According to statistics, 70%-95% of children and adolescents with autism spectrum disorder (ASD) have at least one co-occurring mental health condition. The most common mental health conditions observed in children with ASD are behavior and conduct problems, anxiety, attention deficit disorder, and depression. However, autism often presents with other comorbidities including Down Syndrome, Pervasive Developmental Disorder, and Childhood Disintegrative Disorder.
While the reasons behind the high prevalence of dual diagnoses in children with autism are still debated, experts agree that treatment should focus on both autism and the co-occurring condition. For too long, the emphasis has been solely on treating autism, but there’s now a greater awareness of the need for care that addresses both conditions, that’s where ABA therapy can help.
Applied behavior analysis (ABA) therapy is considered the definitive standard in autism treatment. Thanks to its highly individualized approach, ABA therapy can help children with dual diagnoses by targeting their unique difficulties and reinforcing positive behaviors. By addressing both autism and co-occuring conditions, it can significantly improve a child’s quality of life and overall development.
What is a dual diagnosis?
A dual diagnosis refers to when a person on the autism spectrum is diagnosed with another condition, whether it’s a mental health condition, a developmental disability, or a medical condition.
Some of the most common co-occurring conditions include the following:
- Mental Health Conditions: Anxiety, depression, ADHD, obsessive-compulsive disorder (OCD) and substance use disorders.
- Medical Conditions: Seizures, gastrointestinal issues, metabolic disorders, and sleep disorders.
- Developmental Disabilities: Down Syndrome, Pervasive Development Disorder, Childhood Disintegrative Disorder.
Why do co-occurring conditions go undetected?
There are several reasons why co-occurring health conditions, whether medical, mental, or developmental.
Diagnostic Overshadowing
Often autism overshadows other conditions, leading clinicians to attribute symptoms of co-occurring conditions (i.e. anxiety, depression, ADHD) to autism itself rather than recognizing them as separate diagnoses. For instance, this is especially true with autism symptoms in teens including difficulty with social interactions, sensory processing disorders, and rigid routine, which may mask or overlap with signs for other mental health challenges.
Atypical Presentation
Many co-occurring conditions manifest differently in autistic individuals. For example, anxiety might appear as repetitive behaviors, including finger-flicking, spinning, and rocking, rather than the usual worry or fear that we see in neurotypical people.
Communication Barriers
Autistic individuals, in particular those with limited verbal abilities or selective mutism, may have difficulty expressing their symptoms, whether they’re in pain, distress, or angry, which in turn can lead to an under, or misdiagnosis.
Focus on Primary Diagnosis
Once autism is diagnosed, medical and mental health professionals may not explore additional conditions thoroughly, merely assuming that observed difficulties are part of autism rather than an entirely separate issue requiring its intervention.
Lack of Awareness and Training
Many healthcare professionals are not trained extensively enough in recognizing co-occurring conditions in autistic children, teens, or adults. This is particularly true when symptoms present differently than in neurotypical populations.
Institutional Constraints
Whether it’s long wait times for specialist assessments, difficulty accessing healthcare, a shortage of autism-informed professionals, or insurance denials for necessary evaluations and treatments, all of these factors can delay or prevent the diagnosis of co-occurring conditions, making early intervention less accessible and impacting long-term outcomes.
Limited Screening Tools
The majority of diagnostic tools and assessments were developed for neurotypical individuals, thereby making them less effective at identifying mental health and medical conditions in people on the spectrum.
How does ABA benefit children with dual diagnoses?
When discussing ABA therapy, there’s no such thing as a one-size-fits-all approach. Just because a strategy worked for one child doesn’t mean it will work for another. This is particularly true for children on the spectrum with a dual diagnosis. The following briefly explains how these ABA principles can be beneficial.
Targeted Behavior Modification
ABA therapy can help identify and then use positive reinforcement to modify maladaptive behaviors that may arise from both autism and the co-occurring condition such as OCD. To support behavior modification, ABA therapy incorporates techniques such as discrete trial training (DTT), which breaks skills into small, structured steps with immediate reinforcement, and shaping, reinforcing each of the small steps needed to achieve the desired behavior until the complete skill is mastered.
Additionally, using token economy systems, your autistic child or teen can receive immediate reinforcement. For example, a child earns tokens for positive behaviors and can exchange them for rewards, increasing consistency and motivation.
For example, autistic children with ADHD may struggle with impulsivity and hyperactivity. That’s where ABA therapy can teach them self-control strategies such as waiting for their turn or following multi-step directions.
Improved Emotional Regulation
Often children with a dual diagnosis can experience difficulty with emotional regulation, which in turn can lead to meltdowns, tantrums, difficulty managing frustration and anxiety. ABA can incorporate strategies such as using sensory activities instead of resorting to aggressive behavior to help children respond to stress more adaptively.
Enhanced Social Skills Development
Social difficulties, including the social skills needed to interact with others, are common in autism. They can be further complicated by co-occurring conditions such as depression or anxiety. From social stories to peer modeling, ABA therapy has a number of different techniques that can be used to teach autistic children and teens essential social skills.
Supporting Independent Living Skills
Many autistic children with dual diagnoses require additional support to develop daily living skills, which include dressing, hygiene, meal preparation, and self-care. The ABA task analysis technique helps break down complex activities into smaller, more manageable steps, ensuring gradual learning and eventual mastery. For example, visiting the dentist, a task that can be overwhelming due to sensory sensitivities and anxiety, can be broken down into steps including watching a video about dental visits, practicing sitting in a chair, and gradually introducing dental tools in a non-threatening way.
Errorless learning, in which prompts and guidance are provided to help the child complete the task correctly before errors occur, is often used to minimize frustration and maximize success.
Parent and Caregiver Involvement
ABA promotes parental and caregiver participation to ensure that the skills learned by autistic children or teens are reinforced outside of therapy sessions. Parents receive training on ABA strategies, which allows them to support their child’s progress at home. Teachers can also work with parents and therapists to incorporate ABA-based strategies in the classroom, including visual schedules and tacting. Naturalistic ABA therapy, such as natural environment teaching (NET), can be particularly beneficial in these settings as it focuses on teaching skills in real-life situations rather than structured therapy sessions alone. This consistent reinforcement in various settings helps maintain positive behaviors and prevent regression, making therapy more effective in the long run.
Coping Skills & Skill Generalization
Whether your child is seen by an RBT (registered behavioral therapist) or BCBA (board certified behavior analyst), using ABA will help develop strategies to manage emotions, handle stress, and navigate difficult situations, which is particularly important for those with co-occuring conditions. Many autistic children and teens with a dual diagnosis struggle to apply learned skills across different environments, generalizing a key focus of ABA. By reinforcing coping strategies in real-life situations such as at home, in class, and social conditions, ABA ensures that children can effectively transfer these skills when needed. This is partly achieved through a discriminative stimulus (SD), which signals when a specific behavior is appropriate or will be reinforced. For instance, a teacher prompting a student with a visual cue before a transition serves as an SD, helping the child recognize when to use a learned coping skill, such as deep breathing.
Heartlinks: Help for a Dual Diagnosis
Understanding and addressing the needs of autistic children and teens with a dual diagnosis is crucial for their overall development and wellbeing. While the causes of autism are still being researched, what remains clear is the importance of providing comprehensive support for both autism and the co-occurring condition. Without proper intervention, children may struggle with challenges such as autistic burnout, which results from prolonged stress, sensory overload, and the effort required to mask their difficulties in daily life.
Heartlinks ABA provides specialized ABA therapy designed to support autistic children with dual diagnoses. It helps them build coping skills, regulate emotions, and develop independence across various settings. With locations in North Carolina, Georgia, New Jersey, and Indiana, Heartlinks ABA offers individualized, evidence-based interventions tailored to each child’s needs.
However, an essential part of the journey is accepting your child’s diagnosis and recognizing that every child has unique strengths and challenges. Through the right interventions, parental involvement, and a supportive environment, autistic children with dual diagnoses can thrive and reach their full potential. Contact Heartlinks today to learn more.