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2017/04/12 A CHALLENGING TRANSITION: MANAGING YOUNG ADULTS WITH AUTISM SPECTRUM DISORDER B Y : D R . C E L I A R O B I C H A U D B . S C . , M . D . P G Y 4 R E S I D E N T , D E P A R T M E N T O F P S Y C H I A T R Y D A L H O U S

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2017/04/12 1

A CHALLENGING TRANSITION: MANAGING YOUNG ADULTS WITH AUTISM SPECTRUM DISORDER

B Y : D R . C E L I A R O B I C H A U D B . S C . , M . D . P G Y 4 R E S I D E N T , D E P A R T M E N T O F P S Y C H I A T R Y D A L H O U S I E U N I V E R S I T Y

OBJECTIVES

  • Re

Review w the diagno nosis is of Autis ism Spectrum um Disorder der (ASD), , etiol

  • logy
  • gy, epidemiol

emiology

  • gy, and major
  • r psychi

hiat atric ic comor

  • rbid

idit itie ies (specif ific ical ally ly with h attention ention to trans nsit ition ion aged youth) h)

  • Present

ent cases es of a young g adult lts with h ASD preparing ng for trans nsit ition ion to adult lt services es

  • Re

Review w the basic ic compon

  • nents

ents of the trans nsit ition ion from adolesc escence ence to adult ltho hood,

  • d, as they apply to youth

h with h ASD

  • Re

Review w an approach h to manag aging ing psychia hiatric comor

  • rbid

idit itie ies in young g adult lts with h ASD in the e adult lt mental al healt lth h system em

2

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SLIDE 2

2017/04/12 2 WHEN YOU THINK OF “YOUNG ADULTS WITH AUTISM”…

3

AUTISM SPECTRUM DISORDER

  • Lifelong
  • ng neurod
  • develop
  • pme

mental tal disor

  • rder

er with detrim imen ental tal imp mpact act on funct ction

  • ning

ing

  • A triad of sympt

mptom

  • m domains

ins that t represen esent t imp mpairmen irments ts in:

  • Quality of reciprocal social/emotional interactions
  • Verbal and non verbal communication
  • Repetitive stereotyped behaviors and interests
  • Re

Represen esent t ~1% of the e genera eral populati tion

  • n
  • Herita

tabil ilit ity y ~90%

  • Sex

ex ratio io 4:1 (male:f e:female emale)

  • 2:1 with comorbid intellectual disability

4

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SLIDE 3

2017/04/12 3

5

THREE MAJOR DOMAINS OF IMPAIRMENT

6

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2017/04/12 4

AUTISM: A HIGHLY HERITABLE, HETEROGENEOUS, NEURODEVELOPMENTAL DISORDER

7

Hans Asperger 1906-1980 Leo Kanner 1894-1981

HOW IS A DIAGNOSIS OF AUTISM MADE?

  • A behaviora
  • ral diagn

gnosis:

  • sis: symp

mptom

  • ms

s MUST begin in in early rly childhood

  • od

developm evelopmen enta tal period iod (12-24mos), mos), but may become

  • me more

e appa paren ent t with th increa eased sed socia ial demands

  • I.e. may not fully manifest until social demands exceed capacity
  • Later in life may be masked by learned strategies
  • Specif

cifie iers: s:

  • With or without intellectual impairment
  • With or without language impairment
  • Associated with known medical or genetic factor (~15%)
  • Associated with another mental, neurodevelopmental or behavioral

disorder

  • With or without catatonia

8

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2017/04/12 5

TOOLS

  • Use of struc

uctur ured ed diagn gnos

  • stic

ic tool

  • l important

ant

  • ADI-R: Autism diagnostic interview for caregivers or adults
  • ADOS: Autism Diagnostic Observation Schedule
  • Four modules tailored to age group and verbal ability
  • CARS: Childhood Autism Rating Scale
  • Ideall

ally, coupled ed with h detaile iled develo lopmenta ental history from a caregi giver er

9

COMORBIDITIES: PHYSICAL

10

Sleep

  • Sleep latency
  • Night awakening
  • ?abnormalities in melatonin

production and circadian rhythm?

Epilepsy

  • Higher rates of seizures
  • Estimates 2-46%

Gastrointestinal

  • 3x more common to

have complaints of abdominal pain, constipation and diarrhea

  • Feeding and eating

problems Altere ered d sleep ep, anxiet ety, irritabi bility, and self f injury may y all be indicative e of a physi ysical health h probl roblem em!

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SLIDE 6

2017/04/12 6

COMORBIDITIES: PSYCHIATRIC

  • Approximately 70%

70% of individuals with ASD meet criteria for one additional mental health disorder, 40% 40% have two or more

  • Higher rates of:
  • Depressio

ion n (70% % in high h functionin

  • ning

g young g adult lts with h no comorbid id ID, , Lugenard et al 2011 11)

  • Anxiety (56%)
  • GAD and SAD
  • Intellectual disability (38%)
  • ADHD (30%)
  • OCD
  • Controversial, given symptom overlap. Estimates 7-20%
  • Schizophrenia, solitary auditory hallucinations, Bipolar I

11

https://www.carautismroadmap.org/intellectual-disability-and-asd/

DEPRESSION IN HIGH FUNCTIONING ASD

  • Individuals with normal intelligence and verbal ability still may have

core difficulties in social interactions and communication

  • Vulnerable to negative life circumstances (bullying etc.)
  • High level of alertness is recommended in these individuals for

decline in mental health and psychosocial functioning

12

Lugnegård, Tove, Maria Unenge Hallerbäck, and Christopher Gillberg. "Psychiatric comorbidity in young adults with a clinical diagnosis of Asperger syndrome." Research in developmental disabilities 32.5 (2011): 1910-1917.

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2017/04/12 7

LET’S RECAP

  • I N D I V I D U A L S W I T H A U T I S M H A V E D E F I C I T S I N

C O M M U N I C A T I O N , S O C I A L I N T E R A C T I O N A N D R I G I D I T Y

  • M U L T I P L E P S Y C H I A T R I C C O M O R B I D I T I E S T H A T

A R E D I F F I C U L T T O D I S T I N G U I S H F R O M T H E P R I M A R Y S Y M P T O M S O F A S D

  • H O W M I G H T Y O U N G A D U L T S W I T H A S D F A R E

W I T H T R A N S I T I O N I N G F R O M A D O L E S C E N C E T O A D U L T H O O D ? 13

CASES

  • Joe is a 19

19 ye year r old male, e, lives ves at home e with his siblings ings and paren rents ts

  • Diagnosed with ASD as a toddler by pediatrics
  • Lower functioning, requiring substantial support with activities of daily

living

  • First

st conta tact ct with psych ychiatr iatry y at age 12, referr erred ed by pediatr iatrici ician for esca calati ting g aggr gress essiv ive e behavior ior, tics s and abnor

  • rma

mal repeti etiti tive e behavior ior

  • Also struggles with hyperactivity and impulsiveness in the classroom
  • When stressed: self-injurious, touching mouth to various surfaces

around the house, walking in circles

  • Comor
  • rbid medica

cal conditi tion

  • ns:

s: Epilepsy epsy, GERD RD/int /intermitt ermitten ent vomit iting ing

  • Medica

cati tion

  • ns: risperidone, fluoxetine, lamotrigine

14

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2017/04/12 8

CASES, CONT.

  • Robert is a 19 ye

year r old male, adopt pted ed at age 2, lives indep epen endent ently ly in the basem ement ent of his paren ents home

  • Diagnos

gnosed at age two with delayed speech ch, , ASD and ADHD

  • First seen

n by psyc ychiatr iatry y at the IWK at age 14, seen n by out of

  • f pr

provinc ince e psyc ychiatr iatris ist prior

  • r
  • Main symptoms are anger, aggression, hyperactivity/impulsivity and

inflexibility

  • He has finished

ed school

  • ol and is working

ing part time as a clean aner

  • His current clinician helps him with budgeting, meal planning etc.
  • Biologica
  • gical

l famil ily y history y of schiz izop

  • phrenia,

renia, bipolar lar and ADHD

  • Comorb

rbid id medica cal l cond ndit itions ions: Seizures ures

  • Curren

rent medica ications ions: atomoxet etine, ine, fluoxetine, ine, arip ipip ipraz razol

  • le

15

CASES, CONT.

  • Joe and Ro

Robert have been n followed ed by the e ASD clini nic at the IWK from age 12/14 until l now

  • w
  • What challe

lleng nges es do you foresee ee them em fa facing ng with h a mov

  • ve

e to the adult lt system? em? Will they be the same e for bot

  • th?

h?

  • What challe

lleng nges es do they ey fa face mov

  • ving

ing tow

  • war

ard adult lthood hood in general al?

16

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2017/04/12 9

WHAT DOES IT MEAN TO BE AN ADULT?

17

  • Eriks

iksonian

  • nian stages

ges: identity v.s. role confusion, intimacy v.s. isolation

  • Acti

tivit ities ies of trans nsit ition ion: completing school, gaining employment, post secondary education, contributing to a household, community engagement, satisfactory personal and social relationships

18

TRANSITION FROM ADOLESCENCE TO ADULTHOOD

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2017/04/12 10

FOR A TEEN WITH ASD

  • Schoo
  • ol

l planning ing might ht mean: n:

  • What services and supports are available to make post

secondary goals attainable (such as assistive technology)?

  • Home planning

ing might ht mean:

  • Becoming more integrated into the community and more

independent with age, a continuum of living arrangements and

  • utside support
  • Employ
  • yment

ent planning ing might ht mean: n:

  • Segregated training workshops, day programs, supported

employment programs or entering competitive workforce

19

WHAT ARE THE OUTCOMES FOR YOUNG ADULTS WITH ASD?

  • Canadi

dian study dy of 48 indivi vidu duals s diagnos

  • sed

ed as pres eschoo hoolers ers with h ASD, followed ed up at mean age 6.8y, 11.4y y and 24y y

  • Average CARS score 34 at time 1, 31 at time 2 (mild autism)

20

Eaves, Linda C., and Helena H. Ho. "Young adult outcome of autism spectrum disorders." Journal of autism and developmental disorders 38.4 (2008): 739-747. 17% 17% 33% 33% 35% 35% 15% 15%

VERBAL IQ

Average or above Mild Moderate Severe to profound 17% 17% 24% 24% 26% 26% 33% 33%

NON VERBAL IQ

Average or above Mild Moderate Severe

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2017/04/12 11

WHAT ARE THE OUTCOMES FOR YOUNG ADULTS WITH ASD?

  • 30% attended some sort of post-secondary training, one individual

at university

  • 56% had ever been employed, averaging 5h/week in part time

work

  • 4% competitively employed (only one able to independently

support themselves)

21

Eaves, Linda C., and Helena H. Ho. "Young adult outcome of autism spectrum disorders." Journal of autism and developmental disorders 38.4 (2008): 739-747.

WHAT ARE THE OUTCOMES FOR YOUNG ADULTS WITH ASD?

  • Those with ASD without intellectual disability three times more

likely to have no formal al daily activ ivit ity

  • 86

86% of young g adult lts with h no formal al daily activ ivit ity had a comor

  • rbid

id psychia hiatric ic diagnos nosis is

  • At 24 years of age, 39.5% were on prescribed medication for

behavior (most commonly risperidone)

  • Obesity/metabolic side effects

22

Eaves, Linda C., and Helena H. Ho. "Young adult outcome of autism spectrum disorders." Journal of autism and developmental disorders 38.4 (2008): 739-747.

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2017/04/12 12

WHAT ARE THE OUTCOMES WITH RESPECT TO HEALTH SERVICES USE?

23

YOUNG ADULTS WITH ASD: SERVICE USE

  • Data from the National Longitudinal Transition Study 2 (U.S.)
  • 10 yr prospective study following youth enrolled in special education

programs

  • 680 youth with ASD from a nationally representative sample, 410 of

whom had completed high school in 2007/08

  • 6:1 (male:female)
  • Average age 21.5y
  • Compared rates of service use to data collected 6 years earlier, when all

youth were enrolled in school

24

Shattuck, Paul T., et al. "Post–high school service use among young adults with an autism spectrum disorder." Archives of pediatrics & adolescent medicine 165.2 (2011): 141-146.

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2017/04/12 13

YOUNG ADULTS WITH ASD: SERVICE USE

46.9 46.2 63 63 74.6 23.5 35 35 41.9 9 MEDICAL SERVICES MENTAL HEALTH SERVICES CASE MANAGEMENT SPEECH LANGUAGE

Service ice Use e Durin ing g and After er High Schoo

  • ol

High school Post High school

25

Shattuck, Paul T., et al. "Post–high school service use among young adults with an autism spectrum disorder." Archives of pediatrics & adolescent medicine 165.2 (2011): 141-146.

YOUNG ADULTS WITH ASD: SERVICE USE

  • While in scho

hool, l, only 6% of youth h with h autis ism receiv ived d NO servic ices es at all

  • This number climbed to 39%

39% after exiting school

  • Other findings: those with no services after high school were more

likely to have lower socioeconomic status, and were more likely to be African American

  • Racial and economic barriers to continued service use

26

Shattuck, Paul T., et al. "Post–high school service use among young adults with an autism spectrum disorder." Archives of pediatrics & adolescent medicine 165.2 (2011): 141-146.

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2017/04/12 14

27

How

  • w do we accoun
  • unt

t for such a steep ep drop in servic vice e use?

LIVED EXPERIENCE OF TRANSITION PLANNING

  • Little evidence on mental health transition planning for youth with ASD
  • Qualitative study on educational transition planning for youth with

disabilities showed:

  • Youth themselves rarely engaged at all in planning, and if they are, too

late in the process

  • Inadequate communication
  • Frustration with assumptions made about abilities/needs
  • Blind funneling into traditional adult programs
  • A too little, too late, one size fits all approach

Sound familiar?

28

Hetherington, Susan A., et al. "The lived experiences of adolescents with disabilities and their parents in transition planning." Focus on Autism and Other Developmental Disabilities 25.3 (2010): 163-172.

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SLIDE 15

2017/04/12 15

WHAT COULD BE BETTER?

  • Early and active involvement of the youth
  • Parent and family (system) involvement
  • Individualized/contextualized relationships and plans
  • Especially in culturally or linguistically diverse populations
  • Meaningful employment opportunities
  • Outcome based, youth centered goals

29

Hetherington, Susan A., et al. "The lived experiences of adolescents with disabilities and their parents in transition planning." Focus on Autism and Other Developmental Disabilities 25.3 (2010): 163-172.

APPLYING THESE TRANSITION PRINCIPLES TO MENTAL HEALTH SERVICES

Barriers: riers:

  • Differen

enti tial funding ing of adult t v.s. yo youth th services ices

  • Differin

ing g eligib ibil ilit ity criteria eria for care

  • Limit

ited ed awa waren eness ess or comfor

  • rt

t amon

  • ng

g physi ysicia cians s and allie ied health th profess essiona ionals s about t neurodevel elopmenta

  • pmental disorder

ers

  • Dealing

ing with transiti sition

  • n requir

quires es adapti ptive e skil ill

  • Confusion

sion among g familie ies s and caregiv egivers ers abou

  • ut

t how

  • w to

to naviga igate e adult t services ices

30

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SLIDE 16

2017/04/12 16

31

TREATING ADULTS WITH ASD: THE EVIDENCE

Edwards, Timothy L., et al. "Intervention research to benefit people with autism: How old are the participants?." Research in Autism Spectrum Disorders 6.3 (2012): 996- 999.

IMPROVING AWARENESS AND COMFORT WITH ASD

32

http://www.thinkautism.co.uk/home

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2017/04/12 17

IMPROVING AWARENESS AND COMFORT WITH ASD

  • NICE Guidel

elines ines for Diagn gnosis

  • sis
  • Multidisciplinary assessment
  • Focus on: Early developmental history, family history, behaviors,

education, employment

  • Collateral history
  • Use of validated tools
  • Full Medical history
  • Physical exam
  • Investigations: Genetic/metabolic workup (if family history, associated

health problems or dysmorphic features indicate); hematological/immunological workup; neuro exam +/-EEG; renal u/s if 22q11del suspected

33

IMPROVING AWARENESS AND COMFORT WITH ASD

  • There is no medicat

icatio ion n treat atment nt for core symptoms of autis ism

  • Aripiprazole and risperidone approved for tx of

irritability/aggression in autism by the FDA

  • For psychia

hiatric comor

  • rbid

idit itie ies:

  • NICE recommends treatment informed by existing guidelines for

comorbid conditions, treating with the same algorithms (I.e. for ADHD/OCD)

34

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SLIDE 18

2017/04/12 18

MEDICATION MANAGEMENT

  • Important

ant to consid ider er: once an indiv ivid idua ual l is started ed on a medic icat ation ion, they ey are very likely ly to stay on it

  • Longitudinal study of 286 adolescents with ASD, 57% taking

psychotropic medication at the beginning, 64% 4.5years later

  • Pot
  • tent

ntial al reasons

  • ns for this: increas

asing ng trend of polyphar armacy, escalat alatin ing g comple lexity xity of issues ues, reluctanc nce e to discont

  • ntin

inue ue effectiv ive e medicat ation, ion, lack of medic icat atio ion n review ew?

35

Esbensen, Anna J., et al. "A longitudinal investigation of psychotropic and non-psychotropic medication use among adolescents and adults with autism spectrum disorders." Journal of autism and developmental disorders 39.9 (2009): 1339-1349.

MEDICATION MANAGEMENT

Maudsle ley Good d Prescrib ibing ng Guide delin lines for Adults with h ASD

  • Start at low doses
  • Gradually titrate to maximal efficacy with regular monitoring /use
  • f scales
  • Routine health monitoring
  • Stop any aversive or ineffective medication
  • Seek expert second opinion as needed
  • Avoid polypharmacy
  • Schedule planned medication reviews

36

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SLIDE 19

2017/04/12 19

AUTISM HEALTHCARE ACCOMMODATIONS TOOL

37 http://autismandhealth.org/?p=ahat

AUTISM HEALTHCARE ACCOMMODATIONS TOOL

38 http://autismandhealth.org/?p=ahat

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SLIDE 20

2017/04/12 20

AUTISM HEALTHCARE ACCOMMODATIONS TOOL

39 http://autismandhealth.org/?p=ahat

OTHER RESOURCES

  • http://www.autism

smsp spea eaks.ca/

  • http://www.autism

smnovasc scotia.ca/ 40

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SLIDE 21

2017/04/12 21

CASES

  • Joe is a 19

19 ye year old male, e, lives es at home e with his sibling ings and paren ents ts

  • Diagnosed with ASD as a toddler by pediatrics
  • Lower functioning, requiring substantial support with activities of daily

living

  • First

st conta tact ct with psych ychiatr iatry y at age 12, referr erred ed by pediatr iatrici ician for esca calati ting g aggr gress essiv ive e behavior ior, tics s and abnor

  • rma

mal repeti etiti tive e behavior ior

  • Also struggles with hyperactivity and impulsiveness in the classroom
  • When stressed: self-injurious, touching mouth to various surfaces

around the house, walking in circles

  • Comor
  • rbid medica

cal conditi tion

  • ns:

s: Epilepsy epsy, GERD RD/int /intermitt ermitten ent vomit iting ing

  • Medica

cati tion

  • ns: risperidone, fluoxetine, lamotrigine

41

BACK TO THE CASES

Joe

  • During his time at the IWK, Joe was involved with Applied Behavioral

Analysis (ABA), OT, speech language pathology, psychology

  • After turning 19 was referred to adult community mental health

services

  • Seen by RN + Psychiatrist for first assessment
  • Ongoing issues with property destruction, self-stimulation (slapping)

and caregiver burnout/need for respite care

  • Felt that his needs would be best met elsewhere, referred to COAST

(Dual Diagnosis)

  • Follow up by mental health RN in meantime

42

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SLIDE 22

2017/04/12 22

CASES, CONT.

  • Robert is a 19 ye

year r old male, adopt pted ed at age 2, lives indep epen endent ently ly in the basem ement ent of his paren ents home

  • Diagnos

gnosed at age two with delayed speech ch, , ASD and ADHD

  • First seen

n by psyc ychiatr iatry y at the IWK at age 14, seen n by out of

  • f pr

provinc ince e psyc ychiatr iatris ist prior

  • r
  • Main symptoms are anger, aggression, hyperactivity/impulsivity and

inflexibility

  • He has finished

ed school

  • ol and is working

ing part time as a clean aner

  • His current clinician helps him with budgeting, meal planning etc.
  • Biologica
  • gical

l famil ily y history y of schiz izop

  • phrenia,

renia, bipolar lar and ADHD

  • Comorb

rbid id medica cal l cond ndit itions ions: Seizures ures

  • Curren

rent medica ications ions: atomoxet etine, ine, fluoxetine, ine, arip ipip ipraz razol

  • le

43

CASES

Ro Robert

  • Has yet to be transitioned!
  • How can we (the mental health system) best prepare for his

transition?

44

slide-23
SLIDE 23

2017/04/12 23

SUMMARY

  • Au

Auti tism sm is a comp mplex, heter erogen

  • geneou

eous, s, lifelon

  • ng

g neurod

  • devel

elopmenta

  • pmental

disorder er

  • Main

in imp mpairments airments in social ial interactio eraction, commu munic icatio ation and acti tiviti ties/in es/interes erests ts

  • Multi

tipl ple, e, COMMON, psych ychiatr iatric ic comor

  • rbid

idit itie ies s that t can be easil ily confused sed with the prima mary y sympt mptoms

  • ms of auti

tism sm

  • Young

g adulth thood

  • od/

/ transiti sition

  • n age

e represen esents ts an acute e drop off in service ice use

  • Attention needs to be paid to higher functioning individuals

45

SUMMARY

  • Good

d Transit itio ion Practice ice

  • Early and active involvement of the youth
  • Parent and family (system) involvement
  • Individualized/contextualized relationships and plans
  • Especially in culturally or linguistically diverse populations
  • Meaningful employment opportunities
  • Outcome based, youth centered goals
  • A one size fits all approach doesn’t “fit” ASD!

46

slide-24
SLIDE 24

2017/04/12 24

THANK YOU

47 Special Acknowledgements: Dr. Lukas Propper, Dr. Jillian MacCuspie, Dr. Jillian Filliter

REFERENCES

http tps://www.ca carauti tismroa

  • admap.org
  • rg/inte

ntellect ctual-disability ty-and nd-asd/ http tp://auti tismand ndhealth th.org

  • rg/?p=ahat

Esbens nsen, Anna na J., et al. "A long ngitu tudina nal investi tigati tion

  • n of psych

chotr trop

  • pic

c and non psych chot

  • tropic

c medica cati tion n use among ng adol

  • lesce

cents nts and adults ts with th auti tism spect ctrum disord

  • rders." Journa

nal of auti tism and develop

  • pmenta

ntal disord

  • rders 39.9 (2009): 1339-1349.

http tp://www.th think nkauti tism.co co.uk/hom

  • me

Taylor, Julie Lounds, and Marsha Mailick Seltzer. "Employment and post-secondary educational activities for young adults with autism spectrum disorders during the transition to adulthood." Journal of autism and developmental disorders 41.5 (2011): 566-574. Hendricks, Dawn R., and Paul Wehman. "Transition from school to adulthood for youth with autism spectrum disorders: Review and recommendations." Focus on Autism and Other Developmental Disabilities (2009). Edwards, Timot

  • thy L., et al. "Inte

terventi ntion

  • n research

ch to bene nefit t peop

  • ple with

th auti tism: How old are the parti tici cipants nts?. ?." Research ch in Auti tism Spect ctrum Disord

  • rders 6.3 (2012): 996-999.

Heth thering ngto ton, n, Susan n A., et al. "The lived experience ces of adol

  • lesce

cents nts with th disabiliti ties and their parents nts in trans nsiti tion

  • n planni

nning ng." Focus on Auti tism and Other Develop

  • pmenta

ntal Disabiliti ties 25.3 (2010): 163-172. Shatt ttuck ck, Paul T., et al. "Post–high schoo

  • ol service use among

ng young ng adults ts with an auti tism spect ctrum disord

  • rder." Arch

chives of pediatrics cs & adol

  • lesce

cent nt medici cine ne 165.2 (2011): 141-146. Eaves, Lind nda C., and Helena na H. Ho. "You

  • ung

ng adult t outc tcom

  • me of auti

tism spect ctrum disord

  • rders." Journa

nal of auti tism and develop

  • pmenta

ntal disor

  • rders 38.4

(2008): 739-747. Lugne negård, , Tove, Maria Uneng nge Hallerbäck ck, and Christo topher Gillberg. "Psych chiatr tric comorb

  • rbidity

ty in young ng adults ts with a clini nical diagno nosis of Asperger syndrome." Research ch in develop

  • pmenta

ntal disabiliti ties 32.5 (2011): 1910-1917. Murphy, Clodagh M., et al. "Autism spectrum disorder in adults: diagnosis, management, and health services development." Neuropsychiatric Disease and Treatment 12 (2016): 1669. Joshi, Gagan, et al. "Psychiatric comorbidity and functioning in a clinically referred population of adults with autism spectrum disorders: a comparative study." Journal of Autism and Developmental Disorders 43.6 (2013): 1314-1325.

48