Comorbidity and its Effects on Assessment

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. 

Co-morbidity and FBA

In conducting a functional behavioral assessment, some of the first questions to address via indirect assessment are in regards to the individual’s medical history including diagnosis (or diagnoses), current medications, sleeping patterns, eating habits, etc… The primary reason for this is so the person conducting the assessment can determine how each of these factors, individually or combined, effect the behavior(s) being assessed.  It is important to differentiate between behaviors which can be targeted for change through behavioral intervention and behaviors which manifest as a function of a disorder or possibly a medication used to treat a disorder.  For example, years ago I worked with a student with PDD-NOS who consistently put his head on his desk and subsequently fell asleep every day when it was time for independent reading comprehension tasks.  Because reading comprehension was a weakness for him and he had a history of engaging in behavior to escape difficult work demands it appeared the behavior was escape motivated.  Upon discussing this with the parent however, I learned that the student also had a diagnosis of bipolar disorder for which he was on medication that made him tired when it began to wear off.  Had I attempted to intervene on the behavior I would probably have been unsuccessful and could have potentially set the occasion for a more severe problem behavior.  Instead, we rearranged the student’s schedule slightly for a few days, and found that he put his head down on his desk and subsequently fell asleep at the same time of day during different activities.  His doctor was able to rearrange his medication schedule, making him more alert throughout his school day.    

Perhaps the best way to mitigate the complicating factor of co-morbidity is to stay well informed.  Thoroughly interviewing parents on diagnoses, medications, and side effects is often the best place to start, and sometimes, depending on communicative abilities, the individual may have input as well.  (For example, several years ago my brother, who has ADHD was struggling academically and told me it would be easier for him to focus at school if he wasn’t always hungry.  My mother and I at the time thought he was eating breakfast at school.  We later discovered that his medication was suppressing his appetite, so he wasn’t eating much in the mornings.  He started eating prior to taking his medication and his focus improved resulting in an improvement in his academic performance.)   In some cases it may even be helpful to get a release to speak with an individual’s doctor and in many cases it can be helpful to do your own research, whether on potential side effects of medication or likely manifestations of a disorder.

I think what it basically comes down to is the point that was made in the video about Occam’s razor, that the simplest solution is best.  If a child is exhibiting pica for example, one should seek to determine if there is a medical etiology; perhaps a nutrient deficiency due to a limited diet or a current medication; prior to looking for a more complex explanation.  The rule of parsimony should always apply in behavior analytic research; one should always rule out the simplest explanations prior to looking for more complex explanations for behavior.

Psychiatric Comorbidity & Differential Diagnosis of Autism Spectrum Disorders

Dr. Ozonoff’s presentation on Psychiatric Comorbidity & Differential Diagnosis of Autism Spectrum Disorders was very informative.  Dr. Ozonoff discusses the many reasons why it is difficult to diagnose someone with ASD with a co-morbid disorder due to the many symptoms and deficits that people with ASD can present with.  

Dr. Ozonoff mentioned the importance of Occam’s Razor when diagnosing an individual.  I think the same idea should be applied when conducting an FBA.  The idea behind Occam’s Razor is to find the simplest solution.  The purpose of an FBA is to determine the function of a behavior.  I feel that having a co-morbid disorder would not have any effect on the FBA that is conducted by a behavior specialist, unless it was a deficit such as a visual or hearing impairment.  Impairments such as these could have an effect on the outcome of an FBA if the professional conducting the FBA is not aware of the person’s condition.   Behavior analysts feel that direct observation is the best way to determine the function of a behavior, and indirect measurement should rarely be used, if at all.  If indirect measurement must be used then the person conducting the FBA must be aware of any deficits that would affect the use of indirect measurements such as checklists or questionnaires.   If the person is unable to complete this type of measurement, efforts must be made to measure the behavior in a different way.  The best option is always direct observation, it is the simplest, most objective, and most accurate way to conduct an FBA.

An FBA helps us to identify the type and source of reinforcement for challenging behaviors, and based on these findings we develop an intervention.  Once we determine the antecedents and consequences surrounding the behavior we can make efforts to change and replace that behavior.   We would do the same thing regardless of a person’s diagnosis.   If a behavior is found to be maintained by automatic reinforcement, then we try to find alternative reinforcers that are stronger than the automatic reinforcer.  If it is determined to be a function of attention or escape we would make efforts to change that as well.  The function of a behavior should not be determined by a diagnosis.

Differential Diagnosis and Co-morbidity in Autism Diagnosis

Dr. Ozonoff presents many ways how co-morbidity can complicate the assessment and differential diagnosis of ASD.  Dr. Ozonoff starts off with a great example of the Occam’s Razor that says that all other things being equal, the simplest solution is the best solution.  For example, if the child has hand flapping but doesn’t have social or communication difficulties it would be a Stereotypic movement disorder not autism.  Dr. Ozonoff also goes on to say that treatment for just autism will not treat other difficulties the person may have and may sometimes have a more negative impact if left untreated.  So, when diagnosing someone with ASD it’s very important to see if other diagnoses are needed. 

Dr. Ozonoff  goes on to give great diagnostic considerations to think about when seeing if co-morbidity is occurring.  The number one consideration is if there is a change in function from baseline.  Meaning an onset of new symptoms or worsening of symptoms already present, lack of response to usually effective treatments, and/or signs of problems outside autism spectrum.  A child will present with symptoms of autism before age 3 but very often will present with other symptoms as the child gets older.  If other symptoms become present after age 3, this may indicate that there are other things going on.

Although Dr. Ozonoff doesn’t specifically list ways to deal with co morbidity with a functional assessment, she does give very specific guidelines one consider when looking into co morbidity. She states some Diagnostic Considerations below:

Consistency and pervasiveness of symptoms

Developmental history

Age of symptom onset (autism prior to age 3, most other symptoms don’t develop before age 3)

Package of symptoms – waxing and waning then something else is going on versus autism

Form and quality of symptoms

Are difficulties limited to those plausibly encompassed by DSM autism criteria or do they extend beyond

The major lesson I will take from the presentation is the chart she presented.  This chart will be very helpful when looking to see if a person has ASD, ASD + ____, a different diagnosis, or no diagnosis.  I attempted to re-create the chart as best as I could so I can keep it and refer to it often.

So, with the diagnostic considerations and the chart, I feel that I am better equipped now when performing a functional assessment and considering co morbidity.

                                                            FBA
 FBA is used to better understand the pattern, and purpose, or function, of a behavior. The goal of FBA is to identify events that precede (antecedents) and follow (consequences) a bahavior. Careful understanding of antecedents, behavior, and consequences provides insight into the function of a behavior. It is important to understand the function of a behvior in order to develop more effective interventions.
    According to Carr et al., 1999 research has demonstrated thet the use of FBA increases the effectiveness of interventions. FBA should not be used as a single test, but rather as a multimethod approach. A thorough FBA should includes interventions of parents, teachers, students, classroom observertion, and review of records.
    One limitation of FBA is that it focuses exclusively on observable behaviors without consideration of the underlying autism spectrum disorder. Others have argued that biologiacl factors such hunger or anxiety (Carr, 1994) and diagnostic characteristic and genetic conditions (Reese et al., 2003) should be incorporated when examing behavoir.
    FBA is a useful tool when used by those who understand autism.

                                                          THEORY OF THE MIND
     Theory of the mind is the capacity we have to understand mental states such as:believes, feelings, hope, and intention. This thoery of the mind enables us to understand the behavior people display is as a result of their inner feelings, belives and intensions.
     The absence of the ability to understand what people know, think or feel might be the root of most difficulties people with ASD  have in communication and social interaction.
      The central symptom of autism (anomalies in social interaction, communication and pretense) could be explained by specific deficit of Theory of Mind. Although autistic children have cognitive performance, they lack the ability to understand false belief task. This lead to the conclusion that a major component of autism is a specific deficit in mindreading, and not impairment of general cognitive abilities.For many of those autism, mindblindness or lack of theory of mind creates major barriers to communication and social interaction.
       ASD is one of the main areas of the application of theory of mind. This is because autism is one of the most severe cognitive impairment that can occur during the early stages of development.
        Someone who has a full grasp of the Thoery of Mind will immediately know that Sally will look where she last left the ball. She does not know that the ball has been moved. A person with poor Thoery of Mind skills will believe that Sally will look for the ball in the box, because they do not fully grasp that Sally will not know what Ann has done.
       This has lead many proffessionals to say, as ina quote from Stephen Edelson Ph.D, "many autistic individuals do not understand that people have thier own plans, thoughts, and point of view".
     Given the findings in the aforementioned studies, theory of mind tests do have a reliable and valid place in assessing developmentally delayed children. However, theory of mind does not address the reasons for the varying degree of severity in autism and only address the triad of impairments.
  

Differential Diagnosis and Co-morbidity in Autism Diagnosis

 This week, you will be viewing  a presentation by Dr. Sally Ozonoff concerning issues of co-morbidity in the diagnosis of ASD spectrum disorders. After viewing the  presentation, consider the ways in which Dr. Ozonoff  describes how co-morbidity can complicate the assessment and  differential diagnosis of ASD. Discuss how you would deal with this complicating factor in a  functional behavioral assessment: what methods and techniques can you use to mitigate the complicating factor of co-morbidity?. Here's the video:


Dr. Sallly Ozonoff on Psychiatric Comorbidity of ASD