Psychiatric Disorders in Children With Autism Spectrum Disorders: Prevalence, Comorbidity, and Associated Factors in a Population-Derived Sample
Open accessAbstract
Objective Autism spectrum disorders are now recognized to occur in up to 1% of the population and to be a major public health concern because of their early onset, lifelong persistence, and high levels of associated impairment. Little is known about the associated psychiatric disorders that may contribute to impairment. We identify the rates and type of psychiatric comorbidity associated with ASDs and explore the associations with variables identified as risk factors for child psychiatric disorders.Method A subgroup of 112 ten- to 14-year old children from a population-derived cohort was assessed for other child psychiatric disorders (3 months' prevalence) through parent interview using the Child and Adolescent Psychiatric Assessment. DSM-IV diagnoses for childhood anxiety disorders, depressive disorders, oppositional defiant and conduct disorders, attention-deficit/hyperactivity disorder, tic disorders, trichotillomania, enuresis, and encopresis were identified.Results Seventy percent of participants had at least one comorbid disorder and 41% had two or more. The most common diagnoses were social anxiety disorder (29.2%, 95% confidence interval [CI)] 13.2-45.1), attention-deficit/hyperactivity disorder (28.2%, 95% CI 13.3-43.0), and oppositional defiant disorder (28.1%, 95% CI 13.9-42.2). Of those with attention-deficit/hyperactivity disorder, 84% received a second comorbid diagnosis. There were few associations between putative risk factors and psychiatric disorder.Conclusions Psychiatric disorders are common and frequently multiple in children with autism spectrum disorders. They may provide targets for intervention and should be routinely evaluated in the clinical assessment of this group.
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The most common co-occurring psychiatric conditions are anxiety disorders, attention-deficit/hyperactivity disorder, depressive disorders, and oppositional defiant and conduct disorders.
“The most common co-occurring psychiatric conditions are anxiety disorders, attention-deficit/hyperactivity disorder (ADHD), depressive disorders, and oppositional defiant and conduct disorders (Simonoff et al. 2008), while the most common co-occurring medical conditions include gastro-intestinal problems, sleep difficulties, and seizures (Muskens et al. 2017).”
From The Diagnosis of Autism: From Kanner to DSM-III to DSM-5 and Beyond (2021) · cites this paper as Simonoff et al. 2008
The Rates of Disorder section identifies social anxiety disorder, ADHD, and oppositional defiant disorder as the most common diagnoses. It explicitly says depressive disorders and conduct disorder had low rates, so the source does not support listing those among the most common conditions. (LLM, conf=0.90)
Experimental — accuracy not yet measuredEstimates suggest that 63-78% of individuals with ASD have at least one co-occurring psychiatric condition.
“Co-occurring psychiatric and medical disorders are common among individuals with ASD, with estimates suggesting that 63–78% of individuals with ASD have at least one co-occurring psychiatric condition (Simonoff et al. 2008; Strang et al. 2012), and approximately 10–77% have at least one co-occurring medical condition (Muskens et al. 2017; Betancur 2011).”
From The Diagnosis of Autism: From Kanner to DSM-III to DSM-5 and Beyond (2021) · cites this paper as Simonoff et al. 2008
The Rates of Disorder section reports that 70.8% of children with ASD had at least one current psychiatric disorder, within the cited 63–78% range. The estimate comes from 10- to 14-year-olds assessed for three-month prevalence, so this paper alone does not establish the range for individuals with ASD across all ages. (LLM, conf=0.87)
Experimental — accuracy not yet measuredIn Simonoff et al. (2008), 29.2% of a sample of children aged 10 to 14 had concurrent anxiety and/or depression, with much higher rates than those observed in the general population.
“En el estudio de Simonoff et al. (2008), se detectó que el 29,2 % de una muestra de niños entre 10 y 14 años presentaban ansiedad y/o depresión de forma concurrente, con tasas mucho más altas que las observadas en población general.”
From Ansiedad y trastornos del espectro del autismo: notas para la intervención psicoeducativa (2022) · cites this paper as Simonoff et al. (2008)
The Abstract identifies the sample as children aged 10–14, and the Rates of Disorder section reports 29.2% for social anxiety disorder—not for anxiety and/or depression combined. Table 1 reports 41.9% for any anxiety or phobic disorder and 1.4% for any depressive disorder. The Discussion compares the higher rate of any psychiatric disorder with the general population, but says depressive-disorder rates were not increased. (LLM, conf=0.90)
Experimental — accuracy not yet measuredThe most common mental health challenge for autistic individuals is anxiety.
“The most common mental health challenge for autistic individuals is anxiety [14-16]”
From Autistic Cognition: Charting Routes to Anxiety (2021) · cites this paper as [16]
The Rates of Disorder section identifies social anxiety disorder as the most common individual diagnosis (29.2%), and Table 1 reports anxiety or phobic disorders in 41.9% of the sample. However, the study assessed children aged 10–14, so it does not establish that anxiety is the most common mental health challenge for autistic individuals of all ages. (LLM, conf=0.86)
Experimental — accuracy not yet measuredAround 50% of children with ASD experience significant anxiety.
“It is estimated that around 50 % of children with ASD will experience significant anxiety (Simonoff et al. 2008).”
From Towards a Treatment for Intolerance of Uncertainty in Young People with Autism Spectrum Disorder: Development of the Coping with Uncertainty in Everyday Situations (CUES©) Programme. (2017) · cites this paper as Simonoff et al. 2008
Table 1 reports that 41.9% of the sampled children with ASD had an anxiety or phobic disorder, and the Discussion describes this as a high rate. That supports the broad point, but the figure is below 50% and measures prevalence over three months in children aged 10–14, not the proportion of all children with ASD who will experience anxiety at some point. (LLM, conf=0.86)
Experimental — accuracy not yet measured
The majority of autistic children, adolescents and adults have one or more associated mental health conditions.
“The majority of autistic children, adolescents and adults have one or more associated mental health conditions (Buck et al., 2014; Simonoff et al., 2008), with co-occurring anxiety disorders among the most common concerns.”
From Self-guided mindfulness and cognitive behavioural practices reduce anxiety in autistic adults: A pilot 8-month waitlist-controlled trial of widely available online tools. (2020) · cites this paper as Simonoff et al., 2008
The paper's prevalence table reports that 70.8% of the sampled children had a psychiatric disorder, and the Rates of Disorder section identifies social anxiety as one of the most common diagnoses. The study assessed children aged 10–14, so it does not establish the majority claim for autistic adults or adolescents outside that age range. (LLM, conf=0.88)
Experimental — accuracy not yet measuredASD subjects commonly present co-occurring symptoms that include anxiety and intellectual disability.
“Besides the core symptoms, ASD subjects commonly present co-occurring symptoms that include anxiety and intellectual disability 37, 38.”
From Autism-like social deficit generated by Dock4 deficiency is rescued by restoration of Rac1 activity and NMDA receptor function. (2021) · cites this paper as [37]
The Abstract and Rates of Disorder section report that anxiety disorders are common among the children with ASD studied, including social anxiety disorder in 29.2%. The Measures section reports a wide IQ range but does not establish that intellectual disability is a common co-occurring condition in this sample; it also does not classify intellectual disability as a symptom. Page numbers are not available in our copy. (LLM, conf=0.84)
Experimental — accuracy not yet measuredCo-occurring psychiatric and medical disorders are common among individuals with ASD.
“Co-occurring psychiatric and medical disorders are common among individuals with ASD, with estimates suggesting that 63–78% of individuals with ASD have at least one co-occurring psychiatric condition (Simonoff et al. 2008; Strang et al. 2012), and approximately 10–77% have at least one co-occurring medical condition (Muskens et al. 2017; Betancur 2011).”
From The Diagnosis of Autism: From Kanner to DSM-III to DSM-5 and Beyond (2021) · cites this paper as Simonoff et al. 2008
Parents of autistic children can experience chronic stressors, including high levels of mental health problems in their autistic youth.
“Parents of autistic children can experience chronic stressors, including high levels of mental health problems in their autistic youth (e.g. Simonoff et al., 2008).”
From Parent, child, and family outcomes following Acceptance And Commitment Therapy for parents of autistic children: A randomized controlled trial (2024) · cites this paper as Simonoff et al., 2008
Anxiety and depression are prevalent among autistic adolescents.
“Mental health distress is highly prevalent in autistic adolescents, with up to 70% of autistic adolescents in a community-sourced sample meeting criteria for any DSM-5 disorder (Hollocks et al., 2022) and 41% of youth meeting criteria for more than one psychiatric condition (Simonoff et al., 2008).”
From The relationship between distress tolerance and behavioral activation on anxiety and depression symptomatology in autistic youth: Leveraging self and caregiver perspectives (2024) · cites this paper as Simonoff et al., 2008
Anxiety is a major problem for a lot of autistic people.
“which is a major problem for a lot of autistic people”
From Autistic Cognition: Charting Routes to Anxiety (2021) · cites this paper as [16]
Co-occurring anxiety disorders are among the most common mental health concerns in autism.
“with co-occurring anxiety disorders among the most common concerns.”
From Self-guided mindfulness and cognitive behavioural practices reduce anxiety in autistic adults: A pilot 8-month waitlist-controlled trial of widely available online tools. (2020) · cites this paper as Simonoff et al., 2008
The balance between avoiding misdiagnoses and recognizing the effect that ADHD symptoms have on a child with ASD has shifted because a high frequency of ADHD in children with autism has been documented.
“However, the balance between avoiding misdiagnoses and recognizing the effect that ADHD symptoms have on a child with ASD has shifted because a high frequency of ADHD in children with autism has been documented (Leitner 2014, Simonoff et al. 2008).”
From Recent Advances in Autism Research as Reflected in DSM-5 Criteria for Autism Spectrum Disorder (2015) · cites this paper as Simonoff et al. 2008
Other studies have identified different patterns of regression.
“other studies have identified different patterns of regression [60-64]”
From DSM-5 and autism spectrum disorders (ASDs): an opportunity for identifying ASD subtypes (2013) · cites this paper as [63]
The Measures and Associations Between Disorder and Putative Risk Factors sections use “regression” to mean statistical analysis, not developmental regression. Searches for patterns of regression and loss of skills found no passage identifying different patterns of developmental regression in autism. Page numbers were not available in our copy. (LLM, conf=0.76)
Experimental — accuracy not yet measuredDespite widespread clinician opinion that co-occurrence profiles differ between sexes/genders, the evidence is inconsistent.
“Despite the widespread opinion amongst clinicians that the co-occurrence profiles differ between sexes/genders80,81 — with males more likely to show externalizing problems such as oppositional defiant disorder and conduct disorder, and females more likely to show internalizing problems such as anxiety and mood disorders — the evidence is inconsistent.”
From Sex and gender in neurodevelopmental conditions (2023) · cites this paper as [83]
Population-based research has often failed to identify sex/gender differences in psychiatric illnesses.
“Population-based research, as opposed to clinical studies, has often failed to identify these sex/gender differences in psychiatric illnesses82–84.”
From Sex and gender in neurodevelopmental conditions (2023) · cites this paper as [83]
Typically, larger sex/gender differences are reported in clinical studies, but infrequently the same patterns emerge in population-based studies.
“Typically, larger sex/gender differences are reported in clinical studies, but infrequently the same patterns emerge in population-based studies78,82–84.”
From Sex and gender in neurodevelopmental conditions (2023) · cites this paper as [83]
Approximately 30% of children and adolescents with ASD receive a co-morbid diagnosis of ADHD.
“First, approximately 30% of children and adolescents with ASD receive a co-morbid diagnosis of ADHD (Leyfer et al., 2006; Simonoff et al., 2008)”
From Atypical attentional networks and the emergence of autism (2013) · cites this paper as Simonoff et al., 2008
In clinical cases, other neurodevelopmental conditions, psychiatric disorders and somatic disorders are often co-occurring complications.
“In clinical cases, other neurodevelopmental conditions, psychiatric disorders and somatic disorders are often co-occurring complications [13–15].”
From The contribution of environmental exposure to the etiology of autism spectrum disorder (2019) · cites this paper as [14]
Rates of comorbid ADHD symptoms in children with ASD range from 37-85%, with ADHD the second-most common comorbidity in ASD.
“Rates of comorbid ADHD symptoms in children with ASD range from 37–85%,62 with ADHD the second-most common comorbidity in ASD.63”
From Progress and roadblocks in the search for brain-based biomarkers of autism and attention-deficit/hyperactivity disorder (2017) · cites this paper as [63]
A shared behavioural/cognitive phenotype between ADHD and ASD is inattention.
“A shared behavioural/cognitive phenotype is inattention.4, 5”
From Disorder-specific functional abnormalities during sustained attention in youth with Attention Deficit Hyperactivity Disorder (ADHD) and with Autism (2013) · cites this paper as [4]
About 30% of ASD patients have comorbid ADHD.
“About 30% of ASD patients have comorbid Attention Deficit Hyperactivity Disorder (ADHD),3, 4”
From Disorder-specific functional abnormalities during sustained attention in youth with Attention Deficit Hyperactivity Disorder (ADHD) and with Autism (2013) · cites this paper as [4]
The high rate of co-occurrence between autism and other neurodevelopmental disorders, such as ADHD, suggests that there may be common risk factors.
“The high rate of co-occurrence between autism and other neurodevelopmental disorders, such as ADHD (Simonoff et al., 2008), suggests that there may be common risk factors.”
From From early markers to neuro-developmental mechanisms of autism (2014) · cites this paper as Simonoff et al., 2008
ASD is frequently accompanied by co-occurring conditions targeted for intervention.
“Similarly, ASD is frequently accompanied by co-occurring conditions that are targeted for intervention to minimize the impairments that are more generally associated with ASD [70][71][72].”
From Treatment for Co-Occurring Attention Deficit/Hyperactivity Disorder and Autism Spectrum Disorder (2012) · cites this paper as [71]
Co-occurring mental health conditions are reported in approximately 70% of autistic individuals.
“Co-occurring mental health conditions have been reported in approximately 70% of autistic individuals ranging from attention deficit and hyperactivity disorder (ADHD), irritability, aggression, mood, and anxiety issues [8, 25, 26].”
From An Update on Psychopharmacological Treatment of Autism Spectrum Disorder (2022) · cites this paper as [8]
The most common psychiatric disorder associated with ASD is anxiety.
“The most common psychiatric disorder associated with ASD is anxiety 31”
From Gastrointestinal Issues and Autism Spectrum Disorder (2020) · cites this paper as [31]
Psychiatric disorders occur in up to 70% of patients with ASD.
“Psychiatric disorders occur in up to 70% of patients with ASD.”
From Gastrointestinal Issues and Autism Spectrum Disorder (2020) · cites this paper as [31]
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- Authors
- Simonoff, E., Pickles, A., Charman, T., Chandler, S., Loucas, T., & Baird, G.
- Affiliations
- King's College London (GB)
- University of London (GB)
- Corresponding author
- Simonoff, Emily
- Venue
- Journal of the American Academy of Child & Adolescent Psychiatry
- Publisher
- Elsevier BV
- Published
- 2008-08
- Volume
- 47
- Issue
- 8
- Pages
- 921-929
- ISSN
- 0890-8567 (ISSN-L)
- OpenAlex
- W2158063953
- Semantic Scholar
- 8540dbed80a7b69efa29148b4a342c485751e247
- Cited by
- 3,399
- References
- 50
- Citations by year
- 2026: 121 · 2025: 151 · 2024: 213 · 2023: 184 · 2022: 273 · 2021: 279 · 2020: 295 · 2019: 261 · 2018: 232 · 2017: 267 · 2016: 209 · 2015: 216 · 2014: 194 · 2013: 188 · 2012: 124
- FWCI
- 31.87
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Journal of the American Academy of Child & Adolescent Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- IOE EPrints (submittedVersion)
- UCL Discovery (University College London) (submittedVersion)
- Research Portal (King's College London) (submittedVersion)
- Research Explorer (The University of Manchester) (submittedVersion)
- Funders
- Wellcome Trust
- Topics
- Life Sciences › Neuroscience › Cognitive Neuroscience › Autism Spectrum Disorder Research
- Social Sciences › Psychology › Clinical Psychology › Child and Adolescent Psychosocial and Emotional Development
- Health Sciences › Medicine › Psychiatry and Mental health › Child Nutrition and Feeding Issues
- Keywords
- autism spectrum disorder, psychiatric comorbidity, child psychopathology, social anxiety disorder, attention deficit hyperactivity disorder, oppositional defiant disorder, tic disorders, trichotillomania, enuresis, encopresis, depressive disorders, conduct disorder, anxiety disorders, prevalence, risk factors, children
- MeSH terms
- Adolescent, Attention Deficit Disorder with Hyperactivity, Autistic Disorder, Mental Disorders, Child, Female, Humans, Male, Population Surveillance, Surveys and Questionnaires, Comorbidity, Prevalence, Diagnostic and Statistical Manual of Mental Disorders
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