Diagnosing Autism Spectrum Disorders

A Lifespan Perspective

Donald P. Gallo

• Publisher: Wiley
• Year: 2015
• Print ISBN: 9780470749234, 9780470749241
• eBook ISBN: 9781119175551
• Edition: 1
• Topic: Psychology
• Subtopic: Autism Spectrum Disorders
• Index: Psychology

Diagnosing Autism Spectrum Disorders

The past decade has seen a tremendous increase in the number of people being diagnosed with Autism Spectrum Disorders – and not just young children. Diagnosing Autism Spectrum Disorders: A Lifespan Perspective is the first volume of its kind to provide authoritative information for professionals on how to appropriately evaluate and diagnose these disorders in individuals of all ages.

Donald P. Gallo, a board-certified clinical psychologist, shares his professional insights and expertise garnered from more than 1, 500 autism evaluations over the past ten years. The book includes in-depth interviewing strategies that focus on the three primary areas of impairment – socialization, communication, and behavior – to determine if an individual has an Autism Spectrum Disorder.

Differential diagnostic considerations are also addressed, and numerous case examples provide further clarity. Ways to present the assessment findings to parents and patients that will help them accept the diagnosis are also included. The information is targeted specifically for a wide range of practitioners, including child psychologists, child psychiatrists, speech pathologists, occupational therapists, paediatricians, paediatric neurologists, and students in those disciplines.

Authoritative and timely, Diagnosing Autism Spectrum Disorders: A Lifespan Perspective provides medical and mental health professionals everywhere with an invaluable resource for the proper diagnoses and assessment of an exceedingly complex disorder which affects people of all ages.

Chapter 1
A Brief Look at the History of Autism

In 1910, the Swiss psychiatrist Eugen Bleuler, while talking about schizophrenia, a term that he coined, used the Latin word autismus as a way of describing some of the symptoms of the disorder. The word autismus is derived from the Greek word autos, which means “self”; the English translation of autismus is “autism”.

Twenty years later, Leo Kanner, an Austrian-born physician, developed the first child psychiatry program at Johns Hopkins Hospital in Baltimore, Maryland. His first book, Child Psychiatry, came out in 1935 and was the first English-language textbook to focus on the mental health issues of children. In 1943, he wrote a paper entitled “Autistic Disturbances of Affective Contact”, which marked the first time that autism was discussed in the professional literature.

Dr. Kanner provided case studies of 11 children in his paper. The children were between the ages of two and eight, and all of them faced some form of extreme social difficulties and exhibited strange usage of language along with obsessive behavior. Dr. Kanner noted that although some of the symptoms these children displayed were similar to those in children with schizophrenia, the disorders were not the same. He reported that schizophrenia in children is “preceded by at least two years of essentially average development; the histories specifically emphasize a more or less gradual change in the patient’s behavior.” He further said, “The children in our group have all shown their extreme aloofness from the very beginning of life, not responding to anything that comes to them from the outside world” (Kanner, 1943, p. 248). The children who display the severity of symptoms that Dr. Kanner spoke about are now considered to have “classic” autism. This is most probably what people think about when they hear a child has autism – that is to say the image of the child rocking back and forth, banging her head, flapping her hands and spinning objects, amongst other things.

In 1944 in Austria, Dr. Hans Asperger published a paper in which he described four children, who were his patients, with “autistic psychopathology.” These children, all boys, were noted to lack empathy and engage in one-sided conversations along with having difficulty making friends, intense interests in peculiar topics and poor gross motor coordination. Dr. Asperger went on to describe these children as “little professors” because of their passionate interest in talking at great lengths about topics, regardless of others’ interest in the subject.

Towards the end of World War II, Dr. Asperger opened a school to help these children. Unfortunately, the school was reportedly bombed, and a great deal of his early work was lost. It was not until 1981, when British psychiatrist Lorna Wing published the paper “Asperger’s Syndrome: A Clinical Account” that Dr. Asperger’s research became more widely known. Before that, not much of his work was translated into English from German. Dr. Asperger died in 1980 and never saw his work reach such prominence.

In 1987, the Diagnostic and Statistical Manual of Mental Disorders, Third Edition–Revised (DSM-IIIR) was published. At that time, the prevalence of autistic disorder was thought to be four or five children in every 10,000. The prevalence of pervasive developmental disorders, including both autistic disorder and Pervasive Developmental Disorder – Not Otherwise Specified (PDD-NOS), was estimated to be between 10 and 15 per 10,000 children.

In 1994, when the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) was published, the prevalence rates for autistic disorder were between 2 and 5 per 10,000. Therefore, at the most, only 1 in 2000 children was thought to have autism. Asperger’s disorder was introduced into the field of mainstream mental health at this time, but there was not enough information to estimate its prevalence rates. Prevalence rates were also not provided for overall pervasive developmental disorders as they had been in the DSM-IIIR.

In 2000, the Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition – Text Revision (DSM-IV-TR) was published. It was then noted “The median rate of Autistic Disorder in epidemiological studies is 5 cases per 10,000 individuals, with reported rates ranging from 2 to 20 cases per 10,000 individuals.” There were no reported prevalence rates for either Asperger’s disorder or PDD-NOS. In 2000, the Autism and Developmental Disabilities Monitoring Network (ADDM Network), a Centers for Disease Control and Prevention (CDC) project which is active in 11 states, found the average prevalence of the autism spectrum disorder (ASD) in 6 of those 11 sites to be 6.7 per 1000. Two years later, there were 14 sites in the ADDM Network at which data were being collected, and a prevalence rate of 6.6 per 1000 was found.

According to the 2007 data of the CDC, 1 in 150 eight-year-old children, in multiple areas of the United States, has an ASD. That would translate into 66 children per 10,000 and would be at least a 13-fold increase over the most liberal numbers reported in 1994. According to the website of the organization Autism Speaks (www.Autismspeaks.org) a child is diagnosed with autism every 20 minutes. However, the number of the children (or teens, or adults) who have autism that goes undetected by well-meaning professionals who do not have the depth or breadth of knowledge or the experience necessary to appropriately identify the disorder remains elusive.

With the extreme growth in the number of children with ASDs, combined with the medical profession’s improved ability to understand the range of symptoms which comprise the autism spectrum, significant steps need to be taken to educate today’s professionals so that we do not miss the crucial developmental window to help these individuals. Much more can be done to assist a three-year-old child who has just been diagnosed with autism than a 13-year-old, or even a 31-year-old, who has been misidentified and misdiagnosed for years.

Chapter 2
The Importance of the Autism Referral

In graduate school, I was trained to identify and diagnose the problems with which my patients present with. Psychologists are taught to do this through a combination of observation, interview and, at times, psychological testing instruments. In this process, we are taught to assume that the information we receive is presented in an open and honest manner through which it is seen that the patients and/or their family members are truly interested in understanding the cause of the presenting problem and the ways in which it can be remediated. While I believe this is the case for most evaluations, it is not always so when dealing with autism spectrum disorder (ASD). Because of that, several factors need to be taken into account before the first meeting with the patients and/or their parents.

Where Did the Referral for This Patient Come From?

This is a very important question that needs to be considered because it could have a direct impact upon the doctor’s evaluation. A typical referral comes from the parents, requesting an evaluation for their child.

In my position at Kaiser-Permanente, I receive referrals from parents in one of two ways, either through a phone call directly from the parent (typically the mother, which will be discussed in greater depth later in this chapter) or through a professional, such as a pediatrician, speech therapist, neurologist or mental health professional, stating that they or the parents (or sometimes the patient, depending upon their age) are interested in an evaluation. These types of referrals typically indicate a significant amount of interest from the patients and/or their family in the evaluation. In these situations, it would be quite reasonable to believe that the patients and their parents would provide the examiner with a great deal of useful and factual information, necessary for an appropriate diagnosis.

I also receive referrals from care providers, such as the professionals mentioned above, in which the intent of the evaluation is not completely apparent, for one reason or another. There are times when the referring professional does not have a specific concern to articulate to the parent: “Well, Mrs. Smith, I don’t really know why Ralph isn’t talking [or banging his head against the wall, or wandering away from you whenever you take him outside], but it may be helpful for him to be seen by our specialist in that area.” It may also be possible that the provider does not feel comfortable using the “A” word (autism or Asperger’s) with the parents and simply says something to the effect of “I think it may be helpful for Ralph to be seen by a specialist. Luckily, we have such a person here in our clinic. I will make a referral for you if you would like.”

When you meet parents who have been given a rather ambiguous referral, you may need to start out with rather general questions, or even “beat around the bush” for a while to obtain information about their understanding of why they are seeing you. I have found the following non-threatening statement to work well: “I received a referral from Dr. Jones about Johnny. What kinds of things are going on?” As the evaluation progresses, more information about the referring professional’s, and the parent’s, concerns becomes apparent. One can then proceed to ask more autism-spectrum-specific questions or get the parents to talk about those areas. If within the first minute the parents state, “Well, Dr. Gallo, I think Dr. Jones was concerned because I told him Johnny wasn’t talking and doesn’t have any friends,” I think we know where this evaluation is headed.

It is quite common for parents to have different reactions with regard to a referral being made for their child. The following are examples of some types of parents one may encounter.

The reticent parents

Sometimes the most difficult referrals are those in which the parents have been told by the referring professionals about their concerns, but the parents do not agree with it. The following conversation exemplifies such a situation.

Dr. Jones:	Mrs. Smith, all the information you told me today makes me concerned about the possibility that Ralph may have autism. I would like to have him seen by our specialist in that area to confirm that.
Mrs. Smith:	Well, I don’t think he has autism, and I don’t want a referral.

The parents with pre-formed opinions

If the parents, or the patients, come to the evaluation with a preconceived notion about autism, such as “My child doesn’t bang her head against the wall or spin plates, so she can’t be autistic,” they may be quite unlikely to listen to what you have to say. Much more on this topic will be presented throughout the book.

The parents in denial

These parents could present in a few different ways. One example would be a parent who comes to the evaluation and says that there is nothing wrong with their child and that they have no idea why the doctor wanted their child to be seen by a specialist for an evaluation. Another example could be a parent who doesn’t want to know if there is a problem with their child – yet. They might think that if they viewed their child as “normal,” then people, including themselves, would interact with him in a better manner and would be nicer to him. However, if they view the child as being disabled or “sick,” it will make everyone, including the parent, sad, and their child will never be happy.

Have They Been Evaluated Previously? If So, by Whom?

In this day and age of increased awareness about mental and physical health issues, patients will often be seen by several professionals before coming to see a specialist. It is also possible that the family will have spent some time searching the Internet in an effort to obtain more information about whatever problem they think their child may have.

If you are seeing a very young child for an evaluation (one who is under the age of two) it is quite likely that the only professional they have seen in the past is their pediatrician. Quite often, the concern which first causes the parents to bring their son or daughter to the pediatrician is delayed speech. A “perfect world” scenario of this meeting with the pediatrician would go something like this: A mother brings her 18-month-old son to the pediatrician because he is not talking. The pediatrician shares the mother’s concerns about the delayed speech and makes a referral to a pediatric speech pathologist. The speech pathologist, knowledgeable of the signs and symptoms of the autism spectrum, reports their observations and concerns to the mother and suggests that she take her son to a professional who specializes in ASDs to rule out such a disorder.

Unfortunately, that is often not the case. A more realistic, if somewhat negative, interaction would be the following: The mother takes her 18-month-old son, Ralph, to the pediatrician because he is not talking. The pediatrician infor...

Table of contents

• Cover
• Table of Contents
• Title
• Copyright
• Dedication
• Preface
• Acknowledgments
• About the Author
• Chapter 1: A Brief Look at the History of Autism
• Chapter 2: The Importance of the Autism Referral
• Chapter 3: How to Conduct the Evaluation
• Chapter 4: Information to Gather at the Outset of the Evaluation
• Chapter 5: Diagnostic Criteria for the Autism Spectrum Disorders
• Chapter 6: The Main Problem Areas of Autism: Social Impairment
• Chapter 7: The Main Problem Areas of Autism: Language Impairment
• Chapter 8: The Main Problem Areas of Autism: Behavioral Concerns
• Chapter 9: Additional Questions to be Asked when Interviewing Teens
• Chapter 10: Additional Questions to be Asked when Interviewing Adults
• Chapter 11: Other Important Factors to Take into Consideration
• Chapter 12: Differential Diagnosis through the Lifespan
• Chapter 13: Feedback for the Patient and Family/Parents
• Appendix A: Sample Copy of My Questionnaire
• Appendix B: Sample Copies of Reports
• References
• Index
• End User License Agreement