1. Laurie McGarry Klose, Ph.D., LSSP
Issues in Autism Evaluation: Differential Diagnosis, Special Populations, Accurate and Efficient Measures
Laurie McGarry Klose, Ph.D., LSSP

2. 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

3. 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

4. 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”

5. “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“

6. “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.”

7. 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)”

8. “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).”

9. “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.”

10. 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).”

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

12. 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.”

13. 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.”

14. 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

15. 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)

16. 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

17. 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

18. Neurodevelopmental Disorders, Cont.
Other Specified Tic Disorder
Unspecified Tic Disorder
Other Specified Neurodevelopmental Disorder
Unspecified Neurodevelopmental Disorder

19. Interview/Developmental History
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 + -
Autism Diagnostic Observation Schedule, Second Edition (ADOS-2)
Autism Diagnostic Interview-Revised (ADI-R)
Social Responsiveness Scale, Second Edition (SRS-2)
Social Communication Questionnaire (SCQ)
Behavior Assessment System for Children, Second Edition (BASC-2) Parent and Teacher Reports
Adaptive Behavior Assessment System, Second Edition (ABAS-II)Parent and Teacher Reports
Gilliam Autism Rating Scale, Second Edition (GARS-2)Parent and Teacher Reports
Childhood Autism Rating Scale, Second Edition (CARS2)
Haak Sentence Completion Test
Projective Drawings
Cognitive Assessment

20. Interview/Developmental History
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 + -
Autism Diagnostic Observation Schedule, Second Edition (ADOS-2)
Autism Diagnostic Interview-Revised (ADI-R)
Social Responsiveness Scale, Second Edition (SRS-2)
Social Communication Questionnaire (SCQ)
Behavior Assessment System for Children, Second Edition (BASC-2) Parent and Teacher Reports
Adaptive Behavior Assessment System, Second Edition (ABAS-II)Parent and Teacher Reports
Gilliam Autism Rating Scale, Second Edition (GARS-2)Parent and Teacher Reports
Childhood Autism Rating Scale, Second Edition (CARS2)
Haak Sentence Completion Test
Projective Drawings
Cognitive Assessment

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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.

28. 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

29. 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

30. 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

31. 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

32. Process for Making Differential and Comorbid Diagnoses