Systematic Review of Comorbid Symptomatology and Challenging Behaviors in Infants and Toddlers with Autism Spectrum Disorder

Saturday, May 13, 2017: 12:00 PM-1:40 PM
Golden Gate Ballroom (Marriott Marquis Hotel)
T. L. Benninger1 and A. N. Witwer2, (1)Psychology, The Ohio State University, Columbus, OH, (2)Nisonger Center, The Ohio State University, Columbus, OH

Children with Autism Spectrum Disorder have high rates of co-occurring emotional and behavioral disorders, often contributing to impairments in learning and development. As the field moves toward earlier diagnosis, many of these co-occurring behaviors appear and require treatment in toddlers and very young children. Clinicians often refer to these as co-occurring psychiatric disorders, challenging behaviors, or both interchangeably due to inconsistencies in theories on comorbidities in children this young. It is important to have a clearer picture of the composition of these concerning behaviors in order to successfully intervene.


This study will examine the utility of comorbid diagnoses in very young children with ASD to determine if this is an appropriate term for a toddler and the validity and efficacy of labeling challenging behaviors. In addition, this study will categorize and summarize the prevalence data of comorbid symptomatology and challenging behaviors in multiple samples of toddlers with ASD. 


A range of medical, educational and scientific databases were searched to identify studies of comorbidity and challenging behaviors in toddlers with ASD (i.e., Medline, PSYCHinfo and Education Research Complete). The search was limited to peer-review articles published in English from 1990 to 2016. We searched with the following terms: Psychopathology OR challenging behavior OR problem behavior –AND Infants OR toddlers OR young children –AND Autism OR ASD. Additional searches were performed including terms for each comorbid symptom and group of challenging behaviors (including ‘ADHD’ ‘Hyperactivity’ ‘Anxiety’ ‘Aggression’ ‘Self-Injury’ and ‘Stereotypy’) to attempt to identify all possible studies. A combined 415 results were found through these three search engines. References of identified studies were searched and relevant studies included.A total of 34 articles met criteria and were included in this review. 


Studies reporting total prevalence of challenging behaviors and/or comorbid symptoms of psychopathology estimate between 15.9% and 46.2% of infants and toddlers with ASD have at least one clinically significant area (Eisenhower, Baker & Blacher, 2005; Hartley, Sikora & McCoy, 2008; Rojahn et al., 2009;. Matson, Fodstad, Mahan & Sevin, 2009). Most frequently reported behaviors include externalizing symptoms such as physical aggression, disruptive/tantrum behaviors and ADHD symptoms such as inattention and impulsivity. Much less data is available on internalizing symptoms in toddlers such as depression/withdrawal symptoms. Additionally, demographic differences were reported regarding race, age and sex.


Challenging behaviors in toddlers with ASD present in a wide variety of ways. Evidence is mixed for making a formal psychiatric diagnosis in toddlers as co-morbidities in very young children are often unstable. Despite this, it is clear from this review that many that toddlers with ASD present with significant amounts of challenging behavior which could likely benefit from intervention. Implications for diagnostic practices are discussed along with needed areas of future research.