questions about diagnostic considerations

[smalltownpsych]

A while back, I had a patient that I was to see for behavioral treatment, purportedly. I later found out that the parent merely wanted a diagnosis of Autism to take to the school as part of an IEP dispute of some sort. I had entered a diagnosis of Autism Spectrum Disorder with intellectual impairment and language delay based on observations of the kid and parent's report. Fast forward about 9 months and school psychologist is on the phone with me giving me a hard time because the ADOS says the kid does not have autism and that they don't have an intellectual disability because the IQ is 80. I didn't diagnose intellectual disability, but apparently they are taking the stance that intellectual impairment has to have the same criteria of 70ish or less IQ.

My stance was that my diagnosis or treatment is not the same as a comprehensive assessment and that I don't even do evaluations of autism anyway, but I do have to put in a diagnosis and it is often based on limited information. Also, a specific diagnosis is less important to my treatment plan than identifying specific social, emotional and behavioral problems, identifying specific causes, and coming up with specific interventions. The school and other agencies are more focused on a medical model and also what diagnosis qualifies for what level of services and this creates a much different environment. In my mind, much of the time I don't really need the correct diagnosis, but I feel like that calls into question my competency so I have to act as though I am Dr House or something coming up with the right answer.

Anyway some of this is just venting, but some of this is really trying to spur some dialog and thoughts about these types of situations.

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[bcliff]

Were either of the diagnoses couched as provisional or rule-out?

 

[smalltownpsych]

Were either of the diagnoses couched as provisional or rule-out?

No. Our EMR doesn't lend itself to this and I typically only would specify that when I doubt the diagnosis anyway. When I met with the kid, the observations were consistent with parent's report so didn't see a reason to couch it. Basically, it was a kid with impaired social functioning, verified history of language delays, and a lower than average IQ. I didn't really question the diagnosis, but then again, it was not a referral for testing or diagnostic assessment. If I had continued to see the kid and his parent, perhaps more would have been revealed and I would change the diagnosis. Have definitely done that many times in the past when new information is revealed or when symptoms remit.

 

[Therapist4Chnge]

A good rule of thumb is to not list any diagnosis that your aren’t willing to defend in front of a licensing board or judge. If it’s provisional, then label it as such...same with a rule out. The problem with listing a dx is that it can follow that person for a long time/life, so it really needs to be accurate.

In regard to billing, you can clearly mark in your consult/report the referral question with the associated Dx. Then you have YOUR diagnosis. You bill the referral dx, but clarify that it ended up not being present, and you put in what does apply.

I had this argument many times with prior hospitals and you need to make sure you aren’t just picking a dx for billing reasons because that is not a sufficient defense if you get sued or have a complaint filed against you.

Autism in particular is a dicey dx. I would never dx it without a comprehensive evaluation from a peds neuro and corroborating documentation with direct observation. There are plenty of dx’s that can include social problems, learning delays, etc.

I know you can get a lot of downward pressure about what is a billable code, but there can be significant repercussions if you don’t stick with what has clinical support.

 

[smalltownpsych]

A good rule of thumb is to not list any diagnosis that your aren’t willing to defend in front of a licensing board or judge. If it’s provisional, then label it as such...same with a rule out. The problem with listing a dx is that it can follow that person for a long time/life, so it really needs to be accurate.

In regard to billing, you can clearly mark in your consult/report the referral question with the associated Dx. Then you have YOUR diagnosis. You bill the referral dx, but clarify that it ended up not being present, and you put in what does apply.

I had this argument many times with prior hospitals and you need to make sure you aren’t just picking a dx for billing reasons because that is not a sufficient defense if you get sued or have a complaint filed against you.

Autism in particular is a dicey dx. I would never dx it without a comprehensive evaluation from a peds neuro and corroborating documentation with direct observation. There are plenty of dx’s that can include social problems, learning delays, etc.

I know you can get a lot of downward pressure about what is a billable code, but there can be significant repercussions if you don’t stick with what has clinical support.

Makes sense. I was actually not getting pressure from above, but was manipulated by parent more than anything else. She said she thought it was autism and described a history very consistent with that and the observations matched so I just checked the boxes that fit. Always a lot to learn in this field.

What do you think about including someone else's diagnosis, if it had been an assessment from another provider (as opposed to a parent ). I tend to avoid just repeating others dx'es, but I see it done quite a bit. I have done it when I have the comprehensive report in my hand and I agree with it.

 

[Justanothergrad]

Autism in particular is a dicey dx. I would never dx it without a comprehensive evaluation from a peds neuro and corroborating documentation with direct observation. There are plenty of dx’s that can include social problems, learning delays, etc.

You wouldn't diagnosis autism without a peds neuro eval? I wasn't aware that there was a cognitive profile ubiquitous enough across the diagnosis for cognitive testing to be effective at discriminating the diagnosis - especially with the DSM5 conceptualization of the Dx. I'm not sure how common it is to include this in testing either. From my experience in the school SPED programs over the last few years, that seems to rarely be the case. It's a dicey diagnosis for sure and all sorts of reasons making it difficult, but I'm struggling with that as an expected component.

Can any neuro folk on here versed in this point me towards some reading on the expected cog profiles which would support this as a diagnostic standard?

 

[hamstergang]

You wouldn't diagnosis autism without a peds neuro eval? I wasn't aware that there was a cognitive profile ubiquitous enough across the diagnosis for cognitive testing to be effective at discriminating the diagnosis

I thought he meant pediatric neurology, of the MD variety (also, neurodevelopmental pediatricians would be good for this too). No cognitive or psychological testing involved.

 

[erg923]

I thought he meant pediatric neurology, of the MD variety (also, neurodevelopmental pediatricians would be good for this too). No cognitive or psychological testing involved.

Ideally, an ADOS to help shore things up. Some other brief measures can be useful for treatment planning/recs given co-morbidity. Depends on how we define "medically necessary" though.

 

[Therapist4Chnge]

Whoops...I should have clarified. I meant a comprehensive eval that includes an ADOS, teacher questionnaire, parent questionnaire, etc. There would also need to be a physician involved to rule out medical conditions...though that seems to happen earlier on.

My frame of reference comes from large AMC peds clinics that see all sorts of development disorders. This is likely not typical for a community setting.

 

[Justanothergrad]

Whoops...I should have clarified. I meant a comprehensive eval that includes an ADOS, teacher questionnaire, parent questionnaire, etc. There would also need to be a physician involved to rule out medical conditions...though that seems to happen earlier on.

My frame of reference comes from large AMC peds clinics that see all sorts of development disorders. This is likely not typical for a community setting.

Ah yeh, that makes more sense and is consistent with my experience. I've seen way too much creep for what some folks ascribe to Neuropsych scope (couch, ADHD) and I always inquire to make sure i'm current on anything related to testing.

 

[futureapppsy2]

It's a major professional pet peeve of mine when people dx ASD based on only parent and child report and observation. At the very, very least do an ADOS. At one of placements, we did truly comprehensive ASD evals (medical consult, speech/language testing, cognitive testing, ADOS, parent/teacher rating scales, parent structured interview, etc), and even then, many diagnoses weren't clear cut. When parents get an ASD diagnosis without a rigorous assessment and then are referred for a rigorous assessment only to be told that their child doesn't, in fact, have ASD, that can create a lot of confusion and difficulty for the family. Also, keep in mind that the criteria for qualifying under an autism classification for special education and the diagnostic criteria for ASD aren't a one-to-one match.

 

[ClinicalABA]

My clinical practice exclusively involves assessing children (I specialize in under 3 y.o.) suspected of displaying ASD. A few comments:

- technically, the diagnosis can be made based on history/report, so nothing was unethical here. There’s a local MD with a reputation of giving a dx after a 15-20 min interview, just so kids can get services.

-best practice includes some direct measurement of symptoms (e.g., with an ADOS). For my population, I typically do a hour parent interview session with the child present for unstructured observation. This includes a review of a structured developmental questionnaire. This session is typically attended by the child’s early intervention developmental specialist and/or speech therapist or OT (who are an invaluable source of info for me and support for the family and child).

-for kiddos under three, big rule outs are global developmental delay and pure speech disorders that are impacting social interaction. I’ve diagnosed a smattering of social programmatic communication disorder, as well as a fair share of “typical toddler, diagnostically speaking, but at the upper end of the behaviors that drive parents crazy curve”

-typical battery includes ADOS-2 (to identify ASD symptoms), cognitive testing (helps with ID of global delays), a language eval (primarily to establish baseline and for goal setting- lack of speech at age 2 is most common/obvious symptom and reason for referral). I also do a Vineland (I like it mainly for comparison of parent scores with direct measures of language), and structured parent rating of ASD symptoms (e.g., SRS-2). If a kiddo has obvious motor delays, I’ll throw in a direct measure of motor skills, primarily as a baseline measure.

-I’ve given ASD diagnosis to kiddos who are subclinical on the ADOS, particularly when there aren’t obvious repetitive behaviors/restricted interests, as these may not be as obvious in kids under three or may manifest later. In these cases, I’ve typically had multiple reports of symptoms from other professionals on the case, as well as have seen symptoms at other times during the assessment.

-It’s less common- but has happened- where I’ve not diagnosed a kiddo who is clinical on the ADOS. Usually these guys will meet 2 out of 3 “category A” symptoms (NOTE- I had erroneously initially typed “3 out of 4”- sorry for confusion) by report and observation. I try to see these kiddos again in 6 months, and find They often meet criteria at that point

-In regards to the OP- 9 months can be a significant portion of the life of a real young kid, and it’s possible that both assessments produced accurate results.

-I find it sketchy when schools do diagnoses. There’s too many competing agendas and possible ethical conflicts when the boss of the person doing the diagnosis is in charge and accountable for the SPED budget, not to mention the issue of the kiddo, if diagnosed, being added to the already impossible caseload of the school psychologist. I do home-based treatment as well (as a BCBA), and have a personal policy of not supervising treatment of Kidd’s I diagnose, just to keep things “clean”. Schools should, imho, stick to evaluating the extent to which the symptoms of the diagnosis interfere with educational progress. Also, in my state, as far as insurance based ABA and early intervention services go, an ASD dx must come from a physician or psychologist to “count.”

-ASD, moreso than any other diagnosis I’ve been involved with, is tied to such a jump in available services. Kid I don’t don’t diagnose maybe can get an additional hour or two a week of speech or OT, whereas a ASD dx can mean an additional 20-30 hours per week of services, plus additional SSDI benefits. You better believe that there are kiddos I don’t diagnose who need those extra services much more than some of the kiddos I do diagnose.

Sorry for the long post, but it’s an area I’m deeply ingrained in, plus I’ve been on vacation and away from tech for a week, so I’m catching up quickly with this one post!

 

[smalltownpsych]

My clinical practice exclusively involves assessing children (I specialize in under 3 y.o.) suspected of displaying ASD. A few comments:

- technically, the diagnosis can be made based on history/report, so nothing was unethical here. There’s a local MD with a reputation of giving a dx after a 15-20 min interview, just so kids can get services.

-best practice includes some direct measurement of symptoms (e.g., with an ADOS). For my population, I typically do a hour parent interview session with the child present for unstructured observation. This includes a review of a structured developmental questionnaire. This session is typically attended by the child’s early intervention developmental specialist and/or speech therapist or OT (who are an invaluable source of info for me and support for the family and child).

-for kiddos under three, big rule outs are global developmental delay and pure speech disorders that are impacting social interaction. I’ve diagnosed a smattering of social programmatic communication disorder, as well as a fair share of “typical toddler, diagnostically speaking, but at the upper end of the behaviors that drive parents crazy curve”

-typical battery includes ADOS-2 (to identify ASD symptoms), cognitive testing (helps with ID of global delays), a language eval (primarily to establish baseline and for goal setting- lack of speech at age 2 is most common/obvious symptom and reason for referral). I also do a Vineland (I like it mainly for comparison of parent scores with direct measures of language), and structured parent rating of ASD symptoms (e.g., SRS-2). If a kiddo has obvious motor delays, I’ll throw in a direct measure of motor skills, primarily as a baseline measure.

-I’ve given ASD diagnosis to kiddos who are subclinical on the ADOS, particularly when there aren’t obvious repetitive behaviors/restricted interests, as these may not be as obvious in kids under three or may manifest later. In these cases, I’ve typically had multiple reports of symptoms from other professionals on the case, as well as have seen symptoms at other times during the assessment.

-It’s less common- but has happened- where I’ve not diagnosed a kiddo who is clinical on the ADOS. Usually these guys will meet 3 out of 4 “category A” symptoms by report and observation. I try to see these kiddos again in 6 months, and find They often meet criteria at that point

-In regards to the OP- 9 months can be a significant portion of the life of a real young kid, and it’s possible that both assessments produced accurate results.

-I find it sketchy when schools do diagnoses. There’s too many competing agendas and possible ethical conflicts when the boss of the person doing the diagnosis is in charge and accountable for the SPED budget, not to mention the issue of the kiddo, if diagnosed, being added to the already impossible caseload of the school psychologist. I do home-based treatment as well (as a BCBA), and have a personal policy of not supervising treatment of Kidd’s I diagnose, just to keep things “clean”. Schools should, imho, stick to evaluating the extent to which the symptoms of the diagnosis interfere with educational progress. Also, in my state, as far as insurance based ABA and early intervention services go, an ASD dx must come from a physician or psychologist to “count.”

-ASD, moreso than any other diagnosis I’ve been involved with, is tied to such a jump in available services. Kid I don’t don’t diagnose maybe can get an additional hour or two a week of speech or OT, whereas a ASD dx can mean an additional 20-30 hours per week of services, plus additional SSDI benefits. You better believe that there are kiddos I don’t diagnose who need those extra services much more than some of the kiddos I do diagnose.

Sorry for the long post, but it’s an area I’m deeply ingrained in, plus I’ve been on vacation and away from tech for a week, so I’m catching up quickly with this one post!

Thanks so much for the long post. I was hopeful that you would chime in since it is so clearly an area of expertise.

 

[smalltownpsych]

This whole topic raises a question for me about what is appropriate for me to diagnose and what should require additional testing or expertise. It sounds like there is consensus that best practice is that ASD in kids should require more and as I stated before I wouldn't even take a referral for a diagnostic eval for one of those cases. Most of the posters on this board are primarily involved in diagnostic assessments and the responses reflect that. Since I am primarily providing treatment, what is the expectation of me or other psychologists providing psychotherapy to a patient and giving diagnoses that we have less evidence to support than a more extensive diagnostic eval would reveal? Keep in mind that patients also want to know what I think their diagnosis is and that discussions about this and are often part of treatment.

 

[G Costanza]

I’m at a UCC and don’t do any testing. Every once in while I’ll get someone who thinks they might be on the spectrum and wants to know for sure. I’ll spend a session having them talk about why they think they might be, provide psychoed on what it looks like, and ask what would be different if they knew for sure either way (ranging from accommodations to “I’m just curious”). If at that point we both think pursuing a formal diagnosis makes sense, I’ll refer them to someone for testing. I’ll put it down as a provisional dx but I have never made it principle.

 

[PsyDr]

Whether someone wants to be dr big work up or dr small work up is sort of a personal choice. While most psychologists are trained to emphasize psychometrics, one would be wise to remember that the DSM only recommends testing in the neurocognitive disorders and ADHD.

If you can demonstrate that a patient meets criteria for a disorder, then go for it but be sure to note your limitations as required by ethical standards. There’s more to diagnosis than simple numbers.

 

[futureapppsy2]

-for kiddos under three, big rule outs are global developmental delay and pure speech disorders that are impacting social interaction. I’ve diagnosed a smattering of social programmatic communication disorder, as well as a fair share of “typical toddler, diagnostically speaking, but at the upper end of the behaviors that drive parents crazy curve”

This is interesting to me, as in the probably 70 or so ASD assessment cases I was involved in over two years, I can't recall one case where we diagnosed social-pragmatic communication d/o. Usually, the kids we were on the fence about also failed to meet all four of the criteria for that disorder, and we often had more questions about whether they met all the social-communicative criteria for ASD than if they met two of the four restrictive-repetitive criteria. Our population ranged from 2-3 to (rarely) adult (mostly 4-10, I'd say), though, so in many cases, a lot of our clients had picked up just enough social-communication skills to make those lines slightly blurrier. We did sometimes dx (well, speech did) receptive/expressive language disorders in kids who had basic social pragmatics but lacked the language abilities to communicate those well. We also diagnosed a lot of ADHD.

Usually these guys will meet 3 out of 4 “category A” symptoms by report and observation. I try to see these kiddos again in 6 months, and find They often meet criteria at that point.

There's only three criteria under criterion A (social communicative), though...?

- technically, the diagnosis can be made based on history/report, so nothing was unethical here. There’s a local MD with a reputation of giving a dx after a 15-20 min interview, just so kids can get services.

Not directed at ClinicalABA at all, but I think it's important to point out that there's a difference between what you can ethically do and what's good, ethical practice. Primary care providers can diagnose any psych disorder they want based on a five minute interview, but that doesn't mean it's accurate or appropriate to do so. This is how you get people with PTSD diagnoses with no index trauma or people with bipolar diagnoses who have no maniac or hypomaniac episodes, etc., etc.

Another thing is that we always deliberately spread testing over two days to make sure that we weren't seeing the kid on a particularly good or bad day. Not practical in rural areas but good practice if you can do it...[/quote]

 

[ClinicalABA]

This is interesting to me, as in the probably 70 or so ASD assessment cases I was involved in over two years, I can't recall one case where we diagnosed social-pragmatic communication d/o.

I’ve made this diagnosis once (maybe twice) in the five plus years I’ve been assessing using DSM-5 (I see between 75-100 kids per year). I recall it being a very unusual presentation, and also one where I was pretty upfront about all my uncertainties with the diagnosis, with a strong recommendation to come back in 6 months after some focused EI services, including speech.

 

[biscuitsbiscuits]

I’ve made this diagnosis once (maybe twice) in the five plus years I’ve been assessing using DSM-5 (I see between 75-100 kids per year). I recall it being a very unusual presentation, and also one where I was pretty upfront about all my uncertainties with the diagnosis, with a strong recommendation to come back in 6 months after some focused EI services, including speech.

Would you be able to describe the child's unusual presentation? Just very curious.

 

[futureapppsy2]

@ClinicalABA :
I’m curious as to why you mentioned 4 criteria under A (I am assuming that you’re referring to the social-communication criterion?). As there’s only 3. Am I missing/forgetting something?

 

[ClinicalABA]

@ClinicalABA :
I’m curious as to why you mentioned 4 criteria under A (I am assuming that you’re referring to the social-communication criterion?). As there’s only 3. Am I missing/forgetting something?

Because I made a mistake when typing it all out yesterday morning! There are only 3. I’ll edit with an explanation so these replies make sense. Thanks!

 

[ClinicalABA]

There's only three criteria under criterion A (social communicative), though...?

That’s an error on my part- original post edited. Thanks

Not directed at ClinicalABA at all, but I think it's important to point out that there's a difference between what you can ethically do and what's good, ethical practice. Primary care providers can diagnose any psych disorder they want based on a five minute interview, but that doesn't mean it's accurate or appropriate to do so. This is how you get people with PTSD diagnoses with no index trauma or people with bipolar diagnoses who have no maniac or hypomaniac episodes, etc., etc.

Great point

Another thing is that we always deliberately spread testing over two days to make sure that we weren't seeing the kid on a particularly good or bad day. Not practical in rural areas but good practice if you can do it...

We do this as well, with an intake eval followed 2 weeks later by formal testing session. I also ask parents if this was a typical day for the kiddo and if s/he did or didn’t do anything that surprised them. I also score the Vineland before the parent leaves and probe any discrepancies between parent ratings of skills and what I’ve observed or directly measured.

 

[ClinicalABA]

Would you be able to describe the child's unusual presentation? Just very curious.

Very talkative, but primarily tacting features of objects (“blue car”; “that’s a cat”). No manding with speech (but did so with eye contact and pointing). Average language scores, but a lot of getting an item correct, then missing 2 or 3 in row before getting another right (thus avoiding discontinuation due ceiling rules). Shared excitement/interest with others by smiling at, showing, and giving, but not combined with speech. Limited intraverbals. Appropriate pretend and imaginative play. Parent and EI staff report that speech is same with everyone, regardless of age ore relationship.

 

[barryggg]

Couple points:

1. It is absolutely true that a good majority of the parents come in with an agenda. Often they want a particular diagnosis. You have to be cognizant of that. They will try to push you to a specific diagnosis.

2. The FSIQ is a good indicator of overall intelligence but fairly large variability among indices is more common than not. As a result, you often learn much more from the differences between indices/sub-tests than FSIQ. (in combination with observation, considering the learning strategies, etc)

 

[biscuitsbiscuits]

Very talkative, but primarily tacting features of objects (“blue car”; “that’s a cat”). No manding with speech (but did so with eye contact and pointing). Average language scores, but a lot of getting an item correct, then missing 2 or 3 in row before getting another right (thus avoiding discontinuation due ceiling rules). Shared excitement/interest with others by smiling at, showing, and giving, but not combined with speech. Limited intraverbals. Appropriate pretend and imaginative play. Parent and EI staff report that speech is same with everyone, regardless of age ore relationship.

Thanks for describing- interesting!