Comorbidities and Autism

I have often spoken about comorbidities in autism; meaning, the presence of one or more chronic disorders coexisting with their primary diagnosis.  With aging, comorbidities become a common complaint of the neurotypical population.  It seems that after 60 years of age, neurotypicals are showered with all sorts of intertwined health-related complications like diabetes, high blood pressure, and heart disease. The good thing about modern medicine is that an early diagnosis leads to normalization of health indicators, diminishes potential side effects, and improves quality of life for affected individuals.

Contrary to neurotypicals, comorbidities in autism spectrum disorders (ASD) start making inroads during the preschool years. An epidemiological study from Sweden on 9-year-old children with a diagnosis of ASD reported that close to 50% of their sampled population had four or more comorbid conditions (Lundström et al., 2015).  Only 4% had ASD as the sole diagnosis! This means that whenever an ASD individual walks into a doctor’s office, the physician should screen that patient for potential health confounds.  In autism, catching and managing comorbidities early is an important step towards healthy aging. Just as in neurotypicals, treatment leads to a diminution of potential side effects and an improvement in quality of life.

Through the years the three comorbidities of autism that have called my attention, due to their frequency and importance, are gastrointestinal disorders, obesity/sedentary life, and dental hygiene problems:

  • Among comorbid disorders, gastrointestinal complaints are exceedingly common. Close to 70% of autistic individuals will complain of diarrhea, constipation, or pain related to a GI disorder.  Because of communication problems, and an inability to properly recognize the sensations of their bodies, the GI manifestations often remain unrecognized. Symptoms may be suspected when patients press their abdomen against the edge of a table or when they seemingly gain comfort from the pressure offered by sleeping between the box spring and mattress. For other patients a GI disorder may be manifested as a sleep problem.  These patients may have no problem falling asleep but then wake up in the middle of the night when pain becomes intolerable. Under these circumstances, treating a comorbidity may lead to unexpected benefits: patients feel better about themselves, pay more attention at school, improve their sleep patterns, and seemingly boost their social skills.
  • Lack of exercise, an inadequate diet, a sedentary life style, the use of certain medications and, in some cases, the genetic makeup of autistic individuals, all predispose them to obesity. Indeed, mothers who themselves are obese and diabetic during pregnancy have much greater odds of having children with heart disease, diabetes, behavioral difficulties, and neurodevelopmental disorders, including autism.  All of these risk factors often act synergistically to procreate a cascade of potentially lethal complications, e.g., diabetes type 2, high blood pressure, sleep apnea. Preventing obesity is therefore an important aim of multidisciplinary teams treating autistic individuals. In terms of exercise program, I am partial to aquatherapy (also called hydrotherapy).  This type of exercise is an important intervention of rehabilitation medicine. It provides the soothing comfort of pressure, creates buoyancy for the joints, and is usually conducted in a group setting that helps socialization.
  • When I have helped establish different autism organizations in other countries, I have often advised conducting a needs assessment among the population they service. Invariably, dental hygiene problems are among the top 5 concerns for those individuals screened. It may be that the sound of the drill, the florescent lights and/or the smell of a dentist office detract autistic individuals from pursuing treatment for oral health problems.  If dental hygiene problems are not addressed, the same may increase the risk for other serious health problems including heart attack, stroke and poorly controlled diabetes. In my experience, autistic individuals procrastinate taking care of dental problems until it is too late. Untreated tooth decay and gum disease can lead to abscess formation, receding gum line, and tooth loss. Patients not accustomed to visiting the dentist may need general anesthesia for even simple procedures.

Taking a few precautionary steps may help preserve the dental hygiene of autistic individuals. Explaining the procedure that are going to be undertaken, often with the use of illustrations (story telling) serves to calm preexisting anxiety.  The American Dental Association has a series of useful brochures explaining multiple procedures to children.  Also, a specialized whole-body bean bag that fits over the dentist chair serves to provide a soothing feeling of pressure during dental procedures.  If this is not available, having the child use the lead x-ray apron may provide the same feeling of soothing pressure.

The World Health Organization defines healthy aging “as the process of developing and maintaining the functional ability that enables well-being in older age”. Healthy aging enables an individual to be and do what they have reason to value. This is one of the most important goals in the medical treatment of autistic individuals. It involves early diagnosis of comorbidities, adopting healthy habits and behaviors, and staying involved with community activities.  A regular program of exercise, getting the necessary sleep, a healthy well-balanced diet, and living in a supportive environment are the cornerstone of healthy aging.

References

Casanova MF. Autism Updated: Symptoms, Treatments, an Controversies. Amazon Publishing, 2019.

Casanova MF. Dental Care an Autism.

Casanova MF. Eating Habits and Nutrition in Autism.

Casanova MF. Autism: Screening for Potential Health Problems.

Casanova MF. Exercise and Autism.

Casanova MF. Autism and the Sedentary Life.

Lundström S, Reichenberg A, Melke J, et al. Autism spectrum disorders and coexisting disorders in a nationwide Swedish twin study. J Child Psychol Psychiatry 56(6):702-10, 2015.

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