014 - Autism Spectrum Disorder an A.I's Differential Diagnosis

Dr. O'Leary tries something new by feeding an artificial intelligence a series of peer reviewed papers about autism spectrum disorder and having it generate an audio discussion of the content.  This episode focusses on the differential diagnosis of ASD and how to rule out other neurodevelopmental disorders and even OCD or an anxiety disorder.

Referenced resources can be found within the show transcripts at https://psydactic_caps.buzzsprout.com

Feedback can be emailed to feedback@psydactic.com OR submitted via a form at https://psydactic.com.

This is not medical advice. Please see a licensed physician for any personal questions regarding your own or your child's health.

Transcript

Welcome to PsyDactic CAPs Board Study Edition. I am your host Dr. O’Leary, a child and adolescent psychiatry fellow in the National Capital Region. This is a podcast I designed to help myself and other child and adolescent psychiatry fellows to study for their boards. But anyone interested in human development and mental health will likely get something out of this. I'm using AI to assist me with the content. And prior to this episode, I had used AI only to help summarize and organize content for me. But now, I found a tool that allows me to feed it a lot of high quality peer-reviewed articles and then it will generate an actual audio discussion of the content. The last part of this episode is going to be complete completely AI generated content. So, please let me know what you think about it. I did fact check and edit the content, but other than that, the two voices you will hear talking are completely AI generated. If you find any errors in the content or have suggestions for improvement, I'd love it if you could go toactic.com and fill out a form there to let me know or just send an email to feedback@PsyDactic.com.  I'm going to start this episode with an overview similar to past episodes. And this overview will begin with a case. So, hang on to your earbuds. A mother brings her four-year-old son, Ethan, to your clinic for a developmental evaluation. She reports concerns about his limited communication skills. Ethan primarily uses single words and short phrases, and his speech is sometimes difficult to understand. hand. He rarely initiates any communication and seems to ignore other kids when they try to play with him. He does not appear to engage in any imaginative play, even when he's alone. He throws intense tantrums and his parents can't figure out why. He often slams his body into the wall over and over and over again when he doesn't get something that he wants. He seems indifferent to his parents' attempts to engage him during the interview and instead just keeps playing with the toys in the room, even when his name is called. Sometimes he looks toward his parents, but not often. His gross motor skills are age appropriate, but his fine motor skills, particularly notice when he's trying to dress himself, are delayed. Which of the following are the most likely diagnoses for Ethan? Or diagnosis? Assuming we can choose only one. Is it social pragmatic communication disorder, childhood onset fluency disorder, autism? spectrum disorder, language disorder, or intellectual disability. So, the correct answer here is probably autism spectrum disorder, although we can't just diagnose him based on a single interview we've had. But Ethan's initial presentation aligns most strongly with the diagnostic criteria for ASD. He exhibits significant deficits in social communication and interactions, limited reciprocal interactions, poor eye contact, difficulty with social play, and he has some restricted or repetitive patterns of behavior. He also throws himself into the wall over and over and over again at times. So, these are all features of ASD. There are other options here. The social pragmatic communication disorder is one. And while Ethan has social communication difficulties, and that's what his parents are complaining about, he also has other alarming behaviors that go outside of a pure social communication domain. He could have child onset fluency disorder, but there's no actual mention of fluency problems. And these are things like stuttering or repetitions of sounds, um, prolongations of sounds or lots of introjections in his speech. But that's not Ethan's problem. Ethan's problem is more aosity of speech. He doesn't really talk to the other kids, and when he does, a lot of times people can't really understand him that well. So, he could have a language disorder. Um, while he has language delays, he also has these social emotional reciprocity deficits. Probably not a pure language disorder, but we haven't ruled out a language disorder. He might also have an intellectual disability or an intellectual developmental disorder. That's possible as well. But what this podcast is going to focus on today is autism spectrum disorder. And to do that, I'm going to hand it over to an artificial intelligence. Please let me know how good of a job you think the AI has done by emailing me at feedbackscidactic.com or going toactic.com and filling out a form there. I appreciate you listening to this and I looking forward to your feedback.--

All right, so um we're diving into a really interesting area this time. You've given us a case and we're going to do a deep dive into the world of neurodedevelopmental disorders.--

Yeah.--

But this one's got us a little bit stumped.--

Right.--

So imagine you've got a child who's having some trouble keeping up with their peers. Maybe their language is a little bit delayed or they seem to be fixated on certain objects or routines and maybe they just aren't connecting with other kids the way that you would expect them to.--

Yeah. And what's so challenging about these cases is that the behaviors that we see can really point to a wide range of possibilities. We could be looking at autism. We could be talking about ADHD, language disorders, anxiety, sensory processing issues.--

Like there's so many things that it could be.--

It really is like a tangled web trying to figure this out. Yeah. And and that's why this differential diagnosis is just so important.--

Oh, absolutely.--

It's not about like slapping a label on a kid. It's about really understanding like what's driving those challenges so that we can give them the right support.--

Yeah. Because if you get the diagnosis wrong, that could mean years of interventions that really don't work for that child and that has a ripple effect on their whole life that their development, their education, it really does everything.--

So, let's say we're looking at this child. An autism spectrum disorder is kind of on our radar.--

Okay. Where do we even begin to try to like untangle that from all the other possibilities?--

Well, we have to get to know this child really well. So, we look at their development. Are there any concerns that were there early on? What are the parents seeing at home? How are they functioning in different environments?--

So, it's not just about like one snapshot in time.--

Exactly.--

It's about getting like a full picture of them.--

Exactly. And then we have to look at those core features of ASD. We're looking for those persistent deficits in social communication and interaction. And along with those restricted repetitive patterns of behavior, interests, or activities.--

So, like what does that actually look like in a kid?--

So, think about like a child who struggles with that back and forth conversation.--

They might not initiate interactions. Maybe they miss social cues like facial expressions, tone of voice. They might have trouble understanding jokes or sarcasm. Yeah.--

And it's not just about like the verbal communication either. It's also those non-verbal cues. So, a child with as might avoid eye contact, might have unusual body language or facial expressions.--

Okay. So, you also mentioned those like restricted and repetitive behaviors.--

Yes.--

What are some examples of what that might look like?--

It could be anything from lining up their toys in a very specific order.--

Okay.--

To repeating certain phrases over and over.--

Got it.--

Maybe having those intense fixated interests like let's say dinosaurs or trains, right?--

And it's important to remember that these behaviors, they're not Not just like little quirks, you know, it can really impact a child's daily life and their ability to function.--

Yeah. So, it's not just like they're there or they're not there. It's like the severity of it.--

Exactly. And also distinguishing those behaviors from what you might see in other conditions. So, like a child with ADHD might fidget or have trouble sitting still, but that's driven by inattention and impulsivity, right?--

It's not the same underlying mechanism as the repetitive behaviors you see in ASD.--

So, now we've talked about social communication. We've talked about repetitive behaviors. How do sensory sensitivities fit into this whole picture of ASD?--

Yeah,--

I know that's something parents often bring up.--

Oh, yeah. Sensory sensitivities are a huge part of ASD, though it's not technically part of the core diagnostic criteria.--

Interesting.--

A lot of individuals with ASD, they experience the world in a very different way when it comes to sights, sounds, smells, textures, tastes.--

So, like we might see a child who's like really overwhelmed by loud noises or bright lights or who avoids certain textures or foods.--

Exactly. And those sensory sensitivities They can manifest in so many different ways. So some children might actually take out intense sensory input.--

Wow.--

Like spinning or rocking while others try to avoid certain sensations altogether.--

Yeah. That must be really hard for parents and educators to like try to figure out how to make an environment that works for that kid.--

Absolutely. It takes a lot of observation and experiment figure out what works for each individual child. And that just highlights why it's so important to not just focus on the outward behavior. But to really understand what are those underlying sensory experiences that might be driving them?--

Yeah. Like what's going on in their brain and their body?--

Exactly.--

That's making them react that way.--

Exactly.--

So I'm curious like how do health care professionals actually go about making this diagnosis?--

Yeah.--

It seems really tricky.--

You're right. It's not as simple as like a blood test or something, right?--

It involves a really comprehensive assessment that takes into account all the information we've been discussing. So developmental history, parent reports, observ ations of the child's behavior--

and then standardized diagnostic tools.--

Okay, so let's talk about those tools. What are some of the like gold standard assessments used to diagnose ASD?--

Two of the most widely used are the autism diagnostic observation schedule or ADOS and the autism diagnostic interview revised or ADIR.--

Okay,--

so the ADOS it involves observing the child's social interaction and communication skills during structured activities.--

And then the ADIR is a detailed interview with the parents or caregivers about the child's developmental history and current behaviors.--

So again, we're not just relying on one source.--

Exactly.--

We're like piecing it all together.--

We are.--

So these tools help the clinicians kind of assess like the presence and severity of those core features. We talked about social communication challenges and restricted repetitive behaviors.--

Exactly.--

Okay. So we've got this toolkit now for assessing potential ASD, but like we mentioned earlier, there are all these other conditions that share overlapping symptoms. How do we start to like untangle that?--

That's where the real detective work begins.--

Okay.--

Clinicians have to carefully consider all those possible explanations for a child's behavior and look for those subtle clues that might distinguish one condition from another.--

So, let's dive into that detective work.--

All right.--

What are some of those conditions that might be on the radar when we're considering this ASD diagnosis?--

Well, ADHD is a big one. Children with ADHD can also have trouble with social skills. Okay.--

But it's usually due to their inattention and impulsivity, not the same underlying difficulties with social understanding that you see in ASD.--

So a kid with ADHD might like interrupt a conversation because they're not paying attention.--

Exactly.--

The kid with ASD might interrupt because they don't understand.--

Exactly. That it's not their turn.--

Right. Right. And then we have language disorders which can also impact social interaction. But with a language disorder, the child's social difficulties are usually in line with their overall language development. Okay.--

So, if a child has a limited vocabulary, we wouldn't necessarily expect them to engage in complex conversations regardless of whether or not they have ASD.--

So, like their social skills are basically like on par with their development.--

Exactly. But if their social communication skills are significantly below what we would expect based on their language abilities, that could be a red flag for ASD.--

That's a good distinction. So, we've got ADHD, we've got language disorders.--

Yes.--

What else might be considered in this puzzle? Well, intellectual developmental disorder or ID. Okay, that's another important one. Some individuals with ID, they might also exhibit those social communication challenges and repetitive behaviors, but those difficulties are typically consistent with their overall cognitive abilities.--

So, it's not like they're inherently like worse at it. It's just like everything's developing a little bit slower.--

Exactly. And that's why that developmental and cognitive testing is so crucial. Yeah.--

We need to understand where the child is developmentally to determine if their social communication skills are truly lagging behind or if they're simply developing in line with their other abilities. There are other conditions like anxiety disorders, obsessivecompulsive disorder, even sensory processing disorder.--

Oh, wow.--

That can sometimes mimic or overlap with ASD.--

All right. So, let's start by talking about anxiety disorders, which are incredibly common in children--

and they can often present with behaviors that might initially make you think about ASD, right? So, for example, think about a child with social anxiety. Okay? They might be extremely shy, avoid eye contact, struggle to interact with their peers, all of which, you know, could look like ASD. Right. Right.--

So, how do we tease those two apart?--

Yeah. What are some clues that might point us more towards anxiety than ASD?--

So, one key difference is that children with social anxiety, they typically understand social cues,--

okay,--

and expectations. They're just two too afraid or overwhelmed to actually engage,--

right? Whereas children with ASD might have a more fundamental difficulty grasping those social nuances in the first place. So, they know they should make eye contact, right?--

But they're just like too nervous. Child with ASD might not even understand why.--

Exactly. And another clue is that anxiety tends to fluctuate depending on the situation. So, a child with social anxiety might be perfectly comfortable interacting with family members but completely shut down around strangers. Whereas, The social communication challenges in ASD tend to be more persistent. Okay. Across different environments.--

So it's not just like I'm nervous here. It's like I'm always kind of struggling.--

Exactly.--

Are there other types of anxiety that we might see that look like this?--

So generalized anxiety disorder can also cause social withdrawal and difficulty concentrating which could overlap with some ASD symptoms.--

But again with generalized anxiety the core issue is that excessive worry and fear.--

Got it.--

Not a fundamental difficult Y understanding social situations.--

Okay, so social anxiety, generalized anxiety.--

What about OCD?--

Oh, OCD.--

Yeah,--

that can be a tricky one because it often involves those repetitive behaviors, right?--

Just like ASD, but there's a really crucial difference in the function of those behaviors.--

Okay, what's the difference?--

So, in OCD, those repetitive behaviors or compulsions as they're called,--

are driven by anxiety.--

The individual feels compelled to perform these actions to to reduce their anxiety or to prevent something bad from happening.--

So like washing your hands over and over again because you're afraid of germs,--

right? Whereas a child with ASD might engage in repetitive hand movements because they find it calming or stimulating. So it's that underlying motivation for the behavior that's really key to distinguishing OCD from ASD.--

Okay.--

And it's important to note that while those repetitive behaviors in ASD, they're often intrinsically rewarding,--

they can also become problematic if they start to interfere with daily life or cause distress,--

right? So, it's not just that it's there or not there, like is it actually a problem?--

And we have to be really careful not to pathize every quirk or unusual behavior. Just because a child likes things to be a certain way or enjoy spinning in circles doesn't automatically mean they have OCD or ASD. It's about looking at that bigger picture. Yeah.--

And considering all the factors involved.--

So, anxiety, OCD, are there other things that we should be thinking about?--

Well, what about sensory processing disorder?--

Okay. SPD.--

SPD. Yeah. And that one's a really interesting one. Okay.--

Because it's not actually a formal diagnosis in the DSM5.--

Really?--

But that doesn't mean it's not real, right?--

Or that children aren't struggling with sensory processing issues.--

Yeah.--

It's just that there's still a lot of debate and research going on to try to better understand how sensory processing difficulties fit into the broader landscape of developmental and behavioral challenges.--

So when we say sensory processing disorder, like what are we talking about? What are the challenge challenges that those kids face.--

So, children with SPD might be oversensitive or undersensitive to sensory input.--

Okay?--

They might be really easily overwhelmed by loud noises or bright lights or certain textures--

or they might crave really intense sensory experiences like spinning or jumping or crashing into things.--

So, that can obviously lead to like behavioral problems.--

Oh, absolutely.--

If you're either being overwhelmed or you're seeking that input,--

right? A child who's constantly bombarded by sensory input might become withdrawn and can or even aggressive. And a child who's seeking that intense sensory input might seem hyperactive or impulsive. In ASD, the sensory sensitivities are often intertwined with those social communication challenges and restricted repetitive behaviors. Okay.--

So those three kind of go hand in hand.--

So with SPD, it's like the sensory stuff is the main thing.--

Exactly. And in SPD, we might not see that same level of social communication difficulties or the same types of restricted repetitive behaviors that are really characteristic of ASD.--

So again, it's about looking at the whole picture.--

It is. It is--

and trying to figure out like what's at the root of this.--

And it highlights why it's so important to have a really comprehensive evaluation by a team of professionals who are experienced in working with children with these developmental and behavioral challenges. We need the expertise of psychologists, developmental pediatricians, speech language path pathologists, occupational therapists. Wow.--

And sometimes even neurologists or psychiatrists to really get a complete picture.--

It's a lot. Yeah. This has been amazing. I feel like we've learned so much.--

Me, too.--

It's like we started with this one case,--

right?--

And it's like opened up this whole universe--

and that's the beauty of it, right? Each child is like a unique puzzle--

and the process of understanding and supporting them is both challenging and incredibly rewarding.--

Well, I think we've given everyone a lot to think about today--

and I hope we've instilled aense of hope and empowerment in everyone listening.--

Yeah, so well said. Thanks for joining us on this deep dive. Until next time,--

This has been an episode of PsyDactic Caps Board Study Edition.