Autism Spectrum and Related Disorders: The How and Why of Getting the Diagnosis Right!

Tina K. Veale, Ph.D. Eastern Illinois University

Why is Accurate Diagnosis Important?
To better understand the individual To help others know how to interact with him/her To define his/her learning style To develop targeted, effective interventions To plan for the future
x Education x Living arrangements x Vocation

‡ Physicians
Pediatricians; family practitioners Neurologists Psychiatrists

‡ Therapists
Speech-language pathologists Psychologists Social workers/counselors Occupational therapists

‡ Educators
Team approach
x Teachers, psychologist, social worker, counselor, ST, PT, OT, behavior management specialist, autism consultant, etc.

The Diagnostic Process ‡ Obtain a list of referrals ‡ ³Shop´ for your diagnostician Experience counts! Type/extent of evaluation Report mechanism Availability for follow-up assessment Availability for intervention/consultative services ‡ Complete the diagnostic assessment ‡ Compare results with other opinions Get as many opinions as necessary to plan optimal intervention ‡ Plan intervention ‡ Plan reassessment .

The Process of Differential Diagnosis

Assessment Planning
‡ Formal assessment
Setting: Therapy room or some other quiet setting Format: Select battery of tests to help determine diagnosis x Communication
x Receptive vs. Expressive skills x Syntax vs. Semantics and pragmatics

x Social-pragmatics
x Play

x Behavior x Autism inventories

Assessment Planning
‡ Informal Assessment
Setting: No less than three relevant contexts Format x Observations (video recommended) x Completion of checklists x Communication analysis x Parent/teacher interviews x Client interview

and NVLD perform relatively well on formal communication tests. ‡ Given their relative strength in cognition.Formal Assessment ‡ No single test instrument is designed to differentiate between these disorders ‡ Due to similarity in many symptoms. formal tests to identify autism spectrum disorders may not be helpful. AS. most individuals with HFA. ‡ Formal test batteries can be compiled to evaluate key areas of known deficits. .

... Reichler. 1988) ‡ Gilliam Autism Rating Scale-2nd Edition (GARS. Baron-Cohen. Arick. B. E.Formal Test Battery: Autism Identification ‡ Autism Diagnostic Observation Schedule (ADOS. & Almond. & Rochen-Renner. 2006) ‡ Checklist for Autism in Toddlers (CHAT. R. 1999) ‡ Childhood Autism Rating Scale (CARS. 1992) ‡ Autism Behavior Checklist (ABC. & Risi. Schopler. Gilliam. 1993) . Rutter. DiLavore. Krug. Lord.

Hammill. Carrow-Woolfolk. 1996) ‡ Test of Written Language-4th Edition (TOWL-4. 1999) ‡ Test of Adolescent and Adult Language-4th Edition (TOAL-4. Wiig.Formal Test Battery: Overall Language Skills ‡ Clinical Evaluation of Language Fundamentals-4th Edition (CELF-4. & Wiederholt. Carrow-Wolfolk. 2003) ‡ Comprehensive Assessment of Spoken Language (CASL. 2007) ‡ Oral and Written Language Scales (OWLS. & Secord. Brown. 2009) . Larsen. Semel. Hammill & Larsen.

Steiner. & Secord. 2002) ‡ Clinical Evaluation of Language FundamentalsPreschool-2nd Edition (CELF-P:2. Semel. 2004) . Zimmerman. Wiig. Wetherby & Prizant. 1993) ‡ Preschool Language Scale-4th Edition (PLS-4. & Pond.Formal Test Battery: Overall Language Skills ‡ Communication and Symbolic Behavior Scales (CSBS.

& LoGiudice. 2007) The Social Language Development Test (Bowers. 1987) . & LoGiudice. Huisingh. 2008) Diagnostic Analysis of Nonverbal Accuracy-2nd Edition (Nowicki & Duke. Bowers. 2005) Test of Problem Solving--Adolescent-2nd Edition (Huisingh. & LoGiudice. 1986) Pragmatic Protocol (Prutting & Kirchner. Bowers.Formal Test Battery: Social-Pragmatic Skills Test of Problem Solving--Elementary-3rd Edition (Huisingh. 2006) Test of Pragmatic Skills-Revised (Shulman.

1990) Test of Pragmatic Language-2nd Edition (Phelps-Terasaki & Phelps-Gunn. 1997) The Strange Stories Test (Happe¶. 2003) Social Skills Rating System (SSRS. & Horselenberg. Gresham & Elliott. 2007) Reading the Mind in the Eyes Test (Baron-Cohen. 1999) . Meesters. Merckelbach. 1994) The Theory of Mind Test (Muris.Formal Test Battery: Social-Pragmatic Skills Children¶s Communicative Checklist-2nd Edition (Bishop. Steerneman.

1984) ‡ Symbolic Play Checklist (Westby. 1980) ‡ Symbolic Play Scale (Westby. 1988) .Formal Test Battery: Play Development ‡ Play Observation Scale-Revised (Rubin.

Huisingh. & Orman. 2004) ‡ The Word Test-2nd Edition-Adolescent (Huisingh. & Orman. 2002) ‡ Test of Semantic Skills-Intermediate (Huisingh. 2005) ‡ The Word Test-2nd Edition-Elementary (Bowers. LoGiudice. LoGiudice. Hanner & Richard. & Orman. LoGiudice. Bowers.Formal Test Battery: Semantic Language Skills ‡ The Language Processing Test-3rd Edition (LPT-3. 2004) ‡ Test of Word Knowledge (Wiig & Secord. LoGiudice. Huisingh. Bowers. & Orman. 1992) ‡ Test of Semantic Skills-Primary (Bowers. 2004) .

2006) ‡ The Listening Comprehension Test-Adolescent (Bowers. Bowers. 1999) ‡ The Listening Comprehension Test-2nd Edition (Huisingh. Huisingh. 2009) . Carrow-Wolfolk. & LoGiudice. & LoGiudice.Formal Test Battery: Semantic Language Skills ‡ Test of Auditory Comprehension of Language-3rd Edition (TACL-3.

Cicchetti. 2005) . 1989) ‡ Behavior Assessment System for Children-2nd Edition (BASC-2.Formal Test Battery: Behavior Profile ‡ Connors Comprehensive Behavior Rating Scales (CBRS. 1992) ‡ Vineland Adaptive Behavior Scales-2nd Edition (Sparrow. Bullock & Wilson. & Balla. Reynolds & Kamphaus. Connors. 2008) ‡ Behavior Dimensions Rating Scale (BDRS.

Gioia. 2008) ‡ Woodcock-Johnson Tests of Achievement (Woodcock. 2000) ‡ Behavior Rating Inventory of Executive FunctionPreschool (BRIEF-P. Espy. Guy. Schenk. Clare. Isquith. Nannery. & Mather. Watson Tate. McGrew. McGrew. Gioia.Formal Test Battery: Other Components ‡ Behavior Rating Inventory of Executive Function (BRIEF. & Crawford. & Kenworthy. 2007) ‡ Rivermeade Behavioral Memory Test (RBMT-3. Wilson. Greenfield. Cockburn. 2008) . & Isquith. Baddeley. 2001) ‡ Woodcock-Johnson III Tests of Cognitive Abilities (Woodcock. Sopena.

protesting. commenting) Discourse modalities (description. persuasion. etc. joint engagement Reciprocity Initiation Responding Communicative functions (requesting. narration. giving information. humor. greeting. social routine.) . asking permission/information.Informal Evaluation Components ‡ Social-Pragmatics Eye contact Eye referencing Joint attention. calling.

Informal Evaluation Components ‡ Social-Pragmatics (con¶t) Presupposition x Giving appropriate information--not too much or too little x Taking listener knowledge into account when formulating utterances Cohesion Nonverbal communication--receptive and expresssive x x x x Eye messages Voice messages Space (proximity) messages Body messages .

narrative information (oral and written) Reading aloud vs. antonyms. homonyms x Multiple meaning words Word-level comprehension Sentence-level comprehension Paragraph-level comprehension Following complex directions (oral and written) Expository vs. listening to passages read by another Comprehension monitoring .Informal Evaluation Components ‡ Semantics Concept knowledge Word knowledge x Age-appropriate vocabulary x Synonyms.

Informal Evaluation Components ‡ Syntax Basic and complex sentence structures (oral and written) x x x x Embedded adjectives Relative clauses Adverbial clauses Coordinating conjunctions Cohesion devices x Pronomial reference .

Informal Evaluation Components ‡ Behavior Obsessive interests or thoughts Repetitive acts or sequences Compulsive behaviors Rituals Stereotypies .

Making the Diagnosis ‡ Take time to review all information Formal measures Informal data Video records ‡ Summarize the differential indicators ‡ Note other symptoms ‡ What diagnosis is the best-fit for this individual? .

etc.Preparing the Report ‡ Details relevant aspects of the diagnosis Social Communication Behavior Other observations (play.) ‡ Captures the individual¶s strengths ‡ Details the individual¶s challenges ‡ Makes recommendations for intervention Type and intensity of intervention Does not necessarily suggest vendors ‡ Gives prognosis With/without intervention . motor development. medical issues.

High-Functioning Autism .

2007). ‡ Whole brain is affected.Autism ‡ According to the DSM-IV-TR (APA. individuals with autism present deficits in three domains: Social interaction Communication Behavior ‡ Symptoms must be present by 3 years of age. 2000) and ICD-10 (WHO. Left hemisphere Right hemisphere Cerebellum Diencephalon--limbic system ‡ One of five identified autism spectrum disorders .

High-Functioning Autism Normal or near normal intelligence Competent communication ability x Participates in verbal conversation x Follows verbal directions x Reads and writes Social deficits Repetitive behaviors .

body language. or gestures (nonverbal communication) when interacting with others ‡ Absent or deficient theory of mind ‡ ‡ ‡ ‡ ‡ ‡ ‡ .Autism: Social Interaction Low to absent social drive Absent or reduced initiation Absent or diminished reciprocity Interrupted emotional connectedness Lack of showing off or sharing behaviors Few to no peer relationships Failure to use facial expression. eye gestures.

HFA: Friends? Devaluation of friendship Poor social judgment/ problem solving Avoids social interaction Vague concept of friendship Lack of knowledge about how to make/keep friends Poor concept of qualities most desired in a friend .

HFA: Low Social Drive Prefers to spend time alone Chooses solitary activities Focuses on things and activities over people .

Theory of Mind? ‡ Underdeveloped concept of emotions ‡ Lack of perception of emotional state of others ‡ Difficulty reading and sending appropriate nonverbal messages .

Autism: Communication ‡ Significant delays in emergent language ‡ Diminished verbal fluency and/or facility ‡ Infrequent initiation of communicative exchanges ‡ Limited range of communicative functions ‡ Limited reciprocity ‡ Difficulty with topic maintenance ‡ May be echolalic ‡ May use idiosyncratic phrases .

and/or apraxia .Autism: Communication ‡ Poor understanding of figurative language or indirect messages. poor sound discrimination. very literal thinker ‡ Restricted word knowledge ‡ Word finding problems ‡ Receptive and expressive deficits ‡ Odd vocal prosody ‡ May have imprecise speech patterns.

HFA: Talking is Hard Language formulation problems Significant language processing deficits Comprehension issues Underdeveloped initiation and reciprocity Given the complexity of the task. communicate as little as necessary. .

Global Communication Disorder Poor eye contact Lack of eye referencing Poor attention to conv partner Needs prompts to answer  Poor concept development  Underdeveloped word knowledge  Misses main ideas  Difficulty putting thoughts into words .

Autism: Behavior ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Cognitive inflexibility Ritualistic Intense interest in one or more topics Stereotypies Preoccupation with parts of objects Obsessive-compulsive behavior patterns Repeats behaviors over and over again Noncompliant Adaptive behavior delays .

What Behavior Problem?  Highly inflexible  Anxiety in response to change  Requires support for activities of daily living  Weak self-evaluation .

Autism: Other Indicators
‡ Peculiar play patterns
Tendency to play with construction toys rather than make-believe toys Solitary to parallel play; non-interactive Limited interest in toys Restricted play schema

‡ Severe attention deficit disorder ‡ Information processing differences
Sequential processors Poor simultaneous processing

Autism: Other Indicators
‡ Perceptual differences
Strong visual processing Poor auditory processing

‡ Sensory integration dysfunction
Hypersensitive hearing Crave vestibular and proprioceptive input Tactile defensiveness

‡ Organizational skills
Varies from very neat to indifferent Needs help to organize

‡ Time/Space judgment
Usually excellent sense of time and space

Autism: Other Indicators
‡ Motor skills
Emergent skills on time to delayed Balance may be excellent to average Fine motor may be excellent to delayed Handwriting problems

‡ Intestinal hyperpermeability
Gluten-casein sensitivity-> ³Brain fog´ Constipation Yeast overgrowth

Asperger Syndrome .

2000) and ICD-10 (WHO. individuals with Asperger syndrome present deficits in two areas: Social interaction Behavior ‡ Language is relatively spared ‡ Right hemisphere disorder (frontal lobe) ‡ One of five identified autism spectrum disorders . 2007).Asperger Syndrome ‡ According to DSM-IV-TR (APA.

AS: Social Skills Modest to high social drive Over-initiation Command of reciprocity Emotionally present Shows off and shares accomplishments with others Few friends. body language. and gestures (nonverbal communication) ‡ Deficient theory of mind ‡ Often perceived as abrupt or rude ‡ ‡ ‡ ‡ ‡ ‡ ‡ . superficial relationships Unusual facial expressions eye gestures.

 A friend is«  ³There for you..These are my Friends«.´ My friends are: Unusual In trouble Developmentally disabled .´  ³Some you can hang out with.´  ³Fun!´  ³Someone you can count on.

Drive to Socialize!  Strong desire for friends and intimate relationships  Prefers to spend time with friends  Understands the concept of friendship  Difficulty selecting friends Social difficulties common Need to lead Lack of compromise Deficient social problem solving .

Theory of Mind? .

adheres to routines Intense interest in one or more topics Obsessive-compulsive behavior patterns Policing behavior--makes sure others follow rules ‡ Demand that rules are applied equally to all ‡ ‡ ‡ ‡ ‡ .AS: Behavior Issues Cognitive inflexibility Ritualistic.

Obsessions? What Obsessions? .

AS: Other Indicators ‡ No clinically significant delay in language development ‡ Effortless verbal expression ‡ May demonstrate pedantic speech ‡ No clinically significant delay in cognitive development ‡ Self help skills developed at appropriate times ‡ Appropriate adaptive behaviors (other than social interaction) ‡ Gross and fine motor deficits. including handwriting .

but auditory skills may also be strong ‡ Organization difficulties ‡ Time/space estimation and management issues ‡ Sensory processing differences .Other Indicators ‡ Curious about the environment ‡ Visual learner.

Organized? Not so Much! .

Nonverbal Learning Disorder .

Nonverbal Learning Disorder ‡ Individuals with NVLD present difficulty in these developmental domains: Social Language Motor Visual-spatial ‡ Right hemisphere disorder ‡ Not an identified autism spectrum disorder. but may present similarly in severe cases .

NVLD: Social Skills Intact social drive Interpret social behaviors of others inaccurately May engage in incessant in social attempts Perceived as ³annoying´ or ³attention-seeking´ Often do not understand what is happening or what is expected ‡ May appear withdrawn or out of place in novel social contexts ‡ Social naiveté ‡ ‡ ‡ ‡ ‡ .

desires to be social  Plans to have social relationships throughout lifetime  Knows desired qualities in friends  Engages easily with others .Socially Driven  From early age.

often does not know how to react . perplexed by actions of others  Feels empathy.Social Perspective  Misreads social information.

Interested in Others  Asks about other people  Works to engage the listener  Remembers information relative to other people  Uses this information in conversation .

figurative language Difficulty with multiple meaning words. nuance ‡ Difficulty providing opinions ‡ Pragmatic language deficits Poor interpretation of nonverbal language Often sends unintended messages via body language. or other nonverbal signals . complex sentences Flat tone of voice Fails to adjust discourse to audience ‡ Literal interpretation of language Poor comprehension of humor.NVLD: Communication ‡ May present as an early talker ‡ May speak like a ³little adult´ Average vocabulary. tone of voice. proximity.

. word finding and sentence formulation problems  Language deficits translate to deficits in reading comprehension and composing written documents.Language Profile  Language appears on time  Syntax well developed  Comprehension problems appear as child ages  Nonverbal deficits (pragmatic difficulties) apparent from early age  Connected language suffers from lack of organization.

including finger agnosia ‡ ‡ ‡ ‡ . may avoid crossing midline ‡ Dysgraphia ‡ Impaired tactile discrimination.NVLD: Motor Skills Motor clumsiness Slow reaction times Lack of speed in movement Difference between dominant and nondominant sides of body ‡ Early in development.

‡ Balance problems.NVLD: Motor Skills ‡ Lack of awareness of body position in space ‡ At risk for personal injury. balance perception differences ‡ Fear of heights. Instead. may be hesitant to explore motorically. frequent falling ‡ As toddler. explores his world verbally. gravitational insecurity .

NVLD: Visual-Spatial ‡ ‡ ‡ ‡ ‡ Visual perceptual deficits Visual imagery problems Visual-motor integration problems Visual-spatial confusion Visual memory deficits .

How to Fix a Messy Closet  Poor organization of personal spaces  Hard to think about how to begin organizing .

NVLD: Other Indicators ‡ No early indications of developmental delay. except in psychomotor area ‡ May show remarkable rote memory for auditory information ‡ Does not like constructive play ‡ May have problems dressing self Other adaptive skills average ‡ Prone to excess daydreaming ‡ May develop stories or fantasies Highly creative ‡ May be highly anxious (panic and phobic disorders) ‡ Anger control issues ‡ Depression common in adolescence and adulthood Low self esteem .

NVLD: Other Indicators ‡ May be considered gifted ‡ May struggle to learn effectively ‡ Early letter/number recognition. reading & spelling Difficulty in math. history. social studies ‡ Performance IQ at least 10 points less than verbal IQ ‡ Cognitive inflexibility ‡ Logical thinker Concrete topics easier than abstract ones ‡ Poor executive function Difficulty prioritizing and organizing thoughts and work ‡ Does not naturally generalize learned information or skills ‡ Difficulty adapting to changes in routine Cannot ³wing it´ .

Differential Diagnosis .

Social Skills: Similarities HFA Few Friends Poor Reading NV Signals Poor Sending NV Signals Peculiar/Odd Social Naiveté * * * * * AS * * * * * NVLD * * * * * .

Social Skills: Differences HFA Social Drive Initiates interactions Shows off. Shares Theory of Mind Emotionally Connected Low Low Low Low Low AS Mod-High Mod-High High Low-Mod Mod NVLD High High Mod Mod-High Mod-High .

Communication: Similarities HFA * * (Peculiar) Figurative Lang Deficits Odd Prosody Receptive Lang Deficits Pragmatic Deficits Word finding difficulties AS * * (Peculiar) NVLD * * (Flat-Normal) * * * * * * * * * .

Communication: Differences HFA Expressive Delays Verbal Facility Variety of Com Functions Reciprocity Echolalia Severe Poor Low Poor Ongoing AS Mild-None Good Average Average PeriodicNone NVLD None (Early Dev) Good Average Average None .

Behavior: Similarities HFA Difficulty w/ Change Ritualistic Restricted Interests Anxious Noncompliant * * * * * AS * * * * * NVLD * * * * * .

Behavior: Differences HFA Stereotypies OCD Policing Behavior Fantasizing/ Daydreaming Depression Yes Yes No No No AS Yes Yes Yes No Yes NVLD No No No Yes Yes .

Learning Style: Similarities HFA ADD Cognitive Inflexibility Sequential Processor Problem w/ Salient Details Logical Thinker Poor Generalization * * * * * * AS * * * * * * NVLD * * * * * * .

Learning Style: Differences HFA Visual Learner Auditory Learner Tactile Learner Overfocus on Details Spatial/Temporal Orientation Prob Cognitive Ability Perf IQ<Verbal IQ Yes No Yes Yes No Low averageAbove Ave AS Yes Yes No No Yes AverageGifted NVLD No Yes No No Yes AverageGifted No Yes Yes .

Other Similarities HFA Excellent Rote Memory Psychomotor Delays Executive Function Disorder Sensory Integration Disorder * * Maybe AS * * * * NVLD * * * * * * .

Other Differences HFA Constructive Play Interactive/Pretend Play Play Schema Curious Adaptive Behavior Yes No AS Yes Some NVLD No Yes Reduced Reduced to Average Average No Delayed Yes Average (except dressing) Yes Average (except dressing) .

Let·s Practice Making the Differential Diagnosis .

Meet Sara .

Meet Matthew .

Meet Shannon .

Meet Alex .

Meet Jacob .

Intervention Is Specificity Important? .

Further individualize for each client. or NVLD Some are not useful in one or more population Most work differently from population to population x Important to know how to apply specific interventions appropriately for the diagnostic group ‡ Begin customizing techniques based on your knowledge of the disorders. AS.Customizing Interventions ‡ Many interventions are useful for individuals with HFA. .

Schedules ‡ HFA Ensure predictability. sameness Facilitate transitions Mark completion ‡ AS/NVLD Cue order of events Facilitate transitions Support organization .

Timers ‡ HFA Signal/encourage completion Signal transition Visualize abstract concept ‡ AS/NVLD Judge time increments Teach time management Organizational strategy Encourage completion Visualize abstract concept .

Organizers ‡ HFA--Make it Visual Communicate verbal info between home/school Cue memory--directions for multiple assignments Cue memory--directions for multiple supplies Problem solve steps needed. Plan sequence Self check for completion--visual cue to finish ‡ AS--Make it Visual Get most important info between home and school Plan what to take home Note what needs to be done and estimate how long Self check for completion--visual cue to finish ‡ NVLD--Make it Auditory (otherwise same as AS) .

Social Stories ‡ HFA/AS Tells the individual how to behave Gives a rationale for behavior Explains potential feelings of others Makes social interaction logical ‡ NVLD Most important elements are description of social behavior and rationale Will be able to predict how others feel .

Comic Strip Conversations ‡ HFA/AS/NVLD Work out various solutions to problems Cue nonverbal communication--facial expression. then insert language ‡ NVLD Able to finish on own due to perspective taking abilities . Colors cue emotionality of words ‡ HFA Keep the language level targeted to the individual Draw cartoon one step at a time. tone of voice. etc.

Social Autopsies ‡ HFA May involve too much language ‡ AS/NVLD AS--Keep it visual NVLD--Keep it auditory Helps organize social behavior Allows client to see that s/he has responsibility for social choices .

Cognitive Behavior Therapy ‡ HFA Must be supported with visuals ‡ AS/NVLD Auditory approach.´ often effective Encourages the client to participate actively in analysis of social behavior and plans for future behavior Values the client¶s input . or ³talk therapy.

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edu . IL 61920 (217) 581-7445 tkveale@eiu. Ph.D.Contact Information Tina K. Charleston. CCC-SLP Eastern Illinois University 2207 Human Services Center 600 Lincoln Ave.. Veale.