A Diagnostic Dilemma – Autism (ASD) or Sensory Processing Disorder (SPD)?

This issue is becoming more crucial as we speak. We all believe in early Intervention and providing a diagnosis as young as possible. In order to really explain this question, let us first look at defining the issue in simplistic terms. ASD is a neurobiological disorder impacting function on a wide front of occupational and social functioning and includes sensory difficulties as part of the diagnostic criteria. There is a wide variety of functional ability in different individuals with ASD with cross over into multiple different diagnostic categories including ADHD, OCD, ODD and multiple others. A core issue of difficulty is that social perspective taking (theory of mind) are severely impacted, causing much difficulty with emotional and symbolic thinking such as building empathy. This is not a formal description, but a description containing key elements to the topic.

SPD is a neuro-developmental impairment that may contain elements of both the central and autonomic nervous system. This causes deficiencies in activities of daily living, learning, play, and social skill. Again, here we are looking at a wide variety of profiles, but we are not looking at core deficits such as theory of mind or central coherence (ability to generalize skill from one environment to another). Yes, just as in ASD, these clients can also appear “self-centered”, exhibit stereotypical behavior or line up their toys, but as soon as the child with SPD finds balance in his / her regulatory system and are able to understand incoming sensory information, they are capable of joining the world around them and negotiating theory of mind is not a large work. The autistic child however, is a different story. Their difficulties lie beyond their sensory systems and not only does it take longer to impact on their sensory systems, but it is a long road to work through theory of mind and gaining social perspective over different individuals in their lives.

The importance of this lies in what kind of services both diagnostic categories will be offered. Let us take Barry for example. He is a 3-year-old boy recently diagnosed on the ASD spectrum. As his brain is still undergoing development with an ongoing myelination process, his sensory profile is going to look similar to Eva’s, who has SPD. Barry will be offered ABA through his service providers as in most states this would be the only option available that would be funded. ABA has no research on theory of mind and therefore does not consider this aspect and is mostly focused on any kind of skill to be learnt or behavior to be unlearnt. It plays into central coherence as it teaches skills in specific domains and it frequently does not transmit over into other domains. The whole premise of ABA is that it relies much on prompting, not on the intrinsic motivation of the child. Barry would be taught through long term memory, a particular cognitive strength in ASD, and not through working memory that requires the act of problem solving to develop the richness of being an independent thinker. ABA shows success in their data as it plays into the strengths of ASD, but it does not target the core issues of weakness as noted above. Eva will go into play sessions, OT, and SLP, and she will immediately be required to use her thinking brain. As her sensory systems settle, her ability to entertain and reach out to others will grow far more rapidly.

What if Barry was misdiagnosed and goes into a 20 hour a week program of skill training priming his yet unmyelinated brain to think in long term files, suppressing his individual preferences, and not working on social problem solving in a way that he could be capable of? How is his brain developing? Are we then creating autistic like features, instead of working on what his true capability may be? I have seen such cases. I have seen them leave my practice (private pay) for services that are government funded and after one year of ABA, I have no proof, because we are now looking at a child trained to think in autistic ways, trained in his brain to not use what was there, but to lose it. The growth of the developing mind is a true scientific fact and it is true that “what you do not use, you lose”. Typical children learn through play, through experiences, through trial and error, but a major chunk of Barry’s time will be spent in trying to get him to stay seated, to behave, to pay attention, to “sit on his hands when they flap”. And when he protests, as his psyche wakes up to himself, the reason would be that it is just another “autistic” behavior, and we try to inhibit the budding spirit even more. We are in a very sad situation as we over focus on behavior at the cost of brain development. I do not want to be right in what I am saying, but if I am, what are we going to do about this? Government officials, who mandate such funding have a responsibility to investigate and at least start thinking about providing the families with choices in funding. I love the idea of intensity and would love to have 20 hours a week funded for us to play therapeutically and really let the child’s creative juices flow. Right now, there is no such opportunity and sadly, some children are never going to get the opportunities they deserve. Please think about this.