Issues in Autism Evaluation: Differential Diagnosis, Special Populations, Accurate and

Efficient Measures

Laurie McGarry Klose, Ph.D., LSSP

Objectives

• Examine DSM-V diagnostic criteria for Autism Spectrum Disorders

• Analyze utility of frequently used autism assessment measures in diagnostic formulation

• Consider related neurological, developmental and emotional conditions

• Develop strategies for differential diagnosis

DSM-IV-TR vs DSM-V

• 3 symptom categories• 6 diagnostic items

endorsed• Specifies onset prior to

age 3• Includes Rhett’s,

Childhood Disintegrative Disorder, Asperger’s Syndrome, PDD-NOS

• 2 categories• Three diagnostic items

endorsed• Specifies early

development• Includes parameters for

designating severity

Diagnostic Criteria A

“Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive”

• “Deficits in social-emotional reciprocity, ranging, for example, from abnormal approach and failure of normal back and forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.”

• “Deficits in nonverbal communication behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication“

• “Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.”

• “Specify current severity: Severity is based on social communication impairments and restricted , repetitive patterns of behavior.”

Diagnostic Criteria B

“Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive; see text)”

• “Stereotyped or repetitive motor movements, use of objects, or speech (e.g. simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).”

• “Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take the same route or eat same food everyday).”

• “Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).”

• “Hyper- or hyporeactivity to sensory input or unusual interest in senspry aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement.”

Diagnostic Criteria C

“ Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life).”

Diagnostic Criteria D

“Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.”

Diagnostic Criteria E

“These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnosis of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.”

Concerning Individuals with a Previous Diagnosis of Autism, Asperger’s or PDD-NOS

“Note: Individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger’s disorder, or pervasive developmental disorder not otherwise specified should be given the diagnosis of autism spectrum disorder. Individuals who have marked deficits in social communication, but whose symptoms do not otherwise meet criteria for autism spectrum disorder, should be evaluated for social (pragmatic) communication disorder.”

Additional Specifications to be Included

• With or without accompanying intellectual impairment

• With or without accompanying language impairment

• Associated with a known medical or genetic condition or environmental factor

• Associated with another neurodevelopmental, mental, or behavioral disorder

• With catatonia

Neurodevelopmental Disorders

• Intellectual Disability (Intellectual Developmental Disorder)

• Global Developmental Delay• Unspecified Intellectual Disability (Intellectual

Developmental Disorder)• Language Disorder• Speech Sound Disorder• Childhood-Onset Fluency Disorder (Stuttering)

Neurodevelopmental Disorders, Cont.

• Social (Pragmatic) Communication Disorder• Unspecified Communication Disorder• Autism Spectrum Disorder• Attention-Deficit/Hyperactivity Disorder-

Combined presentation, Predominantly inattentive presentation, Predominantly hyperactive/impulsive presentation

• Unspecified Attention-Deficit/Hyperactivity Disorder

Neurodevelopmental Disorders, Cont.

• Specific Learning Disorder- With impairment in reading, With impairment in written expression, With impairment in mathematics

• Developmental Coordination Disorder• Stereotypic Movement Disorder- With/out self-

injurious behavior• Tourette’s Disorder• Persistent (Chronic) Motor or Vocal Tic Disorder

Neurodevelopmental Disorders, Cont.

• Other Specified Tic Disorder• Unspecified Tic Disorder• Other Specified Neurodevelopmental Disorder• Unspecified Neurodevelopmental Disorder

Persistent deficits in social communication and social interaction across multiple

contexts

Restricted, repetitive patterns of behavior, interests, or activities

Symptoms must be present in the early developmental

period

Symptoms cause clinically significant impairment

Not better explained by intellectual disability

Interview/Developmental History X X + X -

Autism Diagnostic Observation Schedule, Second Edition (ADOS-2)

X + - X -

Autism Diagnostic Interview-Revised (ADI-R)

X X + X -

Social Responsiveness Scale, Second Edition (SRS-2)

+ - - X -

Social Communication Questionnaire (SCQ)

X - - X -

Behavior Assessment System for Children, Second Edition (BASC-2) Parent and Teacher Reports

X - - X -

Adaptive Behavior Assessment System, Second Edition (ABAS-II)Parent and Teacher Reports

X - - + X

Gilliam Autism Rating Scale, Second Edition (GARS-2)Parent and Teacher Reports

X X - X -

Childhood Autism Rating Scale, Second Edition (CARS2)

+ + - X X

Haak Sentence Completion Test - X - X -

Projective Drawings - X - X X

Cognitive Assessment - - - X +

Persistent deficits in social

communication and social

interaction across multiple contexts

Restricted, repetitive patterns

of behavior, interests, or

activities

Symptoms must be present in the early

developmental period

Symptoms cause clinically

significant impairment

Not better explained by intellectual disability

Interview/Developmental History X X + X -

Autism Diagnostic Observation Schedule, Second Edition (ADOS-2)

X + - X -

Autism Diagnostic Interview-Revised (ADI-R)

X X + X -

Social Responsiveness Scale, Second Edition (SRS-2)

+ - - X -

Social Communication Questionnaire (SCQ)

X - - X -

Behavior Assessment System for Children, Second Edition (BASC-2) Parent and Teacher Reports

X - - X -

Adaptive Behavior Assessment System, Second Edition (ABAS-II)Parent and Teacher Reports

X - - + X

Gilliam Autism Rating Scale, Second Edition (GARS-2)Parent and Teacher Reports

X X - X -

Childhood Autism Rating Scale, Second Edition (CARS2)

+ + - X X

Haak Sentence Completion Test - X - X -

Projective Drawings - X - X X

Cognitive Assessment - - - X +

ASD and ID

Differential diagnosis considerations:• Delays in social communication must be

more severe than would be expected for the developmental level.

Tools:Verbal/nonverbal ability tests, Social Responsiveness Scale-2, Social Communication Questionnaire, ADI-R

ASD and Social (Pragmatic) Communication Disorder

• Impairments in social communication without the presence of repetitive, restricted or stereotyped behaviors may meet the criteria for Social Communication Disorder

• When those stereotyped behaviors are present, the diagnosis of ASD supersedes Social Communication Disorder

Tools:ADI-R, ADOS-2, SRS2, SCQ, interview, observation

ASD and ADHD

• Abnormalities of attention- either overly focused or apparent lack of focus- and hyperactivity are common features in persons with ASD.

• ADHD diagnosis should be made when the level of attention difficulties or hyperactivity exceed those that would be seen in individuals with similar developmental levels and similar severity levels of ASD

ASD and Affective Disorders

• Comorbidity rates for ASD and affective or anxiety disorders is as high as 70%

• For individuals who meet diagnostic criteria for ASD, specific symptomology should be investigated for comorbid diagnoses including changes in sleep or eating patterns, irritability, mania, including duration guidelines in diagnostic criteria

ASD and Anxiety Disorders

• Comorbidity up to 70%• When diagnostic criteria for ASD are met, attention is

given to specific criteria for anxiety disorders that are distinct from ASD criteria including significant distress when separating from caregivers, excessive worry about safety of caregivers, school refusal, selective mutism, fear of peer rejection

• Indications of anxiety not consistent with ASD- social impairments do not persist with familiar persons, age appropriate social capacity, but not utilized effectively

ASD and OCD

• Repetitive behavior is performed in order to reduce anxiety; intrusive recurrent thoughts inhibit functioning

• If social communication deficits are present, then ASD may more appropriately account for the repetitive behavior; if not, OCD is more appropriate

Reactive Attachment Disorder and ASD

• Diagnostic criteria include specific event prior to onset of symptoms including inadequate or inconsistent opportunities to form attachments with caregivers

• Reactive Attachment Disorder does not include the restrictive interests, unusual sensory reactions, repetitive (but not stereotyped) behavior.

• Both disorders may include stereotyped behaviors such as rocking or flapping and impaired social reciprocity.

ASD and ODD

• ODD includes an element of vindictiveness• ODD includes an awareness that behavior is

annoying or disruptive to others• ODD includes a pervasive sense of anger or

resentfulness and emotional dysregulation• With ASD, the noncompliant behavior results

in lack of understanding the behavioral expectations for social situations

ASD and Intermittent Explosive Disorder

• Aggression with physical damage or injury: 3 incidents in last 12 months; Aggressive episodes without physical damage or injury: 2X per week for 3 months.

• No precursors identifiable and not used for manipulation

• Magnitude exceeds that expected with ASD

ASD and Conduct Disorder

• Conduct disorder involves the purposeful violation of social rules or violation of the rights of others

• Antisocial behavior is proactive, predatory and purposeful

• ASD related rule breaking behavior results from not understanding social rules or not possessing the skills to negotiate social rules

ASD and Schizoid Personality Disorder

• Flat affect and restricted range of emotions contribute to lack of social interactions

• No interest in social relationships- a rejection rather than a lack of understanding or need for social interactions

• Includes a distinct lack of pleasure in few, if any, activities

• Very similar outward presentation between mild ASD and Schizoid- repetitive behavior and restricted interests are key differentila diagnosis features

Process for Making Differential and Comorbid Diagnoses

Evaluation of Student Completed

ASD Diagnostic Criterion Met ASD Diagnostic Criterion Not Met

ASD adequately characterizes presentation of symptoms

Severity Rating Determined

ASD does not adequately characterizes presentation of symptoms

Consider other disorders whose symptoms are present or overlap with ASD symptoms and Determine if symptoms exceed that which would be expected in ASD or for overall developmental level/age

Report ASD diagnosis Report ASD diagnosis with additional disorder as comorbid

Determine category of primary and secondary symptoms

Determine if diagnostic criteria for a disorder is met

Report diagnosis Report findings without diagnosis