Autism Spectrum Disorder Diagnosis and Treatment | NCMHCE & NCE Test Prep and Exam Review

Hey there, everybody, and welcome to this video on diagnosis and treatment of autism spectrum disorder. This is part of the NCE and NCMHCE exam review. I'm your host, Dr. Donnellice Snipes. In this brief video, we're going to review the DSM criteria for diagnosis of autism spectrum disorders, explore differential diagnosis, include mental health and medical conditions that might present similar to autism spectrum disorders, and identify current best practices in terms of individual, family and group treatment approaches. So I know normally when we diagnose, we start out with the category or criteria A, but when we're talking about autism spectrum disorder, I like to start out with criterion B because it gives us a little bit more information maybe about the person and helps us understand a little bit more maybe about their presenting symptoms, why they have the symptoms that they do. And it's important to remember that behavior is communication. So we need to examine what's going on. It's also important to remember that people with autism spectrum disorders often are neuroatypical and often have sensory differences. They could be hyper reactive to sensory input. So lights, sounds, smells, temperatures may feel way more intense to them than they do to people who are neurotypical. Or they could be hyporeactive. So sight, sounds, smells, temperature, those things feel way less intense to them than to people who are neurotypical. And that's important because autism spectrum disorder is something that they hypothesize exists from the time the child is born. And if a child, let's go with hyper reactive to the environment. If a child is hyper reactive to sensory stimuli, the infant is hyper reactive, then things that parents, caregivers do to be kind could be overstimulating. The lights, the sounds, the smells, just being touched or swaddled could actually be painful for the child. And the caregiver is trying to meet the child's needs as best as they can, but they don't understand, the child can't communicate it. The caregiver doesn't understand, or at least doesn't understand quickly, you know, oh, this is, the child is not experiencing this the same way I am. And that can also go for, you know, formula temperature, for example. If a child is hyper reactive and things that feel lukewarm to somebody who's neurotypical feel really intensely hot to the neuro atypical child, then formula can actually be perceived as painful. You know, when they drink it, it hurts to swallow, it hurts their belly, and it can make them fearful. So a child who is neuroatypical, especially, you know, an infant who is neuroatypical, who does not have the ability to communicate. This is painful, this is too much. May start to perceive their caregivers and their environment as threatening and scary and have difficulty feeling safe. Why is this important? Well, we're going to talk about that, but whenever I do diagnoses, I always ask myself, how do their behaviors make sense? How does the development of this reaction make sense to me in terms of helping the person stay safe and either emotionally, cognitively, or physically? Or how does it help them self soothe their distress? And why might something be causing them distress? So anyway, criterion B we need to have for a diagnosis, two of the following criteria need to be met, either currently or by history. It's also important to remember with autism spectrum you can't double count things. So if you count stimming for one thing, then you can't count it for another criteria. So, you know, that makes it a little bit more challenging. Sometimes you got to remember what you what criteria or what behaviors you use to satisfy which criteria. But I digress. So hyper or hyporeactivity to sensory input or unusual interests in. In sensory aspects of the environment. Some children who are people who are on the spectrum may be particularly drawn to lights or movement or particular colors in the environment. So being aware of that and recognizing how that might be helpful or distressful for that person. For example, if focusing on something that's the color blue helps them feel calm, helps them feel safe, then having something that's the color blue in their emergency toolkit is going to be really important. Likewise, if bright colors like neons are overwhelming to the person and they tend to cause the person stress, we want to be aware of that so we can help them buffer against that sensory overstimulation when, well, highly fixated interests that are abnormal in intensity or focus. And I hate that word abnormal, but that's what the DSM calls it. So somebody who is super duper interested in trains or dinosaurs or something else to the exclusion of other things. And you know, this is a really tricky one because if you've been around children or even some adults, you know that they can have a fascination with something. My son went through a period where he was fascinated by Star wars ships, and then a period where he was fascinated and all he could think or talk about for the most part was dinosaurs. And he's kind of still in that dinosaur phase. But so highly fixated interests, we want to recognize that a love or a passion for something is different than being able to only converse and talk about that topic. Stereotyped or repetitive motor movement, Use of objects or speech. So simple motor stereotypies. So doing something like tapping can be calming to the person because it helps them focus, if you will. Kind of like a metronome can help a musician stay on, you know, pace themselves when they're, when they're playing, when they're playing music. Sometimes stereo stereotyped movements can help a person feel calmer. It gives them rhythm, you know, and it helps them feel like there's some sort of structure to a seemingly chaotic world. Sometimes rocking, you know, and this is where we want to make sure we're not double counting. But rocking behavior can be very self soothing. But it may be something people engage in even when they're not necessarily self soothing. It's just something that they regularly do. Lining up toys. If they feel like they have to line up toys in a certain way or flip objects over, those can be other examples of these stereotyped or repetitive movements or use of objects. Echolalia is when the person repeats a word over and over and over again or uses idiosyncratic phrases. If they have a particular phrase that they regularly use, that could be an indication of a stereotyped speech. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior. It's important to recognize that people who are on the spectrum often have distress at small changes or transitions. So if a different person is picking them up from school, or if they go to see a therapist and it's a different therapist, or if there is a substitute teacher, or even transitions between classes, going from, you know, English to recess and then from recess to lunch, those are huge transitions in terms of expectations for interaction. And that can be really difficult for somebody with autism spectrum issues. And I keep saying spectrum because remember, there are some people who have very mild symptoms and some people who have very severe symptoms. For people who are more on the mild side, sometimes these transitions can can be eased, for example, by giving them a cue word or a cue sound like a bell ringing two minutes before the transition is set to take place. So they know that when the bell rings, they need to get up and move. A lot of times people with autism spectrum really like structure and routine and schedules. And it's difficult for them if their schedule gets thrown off. They have difficulty adapting because used to doing XYZ at 3 o' clock and then something else at 4 o'. Clock. Now back up to criterion A. Persistent deficits in social communication and social interaction across Multiple contexts. So it's not just at school or just at grandma's house as manifested by the following currently or by historical account. So some symptoms may come and go a little bit, but we want to look at throughout this child's life or this person's life, you know, have they experienced these deficits in social emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back and forth conversation to reduced sharing of interests, emotions, or affects, or failure to initiate or respond to social interactions. They may have difficulty starting conversations. They may have difficulty in partner play. They may have difficulty, you know, again, in that just typical back and forth that people who are neurotypical are used to and find comes relatively naturally. They may have nonverbal communication difficulties, including poorly integrated verbal and nonverbal communication. So they may be talking about something that makes them very happy, but really not have much of a facial expression, abnormalities in eye contact and body language. A lot of people with autism spectrum disorder have difficulty with prolonged eye contact. It feels invasive, it feels, feels very overwhelming to them, so they won't make consistent eye contact. There are some people who are on the other end of the spectrum for eye contact, not autism, that actually make too much eye contact. They have difficulty recognizing that their eye contact is almost too penetrating to the other person. No two people with autism are exactly the same. So it's important, important to approach them individually and be curious about what's going on. Now remember, you know, people who have difficulty in social interactions may have difficulty forming relationships. If they have difficulty interpreting verbal and nonverbal cues, they may have experienced failure or rejection in relationships before. And it may be overwhelming to think about trying again. Even for neurotypical people, thinking about trying to form new relationships can be a little anxiety provoking. For people who are neuro atypical, it can feel like they're stepping into this abyss of, you know, unpredictability, which can be very overwhelming. They also may have relationship skill deficits, include difficulties in adjusting behavior to social context, difficulties in cooperative imaginative play or making friends, or an absence of interest in peers. Again, we want to ask ourselves, why has this child or person always had an absence of interest in peers? Is this something that developed as a protective mechanism because other people felt too intrusive, too overwhelming, too painful in some ways? And you know, what is keeping them from having interest in peers? And if they want to have friendships, what is restraining them from trying to do that? Symptoms must be present in the early developmental period, but may not fully manifest until social demands exceed Capacities. So the child may only show a smattering of symptoms early on, but as they get older, they may have more difficulty. The transition, for example, from kindergarten, where there's a lot less structure, to first grade, where there's a lot of structure, can be really problematic and challenging for a lot of people, not just people with autism spectrum disorder. So when there's a big change and the person, the child has to learn how to act and react differently, you know, it's a change in situation, it's a change in routine, then that may suddenly overwhelm their capacities. So they may be able to do pretty well up until a certain point, whatever that certain point is, and then they start to manifest more symptoms. These symptoms are known for to cause clinically significant impairment for the individual. And that's important in all of our diagnoses because, you know, a lot of people have various symptoms of various things occasionally. And it may be something that's very transitory. With autism spectrum disorder, it's something that is pervasive across multiple situations and it's permanent. It's not something that comes and goes and it causes the person distress or impairment in their ability to live independently, for example. These disturbances are not better explained by intellectual disability or intellectual developmental disorder or global developmental delay. Now, intellectual developmental disorder does occur, co occur with autism pretty frequently, but not always. There are a lot of people who have average to above average intelligence and autism. For a comorbid diagnosis of autism spectrum disorder and intellectual disability, what you're wanting to look at is social communication. And the person's interpersonal communication should be below that expected for their general developmental level. So if you're looking at a five year old, obviously their social communication is going to be very different than a 15 or a 25 year old. It's important to remember that some people, especially those that are on the lower end of the spectrum, may not actually get diagnosed even until they are in their late teens or early 20s because they have managed to develop compensatory strategies that have helped them deal until now. Assessment on the NCE and the NCMHCE it's important to know how you would assess these things. And the best strategies include caregiver interviews. So you're getting information about early developmental delays or loss or regression of behaviors, especially social emotional behaviors. If there is a regression in physical behaviors, like toileting, for example, that needs a much more in depth evaluation. But there are some people with autism spectrum who do have a regression of their social emotional behaviors. Obviously clinician observation of the patient and then standardized instruments that can be used for, for assessing autism. The Modified Checklist for Autism and Toddlers or the mChat, the Ages and Stages Questionnaire or the ASQ Screening Tool for autism in toddlers and young children, the stat or the parents evaluation of developmental status, the PEDs. In terms of differential diagnosis, just because something seems to look maybe like autism spectrum doesn't necessarily mean it is. So you want to rule out these other things or rule them in as comorbid diagnoses. So it gets a little confusing. You want to figure out number one, does autism exist for this person? Do they have autism or is it one of these others? And if they do have autism, do, do they also have one of these other things? So in differential diagnosis, Rett syndrome is one of those that could appear like autism. Rett syndrome causes a disruption of social interaction, but often does not also entail the repetitive behaviors. And it often gets better after the child reaches a certain age. So, so you do want to assess for Rett syndrome. You want to assess for intellectual disability, language and communication disorders. You know, it's hard to maintain socio emotional reciprocity when you have a difficulty communicating or understanding what's being said to you. Adhd, schizophrenia and schizoid personality disorder can all have some overlap with symptoms of autism spectrum disorders. Medical conditions. Now the DSM doesn't really talk about these, but it is important to recognize that especially for young children, infants, hearing impairments may make them seem aloof if they are, you know, not responding to their name, if they're not responding to sounds, if they're not. So infants and young children with hearing impairments may have difficulty in relationships because they can't hear or can't hear well, so that what they may hear may sound like it's coming to them from underwater, so they have difficulty deciphering what's being said to them. So obviously getting a full workup can be very helpful. Comorbidity, specific learning disabilities, anxiety, depression, bipolar disorder, epilepsy, sleep problems and schizophrenia all have a relatively high comorbidity with autism spectrum disorders. So that means you can have ASD and one of these others or more avoidant restrictive food intake disorder is another one that is very common in people with autism spectrum. But I want you to think back to what we were talking about with the hypersensitivity or hyposensitivity to sensory input. If a child has difficulty with textures or sensory integration, they may have difficulty eating and swallowing certain foods because it feels gross on their tongue or it feels Sharp on their tongue. So. So we want to recognize that sometimes avoidant restrictive food intake disorder. It's not a child being a picky eater. Their senses, their sensory perception of that food is actually overwhelming or distasteful. Same thing with spices. Some children may find certain spices to be particularly overwhelming and they can't tolerate them. So a nutritionist can help with this. An occupational therapist may be able to help with this in terms of food and eating practical presenting issues. Now, we already talked about the diagnostic criteria, and you want to evaluate the diagnostic criteria and ask yourself, okay, this person has this going on. In what way does this make sense? How is it helping them, you know, feel safe and survive and get through life? What might be causing it, and what can we do to address those things so the person can feel safe and empowered as well as develop more mainstream behaviors. For example, they may also have difficulty adapting to novel situations. So we did talk about that some or quite a bit in the symptoms section. But it's important to figure out, you know, what can this person do to help them adapt. Role play rehearsal can be really helpful if they're getting ready to do something new so they can prepare and it's not a novel situation anymore. And sometimes even walking through the situation, maybe they're getting ready to go on an airplane for the first time. So helping them walk to the, go to the airport, and there's a lot of hustle and bustle, which can be very overwhelming for somebody with autism. Making sure that they know what they need to do in order to, you know, get on the airplane, but also that they have strategies for helping themselves should they start to feel overwhelmed. Some people with autism, not everybody, but some, have a desire to establish friendships without understanding what friendship really entails because they have difficulty with that reciprocity. They want somebody to interact with them the way they expect. So it can be helpful to again, role play what friendships might look like, role play, reciprocity, and talk about it in a very matter of fact way. You know, what, if you do this, what would you want them to do? If they do this, what do you think they might want you to do? Depending on the person's level of degree of autism spectrum, they may or may not be able to participate in certain interventions. They may have difficulty with irony metaphors and white lies. So we may need to help them learn how to ask for clarification. If they are in a situation where somebody says something and they need to be ironic if it doesn't make sense to them, helping them ask questions to clarify what's being meant. They may learn to suppress repetitive behavior in public, but this often causes them great stress. The repetitive behavior is a self soothing behavior for a lot of people. And when they can't do that, when they recognize that they're feeling overwhelmed but they can't engage in that soothing behavior, then basically they're bottling up that stress, that distress. And it's important that they have an outlet for that, a way to decompress some point. They may be more naive and gullible because they have difficulty with irony and metaphors and things, and they have difficulty interpreting nonverbals. They may be more prone to be manipulated by malicious others. So we want to help them learn how to stay safe, learn how to identify safe people. For example, they may have difficulty organizing demands. So helping sitting down with them and developing a schedule that helps them feel like they're in they've got some control can be helpful to them at the beginning of the semester when they get a new syllabus, helping them sit down and plot out how they're going to get everything done. Because a syllabus is new information, new teacher, new setting, lots of newness, which can be very overwhelming for somebody with autism. So sitting down and organizing the demands so they can feel like they've got that structure, they can see it again, they may be prone to anxiety and depression. So the best practices that have been identified individually. Behavioral management therapy is one of the gold standards, if you will, for autism spectrum to help reinforce the behaviors that the individual wants to develop and minimize the behaviors that they don't want to engage in. Cognitive behavior therapy can be very helpful. Remember, addressing cognitions does not require necessarily somebody to be. Typical in their intellectual development. So people who have some developmental delays, cognitive behavioral therapy can be used. It just needs to be modified to a level that that person can understand. Early Intervention and the Early Services Denver Model, a comprehensive ABA program for infants to 4 years old that has been shown to be very helpful for people with autism that's diagnosed obviously before four years old. Some medications have been helpful especially for addressing particular behaviors. There's been a lot of research recently about the connection between autism spectrum behaviors and the gut microbiome. So there are two articles that are referenced in this presentation. You can go to PubMed and look at Gut Brain Access and or Gut Microbiome and Autism and come up with these articles if you want to read them for more in depth information. But just in terms of referrals that you might make to a behavior analyst is One cognitive behavioral therapy is another physician or psychiatrist for medication treatment, a dietitian or maybe a physician for nutritional therapy, an occupational therapist to help them learn independent living skills. And this can also in grade school, it can help them learn the skills they need to find function in the classroom more effectively. Physical therapy may be needed to address gross motor deficits and sensory integration issues. So if they have difficulty integrating what they're seeing and what they're feeling, physical therapy can be very helpful. Social skills and let me go back to physical therapy for a second now, that is not. Physical therapists can't reduce hypersensory reactivity. They can't make something less intense. They can help people figure out, okay, how do you cope with this? If 40 watt bulbs seem impossibly bright to you, wearing sunglasses or blue blocker glasses, for example, if the blue glow is particularly intense for somebody. So physical therapists can help people identify ways to modify their environment and ways to do some sensory integration so they don't feel like they're floating away or have difficulty with proprioception. Social skills training now this can take the form of individual counseling where you talk to somebody about what would you do in this situation. You may role play in session with the individual. Social skills training can also take place in groups where individuals with autism spectrum and it's small groups so people don't feel overwhelmed, but they practice these social skills activities and family where the entire family is taught different activities and different ways to rehearse social skills at home, different expectations and ways to prompt effective behaviors in the individual with autism. Speech language therapy can be helpful for people with autism who have difficulty with verbal communication. And vocational counseling can be really useful for older adolescents and adults. We need to have things that we feel give our life meaning. We need to have things to do. And a lot of people who are on the spectrum want to engage in meaningful activity. Sometimes it may be volunteering, it may be supported employment, it may be regular employment. You know, it depends on the person. But a vocational rehabilitation specialist can help that person identify placements that may be helpful and meaningful for them. In terms of family counseling, parent mediated therapy can be very helpful. And this is where the parent comes in and learns the skills that the therapist is using in session so the PAR can apply those skills, can apply those techniques with the person with autism in between sessions. Joint attention therapy is where the people in the family or even in groups, the person with autism learns to engage in an activity with someone, whether it be imaginary play or playing with Legos or play DOH or something where they are both focused on the same task, they're cooperating, they're not just playing in parallel, they are working together. And parent support groups are really important for parents of people with autism because being a caregiver for somebody who has special needs can be exhausting. And a lot of times the parents find a lot of courage and hope and strength within these support groups. In terms of group therapy best practices, we did talk about social skills training and educational and school based therapies. You know, this is for the individual, but it's important that the teacher and the school know the techniques and know the needs of this individual in order to ensure that they have the highest quality learning experience. That may mean, for example, that they need to be in a quiet room. They may need to sit at a carol. That's what we used to call them. I don't know what they call them now where you've got basically blinders on both sides. What is it that the person needs in order to be able to feel safe, in order to be able to focus, and in order to be able to most effectively learn for them? About one in 54 children. Let me say that again. One in 54 children, or about 2% of children, have been identified with autism spectrum disorder. According to the estimates of the CTC's autism and developmental Disabilities Monitoring Network. Those with only mild symptoms may elude diagnosis for many years. So if they don't get a diagnosis, adulthood, it may come as a great relief to them when they finally understand why they interact differently or why they perceive things differently than other people. There is no one best treatment for people with autism spectrum disorders. And it's really important that we wrap our heads around that. Not every person is going to have the same symptoms, the same presentation, or respond to the same interventions. Treatment must focus on the individuals presenting symptoms and the causes for those symptoms and providing support to their caregivers and the people that are in their daily life.