Diagnostic Confusion Comorbidity in Broad Spectrum ASD March 2012 (Redacted for Posting)

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DIAGNOSTIC CONFUSION &COMORBIDITY IN BROAD

SPECTRUM ASDJosh Feder, MD

Rady Childrens Hospital

Autism Research Seminar

March 27, 2012


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Director of Research, Graduate School,Interdisciplinary Council on Developmental

and Learning Disorders

Assistant Clinical Professor, Voluntary

Dept of Psychiatry, University of Californiaat San Diego School of Medicine

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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

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Vignettes

Adult: compulsive substance use,trouble on the job; few friends; verydiscouraged with life.

Adolescent who was inappropriatewith a young girl he was babysitting.

Third grader tantrums when asked toread the chapter book; trips to office

then home for the day.

Preschooler in a Pre-k class: veryactive; won't stay seated for circle,

plays only with his Thomas toy.

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Usual Diagnosis, driving usual care

Substance dependence: 12-step

Sex Offender: Incarceration

Misbehaving: Positive BehavioralManagement

Not ready: Waiting and retrying Pre-K

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Digging deeper: all is explained?

Wesee them when other approaches havefailed

Allturned out to have long-standing

impairments in social communication and intheir range of interests.

At the rootof their troubles is a form of broad

phenotype ASD We recommend evidence based practice

approaches to addressing these deficits.

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Differential / multiple diagnosticconsiderations: ASD +

ASD + substance dependence, obsessivecompulsive disorder, depression

ASD + conduct disorder, pedophilia ASD + reading disorder, oppositional defiantdisorder, bipolar disorder (or the newerDisruptive Mood Dysregulation Disorder)

ASD + ADHD, ASD, OCD

Genetic links: ASD, ADHD, Bipolar,Schizophrenia

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Differential / multiple diagnostic

considerations:

Crowd Sourcing - depression andAspergers

1. independent have you read the paperalready? Avoiding anchoring influence, andblind rating.

2. Diversity experts and amateurs okavoiding using one expert to answer thequestion.

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Crowd Sourcing - depression and

Aspergers

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Lugnega, et. al. Psychiatric comorbidity in youngadults with a clinical diagnosis of Asperger

syndrome - Research in Developmental Disabilities32 (2011) 19101917

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Diagnosis % - crowd guess

Depression - lifetime

Depression, recurrent

Bipolar Disorder

Anxiety Disorders

OCD

ADHD

Substance Disorders

Tourettes

Psychosis


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Lugnega, et. al. Psychiatric comorbidity in youngadults with a clinical diagnosis of Asperger

syndrome - Research in Developmental Disabilities32 (2011) 19101917

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Diagnosis %

Depression - lifetime 70

Depression, recurrent 50

Bipolar Disorder 9

Anxiety Disorders 56

OCD 7

ADHD 30

Substance Disorders 7

Tourettes 2

Psychosis 2


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Usual Numbers in NT Population

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Diagnosis % Crowd guess

Depression - lifetime

Depression, recurrent

Bipolar Disorder

Anxiety Disorders

OCD

ADHD

Substance Disorders

Tourettes

Psychosis


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Usual Numbers in NT Population

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Diagnosis %

Depression - lifetime 25

Depression, recurrent 12.5

Bipolar Disorder 1

Anxiety Disorders 25

OCD 1

ADHD 5

Substance Disorders 7

Tourettes 1

Psychosis 1


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Maturational/ developmentalconsiderations

Adult - connectingwith a life partnerand being productive

Adolescent - sexual driveandindividuation.

School age child - competenceand

self esteem Pre-k child managing body control

and competing relationshipsamongadults

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Family systems aspects

The adult is expected to take care of himself

The teen was available; mom wanted him tobe doing something productive and social ,

helping out and getting a 'job'. The school aged child is expected to go toschool and do his work

The Pre -K child is similarly expected tocooperateand join the group.

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DSM, and DMIC

DSM: Pure disorders, definitive and effectivetreatment. MDD, ADHD, OCD , etc.

What we do: find morefactors, morediagnoses

Complexsituations require complexapproaches

DSM axes help us address multiple areas.

DMIC: Has even moreaxes .....

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DSM IV TR DMIC

I Major Diagnosis I Primary Diagnosis

II Character,Retardation

II Functional EmotionalDevelopmental Capacities

III Medical Problems III Regulatory-SensoryProcessing Capacities

IV Stress level IV Language Capacities

V Global Function V Visuospatial Capacities

VI Child-Caregiver and FamilyPatterns

VII - Stress

VIII Other Medical and

Neurological Diagnoses

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DSM - IV TR DSM - V

Categorical - Chinesemenu

Dimensional -spectrum

ASD: social, language,

interests

ASD: social-

communication,interests

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But both categorical and dimensional views may bevalid (Zimmerman 2012):

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After a certain threshold of number of symptoms ofborderline personality disorder there is littledifference in overall functional impairment among

pateints Supports categorical - e.g. ADOS (autistic, non-autistic, etc.)

But people with one symptom of borderlinepersonality disorder are significantly impairedcompared to those with no symptoms

Sub clinical - support for dimensional spectrumview e.g. FEDL likert scale asessing eachdimension

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Planning

Brainstorming: diagnosis, causes or factorsat play

More brainstorming about what we might do

Prioritizing and combining to make sense forthe family.

Expect to adjust: reflective processtohelp us navigate better as we move forward

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Summary

1 think broadly - brainstorm2 think practically - prioritize

3 nurture reflective process

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Documents

Diagnostic Confusion Comorbidity in Broad Spectrum ASD March 2012 (Redacted for Posting)