DIAGNOSTIC CONFUSION & COMORBIDITY IN BROAD SPECTRUM ASD

Josh Feder, MD Rady Childrens Hospital Autism Research Seminar March 27, 2012

Director of Research, Graduate School, Interdisciplinary Council on Developmental and Learning Disorders

Assistant Clinical Professor, Voluntary Dept of Psychiatry, University of California at San Diego School of Medicine

Outline
Vignettes

Diagnosis driving care

Digging deeper: is all explained by ASD? Differential / multiple diagnostic considerations Maturational/ developmental considerations Family systems aspects

DSM, and DMIC

Planning

Vignettes
Adult: compulsive substance use,

trouble on the job; few friends; very discouraged with life. Adolescent who was inappropriate with a young girl he was babysitting. Third grader tantrums when asked to read the chapter book; trips to office then home for the day. Preschooler in a Pre-k class: very active; won't stay seated for circle, plays only with his Thomas toy.

Usual Diagnosis, driving usual care

Substance dependence: 12-step Sex Offender: Incarceration Misbehaving: Positive Behavioral

Management Not ready: Waiting and retrying Pre-K

Digging deeper: all is explained?

We see them when other approaches have

failed All turned out to have long-standing impairments in social communication and in their range of interests. At the root of their troubles is a form of broad phenotype ASD We recommend evidence based practice approaches to addressing these deficits.

Differential / multiple diagnostic considerations: ASD +

ASD + substance dependence, obsessive

compulsive disorder, depression ASD + conduct disorder, pedophilia ASD + reading disorder, oppositional defiant disorder, bipolar disorder (or the newer Disruptive Mood Dysregulation Disorder) ASD + ADHD, ASD, OCD Genetic links: ASD, ADHD, Bipolar, Schizophrenia

Differential / multiple diagnostic considerations: Crowd Sourcing - depression and Aspergers

1. independent have you read the paper

already? Avoiding anchoring influence, and blind rating. 2. Diversity experts and amateurs ok avoiding using one expert to answer the question.

10

Crowd Sourcing - depression and Aspergers

11

Lugnega, et. al. Psychiatric comorbidity in young adults with a clinical diagnosis of Asperger syndrome - Research in Developmental Disabilities 32 (2011) 19101917
Diagnosis Depression - lifetime Depression, recurrent Bipolar Disorder Anxiety Disorders OCD ADHD % - crowd guess

Substance Disorders
Tourettes Psychosis

12

Lugnega, et. al. Psychiatric comorbidity in young adults with a clinical diagnosis of Asperger syndrome - Research in Developmental Disabilities 32 (2011) 19101917
Diagnosis Depression - lifetime Depression, recurrent Bipolar Disorder Anxiety Disorders OCD ADHD % 70 50 9 56 7 30

Substance Disorders
Tourettes Psychosis

7
2 2

13

Usual Numbers in NT Population

Diagnosis Depression - lifetime Depression, recurrent Bipolar Disorder Anxiety Disorders OCD ADHD % Crowd guess

Substance Disorders
Tourettes Psychosis

14

Usual Numbers in NT Population

Diagnosis Depression - lifetime Depression, recurrent Bipolar Disorder Anxiety Disorders OCD ADHD % 25 12.5 1 25 1 5

Substance Disorders
Tourettes Psychosis

7
1 1

15

Maturational/ developmental considerations

Adult - connecting with a life partner

and being productive Adolescent - sexual drive and individuation. School age child - competence and self esteem Pre-k child managing body control and competing relationships among adults

16

Family systems aspects

The adult is expected to take care of himself

The teen was available; mom wanted him to

be doing something productive and social , helping out and getting a 'job'. The school aged child is expected to go to school and do his work The Pre -K child is similarly expected to cooperate and join the group.

17

DSM, and DMIC

DSM: Pure disorders, definitive and effective

treatment. MDD, ADHD, OCD , etc. What we do: find more factors, more diagnoses Complex situations require complex approaches DSM axes help us address multiple areas. DMIC: Has even more axes .....

DSM IV TR

DMIC

18

I Major Diagnosis
II Character, Retardation III Medical Problems IV Stress level V Global Function

I Primary Diagnosis
II Functional Emotional Developmental Capacities III Regulatory-Sensory Processing Capacities IV Language Capacities V Visuospatial Capacities VI Child-Caregiver and Family Patterns VII - Stress

VIII Other Medical and Neurological Diagnoses

19

DSM - IV TR Categorical - Chinese menu ASD: social, language, interests

DSM - V Dimensional spectrum ASD: socialcommunication, interests

20

But both categorical and dimensional views may be valid (Zimmerman 2012):
After a certain threshold of number of symptoms of

borderline personality disorder there is little difference in overall functional impairment among pateints Supports categorical - e.g. ADOS (autistic, nonautistic, etc.) But people with one symptom of borderline personality disorder are significantly impaired compared to those with no symptoms Sub clinical - support for dimensional spectrum view e.g. FEDL likert scale asessing each dimension

21

Planning
Brainstorming: diagnosis, causes or factors

at play More brainstorming about what we might do Prioritizing and combining to make sense for the family.
Expect to adjust:

reflective process to

help us navigate better as we move forward

22

Summary

1 think broadly - brainstorm 2 think practically - prioritize 3 nurture reflective process

23