autism spectrum disorders and co morbid conditions

7/28/2019 Autism Spectrum Disorders and Co Morbid Conditions

1/18

AutismSpectrum

Disorders

andComorbidConditions

JudithMiller,PhD

[email protected]
mailto:[email protected]:[email protected]


2/18

Discussthemostfrequentcomorbid

psychiatricconditions

Describetheprocessofdifferentialdiagnosis

Describethe

process

of

treating

comorbid

conditionsandidentifyingtargetsfor

intervention

Educational Objectives


3/18

Autism is heterogeneous


4/18

Languagedisorders

Cognitivedelays

Anxietyandmooddisorders

Attentiondisorders

Neurologicaldisorders

Learningdisorders

Medicalissues(Sleep,GI,geneticdisorders)

Common Comorbidities


5/18

IntellectualImpairment

Attentiondisorders

AnxietyDisorders

TicDisorders

MoodDisorders

Common Psychiatric Comorbidities


6/18

Reviewavailableinformation(records,other

evaluations) Gatherobservationsandhistory

Generatelist

of

possible

diagnostic

explanations

Carefully

consider

overlap

between

diagnoses

andcharacteristicsthatcanfit morethan

onedisorder

How to make a differential diagnosis


7/18

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


8/18

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


9/18

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


10/18

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


11/18

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


12/18

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


13/18

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


14/18

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


15/18

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


16/18

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


17/18

Comorbidconditionsareoftentheprimary

targetsfor

treatment

Differentialdiagnosiscanhelpidentifyaspecifictargetanditslikelysource

E.g.,DifferentiatewhatisADHDv.ASDandthenmeasuretheADHDsymptomsduringintervention

Identifyabehavior

that

needs

intervention,

screenforpossiblecausesotherthanASD,and

thendesignatargetedtreatmentplan

Targets for Intervention

Ch i i t ti


18/18

Chooseevidencebasedinterventionsforyour

targetbehavior

WorkwithaproviderthatknowsenoughaboutASDtodifferentiateASDandnonASD

behaviors

Trackthetargetedbehaviorwithyour

providerto

make

informed

treatment

choices

andchanges

Choosing an intervention

autism spectrum disorders and co morbid conditions

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