Pediatricians usually employ screening methods as a way of identifying health related conditions and treating them early. The American Academy of Pediatrics (AAP) has joined forces with the US Department of Health and Human Services (DHHS), the Health Resources and Services Administration (HRSA), and the Maternal and Child Health Bureau in order to provide, both professionals and the general public, with evidence-based recommendations to help insure the health of our children. You can obtain useful information regarding these educational guidelines from their website “Bright Futures”.
In this blog, I would like to make parents of autistic individuals aware of several health-related threats for which their children are at risk. These complications usually cascade together in a worsening health spiral so as to significantly decrease quality of life and make future interventions all the more difficult. It is important to be aware of them and keep them in check. Where appropriate, I have provided useful internet links to each problem, emphasizing those resources that are derived from the American Academy of Pediatrics’ policies or initiatives. In the following paragraphs I detail some of the relevant information for obesity, bullying, body image/gender, suicide, and substance-use disorder. I have already written a substantial amount on other related problems (e.g., sexual abuse, mood disorders) to which I provide links in the reference section.
Autistic individuals are more likely to be obese. Overweight (body mass index [BMI] of 25 to 29) or obese (body mass index of 30 or over) individuals have a greater likelihood of developing high blood pressure, early heart disease, and/or diabetes. Your pediatrician can help determine your child’s body mass index and compare it to the general population. Most research studies emphasize the importance of tackling weight related issues before 5 years of age. This problem may be more common in a subtype of autistic individuals expressing attention deficit hyperactivity disorder (ADHD). This ADHD subtype sometimes exhibits the propensity to eat compulsively (note: This behavior has given rise to the expression, “Those who live by impulse, eat by impulse”). Otherwise, lack of exercise, improper diets, and genetic makeup can predispose an autistic individual to obesity. Other risk factors include parental obesity, which predisposes a child to both autism and ADHD, and the use of use of certain medications. Neuroleptics (antipsychotics) prescribed in the treatment of irritability and maladaptive behaviors, may lead to weight gain while simultaneously disrupting glucose and lipid metabolism. Treatment for obesity will depend on a child’s age and the presence of comorbidities. Pediatricians, in collaboration with parents, can help institute weight-maintenance programs. The Institute for Healthy Weight provides resources for families and health care professionals by recommending ways of integrating active living styles and proper nutrition.
Marginalized youth are 1.5 to 2X more likely to be bullied. Risks factors include being a member of the LGTBQ (lesbian, gay, transgender, bisexual or queer) community, disabled, and/or obese. These are kids that feel different, are usually unpopular, and are seen as powerless to defend themselves. Bullying includes teasing, hurting someone, and spreading rumors. In todays’ age of the internet a large percentage of the abuse committed is cyberbullying. According to http://www.Stopbullying.gov, some warning signs of bullying include:
- Unexplainable injuries
- Lost or destroyed clothing, books, electronics, or jewelry
- Frequent headaches or stomach aches, feeling sick or faking illness
- Changes in eating habits, like suddenly skipping meals or binge eating. Kids may come home from school hungry because they did not eat lunch.
- Difficulty sleeping or frequent nightmares
- Declining grades, loss of interest in schoolwork, or not wanting to go to school
- Sudden loss of friends or avoidance of social situations
- Feelings of helplessness or decreased self esteem
- Self-destructive behaviors such as running away from home, harming themselves, or talking about suicide
Things that do not work in cases of bullying: ignoring it, blaming the victim, zero tolerance policies, and retaliation. Things that work in cases of bullying: engaging the school, (training teachers, administrators and counselors), family awareness and/or support, establishing a channel of communicating, enacting school policies and state laws. Bullying problems are not likely to stop suddenly, in this regard, there is a need for frequent follow ups.
Body Image and Gender
It is well accepted that reported rates suggest a gender bias in autism of 4 to 1 (male: female). It is less recognized that many autistic individuals are distressed in how they perceive themselves as men, females or a blend both. In these cases, their biological sex differs from their perceived gender identity. Treatment in these cases is aimed at supporting the individual as to the way they want to live and be perceived. In some cases, this may mean referral for surgical treatment. In September of 2018 the American Academy of Pediatrics published its first policy statement regarding the support and care of transgender and gender-diverse children and adolescents The AAP recommendations include:
- Providing youth with access to comprehensive gender-affirming and developmentally appropriate health care.
- Providing family-based therapy and support be available to meet the needs of parents, caregivers and siblings of youth who identify as transgender.
- Making sure that electronic health records, billing systems, patient-centered notification systems and clinical research are designed to respect the asserted gender identity of each patient while maintaining confidentiality.
- Supporting insurance plans that offer coverage specific to the needs of youth who identify as transgender, including coverage for medical, psychological and, when appropriate, surgical interventions.
- Advocacy by pediatricians within their communities, for policies and laws that seek to promote acceptance of all children without fear of harassment, exclusion or bullying because of gender expression.
Please also read Wenn Lawson’s previous blog in Cortical Chauvinism on Transgender kids.
Suicide is the second leading cause of death between the ages of 10-24 years. Although estimates vary widely among studies, one large epidemiological effort that mined data from a large National Patient Registry in Sweden found that autistic individuals were 10 times as likely to die by suicide.
According to the study, women were at particular risk, even though in the general population men are more likely to commit suicide. Predisposing factors for suicide are commonly seen in autistic individuals, including: self-injurious behaviors, interpersonal conflicts, depression, legal or disciplinary problems, bullying, abuse, and body image/gender issues. Protective factors include: parental support, religious involvement, sport or club participation, access to interventions, and social/familial support
Substance Use Disorders
Anywhere from 19% to 30% of autistic individuals, present with comorbid substance use-related problems. As with obesity (see above), substance-use disorder may be more common in a subset of patients characterized by comorbid ADHD. My own personal experience suggests that substance-use disorders may be more prevalent among the higher function ASD individuals. In this patient population, alcohol and other drugs may serve to self-medicate against anxiety. Despite the special needs of this patient population, there is a scarcity of research studies tackling this problem. Programs aimed at prevention include Guiding Good Choices and Triple P resources.
Remember, care is the first step towards taking action. However, being informed, is the best way for those actions to have positive outcomes.