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Spotting the Signs: Depression and Anxiety in Developmental Disabilities

  • Writer: Chris Wong Tak Wee
    Chris Wong Tak Wee
  • 3 days ago
  • 5 min read

Mental health conditions can manifest differently in individuals with developmental disabilities (DD) compared to those without. Even among individuals with DD, conditions such as depression and anxiety can present differently in those with Autism Spectrum Disorder (ASD) and those with Intellectual Disabilities (ID), influenced by distinct cognitive, communicative, and behavioral profiles. While both groups face elevated risks for these mental health challenges compared to the general population, their symptom presentations, diagnostic complexities, and contributing factors diverge significantly. Understanding these differences is crucial for accurate diagnosis and effective treatment.



Depressive Disorders

Depression affects approximately 3–4% of adults with ID at any given time, with lifetime prevalence estimates reaching as high as 42% in some cohorts. For individuals with ASD, around 40% experience depression in their lifetime, with rates increasing during adolescence and adulthood. While depression in neurotypical individuals is often identified by symptoms such as low mood, reduced motivation, and social withdrawal, its presentation in those with ASD or ID can be more nuanced.


For example, some individuals with ASD may already exhibit social withdrawal, making it difficult to detect additional withdrawal related to depression. In those with ID, worsening behaviors of concern may go unnoticed or be misattributed to non-psychiatric causes. Below are some key ways depression may present differently in these populations:


Depression in ASD:

  • Atypical Emotional Expression: Flat affect, reduced eye contact, or monotonic speech may mask internal distress, leading to under-recognition of depressive states.

  • Behavioral Changes: Increased rigidity, repetitive behaviors, or withdrawal from previously enjoyed activities may indicate anhedonia. A loss of interest in special interests—a hallmark of ASD—can be particularly telling.

  • Somatic and Cognitive Symptoms: Sleep disturbances, appetite changes, and self-injurious behaviors (e.g., head-banging) are common. Cognitive symptoms like rumination may revolve around social misunderstandings or communication difficulties.

  • Suicidality: Individuals with ASD are at significantly higher risk, with suicidality rates up to four times higher than the general population. However, verbal expressions of suicidal ideation may be limited, requiring attention to behavioral cues such as increased isolation or aggression.


Depression in ID:

  • Behavioral and Adaptive Decline: Reduced self-care, social withdrawal, or regression in previously acquired skills (e.g., toileting) may be signs of depression. Irritability and aggression can also be presenting features.

  • Nonverbal Cues: Crying, sad facial expressions, and psychomotor agitation (e.g., pacing) may be more prominent than verbal complaints.

  • Somatic Symptoms: Changes in sleep and appetite are frequent but may be misattributed to physical conditions or medication side effects.


Diagnostic Challenges for Depression

The DSM-5 criteria for depression rely heavily on self-reported internal states, which can be inaccessible for minimally verbal individuals or those with cognitive impairments. Clinicians should instead focus on observable changes—such as altered sleep, eating habits, or behavior—and incorporate caregiver observations. Tools like the Diagnostic Criteria for Learning Disabilities (DC-LD), which emphasize observable symptoms, may be more appropriate.



Anxiety Disorders

Anxiety disorders affect 10–22% of individuals with ID, with rates peaking during adolescence. Among individuals with ASD, prevalence ranges from 20–49%, with social anxiety and generalized anxiety disorder being the most common.


Identifying anxiety in these populations is complicated by cognitive and communicative limitations. Core features of anxiety, such as worry or negative thoughts, may not be easily expressed. Additionally, behavioral avoidance—a hallmark of anxiety—may be less evident due to limited autonomy or opportunities to avoid distressing situations. Instead, anxiety may manifest through irritability, aggression, or physical symptoms.


Anxiety in ASD:

  • Social Anxiety: Anxiety may stem less from fear of negative evaluation and more from confusion in social situations or sensory overload (e.g., distress over bright lights rather than judgment).

  • Rigidity and Rituals: Strict adherence to routines can serve as a coping mechanism. Disruptions may trigger meltdowns or shutdowns.

  • Somatic Manifestations: Symptoms like gastrointestinal distress, headaches, or motor tics are frequently reported and may dominate the clinical picture.


Anxiety in ID:

  • Behavioral Outbursts: Aggression, self-injury, or sudden noncompliance (e.g., refusing to go to school) may signal anxiety, especially in nonverbal individuals.

  • Developmental Persistence: Anxiety disorders such as separation anxiety may persist longer than expected developmentally. Specific phobias, often based on traumatic experiences (e.g., fear of medical settings), are also common.

  • Physical Symptoms: Restlessness, trembling, and somatic complaints (e.g., stomachaches) may be overlooked or misattributed to behavioral issues.


Diagnostic Challenges for Anxiety

Diagnosing anxiety in ASD is complicated by overlap with core autism traits, such as social withdrawal. Many assessment tools lack sensitivity for these populations, highlighting the need for adapted methods like visual aids or structured caregiver interviews. For individuals with ID, identifying anxiety requires careful observation over time to detect deviations from baseline functioning.


Key Takeaways

  • Individuals with ASD and ID experience elevated rates of depression and anxiety but may not display typical symptoms seen in the general population.

  • Depression in these groups can appear as increased aggression, withdrawal, self-injury, or decline in daily functioning rather than verbal reports of sadness.

  • Anxiety may manifest through somatic symptoms, behavioral rigidity, or outbursts—often mistaken for behavioral issues or autism traits.

  • Standard diagnostic tools may not be suitable; clinicians should prioritize observable changes and caregiver input.

  • Increased awareness and adapted approaches are critical for better identification, support, and treatment of mental health conditions in individuals with developmental disabilities.


Conclusion

Recognizing the unique presentations of depression and anxiety in individuals with developmental disabilities is essential for timely and effective intervention. Tailored diagnostic approaches that prioritize observable behaviors, involve caregiver input, and consider individual communication styles can improve clinical outcomes. Further research into transdiagnostic screening and trauma-informed care is vital to addressing the mental health needs of these often-overlooked populations.



For easier reference, the infographics below summarize some differences in presentation of depression and anxiety in those with ID and those with ASD:


Referenced from: Diagnostic Criteria for Psychiatric Disorders for Use with Adults with Learning Disabilities/Mental Retardation (DC-LD), Diagnostic Manual – Intellectual Disability (DM-ID-2)



References:

[1] Depression in Youth With Autism Spectrum Disorder - PMC https://pmc.ncbi.nlm.nih.gov/articles/PMC6512853/

[2] Autism and depression: What is the connection? https://www.autismspeaks.org/expert-opinion/autism-depression

[6] Presentation of Depressive Symptoms in Autism Spectrum Disorders https://journals.sagepub.com/doi/10.1177/01939459231190269

[7] Social Functioning and the Presentation of Anxiety in Children on the Autism Spectrum: A Multi-Method, Multi-Informant Analysis

[8] Depression in adults with intellectual disability: symptoms and challenging behaviour

[9] [PDF] Anxiety in children with ID - Sydney North Health Network https://sydneynorthhealthnetwork.org.au/wp-content/uploads/2021/09/PHN-Anxiety-presentation-docx.pdf

[10] Anxiety in students with intellectual disabilities: the influence of staff-perceived social acceptance and rejection in the classroom https://www.frontiersin.org/journals/education/articles/10.3389/feduc.2023.1157248/full

[12] Mental Health Issues in Psychiatry of Intellectual Disability | PPT https://www.slideshare.net/slideshow/mental-health-issues-in-psychiatry-of-intellectual-disability/71062023

[13] Symptoms and development of anxiety in children with or without intellectual disability https://pubmed.ncbi.nlm.nih.gov/24528099/

[14] Depression in autistic people: Symptoms, treatment, and more https://www.medicalnewstoday.com/articles/autistic-depression

[15] Depression in Adults With Mild Intellectual Disability: Role of Stress, Attributions, and Coping https://pmc.ncbi.nlm.nih.gov/articles/PMC2831402/

[16] [PDF] Unlocking and Treating Depression: Adults with Intellectual Disabilities https://hsc.unm.edu/medicine/departments/pediatrics/divisions/continuum-of-care/pdf/unlocking.pdf

[17] Presentation of Depressive Symptoms in Autism Spectrum Disorders https://pubmed.ncbi.nlm.nih.gov/37586013/

[19] What is Intellectual Disability? - American Psychiatric Association https://www.psychiatry.org/patients-families/intellectual-disability/what-is-intellectual-disability

[20] Anxiety in Intellectual Disabilities: Challenges and Next Steps https://www.sciencedirect.com/science/article/abs/pii/B9780123942845000036

 
 

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