AutismSpectrumDisorders andComorbidConditions

JudithMiller,PhD millerj3@email.chop.edu January2012

Educational Objectives
Discussthemostfrequentcomorbid psychiatricconditions Describetheprocessofdifferentialdiagnosis Describetheprocessoftreatingcomorbid conditionsandidentifyingtargetsfor intervention

Autism is heterogeneous

Common Comorbidities
Languagedisorders Cognitivedelays Anxietyandmooddisorders Attentiondisorders Neurologicaldisorders Learningdisorders Medicalissues(Sleep,GI,geneticdisorders)

Common Psychiatric Comorbidities

IntellectualImpairment Attentiondisorders AnxietyDisorders TicDisorders MoodDisorders

How to make a differential diagnosis

Reviewavailableinformation(records,other evaluations) Gatherobservationsandhistory Generatelistofpossiblediagnostic explanations Carefullyconsideroverlapbetweendiagnoses andcharacteristicsthatcanfit morethan onedisorder

Differential: ASD v. ADHD behaviors

Behavior Videogames IsmorelikeASD Repetitiveor asocialqualityto play(circumscribed interest) Couldbeeither ASDorADHD Canplay videogamesfor hours Seemsobsessed IsmorelikeADHD Thriveson constantfeedback videogames provide(high stimulation) Beingactivehelps engagement (standingatdesk whileworking, likestobe physically engaged)

Alwaysmoving

Rhythmicor Alwaysonthego, stereotypedquality cantsitstill, (pacingorflapping fidgety hands)whichtakes attentionaway fromtaskathand

Friendships

Stiffininteractions, Makesfriends,but Seekspeerswho doesntseemvery cantkeepthem engagein interestedinpeers impulsiveorrisky activities

Differential diagnosis: ASD v. ADHD

ASDDiagnosticCriteria NonverbalCommunication Friendships Lackofsharing EmotionalReciprocity DelayedLanguage Conversations StereotypedLanguage Limitedpretendplay CircumscribedInterests NonfunctionalRoutines Motormannerisms Preoccupationwithparts Peersatobjects Repetitivetalkingabout games;gamefacts Videogamesforhours Historyofclearecholalia No Excessivetalking ASD notADHD Stiff,noeyecontact Seekspeersoutbasedon theirtoys/games CouldbeADHD Personalspaceissues Makesfriendsbutloses themquickly

Differential: ASD v. OCD

Behavior Routinesand rituals IsmorelikeASD Paceslunchroom aftereatingunless redirected;walks perimeterof playgroundat recess Anticipatinga transitionornovel event Egosyntonic; repetitivemethod ofplay Couldbeeither ASDorAnxiety Eatsthesamemeal andsitsatthe sametableevery dayforlunch. Ismorelike Anxiety Seemsunder pressuretodo routinesacertain way.

Repetitive language Linesupobjects

Askssame questionoverand overagain Ordersbysize, shape,orcolor; distressedif disrupted

Lookingfor reassurance(OCD theme) Egodystonic,or underpressureto keepthingsjust so

Differential diagnosis: ASD v. OCD

ASDDiagnosticCriteria
NonverbalCommunication

ASD notOCD
Doesnotimprovewithcomfort orfamiliarity Closefriendsbutactivitiesare organizedbyparents

CouldbeOCD
Personalspaceissues;avoids eyecontactortouch Uncomfortablearound unfamiliarpeers

Friendships Lackofsharing EmotionalReciprocity DelayedLanguage Conversations StereotypedLanguage Limitedpretendplay CircumscribedInterests NonfunctionalRoutines Motormannerisms Preoccupationwithparts

No Repetitivemonologues Repetitivereassuranceseeking withparents

Usesechoedwordsandphrases Sayscertainwordsuntilitfeels inconversation right

Samenessisegosyntonic Peersatreflectivesurfaces

Handwashing Avoidsobjectswithcertain characteristics

Cognitive Development
Between2070%ofindividualswithASDalso haveintellectualimpairments
Estimatesdifferbasedonsample(ASDv.Autism),and IQtest(verbalv.nonverbal) Rateisdecreasingwithidentificationofhigher functioningASD,andwithbetterintervention

Unevenprofilesarecommon,butnotuniversal However,manyindividualswithASDhavelow adaptiveskills(eveniftheirIQishigh)

Language Disorders
Communicationimpairment(socialuseof language)ispartofASD Impairmentsinspeech,soundprocessing, grammar,andvocabularyarenotpartofASDbut cancooccur. Delaysinlanguageacquisitionarecommon
20%willnotacquirefunctionalspeech Manywillcontinuetoshowreceptiveorexpressive impairments

IQcorrelateshighlywithlanguage(butnot perfectly)

Attention Disorders
AccordingtoDSMIV,ADHDandASDcannotboth bediagnosed However,researchershavepushedforchange withDSMV Currentresearchquestions:
IsADHDapointalongthesamespectrumasASD? IsADHDaseparatedisorderthatcancooccurwith ASD1,2? HowdoADHDsymptomschangewithageorlevelof functioning3,4,5?
1Kimetal.2000;2LeeandOusley,2006;3Burdetal.2002;4Ghaziuddinetal.1998;5Yoshidaand

Uchiyama2004

Anxiety Disorders
FrequentlyseeninASD
GeneralizedAnxietyDisorder(2%35%)1,2 SeparationAnxiety(2%27%)3,4 SpecificPhobias(10%64%)1,3 SocialPhobia(5%12%)5,6

Widerangesofratesduetodifferencesin samplesanddifferentialdiagnosis Easiertoidentifyanxietydisordersinhigh functioningindividuals,anditrespondswellto cognitivebehaviortherapy7

1

Greenetal.2000;2Leyferetal.2006;3Murisetal.1998;4Szatmarietal.1989;5Gadowetal.2004;6de Bruinetal.2007;7Chalfantetal.2007

Obsessive Compulsive Disorder

OCD AnticipatoryAnxiety(somethingbadwill happenifIdontwashmyhands3times) Obsessionsfollowconsistentthemes (symmetry,numbers,contamination, harm) CompulsionsfollowOCDthemes(hand washing,checking,repeatingthingsa certainnumberoftimes) ASD Needforsameness(Thisishowitmust bedone.) OCDthemesnotseen

OCDthemesnotseen

OCDisdistressing(egodystonic)tothe Needforsamenessisusuallynot individual distressingtotheindividualwithASD (egosyntonic) DoesnothavetriadofASDcharacteristics HastriadofASDcharacteristics

Psychosis
Initially,autismwasviewedasachildhoodonsetformof schizophrenia
DiagnosiswouldbechangedfromAutismtoSchizophreniaat age18 Now,ASDisunderstoodasalifelongdisorder Schizophreniacannowsometimesbeidentifiedinchildhood

Psychosis
Negativesymptoms(flattenedaffect,attentiondifficulties) shareoverlapwithASD Positivesymptoms(hallucinations,delusions)donotoverlap withASD Mustconsiderwhetherpsychosisisduetoamooddisorderv. schizophrenia

Targets for Intervention

Comorbidconditionsareoftentheprimary targetsfortreatment Differentialdiagnosiscanhelpidentifya specifictargetanditslikelysource
E.g.,DifferentiatewhatisADHDv.ASDandthen measuretheADHDsymptomsduringintervention Identifyabehaviorthatneedsintervention, screenforpossiblecausesotherthanASD,and thendesignatargetedtreatmentplan

Choosing an intervention
Chooseevidencebasedinterventionsforyour targetbehavior Workwithaproviderthatknowsenough aboutASDtodifferentiateASDandnonASD behaviors Trackthetargetedbehaviorwithyour providertomakeinformedtreatmentchoices andchanges