Topic 5 - Classification, Assessment and Diagnosis 2010

1Autism, Asperger’s & ADHD (6PS048)

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Classification, Assessment And Diagnosis.

Simon Bignell – Module Leader

Lecture 5


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Introduction To The Lecture.

• What is Classification?

• DSM-IV-TR / ICD-10.

• How does assessment happen in the UK?

• How is a diagnosis of Autism, Asperger’s or ADHD made?


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Learning Outcomes Of This Lecture.

On completion of the lecture and with independent study you should be able to:

1. Understand how assessment of Autism, Asperger’s and ADHD is conducted.

2. Understand issues surrounding assessment and diagnosis of Autism, Asperger’s and ADHD.

3. Be able to form an opinion on some of these issues and contrast the methods and procedures involved.


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Overview of Classification.

• The ‘medical model’.• Diagnosis has to be made on a behavioural basis

(no genetic markers or cognitive/perceptual markers are unique to the disorder).

• Then the crudeness of categorisation has to be adhered to.

• But diagnostic differentiation is often based on parental report of child activity leading to problems of validity and reliability.


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Overview of Classification.

• The individuals concerned are a heterogeneous group, displaying variations in the number of symptoms and the severity of impairments.

• Asperger Syndrome is held to be a useful descriptive term, but it hardly provides a clear-cut category of needs.

• Subtypes of ADHD may not be etiologically related.

• Developmental trajectories are also largely unpredictable from diagnosis using the tick-list approach.


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DSM & ICD.

APA. (1994). DSM-IV Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington DC: American Psychiatric Association.

ICD-10. (1994). International Classification of Diseases. 10th Edition. Geneva, Switzerland: World Health Organisation.


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• Severe childhood disorders characterised by impairment in verbal and non-verbal communication and social interaction.

• Abnormalities occur in the developmental process itself.

• Development is not delayed but is atypical.

• Examples: Autistic Disorder, Asperger’s Disorder.

Pervasive Developmental Disorder.


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The DSM-IV includes five types of disorder under the term ‘Pervasive Developmental Disorder’ PDD.

1) Autistic Disorder*.2) Rett’s Disorder.3) Childhood Disintegrative Disorder.4) Asperger’s Disorder*.5) Pervasive Development Disorder Not

Otherwise Specified*.* Mainly these form the Autistic spectrum ASD.

Pervasive Developmental Disorder.


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Disruptive Behaviour Disorders.• Characterised by under controlled, or externalising

behaviour (i.e., “acting out”; socially disruptive behaviour that is inappropriate given the age of the child and/or setting of the behaviour).

• Behaviour is typically distressing and/or annoying to those in child’s social environment.

• Examples: ADHD, ODD, Conduct Disorder.

Attention-Deficit and Disruptive Behavioural Disorders.


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The DSM-IV includes five types of disorder under the term ‘Attention-Deficit and Disruptive Behavioural Disorders’.

1) Attention-Deficit/Hyperactivity Disorder. Predominantly Inattentive Type. Predominantly Hyperactive-Impulsive Type. Combined Type.

2) Conduct Disorder.3) Oppositional Defiant Disorder.4) Attention-Deficit/Hyperactivity Disorder Not

Otherwise Specified.5) Disruptive Behaviour Disorder Not Otherwise

Specified.

Attention-Deficit and Disruptive Behavioural Disorders.


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Oppositional Defiant Disorder (ODD).

• Involves noncompliance, hostility, losing temper easily, arguing, irritability, deliberately annoying or blaming others

• High comorbidity with ADHD• May be a precursor to Conduct Disorder


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Conduct Disorder (CD).

• Involves antisocial behaviors that violate others’ rights (e.g., lying, stealing, fighting, bullying, truancy, cruelty to people or animals, criminal behaviors)

• Prognosis for child-onset CD is worse than for adolescent-onset CD; worse for aggressive children


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A Reminder…Autistic Spectrum Disorder.

• Autism is defined in terms of abnormalities in social and communication development, in the presence of marked repetitive behaviour and limited imagination (APA, 1994).

• Asperger Syndrome (AS) is defined in terms of the individual meeting the same criteria for Autism but with no history of cognitive or language delay, and not meeting the criteria for PDD (ICD-10, 1994).


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A Reminder… ADHD.

…is a developmental disability with a childhood onset that typically results in a chronic and pervasive pattern of impairment in school, social and/or work domains, and often in daily adaptive functioning.

Problems with Attention, Hyperactivity & Impulsivity.

Symptoms of ADHD.

High Impulsiveness

Poor Attention

High Hyperactivity

Symptoms of ADHD.

High Impulsiveness

Poor Attention

High Hyperactivity

Combined Type

Predominantly Hyperactive-Impulsive Type

Predominantly Inattentive Type


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• Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR).– Criterion A – Persistent pattern of inattention and/or

hyperactivity/impulsivity more frequent and severe than typically observed in those at comparable levels of development.

– Criterion B – Symptoms present before age 7 years.– Criterion C – Symptoms present in at least two

settings.– Criterion D – Evidence of interference with

developmentally appropriate social, academic, or occupational functioning.

– Criterion E – Not better accounted for by another mental disorder.

Diagnostic Criteria for ADHD.

Symptoms of Autistic Disorder.

Restricted, repetitive and stereotyped patterns of behaviour.

Impairment in social interaction.

Impairment in verbal and non verbal communication.

Wing, L., & Gould, J. (1979). Severe impairments of social interaction and associated abnormalities in children: epidemiology and classification. Journal of Autism and Developmental Disorders, 9, 11-29.

Symptoms of Asperger’s Disorder.

• The triad of impairment summarises the difficulties of the Autistic child but the actual manifestation of these can vary. Asperger’s may be a subtler form of ASD.

Impairment in social interaction.

Impairment in verbal and non verbal communication.

Peculiarities in verbal and non verbal communication.

Restricted, repetitive and stereotyped patterns of behaviour.


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Asperger’s DSM Criteria.A. Qualitative impairment in social interaction, as

manifested by at least two of the following: • Marked impairment in the use of multiple

nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction.

• Failure to develop peer relationships appropriate to developmental level.

• A lack of spontaneous seeking to share enjoyment, interests, or achievements with other people.

• Lack of social or emotional reciprocity.


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Asperger’s DSM Criteria.B. Restricted repetitive and stereotyped patterns of

behavior, interests, and activities, as manifested by at least one of the following:

• Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus.

• Apparently inflexible adherence to specific, nonfunctional routines or rituals.

• Stereotyped and repetitive motor mannerisms.• Persistent preoccupation with parts of objects.


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Asperger’s DSM Criteria.C. The disturbance causes clinically significant impairment in social,

occupational, or other important areas of functioning.

D. There is no clinically significant general delay in language (e.g., single words used by age 2 years, communicative phrases used by age 3 years).

E. There is no clinically significant delay in cognitive development or in the development of age-appropriate self-help skills, adaptive behavior (other than in social interaction), and curiosity about the environment in childhood.

F. Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia.


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Some Considerations of Diagnosis.• ASD and ADHD are umbrella terms.• Heterogeneity, hence spectrum.• Assessed on a behavioural basis.• ICD-10 and DSM-IV; tick-list medical approach.• Diagnosis can vary across age!• Missed diagnosis and misdiagnosis.

– Multiple referral routes.– Pressures on LEA resources.– Multiple assessment protocols.

• There’s also pressure NOT to diagnose (limited support resources at LEA level).


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• Clear criteria but reality is different – clinician’s judgement.

• The cut-off between normal-but difficult temperament and ADHD is not clearly definable.

• ICD-10 and DSM-IV; tick-list medical approach.• Subjective nature of responses on behaviour

rating scales.• Assessment performance in clinicians' offices

is often poorer.

Some Considerations of Diagnosis.


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Referral routes. • A long journey…

• Parental pressure on school or GP.– SENCO/Ed Psych via school.– GP referral to paediatric psychiatrist.

• Special Education Needs.– School Action.– School Action plus.– Assessment by LEA.– Diagnosis.– Treatment.

• How much support a family (ultimately) gets depends on several factors (location, social class, education and income!).


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Overview of Diagnosis and Assessment.

• It’s easier to ‘spot’ Autism at the low-functioning end of the spectrum.

• Not so easy to spot Asperger’s Disorder.• High-functioning children do adapt in both

ASD and ADHD.• ADHD tends to be missed as ‘naughty’ or

boisterous behaviour.• Adult AS or ADHD can be seen as quirk of

personality (and be functional).


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• Normal use of cognitive assessment tools is not useful for categorisation.

• Profiles are spikey and individual:– Non Verbal IQ > Verbal IQ in Autism– Verbal IQ > Non Verbal IQ in Asperger's– Developmental delay in ADHD.– Commonly found superiorities in

perceptual skills in ASD.• Disorder- specific tools developed.


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• Thorough assessment depends on information gathered through a variety of methods.– Professionals.– Family members.– Educators.

• There is not a single test that when used alone can provide a definitive diagnosis of an autism spectrum disorder or ADHD.

• Few have been empirically validated.• Behavioural measures are subjective.


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• It’s easier to ‘spot’ autism at the low functioning end of the spectrum.

• High functioning children do adapt .• Early intervention is critical.

– Younger children have a greater degree of brain plasticity (Edelman, 1992).

• Late screening:– Very few tools sensitive to adolescent/adult

diagnosis.– Self-diagnosis common (AQ published on web).


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Diagnostic Tools for Autism.

• Assessment for the purpose of diagnosis occurs in clinics, private practices or home visits and is led by psychiatrists, psychologists, or physicians.

– Childhood Autism Rating Scale (CARS).

– The Checklist for Autism in Toddlers (CHAT).

– Autism Diagnostic Interview (ADI).

– The Autism Screening Questionnaire.

– The Screening Test for Autism in Two-Year Olds.

– The Adolescent Autism Spectrum Quotient (AQ).

• Multi-method approach best (e.g., not just interview).


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Warning Signs of ASD.

The NICHD lists these five behaviours that signal further evaluation is warranted:– Does not babble or ‘coo’ by 12 months.

– Does not gesture (point, wave, grasp) by 12 months.

– Does not say single words by 16 months.

– Does not say two-word phrases on his or her own by 24 months.

– Has any loss of any language or social skill at any age.


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Early indicators of autism.

Within the first year:• Lack of eye contact to initiate joint attention.• Emotionally distant behaviour or dislike of affection.• Lack of imitation or social reciprocity.• Lack of functional use of nonverbal communication. • Inappropriate use of toys.

Screening for Autism is also recommended if a sibling or other family member has a diagnosis within the autism spectrum.


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Assessment of Autism.

• Thorough interview and history from patient and family, especially early development.

• Clarify presence of critical areas of deficit.• Rule out other disorders.• Multidisciplinary team approach is best to

evaluate language/pragmatics, cognitive, adaptive behavior, social and familial, medical/neurological status, sensory/motor.


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An example screener…

The Checklist for Autism in Toddlers (CHAT).Baron-Cohen, Allen, & Gillberg (1992).

• A short screening tool composed of nine questions for parents and involves five structured interactions between the examiner and child.

• The CHAT is used to determine whether further diagnostic testing for autism is warranted, not to obtain a formal diagnosis.


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An example…

Autism Diagnostic Interview-Revised (ADI-R).(Lord, Rutter, & Le Couteur, 1994).• Standardised, semi structured parent interview.• Last approx 1 ½ hours.• Asked to describe past and current behaviour

focussing on preschool years.• Scored using an algorithm consistent with DSM-IV

and ICD-10.• Most consistent of all instruments with the

diagnostic criteria.


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Diagnostic Tools for ADHD.

• As with ASD assessment for the purpose of diagnosis typically occurs in clinics, private practices or home visits and is led by psychiatrists, psychologists, or physicians.

• Typically diagnosed in primary school years.

– Conners Rating Scales (CRS) (Conners, 1996b).

– Child Behaviour Checklist (CBCL) (Achenbach, 1991).

– ADD-H Comprehensive Teacher/Parent Rating Scale (ACTeRS) (Ullmann, Sleator, & Sprague, 1997).


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Teachers/parents rate Hyperactivity, Attention, Social Skills and Oppositional behaviour using 5 point scale.

Almost Never 1 2 3 4 5 Almost Always

Attention examples:•‘Persists with task for reasonable amount of time.’•‘Follows a sequence of instructions.’

Hyperactivity examples:•‘Extremely overactive (out of seat, on the go).’•‘Impulsive (acts or talks without thinking).’

The ADD-H: Comprehensive Teacher Rating Scale (ACTeRS; Ullmann, Sleator, & Sprague, 1997) is used to determine whether further diagnostic testing for ADHD is warranted, not to obtain a formal diagnosis.

Example: ACTeRS - Screening Questionnaire


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Diagnostic Differences.

ADHD

• Usually spotted in school.

• Normal IQ.• Often pragmatic

language problems.• High comorbidity

with other problems.

• Often mistook for bad behaviour.

Classic Autism

• Early onset• IQ tends to be lower• Often fail to develop

spoken language• Problems with non-

verbal communication

• Tend to be adept at basic motor skills

Asperger’s

• Later onset• Higher range of

IQ• No language

deficit• Non-verbal

communication problems less severe

• Clumsiness in basic motor skills