Among 30 possible coded diagnoses, children and adolescents with autism had elevated rates of gastrointestinal (GI) disturbances, feeding problems, sleep difficulties, and anxiety disorders, according to a comparative review published February 26 in the Journal of Pediatric Health Care.
Relevant to practitioners in pediatrics and specialty and primary care, the study underscores the need for screening to holistically understand comorbidities within this population, as well as the need for large-scale studies of autistic comorbidity patterns, wrote April A. Braswell, PhD, APRN, a pediatric nurse practitioner and associate professor at the University of North Carolina Wilmington’s School of Nursing, and colleagues.
According to the review, with comorbidity rates varying considerably by age group, children with autism aged 5-10 years had the highest rate of gastrointestinal problems: 21.6% compared with 5.2% of their peers without autism. Those in the 15-17 age group had a 22.1% prevalence of anxiety disorders vs 3.7% of neurotypical teenagers. In 2-to-4-year-olds, sleep issues affected 14% vs 0.9%, respectively, and rates of feeding problems were higher at 14% vs 1.4%. The highest observed comorbidity rate was 23.8% for anxiety disorders in young adults aged 18-21 with autism vs 5.8% in those without autism.
By gender, rates of feeding and sleeping disorders were higher in younger boys with autism, while GI disorders were more frequent in mid-childhood girls with autism. Older girls had more anxiety-related disorders.
The findings are based on electronic records data from 2019 to 2021 extracted from a health information exchange in southeastern North Carolina. A total of 222,214 children and adolescents aged 2 to 21 years were identified, resulting in more than 1.9 million diagnosis and procedure records. Among these, 1793 (< 1% of all children) had autism, 675 of whom were also diagnosed with at least one gastrointestinal, feeding, sleep, or anxiety-related disorder.
It is well established that children with autism have higher rates of concomitant medical issues, variations in development, and mental health conditions. “There’s an urgent need for training and resources to allow better screening and management of affected children and adolescents,” Braswell told Medscape Medical News.
While the current study replicates previous research, some findings were new and unexpected. “We were surprised that although insomnia has been previously found in many studies of autistic children, it wasn’t noted even among the top 30 diagnoses in our study,” Braswell said.
Moreover, she said, two seizure diagnoses were prevalent in the sample. “Why are these disorders more prevalent in children and adolescents with autism? What is the cause? Is it related to the autism or the treatment or is it unrelated completely?” she said.
Her team was unsettled by the evidence of higher levels of lead exposure risk, poverty, and food hardship in patients with the most prevalent GI, feeding, sleep, and anxiety comorbidities, which warrant further investigation.
Possible Mechanisms
Previous research, said Braswell, suggests the gut and brain are connected. “When the microflora in the GI system is unbalanced, there may be a connection to onset and progression of neurological disorders.”
Alternatively, “GI disease and feeding disorders or feeding disturbances can lead to an unbalanced microflora in the gut and can contribute to increased common autistic behaviors and other daytime or nighttime anxiety symptoms.”
Braswell also noted that sleep pathology appears to be reciprocal in children with autism and can occur as a result of other comorbidities (sleeping issues secondary to anxiety) or lead to comorbidities (sleep problems resulting in daytime anxiety).
“Together, these mechanisms suggest a complex interplay between physical and mental health systems in autistic children.”
Evaluate for Comorbidities
Kara Margolis, MD, a pediatric gastroenterologist at NYU Langone Health and a professor of medicine at NYU Grossman School of Medicine in New York City, called the study significant for its highlighting of the complexity of autism. Commenting on the study for Medscape Medical News, s he pointed out that this condition is not monolithic. “There’s no ‘one autism.’ Along these lines, the investigators importantly show the high rates of GI, sleep, feeding, and anxiety disorders in autistic people and, furthermore, that they often co-occur.” Margolis was not involved with study.
The data support the idea that people with autism should always be evaluated for these comorbidities and, if identified, they should be treated — not only to make the patient feel better but also to avoid the development of other conditions.
“I will certainly be considering this evidence, as it was taken from a large sample of children in my own region, and apply it to my current practice of health history, physical examination, and screening in an important pediatric population,” Braswell said.
She recommends frequent screening for these related disorders and for social determinants of health. She encouraged clinicians to involve interprofessional colleagues and peer experts as valuable resources in primary and acute care settings.
“A more holistic, multifaceted, integrated, and team-based approach is always best for the prevention or early recognition and management of comorbidities in autistic patients,” she said.
The authors declared no relevant financial relationships and no financial assistance for this study. Margolis reported no relevant financial relationships.
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