Causes of mental health issues in the general population
With depression and other mental illnesses having a devastating effect on learners with profound ASC in special schools it is important to understand what might be driving this crisis.
It is unlikely that any single factor is likely to cause depression. Sufferers often talk about a spiral affect (NHS, 2016) with one difficult event leading to another, each affecting their mood, until they develop depression. However, some people are more likely to suffer depression than others (Janowsky, Morter, Hong, 2002) unhelpful factors that may worsen a person’s mental health problems include loneliness, drug use (including alcohol), hormonal and physical changes along with changes to lifestyle and sleep resulting from childbirth, illness, head injuries or an underactive thyroid (hypothyroidism). (NHS, 2016).
To some extent, depression may be hereditary; a person’s genes can make them more likely to suffer depression. The incidence of depression in a close relative, perhaps a parent or sibling, makes it more likely, but not inevitable (Levinson, Nichols, 2012).This is a predictable observation, given the links between genetics and personality (Tellegen, Lykken; Bouchard, Wilcox, Segal, Rich, 1988). The traits of a person’s personality have a direct influence on an individual’s vulnerability to depression, such as poor self-esteem (NHS 2016, Krueger & Johnson 2008, Watson et al. 2006).
Depression may also extend from lived experiences. The risk of depression is increased by traumatic, challenging situations, prolonged feelings of anxiety or stress have been linked to depression (Thurston RC, Kubzansky LD, Kawachi I, Berkman LF. 2006). People who are regularly under stress are at a higher risk of a range of problems from headaches to depression and even high blood pressure (Barton, 2010). Stress increases production of the stress hormone, cortisol, and reduce the reward hormones, serotonin and dopamine, this can trigger depression (Martin, 2011). This is especially likely if the stressful event triggers unhelpful changes in lifestyle such as reduced time outdoors, exercise, work, social time with family and friends or increased drinking or drug use. The experience of tragic events early in life may also lead to an increased risk of depression in the future (NHS, 2016). This is illustrated by the very high rate, 45%, of children in care having a mental health disorder (Ford, 2007).
Causes of mental health issues in learners with ASC in special schools
Variation in individual life experiences, genetics and personality make it impossible to definitively identify causes of depression in an individual with ASC. In fact there is little understood about the factors that place those with ASC at risk of co-occurring mental health disorders (Ghaziuddin et al. 2002).
ASC is a complex spectrum of disorders (Joshi, Petty and Wozniak, 2010) often defined as a condition with a particular presentation. This presentation is described as a triad of impairments, manifesting as difficulty in three areas; social interaction, flexibility of thought and communication research suggests social and emotional skill deficits are risk factors for mental health issues (Humphrey et al. 2007); It is likely, therefore, that a combination of factors relating to these areas of impairment can make functioning in every-day situations stressful and lead to high levels of anxiety. Difficulty in communication, socialisation, sensory processing and executive functioning lead to behavioural deficits that may result in people with ASD being vulnerable to stressors (Groden et al. 1994, 2006).
Living with regular stress increases the susceptibility of a person with ASC to depression (Galanopoulos, Robertson, Spain, Murphy, 2014). Nick Dublin reports in The Autism Spectrum and Depression (2014) that for people with ASC, the stresses of coping with a world that seems alien can lead to depression.
This is especially concerning for a person with ASC and associated learning difficulties in a special school where they might experience stressful situations frequently due to the behaviour, emotional disorders and methods of communication of learners around them.
‘For many the busy nature of our schools is a stressful and at times worrying experience’ (Carpenter, 2016).
Add to this limited access to outdoor environments, exercise, success in work, social engagement with friends and family disruptions to routines and the stress of regularly trying new activities and it is not a surprise that mental health is a concern amongst our learners. This may help explain why individuals with ASD commonly present clinically significant problem behaviours (Bearss et al. 2013)
In order to sustain positive well-being The World Health Organisation (2010) explains a person must feel that they are able to function in the world, including having positive social connections, a sense of purpose and feeling in control. These are far more difficult for someone with ASC (Association AP. Diagnostic and statistical manual of mental disorders; 2000). This struggle to achieve well-being due to a difficulty in functioning can lead to increased anxiety (National Autistic Society, 2010) and could have a long term negative impact on a person’s mental health.
Someone with autism may be affected by medical drug use in relation to co-occurring conditions such as epilepsy (Carol et. al., 2005), and could have experienced separation from parental care givers through hospitalisation early in life, factors listed by the NHS as possible causes of depression.
People with ASC are also more likely to be overweight; this increases the risk for many illnesses, including depression. In the U.S., 16% of children ages 2-19 are overweight, whereas the prevalence among children with ASC is 19% with a further 36% being at risk of being overweight (Carol et. al., 2005).
An aspect of ASC about which understanding is still developing is a difficulty with sensory processing. This refers to difficulty processing sensations common among people with autism. Any of the senses could be over- or under-sensitive and can make perception of the world difficult. The stimulating sensory input of school environments could cause heightened anxiety in a pupil with sensory processing difficulties (Higashida, 2014).
The genes genes of an individual that increase their chances of having have autism are also linked to depression (Smoller, 2013). About 1 in every 10 people with ASC will experience another mental health problem, this does note include anxiety which nearly every person with ASC will experience although it may go undiagnosed (Purkiss, Goodall and Nugent, 2016).
A person with autism can also struggle to respond to poor well-being. A diagnosis of depression is less likely (Hirvikoski, Mittendorfer-Rutz E, Boman M, et al, 2016). Diagnosis may be more difficult in a person who has autism because of difficulties in self-reporting of information (Baron-Cohen S, Leslie AM, Frith U, 1985). It may be more difficult for a person with ASC, being wary of change to access help, anxiety and depression can cause people to be extra introverted, or describe their symptoms, experiencing difficulty sharing their thoughts and feelings (Galanopoulos, et al, 2014). Symptoms of depression in ASC
One of the reasons depression is hard to spot is that some of the symptoms are similar to traits of ASC such as an increased difficulty with routine change, difficulty sleeping and an increase in sensitivity to sensory stimuli (Ghaziuddin et al., 2002).
With raised anxiety and difficulty functioning it is not surprising that learners with ASC in a special school are at an increased risk of developing depression (Galanoppuos, et al, 2014).
The result is an epidemic of mental illness among learners with profound autism in special schools. According to research reported in the Journal of the American Academy suggests that up to 70% of autistic individuals are likely to have one mental health disorder such as anxiety or depression, and 40% have two or more mental health problems (Simonoff, E. et al. 2008).
Importantly, being predisposed to a higher likelihood of having depression does not mean that developing it is guaranteed. However, due to the higher chance than someone in the neuro-typical population it is important that special schools consider how to go about improving the resilience of their learners.