Research in Developmental Disabilities 35 (2014) 2003–2007
Contents lists available at ScienceDirect
Research in Developmental Disabilities
Review article
Depression and mood disorders among persons with Autism Spectrum Disorders Johnny L. Matson, Lindsey W. Williams * Department of Psychology, Louisiana State University, Baton Rouge, LA 70803, United States
A R T I C L E I N F O
A B S T R A C T
Article history: Received 6 March 2014 Accepted 21 April 2014 Available online
In the past decade, Autism Spectrum Disorders (ASD) have both risen in prevalence and become a critical area of research in the field of developmental disabilities. As the body of knowledge about ASD has grown, the overlap of ASD with other problems has also become a rapidly emerging area of study. One of the most studied of these topics is comorbid psychopathology, with depression and mood disorders emerging as one of the more troublesome of these co-occurring conditions. A great deal of research is still needed to determine how best to assess and treat these disorders within the context of ASD. This manuscript reviews current trends and topics relative to this area of study. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Autism Depression Comorbid Psychopathology
Contents 1. 2. 3. 4. 5. 6. 7. 8.
Assessment. . . . . . . . . . . . . . . . . . . . . . . . Depression and mood disorders . . . . . . . Suicidal ideation . . . . . . . . . . . . . . . . . . . Comorbid psychopathologies . . . . . . . . . Factors associated with mood disorders . Depression and anxiety . . . . . . . . . . . . . . Treatment. . . . . . . . . . . . . . . . . . . . . . . . . Conclusions . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . .
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Autism Spectrum Disorders (ASD) have become a highly visible and frequently studied topic (Kuzniewicz et al., 2014; Lai, Tseng, & Guo, 2013; Matson & LoVullo, 2009; Sullivan, 2013). This situation is at least in part due to the increasing prevalence of the condition (Matson & Kozlowski, 2011; Vasa et al., 2013). However, other factors such as better diagnostic methods and greater public awareness have also influenced this trend. While ASD is heterogeneous in overall presentation, core features such as communication and social deficits, and stereotypies are routinely present (Fodstad, Matson, Hess, & Neal, 2009; Horovitz & Matson, 2010; Matson, Dempsey, & Fodstad, 2009a). It is important to evaluate core symptoms across a range of instruments, and where possible, in various settings since the prevalence and intensity of individual symptoms vary from
* Corresponding author. E-mail addresses: [email protected] (J.L. Matson), [email protected], [email protected] (L.W. Williams). http://dx.doi.org/10.1016/j.ridd.2014.04.020 0891-4222/ß 2014 Elsevier Ltd. All rights reserved.
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J.L. Matson, L.W. Williams / Research in Developmental Disabilities 35 (2014) 2003–2007
case to case (Mannion, Leader, & Healy, 2013; Matson & Wilkins, 2009). In addition to these core symptoms, many comorbid problems are also common. Commonly co-occurring difficulties include challenging behaviours, adaptive behaviour, and psychopathology (Matson, Rivet, Fodstad, Dempsey, & Boisjoli, 2009; Smith & Matson, 2010a,b,c). Comorbid psychopathology has been reported at high rates among persons with ASD. These problems occur very early in life and across the lifespan (LoVullo & Matson, 2009; Matson et al., 2009a, 2009b; Matson, Hess, & Boisjoli, 2010). Also, some disorders occur more commonly than others and present at different ages. Several disorders particularly common with respect to their co-occurrence with ASD include ADHD, anxiety disorders, and obsessive-compulsive behaviours (Chasson et al., 2011; Gadow, 2012; MacNeil, Lopes, & Minnes, 2009). Another set of common problems that covary with ASD includes depression and mood disorders (Matson et al., 1999; Matson & Smiroldo, 1997). 1. Assessment Conventional wisdom is that ASD should be identified as early as possible (Matson, Fodstad, Mahan, & Sevin, 2009; Matson, Wilkins, & Gonzalez, 2008; Matson et al., 2009f; Narzisi et al., 2013). Similarly, given the high prevalence rates of comorbid conditions such as challenging behaviours and comorbid psychopathology, they should be assessed earlier rather than later (Matson, Gonzalez, & Rivet, 2008). In addition to being assessed early, an individual with ASD should also be evaluated periodically as the individual ages (Matson, Boisjoli, Gonzalez, Smith, & Wilkins, 2007; Matson, Gonzalez, et al., 2008; Matson, LoVullo, Rivet, & Boisjoli, 2009; Matson & Rivet, 2008; Wachtel & Shorter, 2013). Assessment involves not only identifying core symptoms of ASD but also commonly co-occurring conditions. These difficulties are very serious in their own right. Thus, to better understanding them, important areas of research towards better assessment include how and how often these disorders overlap with ASD, whether problematic behaviours are occurring, and what factors are maintaining or causing co-occurring problem(s). These approaches can then be applied systematically to assessment of the individual. This latter approach has become quite popular, particularly with respect to assessing the challenging behaviours (Matson & Boisjoli, 2007; Matson et al., 2005; Matson, Minshawi, Gonzalez, & Mayville, 2006). Separate diagnostic instruments are advised given the breadth and complexity of this task. The research on comorbidity has further underscored the need to develop and use a wide variety of specialized diagnostic instruments. A review of some of the emerging research on the topic of comorbidity, specifically as applied to the appearance of depression and mood disorders among persons with ASD, is the topic of the remainder of this paper. 2. Depression and mood disorders The research on depression and mood disorders can be categorized into at least five general topics. These issues include mood and depression, suicidal ideation, comorbidity, the relationship of anxiety and mood, and research on treatment. A review of each topic follows. Researchers generally recognize that depression is more common among persons with ASD relative to the general population. One such study was described by Mazzone et al. (2013), who evaluated 20 children and adolescents between 7 and 16 years of age and 10 with High Functioning Autism, 30 males with major depression age 7–27, and 35 typically developing children from a psychiatric hospital in Italy. A battery of depression measures was used. The major depression group evinced slightly more symptoms on these scales than the Asperger-autism group. These two groups had many more symptoms than the typically developing group. Interestingly, depressive symptoms were also more common among parents of persons with ASD in a study of 95 caregivers (Bekhet & Zauszniewski, 2013). Pouw, Rieffe, Stockmann, and Gadow (2013) studied 63 people with ASD and compared them to typically developing peers. In line with previous research, depressive symptoms were correlated with negative factors associated with social difficulties and victimization (Cappadocia, Weiss, & Pepler, 2012; Kim, Szatmari, Bryson, Steiner, & Wilson, 2000). The reasons for these findings require considerably more study. This is a very important area for research, and careers can be built around discovering factors related to this phenomenon. 3. Suicidal ideation Suicidal thoughts, which of course are related to depression and mood disturbances, have also been studied. A particularly impressive study was published by Mayes, Gorman, Hillwig-Garcia and Syed (2013). They evaluated 791 children with autism, 1–16 years of age. These children were compared to 186 typically developing children. The dependent variable was suicidal ideation. Mothers reported that 14% of the ASD group evinced suicidal ideation. This rate was 28 times greater than what was reported for the typically developing group. Risk factors for suicidal ideation included being 10 years of age or older, minority ethnic background, lower SES, and male gender. Kato et al. (2013) looked at clinical features of suicide attempts. They assessed 587 consecutive people who had attempted suicide. These people were all over age 18 and had been hospitalized in an inpatient psychiatric hospital. From this sample, 43 had been diagnosed with ASD. Overall length of hospitalization for the ASD group was longer than for the overall suicidal group. At this point, the factors that lead to these high rates are unknown (Hannon & Taylor, 2013). However, these papers point to the seriousness of the issue and the need to research this topic more extensively.
J.L. Matson, L.W. Williams / Research in Developmental Disabilities 35 (2014) 2003–2007
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4. Comorbid psychopathologies A number of papers have been published looking at how psychopathology in general relates to ASD. Often, mood and depression issues are embedded in a broader comorbidity. For example, La Malfa et al. (2007) evaluated 90 adults with intellectual disability plus the co-occurrence of ASD and various forms of psychopathology. Their overall finding was that mental health issues were common in this group, and the co-occurrence of autism and mood disorders was high. In a second paper, Stahlberg, Soderstrom, Rastam, and Gillberg (2004) reported on 241 consecutive cases of adults referred for ASD or ADHD. They noted that among the persons with ASD, 7% had comorbid bipolar disorder. Rosenberg, Kaufmann, Law, and Law (2011) describe a particularly ambitious study of 4343 children with ASD. Comorbid conditions studied included anxiety, depression, bipolar disorder, and ADHD. These authors found that milder ASD resulted in higher rates of all forms of comorbid psychopathology. They also found that persons with intellectual disability and ASD were as likely to evince comorbid psychopathologies as those with ASD but without intellectual disability. The only exception was depression, which occurred less frequently among persons with intellectual disabilities. Additionally, and in contrast to the general population, no difference in depression by gender was noted in this group. Worley and Matson (2011) studied 125 children with ASD and found no gender differences across disorders, replicating the findings of Rosenberg et al. (2011). Munesue et al. (2008) studied 44 consecutive outpatients with High Functioning Autism who were assessed for mood disorders. Of this group, 16 evinced symptoms of this problem. From this group, four were diagnosed with major depression, two were diagnosed with bipolar I, six had bipolar II, and four met criteria for bipolar disorder not otherwise specified. The bulk of comorbid disorder cases were of the bipolar variety. This finding would not be expected from the overall population. However, this was a convenient sample based on clinical cases, which may have affected these findings. 5. Factors associated with mood disorders While considerably more research is needed regarding mood disorders as they relate to ASD, some efforts have been made in this regard. For example, Ingersoll and Hambrick (2011) studied the effects of ASD on depressive symptoms on parental behaviour. Compared to the general population of parents, caregivers of children with ASD reported higher levels of stress and depression. More severe symptoms of ASD were predictors of more stress and depression among parents. Meltzer (2011) reported similar findings. Additionally, she reported that decreased sleep quality for parents and decreased sleep quantity children were predictors of parental depression. 6. Depression and anxiety To date, one of the largest areas of studies on comorbidity with ASD and depression also involves anxiety. Kim et al. (2000) report on this co-occurring phenomenon among 9–14 year olds with Asperger Syndrome and High Functioning Autism. Fifty-nine children with an ASD were compared to a community sample of 1751 children. Greater rates of anxiety and depression were noted in the ASD sample. Pine, Guyer, Goldwin, Towbin, and Leibenluft (2008) also studied these comorbidities. They tested 352 participants. This group included 107 healthy controls, 88 individuals with an anxiety disorder, 32 people with major depression, 62 persons with bipolar disorder, and 63 individuals with a mood disorder with severe non-episodic irritability. All of the groups scored higher on ASD symptoms than typically developing controls. They also reported that persons with mood disorders evinced language and social impairments, behavioural rigidity, and stereotypies. The ASD symptoms, on average, were less severe for these persons compared to individuals who presented at an ASD clinic. Kanai et al. (2011) assessed these overlapping comorbidities in adults with Asperger’s Syndrome. One-hundred-nine individuals were administered the Japanese version of the Hospital Anxiety and Depression Scale and the NEO Five-Factor Inventory. Neuroticism was higher for the Asperger group compared to the 65 adults with no known psychiatric condition. The extroversion, agreeableness, and conscientiousness were lower in the Asperger’s group. Mayes, Calhoun, Murray, Ahuja and Smith (2011) looked at anxiety, depression, and irritability among 1390 children ages 6–16 years old. Two-hundred-thirty-three children evinced High Functioning Autism while 117 children were diagnosed with Low Functioning Autism. Fifty-four children with High Functioning Autism and 42% of the children with the Low Functioning Autism reported depression. The symptoms were not as severe as for persons who displayed depression only. Lugnegard, Hallerback, and Gillberg (2011) studied 26 men and 28 women whose mean age was 27 years. All of these individuals had a diagnosis of Asperger Syndrome. Among their sample, 70% had experienced at least one episode of major depression and 50% had recurrent episodes of depression or anxiety. Strong et al. (2012) studied 95 children with a diagnosis of ASD. These children were assessed for depression and anxiety symptoms. Forty-four percent of those children and adolescents tested were categorized as borderline or clinically depressed, while 56% met these criteria for an anxiety disorder. Thirty-seven individuals in the sample met the criteria for both depression and anxiety. Russell-Smith, Bayliss, and Maybery (2013) conducted a study that was more conceptual in nature. They tested 284 college undergraduates. These investigators found that ASD symptoms were related to social anxiety while negative schizotypy was related to anhedonia and depression.
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7. Treatment Treatment research is lagging relative to describing and assessing comorbidity among persons with ASD. This situation is understandable at present since the problem must be accurately identified before treatment can proceed. Most intervention to date has been extrapolated from the research on persons without ASD, but more research is urgently needed to improve and target assessment and treatment for those with ASD, as symptoms may present differently among persons with ASD, or they may be masked by the ASD symptoms (Giovinazzo, Marciano, Giana, Curatolo, & Porfirio, 2013). Furthermore, professionals who routinely deal with ASD may not be well versed in diagnosing various forms of concomitant psychopathology (Frazier, Doyle, Chiu, & Coyle, 2002). 8. Conclusions Comorbid psychopathology among persons with ASD has begun to receive attention from the scientific community. This fact is extremely important if the best quality care for persons with ASD is to be realized. The recognition of these comorbidities has been one of the most significant developments in the field of ASD. These developments have markedly changed how the disorder is conceptualized. For example, there will be a need to subtype the ASD syndrome, add more axes, or employ severity and level types, or some combination of these approaches. This notion is not particularly new. Numerous studies over many years have remarked on the heterogeneity of ASD. However, as researchers develop more knowledge, clarity is occurring about what heterogeneity means. How symptoms present, what disorders are likely to present based on age, gender, the effects of core symptom presentation on psychopathology and many other related factors. This knowledge will impact the future decisions on how best to assess and treat persons with ASD and comorbid depression and mood disorders. References Bekhet, A. K., & Zauszniewski, J. A. (2013). 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Contents lists available at ScienceDirect
Research in Developmental Disabilities
Review article
Depression and mood disorders among persons with Autism Spectrum Disorders Johnny L. Matson, Lindsey W. Williams * Department of Psychology, Louisiana State University, Baton Rouge, LA 70803, United States
A R T I C L E I N F O
A B S T R A C T
Article history: Received 6 March 2014 Accepted 21 April 2014 Available online
In the past decade, Autism Spectrum Disorders (ASD) have both risen in prevalence and become a critical area of research in the field of developmental disabilities. As the body of knowledge about ASD has grown, the overlap of ASD with other problems has also become a rapidly emerging area of study. One of the most studied of these topics is comorbid psychopathology, with depression and mood disorders emerging as one of the more troublesome of these co-occurring conditions. A great deal of research is still needed to determine how best to assess and treat these disorders within the context of ASD. This manuscript reviews current trends and topics relative to this area of study. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Autism Depression Comorbid Psychopathology
Contents 1. 2. 3. 4. 5. 6. 7. 8.
Assessment. . . . . . . . . . . . . . . . . . . . . . . . Depression and mood disorders . . . . . . . Suicidal ideation . . . . . . . . . . . . . . . . . . . Comorbid psychopathologies . . . . . . . . . Factors associated with mood disorders . Depression and anxiety . . . . . . . . . . . . . . Treatment. . . . . . . . . . . . . . . . . . . . . . . . . Conclusions . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . .
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Autism Spectrum Disorders (ASD) have become a highly visible and frequently studied topic (Kuzniewicz et al., 2014; Lai, Tseng, & Guo, 2013; Matson & LoVullo, 2009; Sullivan, 2013). This situation is at least in part due to the increasing prevalence of the condition (Matson & Kozlowski, 2011; Vasa et al., 2013). However, other factors such as better diagnostic methods and greater public awareness have also influenced this trend. While ASD is heterogeneous in overall presentation, core features such as communication and social deficits, and stereotypies are routinely present (Fodstad, Matson, Hess, & Neal, 2009; Horovitz & Matson, 2010; Matson, Dempsey, & Fodstad, 2009a). It is important to evaluate core symptoms across a range of instruments, and where possible, in various settings since the prevalence and intensity of individual symptoms vary from
* Corresponding author. E-mail addresses: [email protected] (J.L. Matson), [email protected], [email protected] (L.W. Williams). http://dx.doi.org/10.1016/j.ridd.2014.04.020 0891-4222/ß 2014 Elsevier Ltd. All rights reserved.
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case to case (Mannion, Leader, & Healy, 2013; Matson & Wilkins, 2009). In addition to these core symptoms, many comorbid problems are also common. Commonly co-occurring difficulties include challenging behaviours, adaptive behaviour, and psychopathology (Matson, Rivet, Fodstad, Dempsey, & Boisjoli, 2009; Smith & Matson, 2010a,b,c). Comorbid psychopathology has been reported at high rates among persons with ASD. These problems occur very early in life and across the lifespan (LoVullo & Matson, 2009; Matson et al., 2009a, 2009b; Matson, Hess, & Boisjoli, 2010). Also, some disorders occur more commonly than others and present at different ages. Several disorders particularly common with respect to their co-occurrence with ASD include ADHD, anxiety disorders, and obsessive-compulsive behaviours (Chasson et al., 2011; Gadow, 2012; MacNeil, Lopes, & Minnes, 2009). Another set of common problems that covary with ASD includes depression and mood disorders (Matson et al., 1999; Matson & Smiroldo, 1997). 1. Assessment Conventional wisdom is that ASD should be identified as early as possible (Matson, Fodstad, Mahan, & Sevin, 2009; Matson, Wilkins, & Gonzalez, 2008; Matson et al., 2009f; Narzisi et al., 2013). Similarly, given the high prevalence rates of comorbid conditions such as challenging behaviours and comorbid psychopathology, they should be assessed earlier rather than later (Matson, Gonzalez, & Rivet, 2008). In addition to being assessed early, an individual with ASD should also be evaluated periodically as the individual ages (Matson, Boisjoli, Gonzalez, Smith, & Wilkins, 2007; Matson, Gonzalez, et al., 2008; Matson, LoVullo, Rivet, & Boisjoli, 2009; Matson & Rivet, 2008; Wachtel & Shorter, 2013). Assessment involves not only identifying core symptoms of ASD but also commonly co-occurring conditions. These difficulties are very serious in their own right. Thus, to better understanding them, important areas of research towards better assessment include how and how often these disorders overlap with ASD, whether problematic behaviours are occurring, and what factors are maintaining or causing co-occurring problem(s). These approaches can then be applied systematically to assessment of the individual. This latter approach has become quite popular, particularly with respect to assessing the challenging behaviours (Matson & Boisjoli, 2007; Matson et al., 2005; Matson, Minshawi, Gonzalez, & Mayville, 2006). Separate diagnostic instruments are advised given the breadth and complexity of this task. The research on comorbidity has further underscored the need to develop and use a wide variety of specialized diagnostic instruments. A review of some of the emerging research on the topic of comorbidity, specifically as applied to the appearance of depression and mood disorders among persons with ASD, is the topic of the remainder of this paper. 2. Depression and mood disorders The research on depression and mood disorders can be categorized into at least five general topics. These issues include mood and depression, suicidal ideation, comorbidity, the relationship of anxiety and mood, and research on treatment. A review of each topic follows. Researchers generally recognize that depression is more common among persons with ASD relative to the general population. One such study was described by Mazzone et al. (2013), who evaluated 20 children and adolescents between 7 and 16 years of age and 10 with High Functioning Autism, 30 males with major depression age 7–27, and 35 typically developing children from a psychiatric hospital in Italy. A battery of depression measures was used. The major depression group evinced slightly more symptoms on these scales than the Asperger-autism group. These two groups had many more symptoms than the typically developing group. Interestingly, depressive symptoms were also more common among parents of persons with ASD in a study of 95 caregivers (Bekhet & Zauszniewski, 2013). Pouw, Rieffe, Stockmann, and Gadow (2013) studied 63 people with ASD and compared them to typically developing peers. In line with previous research, depressive symptoms were correlated with negative factors associated with social difficulties and victimization (Cappadocia, Weiss, & Pepler, 2012; Kim, Szatmari, Bryson, Steiner, & Wilson, 2000). The reasons for these findings require considerably more study. This is a very important area for research, and careers can be built around discovering factors related to this phenomenon. 3. Suicidal ideation Suicidal thoughts, which of course are related to depression and mood disturbances, have also been studied. A particularly impressive study was published by Mayes, Gorman, Hillwig-Garcia and Syed (2013). They evaluated 791 children with autism, 1–16 years of age. These children were compared to 186 typically developing children. The dependent variable was suicidal ideation. Mothers reported that 14% of the ASD group evinced suicidal ideation. This rate was 28 times greater than what was reported for the typically developing group. Risk factors for suicidal ideation included being 10 years of age or older, minority ethnic background, lower SES, and male gender. Kato et al. (2013) looked at clinical features of suicide attempts. They assessed 587 consecutive people who had attempted suicide. These people were all over age 18 and had been hospitalized in an inpatient psychiatric hospital. From this sample, 43 had been diagnosed with ASD. Overall length of hospitalization for the ASD group was longer than for the overall suicidal group. At this point, the factors that lead to these high rates are unknown (Hannon & Taylor, 2013). However, these papers point to the seriousness of the issue and the need to research this topic more extensively.
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4. Comorbid psychopathologies A number of papers have been published looking at how psychopathology in general relates to ASD. Often, mood and depression issues are embedded in a broader comorbidity. For example, La Malfa et al. (2007) evaluated 90 adults with intellectual disability plus the co-occurrence of ASD and various forms of psychopathology. Their overall finding was that mental health issues were common in this group, and the co-occurrence of autism and mood disorders was high. In a second paper, Stahlberg, Soderstrom, Rastam, and Gillberg (2004) reported on 241 consecutive cases of adults referred for ASD or ADHD. They noted that among the persons with ASD, 7% had comorbid bipolar disorder. Rosenberg, Kaufmann, Law, and Law (2011) describe a particularly ambitious study of 4343 children with ASD. Comorbid conditions studied included anxiety, depression, bipolar disorder, and ADHD. These authors found that milder ASD resulted in higher rates of all forms of comorbid psychopathology. They also found that persons with intellectual disability and ASD were as likely to evince comorbid psychopathologies as those with ASD but without intellectual disability. The only exception was depression, which occurred less frequently among persons with intellectual disabilities. Additionally, and in contrast to the general population, no difference in depression by gender was noted in this group. Worley and Matson (2011) studied 125 children with ASD and found no gender differences across disorders, replicating the findings of Rosenberg et al. (2011). Munesue et al. (2008) studied 44 consecutive outpatients with High Functioning Autism who were assessed for mood disorders. Of this group, 16 evinced symptoms of this problem. From this group, four were diagnosed with major depression, two were diagnosed with bipolar I, six had bipolar II, and four met criteria for bipolar disorder not otherwise specified. The bulk of comorbid disorder cases were of the bipolar variety. This finding would not be expected from the overall population. However, this was a convenient sample based on clinical cases, which may have affected these findings. 5. Factors associated with mood disorders While considerably more research is needed regarding mood disorders as they relate to ASD, some efforts have been made in this regard. For example, Ingersoll and Hambrick (2011) studied the effects of ASD on depressive symptoms on parental behaviour. Compared to the general population of parents, caregivers of children with ASD reported higher levels of stress and depression. More severe symptoms of ASD were predictors of more stress and depression among parents. Meltzer (2011) reported similar findings. Additionally, she reported that decreased sleep quality for parents and decreased sleep quantity children were predictors of parental depression. 6. Depression and anxiety To date, one of the largest areas of studies on comorbidity with ASD and depression also involves anxiety. Kim et al. (2000) report on this co-occurring phenomenon among 9–14 year olds with Asperger Syndrome and High Functioning Autism. Fifty-nine children with an ASD were compared to a community sample of 1751 children. Greater rates of anxiety and depression were noted in the ASD sample. Pine, Guyer, Goldwin, Towbin, and Leibenluft (2008) also studied these comorbidities. They tested 352 participants. This group included 107 healthy controls, 88 individuals with an anxiety disorder, 32 people with major depression, 62 persons with bipolar disorder, and 63 individuals with a mood disorder with severe non-episodic irritability. All of the groups scored higher on ASD symptoms than typically developing controls. They also reported that persons with mood disorders evinced language and social impairments, behavioural rigidity, and stereotypies. The ASD symptoms, on average, were less severe for these persons compared to individuals who presented at an ASD clinic. Kanai et al. (2011) assessed these overlapping comorbidities in adults with Asperger’s Syndrome. One-hundred-nine individuals were administered the Japanese version of the Hospital Anxiety and Depression Scale and the NEO Five-Factor Inventory. Neuroticism was higher for the Asperger group compared to the 65 adults with no known psychiatric condition. The extroversion, agreeableness, and conscientiousness were lower in the Asperger’s group. Mayes, Calhoun, Murray, Ahuja and Smith (2011) looked at anxiety, depression, and irritability among 1390 children ages 6–16 years old. Two-hundred-thirty-three children evinced High Functioning Autism while 117 children were diagnosed with Low Functioning Autism. Fifty-four children with High Functioning Autism and 42% of the children with the Low Functioning Autism reported depression. The symptoms were not as severe as for persons who displayed depression only. Lugnegard, Hallerback, and Gillberg (2011) studied 26 men and 28 women whose mean age was 27 years. All of these individuals had a diagnosis of Asperger Syndrome. Among their sample, 70% had experienced at least one episode of major depression and 50% had recurrent episodes of depression or anxiety. Strong et al. (2012) studied 95 children with a diagnosis of ASD. These children were assessed for depression and anxiety symptoms. Forty-four percent of those children and adolescents tested were categorized as borderline or clinically depressed, while 56% met these criteria for an anxiety disorder. Thirty-seven individuals in the sample met the criteria for both depression and anxiety. Russell-Smith, Bayliss, and Maybery (2013) conducted a study that was more conceptual in nature. They tested 284 college undergraduates. These investigators found that ASD symptoms were related to social anxiety while negative schizotypy was related to anhedonia and depression.
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7. Treatment Treatment research is lagging relative to describing and assessing comorbidity among persons with ASD. This situation is understandable at present since the problem must be accurately identified before treatment can proceed. Most intervention to date has been extrapolated from the research on persons without ASD, but more research is urgently needed to improve and target assessment and treatment for those with ASD, as symptoms may present differently among persons with ASD, or they may be masked by the ASD symptoms (Giovinazzo, Marciano, Giana, Curatolo, & Porfirio, 2013). Furthermore, professionals who routinely deal with ASD may not be well versed in diagnosing various forms of concomitant psychopathology (Frazier, Doyle, Chiu, & Coyle, 2002). 8. Conclusions Comorbid psychopathology among persons with ASD has begun to receive attention from the scientific community. This fact is extremely important if the best quality care for persons with ASD is to be realized. 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