Differential Diagnosis

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Differential Diagnosis

• Conditions Commonly Observed in Children Referred
  for an Evaluation for Autism
• Susan Hepburn, Ph.D.
• University of Colorado at Denver and Health
  Sciences
• SESA, Alaska (March 2008)

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Goal

• Provide a brief review of several
• conditions of childhood that either
• Co-occur with an autism spectrum disorder
• OR
• Better explain a childs challenges than an
  autism spectrum disorder (ASD)

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Remember, autism is

• Behaviorally-based diagnosis, relying upon
  parental report and clinician judgment
• Reflective of a pattern of deficits in social,
  communication, and restricted behaviors
• problems in one area is not sufficient!
• A spectrum diagnosis (lots of variability)
• Diagnosis of vulnerability

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Behaviors That, Alone, Do Not Differentiate
Autism in Young Children

• Social anxiety or avoidance
• Delay in spoken language
• Repetitive motor behaviors
• Restricted interests
• Over-sensitivity or under-sensitivity to stimuli
• Maladaptive behaviors (tantrums, self-injury)

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Candidate Conditions

• Developmental
• Neurobiological
• Psychiatric

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Remember to seek consultation, especially if you
suspect a psychiatric disorder.

• Complex children require complicated diagnostic
  protocols and multidisciplinary collaboration

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Candidate Conditions Developmental

• Global Developmental Delay or
• Mental Retardation
• Developmental Language Disorders

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Global Developmental Delay or Mental Retardation

• Better explanation if
• Social relating is good (emotional contagion,
  early social games, referencing, affect)
• Joint attention is emerging
• Child engages in simple symbolic play (e.g.,
  feeding a doll)
• Imitation skills are good

• Co-occurs
• In approximately
• 60-80 of young children with ASD
• Cant say for sure until after ages 5-8
• Involves deficits in both intellectual and
  adaptive functioning

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Possible Red Flags for DD Instead of Autism

• Developmental skills tend to be delayed instead
  of disordered
• No split between verbal and nonverbal
• Early use of language is delayed, not aberrant
• Child makes attempts to compensate for lack of
  language through nonverbal means
• Social relating and reciprocity are evident
  across familiar and non-familiar adults

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Developmental Language Disorders

• Social overtures occur frequently and with rich
  integration of nonverbal behaviors
• Child demonstrates communicative intention and
  actively compensates for difficulties in language
• Child may insist on routines and sameness as a
  coping strategy. May tantrum a lot.
• Language skills are more impaired than other
  cognitive or adaptive skills

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Candidate Conditions Neurobiological

• Sensory Integration Disorders
• Attention Disorders
• Movement and Tic Disorders
• Learning Disabilities

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Sensory Integration Disorders

• Co-occur
• Commonly reported in younger children with ASD
• Empirical studies suggest sensory issues are not
  diagnostic, but do effect treatment
• Visual and auditory more often than tactile

• Better explanation, if
• Developmental levels are within average range
• Social reciprocity is evident
• Communicative intents are intact (e.g., requests,
  comments, shares attention)

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Attention Problems Sometimes Observed in Children
with ASD

• Deficits sustaining attention (particularly in
  developmentally younger children)
• Deficits shifting attention, which often emerge
  over time
• Deficits focusing attention on relevant aspects
  of a situation
• Deficits sharing attention with others

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Red Flags for ADHD and Not Autism

• Social relating is qualitatively different
• Overtures may be impulsive and somewhat 1-sided,
  but engagement, enjoyment, and initiation are
  clearly evident
• Child may have difficulty picking up on nonverbal
  behaviors of others, but integrates own
  nonverbals well
• Communicative intent is intact, child compensates
• Attentional difficulties more likely to be
  distractibility and inhibition instead of
  over-focusing or having problems shifting
• Symbolic and imaginative play are better, but a
  little disorganized

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Movement and Tic Disorders

• Co-occurrence with autism
• Dyspraxia
• Muscle tone abnormalites
• Abnormal posture and gait
• Repetitive motor behaviors
• Clumsiness
• Tics (vocal or motor)

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If Its a Motor or Tic Disorder Instead of Autism

• Social, communicative, and play behaviors are
  qualitatively different
• Developmental and adjustment problems can be
  attributed to difficulties in motor/neurological
  function and not problems in core social and
  communicative functioning

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Learning Disabilities

• Co-occur
• Nonverbal Learning Disability
• Developmental Language Disorder
• Reading
• Writing

• Better explanation if
• Profile of skills is uneven and deficits are
  circumscribed
• Social and communicative intent are intact
• Imaginary play is pretty good
• Early history not significant for social problems

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Candidate Conditions Psychiatric

• Attachment Disorders
• Mood Disorders
• Anxiety and Obsessive-Compulsive Disorders
• Childhood Psychosis

• All of these conditions necessitate in-depth
  assessment by a qualified mental health
  practitioner
• Treatment often involves medication

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Attachment Disorders

• Not likely to co-occur with autism
• Different early history requires some kind of
  event, precipitating factor, environmental
  occurrence (e.g., abuse, neglect)
• Social relating may be impaired could be
  avoidant or overly familiar
• Not a neurobiological disorder cognitive and
  language skills are different
• Play more likely to be imaginative or symbolic

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Mood Disorders

• Depression and/or mania can co-occur with ASD and
  are most likely to emerge at adolescence
• Symptoms of depression pervasive sadness,
  frequent crying, disrupted sleep, poor eating,
  impaired initiation, lack of enjoyment in
  activities that used to be fun
• Symptoms of mania bursts of overactivity, lack
  of sleep, grandiosity, excessive everything

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Mood Disorders (cont.)

• Symptoms of bipolar shifting between depression
  and mania
• Symptoms can also occur at a lower level and
  still be clinically relevant (e.g., dysthymia)
• May be behaviorally expressed through
  irritability, agitation, tantrums, self-injury,
  aggression, non-compliance, lack of initiation or
  engagement

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How Can You Tell if its a Mood Disorder and Not
ASD?

• Once again look at social, communicative, and
  play functioning
• Examine early history
• Look for cyclical patterns of mood and behavior

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Anxiety and OCD

• Co-occurs fairly often, especially in school-aged
  children and adolescents
• Could be observable as intense fearfulness,
  frequent tantrums, mood instability, increased
  repetitive activities, self-injury, avoidance,
  intense insistence on specific behaviors and
  routines

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Red Flags That Its Anxiety and Not Autism

• Once again social relating, communicative
  intent, and play are qualitatively different
• Early history is different (child had joint
  attention, imitation, play, no delay in language
  expected)
• Child meets DSM-IV criteria for anxiety/OCD

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Childhood Psychosis

• Can co-occur, but diagnostically distinct
• Psychosis involves delusions and hallucinations
  must be distinguished from language disorder
• Onset is usually later than in autism (which is
  observable under 30 months)
• If you suspect it get a mental health
  practitioner involved

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Conclusions

• Autism is diagnosed through observation of a
  pattern of social, communicative, and play
  behaviors
• The most important differentiating behaviors are
  the negative symptoms, or a lack of subtle social
  and communicative behaviors, as opposed to the
  presence of weird behaviors

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It is important to remember

• Many developmental, neurobiological, and
  psychiatric disorders may co-occur with autism
• Accurate assessment requires multidisciplinary
  collaboration
• Effective treatment depends upon comprehensive
  assessment