Mental Health Blog

Tips for Managing Mental Health Disorders in Children with Autism

• April 24, 2025
• The REACH Institute
• Assessment & screening, Autism, Child mental health

“It used to be that when a diagnosis of autism was given, no other mental health comorbidities could be recognized,” explains Ruth E.K. Stein, MD, a REACH faculty member and Professor of Pediatrics at Albert Einstein College of Medicine and the Children’s Hospital at Montefiore. “That changed in 2013 with the release of the DSM-5. For the first time, we could give additional mental health diagnoses to children with Autism Spectrum Disorder (ASD).”

Research has since revealed that children with ASD are far more likely than typical children to also have mental health disorders. Studies show that up to 78% of children with autism have at least one comorbid mental health disorder, with conditions emerging as early as preschool for 44% of children. This suggests children with ASD should be screened early and often.

Yet, making a mental health diagnosis can be challenging in children with ASD. This is because of the wide range of ways that autism affects individuals (from severely impaired children to those who are high-functioning) and the fact that intrinsic symptoms of autism may overlap with some mental health disorders like anxiety and OCD.

To help clinicians, Dr. Stein walks us through the basics of what primary care providers should know about screening and treatment for mental health disorders in pediatric patients with autism.

Screening for Comorbid Mental Health Disorders in Children with ASD

The most common mental health disorders diagnosed in children with ASD, with rates higher than the general population, are behavior disorders, ADHD, anxiety, OCD, and depression. Children and youth with ASD also have disproportionately high rates of suicidality.

Few pediatric mental health screening tools have been validated in children with ASD, as of this writing, with some exceptions:

• For anxiety, the PROMIS Autism Battery developed by the NIH and the Parent-Rated Anxiety Scale for ASD (PRAS-ASD) have both been validated in children with autism.

• The Vanderbilt assessment scale is often used for screening for ADHD, but it is not a diagnostic instrument. A benefit is that it relies heavily on reporting from parents, teachers, and others who interact with the child, reducing the need to rely on self-reporting, which is often difficult for children with greater ASD impairment.

• For most mental health conditions, clinicians must rely on a combination of general screening tools, close observation, and input from caregivers.

In all cases, Dr. Stein advises clinicians to focus on identifying changes in behavior that may indicate a mental health disorder. This is especially critical when children cannot communicate well, particularly about their emotions.

Behavioral changes reported by parents, teachers, or other caregivers can provide key insights in these cases. For example, a child with autism who develops anxiety may show new avoidance of certain situations. This may manifest as withdrawal or temper tantrums as the child attempts to avoid something. A child may start sleeping poorly, biting their nails, or changing other small habits, such as becoming extremely fidgety or stimming more (e.g., flapping, rocking, bouncing).

Noticing changes in behavior over time is essential for distinguishing between core features of autism and symptoms of mental health conditions. For instance, repetitive or ritualistic behaviors—hallmarks of an autism diagnosis—may closely resemble behaviors seen in anxiety or obsessive-compulsive disorder (OCD), but they often have different underlying motivations or patterns.

“As with any other chronic condition, it has to be a real partnership between the clinician and the family,” explains Dr. Stein. “There has to be ongoing dialogue.” You need to look at not only the symptoms of the condition but also how they impair the child’s functioning.”

Treatment Considerations: Autism as a Spectrum Disorder

Since children and adolescents with ASD can range from highly functional to severely impaired, Dr. Stein explains that “the different ends of the spectrum require different approaches to diagnosing and treating comorbid mental health disorders.”

Clinicians will need to consider which evidence-based treatments the child can actively participate in and benefit from. For example, in treating anxiety and depression, Cognitive Behavioral Therapy (CBT) should be a first-line therapy for high-functioning children and adolescents with autism. However, CBT would not be an option for children who are more impaired or nonverbal.

In treating ADHD, evidence suggests that standard ADHD medications are effective for children and youth with ASD, though some have difficulty taking medication due to sensory issues. Clinicians may need to experiment with different medication formulations. As with children without ASD, clinicians will also want to work with parents on updating any school-based accommodations.

Talking about Mental Health with Parents of Children with ASD

Finally, Dr. Stein suggests being prepared for communicating with parents, who may experience a mental health diagnosis for their child with ASD as “yet another thing wrong with their child.” 

Clinicians can help parents understand that mental health conditions are common, that research shows children with ASD are at especially high risk of having co-occurring mental health conditions, and that neither the autism nor the other mental health conditions are their fault.

RESOURCES

• While treating mental health conditions in children with ASD can be complicated, new recommendations for treating specific conditions are emerging. 
  
  • In 2023, the American Psychiatric Association and American Academy of Child & Adolescent Psychiatry co-published ADHD in Youth with ASD: Parents’ Medication Guide. 
  • Research also reinforces the effectiveness of CBT for treating anxiety in children with autism. 
  • The SPARK for autism research network shares emerging best practices for managing depression in autistic patients, as do research papers on the topic.  
  • The International OCD Foundation has compiled current recommendations for treating OCD in autistic patients. 

• For more information on how autism may manifest at different ages, check out this article.
• The REACH Mental Health Blog also offers advice on using CBT to treat depression and anxiety.