Issues in Autism Evaluation:
Differential Diagnosis, Special
Populations, Accurate and Efficient
Measures
Laurie McGarry Klose, Ph.D., LSSP
Objectives
• Examine DSM-V diagnostic criteria for Autism
Spectrum Disorders
• Analyze utility of frequently used autism
assessment measures in diagnostic
formulation
• Consider related neurological, developmental
and emotional conditions
• Develop strategies for differential diagnosis
DSM-IV-TR vs DSM-V
• 3 symptom categories
• 6 diagnostic items
endorsed
• Specifies onset prior to
age 3
• Includes Rhett’s,
Childhood
Disintegrative Disorder,
Asperger’s Syndrome,
PDD-NOS
• 2 categories
• Three diagnostic items
endorsed
• Specifies early
development
• Includes parameters for
designating severity
Diagnostic Criteria A
“Persistent deficits in social communication and
social interaction across multiple contexts, as
manifested by the following, currently or by
history (examples are illustrative, not
exhaustive”
• “Deficits in social-emotional reciprocity, ranging,
for example, from abnormal approach and failure
of normal back and forth conversation; to
reduced sharing of interests, emotions, or affect;
to failure to initiate or respond to social
interactions.”
• “Deficits in nonverbal communication behaviors
used for social interaction, ranging, for example,
from poorly integrated verbal and nonverbal
communication; to abnormalities in eye contact
and body language or deficits in understanding
and use of gestures; to a total lack of facial
expressions and nonverbal communication“
• “Deficits in developing, maintaining, and
understanding relationships, ranging, for
example, from difficulties adjusting behavior
to suit various social contexts; to difficulties in
sharing imaginative play or in making friends;
to absence of interest in peers.”
• “Specify current severity: Severity is based on
social communication impairments and
restricted , repetitive patterns of behavior.”
Diagnostic Criteria B
“Restricted, repetitive patterns of behavior,
interests, or activities, as manifested by at least
two of the following, currently or by history
(examples are illustrative, not exhaustive; see
text)”
• “Stereotyped or repetitive motor movements,
use of objects, or speech (e.g. simple motor
stereotypies, lining up toys or flipping objects,
echolalia, idiosyncratic phrases).”
• “Insistence on sameness, inflexible adherence
to routines, or ritualized patterns of verbal or
nonverbal behavior (e.g., extreme distress at
small changes, difficulties with transitions,
rigid thinking patterns, greeting rituals, need
to take the same route or eat same food
everyday).”
• “Highly restricted, fixated interests that are
abnormal in intensity or focus (e.g., strong
attachment to or preoccupation with unusual
objects, excessively circumscribed or
perseverative interests).”
• “Hyper- or hyporeactivity to sensory input or
unusual interest in senspry aspects of the
environment (e.g., apparent indifference to
pain/temperature, adverse response to
specific sounds or textures, excessive smelling
or touching of objects, visual fascination with
lights or movement.”
Diagnostic Criteria C
“ Symptoms must be present in the early
developmental period (but may not become fully
manifest until social demands exceed limited
capacities, or may be masked by learned
strategies in later life).”
Diagnostic Criteria D
“Symptoms cause clinically significant
impairment in social, occupational, or other
important areas of current functioning.”
Diagnostic Criteria E
“These disturbances are not better explained by
intellectual disability (intellectual developmental
disorder) or global developmental delay.
Intellectual disability and autism spectrum
disorder frequently co-occur; to make comorbid
diagnosis of autism spectrum disorder and
intellectual disability, social communication
should be below that expected for general
developmental level.”
Concerning Individuals with a Previous Diagnosis
of Autism, Asperger’s or PDD-NOS
“Note: Individuals with a well-established DSMIV diagnosis of autistic disorder, Asperger’s
disorder, or pervasive developmental disorder
not otherwise specified should be given the
diagnosis of autism spectrum disorder.
Individuals who have marked deficits in social
communication, but whose symptoms do not
otherwise meet criteria for autism spectrum
disorder, should be evaluated for social
(pragmatic) communication disorder.”
Additional Specifications to be
Included
• With or without accompanying intellectual
impairment
• With or without accompanying language
impairment
• Associated with a known medical or genetic
condition or environmental factor
• Associated with another neurodevelopmental,
mental, or behavioral disorder
• With catatonia
Neurodevelopmental Disorders
• Intellectual Disability (Intellectual
Developmental Disorder)
• Global Developmental Delay
• Unspecified Intellectual Disability (Intellectual
Developmental Disorder)
• Language Disorder
• Speech Sound Disorder
• Childhood-Onset Fluency Disorder (Stuttering)
Neurodevelopmental Disorders, Cont.
•
•
•
•
Social (Pragmatic) Communication Disorder
Unspecified Communication Disorder
Autism Spectrum Disorder
Attention-Deficit/Hyperactivity DisorderCombined presentation, Predominantly
inattentive presentation, Predominantly
hyperactive/impulsive presentation
• Unspecified Attention-Deficit/Hyperactivity
Disorder
Neurodevelopmental Disorders, Cont.
• Specific Learning Disorder- With impairment
in reading, With impairment in written
expression, With impairment in mathematics
• Developmental Coordination Disorder
• Stereotypic Movement Disorder- With/out
self-injurious behavior
• Tourette’s Disorder
• Persistent (Chronic) Motor or Vocal Tic
Disorder
Neurodevelopmental Disorders, Cont.
•
•
•
•
Other Specified Tic Disorder
Unspecified Tic Disorder
Other Specified Neurodevelopmental Disorder
Unspecified Neurodevelopmental Disorder
Persistent deficits in social
communication and social
interaction across multiple
contexts
Restricted, repetitive
patterns of behavior,
interests, or activities
Symptoms must be present
in the early developmental
period
Symptoms cause clinically
significant impairment
Not better explained by
intellectual disability
Interview/Developmental History
Autism Diagnostic Observation
Schedule, Second Edition (ADOS-2)
X
X
+
X
-
X
+
-
X
-
Autism Diagnostic Interview-Revised
(ADI-R)
X
X
+
X
-
Social Responsiveness Scale, Second
Edition (SRS-2)
+
-
-
X
-
Social Communication Questionnaire
(SCQ)
X
-
-
X
-
Behavior Assessment System for
Children, Second Edition (BASC-2)
Parent and Teacher Reports
X
-
-
X
-
Adaptive Behavior Assessment System,
Second Edition (ABAS-II)Parent and
Teacher Reports
X
-
-
+
X
Gilliam Autism Rating Scale, Second
Edition (GARS-2)Parent and Teacher
Reports
X
X
-
X
-
Childhood Autism Rating Scale, Second
Edition (CARS2)
+
+
-
X
X
Haak Sentence Completion Test
Projective Drawings
Cognitive Assessment
-
X
-
X
-
-
X
-
X
X
-
-
-
X
+
Persistent deficits
in social
communication
and social
interaction across
multiple contexts
Restricted,
repetitive patterns
of behavior,
interests, or
activities
Symptoms must be
present in the early
developmental
period
Symptoms cause
clinically
significant
impairment
Not better
explained by
intellectual
disability
Interview/Developmental History
X
X
+
X
-
Autism Diagnostic Observation
Schedule, Second Edition (ADOS-2)
Autism Diagnostic Interview-Revised
(ADI-R)
Social Responsiveness Scale, Second
Edition (SRS-2)
Social Communication Questionnaire
(SCQ)
Behavior Assessment System for
Children, Second Edition (BASC-2)
Parent and Teacher Reports
Adaptive Behavior Assessment System,
Second Edition (ABAS-II)Parent and
Teacher Reports
Gilliam Autism Rating Scale, Second
Edition (GARS-2)Parent and Teacher
Reports
Childhood Autism Rating Scale, Second
Edition (CARS2)
Haak Sentence Completion Test
X
+
-
X
-
X
X
+
X
-
+
-
-
X
-
X
-
-
X
-
X
-
-
X
-
X
-
-
+
X
X
X
-
X
-
+
+
-
X
X
-
X
-
X
-
Projective Drawings
-
X
-
X
X
Cognitive Assessment
-
-
-
X
+
ASD and ID
Differential diagnosis considerations:
•
Delays in social communication must be
more severe than would be expected for the
developmental level.
Tools:
Verbal/nonverbal ability tests, Social
Responsiveness Scale-2, Social Communication
Questionnaire, ADI-R
ASD and Social (Pragmatic)
Communication Disorder
• Impairments in social communication without the
presence of repetitive, restricted or stereotyped
behaviors may meet the criteria for Social
Communication Disorder
• When those stereotyped behaviors are present,
the diagnosis of ASD supersedes Social
Communication Disorder
Tools:
ADI-R, ADOS-2, SRS2, SCQ, interview, observation
ASD and ADHD
• Abnormalities of attention- either overly
focused or apparent lack of focus- and
hyperactivity are common features in persons
with ASD.
• ADHD diagnosis should be made when the
level of attention difficulties or hyperactivity
exceed those that would be seen in individuals
with similar developmental levels and similar
severity levels of ASD
ASD and Affective Disorders
• Comorbidity rates for ASD and affective or
anxiety disorders is as high as 70%
• For individuals who meet diagnostic criteria
for ASD, specific symptomology should be
investigated for comorbid diagnoses including
changes in sleep or eating patterns, irritability,
mania, including duration guidelines in
diagnostic criteria
ASD and Anxiety Disorders
• Comorbidity up to 70%
• When diagnostic criteria for ASD are met, attention is
given to specific criteria for anxiety disorders that are
distinct from ASD criteria including significant distress
when separating from caregivers, excessive worry
about safety of caregivers, school refusal, selective
mutism, fear of peer rejection
• Indications of anxiety not consistent with ASD- social
impairments do not persist with familiar persons, age
appropriate social capacity, but not utilized effectively
ASD and OCD
• Repetitive behavior is performed in order to
reduce anxiety; intrusive recurrent thoughts
inhibit functioning
• If social communication deficits are present,
then ASD may more appropriately account for
the repetitive behavior; if not, OCD is more
appropriate
Reactive Attachment Disorder and ASD
• Diagnostic criteria include specific event prior to
onset of symptoms including inadequate or
inconsistent opportunities to form attachments
with caregivers
• Reactive Attachment Disorder does not include
the restrictive interests, unusual sensory
reactions, repetitive (but not stereotyped)
behavior.
• Both disorders may include stereotyped
behaviors such as rocking or flapping and
impaired social reciprocity.
ASD and ODD
• ODD includes an element of vindictiveness
• ODD includes an awareness that behavior is
annoying or disruptive to others
• ODD includes a pervasive sense of anger or
resentfulness and emotional dysregulation
• With ASD, the noncompliant behavior results
in lack of understanding the behavioral
expectations for social situations
ASD and Intermittent Explosive
Disorder
• Aggression with physical damage or injury: 3
incidents in last 12 months; Aggressive
episodes without physical damage or injury:
2X per week for 3 months.
• No precursors identifiable and not used for
manipulation
• Magnitude exceeds that expected with ASD
ASD and Conduct Disorder
• Conduct disorder involves the purposeful
violation of social rules or violation of the
rights of others
• Antisocial behavior is proactive, predatory and
purposeful
• ASD related rule breaking behavior results
from not understanding social rules or not
possessing the skills to negotiate social rules
ASD and Schizoid Personality Disorder
• Flat affect and restricted range of emotions
contribute to lack of social interactions
• No interest in social relationships- a rejection
rather than a lack of understanding or need for
social interactions
• Includes a distinct lack of pleasure in few, if any,
activities
• Very similar outward presentation between mild
ASD and Schizoid- repetitive behavior and
restricted interests are key differentila diagnosis
features
Process for Making Differential and
Comorbid Diagnoses
Evaluation of Student Completed
ASD Diagnostic Criterion Met
Severity Rating Determined
ASD adequately characterizes
presentation of symptoms
ASD does not adequately
characterizes presentation of
symptoms
Consider other disorders whose
symptoms are present or
overlap with ASD symptoms
and Determine if symptoms
exceed that which would be
expected in ASD or for overall
developmental level/age
Report ASD diagnosis
Report ASD diagnosis with
additional disorder as comorbid
ASD Diagnostic Criterion Not Met
Determine category of
primary and secondary
symptoms
Determine if diagnostic
criteria for a disorder is
met
Report diagnosis
Report findings without
diagnosis