Differential Diagnosis

Document Sample
Differential Diagnosis Powered By Docstoc
					  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)
Provide a brief review of several
conditions of childhood that either:

   Co-occur with an autism spectrum disorder


   Better explain a child’s challenges than an
    autism spectrum disorder (ASD)
         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
    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)
Candidate Conditions
   Developmental

   Neurobiological

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

     Complex children require
  complicated diagnostic protocols
 and multidisciplinary collaboration
Candidate Conditions: Developmental
   Global Developmental Delay or
    Mental Retardation

   Developmental Language Disorders
        Global Developmental Delay or
        Mental Retardation
                                   Better explanation if:
   Co-occurs:
       In approximately
                                       Social relating is good
        60-80% of young
                                        (emotional contagion,
        children with ASD
                                        early social games,
                                        referencing, affect)
       Can’t say for sure             Joint attention is
        until after ages 5-8            emerging
                                       Child engages in simple
       Involves deficits in            symbolic play (e.g.,
        both intellectual and           feeding a doll)
        adaptive functioning           Imitation skills are good
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
         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
Candidate Conditions: Neurobiological
   Sensory Integration Disorders

   Attention Disorders

   Movement and Tic Disorders

   Learning Disabilities
        Sensory Integration Disorders
   Co-occur                           Better explanation, if:
       Commonly reported in               Developmental levels
        younger children with ASD           are within average

       Empirical studies suggest          Social reciprocity is
        sensory issues are not              evident
        diagnostic, but do effect
                                           Communicative intents
                                            are intact (e.g.,
       Visual and auditory more            requests, comments,
        often than tactile                  shares attention)
    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
          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
   Symbolic and imaginative play are better, but a little
        Movement and Tic Disorders
   Co-occurrence with autism
       Dyspraxia
       Muscle tone abnormalites
       Abnormal posture and gait
       Repetitive motor behaviors
       Clumsiness
       Tics (vocal or motor)
If It’s 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
Learning Disabilities
   Co-occur                    Better explanation if:
                                    Profile of skills is uneven
       Nonverbal Learning           and deficits are
        Disability                   circumscribed

                                    Social and
       Developmental                communicative intent are
        Language Disorder            intact
            Reading
            Writing                Imaginary play is pretty

                                    Early history not
                                     significant for social
Candidate Conditions: Psychiatric
   Attachment               All of these
    Disorders                 conditions
                              necessitate in-depth
   Mood Disorders            assessment by a
                              qualified mental
   Anxiety and               health practitioner
    Compulsive               Treatment often
                              involves medication

   Childhood Psychosis
          Attachment Disorders
   Not likely to co-occur with autism

   Different early history – requires some kind of event,
    precipitating factor, environmental occurrence (e.g., abuse,

   Social relating may be impaired – could be avoidant or overly

   Not a neurobiological disorder; cognitive and language skills
    are different
         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
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
How Can You Tell if it’s 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
      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
        Red Flags That It’s 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

   Child meets DSM-IV criteria for anxiety/OCD
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
   Autism is diagnosed through observation of a
    pattern of social, communicative, and play

   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”
It is important to remember…
   Many developmental, neurobiological, and
    psychiatric disorders may co-occur with

   Accurate assessment requires
    multidisciplinary collaboration

   Effective treatment depends upon
    comprehensive assessment

Shared By: