Prevention of absenteeism and school failure in students with ASD: Improving the transition from primary to secondary school

Autism can occur in conjunction with other disorders, in which case we are talking about comorbidity. It is estimated that more than 60% of people with autism have at least one associated psychiatric condition, and many people with autism also have physical health problems (Rosen et al., 2021). The occurrence of comorbidities is associated with a poorer outcome and prognosis, higher needs for medical support, reduced level of social well-being, and in some cases with a higher mortality rate. Behavioral changes, and even some forms of aggressive and autoaggressive behavior, may indicate certain comorbid conditions. The most occuring medical conditions include gastrointestinal problems, seizures, and sleep problems, and all of these conditions can significantly worsen behavioral symptoms. These conditions are often not recognized because behavioral changes are attributed to autism itself or to the influence of some environmental, especially sensory, factors (Casanova et al., 2020). These authors believe that the possibility of concealed comorbidity should be suspected if:

• functional analysis of behavior cannot determine the exact reason for the occurrence of self-harm, heteroaggression and other forms of maladaptive behavior;

• the person with autism regressed in relation to the previous level of functioning (especially after the third year of life); 

• a person with autism does not respond well to treatment and support provided;

•  there is a history of perinatal complications, frequent visits to the emergency room, taking a variety of medications, including those not available on prescription.

In case of suspicion of a comorbid condition, it is necessary to first conduct a review of the system (a list of questions arranged by the organ system, design to uncover dysfunction and disease within that area), and then, if necessary, refer a person with autism to a specialist of a particular profile.

Autism can occur in combination with other neurodevelopmental disorders such as intellectual disability, ADHD, developmental coordination disorder, etc. ASD can be accompanied by any level of intellectual functioning, although in the last few decades, people with high-functioning autism, who often remained unrecognized in the past, are being better diagnosed. People with intellectual disabilities can have only some traits of autism, and the diagnosis is made if all diagnostic criteria are met and if deficits in the field of social communication are significantly higher than the level that would be expected in relation to the degree of cognitive functioning (APA, 2013). Autism and ADHD are neurobiological disorders with similar underlying neuropsychological deficits. Until the publication of DSM-5 (APA, 2013), these two disorders were mutually exclusive. However, everyday experience and numerous research papers have indicated a large overlap of symptomatology, as well as the possibility of coexistence of these two disorders. The prevalence of ADHD in people with autism varies in a wide range from 17% to as much as 78%, depending on the research sample and the applied research methodology. A quantitative synthesis of 18 research studies found that the prevalence of ADHD and adults with autism was 25.7% (Lugo-Marín et al., 2019). People with comorbid autism and ADHD typically have more severe symptoms, especially in the social domain, as well as a greater tendency for repetitive activities (Rosen et al., 2021). In the school context, it is important to pay attention to the fact that children with autism and ADHD are at high risk of bullying. Although it has long been known that children with autism have atypical motor development, there is a relatively small number of studies that deal with the diagnosis of comorbid developmental coordination disorder in people with autism. In a recent study, it was found that over 90% of respondents with ASD met criteria for co-occurring developmental coordination disorder (Miller et al., 2021).

As already mentioned, autism can be associated with various syndromes. The combination of autism, syndrome, and intellectual disability alters the behavioral phenotype, which significantly affects the accuracy of diagnosis. Although most people with Fragile X chromosome meet the DSM-5 criteria for autism in the area of stereotyped forms of activity, slightly less than 30% of men and only 13% of women with Fragile X meet the same criteria in the area of social communication. The situation is quite the opposite in Phelan-McDermid syndrome where most respondents have more significant deficits in the area of social communication than in the area of stereotypical behavior (Oberman, & Kaufmann, 2020). The prevalence of autism in samples of children with Down syndrome ranges from 16% to as much as 42%. Children with this form of syndrome autism have, as a rule, fewer difficulties in the field of social communication than children with idiopathic autism (Godfrey et al., 2019). Detection of an associated genetic disorder is important for several reasons: better understanding of atypical behavioral manifestations and adaptation of support services; recognition of diseases and conditions characteristic of certain syndromes and their treatment; genetic family counselling.

Although epilepsy, as the most common comorbid, neurological disease, can sometimes be associated with a syndromic condition, in many cases the etiology of epilepsy in people with autism is not entirely clear. Epilepsy is especially common in people with autism and intellectual disabilities. Studies show that some other neurological conditions are more common in people with autism than in neurotypical subjects: macrocephaly, cerebral palsy, migraine / headache, etc. (for the review see Pan et al., 2020). The associated neurological disorder can have a significant impact on the further developmental course, both directly and through the adverse effects of the drugs used. Therefore, “neurological check-ups are indicated in autism to ensure adequate physical health care and support” (Pan et al., 2020).

In addition to neurological, people with autism can have a number of psychiatric conditions. It is estimated that about 70% of people with autism have a comorbid psychiatric condition. In addition to the ADHD already described, the most common comorbid conditions are anxiety and mood disorders. Depression may be related to ongoing bullying and environmental changes. Research on samples of children and adolescents with autism shows that additional psychiatric condition has a negative impact on adaptive functioning, nutrition and sleep, as well as being able to increase social isolation, anxiety, irritability, aggression and self-harm. Supportive school services should be the main source of support for children with autism and comorbid psychiatric conditions, while ensuring cooperation with family and psychiatric services.

With the exception of ADHD, the most common psychiatric disorders in adults with autism are mood disorders (depression and bipolar disorder), as well as anxiety disorders (social anxiety disorder, obsessive-compulsive disorder, adjustment disorder, agoraphobia, panic disorder, generalized anxiety disorder), with a prevalence of about 18%. Rare studies of anxiety at different stages of the life cycle show that anxiety usually occurs in early childhood, reaching a maximum in late childhood and adolescence, and then declining in younger adulthood, only to rise again in the elderly with autism. In adults with autism, the pooled prevalence of schizophrenia spectrum disorders is 11.8% (schizophrenia is the most common in this category while other schizophrenia spectrum disorders are extremely rare), and personality disorders have a similar prevalence. Other psychiatric disorders are significantly rarer (for the review see Lugo-Marín et al., 2019). Psychiatric comorbidity requires close cooperation between the psychiatric service, parents and teachers, because the intervention is not limited to taking medication, but also to monitoring the condition, providing individualized support and removing social barriers and stigma that is often associated with psychiatric illness.

Eating and sleeping problems are relatively common in people with autism. If they occur, it is necessary to determine the real cause of the problem and create an individual intervention plan. In addition to pharmacological agents, there are a number of evidence-based strategies used to overcome these problems.