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I once worked with a 6-year old boy who was referred for a special education assessment following a report from a clinical psychologist that diagnosed him with Attention Deficit Hyperactivity Disorder (ADHD), Anxiety Disorder—Not otherwise Specified (NOS), Tic Disorder, Autism Spectrum Disorder (ASD) and a Speech and Language Disorder. He was also being seen by a neurologist for a sleep disorder. The summary page read a lot like, ASD, ADHD, ASD, LMNOP. XYZ. That is a lot of diagnoses for a 6 year old.
I expected this child to be falling apart in the classroom. After all, he was anxious, hyperactive, inattentive, autistic, couldn’t speak or understand language, was having tics, and was working on barely any sleep. What I found was a friendly little boy working in a small group of students on an art project. He was sharing his art supplies, taking turns with the green marker, and sitting in his chair. At one point, he went to the teacher and gave her a hug. He used a robot-like voice with her, saying "I sure am glad you are my teacher." During an academic setting, he struggled with math—he counted 1-2-5-7-8 on his fingers when working out if there were more red or green marbles. Reading appeared to be a strong skill for him. He read outloud fairly fluently when called on to read from a predictable rhyming book.
On the playground, I observed him playing ball with some other boys. He was bossy. He demanded that they all play kickball and ignored other suggestions. There was nothing outrageous about his behavior though. After double-checking that I was indeed observing the same child as the report, I was perplexed.
Did I catch this kid on the best day of his life? It was unclear where the symptoms of his hefty portion of alphabet soup o’ diagnoses had gone. What was clear is that I needed more information. The teacher and mom shared that the boy sometimes “misperceived social situations” or “got upset for no reason.” I asked the teacher and parent for examples. His teacher said that last week, he told the boy to “Put your eyes on your own paper!” and he screamed “No!!! Gross!!!” The week before, he started crying when the teacher asked him to “Give me your hand.” He yelled “No!!! It’s mine!” His mom said that one time he went up to a man on the street and asked him if he wanted to go to school with him. Now that’s kind of odd, you have to admit.
What disability results in these types of social difficulties? He had a hard time interpreting metaphors and abstract language. He was bossy with peers. He had major difficulties in math (and ultimately on all visual tasks I gave him). This was a student who on the first day of testing bounded over to me like Tigger and grabbed my hand to show me where the testing room was; the next day he gave me a huge “hi-five,” and then one second later asked point blank, “Wait. Do I know you?”
A number of hypotheses came to mind about what was going on for this little guy---and most of them fell somewhere along the Autism Spectrum. School psychologists could write multiple dissertations on the differential diagnoses of Autism from Aspergers, Nonverbal Learning Disabilities, ADHD, PDD, and all the other diagnoses this boy had from the clinical setting. And after we published said dissertations, we would still meet a kid the next day who didn’t quite fit in any of these diagnostic categories. We might say to a colleague, I’m working with this kid whose kind of “spectrumy.”
After obtaining all the information, this little guy was ultimately diagnosed with a Nonverbal Learning Disability (NLD)*, based upon his poor visual processing, difficulties with language pragmatics, and problems reading social cues. Making differential diagnoses is one of the most difficult parts of our jobs. Some have argued that these diagnoses are arbitrary, and that we should just give kids what they need. It is tempting, I must admit, to pour the alphabet soup o’ diagnoses down the proverbial drain. I am torn though, because a good diagnosis can provide information about how to intervene. I will take the middle road and say that a diagnosis is good to the degree that it provides access to services and appropriate intervention.
*The best book on NLD I’ve found is called (big surprise!) Nonverbal Learning Disabilities: A Clinical Perspective, by Joseph Palombo. It details the diagnosis, assessment, and intervention with this population of students.