Differential Diagnosis. Not a Cookbook. Diagnostic Myths. Starting Points. Starting Points

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1 Educational Identification of Individuals with Autism Spectrum Disorders Ohio Center for Autism and Low Incidence (OCALI) 5220 N. High Street Columbus, OH Main Line: Fax: The Ziggurat Group Plano, Texas PDD Umbrella Autistic Disorder/Autism Asperger Syndrome Childhood Disintegrative Disorder Rett s Disorder Pervasive Developmental Disorder Not Otherwise Specified Diagnosis There are no medical tests for diagnosing autism. An accurate diagnosis must be based on the individual s communication, behavior, and developmental levels (Autism Society of America, n.d.). While individuals on the autism spectrum have some similar characteristics, no two individuals with autism spectrum disorders (ASD) will appear the same. The Autism Spectrum Asperger Syndrome In own world Active but inept Non-verbal Verbal but inept Stereotypical behaviors Limited flexibility Restricted interests Rigid routines High Sensitivity Preferences in response to anxiety Clinical Judgment It is important to remember that ASD is first of all a clinical diagnosis. Therefore, it is mandatory to have a trained and experienced provider coordinate the results of the complex diagnostic process (Freeman & Cronin, 2002, p. 4) Freeman & Cronin (2002). Diagnosing autism spectrum disorder in young children: An Update. Infants and Young Children, 14(3), 1-10.

2 Not a Cookbook Differential Diagnosis The specific diagnostic criteria included in the DSM are meant to serve as guidelines to be informed by clinical judgment and are not meant to be used in a cookbook fashion (APA, p. xxxii) ADHD OCD Bipolar MR Early Speech Delays Reactive Attachment Disorder Schizophrenia Visual Impairment Sensory Integration Disorder Comorbid Psychiatric Disorders Diagnostic Myths Comorbidity is to be expected (Gillberg & Billstedt, 200, p.237) 65% comorbid psychiatric disorder (Ghaziuddin et al, 1998) 44% Specific Phobia (Leyfer, et al., 2006) 37% Obsessive Compulsive Disorder (Leyfer, et al., 2006) 31% ADHD (Leyfer, et al., 2006) Purpose of the DSM is to provide concrete rules for diagnosis Individuals with Asperger s do not have communication deficits Individuals with Asperger s have average adaptive skills Individuals with Autism do not make good eye contact ~10% Major Depression (Leyfer, et al., 2006) Starting Points Starting Points Autism spectrum disorders (ASDs) are not rare. They are more prevalent in children than cancer, diabetes, spina bifida, and Down syndrome (Filipek, et al., 1999, p.440) A growing body of research suggests that autism can be accurately diagnosed by 2 years old Filipek, P.A., et al. (1999). The screening and diagnosis of autistic spectrum disorders. Journal of Autism and Developmental Disorders, 29, Bishop, S.L., Luyster, R., Richler, J., & Lord, C. (2008). Diagnostic Assessment. In K. Chawarska, A. Klin, & F.R. Volkmar (Eds.), Autism Spectrum Disorders in Infants and Toddlers: Diagnosis, Assessment, and Treatment (pp ). New York, NY: Guilford Press.

3 Typical Age of Identification Autistic Disorder 5.5 years Asperger s Disorder 11 years The consequences of a missed or late diagnosis include social isolation, peer rejection, lowered grades, and a greater risk for mental health and behavioral distress such as anxiety and depression during adolescence and adulthood. (Wilkinson, 2008, p.3) What factors contribute to early or delayed identification? Outcome Race and gender Attitudes towards diagnosis Fear of the impact of identification Level of functioning Findings of a 2002 U.S. study of 405 children and adults on the spectrum (Seltzer and Krauss, 2002) Of adults 22 and older, 73% lived with their parents 90% could not gain or keep employment 95% had difficulty making and keeping friends The primary treatment for autism is education... (Hann, 2007, p. 44) Educational Identification is not Diagnosis Hann, L. (October, 2007). Addressing autism.

4 Diagnosis vs. Eligibility Diagnosis Eligibility IDEA 2004 defines autism as. Based on a set of criteria (e.g., DSM-IV-TR) Refers to a specific disorder (e.g., Autistic Disorder, Asperger Syndrome) Used in private settings May be determined by an individual or team Based on federal law (IDEA) Refers to a broad disability category Used only in the public school system Must be determined by a team Developmental disability Significantly affecting: Non-verbal and verbal communication Social interaction Generally evident prior to age 3 Other characteristics often associated with autism: Engagement in repetitive activities and stereotypic movement Resistant to environmental change or change in daily routine Unusual responses to sensory experiences Aspy & Grossman, 2008 Educational Identification Multidisciplinary vs. Interdisciplinary Multi-factored Evaluation team process Who can begin that process? What documentation is needed for eligibility? What categories can be considered? Comfort level with educational identification? Developing a plan How does diagnosis fit into the plan? Multidisciplinary Members represent different disciplines Members provide information towards decision making Decisions made in isolation Parallel play Interdisciplinary Members represent different disciplines Members provide information and combine input into a common decision making process Decisions are made by a group Source: GRECC Education Program Cooperative play Interdisciplinary vs. Multidisciplinary Summary Multidisciplinary The multidisciplinary approach involves the compilation of work from professionals in various fields The interdisciplinary approach involves professionals from various fields collaboratively working together The interdisciplinary approach results in the strongest diagnostic and programming decisions

5 Who should conduct the assessment? A number of professionals may be qualified including psychologist, neurologists, pediatricians, or psychiatrists Avoid assuming the knowledge base of professionals The field of the professional is less important than expertise Involve Parents Parents should be part of the assessment and intervention process [IDEA, NCLB, PBIS, RTI] Parents offer insight that educators require [NCLB-evidenced based] Parents are required members of the team [IDEA, NCLB, RTI] Parents are Accurate Reporters of Early Signs Signs are seen within the first two years of life (Short & Schopler, 1988; Wimpory, Hobson, Williams, & Nash, 2000). Speech and language delays are the first concerns reported (Chawarska, Paul, et al., 2007) Concerns are initially expressed to the pediatrician by the time the child is 18 months (Howlin & Moore, 1997; Siegel, Pliner, Eschler, & Elliot, 1988) Survey of 1,300 Parents: The Diagnostic Process Symptoms are Evident by 18 months At 2 years: Fewer than 10% diagnosed at initial consultation 10% told to return if concerns persisted or that their child would, Grow out of it Remaining were referred to another professional (at mean age of 40 months) Of those referred: 40% diagnosed 25% told, Not to worry 25% referred to a third or fourth professional Howlin P, Moore A. (1997). Diagnosis of autism. A survey of over 1200 patients in the UK. Autism 1, How do I avoid common pitfalls? Special Consideration for Assessment of Asperger s Disorder Experienced professionals prevent delays Listen carefully to parent reports Consider patterns of behavior rather than isolated symptoms Avoid false reassurance a short encounter or routine interaction will not reveal anything unusual. However, over time and in unexpected situations, it appears that the façade of normality cannot be kept up. Frith, 2004

6 What should be included in an assessment? What information do we need? Developmental history Observations Direct interaction Parent interview Evaluation of social, communication, sensory, emotional, cognitive, and adaptive behavior If the MFE team determines within its plan that an outside diagnosis is needed to assist that team in determining eligibility for special education services, then they can request that the parent obtain that diagnosis. With this request, it is then the responsibility of the district to pay for that outside diagnosis What information do we need? If the parent of the child brings in an outside evaluation.. If it is just a prescription pad diagnosis, the team should request a report to consider along with that prescription pad If a report is presented, the MFE team must consider that report along with all the other aspects of the plan they have developed for determining eligibility. It need not be given more or less weight than any other piece of information What categories can be considered? It is left to the discretion of the MFE team whether they consider autism or another category when determining eligibility for special education services To be eligible for the autism scholarship the child must have an educational eligibility for special education under the category of autism OR have a medical diagnosis of PDD- NOS and be eligible for special education services under another categorical label such as LD, OHI, etc. Link Intervention to Assessment IEP Development Requirements 614(d)(3)(A) Match programs and strategies to assessment results [IDEA, NCLB, PBIS, RTI] IEPs are based on evaluation results [IDEA, NCLB, PBIS, RTI] Requires the IEP Team consider: Strengths of the child Concerns of the parents Evaluation results Academic, developmental, and functional needs of the child

7 Contact Information Guiding Questions Developed by the SWORAAC Ohio Center for Autism and Low Incidence (OCALI) 5220 N. High Street Columbus, OH Sheila M. Smith, Ph.D. Assistant Director Contact Information Ruth Aspy, Ph.D Barry G. Grossman, Ph.D