By Marysa Enis and Maria Gregory
Is it Autism?
Sometimes it feels like we are in the dark ages of psychoeducational assessment. We don’t have blood tests or brain scans or genetic tests. We have checklists and definitions and activities. And when it comes to mental health and learning needs, lots of things look like lots of things, so checklists and definitions don’t always help.
Take the California Code of Regulations eligibility criteria for autism, for example. It states that autism is a developmental disability that significantly affects verbal and nonverbal communication and social interaction and is generally evident before age three. Couldn’t that describe other conditions, as well? Depending on the severity of symptoms and types of tools used, other issues can mimic autism – especially if two disorders occur together.
It is common for children with attention-deficit/hyperactivity disorder (ADHD), autism, and emotional disorders to experience overlapping symptoms. In fact, there are A LOT of them. Depending on other factors (like when, where, and how often behaviors occur), the following issues may be related to something other than autism:
Autism, ADHD, and Anxiety May Look Similar
1. Failure to notice or respond to social cues
For (some) children with ADHD, it is incredibly hard to slow down enough to process what others are saying or doing. For them, thoughts are like a train on a train track – headed straight for their destination with no chance for a detour. This means they may interrupt others, talk too much about the same thing, and fail to use social pleasantries, like greetings and apologies. The end result can look similar to delays in social cognition associated with autism.
2. Tendency to misinterpret the actions and statements of others
Children with autism, ADHD, and emotional disorders may misperceive events for different reasons. In the case of ADHD, children may miss important details while distracted, then make faulty connections with the information they do have. In the case of emotional disorders, overly negative or fearful thought processes are key elements of the condition itself.
3. Lengthy emotional outbursts and a tendency to overreact
The primary traits of ADHD are often misunderstood, and the name itself can be misleading. Difficulty with self-regulation is a symptom of ADHD, with some children internalizing (i.e., experiencing strong emotions, like anxiety and self-doubt, in their bodies and thoughts) and some externalizing (i.e., demonstrating strong emotions, like aggression or defiance, for others to see). The same goes for children with emotional disorders routed in anxiety, as their fear response may become triggered for reasons that aren’t obvious to others. Read our previous article on trauma for a closer look at how these feelings might present in the classroom.
4. Strong aversion to sensory experiences
People tend to associate autism with traits like hating noise, avoiding public outings or crowds, complaining about shirt tags or clothing textures, and refusing to eat certain foods. However, ADHD and anxiety can cause similar issues for different reasons. Read these Sensory Processing FAQs from the Child Mind Institute for a good breakdown of what we mean.
5. Strong resistance to changes in routine and insisting on “sameness”
Children with ADHD can have an incredibly hard time “switching gears” from one thought or feeling to another, causing them a lot of distress if they are pressured to transition too quickly. To cope with the difficulty, they may overreact to changes as a way of avoiding them. The same goes for children with anxiety, who may cling to routine as one way of coping with feelings and maintaining control. As with other traits, the end result can mimic autism.
6. Tendency to withdraw from social interaction and avoid eye contact
Children with emotional disorders routed in social anxiety or trauma may also avoid eye contact and group participation, especially in a new or unfamiliar setting. To complicate matters further, not all children with autism have trouble maintaining eye contact, especially if they’ve been raised with the expectation that they do so.
Not Sure? These Assessment Tools Can Help
Since most children with autism also have another disorder, it is essential for clinicians to be thorough and comprehensive in their assessments. A recent study suggested that traits of autism are often overlooked or misdiagnosed when other conditions are present, and this may be even more true for girls. The key to differentiating is to determine why, when, and where a child engages in certain behavior. Checklists, rating scales, and “gold standard” tools (such as the ADOS-2) don’t always give that information — especially when used in isolation. Since it’s easy to be misled by assessment tools, clinical judgment is key.
- Is it that a child can’t, or doesn’t?
- What were the child’s favorite activities as a toddler?
- What motivates the child? What makes them happy?
- Would behavior continue if no people were present?
- How often does a child develop new interests and vary their play?
- What type of humor does the child enjoy?
- What depth and variety of emotion does the child show? Fear, jealousy, embarrassment, caution?
- How does the child express emotion? Words, body movement, voice tone, facial expressions, gestures?
- What does a child’s social interaction and behavior look like when at their very best?
- How much introspection and perspective-taking does a child have when calm?
- What life experiences has the child had? What role might those experiences play in development?
Get as many details about early development as possible. Many people don’t realize how young children are when they start to interact socially, or that anger and defiance are important developmental milestones we want to see in toddlerhood. A child with autism may not have pointed, waved goodbye, or played peek-a-boo as expected (which is around age one). They may not have shown the expected emotions, such as fear, jealousy, guilt, and affection. When autism is suspected, an autism-specific interview may be the single most important piece of data to obtain. Unlike rating scales or more generic parent interviews, these help distinguish traits of autism from those of another disorder.
- Autism Diagnostic Interview-Revised (ADI-R)
- Childhood Autism Rating Scale, 2nd Edition (CARS-2) Caregiver Questionnaire
Student interview/reciprocal play
Typically developing children become curious about gender, relationships, and the concept of “me” versus “you” around the age of two. By age three, they start to adjust their emotional responses to match others. By age six, they compare their skills to others, makeup jokes, and do things to be liked. Just like language, motor skills, and academics, social cognition and emotional intelligence continue to develop each year until adulthood. Since most people have not been trained in what typical development looks like, it is crucial for clinicians to spend time building rapport and getting to know a child for themselves. In doing so, the following may help:
- To alleviate pressure, engage in another activity, such as playing a game, going for a walk, or using play-dough, while talking.
- Attend to the range of gestures, facial expressions, voice tone, and emotional vocabulary a child uses to communicate.
- Show emotion and share feelings to gauge a child’s response.
- Experiment with humor to gauge what makes a child laugh.
- Use the Double Interview by Michelle Garcia Winner. Show the student a picture of your family and use it to gauge theory of mind.
- At the end, tell the student “I’m all done with my questions, do you have anything you’d like to ask about me?”
Multiple observations across settings are necessary to differentiate autism from other disorders, especially if rapport was not established during assessment sessions. We recommend at least two hours, but more may be needed in complicated cases. Try to observe as many settings as possible (recess and lunch; academic activities that require group work or peer collaboration; high and low-interest activities; demanding sensory experiences, such as PE, and less demanding experiences, such as silent reading). While observing, pay special attention to the following:
- Joint attention – How often does a child pay attention to the same thing, at the same time, and for the same reason as another person?
- Social referencing – Does a child observe others to gauge how they respond to different situations? Do they use that information to guide their own behavior?
- Reciprocal interaction – Are interactions one-sided and purely about a child’s interests? Or do they tolerate a balance between their own interests and those of someone else?
Parent and Teacher Rating Scales
There are, of course, the standard autism-specific rating scales that are typically used when autism is suspected (our favorite is the Autism Spectrum Rating Scales – ASRS). These are important and helpful when establishing patterns and determining how a child’s behavior compares with peers, but they aren’t always helpful if the goal is to differentiate symptoms. Such rating scales often suggest traits of autism when symptoms of ADHD or an emotional disorder are severe. In those cases, the following scales act as good screeners and can help clinicians know where to dig next:
- Behavior Assessment System for Children, 3rd Edition (BASC-3)
- Conners 3rd Edition
- Revised Children’s Manifest Anxiety Scale, 2nd Edition (RCMAS-2)
- Children’s Depression Inventory, 2nd Edition (CDI-2)
- Social Skills Improvement System (SSIS)
Delayed development of executive functions is common to many disorders, but the patterns vary. The following tools can help tease out the differences:
- Behavior Rating Inventory of Executive Functions, Second Edition (BRIEF-2)
- Delis Kaplan Test of Executive Functions (D-KEFS)
- NEPSY, 2nd Edition (NEPSY-II) Executive Functioning/Attention composite
Pragmatic Language and Social Communication
In all likelihood, children with autism will have difficulty understanding and using non-literal language (i.e. idioms and sarcasm). They may also have unusual speech patterns, such as maintaining the same voice-tone and rate of speech regardless of the situation (sometimes described as “robotic”) or repeating words and phrases from TV programs or a past event that do not obviously match the context (delayed echolalia). Ideally, clinicians will work closely with a speech and language pathologist (SLP) when evaluating these traits. However, if that isn’t possible, the following tools can help:
- Clinical Evaluation of Language Fundamentals, 5th Edition (CELF-5)
- Pragmatic Language Skills Inventory (PLSI)
- Pragmatic Language Checklist
- Receptive, Expressive and Social Communication Assessment (RESCA)
- The Social-Language Development Test Normative Update (SLDT-E)
- Clinical Assessment of Pragmatics (CAPs)
Measures of adaptive behavior are not helpful for differentiating traits of autism from those of an intellectual disability (ID), but they are helpful for establishing patterns in higher-functioning kids. In the case of autism, we’d expect to see primary concerns in the areas of communication, socialization, and leisure. These are the most commonly used adaptive scales:
- Adaptive Behavior Assessment System, Third Edition (ABAS-3)
- Vineland Adaptive Behavior Scales, Third Edition (Vineland-3)
- Developmental Assessment of Young Children, Second Edition (DAYC-2)
- Developmental Profile, Third Edition (DP-3)
Individuals with Autism may show atypical responses to sensory information. Responses may be hypo (i.e.,under) responsive or hyper (i.e., over) responsive. Rating tools such as the ASRS and CARS-2 include questions regarding sensory processing behaviors, and here are some more:
- Sensory Processing Measure (SPM)
- Sensory Profile, 2nd Edition (Sensory Profile 2)
Social Cognition/Theory of Mind
Finally, when it comes to differentiating “can’t” versus “doesn’t,” for children with social delays, measures of social cognition can help. Children with autism have significant difficulty interpreting facial expressions, body postures, and tone of voice. They are not very good at guessing what others are thinking and feeling, predicting what others might do, or determining what they can do to help a situation. While they may have learned the “right” thing to say or do in common situations, they will likely struggle to apply those skills in the natural environment. These tools help identify a child’s thought processes for interpreting and managing social interactions:
- Test of Problem Solving, 3rd Edition (TOPS-3)
- Theory of Mind Battery Task (TOMTB)
- NEPSY-2 Social Perception composite