Sociodemographic characteristics of patients with adult autism spectrum disorder

INTRODUCTION: The term “autism” was first mentioned by Bleuler as a sign of schizophrenia. However, Kanner used the term closer to its current conceptualization. He described “early infantile autism” characterized by an inborn “disorder of affective contact”. While Kanner’s descriptions of patients with Autism Spectrum Disorder (ASD) focused mainly on children, Asperger described some examples of adults with this condition. ASD is a neurodevelopmental disorder characterized by persistent deficits in social communication and interaction and restricted, repetitive patterns of behavior, interests or activities. Brugha et al. reported ASD prevalence rates of about 1%1 . People with ASD are more likely to be unmarried, poorly educated and economically deprived than the general population. In Turkey, there is limited data about adult ASD. In our study, we aimed to present sociodemographic characteristics of ASD patients.

METHOD: Medical charts of patients who presented to the psychiatry outpatient clinic at Istanbul Medical Faculty between January 2014 and January 2015 were reviewed. 44 individuals who fulfilled the criteria of ASD according to DSM-5 were detected. Parameters such as age, gender, education, working status, psychiatry comorbidities, psychotropic drug use, and IQ scores were noted. Upon rater evaluation, a rating score was derived by summing individual scores for independent living, friendships, and overall social outcomes.

RESULTS: 38 (86.4%) were male, 6 (13.6%) were female. Mean age was 20.8±2.3. Mean education time was 11.5±4 years. 56.8% of the patients had had special training, 38.6% of patients had had mainstream education. None of them was married. 79.5% of the patients had no specific occupation. 9.1% were part-time workers, 6.8% worked on a supported/sheltered basis, 4.5% were working full time. The comorbid psychiatric diagnosis rate was 91%. 11.3% had two or more comorbid psychiatric disorders. In decreasing order, the diagnoses were Mental Retardation (43.2%), Attention Deficit and Hyperactivity Disorder (20.4%), and Anxiety Disorder (9%). 91% of patients were using psychotropic agents, mostly antipsychotic drugs (65.9%). Based on the data of friendship relations, 27.3% of patients were rated as having a relationship with at least one other person in their age group, 25% of patients were rated as having no friends, 22.7% of patients were rated as having some acquaintances with whom they might talk or share activities, but these were generally within arranged social groups, 20.5% of patients were rated as having healthy relationships. 38.6% of patients still lived at home but with considerable independence, 6.8% of patients lived by themselves with only limited support. 22.7% of patients were rated as having a ‘good’ outcome, i.e., they were working with some support, could organize their own activities. 11.4% of patients had a ‘very good’ outcome, i.e., they were in paid employment, had some friends and a high level of independence.

DISCUSSION: ASD represents one of the most common neurodevelopmental disorders and can cause significant lifetime disabilities. The prevalence of ASD tends to remain stable, so those diagnosed with ASD during childhood are likely to suffer the disorder in adulthood. Nevertheless, the clinical characteristics may vary over time. Stereotyped movements and language problems, especially in subjects with a normal IQ, tend to decrease in severity and pervasiveness with age. On the other hand, obsessive-compulsive features (complex rituals, repetitiveness, and compulsions) often become the prominent aspect of the clinical picture. Impulsive behaviors, self-injuring and peculiarity of interests remain stable over time2 . With respect to social abilities, the literature quite uniformly reports that both expressive and receptive languages tend to improve with age. In addition, difficulties with fundamental social skills may decrease as children grow older; similarly, poor eye contact and reduced responsiveness and conflicts with peers are mitigated in adults. The most typical social manifestations of the autistic spectrum disorder in adults include dull intonation, repetitiveness on limited topics with difficulties in shifting attention between different subjects, deficits in discriminating emotional nuances and in communicating with others, poor sympathetic abilities, and a high tendency towards systematization of relationships2,3. Although the outcome of ASD in adulthood was extremely poor in studies conducted pre-2000, the prospects for patients have improved in the last 2 decades. Fewer adults were continuing to live with their parents, and a much smaller number compared to previous studies was in any form of hospital. Nevertheless, the mean percentage of patients having a good-very good outcome remains below 20%. The rate of patients who were in some form of work or educational programs remained relatively low4 . It has been evident that intellectual disability is one of the determining prognostic factors for ASD patients, with very few people with a childhood IQ below 75 living independently as adults. Early language development is another crucial factor. Thus most people who do well as adults have usually developed at least some useful speech by the age of 5 years. There also appears to be an association between the severity of early autistic symptomatology (severity of repetitive and stereotyped behaviors, level of impairment in the social domain, overall symptom severity) and later outcome. Mental health and medical problems also tend to have a negative impact on outcome. Although little is known about the effect of educational programs, appropriate educational programs may have a positive impact in later life4,5. Psychiatric comorbidity in adult ASD is highly frequent and may represent the main reason for high rates of psychotropic drug use. Different classes of psychotropic drugs have been suggested for specific dimensions of ASD. The majority of data are focused on second-generation antipsychotics in children and adolescents, with a supposed efficacy on some core dimensions of ASD as well as on the management of several comorbidities. Psychopharmacological treatment is essential for the management of some behavioral problems and comorbidities2 . Risperidone and aripiprazole are the drugs that have been studied most and have been shown to be effective in reducing psychotic symptoms (irritability; repetitive, aggressive, and impulsive behavior) and in improving some aspects of sociability in controlled clinical trials. They can also be useful in the management of the manic phases of Bipolar Disorder (BD)5 . Mood stabilizers are preferable as maintenance treatment in comorbid ASD-BD, although there is a substantial lack of studies in this area. Several observations suggest the efficacy and safety of anticonvulsants, particularly valproate and lithium. The use of antidepressants, both tricyclics and selective serotonin reuptake inhibitors should be considered in the presence of comorbid anxiety disorders5 . The category of ASD includes heterogeneous entities, in terms of both specific clinical manifestations and psychiatric comorbidities. The progression of ASD from childhood to adulthood is influenced by the severity of the clinical picture, gender, onset of neurological disorders, such as epilepsy during adolescence, and by psychiatric comorbidity. Due the heterogeneity of clinical manifestations and the poor knowledge of specific childhood disorders, adult psychiatrists too often underdiagnose ASD, classifying these patients as affected by mental retardation, schizophrenia, or other psychotic disorders2 . Long-term prospective investigations are needed in order to provide more extensive and appropriate supported living and employment schemes