Diagnosis of Autism Spectrum Disorders

Diagnosis of Autism Spectrum Disorders Kristn Currans, PsyD Bridget Kent, MA, CCC-SLP The Kelly O’Leary Center for Autism Spectrum Disorders (TKOC) Di...
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Diagnosis of Autism Spectrum Disorders Kristn Currans, PsyD Bridget Kent, MA, CCC-SLP The Kelly O’Leary Center for Autism Spectrum Disorders (TKOC) Division of Developmental and Behavioral Pediatrics Cincinnati Children's Hospital Medical Center

Objectives • Review of Autism Spectrum Disorders • Discuss best practice in ASD diagnosis • Review R i components t off a multidisciplinary ltidi i li evaluation • Age related issues in assessment • “Red Flags” g

Autism Spectrum Disorders Brain based developmental disorders which: Brain-based - appear during the first 3 years of life - cause difficulties with the following: - understanding language - using language - relating to the environment - processing sensory information - are diagnosed by behavioral observation

Autism Spectrum Disorders

Autistic Disorder • • • • • • •

Difficulties with social interaction. Difficulties with communication. Very limited pretend play play. Occurs prior to age three years. Often have stereotyped behaviors behaviors. May have restricted interests and activities. Subgroup may have experienced regression.

Asperger Syndrome • Difficulties with social interactions interactions. • Presence of communication issues, but more subtle than those seen in autistic disorder. • Restricted R t i t d interests i t t and d activities. ti iti • Intelligence ranges from average to well above average.


(Pervasive Developmental Disorder Not Otherwise Specified)

• Diagnosis made when a child does not meet the criteria for a specific diagnosis (Autism Asperger). (Autism, Asperger) There is generally a severe and pervasive impairment in communication social interactions, communication, interactions or restricted interests.

Autism Spectrum Disorders Diagnosis i i • Individuals are more unique than similar, similar which can make diagnosis a challenge • Diagnosis encompasses a wide range of presentations “If you’ve met one person with autism, then you’ve ’ mett one person with ith autism.” ti ” -Stephen Shore

Best Practice in ASD Diagnosis Best practice for diagnosis of ASD should be multidisciplinary, including a medical professional,, psychologist, p p y g , and speech p language pathologist. (Other related fields as needed) Ozonoff,, S.,, Goodlin-Jones,, B.,, Solomon,, M. (2005)

Best Practice:

Roles of Team Members • Physician: ys c a R/O /O ot other e medical ed ca co conditions, d t o s, medical history, determine additional testing needed • Psychologist: P h l i cognitive, ii R/O other h mentall health conditions, detailed history, behavior, autism specific tools, attention • Speech-Language Pathologist: communication and social differences specific to ASD, strengths and weaknesses, some autism specific tools (at TKOC administer ADOS)

Best PracticeRoles l off Team Members b • Occupational Therapist: motor/sensory differences, sensory profile, arousal levels • Education: academic functioning, behavior in different contexts • Audiology: R/O hearing loss • Neuropsychology: higher functioning to explore discrepancies, profile of strengths and weaknesses, executive functioning

Diagnosing Autism at TKOC • Multidisciplinary evaluation – Pediatrics, psychology, speech pathology – Neuropsychology, Neuropsychology audiology audiology, occupational therapy, and special education as needed

General Assessment Guidelines • No one assessment measure should be used in isolation • Autism is a diagnosis based on behavioral symptoms • Good G d tto iinclude l d assessmentt across settings if possible (parent report, teacher report, t and d di directt observation) b ti )


Psychology Evaluation: Basic i Components C • • • • • • • •

Relevant Background Information Child Interview (if possible) Behavioral Observations including play Cognitive Functioning Adaptive Behavior Executive Functioning Behavior Checklists Autism Specific Measures

Relevant Background Information • • • • • •

Pregnancy history Developmental Milestones M di l Concerns Medical C Past and current medications Sleep Feeding

Relevant Background Information • Family History • School History • Family F il Stressors/History St /Hi t off ttrauma and d abuse • Past treatment/services

Relevant Background Information • Communication – Current level of communication and use of communication – History of regression – Disordered Communication (scripted language, echolalia, repetitive phrases, pronoun confusion, idiosyncratic use of words etc ) etc.) – Nonverbal communication (gestures, pointing)

Relevant Background Information • Sensory Concerns – Adverse reaction to noise, smells, texture – Seeking sensory input such as sniffing or mouthing objects, peering at objects or interest in the feel of objects

Relevant Background Information • Social Interaction – Seeking to share enjoyment or interests – Initiation of interaction – Eye contact and facial expressions – Peer play (cooperative (cooperative, parallel etc etc.)) – Play skills (imaginative play, imitation, repetitive play) • Be sure to get examples of play

Relevant Background Information • Stereotyped/Repetitive Behaviors – Preoccupation with activity/objects ƒ Takes up a significant amount of time and interferes with f functioning ti i

– Inflexibility with routines and difficulty with transition – Motor Mannerisms (hand flapping, rocking, spinning, complex body movements, finger flicking, twisting) – Fascination with parts of objects

Relevant Background Information • Behavioral Concerns – Tantrums, aggression (frequency, intensity) – Self injury – Anxiety – Mood related symptoms

• Strategies used to address behavior

Cognitive Functioning: What h are we looking l ki for? f ? • • • •

General developmental level Strengths and weaknesses R/O mental retardation Split in verbal vs. non-verbal skills – ASD: often higher non-verbal non verbal than verbal skills – Asperger: often higher verbal skills and average to above average intelligence

Cognitive Measures • Stanford Stanford-Binet Binet Intelligence ScaleScale Fifth Edition – Age 2+

• Mullen Scales of Early Learning -Birth to 68 months -Given when under 2 or cannot achieve basal on the SB-V

• Leiter-R – Non-verbal test of intelligence

Adaptive Functioning: What h are we looking l ki for? f ? • Children with ASD often have deficits in adaptive functioning • Particular focus on communication and social skills • Also Al use to t assist i t in i diagnosis di i off mental t l retardation

Adaptive Functioning Measure • Vineland Adaptive Behavior Scales Scales-Second Second Edition (VABS-II) – Communication ((receptive, p , expressive, p , written) – Socialization (interpersonal relationships, play and d leisure, l i coping i skills) kill ) – Daily Living Skills (personal, domestic, community) – Motor Skills (fine and gross)

Executive Functioning: What h are we looking l ki for? f ? • Compilation of skills required for problem solving, planning, and modulation of emotion and behavior • Children with ASD often have deficits in one or more areas of executive functioning • Valuable V l bl for f treatment t t t recommendations d ti

Executive Function Measure • Behavior Rating Inventory of Executive Function (BRIEF and BRIEF-P) – BRIEF-P for age 2 years years, 0 months to 5 years years, 11 months – BRIEF for age 5 years to 18 years

Behavioral Checklists: What are we l ki for? looking f ? • R/O co co-morbid morbid mental health conditions • Can symptoms be explained by another diagnosis beside ASD • On the CBCL look at withdrawn behaviors ( (younger) ) and d social i l problems bl (older) ( ld )

Behavioral Checklists • Achenbach Child Behavior Checklist • Achenbach Teacher Report Form • Anxiety, A i t Depression, D i ADHD measures as needed – Conners’ Parent Rating Scale- Revised: Long Version, Screen for Anxiety Related Disorders, Beck Youth Inventory Inventory, Child Depression Inventory, Youth Self Report Form

Autism Specific Instruments • Autism Diagnostic g Interview-Revised ((ADI-R))

– Semi-structured parent interview – Administration time: 2 – 3 hours – Current C tb behavior h i and d focused f d time ti between b t 4–5 years old – Provides a diagnostic algorithm – Classification of autism given when scores in all three content areas (communication, social interaction, and patterns of behavior) meet or exceed the specified cutoffs, t ff and d onsett off th the di disorder d iis evident id t b by 36 months of age

Autism Specific Instruments • Components of ADI ADI-R R Interview: – Background, including family, education, previous diagnoses, and medications – Overview O i off the th subject's bj t' behavior b h i – Early development – Language acquisition and loss of language or other skills – Current functioning in regard to language and communication – Social development and play – Interests and behaviors – Clinically relevant behaviors, such as aggression, self-injury

Autism Specific Instruments • G Gilliam a Autism ut s Rating at g Sca Scale-2 e (G (GARS-2) S ) – Used for age 3-22 – Informant should be someone who knows the behavior of the child well – Normed on children with autism spectrum diagnoses – Based on 3 subscales: stereotyped yp behaviors,, communication, and social interaction – Result in Autism Index which correlates to probability of an autism spectrum diagnosis – Mean=100, SD=15

Autism Specific Instruments • Childhood Autism Rating Scale (CARS) – completed by psychologist – based on observation and parent report – behaviors are scored based on comparison to “typical” typical children – range of scores 15 to 60 – not intended to be a stand alone assessment

Autism Specific Instruments

(Asperger or High Functioning Autism) • Gilliam Asperger Diagnostic Scale (GADS) – Informant should be someone who knows the behavior of the child well – Normed on children with Asperger diagnosis – Based on 4 subscales: social interaction, restricted patterns off behavior, cognitive patterns, and pragmatic skills – Result in Asperger Asperger’ss Disorder Quotient which correlates to probability of Asperger’s Disorder


Communication Evaluation: Basic i Components C • • • • •

Relevant Background Information Expressive Language Functioning R Receptive ti Language L Functioning F ti i Social/Pragmatic Language Functioning Autism Specific Measures

Relevant Background Information • Presence of normal audiologic evaluation – History of recurrent ear infections • Speech and Language Development – Within Normal Limits – Delayed – History of regression • Access to intervention services • Feeding difficulties

Receptive & Expressive Language Skills: Wh t are we llooking What ki for? f ? • General language level • Strengths and weaknesses • Split S lit in i receptive ti and d expressive i language l skills – ASD: often higher expressive language skills than receptive language skills

• Presence of stereotyped language

Receptive & Expressive Language Skills Measures • Preschool Language Scale – Fourth Edition (Ages birth to 6 years, 11 months) • Clinical Evaluation of Language Fundamentals – Preschool 2 (Ages 3 years to 6 yyears,, 11 months)) • Peabody Picture Vocabulary Test – Fourth g 2 years, y , 6 months Edition ((Norms for ages to 90 years)

Social/Pragmatic Language Skills: What h are we looking l ki for? f ? • • • • • • • • •

Communicative functions Nonverbal language skills Turn taking (verbal and nonverbal) Maintenance of personal space Facial expressions Eye gaze Social overtures Maintenance of attention Providing clarification

Social/Pragmatic Language Measures • Common Co o Measures easu es – Descriptive Pragmatics Profile from Clinical Evaluation of Language Fundamentals P Preschool h l – Second S d edition di i (Ages (A 3 years to 6 years, 11 months) – Comprehensive Assessment of Spoken Language (Ages 3 years to 21 years) • Observations of skills

Autism Specific Measures • Autism Diagnostic g Observation Schedule (ADOS) ( ) – Semi-structured standardized assessment of communication, social interaction, and play/imaginative use of materials – Consists of standard activities that allow the examiner to observe behaviors that have been identified as important to the diagnosis of ASD at different developmental levels and chronological ages – Includes 4 modules based on language level – Provides a diagnostic algorithm – Results yyield a score that falls into one of three ranges g – autism, autism spectrum, or neither

Autism/Communication Related Concerns • Lack of speech coupled with lack of desire to communicate and d nonverbal b l compensatory t efforts ff t • Scripted and stereotyped language • Dissociation between “advanced” expressive skills and delayed receptive skills • Hyperlexia or advanced verbal reading without corresponding comprehension skills • Use of gestalt phrases • Other prespeech deficits include

– Lack of appropriate gaze; warm, joyful expressions with gaze; lack of recognition of mother’s voice; disregard for vocalizations, yet keen awareness off environmental i l sounds; d delayed d l d onset off babbling b bbli past 9 months; and decreased or absent use of prespeech gestures (Johnson & Myers, 2007)

Assessing Social Behavior • • • • •

Eye Contact Joint Attention Di t d Facial Directed F i l Expressions E i Showing Giving

Assessment of Social Behavior • Children C d e with t ASD S u universally e sa y de demonstrate o st ate deficits in social relatedness defined as the inherent drive to connect with others and share complementary feeling states (Johnson & Meyers, 2007) • To ensure accuracy and consistency of observations, assessment of social behavior should occur across settings and clinicians • Multi-disciplinary assessment allows for different viewpoints of social behavior

Assessment of Social Behavior • Deficits in jjoint attention (JA) ( ) seem to be one of the most distinguishing characteristics of very young children with ASD (Johnson & Myers, 2007) – JA is a normal spontaneously p y occurring g behavior – At approximately 8 months – infant will follow the parent’s gaze and look in the same direction – At approximately 10-12 months – infant will follow a point – At approximately 12-14 months – child will begin to initiate a point to request – At approximately 14-16 months – child will begin to point simply to “comment” “ ” or ““share” h ” an iinterest

Additional Assessment C Considerations id i

Age-Related Age Related Issues to Assessment • Accurate assessment requires q engaging g g g a child’s attention and motivation to demonstrate his or her skills (Koegel, Koegel, & Smith, 1997; Ozonoff, Rogers, & Hendren) • Before the age of 3 years, skill assessment generally does not require intentional cooperation on the part of the child with ASD; it relies instead on observation of the child’s exploration of standardized materials and reaction to events in the assessment setting (Shea & Mesibov, 2009)

Issues Around Assessment of Young Children Child • • • •

Experience Parent Report B h i Behavior Typical Development

Screening for ASD • AAP formally recommends all children be screened for ASD at 10-mos and 24-mos • Modified Checklist for Autism in Toddlers (M-CHAT)

“Red Red Flags Flags” • No babbling or pointing or other gesture by 12-mos • No single words by 16 mos • No two-word spontaneous (not echolalic) phrases h by b 24-mos 24 • Loss of language or social skills at any age (Johnson & Myers, 2007)

Early Signs – Autism Society of America i • Lack of or delay in spoken language • Repetitive use of language and/or motor mannerisms (e.g., hand hand-flapping, flapping, twirling objects) • Little or no eye contact • Lack of interest in peer relationships • Lack of spontaneous or make-believe play • Persistent fixation on parts of objects

Referral • Discuss concerns with family • Recommend follow-up with pediatrician • Evaluation E l ti with ith multi-disciplinary lti di i li team, t if appropriate

References • American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). ed ) Washington, Washington DC: Author. Author • Goldstein, S., Naglieri, J. A., & Ozonoff, S. (Eds.). (2009). Assessment of autism spectrum disorders. New York: The Guildford Press. • Johnson, C. P., Myers, S.M., & The Council on Children with Disabilities. (2007). Identification and evaluation of children with autism spectrum disorders. Pediatrics, 120, 1183-1215. • Koegel, Koegel L. L K., K Koegel, Koegel R., R & Smith, Smith A. A (1997). (1997) Variables related to differences in standardized outcomes for children with autism. Journal of Autism and Developmental Disorders, 27, 233-243. • Ozonoff, S., Rogers, S. J., & Hendren, R. L. (2003). Autism

spectrum disorders: A research review for practitioners. practitioners Washington, DC: American Psychiatric Publishing.

Resources • Autism Societyy of America – www.autism-society.org – Click on ‘Resources’ then ‘Downloads’

• Autism Society of Ohio – www.autismohio.org – Click on ‘Resources/Guidelines’

• Autism Society of Greater Cincinnati – www.autismcincy.org – Click on ‘Calendar of Events’ or ‘Links’

• The Kelly O’Leary Center for Autism Spectrum Disorders – www.cincinnatichildrens.org/autism

Resources • Ohio Center for Autism and Low Incidence Disorders – www.ocali.org www ocali org – Click on ‘Resources’

• Organization O i ti for f Autism A ti Research R h – www.researchautism.org – Click on ‘Educators & Service Providers’