Young Adults With Autism at High Risk for Psychiatric Disorders

Pauline Anderson

September 13, 2017

Young adults with autism spectrum disorder (ASD) are at significantly higher risk for an associated psychiatric disorder compared to peers with other developmental disabilities (DDs) and their typically developing counterparts, new research shows.

Investigators at the Institute for Clinical Evaluative Sciences (ICES) and York University in Toronto, Canada, found that 51% of young adults aged 18 to 24 years with ASD had received at least one psychiatric diagnosis, compared to 38% of young adults with other DDs and 20% of the general population.

The study also showed young adults with ASD generally used more healthcare resources compared to both the general population and those with another DD, and they displayed a unique pattern of mental health service use.

The study was published online September 13 in the Journal of Autism and Developmental Disorders.

Heightened Demand for Services

It's important to understand the healthcare needs of young adults with ASD, said lead author Jonathan A. Weiss, PhD, associate professor, Department of Psychology, York University, Toronto.

Dr Jonathan Weiss

"Transitions to adulthood are challenging for many people with and without developmental disabilities, but there is considerable work to suggest that this is even more critical for people with autism," Dr Weiss told Medscape Medical News.

He noted the "service gaps" young adults with autism can experience and the "maturational changes" and "gamut of new stressors" that they may face during this transition period.

Previous research has shown that patients with ASD and other DDs have more medical and mental health problems than the general population and that they are more likely to use healthcare services. But most of this research has not focused on the young adult population, said Dr Weiss.

With the rise in prevalence of ASD in children during the past decade, there could be a heightened demand for adult services. Currently, the prevalence of ASD among 8-year-olds is estimated to be 1 in 68.

For the new study, the researchers used linked health and social service administrative health data in the province of Ontario, Canada. In Ontario, the switch from child to adult social and mental services occurs at age 18 years. Individuals with a DD typically remain in school until age 22.

Young adulthood is a time when daily school routines are altered and access to community services is disrupted, and it's a period during which health service providers typically change, the authors note.

From a larger cohort of 66,484 adults aged 18 to 64 years who had DDs, the researchers identified 15,980 who were aged 18 to 24 years. Using specific diagnostic codes, the researchers then focused their study on those with ASD.

The analysis included 5095 patients with ASD, 10,487 with another DD (designated as "other DD"), and 393,263 without DD (designed as "non-DD"). Non-DD patients were drawn randomly from Ontario health administrative data.

Adjusted odds ratios (ORs) were controlled for age, sex, "rurality" (urban vs rural), and neighborhood income quintile.

The researchers found that those with ASD were likely to use more healthcare services compared to non-DD patients. They were less likely to have diabetes, hypertension, and asthma than those with other DDs but were more likely to use certain healthcare services.

Unexpected Finding

For example, for ASD patients, there was a slightly higher likelihood of visiting a pediatrician than for those with another DD (OR, 1.30), and there was a much higher likelihood than in the general population (OR, 4.00). This finding, the authors note, was unexpected.

"One explanation is that the transition from pediatrician to family physician is more difficult for this group," they write. "In the US, it has been shown that adults with ASD have problems accessing family medicine."

What "stood out" in the ASD group was their use of mental health services, said Dr Weiss.

Compared to those with another DD, those with ASD were more likely to have received at least one psychiatric diagnosis (adjusted OR, 1.89; 95% confidence interval [CI], 1.77 - 2.03). And compared to the non-DD group, the ASD group was more than five times as likely to have received at least one psychiatric diagnosis (OR, 5.23; 95% CI, 4.95 - 5.33) after adjustments.

The ASD group was also more likely to have visited a psychiatrist (adjusted OR, 2.34 vs other-DD patients; OR, 12.03 vs non-DD patients) and to have visited the emergency department (ED) specifically for a psychiatric reason (OR, 1.23 vs other-DD; OR, 4.58 vs non-DD).

"While those with other kinds of developmental disabilities might also have higher rates of mental health problems compared to the general population, the mental health piece is particularly important to recognize for patients with autism," said Dr Weiss.

In some cases, the ASD group was less likely than the other-DD group to use healthcare services. For example, they were less likely to have visited a pulmonologist or a surgeon and to have had any type of ED visit.

Having fewer healthcare visits could signal ASD-related stressors in the healthcare environment or past negative experiences. For example, patients may be reluctant to return to an ED if a previous visit was highly stressful or traumatic.

"It's important that we create healthcare environments that are well suited for people with developmental challenges, who may have communication challenges, social challenges, or sensory-related challenges, so their experience there is one where they are able to use those services effectively, in the same way anyone else could," said Dr Weiss.

A limitation of the study was that for some young adults with ASD or other DD, cases may have been missed if the patients had not been receiving income support for their disability and had not had a healthcare encounter in which they received a relevant diagnostic code.

Also, the study was unable to capture information on variability in use of healthcare services in accord with the severity of the disability or on key medical issues such as seizures, which are known to be a problem for patients with ASD. In addition, the study did not include information on mental health services provided by nonphysicians, including psychologists.

Welcome Research

Commenting on the findings for Medscape Medical News, Arshya Vahabzadeh, MD, innovation officer, Massachusetts General Hospital Psychiatry Academy, director of digital health for the autism technology company Brain Power, and chairperson of the Council on Communications of the American Psychiatric Association, said that it was important to study young adults with ASD, "given that they are an increasingly large group, and they face a complex set of social, educational, and occupational challenges as they enter adulthood."

Research and services for children with ASD far outweigh those for adults with ASD, many of whom do not receive a diagnosis, said Dr Vahabzadeh. "In this regard, this study is particularly welcome."

The relatively high levels of healthcare utilization for psychiatric services among young adults with ASD was of particular concern for Dr Vahabzadeh.

"These findings should prompt further calls to provide resources to train mental health professionals to work with transitional-age youth with autism and to provide accessible, integrated, clinical psychiatric services for this population," he said.

The study was supported by the Province of Ontario and the ICES, which is funded by the Ontario Ministry of Health and Long-Term Care. The opinions, results, and conclusions expressed in the article are those of the authors and do not reflect those of the Province of Ontario, the data providers, or the Canadian Institute for Health Information. The authors and Dr Vahabzadeh have disclosed no relevant financial relationships.

J Autism Dev Disord. Published online September 13, 2017.

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