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Presentation, Assessment and Diagnosis of Autism Spectrum

Disorders and Associated Psychiatric Disorders in CAMHS

By

Dr Andrea Mowthorpe (Consultant Clinical Psychologist)

Dr Laura Davies (Clinical Psychologist) Dr Sasha Walters (Assistant Psychologist)

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Aims and Objectives

To introduce and briefly explore Autistic Spectrum Disorders (ASDs)

Overview of our Sp. CAMHS ASD assessment clinic

Common comorbid disorders & ways of differentiating them from ASD

Identifying Features of Autism Spectrum Disorders Observed

within CAMH Services

Dr Laura Davies

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The Autistic Spectrum

Asperger’s

Autism HFA*

Neuro-typical

Semantic Pragmatic Difficulties

PDD-NOS**

*High Functioning Autism **Pervasive developmental disorder – not otherwise specified ***Pathological demand avoidance (syndrome)

PDA***

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Prevalence:

The National Autistic society estimates that one in every 100 people have an ASD

Prevalence appears to be increasing 4:1 boys vs. girls Between 75% and 90% of people with ASD will

also have a learning disability Other conditions that are often diagnosed with

ASD: ADHD, epilepsy and more specific learning difficulties such as dyslexia and dyspraxia.

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Causes of ASD:

Evidence that it’s not a psychological disorder but organic in origin

Growing research suggests it’s a genetic condition/genetic predisposition -which genes remains unclear

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Triad of Impairments

SENSORY DIFFERENCES

Difficulties with Communication

Delay or lack of development of speech Unusual patterns of speech, tone of voice,

echolalia, making up words, difficulties with “I” and “you”

Using language in social situations Interpreting non-verbal information Understanding others’ verbal / non-verbal Literal understanding

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Difficulties with Social Interaction

Poor emotional literacy leading to lack of understanding of emotions / reactions

Lack of empathy Problems understanding alternative

opinions Contact on their terms Lack social norm awareness

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Flexibility in Thinking & Behaviour (Imagination)

Desire for routine & ‘sameness’ Repetitive mannerisms, speech & behaviour Obsessions or very focused interests Difficulties in imagination / generalisation

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What you might see…

Repetitive behaviours Obsessions e.g. topics, objects or people Resistance to change Decision making is hard Different ways of coping with feelings Wanting to be alone Problems coping at school Possibly particularly good at something

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Sensory Differences

Different pain threshold Might enjoy unusual smells or tastes Might enjoy particular sensations Might be frightened by extremes in sensory

stimuli (e.g. noise; light) Might experience sensory overload in busy

places Self-stimulatory behaviours

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Asperger’s Syndrome Average or higher level of intelligence No delay in language development Less difficulty in speech and language skills. Verbal skills significantly greater than non-

verbal skills May be more motivated to develop friendships

but will find this difficult due to impairments. More symbolic play

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High Functioning Autism

Average or higher level of intelligence Delay in language development Non-verbal skills significantly greater than

verbal skills

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Atypical Autism

Generally do not quite tick all the boxes for autism but are severely impaired in at least two areas of triad.

Impairments have a significant impact on day to day functioning

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Pervasive developmental disorder – not otherwise specified (PDD-

NOS)

Impaired social interaction – Or

Impaired communication – Or

Restricted repetitive patterns of behaviour / interests / activities

Semantic-Pragmatic difficulties

Affects the use of language in a social context – Semantic (meaning of language) =

understanding the meaning of word – Pragmatic (use of language) = knowing what

to say and when to say it Same underlying triad of difficulties as

HFA

Pathological Demand Avoidance (PDA) Syndrome (?)

More girls affected than boys Central feature ‘an obsessional avoidance of

the ordinary demands of everyday life’ (Newson et al. 2003)

Social understanding and sociability Capacity for imaginative play Share same behavioural features of autism

(triad of impairments)

Assessment and Diagnosis Process within CAMHS ASD

Assessment Clinics

Dr Andrea Mowthorpe

Screening process

Discuss with young person and family Children’s Communication Checklist 2

(CCC2) Adolescent Autism Spectrum Quotient

(AASQ) Qualitative questionnaire for school

AASQ

S/he prefers to do things with others rather than on her/his own

S/he usually notices car number plates or similar strings of information

S/he can easily keep track of several different people’s conversations

S/he enjoys social chit chat S/he notices small changes in a situation, or a

person’s appearance

School questionnaire

How do teachers see this child? How do peers see this child? What is it like to have a conversation with them? Tell us about the child’s way of speaking How does the child cope with change? How does the child behave in the classroom? What does the child do at break/lunch time? Does the child show any unusual behaviours?

Waiting list

Will prioritise but generally seen in order of referral

Some profiling assessment carried out whilst waiting for core assessments

Profiling Assessments

Assessment of intellectual ability if one not available (WISC-IV, BAS III)

NEPSY-II– Theory of Mind, Affect Recognition and Animal Sorting

Literal understanding (Understanding Ambiguity, Wendy Rinaldi)

Young person’s view of their emotional literacy (Bar-On EQi)

Assessment

2 cornerstone assessments used: Autism Diagnostic Observation Schedule

(ADOS) Autism Diagnostic Interview – Revised

(ADI-R)

ADOS

Lord, Rutter, et al (1999) Semi-structured, standardised assessment of

communication, social interaction and play/imaginative use of materials

4 modules (we use 3 & 4) Includes tasks such as make-believe play,

conversation, creating a story, sharing a book, understanding cartoon stories

ADOS ctd….

COMMUNICATION Use of stereotyped or idiosyncratic words Reporting of events Conversation skills Use of gestures

ADOS ctd….

RECIPROCAL SOCIAL INTERACTION Eye-contact Facial expressions directed to others Insight Quality of social overtures Quality of social response Amount of reciprocal social interaction Quality of rapport

ADOS ctd….

IMAGINATION/CREATIVITY How creative is the story.. Is there a central character and a plot.. Is prompting required, if so how much..

ADOS ctd…

STEREOTYPED BEHAVIOURS AND RESTRICTED INTERESTS

Unusual sensory interest in materials Hand and finger and other complex

mannerisms Excessive interest in unusual or highly

specific topics or objects Compulsions or rituals

ADI-R

Rutter, Le Couteur and Lord (2003) Interview with parents/carers with focus on

current and past developmental history Looks at same areas but also looks at age of

first difficulties

Diagnosis

Use all of the information from the assessments to inform clinical judgment, using MDT discussion/decision

Follow-up with a report and appointment Report aims to give a profile of strengths and

difficulties as well as statement on diagnosis Hand back to referring clinician from the locality

Team Evaluation questionnaires

Outcome of assessment Outcomes of Pembs Assessments

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18AutismAspergersAtypical ASDASD TraitsNo

Gender differences in our clinics

Girls with ASD

Same profile but more subtle expression Less likely to be aggressive and so less likely to

come to people’s attention Can be better than boys at emotions Girls are more likely to be ‘mothered’ by peers

whilst boys are more likely to be rejected Girls more likely to develop their social skills,

albeit at a slower rate than their peers

Girls ctd…

Girls more likely to observe and imitate, copying mannerisms

Often have imaginary friends which gives appearance of having imagination

Interests can appear typical for girls e.g., horses, classic literature

May not value fashion, preferring practical clothing, no make-up

Difficulties become apparent later?

Current Projects…

Comorbid Psychiatric Disorders; Identification and

Differentiation from ASD

Dr Sasha Walters

Why Differentiate Between ASD and Mental Health?

ASDs are associated with high levels of impairment due to increased rates of mental health difficulties (Ozsivadjian & Knott, 2011; Siminoff et al, 2008)

This can lead to confusion in diagnosis, treatment and management because:

1) The psychiatric symptoms can mask the ASD 2) The ASD can be used as a label to explain the

psychiatric symptoms

Difficulties Caused by Not Differentiating ASD from Mental Health

Psychiatric disorders masking ASD Traditional methods of managing psychiatric

disorders may seem ineffective and young people may struggle to make changes

Difficulties will seem compounded as the young person moves through developmental transitions

Impairment caused by psychiatric disorders in YPs with ASD may seem enhanced in comparison with psychiatric disorders in TD YPs

Difficulties Caused by Not Differentiating ASD from Mental Health

ASD being used as a label to explain psychiatric symptoms

Can cause important symptoms to be overlooked putting YPs in danger

Traditional ways of managing ASD may seem ineffective making it more challenging for parents and teachers

Effective methods of working with psychiatric disorders, including therapeutic models and medication, can be less readily used

The young person may struggle to cope with the psychiatric disorder more than their typically developing peers

Comorbid Psychiatric Disorders with ASD

Medical Conditions

Other disorders

Mood disorders ADHD

Anxiety disorders

Learning Difficulties/Disabilities

Epilepsy/Seizure disorder

Psychosis

Autism/Asperger Syndrome

Aggression

Adapted from Ghaziuddin (2005)

Comorbid Psychiatric Disorders with ASD

ADHD, ODD, EBD (up to 63% comorbidity Anderson, Williams, McGee & Silva, 1987; Caron & Rutter, 1991; Siminoff et al, 2008)

OCD (37%; Leyfer et al, 2006)

Anxiety Disorders (up to 30%; Siminoff, et al, 2008).

Depression (up to 30% comorbidity; Ghaziuddin, Weidmer-Mikhail & Ghaziuddin, 1998)

Eating Disorders (18%; Wentz Nilsson,Gillberg, Gillberg, Rastam, 1999)

Psychosis (comorbidity suspected but yet to be confirmed; Leyfer et al, 2006; Matson & Nebel-Schwalm, 2007)

Differentiating ASD from Mental Health Obsessive Compulsive Disorder Autism Spectrum Disorders

1) Repetitive behaviours are completed to reduce distress

1) Repetitive behaviours are completed as a source of pleasure

2) Behaviours must be considered ego-dystonic (unwanted/foreign)

2) Difficult to diagnose ego-dystonicity/distress due to emotional impairment

3) Compulsions centre around cleaning, checking, repeating, arranging and counting

3) Compulsions focus on, ordering, hoarding, telling and asking, touching, tapping, self-mutilation

4) Compulsions centre around common themes such as contamination and superstitions

4) Compulsions are more random and specific to the individual

5) Can have obsessions only (Pure-O) 5) Obsessions are generally accompanied by compulsions

6) Obsessions and compulsions change with age and developmental stages

6) Age does not appear to impact obsessions and compulsions

Case Study: OCD 16 year old girl (ASD, Learning Disability & OCD) Obsessions: Contamination fears Associated with high level of distress

Compulsions: Not touching things, cleaning rituals (demanded mum to do), checking behaviours Rationale for use to neutralise thoughts

Confusion: Some compulsive behaviours seemed random with no rational and no associated distress. CBT approach successful to an extent but difficulty generalising

Differentiating ASD from Mental Health Anxiety Disorders (GAD, PTSD, social phobia, panic disorder, phobic disorder)

Autism Spectrum Disorders

1) Anxiety or distress can be in response to a traumatic event or learned behaviour that is persistent across contexts

1) Anxiety or distress in response to small changes to daily routines caused by the desire for sameness, usually one fear or one theme of fears

2) Regression in language or behaviour following traumatic event

2)Missing developmental milestones in language or behaviour can be mislabelled as regression

3) School refusal may be triggered by specific fears

3) School refusal may be related to upset in desires, can be accompanied by selective mutism

4) Family history of anxiety disorders 4) Immediate family members having a diagnosis/presentation of ASD, schizophrenia or bipolar disorder

5) Anxiety symptoms improve with anti-anxiety medication

5) Anti-anxiety medication may not reduce ‘anxiety’ symptoms

Case Study: School Refusal 12 year old boy Reported bullying that School did not acknowledge Gradually stopped attending, claiming to be ill, getting very

distressed and angry when parents were trying to get him up for school

Family history of anxiety disorders specifically social anxiety Confusion

Inability to work with a CBT approach and increasingly concrete perceptions of how social interactions should occur

School refusal still present due to ASD fears rather than standard anxiety but responding to ASD management techniques

Differentiating ASD from Mental Health Depression and Self-harm Autism Spectrum Disorders 1) Sudden loss of interest in social activities

1) Typical levels of social withdrawal

2) Rumination on experienced events/ thoughts of the future

2) Fixation of obsessions

3) Disturbance in sleep and eating, speech tone, eye contact

3) Typically poorly modulated eye contact and constant flat, monotonous tone of voice, usual sleep/eating problems

4) Crying spells 4) Shouting, noises and irritability when distressed

5) Cutting, scratching, re-opening wounds to experience a physical manifestation of pain

5) Head banging, wrist biting, hair pulling, skin and eye gouging as a sensory interest

6) Family history of mood disorder 6) Immediate family members having a diagnosis/presentation of ASD, schizophrenia

Case Study: Depression/ Self-harm 18 year old girl low mood, suicidal ideations and self-harm Dropped out of college and frequent fears that the future was bleak Reported sleep disturbance Use of cutting to ‘feel’ and overdoses Family history of depression and suicide attempts Confusion Worked well with a CBT approach initially but could not transfer skills

beyond the situation discussed in session Increasing references to difficulties with friends, panic when in crowds,

dislike of group work, sense of not fitting in, apathy in response to difficulty picturing future and sexual identity crisis

Sibling with a delay of some kind resulting in inability to live independently and parents who struggle to communicate feelings

Differentiating ASD from Mental Health

Eating Disorders Autism Spectrum Disorders 1) Obsession with food for calorific content

1) Obsessions with foods in a ritualistic manner for comfort

2) Intense fear of gaining weight or becoming fat

2) Intense fears of particular foods i.e. soft in texture, red in colour

3) Body Dysmorphia 3) Unusual perceptions of foods resulting in food fads

4) Efforts to expel food to maintain weight

4) Vomiting due to sensory dislike of food

5) Problematic relationships with parents or loved ones involving emotional disturbance and/or conflict

5) Typical social difficulties in relationships/ lack of socio-emotional reciprocity

Case Study: Anorexia 15 year old girl BMI 16.5 restricting quantity and type of food eaten Confusion Poor eye contact All feelings were ‘annoying’ Rules around food were not directly linked to

restricting intake more to do with dislike of many foods and a fear that eating specific foods in a certain order would lead to dislike of more foods

Differentiating ASD from Mental Health

Psychotic Disorders Autism Spectrum Disorders 1)Adolescent or early adult onset 1) Typical onset is less than 36 months but

full spectrum of symptoms may not be observed until adolescence

2) Hallucinations, aural, visual, sensory 2) Often reported aural hallucinations are linked with an imaginary friend

3) Delusions of grandeur/ persecution 3) No specific link with delusions, rather distorted perceptions of social interactions

4) Disorganised speech specifically with sudden or sporadic onset

4) Speech abnormalities i.e, monotonous, mechanic, Americanised, echolalia, lifelong absence of speech

5) Family history of psychotic illness 5) Family history of ASDs or social communication difficulties

6) Reactive to anti-psychotic medication 6) No observable reaction to anti-psychotic medication

Case Study: Psychosis

15 year old boy, learning disability Admitted on short term emergency basis due to

challenging behaviour Query psychosis Demonstrated triad of impairments High levels of anxiety Diagnosed with ASD Longer admission for psychiatric assessment to

rule out psychosis.

Comorbid Psychiatric Disorders with ASD from our Assessment Clinics

Thank you for listening!