Adults with Autism Spectrum Disorders using psychiatric hospitals in Ontario: Clinical profile and service needs

Abstract

Background

Adults with Autism Spectrum Disorders (ASD) represent a small, but challenging sub-group of patients within Ontario's mental health care system. However, few studies have documented the clinical characteristics of this population and examined how such individuals differ from other psychiatric patients, with or without intellectual disabilities (ID).

Method

A secondary analysis of data from the 2003 Comprehensive Assessment Projects from three psychiatric hospitals in Ontario was conducted to describe patients with ASD and ID and to determine how their profile compared to other hospital users.

Results

Twenty-three patients with ASD and ID were matched on gender and patient status (inpatient/outpatient) to individuals with and without ID. Individuals with ASD and ID were similar in terms of demographics to patients with and without ID. However, individuals with ASD and ID were younger, spent more days in hospital and were less likely to have a psychotic disorder diagnosis than both patients with and without ID. Inpatients with ASD and ID were recommended for a higher level of care than hospital service users without ID.

Conclusions

Clearly, this small sub-group of individuals within the hospital population has high clinical needs that are not always well met.

Introduction

Individuals with Autism Spectrum Disorders (ASD) are one of the more complex yet underserved patient groups. Individuals with ASD make up as much as 0.6% of the population (Fombonne, 2003, Fombonne, 2005, Ouellette-Kuntz et al., 2006, Wing and Potter, 2002), and share a common triad of impairments in communication, socialization, and behaviour and interests (APA, 1994). The majority of the mental health research conducted on individuals with ASD has focused on the presence of psychiatric disorders and behavioural issues in children and adolescents (Bradley and Bolton, 2006, Bradley et al., 2004, Brereton et al., 2006, de Bruin et al., 2007, Leyfer et al., 2006, Simonoff et al., 2008). More recently however, attention has been directed toward investigating mental health issues in adults with ASD (Howlin, 2004, Mouridsen et al., 2008, Palucka and Lunsky, 2007, Tsakanikos et al., 2006, Tsakanikos et al., 2007a). Mental health problems are estimated to occur in 35% of adults with ASD living in the community (Ghaziuddin et al., 1998, Morgan et al., 2003, Tsakanikos et al., 2006). Individuals with ASD have increased rates of mental health disorders compared to the general population (Ghaziuddin et al., 1998, Morgan et al., 2003, Tsakanikos et al., 2006), and to individuals with intellectual disabilities (ID) without ASD (Bradley and Bolton, 2006, Brereton et al., 2006, Morgan et al., 2003). Poor understanding of the ASD and mental health concerns puts them at significant risk for psychiatric hospitalization. In the only known large scale study of hospital utilization in youth with ASD from the US, 11% of children with ASD aged 5–21 years experienced at least one psychiatric hospital inpatient admission (Mandell, 2008). These numbers are even more dramatic in adulthood: in a Danish study that followed children with ASD into adulthood, 48% of the sample used psychiatric hospital services by age 40, compared to only 6% of age and SES matched controls (Mouridsen et al., 2008).

There has been increasing awareness of the need for accessible and appropriate mental health services for adults with ASD, given how common hospitalization can be. A number of studies have described adults with ASD using outpatient (Nylander and Gillberg, 2001, Tsakanikos et al., 2007a) and inpatient (Hare et al., 1999, Palucka and Lunsky, 2007) psychiatric services. A recent study investigating predictors of hospital admissions of individuals with ID found that an autism diagnosis was one of the strongest predictors of admission (Cowley, Newton, Sturmey, Bouras, & Holt, 2005). In one Canadian study that examined the clinical profiles of inpatients with ASD, Palucka and Lunsky (2007) reported on the profiles of 13 patients with ASD in a specialized dual diagnosis unit. They made up 36% of admissions over a 6-year period. These individuals were likely to display problems with aggression, the most common diagnosis was mood disorder, and they frequently faced challenges in terms of discharge. Many of these individuals came from other cultural backgrounds; 46% were born outside of Canada, and another 6% were born in Canada to immigrant parents.

Besides the descriptive studies reviewed above, very few papers have considered how psychiatric inpatients and outpatients with ASD differ from other psychiatric service users, with and without intellectual impairments. Tsakanikos et al. (2006) conducted one of the few comparisons and reported lower rates of comorbid psychopathology but still significant behaviour problems in an adult sample of individuals with ASD and ID compared to individuals with ID and no ASD. Had such “behaviour issues” been conceptualized as psychopathology, the rates in the ASD group would have been higher. Clearly, more research is needed to understand the psychiatric profile of this group of individuals so their needs can be better met in the hospitals that serve them.

The Comprehensive Assessment Projects (CAPs) explored the clinical profile and service needs of individuals with ID receiving tertiary level mental health care across Ontario. Lunsky et al. (2006) compared inpatients and outpatients with ID and psychiatric diagnoses to other Ontario psychiatric hospital users. Individuals with ID were found to have more severe clinical symptoms and fewer resources (i.e., personal, economic, support, etc.) than individuals without ID. However, Lunsky et al. (2006) made no distinction between individuals with and without ASD. The purpose of the current study was to describe the clinical profile of adults with ASD and ID accessing Ontario's mental health care system, and to contrast them to individuals with and without ID using similar hospital services. It was hypothesized that individuals with ASD would have the highest recommended level of care and the most complex clinical profile when compared to psychiatric patients with and without ID.