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7/28/2019 Autism Spectrum Disorders and Co Morbid Conditions
1/18
AutismSpectrum
Disorders
andComorbidConditions
JudithMiller,PhD
mailto:[email protected]:[email protected]7/28/2019 Autism Spectrum Disorders and Co Morbid Conditions
2/18
Discussthemostfrequentcomorbid
psychiatricconditions
Describetheprocessofdifferentialdiagnosis
Describethe
process
of
treating
comorbid
conditionsandidentifyingtargetsfor
intervention
Educational Objectives
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Autism is heterogeneous
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Languagedisorders
Cognitivedelays
Anxietyandmooddisorders
Attentiondisorders
Neurologicaldisorders
Learningdisorders
Medicalissues(Sleep,GI,geneticdisorders)
Common Comorbidities
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IntellectualImpairment
Attentiondisorders
AnxietyDisorders
TicDisorders
MoodDisorders
Common Psychiatric Comorbidities
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Reviewavailableinformation(records,other
evaluations) Gatherobservationsandhistory
Generatelist
of
possible
diagnostic
explanations
Carefully
consider
overlap
between
diagnoses
andcharacteristicsthatcanfit morethan
onedisorder
How to make a differential diagnosis
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Behavior IsmorelikeASD CouldbeeitherASDorADHD IsmorelikeADHD
Videogames Repetitiveor
asocial
quality
to
play(circumscribed
interest)
Canplay
videogames
for
hours
Seemsobsessed
Thriveson
constant
feedback
videogames
provide(high
stimulation)
Alwaysmoving Rhythmicor
stereotypedquality
(pacingorflapping
hands)whichtakes
attentionaway
fromtask
at
hand
Alwaysonthego,
cantsitstill,
fidgety
Beingactivehelps
engagement
(standingatdesk
whileworking,
likestobe
physically
engaged)
Friendships Stiff ininteractions,
doesntseemvery
interestedin
peers
Makesfriends,but
cantkeepthem
Seekspeerswho
engagein
impulsiveor
risky
activities
Differential: ASD v. ADHD behaviors
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ASDDiagnosticCriteria ASD notADHD CouldbeADHDNonverbalCommunication Stiff,noeyecontact Personalspaceissues
Friendships Seekspeersoutbasedon
theirtoys/games
Makesfriendsbutloses
themquickly
Lackofsharing
EmotionalReciprocity
DelayedLanguage No
Conversations Excessivetalking
StereotypedLanguage Historyofclearecholalia
Limitedpretendplay
CircumscribedInterests Repetitive
talking
about
games;gamefactsVideo
games
for
hours
NonfunctionalRoutines
Motormannerisms
Preoccupationwithparts Peersatobjects
Differential diagnosis: ASD v. ADHD
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Behavior IsmorelikeASD CouldbeeitherASDorAnxiety IsmorelikeAnxiety
Routinesand
rituals
Paceslunchroom
after
eating
unless
redirected;walks
perimeterof
playgroundat
recess
Eatsthesamemeal
and
sits
at
the
sametableevery
dayforlunch.
Seemsunder
pressure
to
do
routinesacertain
way.
Repetitive
language
Anticipatinga
transitionornovel
event
Askssame
questionoverand
overagain
Lookingfor
reassurance(OCD
theme)
Linesupobjects Egosyntonic;
repetitivemethod
ofplay
Ordersbysize,
shape,orcolor;
distressedif
disrupted
Egodystonic,or
underpressureto
keepthingsjust
so
Differential: ASD v. OCD
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ASDDiagnostic
Criteria ASD
not
OCD Could
be
OCD
NonverbalCommunication Doesnotimprovewithcomfort
orfamiliarity
Personalspaceissues;avoids
eyecontactortouch
Friendships Closefriendsbutactivitiesare
organizedby
parents
Uncomfortablearound
unfamiliarpeers
Lackofsharing
EmotionalReciprocity
DelayedLanguage No
Conversations Repetitivemonologues Repetitivereassuranceseeking
withparents
StereotypedLanguage Usesechoedwordsandphrases
inconversation
Sayscertainwordsuntilitfeels
right
Limitedpretendplay
CircumscribedInterests
NonfunctionalRoutines Samenessisegosyntonic Handwashing
Motormannerisms
Preoccupationwithparts Peersatreflectivesurfaces Avoidsobjectswithcertain
characteristics
Differential diagnosis: ASD v. OCD
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Between2070%ofindividualswithASDalso
haveintellectual
impairments
Estimatesdifferbasedonsample(ASDv.Autism),andIQtest(verbalv.nonverbal)
Rateis
decreasing
with
identification
of
higher
functioningASD,andwithbetterintervention
Unevenprofilesarecommon,butnotuniversal
However,manyindividualswithASDhavelowadaptiveskills(eveniftheirIQishigh)
Cognitive Development
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Communicationimpairment(socialuseoflanguage)ispartofASD
Impairmentsin
speech,
sound
processing,
grammar,andvocabularyarenotpartofASDbutcancooccur.
Delaysin
language
acquisition
are
common
20%willnotacquirefunctionalspeech Manywillcontinuetoshowreceptiveorexpressive
impairments
IQcorrelateshighlywithlanguage(butnotperfectly)
Language Disorders
i i d
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AccordingtoDSMIV,ADHDandASDcannotbothbediagnosed
However,researchers
have
pushed
for
change
withDSMV
Currentresearchquestions: IsADHDapointalongthesamespectrumasASD? IsADHDaseparatedisorderthatcancooccurwith
ASD1,2?
Howdo
ADHD
symptoms
change
with
age
or
level
of
functioning3,4,5?1Kimetal.2000;2LeeandOusley,2006;3Burdetal.2002;4Ghaziuddinetal.1998;5Yoshidaand
Uchiyama2004
Attention Disorders
A i Di d
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Frequentlyseen
in
ASD
GeneralizedAnxietyDisorder(2%35%)1,2
SeparationAnxiety(2%27%)3,4
SpecificPhobias
(10%
64%)1,3
SocialPhobia(5%12%)5,6
Widerangesofratesduetodifferencesin
samplesand
differential
diagnosis
Easiertoidentifyanxietydisordersinhighfunctioningindividuals,anditrespondswellto
cognitivebehavior
therapy7
1 Greenetal.2000;2Leyferetal.2006;3Murisetal.1998;4Szatmarietal.1989;5Gadowetal.2004;6deBruinetal.2007;7Chalfantetal.2007
Anxiety Disorders
Ob i C l i Di d
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OCD ASD
AnticipatoryAnxiety(somethingbadwill
happenif
Idont
wash
my
hands
3times)
Needforsameness(Thisishowitmust
bedone.)
Obsessionsfollowconsistentthemes
(symmetry,numbers,contamination,
harm)
OCDthemesnotseen
Compulsionsfollow
OCD
themes
(hand
washing,checking,repeatingthingsa
certainnumberoftimes)
OCDthemes
not
seen
OCDisdistressing(egodystonic)tothe
individual
Needforsamenessisusuallynot
distressingto
the
individual
with
ASD
(egosyntonic)
DoesnothavetriadofASDcharacteristics HastriadofASDcharacteristics
Obsessive Compulsive Disorder
P h i
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Initially,autismwasviewedasachildhoodonsetformofschizophrenia
Diagnosiswould
be
changed
from
Autism
to
Schizophrenia
at
age18
Now,ASDisunderstoodasalifelongdisorder Schizophreniacannowsometimesbeidentifiedinchildhood
Psychosis Negativesymptoms(flattenedaffect,attentiondifficulties)
shareoverlapwithASD
Positivesymptoms(hallucinations,delusions)donotoverlapwith
ASD
Mustconsiderwhetherpsychosisisduetoamooddisorderv.schizophrenia
Psychosis
T t f I t ti
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Comorbidconditionsareoftentheprimary
targetsfor
treatment
Differentialdiagnosiscanhelpidentifyaspecifictargetanditslikelysource
E.g.,DifferentiatewhatisADHDv.ASDandthenmeasuretheADHDsymptomsduringintervention
Identifyabehavior
that
needs
intervention,
screenforpossiblecausesotherthanASD,and
thendesignatargetedtreatmentplan
Targets for Intervention
Ch i i t ti
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Chooseevidencebasedinterventionsforyour
targetbehavior
WorkwithaproviderthatknowsenoughaboutASDtodifferentiateASDandnonASD
behaviors
Trackthetargetedbehaviorwithyour
providerto
make
informed
treatment
choices
andchanges
Choosing an intervention