This guide draws 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 extends it with peer-reviewed research from our library of 27,900+ ABA research articles. Citations, clinical framing, and cross-links below are synthesized by Behaviorist Book Club.
View the original presentation →The co-occurrence of autism spectrum disorder and mental health conditions represents one of the most clinically significant and underaddressed challenges in behavior analytic practice. Individuals with autism and other neurodevelopmental disorders face a substantially elevated risk of developing mental health disorders compared to the general population. This reality demands that behavior analysts possess the knowledge and skills to recognize warning signs, understand risk factors, screen effectively, make appropriate referrals, and coordinate care with mental health professionals.
The clinical significance of this topic is underscored by prevalence data. Anxiety disorders, depression, attention-deficit/hyperactivity disorder, obsessive-compulsive disorder, and other mental health conditions occur at markedly higher rates among individuals with autism than in the general population. These co-occurring conditions can substantially impair quality of life, interfere with the effectiveness of ABA interventions, and create diagnostic confusion that delays appropriate treatment.
For behavior analysts, the challenge is multifaceted. The overlapping symptoms of developmental disabilities and mental health disorders make detection difficult. A change in behavior that might indicate depression in a neurotypical individual, such as social withdrawal or decreased activity, may be attributed to autism-related characteristics rather than investigated as a possible mental health concern. Similarly, repetitive behaviors associated with autism may mask obsessive-compulsive symptoms, and communication difficulties may prevent individuals from reporting internal experiences of anxiety, sadness, or distress.
This course, developed as part of CASP's Multi-Specialty Practices Special Interest Group, takes a collaborative approach to addressing these challenges. The interactive discussion format allows attendees to engage with complex clinical scenarios and practice the communication and decision-making skills needed to navigate co-occurring conditions in their daily practice.
The clinical implications extend beyond individual client care to broader systems issues. Behavior analysts often serve as primary service providers for individuals with autism, positioning them as potential first identifiers of emerging mental health conditions. When behavior analysts are equipped to recognize warning signs and facilitate timely referrals, they can significantly improve outcomes for clients who might otherwise go undiagnosed and untreated for co-occurring mental health disorders.
The ethical and supervisory dimensions of this topic are equally significant. Behavior analysts must recognize the boundaries of their scope of practice when it comes to mental health assessment and treatment, while also fulfilling their responsibility to act in the best interest of their clients. This requires a nuanced understanding of when to adapt behavioral interventions, when to refer, and how to coordinate effectively with other professionals.
The recognition of co-occurring mental health conditions in individuals with autism has grown substantially over the past two decades, driven by improvements in diagnostic practices, longitudinal research, and the voices of autistic self-advocates. Historically, a practice known as diagnostic overshadowing led clinicians to attribute all behavioral and emotional difficulties to the primary diagnosis of autism, overlooking co-occurring conditions that required separate identification and treatment.
Diagnostic overshadowing occurs when the presence of one diagnosis reduces the clinical attention given to other conditions. In the context of autism, this means that anxiety symptoms might be dismissed as rigid thinking, depressive symptoms might be attributed to social skill deficits, and ADHD symptoms might be conflated with the attention differences commonly associated with autism. This overshadowing has historically resulted in significant under-identification and under-treatment of mental health conditions in this population.
The challenges of assessment are compounded by the communication differences associated with autism and other neurodevelopmental disorders. Many standardized mental health assessment tools rely on self-report, which may not be accessible to individuals with limited verbal communication or those who have difficulty identifying and describing internal emotional states. Even for individuals with strong verbal skills, alexithymia, the difficulty identifying and describing one's own emotions, is more prevalent among autistic individuals and can complicate self-report measures.
Risk factors for mental health conditions in individuals with autism include both biological and environmental factors. Shared genetic vulnerabilities contribute to the co-occurrence of autism with conditions such as anxiety and ADHD. Environmental factors include the chronic stress of navigating a neurotypical world, experiences of bullying and social rejection, sensory overwhelm, and, in some cases, the effects of interventions that did not adequately account for the individual's needs and preferences.
The role of behavior analysts in addressing co-occurring conditions has evolved as the field has broadened its scope from a narrow focus on discrete behavior change to a more comprehensive approach that considers overall quality of life, emotional wellbeing, and holistic functioning. This evolution is reflected in the BACB Ethics Code (2022), which emphasizes the obligation to act in clients' best interests and to recognize the boundaries of one's competence.
CASP's Multi-Specialty Practices Special Interest Group, which developed this course, represents the field's recognition that effective care for individuals with autism requires collaboration across disciplines. Behavior analysts, psychologists, psychiatrists, counselors, and other professionals each bring essential expertise to the care of individuals with co-occurring conditions. The challenge is creating the communication channels and collaborative frameworks that allow this expertise to be integrated effectively.
The clinical implications of co-occurring autism and mental health disorders permeate every aspect of ABA service delivery. When a client has an unidentified or untreated mental health condition, the effectiveness of behavioral interventions is often compromised, and the client's overall trajectory may be significantly worse than it would be with appropriate comprehensive care.
Behavior analysts should be aware of how common co-occurring conditions present in the context of autism. Anxiety in autistic individuals may manifest as increased rigidity, heightened sensory sensitivity, avoidance of previously tolerated situations, increased repetitive behaviors, sleep disruption, or physical complaints. Depression may present as withdrawal from preferred activities, changes in appetite or sleep, increased irritability, decreased engagement in sessions, or regression in previously acquired skills. ADHD symptoms such as difficulty sustaining attention, impulsivity, and hyperactivity may overlap with autism characteristics but respond to different interventions.
When behavioral changes occur that cannot be adequately explained by environmental variables or changes in programming, behavior analysts should consider the possibility of an emerging or worsening mental health condition. This does not mean diagnosing the condition but rather recognizing that the behavioral presentation warrants further evaluation by a qualified professional.
Screening is an area where behavior analysts can contribute meaningfully without exceeding their scope of practice. While behavior analysts should not conduct formal mental health assessments, they can use validated screening tools to identify clients who may benefit from referral. The selection of screening tools should account for the individual's communication abilities and developmental level, as many standard screening instruments have not been validated for use with autistic populations.
Referral is a critical clinical skill that behavior analysts should develop. An effective referral involves more than simply suggesting that a family seek evaluation. It includes providing specific information about what has been observed, why a referral is being recommended, and what type of professional may be most appropriate. It also involves helping families navigate potential barriers to accessing mental health services, which can be substantial for individuals with developmental disabilities.
Care coordination represents the ongoing clinical implication of co-occurring conditions. When a client is receiving both ABA services and mental health treatment, the behavior analyst and mental health provider must communicate regularly to ensure that their interventions are complementary rather than contradictory. Behavioral interventions may need to be modified to accommodate psychiatric medication changes, and mental health treatment may benefit from behavioral data that the behavior analyst can provide.
The impact on treatment planning is significant. When co-occurring conditions are identified, treatment plans should be reviewed and potentially modified. Targets may need to be adjusted, reinforcement systems may need to be adapted to account for changes in motivation associated with depression or anxiety, and environmental modifications may be needed to reduce triggers for mental health symptoms.
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The ethical landscape surrounding co-occurring conditions is complex and requires behavior analysts to navigate competing obligations with care and professionalism. The BACB Ethics Code (2022) provides the framework for these decisions, but applying it to real-world situations involving co-occurring conditions requires thoughtful interpretation.
Code 1.05 (Practicing Within Scope of Competence) is perhaps the most directly relevant ethical standard. Behavior analysts are trained in the principles and practices of behavior analysis, not in the diagnosis and treatment of mental health disorders. Attempting to diagnose a mental health condition, recommending specific psychiatric medications, or implementing therapeutic interventions for mental health conditions outside the scope of ABA practice would exceed the behavior analyst's competence. However, failing to recognize signs of a mental health condition and failing to facilitate appropriate evaluation would also be an ethical failure.
The ethical obligation exists in the space between these two boundaries. Behavior analysts must be knowledgeable enough about co-occurring conditions to recognize when something beyond ABA is needed, skilled enough to communicate this to families effectively, and humble enough to defer to professionals with appropriate expertise for assessment and treatment.
Code 2.01 (Providing Effective Treatment) requires behavior analysts to use the most effective treatment available. When a client's behavioral presentation is influenced by a co-occurring mental health condition, purely behavioral interventions may not be the most effective treatment. Ethical practice in this situation involves acknowledging the limitation and facilitating access to additional treatment rather than continuing to apply behavioral interventions that are not producing expected results.
Informed consent obligations (Code 2.11) extend to communicating with families about the possibility of co-occurring conditions. When a behavior analyst observes signs that suggest a mental health concern, sharing this observation with the family is part of transparent, informed service delivery. Families have a right to know about factors that may be affecting their child's progress and to make informed decisions about seeking additional evaluation.
Supervisory obligations are significant in this context. Supervisors must ensure that their supervisees are trained to recognize signs of co-occurring conditions and to escalate concerns appropriately. An RBT who observes a significant behavioral change should know to report this to their supervisor, and the supervisor should have a system for evaluating whether the change warrants investigation beyond the behavioral domain.
Communication with other professionals raises ethical considerations around confidentiality. Sharing client information with mental health providers requires appropriate consent and should be limited to information relevant to the client's care. Behavior analysts should understand HIPAA requirements and their organization's policies regarding information sharing with external providers.
The ethical obligation to advocate for clients extends to advocating for access to mental health services. Individuals with autism often face significant barriers to accessing mental health care, including provider shortages, lack of clinicians trained to work with neurodivergent populations, and insurance coverage limitations. Behavior analysts who recognize these barriers can support families in navigating them, though the extent of this advocacy will depend on the practitioner's role and resources.
Assessment and decision-making around co-occurring conditions requires behavior analysts to integrate behavioral data with broader clinical observations and to develop systematic approaches for identifying when further evaluation is warranted.
The first assessment consideration is establishing behavioral baselines that are comprehensive enough to detect meaningful changes. When behavior analysts track only target behaviors and treatment integrity, they may miss subtle shifts in overall functioning that could indicate emerging mental health concerns. Broader behavioral monitoring that includes measures of engagement, affect, sleep patterns reported by caregivers, appetite changes, and general activity level provides a more complete picture of the client's status.
Decision-making about when to express concern about a potential co-occurring condition should be guided by several factors. Consider whether the behavioral change is significant in magnitude or duration, whether it cannot be adequately explained by environmental variables or changes in programming, whether it represents a departure from the individual's established pattern, and whether it is consistent with known presentations of mental health conditions in autistic individuals. No single factor is definitive, but a combination of factors should increase the behavior analyst's index of suspicion.
Screening tools can support decision-making but must be selected carefully. Many widely used mental health screening instruments were not developed for or validated with autistic populations. When using screening tools, behavior analysts should be aware of their limitations and interpret results cautiously. Informant-based measures completed by caregivers or teachers may be more appropriate than self-report measures for individuals with communication challenges.
The decision to refer involves weighing the potential benefits of evaluation against the practical and emotional costs to the family. Referral should not be approached as passing a problem to someone else but as adding a needed perspective to the client's care team. The behavior analyst should communicate clearly about what has been observed, why a referral is being recommended, and what the family can expect from the evaluation process.
After referral, decision-making shifts to how to integrate information from the mental health evaluation into ABA treatment planning. If a co-occurring condition is diagnosed and treatment is initiated, the behavior analyst should review the client's ABA program for potential interactions. For example, if a client begins taking medication for anxiety, the behavior analyst should monitor for changes in behavior that may reflect medication effects and adjust intervention strategies accordingly.
Ongoing monitoring is essential. Co-occurring conditions may emerge at any point during ABA services, not just during intake. Behavior analysts should maintain awareness of the possibility of co-occurring conditions throughout the course of treatment and should have systems in place for regular re-evaluation of client status.
Documentation of clinical observations related to potential co-occurring conditions is important for both clinical and legal reasons. Notes should describe observed behaviors objectively, note the context and duration of changes, and document any communications with families or other professionals about concerns. This documentation supports continuity of care and provides a record of the behavior analyst's due diligence.
Understanding co-occurring conditions fundamentally changes how you approach your work as a behavior analyst. It adds a layer of clinical awareness that improves your ability to serve your clients comprehensively and ethically.
Develop your knowledge of how common mental health conditions present in autistic individuals. This does not mean becoming a diagnostician but rather becoming an informed observer who can recognize when behavioral changes may warrant further evaluation. Read about anxiety, depression, OCD, and ADHD as they present in the context of autism. Attend continuing education on these topics. Discuss co-occurring conditions in supervision.
Build screening into your clinical practice. Work with your organization to identify appropriate screening tools and develop protocols for when and how to use them. Ensure that your intake process includes questions about mental health history and current concerns.
Develop your referral skills. Know who in your community can provide mental health evaluation and treatment for individuals with autism. Build relationships with these providers before you need them. When making referrals, provide families with specific guidance about what to expect and how to access services.
Practice care coordination. When your clients are receiving mental health treatment alongside ABA, establish communication channels with the mental health provider. Share behavioral data that may be relevant to their treatment. Ask about changes in treatment that may affect your ABA program. This collaboration improves outcomes for the client and enriches your own clinical understanding.
Recognize the limits of your scope and be comfortable with them. You do not need to be a mental health expert to be an excellent behavior analyst. What you need is the awareness to recognize when something beyond your expertise is needed and the skills to facilitate appropriate care.
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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.