health assessment seems particularly vulnerable. Individuals with intellectual disabilities have increased risk of developing co-occurring mental disorder. Due to the inherent difficulties associated with intellectual disabilities, assessment of mental health in this population often relies on a different set of strategies, and it is unclear how these may affect risk of bias. In this theoretical paper, we apply recent conceptualisations of bias in clinical decision-making to the specific challenges and strategies in mental health assessment in intellectual disabilities. We suggest that clinical decision-making in these assessments is particularly vulnerable to bias, including sources of bias present in mental health assessment in the general population, as well as potential sources of bias which may be specific to assessments in this population. It follows that to manage potential bias, triangulating information from multi-informant, multi-method, interdisciplinary assessment strategies is likely to be necessary.

"If we do not look for it, we do not see it": Clinicians' experiences and understanding of identifying post-traumatic stress disorder in adults with autism and intellectual disability.

BACKGROUND: Individuals with autism spectrum disorder (ASD) and intellectual disability (ID) are at increased risk of potentially traumatic events and may be at increased risk of post-traumatic stress disorder (PTSD). However, knowledge regarding identification of PTSD in this population is limited. The aim of this study was to investigate clinical experience regarding PTSD and trauma assessment in individuals with co-occurring ASD and ID. METHOD: Interpretative phenomenological analysis was used to explore experiences of identifying PTSD in this population among 18 mental health clinicians working with ASD and ID. RESULTS: Informants viewed PTSD in individuals with ASD and ID as equivalent to PTSD in the general population, but with causes and expressions potentially differing. Several factors were described to contribute to challenges in identification. CONCLUSIONS: Trauma may have severe impact in individuals with ASD and ID. Multidimensional, individualized assessment strategies seem necessary to recognize PTSD or trauma-related symptoms in this population.

Violence and sexual offending behavior in people with autism spectrum disorder who have undergone a psychiatric forensic examination.

The increased awareness of Autism Spectrum Disorders (ASD) over the last few decades as well as the potential association between ASD and offending behaviors has spurred a need for increased research in this area. In order to explore any possible relationship between ASD and violent or sexual crime the present study examines all forensic examination reports over a 10-yr. period in Norway where the charged persons were diagnosed with ASD and charged with either a violent (N = 21) or a sexual (N = 12) offense. Differences between these two groups regarding previous contact with child welfare and confessions to the offense were found. There was also a tendency toward more severe mental health problems and less intellectual problems among the violent offenders than the sexual offenders.

Applicability and Psychometric Properties of General Mental Health Assessment Tools in Autistic People: A Systematic Review.

In recent years, there has been a proliferation of instruments for assessing mental health (MH) among autistic people. This study aimed to review the psychometric properties of broadband instruments used to assess MH problems among autistic people. In accordance with the PRISMA guidelines (PROSPERO: CRD42022316571) we searched the APA PsycINFO via Ovid, Ovid MEDLINE, Ovid Embase and the Web of Science via Clarivate databases from 1980 to March 2022, with an updated search in January 2024, to identify very recent empirical studies. Independent reviewers evaluated the titles and abstracts of the retrieved records (n = 11,577) and full-text articles (n = 1000). Data were extracted from eligible studies, and the quality of the included papers was appraised. In all, 164empirical articles reporting on 35 instruments were included. The review showed variable evidence of reliability and validity of the various instruments. Among the instruments reported in more than one study, the Aberrant Behavior Checklist had consistently good or excellent psychometric evidence. The reliability and validity of other instruments, including: the Developmental Behavior Checklist, Emotion Dysregulation Inventory, Eyberg Child Behavior Inventory, Autism Spectrum Disorder-Comorbid for Children Scale, and Psychopathology in Autism Checklist, were less documented. There is a need for a greater evidence-base for MH assessment tools for autistic people.

Post-traumatic stress disorder and experiences involving violence or sexual abuse in a clinical sample of autistic adults with intellectual disabilities: Prevalence and clinical correlates.

LAY ABSTRACT: Post-traumatic stress disorder is a mental health disorder that may be triggered by the experience of events perceived as terrifying or overwhelming. Examples of such events include being the victim of violence or sexual abuse. Compared with other people, autistic people have increased risk of being exposed to violence or sexual abuse. In addition, autistic people may be more vulnerable to developing post-traumatic stress disorder following such exposure. However, knowledge is limited concerning the prevalence of experiences involving violence and sexual abuse, and post-traumatic stress disorder, in autistic people with co-occurring intellectual disabilities. Detection of these experiences, and identification of post-traumatic stress disorder, may be challenging in these individuals, and previous research indicates that post-traumatic stress disorder symptoms may be overlooked or misinterpreted. In this study, we examined prevalence of post-traumatic stress disorder, violence and sexual abuse in a clinical sample of 88 autistic adults with intellectual disabilities referred for mental health assessment. Only 3.4% were diagnosed with post-traumatic stress disorder, even if experiences involving violence (34.1%) or sexual abuse (17.0%) were common. Anxiety and affective disorders were common diagnoses among participants with these experiences. Controlling for autism characteristics, level of intellectual disability and communication skills, experiences of violence/sexual abuse were found to be associated with a measure of 'challenging' behaviours. These results indicate that potentially traumatic experiences are common in autistic adults with intellectual disabilities referred for mental health assessment, and that post-traumatic stress disorder may be under-recognised. The findings highlight the importance of trauma screening and post-traumatic stress disorder assessment, as well as the importance of trauma-informed care, in this population.

General Measurement Tools for Assessing Mental Health Problems Among Children and Adolescents with an Intellectual Disability: A Systematic Review.

There is a need for more knowledge of valid and standardized measures of mental health problems among children and adolescents with intellectual disability (ID). In this study, we systematically reviewed and evaluated the psychometric properties of instruments used to assess general mental health problems in this population. Following PRISMA guidelines, we reviewed empirical research published from 1980 through February 2020 with an updated search in March 2021 in Medline, Embase, PsycINFO, Health and Psychological Instruments, CINAHL, ERIC, and Web of Science databases. Forty-nine empirical articles were included in this review. Overall, the review indicated consistently better documentation of the reliability and validity of instruments designed for the ID population compared to instruments developed for the general child population.

Autistic Characteristics in a Nationally Representative Clinical Sample of Adolescents Seeking Medical Gender-Affirming Treatment in Norway.

PURPOSE: Several studies have reported on the intersection of autism and gender incongruence (GI) in clinical populations. This study aims to investigate autistic characteristics and registered autism spectrum diagnoses (ASD) in a clinical cohort of 83 adolescents referred to the National Gender Team for Children and Adolescents in Norway during 2020. METHODS: Parents completed the Social Responsiveness Scale (SRS). Background information and registered psychiatric diagnoses were extracted from patient files. RESULTS: The results showed that 25% of the participants scored within the clinical range on the SRS: 27.4% of adolescents who were assigned female at birth (AFAB) and 19.0% of adolescents who were assigned male at birth (AMAB). AFAB had significantly higher scores on SRS Total Scale and the Social Motivation and Autistic Mannerisms subscales compared to the female norm group. AMAB had higher scores on the Social Motivation subscale and lower scores on the Social Awareness subscale, compared to the male norm population. Information from patient files revealed that 67.5% had one or more registered psychiatric diagnosis. 9.6% had received an ASD diagnosis, all AFAB. 18.1% had received an attention deficit hyperactivity disorder (ADHD) diagnosis. The most common psychiatric diagnoses were depression (25.3%) and anxiety disorders (18.1%). Further, 44.6% had a history of self-harm, and 15.7% had a history of a suicide attempt. CONCLUSION: The results showed an overrepresentation of ASD diagnoses and autistic characteristics measured by SRS for AFAB. There was an overrepresentation of psychiatric diagnoses for both the AFAB and the AMAB group in this study sample. Implications for treatment and future research are discussed.

Case study: organizing outpatient pharmacological treatment of bipolar disorder in autism, intellectual disability and Phelan-McDermid syndrome (22q13.3 deletion syndrome).

Phelan-McDermid syndrome (PHMDS)/22q13.3 deletion syndrome is a rare genetic disorder associated with autism spectrum disorder (ASD), intellectual disability (ID), and bipolar disorder. While numerous cases have been reported describing successful pharmacological treatment of bipolar disorder in PHMDS, there is currently little guidance available on how to organize and execute such treatment. The aim of the current case study was to explore how pharmacological treatment of bipolar disorder in PHMDS may be organized and evaluated in an outpatient setting. Through a complex process of try and fail, including systematic evaluation of any change to the intervention and never implementing more than one change at the time, the patient gradually improved, regaining his communicative and adaptive skills. Four years passed from referral to this result was achieved. Organizing assessment and treatment as a collaborative effort involving specialized mental health professionals, professional caregivers and the patient's family proved feasible. Many of the challenges present in assessment of psychiatric disorder in individuals with ASD and ID are likely to be present also in evaluation of treatment effects, particularly in disorders where symptoms occur in phases. The approach described in the current paper may contribute to reducing the impact of these challenges.

Psychometric properties of the Psychopathology in Autism Checklist (PAC).

Psychiatric disorders in individuals with co-occurring autism spectrum disorders (ASD) and intellectual disability (ID) are common, but diagnosis presents many challenges. The Psychopathology in Autism checklist (PAC) is among the very few instruments specifically developed for this group of individuals. The psychometric properties of the PAC (i.e. criterion validity, specificity, sensitivity and predictive values) were explored by comparing scores with assessments on the Aberrant Behavior Checklist (ABC) and examining how well assessment by the PAC at referral predicts final clinical diagnoses. Results indicated a significant correlation with the ABC, further supporting the validity of the PAC. Sensitivity and Specificity for specific diagnoses were variable, although positive predictive value for "any diagnosis' was relatively high. The study confirms the potential value of the PAC as a screening checklist but highlights the need for clinical diagnosis to be based on a multimodal, multidisciplinary assessment.

Case study: identification of anxiety and subsequent intervention in an adolescent male with autism, severe intellectual disability and self-injurious behaviour.

Introduction: Anxiety disorders are highly prevalent in individuals with autism spectrum disorder (ASD), but knowledge is limited regarding identification and treatment of these disorders in individuals with ASD and more severe levels of intellectual disability (ID). The current case study aims to explore and describe the inpatient, psychiatric assessment in an adolescent male with ASD, severe ID and self-injurious behaviour (SIB) who was diagnosed with a co-occurring anxiety disorder. The study further aims to explore the implications of this diagnosis for subsequent intervention and care, including management of SIB. Materials and methods: Case study including multimodal, psychiatric assessment and subsequent intervention. Results: Following changes in care strategies attempting to incorporate the understanding of anxiety/trauma as contributing to SIB, a reduction of SIB was observed, and this reduced frequency was maintained when the patient was discharged from the inpatient setting. Conclusions: Though no causal inferences are possible, these experiences indicate that further research is needed regarding possible associations between SIB and anxiety in individuals with ASD, including implications for treatment. Experiences from the current case further indicate that it is possible to recognize and diagnose anxiety disorder in complex cases involving ASD, severe ID, limited verbal language skills, and severe SIB.

Potentially traumatic experiences and behavioural symptoms in adults with autism and intellectual disability referred for psychiatric assessment.

BACKGROUND: Individuals with autism spectrum disorder (ASD) and intellectual disability (ID) more frequently experience potentially traumatic events (PTEs), and may be more vulnerable to trauma-related symptoms. However, it is unclear how such symptoms are captured on tools used for behavioural and psychiatric assessment in this population. AIMS: To explore whether and how PTEs are associated with symptom reports in adults with ASD and ID. METHODS AND PROCEDURES: Associations and group differences for death of a close relative and serious disease/injury in a close relative/caregiver/friend were explored in a clinical sample of 171 adults with ASD and ID referred for psychiatric assessment. Symptoms were measured using Aberrant Behavior Checklist (ABC) and Psychopathology in Autism Checklist (PAC). OUTCOMES AND RESULTS: Disease/injury was associated with higher scores on ABC irritability, ABC hyperactivity and self-injurious behaviour. Death was associated with lower scores on ABC lethargy and ABC stereotypic behaviour. Some associations reached significance only when controlling for ASD, ID, or verbal language skills, but the identified associations were not robust. No associations were found for PAC. CONCLUSIONS AND IMPLICATIONS: There is a risk of under-appreciating the impact of PTEs in this population unless ASD, ID and verbal language skills are taken into account.

Treating Patients With Co-occurring Autism Spectrum Disorder and Substance Use Disorder: A Clinical Explorative Study.

BACKGROUND: Substance use disorders (SUDs) have been assumed to be rare in individuals with autism spectrum disorder (ASD). Recent research suggests that the rates of SUD among individuals with ASD may be higher than assumed although reliable data on the prevalence of SUD in ASD are lacking. Typical interventions for SUD may be particularly unsuitable for people with ASD but research on intervention and therapy are limited. METHODS: This study addresses ways of improving services for individuals with ASD and SUD by enhancing the competence of professionals in ordinary SUD outpatient clinics. Three therapists were given monthly ASD education and group supervision. The participants were ordinary referred patients who wanted to master their problems with alcohol or drugs. Four patients, all men diagnosed with ASD and intelligence quotient (IQ) ⩾ 70 completed the treatment. The participants were given cognitive behavioural therapy (CBT) modified for their ASD over a minimum of 10 sessions. The therapies lasted between 8 and 15 months. Standardised assessments were conducted pre- and post-treatment. RESULTS: Post-treatment, 2 participants had ended their drug and alcohol abuse completely, 1 had reduced his abuse, and 1 still had a heavy abuse of alcohol. Physical well-being was the most prevalent reported positive aspect of drug or alcohol use, whereas the experience of being left out from social interaction was the most frequent negative aspects of intoxication. CONCLUSIONS: CBT may represent a promising treatment option for individuals with ASD and SUD. The results suggest that patients' symptoms can be reduced by providing monthly ASD education and group supervision to therapists in ordinary SUD outpatient clinics. This group of patients need more sessions than other client groups, the therapy has to be adapted to ASD, ie, direct, individualised, and more extensive. Moreover, the patients need psychoeducation on ASD generally, social training, and support to organise several aspects of their lives and some patients need more support than can be provided in an outpatient clinic.

Personal experiences of the Criminal Justice System by individuals with autism spectrum disorders.

The processes of arrest, investigation, trial and imprisonment are often extremely difficult for individuals with autism spectrum disorders. In this study, nine offenders with autism spectrum disorders were interviewed about the circumstance surrounding the criminal acts, their views of the arrest, the police interrogation, the trial and the defence and their experiences of being in prison and/or life following the offence. The nine individuals described a range of different and often negative experiences with the Criminal Justice System. However, the majority of those given a custodial sentence coped well in prison, probably due to the high levels of structure and firm frameworks in that environment. Explanation factors associated with the offences indicated that autism spectrum disorder characteristics such as misunderstandings, obsessions and idiosyncratic beliefs and/or behaviours were frequently involved, but stress was the most common explanation provided by the participants. The findings suggest limited understanding of autism spectrum disorders within the Criminal Justice System which needs to be significantly improved in order to secure their legal protection.

Autism Spectrum Disorder and Co-occurring Substance Use Disorder - A Systematic Review.

OBJECTIVE: Patients with co-occurring autism spectrum disorders (ASD) and substance use disorder (SUD) require special attention from clinical services. Screening for this co-occurrence is not generally an integral part of routine clinical assessments, and failure to identify and understand this group of patients may contribute to a worsening of their symptoms and/or an increase in drug abuse. Thus, there is a need to review the evidence base on patients with co-occurring ASD and SUD in order to enhance clinical practice and future research. METHODS: We reviewed all identified papers on patients with co-occurring ASD and SUD. The focus of the review was on epidemiology, patient characteristics, function of drug use, and the effect of current interventions. RESULTS: A total of 18 papers were included in the analysis. Eleven papers were based on epidemiological studies, although only one study reported the prevalence of ASD in an SUD population. Two papers explored the role of personality, three papers studied subgroups of individuals serving prison for violent or sexual crimes, and one paper explored the function of drugs in the ASD patient group. There were no studies testing specific treatment interventions. CONCLUSIONS: In most of the treatment settings studied, there were relatively few patients with co-occurring ASD and SUD, but due to differences in study samples it was difficult to establish a general prevalence rate. The one consistent finding was the lack of focused treatment studies. There is clearly a need for research on interventions that take account of the special needs of this patient group.

Offending profiles of individuals with autism spectrum disorder: A study of all individuals with autism spectrum disorder examined by the forensic psychiatric service in Norway between 2000 and 2010.

This study examined the characteristics of adults with autism spectrum disorder who have undergone a forensic examination and explored any relationships between the diagnosis and the offence. The reports described 41 men and 7 women. The autism spectrum disorder was diagnosed late (mean age: 25.3 years), and 22 of the 48 cases were diagnosed with autism spectrum disorder for the first time by the forensic experts. The education level and employment status were low. Family networks were close, but social networks outside the family were limited. Co-morbid diagnoses were common, and more than half of the group knew their victims. The examined individuals constitute a vulnerable and heterogeneous group, as do offenders within other diagnostic categories. Unlike most others who commit criminal acts, the majority of the individuals with autism spectrum disorder in this study showed no evidence of substance abuse, had a close relationship to their victims and were willing to confess to the accused crime. No clear association between the characteristics of autism spectrum disorder and the criminal act were identified, but in most cases, autism spectrum disorder characteristics, such as idiosyncratic comprehensions and obsessions appeared to be related to the motive for the offence.