For this blog, I invite Dr. Emily Neuhaus (who also blogs under “Ask Dr. Emily”) to join me in talking about her recent paper — Gastrointestinal and Psychiatric Symptoms Among Children and Adolescents with Autism Spectrum Disorder.
With Dr. Raphe Bernier (Executive Director of the Seattle Children’s Autism Center) and Dr. See Wan Tham (Anesthesiologist and specialist in GI pain management), we examined the relation between GI problems and other problem behaviors in children with ASD. To do this, we used the large Simon’s Simplex Sample (SSC) data set– which is a data set of 2,800 4 to 18 year old children and adolescents with ASD, and includes detailed information about the child’s symptoms, adaptive functioning (ability to handle everyday tasks like getting dressed, eating, grooming, etc.), medical concerns, and genetic events. The paper is available free through Frontiers in Psychiatry.
Why examine the relation between GI symptoms and psychiatric problems? The actual prevalence of GI problems in children with autism varies wildly across different reports – some estimates are relatively low, suggesting that 15-20% of children with autism experience GI difficulties, while other researchers have found rates of GI problems as high as 90% (see Neuhaus et al., 2018). While the links between GI problems and ASD is unclear, it is clear that children with ASD have elevated rates of GI problems.
Individuals with ASD are also at elevated risk for developing additional psychiatric problems across the lifespan with over 92% of children aged 4-14 with ASD reported as meeting criteria for attention-deficit/hyperactivity disorder, oppositional defiant disorder, anxiety, or mood disorder (Brookman-Frazee et al., 2018).
Given that GI problems can cause significant pain and disruption of daily activities, might they also be playing a role in whether or not children develop other psychiatric problems?
What are GI problems?
In the SSC sample data set, 7 GI problems were included in our analyses– constipation, diarrhea, severe abdominal pain, gastro-esophageal reflux, vomiting, excessive gas, and bloating. We limited our analysis to symptoms that occurred after 36 months of age, were recurrent, not attributed to illness, and caused “significant bother”. We examined psychiatric problems via parent report of internalizing (anxiety and depression), externalizing (aggression and rule breaking) and self-injurious behavior (e.g., biting or hitting self). (We will focus on externalizing and self-injury in this blog.) In addition, we considered child characteristics such as race/ethnicity, sex, age, extent of ASD symptoms, IQ (verbal and non-verbal), and adaptive behavior; as well as family factors such as household income.
Overall, 37.7% of the children with ASD were reported as having at least 1 GI problem, including constipation (24.1%), diarrhea (10.6%), and gas, reflux, and abdominal pain (~5-6% each). Moreover, 22.8% of the children had clinical levels of externalizing problems (aggression and rule breaking), suggesting that these were meaningful issues for those children and their families.
What childhood characteristics were related to externalizing problems (aggression and rule breaking) and self-injury? In children aged 4-18 years, children with more ASD symptoms, better language, lower adaptive skills, lower household income, and more GI problems had more externalizing problems (aggression and rule breaking). Similarly, more self-injurious behavior was also related to more ASD symptoms, lower adaptive skills, and lower household income. In the younger group (4 to 9 years) (but not in the older group aged 10 to 18 years), more GI problems were also related to self-injury.
Of note, a similar study by Rattaz et al. in 106 young adults with ASD found that more autism symptoms and more GI problems predicted the development of more stereotypy behaviors in adulthood.
Thus, in children with ASD, GI problems may be contributing to the presence of externalizing behaviors in children with ASD, and self-injury in younger children with ASD. This is important to consider in providing mental health care to children and families with ASD, since addressing GI problems could be a helpful part of reducing behavior problems.
While we can’t determine if GI problems play a role in whether or not a child will develop other psychiatric problems – we would need a longitudinal study to do this– GI problems likely negatively impact daily living and quality of life.
Another resource for an update on GI issues in ASD is the recent ASF podcast by Alycia Halladay.
Brookman-Frazee L, Stadnick N, Chlebowski C, Baker-Ericzén M, Ganger W. Characterizing psychiatric comorbidity in children with autism spectrum disorder receiving publicly funded mental health services. Autism. SAGE PublicationsSage UK: London, England; 2018 Nov;22(8):938–952. PMID: 28914082. https://doi.org/10.1177/1362361317712650
Halladay, A. (2018, Nov). Scientist know in their gut how the GI symptoms are linked to autism.
Neuhaus E, Bernier RA, Tham SW, Webb SJ. (2018). Gastrointestinal and Psychiatric Symptoms Among Children and Adolescents With Autism Spectrum Disorder. Frontiers in Psychiatry. 9:515. PMCID: PMC6204460. https://www.frontiersin.org/article/10.3389/fpsyt.2018.00515/full
Rattaz C, Michelon C, Munir K, Baghdadli A. Challenging behaviours at early adulthood in autism spectrum disorders: topography, risk factors and evolution. Journal of Intellectual Disability Research. Wiley/Blackwell (10.1111); 2018 Jul;62(7):637–649. PMID: 29797498. https://onlinelibrary.wiley.com/doi/abs/10.1111/jir.12503