Diagnosis of Autism Spectrum Disorders

Kristn Currans, PsyD Bridget Kent, MA, CCC-SLP

The Kelly OLeary 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 of f 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)

PDD-NOS

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 youve met one person with autism, then youve met t 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, p , psychologist, p y g , and speech p language pathologist. (Other related fields as needed) Ozonoff, , S., , Goodlin-Jones, , B., , Solomon, , M. (2005)

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 mental l 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 Practice:

Best PracticeRoles l of f 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 dt to i include l d assessment t across settings if possible (parent report, teacher report, t and d di direct t observation) b ti )

Psychology

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 of ft trauma 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
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 of f 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 45 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 onset t of f th the di disorder d i is 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 of f 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

(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 of f behavior, cognitive patterns, and pragmatic skills Result in Asperger Aspergers s Disorder Quotient which correlates to probability of Aspergers Disorder

Autism Specific Instruments

Communication

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 l What looking 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 years, , 11 months) ) to 6 y Peabody Picture Vocabulary Test Fourth (Norms for ages g 2 years, y , 6 months Edition ( 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 y yield 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 mothers voice; disregard for vocalizations, yet keen awareness of f environmental i l sounds; d delayed d l d onset of f 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 j joint 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 parents 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 i interest

Additional Assessment C Considerations id i

Age-Related Age Related Issues to Assessment

Accurate assessment requires q engaging g g g a childs 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 childs 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 Society y 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 OLeary 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

Questions?