By Emma Hinze, Professor Tony Attwood and Dr. Michelle Garnett.
Depression is a significant mental health concern affecting many individuals worldwide. In autistic children and adolescents, it presents unique challenges. This blog explores the challenges of depression within this population, exploring its prevalence, presentations, underlying causes, and support ideas for depression.
Prevalence of Depression in Autistic Youth
Depression is notably prevalent among autistic individuals, with approximately one in three adolescents experiencing at least one episode of depression (Hollocks et al., 2019). This rate is alarmingly higher compared to their neurotypical peers, emphasising the need for timely and targeted mental health support and intervention, including accurate diagnosis and the prompt provision of appropriate support services.
What is Depression?
Major Depressive Disorder (MDD) is characterised by a persistent feeling of sadness or loss of interest in previously enjoyed activities, impairing daily functioning. According to the DSM-5-TR (APA, 2022), a diagnosis requires the presence of at least five symptoms over a two-week period, including changes in appetite, sleep disturbances, fatigue, feelings of worthlessness or guilt, difficulty concentrating, and recurrent thoughts of death or suicide.
Challenges in Diagnosing Depression in Autistic Youth
Recognising depression in autistic children and adolescents is challenging due to the overlapping of autism characteristics and depression symptoms. Characteristics such as social withdrawal, sleep disturbances, and changes in appetite can be attributed to either condition, leading to potential misdiagnosis or underdiagnosis. This phenomenon, known as diagnostic overshadowing, often results in depressive symptoms being mistaken for autistic behaviour (Oakley et al., 2021).
Presentations of Depression in Autistic Youth
While many depressive symptoms are similar across different populations, autistic children and adolescents may experience and therefore express these symptoms differently. In addition to the DSM-5-TR symptoms for depression, other presentations may be experienced:
- Changes from Personal Baseline: Any changes from an individual’s usual behaviour or baseline should not be solely attributed to the dynamic nature of autism; they might signal underlying mental health issues.
- Irritability and Frustration: Increased irritability or frustration, especially when finding it difficult to articulate their feelings or when overwhelmed.
- Loss of Interest in Special Interests: Changes in the frequency or topic of special interests are common, including reduced engagement and motivation or shifts to new, often more negative topics. Some may maintain or increase special interests out of a sense of obligation or routine, despite a loss of genuine enjoyment.
- Changes in Autistic Characteristics: Increased self-soothing behaviours such as stimming during periods of stress or depression. Additionally, there is often a heightened need for routine and structure to cope.
- Social Withdrawal and Camouflaging: Some individuals may feel an increased need to mask both autistic characteristics and signs of depression to fit in or to lessen the perceived burden on others. This can lead to significant mental and physical exhaustion, necessitating withdrawal from social interactions to cope and reduce sensory input. For many, the ability to mask diminishes during depressive episodes, which can further exacerbate depressive symptoms due to increased vulnerability and exposure of their authentic selves without the usual protective barriers of masking.
- Physical Symptoms: Emotional distress can often present as physical complaints, including headaches, body pains, and stomach aches.
- Emotional Dyskinesia: A reduced range of emotional expression in the face and body language, which can result in their feelings being overlooked. This lack of recognition can lead to feelings of alienation and increased depression.
- Externalised Agitated Depression: Depression can present as agitation and blame directed towards others. This may appear as aggressive behaviour but often stems from low self-worth and underlying depression.
- Suppression of Emotions: Suppressing painful emotions can hide depressive symptoms, leading to a lack of recognition and support. This suppression can intensify depressive episodes and create intermittent ‘depression attacks.’ The effort to mask true emotions can lead to chronic feelings of alienation and personal defectiveness, significantly contributing to depression.
- Functional Use of Anger: Using anger functionally to achieve solitude.
- Depression Attacks: Intense episodes where suicidal ideation rapidly intensifies, marked by a deep, out-of-control feeling and a dangerous urgency to act on impulses. These attacks can be overwhelming and require immediate attention and support.
Underlying Causes of Depression in Autistic Youth
Several factors contribute to the heightened risk of depression among autistic children and adolescents:
- Social Isolation and Loneliness: Difficulties in social interaction often led to feelings of isolation, unheard, and loneliness, significantly impacting mental health.
- Peer Rejection and Bullying: Repeated negative social experiences can erode self-esteem and lead to a persistent sense of worthlessness.
- Mental Exhaustion: The continuous effort to analyse and navigate social interactions can be mentally draining, leading to depression.
- Internalising Criticism: Frequent bullying and negative feedback can result in internalised negative beliefs about oneself, perpetuating depressive feelings.
- Cognitive Patterns: Autistic individuals may tend to focus on errors and potential problems, contributing to a negative self-image and hopelessness about the future.
- Family History: A higher incidence of mood disorders in the families of autistic individuals suggests a genetic predisposition to depression.
- Autistic Burnout: Many autistic individuals experience autistic burnout, characterised by extreme mental, physical, and emotional exhaustion, often due to prolonged periods of stress and masking autistic characteristics. If left untreated, autistic burnout can lead to the development of depression.
- Hyperarousal of Emotional Empathy: Intense affective empathy can lead to self-imposed social isolation to protect one’s mental health.
- Alexithymia: Many autistic individuals also experience alexithymia, a condition characterised by difficulty in identifying and describing emotions. Alexithymia can mask depressive symptoms, making it harder for individuals to recognise and communicate their distress. This can lead to underreporting of symptoms and delays in receiving appropriate treatment, thereby increasing the risk and severity of depression.
Interventions and Support Strategies
Effective interventions require a multi-faceted approach tailored to the unique needs of autistic children and adolescents. Each intervention should be individually tailored and person-centered, considering the person’s sensory profile, cognitive needs, history, and other personal characteristics. It’s important to recognise that not all programs will be suitable for every individual, and flexibility in approach is crucial to provide effective support:
- Early Recognition and Diagnosis: Improving awareness and training among healthcare professionals to accurately recognise and diagnose depression in autistic youth.
- Therapeutic Interventions:
- Cognitive-Behavioural Therapy (CBT): Adapted for autistic individuals, CBT can help address depressive symptoms and improve coping strategies by focusing on changing negative thought patterns and behaviours.
- Dialectical Behaviour Therapy (DBT): This therapy can be beneficial for managing intense emotions and improving interpersonal effectiveness and distress tolerance.
- Acceptance and Commitment Therapy (ACT): ACT focuses on helping individuals accept their thoughts and feelings rather than fighting them, encouraging them to commit to personal values and take action towards a meaningful life.
- Behavioural Activation: This strategy involves encouraging engagement in enjoyable or meaningful activities to counteract the withdrawal and inactivity common in depression. However, this might not be suitable during periods of autistic burnout due to the additional mental and physical exhaustion.
- Mindfulness and Relaxation Techniques: can help manage stress and improve emotional regulation. Techniques include mindfulness meditation, deep breathing exercises, and progressive muscle relaxation.
- Social Skills Training: Programs designed to enhance social interaction skills can reduce feelings of isolation and improve self-esteem. These can be particularly effective when tailored to the specific needs of autistic individuals.
- Parental and Caregiver Support: Providing resources and support to caregivers can help them better understand and support their child’s mental health needs. This includes psychoeducation, support groups, and respite care to alleviate caregiver stress.
- Creating Inclusive Environments: Schools and communities should foster inclusive environments that promote acceptance and understanding of autistic individuals. Reducing the risk of social isolation and bullying can significantly improve mental health outcomes.
- Monitoring and Addressing Autistic Burnout: Recognising the signs of autistic burnout and implementing strategies to manage it, such as reducing demands, increasing downtime, and providing supportive environments, can prevent the progression to depression.
Where to From Here?
We have created a brand new event to assist clinicians who see adolescents to increase their knowledge and skill in recognising autism and distinguishing autism from other conditions, such as ADHD and depression, and in the provision of support and therapy for autistic teenagers who are often suffering with mental health issues. Our event comprises two days, Masterclass Day 1: Diagnosis for Autistic Teenagers and Masterclass Day 2: Support and Therapy for Autistic Teenagers. The events will be held live in London and can be attended live via webcast and watched later for 60 days after the event.
References
American Psychiatric Association [APA]. (2022). Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR).
Cassidy, Sarah, Au-Yeung, Sheena, Robertson, Ashley, Cogger-Ward, Heather, Richards, Gareth, Allison, Carrie, Bradley, Louise, Kenny, Rebecca, O’Connor, Rory, & Mosse, David. (2022). Autism and autistic traits in those who died by suicide in England. The British Journal of Psychiatry, 221(5), 683-691. https://doi.org/https://doi.org/10.1192/bjp.2022.21
Cassidy, S. A., Bradley, L., Bowen, E., Wigham, S., & Rodgers, J. (2018). Measurement properties of tools used to assess depression in adults with and without autism spectrum conditions: A systematic review. Autism Research, 11(5), 738-754.
Chandrasekhar, T., & Sikich, L. (2015). Challenges in the diagnosis and treatment of depression in autism spectrum disorders across the lifespan. Dialogues in clinical neuroscience, 17(2), 219-227.
Hedley, D., Uljarević, M., Wilmot, M., Richdale, A., & Dissanayake, C. (2017). Brief report: Social support, depression and suicidal ideation in adults with autism spectrum disorder. Journal of Autism and Developmental Disorders, 47, 3669-3677
Hedley, D., Uljarević, M., Foley, K. R., Richdale, A., & Trollor, J. (2018). Risk and protective factors underlying depression and suicidal ideation in Autism Spectrum Disorder. Depress Anxiety, 35(7), 648-657. https://doi.org/10.1002/da.22759
Hollocks, M. J., Lerh, J. W., Magiati, I., Meiser-Stedman, R., & Brugha, T. S. (2019). Anxiety and depression in adults with autism spectrum disorder: a systematic review and meta-analysis. Psychological Medicine, 49(4), 559-572. https://doi.org/10.1017/s0033291718002283
Kinnaird, E., Stewart, C., & Tchanturia, K. (2019). Investigating alexithymia in autism: A systematic review and meta-analysis. European Psychiatry, 55, 80–89.
Oakley, B., Loth, E., & Murphy, D. G. (2021). Autism and mood disorders. Int Rev Psychiatry, 33(3), 280–299. https://doi.org/10.1080/09540261.2021.1872506
Rhodes, S. M., Eaton, C. B., Oldridge, J., Rodgers, J., Chan, S., Skouta, E., McKechanie, A. G., Mackie, L., & Stewart, T. M. (2023). Lived experiences of depression in autistic children and adolescents: A qualitative study on child and parent perspectives. Res Dev Disabil, 138, 104516. https://doi.org/10.1016/j.ridd.2023.104516
