Psychopathology and Impairment in Children with ASD

Background:  To meet diagnostic criteria for most psychiatric disorders, the DSM-IV-TR requires that a certain number of symptoms be present and cause impairment in social, academic, or occupational functioning.  Little research has been done on the relationship between psychiatric symptoms and impairment in children with Autism Spectrum Disorders (ASD).  The Child and Adolescent Symptom Inventory (CASI-4R), a DSM-IV based symptom checklist, was recently revised to include impairment ratings for several major disorders.

Objectives:  The objective of this study was to examine the relationship between psychiatric symptoms and impairment in a large sample of clinically referred children with ASD.  Specifically, the objective was to examine how many children screened positive for a disorder based on symptoms only, had significant impairment only, or had both positive screens and impairment.  The following disorders were considered: Attention Deficit/Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder (ODD), Conduct Disorder (CD), Generalized Anxiety Disorder (GAD), Social Phobia, Major Depressive Episode (MDE), and Dysthymia.

Methods:  Participants were consecutive referrals to a specialty clinic for autism and developmental disorders who met inclusion criteria for this study.  Parents and teachers completed the CASI-4R.  A positive screen on the CASI-4R occurs when the rater endorses the DSM-required number of symptoms for a disorder as occurring ‘often’ or ‘very often’.  Parent-reported data were available for 104 children (88 boys, 16 girls) and teacher-reported data for 88 children (79 boys, 10 girls) with a mean age of 8.5 years (SD = 1.8) and FSIQ of 86 (SD= 22).  Additional socio-demographic variables were also collected.  Analyses were conducted on parent and teacher data separately.

Results:  Parents and teachers showed low but significant levels of agreement.  The correlations between symptom severity scores and impairment scores varied from .49 (for CD) to .83 (for ODD) for parents and from .59 (for ADHD-HI) to .84 (for CD) for teachers.  By parent-report, 84 children (81%) were impaired in at least one disorder.  For teachers, 76 children (86%) were impaired.  Rates of impairment varied significantly across disorders from 20% (for depressive disorders) to 67% (for ADHD).  With the exception of parent-reported dysthymia and teacher-reported CD, more children showed impairment than met the symptom count requirements for a disorder.  Just because children showed impairment did not mean that they met symptom count requirements.  But for parents, children who met symptom count requirements usually also showed impairment.  By teacher-report, not all children who met symptom count requirements were impaired.

Conclusions:  Many children with ASD present with psychiatric symptoms.  Symptoms of other disorders are present and impairing in most children’s lives.  Of the children who met symptom count requirements, most also met impairment requirements.  However, a significant proportion of children failed to reach symptom count requirements, but showed impairment.  These subthreshold cases warrant additional evaluation to ensure that all needs are appropriately addressed in treatment.