These answers draw in part from “**Co-occurring Autism Spectrum and Mental Health Disorders: What Practitioners should Know, Do, and Say, when it comes to Prevalence, Risk factors, Screening, Referral, and Care Coordination” by Allyson Moore, M.S., BCBA, LMFT (BehaviorLive), and extend it with peer-reviewed research from our library of 27,900+ ABA research articles. Clinical framing, BACB ethics code references, and cross-links below are synthesized by Behaviorist Book Club.
View the original presentation →The most commonly co-occurring mental health disorders with autism include anxiety disorders (including generalized anxiety, social anxiety, and specific phobias), attention-deficit/hyperactivity disorder, depression, obsessive-compulsive disorder, and sleep disorders. Prevalence estimates vary, but research consistently shows that these conditions occur at significantly higher rates in autistic individuals compared to the general population. Some estimates suggest that up to 70% of autistic individuals meet criteria for at least one co-occurring mental health condition, and approximately 40% meet criteria for two or more. These conditions can emerge at any age and may become more apparent during transitions such as school entry, adolescence, or changes in service provision.
Diagnostic overshadowing occurs when the presence of a primary diagnosis, such as autism, leads clinicians to attribute all behavioral and emotional symptoms to that diagnosis, overlooking co-occurring conditions that require separate identification and treatment. For behavior analysts, this is relevant because they may inadvertently engage in diagnostic overshadowing by attributing behavioral changes to autism-related characteristics or environmental variables without considering the possibility of a co-occurring mental health condition. For example, increased rigidity might be attributed to autism rather than investigated as a potential symptom of anxiety. Awareness of diagnostic overshadowing helps behavior analysts maintain a broader clinical perspective.
No. Diagnosing mental health conditions falls outside the scope of practice for behavior analysts. Diagnosis is the purview of licensed psychologists, psychiatrists, and other qualified mental health professionals. However, behavior analysts have an important role in recognizing signs that may indicate a mental health condition and facilitating appropriate referrals. Behavior analysts are uniquely positioned to observe behavioral changes over time, collect systematic data on behavioral patterns, and provide detailed information to diagnosticians that can support the evaluation process. The ethical behavior analyst works within their scope while ensuring clients access the additional services they need.
Anxiety in autistic individuals may present as increased repetitive behaviors or stimming, heightened insistence on sameness or routines, increased sensory sensitivity, avoidance of previously tolerated situations or activities, physical complaints such as stomachaches or headaches, sleep disruption, increased challenging behavior, regression in previously acquired skills, or withdrawal from social interactions. Unlike neurotypical individuals who may verbally report feeling anxious, autistic individuals, particularly those with limited verbal communication, may express anxiety primarily through behavioral changes. This behavioral presentation can be misinterpreted as autism-related behavior rather than recognized as anxiety.
An effective referral should include a description of the specific behavioral changes you have observed, including onset, frequency, duration, and intensity. Provide relevant baseline data showing how the client's behavior has changed from their typical pattern. Include information about environmental factors that have been ruled out as explanations for the change. Note any relevant medical history or medication changes you are aware of. Describe the client's communication abilities so the evaluating professional can plan appropriate assessment strategies. If possible, recommend a mental health professional who has experience working with autistic individuals, as assessment and treatment approaches may need to be adapted for this population.
Approach this conversation with sensitivity, honesty, and specificity. Begin by describing the specific behavioral changes you have observed, using objective language and data when possible. Explain that these changes are different from what you would expect based on the client's typical pattern and programming changes. Share that you believe further evaluation by a mental health professional could help determine whether additional support is needed. Avoid making diagnostic statements or predictions about what the evaluation will find. Acknowledge that this information may be difficult to hear and provide space for the family's emotional response. Offer practical next steps, including specific referral resources, and reassure the family that seeking evaluation is a responsible step in supporting their child's wellbeing.
Treatment plan modifications should be individualized based on the specific co-occurring condition and its impact on the client. General considerations include reviewing current targets to ensure they are still appropriate and achievable given the co-occurring condition, adjusting reinforcement systems to account for changes in motivation, modifying environmental arrangements to reduce triggers for mental health symptoms, increasing monitoring of overall functioning beyond target behaviors, and building skills that support mental health such as coping strategies and communication about emotions. Collaborate with the mental health provider to ensure that ABA modifications complement the mental health treatment plan. Document all modifications and the rationale behind them.
Behavior analysts play a critical role in care coordination by sharing behavioral data and clinical observations with mental health providers, implementing behavioral strategies that complement mental health treatment, monitoring behavioral changes that may be associated with medication adjustments or therapeutic interventions, communicating with families about how different services fit together, and advocating for the client's needs across service systems. Effective care coordination requires regular communication with other providers, which should be supported by appropriate consents for information sharing. Behavior analysts bring unique value to the care team through their systematic data collection and analysis skills, which can inform and enhance the work of other professionals.
Many standard mental health screening tools have limited validity when used with autistic individuals because they were developed and normed on neurotypical populations. Items that reference social behaviors, communication patterns, or internal emotional experiences may be interpreted differently by or about autistic individuals. Some tools have been adapted or developed specifically for use with autistic populations, though the availability of such tools is still limited. When using standard screening tools, behavior analysts should interpret results cautiously, consider how autism-related characteristics may affect responses, supplement screening with direct behavioral observation, and consult with professionals experienced in assessing co-occurring conditions in autistic individuals.
Developing competence in this area involves several strategies. Pursue continuing education specifically focused on co-occurring conditions in neurodevelopmental disorders. Read current literature on the presentation of mental health conditions in autistic individuals. Seek supervision or consultation from experienced behavior analysts or mental health professionals who work with this population. Practice describing behavioral observations in terms that are useful to mental health professionals. Build relationships with mental health providers in your community so you can learn from their expertise and facilitate smooth referrals. Attend interdisciplinary conferences or workshops that bring together behavior analysts and mental health professionals.
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**Co-occurring Autism Spectrum and Mental Health Disorders: What Practitioners should Know, Do, and Say, when it comes to Prevalence, Risk factors, Screening, Referral, and Care Coordination — Allyson Moore · 1 BACB Ethics CEUs · $30
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All behavior-analytic intervention is individualized. The information on this page is for educational purposes and does not constitute clinical advice. Treatment decisions should be informed by the best available published research, individualized assessment, and obtained with the informed consent of the client or their legal guardian. Behavior analysts are responsible for practicing within the boundaries of their competence and adhering to the BACB Ethics Code for Behavior Analysts.