Diagnostic confusion comorbidity in broad spectrum asd mfa 041412 with mfa slides by Circlestretch

Broad Spectrum ASD: What's the diagnosis? What should we do? Josh Feder, MD Momsfightingautism April 14, 2012

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Broad Spectrum ASD: What's the diagnosis? What should we do? Josh Feder, MD Momsfightingautism April 14, 2012

Director of Research, Graduate School, Interdisciplinary Council on Developmental and Learning Disorders

Assistant Clinical Professor, Voluntary Dept of Psychiatry, University of California at San Diego School of Medicine

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Outline •Vignettes: four ‘typical’(?) cases •How Diagnosis drives care decisions •Digging deeper: is ‘all’ explained’ by ASD? •Understanding Evidence Based Practice in ASD •Differential / multiple diagnostic considerations •Maturational and developmental considerations •Family systems aspects of complex situations •DSM, and DMIC diagnostic systems •Planning & Reflective Process

Three Big Ideas about how we can improve what we know and figure out what to do •Evidence Based Practice •Crowd sourcing •Reflective practice

Vignettes •Adult: compulsive substance use,

trouble on the job; few friends; very discouraged with life. •Adolescent who was inappropriate with a young girl he was babysitting. •Third grader tantrums when asked to read the chapter book; trips to office then home for the day. •Preschooler in a Pre-k class: very active; won't stay seated for circle, plays only with his Thomas toy.

Usual Diagnosis, driving usual care • Substance dependence: 12-step • Sex Offender: Incarceration • Misbehaving: Positive Behavioral

Management • Not ready: Waiting and retrying Pre-K

Digging deeper: ‘all is explained’? • We see them when other approaches have

failed • All turned out to have long-standing impairments in social communication and in their range of interests. • At the root of their troubles is a form of broad phenotype ASD • We recommend evidence based practice approaches to addressing these deficits.

Evidence Based Practice

Evidence Based Practice: â&#x20AC;˘ We do not usually have good enough

research to really say what is going to be best; but we use what we have of relevant research.

â&#x20AC;˘ Clinicians need to use their judgment and experience in vetting relevant research

â&#x20AC;˘ To provide

families with choices so

that they can make informed consent decisions based on their own family culture and values.

Differential / multiple diagnostic considerations: ASD + in our ‘cases’ •ASD + substance dependence, obsessive

compulsive disorder, depression •ASD + conduct disorder, pedophilia •ASD + reading disorder, oppositional defiant disorder, bipolar disorder (or the newer Disruptive Mood Dysregulation Disorder) •ASD + ADHD, ASD, OCD •Genetic links: ASD, ADHD, Bipolar, Schizophrenia…

Differential / multiple diagnostic considerations •We have very little research on numbers or

on treatment of ASDs combined with other conditions •So we need to rely on clinician intuition – which, as it turns out, can be pretty consistent with the research that we have.

Differential / multiple diagnostic considerations: Crowd Sourcing •The Wisdom of Crowds – James Surowiecki •From the weight of a cow to the location of a

lost sub, to the shapes of protein molecules and cooperative traffic patterns •Many people together can create a powerful form of ‘artificial-artificial intelligence’ •Feder 2012: crowd sourcing – tapping clinician intuition.

Differential / multiple diagnostic considerations: Crowd Sourcing requirements •1. Independence – have you read the paper

already? Avoiding anchoring influence (reviewed usual rates afterward), and ‘blind’ rating – not seeing what others are voting. •2. Diversity – experts and amateurs ok – avoiding using just one distinguished expert to answer the question. •(3. Feder’s sorting mechanism: used independent ‘crowd reader’ to keep results independent from Feder)

Differential / multiple diagnostic considerations: Crowd Sourcing ‘play at home!’ •We’ll do ‘Artificial artificial-artificial

intelligence’ (sort of pretending) •Make your guesses in the comfort of your own home – I’ll show you how! •I’ll tell you what the diverse group of experts said: compare your answer! •One day we’ll have real time tech for this...and more research on numbers and treatment for comparison too!

Crowd Sourcing - how to ‘vote’

Lugnega, et. al. Psychiatric comorbidity in young adults with a clinical diagnosis of Asperger Syndrome. Res. Dev. Disab. 32 (2011) 1910–1917 • This is the study we are comparing

with our intuition. • Then we’ll look at what the numbers are in the neuro-typical population

Maturational/ developmental considerations •Adult - connecting with a life partner

and being productive •Adolescent - sexual drive and individuation. •School age child - competence and self esteem •Pre-k child managing body control and competing relationships among adults

Family systems aspects • The adult is expected to take care of himself • The teen was available; mom wanted him to

be doing something productive and social , helping out and getting a 'job'. • The school aged child is expected to go to school and do his work • The Pre -K child is similarly expected to cooperate and join the group.

DSM, and DMIC • DSM: Pure disorders, definitive and effective

treatment. MDD, ADHD, OCD , etc. • What we do: find more factors, more diagnoses • Complex situations require complex approaches • DSM axes help us address multiple areas. • DMIC: Has even more axes .....

DSM – IV TR

DMIC

I – Major Diagnosis

I – Primary Diagnosis

II – Character, Retardation

II – Functional Emotional Developmental Capacities (FEDL)

III – Medical Problems

III – Regulatory-Sensory Processing Capacities

IV – Stress level

IV – Language Capacities

V – Global Function

V – Visuospatial Capacities VI – Child-Caregiver and Family Patterns VII - Stress VIII – Other Medical and Neurological Diagnoses

DSM - IV TR DSM - V Categorical - â&#x20AC;&#x2DC;Chinese Dimensional menuâ&#x20AC;&#x2122; spectrum ASD: social, language, ASD: socialinterests communication, interests

But both categorical and dimensional views may be valid (Zimmerman 2012): • After a certain threshold of number of symptoms of

borderline personality disorder there is little difference in overall functional impairment among patients • Supports categorical - e.g. ADOS (autistic, nonautistic, etc.) • But people with one symptom of borderline personality disorder are significantly impaired compared to those with no symptoms • Sub clinical - support for dimensional spectrum view e.g. FEDL Likert scale assessing each dimension

Planning •Brainstorming: diagnosis, causes or factors

at play •More brainstorming about what we might do •Prioritizing and combining to make sense for the family. •Expect to adjust:

reflective process to

help us navigate better as we move forward

Reflective Parallel Process • Colleagues support professionals • who support parents & caregivers • who support people with challenges

Reflective means Non-Directive • Avoid telling people what to do, but help them problem solve – • creates confidence in one’s own competence to solve problems in everyday life and intervention*

* This is like Tronick’s ideas of repair leading to confidence and ability to tolerate stress

Platinum Rule â&#x20AC;˘ Treat others as you would like

them to treat others.

â&#x20AC;˘ A good listener treats you with respect so that

you have the support to be able to tolerate the natural stress of helping your child.

Good Listening (It’s not therapy – but it is very helpful) • Look – at the person and how they seem to be feeling

• Listen – to what the person is saying – what are the main concerns?

• Learn – try to figure out how to support the person in problem solving

(from Zero to Three)

A Reflective Community Requires Nurturing • There are always new challenges • Nothing ever goes exactly as expected • We rarely have the support and time we need

to think things through with others • When we do this, we save a lot of time and energy in the long run. • Make time – regular meetings

Reflective Process: in the moment • Humility: you do not have the ‘answer’ • Facilitate problem solving • Wonder about the situation • Track the emotion, then and now • Statements vs. questions. • Empowering vs. dictating.

Summary

1 think broadly - brainstorm 2 think practically - prioritize 3 nurture reflective process

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