Dr. Ozonoff describes comorbidity as a phenomenon that occurs when an individual meets criteria for two (or more) independent diagnosis. She spends a great deal of time cautioning her audience to use caution when considering comorbidity. I really appreciate that before she delved into her lecture she spent time reviewing Occam's Razor (the simplest solution is usually the most likely, the foundation of the behavioral principle of parsimony). I think to quickly as practitioners we often give up on a students ability to achieve a skill because we think that the child is (for some other medical reason) incapable of learning it when really we are not assessing and teaching it in the most efficient way. Dr. Ozonoff admits that comorbidity is difficult to assess and in fact percentile data of comorbid diagnosis is skewed because research often comes out of a clinic setting where people with comorbid diagnosis have a higher likelihood of being. Furthermore with the amount of overlapping symptoms and possible subdivision of symptoms in the DSM IV, differential diagnosis becomes an extremely difficult task. She recommends looking at the difficulties of the individual and assessing whether or not those difficulties could be part of the autism spectrum. If there is something that stands out and there is no way to tie it to the spectrum, then considering other possibilities. She uses the example of attending problems which are classic in autism spectrum disorders, then asks how much worse attending needs to be to warrant a diagnosis of ADHD. You need a good baseline of typical functioning for this individual because often times comorbid diagnosis develop or worsen overtime or the person is unresponsive for effective treatments then they may be considered for a comorbid diagnosis.
I work with a student with that exact comorbid diagnosis. His attending has suddenly dropped in his classroom and his doctor is considering increasing his stimulant medication, however since his attending has not dropped in the home setting the doctor recommended more behavioral supports to be carried over into the classroom (his current ASD treatment plan) and after a few team meetings and consultations in his classroom his attending increased. So it begs the question was it the ASD or the ADHD that made it difficult to attend. For my purposes the answer to that question is irrelevant, my role is to educate and assess skills effectively not diagnose. Supports were put in place, and were effective in increasing an appropriate behavior without an increase in a medication. However perhaps the bigger lesson here is that while assessing or expecting this student to demonstrate his skills, all the educators in his life need to be vigilant to provide behavioral support geared at increasing his attending.
This is what I gained the most from Dr. Ozonoff. Her audience is clearly people making the diagnosis and she speaks to them about figuring out the other diagnosis. For my purpose assessing a child with a comorbid diagnosis, I need to make modifications to my assessment process to attempt to control for some of the symptoms of the other diagnosis. This will probably take longer considering I have to get to know the child first and see where there problems lie, then set up the sessions and environment for success. If there is a child with ASD and ADHD then they may need to do shorter tasks and a more controlled environment to demonstrate skills.
The issue with the FBA is that depending on the symptoms the behavior may be more symptomatic than operant (it may be more inherent than learned). For instance fatigue in a student with depression and ASD may explain why they frequently lie on the floor. As my rule of thumb, I do not even consider the possibility of a comorbid diagnosis interfering with patterns of behavior, unless there is one AND after monitoring the behavior for an extended period of time there no clear pattern to the behavior emerges.
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