ADHD and AutismMaking Data-Based Eligibility Decisions

Association of School Psychologists of Pennsylvania &

Pennsylvania State University

2020 Virtual Fall ConferenceNovember 4 & 5, 2020

Amanda Zanko, M.Ed., Ed.S., NCSP

Victoria Petit, M.Ed.

Doctoral Students, The Pennsylvania State University

● Background Information: Review how ASD and ADHD fit into IDEA criteria○ Provide information regarding symptoms of ADHD and ASD and how these may overlap

● Objective 1: Provide school psychologists with the tools needed to complete a comprehensive, multidisciplinary evaluation to:

○ Gather the data needed to differentiate between ASD and ADHD ○ Make appropriate recommendations for programming and interventions

● Objective 2: Develop critical-thinking skills needed to analyze data to arrive at appropriate eligibility decisions

○ Take a look at real-life case data to apply these skills

● Objective 3: Provide recommendations for school-based and IEP teams

What’s Ahead

ADHD & Autism:Two Common Neurodevelopmental Disorders & Comorbidity

The Stats

Centers for Disease Control and Prevention (CDC, 2020)

● 6.1 million children aged 2-17 years had a diagnosis of ADHD (2016)○ This has drastically increased from the

previous estimates of 4.4 million children aged 4-17 years old in 2003

● 1 in 54 children are diagnosed with Autism○ This has increased from 1 in 150 in 2000

● Both ASD and ADHD are more common in boys than girls

The dilemma… Is it ADHD? Autism? Both?

● ADHD is the most common comorbidity in children with ASD (Antshel & Russo, 2019)○ 30-75% of students with ASD

have symptoms consistent with ADHD (Grzadinski, Dick, Lord, & Bishop, 2016)

● 64% of children with ADHD have a comorbid diagnosis, including autism (CDC, 2020)○ 14% of these children also have

a diagnosis of ASD● 20-60% of students with ADHD have

social difficulties similar to students with ASD (Grzadinski, Dick, Lord, & Bishop, 2016)

● 21% of participants diagnosed with ADHD met criteria for autism on the ADOS (Zablotsky, Bramlett, & Blumberg, 2020)

Attention Deficit/Hyperactivity Disorder (ADHD): Diagnostic Criteria

● DSM-5: “A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development”

○ Inattention: “Wandering off task, lacking persistence, having difficulty sustaining focus, and being disorganized”

○ Hyperactivity: “Excessive motor activity when it is not appropriate, or excessive fidgeting, tapping, or talkativeness”

○ Impulsivity: “Hasty actions that occur in the moment without forethought and that have high potential for harm to the individual”

● Must manifest in more than one setting● Presentations:

○ Predominantly Inattentive○ Predominantly Hyperactive/Impulsive○ Combined

The Individuals with Disabilities Education Act (IDEA) and ADHD

● OTHER HEALTH IMPAIRMENT (OHI)● “OHI means having limited strength, vitality, or

alertness, including a heightened alertness to environmental stimuli, that results in limited alertness with respect to the educational environment, that -

○ (i) Is due to chronic or acute health problems such as asthma, attention deficit disorder or attention deficit hyperactivity disorder, diabetes, epilepsy, a heart condition, hemophilia, lead poisoning, leukemia, nephritis, rheumatic fever, sickle cell disease, anemia, and Tourette syndrome; and

○ (ii) Adversely affects a child’s educational performance.

IDEA and ADHD EMOTIONAL DISTURBANCE(i) Emotional disturbance means a condition exhibiting one or more of the following characteristics over a long period of time and to a marked degree that adversely affects a child’s educational performance:

(A) An inability to learn that cannot be explained by intellectual, sensory, or health factors.(B) An inability to build or maintain satisfactory interpersonal relationships with peers and teachers. (C) Inappropriate types of behavior or feelings under normal circumstances.(D) A general pervasive mood of unhappiness or depression.(E) A tendency to develop physical symptoms or fears associated with personal or school problems.

(ii) Emotional disturbance includes schizophrenia. The term does not apply to children who are socially maladjusted, unless it is determined that they have an emotional disturbance under paragraph (c)(4)(i) of this section.

https://sites.ed.gov/idea/regs/b/a/300.8/c/4/ihttps://sites.ed.gov/idea/regs/b/a/300.8/c/4/i/ahttps://sites.ed.gov/idea/regs/b/a/300.8/c/4/i/bhttps://sites.ed.gov/idea/regs/b/a/300.8/c/4/i/chttps://sites.ed.gov/idea/regs/b/a/300.8/c/4/i/dhttps://sites.ed.gov/idea/regs/b/a/300.8/c/4/i/ehttps://sites.ed.gov/idea/regs/b/a/300.8/c/4/ii

Autism Spectrum Disorder (ASD): Diagnostic Criteria

● DSM-5: “Essential features of ASD are persistent impairment in reciprocal social communication and social interaction (Criterion A), and restricted, repetitive patterns of behavior, interests, or activities (Criterion B). These symptoms are present from early childhood and limit or impair everyday functioning (Criteria C and D).”

○ “Diagnoses are most valid and reliable when based on multiple sources of information, including clinician’s observations, caregiver history, and, when possible, self-report.”

■ Criterion A: Impaired use of language; deficits in social-emotional reciprocity; deficits in nonverbal communicative behaviors; and deficits in developing, maintaining, and understanding relationships.

■ Criterion B: Simple motor stereotypies, repetitive use of objects, repetitive speech, excessive adherence to routines, ritualistic patterns of verbal and nonverbal behavior

IDEA and ASD

● AUTISM○ “Autism means a developmental disability

significantly affecting verbal and nonverbal communication and social interaction, generally evident before age three, that adversely affects a child’s educational performance. Other characteristics often associated with autism are engagement in repetitive activities and stereotyped movements, resistance to environmental change or change in daily routines, and unusual sensory responses to sensory experiences.”

When ADHD and Autism criteria collides...

ADHD?

Inattention

Social Skill Difficulties

Self-Regulation Difficulties

Hyperactivity

Pragmatic language difficulties

Autism Spectrum Disorder?

Questions to Consider...

● Are there self-regulation difficulties?○ If so…

■ Does the student demonstrate externalizing behaviors due to a lack of impulse or self-control?

■ Does the student have difficulties tolerating changes in their environment?

Questions to Consider...

● Are there social skill deficits?○ If so...

■ Are the social difficulties related to hyperactivity/impulsivity or inattention?■ Are these difficulties related to isolation and withdrawal typical of students

with Autism? Does the student have difficulty understanding appropriate social interactions?

■ Is the student withdrawing due to other comorbidities (i.e., Anxiety and Depression)?

Questions to Consider...

● Hyperactivity can be misinterpreted as repetitive behaviors seen in students with Autism○ Are the repetitive behaviors generalized and related to hyperactivity and

a lack of self-regulation?○ Are the repetitive behaviors stereotypical in nature?

Questions to Consider...

● Are there difficulties with pragmatic language skills?○ If so…

■ Is the language stereotypical in nature?■ Is the language restricted to the individual’s own interests?

Thoughts to Consider...

● Inattention is a diagnostic consideration for ADHD; AND● Inattention is not uncommon in students with Autism

○ If students with Autism also meet criteria for ADHD, they meet criteria for BOTH Autism and ADHD (Comorbid disorders)

○ In these cases, school teams may consider criteria for both Autism and OHI in your eligibility decisions

Completing Comprehensive Evaluations

Case Planning

Gathering Background Information:

Interviews

● Interviews○ Parent interview○ Teacher interview○ Paraprofessional interview ○ Speech pathologist○ Student interview ○ Standardized/Structured

Interviews■ Autism Diagnostic Interview

- Revised (ADI-R)

Observations ● Direct Observations ○ Functional Behavior Assessment (FBA)

■ Consider observations during direct instruction and independent work, as well as observations when peer interactions are likely to occur (i.e., lunch, recess)

■ Make note of teacher interactions, peer interactions, and any repetitive behaviors/speech

■ Collect time-on task assessment during instruction and/or independent work

Assessments for ADHD

Rating Scales

● Conners - Third Edition (Conners-3)○ Age 5 or below: DSM-5 Checklist

Direct Assessments

● Conners Continuous Performance Test - Third Edition (CPT-3)

○ Kiddie Conners Continuous Performance Test - Second Edition (K CPT 2)

○ Conners Continuous Auditory Test of Attention (Conners CATA)

● NEPSY-II○ Attention and Executive Functioning Battery

● IQ Assessments

Assessments for Autism Rating Scales● Autism Spectrum Rating Scales (ASRS)● Gilliam Autism Rating Scale - Third Edition

(GARS-3) ● Childhood Autism Rating Scale - Second

Edition (CARS-2)● Social Communication Questionnaire (SCQ)

Standardized Assessments

● Autism Diagnostic Observation Schedule - Second Edition (ADOS-2)

○ COVID-19 Alternative: Brief Observation of Symptoms of Autism (BOSA)

Additional Assessments to Consider

Rating Scales

● Behavior Assessment System for Children - Third Edition (BASC-3)

○ Consider: Hyperactivity and Attention Problems scales; Withdrawal and Atypicality

● Behavior Rating Inventory for Executive Function - Second Edition (BRIEF-2)

● Social Skills Improvement System (SSiS) Rating Scales● Adaptive Behavior:

○ Adaptive Behavior Assessment System - Third Edition (ABAS-3)

○ Vineland Adaptive Behavior Scales - Third Edition (Vineland-3)

Executive Functioning

● Delis-Kaplan Executive Function System (D-KEFS)● NEPSY-II

Sensory Evaluation

Achievement Measures

CASE STUDIES

Case Studies #1: Ivan YReferral: autism

Background information: ● 8th grade student● Previous identification: OHI + SLI● Currently takes medication for ADHD, OCD, and ODD:

- Concerta, 54mg- Strattera, 40mg- Clonidine ER, 0.2mg am/ 0.2 mg pm- Escitalopram, 5mg

Referral concerns:● Concerns with volatile words and actions, impulses, lying, stealing, and arguing

(across settings)● Peer relations

Case Plan:

1. Rating scalesa. BASC-3b. Conners 3c. ASRS

2. CPT33. ADOS-24. Behavioral

Observations5. WISC-V6. KTEA7. Parent interview8. Child interview

BASC-3

Conners 3 & CPT 3

ADOS-2 & ASRS

ResultsDiagnosis:

● ADHD● Anxiety● Depression

Identification recommendations:

● Other Health Impairment● Emotional Disturbance

Ruled out:

● Autism

Discussion Do these results surprise you?

What disability category would you recommend?

What would you recommend for treatment? Next steps?

Case Study #2: Collin SReferral: autism and math concerns

Background information:

● 7 years old, 2nd grade● Only child● Recently diagnosed with dyscalculia and ADHD

Referral concerns:

● Hand flapping● Rocking in chair● Staring off into the distance● Swinging legs in chair● Talks quickly and without receiving a response● Has to go up and down aisles of the grocery store in a certain order

Case Plan: YOUR TURN

1. What is your initial reaction?2. What information do you want to

know?3. What assessments would you

give?

WISC-V

WIAT-IIISubtest/Composite Standard Score 90% Confidence Interval Percentile Rank Classification

Listening Comprehension 105 95-115 63 Average

Oral Expression 103 94-112 58 Average

Oral Language 104 96-112 61 Average

Word Reading 102 98-106 55 Average

Pseudoword Decoding 109 105-113 73 Average

Basic Reading 104 101-107 61 Average

Reading Comprehension 114 107-121 82 High Average

Oral Reading Fluency 88 81-95 21 Low Average

Reading Comprehension and Fluency 101 95-107 53 Average

Total Reading 102 98-106 55 Average

WIAT-III continued

Math Problem Solving 88 80-96 21 Low Average

Numerical Operations 74 67-81 4 Very Low

Mathematics 80 74-86 9 Low Average

Math Facts Fluency - Addition 66 55-77 1 Extremely Low

Math Facts Fluency - Subtraction 67 59-75 1 Extremely Low

Math Fluency

66 59-73 1 Extremely Low

Spelling 96 90-102 39 Average

Alphabet Writing Fluency 93 79-107 32 Average

Sentence Composition 88 80-96 21 Low Average

Written Expression 89 82-96 23 Low Average

Early Reading Skills 88 77-99 21 Low Average

Total Achievement 93 90-96 32 Average

BASC-3At-Risk:

● Subcategories○ Hyperactivity (mom, dad)○ Attention Problems (dad, teacher)○ Atypicality (mom)○ Adaptability (mom, dad)○ Functional communication (all)○ Activities of daily living (mom, dad)○ Social Skills (mom, dad)○ Leadership (mom, dad)

● Composites○ School Problems (teacher)○ Behavioral Symptoms Index (mom)○ Adaptive Skills (mom, dad)

Clinically Significant:● Subcategories

○ Anxiety (dad)○ Attention Problems (mom)○ Atypicality (dad)○ Withdrawal (dad)

● Composites○ Internalizing Problems (dad)○ Behavioral Symptoms Index

(dad)

ASRSAreas DAD

T score (CI) PR

MOM T score (CI) PR

TEACHERT score (CI)

PR

ASRS Scales

Social/ Communication

(SC)

62 88 Slightly Elevated

53 62 Average

57 76

Average

Unusual Behaviors (UB)

73** 99 Very Elevated

64 92 Slightly Elevated

58 79 Average

Self-Regulation (SER)

69* 97 Elevated

62 88Slightly Elevated

53 62

Average

Total Score 71** 98 Very Elevated

61 86Slightly Elevated

57 76 Average

DSM-IV-TR Scale (DSM)

72** 99Very Elevated

60 84Slightly Elevated

59 82 Average

Peer Socialization 70** 98Very Elevated

56 73Average

55 69 Average

Adult Socialization 62 88Slightly Elevated

52 58Average

51 54

Average

Social/Emotional Reciprocity 62 88Slightly Elevated

55 69 Average

60 84Slightly Elevated

Atypical Language 71** 98Very Elevated

52 58 Average

64 92Slightly Elevated

Stereotypy 72** 99Very Elevated

58 79Average

60 84Slightly Elevated

Behavioral Rigidity 78** 99Very Elevated

74** 99Very Elevated

55 69

Average

Sensory Sensitivity 69* 97Elevated

53 62Average

57 76

Average

Attention 72** 99Very Elevated

67* 96Elevated

58 79Average

Areas DADT score (CI) PR

MOM T score (CI) PR

TEACHERT score (CI)

PR

Behavioral Observations

● Appropriate eye contact● Frequently turned around in his chair to ask about pictures/posters on the wall● Swung his legs● Flapped arms when he felt he got something correct● High-pitch inflection of voice when he felt he answered correctly● Told stories about friends, family, and pets● Eager to come back after the first test session

Discussion What do you think? What data pointed you to that conclusion?

What would you recommend?

Would you have collected more information?

ResultsDiagnosis:

● ADHD● SLD in math calculation

Identification:

● Primary: Specific Learning Disability● Secondary: Other Health Impairment

Ruled out:

● Autism

CASE STUDY #3: Jackie B.Referral Question: SLD, Autism, ADHD, SLI, ED

Background Information:

● 1st grade student; Retained in K● Attendance issues● Environmental factors: Access to language ● 504 Service Agreement for OT services● Previous evaluation in K - Found not eligible for services

Referral Concerns:

● Academic concerns: Math and reading ● Inattentive during instruction/independent work● Typically plays alone, enjoys playing with paper/making hats to flap paper● Does not like raindrops touching her● Fixated and obsessed with ideas/things (i.e., what she is doing after school, ponytail)● Imitates the teacher● Frequent mood swings, irritable

Case Plan: YOUR TURN

1. What is your initial reaction?2. What information do you want to

know?3. What assessments would you

give?

KBIT-2

Subscales Standard Score

(90% Confidence Interval)

Percentile Rank Qualitative Descriptor

Verbal 82 (75-91) 12 Very Low - Average

Nonverbal

102 (93-111) 55 Average – High Average

IQ Composite 91 (85-98) 27 Low Average - Average

WIAT-III

BASC-3

ASRS

Conners-3

Conners CPT 3

Total of 8 atypical T-scores

● Associated with a very high likelihood of having a disorder characterized by attention deficits

Profile of scores and response pattern indicate issues related to:

● Inattentiveness (strong indication), sustained attention (strong indication), and vigilance (strong indication).

ADOS-2

Discussion What do you think? What data pointed you to that conclusion?

What would you recommend?

Would you have collected more information? What would you have done differently?

ResultsIdentification:

● OHI (ADHD - Inattentive Type)

Ruled Out:

● Emotional Disturbance● Autism● Specific Learning Disability

Do these results surprise you? Do you agree with these conclusions?

What would you recommend for treatment? Next steps?

Recommendations

Treatment Options - ADHD

Medication:

● Stimulant vs. non-stimulant

*Consider as-needed versus daily dosage

Behavioral Intervention:● Organizational training● Parent/teacher training● Therapeutic approaches

Medication

● Stimulant○ Methylphenidate (Ritalin/Concerta)○ Amphetamine (Adderall)○ Lisdexamfetamine (Vyvanse)

● Non-stimulant○ Atomoxetine (Strattera)○ Guanfacine (Tenex)

ADHD Interventions

Behavioral Interventions:

● Parent/teacher training ○ Contingency management

● Organizational intervention

Other:

● Peer education● Cognitive Behavioral Therapy

(CBT)● Self-monitoring intervention

ADHD - Accommodations

Preferential seating

Brain breaks/movement breaks

Extended time to complete assignments

Testing accommodations

Repeating of directions/frequent teacher check-ins

Frequent teacher praise/redirection

Sensory interventions (Velcro, bouncy band)

Treatment Options - Autism

Applied behavior analysis (ABA)● Reinforcement (R+, R-)● Visual schedules● Token economies● Social skills training● Life skills training● Self-monitoring

Parent training● Home-school communication● Behavior management in home setting● Home-based services

Classroom behavior management● Behavior-specific praise● Reminders/pre-corrects● Modeling● Self-monitoring

Related Services● Speech Services● Occupational Therapy● Physical Therapy● Assistive Technology

Overlapping Treatment Options

Behavior management

ABA

Parent training

Home-school communication

Structure/routines

Exercise

Reflection

What are some potential challenges that could come up regarding the discussion of medication as a treatment option?

What are the stigmas for each diagnosis? What about comorbidity?

How does ADHD present in females? Autism?

What might ADHD or autism look like in adults?

What is the benefit for comorbid diagnoses? Downsides?

Resourceshttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC4010758/

https://www.pbisworld.com/

https://www.classroomcheckup.org/

https://chadd.org/about-adhd/adhd-and-autism-spectrum-disorder/

https://www.autismspeaks.org/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4010758/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4010758/https://www.pbisworld.com/https://www.classroomcheckup.org/https://www.classroomcheckup.org/https://chadd.org/about-adhd/adhd-and-autism-spectrum-disorder/https://chadd.org/about-adhd/adhd-and-autism-spectrum-disorder/https://chadd.org/about-adhd/adhd-and-autism-spectrum-disorder/https://www.autismspeaks.org/

ConferencesNational Association of School Psychologists (NASP) Annual Convention

● February 23–26 virtually

Teacher Educators for Children with Behavior Disorders (TECBD)

● November 3, 10, 17, and 24 virtually

American Psychological Association (APA)● August 12-15

American Educational Research Association (AERA) ● April 9 – April 12

15th Annual Autism Conference

● February 28–March 2, 2021 virtually

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Publisher.

Antshel, K. M., & Russo, N. (2019). Autism Spectrum Disorders and ADHD: Overlapping phenomenology, diagnostic issues, and treatment considerations. Current Psychiatry Reports, 21, 1-11.

Centers for Disease Control and Prevention. (2020). Data and statistics about ADHD. Retrieved from: https://www.cdc.gov/ncbddd/adhd/data.html

Centers for Disease Control and Prevention. (2020). Data and statistics on autism spectrum disorder. Retrieved from: https://www.cdc.gov/ncbddd/autism/data.html

Baixauli Forteaa, I., Berenguer Forner, C., Colomer, C., Miranda Casas, A., & Rosello Miranda, B. (2018). Communicative skills in spanish children with autism spectrum disorder and children with attention deficit hyperactivity disorder: Analysis through parents’ perceptions and narrative production. Research in Autism Spectrum Disorders, 50, 22-31.

Cooper, J., Heron, T. and Heward, W., 2007. Applied Behavior Analysis. 2nd ed. Upper Saddle River, NJ: Pearson.

Grzadinski, R., Dick, C., Lord, C., & Bishop, S. (2016). Parent-reported and clinician-observed autism spectrum disorder (ASD) symptoms in children with attention deficit/hyperactivity disorder (ADHD): Implications for practice under DSM-5. Molecular Autism, 7, 1-12.

https://www.cdc.gov/ncbddd/adhd/data.htmlhttps://www.cdc.gov/ncbddd/autism/data.html

References

Handen, B.L. et al. (2015). Atomoxetine, parent training, and their combination in children with autism spectrum disorder and attention-deficit/hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 54(11), 905-915.

Leitner, Y. (2014). The co-occurrence of autism and attention deficit hyperactivity disorder in children - What do we know? Frontiers in Human Neuroscience, 8, 268.

Individuals with Disabilities Education Act, 20 U.S.C. § 300.8 (2004).

Mikami, A. Y., Smit, S., & Khalis, A. (2017). Social skills training and ADHD - What works? Current Psychiatry Reports, 19(93).

Zablostky, B., Bramlett, M. D., & Blumberg, S. J. (2020). The co-occurrence of autism spectrum disorder in children with ADHD. Journal of Attention Disorders, 24, 94-103.

Contact Information

Victoria Petit: vtp4@psu.edu

Amanda Zanko: aez32@psu.edu

mailto:vtp4@psu.edumailto:aez32@psu.edu