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J Dev Phys Disabil (2014) 26:23–33

DOI 10.1007/s10882-013-9342-4
O R I G I N A L A RT I C L E

Comorbid Symptoms in Children with Anxiety Disorders
Compared to Children with Autism Spectrum Disorders
Kim Tureck & Johnny L. Matson & Anna May &
Sara E. Whiting & Thompson E. Davis III

Published online: 22 March 2013
# Springer Science+Business Media New York 2013

Abstract Autism spectrum disorders (ASD) have been shown to be highly comorbid
with other psychological disorders. Currently, there is a dearth of research examining
how comorbidity impacts the assessment of core symptoms and co-occurring problem behaviors in children with ASD. The present study evaluated the rates of
comorbid symptoms in children with ASD and children with anxiety disorders.
Participants included 29 children with ASD, 25 children with anxiety disorders,
and 31 children with no psychological disorder who served as the control group.
Commonly co-occurring internalizing and externalizing symptoms were assessed
with the Autism Spectrum Disorders-Comorbidity for Children (ASD-CC).
Multivariate and univariate main effect analyses with post-hoc comparisons were
conducted on seven symptom subscales (tantrum behaviors, repetitive behaviors,
worry/depressed symptoms, avoidant behaviors, under-eating, overeating, and conduct problems). Children with ASD evinced higher rates of comorbid symptoms
than children with anxiety disorders. Additionally, both children with ASD and
those with anxiety disorders exhibited more comorbid symptoms than children in
the control group. Our findings support the importance of conducting broadband
assessments for comorbid symptoms when evaluating children with atypical development. Implications of these findings will be discussed in the context of
previous research.
Keywords Autism spectrum disorders . Anxiety disorders . Autism Spectrum
Disorders-Comorbidity for Children (ASD-CC) . Comorbidity

Self-report measures have been developed to screen and assess children on the autism
spectrum. The Autism Spectrum Disorders-Comorbidity Child Version (ASD-CC;

K. Tureck (*) : J. L. Matson : A. May : S. E. Whiting : T. E. Davis III
Department of Psychology, Louisiana State University, Baton Rouge, LA 70803, USA
e-mail: kturec1@lsu.edu

Anxiety responses are normal. 1997). 2008. 1996. Costello et al. Kovacs et al. epilepsy. However. 1993. 2003. Anxiety is found at a higher frequency in children with ASD when compared to typically developing children (Gillott et al. 2007. Brown and Barlow 1992). One study found anxiety to be the second most comorbid disorder in those with ASD with a prevalence rate of 50 %. 2003. Matson et al. 2007). Fodstad et al. often developmentally appropriate reactions to dangerous or scary situations. 2008). Those with ASD present with a high rate of co-occurring disorders. 2006. Anxiety disorders interfere with children’s adaptive functioning (Silverman and Ollendick 2008). Klein and Pine 2002. 2011. Last et al. Rates of ASDs are estimated at about 110 per 10. Duffy and Healy 2011. as well as rates. (2006) found that specific phobia was the most common comorbid anxiety disorder in those diagnosed with ASD. especially in children. 2010. Prevalence rates of anxiety range from 11 % to 84 %. disruptive behavior disorder is the most common comorbid disorder (De Bruin. Furthermore. with an average rate between 40 % and 50 %. They also reported a 37 % prevalence rate for obsessive compulsive disorder (OCD) and ASD. Grills and Ollendick 2002. Leyfer et al. 2009). Davis et al. Anxiety disorders are often comorbid with other disorders. 2008). lifelong developmental disorders characterized by deficits in three core domains: deficits in social skills. Prevalence rates are estimated to be between 5 % and 10 % (Anderson et al.. White et al. 1987. Often this self-report is given to children suspected of having autism spectrum disorder (ASD) along with a larger battery of measures. Matson and Boisjoli 2007. or are out of proportion in intensity or frequency. last longer than is reasonable. associations have been found between childhood anxiety disorders and academic problems (Albano et al. IQ. McGee et al. leading to long-term problems if left untreated (Silverman and Ollendick 2008). and emotional difficulties (Albano et al. are impairing. Other comorbid disorders often seen with ASD are anxiety disorders. and aggressive or self-injurious behaviors (Maski et al. 1998. Simonoff et al. in those diagnosed with ASD (White et al. Matson and Love 1990).000 with similar symptom presentations. Brown 2002. Sipes et al. 2001. ASDs. 2009). observed worldwide (Fujiwara et al. 2009. and repetitive behaviors or interests (Chowdhury et al. and deficits are thought to be neurodevelopmental in origin (Matson et al. and family. Ming et al. 2007). et al. ASD is believed to be present at birth (Baghdadli et al. 1989. Simonoff et al. . While. when these anxious responses are provoked in events that are unusual in content. social. verbal and nonverbal communication problems. impaired intellectual ability (i. motor impairment. Silverman and Ollendick 2008). including sleep disorders. 1996). 2011). 1992).24 J Dev Phys Disabil (2014) 26:23–33 Matson and Gonzalez 2007a) is used to determine commonly occurring psychopathology for children 2–16 years of age. especially other anxiety disorders (Brawman-Mintzer et al. also referred to as pervasive developmental disorders. Researchers have also demonstrated high rates of comorbid ASD and anxiety disorders (De Bruin et al. 2011). 2003). Matson 2007. Anxiety disorders are prevalent and impairing.e. gastrointestinal dysfunction. mood disorders. Leyfer et al. then they are considered problematic (Bittner et al. (2008) found a comorbid anxiety prevalence of 42 %.

There were 31 children in the no diagnosis (i.0 % 79.5 % 3. and a control group with no diagnosis).2 % “Other” 12.4 % African-American 24. Based on caregiver reported ethnicity of the child.2 % Hispanic 0% 3. 29 children in the ASD group.91) 9. gender.77) with 53 males and 32 females.0 % 90.5 % Caucasian. the sample was 83. and race).0 % 3. 2. and 25 children in the anxiety disorder group. It is hypothesized that children with ASD would demonstrate the highest rates of comorbid behaviors. age.00 (2.84. control) group.J Dev Phys Disabil (2014) 26:23–33 25 The current study examined comorbidity in three different diagnostic groups (ASD.3 % 64. Method Participants Participants in the current study were 85 children and adolescents referred to an outpatient university psychology clinic within the last six years for a range of presenting problems.2 % African American. The Autism Spectrum Disorders-Comorbidity Child Version (ASD-CC.0 % 93.29 (2. Demographic characteristics were gathered on the participants (i. SD=2. and 5. The final sample consisted of only participants who did not have a comorbid diagnosis that overlapped with another diagnostic group. % . Participants were separated into three separate groups based on the diagnostic system described in the procedure section.0 % 0% 3. anxiety disorders. Table 2 contains the percentage of participants in each diagnostic group that met criteria for the comorbid disorders based on established cutoff scores (Thorson and Matson 2012).5 % 3.e.5 % Caucasian 64.9 % other or unreported. Comorbidity was determined using a self-report measure that was developed to screen and assess children on the autism spectrum..21 (2. Refer to Table 1 for the demographic break-down by diagnostic group.5 % Female 60. 8. Table 1 Demographic characteristics by diagnostic group (N=85) Demographic Characteristics Anxiety (n=25) ASD (n=29) Control (n=31) Mean (SD) 9.2 % Age (in years) Gender. Participants ranged in age from 4 to 16 years (M=8. % Race/Ethnicity.4 % Hispanic/Latino.0 % 20. followed by children with anxiety disorders who would demonstrate higher rates than the controls.82) Range 4–14 5–16 5–14 Male 40.e. Matson and Gonzalez 2007a) is used to determine commonly occurring psychopathology for children 2–16 years of age.50) 8.7 % 35.

24 (2.41 % 100 % Moderate impairment 4% 10.31) .59 % 0% Severe impairment 8% 27.10 (.90 (3.09) No/minimal impairment 88 % 44.14) 1.34 % 0% Cutoff scores for no/minimal impairment.30) .16 (.24 % 0% M (SD) 2.76) .29 (.95) .82 % 0% Severe impairment 8% 6.99) 7.76 (1.59) No/minimal impairment 96 % 72.79 % 0% M (SD) 1. moderate impairment.48 (4.96) 1.21) 7.61 (1.48 (1.60 (4.93 (2.90 % 0% M (SD) .28 % 100 % Moderate impairment 4% 44.14 % 0% Severe impairment 8% 13.48 % 0% Severe impairment 0% 20.31) 3. and severe impairment can be found in Thorson and Matson (2012) Diagnostic Procedure Multi-method and multi-informant assessment batteries were used to make all diagnoses.06) 10.14 % 0% Severe impairment 4% 10.80 (2.72) No/minimal impairment 84 % 44.94) 2.52) No/minimal impairment 88 % 48.07 % 100 % Moderate impairment 8% 24.30) No/minimal impairment 92 % 65.54) .23 (.83 (1.26 (4.10 (1.82 % 100 % Moderate impairment 8% 27.35 % 0% Severe impairment 4% 17.26 J Dev Phys Disabil (2014) 26:23–33 Table 2 Comorbid symptoms by diagnostic group (N=85) Comorbidity Subscale Anxiety (n=25) ASD (n=29) Control (n=31) M (SD) 4.59 % 0% M (SD) .45 % 0% M (SD) 2.00) No/minimal impairment 84 % 62.20 (2.00 (1.45) No/minimal impairment 92 % 72.14 % 0% Severe impairment 4% 3. Trained graduate clinicians performed all assessments under the supervision of .00 (.32 (4.55) .52 % 100 % Tantrum Repetitive Behaviors Worry/Depressed Avoidant Under-eating Conduct Overeating Moderate impairment 4% 24.83) .83 % 100 % Moderate impairment 12 % 34.41 % 100 % Moderate impairment 0% 24.16 (.69 % 0% M (SD) 2.

ADHD. Matson and Wilkins 2008) with good test-retest and interrater reliability (κ=. all individual subscales on the ASD-CC have been found to have adequate internal consistency (αs=. the Childhood Autism Rating Scale (Schopler et al. The ASD-CC has 7-subscales: tantrum behavior. The ASD-CC (Matson and Gonzalez 2007a) assesses for symptoms of commonly occurring psychopathology in children between the ages of 2 and 16. checklists. Procedure Institutional review board approval and parent/guardian informed consent was obtained for the current study. Measures Autism Spectrum Disorders-Comorbidity Child Version (ASD-CC). Further. tic disorders. Asperger’s Syndrome. 2009) and moderately to strong correlations with relevant subscales on the Behavior Assessment System for Children. 1 (mild problem or impairment). .70–. When appropriate.51 and κ=. interviews about developmental and medical history were conducted with caregivers. American Psychiatric Association 2000) and International Statistical Classification of Diseases and Related Health Problems (ICD-10. avoidant behavior. For all participants in the ASD group. Anxiety disorders were diagnosed using consensus data from an assessment battery that included the Anxiety Disorders Interview Schedule for DSM IV—Child and Parent version (Silverman and Albano 1996).J Dev Phys Disabil (2014) 26:23–33 27 a licensed psychologist. Second Edition (Reynolds and Kamphaus 2004). and worry/depressed symptoms (Matson et al. Matson et al. or 2 (severe problem or impairment). the Autism Diagnostic Interview-Revised (Lord et al. and PDD-NOS was used to ensure diagnostic criteria for ASD were met. The ASD-CC is a caregiver-rated instrument and contains 37 items rated on a 3-point scale of severity: 0 (not a problem or impairment). Second Edition (Sparrow et al. and intellectual and achievement tests. Assessments for the ASD group varied based on participant age and level of functioning. A consensus procedure that integrated data from interviews. over-eating. Likewise. The ASD-CC assesses for anxiety. normative child and caregiver report scales. the Krug Asperger’s Disorder Index (Krug and Arick 2003). World Health Organization 1992) symptom criteria for Autistic Disorder. 2005). under-eating. Caregivers and their children completed the aforementioned measures during their comprehensive assessment at the clinic. and disordered eating symptomatology. and test results was used to make all diagnoses. 1994). a checklist of Diagnostic and Statistical Manual of Mental Disorders (DSM-IVTR. The total ASD-CC has been shown to be highly internally consistent (α=.86.46. conduct problems. 2009). respectively. repetitive behavior. Behavioral observations and caregiver rating scales were also included in ASD assessments. depression. other psychometrically sound instruments for ASD were also included such as the Autism Spectrum Disorders-Diagnostic Child Version (Matson and Gonzalez 2007b). and/or the Vineland Adaptive Behavior Scales. 1980). Matson and Wilkins 2008). rating scales. Child/adolescent assent was obtained when it was developmentally appropriate.91.

99]) demonstrated significantly more worry/depressed symptoms than children in the control group (M=. 4. A oneway multivariate analysis of variance (MANOVA) was conducted to determine the effect of diagnostic group (anxiety disorder. 7. 95 % CI [2.24.001) and children in the control group (M=.38. children with anxiety disorders demonstrated significantly more tantrum behaviors than children in the control group. 3. p<. F (2.001.50. ASD. Post-hoc analyses for all subscales were conducted using the Games-Howell test to account for unequal variances between groups as well as unequal sample sizes. Rates of tantrum behaviors differed significantly across the groups.28 J Dev Phys Disabil (2014) 26:23–33 Results Statistical analyses were conducted on the children’s scores on the ASD-CC.36]) demonstrated significantly more avoidant behaviors than children with anxiety disorders (M=3. p<. A significant Box’s M indicated that the homogeneity of variance matrix assumption was violated.007. p<. significance level. 5.16. 82)=42.001). No other comparisons were statistically significant. p<. Further comparisons indicated that children with anxiety disorder also significantly differed from children in the control group in rates of avoidant behaviors. Rates of avoidant behaviors differed significantly across the groups. Games-Howell posthoc comparisons of the groups indicated that children with ASD (M=7. Significant differences were found among the three diagnostic groups on the dependent measures.007) and children in the control group (M=. p<. p<.90.49].007.61.007. .09]. Wilks’ λ=.001). Games-Howell post-hoc comparisons of the three groups indicated that children with ASD (M=3.12.12]) demonstrated significantly more tantrum behaviors than children with anxiety disorders (M=3. Children with anxiety disorders (M=2. p<. 95 % CI . Games-Howell post-hoc comparisons of the three groups indicated that children with ASD (M=10.001. 82)=44.04. p<. 95 % CI [3. 82)=63.36. 95 % CI [2. F (2. p < .84. 95 % CI [2. The Bonferroni method was utilized for controlling Type I error rates for multiple comparisons and each ANOVA was tested at the (. Games-Howell post-hoc comparisons of the three groups indicated that children with ASD (M=7.46.48. A fourth one-way ANOVA was used to test differences in ratings of repetitive behaviors among the three diagnostic groups. p<. 82)= 23.23.24.07.24.001.41. .20. F (7.001). 12. 95 % CI [. F (2. 95 % CI [1.93. or . A second one-way ANOVA was used to test differences in ratings of avoidant behaviors among the three diagnostic groups.001.03]) also demonstrated significantly more worry/depressed symptoms than children in the control group.38. p<.001.001.51]. p<.88.21. Rates of repetitive behaviors differed significantly across the three groups.29. 4. A one-way ANOVA was used to test differences in caregiver ratings of worry/depressed behaviors among the three diagnostic categories. F (2. and control) on rates of comorbid behaviors. Univariate analyses of variance (ANOVAs) were conducted for each dependent variable as follow-up tests to the MANOVA. 8.51]. 95 % CI [−. Rates of worry/depressed symptoms differed significantly across the groups.05/7). 95 % CI [8. A third one-way ANOVA was used to test differences in ratings of tantrum behaviors among the three diagnostic groups.29. 95 % CI [6.96]. p<. Additionally.14.76)=9.

p<. worry/depressed behaviors. which replicates findings from previous studies (Chung et al. .001). both children with ASD and those with anxiety disorders exhibited more comorbid symptoms than children in the control group. 82)=4. 2008. repetitive behaviors. p<. In regard to children with anxiety disorders.15]) demonstrated significantly more repetitive behaviors than children with anxiety disorders (M=2. p<. Additionally. Games-Howell post-hoc comparisons of the groups indicated that children with ASD (M=2.007. 95 % CI [1.21].01. Discussion Rates of comorbidity are elevated in both children with ASD and those with anxiety disorders (Brown 2002. A fifth one-way ANOVA was used to test differences in rates of conduct behaviors across the three diagnostic groups. .64].03. a seventh one-way ANOVA was used to test differences in rates of overeating across the diagnostic groups.07]) demonstrated significantly more conduct behaviors than children in the control group (M=.J Dev Phys Disabil (2014) 26:23–33 29 [6. Rates of conduct behaviors differed significantly across the groups. we found higher rates of oppositional behavior than conduct behavior in children with ASD.001) and children in the control group (M=.00. No other comparisons were statistically significant at p<. p=.83. the aim of the current study was to examine rates of comorbid disorders across different diagnostic groups. 3.53. Steinhausen and Merzke 2004). we found high rates of avoidant/depressed symptoms. p<. 1990. The results of the current research supported our hypotheses. p<.001.007. No other comparisons were statistically significant at p<. p<. This relatively high rate of psychiatric comorbidity is common in children with anxiety disorders and can significantly impact treatment outcomes (Kendall et . 82)=9.007. No other comparisons were statistically significant at p<. F (2. 1998). An increase in comorbid symptoms is associated with increases in functional and emotional impairments.53]) demonstrated significantly more over-eating behaviors than children in the control group (M=. 2006. Rates of under-eating behaviors did not significantly differ across the three groups. 82)=20.13. and avoidant behaviors in comparison to children with no psychological diagnosis. In regard to children with ASD. Additionally. which is in accordance with previous findings that indicate high levels of comorbid anxiety disorders in children with ASD (Muris et al. 95 % CI [1. Thus.89. which affects long-term prognosis and treatment planning (Silverman and Ollendick 2008). LoVullo and Matson 2009).10. F (2. (2007) found anxiety disorders to be the second most common co-occurring disorder in children with ASD. 95 % CI [−. 3. Simonoff et al.64. De Bruin et al.001). 95 % CI [−. 95 % CI [−.01.16.001). therefore follow-up analyses were not conducted.001.33]. .35].48. Finally. A sixth one-way ANOVA was used to test differences in rates of under-eating across the diagnostic groups.36. 9.83. F (2. we found elevated rates of tantrum behaviors.16. Children with ASD evinced higher rates of comorbid symptoms than children with anxiety disorders. Games-Howell post-hoc comparisons of the groups indicated that children with ASD (M=1. 95 % CI [1. Leyfer et al.01.32. 2. Rates of over-eating behaviors differed significantly across the groups.

2001.30 J Dev Phys Disabil (2014) 26:23–33 al. 2005). Early identification is critical and produces the best long-term prognoses for these children (Matson and Smith 2008. but there is a scarcity of psychometric data on these modified measures. 2006). 2001). T. Manual for the ASEBA school-age forms and profiles. The ASD-CC was developed to address the need for an accurate measure of comorbidity that was specifically designed for use with children with ASD (Matson and Wilkins 2008). Attempts have been made to modify standard screening instruments for use with children with ASD (Leyfer et al. clinicians are encouraged to screen for a variety of comorbid disorders as part of a comprehensive psychological evaluation. This is similar to the use of the Achenbach scales (Achenbach and Rescorla 2001). because it helps clinicians develop individualized treatment plans with interventions to target multiple sources of impairment. 2005). Moree and Davis 2010. 2005. References Achenbach. Muris et al. L. & Rescorla. Previous research has focused on the effectiveness of identifying comorbid disorders in children with ASD utilizing broadband screeners of psychopathology that were intended for use with typically developing children (De Bruin et al. 2004. Department of Psychiatry. 1998). for example. A. academic difficulties. 2007. 2006). M. However. Cognitive and behavioral treatments have been shown to be highly effective at treating internalizing and externalizing symptoms in children with or without comorbid ASD (Barrett et al. Burlington: University of Vermont. Those with elevated ratings on the symptom subscales would then need to be evaluated with domainspecific assessments before a clinician could make any diagnostic decisions. (2001). Rapee et al. This method has been criticized by researchers and clinicians due to the absence of normative data for individuals with ASD (MacNeil et al. the use of the ASD-CC to screen for psychological disorders in children who are typically developing had not been previously examined. 2009). Sofronoff et al. Compton et al. Thus. The findings of this research have important implications for assessment of psychological disorders in children presenting with educational or emotional difficulties. Stewart et al. as initial screening instruments for atypical development or ASD. Russell et al. Identification of comorbid symptoms is critical in children presenting with developmental delays. Without population specific norms it may be difficult to determine if the measure is accurately distinguishing between symptoms of ASD and symptoms of anxiety or other disorders (Matson and Nebel-Schwalm 2007. or emotional problems. The ASD-CC could be utilized as an initial screening instrument for psychopathology in typically and atypically developing children. Declaration of Interests The authors report no conflicts of interests and are solely responsible for the content and writing of this paper. .. Findings from this study are supportive of the utilization of the ASD-CC as a broadband screener for symptoms of comorbid disorders in typically and atypically developing children.

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