8/2/2019 Diagnostic Confusion Comorbidity in Broad Spectrum ASD March 2012 (Redacted for Posting)
1/23
DIAGNOSTIC CONFUSION &COMORBIDITY IN BROAD
SPECTRUM ASDJosh Feder, MD
Rady Childrens Hospital
Autism Research Seminar
March 27, 2012
8/2/2019 Diagnostic Confusion Comorbidity in Broad Spectrum ASD March 2012 (Redacted for Posting)
2/23
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
2
8/2/2019 Diagnostic Confusion Comorbidity in Broad Spectrum ASD March 2012 (Redacted for Posting)
3/23
3
8/2/2019 Diagnostic Confusion Comorbidity in Broad Spectrum ASD March 2012 (Redacted for Posting)
4/23
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
4
8/2/2019 Diagnostic Confusion Comorbidity in Broad Spectrum ASD March 2012 (Redacted for Posting)
5/23
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.
5
8/2/2019 Diagnostic Confusion Comorbidity in Broad Spectrum ASD March 2012 (Redacted for Posting)
6/23
Usual Diagnosis, driving usual care
Substance dependence: 12-step
Sex Offender: Incarceration
Misbehaving: Positive BehavioralManagement
Not ready: Waiting and retrying Pre-K
6
8/2/2019 Diagnostic Confusion Comorbidity in Broad Spectrum ASD March 2012 (Redacted for Posting)
7/23
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.
7
8/2/2019 Diagnostic Confusion Comorbidity in Broad Spectrum ASD March 2012 (Redacted for Posting)
8/23
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
8
8/2/2019 Diagnostic Confusion Comorbidity in Broad Spectrum ASD March 2012 (Redacted for Posting)
9/23
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.
9
8/2/2019 Diagnostic Confusion Comorbidity in Broad Spectrum ASD March 2012 (Redacted for Posting)
10/23
Crowd Sourcing - depression and
Aspergers
10
8/2/2019 Diagnostic Confusion Comorbidity in Broad Spectrum ASD March 2012 (Redacted for Posting)
11/23
Lugnega, et. al. Psychiatric comorbidity in youngadults with a clinical diagnosis of Asperger
syndrome - Research in Developmental Disabilities32 (2011) 19101917
11
Diagnosis % - crowd guess
Depression - lifetime
Depression, recurrent
Bipolar Disorder
Anxiety Disorders
OCD
ADHD
Substance Disorders
Tourettes
Psychosis
8/2/2019 Diagnostic Confusion Comorbidity in Broad Spectrum ASD March 2012 (Redacted for Posting)
12/23
Lugnega, et. al. Psychiatric comorbidity in youngadults with a clinical diagnosis of Asperger
syndrome - Research in Developmental Disabilities32 (2011) 19101917
12
Diagnosis %
Depression - lifetime 70
Depression, recurrent 50
Bipolar Disorder 9
Anxiety Disorders 56
OCD 7
ADHD 30
Substance Disorders 7
Tourettes 2
Psychosis 2
8/2/2019 Diagnostic Confusion Comorbidity in Broad Spectrum ASD March 2012 (Redacted for Posting)
13/23
Usual Numbers in NT Population
13
Diagnosis % Crowd guess
Depression - lifetime
Depression, recurrent
Bipolar Disorder
Anxiety Disorders
OCD
ADHD
Substance Disorders
Tourettes
Psychosis
8/2/2019 Diagnostic Confusion Comorbidity in Broad Spectrum ASD March 2012 (Redacted for Posting)
14/23
Usual Numbers in NT Population
14
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
8/2/2019 Diagnostic Confusion Comorbidity in Broad Spectrum ASD March 2012 (Redacted for Posting)
15/23
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
15
8/2/2019 Diagnostic Confusion Comorbidity in Broad Spectrum ASD March 2012 (Redacted for Posting)
16/23
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.
16
8/2/2019 Diagnostic Confusion Comorbidity in Broad Spectrum ASD March 2012 (Redacted for Posting)
17/23
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 .....
17
8/2/2019 Diagnostic Confusion Comorbidity in Broad Spectrum ASD March 2012 (Redacted for Posting)
18/23
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
18
9
8/2/2019 Diagnostic Confusion Comorbidity in Broad Spectrum ASD March 2012 (Redacted for Posting)
19/23
DSM - IV TR DSM - V
Categorical - Chinesemenu
Dimensional -spectrum
ASD: social, language,
interests
ASD: social-
communication,interests
19
20
8/2/2019 Diagnostic Confusion Comorbidity in Broad Spectrum ASD March 2012 (Redacted for Posting)
20/23
But both categorical and dimensional views may bevalid (Zimmerman 2012):
20
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
21
8/2/2019 Diagnostic Confusion Comorbidity in Broad Spectrum ASD March 2012 (Redacted for Posting)
21/23
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
21
22
8/2/2019 Diagnostic Confusion Comorbidity in Broad Spectrum ASD March 2012 (Redacted for Posting)
22/23
Summary
1 think broadly - brainstorm2 think practically - prioritize
3 nurture reflective process
22
23
8/2/2019 Diagnostic Confusion Comorbidity in Broad Spectrum ASD March 2012 (Redacted for Posting)
23/23
23