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Diagnosing
Autism
Spectrum Disorders
Diagnosing Autism Spectrum Disorders: A Lifespan Perspective Donald P. Gallo
© 2010 Donald P. Gallo. ISBN: 978-0-470-74924-1
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Donald P. Gallo
Diagnosing
Autism
Spectrum Disorders
A Lifespan Perspective
AJohnWiley&Sons,Ltd,Publication
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Thiseditionfirstpublished2010
(cid:2)C 2010DonaldP.Gallo
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Gallo,DonaldP.
Diagnosingautism:alifespanperspective/byDonaldP.Gallo.
p.cm.
Includesbibliographicalreferencesandindex.
ISBN978-0-470-74924-1(cloth)–ISBN978-0-470-74923-4(pbk.) 1.Autism–Diagnosis. I.Title.
[DNLM:1.AutisticDisorder–diagnosis.WM203.5G172d2009]
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1 2010
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Formylovingfamily.ToEmilyandJosh—Iwishthatallparents
wouldbeasblessedasIhavebeenwithsuchwonderfulchildren.
ToDebbie—youaremyeverything.
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Contents
Preface ix
Acknowledgments xiii
AbouttheAuthor xv
1. ABriefLookattheHistoryofAutism 1
2. TheImportanceoftheAutismReferral 5
3. HowtoConducttheEvaluation 17
4. InformationtoGatherattheOutsetoftheEvaluation 33
5. DiagnosticCriteriafortheAutismSpectrumDisorders 39
6. TheMainProblemAreasofAutism:SocialImpairment 45
7. TheMainProblemAreasofAutism:LanguageImpairment 61
8. TheMainProblemAreasofAutism:BehavioralConcerns 79
9. AdditionalQuestionstobeAskedwhenInterviewingTeens 87
10. AdditionalQuestionstobeAskedwhenInterviewingAdults 97
11. OtherImportantFactorstoTakeintoConsideration 105
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viii Contents
12. DifferentialDiagnosisthroughtheLifespan 117
13. FeedbackforthePatientandFamily/Parents 143
AppendixA: SampleCopyofMyQuestionnaire 151
AppendixB: SampleCopiesofReports 157
References 179
Index 181
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Preface
In late 2000, I was hired by Kaiser-Permanente to be the psychologist for their
AutismSpectrumDisorderDiagnosticServiceintheSanFernandoValleyofLos
Angeles.ThispositioncameaboutbecauseCalifornia’sAssemblyBill88requires
insurance plans to provide coverage for the diagnosis and medically necessary
treatmentofnineseverementalillnesses,includingautismandpervasivedevel-
opmentaldisorder.
Between my position there and my private practice, I have conducted ap-
proximately 1,500 evaluations on a wide variety of individuals ranging in age
from12monthsto65years.Itypicallyconductfivetosixevaluationsaweek.In
the beginning, I was seeing mostly young children for autism evaluations after
receivingreferralsfromtheirpediatricians.Afterawhile,Ibeganseeingpatients
inallageranges,from16monthsto55yearsold.
Atfirst,Ireliedratherheavilyontheuseofformalscreeningdevices,suchas
theChildhoodAutismRatingScale(CARS)andtheGilliamAutismRatingScale
(GARS), in addition to the wisdom of a senior psychologist who had worked
with Dr. Ivar Lovaas at University of California at Los Angeles decades earlier.
Dr. Lovaas is one of the early pioneers of applied behavioral analysis, a way of
modifyingthebehaviorofchildrenwithautism.
AstimeprogressedandIconductedmoreevaluations,attendedmoreconfer-
ences,andreadmorebooksaboutautism,Iincreasedmyunderstandingofthe
vastnessoftheautismspectrumandtheneedtobroadenmyapproachtomore
fullycomprehendandappropriatelydiagnosetheseindividuals.Inaddition,the
early childhood rating scales did not translate easily for adults. As you could
imagine,itwouldbemoredifficultforthemotherofa40-year-oldmantorecall
earlydevelopmentalmilestonesthanthemotherofafour-year-old.
In2001,Icreatedmyownscreeningquestionnaire,whichisreproducedinAp-
pendixA.Thisquestionnaireisnotanytypeofempiricallyvalidatedinstrument
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x Preface
butmoreofthequestionsthatencompassallaspectsofthespectrumthatIfeel
arenecessarytomakeanappropriatediagnosis.BythetimeIfeltcomfortablein
myabilitytoappropriatelyidentifychildrenonthespectrum,Iwasbeginningto
seeabroaderarrayofagesandwasreadingotherprofessionals’reportsinwhich
theyandIappearedtohavevastlydifferentpicturesofthesameindividual.
I was diagnosing children and teens as “being on the spectrum” after their
parents reported a history consistent with the disorder, and my observations
of the individual in my office were consistent with what the parents had told
me. However, other professionals were coming up with alternative diagnoses.
ChildrenIdiagnosedwithautismwerebeingdiagnosedwithADHD,obsessive-
compulsivedisorder,andanxietydisorders,withoutautismbeingconsideredas
thereasonforthechild’sproblems.
In an effort to better understand the reasons for these various diagnoses, I
placedafewphonecallstootherexperiencedautismprofessionalsthroughout
theLosAngelesarea,whoseopinionIrespected.WhenIspokewithDr.Laurie
Stephens, the former director of the Help Group Center for Autism Spectrum
DisordersandnowtheDirectorofClinicalServicesforEducationSpectrumin
AltaDena,California,shereportedthatshetoowasfacingthesamedifficulties
that I was, namely, that the combination of the broadness of the autism spec-
trum, the high number of children and teens being evaluated, and the lack of
a commensurate number of professionals trained to diagnose autism created a
greatdealofmissedorincorrectdiagnoses.
This was the main reason why I felt the need to write this book. I consider
myself quite lucky to have been able to learn how to identify symptoms of the
autismspectruminanenvironmentincludingothertrainedprofessionalswho
have had significant experience in that area and were trained by leaders in the
field.Whatabouttheotherprofessionalswhodonothavethatopportunityor
whoarenotexposedtoindividualsonthespectruminthenumbersthatIhave
seenbecauseofworkingforsuchalargeorganization?Conductingevaluations
with children and teens who may have autism on an occasional, monthly, or
fortnightly basis is incredibly different than seeing a half-dozen children and
teensforevaluationseveryweekforthepast10years.
This book is formatted to follow the chronology of an autism evaluation
fromstarttofinish.InChapter1,averybriefsynopsisofthehistoryofautism
is presented. While that topic could fill an entire book on its own, only the
informationthatprovidesthereaderwithbackgroundinformationaboutautism
and helps them to answer the main question posed by this book is included;
namely,doesthepersonyouareevaluatinghaveanautismspectrumdisorder?
In Chapters 2 and 3, information that is necessary for the professional to
considerbeforeevenseeingthechildispresented.Chapter4focusesonadditional
questionsthatneedtobeaskedbeforeautismisevenconsidered.Chapter5lists
the diagnostic criteria of the autism spectrum disorders, while Chapters 6–8
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Preface xi
delveintothespecificareasofimpairmentthatarenecessaryforadiagnosisof
autism.Withineachofthosethreechapters,informationwillbepresentedabout
several different ranges and the type of information that needs to be obtained
beforeadiagnosiscanbemadeorruledout.
Chapter9consistsofadditionalquestionstoaskwheninterviewingteensand
their families, while Chapter 10 covers interviewing adults and the particular
challenges inherent in doing so. Chapter 11 is a compilation of supplemental
informationthatIhavefoundtobeextremelyhelpfulinmakingadiagnosisbut
arenotfactorsincludedintheDSM-IV-TR.Chapter12includesthenumerous
“rule-out diagnoses” that need to be considered before a diagnosis is finalized.
The final chapter, Chapter 13, deals with the conclusion of the evaluation and
waystoimpartyourfindingstothepatientandtheirparentsorfamily.Copiesof
thequestionnaireIcreated,aswellassamplereports,arealsoincluded.Examples
ofevaluationsIhaveconductedwillalsobepresentedthroughoutthebook.
While this book is obviously not all that a professional would need to be
qualifiedtoconductautismevaluations,itprovidesthereaderwith“real-world”
experiencesandexamplesthattheywouldnotreceive,orpotentiallyeventhink
about,fromlearningaboutthisdisorderinaclassroom.
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Acknowledgments
I owe a great debt of gratitude to Kaiser-Permanente in general and Dr. Len
Sushinsky in particular for having faith that a newly licensed psychologist can
notonlyhandlebutalsoexcelinthepositionthatIwasgiven.Iwouldalsolike
tothankSusanBassettforherconstantsupportandforbeingsuchawonderful
coworker.AspecialthankstoDr.JerroldParrishforallofhiseditingassistance
andbrainstorming,nottomentionallthewonderfulcoffee.
