JOURNAL OF MENTAL HEALTH RESEARCH IN INTELLECTUAL DISABILITIES

2016, VOL. 9, NO. 4, 232–249

http://dx.doi.org/10.1080/19315864.2016.1192708

Multidisciplinary Treatment for Adults with Autism

Spectrum Disorder and Co-Occurring Mental Health
Disorders: Adapting Clinical Research Tools to Everyday
Clinical Practice
Maurizio Battaglia , Susan Detrick, and Anna Fernandez
Hope Counseling Center, Hope Services, San Jose, California

ABSTRACT KEYWORDS
In California, individuals with autism and co-occurring mental Autism spectrum disorder;
disorders, and their families, face two serious barriers when co-occurring mental health
attempting to access the mental health services they need. The disorders; multidisciplinary
first is that the State Mental Health Specialty Service guidelines treatment
specifically exclude autism as a qualifying primary diagnosis for
eligibility for mental health treatment and funding. The second
is the lack of understanding and awareness regarding the
challenges faced by individuals with classic autism and co-
occurring mental disorders and their families. These two bar-
riers, combined with the absence of a clear protocol for referral
and assessment, have made access to services for clients and
their families difficult. The Adult Autism Spectrum Disorder and
Co-Occurring Mental Health Disorders project was an opportu-
nity to study potential assessment tools and referral guidelines.
We evaluated the use in a clinical setting of the Schedule for
the Assessment of Psychiatric Problems Associated with
Autism—a research instrument designed specifically for the
psychiatric evaluation of patients with autism—to assist in
diagnosing co-occurring mental health disorders. The experi-
ence gained in this study helped identify effective treatment
options as well. After the assessment, clients were offered
choices among several possible treatments fitting their specific
needs. Our experience indicates that while adapting a research
tool to everyday clinical service may encourage a more rigor-
ous standardized approach to clinical assessment and evalua-
tion, it may be difficult to employ such a tool in a clinical
setting because of service needs and managed care constraints
of serving a large and diverse population.

Autism spectrum disorders (ASD) are complex, lifelong, neurodevelopmental

conditions of largely unknown cause. They are much more common than
previously believed, affecting about 1% of the general population, second in
frequency only to intellectual disability among the serious developmental dis-
orders (e.g., Fernell & Gillberg, 2010). A heritable component has been

CONTACT Susan Detrick [email protected] Hope Counseling Center, 1555 Parkmoor Ave, San
Jose, CA 95128.
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/UMID.
© 2016 Taylor & Francis
 JOURNAL OF MENTAL HEALTH RESEARCH IN INTELLECTUAL DISABILITIES 233

suggested in ASD etiology and recent work has led to the identification of several
autism susceptibility genes (Abrahams & Geschwind, 2008). Environmental risk
factors may also play a role, perhaps via complex gene-environment interac-
tions, but no specific exposures with significant population effects are certain
(Newschaffer et al., 2007). Because no clear biological marker has been identified
yet, the diagnosis of autism is still based on generic criteria reflecting broadly
based behavioral manifestations (Bradley & Bolton, 2006; Tomanik, Pearson,
Loveland, Lane, & Shaw, 2007; Young & Brewer, 2002) such as those outlined in
the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR;
American Psychiatric Association, 2000). ASDs share a core triad of abnormal-
ities: (1) qualitative impairments in reciprocal social interactions, (2) qualitative
impairments in verbal and nonverbal communication, and (3) restricted social
imagination with repetitive and stereotyped patterns of interests and behavior
(Lugnegård, Hallerbäck, & Gillberg, 2011). Observational studies have revealed
high levels of co-occurring mental health disorders in ASD that are likely to be of
further detriment to long-term functioning and outcomes. Among others, co-
occurring mental disorders that commonly occur in ASD include aggression,
anxiety, phobias, hyperactivity, compulsive behavior, depression, and sleep
disorders (e.g., Levy et al., 2010; Lugnegård et al., 2011; Matson & Nebel-
Schwalm, 2007; Mouridsen, Rich, & Isager, 2008; White, Oswald, Ollendick, &
Scahill, 2009).
Although some symptoms of autism may show improvement over time,
the majority of individuals with autism may need substantial support
throughout their lives. Intellectual impairment and the development of
mental health problems during adolescence or early adulthood are strong
predictors of the long-term prognosis and outcome. For people with autism,
the poorest long-term diagnoses and outcomes are being experienced by
those with the severest intellectual impairment and those who develop
psychiatric problems (Matson & Shoemaker, 2009). Although a minority of
adults may achieve relatively high levels of independence, most remain very
dependent on their families or other support services. Few live alone, or have
close friends or permanent employment; communication generally is
impaired, and reading and spelling abilities are poor (Howlin, Goode,
Hutton, & Rutter, 2004).
Determining the prevalence of mental health disorders among individuals
with autism has implications for service development, treatment, and pre-
diction of outcomes. These disorders can themselves form important treat-
ment targets or could be indicative of the presence of a co-occurring
condition requiring further investigation. Finally, even if the field of autism
spectrum disorders is expanding at an exponential rate (Matson & LoVullo,
2009), in our experience adapting clinical research tools (designed specifically
for the psychiatric evaluation of patients with autism) to everyday clinical
practice is still a field with many challenges (Proctor et al, 2009).
234 M. BATTAGLIA ET AL.

One of the most critical issues in mental health services research is the gap
between what is known from research and what is provided to consumers in
routine care (Proctor et al, 2009). The implicated barriers are numerous. The
one most cited by practitioners is the difficulty in applying treatments that
have been developed in the controlled environment of academic research to
the real world of everyday practice.
Furthermore, there are risks and benefits in adapting clinical research tools
for everyday clinical service. Adapting a clinical research tool to everyday
clinical service may encourage a more rigorous, standardized approach to
clinical assessment and evaluation, and allow for the use of hard data to
advocate for access to and better mental health services available for persons
with autism. On the other hand, service needs and the constraints from
budgets and managed care may be in conflict with the rigid protocols
designed to ensure the internal validity of clinical research (e.g., the ability
to select a random sample of people with ASD to test a new diagnostic tool;
Green, Glasgow, Atkins, & Stange, 2009).

California Innovation Projects

The Santa Clara County Mental Health Department (California, USA) has
identified two serious barriers for clients with autism and their families
attempting to access the mental health services they need. The first is that
the California State Mental Health Specialty Service Medical Necessity guide-
lines, which apply to county and contract agency mental health programs,
specifically exclude autism as a qualifying primary diagnosis for mental health
treatment and funding. The second is a lack of understanding and awareness
of individuals with classic autism and co-occurring mental health disorders.
The goal of the Innovation Project (INN-03), funded through California
Proposition 63, the Mental Health Services Act, was to test and evaluate an
assessment tool that would increase access for individuals and expand treat-
ment options. In particular, we investigated whether the Schedule for the
Assessment of Psychiatric Problems Associated with Autism (SAPPA) by
Bolton and Rutter (1994) could be utilized in a clinical setting and assist in
diagnosing co-occurring mental health disorders.
The SAPPA (Bolton & Rutter, 1994) is a semi-structured evaluation tool
—based on interviews with the client and/or an informant—developed for
clinical research. SAPPA helps in identifying each autistic individual’s
unique baseline of behaviors and symptoms (prior to the onset of any
psychiatric distress) and then determines whether changes from this
unique baseline represent a new onset psychiatric disorder according to
the Research Diagnostic Criteria (RDC) for major psychiatric disorders
(Spitzer, 1989). SAPPA differentiates between those disturbances that were
long-standing and those that were episodic, and assessed if these
 JOURNAL OF MENTAL HEALTH RESEARCH IN INTELLECTUAL DISABILITIES 235

Table 1. Adjusted SAPPA Psychiatric Diagnoses.

Original diagnosis based on RDC Adjusted diagnosis based on DSM-IV-TR
Manic disorder Bipolar disorder
Hypomanic disorder
New diagnoses not present in the original SAPPA
ADHD
Impulse control
PICA

disturbances met clinical criteria for psychiatric illness. Episodic psychia-

tric disorders (such as mood and psychotic disorders) represent some of
the most frequently presented mental health disorders found in the general
population (Bradley & Bolton, 2006). Furthermore, the SAPPA can pro-
vide an assessment framework for use by the clinician experienced in the
psychiatric assessment of persons with autism and with intellectual dis-
abilities, and has been used in a number of follow-up studies (Bolton et al.,
2011; Bradley & Bolton, 2006; Hutton, 1998; Hutton, Goode, Murphy, Le
Couteur, & Rutter, 2008).
Because of the need to adapt a research tool to the reality of an outpatient
clinic in Santa Clara County, California, psychiatric diagnoses were adjusted
to better reflect the DSM-IV-TR (American Psychiatric Association, 2000).
The diagnoses described in the final assessment schedule of the SAPPA are
rooted in the Research Diagnostic Criteria (Spitzer, 1989) and the British
clinical and academic environment. The Research Diagnostic Criteria were
associated with the DSM-III (American Psychiatric Association, 1980;
Spitzer, 1989). For these reasons, the clinical staff of Hope Counseling
Center modified—for internal use only—some of the original criteria so
that they could better fit the clinical environment of a mental health clinic
in California (see Table 1). Finally, a digital version of the SAPPA was
created to make administration of the instrument more efficient, implement
paperless storage, and manage the dissemination of data.

Method
Selection of Participants
The study was conducted in several successive stages, including:

(1) identifying the population and inviting participants to the study;

(2) doing individual (chart review) assessments of participants to ensure
there was a previous autism diagnosis present in the medical records;
and
236 M. BATTAGLIA ET AL.

(3) completing individual psychiatric assessment of clients using the

SAPPA interview for clients and/or parent/caregivers and the Santa
Clara County Mental Health Clinic psychiatric assessment tool.

Signing of appropriate informed consent forms occurred prior to partici-

pation in the study. The Santa Clara County Internal Review Board approved
both the consent form and the study.
Clients with autism living in Santa Clara County were identified through
referrals from the San Andreas Regional Center (SARC), HOPE Services, and
the Santa Clara County Mental Health Call Center. Clients had been diag-
nosed with autism but showed problems for which it was unknown if they
were related to autism or a co-occurring mental illness. The clients referred
by the outside referral sources did not have official mental health diagnoses.

Psychiatric Assessment
The first part of the SAPPA focuses on identifying episodes of behavioral
change against the background of usual baseline behaviors for the individual;
the latter include pervasive and chronic problems that may have been present
from an early age (such as self-injurious, hyperkinetic, obsessive, compulsive,
and other anxiety-type behaviors, tics, stereotypies and other non-specific
challenging behaviors). A significant part of the interview is spent, therefore,
establishing baseline behaviors for the individual against whom any episode
of change in behavior is evaluated (see Bradley & Bolton, 2006).
The criteria employed to evaluate an episode of behavior change include
(Bolton & Rutter, 1994):

(1) psychotic symptoms (delusions, hallucinations, catatonia, etc.);

(2) a change in behavior outside the range of normal variation for the
individual;
(3) definite diminution in level of social functioning as shown by at least
two of the following: loss of interest in play, loss of self-care, loss of
social involvement, loss of initiative; and
(4) need for change in supervision and/or placement.

Episodes of changed behavior are explored further to obtain systematic

standardized information on symptoms. A symptom is deemed clinically
significant if:

(1) it is outside the range of normal behavior for that individual;

(2) it intrudes into, or disrupts, the individual’s ordinary activities;
 JOURNAL OF MENTAL HEALTH RESEARCH IN INTELLECTUAL DISABILITIES 237

(3) it is of a degree that is not readily controlled by the individual or

caregivers; and
(4) it is sufficiently pervasive to extend into at least two activities.

In addition, the duration of each episode is determined, as well as the

timing in the context of other circumstances (e.g., life events such as loss,
bereavement, medication changes, or medical concerns such as seizures)
occurring in the person’s life. The symptoms during an episode that meet
diagnostic criteria and the pattern of the episodes are used to establish a
psychiatric diagnosis.
Psychiatric disorders are identified as being absent, possible, probable, or
definite according to SAPPA criteria. Episodic psychiatric disorders identi-
fied using the SAPPA interview include mood, anxiety, and psychotic dis-
orders. Disorders with intensity level 2 or above for three prominent
symptoms are referred to as unclassified disorders if the pattern of symptoms
is not clearly indicative of a specific DSM-IV-TR diagnosis.
A full SAPPA evaluation requires a face-to-face clinical interview with
the client and/or the caregivers (informants) for nonverbal clients. The
SAPPA interviews were administered by licensed clinicians, one clinical
social worker, and two PhDs in clinical psychology with more than 20 years
of experience in developmental and psychiatric evaluations. All were
experienced in diagnosis of autism, as well mental health disorders as
they present in individuals with developmental disabilities. Specific training
in the use of SAPPA was from a training of one of the SAPPA authors (Dr.
Bolton) to two clinical project monitors from our county, who trained
Hope clinicians, and information available in the existing literature (e.g.,
Bradley & Bolton, 2006; Bolton & Rutter, 1994). Difficult diagnoses were
discussed during the weekly staff meeting of the clinic. Although these
practices may not perfectly comply with the rigorous requirements for
clinical research, they are all well-established, appropriate clinical practices
for a working outpatient treatment clinic.
In the first part of the SAPPA interview, inquiry is also made as to the
family history of psychiatric illness. The second part of the SAPPA interview
deals with behaviors and disorders that do not follow an episodic course (e.g.
some self-injurious, hyperkinetic, obsessive, compulsive and other anxiety-type
behaviors; tics; stereotypies; and other nonspecific challenging behaviors)—see
also Bradley and Bolton (2006). Interviews were completed with information
provided by either parents (67%) or caregivers (28%); only 4% of the clients
interviewed have been able to self-report—with an average contact of 19.6
years (standard deviation: 11.7 years); 72% of the informants were in contact
with the clients every day, 23% weekly, and 4% every month. Diagnoses were
established using the specific criteria defined in the DSM-IV-TR. Data collected
using the SAPPA are reported in Table 2.
 238

Table 2. Data Collected during the INN-3 Project.

Medication
Number of episodic disorders
Client # Age Gender Housing Sleeping Mood Stabilizer Anti-psychotics Stimulants Antidepressant Autism Epilepsy Anxiety Definite Probable
1 40 M H Y Y 1
2 19 F BCH Y Y Y 1 1
3 20 M H Y Y 1
4 23 F H Y Y Y Y 1 1
5 20 M BCH Y Y Y 1 2
M. BATTAGLIA ET AL.

6 26 M BCH Y Y Y Y Y Y Y 1 1
7 47 F BCH Y Y Y Y Y 1 1
8 21 M BCH Y Y Y 1 1
9 18 F H Y Y Y Y 3
10 21 M H 1
11 21 M H Y Y Y Y 1
12 29 M N/A Y Y Y Y 1 1
13 27 M BCH Y Y 1 1
14 29 F H Y Y Y Y 1
15 24 F BCH Y Y 1 1
16 35 F BCH Y Y Y Y Y 1 2
17 19 M H Y Y 1 4
18 30 M BCH Y Y Y Y Y 1
19 29 M H Y Y Y Y 1 1
20 27 M BCH Y Y Y Y Y Y 1 3
21 21 F H Y 2
22 25 M BCH Y Y Y 1 2
23 28 M H Y Y Y 1 1
24 20 M BCH Y Y Y Y Y 2 1
25 18 M H Y Y 1 3
26 24 M BCH Y Y Y Y Y 1 2
27 19 M H Y Y 1
28 43 M H Y Y 6
29 18 M H 4
(Continued )
Table 2. (Continued).
Medication
Number of episodic disorders
Client # Age Gender Housing Sleeping Mood Stabilizer Anti-psychotics Stimulants Antidepressant Autism Epilepsy Anxiety Definite Probable
30 20 F H Y Y Y 2 4
31 40 M BCH Y Y Y Y Y Y 2
32 27 M H Y Y Y Y 2
33 21 M H Y 1 4
34 29 M BCH Y Y Y Y 1 2
35 18 M H Y Y 5
36 18 F BCH Y Y 2
37 18 M BCH Y Y Y Y 1
38 22 M H Y Y 3
39 35 F H Y Y Y 1 1
40 22 M BCH Y Y Y Y Y 2 2
41 21 M H Y 3
42 18 M H Y 3 3
43 42 F H Y Y Y 2
44 20 M H Y Y Y Y 4 2
45 20 M H Y Y Y 3
46 20 M H Y Y Y 2 1
47 42 M BCH Y Y Y 2
48 21 M BCH Y Y Y Y 1 1
49 20 M H Y Y Y Y Y 2 2
50 22 M H Y Y Y Y Y 2 1
51 20 F H Y Y Y Y 3 1
52 24 M BCH 1 2
53 22 M H Y Y Y Y Y 3 1
54 29 M BCH Y 1 3
55 51 M H Y 3 2
JOURNAL OF MENTAL HEALTH RESEARCH IN INTELLECTUAL DISABILITIES

56 20 M H Y Y Y 2
57 30 M H Y Y Y 5
58 20 M BCH Y 1
(Continued )
239
Table 2. (Continued).
240

Medication
Number of episodic disorders
Client # Age Gender Housing Sleeping Mood Stabilizer Anti-psychotics Stimulants Antidepressant Autism Epilepsy Anxiety Definite Probable
59 28 M BCH Y Y Y 2
60 21 F BCH Y Y 2
61 47 M H Y Y Y 2
62 52 M BCH Y Y Y Y 4
63 20 M H Y Y 4
M. BATTAGLIA ET AL.

64 46 M BCH 1
65 21 M BCH Y Y 1 1
66 44 M BCH 1
67 22 M H Y 3
68 57 M BCH Y Y Y 4
69 32 M BCH Y Y Y Y Y 2
70 19 M H Y Y Y Y 3
71 58 M BCH Y Y Y Y Y Y 2
72 21 F BCH Y Y 1
73 29 M BCH Y Y Y 2
74 20 M BCH Y Y Y 2
75 43 M H Y Y Y Y 2
76 53 F N/A Y Y Y 4
77 26 M H Y Y 1
78 40 M H Y 2
79 22 M H Y Y Y Y 2
80 18 M H Y 2
81 46 M H Y 2
82 19 M H Y Y 3
83 18 M H Y Y 3
84 21 M BCH Y Y Y Y Y 1 3
85 19 M BCH Y Y 2 2
86 51 M BCH Y Y Y 2
87 27 M BCH Y Y Y Y 4 2
(Continued )
Table 2. (Continued).
Medication
Number of episodic disorders
Client # Age Gender Housing Sleeping Mood Stabilizer Anti-psychotics Stimulants Antidepressant Autism Epilepsy Anxiety Definite Probable
88 37 F H Y Y 1 3
89 32 M H Y Y Y 2
90 21 M H Y Y Y Y 1 4
91 46 M BCH Y 3
92 19 M H Y Y Y Y Y 1 2
93 21 M H Y 1 1
94 18 F H 3
95 26 M H Y Y 1 1
96 19 M H Y Y Y Y Y Y 1 6
97 20 M H Y Y Y 1 3
98 18 M H 4
99 21 M BCH Y Y Y 2 1
100 31 M BCH Y 1 1
101 18 M H Y Y Y 1 1
102 41 M BCH Y Y Y Y Y 1 3
103 49 M BCH Y Y Y 1 1
104 19 M BCH Y Y 3
105 28 M H Y Y Y 1 2
106 21 M H Y Y Y 1 5
107 22 M H Y Y 2
108 18 M BCH Y Y Y Y 2 4
109 18 M H Y Y Y Y 2 3
110 18 M H Y Y 1 4
111 20 M BCH Y Y Y Y 1 3
112 18 M H Y Y Y 1 1
113 39 F BCH Y Y Y 1 2
JOURNAL OF MENTAL HEALTH RESEARCH IN INTELLECTUAL DISABILITIES

114 21 M H Y Y Y Y 3 6
115 48 M BCH Y Y Y Y 5
116 34 M BCH Y Y Y Y Y 3 5
241

Note. H: Home; BCH: Board/Care Home; Y: Yes.

242 M. BATTAGLIA ET AL.

Results
Demographics
Whites (non-Hispanic) comprised the largest ethnic group (56%), followed
by Asians (24%) and Hispanics (17%)—for a total of 97% of total clients
interviewed. The ethnic composition of the County of Santa Clara consists of
Whites (35%), Asians (33%) and Hispanics (27%) totaling 95% of the county
population, according to figures from the 2010 US Census (available online
at quickfacts.census.gov/qfd/states/06/06085.html). The clients involved in
this study were young adults. The median age was 22 years, average age
27.1 years, with a standard deviation of 10.5 years. Eighty percent of clients
were between 18 and 35 years old. While a significant percentage of clients
were living in board/care homes (44%), the majority of the clients involved in
this project were living with the family of origin (55%). Only one client was
able to live independently.

Co-Occurring Diagnoses
The SAPPA allows four different levels of likelihood for a psychiatric dis-
order (absent, possible, probable, or definite). We present quantitative data
for both definite and probable diagnoses (see Figure 1). A definite diagnosis
meets all the DSM-IV-TR psychiatric criteria for mental disability; a probable
diagnoses does not reach the DSM criteria mainly because of communication
difficulties (e.g., the client is not verbal). Probable diagnoses have been
proposed for 28% of clients (Figure 1a).
Data from the SAPPA surveys indicate a broad range of definite co-
occurring diagnoses (Figure 1b). The three more common co-occurring
diagnoses (affecting 69% of clients) are impulse control (28%), followed by
anxiety disorder (17%) and obsessive-compulsive disorder (14%). The more
common probable co-occurring diagnoses are major depression (34%) and
impulse control (14%); see Figure 1c.
The large percentage of definitive diagnoses present can be explained by
the fact that we did not work with a random population sample. A compar-
ison between existing and SAPPA psychiatric assessment for the 10 HOPE
clients involved in the study is available in Table 3.

Treatment Options
Clients evaluated through the project have access to several treatment options
fitting their individual diagnoses (see Figure 2). Caregivers (e.g., family mem-
bers, case managers, residential care facility staff, legal guardians) and others
 JOURNAL OF MENTAL HEALTH RESEARCH IN INTELLECTUAL DISABILITIES 243

(a)
50%

Percentage of Clients
Clients = 116
40%
30%
(%) 20%
10%
0%
probable 1 2 3 4 5
(b) Number of Co-occurring Diagnosis per Client
Percentage of Clients (%)

30%
25%
20%
15%
10%
5%
0%

Co-occurring Definite Diagnosis

35%
(c) 30%
Percentage (%)

25%
20%
15%
10%
5%
0%

Co-occurring Probable Diagnosis

Figure 1. Definite and probable co-occurring mental illness diagnosis, based on SAPPA inter-
views of 90 clients from Santa Clara County, California. Note. (a) Number of clients with probable
diagnoses and number of co-concurring definite diagnoses; (b) Co-occurring definite diagnoses;
(c) Co-occurring probable diagnoses. OCD: obsessive compulsive disorder; Imp Cont: impulse
control; Anxiety Dis: anxiety disorder; Major Deprsn: major depressive illness; ADHD: attention-
deficit/hyperactive disorder; Bipolar: bipolar disorder; Eating Dis: eating disorder.

Table 3. Existing and SAPPA Psychiatric Assessment for 10 HOPE Clients.

SAPPA
Client ID Existing disorder Definite disorder Probable disorder
1 300.3 Obsessive compulsive Obsessive/compulsive
33 300.0 Anxiety NOS Anxiety Obsessive/compulsive, phobia
34 295.70 Schizoaffective Schizoaffective Obsessive/compulsive
39 300.3 Obsessive compulsive Obsessive/compulsive
40 312.34 Intermittent explosive ADHD, impulse control Anxiety
61 312.3 Impulse control NOS Impulse control, anxiety ADHD, obsessive/compulsive
65 296.9 Mood NOS Impulse control Tics
77 296.33 Major depression Major depression
78 311 Depressive NOS Major depression
88 312.3 Impulse control DNOS Impulse control Anxiety, obsessive/compulsive
244 M. BATTAGLIA ET AL.

Figure 2. Treatment options: (a) treatment available to clients; (b) number of treatment choices
per client.

directly responsible for the wellbeing of the client had access to collateral therapy
(individual or family). Medication management was the most frequently treat-
ment chosen (36%), followed by individual counseling with or without art
therapy (19%), collateral therapy (15%), and social skills group (13%).
The majority (66%) of clients involved in the SAPPA study chose to take
advantage of two or more treatment options; only 4% of clients involved in
this study declined any treatment. It is worth noting that Innovation Projects
are designed for voluntary participation and no person can be denied access
solely on voluntary or involuntary status.

Prescribed Medication
According to information extracted from the SAPPA, 94% of the clients
involved in this study had at some point received psychotropic medication
(Table 2). Antidepressants (70% of clients), antipsychotics (63%), and mood
stabilizers (47%) were most frequently prescribed. Clients were also pre-
scribed medications for epilepsy (29%) and sleeping (32%), stimulants
(32%), and anti-anxiety medications (16%). A small group (6%) received
medication (generally risperidone) to treat autism. Fifty-seven percent of the
clients were multi-medicated, taking 3 or more psychotropic drugs. For
example, 35 out of 73 individuals who received antipsychotic medication
also received antidepressant and mood stabilizer medication (Table 2).
 JOURNAL OF MENTAL HEALTH RESEARCH IN INTELLECTUAL DISABILITIES 245

Discussion
Psychiatric Disorder
The focus of the present study was on testing whether the SAPPA (Bolton &
Rutter, 1994) could be employed in a clinical setting to better assess co-
occurring psychiatric illness, to provide clients with mental health service
and help clients and their families to choose the treatment best fitting their
unique needs. Because of the nature of work at an outpatient clinic, we would
like to mention that this is a study on referred clients.
We found that almost two in three of the clients involved in this study
had a definite diagnosis of mental illness and many of the clients had
more than one co-occurring mental illness diagnosed (Figure 1 and
Table 2). The wide range of significantly elevated psychiatric disorders
diagnosed indicates that autism in adult populations is not associated with
just one specific mental disorder. This finding is in agreement with
similar studies on adults diagnosed with autism (Kanne, Christ, &
Reiersen, 2009). On the other hand, the prevalence of anxiety and mood
disorders relative to psychotic disorder reported in this study, using an
instrument more specifically designed for persons with communication
and cognitive impairments, is in accord with similar studies on mood
disorders in persons with autism (DeLong, 2004; Kim, Szatmari, Bryson,
Streiner, & Wilson, 2000; Lainhart & Folstein, 1994). While previous
studies have suggested that depression is probably the most common
psychiatric disorder seen in those with autism (Ghaziuddin, Ghaziuddin,
& Greden, 2002), we found that in our population impulse control,
anxiety, and obsessive-compulsive disorders may also have a significant
influence (Figure 1). Individual adults with autism may experience
chronic stressors which are beyond their capacity to escape or change
independently, and which may not be recognized by care providers. We
used the data on onset and continuation of challenging behaviors to alert
care providers to possible adjustment disorders and to look for possible
stressors in the individual’s life.
Our data show a gender ratio (male to female) of 5.1:1 (97 male and 19
female clients). Again, these results are in accord with existing epidemio-
logical studies. For example, Newschaffer et al. (2007) report that males
represent a higher risk group than females. Males are affected with autism
spectrum disorders more frequently than are females, with an average
male-to-female ratio of 4.3:1. The gender ratio is modified substantially by
cognitive impairment; among cases without intellectual disability the gen-
der ratio (male-to-female) may be more than 5.5:1, whereas among those
with intellectual disability the gender ratio (male-to-female) may be closer
to 2:1.
246 M. BATTAGLIA ET AL.

Prescribed Medication
Definite and probable diagnosis groups did not differ significantly in lifetime
exposure to psychotropic medication (Table 2). The large use of antidepres-
sants (prescribed to 70% of the clients) is in agreement with previous studies
suggesting that depression is probably the most common psychiatric disorder
seen in those with autism (Ghaziuddin et al., 2002). It is worth noting that
depression was the fourth definite diagnosis and the first of probable diag-
noses (Figure 1). Mood stabilizers were used to reduce the impact of irrit-
ability, hyperactivity, and repetitive behavior in 47% of the population.
However, the individuals with autism also more often received stimulant
medications (32% in our study). It seems likely that stimulants were pre-
scribed for the treatment of hyperactivity and attentional problems, which
are often comorbid problems with autism (Geurts, Verté, Oosterlaan,
Roeyers, & Sergeant, 2004). Although a definitive psychosis and schizophre-
nia were diagnosed only in a small sample of our population (6% and 1%,
respectively), it is worth noting that 63% of the population was prescribed
anti-psychotic medication to treat psychotic symptoms (hallucinations, cat-
atonia, delusions, paranoia) that are common in a substantial proportion (up
to 50%) of adults with ASD (Taylor, 2016). It is noteworthy that 48% of the
individuals who received mood stabilizers and antidepressants also received
antipsychotics, together with 63% of clients receiving anxiety medication.
This suggests that individuals with autism often present with a complex mix
of behavioral and psychiatric problems that require treatment with several
drugs (Peacock, Amendah, Ouyang, & Grosse, 2012). The percentage of
clients affected by seizures in our study is 29%, the same order of magnitude
reported in other studies (Olsson, Steffenburg, & Gillberg, 1988). The asso-
ciation of autism with clinical or subclinical epilepsy is well known and might
denote common genetic factors in some cases (Tuchman & Rapin, 2002).

Summary and Conclusions

The focus of the present study was the application and evaluation of the
Schedule for the Assessment of Psychiatric Problems Associated with
Autism (and Other Developmental Disorders) (SAPPA; Bolton &
Rutter, 1994) within a clinical setting. We attempted to modify a research
instrument (designed specifically for the psychiatric evaluation of patients
with autism) for use in everyday practice. This investigation (Innovation
Project INN-3) was also an effort to increase access to care and expand
treatment options to adults with autism spectrum disorders and co-
occurring mental health disorders. This study involved 116 individuals
in Santa Clara County, California, referred by county agencies. Finally,
this was the only Innovation Project in California that addressed any
 JOURNAL OF MENTAL HEALTH RESEARCH IN INTELLECTUAL DISABILITIES 247

issues pertaining to individuals diagnosed with autism. Given that the

California State Mental Health Specialty Service Medical Necessity guide-
lines specifically exclude autism as a qualifying primary diagnosis for
mental health treatment and reimbursement, the correct identification
of co-occurring mental health disorders is a key to helping clients and
caregivers obtain the most appropriate treatment to fit their unique
diagnosis.
The SAPPA survey is rooted in a research environment and may need
significant adaptation to make it consistent with the clinical needs of mental
health clinics in Santa Clara County. In particular, we reviewed the SAPPA to
make it consistent with the latest Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV-TR and now DSM-5).
Our experience indicates that on one hand a semi-structured interview
using information gathered from an informant/caregiver/parent may assist
clinicians to better identify the co-occurring mental health disorders, but on
the other hand there may be some issues in employing a diagnostic tool
developed for academic research in a clinical setting because of service needs
and managed-care constraints of serving a large and diverse population. The
risks include compromising the rigor of research methodology because of
service needs. For example, a clinic may not be able to implement standar-
dized training in the use of the SAPPA, or the necessary protocols to ensure
reliability and validity in its application (e.g., because of the length of the
instrument—over 70 pages long—some clients/parents/caregivers may object
to undergoing the interview).

Acknowledgments
Comments from S. Einfeld (Associate Editor) and two anonymous reviewers greatly helped to
improve our article.

Funding
This research was supported by the Santa Clara County Innovation Project INN-03 grant,
funded through California Proposition 63, the Mental Health Services Act (MHSA), awarded
to Hope Services’ Counseling Center.

ORCID
Maurizio Battaglia http://orcid.org/0000-0003-4726-5287

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