Co-occurring Psychopathology in Children With and Without Autism Spectrum Disorder (ASD): Differences by Sex in the ECHO Cohorts.

This large study of nearly 8,000 children found that autistic children experience more behavioral and emotional difficulties than non-autistic children. Autistic girls were more likely to have depression and anxiety compared to autistic boys. Children with more severe autism-related social challenges also had more behavioral problems. The research suggests autistic children need extra monitoring and support for mental health issues throughout their development.

This large cross-sectional study examined behavioral and emotional symptoms in 7,998 children from 37 ECHO cohorts, including 553 with autism spectrum disorder (78% boys, 22% girls). Children with autism showed significantly higher rates of behavioral and emotional problems across all Child Behavior Checklist measures compared to neurotypical peers. Autistic girls demonstrated higher rates of depression and anxiety compared to autistic boys. The study found stronger associations between autism-related social communication deficits and behavioral problems among children with the most severe difficulties.

Results suggest autistic children experience elevated co-occurring mental health challenges throughout development, with sex-specific patterns requiring targeted monitoring and intervention approaches.

Results support implementing routine mental health screening for autistic children, with particular attention to depression and anxiety in girls. Clinicians should consider sex-specific approaches to assessment and intervention. Children with severe social communication deficits may require enhanced behavioral support and monitoring throughout development.

Cross-sectional design prevents causal inferences. Reliance on parent-reported autism diagnoses may introduce bias. Study does not control for potential confounding variables or examine intervention effects. Sample demographic characteristics and representativeness are not fully described.

Our goals were to: 1) examine the occurrence of behavioral and emotional symptoms in children on the autism spectrum in a large national sample, stratifying by sex, and 2) evaluate whether children with increased autism-related social communication deficits also experience more behavioral and emotional problems. Participants (n = 7,998) were from 37 cohorts from the Environmental influences on Child Health Outcomes (ECHO) Program. Cross-sectional information on demographic factors, parent-report of an ASD diagnosis by clinician, Social Responsiveness Scale (SRS) scores, and Child Behavior Checklist (CBCL) scores were obtained for children aged 2.5-18 years by surveys. We examined mean differences in CBCL Total Problems and DSM-oriented subscale scores by autism diagnosis and by child sex.

Analyses using logistic regression were conducted to examine whether autism was associated with higher CBCL scores. We further examined if these relationships differed by child age category (< 6 years, 6-11 years, 12 + years). The relationships between SRS score and CBCL total and subscale scores were examined using quantile regression models, with analyses adjusted for child sex and age. In ECHO, 553 youth were reported by a parent to have a clinician diagnosis of autism spectrum disorder (ASD) (432 [78%] boys and 121 [22%] girls).

Youth on the spectrum had higher mean CBCL raw scores on Total Problems and all DSM-oriented subscales compared to those not on the spectrum (all p < 0.0001). Analyses adjusted for sex and stratified by age group indicated that higher odds of autism diagnosis were associated with total, depression, anxiety, and attention-deficit/hyperactivity disorder (ADHD) scales in the top 30% of the CBCL score distribution. Autistic girls were more likely to have parent-reported depression and anxiety compared to autistic boys. In quantile regression analyses, we observed evidence of stronger associations between SRS and CBCL for those in higher quantiles of CBCL total problems scale score (beta representing 1-unit change in SRS associated with 1-unit increase in CBCL total problems scale score), among children in the 70-90th percentile (β = 1.60, p < 0.01), or top 10th percentile (β = 2.43, p < 0.01) of the CBCL total problems scale score distribution.

Similar findings were seen for the DSM-oriented depression, anxiety, and ADHD subscales. Results from this large national sample suggest increased behavioral and emotional problems among autistic children compared to non-autistic children throughout early life. Among children on the spectrum this may warrant increased monitoring for co-occurring behavioral and emotional problems.