Gastrointestinal Problems, and Abdominal Pain in Particular, Are Associated with Affective Problems but Not Externalizing Behaviors in Children with High-Functioning Autism

Background: Many children with autism spectrum disorders (ASD) exhibit emotional and behavioral problems as well as gastrointestinal (GI) symptoms at high rates. While both problems have received attention separately, there is limited knowledge concerning how emotional and behavioral problems may be associated with GI symptoms in ASD.  As emotional and behavioral problems can often be manifestations of underlying medical conditions, it was of interest to explore how GI symptoms may relate to behavioral problems in a population of children with high-functioning ASD. Further, there has been extensive research in typical populations on associations between abdominal pain and anxiety and depression, but little information exists on this relationship in ASD.

Objectives: The goals of this study were to identify patterns of emotional and behavioral problems and GI symptoms in children with high-functioning autism, and to explore how GI conditions may relate to emotional and behavioral problems in this population. This included a more targeted exploration of the relationship between abdominal pain in particular and emotional and behavioral presentation in ASD.

Methods: Participants included 95 children who met criteria for autism on The Autism Diagnostic Observation Schedule (ADOS-G) and the Autism Diagnostic Interview (ADI-R).  All children had IQ scores ≥80. Parents completed the Social Responsiveness Scale (SRS), the Vineland Adaptive Behavior Scale and the Child Behavior Checklist (CBCL).  GI symptoms were measured with the Autism Treatment Network’s (ATN) GI Symptoms Inventory Questionnaire.  

Results: Overall, 61% of children were reported to have some type of GI symptom. Of the GI symptoms, abdominal pain was most common (41.1%) followed by not feeling hungry after eating very little (40%), other symptoms not otherwise reported (17.9%; e.g. constipation, diarrhea), and bloating (10.5%). There was no difference between children with GI symptoms and those without GI symptoms on scores on the SRS, overall adaptive behavior, or the Total Problems scale of the CBCL. When specifically looking at the DSM-oriented scales on the CBCL, it was found that the number of GI symptoms was positively correlated with Affective Problems (r = .39) and Somatic Complaints (r = .36), p < .001. Children with reported abdominal pain had higher CBCL t-scores for Somatic Complaints (p < .001) and Affective Problems (p = .001) compared to children without abdominal pain. The presence of abdominal pain accounted for 7.2% of the variance in Affective Problems above and beyond IQ and age.

Conclusions: A high prevalence of GI conditions is reported by parents of children with high-functioning autism. A relationship between abdominal pain and externalizing behaviors was not supported.  However, abdominal pain was significantly associated with both somatic complaints and affective problems, consistent with research in typically-developing populations. This is an important finding given that research in typical populations suggests a greater degree of functional disability when both abdominal pain and depression co-occur. Additional research is needed to further explore the relationship between GI symptoms and behavioral and emotional concerns in ASD, as well as to identify potential casual factors and treatment implications.