10 Issues in the Diagnosis of Developmental and Neurocognitive Disorders
Instructor: Dr. Dawn-Elise Snipes, PhD
Executive Director: AllCEUs.com, Counselor Education and Training
Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery

Objectives
~ Autism Spectrum Disorder
~ ADHD
~ Oppositional Defiant and Conduct Disorder
~ Dementia (Vascular, Lewy Body)
~ Mystery Dx

Autism Spectrum Disorder
~ A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history
~ 1. Deficits in social-emotional reciprocity: abnormal social approach, failure of normal back-and-forth conversation, reduced sharing of interests, emotions, or affect; failure to initiate or respond to social interactions.
~ 2. Deficits in nonverbal communicative behaviors: Poorly integrated verbal and nonverbal communication; abnormalities in eye contact and body language; deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.
~ 3. Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.
Autism Spectrum Disorder
~ B. Restricted, repetitive patterns of behavior, interests, or activities (2+)
~ Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).
~ Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat food every day).
~ Highly restricted, fixated interests that are abnormal in intensity or focus
~ Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment
Autism Spectrum Disorder
~ Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life).
~ Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.
~ These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay.
~ Individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger’s disorder, or pervasive developmental disorder not otherwise specified should be given the diagnosis of autism spectrum disorder.
~ Individuals who have marked deficits in social communication, but whose symptoms do not otherwise meet criteria for autism spectrum disorder, should be evaluated for social (pragmatic) communication disorder.

Autism Spectrum Disorder
~ 4. Avoid using the exact same behavioral exemplar to satisfy two criteria.
~ For example, ‘repetitively putting hands over ears’ may be considered a repetitive motor movement, or it may be considered hyper-reaction to stimuli/adverse reaction to sounds.
~ 5. One example of a specific criterion may not be sufficient to assign the criterion as being present.
~ Is the example behavior clearly atypical?
~ Is the example behavior present across multiple contexts, or rarely occur/occur in only one context.
ADHD –Children and Adults
~ For children, six or more of the symptoms (5+ for adolescents or adults) have persisted for at least 6 months, in two or more settings to a degree that is inconsistent with developmental level
~ Symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder
~ Not better explained by another mental disorder (e.g. mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal)
ADHD –Children and Adults
~ Inattention
~ Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
~ Often has trouble holding attention on tasks or play activities. (Hyperfocus/dysregulated attentional system, Kathleen Nadeau, Ph.D.)
~ Often does not seem to listen when spoken to directly.
~ Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).
~ Disorganized, time management problems
~ Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time
~ Often loses things necessary for tasks and activities (e.g. school materials, wallets, keys, eyeglasses, phone).
~ Distractibility
~ Forgetfulness

ADHD –Children and Adults
~ Hyperactive (Impulsivity?)
~ Often fidgets with or taps hands or feet, or squirms in seat.
~ Often leaves seat in situations when remaining seated is expected.
~ Often runs about or climbs in situations where it is not appropriate (adolescents or adults may feel restless).
~ Often unable to play or take part in leisure activities quietly.
~ Is often “on the go” acting as if “driven by a motor”.
~ Often talks excessively.
~ Often blurts out an answer before a question has been completed.
~ Often has trouble waiting his/her turn.
~ Often interrupts or intrudes on others (e.g., butts into conversations or games)

ADHD Differential Dx
~ Common Errors cont…
~ ADHD mood swings:
~ Are a response to something happening in a person’s life.
~ Match the person’s perception of that trigger.
~ Shift instantaneously.
~ Go away quickly, usually when the person with ADHD becomes engaged in something new and interesting.

ADHD
~ Common errors in diagnosis and treatment of adult ADHD
~ Sleep issues, racing thoughts and restlessness – hypomania, mania, anxiety, sleep apnea (fatigue)
~ Difficulty completing projects – Learning disability, obsessive compulsive personality disorder, anxiety, PTSD
~ Easily distracted/difficulty concentrating: Anxiety, depression, OCD. ADHD distractions are often happy thoughts
~ Social awkwardness and difficulty reading social cues: Autism spectrum disorders unusual interests and over fixation vs. interrupting and talking over people
Disruptive Mood Dysregulation Disorder
~ Severe temper outbursts that occur, on average, 3x or more per week.
~ Mood between outbursts must be consistently and observably angry or irritable for 12 or more months without a break of 3+ months
~ Note: Outbursts, or elevated or expansive moods that last for longer than a few hours or for days on end, are more likely to be signs of mania
Conduct Disorder
~ Aggression to people and animals
~ Bullies, threatens or intimidates others
~ Is physically cruel to people or animals
~ Deliberate destruction of property
~ Deceitfulness, lying, or stealing to obtain goods, or favors or to avoid obligations
~ Serious violations of rules (runaway/truancy)

~ Rule Out: Mood disorders, anxiety, PTSD, substance abuse, ADHD, learning problems
Oppositional Defiant Disorder
~ A. A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, (4+)
~ Often loses temper
~ Often argues with adults
~ Often actively defies or refuses to comply with adults' requests or rules
~ Often deliberately annoys people
~ Often blames others for his or her mistakes or misbehavior
~ Is often touchy or easily annoyed by others
~ Is often angry and resentful
~ Is often spiteful or vindictive

Note: Consider a criterion met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level.
Oppositional Defiant Disorder
~ B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.
~ C. The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder.
~ D. Criteria are not met for Conduct Disorder, and, if the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder.

Neurocognitive Disorder
~ Due to TBI
~ Vascular Neurocognitive Disorder
~ HIV
~ Alzheimer’s Dementia
~ Difficulty completing familiar tasks
~ Can’t determine time or place
~ Misplace items often
~ Difficulty making decisions
~ Social withdrawal
~ Mood and personality changes
Neurocognitive Disorder
~ Lewy Bodies & Parkinson’s
~ Visual hallucinations. Often one of the first symptoms
~ Movement disorders
~ Poor regulation of body functions (autonomic nervous system)
~ Cognitive problems
~ Sleep difficulties
~ Fluctuating attention
~ Depression
~ Apathy
Neurocognitive Disorder
~ Huntington’s Disease
~ Onset often in 30s or 40s.
~ Onset before age 20, is called juvenile Huntington's disease
~ Inherited disease that causes the progressive breakdown (degeneration) of nerve cells in the brain
~ Disease emergence to death is often about 10 to 30 years
~ Symptoms
~ Mood: Similar to depression
~ Cognitive:
~ Dementia
~ Difficulties with impulse control

What Would You Diagnose?
~ Anger/irritability
~ Boredom/Restlessness
~ Overexcitable
~ Underachievement
~ Peer Issues
~ Large amounts of alone time (adults & children)
~ Excessively high expectations of others
~ Lack of a sense of belonging
~ Power struggles
~ Stress and perfectionism
~ Judgement lags behind intellect
~ Reactive hypoglycemia
Mystery
~ Asperger’s, ADHD, Giftedness?
~ 17:32-31:22
~ 34:14-38:48
~ Full Video Here

~ “Many gifted children are incorrectly diagnosed as having emotional disorders. Other diagnoses are actually more common among gifted children, but are often overlooked. Because few psychologists, pediatricians, or other health care professionals receive training about gifted children, this session offers information about characteristics of gifted children, frequent issues that arise, and guidelines to distinguish whether a child is simply showing gifted behaviors or suffers from disorders such as ADHD or Asperger's Disorder. Because some disorders are more frequently found in gifted children, additional focus is given to these dual diagnoses of gifted children.”
~ Giftedness can be considered top 10% above the mean (IQ 120)

Summary
~ Many disorders of childhood represent endpoints on a continuum
~ 1. Differentiate pediatric PTSD from Autism
~ 2. Differentiate giftedness
~ Disruptive mood dysregulation
~ Bipolar
~ ADHD
~ Autism
~ 3. Don’t negate an Autism dx if the adult appears to not have significant deficits
~ 4. Avoid using the exact same behavioral exemplar to satisfy two criteria

Summary
~ 5. One example of a criterion may not be sufficient to say the criterion is present.
~ 6. People with ADHD may have hyperfocus to something they are really interested in
~ 7. Do not dx ODD if developmentally appropriate
~ 8. Rule out Lewy Bodies esp. if there are visual hallucinations
~ 9. Misdiagnosing giftedness
~ 10. Assuming the gifted “have it made” or “will work it out”