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

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

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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

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

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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

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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.

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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

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

Management • Not ready: Waiting and retrying Pre-K

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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

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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.

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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

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Evidence Based Practice

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Evidence Based Practice: • 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.

• Clinicians need to use their judgment and experience in vetting relevant research

• To provide

families with choices so

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

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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

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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…

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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.

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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.

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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)

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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!

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Crowd Sourcing - how to ‘vote’

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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

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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

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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

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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

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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.

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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

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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 .....

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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

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DSM - IV TR DSM - V Categorical - ‘Chinese Dimensional menu’ spectrum ASD: social, language, ASD: socialinterests communication, interests

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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

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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

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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 • Treat others as you would like

them to treat others.

• 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)

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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

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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.

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Summary

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

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