Keywords : Autism ; Depression ; Treatments ; Interventions ; Diagnosis
Introduction
Although the existence of connections between depressive symptoms and autism spectrum disorders has often been suggested (Kanner, 1943 ; Rutter, 1970 ; Wing, 1996), evidence of the appearance of depressive symptoms in a person with autism spectrum disorders is limited to a few studies. These studies all suggest that depression in people with autism is the most common and frequent psychiatric disorder within this group of individuals.
Symptoms of depression in people with autism
Depression in people with autism depends on a variety of factors. In addition to the general symptoms that are also observed in neurotypical people (e.g., permanent sadness, loss of interest in usual activities), people with autism who suffer from depression can have unique characteristics.
According to Stewart, Barnard, Pearson, Hasan and O’Brien (2006), depressive symptoms in a person with autism include :
- Miserable or sad facial appearance, changes in behaviour (e.g., increased frequency of crying or anger)
- Loss of interest in the activities
- Loss of appetite
- Sleep disorders
- Psychomotor backwardness (e.g., slower and less fluid speech flow)
- Change in functioning
- Decreased skills (e.g., incontinence, severe appetite, etc.)
- Occasional presence of aggressiveness
- Decreased body hygiene
- Obsessive traits
- Rituals
Autism and depression
Studies on autism and depression suggest that depressive symptoms are the most common disorders in individuals with autism and are more likely to appear in adolescence and adulthood (Ghaziuddin, Ghaziuddin, & Greden, 2002).
Major depressive disorders and dysthymia share similar symptoms to those of autism, such as social withdrawal, or sleep and appetite disorders (Mayes & Calhoun, 1999), but these characteristics are chronic in autism and not episodic as in depression. A literature review written by Stewart and al. (2006) indicates thatdepressed mood is frequently reported in people with autism,but other symptoms of depression (e.g., feeling of uselessness, guilt, reduced ability to concentrate and suicidal thoughts) are unusual. However, the researchers note that these feelings are subjective therefore difficult to measure in individuals with autism.
Patients with autism and suffering from depression often have other psychiatric symptoms in parallel. Depressed patients may show an increase in their obsessive-compulsive behaviours and, very often, these behaviours tend to be morbid. Ruminations and perseverations can become intense (Ghaziuddin, Alessi, & Greden, 1995). Sometimes, there is an increase in stereotypical behaviours, such as flapping. Symptoms of hyperactivity can occasionally be associated with depression.
Depression measures
Several measures can be used to assess depressive symptoms in children, adults and adolescents. However, these measures are adapted for neurotypical people and there is currently no specific measurement scale for people with autism. Depression is often diagnosed using DSM-IV criteria (American Psychiatric Association, 2000), but scales can also be used to measure psychopathology in children with autism, such as the Children’s Depression Inventory (Barnhill, 2001).
Diagnosis of depression
Despite the emergence of interest in the occurrence of depression in people with autism, there is still a difficulty regarding the validity of the diagnosis. To assess the validity of the diagnosis of depression in people with autism, the psychiatric history of the family of patients with autism diagnosed with depression can be examined (Lainhart & Folstein, 1994). Studies suggest that there is a higher risk of developing depressive symptoms for people with depressed relatives (DeLong & Dwyer, 1988).
Treatments and interventions
- Treatments
It is important to clearly identify the person’s difficulties in order to be able to provide appropriate treatment. Despite this, there is little research on how to treat depression in people with autism, so it is difficult to adapt treatment.
The most commonly used treatments for depression in people with autism are medications (12 cases out of 15). These treatments include tricyclic antidepressants and serotonin reuptake inhibitors, mood stabilizers, antipsychotics and hypnotics.
In the most severe cases (i.e., when all means have been used without result), electroshock treatments may be attempted. There is no impact on the treatment of autism. For some people, this can reduce the effects of depression (Ghaziuddin et al., 2002).
Although medications are an important component of therapeutic interventions, understanding the psychosocial development of depressive symptoms in people with Asperger’s Disorder seems necessary for the development of effective interventions.
- Interventions
Ideally, drugs should be used in conjunction with other therapies. Few studies have focused on the treatment of depression for people with autism. Most studies recommend the use of a structured form of psychotherapy alongwith appropriate educational and behavioural interventions.
By targeting the social component of autistic disorder, it is possible to intervene and improve depressed mood and suicidal thoughts. If a professional wishes to work with a teenager with autism (especially with Asperger’s syndrome), it is also important to assess suicidal thoughts, comorbid disorders and peer victimization.
- Cognitive-behavioural therapy (Hare, 1997) : in elderly people with autism, cognitive-behavioural strategies can help manage anxiety and depression, even if they are rarely effective in isolation (Howlin, 1998).
- Psychological intervention in parallel with zopiclone (hypnotic) use (Long, Wood & Holmes, 2000).
- Phototherapy for seasonal depression : improves mood, reduces self-aggression, anxiety and suicidal thoughts (Cooke & Thompson, 1998).
Finally, other interventions than therapies would reduce depressive symptoms (Ministry of Children and Youth Services, 2018). For example, it may be interesting to include the child or teenager in a support group or a drop-in daycare centre to build new friendships. The person can practice social, and physical activities, but also soothing, relaxing and enjoyable activities. It is also interesting to develop self-management strategies (deep breathing) and, finally, to respect good sleeping and eating habits.
Risk factors for depressive disorders in people with autism
Researchers recognize that depression is more common in people with autism than in people without autism spectrum disorders (Mayes, Gorman, Hillwig-Garcia and Syed, 2013).
Several risk factors could lead to the development and maintenance of depressive symptoms:
- age
- sex
- life events
- genetics
- social skills
- friendly relationships
- negative interactions with friends
- victimization
- social comparison
- Intellectual Quotient
Thus, empirical studies agree that people with autism and high intellectual abilities have a greater awareness of their social difficulties, which may put them at risk for depression.
Words we have learned : feeling of uselessness (sentiment d’inutilité) ; feeling of guilt (sentiment de culpabilité) ; daycare (garderie) ; to assess (évaluer) ; backwardness (retard/ralentissement).
Bibliographical references
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders(4th ed., text rev.). Washington, DC: American Psychiatric Association.
Barnhill, G. P. (2001). Social attributions and depression in adolescents with Asperger syndrome. Focus on autism and other developmental disabilities, 16(1), 46-53. doi: 10.1177/108835760101600112.
Cooke, L. B., & Thompson, C. (1998). Seasonal affective disorder and response to light in two patients with learning disability. Journal of affective disorders, 48(2), 145-148. doi:10.1016/S0165-0327(97)00167-5.
DeLong, G. R., & Dwyer, J. T. (1988). Correlation of family history with specific autistic subgroups : Asperger’s syndrome and bipolar affective disease. Journal of autism and developmental disorders, 18(4), 593-600. doi: 10.1007/BF02211877.
Hare, D. J. (1997). The use of cognitive-behavioural therapy with people with Asperger syndrome : A case study. Autism, 1(2), 215-225. doi: 10.1177/1362361397012007.
Howlin, P. (1998). Psychological and educational treatments for autism. The Journal of Child Psychology and Psychiatry and Allied Disciplines, 39(3), 307-322.
Ghaziuddin, M., Alessi, N., & Greden, J. F. (1995). Life events and depression in children with pervasive developmental disorders. Journal of autism and developmental disorders, 25(5), 495-502. doi: 10.1007/BF02178296.
Ghaziuddin, M., Ghaziuddin, N., & Greden, J. (2002). Depression in persons with autism : Implications for research and clinical care. Journal of autism and developmental disorders, 32(4), 299-306. doi: 10.1023/A:1016330802348.
Kanner, L. (1943). Autistic disturbances of affective contact. Nervous child, 2(3), 217-250.
Lainhart, J. E., & Folstein, S. E. (1994). Affective disorders in people with autism: A review of published cases. Journal of autism and developmental disorders, 24(5), 587-601. doi: 10.1007/BF02172140.
Long, K., Wood, H., & Holmes, N. (2000). Presentation, assessment and treatment of depression in a young woman with learning disability and autism. British Journal of Learning Disabilities, 28(3), 102-108. doi: 10.1046/j.1468-3156.2000.00056.x
Mayes, S. D., & Calhoun, S. L. (1999). Symptoms of Autism in Young Children and Correspondence with the DSM. Infants & Young Children, 12(2), 90-97.
Mayes, S. D., Gorman, A. A., Hillwig-Garcia, J., & Syed, E. (2013). Suicide ideation and attempts in children with autism. Research in Autism Spectrum Disorders, 7(1), 109-119. doi: 10.1016/j.rasd.2012.07.009.
Ministry of Children and Youth Services. (2018). Anxiété et dépression. Repéré à http://www.children.gov.on.ca/htdocs/French/specialneeds/autism/aprk/emotional-and-mental health/anxiety-and-depression.aspx
Stewart, M. E., Barnard, L., Pearson, J., Hasan, R., & O’Brien, G. (2006). Presentation of depression in autism and Asperger syndrome: A review. Autism, 10(1), 103-116. doi: 10.1177/1362361306062013.
Rutter, M. (1970). Autistic children: infancy to adulthood. In Seminars in psychiatry (Vol. 2, No. 4, p. 435).
Wing, L. (1996). Autistic spectrum disorder: No evidence for or against an increase in prevalence. British Medical Journal,312, 327–328.