Multi-Informant Ratings of Psychiatric Symptom Severity in Children with Autism Spectrum Disorders: The Importance of Environmental Context

Background: Individuals diagnosed with an ASD often have concomitant emotional and behavioral difficulties that have a significant impact on their functioning. Knowing prevalence rates of psychiatric symptoms in individuals with ASD and understanding of how these psychiatric symptoms are reported across settings directly impacts diagnostic decisions and treatment planning. Interpretive challenges exist when this information is discrepant or contradictory. Despite the weight clinicians give to reports of psychiatric symptoms from various settings (e.g., parents and teachers), few researchers have examined the nature of cross-informant reporting differences in individuals with ASD.

Objectives:   The objectives of this study were threefold: a) we examined a consecutively ascertained population of children and adolescents diagnosed with ASD to estimate the prevalence rates of comorbid psychiatric syndromes and sought to determine whether the various symptoms were either present, absent, or manifested in a range of severity in this clinical sample; b)  we examined the extent to which parents and teachers agreed on quantitative characterization of these symptom domains in youth with ASD and their siblings; c) we attempted to elucidate domains of symptoms that might be better appreciated in home/family environments versus educational settings.

Methods:   This sample included youths with autism spectrum disorders (n=177) and their siblings (n = 148), all phenotypically characterized using the Child Behavioral Checklist (CBCL),  C-Teacher Report Form (C-TRF), Social Responsiveness Scale (SRS)-parent report; SRS teacher-report was also available in 98% of the cases.  All ASD diagnoses were given by a professional clinician and were confirmed using the ADI-R and/or the ADOS. 

Results:   In ASD, parents reported substantial comorbidity with affective (26%), anxiety (25%), attentional (25%), conduct (16%), oppositional (15%), and somatic problems (6%). Teachers reported a much lower prevalence: affective (6%), anxiety (15%), attentional (12%), conduct (2%), oppositional (9%), and somatic problems (3%). Autistic severity scores for children with ASD exhibited moderate correlations with general psychopathology within- but not across-informants, whereas sibling correlations were significant both within- and across-informants.

Conclusions:   This study indicates a large proportion of individuals with ASD also display significant emotional and behavioral difficulties.  In contrast to non-ASD siblings, when an ASD-affected child manifests more severe ASD symptoms in a particular setting, they also manifest more psychiatric symptoms. Informants across settings were discrepant in their ratings of psychiatric symptoms, especially internalizing symptoms, and more so in children with ASD compared to siblings. These discrepancies likely represent variations in state characteristics manifested in different contexts. This pattern of results supports the role of environmental context differentially affecting individuals with ASD.  Implications for this study support the role of environmental context in psychiatric symptom expression in children affected by autism and suggest that informant discrepancies may more provide critical cues for these children via specific environmental modifications.